Socioeconomic inequalities, psychosocial stressors at work and physician-diagnosed depression: Time-to-event mediation analysis in the presence of time-varying confounders

OBJECTIVES: There is evidence that both low socioeconomic status (SES) and psychosocial stressors at work (PSW) increase risk of depression, but prospective studies on the contribution of PSW to the socioeconomic gradient of depression are still limited. METHODS: Using a prospective cohort of Quebec white-collar workers (n = 9188 participants, 50% women), we estimated randomized interventional analogues of the natural direct effect of SES indicators at baseline (education level, household income, occupation type and a combined measure) and of their natural indirect effects mediated through PSW (job strain and effort-reward imbalance (ERI) measured at the follow-up in 1999–2001) on incident physician-diagnosed depression. RESULTS: During 3 years of follow-up, we identified 469 new cases (women: 33.1 per 1000 person-years; men: 16.8). Mainly in men, low SES was a risk factor for depression [education: hazard ratio 1.72 (1.08–2.73); family income: 1.67 (1.04–2.67); occupational type: 2.13 (1.08–4.19)]. In the entire population, exposure to psychosocial stressors at work was associated with increased risk of depression [job strain: 1.42 (1.14–1.78); effort-reward imbalance (ERI) 1.73 (1.41–2.12)]. The estimated indirect effects of socioeconomic indicators on depression mediated through job strain ranged from 1.01 (0.99–1.03) to 1.04 (0.98–1.10), 4–15% of total effects, and for low reward from 1.02 (1.00–1.03) to 1.06 (1.01–1.11), 10–15% of total effects. DISCUSSION: Our study suggests that PSW only slightly mediate the socioeconomic gradient of depression, but that socioeconomic inequalities, especially among men, and PSW both increase the incidence of depression.