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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.
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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, 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 (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.
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.
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.
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.
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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