Introduction

Why do some people seem to be always cheerful, whereas others are often sad? Most of us believe that our moods have to do with aspects of our personalities that make us more or less depressed, anxious, or exuberant. Others think that temperament results from biological factors such as our genes and neurochemicals. People usually also assume that engaging in therapies that change their states of mind is the natural response to mental problems. These treatments might involve psychotherapies that modify the way people view the world or drugs that alter their brain chemistry. Thus, typical approaches to the nature, causes, and cures of various states of mind emphasize individual traits, temperaments, and behaviors.

Sociological approaches to psychological well-being are fundamentally different. Unlike psychological and biological perspectives that look at personal qualities and brain characteristics, sociologists focus on the impact of social circumstances on mental health and illness. The distinctive emphasis of sociological approaches is on how processes such as life events, social conditions, social roles, social structures, and cultural systems of meaning affect states of mind. Social perspectives assume that different individuals who are in the same circumstances will have similar levels of mental health and illness. That is, what determines how good or bad people feel does not just depend on their own personalities or brains but also on the sorts of social conditions they face. These conditions vary tremendously across different social groups, societies, and historical eras.

Some important social influences involve how many stressful life events people confront (Holmes & Rahe, 1967). These events include such circumstances as getting divorced, losing a valued job, having a serious automobile accident, receiving a diagnosis of a serious physical illness, or having a close relative die. Especially serious stressors such as being a victim of a violent crime, natural disaster, military combat, or physical or sexual abuse during childhood are particularly powerful causes of adverse mental health outcomes (Dohrenwend, 2000). The more frequently such events occur and the more serious they are, the worse any person's mental health is likely to be.

Other social causes of poor mental health lie in persistent living conditions that do not appear at a particular time and then go away but are instead rooted in ongoing circumstances (Turner, Wheaton, & Lloyd, 1995). For example, people who live in social environments that feature high rates of poverty, neighborhood instability, crime rates, dilapidated housing, and broken families are likely to have high rates of psychological distress (Ross, 2000). Other enduring stressful circumstances are troubled marriages, oppressive working conditions, or unreasonable parents. Sociological perspectives predict that especially taxing living conditions, roles, and relationships are related to low levels of psychological well-being, over and above the qualities of the particular individuals who must deal with these situations.

Many sociologists study how social conditions affect levels of mental health. Others look at the social reactions to mental health problems. Some factors that lead people to respond to emotional difficulties in different ways involve social characteristics such as gender, ethnicity, age, and education. These traits make people more or less likely to define themselves as having some kind of psychological problem and to seek help once they have made these definitions. Other aspects involved in the reaction to mental troubles concern varying cultural values toward mental health and illness. Culture refers to socially shared systems of beliefs, values, and meanings. It encompasses, among many other factors, people's ethnic heritage, religious beliefs, and political principles and the tastes of their age peers. For example, responses to emotional problems in cultures that stigmatize the mentally ill will be very different from those in cultures that highly value professional treatment for these problems. Additional factors that shape the social response to psychological problems involve the accessibility, quality, type, and amount of health care that is available to people.

Sociological approaches share the idea that mental health and illness are not just qualities of individuals but also stem from various aspects of social circumstances. What social groups people belong to, what historical periods and societies they live in, and what cultural values they hold profoundly shape how people feel about themselves, how likely they are to become mentally ill, the kinds of problems they are likely to develop, what they do if they develop mental difficulties, and the kinds of help that are available to them.

What Outcomes Do Sociologists Study?

Most sociologists examine levels of mental health and illness in the natural settings where people live. Sociological research is more likely to take place in schools, family settings, neighborhoods, and communities than in clinical settings where people seek professional mental health care. Therefore, the kinds of mental health conditions that sociologists study are usually different from those examined by other disciplines such as psychiatry or clinical psychology.

Most research that takes place in clinical settings examines particular types of mental illnesses, such as schizophrenia, bipolar disorder, major depression, and obsessive-compulsive disorder. These conditions have symptoms that are believed to indicate the presence of some underlying disease entity and that are different from the symptoms of other diseases. Diagnoses of particular mental disorders are usually dichotomous; that is, someone either has or does not have an anxiety, depressive, substance abuse, attention-deficit, or eating disorder.

In contrast, most sociologists use outcomes that reflect more generalized conditions of distress, not particular types of mental illnesses. For example, the Center for Epidemiologic Studies–Depression scale (CES-D) is the most common instrument that sociologists use to measure mental health (Radloff, 1977). It consists of 20 questions that ask people how they have felt over the past week; for example, “I enjoyed life,” “My sleep was restless,” or “I felt lonely.” The scale is not comparable to any specific mental illness, but instead contains items relating to more global states of well-being. Many of its items (e.g., “I felt hopeful about the future,” “I felt I was just as good as other people”) tap general attitudes about life or personal qualities such as self-esteem. The CES-D and other scales that sociologists typically use measure global qualities of well-being rather than discrete psychiatric conditions.

The broad nature of these outcomes means that they provide good measures of general states of psychological well-being or ill health, but are not comparable to psychiatric diagnoses and do not measure mental illness. In addition, scales such as the CES-D are limited because they only measure qualities of mental health that reflect internal types of suffering. They do not contain items that ask about other possible indicators of mental health such as heavy drinking or drug taking, violent and aggressive behavior, or severe symptoms such as delusions and hallucinations. To adequately capture the full range of psychological symptoms, these scales need to be supplemented by a broader range of mental health outcomes.

Sociologists who examine the social response to emotional problems must use different sorts of outcomes from those used in studies that examine the social determinants of well-being and distress. They do not try to explain how symptoms develop in the first place; rather, they ask how, once symptoms emerge, sufferers themselves and others around them define, classify, and respond to experiences of mental distress. Some of these studies ask people about their attitudes toward mental illness and see how their answers reflect who does or does not enter mental health treatment. Others use official statistics that are collected about how many people with psychological problems enter different kinds of facilities such as general medical practices, outpatient psychiatric care, or inpatient mental hospitals. They then view how rates of various kinds of treatment vary across groups with divergent social characteristics such as race, socioeconomic circumstances, and immigrant status. Another type of study compares treatment rates across large geographic areas such as different states, regions of the country, or different countries to see how general aspects of the mental health system influence patterns of seeking professional help. For example, far more people with mild psychological problems are likely to enter professional mental health treatment in the United States than in other countries (Katz et al., 1997).

Sociological studies, then, are less likely than clinical studies to use small groups of people who are found in mental health treatment. Instead, they use general scales that measure mental health in samples of community members. They also rely on statistics about rates of mental health care across a wide range of facilities and regions. These studies are good at showing broad social variations in the development of and response to psychological problems, although they are unable to say much about individual experiences of mental health and illness.

What Social Factors Relate to Mental Health and Illness?

Sociological studies reveal that psychological well-being and distress are related to several general aspects of social life: the degree of social integration, inequality, and meaningful collective belief systems. In addition, the periods of time when individuals were born and the countries they live in are associated with their states of mental health. The influence of these factors means that levels of mental health diverge considerably among people in different social locations.

Social Responses to Mental Disorder

Another type of sociological research examines how people themselves, those around them, and their societies define and respond to psychological problems. Social influences profoundly affect how people and groups react to mental health troubles.

Images of mental illness have undergone radical changes in recent decades. For most of history, people associated mental illness with crazy, mad, and bizarre behaviors (Grob, 1995). These conceptions also carried a great deal of stigma so that people would resist defining themselves as mentally ill and seeking mental health treatment. Because only the most severe and disruptive conditions would come to the attention of mental health professionals, treatment often occurred in locked wards of inpatient mental hospitals.

An enormous change has occurred in recent decades in how Americans define, seek help for, and treat psychological and behavioral problems. In particular, a dramatic upsurge in the medicalization of social life occurred in the 1990s and 2000s. Medicalization means that conditions that previously had been defined as nonmedical difficulties are now seen as medical problems that ought to be treated through medical techniques (Conrad, 2007). Troubles that in the past were considered as spiritual, moral, or behavioral harms that were handled through prayer, counseling, or punishment or were simply tolerated are now defined as diseases and addressed through biomedical treatments. In the field of mental health, medicalization has had these effects: people are more willing to seek professional help for their emotional problems, social definitions emphasize how mental troubles are signs of diseases, and treatments primarily involve biomedical interventions, especially drugs.

The fundamental categories of mental illness themselves have undergone notable changes in recent years. For example, distressing and disruptive but not necessarily disordered childhood behaviors are increasingly being labeled as mental illnesses. Children have always behaved in ways that annoy and frustrate their parents and disturb their teachers. Only recently, however, have these behaviors been considered to be mental disorders that must be treated with medications. Just 20 years ago less than 1% of children were diagnosed and treated for ADHD (Olfson, Gameroff, Marcus, & Jensen, 2003). By 2003, ADHD had become a widely prevalent psychiatric condition among children and adolescents, with 7.8% of youth aged 4 to 17 years reporting a diagnosis of ADHD and 4.3% taking medication for the condition (Visser, Lesesne, & Perou, 2007).

The spectacular rise in rates of bipolar (or manic-depressive) disorder in youth provides another dramatic instance of a new childhood mental disorder. This disorder was traditionally thought to arise in mid-life and until recently was virtually unknown among youth. Then, in 2007 a national survey discovered an astonishing 40-fold increase in the number of children and adolescents treated for bipolar disorder from 1994 to 2003 (Moreno et al., 2007). The common denominator among children treated for this condition seems to be that their behavior is extremely disturbing to adults, usually their parents or teachers. The rising rates of the pediatric bipolar diagnosis and resulting prescriptions for powerful drugs seem more due to their usefulness for pacifying disruptive behavior than to the discovery of a previously unknown disease.

Among adults, major depressive disorder (MDD) is the most common diagnosis in psychiatric treatment and one of the most common conditions reported in community surveys. Its typical symptoms are states of low mood, diminished pleasure, sleep and appetite difficulties, fatigue, and lack of concentration that persist for a 2-week period. Studies estimate that about 17% of people suffer from MDD over their lifetime (Kessler, Berglund, et al., 2005). In the past, the symptoms of MDD would often have been viewed as natural responses to some serious loss such as the breakup of a marriage or a long-term romantic relationship, the unexpected loss of a valued job, or the discovery that an intimate has a life-threatening illness. The expansion of medicalization has led American culture to define sadness as a depressive mental disorder and to treat it with medications (Horwitz & Wakefield, 2007).

Social phobia provides another example of medicalization. Social phobias are conditions that feature extreme anxiety over situations in which people are exposed to the scrutiny of others, such as when they must speak in public, have their performance evaluated, or attend social events that involve interacting with strangers. When this condition first appeared in the official psychiatric manual in 1980, it was noted that “the disorder is apparently relatively rare” (American Psychiatric Association, 1980, p. 228). Initial studies of the disorder in the early 1980s indicated that about 1% to 2% of the population reported this condition. Yet, more recent studies indicate that about 13%, or one of eight people, has had a social phobia at some point in their lives (Magee et al., 1996). Indeed, by the early 2000s, social phobias were one of the two most common mental disorders. Rising rates of conditions such as social phobia largely result from growing cultural tendencies to treat personality traits such as shyness as if they were diseases and from widespread drug advertisements that urge people to seek medical help for their distressing conditions (Lane, 2007).

It is not just conceptions of what mental disorders are that have changed in recent years. People are now far more willing to seek mental health treatment than they were just 20 years ago. The treatment of depression illustrates this change. The percentage of the population in therapy for depression in a given year increased by 76% between the early 1980s to the early 2000s (Wang et al., 2006). Although the willingness to seek professional help for mental health problems such as depression has increased among all social groups in recent years, a number of social characteristics are associated with defining oneself as in need of mental health treatment. Women, younger and middle-aged people, Whites, and highly educated individuals are considerably more likely to seek professional treatment than men, the elderly, racial and ethnic minorities, and the less educated (Pescosolido & Boyer, 1999).

The places where people receive mental health treatment have also dramatically changed in recent years. Since the 1950s rates of inpatient treatment in mental hospitals have plunged, and few mentally ill people now enter these institutions (Grob, 1995). When people do receive inpatient treatment it is likely to be given in general hospitals or private clinics. The vast majority of people treated in the mental health system now go to outpatient facilities in the community or see general physicians for their emotional problems.

Several factors account for the dramatically rising rates of professional treatment during the recent past. The earlier emphasis of cultural conceptions of mental illness on the most serious and stigmatizing conditions has shifted toward a focus on a broad range of emotional and psychosocial problems. Younger birth cohorts, in particular, have been socialized to a therapeutic culture that emphasizes using mental health services and, especially, taking psychotropic medications to ease suffering. Various mental illnesses are common topics in television shows, movies, and popular magazines. Direct-to-consumer (DTC) advertisements of medications that treat psychological problems are another prominent reason for rising rates of treatment. These ads, which have only been allowed since the late 1990s, are now widely featured in the media.

The drug industry has had an especially important influence on the growth and evolution of mental health treatment (Barber, 2008). The most striking change in treatment is the vast increase in prescriptions for antidepressant medications. The use of antidepressants, including fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), venlafaxine (Effexor), and fluvoxamine (Luvox), nearly tripled between 1988 and 2000; in any given month, 10% of women and 4% of men use these drugs (Health United States, 2004). The increasing use of antidepressants is especially apparent among young adults. The period from 1994 to 2001 witnessed a 250% increase in the number of visits to physicians that resulted in a prescription for some medication that treats psychological problems among adolescents (Thomas, Conrad, Casler, & Goodman, 2006). Recent years have also seen rising rates of stimulant drugs such as Ritalin that treat ADHD. More than two million children now receive these drugs each year (Zuvekas, Vitiello, & Norquist, 2006). The numbers of persons 20 years old and younger who received a prescription for the strongest kind of medications, the antipsychotics, jumped from about 200,000 in 1993–1995 to about 1,225,000 in 2002, a more than sixfold increase in less than a decade (Olfson et al., 2006). A sharp drop in the use of psychotherapies – treatments of emotional disorders that rely on talk therapies – has accompanied the growing reliance on drugs (Olfson et al., 2002).

On the one hand, changes in the social response to mental health conditions have meant that far more people are getting professional help for their psychological problems. The stigma associated with seeking help for emotional problems and mental illness has also declined as a broader range of conditions have become associated with this label. However, people who suffer from more serious types of mental disorders such as schizophrenia remain highly stigmatized. The availability of effective medications is also partly responsible for why far fewer people enter mental hospitals and far more live in the community than in past decades. Psychotropic drugs allow many people to lead brighter lives and accomplish more than they would if they were not taking medications for their problems.

On the other hand, critics have emphasized how a number of problems are due to the rising use of drug therapies (Conrad, 2007; Elliott, 2003; Healy, 2004). Growing medicalization has led to the assumption that drugs are the treatment of choice for numerous psychosocial problems. Prescribing a pill can communicate the message that issues such as unfulfilling marriages, poor parenting, and inadequate finances are easily remedied through pharmaceuticals. Current health policy might be overly reliant on using medical remedies for concerns that often can be addressed through alternative social policies. For example, enhancing parenting skills, investing in childhood development programs and child care, and creating more stimulating classroom experiences might be more effective responses to childhood behavioral problems than pharmaceutical treatments. It is possible that promoting healthy lifestyles and reducing socioeconomic inequality, workplace pressures, and family demands could enhance mental health to a greater extent than telling people they have a disease and prescribing pills to remedy their conditions.

Another problem is that the benefits of medicalization are often overstated. Although these drugs do help control the worst symptoms of serious mental illnesses, their effectiveness for less severe conditions does not greatly exceed that of placebo treatments (Kirsch et al., 2008). If the benefits of drugs have been exaggerated, their risks including negative side effects such as diminished sexual desire, increased somatic symptoms, and sleep problems, withdrawal problems from ceasing use, and heightened suicidal potential might be underestimated (Healy, 2004). An additional issue is that little is known about the impact of long-term use of psychotropic medications, an especially important concern for young adults who begin using them during early stages of their life cycle. Whatever the exact balance is between the benefits and risks of the medicalized response to emotional problems, it is undoubtedly one of the most important recent trends in the field of the sociology of mental health and illness.

Conclusion

Sociological research about mental health and illness shows how the emergence of psychological well-being and distress are consequences of basic aspects of social organization (Pearlin, 1989). Dimensions of social life including integration, stratification, and cultural systems of meanings shape resulting rates of emotional problems. Even such extreme behaviors as suicide can often result from the way people are attached to social institutions rather than from the irrational behavior of abnormal individuals. From a sociological point of view, regular features of social life rather than abnormal processes within individuals explain how much distress will emerge among people living in any given time and place.

The response to mental problems is also rooted in essential dimensions of social life. Social processes influence how people classify what kinds of problems they have, what sort of remedies they seek, and what kind of resources are available to treat them. Cultural conceptions of what it means to be emotionally healthy or disturbed have radically altered in recent decades. A number of particular social groups including pharmaceutical companies, the mental health professions, the media, and governmental bodies encourage people to medicalize their emotional suffering. The result is that notions of mental illness are far broader than in the past, allowing many more people to view themselves as having emotional problems that require professional treatment.

Rooting the emergence and response to psychological problems in social practices rather than within individuals might seem to be counterintuitive. Most people think that their emotions are profoundly individual processes that are uniquely their own. Yet, as the various chapters in this volume will demonstrate, the kinds of societies we live in and the sorts of cultural beliefs that we share shape the seemingly most innermost aspects of our thoughts, feelings, and behaviors. They will also suggest some answers to what is possibly the most important sociological question: What sorts of social arrangements can optimize happiness and minimize distress?