Mohammed T. Abou-Saleh

THE INFLUENCE OF SOCIAL FACTORS ON MENTAL HEALTH 97different stages of their conditions remain unclear 25 . There ismuch research suggesting especially that intrusive forms of socialinteraction involving criticism may be detrimental to schizophrenicpatients, and the relative protectiveness of intimacy,friendship and instrumental assistance in depression remainunclear. Social support remains a vague concept, having varyingoperational definitions. Contrasting views of social supportexplain some of the conflicting research results.There is increasing research attention being given to the role ofreligion and religious participation in health outcomes for theelderly and a variety of studies suggest that different aspects ofreligious involvement play an important role 26 . The pathwaysthrough which such effects are manifested remain unclear,although there is increasing suggestion that the social supportsand instrumental assistance that might result from religiousinvolvement contribute to better health. Research in this areaconfronts difficult selection biases, in that persons in better healthmay be more able and inclined toward religious participation andthat persons drawn to varying religious practices may be differentin their personalities, attitudes and behaviors than those withlesser or no participation. Nevertheless, the research in this area isgaining rigor and is suggestive of potential pathways.The focus on coping skills as an important determinant ofadaptation in more theoretically orientated studies has foundexpression in the development of psycho-educational programs toassist chronic mental patients in their rehabilitation. Although theresearch is modest, it supports the value of problem-orientatededucational approaches that assist patients to manage everydaylife situations better 27 . Psychosocial research on the importance ofself-efficacy has been translated into programs to increase patientempowerment. It has been suggested that such empowerment is animportant feature of the success of some commonly studiedrehabilitation programs 28 . Increased empowerment may be animportant factor, ameliorating the negative impact of highlyregimented settings, such as nursing homes and other custodialinstitutions, but its therapeutic role in the normal range of lifesettings is yet to be established 29 .Social factors shape the processes through which individualsand families define illness, evaluate its meaning and significanceand make decisions about needed care and appropriate practitioners.Epidemiological evidence shows that much serious mentalillness is untreated, and those receiving treatment obtain servicesfrom a wide variety of practitioners. Processes of help-seeking areinfluenced by broad social beliefs about the nature of illness andwhat should be treated, characteristics of the individual and thesocial contexts in which mental illness occurs, and the organizationof services and their physical, social and economicaccessibility 1 . Members of varying age cohorts have beensocialized differently in relation to the recognition of symptoms,appropriate sources of help and the social stigma of seeking carefor particular types of problems. Selection from the community tovarying types of service providers is a two-stage process, whichdepends on general factors affecting the inclination to seekassistance, and other factors more specific to the choice amongalternative practitioners. A large proportion of all patientsreceiving care for a mental illness receive such care exclusivelyfrom general medical practitioners, and decisions affecting referralto the specialty mental health sector result not only from personaldefinitions and inclinations of patients and their families, but alsofrom the organized pathways within a health care system, theability of generalists to recognize mental illness in their patientsand their attitudes to specialty mental health services. Patientswith mental illness are referred more readily to specialized serviceswhen illness and illness behavior imply social risk and disruption30 . Diagnosis, itself, is a poor predictor of the referral process.Patterns of help seeking differ by age. The elderly are less likelyto seek psychiatric care than younger adults, and probably aremore reluctant to report affective symptoms to interviewers orphysicians. In contrast, the elderly complain commonly in generalmedical settings of diffuse physical symptoms and vegetativesymptoms characteristic of depression, and have relatively highrates of receiving prescribed psychoactive drugs. While somatization,as measured more formally, does not seem to vary by age,the elderly are more likely to present distress in a somatic idiom.Interpretation is complicated by the fact that the elderly havehigher rates of ill-health and chronic disease than youngerindividuals, and it is difficult to sort out physical concomitantsof chronic disease from somatization of psychosocial distress anddepression. Psychoactive drug use also reflects physician behavior,which may be shaped by stereotypes of the elderly and otherfactors.The social response to mental illness is influenced by suchfactors as general attitudes, values and ideologies, concepts of thenature of disorders and their causes, available treatmenttechnologies, the structure of health and welfare services, andthe system of social entitlements that a society makes available.The deinstitutionalization of the mentally ill has followed adifferent course in varying countries, but each of the above factorsplays some role in every instance. In the USA, large-scaledeinstitutionalization only became possible in the middle 1960swith the expansion of welfare programs that provided subsistenceand payment for alternative residential care for mentally illpatients in the community. Some of the evident difficulties incommunity mental health services reflect cutbacks or fluctuationsin welfare and housing entitlements 1 .The magnitude of serious mental illness depends on thedistribution of the population, and the numbers of persons inage groups at risk for varying diseases and disabilities. The burdenof mental illness depends not only on its magnitude but also onthe types of social institutions and programs that help insulatepatients, families and communities from its most disruptivestresses. The elderly population, and persons at very old ages,are growing in the USA and many Western countries. Thedementias are increasingly important, and patients with suchdisabilities constitute a growing proportion of the severe mentallyill population. Depending on the constellation of institutionalservices and home-care programs, patients with dementia aretreated in a variety of settings, some placing very large burdens onfamilies and friends. The distribution of such burdens, and thedefinition of responsibilities, is a political process and a key socialpolicy issue throughout the world.For the last several decades, the nursing home has been thesetting for care of persons who are greatly restricted in theactivities of daily living, and a large proportion of persons in thesesettings have dementia and depression as a secondary condition 31 .Typically, admission to nursing homes occur when individuals areincapable of caring for themselves, when their physical andpsychiatric problems create unmanageable burdens for theircaretakers, or when community caretakers are no longeravailable. Admission is often triggered by such events assignificant loss of function following trauma, such as hipfractures, confusion and wandering, and incontinence. Relativelyfew elderly with a primary diagnosis of mental illness, withoutdementia, are in nursing homes, although nursing home admissionoften exacerbates confusion, apathy and depression. Mostelderly persons resist nursing home admission as long as they can,and increasingly alternative community settings and home-careservices are provided to prevent or delay such admission 32 .Nursing homes, like the traditional long-term mental hospital,contribute to an institutional syndrome resulting from vulnerabilitesof patients as they respond to decreased socialparticipation, sensory deprivation, loss of efficacy and controlover daily life decisions, institutional routinization and the like.There is persuasive evidence that efforts to keep patients involved