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Social class and measures of social status correlates with mental ill-health. Why might this be?

The social classes in the UK defined by socio-economic status are widely used to categorise people in the numbers of studies and researches. One of the reasons why they are used is that the classes are thought to show the inequality in the level of income. Some researchers think that there may be connections between the social classes and the quality of physical health. For instance, the Marmot Review (2010) suggests that income and wealth may be important for health because they are makers of socio-economic position, and social status is important for health.
The aim of this paper is whether the social class will also correlate with mental health. In order to do this, the impact of social class on our mental health will be discussed from the point of “social capital”. Then, the discussion will be furthered by assessing if the quality of the place where people live will have impact on our mental health well-being.

The definition of social class

According to Office for National Statistics (ONS), the central concept of the National Statistics Socio-economic Classifications (NS-SEC) is to show the structure of socio-economic positions in modern societies in the UK and to help to explain variations in social behaviour and other social phenomena (Office for National Statistics, 2010).
The definition of the social classes has been revised from time to time. For instance, in a study that tried to investigate correlations between mental illness and social classes from 1949 to 1953 in Bristol (Hare, 1955), the classes that Hare used were divided into only five classes of the socio-economic status comparing the currently used set which have eight classes.
The definition of the social class used in a recent longitudinal study of the mental health (Singleton and Lewis, 2003) is based on Registrar general’s 1991 Standard Occupational Classification.

Social Class Descriptive Definition
I Professional
II Intermediate occupations
III NM Skilled occupations (non-manual)
III M Skilled occupations (manual)
IV Partly-skilled
V Unskilled occupations
(Singleton and Lewis, 2003, P.169)

ONS has revised the NS-SEC in 2010 and the current classes are;

1 Higher managerial, administrative and professional occupations
2 Lower managerial, administrative and professional occupations
3 Intermediate occupations
4 Small employers and own account workers
5 Lower supervisory and technical occupations
6 Semi-routine occupations
7 Routine occupations
8 Never worked and long-term unemployed
(Office for National Statistics, 2010)

Although it is worth remembering that definitions occasionally need to be subdivided within a class, in terms of difference grades or difference income (Marmot and Smith, 1991), this issue will not be discussed in this paper. However, the point that in cross-cultural surveys the definitions of the socio-economic status from one society might need to be adjusted in order to avoid misunderstanding the impact caused by cultural differences. This will be explored later.

Mental health and social status
One of its result of the Marmot Review (2010) is that there is a clear gap in the mortality rate between the class 1, higher managerial, and 7, routine occupations (P.17). There is another gap between 1 and 7 on physical health. Nearly 40% of both men and women, age group between 45-64, in routine occupations, suffer from long-term illness. Whereas, the percentage of long-term illness shows by class 1 is just over 10% (P.50). It could, therefore, be said that there are statistical correlations between social classes and physical health.

What if these findings and correlations are applied to social status and mental ill-health; what aspects should be considered? In order to explore this point, it would be good to analyse some findings from the particular study. The study is Better or worse: a longitudinal study of the mental health of adults living in private households in Great Britain (Singleton and Lewis, 2003). This study chooses to investigate those who recovered from common mental disorders, such as depression and anxiety and how this recovery was linked to the socio-demographic and social factors.
The study finds that men who had been unemployed were at high risk of developing an episode of the common mental disorders (Table 2.3, P.27). Both men and women who had had long-term sickness or disability had a high likelihood with onset of the disorder (Table 2.3, P.28), the ratio of which was significantly higher than of both working full- and part-time (P.28). Whereas, people categorised as professional in the social class 1 had a very lower rate of onset with depression and anxiety.
The researchers also find differences between the social classes in how people recovered from the mental disorders. According to the results, there is an evidence that people of lower socio-economic status, such as manual skilled occupations and unskilled occupations, were less likely to recover: this was true for both men and women (Table 3.3, P.42). In addition, both men and women who had long-term sickness or who were disabled showed the lowest percentage of recovery from the disorders (Table 3.3, P42).
These findings would lead us to conclude that the differences between the socio-economic status are defined by the gap of the income and wealth between the classes. The Marmot Review (2010) reports that when the head of household was classified as ‘large employer or higher managerial’, the median household wealth was £530,000, compared with £15,000 where the head of household never worked or was long-term unemployed (P.77).
Analysing the findings from these two studies when we consider the financial inequality between the socio-economic classes, it seems possible to say that people of lower income status are at a higher risk of suffering from mental ill-health than people of higher income. The point of income inequality will later be discussed further, relating to the concept of social capital.
Moreover, there is further factor about the correlation between the social class and mental ill-health; the place where people live and its impact on mental health well-being.
Although there is no direct evidence relating to mental ill-health, the Marmot Review (2010) finds that there are the different mortality rates for those in the same socio-economic classification but who live in different areas in the UK. On the one hand, the mortality rate of routine occupations living in the South-West of England is 400 per 100,000. On the other hand, the mortality rate of those in the same class but living in the North-East of England is 700 per 100,000 (Figure 2.6, P.49).
The study of Singleton and Lewis (2003), though not as significant as the Marmot Review, also provides a clue that the quality of life and infrastructure of a place, including such things as social networks and the neighbourhood where people live, exerts an influence on how likely they will suffer from the mental disorders and how likely they will recover from them.
In the study of Singleton and Lewis, both ratios with the onset of the disorders (P.25) and of the recovery from them (P.39) in all adults are statistically not significant between the areas of urban, semi-urban and rural. There are some studies and meta-analyses that investigate possibilities as to whether both sense and quality of belonging to an area where people live may have an impact on their mental health and well-being when combined with their socio-economic class. This point will be discussed later.

Mental health and income inequality
In an article about life expectancy gap (the Guardian, 3/Jul/2009), a professor at the University of Sheffield said, “when you are poor, you simply can’t choose what you eat”. Another recent survey reports that poor families on low income are forced to pay more and get less (the Guardian, 11/Jan/2011). The economically difficult situations for people in low-income class echo the discussion by some researchers who try to find connections between mental well-being and socio-economic classes.
Stansfeld et al (1998) argue that people in lower socio-economic status groups have less access to material resources, which may also be accompanied by less psychological resources. Fone et al (2006) claim that economic inactivity is a well established risk factor for poor mental health status.
Unsurprisingly, these debates are not new in considering a connection between mental ill-health and socio-economic class. In their study at the Camberwell Reception Center which was a local psychiatric service in a London borough, Tidmarsh and Wood (1972) conclude that most Centre users were living at a very low economic level and had few resources to fall back on when things went wrong.
Once people fall in a lower socio-economic status as well as in a lower income condition, they are likely to be greater risk of suffering from mental ill-health. A possible reason of this condition may be a difficulty in retrieving a better condition, in which the level of their emotional distress could be less. Sayce (2003) quotes a point from a paper by Link and Phelan (2001): status loss and discrimination lead to unequal outcomes or life chances. In other words, if people lose their better socio-economic class to a lower or the lowest one, it would be much harder for them to obtain resources to recover. As Elliott and Masters (2009) suggest, people with mental ill-health may find it extremely difficult to move out of poverty and poverty in turns affects mental health. Ironically, once people accept their illness, this can mean losing the capacity to cope with it (Warner, 2000). In other words, if people’s social status becomes low, their psychological wellbeing has a direct impact on their mental health (Wilkinson and Pickett, 2010).
Warner (2000) describes how harsh society becomes once people fall in mental ill-health.

The mentally ill are some of the least powerful people in society, confronting the restriction of poverty, unemployment, stigma, discrimination and social exclusion (P.37).

They are also among the most alienated people in our society, daily confronting the key elements of alienation - meaninglessness, normlessness and estrangement from society (P.59).

It can be argued that what mentally ill people lose by being classified as low socio-economic status is an own environment to retain their social capital and to use it in order to keep their mental health well-being. According to their literature review on social capital, Whitley et al (2005) defines “social capital” as the sum of an individual’s social relationships which are perceived as assets that allow differential access to societal resources, such as social networks, relation, trust, power and the quality of neighbourhood. They cite an example that any resident in a high social capital neighbourhood will be less likely to be a victim of crime and, in times of need, will be able to access a comprehensive social safety net. This means that high level of social capital will provide people with a more stable life which will in turn enable them to maintain their own mental health well-being.
It could also be another fact, though it seems paradoxical, that people with the low level of social capital might have a difficulty to make their lives better when society changes or even improves its quality. Warner (2004) says;

People with low income respond much more severely to economic change.

When the economy improves, it may be the low-income group that disproportionately has to pay the psychological price of adapting to new jobs in new location with new people (P.38).

Thus, we can summarise that higher rates of emotional distress and mental illness will be found in lower rather than in higher socio-economic groups (Stansfeld et al, 1998). Therefore, considering the level of the income inequality will be one of the probable approaches to understand why the people in the particular social class would have more risk to suffer from the mental ill-health than the others.

Mental health and social ties

Although the study of social capital and health is relatively new (Whitley et al, 2005), there have been increasing numbers of studies that focus on investigating whether social capital influences the quality of mental health well-being.
Whitley et al (2005) quote Putnam’s definition of social capital as the most common one.

1. Community networks: number and density of voluntary, state, and personal networks.
2. Civic engagement: participation and use of civic networks.
3. Local civic identity: sense of belonging, of solidarity, and of equality with other members of the community.
4. Reciprocity and norms of cooperation: a sense of obligation to help others, along with a confidence that such assistance will be returned.
5. Trust in the community

These definitions of social capital seem to lead us to wonder if the quality of life created by the place where we live might provide another clue to understand why social class correlates with mental ill-health.
Phongsavan et al (2006) focuses on trust in community in order to investigate associations between metal health and social capital. They argue that whether social networks and social supports, as distinct from socio-economic status, can buffer the negative effects of life events on mental health for individuals already under stress. They find, then, that having trust in people, feeling safe in the community and engaging in social reciprocity are associated with lower risk of mental health distress.
Although their findings cannot be generalised to clinical diagnoses such as major depression, Kruger et al (2007) suggest that promoting social contact may lead to more positive perceptions of one’s neighbourhood and improve the quality of mental health. What these studies suggest is that the quality of social networks, or social ties (Kawachi and Berkman, 2001), in community, in urban or rural areas, may be a factor that can promote mental health or will conversely lead to a deterioration in mental ill-health.
Kawachi and Berkman (2001) claim that it is agreed that social ties play a beneficial role in the maintenance of psychological well-being. They confirm that integration in a social network may directly produce positive psychological states, which, in turn, may benefit mental health because of increased motivation for self-care. In other words, someone in a well integrated community would be likely to achieve a high level of mental health well-being.
Can we take this finding and transfer it to other countries and cultures?
For example, some people in Japan, particularly men, have recently died alone but their deaths have not been recognised by community and others for long time.
According to a chart from The Spirit Level (P. 20, Wilkinson and Pickett, 2010), Japan is seen as one of the countries with lowest income inequality and also as one of the countries which have least social problems. However, this does not provide a convincing reason why the deaths of some Japanese men have not been found for a month or more. A possible explanation of this situation is that although Japan seems to be a country where the level of income inequality and the gap between socio-economic status groups are relatively small, people might have difficulty in maintaining the quality of their social networks and so keeping their mental health well-being. A probability that a western concept of income inequality is inappropriate to determine the degree of the inequality in different counties, such as Japan, must be considered. In addition, it should be remembered that even if a theory can well describe the identity of one society and culture, the theory might not be useful to describe the identity of a different society.
Our discussion as to whether mental health is affected by the identity of the community must not lose this point. Boydell et al (2001) find that the risk of schizophrenia increases among ethnic minority individuals who are living in neighbourhood where they make up a lower proportion of the population. Whitley et al (2005) also argue this point that high levels of social capital can alienate those who are different from the norm, and heighten their exclusion. A point claimed by Kawachi and Berkman (2001) is worth considering: cohesiveness protects against depressive illness. Whereas, the repressive nature of social regulation is associated with an excess of anxiety disorders.
Some of the findings by Warner will be useful to summarise this part.

Outcome from schizophrenia is much better in the developing world, especially in rural areas where employment in subsistence agriculture is available (P.72, 2000).

In the developed world, outcome from schizophrenia is better among the higher classes in which unemployment rates are low; but, in the developing world, outcome from schizophrenia is better among the lower classes which maintain opportunities for employment in subsistence agriculture (P.72, 2000)

In the developing world, outcome from schizophrenia is worse the better educated (P.182, 2004).

Warner’s main focus is on the correlation between mental health and employment. However, another point of difference between developed and developing worlds would cast a light on the discussion about mental health and social ties. Although we cannot generalise, it seems that if people share a similar social class and similar income in a similar social structure without any unnecessary force, such as any form of least wanted capitalisation, to change their life, people will not be alienated when they suffer from mental disorders.

As mentioned already, the study of social capital and health/ mental health is still new. A careful handling of the concept of social capital is needed when we try to use it to discuss mental health well-being. However, the concept of social capital is useful when we try to investigate the correlation between social status and mental ill-health.

As we have seen that socio-economic status associated with unequal income level has a huge impact on the quality of the mental health and well-being. People of lower social class are more likely to suffer from the mental disorders such as depression and anxiety. Furthermore, because of lower social status correlates with their lower income, these same groups will have difficulty in accessing resources by which people can maintain their mental health well-being. Although it seems that the structure and hierarchy of the modern society is too complicated to bridge the gap between the social classes and income inequality, as a part of the concept of “social capital”, we see that the quality and identity of the place where people live also exerts an influence on our mental health well-being. It should be remembered, however, that more studies will be done to further clarify this issue.



SOC2010 Volume 3 NS-SEC User Manual (2010)

Singleton, N. and Lewis, G (2003) Better or worse: a longitudinal study of the mental health of adults living in private households in Great Britain

The Marmot Review (2010): Fair Society, Healthy Lives

Life expectancy gap between rich and poor is widening
(Friday 3 July 2009 22.38 BST)

Poor families must pay an extra £1,300 a year for basic goods and services
(Tuesday 11 January 2011)

Journals and books
Boydell. J., Os, J., Mckenzie, K., Goel, R., McCreadie, R.G. and Murray, R.M. (2001) Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment. British Medical Journal Vol. 323, 8 Dec, 1-4.

Elliott, L. and Masters, H. (2009) Mental health inequalities and mental health nursing. Journal of Psychiatric and Mental Health Nursing 16, 762-771.

Fone, D., Dunstan, F., Williams, G., Lloyd, K. and Palmer, S. (2007) Places, people and mental health: A multilevel analysis of economic inactivity. Social Science & Medicine 64, 633-645.

Hare, E.H. (1955) Mental Health and Social Class in Bristol. British Journal of Preventive & Social Medicine 9, 191-195

Kawachi, I. and Berkman, L.F. (2001) Social Ties and Mental Health. Journal of Urban Health Vol. 78, No. 3, 458-467.

Kruger, D.J., Reischl, T.M. and Gee, G.C. (2007) Neighborhood Social Conditions Mediate the Association Between Physical Deterioration and Mental Health. American Journal of Community Psychology 40, 261-271.

Marmot, M.G. and Smith, D.G. (1991) Health inequalities among British civil servants: The Whitehall II study. Lancet 337, 1387-93.

Phongsavan, P., Chey, T., Bauman, A., Brooks, R. and Silove, D. (2006) Social Capital, socio-economic status and psychological distress among Australian adults. Social Science & Medicine 63, 2546-2561.

Sayce, L. (2003) Beyond Good Intentions. Making Anti-discrimination Strategies Work. Disability & Society Vol. 18, No. 5, 625-642.

Stansfeld, S.A., Head, J. and Marmot, M.G. (1998) Explaining social class difference in depression and well-being. Social Psychiatry and Psychiatric Epidemiology Vol. 13, No. 1, 1-9.

Tidmarsh, D. and Wood, S. Psychiatric aspects of destitution: a study of the Camberwell Reception Centre from Evaluating a community psychiatric service edited by Wing, J.K. and Hailey, A.M. London: Oxford University Press, 1972.

Warner, R. The Environment of Schizophrenia. London: Brunner-Routledge, 2000.

Warner, R. Recovery from Schizophrenia. 3rd ed. London: Routledge, 2004.

Wilkinson, R. and Pickett, K. The Spirit Level. London: Penguin, 2010.

Whitley, R. and McKenzie, K. (2005) Social Capital and Psychiatry: Review of the Literature. Harvard Review of Psychiatry Vol. 13, No. 2, 71-84.




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