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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

July 3, 1998

Mental Health and Illness Research: Millennium and Beyond *,**




Rumi Kato Price, Ph.D., M.P.E.

Department of Psychiatry

Washington University School of Medicine

Medical Box 8134

St. Louis MO 63110, U.S.A.

Clyde R. Pope, Ph.D.

Kaiser Permanente Center for Health Research

Portland State University

Oregon Health Sciences University

3800 N. Kaiser Center Dr.

Portland OR 97227, U.S.A.

Carla A. Green, Ph.D.

Kaiser Permanente Center for Health Research

3800 N. Kaiser Center Dr.

Portland OR 97227, U.S.A.

Susan C. Kinnevy, M.S.W.

School of Social Welfare

University of Pennsylvania

Philadelphia, PA 19104 U.S.A.

 

* The chapter was prepared as a position paper of the Research Committee on Mental Health and Illnesses (RC49), International Sociological Association (ISA); and was presented at the ISA Research Council Meeting, Montreal, August, 1997.

** All correspondence to: Rumi Kato Price, Ph.D., M.P.E. at the above address, voice mail (314) 286-2282, fax 286-2285, e-mail price@rkp.wustl.edu.

ACKNOWLEDGMENTS

The preparation of this paper was supported in part by the Independent Scientist Award and a research grant (K02DA00221, R01DA010021) from the U.S. National Institute on Drug Abuse/National Institues of Health (R.K.P); and a National Research Service Award (HS00069) from the U.S. Agency for Health Care Policy Research (C.A.G.). We also thank two anonymous reviewers. Their comments are incorporated where feasible.

ABSTRACT

The Mental Health and Illness Research Committee (RC49) of the International Sociological Association (ISA) previously published its position paper with the World Health Organization (Price et al., 1994). Three points were made in that paper: a) practitioners of mental health and illness research come from diverse disciplinary backgrounds; b) historical tensions exist between medical and social science understanding of the etiology of mental health problems and psychiatric illnesses; and c) a discrepancy also exists between theoretical developments and the mission of mental health researchers to provide knowledge which leads to tangible solutions for mental health problems. Building upon the previous paper and the authors' recent research, this second position paper discusses social science perspectives in areas of mental health and illness research that are expected to become increasingly salient toward the Millennium and beyond. Issues in the cross-cultural and international research, conceived as an epistemological and methodological framework, are discussed. As concrete examples of such issues, we discuss research progress in two topical areas, children and adolescent mental health and illness, mental health care utilization. We argue that future international research in mental health and illness require taking consideration for the practical needs of societies in questions, and that contemporary mental health and illness research must pay greater attention to the salient problems of the time. The research must also become more sensitive to its "partner" relationships with those segments of the population who benefit most from research findings.

1. Introduction

In the study of mental health and illness, social scientists have pursued better understanding of the societal and micro-environmental factors that influence the development, treatment, and outcome of mental health and psychiatric disorders. The previously published position paper (Price et al., 1994) of the Mental Health and Illness Research Committee of the International Sociological Association (RC49/ISA) covered conceptual and historical issues. The current paper focuses on applications and discusses contributions of social science perspectives to the areas of mental health and illness research that are expected to become increasingly salient toward the Millennium and beyond. Three such areas involve cross-cultural and international research, child and adolescent mental health and illness, and mental health care utilization. We conclude with an assessment of the potential value of future social science research in general, and in the three areas, in particular.

1.1. RC49's Previous Work

Our previous paper identified historical tensions that exist between medical and social science understandings of the etiology of mental health problems and psychiatric illness. We also argued that there is a discrepancy between theoretical developments and the mission of mental health researchers to provide knowledge that leads to tangible solutions for mental health problems. These tensions may be attributable to the fact that a majority of mental health practitioners-psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses, and occupational therapists treat and counsel patients and, to a lesser extent, teach students of these professions. Their contributions have generally been clinical, while social scientists have contributed primarily through their research activities. Social scientists bring social science perspectives and research to bear on mental health problems, provide consultation and training to mental health professionals, and engage in analyses of the process and outcomes of mental health services provision.

Because their major contributions are research-oriented, social scientists must excel in innovative research activities. This task is difficult to accomplish in the face of dwindling research-related resources in most developed countries. We contended that social scientists in the field of mental health and illness research will need to target efforts in areas which can most benefit from a social science perspective. Extending this position, the current paper selected three areas: cross-cultural and international perspective as an epistemological and methodological framework suited for research in the age of globalization of science; and two topical areas in which social science perspective is salient for several reasons.

1.2. Globalization of Research

Research pertaining to mental health and illness is affected by the forces underlane beneath the shifting of research methodologies and agenda in all social sciences. With rapid advances in transportation, communication and information technology, the rate of globalization seems forever accelerating. Indeed, as implied by its theme, "Contested Boundaries," globalization was a center of previous ISA World Congress in 1994. The globalization characterizes a major impetus for social change currently and the near future. The notion of globalization is useful for studying its impact on mental health and illness, for example, impact of migration and immigration on child and adolescent mental health (see below).

Furthermore, research enterprise itself is no longer constrained much by geopolitical boundaries. Research is becoming increasingly global, a trend which is clearly seen the field of mental health and illness and is expected to continue for some time. With these expectations, globalization as a major trend of current social change on one hand and globalization of research, on the other, we attempt to promote the cross-cultural and international perspective as an epistemological and methodological orientation, which should guide our emphasis areas of research into the future (Price, et al., 1995b). We believe that cross-cultural research, while far from having a place on the mainstream research agenda, will become more important as the demography continue to shift globally over the next several decades.

A characteristic of mental health and illness research, which has traditionally been less pronounced in other fields of social sciences, relate to the multidisciplinary nature of research enterprise. Traditional disciplines engaged in mental health and illness research include psychiatry, psychology, social work, public health, public policy, anthropology, in addition to sociology. Such diversity reflects the complexity of questions studied, as well as the multi-faceted methodologies used to study the phenomena in depth. The multidisciplinary approach creates tension, inefficiency, and territorial disputes over finding, which can hinder smooth progress in science. Nonetheless, this trend is expected to grow, in particular in large-scale studies because no one discipline can provide sufficient expertise to provide answers to the complex forces affecting mental illness and services utilization. Cross-cultural and international research, where multidisciplinary approach is a common place, reflect advantages and disadvantages of mutidisciplinary research.

1.3. Two Emphasis Areas

In this paper, two emphasis areas, child and adolescent mental health, and mental health services utilization, are chosen. Although may other areas of research are equally important, these two areas, in the light of our cross-cultural and international perspective, can be considered as representing new "frontiers" in the mental health and illness research. There is an increasing concern, at least in the United States, about the future of children and adolescents. The public in general perceive the need to understand mental health of children and adolescents because they are the generation of the future, the fact that is becoming concerning more important with decline of babyboomers' productivity. From a public health viewpoint, prevention for children and youth is more cost-effective than intervention for the affected adults. Yet, research on classification, etiology and course of children and adolescents has not accumulated to the same level of knowledge as available for mental health and illness in adult populations. This also seem to be the case for mental health utilization on children and adolescents, even though thousands of articles exist in this area.

In the wake of current health care reform efforts in the U.S., interest in parity for mental health care, and the results of utilization of that care, is higher than ever before. In developing countries, research demands for mental health services utilization are expected to grow, as economic wealth becomes more stabilized and people's preoccupations move beyond those with natural disasters, human warfare and infectious diseases. Social scientists are valuable to the consumers of mental health services, because of critical social and environmental perspectives they are able to integrate into the complex models of the course of mental illness and factors affecting mental health utilization. Such research results can make their way into the hands of consumers, such as the National Alliance of Mental Illness and consumer scorecards for health plans.

People who have mental health problems, especially young people and minorities, are often the most vulnerable segments of society. One of the challenges in conducting research in these areas is that our existing paradigms may need substantial modifications if we are to have an in-depth understanding of the populations most likely be involved in the research. As we will see, the sociocultural approach which employ qualitative or exploratory research is a unique asset of social sciences, that could aid our effort in this direction, in particular in cross-cultural and international research.

The need for substantial modification in the existing paradigms arise also because much of mental health research accepts the medical model approach with little question. Social scientists are in a position to provide significant contributions to the development of a new paradigm or modification of the existing ones, because they takes a critical stance to this medical model (Brown, 1995). In short, by exploring the needed areas of research in the two topical areas, this paper will also address the need for, and a potential direction toward, a new paradigm in mental health and illness research.

2. Cross-Cultural and International Studies

Cross-cultural investigation has grown out of the current dominant modes of mental health research, by replicating, refining and modifying the findings from Western societies. Additionally, cross-cultural investigation has informed areas of inquiry neglected in Western research. In this light, we will first discuss two commonly held positions or paradigms of cross-cultural or international research, followed by a discussion on the converging trend. The focus on epistemological and methodological issues is intended to provide an analytical understanding of some "one sided" efforts shown in the current research.

2.1. Approaches to Cross-Cultural Psychiatry

Comparative psychiatric and mental health research has existed for some time. However, the emergence of cross-cultural studies as part of mainstream mental health research went parallel to the development of social psychiatry or psychiatric epidemiology in North America and Europe. The period from the late 1970's through the 1980's marked the flowering of psychiatric epidemiology, a hybrid of survey research, epidemiology and clinical psychiatry designed to estimate the incidence and prevalence of psychiatric disorders and to identify their risk factors (Regier et al., 1984). The emphasis was placed on the use of precise and uniform case definitions of psychiatric disorder with standardized psychiatric assessment and application of biostatistical analysis methods (Eaton & Kessler, 1985).

Extending these efforts, major large-scale cross-national studies were initiated by the World Health Organization (WHO). The U.S. National Institute of Mental Health (NIMH) also took an initiative in developing standardized diagnostic instruments that can be applied cross-culturally and cross-nationally (Robins et al., 1988). Such major initiatives by the "universalists" met with strong ideological opposition in the early 1980's from "new cross-cultural psychiatry", championed by cultural anthropologists and cultural psychiatrists (Kleinmen, 1987).

2.1.1. The Universalist Approach

The universalist approach is built on the premise of that uniform methodologies are key to understanding cross-cultural differences in mental disorders, and universalists view cultural differences in these disorders as differences in content but not differences in form (Jablensky, 1989). At the universalist core lies the use of standardized instruments to produce nearly-identical assessments across societies. This belief in standardized assessment stems from the medical model in which the use of diagnostic tools on individuals across many different environmental situations is an essential component of accurate disease identification.

The most well-known universalist studies are of schizophrenia (Sartorius et al., 1986), pathways to care (Gater et al., 1991), and mental illness in primary care (Üstün & Sartorius, 1995). Concurrent massive instrumentation efforts, such as the development of the Composite International Diagnostic Interview (WHO, 1994; Takeuchi et al., 1997), represent an attempt to establish a "common language" that would ensure a high degree of comparability across studies of different societies. A problem, however, is that psychiatric studies, unlike medical ones, cannot be conducted in a strict laboratory setting and consequently must rely on patient reports of symptoms. Since societies differ in their perception of both problems and symptoms, it may not be possible to use standardized assessment tools to understand differences in different populations.

2.1.2. The Culturalist Approach

Contrary to the universalist approach, some cultural anthropologists, or the so-called "new" cross-cultural psychiatry school (Littlewood, 1990), insist that such a uniform assessment leads to a "categorical fallacy" in which a construct developed in one society is applied to indicators of a different construct, which nevertheless have similar expressions of the construct of the first society. Kleinman (Obeyesekere 1985; Kleinman, 1987) provides an example of a South Asian psychiatrist studying semen loss syndrome in North America. He argues that "[categorical fallacy] occurs routinely, but [usually] the other way around by imposition of Western categories in societies for which they lack coherence and validity."

The culturalist approach emphasizes the importance of understanding culturally specific manifestations of psychiatric disorders. Researchers need to see the disorder and symptoms as part of a culturally-specific system of beliefs and practices. From the viewpoint of the culturalists, the disorder cannot be teased out without understanding the whole system, although biological factors are not be discarded.

2.2. Converging Trends

Issues in cross-cultural and international research are complex. Conceptual issues include whether or not the underlying construct exists across societies, and if so, the degree to which the constructs overlap across multiple societies and whether or not the assessment measures for the underlying concept are comparable (Flaherty, 1988). Sometimes, the methodological issues involve topics that are beyond measurement capabilities in specific settings. For example, the type of general-population sampling methodology employed in American psychiatry may not be the most informative nor efficient approach for cross-cultural or international research. Parametric statistics tend to ignore a moderate but detectable effect unless sample size is very large, and qualitative differences in a cross-cultural setting may be better articulated by means of ethnographic studies (Price et al., 1995b).

Polemic arguments by the universalists and the new cross-cultural school proponents are extreme. At one extreme are clear cases of categorical fallacy where the constructs in comparison are of different entities, although observed measures seem comparable without in-depth knowledge of both societies. At the other are studies in which measures are limited to only those present across multiple societies; therefore, measures that are good indicators of the construct in the society compared are omitted, and unique cultural aspects will not be observed. Significant results tend to gravitate toward establishing cross-cultural similarities. There is cross-cultural comparability, yet results are biased (Price, 1996).

Between the two extremes, there exits a situation in which, while underlying constructs are conceptually equivalent, measures expressed no not overlap perfectly because of unique customs and expressions (Price, 1996). For example, mothers failing to fix breakfast for children is a sign of lack of parental monitoring is Japan. For U.S. children, it is normal to fix their own bowls of cereal, but the number of hours parents spend with children for extracurricular activities (e.g., soccer) may actually be a measure of parental monitoring equivalent or similar to that in Japan. Semantic comparability is compromised and the validity of the concept cannot absolutely be assured. Nevertheless, results may still be more informative and perhaps more useful to the general public than in either the universalist or culturalist situations, because there is an agreement that the construct exists across societies and that we have knowledge of how expressions are similar or different. Unfortunately, we don't have a splendid method for testing the construct validity. If one were to accept this position, the whole notion of current scientific standards of validity may need reconsideration.

3. Child and Adolescent Mental Health

The issues salient in the cross-cultural perspective is pertinent whenever researchers are unfamiliar with values, brief system and customs of the population under inquiry. Although studying our children and adolescents are not quite like studying aborigines in a Pacific island, it is nevertheless, important to recognize that studying children and adolescents present situations unique to them.

3.1. Problems Unique to Children and Adolescents

The mental health problems of children and adolescents are not simply variations on adult mental health problems, but carry unique signifiers and require unique solutions. Children and adolescents are affected by the same kinds of societal problems as adults, but may manifest those effects in different ways because of their cognitive, emotional, linguistic and physical differences (Garbarino & Kostelny, 1996). Furthermore, untreated mental health problems in children and adolescents compound as they develop into adults, increasing the burden to self and society (Price, et al., 1994). Also, children have a legal status different from adults so that solutions to their mental health problems may be drastically different from those for adults. Our research protocols are also different due to their legal status.

It seems increasingly evident that more children suffer from mental health problems than previously realized. Estimates in the United States alone suggest that as many as 11 to 14 million children under the age of 18 suffer from some sort of mental disorder (LeCroy & Ashford, 1992). This figure represents 22 percent of all children and, high as it is, fails to illustrate the multiplicative effect of child and adolescent mental illness on families, communities, and the larger society.

Of those children with mental health disorders, only half receive the services they need and those services are often inappropriate (LeCroy & Ashford, 1992). According to both the Epidemiologic Catchment Area and the National Comorbidity Studies, mental health needs are consistently undermet among adults, and the available data suggest that the problems are even more pronounced in children and adolescents (Proctor & Stiffman, in press xxx update xxxx). Mentally-ill youth are more likely to receive services through non-specialty sectors, in part due to the fact that so few services are designed specifically for them. Furthermore, mental health services for youth are often contextualized within the framework of adult services, making it difficult to properly diagnose and treat illnesses specific to children and adolescents.

3.2. Global Trends

Worldwide, two global trends appear having particularly important effects on the mental health of children and adolescents. The first is patterns of migration and immigration that result in familial disruption, while the second is the trend toward increasing urbanization and westernization in developing countries.

3.2.1. Migration and Immigration

Migration, which is often the result of war, political unrest, or social upheaval, involves women and children far more often than it involves men. At any given point in time, over half the refugees in the world are under age 18 (Westermeyer & Wahmanholm, 1996). In some instances, youth migrate to neighboring countries for the sake of familiarity with language and custom, while in others, they are dispatched to countries with which they have historical and political ties (Westermeyer & Wahmanholm, 1996). The mental-health consequences of such moves can be significant, in particular, those who arrive under circumstances where they have no resources often exhibit a variety of trauma-related illnesses (Ahmad, 1992).

A recent study of Central American refugee children found that they suffered the same elevated psychological symptoms as a comparison group of Mexican children who had been exposed to domestic violence (McCloskey et al., 1995). Clinical researchers in Germany report that the changes in sociocultural identity brought on by migration can destabilize ego identity and, in children, impede normal personality development (Kohte-Meyer, 1994). Immigrant children often feel isolated and rejected in school due to cultural conflict (London, 1990). Adaptation problems encountered by immigrant children include delayed development, school failure, and school dropout (Jacques, 1989). In a review of the literature on refugee children, Rousseau (1995) includes insomnia, introversion, depressive symptoms, behavioral difficulties, and anorexia among the mental health problems suffered by immigrant children.

In a global report on mental health worldwide, the refugee experience was divided into four phases: pre-flight, flight and separation, asylum, and resettlement (Desjarlais et al., 1995). Because traditional research has focused on the individual psychopathology involved, there is relatively little information on different types of flight and separation situations or the impact of these situations on children's ability to successfully resettle (Rousseau, et al., 1997). Even less is known about the link between pre-flight situation and post-flight resettlement, although it seems that country of origin (Rousseau et al., 1997) and pre- and post-migration family and community environments (Rousseau, 1995) are important determinants of post-migration mental health problems.

3.2.2. Urbanization and Westernization

United Nations figures show that 45 percent of the world's population are urban dwellers, with that number expected to increase to at least 50 percent by the year 2005 (UNPD, 1994). Densely populated city living breeds the high levels of poverty and low standards of living (Cadman & Payne, 1997) that can lead directly and indirectly to mental health problems for children and adolescents. Urbanization has been found to have a negative impact on family systems in Nigeria (Obayan, 1995) and India (Lacpsyis, 1989); to correlate with hypertension (Somova et al, 1995), eating disorders in Netherlands (Hock et al., 1995), and juvenile delinquency in Hong Kong (Oi-Bing, 1995); and to affect cognitive development among Santhal children (Sinha, 1990).

Westernization can bring about a clash with a society's indigenous culture, forming a hybrid culture where conflict between cultural roots and present sociocultural location can produce tension (Bibeau, 1997). In the adult population, westernization has been linked to an increase in alcohol abuse in Taiwan (Colon & Wuollet, 1994), and to schizophrenia in Japan (Ohta et al, 1992). In the child and adolescent population, westernization has been linked to antisocial behavior and substance abuse (Desjarlais, et al., 1995). Nevertheless, the links between westernization and mental disorders by and large remain tenuous.

Westernization should not be confused with modernization, although the two have been equated throughout much of the 20th century (Buntrock, 1996). Huntington (1996) maintains that the power of the West is declining relative to the power of non-Western societies in a multicivilizational world, but that the changing power balance does not preclude westernization in non-Western worlds such as Japan, Singapore, and Saudi Arabia. Many Asian scholars insist that adherence to tradition does not interfere with modernization and that the Western model will not fit all modernizing nations (Marsella & Choi, 1993). Perhaps a key to promote mental health of children in developing countries may rest in preserving traditions in the fact of rapid modernization.

3.3. Child and Adolescent Mental Health Research Areas in Need of Increased Attention

3.3.1. Violence and Clinical Disorders

Most research on psychological trauma in children and adolescents has been conducted using paradigms developed among adult populations that do not account for major variations in the responses of children and adolescents under such circumstances (Arroyo & Eth, 1996). There have been positive developments in this area, however, and children can now be diagnosed through the use of a set of criteria modified from the DSM-IV criteria for adult PTSD, criteria which are less reliant on verbalization, more reliant on behavior, and geared to developmental issues (Zeanah & Scheeringa, 1997). Despite these improvements, the prevalence of post-traumatic stress disorder (PTSD) in children and adolescents is difficult to determine due to the wide methodological variance in collecting data. Additionally, since the cultural relevance of PTSD symptoms has been raised in the past, it is important for researchers to learn symptomatic variations affected by cultural differences. Cultural equivalencies must be established so that assessment tools can be culturally targeted to capture the PTSD experiences of children and adolescents in an increasing number of multicultural societies.

Traumas that result in identity fragmentation affect children differently than adults, because children tend to have fewer psychological resources and are more vulnerable to disruption (Marans & Adelman, 1997). Learning to cope with trauma can lead children to maladaptive behaviors and accommodating developmental adjustments (Garborino & Kostelny, 1997). In the United States, inner-city children have been found to experience a range of post-traumatic stress symptoms, including sleep disturbances, emotional numbing, and biochemical alterations that might reduce their ability to move into productive adulthood (Osofsky, 1995).

3.3.2. Comorbid Substance Use and Abuse

Pioneering work done variously by Brunswick (1979), Kandel (1975), Jessor and Jessor (1977), among others, showed that pathways to substance abuse in adolescence are different than those in adulthood, that high-risk behaviors are interrelated with substance abuse, and that experimenting with substances is often a right-of-passage during childhood and early adolescence. These findings are now well established.

The annual National High School Seniors Survey (e.g., O'Mally et al., 1995) is a current major source of national data in the U.S. regarding adolescent drug use. These nationwide surveys prove to be a stable source of trend data, but incomplete with regard to prevalence because they do not collect data from school dropouts or truants, the group at higher risk for substance abuse (Kaminer, 1994). The National Household Survey on Drug Abuse (e.g., SAMHSA, 1997) tracks children age 12 to 17, but does not include homeless or runaway youths. There is no national data on children younger than 10 who use or abuse drugs, and prevalence among this group is usually an estimate based on extrapolation from various state and local sources (Dryfoos, 1990).

Research in the area of comorbid substance use and abuse has traditionally focused on adults. One large epidemiological study of adult mental health problems found that 37 percent of adults with substance abuse problems had comorbid psychiatric disorders. There is dearth of comparable studies of adolescents and children, and existing studies of substance abuse comorbidity in children and adolescents have methodological problems which preclude generalizability (Bukstein, 1995). Although significant improvements have been made, a problem lies in the lack of operationalized definitions for many of the common comorbid psychiatric disorders, which are distinctive to different age groups of children and adolescents (Kaminer, 1994). The Institute of Medicine recently recommended expanding epidemiological research to include "the nature and extent of co-occurring drug abuse and psychiatric disorders; and improvement in the reliability and validity of the methods for collecting and analyzing data" (IOM, 1996). Developing valid terminology specific to this population with substance abuse and related problems is necessary before such expansion can take place.

Although Kaminer (1994) reports that the substance abuse diagnostic instruments commonly used in child and adolescent psychiatry are "reasonably capable of differentiating users from abusers," research has traditionally focused on the genesis of drug use, with almost no attention given to mediating influences that may account for the differences between users and abusers (Mas & Parga, 1995). Another distinction that needs to be made is between vulnerability to drug use and the causal pathways to that use, with hypothesis-tested research and prospective longitudinal studies conducted to distinguish between drug-related factors and broader contextual factors (IOM, 1996).

    

3.3.3. Risk and Resilience

The social sciences have a long tradition of identifying risk factors for mental illness and substance abuse among the adult population. We know much less about risk factors of this type among children, although there is agreement on the most common variables associated with putting children and adolescents at risk for substance abuse. They can be divided into biological, psychosocial, and environmental factors, and include genetic and physiological vulnerability, metabolic variations, personality traits, familial and peer groups, and socioeconomic status (Thomas & Hsiu, 1993; Webster et al., 1994; Adrados, 1995). Of particular interest is the fact that children and adolescents living with chronic violence accumulate more risks than they can reasonably be expected to handle (Garborino & Kostelny, 1997).

Unfortunately, risk factors are most often defined through post hoc evaluation, after factors have combined to produce a negative outcome (Fraser, 1997). Also, not all risks are causally related to outcome (Kirby & Fraser, 1997), in part because of mitigating protective factors. Relative to the research on risk factors, research on factors that promote resilience in children and adolescents is relatively scarce. Luthar (1991) stresses the protective effects of personality in enabling young children to handle the stress associated with inner-city living. Benard (1993) lists social competence, problem-solving skills, autonomy, and a sense of purpose as measures of resilience in children. Family, community, and personal coping skills are thought to moderate the effects of stress and operate to protect against adverse outcomes (Barbarin, 1993).

In addition to lack of information regarding resilience in children and adolescents, there is also a scarcity of information regarding the mechanism by which risk and protective factors interact. Longitudinal data collection of risk factors and identification of protective factors against adverse outcomes is needed to fill the gap in knowledge (Nash & Fraser, 1997). Many longitudinal studies of children exist from various Western nations (e.g., Hagan et al., 1993). However, because protective factors are likely to be environmentally specific, studies on a wider variety of populations may prove beneficial (Price et al., 1995c).

4. Utilization of Mental Health Services

Although clinicians were long interested in treatment efficacy and prognosis, knowledge on the patterns of services use at the community or population levels were uniquely contributed by social sciences. The U.S. and other Western countries have dominated research on most topics in this area until recent. Our review therefore is based on those findings from U.S. and other Western countries for the most part.

4.1. Trends in the Delivery of Services

4.1.1. Deinstitutionalization

Sociological researchers have long examined the social policies surrounding deinstitutionalization, the transition from institutional to community-based care, including assessments of changes, evaluations of different aspects of local and national systems, and the effects of those systems on various patient outcomes. These studies, for example, include analyses of US policy on provision of community mental health care, suggesting priorities (Mechanic, 1994a), identifying issues related to health insurance reform (Mechanic, 1993), and illuminating gaps and fragmentation in services (e.g., Mechanic, 1991a & b).

Outside U.S., De Leonardis & Mauri (1992) studied deinstitutionalization in Italy, arguing that the Italian experience, unlike what happened in the United States, has been beneficial to both patients and those who provide care for them. Hall (1988) examined New Zealand's policies, making suggestions for proper siting of community mental health facilities, and in a recent work focusing on Quebec, White (1996) described the incremental processes of deinstitutionalization, outlining the political context, public expectations and the successes and failures experienced throughout the transition. Prior (1991) studied the discourse of psychiatric nurses and psychiatrists in Northern Ireland, arguing that these key players are the source of many of the transformations which have taken place in the traditional roles played by psychiatric hospitals, while Stefanis et al. (1986) explored the history of treatment of the severely mentally ill in Greece.

Investigators have also explored the consequences of deinstitutionalization for the judicial system (Arvanites, 1989; Meehan, 1995), and on patient outcomes. Herman & Smith (1989) used qualitative methodologies to study the experiences of ex-mental patients after deinstitutionalization in Canada, identifying problems arising from stigma, poverty and poor housing, lack of basic living skills and appropriate aftercare, and unemployment. In Germany, Kaiser et al., (1996) found significant differences in the subjective quality of life of patients living in different settings, while in Britain, Dayson et al., (1992) examined the causes of resettlement failures after the closure of two mental hospital. O'Brien (1992) studied former long-stay mental hospital patients after they were released to the British Somerset Health District, finding that they were settled in stable situations, but lacked adequate structured day care, living space, work, and leisure activities.

4.1.2. Case Management and Continuity of Care

In the US, the process deinstitutionalization is essentially complete. The focus of community-based treatment programs is now primarily on case management, and various strategies have developed during the transition to community-based care. Additionally, as managed care has become increasingly an important provider of mental health care, case management has come to be viewed as a critical mechanism for cost containment and improving continuity of care for the chronic mental ill.

Current research in this area includes many studies of case management systems and techniques in various settings (Bigelow & Young, 1991; Modrcin, et al., 1988; Rossler et al., 1995; Ridgely et al., 1996; Rubin, 1992; Sands & Cnaan, 1994; Surles et al., 1992; Thornicroft & Breakey, 1991), with mixed but hopeful results, especially for intensive case management strategies. Others have worked to evaluate efforts to improve coordination and continuity of care for the severely mentally ill (Dorwart & Hoover, 1994; Mezzina & Vidoni, 1995; Torrey, 1986; White, 1992). Several significant demonstration projects have also been developed, implemented, and evaluated (Goldman et al., 1994; Marshall, 1992; Rosenfield et al., 1986; Shern et al., 1986; Von Holden, 1993). In particular, the Robert Wood Johnson Foundation's project on chronic mental illness has been well-described and evaluated from multiple perspectives-those of the patients and their families, as well as the providers of care, and as a function of the fiscal outcomes of that care (Cleary, 1994).

4.1.3. Managed Care

As with physical health care, the trend is for mental health services to be provided through managed care systems (Mechanic et al., 1995), with public hospitals continuing to play an important role in caring for uninsured psychiatric patients (Olfson & Mechanic, 1996). Many mental health care services are now supplied through integrated health care systems such as those found in group and staff model HMOs (Durham, 1995) or through specialized systems which are free-standing or carved-out from systems providing physical health services. Payment is frequently by capitation or discounted fee-schedules, whether financing is from government or private health insurance (Christianson et al., 1992; Wells et al., 1995).

4.1.4. Consumer Satisfaction Advocacy

In U.S., highly active and increasingly powerful consumer groups have been at the forefront in demanding more equity in mental health coverage through both private insurance and government programs. For example, the National Alliance for the Mentally Ill (NAMI), has become an increasingly powerful advocate for the mentally ill and their families (Sommer, 1990; Uttaro & Mechanic, 1994; Williams et al., 1986). NAMI has been very successful in redefining mental illness as a biological problem and in gaining access to state and federal legislators. These efforts have sensitized legislators to the problems of those with mental illness (e.g., Domenici, 1993), and have resulted in legislation favorable to the organization's goal of increasing access to care for severe and chronic mental illnesses.

These and other efforts by consumers have led managed care and other systems that provide mental health services to become more sensitive to consumer and purchaser demands for quality and continuity of care. With the increasing consumerism movement, consumer representatives have come to be included in designing and evaluating mental health care systems and services, a feature of many community-based programs established and evaluated as demonstration projects (Kaufmann et al., 1993; Sherman & Porter, 1991). Consumers are also working as service providers in self-help groups (Emerick, 1990); as key parts of community organizations (White & Mercier, 1991), and as case managers (Sherman & Porter, 1991).

4.2. Social Factors Influencing Mental Health Care Utilization

4.2.1. Attributes of Mental Health Service Utilizers

While epidemiological studies indicate that many people receive no treatment for their mental illnesses, the data are quite consistent with regard to the attributes of those who do receive care. For example, Greenley et al. (1987) examined factors associated with seeking help for mental health problems, finding that service users were younger, more likely to be separated or divorced, more psychologically distressed, and had more physical symptoms. Scheffler and Miller (1989) estimated the demand for mental health services among several ethnic subpopulations, finding large differences in demand for care by gender and ethnicity among individuals with the same insurance coverage. Takeuchi et al. (1993) studied referrals to community mental health centers among minority adolescents and found that, compared to whites, African Americans were most likely to be referred by social services agencies and Mexican Americans via school sources.

Additionally, these authors found that poverty was the most important predictor of coercive referrals among adolescents. Portes et al. (1992) looked at differential mental health service needs and use among Mariel Cuban and Haitian refugees in Florida, finding that Haitians' needs were lower than those of Mariel Cubans, but that they were much less likely to be adequately treated. Overall, these and other studies suggest that minority and ethnic groups have both differing needs and access to mental health services.

Various researchers have studied the effects of gender on use of mental health services. Leaf & Bruce (1987) found that women were more likely to receive mental health services in primary care settings than men, but that there were no gender differences in specialty service use. Mechanic et al. found that women, younger, and more highly educated individuals used more psychiatric services (1991). Cleary et al. (1990) studied the effects of patient gender on identification of psychiatric illness in health care settings and found no gender differences after controlling for utilization and type of psychiatric illness. Koss-Chioino (1989) studied beliefs and meanings of nervousness and anxiety among Puerto Rican women, their expression in medical settings, and subsequent diagnoses.

4.2.2. Stigma and Its Effects

Sociologists have a longstanding interest in understanding the effects of stigma on people with mental health problems. Link and his associates have contributed greatly to our understanding of the pervasiveness and consequences of stigma in these populations (e.g., Link, 1987; Link, et al., 1989). Of particular interest is the outcome of Link et al.'s (1991) study in which they evaluated strategies for coping with stigma and found that such efforts produced more harm than good among the patients they studied. Additionally, Lefley (1990) added to our understanding of ethnic and cultural differences in understanding and beliefs that may reduce stigma and improve prognosis among the chronically mentally ill. Researchers have also examined stigma-related process in a variety of non-western cultures. Pearson and Phillips (1994) examined potential roles for social workers with the mentally ill and their families in China, elucidating how stigma-related beliefs and practices produce barriers to care. Kirmayer et al. (1997) studied attitudes and mental illness-associated stigma among the Inuit in Quebec.

A number of stigma-related barriers to receiving mental health have been identified (Domenici, 1993; Smith & Buckwalter, 1993). Some have begun to focus on the portrayal of the mentally ill in the media (Wahl & Lefkowits, 1989; Williams & Taylor, 1995). A major policy-based campaign is underway in the U.S. , spearheaded by NAMI, to further reduce the stigma associated with mental illness by redefining these illnesses as biological in origin.

4.2.3. Treatment and Its Outcomes

Pharmacologic therapy, which has come to be the standard treatment for most patients with a chronic psychiatric disorder, is highly compatible with the shift from inpatient to outpatient treatment, but does not address other problems faced by those with severe and chronic mental disorders. A number of studies have attempted to address how social circumstances influence treatment and its outcomes. Mechanic and Davis (1990) studied how the patterns of inpatient care for patients with psychiatric diagnoses admitted to general hospitals were influenced by their social characteristics and referral sources. Benson (1986) studied patient characteristics and antipsychotic medication prescribing practices of psychiatrists in state mental hospitals. Thara and Eaton (1996) described the effects of demographic, social, and clinical characteristics on long-term outcomes of schizophrenic patients in India. Boyer et al. (1995) studied the treatment practices and the role of inpatient psychiatric care within the mental health care system. Haro et al. (1994) examined social and clinical characteristics associated with risk of rehospitalization for schizophrenia in Denmark.

4.3. Research Areas in Need of Increased Attention

There are a number of new trends in research on mental health utilization. We have selected a few which seem to warrant further attention: mental health care in primary care settings, special population studies, and effects of comorbidities. Not only less knowledge has been accumulated on these topics, but studies on these topics require understanding of unfamiliar settings, populations, or knowledge from different disciplines.

5.3.1. Mental Health Care in Primary Care Settings

There has recently been an emergence of increased interest in the milder forms of mental illness (Cleary et al., 1987). In particular, mild to moderate depression has been recognized as a common morbidity that is often treated in the context of primary care visits. This enhanced awareness has prompted interest in providing guidelines to improve the quality of psychological treatment in primary care, and to evaluate treatment outcomes in a variety of settings (Broman et al., 1994). For the sporadic or less severe mental illnesses, a limited form of psychotherapy, generically known as brief therapy, is replacing other longer-term insight-oriented therapies. Brief therapy has been demonstrated to be effective for some disorders (Crits-Christoph, 1992; Foa et al., 1995; Goenjian et al., 1997; Schramm & Berger, 1994; Tillett, 1996), and therefore complements the cost-containment objectives of managed care (Baker, 1994; Budman & Armstrong, 1994; Chubb & Evans, 1990). However, we do not fully understand the processes leading to the use of either pharmacologic agents or brief therapy, or their attendant outcomes with specific populations. Additional research in these areas can help identify sectors in need of improvement and the types of care most effective for specific groups.

4.3.2. Mental Health Utilization among Specific Populations

Various investigators have begun to assess the utilization of mental health services among populations in different settings (e.g., Jackson et al., 1995). Camino (1989) studied the experience of "nerves" among a group of low-income Black women and described how their distress led them to seek general medical help rather than mental health services; and McFarland et al. (1996) examined patterns of medical and mental health service use, duration of enrollment, and costs of care in a group of severely mentally ill HMO members. With respect to compartive or international research, Eaton et al. (1992a & b) and Ram et al. (1992) used data from psychiatric case registers in Australia, the U.S., Denmark, and Great Britain to explore the long-term course of schizophrenia, and to examine patterns of hospitalization, risks for rehospitalization, and the natural course of the disorder. Keatinge (1987) explored social factors that influenced utilization of psychiatric hospitalization in rural and urban Ireland. As mental health utilization is expected to become a salient problem in developing counties for years to come, much remains to be known about how the mentally ill fare under vastly different mental health systems.

4.3.3. Comorbidities and the Utilization of Services

Introduced already for child and adolescent populations, a great deal of attention has been focused on problems of comorbidity of psychiatric problems and disorders with substance abuse. The research on the processes underlying conditions comorbid to mental health problems has been as varied as the comorbidities and the problems resulting from them. For example, Menezes et al. (1996) described the substance abuse problems of severely mentally ill residents of South London. Jackson et al. (1995) studied the patterns of medical care utilization by depressed patients who used alcohol, while Wittchen et al. (1994) investigated the demographic and social factors associated with generalized anxiety disorder. Forthofer et al. (1996) studied the effects of comorbid psychiatric disorders on the probability and timing of first marriages, while McLeod (1994) studied the effects of anxiety disorders and substance abuse on marital quality.

It has also become evident that significant comorbidity exists between psychiatric and medical illness. Kendrick (1996) explored cardiovascular and respiratory symptoms among primary care patients with long-term mental illness. Barsky et al. (1992) examined the effects of medical morbidity, psychiatric disorder, functional status, and hypochondriacal attitudes on self-assessed health status, and later, Barsky and others investigated the prevalence of psychiatric disorders in patients presenting with palpitations (1994). Susser et al. (1996) researched the risk of HIV transmission among the homeless mentally ill who inject drugs.

Finally, in the policy arena, Mechanic (1994b) discussed issues of parity between mental health/substance abuse benefits and those provided for health care. Herrell et al. (1996) tackled the issue of whether or not severely mentally ill patients with substance abuse problems should be excluded from residential alternatives to hospitalization. As the range of these studies indicate, comorbidity is a key issue in the delivery and outcome of mental health care services. Continued and expanded interest in these areas is critical for providing adequate care to those with mental illnesses and other conditions.

5. Conclusions

In this last section, we first revisit the notion of globalization and our proposal for increased attention to cross-cultural and international research. We conclude this chapter with our assessment of potential values of the social sciences in the field, and our hope for the development of a new paradigm in the future.

5.1. Issues in Cross-Cultural and International Studies: Programmatic or Paradigmatic?

Cross-cultural and interanationl research on mental health and illness is still in its infancy. There are research "infrastructure" requirements needed to conduct research with reasonable rigor in this area, including stable political systems, availability of scientist manpower, technology advances, and the availability of other resources. Not many countries can meet all of these requirements. Therefore, a large-scale international study is often initiated by a Western government (e.g., WHO), or Western researchers who want data from less developed countries. However, such initiatives by Western research can lead to inequality in science. The negative effects of such "foreign aid", unwitting and complex, have not been widely discussed. A ready example is the unquestioned expectation that non-Western researchers adopt Western concepts as a condition for successfully completing educational training.

Western research to date has often led to the belief that good science must be big science. Cross-national studies on mental illness are particularly vulnerable to becoming prey to this belief. Research does tend to become big when international sites are involved. In our opinion, informative cross-cultural and international studies need not to be big in size of participants or a number of sites, but size of input from different groups and different disciplines need to be substantially large. In particular, participation by "indigenous" researchers is absolutely necessary (Price et al., 1995b). Indigenously driven research should not necessarily conform to the standardized assessment protocols, and inequality in science brought about by Western control of research paradigms needs to be sorted out to avoid undue bias in scientific conclusions.

Researchers must remind themselves why they are doing the particular research project to begin with. Results that do not inform the particular society being studied, or do not solve problems in that society, should not be pursued under the guise of science. In the realm of prevention and intervention, where direct returns from research investments can be most clearly seen, protocols must be culturally specific in order for people to understand and accept them. A fairly recent halt in Phase III HIV vaccine clinical trials in the United States (Cohen, 1994) serves to remind us that successful research efforts require community acceptance and support, both in terms of design and outcome. The search for generalizability is useful for those who "finance" research only insofar as its returns are tangible. The discovery of a gene responsible for bipolar disorder would be helpful for genetic engineering and for science as a whole in the long run. However, in a short run it would not help those suffering from the disorder whose episodes are so much affected by their immediate social environments. The utility of cross-cultural and internationsal studies has to be assessed in terms of how the results can be applied to mental health problems in both societies. There are many examples of "tangible returns" in alternative medicine: for example, herbal medicine (Keung & Vallee, 1993) and acupuncture (Colquhoun, 1993). Also in the prevention area, examples exist such as importation of non-Western practices against coronary heart disease (Willett, 1994) and some forms of cancer (Henderson, et al., 1991). Linking etiological factors to prevention at the societal level, however, remains one of the greater challenges facing cross-cultural research in the mental health field.

5.2. Values of Social Science Perspectives

Social scientists work within a multidisciplinary environment long fostered in the field of mental health and illness research. Social science perspectives are particularly valuable in cross-cultural and international work since this research attempts to go beyond the universalist belief in medical models. The development of a new research paradigm depends on an understanding of the way in which social forces differentially impact mental health and illness across a wide range of environments. Providing the basis for such understanding has always been the role of social scientists and will continue to be so in the future.

Cross-cultural and international research can provide tangible returns that may not be universal facts. Prevention and intervention in the mental health and illness field necessarily involves workable change in social environments, and the comparative framework inherent in cross-cultural and international research is particularly amenable to identifying protective factors that may not be apparent in high-prevalence societies (Price et al., 1995c). Another challenge for social scientists is to understand the mechanism by which such protective factors actually affect behavior in a specific society because cultural transfer of preventive measures become possible with such an understanding. Social scientists are uniquely qualified, whether by training or upbringing, to gain the indigenous insights necessary for achieving this understanding.

As the foregoing analysis indicates, child and adolescent mental health and illness research in the 21st century will be affected by migration and immigration, global urbanization and westernization. A comparative framework will be beneficial to identify protective factors (Zeanah & Scheeringa, 1997), since they are difficult to assess if a study focuses only on "cases." Along with developing multicultural assessment tools, it is important to develop a multimodal and multisystemic approach to research with children and adolescents (Gopaul-McNicol, 1997). Such an approach naturally lend to intellectual tradition of social sciences..

Social science disciplines have been important in advancing our understanding of the social processes that affect mental illness, its treatment and outcomes, and the ways in which different societies manage the afflicted (Cook & Wright, 1995; Killian & Killian, 1990). In the area of utilization studies, future studies are particularly needed for better understanding of mental health services in managed care. A greater attention to the social factors that influence the pathways to or away from mental health care in this changing environment (Pescosolido, 1992) will be very important to our understanding of the system, and to providing better care for those who need it. International differences and changes in the provision of mental health care are a variety of natural experiments that social scientists are uniquely qualified to examine.

5.3. Into the Millennium and Beyond

Contemporary mental health and illness research must pay greater attention to the salient problems of the time, and social scientists are in a unique position to provide solutions for contemporary problems related to mental health. Some of the reasons for our ability are historical, some are found in the nature of the discipline, and some are what we bring into the field from our own experiences. In this chapter, we have attempted to specify a few areas in which our expertise would be valuable. For example, because the social sciences have historically mediated between the medical establishment and vulnerable populations, we are particularly able to study mental health problems and comorbid illness among special populations such as children, adolescents, minority groups, and people in developing countries. We are in a unique position to study mental health utilization, because of our understanding of societal impact on system of care.

As social science researchers, nevertheless, we should be reminded that research frontiers for which we are particularly suited are to be served with care. The recent unfortunate closure of the U.S. NIMH-initiated Multisite Study of Mental Health Services Use, Need, Outcomes and Costs in Child and Adolescent Populations (UNOCAP) seems to point to an uneasiness with promoting a big science paradigm when resource allocation to science is limited. Big science may be perceived as even less valuable in the future, unless people who benefit from big science studies see tangible returns on their investment. While maintaining alliance with medicine is important, it is more important in the future to increase sensitivity to "partner" relationships with those segments of the population who benefit most from research findings. Our "subjects" are our customers-people who need new knowledge that helps them. Without understanding this fundamental force for new knowledge, social science perspectives in studying mental health and illness could instead be endangered in the twenty-first century.

    

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