July 3, 1998
Health and Illness Research: Millennium and Beyond
Rumi Kato Price,
University School of Medicine
Medical Box 8134
St. Louis MO
Clyde R. Pope,
Center for Health Research
3800 N. Kaiser
Portland OR 97227,
Carla A. Green,
Center for Health Research
3800 N. Kaiser
Portland OR 97227,
Susan C. Kinnevy,
School of Social
* 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,
** All correspondence to: Rumi Kato Price, Ph.D., M.P.E. at
the above address, voice mail (314) 286-2282, fax 286-2285,
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
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.
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
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
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.
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
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
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
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
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
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
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
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
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,
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
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,
4.2. Social Factors Influencing Mental Health
4.2.1. Attributes of Mental Health Service
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
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
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
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
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
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
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
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
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
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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