Psychotic inpatients' social class and their first admission to state or private psychiatric Baltimore hospitals

Social Inequalities in Mental Health: A Review of Concepts and Underlying Assumptions

We provide an overview of two major theoretical subjects in the study of the relation between social inequalities and mental health in the last 50 years: the conceptualization of social inequalities, and assumptions about their causes. The two conceptual approaches to the conceptualization of social inequalities are: 1) ‘social stratification’ or the ordering of individuals according to economic, political, or cultural rankings; and 2) ‘social class’ relations that yield a set of class positions for individuals according to their control over different types of assets (economic, political, cultural). The two major assumptions underlying these conceptual choices in studies of social inequalities and mental health are: 1) whether effects on mental health originate at the individual or at the group level (i.e. the ‘levels-of-analysis’ issue); and 2) whether mental health is the consequence of environmental determination or the individual’s capacity for making independent decisions (the ‘agency’ issue). We propose a typology of models of social inequalities in mental health that relates these levels-of-analysis and agency issues. The typology provides an efficient conceptual reorganization that uncovers the assumptions and policy implications of research on social inequalities in mental health.

Researching Health Inequities among African Americans: The Imperative to Understand Social Class

Racial and ethnic inequities in health abound in many disease categories. African-American communities suffer from an increased burden of illness, with higher incidence and mortality rates and more severe morbidity in cerebrovascular disease, heart disease, several cancers, diabetes, and many other ailments. Healthy People 2010, the federal government's health plan, calls for eliminating health disparities by race, ethnicity, gender, education, income, disability, geographic location, or sexual orientation. Research aimed at increasing our understanding of these health disparities and designing and evaluating interventions to improve African-American health is hampered by a liberal, classless approach. The authors argue for a theoretical framework in this research that recognizes that class exploitation sets the stage for and interacts with racial discrimination to determine racial inequities in health.

Social class at birth and risk of psychosis

BACKGROUND

Individuals with psychotic disorders are represented more in the lower social classes, yet there is conflicting evidence to whether these individuals drift into the lower social classes or whether lower social class is a risk factor for developing psychosis. The aim of this study was to examine whether the social class at birth is a risk factor for developing psychosis.

METHODS

We included individuals with a first episode of psychosis (FEP) whose social class at birth was determined from birth records. We employed a case-control study design and also compared the distribution of the social classes at birth of the cases to that of the general population.

RESULTS

A total of 380 individuals with an FEP and 760 controls were included in the case-control study. The odds ratio for developing an FEP associated with social class (low vs high) was .62 (95% confidence interval (CI): .46-.85, p < .001), indicating that individuals from a lower social class at birth have a reduced risk of psychosis. Individuals born between 1961 and 1980 with an FEP were more likely to be from a higher social class at birth compared to the general population (60.8% vs 36.7%, χ(2) = 60.85, df = 1, p < .001). However, this association was not observed for those born between 1981 and 1990.

CONCLUSION

A higher social class at birth is associated with a greater risk for developing a psychotic disorder; however, this effect may show temporal variation.

Two decades of Neo-Marxist class analysis and health inequalities: A critical reconstruction

Most population health researchers conceptualize social class as a set of attributes and material conditions of life of individuals. The empiricist tradition of 'class as an individual attribute' equates class to an 'observation', precluding the investigation of unobservable social mechanisms. Another consequence of this view of social class is that it cannot be conceptualized, measured, or intervened upon at the meso- or macro levels, being reduced to a personal attribute. Thus, population health disciplines marginalize rich traditions in Marxist theory whereby 'class' is understood as a 'hidden' social mechanism such as exploitation. Yet Neo-Marxist social class has been used over the last two decades in population health research as a way of understanding how health inequalities are produced. The Neo-Marxist approach views social class in terms of class relations that give persons control over productive assets and the labour power of others (property and managerial relations). We critically appraise the contribution of the Neo-Marxist approach during the last two decades and suggest realist amendments to understand class effects on the social determinants of health and health outcomes. We argue that when social class is viewed as a social causal mechanism it can inform social change to reduce health inequalities.

Socioeconomic inequalities in common mental disorders and psychotherapy treatment in the UK between 1991 and 2009

BACKGROUND

Inequality in health and treatment of disease across socioeconomic status groups is a major public health issue.

AIMS

To examine differences in socioeconomic status in common mental disorders and use of psychotherapy provided by the public and private sector in the UK between 1991 and 2009.

METHOD

During these years, 28 054 men and women responded to annual surveys by the nationally representative, population-based British Household Panel Survey (on average 7 measurements per participant; 207 545 person-observations). In each year, common mental disorders were assessed with the self-reported 12-item General Health Questionnaire and socioeconomic status was assessed on the basis of household income, occupational status and education.

RESULTS

Higher socioeconomic status was associated with lower odds of common mental disorder (highest v. lowest household income quintile odds ratio (OR) 0.88, 95% CI 0.82-0.94) and of being treated by publicly provided psychotherapy (OR = 0.43, 95% CI 0.34-0.55), but higher odds of being a client of private psychotherapy (OR = 3.33, 95% CI 2.36-4.71). The status difference in publicly provided psychotherapy treatment was more pronounced at the end of follow-up (OR = 0.36, 95% CI 0.23-0.56, in 2005-2009) than at the beginning of the follow-up period (OR = 0.96, 95% CI 0.66-1.39, in 1991-1994; time interaction P<0.001). The findings for occupational status and education were similar to those for household income.

CONCLUSIONS

The use of publicly provided psychotherapy has improved between 1991 and 2009 among those with low socioeconomic status, although social inequalities in common mental disorders remain.

Indicators of socioeconomic position (part 2)

This is the second part of a glossary on indicators of socioeconomic position used in health research (the first part was published in the January issue of the journal).

Social class and self-reported health status among men and women: what is the role of work organisation, household material standards and household labour?

Social class understood as social relations of ownership and control over productive assets taps into parts of the social variation in health that are not captured by conventional measures of social stratification. The objectives of this study are to analyse the association between self-reported health status and social class and to examine the role of work organisation, material standards and household labour as potential mediating factors in explaining this association. We used the Barcelona Health Interview Survey, a cross-sectional survey of 10,000 residents of the city's non-institutionalised population in 2000. This was a stratified sample, strata being the 10 districts of the city. The present study was conducted on the working population, aged 16-64 years (2345 men and 1874 women). Social class position was measured with Erik Olin Wright's indicators according to ownership and control over productive assets. The dependent variable was self-reported health status. The independent variables were social class, age, psychosocial and physical working conditions, job insecurity, type of labour contract, number of hours worked per week, possession of appliances at home, as well as household labour (number of hours per week, doing the housework alone and having children, elderly or disabled at home). Several hierarchical logistic regression models were performed by adding different blocks of independent variables. Among men the prevalence of poor reported health was higher among small employers and petit bourgeois, supervisors, semi-skilled (adjusted odds ratio-aOR: 4.92; 95% CI: 1.88-12.88) and unskilled workers (aOR: 7.69; 95%CI: 3.01-19.64). Work organisation and household material standards were associated with poor health status with the exception of number of hours worked per week. Work organisation variables were the main explanatory variables of social class inequalities in health, although material standards also contributed. Among women, only unskilled workers had poorer health status than the referent category of manager and skilled supervisors (aOR: 3.25; 95%CI: 1.37-7.74). All indicators of work organisation and household material standards reached statistical significance, excepting the number of hours worked per week. In contrast to men, among women the number of hours per week of household labour was associated with poor health status (aOR: 1.02; 95% CI: 1.01-1.03). Showing a different pattern from men in the full model, household material deprivation and hours of household labour per week were associated with poor health status among women. Our findings suggest that among men, part of the association between social class positions and poor health can be accounted for psychosocial and physical working conditions and job insecurity. Among women, the association between the worker (non-owner, non-managerial, and un-credentiated) class positions and health is substantially explained by working conditions, material well being at home and amount of household labour.

The associations of social class and social stratification with patterns of general and mental health in a Spanish population

BACKGROUND

Social class, as a theoretical framework, represents a complementary approach to social stratification by introducing social relations of ownership and control over productive assets to the analysis of inequalities in economic, political, and cultural resources. In this study we examined whether measures of social class were able to explain and predict self-reported general and mental health over and above measures of social stratification.

METHODS

We tested this using the Barcelona Health Interview Survey, a cross-sectional survey of 10 000 residents of the city's non-institutionalized population in 2000. We used Erik Olin Wright's indicators of social class position, based on ownership and control over productive assets. As measures of social stratification we used the Spanish version of the British Registrar General (BRG) classification, and education. Health-related variables included self-perceived health and mental health as measured by Goldberg's questionnaire.

RESULTS

Among men, high level managers and supervisors reported better health than all other classes, including small business owners. Low-level supervisors reported worse mental health than high-level managers and non-managerial workers, giving support to Wright's contradictory class location hypothesis with regard to mental health. Social class indicators were less useful correlates of health and mental health among women.

CONCLUSIONS

Our findings highlight the potential health consequences of social class positions defined by power relations within the labour process. They also confirm that social class taps into parts of the social variation in health that are not captured by conventional measures of social stratification and education.

Socio-economic differences in psychiatric in-patient care

OBJECTIVE

We seek to investigate socio-economic differences in psychiatric in-patient care regarding admission, treatment and outcome.

METHOD

This study is undertaken on a comprehensive and exhaustive psychiatric case register of all psychiatric in-patient care carried out in Belgium in 1997 and 1998 (n=144 754).

RESULTS

Lower socio-economic groups were more likely to be compulsorily admitted, to be cared for in a non-teaching or psychiatric hospital, to be admitted in a hospital with unexpectedly long average length of stay and to be admitted to a ward with a more severe case-mix. They were less likely to receive antidepressants and psychotherapies. The improvements in functioning and in symptoms were also less favourable for these groups. The lowest group had a higher risk of dying in the hospital.

CONCLUSION

Psychiatric in-patient care is associated with moderate socio-economic differences in access, treatment and outcome. Further research is needed to clarify the causes of such disparities.

The social class determinants of income inequality and social cohesion

The authors argue that Wilkinson's model omits important variables (social class) that make it vulnerable to biases due to model mis-specification. Furthermore, the culture of inequality hypothesis unnecessarily "psychopathologizes" the relatively deprived while omitting social determinants of disease related to production (environmental and occupational hazards) and the capacity of the relatively deprived for collective action. In addition, the hypothesis that being "disrespected" is a fundamental determinant of violence has already been refuted. Shying away from social mechanisms such as exploitation, workplace domination, or classist ideology might avoid conflict but reduce the income inequality model to a set of useful, but simple and wanting associations. Using a nonrecursive structural equation model that tests for reciprocal effects, the authors show that working-class position is negatively associated with social cohesion but positively associated with union membership. Thus, current indicators of social cohesion use middle-class standards for collective action that working-class communities are unlikely to meet. An erroneous characterization of working-class communities as noncohesive could be used to justify paternalistic or punitive social policies. These criticisms should not detract from an acknowledgment of Wilkinson's investigations as a leading empirical contribution to reviving social epidemiology at the end of the century.

Income, social stratification, class, and private health insurance: a study of the Baltimore metropolitan area

Most studies of inequalities and access to health care have used income as the sole indicator of social stratification. Despite the significance of social theory in health insurance research, there are no empirical studies comparing the ability of different models of social stratification to predict health insurance coverage. The aim of this study is to provide a comparative analysis using a variety of theory-driven indicators of social stratification and assess the relative strength of the association between these indicators and private health insurance. Data were collected in a 1993 telephone interview of a random digit dialing sample of the white population in the Baltimore Metropolitan Statistical Area. Indicators of social stratification included employment status, full-time work, education, occupation, industry, household income, firm size, and three types of assets: ownership, organizational, and skill/credential. The association between social stratification and private health insurance was strongest for those having higher household incomes, having attained at least a bachelor's degree, and working in a firm with more than 50 employees, followed by being an owner or manager, and by being employed. The addition of education and firm size improved the prediction of the household income model. The authors conclude that studies of inequalities in health insurance coverage can benefit from the inclusion of theory-driven indicators of social stratification such as human capital, labor market segmentation, and control over productive assets.

Work environment and schizophrenia: an extension of the arousal hypothesis to occupational self-selection

The present study investigated a possible mechanism underlying the occupational self-selection of future schizophrenic patients prior to their first admission. More precisely, we explored whether schizophrenic patients are more likely than other psychotic patients to work in environments with a low potential for arousal (low complexity environments) in the last full-time job that preceded their hospitalization. All first admissions with psychotic symptoms to 15 hospitals providing inpatient psychiatric services in the Baltimore-Washington area were surveyed during a 6-year period. Patients diagnosed with schizophrenia were compared to patients diagnosed with bipolar disorder and other psychotic disorders to evaluate the suspected association. Study participants were assessed with a modified version of the Diagnostic Interview Schedule. Standard survey questions were used to assess occupational background. A measure based on the dictionary of occupational titles (DOT) was used to estimate the degree of complexity to which patients had been exposed in their last full-time occupation. Data were analyzed using multinomial logistic regression. After adjustment for age, gender, marital status, unemployment, socioeconomic status, hospital type, and physical demands and hazards on the job, patients with schizophrenia were more likely to have been working in low complexity environments in their last full-time jobs (e.g., janitors, gardeners, guards) than patients with bipolar disorder or with other psychotic disorders. Alternative explanations and potential implications regarding which work environments might be best suited to the social behavior of patients with schizophrenia are examined.