Social context and consequences of mental illness in changing scenario

Mental illness has very close and intimate relationship with societal factors and components. There have been many theoretical postulations that come from time to time to explain this relationship. Mental disorder has definite aetiological association with various socio-cultural and economic factors, and ideal interventions of mental disorders should include equal appraisal to biological, psychological, and social aspects. Kumar A, Srivastava P, Kumar P, Kiran M. Social context and consequences of mental illness in changing scenario. Open J Psychiatry Allied Sci.2015;6:156-9. doi: 10.5958/2394-2061.2015.00017.8

Mental illness has very close and intimate relationship with societal factors and components. There have been many theoretical postulations that come from time to time to explain this relationship. In recent years, there is a surge in the researches to explore the biological underpinnings of various psychiatric disorders; despite this, role of societal and cultural factors in the development of psychiatric disorders have not been ruled out by even the most ardent supporter of biological psychiatry. Sarma and Konwar [1] studied health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD) and found significantly reduced HRQOL. Moreover, HRQOL was positively correlated with psychosocial factors. Regarding global burden of disease in terms of daily adjusted life years, the World Health Organization [2] found that: mental disorders contribute four of the ten leading causes of disability; neuropsychiatric disorders contribute 28% of years of life lived with a disability.

Current scenario and challenges of social aspects of mental health
Impact of modernisation, industrialisation, urbanisation, and globalisation on mental health: Different philosophical and ideological approaches have led to polarised views about the impact of globalisation on individuals and society. However, the process clearly has both negative and positive results, and it is likely to create both losers and winners.Globalisation affects psychiatry in three main ways: through its effect on the forms of individual and collective identity, through the impact of economic inequalities on mental health, and through the shaping and dissemination of psychiatric knowledge itself.
The key factor in globalisation is urbanisation.
The rapid increase in urban population worldwide is one among the important global health issues of the 21st century. According to the projections of the United Nations Population Division, by 2030, more people in the developing world will live in urban than rural areas; by 2050, two-thirds of its population is likely to be urban. The scenario in India is also affected by this trend. In India, approximately 28% of the India's population lives in cities and this is expected to increase to 41% by the year 2020. [3] Natural calamity, political pressure, and terrorism: All age groups are affected by the violence of terrorism and the victims can develop a variety of mental health related problems. [4] In a national representative survey in the United States conducted a week after the September 11 terrorist attack, 44% of the adult reported one or more substantial symptoms of stress, and 90% of the adults reported at least low levels of stress symptoms. [5] It was also a matter of study about the childhood reactions to trauma induced by the terrorism worldwide. Children's responses include acute stress disorder, posttraumatic stress disorder, anxiety, depression, regressive behaviours, separation problems, sleep difficulties, and behavioural problems. The recent natural disasters like tsunami, earthquakes, and storms resulting in devastating losses, and high rates of long-term mental health consequences in adult survivors were reported in the surveys. Pillai and Sekar [6] attempted to find out the impact of tsunami on the children. The impact of disaster was substantial and the children suffered from multiple losses. Intrusion and avoidance was equally present.
Change in the family system and life style: While the nuclear family system is increasingly becoming the norm, modern life-styles, changing professional and personal expectations are impacting relationships of marriage and commitment. In cities, young people are starting to choose their own partners and they are in living relationships. On the other hand, lesbian, gay men, and bisexual marriages, however, continue. There are a range of mental health issues that have only relatively recently begun to be acknowledged and researched that relate to people who are lesbian, gay, or bisexual (LGB). [7] Adoption of urban life styles tended to influence health profiles in the family. Changes in the quality of food consumed, including adoption of a 'fast food culture' for convenience, and increased preferences for such food types particularly among the younger generations, are beginning to show negative results.

Critical appraisal of social theories of mental illness
Many hypotheses and theories were developed to discover the aetiological role of society and environment in psychiatric disorders; evaluation in short, more philosophical than practical.

Bio-psycho-social model:
The bio-psycho-social model is simultaneously a philosophy of clinical care and guiding principle for providing practical clinical services to patients. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organisation, from the societal to the molecular.

Vulnerability-diathesis-stress model:
In the past, this model often had limited use because it was impossible to identify diathesis or stressors independently of one another or of an occurrence of maladaptive behaviour. However, increasing sophisticated methods of measuring both diathesis and stressors have developed that have made many of these models more useful. [8] The interplay of both diathesis and stress are not always one sided, to further complicate matters, factors contributing to the development of a diathesis are themselves sometimes highly potent stressors. Death of a parent may acquire a diathesis for becoming depressed in later life. [9] Social causation and selection hypothesis: Social causation states that adversity associated with low socioeconomic status causes disorder. [10] While social selection describes that people with severe mental disorders tend to have downward social mobility ('downward drift' or 'failure to rise') because of their psychopathology. [11] Labeling and modified labeling theory: Labeling theory was developed in 1960's as an explanation to societal attitude and reaction on mentally ill persons. [12] When it came, it had to go through a lot of empirical criticisms. Researchers pointed that they did not seem to confirm the detrimental impact of negative social reaction on people with mental health problems.

How social factors are related to course & outcome of mental illness? An overview of different studies
Social status: The relationship between socioeconomic status and mental illness has been recognised for some time. The income, education, and occupation were used as an index of social status. [13] The National Comorbidity Survey (NCS) in 2004 concluded that individuals with low socioeconomic status demonstrate higher risk for mood disorder than individuals who are economically well-off. Goldberg and Morrison [14] investigated the relationship between schizophrenia and social class, and found that the social class in the schizophrenia patients did not have significant relationship with the onset of illness.

Poverty and unemployment:
It is a well-studied fact that poverty has important implications for both physical and mental health of people. [15] Studies had been done in past for exploring the fact of high concentration of mentally ill people among economically backward segment of the population. One notable hypothesis had been proposed by researchers regarding this issue.The drift hypothesis which suggests that severe mental illness incapacitates the social competence of the affected people, let them shift to poorer urban areas, and also drift down the social scale.

Culture and mental illness:
In recent years, study suggests that there are ethnic differences in rates of mental disorders and acculturation also play role in mental disorder. Various minority or smaller ethnic groups within a large multicultural umbrella conceptualise, treat, and cope with mental disorders much differently than the 'people of dominant' culture. [16] Very often ethnic minority people have to face problems like 'discrimination', 'fear of being swallowed by dominant culture', 'economic and political disparities', etc. Those factors would make them susceptible for developing mental disorders. [17] For better understanding of psychiatric symptoms, their meaning and interpretation in relation to eco-specificity of the region and the cultural context (including religion and myth) signifies need for new focus on ecopsychiatry. [18] Religion and mental illness: The relationship between religion and mental health is not so straightforward and free from debates. Some researchers showed that religiousness could increase mentally ill patients' satisfaction and adherence to treatment.The positive impact of spirituality on adherence to treatmentis explained by an improved quality of life, a better socialsupport, and more positive representations of the illness bybelievers. [19] The close relationship between religion and mental abnormality explained in various psychiatric literatures, which have focused on 'religiosity' of mentally ill people or tried to distinguish between healthy and pathological religious commitment. [20] Stigma and mental illness: Stigma is the negative attitudes or beliefs held about people who are perceived as different. [21] Stigma has several interrelated components, i.e. labeling, stereotyping, discrimination, and exercise of power, and stigmatising attitudes may be related to various factors like demographic and socioeconomic characteristics, illness status, knowledge and attitudes toward mental illness and treatment. [22] Personal experience (or contact) with the person with mental illness (PWMI) had positive impact on knowledge about mental illness and attitude (reactions) towards PWMI. [23] In their study, Kumar et al. [24] found significant difference in the area of nature, cause, after effect, and community mental health ideology between key informants of patients and general population. But, interestingly, there was no significant difference in the area of treatment and stigma.
Some people with mental illness may accept the common prejudices about mental illness, turn them against themselves, and lose self-confidence. This is referred as 'self-stigma'. Self-stigma refers to the reactions of individuals who belong to a stigmatised group and turn the stigmatising attitudes against themselves. [25] The role of mass media: Often media (both print and audio-visual) portrays mental illness in a negative manner owing to lack of actual knowledge about it. The distorted portrayal of mental illness before common people could let down the social status and acceptance of the mentally ill people and their acquaintances. The unfavourable and inaccurate images about mentally ill people often contribute stigma and discrimination that create barriers to treatment and recovery of the individuals. Films, novels, television, and other media represent mentally ill people as unpredictable, child-like, hypersexual, evil, violent, and often committing violent crimes.

Developmental strategies for positive impact of mental health
So, it is quite reasonable that the development of strategies designed to address the socioeconomic determinants of mental health could also have a positive impact in the status of mental health. The different ways in which social factors can be incorporated in promotion of mental health are briefly summarised under the following headings.

Increasing social inclusion:
The evidences clearly indicate that the interventions to improve social networks in terms of social support, social influence, and opportunities for social engagement have positive impact on mental health. It can have two types of effects, as it would improve the quality of life and well-being of the people who are not under stress or as a stress buffer, in which social networks improve the well-being of those under stress by acting as a buffer or moderator of that stress. [26] Widespread negative attitudes towards PWMI impair social reintegration into the community. Therefore, strategies to enlighten the public on mental illness are urgently needed. These can help in the acceptance of PWMI. [27] Reducing discrimination and violence: Evidence suggests that the people who have been exposed to higher levels of discrimination and violence of any forms would likely have poor mental health outcomes in terms of diminished sense of well-being, low self-esteem, lack of control or mastery, psychological distress, and depression, anxiety, and other mental illnesses. Interventions such as racial vilification legislation designed to combat discrimination on the basis of race or ethnicity, sexual harassment complaint procedures designed to combat discrimination on the basis of gender, and codes of conduct are found to be effective mechanisms for reducing discriminating attitudes and behaviours of the public. [28] Increasing economic participation: The socioeconomic conditions such as low income, low literacy, limited education, insecure employment, stressful work conditions or unemployment, poor quality housing, violent and run-down neighbourhoods, and social and political disenfranchisement would lead to exacerbating the mental health problems. So, the strategies which are trying to alter these conditions should be an integral part of promotion of mental health. Economic participation includes a continuum ranging from adequate employment (e.g. secure, appropriately paid, good job satisfaction) to inadequate employment, through to unemployment as well as access to the money and education necessary to feed, clothe, and house one's self and to participate in community life. [29] Enhancing social capital: Social capital can improve access to services for people with mental disorders and so, shorten the duration of these disorders.
[30] The interventions planned for developing and enhancing social capital should be a key consideration while planning interventions to promote mental health, as mental health is a strong factor behind human productivity.

Conclusion
In conclusion, there is sufficient evidence to imply that mental disorder have definite aetiological association with various socio-cultural and economic factors, and ideal interventions of mental disorders should include equal appraisal to biological, psychological, and social aspects. Although researches are going on in this field, it is very difficult to draw conclusion how much social factors play role in the causation and maintenance of mental disorders. Different theories and hypotheses related to social factors add another dimension to our understanding of mental health and mental disorder. This also adds to and enriches the existing interventional strategies. Maintaining mental health in this 21st century is a complex multi-dimensional task. The social mobilisation and social change occur very drastically. The individual has become part of a global village; however, all the changes happening globally in the socioeconomical and political areas like recent economic recession, terrorism, globalisation significantly determine the mental health of each individual. However, the importance of social factors cannot be ignored in the maintaining of mental disorder.