Socioeconomic status and mental health

Numerous studies around the world have found a relationship between socioeconomic status and mental health. There are higher rates of mental illness in groups with lower socioeconomic status, but there is no clear consensus on the exact causative factors. The two principal models that attempt to explain this relationship are the social causation theory, which posits that socioeconomic inequality causes stress that gives rise to mental illness, and the downward drift approach, which assumes that people predisposed to mental illness are reduced in socioeconomic status as a result of the illness. Most literature on these concepts dates back to the mid-1990s and leans heavily towards the social causation model.

Social causation

The social causation theory is the older theory with more evidence and research behind it.[1] This hypothesis states that one’s socioeconomic status (SES) is the cause of weakening mental functions. As Perry[2] writes in The Journal of Prevention, “members of the lower social classes experience excess psychological stress and relatively few societal rewards, the results of which are manifested in psychological disorder”. Examples of excess stress that low SES people experience could be inadequate health care,[3] job insecurity,[4] poverty,[5] which can bring about many other psychosocial and physical stressors, discrimination,[6] etc. Thus, lower SES predisposes individuals to the development of a mental illness.

Research

Faris and Dunham (1939)[7]

Analyzed the prevalence of mental disorders, including Schizophrenia, in different areas of Chicago. The researchers plotted the homes of patients preceding their admission to hospitals. They found a remarkable increase of cases from the outskirts of the city moving inwards to the center. This reflected other rates of distributions, such as unemployment, poverty and family desertion. They also found that cases of Schizophrenia were most pervasive in public housing neighborhoods as well as communities with higher amounts of immigrants. This was one of the first empirical, evidence-based studies supporting social causation Theory.

Hollingshead and Redlich (1958)[8]

A study conducted in New Haven, Connecticut that is considered a major breakthrough in this field of research.[9] The authors identified anyone who was hospitalized or in treatment for mental illness by looking at files from clinics, hospitals and the like. They were able to design a valid and reliable construct to relate these findings to social class, using education and occupation as measures for five social class groups. Their results showed high disproportions of Schizophrenia among the lowest social group. They also found that the lower people were on the scale of social class, the likelier they were to be admitted to a hospital for their psychosis.

Srole et al. (1962)[10]

This study, known as the Midtown Manhattan Study, has become a quintessential study in mental health.[11] A main focus of Srole et al.'s research was to “uncover [the] unknown portion of mental illness which is submerged in the community and thus hidden from sociological and psychiatric investigators alike”.[12] They managed to probe deep into the community to include in their research subjects with mental disorders usually left out of such studies. The experimenters used both parental and personal SES to investigate the correlation between mental illness and social class. When basing their results on parental SES, approximately 33% of Midtown inhabitants in the lowest SES showed some signs of impairments in mental functioning while only 18% of the inhabitants in the highest SES showed these signs. When assessing the relationship based on personal SES, 47% of inhabitants in the lowest SES showed signs of weakening mental functions while only 13% of the highest SES demonstrated these symptoms. These findings remained the same for all ages and genders.

The studies discussed above are three of the most influential[13] in the debate between social causation and downward drift. They lend important evidence[14] to the linear correlation between mental illness and SES, more specifically that a low SES begets a mental illness. The higher rates in lower SES can likely be due to the greater stress individual’s experience. Issues that are not experienced in high SES, such as lack of housing, hunger, unemployment, etc. contribute to the psychological stress levels which can lead to the onset of mental illness. Additionally, while experiencing greater stress levels, there are fewer societal rewards as well as resources for those at the bottom of the socioeconomic ladder. Even just one level above the lowest socioeconomic group allows for moderate economic assets for preventative action and/or treatment for psychoses. However, this approach is disputed by the downward drift model.

Downward drift

In contrast to social causation, downward drift (also known as social selection) postulates that there is likely a genetic component that causes the onset of mental illness which then may lead to “a drift down into or fail to rise out of lower SES groups”.[15] This means that SES level is a consequence rather than a cause of weakening mental functions. This theory has much validity[16] when studying mental illness, specifically individuals with a diagnosis of schizophrenia.

Research

Weich and Lewis[17] (1998)

In this study conducted in the United Kingdom, the researchers looked at 7,725 adults who developed mental illnesses. They found that while low SES and unemployment may increase the length of psychiatric episodes they did not increase the likelihood of the initial psychotic break.

Isohanni et al.[18] (2001)

In this longitudinal study, the researchers looked at how mental disorders treated in hospitals for individuals aged 16–29 effected their educational achievement over the following 31 years in Finland. They had a total of 80 patients and compared those who had been treated in the hospital for diagnoses of schizophrenia and other psychotic/non-psychotic diagnoses to those of the same 1966 birth cohort who had received no psychiatric treatment. They found that individuals who were hospitalized at 22 years or younger (early onset) were more likely to only complete a basic education and remain stagnant.[19]

Some were able to complete secondary education, but none advanced to tertiary education. Those with no hospitalization had lower completion of basic education but much higher percentages of completing both secondary and tertiary education, 62% and 26%, respectfully. This study insinuates that mental disorders, especially Schizophrenia, impede educational achievement. This inability to complete higher education may be one of the possible contributors to the downward drift in SES by individuals with mental illness.

Wiersma, Giel, De Jong and Slooff (1983)[20]

The researchers in this study looked at both educational and occupational attainment of patients with psychosis compared to their fathers. They assessed both topic areas in the fathers as well as in the patients. In a two year follow-up, the downward mobility in both education and occupation was greater than expected in the patients. They looked at the occupational mobility before and after the onset of psychosis which showed that only a small percentage were able to keep their regular job or find a new one. Most of the individuals participating in the study had a lower SES than when they were born. This study also shows that the drift may begin with prodromal symptoms rather than a full onset.[21]

Debate

Many researchers argue against the downward drift model, because unlike its counterpart, “it does not address the psychological stress of being impoverished and fails to validate that persistent economic stress can lead to psychological disturbance”.[22] Mirowsky and Ross[23] discuss in their book, Social Causes of Psychological Distress, that stress very frequently stems from lack of control, or the feeling of lack of control, over one’s life. Those in lower SES have a minimal sense of control over the events that occur in their lives.[24]

They argue that this dysfunction does not only stem from jobs with low income, but that “minority status also lowers the sense of control, partly because of lower education, income, and unemployment, and partly because any given level of achievement requires greater effort and provides fewer opportunities”[25] which is found across many countries. The arguments posed in their book support social causation since such high stress levels are involved. Although both models can be existing, they do not need to be mutually exclusive, researchers tend to agree that downward drift has more relevance to someone diagnosed with schizophrenia.[26]

Implications for schizophrenia

Although social causation can explain some forms of mental illnesses, downward drift “has the greatest empirical support and is one of the cardinal features of schizophrenia”.[27] This theory is more applicable to schizophrenia for a number of reasons. There are varying degrees of the disease, but once a psychotic break is experienced, the person often cannot function at the same level as before. This impairment affects all areas of life, education, occupation, social and family connections, education, etc. Because of the multiplicity of challenges, the sufferer will likely drift lower in society, unable to keep up with previous standards.

Another reason why the downward drift theory is preferred is that, unlike other mental illnesses such as depression, once someone is diagnosed with schizophrenia they have the diagnosis for life.[28] While symptoms may not be constant "individuals with this diagnosis often experience cycles of remission and relapse throughout their lives".[29]

This explains the large discrepancy between the incidence and prevalence of the disease. There is a very low rate of new cases in comparison to the amount of total cases because "it often starts in early adult life and becomes chronic".[30] Patients will usually function at a lower level once the illness has manifested itself. Even with the help of antipsychotic medication and psychosocial support, most will still live their lives experiencing some symptoms.[31] Because of this, moving up out of a lower SES becomes nearly impossible.

Another possible explanation discussed in literature regarding the relation between this theory and schizophrenia is the stigma associated with mental illness. Individuals with mental illnesses are many times treated differently, almost always negatively, in our society.[32] Although we have made great strides, there is quite often an unfavorable stigma linked to how mental illness is viewed. As Livingston explains, “stigma can produce a negative spiraling effect on the life course of people with mental illnesses, which tends to create...a decline in social class”.[33]

These individuals already cannot function at the level they are used to, and "are particularly likely to experience the effects of ostracism, being amongst the most stigmatized of all the mental illnesses.".[34] The complete exclusion they experience helps to maintain their new lower status, preventing any upward mobility. This theory may be mainly applicable to Schizophrenia, however it also has applications to other mental illnesses since each is accompanied by the negative stigma.

While it can be hard to maintain status once the illness appears, some individuals are able to resist. This, again, is mainly due to SES, as well as other factors. If the person is from a high SES, they have the ability to access preventative resources and possible treatment for the disease. This can help buffer the drift downwards and help maintain their status. It is also important to have a strong network of friends and/or family.[35] This can also act as a barrier since they may notice signs of the illness before the full onset.[36] For example, individuals that are married show less of a drift downwards than those who are not[37] because this added social system creates more of a support. Individuals who do not have this support system may show early symptoms that will go unnoticed with no preventative action done.

See also

References

  1. ↑ Warren, J. R. (15 April 2013). "Socioeconomic status and health across the life course: A test of the social causation and health selection hypotheses". Social Forces: Oxford Academic. 87 (4): 2125–2153.
  2. ↑ Perry, Melissa J. (September 1996). "The Relationship Between Social Class and Mental Disorder". The Journal of Prevention. 17 (1): 17–30. doi:10.1007/BF02262736.
  3. ↑ Jensen, E. (November 2009). Teaching with poverty in mind. Alexandria, VA: Association for Supervision & Curriculum Development; 1st Edition. pp. 13–45.
  4. ↑ Wang, H., Xiaozhao, Y. Y., Tingzhong, Y., Randall, C. R., Lingwei, Y., Xueying, F., & Jiang, S. (7 March 2015). "Socioeconomic inequalities and mental stress in individual and regional level: A twenty one cities study in China". International Journal for Equity in Health. 14 (25).
  5. ↑ "Work, Stress, and Health & Socioeconomic Status". American Psychological Association. 2018 American Psychological Association.
  6. ↑ Baum, A., Garofalo, J. P., & Yali, A. M. (6 February 2006). "Socioeconomic status and chronic stress: Does stress account for SES effects on health?". Annals of the New York Academy of Sciences. 896 (1): 131–144.
  7. ↑ Faris, R. & Dunham, H. (1939). Mental Disorders in Urban Areas: An ecological study of Schizophrenia and other psychoses. Oxford, England: University of Chicago Press.
  8. ↑ Hollingshead, A. B. & Redlich, F. C. (1958). Social Class and Mental Illness. New York: John Wiley & Sons.
  9. ↑ Perry, Melissa J. (September 1996). "The Relationship Between Social Class and Mental Disorder". The Journal of Prevention. 17 (1): 17–30. doi:10.1007/BF02262736.
  10. ↑ Srole, L., Langner, T. S., Micheal, S. T., Oplear, M. K., & Rennie, T. A. C. (1962). Mental Health in the Metropolis: The Midtown Manhattan Study. New York: McGraw-Hill Book Company Inc.
  11. ↑ Perry, Melissa J. (September 1996). "The Relationship Between Social Class and Mental Disorder". The Journal of Prevention. 17 (1): 17–30. doi:10.1007/BF02262736.
  12. ↑ Srole, L., Langner, T. S., Micheal, S. T., Oplear, M. K., & Rennie, T. A. C. (1962). Mental Health in the Metropolis: The Midtown Manhattan Study. New York: McGraw-Hill Book Company Inc.
  13. ↑ Perry, Melissa J. (September 1996). "The Relationship Between Social Class and Mental Disorder". The Journal of Prevention. 17 (1): 17–30. doi:10.1007/BF02262736.
  14. ↑ Perry, Melissa J. (September 1996). "The Relationship Between Social Class and Mental Disorder". The Journal of Prevention. 17 (1): 17–30. doi:10.1007/BF02262736.
  15. ↑ Dohrenwend, B. P. (1990). "Socioeconomic Status (SES) and Psychiatric Disorders". Social Psychiatry and Psychiatric Epidemiology. 25: 41–47.
  16. ↑ Bhatia, T., Chakraborty, S., Thomas, P., Naik, A., Mazumdar, S., Nimgaonkar, V. L., & Deshpande, S. N. (September 2008). "Is Familiality Associated with Downward Occupation Drift in Schizophrenia". Psychiatry Investigation. 5 (3): 168–174. doi:10.4306/pi.2008.5.3.168.
  17. ↑ Weich, S. & Lewis, G. (1998). "Poverty, Unemployment, and Common Mental Disorders: Population Based Cohort Study". British Medical Journal. 317: 115–119.
  18. ↑ Isohanni, I., Jones, P. B., Jarvelin, M. R., Nieminen, P., Rantakallio, P., Jokelainen, J., Croudace, T. J., & Isohanni, M. (Feb 2001). "Educational consequences of mental disorders treated in hospital. A 31-year follow-up of the Northern Finland 1966 Birth Cohort". Psychological Medicine. 31 (2): 339–349.
  19. ↑ Benedetto, S., Itzhak, L., & Kohn, R. (Oct 2005). "The public mental health significance of research on socio-economic factors in schizophrenia and major depression". World Psychiatry. 4 (3): 181–185.
  20. ↑ Wiersma, D., Giel, R., De Jong, A., & Slooff, C. J. (Feb 1983). "Social class and schizophrenia in a Dutch Cohort". Psychological Medicine. 13 (1): 141–150.
  21. ↑ Croudace, T. J., Kayne, R., Jones, P. B., & Harrison, G. L. (Jan 2000). "Non-linear relationship between an index of social deprivation, psychiatric admission prevalence and the incidence of psychosis". Psychological Medicine. 30 (1): 177–185.
  22. ↑ Perry, Melissa J. (September 1996). "The Relationship Between Social Class and Mental Disorder". The Journal of Prevention. 17 (1): 17–30. doi:10.1007/BF02262736.
  23. ↑ Mirowsky, J. & Ross, C. E. (1989). Social Causes of Psychological Distress. New York: Aldine de Gruyter.
  24. ↑ Mirowsky, J. & Ross, C. E. (1989). Social Causes of Psychological Distress. New York: Aldine de Gruyter.
  25. ↑ Mirowsky, J. & Ross, C. E. (1989). Social Causes of Psychological Distress. New York: Aldine de Gruyter.
  26. ↑ Mirowsky, J. & Ross, C. E. (1989). Social Causes of Psychological Distress. New York: Aldine de Gruyter.
  27. ↑ Bhatia, T., Chakraborty, S., Thomas, P., Naik, A., Mazumdar, S., Nimgaonkar, V. L., & Deshpande, S. N. (September 2008). "Is Familiality Associated with Downward Occupation Drift in Schizophrenia". Psychiatry Investigation. 5 (3): 168–174. doi:10.4306/pi.2008.5.3.168.
  28. ↑ Picchioni, M. M. & Murray, R. M. (14 July 2007). "Schizophrenia". The British Medical Journal. 335 (7610): 91–95.
  29. ↑ Shean, G. D. (2010). Recovery from schizophrenia: Etiological models and evidence-based treatments (PDF). New York: Hindawi Publishing Corporation.
  30. ↑ Picchioni, M. M. & Murray, R. M. (14 July 2007). "Schizophrenia". The British Medical Journal. 335 (7610): 91–95.
  31. ↑ "Schizophrenia treatment". American Psychological Association.
  32. ↑ Livingston, J. D. (31 October 2013). "Mental Illness-Related Structural Stigma: The Downward Spiral of Systemic Exclusion Final Report". Mental Health Commission of Canada.
  33. ↑ Livingston, J. D. (31 October 2013). "Mental Illness-Related Structural Stigma: The Downward Spiral of Systemic Exclusion Final Report". Mental Health Commission of Canada.
  34. ↑ Perry, Y., Henry, J. D., Sethi, N., & Grisham, J. R. (November 2011). "The pain persists: How social exclusion affects individuals with schizophrenia". The British Journal of Clinical Psychology. 50 (4): 339–349. PMID 22003945.
  35. ↑ "Friendship and mental health". Mental Health Foundation. Registered Charity No. England.
  36. ↑ Magliano, L., Marasco, C., Fiorillo, A., Malangone, C., Guarneri, M., & Maj, M. (11 September 2002). "The impact of professional and social network support on the burden of families of patients with schizophrenia in Italy". Acta Psychiatrica Scandinavica. 106 (4): 291–298.
  37. ↑ Honkonen, T., Virtanen, M., Ahola, K., Kivimaki, M., Pirkola, S., Isometsa, E., Aromaa, A., & Lonngvist, J. (1 February 2007). "Employment Status, Mental Disorders and Service Use in the Working Age Popuation". Scandinavian Journal of Work, Environment & Health. 33 (1): 29–36. PMID 17353962.
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