Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-017The Influence of Social Factors on Mental HealthDavid Mechanic* and Donna D. McAlpineInstitute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USASocial factors have an enormous influence on the life course,affecting development and socialization, the relative influence offamilies and peer groups, opportunities for work, recreation andsocial participation, and patterns of social integration andindependence as one reaches the later years. With the rapidityof social change, persons living a normal lifespan are required tomodify their expectations and behavior on many occasions if theyare to adapt successfully to shifting social conditions. Transformationsin technology, sexuality, fertility, family and work life,household structure and many other facets of life, also make itinevitable that different age cohorts will have diverse lifeexperiences.Almost every aspect of mental health and well-being areinfluenced by social factors and social institutions 1 . The effectivenessof social institutions, and the extent to which they buildsupportive relationships, coping capacities and personal commitment,contribute importantly to mental health outcomes. Thedynamics of populations, and the distribution of persons atvarying ages, also affect the productive capacities of nations, theprevalence of disability and dependence, and the capacity of asociety to protect its citizens against the risks of disadvantage.Social attitudes and patterns of community organization caneither encourage or inhibit full participation and meaningful rolesfor children, the elderly, the disabled or other groups, affectingfunctioning, quality of life and psychological well-being.The discussion that follows focuses more on severe mentalillness than on levels of psychological distress or emotional wellbeing.The distinction is not clear-cut because even depressivesymptoms short of a clinically diagnosable disorder can havedevastating effects on functioning and quality of life and are amajor source of disability, surpassing in impact many seriouschronic diseases 2 .Severe mental disorder, such as depression, bipolar conditions,and schizophrenia results from complex, but poorly understood,interactions between biological vulnerabilities and psychologicaland social influences. Adverse social and developmental factorsmay increase susceptibility to serious mental illness, or maycontribute to triggering illness among vulnerable persons. Amongpersons with mental illness, social factors may significantlyameliorate symptoms, influence treatment patterns and enhanceor impair quality of life. Most of the major social factors—age,gender, social class, race and ethnicity, familial arrangements andthe like—are associated with mental illness, either by contributingto its onset or course or because of social selection factors.Moreover, there are complex interactions among social factors*To whom correspondence should be addressedsuch that, for example, the impact of socioeconomic status orgender on mental health outcomes may vary by age or by birthcohort.The epidemiology of illnesses that first occur later in life maybe quite different from chronic conditions that persist throughmuch of the life course. Understanding the occurrence of mentalillness later in life, however, is complicated by the relationshipsbetween physical illness, drug use (commonly prescription drugs)and the occurrence of symptoms consistent with mental illness.Prescription and non-prescription drug use is high in elderlypopulations because of the prevalence of illness. The inappropriateuse of pharmaceuticals among elderly persons is also commonand includes physicians over-prescribing to older patients, selfmedicationand drug interactions 3 . Moreover, drug sensitivitychanges with age-related changes in individuals’ capacity toabsorb and metabolize drugs; therefore, dosages effective inyounger patients may be ineffective or excessively high for olderpatients. There continues to be considerable concern that institutionalsettings over-use medication in order to sedate and controlpatients. Drug reactions, including confusion, hallucinations,paranoia and mania, are common and may be inappropriatelydiagnosed as mental illness.Schizophrenia typically first occurs in late adolescence or inearly adulthood and may have a complex and fluctuatingcourse. Follow-up studies of early-onset schizophrenia indicatethat, with aging, the positive symptoms of schizophrenia abateor remain in remission for longer periods of time, and that fora significant minority of persons complete remission ispossible, although the processes that lead to such outcomesare not well understood 4 . Selective mortality or the naturalcourse of the disorder may be responsible for the relativelypositive outcomes observed among older persons with schizophrenia.It is also possible that lowered personal expectations,the development of coping strategies, improved adaptation andlearning how to avoid upsetting stresses also contribute topositive outcomes for persons with schizophrenia. On the onehand, persons with chronic schizophrenia bring into their lateryears life histories that are likely to be characterized bysignificant periods of disorder and disruption. On the other hand,they bring an array of skills and coping strategies, developedthrough dealing with illness over many years, and these maymitigate the potentially negative impact of the illness during laterlife.Late-onset schizophrenia is relatively rare and little is knownabout its course 5,6 . The lack of evidence of late onset ofschizophrenia and other psychoses among the elderly may inpart result from diagnostic practices that give priority to cooccurringdementia and confusion that are highly prevalent inPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd