The Journal of Primary Prevention, Vol. 17, No. 1, 1996
The Relationship Between Social Class and Mental Disorder Melissa J. Perry 1,2
The inverse relationship between social class and rates of mental disorders was first documented in early mental hygiene studies at the beginning of this century and similar findings have been demonstrated in numerous contemporary studies. Interpretations of this persistent relationship include a downward drifi explanation that posits that a decline in social status occurs as a result of precipitating mental illness, and a social causation model that emphasizes the importance of psychosocial stressors in the onset of mental disorders. A wealth of evidence supporting the social causation model is reviewed, drawing on mental health epidemiology, women's mental health, unemployment and physical health research. Political and economic origins of the downward drift hypothesis are also discussed. KEY WORDS: social class; mental disorder; social epidemiology.
The inverse relationship between social class and the occurrence of mental disorders is one of the most well established in the field of mental health epidemiology. This relationship was first documented empirically in early mental hygiene studies in the 1930s and such findings continue to be replicated in numerous contemporary studies (c.f. Neugebauer, Dohrenwend and Dohrenwend, 1980). Based on ample scientific evidence, the excess rates of most of the major mental disorders such as depression, anxiety disorders, schizophrenia, and even organic brain diseases found among the lowest social class seems indisputable. What remains in dispute, however, 1University of Vermont. 2Address correspondence to Melissa J. Perry, Sc.D, Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, 1249 North Franklin Place, Medical College of Wisconsin, Milwaukee, WI 53202. 17 © 1996Human Sciences Press, Inc.
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are interpretations of such findings, particularly what causal mechanisms underlie the relationship between class and mental health and whether stresses associated with lower social class status c a u s e the higher rate of mental disorders. Conflicting theories surrounding the causal mechanisms for the observed social class relationship have resulted in an ongoing debate that borrows from biological, social and psychological evidence to argue the respective positions. These theories have typically taken two forms, specifically a natural selection or "downward drift" explanation and a social causation theory of mental disorders. The natural selection position argues that cases of mental disorders are more often represented in the lower social classes because individuals decline in social and economic status once the onset of mental/emotional disturbance occurs. This position argues that the circumstances of one's social class do not have a causal connection to the onset of a mental disorder, but rather, individual weaknesses in mental functioning occur first, and result in low social class attainment. While some empirical evidence of downward drift does exist, such studies fall short of explaining most of the excess rates of psychopathology in the lowest social class. They fail to refute the likelihood that individuals in poverty are at much greater risk of developing a mental disorder than individuals with moderate to abundant economic resources. The other contrasting explanation of the socioeconomic differentials in rates of mental disorders is the social causation theory that argues that members of the lower social classes experience excess psychological stress and relatively few societal rewards, the results of which are manifested in psychological disorder. Compared to the downward drift hypothesis, a respectable amount of empirical support for the social causation hypothesis has been reported. This paper will review studies documenting the inverse relationship of social class to psychopathology, beginning with some early investigations, and will discuss how evidence for the social causation theory has been repeatedly demonstrated.
EARLY MENTAL HEALTH EPIDEMIOLOGY STUDIES In 1934, mental hygiene researchers at Johns Hopkins University launched a community study of mental disorder in the eastern section of Baltimore, Maryland. These researchers reviewed the records of all the people sent to a mental hygiene clinic, admitted to a mental hospital, or recorded by any agency as "exhibiting behavior indicating the probability of some mental defect or disorder" (cited in Fee, 1987, p. 199). The researchers then classified each afflicted individual by specific mental disor-
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ders and calculated a treated prevalence rate for each disorder. This study was one of the first to look beyond hospital treatment populations to determine the number of cases of mental disorders residing in the community. Upon examining the prevalence of personality disorders, defined as failures of personality or social adjustment, they found an "unmistakable association between personality problems and low economic status, with the lowest income groups having about six times the number of problems as the highest income groups" (cited in Fee, 1987, pp. 199-200). This was one of the first epidemiology studies to examine and report an association between social class and mental disorder in the United States. Replications of the socioeconomic correlations with the prevalence of mental disorders reported in the East Baltimore study followed in other parts of the country. Faris and Dunham (1939) conducted a communitybased study of the prevalence of psychoses and schizophrenia in Chicago and used cluster maps to plot residences of patients prior to admission to public and private hospitals. The maps showed a marked decrease in the distribution of cases from the center to the periphery of the city, "a pattern of distribution previously shown for other kinds of social and economic phenomena as poverty, unemployment, juvenile delinquency, adult crime, suicide, family desertion, infant mortality, communicable disease, and general mortality (Faris & Dunham, 1939, p. x). The investigators reported that cases of paranoid and catatonic schizophrenia and manic-depressive and alcoholic psychoses tended to originate from rooming house sections of the city and from neighborhoods with large proportions of immigrant and foreign born residents. Hollingshead and Redlich conducted what has come to be viewed as a classic study of community based mental disorders in New Haven, Connecticut in 1950. These researchers attempted to enumerate all persons from the New Haven area who were being treated or hospitalized for a mental condition by reviewing clinic, hospital, and private practice records. To explore a possible relationship to social class, Hollingshead and Redlich used education and occupation to design an "Index of Social Positions" from which five social class categories, I-V, were constructed, with I being the highest social class and V being the lowest. The researchers determined that cases of psychoses and schizophrenia were disproportionately represented in class V, and the lower the social class, the more likely the patients were to be hospitalized. Dunham conducted a community based epidemiologic study of schizophrenia in Detroit in 1958. He mapped first contact cases of schizophrenia as reported by 176 mental health facilities in the city. His maps revealed an incidence rate of schizophrenia in the poorest sections of the city that was 2.8 times higher than the rate in the more affluent upper middle class
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sections (Dunham, 1965). Lewis (1978) revisited the maps created by Dunham and, using a technique known as "nearest neighbor analysis", determined that not only were the cases of schizophrenia greater in the poorer sections of the city, but they were also more clustered in specific geographical patterns, whereas the cases in the wealthier sections of town were distributed randomly. The Midtown Manhattan Study (Srole, Langer, Michael, Opler & Rennie, 1962), has also come to be known as a classic public mental health study. This investigation sought to document the prevalence of untreated mental disorders in a delineated section of Manhattan in the mid 1950's. Using parental socioeconomic status (SES), the cross-sectional data from this investigation showed that 33% of Midtown residents in the lowest socioeconomic strata showed some signs of psychological distress, whereas only 18% of residents from the highest socioeconomic group showed impairment. This finding was true across age and gender categories. Upon using own-SES to explore this relationship, the association was heightened; 47% of residents in the lowest socioeconomic stratum showed signs of mental impairment, whereas only 13% of the highest social strata showed similar symptoms.
CONTEMPORARY FINDINGS In an important review of studies documenting prevalence rates of the functional psychological disorders among American adults, Neugebauer, Dohrenwend and Dohrenwend (1980) explored trends in prevalence estimates by mental disorder and social characteristics. Upon examining studies conducted both in and outside the U.S. since 1950, the authors demonstrate trends in both gender and social class differences. For example, upon reviewing 27 studies reporting prevalence estimates for specific mental disorders by gender, no gender related trend was apparent for psychoses and schizophrenia, whereas female to male ratios ranged between 2.1 and 5.6 for affective disorders and neuroses, and 0.6 to 0.9 for personality disorder. While illustrating the importance of gender for understanding the distribution of psychopathology, these findings also seek explanations for such marked trends. The role of gender in predicting psychopathology risk will be discussed further in a later section of this paper, but the interrelationship between gender and social and economic factors should be kept in mind. In the same review, Neugebauer et al. also explored studies documenting psychopathology among different social classes. They report that among 42 studies, 35 found the rate of all types of psychopathology to be largest among the lowest social class whereas 12 found the same rate to be greater among
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classes other than the lowest. Regarding specific diagnoses, no social class differential was apparent for neuroses, whereas trends were evident for psychoses, with low to high class ratios ranging between 1.4 and 2.6; and personality disorders, with low to high class ratios ranging between 1.4 and 3.3. More recent community based studies of the incidence and prevalence of psychological disturbance have also demonstrated a social class connection. The most thorough investigation of mental disorders in community samples occurred in the early 1980's, known as the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Surveys (ECA). These surveys were conducted in sample households nationally to determine the community prevalence of diagnosable mental disorders in adults. The ECA surveys were repeated one to three years later to determine the incidence, or number of new cases of mental disorder, in the same community areas. The ECA surveys, using five sites nationally, did not demonstrate a relationship between social class and mental disorders within individual sites. However, when the data were aggregated across all sites, the inverse relationship between social class and mental disorders was once again evident (Holzer et al., 1986) The six-month prevalence rate for any DSM-III diagnosis was 2.9 times greater among members of the lowest socioeconomic group as compared to the highest socioeconomic group. These differentials were found across specific diagnoses, with the relative risk for the lowest socioeconomic group as compared to highest of 1.8 for major depression, 3.6 for alcohol abuse or dependence, and 7.9 for schizophrenia. The persistence of these gender and social class differentials, particularly in terms of direction and magnitude, across a number of different studies, is sound evidence to assert that the patterns of occurrence of mental disorders are far from random and are directly influenced by gender and social class. Further, it seems logical to assume that being female, and/or being a member of the lowest social class places one at excess risk for developing a mental disorder. Yet, however logical this assumption appears, the causal influence of social class on the risk of developing a mental disorder remains challenged by the downward drift hypothesis. As mentioned earlier, this latter position asserts that experiences associated with low social class status does not cause psychopathology but is rather the result of being afflicted with a mental disorder. Let us now turn to evidence that suggests the contrary.
SOCIAL O ~ G I N S OF PSYCHOLOGICAL DISORDERS Although there is some evidence to suggest that the onset of a mental disorder is a precipitant to a decline in social class (Link, Dohrenwend &
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Skodol, 1986), this evidence fails to refute the fact that having few socioeconomic resources and experiencing the stress associated with poverty can lead to the onset of a mental disorder. Several bodies of empirical literature lend strong evidence to the existence of this causal relationship. The work of Bruce and Barbara Dohrenwend has concentrated largely on testing the social causation theory of mental disorders. They have challenged the downward drift hypothesis because it does not address the psychological stress of being impoverished and fails to validate that persistent economic stress can lead to psychological disturbance. Early work by these two researchers has carefully documented the relationship of psychopathology to social class in a variety of settings (Dohrenwend, Shrout, Link, Martin, and Skodol, 1986). Bruce Dohrenwend and his colleagues recently conducted a study in New York City designed to test a social causation explanation of the social class differentials that have been so well documented (Link, Lennon and Dohrenwend, 1993). The primary hypothesis of this study was that individuals who held occupations that involved high levels of direction, control and planning would be less likely to experience depressive symptoms than individuals whose occupations involved low levels of these characteristics. The occupational elements of direction, control and planning are directly connected to social class in that higher pay and prestige occupations include higher levels of these characteristics. Conversely, low pay and low status jobs entail relatively minor degrees of direction, control and planning. Further, these researchers argue that these occupational elements are also directly linked to mental health because they provide avenues for workers to exercise autonomy and gain a sense of personal mastery. The design of their study involved interviews of community residents and persons being treated for either a first or recurrent episode of major depression. Because some episodes of major depression were evident in the community sample, both cross-sectional and case-control comparisons were made. Non-depressed community residents were compared to depressed individuals in treatment on degree of occupational direction, control and planning. Significantly fewer depressed patients had occupations involving direction, control and planning prior to the onset of depressive symptoms than the non-depressed community residents. This finding was also true for the first episode cases of depression, therefore refuting the possibility that depressive state preceded occupational attainment. The authors concluded that socioeconomic status and occupational attainment resulting in low levels of occupational direction, control and planning strongly influenced the onset of a major depressive episode in this New York City sample. This study is an elegant example of the causal mechanisms inherent in a low socioeconomic standing that predispose individuals to experience inordinate psychological distress.
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The work of John Mirowsky and Catherine Ross (1989) further demonstrates the centrality of perceived personal control and autonomy to the development of psychological distress. In their important book Social Causes of Psychological Distress (1989), Mirowsky and Ross draw from the results of four large scale community-based studies of mental disorders (Illinois Survey of Well-Being, Women and Work Study, the Health Behavior Study, and the Life Stress and Illness Project) with samples totaling more than 3000 respondents to illustrate how closely social status and mental disorders are linked. The authors argue that control over one's life is central to the causal mechanism for psychological distress, and that low social class members have very little sense of control over their lives. This lack of autonomy is not only dictated by the nature of low income jobs, it is also the result of social and cultural memberships that have been ascribed low status. Ethnic minorities also experience decreased levels of personal control because, due to racial prejudices, achievement requires greater effort and often results in fewer opportunities for people of color. The result of these circumstances, Mirowsky and Ross argue, is a lower sense of personal control and consequently the occurrence of psychological distress. In addition to class, status and ethnic identity, age and gender also exert powerful influences over personal control and therefore increase risks for mental disorders. In their analysis of the Illinois survey of well-being, Mirowsky and Ross use social traits such as income, education, gender, full-time employment, minority status, retired status, social support, and personal control to create "best" and "worst" social deciles to represent the composition of society. The authors compellingly illustrate, "In fact, if we split society into two halves, better and worse, the worse half of society has 83.8% of all severe distress. The better half has only 16.2% of the severe distress. Stated another way, the odds of being severely distressed is 5.9 times greater in the worse half than in the better half. Severe distress is particularly concentrated in the worst 10% of society. In the worst decile, 16.1% are severely distressed (compared to 4.6% in the total sample). This means that the 10% of society with the worst profile of traits has 35% of all the severely distressed in the entire population." (Mirowsky & Ross, 1989, p. 176).
THE EFFECTS OF UNEMPLOYMENT ON MENTAL HEALTH Research on the mental health effects of involuntary unemployment has produced strong and consistent results demonstrating the deleterious
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psychological consequences of a loss of income. These associations have been demonstrated in studies ranging from environmental indices of economic and mental status to prospective investigations of individuals' employment and mental health profiles. Brenner for example (1976) has demonstrated the correlation between four economic indicators: per capita income, unemployment rates, labor force participation and business failures; with nine social stress indicators: mental hospital admissions, total mortality rates, cardiovascular-renal disease mortality, cirrhosis of the liver mortality, suicide rates, homicide rates, state prison admissions, total arrest rates, and number of major crimes reported. Although correlational, Brenner's findings demonstrate the profound connection between a society's economic and social health. A number of other studies have also demonstrated these relationships (Catalano, 1991; Jarman, Hirsch, White and DriscoU, 1992; Kammerling & O'Conner, 1993). Psychological case studies of the mental health effects of unemployment have also repeatedly demonstrated the adverse consequences that loss of one's job or the inability to secure gainful employment have on mental well being. Unemployed people are at least two times more likely to suffer mental health problems than employed individuals (Gray, 1985). Unemployment has been found to cause a myriad of mental and emotional problems including depression, drug and substance abuse, spouse and child abuse, criminal violence and episodes of mental illness requiring hospitalization (Gray, 1985). Differential psychological effects have been identified across the unemployment continuum, from the time before job loss occurs, when threat of unemployment is imminent, to prolonged periods of unemployment. Further, unemployment has differential effects according to demographics such as age, gender and occupational background (Osipow & Fitzgerald, 1993). Interestingly, studies of the transition to reemployment have demonstrated dramatic decreases in suicidal and depressive symptoms and substance use.
POVERTY AND MENTAL HEALTH The relationship between poverty and psychological distress is best understood by examining the chronic stressors that impoverished people must encounter on a daily basis, in conjunction with the limited sources of social support that are available. The usefulness of this stress-support model of psychopathology has been demonstrated in numerous studies (see DHHS, 1985 for a review) documenting that individuals who experience a multitude of stressful life events are at increased risk of subsequently developing some form of psychopathology. Poor people experience more frequent and more
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uncontrollable stressful life events than individuals of moderate to high incomes (Dohrenwend, 1975). Such stressful events can occur acutely, such as the death of a child, or chronically, such as inadequate housing and perpetual worries about buying food and necessities (Belle, 1990). Having sources of social support to rely on in times of stress has been shown to enhance personal coping and to serve as a buffer against resulting psychopathology (Cassel, 1976). The support networks of poor people are often undermined by the chronic stress associated with poverty. Because the friends, relatives and neighbors of poor people are also likely to be poor their social networks are less capable of providing material and emotional support (Belle, 1990). The domestic relationship is also taxed by poverty and divorce is more common among married couples in which men provide low or unstable income (Cherlin, 1979). Marital satisfaction has been found to be lower among couples living below the poverty line than among married couples above the poverty line (Zill, 1978). Further, poor people have less freedom to choose who they depend on due to economic necessity such as families who need to cohabit with other relatives to meet housing costs or women who are forced to stay with abusive partners due to economic dependence. Taken together the inordinate levels of stress that poor people are perpetually faced with, and the often compromised social support networks available to counteract the psychological effects of such stress, it is hardly surprising that mental disorders occur at higher rates among poor people. In fact, one is left to wonder how poor people who don't develop psychological distress cope with such high levels of adversity. The stress-support model of psychopathology is once again a direct challenge to natural selection theories about the inverse relationship of social class to mental disorders.
WOMEN AND MENTAL HEALTH Upon exploring the psychological realities of poverty, it is now helpful to return to the finding that women are overly represented among cases of psychopathology. As mentioned previously among the findings of Neugebauer, Dohrenwend and Dohrenwend (1980), women are more likely to develop a mental disorder than men, especially anxiety and depression that are the two most commonly occurring mental conditions. Along with the social class correlation, this gender differential has been repeatedly demonstrated. This finding is particularly striking once one discovers that the majority of people mired in poverty are women. The risk of poverty among women can largely be explained by acknowledging women's lack of social and economic power. Women experience inequity in employment and are
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over-represented in low paying jobs (Department of Labor, 1993). Women on the average, currently earn 25-30 percent less than men for the same level of jobs. Women are also more likely to be single parents than men and are often left to support their children independent of economic assistance from the father. That the proportion of Americans living below the poverty line is greater than ten years ago can largely be attributed to the growing number of women heading single parent families. In an important review of the literature on poverty and women's mental health, Belle explores the psychological stressors that poor women, particularly poor mothers, experience. A number of community studies conducted in the 1970s reported that mothers who were in financially strained circumstances were more likely to develop depressive symptoms than other women (Belie, 1990). Several studies have found that risk factors for depression among women include chronic stressful economic conditions, few sources of social support including child rearing assistance, and unemployment (Belle, 1982; Brown, Bhrolchain & Harris, 1975; Makosky, 1982 cited in Belle, 1990). As mentioned earlier, chronic stressors such as inadequate housing, continuing financial uncertainty and threats to personal safety challenge women's psychological coping abilities and "low income women are at very high risk of experiencing just such noxious, long-term conditions" (Belle, 1990). That all women are often stereotyped as powerless and by nature dependent on males only exacerbates the mental health status of poor women.
SOCIAL CLASS AND PHYSICAL HEALTH It is important to mention another body of literature that lends support to the causal connection between social class and the occurrence of mental disorders, namely the many studies demonstrating the socioeconomic inequalities in health status and care. Just as the inverse relationship of social class to mental distress has been repeatedly demonstrated, so too has the inverse relationship between social status and morbidity and mortality. Poor people have shorter life expectancy, higher morbidity rates for most diseases, and higher all-cause and specific mortality rates (Adler, Boyce, Chesney, Folkman and Syme, 1993). These inequities in health status have been observed repeatedly since the late 1800's. A difference in life expectancy of seven years between the highest and lowest groups of the socioeconomic strata was reported as early as the first half of the twentieth century (Antonovsky, 1967; cited in Adler et al., 1993). Individuals low in socioeconomic status experience physical morbidity and premature mortality at much higher rates than individuals in the middle or upper economic strata.
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For example, McLoone and Boddy (1994) show a 162% higher death rate in deprived as compared to affluent regions in Scotland in 1991. Sloggett and Joshi (1994) showed that positive correlations between level of deprivation and premature death in electoral wards in England between 1981 and 1990 could be directly attributed to the social position of the individuals affected. This study illustrated that socioeconomic status was the strongest single predictor, above place of residence, of premature death in this English sample. Mcgarron, Smith and Womersley (1994) also found major social class differentials in mortality in Britain and demonstrated that these differentials have increased further in the past two decades.
ANALYSIS AND INTERPRETATION A wealth of epidemiologic literature spanning sixty years of research has been reviewed illustrating the enduring relationship of social class to mental distress. Now that the empirical connection has been established and the overwhelming evidence for a social causation model has been reviewed, it is necessary to reflect on why social drift and organic defect theories, seem to continue to pervade psychiatric and political circles. Simply stated, it is much easier both from a conservative political position and from a treatment perspective, to believe in internal and largely organic explanations of mental disorders. This approach to explaining defect has deep underpinnings in the history of economic politics, and the history of medicine in the United States and Europe. For example, the organic model of mental "disease" relates directly to Herbert Spencer's proposals of Social Darwinism, his attempt to apply Darwinian principles to societal phenomenon (Spencer, 1873-1881; Albee, 1986). Under these teachings, the most superior (i.e., intelligent) beings will endure, whereas as the less superior, deficient beings will as a matter of course dwindle, due to inferior genes. According to Social Darwinism, as the human species evolves, less intelligent and less mentally competent beings will remain at the bottom of the social hierarchy while the most superior individuals advance. Therefore, because it is the functional nature of this hierarchy that deficient individuals remain in the lowest social class, it is not the duty of society to better the conditions of the poor; impoverished circumstances are in fact their fate. Strikingly similar lines of reasoning are found in the IQ debates that have dominated psychology since the early 1900's and that remain visible today. Biological determinists argue that we must accept inferior intelligence as part of the natural order of society; as part of the "normal distribution" of individuals (Herrnstein & Murray, 1994) and that there is little we should feel compelled to do to improve IQ standings. Interestingly,
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those with the lowest IQs also belong to the most marginalized groups of our society: the poor, ethnic minorities, immigrants, and those exploited by industry, such as migrant farm workers. The weight of evidence that suggests that these groups show lower IQ scores because they have not been afforded adequate education and equal access to economic opportunities, is too great to be ignored. Further, the middle class cultural biases inherent in the IQ testing system are also far too obvious to be dismissed. This type of economic determinism has great implications for political philosophy as well. If we accept that poor people must exist due to a biological imperative, we will have no need to address injustices or inequities in the economic system and can therefore justify the poor's unfortunate circumstance as necessary and beyond our control. As long as we can attribute the source of defect to the individual, rather than the environment, we can feel comfortable that poverty, mental inferiority and psychological trauma are the result of inferior status. Given this line of reasoning, it is in no way surprising that low social class status and psychopathology cluster together. After all, conservatives may argue, they are simply byproducts of low intelligence and inferior mental constitution. The downward drift explanation of the social class/psychopathology connection is also consistent with strict internal or organic explanations of mental disorders. Downward drift theorists argue that psychopathology is more prevalent in the lower class because individuals become mentally unstable first, and therefore fall in economic status due to impaired functioning. Downward drift argues that the responsibility for social status remains first with the individual, rather than attributing mental disturbance to the potentially psychologically damaging effects of poverty. As long as we can comfortably assert these positions to be true, there will be no need for political action and social change. We can just continue to blame the victims. This paper has reviewed several bodies of literature to illustrate the powerful connection between mental well-being and socioeconomic status. Over the past century numerous studies have demonstrated this connection. Although the causal link between economic deprivation and the occurrence of mental distress remains challenged, the purpose of this paper was to review the evidence for a social causation model of mental disorders, and to demonstrate that this model remains quite compelling. In fact, given the wealth of longitudinal, historical and policy studies that give support to the social causation model of both mental distress and physical disease, it is not surprising that many sociologists and psychologists have moved beyond the need to document further this relationship empirically (Albee, Joffe, & Dusenbury, 1988). The next logical step is to recommend social policy solutions that are aimed at reducing vast eco-
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nomic inequities. Only these will likely be effective in making meaningful reductions in the prevalence and incidence of mental disorders both in the U.S. and in other countries.
REFERENCES Adler, N.E., Boyce, T, Chesney, M.A., Folkman, S., and Syme, L. (1993). Socioeconomic inequalities in health. Journal of the American Medical Association, 269(24), 3140-3145. Albee, G.W. (1986). Toward a just society: Lessons from observations on the primary prevention of psychopathology. American Psychologist, 41, 891-898. Albee, G.W., Joffe, J.M., and Dusenbury, L.A. (I988). Prevention, powerlessness, and politics. Newbury Park, CA: SAGE Publications. Brenner, M. (1976). Estimating the Social Costs of Economic Policy: Implications For Mental and Physical Health and Criminal Aggression. Report to the Congressional Research Service of the Library of Congress and Joint Economic Committee of Congress. Washington, DC: US Government Printing Office. Brown, G., Bhrolchain, M., and Harris, T. (1975). Social class and psychiatric disturbance among women in an urban population. Sociology, 9, 225-254. Belle, D. (1990). Poverty and women's mental health. American Psychologist, 45(3), 385-389. Cassel, J. (1976). The contribution of the environment to host resistance. American Journal of Epidemiology, 104, 1040-1043. Catalano, R. (1991). The health effects of economic insecurity. American Journal of Public Health, 81(9), 1148-1152. Dohrenwend, B.P. (1975). Sociocultural and social-psychological factors in the genesis of mental disorders. Journal of Health and Social Behavior, 16, 365-392. Dohrenwend, B.P., Shrout, EE., Link, B.G., Martin, J. and Skodol, A.E. (1986). Overview and initial results from a risk-factor study of depression and schizophrenia. In J.E. Barret and R.M. Rose (Eds.) Mental Disorders in the Community (pp. 184-215). New York: Guilford Press. Dunham, H.W (1965). Community and Schizophrenia. Detroit, MI: Wayne State University Press. Faris, R.E.L. and Dunham, H.W (1939). Mental Disorders in Urban Areas. New York: Hafner Publishing Co. Fee, L. (1987). Disease and Discovery. Baltimore, MD: Johns Hopkins University Press. Gray, G. (1985). National commission on unemployment and mental health. Resource Papers to the Report of The National Mental Health Association Commission on the Prevention of Mental-Emotional Disabilities. Alexandria, VA: National Mental Health Association. Herrnstein, and Murray. (1994) The Bell Curve: Intelligence and Class Structure in American Life. New York: The Free Press. Hollingshead, A.B. and Redlich, EC. (1958). Social Class and Mental Illness. New York: John Wiley & Sons. Holzer, C., Shea, B., Swanson, J., Leaf, R, Myers, J., George, L., Weissman, M. and Bednarski, E (1986). The increased risk for specific psychiatric disorders among persons of low socioeconomic status. American Journal of Social Psychiatry, 6, 259-271. Jarman, B., Hirsch, S., White, E, and Driscotl, R. (1992). Predicting psychiatric admission rates. British Medical Journal, 304, 1146-1150. Kammerting, R.M., and O'Connor, S. (1993). Unemployment rate as a predictor of rate of psychiatric admission. British Medical Journal, 307, 1536-1539. Lewis, M., (1978). Nearest neighbor analysis of epidemiological and community variables. Psychological Bulletin, 85(6), 1302-1308.
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Link, B.G., Dohrenwend, B.P., and Skodol, A.E. (1986). Socioeconomic status and schizophrenia: Noisome occupational characteristics as a risk factor. American Sociological Review, 51, 242-258. Link, B.G. Lennon, M.C., Dohrenwend, B.P. (1993). Socioeconomic status and depression: The role of occupations involving direction, control and planning. American Journal of Sociology, 98(6), 1351-1387. McCarron, P.G., Smith, G.D., and Womersley, J.J. (1994). Deprivation and mortality in Glasgow: Changes from 1980 to 1992. British Medical Journal, 309, 1481-1482. McLoone, P. and Boddy, EA. (1994). Deprivation and mortality in Scotland, 1981-1991. British Medical Journal, 309, 1465-1470. Mirowsky, J. and Ross, C.E. (1989). Social Causes of Psychological Distress. New York: Aldine de Gruyter. Neugebauer, R., Dohrenwend, B.P., & Dohrenwend, B.S. (1980). Formulation of hypotheses about the true prevalence of functional psychiatric disorders among adults in the United States. In B.P. Dohrenwend, Mental Illness in the United States (pp. 45-94). New York: Praeger Publishers. Osipow, S.H. and Fitzgerald, L E (1993). Unemployment and mental health: A neglected relationship. Applied and Preventive Psychology, 2, 59-63. SloggeR, A. and Joshi, H. (1994). Higher mortality in deprived areas: Community or personal disadvantage? British Medical Journal, 309, 1470-1474. Spencer, H. (1873-1881). Descriptive Sociology. New York: D. Appleton. Stole, L., Langner, TS., Micheal, S.'E, Opler, M.K., and Rennie, T.A.C. (1962). Mental Health in the Metropolis: The Midtown Manhattan Study. New York: McGraw-Hill Book Company Inc. United States Department of Health and Human Service (1985). Stressful Life Event Theory and Research: Implications for Primary Prevention. Rockville, MD: Alcohol, Drug Abuse and Mental Health Administration, DHHS Publication No. (ADM) 85-I385. United States Department of Labor (1993). Earning Differences Between Women and Men. U.S. Department of Labor Women's Bureau Report No. 93-5.
The Relationship Between Social Class and Mental Disorder Melissa J. Perry 1,2
The inverse relationship between social class and rates of mental disorders was first documented in early mental hygiene studies at the beginning of this century and similar findings have been demonstrated in numerous contemporary studies. Interpretations of this persistent relationship include a downward drifi explanation that posits that a decline in social status occurs as a result of precipitating mental illness, and a social causation model that emphasizes the importance of psychosocial stressors in the onset of mental disorders. A wealth of evidence supporting the social causation model is reviewed, drawing on mental health epidemiology, women's mental health, unemployment and physical health research. Political and economic origins of the downward drift hypothesis are also discussed. KEY WORDS: social class; mental disorder; social epidemiology.
The inverse relationship between social class and the occurrence of mental disorders is one of the most well established in the field of mental health epidemiology. This relationship was first documented empirically in early mental hygiene studies in the 1930s and such findings continue to be replicated in numerous contemporary studies (c.f. Neugebauer, Dohrenwend and Dohrenwend, 1980). Based on ample scientific evidence, the excess rates of most of the major mental disorders such as depression, anxiety disorders, schizophrenia, and even organic brain diseases found among the lowest social class seems indisputable. What remains in dispute, however, 1University of Vermont. 2Address correspondence to Melissa J. Perry, Sc.D, Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, 1249 North Franklin Place, Medical College of Wisconsin, Milwaukee, WI 53202. 17 © 1996Human Sciences Press, Inc.
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are interpretations of such findings, particularly what causal mechanisms underlie the relationship between class and mental health and whether stresses associated with lower social class status c a u s e the higher rate of mental disorders. Conflicting theories surrounding the causal mechanisms for the observed social class relationship have resulted in an ongoing debate that borrows from biological, social and psychological evidence to argue the respective positions. These theories have typically taken two forms, specifically a natural selection or "downward drift" explanation and a social causation theory of mental disorders. The natural selection position argues that cases of mental disorders are more often represented in the lower social classes because individuals decline in social and economic status once the onset of mental/emotional disturbance occurs. This position argues that the circumstances of one's social class do not have a causal connection to the onset of a mental disorder, but rather, individual weaknesses in mental functioning occur first, and result in low social class attainment. While some empirical evidence of downward drift does exist, such studies fall short of explaining most of the excess rates of psychopathology in the lowest social class. They fail to refute the likelihood that individuals in poverty are at much greater risk of developing a mental disorder than individuals with moderate to abundant economic resources. The other contrasting explanation of the socioeconomic differentials in rates of mental disorders is the social causation theory that argues that members of the lower social classes experience excess psychological stress and relatively few societal rewards, the results of which are manifested in psychological disorder. Compared to the downward drift hypothesis, a respectable amount of empirical support for the social causation hypothesis has been reported. This paper will review studies documenting the inverse relationship of social class to psychopathology, beginning with some early investigations, and will discuss how evidence for the social causation theory has been repeatedly demonstrated.
EARLY MENTAL HEALTH EPIDEMIOLOGY STUDIES In 1934, mental hygiene researchers at Johns Hopkins University launched a community study of mental disorder in the eastern section of Baltimore, Maryland. These researchers reviewed the records of all the people sent to a mental hygiene clinic, admitted to a mental hospital, or recorded by any agency as "exhibiting behavior indicating the probability of some mental defect or disorder" (cited in Fee, 1987, p. 199). The researchers then classified each afflicted individual by specific mental disor-
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ders and calculated a treated prevalence rate for each disorder. This study was one of the first to look beyond hospital treatment populations to determine the number of cases of mental disorders residing in the community. Upon examining the prevalence of personality disorders, defined as failures of personality or social adjustment, they found an "unmistakable association between personality problems and low economic status, with the lowest income groups having about six times the number of problems as the highest income groups" (cited in Fee, 1987, pp. 199-200). This was one of the first epidemiology studies to examine and report an association between social class and mental disorder in the United States. Replications of the socioeconomic correlations with the prevalence of mental disorders reported in the East Baltimore study followed in other parts of the country. Faris and Dunham (1939) conducted a communitybased study of the prevalence of psychoses and schizophrenia in Chicago and used cluster maps to plot residences of patients prior to admission to public and private hospitals. The maps showed a marked decrease in the distribution of cases from the center to the periphery of the city, "a pattern of distribution previously shown for other kinds of social and economic phenomena as poverty, unemployment, juvenile delinquency, adult crime, suicide, family desertion, infant mortality, communicable disease, and general mortality (Faris & Dunham, 1939, p. x). The investigators reported that cases of paranoid and catatonic schizophrenia and manic-depressive and alcoholic psychoses tended to originate from rooming house sections of the city and from neighborhoods with large proportions of immigrant and foreign born residents. Hollingshead and Redlich conducted what has come to be viewed as a classic study of community based mental disorders in New Haven, Connecticut in 1950. These researchers attempted to enumerate all persons from the New Haven area who were being treated or hospitalized for a mental condition by reviewing clinic, hospital, and private practice records. To explore a possible relationship to social class, Hollingshead and Redlich used education and occupation to design an "Index of Social Positions" from which five social class categories, I-V, were constructed, with I being the highest social class and V being the lowest. The researchers determined that cases of psychoses and schizophrenia were disproportionately represented in class V, and the lower the social class, the more likely the patients were to be hospitalized. Dunham conducted a community based epidemiologic study of schizophrenia in Detroit in 1958. He mapped first contact cases of schizophrenia as reported by 176 mental health facilities in the city. His maps revealed an incidence rate of schizophrenia in the poorest sections of the city that was 2.8 times higher than the rate in the more affluent upper middle class
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sections (Dunham, 1965). Lewis (1978) revisited the maps created by Dunham and, using a technique known as "nearest neighbor analysis", determined that not only were the cases of schizophrenia greater in the poorer sections of the city, but they were also more clustered in specific geographical patterns, whereas the cases in the wealthier sections of town were distributed randomly. The Midtown Manhattan Study (Srole, Langer, Michael, Opler & Rennie, 1962), has also come to be known as a classic public mental health study. This investigation sought to document the prevalence of untreated mental disorders in a delineated section of Manhattan in the mid 1950's. Using parental socioeconomic status (SES), the cross-sectional data from this investigation showed that 33% of Midtown residents in the lowest socioeconomic strata showed some signs of psychological distress, whereas only 18% of residents from the highest socioeconomic group showed impairment. This finding was true across age and gender categories. Upon using own-SES to explore this relationship, the association was heightened; 47% of residents in the lowest socioeconomic stratum showed signs of mental impairment, whereas only 13% of the highest social strata showed similar symptoms.
CONTEMPORARY FINDINGS In an important review of studies documenting prevalence rates of the functional psychological disorders among American adults, Neugebauer, Dohrenwend and Dohrenwend (1980) explored trends in prevalence estimates by mental disorder and social characteristics. Upon examining studies conducted both in and outside the U.S. since 1950, the authors demonstrate trends in both gender and social class differences. For example, upon reviewing 27 studies reporting prevalence estimates for specific mental disorders by gender, no gender related trend was apparent for psychoses and schizophrenia, whereas female to male ratios ranged between 2.1 and 5.6 for affective disorders and neuroses, and 0.6 to 0.9 for personality disorder. While illustrating the importance of gender for understanding the distribution of psychopathology, these findings also seek explanations for such marked trends. The role of gender in predicting psychopathology risk will be discussed further in a later section of this paper, but the interrelationship between gender and social and economic factors should be kept in mind. In the same review, Neugebauer et al. also explored studies documenting psychopathology among different social classes. They report that among 42 studies, 35 found the rate of all types of psychopathology to be largest among the lowest social class whereas 12 found the same rate to be greater among
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classes other than the lowest. Regarding specific diagnoses, no social class differential was apparent for neuroses, whereas trends were evident for psychoses, with low to high class ratios ranging between 1.4 and 2.6; and personality disorders, with low to high class ratios ranging between 1.4 and 3.3. More recent community based studies of the incidence and prevalence of psychological disturbance have also demonstrated a social class connection. The most thorough investigation of mental disorders in community samples occurred in the early 1980's, known as the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Surveys (ECA). These surveys were conducted in sample households nationally to determine the community prevalence of diagnosable mental disorders in adults. The ECA surveys were repeated one to three years later to determine the incidence, or number of new cases of mental disorder, in the same community areas. The ECA surveys, using five sites nationally, did not demonstrate a relationship between social class and mental disorders within individual sites. However, when the data were aggregated across all sites, the inverse relationship between social class and mental disorders was once again evident (Holzer et al., 1986) The six-month prevalence rate for any DSM-III diagnosis was 2.9 times greater among members of the lowest socioeconomic group as compared to the highest socioeconomic group. These differentials were found across specific diagnoses, with the relative risk for the lowest socioeconomic group as compared to highest of 1.8 for major depression, 3.6 for alcohol abuse or dependence, and 7.9 for schizophrenia. The persistence of these gender and social class differentials, particularly in terms of direction and magnitude, across a number of different studies, is sound evidence to assert that the patterns of occurrence of mental disorders are far from random and are directly influenced by gender and social class. Further, it seems logical to assume that being female, and/or being a member of the lowest social class places one at excess risk for developing a mental disorder. Yet, however logical this assumption appears, the causal influence of social class on the risk of developing a mental disorder remains challenged by the downward drift hypothesis. As mentioned earlier, this latter position asserts that experiences associated with low social class status does not cause psychopathology but is rather the result of being afflicted with a mental disorder. Let us now turn to evidence that suggests the contrary.
SOCIAL O ~ G I N S OF PSYCHOLOGICAL DISORDERS Although there is some evidence to suggest that the onset of a mental disorder is a precipitant to a decline in social class (Link, Dohrenwend &
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Skodol, 1986), this evidence fails to refute the fact that having few socioeconomic resources and experiencing the stress associated with poverty can lead to the onset of a mental disorder. Several bodies of empirical literature lend strong evidence to the existence of this causal relationship. The work of Bruce and Barbara Dohrenwend has concentrated largely on testing the social causation theory of mental disorders. They have challenged the downward drift hypothesis because it does not address the psychological stress of being impoverished and fails to validate that persistent economic stress can lead to psychological disturbance. Early work by these two researchers has carefully documented the relationship of psychopathology to social class in a variety of settings (Dohrenwend, Shrout, Link, Martin, and Skodol, 1986). Bruce Dohrenwend and his colleagues recently conducted a study in New York City designed to test a social causation explanation of the social class differentials that have been so well documented (Link, Lennon and Dohrenwend, 1993). The primary hypothesis of this study was that individuals who held occupations that involved high levels of direction, control and planning would be less likely to experience depressive symptoms than individuals whose occupations involved low levels of these characteristics. The occupational elements of direction, control and planning are directly connected to social class in that higher pay and prestige occupations include higher levels of these characteristics. Conversely, low pay and low status jobs entail relatively minor degrees of direction, control and planning. Further, these researchers argue that these occupational elements are also directly linked to mental health because they provide avenues for workers to exercise autonomy and gain a sense of personal mastery. The design of their study involved interviews of community residents and persons being treated for either a first or recurrent episode of major depression. Because some episodes of major depression were evident in the community sample, both cross-sectional and case-control comparisons were made. Non-depressed community residents were compared to depressed individuals in treatment on degree of occupational direction, control and planning. Significantly fewer depressed patients had occupations involving direction, control and planning prior to the onset of depressive symptoms than the non-depressed community residents. This finding was also true for the first episode cases of depression, therefore refuting the possibility that depressive state preceded occupational attainment. The authors concluded that socioeconomic status and occupational attainment resulting in low levels of occupational direction, control and planning strongly influenced the onset of a major depressive episode in this New York City sample. This study is an elegant example of the causal mechanisms inherent in a low socioeconomic standing that predispose individuals to experience inordinate psychological distress.
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The work of John Mirowsky and Catherine Ross (1989) further demonstrates the centrality of perceived personal control and autonomy to the development of psychological distress. In their important book Social Causes of Psychological Distress (1989), Mirowsky and Ross draw from the results of four large scale community-based studies of mental disorders (Illinois Survey of Well-Being, Women and Work Study, the Health Behavior Study, and the Life Stress and Illness Project) with samples totaling more than 3000 respondents to illustrate how closely social status and mental disorders are linked. The authors argue that control over one's life is central to the causal mechanism for psychological distress, and that low social class members have very little sense of control over their lives. This lack of autonomy is not only dictated by the nature of low income jobs, it is also the result of social and cultural memberships that have been ascribed low status. Ethnic minorities also experience decreased levels of personal control because, due to racial prejudices, achievement requires greater effort and often results in fewer opportunities for people of color. The result of these circumstances, Mirowsky and Ross argue, is a lower sense of personal control and consequently the occurrence of psychological distress. In addition to class, status and ethnic identity, age and gender also exert powerful influences over personal control and therefore increase risks for mental disorders. In their analysis of the Illinois survey of well-being, Mirowsky and Ross use social traits such as income, education, gender, full-time employment, minority status, retired status, social support, and personal control to create "best" and "worst" social deciles to represent the composition of society. The authors compellingly illustrate, "In fact, if we split society into two halves, better and worse, the worse half of society has 83.8% of all severe distress. The better half has only 16.2% of the severe distress. Stated another way, the odds of being severely distressed is 5.9 times greater in the worse half than in the better half. Severe distress is particularly concentrated in the worst 10% of society. In the worst decile, 16.1% are severely distressed (compared to 4.6% in the total sample). This means that the 10% of society with the worst profile of traits has 35% of all the severely distressed in the entire population." (Mirowsky & Ross, 1989, p. 176).
THE EFFECTS OF UNEMPLOYMENT ON MENTAL HEALTH Research on the mental health effects of involuntary unemployment has produced strong and consistent results demonstrating the deleterious
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psychological consequences of a loss of income. These associations have been demonstrated in studies ranging from environmental indices of economic and mental status to prospective investigations of individuals' employment and mental health profiles. Brenner for example (1976) has demonstrated the correlation between four economic indicators: per capita income, unemployment rates, labor force participation and business failures; with nine social stress indicators: mental hospital admissions, total mortality rates, cardiovascular-renal disease mortality, cirrhosis of the liver mortality, suicide rates, homicide rates, state prison admissions, total arrest rates, and number of major crimes reported. Although correlational, Brenner's findings demonstrate the profound connection between a society's economic and social health. A number of other studies have also demonstrated these relationships (Catalano, 1991; Jarman, Hirsch, White and DriscoU, 1992; Kammerling & O'Conner, 1993). Psychological case studies of the mental health effects of unemployment have also repeatedly demonstrated the adverse consequences that loss of one's job or the inability to secure gainful employment have on mental well being. Unemployed people are at least two times more likely to suffer mental health problems than employed individuals (Gray, 1985). Unemployment has been found to cause a myriad of mental and emotional problems including depression, drug and substance abuse, spouse and child abuse, criminal violence and episodes of mental illness requiring hospitalization (Gray, 1985). Differential psychological effects have been identified across the unemployment continuum, from the time before job loss occurs, when threat of unemployment is imminent, to prolonged periods of unemployment. Further, unemployment has differential effects according to demographics such as age, gender and occupational background (Osipow & Fitzgerald, 1993). Interestingly, studies of the transition to reemployment have demonstrated dramatic decreases in suicidal and depressive symptoms and substance use.
POVERTY AND MENTAL HEALTH The relationship between poverty and psychological distress is best understood by examining the chronic stressors that impoverished people must encounter on a daily basis, in conjunction with the limited sources of social support that are available. The usefulness of this stress-support model of psychopathology has been demonstrated in numerous studies (see DHHS, 1985 for a review) documenting that individuals who experience a multitude of stressful life events are at increased risk of subsequently developing some form of psychopathology. Poor people experience more frequent and more
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uncontrollable stressful life events than individuals of moderate to high incomes (Dohrenwend, 1975). Such stressful events can occur acutely, such as the death of a child, or chronically, such as inadequate housing and perpetual worries about buying food and necessities (Belle, 1990). Having sources of social support to rely on in times of stress has been shown to enhance personal coping and to serve as a buffer against resulting psychopathology (Cassel, 1976). The support networks of poor people are often undermined by the chronic stress associated with poverty. Because the friends, relatives and neighbors of poor people are also likely to be poor their social networks are less capable of providing material and emotional support (Belle, 1990). The domestic relationship is also taxed by poverty and divorce is more common among married couples in which men provide low or unstable income (Cherlin, 1979). Marital satisfaction has been found to be lower among couples living below the poverty line than among married couples above the poverty line (Zill, 1978). Further, poor people have less freedom to choose who they depend on due to economic necessity such as families who need to cohabit with other relatives to meet housing costs or women who are forced to stay with abusive partners due to economic dependence. Taken together the inordinate levels of stress that poor people are perpetually faced with, and the often compromised social support networks available to counteract the psychological effects of such stress, it is hardly surprising that mental disorders occur at higher rates among poor people. In fact, one is left to wonder how poor people who don't develop psychological distress cope with such high levels of adversity. The stress-support model of psychopathology is once again a direct challenge to natural selection theories about the inverse relationship of social class to mental disorders.
WOMEN AND MENTAL HEALTH Upon exploring the psychological realities of poverty, it is now helpful to return to the finding that women are overly represented among cases of psychopathology. As mentioned previously among the findings of Neugebauer, Dohrenwend and Dohrenwend (1980), women are more likely to develop a mental disorder than men, especially anxiety and depression that are the two most commonly occurring mental conditions. Along with the social class correlation, this gender differential has been repeatedly demonstrated. This finding is particularly striking once one discovers that the majority of people mired in poverty are women. The risk of poverty among women can largely be explained by acknowledging women's lack of social and economic power. Women experience inequity in employment and are
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over-represented in low paying jobs (Department of Labor, 1993). Women on the average, currently earn 25-30 percent less than men for the same level of jobs. Women are also more likely to be single parents than men and are often left to support their children independent of economic assistance from the father. That the proportion of Americans living below the poverty line is greater than ten years ago can largely be attributed to the growing number of women heading single parent families. In an important review of the literature on poverty and women's mental health, Belle explores the psychological stressors that poor women, particularly poor mothers, experience. A number of community studies conducted in the 1970s reported that mothers who were in financially strained circumstances were more likely to develop depressive symptoms than other women (Belie, 1990). Several studies have found that risk factors for depression among women include chronic stressful economic conditions, few sources of social support including child rearing assistance, and unemployment (Belle, 1982; Brown, Bhrolchain & Harris, 1975; Makosky, 1982 cited in Belle, 1990). As mentioned earlier, chronic stressors such as inadequate housing, continuing financial uncertainty and threats to personal safety challenge women's psychological coping abilities and "low income women are at very high risk of experiencing just such noxious, long-term conditions" (Belle, 1990). That all women are often stereotyped as powerless and by nature dependent on males only exacerbates the mental health status of poor women.
SOCIAL CLASS AND PHYSICAL HEALTH It is important to mention another body of literature that lends support to the causal connection between social class and the occurrence of mental disorders, namely the many studies demonstrating the socioeconomic inequalities in health status and care. Just as the inverse relationship of social class to mental distress has been repeatedly demonstrated, so too has the inverse relationship between social status and morbidity and mortality. Poor people have shorter life expectancy, higher morbidity rates for most diseases, and higher all-cause and specific mortality rates (Adler, Boyce, Chesney, Folkman and Syme, 1993). These inequities in health status have been observed repeatedly since the late 1800's. A difference in life expectancy of seven years between the highest and lowest groups of the socioeconomic strata was reported as early as the first half of the twentieth century (Antonovsky, 1967; cited in Adler et al., 1993). Individuals low in socioeconomic status experience physical morbidity and premature mortality at much higher rates than individuals in the middle or upper economic strata.
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For example, McLoone and Boddy (1994) show a 162% higher death rate in deprived as compared to affluent regions in Scotland in 1991. Sloggett and Joshi (1994) showed that positive correlations between level of deprivation and premature death in electoral wards in England between 1981 and 1990 could be directly attributed to the social position of the individuals affected. This study illustrated that socioeconomic status was the strongest single predictor, above place of residence, of premature death in this English sample. Mcgarron, Smith and Womersley (1994) also found major social class differentials in mortality in Britain and demonstrated that these differentials have increased further in the past two decades.
ANALYSIS AND INTERPRETATION A wealth of epidemiologic literature spanning sixty years of research has been reviewed illustrating the enduring relationship of social class to mental distress. Now that the empirical connection has been established and the overwhelming evidence for a social causation model has been reviewed, it is necessary to reflect on why social drift and organic defect theories, seem to continue to pervade psychiatric and political circles. Simply stated, it is much easier both from a conservative political position and from a treatment perspective, to believe in internal and largely organic explanations of mental disorders. This approach to explaining defect has deep underpinnings in the history of economic politics, and the history of medicine in the United States and Europe. For example, the organic model of mental "disease" relates directly to Herbert Spencer's proposals of Social Darwinism, his attempt to apply Darwinian principles to societal phenomenon (Spencer, 1873-1881; Albee, 1986). Under these teachings, the most superior (i.e., intelligent) beings will endure, whereas as the less superior, deficient beings will as a matter of course dwindle, due to inferior genes. According to Social Darwinism, as the human species evolves, less intelligent and less mentally competent beings will remain at the bottom of the social hierarchy while the most superior individuals advance. Therefore, because it is the functional nature of this hierarchy that deficient individuals remain in the lowest social class, it is not the duty of society to better the conditions of the poor; impoverished circumstances are in fact their fate. Strikingly similar lines of reasoning are found in the IQ debates that have dominated psychology since the early 1900's and that remain visible today. Biological determinists argue that we must accept inferior intelligence as part of the natural order of society; as part of the "normal distribution" of individuals (Herrnstein & Murray, 1994) and that there is little we should feel compelled to do to improve IQ standings. Interestingly,
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those with the lowest IQs also belong to the most marginalized groups of our society: the poor, ethnic minorities, immigrants, and those exploited by industry, such as migrant farm workers. The weight of evidence that suggests that these groups show lower IQ scores because they have not been afforded adequate education and equal access to economic opportunities, is too great to be ignored. Further, the middle class cultural biases inherent in the IQ testing system are also far too obvious to be dismissed. This type of economic determinism has great implications for political philosophy as well. If we accept that poor people must exist due to a biological imperative, we will have no need to address injustices or inequities in the economic system and can therefore justify the poor's unfortunate circumstance as necessary and beyond our control. As long as we can attribute the source of defect to the individual, rather than the environment, we can feel comfortable that poverty, mental inferiority and psychological trauma are the result of inferior status. Given this line of reasoning, it is in no way surprising that low social class status and psychopathology cluster together. After all, conservatives may argue, they are simply byproducts of low intelligence and inferior mental constitution. The downward drift explanation of the social class/psychopathology connection is also consistent with strict internal or organic explanations of mental disorders. Downward drift theorists argue that psychopathology is more prevalent in the lower class because individuals become mentally unstable first, and therefore fall in economic status due to impaired functioning. Downward drift argues that the responsibility for social status remains first with the individual, rather than attributing mental disturbance to the potentially psychologically damaging effects of poverty. As long as we can comfortably assert these positions to be true, there will be no need for political action and social change. We can just continue to blame the victims. This paper has reviewed several bodies of literature to illustrate the powerful connection between mental well-being and socioeconomic status. Over the past century numerous studies have demonstrated this connection. Although the causal link between economic deprivation and the occurrence of mental distress remains challenged, the purpose of this paper was to review the evidence for a social causation model of mental disorders, and to demonstrate that this model remains quite compelling. In fact, given the wealth of longitudinal, historical and policy studies that give support to the social causation model of both mental distress and physical disease, it is not surprising that many sociologists and psychologists have moved beyond the need to document further this relationship empirically (Albee, Joffe, & Dusenbury, 1988). The next logical step is to recommend social policy solutions that are aimed at reducing vast eco-
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nomic inequities. Only these will likely be effective in making meaningful reductions in the prevalence and incidence of mental disorders both in the U.S. and in other countries.
REFERENCES Adler, N.E., Boyce, T, Chesney, M.A., Folkman, S., and Syme, L. (1993). Socioeconomic inequalities in health. Journal of the American Medical Association, 269(24), 3140-3145. Albee, G.W. (1986). Toward a just society: Lessons from observations on the primary prevention of psychopathology. American Psychologist, 41, 891-898. Albee, G.W., Joffe, J.M., and Dusenbury, L.A. (I988). Prevention, powerlessness, and politics. Newbury Park, CA: SAGE Publications. Brenner, M. (1976). Estimating the Social Costs of Economic Policy: Implications For Mental and Physical Health and Criminal Aggression. Report to the Congressional Research Service of the Library of Congress and Joint Economic Committee of Congress. Washington, DC: US Government Printing Office. Brown, G., Bhrolchain, M., and Harris, T. (1975). Social class and psychiatric disturbance among women in an urban population. Sociology, 9, 225-254. Belle, D. (1990). Poverty and women's mental health. American Psychologist, 45(3), 385-389. Cassel, J. (1976). The contribution of the environment to host resistance. American Journal of Epidemiology, 104, 1040-1043. Catalano, R. (1991). The health effects of economic insecurity. American Journal of Public Health, 81(9), 1148-1152. Dohrenwend, B.P. (1975). Sociocultural and social-psychological factors in the genesis of mental disorders. Journal of Health and Social Behavior, 16, 365-392. Dohrenwend, B.P., Shrout, EE., Link, B.G., Martin, J. and Skodol, A.E. (1986). Overview and initial results from a risk-factor study of depression and schizophrenia. In J.E. Barret and R.M. Rose (Eds.) Mental Disorders in the Community (pp. 184-215). New York: Guilford Press. Dunham, H.W (1965). Community and Schizophrenia. Detroit, MI: Wayne State University Press. Faris, R.E.L. and Dunham, H.W (1939). Mental Disorders in Urban Areas. New York: Hafner Publishing Co. Fee, L. (1987). Disease and Discovery. Baltimore, MD: Johns Hopkins University Press. Gray, G. (1985). National commission on unemployment and mental health. Resource Papers to the Report of The National Mental Health Association Commission on the Prevention of Mental-Emotional Disabilities. Alexandria, VA: National Mental Health Association. Herrnstein, and Murray. (1994) The Bell Curve: Intelligence and Class Structure in American Life. New York: The Free Press. Hollingshead, A.B. and Redlich, EC. (1958). Social Class and Mental Illness. New York: John Wiley & Sons. Holzer, C., Shea, B., Swanson, J., Leaf, R, Myers, J., George, L., Weissman, M. and Bednarski, E (1986). The increased risk for specific psychiatric disorders among persons of low socioeconomic status. American Journal of Social Psychiatry, 6, 259-271. Jarman, B., Hirsch, S., White, E, and Driscotl, R. (1992). Predicting psychiatric admission rates. British Medical Journal, 304, 1146-1150. Kammerting, R.M., and O'Connor, S. (1993). Unemployment rate as a predictor of rate of psychiatric admission. British Medical Journal, 307, 1536-1539. Lewis, M., (1978). Nearest neighbor analysis of epidemiological and community variables. Psychological Bulletin, 85(6), 1302-1308.
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Link, B.G., Dohrenwend, B.P., and Skodol, A.E. (1986). Socioeconomic status and schizophrenia: Noisome occupational characteristics as a risk factor. American Sociological Review, 51, 242-258. Link, B.G. Lennon, M.C., Dohrenwend, B.P. (1993). Socioeconomic status and depression: The role of occupations involving direction, control and planning. American Journal of Sociology, 98(6), 1351-1387. McCarron, P.G., Smith, G.D., and Womersley, J.J. (1994). Deprivation and mortality in Glasgow: Changes from 1980 to 1992. British Medical Journal, 309, 1481-1482. McLoone, P. and Boddy, EA. (1994). Deprivation and mortality in Scotland, 1981-1991. British Medical Journal, 309, 1465-1470. Mirowsky, J. and Ross, C.E. (1989). Social Causes of Psychological Distress. New York: Aldine de Gruyter. Neugebauer, R., Dohrenwend, B.P., & Dohrenwend, B.S. (1980). Formulation of hypotheses about the true prevalence of functional psychiatric disorders among adults in the United States. In B.P. Dohrenwend, Mental Illness in the United States (pp. 45-94). New York: Praeger Publishers. Osipow, S.H. and Fitzgerald, L E (1993). Unemployment and mental health: A neglected relationship. Applied and Preventive Psychology, 2, 59-63. SloggeR, A. and Joshi, H. (1994). Higher mortality in deprived areas: Community or personal disadvantage? British Medical Journal, 309, 1470-1474. Spencer, H. (1873-1881). Descriptive Sociology. New York: D. Appleton. Stole, L., Langner, TS., Micheal, S.'E, Opler, M.K., and Rennie, T.A.C. (1962). Mental Health in the Metropolis: The Midtown Manhattan Study. New York: McGraw-Hill Book Company Inc. United States Department of Health and Human Service (1985). Stressful Life Event Theory and Research: Implications for Primary Prevention. Rockville, MD: Alcohol, Drug Abuse and Mental Health Administration, DHHS Publication No. (ADM) 85-I385. United States Department of Labor (1993). Earning Differences Between Women and Men. U.S. Department of Labor Women's Bureau Report No. 93-5.
