Addi van Bergen

Systematic review: social exclusion or inclusion and health 33 2 case control studies [42, 49] and five cross-sectional studies [36, 40, 45, 50, 51]. The case control studies showed an elevated prevalence of DSM III personality features associated with SE in men with AIDS and/or drug addiction [42]; and an elevated prevalence of substance use disorders in clients of mental health services with SE characteristics [49]. The cross-sectional studies found significant associations between SE/SI and, respectively, perceived stress in patients in substance abuse treatment [36]; elevated intravenous drug use in drug users in public places [50]; symptoms of depression [45] and mental symptoms and impairments in HIV patients [51] and higher levels of complex post-traumatic symptoms in torture survivors [40]. Partial evidence was found in a study among patients of Assertive Outreach teams [52]. In this population, alcohol abuse and dependency was associated with the social and cultural dimensions of SE, but not with the political dimension. Drug abuse and dependency was associated with the political and part of the cultural dimension of SE and not with the social dimension. Partial evidence was also found by Killaspy et al. [33]. Patients interviewed after developing a psychotic illness showed a significant deterioration in two of the four SI dimensions measured i.e. the social and economic dimensions. Older age at onset of illness and longer duration of illness were associated with greater changes in the economic dimension. Higher current quality of life was associated with less decline in the social dimension. Our hypothesis was not supported by two case control studies (490 persons, 2 instances) [39, 49]. One study found that in clients with substance use disorder, the co-occurrence of mental health problems was not associated with higher levels of SE [49]. The authors suggest that the association between substance abuse and SE is stronger than between mental health and SE. The second study [39] showed that SE increased the likelihood of compulsory admission among people assessed under the Mental Health Act, but, when other factors such as diagnosis, life-threatening self-neglect and physical aggression towards others, were taken into account, the association became non-significant. It is plausible that these factors might act as mediators in the relation between SE and compulsory admission. Physical health in the general population Figure 4 shows a more mixed picture for PH in the general population. Two studies support the hypothesis that high SE is associatedwith adverse PH (56%of the combined sample, 21,058 persons), two studies partly support the hypothesis (33%, 7,879 persons) and two studies do not (21%, 9,001 persons). Findings from a prospective cohort study [43] showed that elderly Japanese women who were excluded both in the social and in the economic dimension were 1.7 times more likely to die prematurely than those who were not socially excluded. In elderly men, the association between SE and mortality was not significant. The results were adjusted for age, marital status, education, municipality, disease and impairment. Supporting evidence was also found from cross-sectional studies on severe obstetric complications in general, on severe