Public Attitudes to Mental Illness Research Paper

1. DEFINITIONS

Mental illness is a broad generic term which includes major mental illnesses such as schizophrenia, bipolar aﬀective disorders, common mental disorders such as anxiety and depression, personality disorders, and various other conditions sometimes named after etiology (for example, post-traumatic stress disorder), or after abnormal behavior (for example, episodic dyscontrol syndrome). Therefore, when discussing attitudes towards mental illness, it is important that individual categories are accepted rather than broad generic terms.

1.1 ATTITUDES

Attitudes form a key point of an individual’s thinking, especially toward things that matter to the individual. Attitudes have several components—some a function of the dimensions of personality traits, whereas others are a function of access. By assessing attitudes, one can measure beliefs, but it is not always likely that these beliefs can be turned into behavior. Thus, both cognitive and aﬀective components of these attitudes must be assessed, separately and together. These attitudes do not always remain static and are inﬂuenced markedly by a number of factors such as media, education, and societal conditions.

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Public attitudes to mental illness and mentally ill individuals vary according to a number of internal and external factors. In addition, these attitudes are related to how the illness is perceived in itself, and its causation. The portrayal of mentally ill individuals and psychiatrists in the written and visual media are often negative. Such portrayals not only inﬂuence attitudes of the general public but are also inﬂuenced in turn by the public’s attitudes. Although some cultures may attribute special powers to the mentally ill, by and large societies see mentally ill individuals as violent, frightening, and dangerous, and mental illness as an incurable condition without distinguishing between diﬀerent types of mental illness. There is considerable research evidence to suggest that common mental disorders such as depression and anxiety may well aﬀect up to one third of the adult population, but most of the negative attitudes are linked with severe major mental illness such as schizophrenia or bipolar aﬀective illness. It can be argued that it is not the illnesses per se which provoke negative attitudes, but what they represent (i.e., ‘the outsiderness’) that is more frightening. These attitudes may or may not always translate into behavior, but will signiﬁcantly inﬂuence the allocation of resources into the delivery of mental health services, recruitment into various branches of mental health professions, and general acceptance of mentally ill individuals by the larger community. In addition, attitudes toward medication can prove to be negative.

1.2 STIGMA

Stigma is the expectation of stereotypical and discrediting judgment of oneself by others in a particular context. The term originates from Goﬀman’s (1963) deﬁnition of stigma, which states that stigma originates when an individual, because of some attributes, is disqualiﬁed from full social acceptance. Stigma, like the attributes, is deeply embedded in the sociocultural milieu in which it originates and is thus negotiable.

The Greeks in ancient times used the word stigma to refer to bodily signs that exposed something unusual and negative about the signiﬁer. Further conceptualization of stigma has included a mark that sets an individual apart (by virtue of mental illness in this case), that links that individual to some undesirable characteristic (perceived or real in cases of mental illness using violence, fear, and aggression) and rejection, isolation, or discrimination against the individual (e.g., at the workplace by virtue of the sick role and mental illness). Stigma thus includes cognitive and behavioral components and can be applied to age, race, sexual orientation, criminal behavior, and substance misuse, as well as to mental illness. Stigmatizing reactions are always negative and related to negative stereotypes. Stigma allows the society to extend the label of being outside the society to all those who have negative stereotypes. Such an exclusion may be seen as necessary for bifurcation of society, and will take the same role as scapegoating. The deﬁnitions of sickness and sick roles will change with the society, and stigma will also inﬂuence how distress is expressed, what idioms are used, and how help is sought.

Stigma and negative attitudes to mental illness are by and large universal. These are brieﬂy discussed below to highlight similarities prior to discussing various factors responsible for these attitudes.

2. ATTITUDES IN EUROPE

The attitudes of public and professionals alike across diﬀerent countries of Europe have been shown to vary enormously. In this section some of the key studies and the ﬁndings are reported.

2.1 HISTORICAL

In ancient Greece, stigma and shame were interlinked and these can be studied using theories of causation and the balance within the culture between exclusion of mentally ill individuals and the ritual means of cleansing and re-inclusion. The interwoven theories of shame, stigma, pollution, and the erratic unpredictability of the behavior of severely mentally ill individuals suggest that, in spite of scientiﬁc and religious explanations, attitudes were generally negative. Simon (1992) suggests that the ambivalence of the ancient Greeks can explain their attitudes toward mental illness. The diseases of the mind were seen in parallel with those of the body, and even the doctors were part and parcel of the same cultural ambience of competition, shame, and fear of failure. During the Medieval and Renaissance periods, mental illness was perceived as a result of imbalance of various humors of the body, and related concepts of shame contributed to this. As Christianity encouraged a God-fearing attitude to the world, mental illness was seen as a sign that God was displeased and punishing the individual, thereby making negative attitudes more likely and more acceptable.

In the seventeenth and eighteenth centuries attitudes shifted, but overall remained negative and in turn provided entertainment to the visitors to Bedlam asylum where individual visitors paid a penny to see the inmates.

2.2 CURRENT RECENT

In the nineteenth century, with the establishment of various psychiatric asylums in the UK and the USA, there was generally a growing perception among the lay public and physicians alike that the mind is a function of the brain, thereby inﬂuencing a shift toward more humane treatments—although these were still called moral therapy, thereby giving it a moral religious tinge. The Athenian thinking on psyche has inﬂuenced these attitudes. Porter (1987) proposed that the growing importance of science and technology (among other things) was inﬂuential in channeling the power of right thinking people in imposing the social norms. The men of the church (also men of power) inﬂuenced public opinion, and informed attitudes and behavior toward marginal social elements that would then become disturbed and alien. Central state or market economy inﬂuenced the expectations which then divided those who set and met the norms from those who did not.

In a survey, the British Broadcasting Corporation (BBC 1957) reported that the public’s tolerance of mentally ill individuals depended upon the circumstances in which contact was made. More than three quarters of those surveyed were willing to mix with mentally ill individuals in areas where low personal involvement occurred; only half were willing to work with people with mental illness, whereas only a quarter were agreeable to such an individual being in authority over them. Attitudes toward mental illness and mentally ill individuals is inﬂuenced by a number of external factors such as legal conditions, expectations of treatment, etc.

In Turkey, for example, Eker (1989) reported that paranoid schizophrenia was identiﬁed easily among various groups. These attitudes inﬂuenced family perceptions, helpseeking, and caring for the individual who is mentally ill, and are inﬂuenced by educational status, gender, age, social class, and knowledge. Brandli (1999) observed that in Switzerland stigma was more common in older nonurban males with low education, and poorly informed. There were diﬀerences in public knowledge about Alzheimer’s disease, depression, and other psychiatric conditions. The ﬁndings also suggested that the general public was more accepting of seeking help from their primary care physician rather than a psychiatrist. In Greece, a study revealed that the younger, more educated, and higher social class individuals saw mental illness as a psychosocial problem, whereas older people saw it as a disorder of the nervous system (Lyketsos et al. 1985). Follow-up studies showed an improvement in people’s attitudes. Religion has been shown to play a role in forming these attitudes, but a sample from Israel (Shurka 1983) demonstrated that attitudes were more likely to be mixed and inconsistent. From the UK, the role of gender (Bhugra and Scott 1989) and ethnicity (Wolf et al. 1999) have been shown to inﬂuence attitudes to mentally ill individuals. The attitudes of other medical and nonmedical professions are also important, but are beyond the scope of this research paper.

3. ATTITUDES IN AMERICA

Most of the studies from North America have been carried out by social scientists and have illustrated a range of attitudes to a number of conditions. Here only some of the important studies will be discussed.

3.1 HISTORICAL

In America from the seventeenth century onward, the traditional belief prevailed among Christians that madness is often a punishment visited by God on the sinner, and this inﬂuenced subsequent views and attitudes. Although both physical and mental illnesses were seen as punishments, it was only in the latter that moral components were seen, especially in the context of teachings from the Bible. A lack of faith and persistence of sinful and lewd thoughts, were seen as key causation factors in the development of insanity. In the early 1940s, Cumming and Cumming (1957), in their classic study of lay public perceptions of the mentally ill, demonstrated that, when asked to agree with the proposition that anyone in the community could become mentally ill, as normal and abnormal occur on a continuum, the whole educational package was rejected. An explanation was that expression of shame and inferiority was seen as important.

In the 1940s, Ramsey and Seipp (1948) demonstrated that subjects who had higher socioeconomic and educational levels were less likely to view mental illness as a punishment for sins and or poor living conditions. Yet they were less pessimistic about recovery. In the 1960s, studies from the USA were seen as either optimistic or pessimistic depending upon whether the researcher saw changes in attitudes toward the mentally ill as positive accepting, or negative rejecting. It is often diﬃcult to ascertain whether stigma or deviant behavior causes the rejection.

3.2 RECENT STUDIES

Star vignettes have been used in determining public knowledge of mental illness, and public attitudes to mental illness and mentally ill people (Rabkin 1974). Crocetti and Lemkau (1963) used vignettes to demonstrate that virtually all the subjects in their sample agreed with the question, ‘Do you think that people who are mentally ill require a doctor’s care as people who have any other sort of illness do?’ In this sample, low social class and low educational levels did not predict negative attitudes. In another study using case vignettes, it was shown that the largest increase in rejection rates occurred when a person had been admitted to a mental hospital and this was seen as due not to the fact that they were unable to help themselves, but that a psychiatrist or mental health professional had conﬁrmed their status as mentally ill (Phillips 1963). The rejection appeared to be based on how visibly the behavior deviates from the customary role expectations. Continuance of symptoms, and public visibility of these symptoms, and behavior, inﬂuences attitudes and makes them more negative. Social distance is the distance between mentally ill individuals and the lay public on a number of parameters, especially in social interactions. It may also show how individuals will employ mentally ill persons at diﬀerent levels of responsibility, thereby denoting acceptance or rejection. People may feel reasonably comfortable with mentally ill individuals if they do not have to mix with them on a regular basis. Meyer (1964) reported that three quarters of the subjects in his sample were willing to work with mentally ill people, but only 44 percent would imagine falling in love with such a person. There is no doubt that some illnesses are more stigmatizing than others, as is the severity of the illness, presence of a diagnostic label, and availability of alternative roles. In addition, attitudes can be inﬂuenced by the type of treatment and the patient’s response to it. Dovidio et al. (1985) reported that people are ambivalent in their attitude toward persons with psychological problems. In an undergraduate class of 94 males and 81 females, the students were asked to give their ﬁrst impressions of mentally ill applicants in the process of college applications. The results showed that individuals with mental illness were seen favorably in terms of character and competence, but negatively in the context of security and sociability.

Link et al. (1992) suggest that patients’ perceptions of how others see them are extremely important. A mental illness label gives personal relevance to an individual’s beliefs about how most people respond to mental patients. The degree to which the individual with mental illness expects to be rejected is associated with demoralization, income loss, and unemployment in individuals labeled mentally ill, but not in those without mental illness. Thus it appears that labeling activates beliefs that lead to negative consequences. Patients may use such strategies to protect themselves or their networks.

Such stigmatized attitudes are also reﬂected in relationships with other outsider groups, such as the homeless, and inﬂuence portrayals of negative spoken and visual media (see Fink and Tasman 1992).

4. ATTITUDES ELSEWHERE IN THE WORLD

Attitudes to the mentally ill from other societies and cultural settings are also inﬂuenced by a number of factors. Studies on the topic vary tremendously in their methods and data access. The beliefs about mentally ill people and toward mental illness are likely to be related to types of illness prevalent in that group.

4.1 HISTORICAL

In ancient Ayurvedic texts, the description of mental illness also suggested physical forms of treatment. In addition, diet and seasons were reported as playing key roles in the genesis of such conditions. This approach allowed the locus of control to be shifted to some degree away from the individual, thereby making that individual less responsible and less likely to be stigmatized.

4.2 CURRENT

Ilechukwu (1988), in a survey of 50 male and 50 female psychiatric outpatients in Lagos, was able to demonstrate that some patients did believe in supernatural causes of neuroses and disorders, but psychosocial causes were cited most commonly. The attitudes and beliefs of patients are important, but beyond the scope of this research paper.

Wig et al. (1980), in a three-site study from India, Sudan, and the Philippines, found that, when asked to comment on case vignettes, community leaders were able to identify mental retardation (in all sites), alcohol and drug-related problems (in the Sudanese and Philippines areas), and acute psychosis (in India). Thus it appears that there are cultural diﬀerences in the identiﬁcation of diﬀerent clinical conditions. They also reported that attitudes toward mentally ill people were more negative in India compared with the other two sites. Thus the studies can be used to establish the needs of the general public and will allow planners to develop appropriate services.

Verghese and Beig (1974), in a survey from South India, reported that over 40 percent of Muslim and Christian respondents reported that marriage can help mental illness, although only 20 percent of Hindus shared this belief. Virtually no respondents reported believing in evil spirits. The most commonly recognized causes mentioned were emotional factors, including excessive thinking. In respondents over the age of 40, one ﬁfth saw mental illness as God’s punishment. Christians were again more likely than Hindus to fear mentally ill people (although this fear disappeared with education), and yet the Christians believed strongly in the possibility of a complete cure. Nearly three-quarters of Hindus believed that the moon inﬂuences mental illness. These are interesting ﬁndings in that they address religious diﬀerences in public attitudes.

5. REASONS FOR NEGATI E ATTITUDES

Reactions to any taboo or outsider group depend upon a number of factors. These include the frequency of the actual or anticipated behavioral events, intensity and visibility of such behavior, and circumstances and location of such behavior on the one hand, and personal factors on the other. In this section we focus on the latter.

5.1 AGE

Several studies have shown that older people tend to have more negative attitudes toward mentally ill people. The reasons for this are many. Older people, in spite of their life experiences, are generally more conservative and equally rejecting of behavior which is seen as odd and alien. The role of age is likely to be mediated by other factors such as education, social and economic class, etc.

5.2 TYPES OF ILLNESS

Attitudes towards people with schizophrenia are likely to diﬀer from those reported toward people with depression or personality disorder. This may reﬂect the stereotypic images of the condition or fear related to the condition. It may also be due to previous knowledge about the illness. The perceived causative etiological factors also play a role in attitudes.

5.3 GENDER

Males tend to have more negative attitudes and, as noted above, are also more likely to be rejected when they suﬀer mental illness. Females may be more sympathetic, for a number of reasons. Other studies of attitudes toward other alien groups also demonstrate that females are more positive. They are also more likely to be carers, and may be the ﬁrst to contact psychiatric services on behalf of individuals. For women, change in role after mental illness is likely to produce more stigma. Yet they are more likely to be admitted with more ‘masculine’ illnesses such as personality disorder and drug abuse. The gender roles in the context of illness may well play a role in generating negative attitudes.

5.4 RELIGIOUS BELIEFS

Some studies have demonstrated that Christians tend to have more negative attitudes toward mental illness, but again this is not a consistent ﬁnding. The individual subject’s level of religiosity and depth of religious values must be studied rather than simple religious ascription.

5.5 EDUCATIONAL STATUS

The eﬀects of education on attitudes are mixed (Bhugra 1989). Some studies have related negative attitudes clearly with low educational status, whereas others have failed to show such association, or showed that highly educated subjects held more negative attitudes, including those studying professionally.

5.6 PROFESSIONS

Medical students may hold more negative and stereotypical attitudes, and other branches of medicine too have been shown to have negative attitudes to mentally ill people (e.g., schizophrenics), those with odd behavior (e.g., deliberate self-harm), and psychiatry as a profession. The psychiatrist is often lampooned and seen as a ‘head shrinker’ or a modern-day witchdoctor. There are individuals who are well educated and belong to a high socioeconomic class and yet hold negative attitudes.

5.7 OTHERS

Some ethnic groups such as African-Caribbeans in the UK, and Hispanics, Asian-Americans, and Mexican-Americans in the USA have been found to have more negative attitudes toward mentally ill individuals or be far more restrictive in their description of etiology of mental illness compared to the white majority population. Nonacculturated individuals appeared to have more old-fashioned attitudes (i.e., negative stereotypes).

These are some of the complex set of factors that inﬂuence attitudes and stereotypes.

6. EDUCATIONAL INTERVENTIONS

Educational interventions in order to reduce stigma toward mentally ill individuals and foster positive attitudes towards mental illness and those who are mentally ill are based on several levels of education. One-oﬀ educational programs and fact sheets on any illness are not likely to produce long-term changes. There is considerable evidence in the literature to suggest that education, if given at an appropriate and stable level, and repeated as required, will produce changes that can be sustained. In addition, educational interventions must target speciﬁc populations, bearing in mind their age, gender, ethnic composition, primary language, educational attainments, social class, etc.

Wolﬀ et al. (1999) reported on the results of followup of neighbors, where two group homes for people with mental illness had been set up and one set of neighbors had received extensive education. They found that although the public education intervention may have had at best only a modest eﬀect on knowledge, behavior toward the mentally ill residents changed. There was a decrease in fear and exclusion, and increased levels of social contact in the experimental area. They observed that educational intervention per se did not in itself lead directly to a reduction in fearful attitudes, whereas contact with patients did. Thus, any campaign which encourages subjects to increase contact with mentally ill individuals may prove to be more successful. The educational programs must be paced slowly and in a sustainable manner. The patients and their carers must be involved in planning these interventions without turning the whole exercise into a circus.

Any educational intervention must target the intervention either at the group most at risk of negative attitudes or at those already having negative attitudes. Repeated packages and adequate time for consultation and discussion will inﬂuence attitudes. Using small groups with experiential teaching is more likely to be successful compared with seminars or lectures with large groups. Any educational campaign must be sustained and momentum maintained. The eﬀect on attitudes following several interventions is more sustained, and greater than the sum of the individual eﬀects. Using a number of strategies, involving participation on the part of the public, carers, and patients, can inﬂuence attitudes.

The educational packages and interventions aimed at improving attitudes will, in the long run, inﬂuence resource allocation into mental health, improve recruitment, and move toward acceptance of community care. Such interventions can reduce fear, make expectations more realistic, and prevent attitudes from hardening. However, these interventions must be clear, focused, and appropriate, based upon the needs of the group that is being educated rather than on perceptions of need by the professionals. These packages must deal with alienation experienced by patients at diﬀerent levels and in diﬀerent settings, such as housing, employment, and social settings.

7. CONCLUSIONS

The attitudes of the public toward mentally ill individuals reﬂect prevalent social norms and mores. Expectations from psychiatric services, response to treatment, type of treatment, type of mental illness, and inaccessibility to treatment are external factors that will inﬂuence public attitudes. Age, gender, personality traits, and social and economic class are some of the personal factors that will inﬂuence these attitudes. These attitudes will not always translate into behavior, but one will be inﬂuenced by the other. Labeling of mental illness and the perception of mentally ill individuals as dangerous along with associated fear will all inﬂuence attitude formation. Any educational intervention must include some or all of these factors. Negative attitudes will inﬂuence helpseeking as well as compliance. These attitudes may well be linked to illness, but also to stereotypes of the illness, and to associated or perceived impairment as a result of that illness. These negative attitudes will also inﬂuence rejection of any preventative strategies the psychiatric profession may wish to advocate.

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Social Determinants of Mental Health Research Paper

View sample mental health research paper on social determinants of mental health. Browse other research paper examples for more inspiration. If you need a thorough research paper written according to all the academic standards, you can always turn to our experienced writers for help. This is how your paper can get an A! Feel free to contact our writing service for professional assistance. We offer high-quality assignments for reasonable rates.

HISTORICAL BACKGROUND

The origin of modern research on the social determinants of mental health and disorders is often traced to the work of Emile Durkheim, who demonstrated that cross-national variations in suicide rates reflected differences in social conditions rather than the characteristics of individuals. This line of reasoning – that social structures exert profound influence on the lives and well-being of individuals – has dominated thinking about the social determinants of mental disorders ever since. For example, the work of Robert Faris and H. Warren Dunham demonstrated that the prevalence of psychosis was higher in the poor and slum neighborhoods of Chicago than in wealthier districts of the city. Similarly, the research of Alexander Leighton and colleagues found that rates of mental disorder in Nigeria and Nova Scotia, Canada were highest in communities experiencing social disorganization. Durkheim’s influence is apparent in more recent research on the characteristics of neighborhoods and variations in physical and mental health, a growing interest in the concept of social capital (see below), as well as, more generally, in research on the association of socioeconomic status and well-being.

STRESS MODELS OF PSYCHOPATHOLOGY

The ‘stress-adversity’ model of psychopathology, as formulated by Bruce Dohrenwend (2000), proposes that the degree to which environments present danger and hardship to individuals will be positively associated with risk for psychopathology. The association between environment and psychopathology will be reduced by the degree to which individuals have the ability to respond to and cope with the adversities.

How social groups come to be at increased risk of stress is central to considerations of the social determinants of mental health and disorders. As suggested by Leonard Pearlin (1989), relative well-being is associated with ‘the structured arrangements of people’s lives and by the repeated experiences that stem from these arrangements.’ Thus, the social positions of particular populations put them at differential risk of stress. For example, the stress associated with becoming unemployed is different for a member of a poor family than it is for a member of a wealthy family. Further, being poor often means living in a crowded, polluted, and dangerous neighborhood, which is far more stressful, physically and psychologically, than being wealthy and able to afford living in a quiet suburb with tree-lined streets. Finally, differential access to effective medical care will have consequences for the relative well-being of social groups.

The ‘stress-diathesis’ model builds on the stress adversity model by positing that risk for psychopathology is produced by an interaction between environmental stressors and individual vulnerability. One must not suppose, however, that individual vulnerability negates the notion of social determinants of well-being (Monroe and Simons, 1991). It is likely that individual vulnerability to common physical and mental disorders is evenly distributed in large populations. Therefore, exposure of subpopulations to different levels of stress will result in social differentials in the expression of those vulnerabilities. In view of this, one could say that the term ‘social determinants’ is an overly simplistic consideration of causality. It would be more accurate to refer to ‘environment–gene interactions’ as a primary source of social differentials in health and well-being. Even this is something of an oversimplification. Environments contain features that may mitigate or intensify the effects of social adversities. Thus, residents of a neighborhood with a relatively high degree of social capital (see below) may be less affected by an economic crisis; in contrast, residents of a neighborhood wracked by violence may be less capable of resilience in the face of a natural disaster.

SOCIAL RISK FACTORS FOR MENTAL DISORDERS

GENDER

Gender, which may be thought of as the social roles designated for men and women in different sociocultural settings, carries with it differential risk for a range of mental disorders. For example, women are two to three times more likely than men to experience depression, and postnatal depression has been recognized as a significant problem worldwide. In most societies, completed suicide rates among men are much higher than among women, but rates of attempted suicide are much higher in women. Men are many times more likely to abuse substances, particularly alcohol. While it is likely that gender differences for common mental disorders are at least partially due to sociocultural factors, biological factors likely also play an important role.

SOCIOECONOMIC STATUS

Socioeconomic status (SES), which is variously measured by levels of income, educational attainment, occupation, and neighborhood characteristics (see below), exerts a profound influence on health status. On average, people of higher SES have rates of mortality and morbidity that are significantly lower than people of lower SES. The same relationship is true for mental disorders. For example, Ronald Kessler and colleagues (2003) have found that being unemployed, having less than 12 years of education, and having a low income are all associated with elevated prevalence of depression in a representative sample of adults in the United States. Findings from the Whitehall study (Stansfeld et al., 2003), which examined the health of civil servants in the United Kingdom, also supports the notion of social inequalities in depression: Higher-grade civil servants had lower levels of depression than those in the lower grades. Other research demonstrates that the same relationship is true for psychosis: Low SES is associated with elevated rates of the disorder.

For a long time, there has been a debate over whether this pattern is the result of social drift or social causation. According to social drift theory, elevated rates of mental disorder are found among low SES groups because mental disorders impair the ability of individuals to raise themselves out of that status or limit the ability of individuals to maintain their higher status. Thus, mentally ill individuals drift into low SES. In contrast, the social causation theory suggests that risk for mental disorder is heightened for low SES individuals because of the stressful social environments in which they live.

Probably the best research to test the validity of these two competing theories was conducted by Bruce Dohrenwend and colleagues (1992). In an investigation of nearly 5000 Israeli-born adults, they found that (1) persons who had not graduated high school had rates of depression that were higher than persons who had graduated either high school or college; and, (2) educational status had no association with rates for schizophrenia. To further examine the relation between social status and mental disorder, Dohrenwend and colleagues also looked at rates of depression among adults of European (advantaged) and North African (disadvantaged) backgrounds. The results mirrored those for educational status: Those from disadvantaged backgrounds had elevated rates of depression, but rates of schizophrenia were the same for advantaged and disadvantaged groups. Thus, this research suggests that the social causation theory accounts for subpopulation inequalities in rates of depression, while the social drift theory accounts for subpopulation inequalities in rates of schizophrenia.

One must not assume that the various measures of SES, income and education in particular, are interchangeable. As demonstrated by Araya and colleagues (2003), the predictive power of these variables is very much context-dependent. They found an inverse relation between levels of education and the prevalence of common mental disorders in Chile, while in the United Kingdom level of income, but not education, was associated with prevalence, and in the United States both income and education were found to have significant associations with prevalence of common mental disorders.

RACE/ETHNICITY

Too often, social status as measured by membership in racial/ethnic groups is seen as a proxy for socioeconomic status. However, the relationship is much more complex. For example, although African-Americans in the United States are a socially disadvantaged group, their rates of depression and suicide are lower than the majority white population (in contrast to predictions based on SES). Other evidence suggests that African-Americans have higher rates of depressive symptoms and that their risk for persistent mood and anxiety disorders is higher (in keeping with predictions based on SES). The AESOP study (Fearon et al., 2006) reports that incidence rates of psychosis among the African-Caribbean and black African populations in the United Kingdom are substantially higher than in white Britons, a finding that suggests that membership in a racial or ethnic minority may confer risk for mental disorder, independent of SES. In general, research from Australia, the United Kingdom, the Netherlands, Denmark, and Sweden support these findings in that immigrants, especially those from racial or ethnic backgrounds that are different from the host countries, are at increased risk for psychosis.

PSYCHOSOCIAL ENVIRONMENTS

SOCIAL CAPITAL

The concept of social capital emerges from the work of Durkheim in that it looks to features of social environments to explain the collective behavior of individuals. Specifically, social capital may be defined as those properties of social units (e.g., neighborhoods, communities, cities, or provinces) that include, as defined by De Silva and colleagues (2005), ‘the quantity and quality of formal and informal social interactions, civic participation, norms of reciprocity, and trust in others.’ Research literature has demonstrated a strong and positive association between levels of social capital and the health status of communities, and there is growing evidence of an inverse association between social capital and risk for common mental disorders such as depression and anxiety. However, difficulties in precise definition and measurement of social capital must be overcome before it is possible to develop public mental health policies based on the concept of social capital.

NEIGHBORHOODS

There is now a large body of evidence demonstrating the association of neighborhood characteristics (e.g., proportion of households living in poverty) with physical health. There is also evidence that the collective level of depressive symptoms is influenced by the characteristics of neighborhoods. Indeed, a 2006 study by Cohen and colleagues shows that, compared to older residents of middle and high-income neighborhoods, older residents of low-income neighborhoods are less likely to respond to even the best of antidepressant treatment. As noted above, Faris and Dunham found high rates of psychosis in the inner city of Chicago. Additionally, a recent meta-analysis by John McGrath and colleagues at the University of Queensland (2004) suggests that relatively high rates of schizophrenia are associated with urban residence.

OCCUPATION AND SOCIAL STATUS

There is increasing evidence that social inequalities in well-being are the consequence of psychological processes. For example, the Whitehall study (Stansfeld et al., 2003) suggests that psychosocial work environments (e.g., the extent to which one may make decisions and use skills creatively) were more important than socioeconomic status in determining risk for depression. More generally, research by Michael Marmot (2004) suggests that subjective social status, that is, the perception of one’s relative position in the social order, accounts for much of the social gradient in health and well-being.

RAPID SOCIAL CHANGE AND SOCIAL DISORGANIZATION

Durkheim associated rapid social change (e.g., political and economic upheavals) with what he termed as ‘anomic’ suicide – suicide caused by a collective experience of chaos and/or loss of meaning and purpose. The validity of the concept can be found in a number of examples. As a result of decades of political violence, suicide rates in Sri Lanka have gone from being among the lowest to among the highest in the world, particularly among young adults (Somasundaram, 2007). The startling increase of suicides in Japan since 1998 has been attributed to a range of economic factors, including unemployment, bankruptcy, and debt (Curtin, 2004). Gender inequities, as well as economic and social changes, are often cited to explain the high rates of suicide among young women in rural China. Perhaps the most dramatic example of anomic suicide is found among the indigenous peoples of the world, who have experienced massive social and cultural dislocations for hundreds of years. In Micronesia and Australia, for example, high rates of suicide and self-harm among young men are likely the result of social changes that have eroded traditional cultural activities and social structures that helped to guide this age group through the difficult transition to adulthood.

Difficult and rapid social transformations are often associated with increased rates of substance abuse, alcohol-related problems, and suicide. Evidence of this is found, again, among the indigenous peoples of the world; high rates of alcoholism are found among indigenous groups in such disparate places as Australia, Taiwan, and North America.

Rates of mortality in Russia have gone through dramatic changes since the dissolution of the Soviet Union: a sharp increase immediately after 1991, substantial improvement between 1994 and 1998, and another decline after 1998. The result is that life expectancy in Russia (66 years) is alarmingly shorter than in the developed nations of the world ( 78 years). To a large degree, the overall decline in the health status of the Russian population is due to alcohol abuse and related deaths, as well as violence. Since 1991, the rate of suicide in Russia has remained one of the highest in the world; it is also presumed that high levels of depression have contributed to high levels of alcohol abuse and suicide. Again, the indigenous peoples of the world provide a shocking example: Throughout the world, their life expectancies are much shorter – almost 20 years shorter in Australia, for example – than the general populations in which they live.

Globalization, specifically the spread of Western media and cultural values, has been associated with the appearance of anorexia nervosa in Hong Kong and other cities in China. Research in the late 1990s demonstrated an association between eating disorders among female Chinese high school students and their relative exposure to Western media and values. In Hong Kong, a highly Westernized city, the prevalence of eating disorders was high, while in the city of Shenzen and in rural Hunan the prevalence was moderate and low, respectively. Research from Fiji provides even stronger evidence of the causal relationship between the images portrayed in Western media and eating disorders. Just prior to the introduction of television (with programming primarily from the United States), a survey showed that female Fijian high school students had very low levels of eating disorders. Three years after the introduction of television, the same survey was administered among a comparable group of students. This time the respondents reported much higher levels of disordered eating behaviors. The change was attributed to the introduction of television and the pervasive images of women who were exceedingly thin (Becker, 2004).

VIOLENCE AND TRAUMA

There is now a large body of evidence that links the experiences of violence and trauma to risk for depression and posttraumatic stress disorder (PTSD), in particular. The sociopolitical context of the refugee experience, predisplacement and post displacement, is associated with refugee mental health. Conflict, war, and disaster situations impact on fundamental family and community dynamics, resulting in profound negative changes at a collective level. Vietnamese and Cambodian victims of political violence and torture have been found to suffer from elevated rates of these disorders. Under the rule of the Taliban in Afghanistan, women suffered from high rates of depression and anxiety as a result of the extreme social restrictions under which they were forced to live. Indeed, there is extensive evidence from throughout the world about the mental health consequences of violence against women. The trauma of natural disasters – such as the tsunami that struck Aceh, Indonesia in 2004, earthquakes in China and India, or hurricanes in the southern United States – has been linked to increased rates of depression and PTSD. In sum, experiencing violence and/or trauma substantially increases the risk for mental distress.

CONCLUSION

There is strong evidence that links the social conditions in which people live and their psychological well-being. Socioeconomic status, characteristics of neighborhoods, exposure to violence, membership in racial or ethnic minorities, gender, and rapid social change all influence psychological well-being and confer differential risk for a range of mental disorders.

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