Sociology of Mental Health Research Paper

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Outline

I. Introduction

II. The Sociology of Mental Health: A Brief History

A. The Development of Social Epidemiology of Mental Health and Disorders

III. The Study of Mental Health in Contemporary Sociology

A. The Influence of Other Disciplines on the Sociology of Mental Health

B. Theoretical Perspectives on Mental Health and Disorder in Sociology

C. Defining a Unique Sociological Approach to Mental Health and Illness

1. The Stressor Exposure Perspective

2. The Social Relationships Perspective

3. The Societal Reaction Perspective

D. The Influence of Psychological Models on the Sociology of Mental Health and Illness

E. Methodological Controversies

1. Measures of Mental Health and Disorder

2. Measures of Stressor Exposure

F. The Social Epidemiology of Mental Disorders

1. Gender

2. Socioeconomic Status

3. Race

4. Marital Status

IV. Future Directions in the Sociology of Mental Health

A. Comorbidity

B. Mental Health Services and Policy

C. Better Measures of Stress Exposure

D. Better Measures of Social Resources

E. The Biological Perspective on Mental Disorders

I. Introduction

This research paper describes the history, application, and development in sociology of the study of mental health, illness, and disorders. Mental health, mental illness, social and mental functioning, and its social indicators are a classic theme in the field of sociology. Emile Durkheim’s (1951) Suicide was a landmark study in both sociology and epidemiology, laying out a sociological course of research that remains an intellectual force in contemporary social science (Berkman and Glass 2000). The influence of the sociology of mental health and illness goes well beyond its sociological roots; its major theoretical perspectives interact with major research streams in psychiatry, psychology, anthropology, public health, and medicine (Aneshensel and Phelan 1999; Horwitz and Scheid 1999; Eaton 2001; Gallagher 2002; Cockerham 2005). The sociology of mental health also connects to numerous other fields in sociology, including general medical sociology, the sociology of aging, demography and biodemograpy, statistics, childhood studies, sociology of the life course, deviance, criminology, stratification, and studies of the quality of life.

Mental health, mental illness, and mental disorder are closely related but distinguishable concepts. Mental health refers to a state of well-being or alternatively, a state of mental normality, free of disorder or illness. Mental illness refers to a persistent state of mental abnormality. The term mental disorder is applied to a specific diagnosis of mental abnormality, such as depression, anxiety, schizophrenia, agoraphobia, mania or substance dependence.

In this research paper, the term sociology of mental health is used to refer to general theories and research that encompass the causes, development, and consequences of mental disorders and the state or symptoms of mental distress. The term also includes the study of personal and situational resources that preserve or restore the state of mental wellbeing. Sociologists who practice in the field of mental health examine a variety of outcomes and indicators of mental health as well as mental disorders.

The paper is organized into three sections: (1) a brief historical perspective on the study of mental health and illness in sociology; (2) the current state of research in the field, including its major themes and methodological problems; and (3) the future directions of the field. This research paper has four pervasive themes: (1) the interaction of the sociology of mental health and disorder with psychology, psychiatry, public health, and medicine; (2) the environmental perspective, which is the major contribution of the sociology to the mix of disciplines examining mental health in society; (3) the relationship between the study of mental health and studies of mental disorder; and (4) the emergence of the life course perspective as a dominant theoretical perspective in the sociology of mental health.

II. The Sociology of Mental Health: A Brief History

The topic of mental health has a venerable tradition in sociology. Durkheim’s classic work Suicide was translated into English in 1921, and it is still widely cited in the field. Durkheim’s work encouraged interest in the relationship of mental health and disorders with social structure, group membership, geographical location, and other indicators of social integration and organization. One of the most famous early applications of Durkheim’s perspective was Robert Merton’s (1938) work on social structure and anomie. Taken together, Durkheim and Merton introduced the influential idea that social systems can produce “stress” for individuals, who in turn may act in deviant or disordered ways (Cockerham 2005). Also applying Durkheim’s ideas, Faris and Dunham (1939) conducted a study of the distribution of schizophrenia in Chicago. Observing that people with schizophrenia clustered in high poverty areas, they argued that social isolation encouraged the development of symptoms characterizing schizophrenia.

Although Merton’s and Faris and Dunham’s theories no longer hold sway among contemporary sociologists of mental health, they are significant in their historical impact on the field. The organized field of the sociology of mental health grew out of the larger field of general medical sociology in the late 1930s and 1940s. Interest in mental illness and its causes were heightened by extraordinary events in the mid-twentieth century. The suffering of many ordinary Americans during the Great Depression, the discovery of psychiatric impairments among many World War II draftees, and the traumatic effects of combat on soldiers and civilians were powerful arguments for government support of efforts to mitigate mental illness (Kirk 1999).

The founding of the National Institutes of Mental Health (NIMH) in 1949 contributed to the development of medical sociology in general. The establishment of the Laboratory of Socio-Environmental Studies at NIMH in 1952 was a critical event in the development of studies of mental health in medical sociology. The sociologist John Clausen, who headed the laboratory, recruited and supported a number of sociologists who became leaders in the field, among them Melvin Kohn, Leonard Pearlin, Erving Goffman, and Morris Rosenberg (Kirk 1999). Using a strategy still dominant in behavioral science approaches to mental disorders, Clausen (1956) recruited social scientists from multiple disciplines as well as sociologists, stating that “the roles to be filled by sociologists within the mental health field call for collaboration with clinicians” (p. 47).

Throughout the 1950s, 1960s, and 1970s, NIMH was a major supporter of sociological and psychological research on mental health and illness. According to figures assembled by Kirk (1999), in 1976 more than 50 percent of NIMH research grants were to social, psychological, and behavioral scientists. A smaller proportion of grants were awarded to psychiatrists and physicians (a situation that no longer holds at NIMH).

A. The Development of Social Epidemiology of Mental Health and Disorders

Social epidemiology, sometimes labeled psychiatric epidemiology or social psychiatry (Gallagher 2002), is the discovery and documentation of the social and demographic distribution of mental disorders and health. The distribution of mental disorders can be documented via the study of medical records, mental hospital admissions, and surveys of the general population. Surveys in representative community populations, using clinically validated questions that identify and classify mental disorder symptoms by diagnostic categories, are the current tools used to estimate the prevalence of disorders (Cockerham 2005). The diagnostic estimates are then analyzed to determine their distribution by social and demographic group.

Hollingshead and Redlich (1958) (a sociologist and a psychiatrist) conducted an innovative study of mental disorders in New Haven, Connecticut, in which they compared mental illness inpatients and outpatients to a sample representative of the general community. Although not a study of prevalence the study had wide influence because of their findings that different types of mental disorder were distributed by social class, with more disorders among lower social class groups. The study also found that treatment for mental disorder varied by class. Because Hollingshead and Redlich’s study included only treated cases, however, they could not draw inferences about possible social causes of mental disorders.

The Midtown Manhattan Study in the 1950s (Srole et al. 1962) investigated the distribution of mental disorders using a random selection household survey design. The interview responses were rated by psychiatrists on the team. The findings from this study continue to shape social epidemiology today. Mental disorders were found to be more prevalent among respondents of lower socioeconomic status. Childhood poverty was linked to psychiatric impairment in adulthood (an early application of the life course perspective on mental health). Those who had mental disorders were less likely to be upwardly mobile. The investigators hypothesized that exposure to childhood and adult stressors played a key role in the distribution of mental disorders as well as mental health (Cockerham 2005). Many of these findings were replicated in a study of Nova Scotia communities (Leighton et al. 1963).

The environmental perspective on mental health was also advanced by studies led by social psychologists. Americans View Their Mental Health, two nationally representative interview studies conducted in 1956 and 1976 (Veroff, Douvan, and Kulka 1981), examined patterns over time in the contributions of the social environment to both positive and negative mental well-being as well as to patterns of help seeking for those who experienced mental distress.

A notable advance in the survey technology for measuring the prevalence of mental disorders and their social correlates was the Epidemiological Catchment Area (ECA) project, conducted by NIMH and five universities in the 1980s (Yale University, Johns Hopkins University, Washington University, Duke University, and the University of California at Los Angeles). A multidisciplinary team, including sociologists, psychiatrists, and psychologists developed new diagnosis instruments to detect mental disorders for use in the general population (Robins and Regier 1991). These diagnostic instruments, derived from the third version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSMIII), were coupled with interviews that measured environmental factors, social class, race, ethnicity, stressors, social relationships, and other factors believed to correlate with the risk of developing mental disorders.

The separate samples for the ECA studies, however, were not representative of the entire population of the United States. In 1990 through 1992, NIMH funded the first national survey of mental disorders in the general U.S. population (n = 8,068), the National Comorbidity Survey (NCS; Kessler and Zhao 1999). The investigators updated the interview diagnostic measures to reflect those recently developed by the American Psychiatric Association and the World Health Organization (Kessler et al. 1994). Along with diagnostic measures of depression, mania, anxiety, substance abuse, phobias, posttraumatic stress disorder, and other mood and psychotic disorders, the NCS interviews included measures of environmental factors, personality, childhood conditions, physical health, and mental health care utilization. NCS investigated the concept of comorbidity, which is defined as the occurrence of more than one type of mental disorder in an individual.

The NCS has been widely emulated and expanded. A version of the NCS was also conducted in Canada. NIMH also funded a series of replications of the NCS in 2000 to 2003 (Kessler et al. 2005), and the method has been extended to studying mental health and illness in children. The World Health Association is currently coordinating international replications of the NCS (http://www.hcp.med.harvard.edu/ncs/).

III. The Study of Mental Health in Contemporary Sociology

As the foregoing brief historical overview shows, the study of mental health in sociology has been influenced by multiple disciplines. It is also host to a number of competing theoretical perspectives. The most widely discussed is the tension among medical, environmental, and societal reaction perspectives on the causes, consequences, and appropriate treatment of mental disorders. As a consequence of the host of influences on the field, there is considerable disagreement over the measurement of basic concepts in research, including how to define mental health and disorders (Kessler and Zhao 1999), environmental factors such as stressors, location, and socioeconomic status (Wheaton 1999); and social consequences such as disability, labeling, and social isolation (Horwitz and Scheid 1999; Pillemer et al. 2000). In addition, there is considerable creative tension between those who concentrate on establishing the incidence and prevalence of mental disorders and those who focus more on the correlates of mental health and mental illness (Mirowsky and Ross 2002, 2004). Finally, there is considerable research on the use of mental health services and on mental health policy.

A. The Influence of Other Disciplines on the Sociology of Mental Health

As Clausen (1956) prophetically foresaw, sociologists who specialize in mental health frequently collaborate with those in other disciplines, such as developmental and social psychology, psychiatry, epidemiology, economics (Aneshensel and Phelan 1999; Gallagher 2002), and increasingly biology (Shanahan and Hofer 2005). The National Institutes of Health has encouraged and continues to encourage multidisciplinary approaches to the study of mental illness and disorders. Psychiatrists and clinical psychologists lay claim to the definitions of mental illness and disorder through the continuing revisions of the Diagnostic and Statistical Manual Mental Disorders, currently in its fourth edition (American Psychiatric Association 2000), as well as to measurements of mental distress (Radloff 1977), quality of life (Veroff et al. 1981), and social relationships and support (Cohen, Underwood, and Gottlieb 2000). Sociologists who study mental health compete for federal funds and intellectual prestige with those from other disciplines.

The presence of sociologists in interdisciplinary efforts to understand the causes, course, and consequences of mental illness and disorders is a positive situation; the influence of the sociology of mental health on other disciplines is tangible. A negative aspect of the interdisciplinary effort is that the sociology of mental health is sometimes viewed as isolated from the general field of sociology (Aneshensel and Phelan 1999). This perception may be exacerbated by the employment of sociologists of mental health (and other medical sociologists) in academic units other than Sociology departments. Members of the Sociology of Mental Health section of the American Sociological Association are employed in medical schools, schools of public health, schools of social work, and departments of human development. When theories of cause and measures of critical outcomes are shared with other disciplines, the question arises: What is the unique contribution of sociology to the study of mental health and illness? The answer to this question is pressing as there are calls for proposals that contribute to “the development, enhancement, and assembly of new data sets from existing data” and for research “that combines diverse levels of analysis” from national research and review bodies (National Institutes of Health 2004) as well as for research that examines the causes of health differences by socioeconomic status and behavioral risk factors across the life course (National Research Council 2004).

B. Theoretical Perspectives on Mental Health and Disorder in Sociology

Five major perspectives, and combinations of these perspectives, are used in the contemporary sociology of mental health. The five major perspectives are (1) the medical model, (2) the environmental perspective, (3) the social psychological perspective, (4) societal reaction (or labeling), and (5) the life course perspective. The medical model views mental disorders as diseases and prescribes medical treatment as the appropriate cure. The environmental perspective asserts that factors such as social class, race, ethnicity, gender, urban location, and exposure to stressors may cause and most certainly shape risks for mental disorder. The social psychological perspective contributes insight into the social and relational factors that provide resources for adjusting to environmental stressors and restoring mental health and well-being. The social reaction perspective argues that mental illness emerges from social strain processes that produce deviance. The life course perspective views mental health and mental disorder as resulting from the accumulation of environmental stressors and exposures across the lifetime, in interaction with developmental and personal factors such as family structure, personality, and even genetic endowment. Researchers in the sociology of mental health often combine one or more of these perspectives in their research, with the life course perspective now generally seen as an emerging unifying paradigm (George 1999).

C. Defining a Unique Sociological Approach to Mental Health and Illness

Although there is constant interaction between the mental health disciplines, several recent analyses of the state of theory in the sociology of mental health in the late twentieth century indicate the emergence of a distinct sociological approach. Horwitz and Scheid (1999) outlined two major approaches in the study of the sociology of mental health and illness. These two approaches are: (1) the social contexts producing or shaping mental health and disorder and (2) the recognition, treatment, and policy response to mental illness and disorder. In the same volume, Thoits (1999) described three major approaches that uniquely characterize the sociology of mental health: (1) stress exposure (a subset of the social context approach described by Horwitz and Scheid); (2) structural strain theory, which derives from Merton (1938); and (3) societal reaction, or labeling theory. Aneshensel and Phelan (1999) argue that the distinguishing issue in the sociological approach to mental illness is attention to how social stratification produces the unequal distribution of both disorders and mental health.

Aneshensel and Phelan also argue that a major challenge to the sociological approach to mental disorders is the debate between social causation and social selection explanations for the relationship between mental disorders and social class. The social selection approach hypothesizes that the reason there are more mental disorders in the lower economic class is because those with mental disorders are downwardly mobile economically or are unable to be upwardly mobile. This debate has many implications for interpreting how social stratification is linked to mental disorders and health (e.g., Miech et al. 1999).

The sociological approach also provides unique insight into the serious social consequences for those who have mental disorders, including socioeconomic success. The sociological approach also contributes research on the social factors that influence how institutions and individuals recognize when someone is mentally ill, how individuals are treated and how that treatment varies by social class, gender, and race, and who is more likely to use mental health care (e.g., Phelan et al. 2000).

The application of the sociological approach to mental health generates considerable empirical work that focuses on economic and other types of social stratification as determinants of mental health and mental disorder. This work is concentrated in research on stressor exposure, social relationships, and societal reaction to mental disorders.

1. The Stressor Exposure Perspective

The social context approach is a set of perspectives; the most well-known and applied outside the field of the sociology of mental health is the stress exposure perspective, which assumes that a combination or accumulation of stressors and difficulties can cause an onset of mental disorder. This perspective (Brown and Harris 1978; Dohrenwend et al. 1978), dominant in sociology, focuses on the level of change or threat posed by external events, and more recently, on the potential for chronic, unresolved stressors to threaten physical and mental health (Wheaton 1999).

Building on the strong history of social epidemiology in the field, the major assumption of this approach is that differential exposure to stressors by social class or social location is largely determined by social inequalities. In turn, the effects of prolonged stress exposure may perpetuate social inequality through the development of mental illness or disorder in disadvantaged populations (Pearlin et al. 2005). The latter point is more controversial (and in general less well developed theoretically); however the emerging life course or human developmental approach to the accumulation of disadvantage derives in some part from the stress exposure perspective (George 1999). The life course approach assumes that there is an accumulation of the negative effects of differential stressor exposure across life that perpetuates and magnifies inequalities and that many of these processes originate in childhood (e.g., McLeod and Kaiser 2004; McLeod and Nonnemaker 2000). A related stress exposure approach is stress diathesis, which assumes that stress exposure causes disorder only when there is a latent vulnerability (Eaton 2001). The diathesis approach is widely applied in psychiatric research on mental disorders.

2. The Social Relationships Perspective

Horwitz and Scheid (1999) add that in addition to stressor exposure, resources to help counter the negative impact of stressor exposure or to avoid stressor exposure also are differentially distributed by social class and location. The major types of social resources that vary by social class are (1) social integration, usually measured as access to meaningful and productive social roles (e.g., Pillemer et al. 2000); (2) social network characteristics (Turner and Turner 1999); (3) family structure (e.g., Turner, Sorenson, and Turner 2000); (4) received and perceived social support (Wethington and Kessler 1986); and (5) coping choices and styles (Pearlin and Schooler 1978; Pearlin et al. 1981). Thoits (1999) has pointed out that this approach, although distinct from the stressor exposure perspective, relies on stress exposure as a mechanism to activate the protective factors.

3. The Societal Reaction Perspective

In an overview of the sociology of mental health, Thoits (1999) argued that there is no strong evidence that labeling or other societal reaction processes produce mental illness. However, the societal reaction perspective does provide an insight into social biases against those who display symptoms of mental disorder, which are often viewed as socially deviant. Aneshensel and Phelan (1999) concluded that there is a consensus among sociologists of mental health that mental disorders are objective entities and are not completely a product of social constructions. The strongest evidence for this conclusion is that symptoms of mental disorders are observed in all societies, although there are cultural variations in the ways that such symptoms are described and diagnosed.

A difficulty with this position for sociologists of mental health is that it implies there is widespread acceptance of the medical model, which can make theoretical interaction with other streams of sociology (e.g., the sociology of deviance) more contentious. Studies of the etiology of mental disorders in the population no longer routinely employ a deviance perspective. The stressor exposure model also applies a variation of the dose-response paradigm widely used in medical research. This acceptance of a variation of the medical model remains controversial and is probably related to the distance perceived between the sociology of mental health and the more mainstream sociology of stratification.

Yet another tension exists between opposing explanations of what causes social stratification in the distributions of mental disorders. On one side is the belief that routine functioning of society produces some of this stratification, as for example gender differences in the distribution of different types of disorders (Rosenfield 1999). In this view, mental distress and mental disorders can be produced by normal social processes such as gender role socialization. The stress exposure perspective, on the other hand, assumes that abnormal circumstances and events produce mental disorders and distress (Almeida and Kessler 1998). These two views are not necessarily impossible to resolve, but they continue to produce theoretical tensions.

D. The Influence of Psychological Models on the Sociology of Mental Health and Illness

Another factor producing distance between the sociology of mental health and the general field of sociology is the influence of social psychological theories on the field. As psychology has incorporated facets of the stress exposure perspective, sociologists of mental health have adopted ideas from social and developmental psychology on social support and relationships, coping, and life course development. An influential psychological perspective, the process of appraisal and coping, was developed by Lazarus and Folkman (1984), updated by Lazarus (1999), and has been further elaborated by Folkman and Moskowitz (2004). This perspective, dominant in the field of psychology, has emphasized how individual differences in perceptions of external stressors affect mental health. The focus of appraisal researchers on emotions as motivation for appraisal suggests commonality with biological research on emotion (Massey 2002). The theory of appraisal has been widely cited by sociologists who examine the impact of events on mental health (e.g.,Wethington and Kessler 1986).

The life course perspective (Elder 1974), now widely applied in the sociology of mental health (e.g., Wheaton and Clarke 2003; McLeod and Kaiser 2004), traces many of its components to the ecological perspective on human development pioneered by the developmental psychologist Urie Bronfenbrenner (1979). The life course perspective theorizes that developmental trajectories, developmental or socially normative timing of the stressor, and the accumulation of stressor exposure and resistance factors shape reaction to stressors (Elder, George, and Shanahan 1996). In the last decade, the life course perspective on stress accumulation has also been applied by psychologists, clinical psychologists, and neuroscientists (e.g., Singer and Ryff 1999; McEwen 2002; Repetti, Taylor, and Seeman 2002). Neuroscientists McEwen and Stellar (1993) have developed the concept of allostatic load which describes physiological mechanisms for the accumulated effects of past adaptation to stressors on health. Allostatic load is currently being adapted by sociologists to use in studies of stressor exposure across the life course and its relationship to mental health and disorder (Shanahan, Hofer and Shanahan 2003; Shanahan and Hofer 2005).

Sociological and psychological research streams on the relationship between stressor exposure and mental health are converging through collaborative efforts that examine the impact of stressor accumulation along the individual life course (Elder et al. 1996; Singer et al. 1998). A serious problem, however, is that most measures of stressor exposure available to researchers focus on recent exposures rather than the interactions of different types of stressor exposure over the long term; the majority of stressor exposure measures used in research are simple counts or sums of life events occurring over a short period of time (Wheaton 1999). Investigating the relationships between stressors over time and their combined associations with mental health and well-being is an important strategy for examining the impact of stressors over the life course (George 1999).

E. Methodological Controversies

Issues of causality and theoretical approach are controversial in the field. Given the complexity and controversies in the sociology of mental health and illness, it is not surprising that one of the critical areas of the field is measurement. The two most disputed areas involve the measurement of outcomes and the measurement of stressor exposure.

1. Measures of Mental Health and Disorder

The controversy begins with the outcomes. There is an increasing consensus that positive mental health and wellbeing is not just the absence of mental illness or disorder (Keyes 2002). There is also a controversy over whether dichotomous diagnoses of psychiatric disorder should be a proper outcome for sociological inquiry, in contrast to scales of distress symptoms (Kessler 2002; Mirowsky and Ross 2002).

Research diagnostic measures of mental disorder are controversial on many dimensions. Wakefield (1999) criticized the diagnostic measures used in the Epidemiological Catchment Area and National Comorbodity Studies for overestimating the prevalence of lifetime mental disorder in the United States. The NCS estimated that one-half of all Americans will suffer from a mental disorder over their lifetime (Kessler et al. 1994). A recent reanalysis of the NCS (Narrow et al. 2002), applying a standard of clinical seriousness based on other questions available in the survey, reduced the lifetime prevalence estimates significantly to 32 percent lifetime prevalence.

Another issue of controversy is whether a dichotomous outcome measure of disorder, one either has the disorder or not, misses levels of distress or poor social functioning that indicate considerable mental suffering (Kessler 2002; Mirowsky and Ross 2002). Persistent or recurring symptoms of sleeplessness, fatigue, sadness, loneliness, lack of appetite, and loss of interest in things in response to chronic stressors or unexpected life events can be unpleasant and disabling even if the sufferer does not show all of the symptoms of depression required for a diagnosis. The high threshold required for a diagnosis of disorder may understate emotional responses to events in the population at large. Whereas mental disorders may be relatively uncommon, symptoms of distress in response to life events are commonly observed and may indicate the presence of social dysfunction and strain in ways that surveys of mental disorders do not.

2. Measures of Stressor Exposure

Measures of stressor exposure are particularly problematic in the sociology of mental health (Wheaton 1999). A complicating factor is that other mental health disciplines enforce higher standards of precision in measurement than does sociology. In addition, the majority of studies using stressor exposure measures do not account for any interaction between combinations of particular types of stressors. Applying the life course perspective model on mental health would ultimately require more sophisticated measures on how stressors combine and interact across time.

Both the biomedical and sociological streams of research on stress processes share an interest in environmental triggers of distress (Selye 1956). Following Selye, early stress researchers applied Selye’s assumption that all environmental threats activated the same or similar physiological response, using sums of exposures to different types of stressful events (Turner and Wheaton 1995). Almost immediately, sociologists and other social researchers modified this assumption, finding that more explicit and comprehensive measurement of the characteristics of stressors often increased the amount of variance explained in the mental health outcome. These measures included the estimated average “magnitude of change” scores in Social Readjustment Rating Scale (the SRRS: Holmes and Rahe 1967) and the Psychiatric Epidemiology Research Interview for Life Events (the PERI; Dohrenwend et al. 1978). Furthermore, it became clear that other characteristics of stressors, such as their type, timing, duration, severity, unexpectedness, controllability and impacts on other aspects of life make significant contributions to the stress response and mental health outcome (e.g., Brown and Harris 1978, 1989; Pearlin and Schooler 1978; Wethington, Brown, and Kessler 1995).

The stress exposure model is evolving to model the dynamic, continuous adaptation to stressors over time (e.g., Heckhausen and Schulz 1995; Lazarus 1999; Folkman and Moskowitz 2004). Sociologists have developed measures of chronic stress exposure (Pearlin and Schooler 1978) and exposure to stressors and hassles on a daily basis (Almeida, Wethington, and Kessler 2002). Researchers debate the relative reliability and validity of self-report checklist and interview measures of life events that include detailed probes that enable investigators to rate the severity of life events (Wheaton 1999). Most recently, psychologists have contributed to understanding variations in the relationships of different types of stressors (social loss vs. trauma and chronic vs. acute stressor exposure), to immune system function and cortisol activity (e.g., Dickerson and Kemeny 2004; Segerstrom and Miller 2004). Sociologists are now considering the potential for using measures of physiological activity (e.g., cortisol measurement) in their studies (Shanahan et al. 2003).

Applying the life course perspective to studying mental disorders and health over time has led to concern about the reliability and validity of retrospective measures of stressor exposure (Wethington et al. 1995; Wheaton 1999). Empirical research on memory for life events over a relatively short recall period is reassuring; most severe events can be recalled quite well over a 12-month retrospective period (Kessler and Wethington 1991). Serious concerns remain about longer retrospective recall periods. This concern is partially mitigated by the development of life history calendar methods, visual memory aids that can be used in interviews to enhance memory for life events (Freedman et al. 1988).

F. The Social Epidemiology of Mental Disorders

Despite the complexity of measurement, sociologists have pioneered the study of psychiatric sociology, or the epidemiology of mental disorders. The recent advances of measurement in the ECA and NCS studies have produced measures of outcomes that are scientifically accepted across disciplines (Cockerham 2005). These studies have also provided critical data on the use of mental health services by those who suffer from significant disorders and have had a major influence on other fields of study. The major epidemiological research questions have focused around the distribution of mental disorders and illnesses by social factors, including gender, socioeconomic status, marital status, race, and ethnicity. There is some, but more limited work, on factors such as ethnicity, migration, and location.

1. Gender

There is dispute whether the overall rate of mental disorders and illnesses differs by gender. The consensus before the publication of national data from the NCS was that men and women did not differ overall in rates of mental disorders; rather, different types of disorders are distributed differently. Women are more likely to report depressed affect and depressive disorders. Men, in turn, are more likely to report alcohol and drug disorders, violent behavior, and other indicators of acting out. Major psychoses such as schizophrenia and bipolar disorder are not distributed unequally by gender. There is now accumulating evidence that women are also more likely to report anxiety disorders (Kessler et al. 1994, 2005), which would mean that women are overall more likely to have mental disorders. Although there is continuing interest among biological and medical scientists to find a biological cause for women’s higher rates of some disorders, particularly depression, among sociologists social cause explanations still hold sway (e.g., Rosenfield 1999).

2. Socioeconomic Status

One of the most consistent findings in the epidemiology of mental disorders is that those of lower socioeconomic status are more likely to develop mental disorders (Cockerham 2005; Gallagher 2002). This general finding was confirmed by the NCS (Kessler and Zhao 1999). There is evidence, however, that those of higher statuses are more likely to suffer from affective disorders; the overrepresentation of mental disorders is due to higher rates of schizophrenia and some personality disorders among those of lower socioeconomic status.

Among sociologists of mental health, social causation theories continue to dominate, but more attention is being given to selection processes, especially the impact of mental disorders on upward economic mobility (e.g., Miech et al. 1999). Researchers who apply the life course perspective often study selection and economic mobility processes directly, most particularly those processes that affect educational attainment in early adulthood (e.g., McLeod and Kaiser 2004).

3. Race

There remains considerable controversy in the literature whether members of racial minority groups report higher rates of mental disorder than majority racial groups. Given the relationship of socioeconomic status to mental health and disorders, it is logical to predict that rates of mental disorder in African Americans would be higher than the rates among white Americans because of the average lower socioeconomic status of blacks. Such a pattern would also reflect the additional burden of discrimination and prejudice and the impact such burdens have on mental well-being (Kessler, Mickelson, and Williams 1999).

The pattern of racial and ethnic differences, however, is more complex. For example, an analysis of risk and persistence of mental disorders among U.S. ethnic groups (Breslau et al. 2005) found that Hispanics reported lower lifetime prevalence of substance use disorders than whites, and that blacks reported lower lifetime prevalence of mood (depression or mania), anxiety, and substance use disorders. However, Hispanics were more likely to report persistent mood disorders (defined as recurrence of a past disorder), and blacks were more likely to report persistent mood and anxiety disorders. Research is needed on the factors that mitigate the impact of stressors on mental health of minority groups. Other researchers call for more attention to how mental disorders are measured and diagnosed in African Americans and other minority groups (e.g., Neighbors et al. 2003).

4. Marital Status

Although there is some evidence that pattern of mental distress by marital status may be changing as cohabitation becomes more socially accepted, the consensus still holds that married people are in better mental health and report fewer mental disorders than those who are not currently married. New research (Umberson and Williams 1999) points to the quality of the marital relationship as critical to mental well-being and health; those in unsatisfying or high-conflict marriages report poor mental health. Divorce is associated with poorer mental health over time, particularly among those who did not initiate the divorce.

Evidence such as that noted above is taken to mean that marriage confers benefits on mental health and may provide some protection against mental illness. Umberson and Williams (1999) note, however, that relatively little research has been done that has pitted the benefits of marriage perspective directly against the alternative social selection perspective that those who have mental disorders are less likely to marry or to remain married. Forthofer et al. (1996) estimated the relationship of age of onset of mental disorder on the probability of subsequent marriage. They found that those who have disorders are less likely to be married and when they marry have a higher risk of divorce. Unfortunately, studies that examine both social causation and social selection perspectives on marital status and mental health remain relatively rare, most likely because of the absence of satisfactory longitudinal data that can be used to address this issue.

IV. Future Directions in the Sociology of Mental Health

One of the tensions in the sociology of mental health and illness is the interdisciplinary orientation of the field. Concepts are freely borrowed along the border of sociology and psychiatry/psychology. Much work is applied, or meant to be applied, to issues of importance to social policy, such as the social costs of untreated mental disorders. The life course perspective (Elder et al. 1996) is changing how research is done and how questions are being asked. New directions in the field include (1) a focus on comorbidity and severity of illness and its social impact, (2) the need for a closer connection between epidemiology and research on mental health services and policy, (3) the press to develop better measures of stressor exposure, (4) demand for more sophisticated measures and analyses of social resources, and (5) and the challenge of biological research on the stress process to the sociological study of mental health.

A. Comorbidity

The study of comorbidity of mental disorders in people has transformed some aspects of the sociology of mental health. First, the documentation of comorbidity has influenced sociologists in the field to accept that mental illness is an objective reality. Second, it has become clear that those who are comorbid for multiple disorders are severely disabled in many important life roles. Their progress through life resembles the life path of “social selection.” Third, the acceptance that mental disorders are real physical entities, and the evidence for comorbidity are challenges to the environmental perspective on mental disorders. It is likely that those who have mental disorders attract or create stressor exposure (Eaton 2001). Thus, one major direction for sociological research in the future might be an emphasis on mental disorders as predictors, rather than outcomes, of social functioning and processes.

B. Mental Health Services and Policy

When reviewing the state of the sociology of mental health, Horwitz and Scheid (1999) observed that research on the social contexts of mental disorder and research on mental health services do not intersect all that much. They believed that this is because the two fields of research operate on different levels of analysis, one at the individual level and the other at the social or institutional level. A challenge for future research is to connect these two levels of analysis. Research on the social epidemiology of mental health and illness can inform organizations at all levels about the costs of untreated mental disorders to organizations and society in general.

C. Better Measures of Stress Exposure

As Wheaton (1999) observed, the social stress model requires considerable new development. This research paper has pointed out a number of methodological difficulties in measuring stressor exposure and the lack of fit between the most widely used measures of stressor exposure and the newly emerging life course perspective. Another advance would come through more detailed studies of how stressors are distributed in the population at large. Does the uneven distribution of stressors in the population “explain” the negative mental health outcomes for some groups? More research is needed in this area, ideally from the life course perspective, using longitudinal samples.

D. Better Measures of Social Resources

There is also a need for more research on the social distribution of resources that mitigate the impact of environmental challenges and stresses. Reviews of research on social support and social integration (e.g., Berkman and Glass 2000; Cohen et al. 2000; Pillemer et al. 2000) point out deficiencies in current measures of these resources. Do minority groups gain extra protection by asserting their identity and uniqueness? What is the social distribution of protective social resources? Do differences in distribution explain group differences in mental health?

E. The Biological Perspective on Mental Disorders

The sociology of mental health is faced with a new challenge from the field of neuroscience. This research tends to be favored by federal funding agencies because of beliefs that neuroscience can lead to the discovery of new cures or therapeutic approaches to mental disorders. Neuroscience and its measurement equipment such as functional magnetic resonance imaging (fMRI) and cortisol sampling have the cachet of basic or “bench” science, while the observational and epidemiological approach of sociology is being portrayed as lower-quality science. However, the rise of neuroscience in research on mental disorders does not necessarily mean that social causes are irrelevant. The power of the new neuroscience of mental disorders is that it assumes there is an interaction between social factors and biological processes (McEwen 2002).

Yet there are serious impediments to the integration of sociological and biological research. One formidable impediment in sociology is the assumption that the biological perspective would reduce the entire stress process to individual differences in physical response, thus making environmental causation moot. Another impediment is that sociologists do not yet fully appreciate how much the biological approach to stress already incorporates measures of social context and stressors in studying adjustment to stressful events and situations (Singer and Ryff 1999). Sociologists (e.g., Pearlin et al. 1981) have long pointed out that the process of adjusting to stressors is a critical component of sociological and social psychological theories of the stress process (Thoits 1995). Thus, another challenge to sociologists of mental health is to incorporate techniques and measures that will powerfully represent the social context in multidisciplinary studies of mental health and mental disorders.

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