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Journal ArticleDOI

The relationship between personal unsecured debt and mental and physical health: a systematic review and meta-analysis.

01 Dec 2013-Clinical Psychology Review (Clin Psychol Rev)-Vol. 33, Iss: 8, pp 1148-1162
TL;DR: The majority of studies found that more severe debt is related to worse health; however causality is hard to establish, and future longitudinal research is needed to determine causality and establish potential mechanisms and mediators of the relationship.
About: This article is published in Clinical Psychology Review.The article was published on 2013-12-01 and is currently open access. It has received 301 citations till now. The article focuses on the topics: Mental health & Unsecured debt.

Summary (5 min read)

Introduction

  • A large body of literature has established that health problems, in particular mental health problems, are more prevalent in certain parts of society.
  • A study of ten European countries demonstrated that socioeconomic deprivation increases the risk of suicide (Lorant, Kunst, Huisman, Costa, & Mackenbach, 2005), and a study of 65 countries by the World Health Organisation found that rates of depression varied by levels of income equality.
  • A systematic review DEBT AND HEALTH 4 suggested that wealth is related to health, and the authors suggest this should be used as an indicator of SES (Pollack, et al., 2007).
  • It has also been suggested that measures of SES are often not related to each other, for example correlations between education and income are moderate and differ by ethnicity (Braveman, et al., 2005).
  • There is currently around £156 billion in unsecured debt in the UK, and this is predicted to increase (Credit Action, 2013).

Databases and Search Terms

  • Psychinfo, Medline and Embase, also known as Three databases were searched.
  • The following search terms were used to search all fields: „Indebtedness‟ or „Debt‟ and „Health‟ or „Mental disorder‟ or „Mental illness‟ or „Depression‟ or „Anxiety‟ or „Stress‟ or „Distress‟ or „Alcohol‟ or „Drug‟ or „Suicide‟ or „Eating Disorder‟ or „Psychosis‟ or „Schizophrenia‟.

Inclusion and Exclusion Criteria

  • Papers had to examine the relationship between personal debt and physical health, mental health, drug or alcohol problems or suicide.
  • References had to be full papers written in English in a peer reviewed journal.
  • Only research studies were included: reviews, meta-analyses or letters/commentaries on the area were excluded.
  • Studies which for example simply reported the percentage of those with debt who had a health problem were excluded.

Search procedure

  • References were initially screened at title to see whether they met inclusion criteria.
  • If accepted at title the abstract was screened, and if this was accepted the full paper was screened.
  • Main reasons for rejection noted were: not relevant/multiple reasons, not debt specific, Review/Meta-analysis/Letter, not in English, not full paper/not peer reviewed, Duplicate (found in previous search), or Other.
  • Included papers were then hand-searched for DEBT AND HEALTH 7 any additional references.
  • A cited-by search was also conducted to identify references which had cited the included papers.

Meta-Analysis Method

  • All included papers was screened for relevant data which could be subjected to a meta-analysis in the form of number of participants in different categories to be used for pooled unadjusted odds ratios, or means, SDs and sample sizes which could be used for meta-analysis of the standardised mean difference.
  • If insufficient detail was given in the paper but the data was otherwise appropriate, authors were contacted for additional details.
  • Studies had to report differences in the prevalence or severity of health conditions based on debt versus no debt.
  • If more than one set of data which could not be pooled was given by a single study, then this was included in the meta-analysis as if it were two studies, and total sample size was adjusted accordingly.
  • Random effects models were used for all analyses to account for possible heterogeneity.

Characteristics of studies

  • Appendices A-I display the characteristics of studies in terms of country, design, sample, measures used, main findings and confounds controlled for.
  • In addition the measures used reported are only for those relevant to debt and health.
  • These were panel surveys (n=6), nationally representative surveys (n=11), psychological autopsy studies (n=4), studies with students (n=13), studies with other specific populations (n=22), and other (n=7).
  • One study per country was conducted in New Zealand, the Netherlands, Finland, Thailand, Uganda, Austria and Japan.
  • Twenty-nine of the studies were retrospective analyses of existing data.

Measures Used

  • Thirty-four of the studies examined only mental health, whilst nine physical health only, and eight both physical and mental health.
  • Eight examined suicide, and one both mental health and suicide.
  • One study examined death as its dependent variable.
  • Studies examining physical health were more likely not to use standardised measures (8/9 studies) than studies examining mental health (4/34 studies).
  • The most commonly used measure of mental health was the Clinical Interview Schedule Revised (CIS-R, Lewis, Pelosi, Araya, & Dunn, 1992) which was used by (13 studies.),.

General Findings

  • A total of 43 of the studies used multiple regression to control for potential confounding variables such as demographics.
  • Overall 78.5% (n=51) of the studies reported DEBT AND HEALTH 10 that being in debt was related to worse health.
  • Seven studies found no effect, whilst two found that debt was related to better health.
  • Three studies found an effect for worry about debt rather than debt per se, whilst two found that financial strain rather than debt was related to health.

Studies with Students

  • Thirteen studies looked at the relationship between debt and health in university students, primarily in the UK and US.
  • Studies in the UK had smaller sample sizes, but all used a standardised measure of mental or physical health.
  • Across the thirteen studies, there was one which was longitudinal (Cooke, Barkham, Audin, Bradley, & Davy, 2004), which followed British students across the three years of their degree.
  • Demographics such as age and gender were controlled for by many studies, though six studies did not control for any variables.
  • Lange and Byrd (1998) similarly found that debt levels led to anxiety and depression via increase financial stress and strain, and cognitions such as locus of control around finances.

Panel Surveys

  • A total of five panel surveys were included.
  • They typically had sample sizes of several thousand, and all controlled for potential confiding demographic variables.
  • With only two using standardised measures (Brown, Taylor, & Price, 2005; Keese & Schmitz, 2012).
  • Bridges and Disney (2010) found that debt, including past debt increased the risk of depression, and Brown, et al. (2005) found a relationship with higher GHQ scores.
  • Brown, et al. (2005) found a dose-response effect with more debts increasing risk further, whilst Bridges and Disney (2010) found no such effect.

Psychological Autopsy Studies

  • Four studies, all conducted in Hong Kong, used psychological autopsy of suicide completers to examine the prevalence of debt compared to age matched community controls.
  • These typically examined a number of different predictors of suicide, with multiple regression models including factors such as marital status, psychiatric diagnoses as well as debt.
  • All but one therefore controlled for potential DEBT AND HEALTH 13 confounds, by examining whether the effect of debt was independent of other variables.
  • These all looked at the presence of unmanageable debt, which was defined as more than four years to repay given monthly income and expenses (P. W. Wong, Chan, Conwell, Conner, & Yip, 2010).
  • P. W. Wong, et al. (2010) simply reported descriptive statistics with a higher proportion on unmanageable debt in suicide completers.

Nationally Representative Surveys

  • Ten papers were epidemiological studies with nationally representative samples of the general population.
  • Six of which were secondary analysis of data from the British National Psychiatric Morbidity Survey.
  • All but one (Jenkins, Fitch, Hurlston, & Walker, 2009) controlled for confounds, and all but one (Lyons & Yilmazer, 2005) used standardised measures.
  • Sawangdee, Porrapakham, Guo, & Sirirassamee, 2006) were cross-sectional, making causality hard to establish.
  • Hintikka, Kontula, Saarinen, Tanskanen, Koskela, and Viinamaki (1998) similarly found that debt problems increased the risk of suicidal ideation, but there was no relationship with attempts.

Health Service User Populations

  • As specific populations were studied sample sizes were inevitably small, ranging from 43 to 87.
  • Standardised measures of health were used in all of these studies, however only two controlled for confounds.
  • Patel, et al. (1998) and Pothen, Kuruvilla, Philip, Joseph, and Jacob (2003) found that debt increased the risk of common mental disorders and depression specifically amongst primary care attenders in India after controlling for demographics.
  • Hatcher (1994) examined self-harmers, finding higher levels of depression, psychiatric diagnosis and suicidal intent in those with debt.

Debt Management Clients

  • Two cohort studies compared over-indebted clients to the general population, finding an increased likelihood being overweight and reporting back pain after controlling for confounds (Munster, Ruger, Ochsmann, Letzel, & Toschke, 2009; Ochsmann, Rueger, Letzel, Drexler, & Muenster, 2009).
  • O‟Neill, Sorhaindo, Xiao, and Garman (2005) found that self-rated health was linked to reduced debts after a debt management intervention.
  • DEBT AND HEALTH 16 Selenko and Batinic (2011) found that financial strain, but not amount of debt was related to mental health as measured by the GHQ.

Older adults

  • All of these used data from existing wider studies, and therefore had large sample sizes.
  • However Drentea and Reynolds (2012) found this relationship was moderated by stress about debt.
  • Drentea and Reynolds (2012) also found a relationship with self- reported anxiety.
  • (Lee, Lown, & Sharpe, 2007) found no relationship between self-rated health and debt.

Other Specific Populations

  • Eight studies focused on other specific populations.
  • But only four used standardised measures.
  • One found debt increased risk of Common Mental Disorders (CMD) but not depression in mothers and fathers (Cooper, et al., 2008).
  • Four studies looked at Ethnic minority populations in the US.
  • DEBT AND HEALTH 17 Yao, Sharpe, and Gorham (2011) found a non-significant trend for better self-rated health to increase the likelihood of debt, whilst Xu (2011) found that debt increased psychological distress only in specific ethnicities.

Other Studies

  • A further seven studies examined the relationship between debt and health but did not fit into any of the above categories.
  • Kassim and Croucher (2006) found that in Khat users, those in debt to the dealer were more likely to be dependent.
  • In a longitudinal study Molander, Yonker, and Krahn (2010) found that debt had little impact on changes in drinking over time, though debt increased the likelihood of stopping heavy drinking.
  • Hainer and Palesch (1998) found no relationship between debt and depression in junior doctors.
  • Finally, Turvey, Stromquist, Kelly, Zwerling, and Merchant (2002) found that a rural US population were more likely to have suicidal thoughts if they had an increase in debt.

Meta-Analysis Results

  • A meta-analysis was conducted to determine pooled odds ratios for variables reported by multiple studies.
  • There was a statistically significant relationship between debt and presence of a mental disorder, depression, suicide completion, suicide completion or attempt, problem drinking, drug dependence, neurotic disorders (Depression, OCD, Panic, Phobia, GAD), and psychotic disorders.
  • The only variable where there was not a significant difference was smoking.
  • Changing this to a fixed model had little impact on the effect size for the analysis on drug dependence and suicide completion or attempt.
  • Thus for these two variables heterogeneity is problematic.

Discussion

  • The aim of this paper was to systematically review all the literature examining the relationship between personal unsecured debt and health.
  • However it is important to note the limitations of this meta-analysis.
  • Firstly, only a few studies provided sufficient data on similar areas to be included.
  • This area needs further research, however it suggests, at an epidemiological level, that recent increases in personal debt in the UK (Credit Action, 2013), may only impact mental health if they lead to an increase in stress and worry about debt.
  • The specific mechanisms by which debt is related to health are therefore key to examine in further research in order to develop preventative interventions both to ensure that those with poor health are not at greater risk of problem debt, and that those in debt are not at a greater risk of developing mental health problems.

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Citations
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01 Jan 2016
TL;DR: Knowing the underlying mechanisms of the relationship between SES and alcohol outcomes should be applied toward the development of multilevel interventions that address not only individual-level risks but also economic disparities that have precipitated and maintained a disproportionate level of alcohol-related consequences among more marginalized and vulnerable populations.
Abstract: Socioeconomic status (SES) is one of the many factors influencing a person's alcohol use and related outcomes. Findings have indicated that people with higher SES may consume similar or greater amounts of alcohol compared with people with lower SES, although the latter group seems to bear a disproportionate burden of negative alcohol-related consequences. These associations are further complicated by a variety of moderating factors, such as race, ethnicity, and gender. Thus, among individuals with lower SES, members of further marginalized communities, such as racial and ethnic minorities and homeless individuals, experience greater alcohol-related consequences. Future studies are needed to more fully explore the underlying mechanisms of the relationship between SES and alcohol outcomes. This knowledge should be applied toward the development of multilevel interventions that address not only individual-level risks but also economic disparities that have precipitated and maintained a disproportionate level of alcohol-related consequences among more marginalized and vulnerable populations.

305 citations

01 Jan 2005
TL;DR: In this article, the authors presented a European overview of socio-economic inequalities in suicide mortality among men and women, and found that the greater the socioeconomic disadvantage, the higher the risk of suicide.
Abstract: BACKGROUND Social factors have been shown to be predictors of suicide. It is not known whether these factors vary between countries. AIMS To present a first European overview of socio-economic inequalities in suicide mortality among men and women. METHOD We used a prospective follow-up of censuses matched with vital statistics in ten European populations. Directly standardised rates of suicide were computed for each country. RESULTS In men, a low level of educational attainment was a risk factor for suicide in eight out of ten countries. Suicide inequalities were smaller and less consistent in women. In most countries, the greater the socio-economic disadvantage, the higher is the risk of suicide. The population of Turin evidenced no socio-economic inequalities. CONCLUSIONS Socio-economic inequalities in suicide are a generalised phenomenon in western Europe, but the pattern and magnitude of these inequalities vary between countries. These inequalities call for improved access to psychiatric care for lower socio-economic groups.

178 citations

Posted Content
01 Jan 2008
TL;DR: Variation across Europe in the magnitude of inequalities in health associated with socioeconomic status is observed, which might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care.
Abstract: Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe.

176 citations

Journal ArticleDOI
TL;DR: This paper examined longitudinal relationships over time between financial variables and mental health in students and found that greater financial difficulties predicted greater depression and stress cross-sectionally, and also predicted poorer anxiety, global mental health and alcohol dependence over time.
Abstract: Previous research has shown a relationship between financial difficulties and poor mental health in students, but most research is cross-sectional. To examine longitudinal relationships over time between financial variables and mental health in students. A national sample of 454 first year British undergraduate students completed measures of mental health and financial variables at up to four time points across a year. Cross-sectional relationships were found between poorer mental health and female gender, having a disability and non-white ethnicity. Greater financial difficulties predicted greater depression and stress cross-sectionally, and also predicted poorer anxiety, global mental health and alcohol dependence over time. Depression worsened over time for those who had considered abandoning studies or not coming to university for financial reasons, and there were effects for how students viewed their student loan. Anxiety and alcohol dependence also predicted worsening financial situation suggesting a bi-directional relationship. Financial difficulties appear to lead to poor mental health in students with the possibility of a vicious cycle occurring.

160 citations


Cites background or result from "The relationship between personal u..."

  • ...The pooled findings from a meta-analysis by Richardson et al. (2013) found that 41.7 % of those with a mental health disorder report being in debt, in comparison to 17.5 % who report having no debt....

    [...]

  • ...A statistically significant relationship was also found between debt and depression, suicide completion or attempt, problem drinking, drug dependence, neurotic disorders and psychotic disorders (Richardson et al. 2013)....

    [...]

  • ...This is in contrast to the majority of the literature, which is predominately cross-sectional in nature and therefore limits the possibility of inferring causality (Richardson et al. 2013)....

    [...]

  • ...The majority of the previous literature was based on various author constructed questionnaires for financial and health measures (Richardson et al. 2013), which consequently can reduce the reliability and validity of these measures....

    [...]

Journal ArticleDOI
01 Jun 2020
TL;DR: Ten experts were invited to comment on occupational health issues unique to their areas of expertise and discuss both unanswered research questions and recommendations to help organizations reduce the impacts of COVID-19 on workers.
Abstract: Workers bear a heavy share of the burden of how countries contend with COVID-19; they face numerous serious threats to their occupational health ranging from those associated with direct exposure to the virus to those reflecting the conflicts between work and family demands. Ten experts were invited to comment on occupational health issues unique to their areas of expertise. The topics include work-family issues, occupational health issues faced by emergency medical personnel, the transition to telework, discrimination against Asian-Americans, work stressors, presenteeism, the need for supportive supervision, safety concerns, economic stressors, and reminders of death at work. Their comments describe the nature of the occupational health concerns created by COVID-19 and discuss both unanswered research questions and recommendations to help organizations reduce the impacts of COVID-19 on workers.

140 citations


Cites background from "The relationship between personal u..."

  • ...…can have on workers and their families, including reduced physical and mental health, poorer long-term career outcomes, and impaired marital, family, and social relationships (see meta-analyses by Jiang and Lavaysse 2018; McKee-Ryan et al. 2005; McKee-Ryan and Harvey 2011; Richardson et al. 2013)....

    [...]

  • ...Decades of research demonstrates the numerous adverse negative effects that these stressors can have on workers and their families, including reduced physical and mental health, poorer long-term career outcomes, and impaired marital, family, and social relationships (see meta-analyses by Jiang and Lavaysse 2018; McKee-Ryan et al. 2005; McKee-Ryan and Harvey 2011; Richardson et al. 2013)....

    [...]

References
More filters
Journal ArticleDOI
TL;DR: The CES-D scale as discussed by the authors is a short self-report scale designed to measure depressive symptomatology in the general population, which has been used in household interview surveys and in psychiatric settings.
Abstract: The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.

48,339 citations

Journal ArticleDOI
TL;DR: The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out and a wide variety of psychiatric rating scales have been developed.
Abstract: The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations." Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15These have been well summarized in a review article by Lorr11on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific

35,176 citations

Book
01 Jan 2003
TL;DR: TheSF-36 is a generic health status measure which has gained popularity as a measure of outcome in a wide variety of patient groups and social and the contribution of baseline health, sociodemographic and work-related factors to the SF-36 Health Survey: manual and interpretation guide is tested.
Abstract: The SF-36 is a generic health status measure which has gained popularity as a measure of outcome in a wide variety of patient groups and social. The 36-Item Short-Form Health Survey (SF-36) and its shorter version, the SF-12, are the measures SF-36 Health Survey manual and interpretation guide. Health Services Research Unit, University of Oxford, Headington. Postal survey using a questionnaire booklet, containing the SF-36-II and questions. The SMFA, the health survey short form (SF-36) along with a region-specific questionnaire Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. The SF Health Surveys capture practical, reliable and valid information about or need assistance with an FDA dossier, we will guide you every step of the way. The 36 Item Short Form Health Survey (SF-36) is a generic patient-reported outcome measure, SF-36 health survey: Manual and interpretation guide. Boston. The SF-36 Health Survey is a self-administered questionnaire of 36 questions to M, and Gendek, B. SF-36 Health Survey: Manual and Interpretation Guide. The patients' self-assessment of QL was measured with the SF-36TM form at 3, M & Gandek B. SF-36 Health Survey: Manual and Interpretation Guide 1993. We aimed to determine whether health outcomes (pain severity and quality of life Gandeck B. SF-36 Health survey manual and interpretation Guide. Boston:. Ware JE (1993) Health survey manual and interpretation guide. Thomas KJ, Usherwood T et al (1992) Validating the SF-36 health survey questionnaire: new. Health Related Quality of Life (HRQL) is one of the increasing subjects used Jr, Kristin KS., Kosinski M, SF-36 Health Survey Manual and Interpretation Guide. They commonly take up low paid manual jobs and work long hours (6), mostly live in conditions that SF-36 health survey : manual and interpretation guide. Additionally, the contribution of baseline health, sociodemographic and work-related factors to the SF-36 Health Survey: manual and interpretation guide. cal Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component SF-36 health survey: Manual and interpretation guide. results from a national survey. Archives of to test the construct validity of the SF-36 Health Survey in Ten Countries: Survey: manual and interpretation guide. The Short Form-36 health survey (SF-36v2) is a widely used patient-reported Dewey JE, Gandek B. SF-36 health survey: manual and interpretation guide. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, the Health Institute. The Short Form Health Survey 36 (SF-36) and a cross-cultural validated Snow KK, Kosinski M. SF-36 Health Survey: Manual and Interpretation Guide. the SF-36 Health Survey subscales, the Hospital Anxiety and Depression Scale. Social Provisions activities emerged as enhancing meaning in life for the residents. A systematic their experience regarding the questions in the interview guide. SF-36 Health Survey manual and interpretation guide. Boston:. ABSTRACT Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). SF-36 physical function tended to be better with the HFC (p=0.08) in addition to SF-36 SF-36 Health Survey Manual and Interpretation Guide. Boston: The. HRQL was measured by the Greek version of SF-36 Health Survey and further B., Kosinski, M. SF-36 Health Survey Manual and Interpretation Guide. SF-36 ® (MOS 36-Item Short-Form Health Survey) SF-36 ® ? PDFSF-36 Health Survey Manual and Interpretation Guide John E. Ware, Jr., Ph.D. with Kristin K. Subjects (N = 79) completed the SF-36 at baseline and every three weeks throughout the treatment SF-36v2 health survey: manual and interpretation guide.

11,954 citations

Journal ArticleDOI
TL;DR: In this article, the authors compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe and found that in almost all countries, the rates of death and poorer selfassessments of health were substantially higher in groups of lower socioeconomic status.
Abstract: A b s t r ac t Background Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe. Methods We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes. Results In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern. Conclusions We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care.

2,835 citations

Frequently Asked Questions (9)
Q1. What are the contributions mentioned in the paper "The relationship between personal unsecured debt and mental and physical health: a systematic review and meta-analysis" ?

This paper systematically reviews the relationship between personal unsecured debt and health. Future longitudinal research is needed to determine causality and establish potential mechanisms and mediators of the relationship. 

This area needs further research, however it suggests, at an epidemiological level, that recent increases in personal debt in the UK ( Credit Action, 2013 ), may only impact mental health if they lead to an increase in stress and worry about debt. The specific mechanisms by which debt is related to health are therefore key to examine in further research in order to develop preventative interventions both to ensure that those with poor health are not at greater risk of problem debt, and that those in debt are not at a greater risk of developing mental health problems. Only three databases were searched, though the relatively small number of papers found via a hand and cited-by search suggest that the search was comprehensive. Nonetheless this review suggests that personal unsecured debt is related to health, and is therefore important to consider by health professionals. 

The main problem with the current research is that the vast majorityof studies are cross-sectional, meaning that causality cannot be established. 

The specificpopulations included studies with health service users (n=8), parents (n=2), ethnic minorities(n=4), farmers (n=2), older adults (n=4) and problem gamblers (n=2). 

The US studies also tended to focus on other health riskbehaviours, such as unprotected sex and drink-driving, and also focused on credit card debtspecifically. 

Papers were not excluded on the basis of year of publication, study design,measures used, participant characteristics or sample size. 

Odds ratios demonstrate more than athree-fold risk of a mental disorder in those with debt, or alternatively a three-fold risk ofdebt in those with a mental disorder. 

In the Method, Search Procedure the authors have changed „Classes‟ into „Classed‟ - In Appendix B (Characteristics of Panel Surveys) the authors have added „years‟ to 4-6. 

Three studies found an effect for worry aboutdebt rather than debt per se, whilst two found that financial strain rather than debt was relatedto health.