Radically reframing studies on neurobiology and socioeconomic circumstances: A call for social justice-oriented neuroscience

Socioeconomic circumstances are associated with symptoms and diagnostic status of nearly all mental health conditions. Given these robust relationships, neuroscientists have attempted to elucidate how socioeconomic-based adversity "gets under the skin." Historically, this work emphasized individual proxies of socioeconomic position (e.g., income, education), ignoring the effects of broader socioeconomic contexts (e.g., neighborhood socioeconomic disadvantage) which may uniquely contribute to chronic stress. This omission represented a disconnect between neuroscience and other allied fields that have recognized health is undeniably linked to interactions between systems of power and individual characteristics. More recently, neuroscience work has considered how sociopolitical context affects brain structure and function; however, the products of this exciting line of research have lacked critical sociological and historical perspectives. While empirical evidence on this topic is burgeoning, the cultural, ethical, societal, and legal implications of this work have been elusive. Although the mechanisms by which socioeconomic circumstances impact brain structure and function may be similar across people, not everyone is exposed to these factors at similar rates. Individuals from ethnoracially minoritized groups are disproportionally exposed to neighborhood disadvantage. Thus, socioeconomic inequities examined in neuroscience research are undergirding with other forms of oppression, namely structural racism. We utilize a holistic, interdisciplinary approach to interpret findings from neuroscience research and interweave relevant theories from the fields of public health, social sciences, and Black feminist thought. In this perspective piece, we discuss the complex relationship that continues to exist between academic institutions and underserved surrounding communities, acknowledging the areas in which neuroscience research has historically harmed and/or excluded structurally disadvantaged communities. We conclude by envisioning how this work can be used; not just to inform policymakers, but also to engage and partner with communities and shape the future direction of human neuroscience research.

The Serpent of Their Agonies: Exploitation as Structural Determinant of Mental Illness

BACKGROUND

Social stratification is a well-documented determinant of mental health. Traditional measures of stratification (e.g., socioeconomic status) reduce dynamic social processes to individual attributes downstream of mechanisms that generate stratification. In this study, we measure one process theorized to generate and reproduce social stratification-economic exploitation-and explore its association with mental health.

METHODS

Data are from the 1983 to 2017 waves of the Panel Study of Income Dynamics, a nationally representative cohort study (baseline N = 3059). We operationalized "unconcealed exploitation" as the percentage of individuals' labor income they were hypothetically not paid for productive hours. We ascertained psychologic distress and mental illness with the Kessler-6 (K6) scale.

RESULTS

We fit inverse probability-weighted marginal structural models and found that for each unit increase in unconcealed exploitation, psychologic distress increased by 1.6 points (95% confidence interval = 0.71, 2.5) on the K6 scale and the odds of mental illness tripled (odds ratio = 3.0, 95% confidence interval = 1.5, 6.1). Results were not driven entirely by overwork and were robust to different inverse probability-weighted estimation strategies and sensitivity analyses.

CONCLUSIONS

Exploitation is associated with mental illness. Focusing on exploitation rather than its consequences (e.g., socioeconomic status), shifts attention to a structural process that may be a more appropriate explanatory mechanism, and a more pragmatic intervention target, for mental illness.

A Call to Action. A Critical Review of Mental Health Related Anti-stigma Campaigns

Using a knowledge-attitudes-behavior practice (KABP) paradigm, professionals have focused on educating the public in biomedical explanations of mental illness. Especially in high-income countries, it is now common for education-based campaigns to also include some form of social contact and to be tailored to key groups. However, and despite over 20 years of high-profile national campaigns (e.g., Time to Change in England; Beyond Blue in Australia), examinations suggest that the public continue to Other those with experiences of mental ill-health. Furthermore, evaluations of anti-stigma programs are found to have weak- to no significant long-term effects, and serious concerns have been raised over their possible unintended consequences. Accordingly, this article critically re-engages with the literature. We evidence that there have been systematic issues in problem conceptualization. Namely, the KABP paradigm does not respond to the multiple forms of knowledge embodied in every life, often outside conscious awareness. Furthermore, we highlight how a singular focus on addressing the public's perceived deficits in professionalized forms of knowledge has sustained public practices which divide between "us" and "them." In addition, we show that practitioners have not fully appreciated the social processes which Other individuals with experiences of mental illness, nor how these processes motivate the public to maintain distance from those perceived to embody this devalued form of social identity. Lastly, we suggest methodological tools which would allow public health professionals to fully explore these identity-related social processes. Whilst some readers may be frustrated by the lack of clear solutions provided in this paper, given the serious unintended consequences of anti-stigma campaigns, we caution against making simplified statements on how to correct public health campaigns. Instead, this review should be seen as a call to action. We hope that by fully exploring these processes, we can develop new interventions rooted in the ways the public make sense of mental health and illness.

Theorising social class and its application to the study of health inequalities

The literature on health inequalities often uses measures of socio-economic position pragmatically to rank the population to describe inequalities in health rather than to understand social and economic relationships between groups. Theoretical considerations about the meaning of different measures, the social processes they describe, and how these might link to health are often limited. This paper builds upon Wright's synthesis of social class theories to propose a new integrated model for understanding social class as applied to health. This model incorporates several social class mechanisms: social background and early years' circumstances; Bourdieu's habitus and distinction; social closure and opportunity hoarding; Marxist conflict over production (domination and exploitation); and Weberian conflict over distribution. The importance of discrimination and prejudice in determining the opportunities for groups is also explicitly recognised, as is the relationship with health behaviours. In linking the different social class processes we have created an integrated theory of how and why social class causes inequalities in health. Further work is required to test this approach, to promote greater understanding of researchers of the social processes underlying different measures, and to understand how better and more comprehensive data on the range of social class processes these might be collected in the future.

Digital Platforms, Gig Economy, Precarious Employment, and the Invisible Hand of Social Class

Digital platform capitalism, as exemplified by companies like Uber or Lyft has the potential to transform employment and working conditions for an increasing segment of the worforce. Most digital economy workers are exposed to the health damaging precarious employment conditions characteristic of the contemporary working class in high income countries. Just as with Guy Standing or Mike Savage's "precariat" it might appear that digital platform workers are a new social class or that they do not belong to any social class. Yet the class conflict interests (wages, benefits, employment and working conditions, collective action) of digital platform workers are similar to other members of the working class.

Economic, Cultural, and Social Origins of Emotional Well-Being

Linking theories of social stratification, ethnicity, and mental health with theories of human and social capital, the authors examine the impact of economic, cultural, and social factors on five different dimensions of emotional well-being for immigrants and natives at midlife. Based on data from the 1992 wave of the Health and Retirement Study, the authors found that economic factors and human capital variables are the most important determinants of emotional health for both immigrants and natives. The results indicate that cultural factors can enhance emotional well-being. Religious affiliation and participation are important for both immigrants and natives, but religious participation appears to be more beneficial for immigrants. Being part of a couple was also associated with better emotional health, especially for immigrants. The effects of several determinants of emotional health differed across immigrant groups. It was found that marriage, education, and the presence of economically stable kin are particularly important for Cubans.

Anti-Egalitarianism, Legitimizing Myths, Racism, and “Neo-McCarthyism” in Social Epidemiology and Public Health: A Review of Sally Satel's PC, M.D

Sally Satel's PC, M.D.: How Political Correctness Is Corrupting Medicine constitutes an attempt to weaken the influence of egalitarian and antiracist scholarship in contemporary public health. This book has been widely distributed and has received many positive reviews in academia and the general press. Surprisingly, Satel has enlisted the direct or indirect support of prominent public health academics. The authors' critical review of this book indicates that Satel uses a combination of tactics to convince the reader of the danger involved in egalitarian public health efforts. Among them are insults, traditional “red baiting” tactics, “triangulation,” exaggeration, emotionally charged examples, omissions, and a strong appeal to individual responsibility to explain social inequalities in health. PC, M.D. reveals a scientific and ideological conflict over the determinants of health in populations that takes place within and outside the public health discipline. Efforts such as PC, M.D. suggest that social epidemiologists and other egalitarian public health scholars are having some impact in shaping how the public views health disparities.

Anxious? Depressed? You might be suffering from capitalism: contradictory class locations and the prevalence of depression and anxiety in the USA

Despite a well-established social gradient for many mental disorders, there is evidence that individuals near the middle of the social hierarchy suffer higher rates of depression and anxiety than those at the top or bottom. Although prevailing indicators of socioeconomic status (SES) cannot detect or easily explain such patterns, relational theories of social class, which emphasise political-economic processes and dimensions of power, might. We test whether the relational construct of contradictory class location, which embodies aspects of both ownership and labour, can explain this nonlinear pattern. Data on full-time workers from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 21859) show that occupants of contradictory class locations have higher prevalence and odds of depression and anxiety than occupants of non-contradictory class locations. These findings suggest that the effects of class relations on depression and anxiety extend beyond those of SES, pointing to under-studied mechanisms in social epidemiology, for example, domination and exploitation.

Two decades of Neo-Marxist class analysis and health inequalities: A critical reconstruction

Most population health researchers conceptualize social class as a set of attributes and material conditions of life of individuals. The empiricist tradition of 'class as an individual attribute' equates class to an 'observation', precluding the investigation of unobservable social mechanisms. Another consequence of this view of social class is that it cannot be conceptualized, measured, or intervened upon at the meso- or macro levels, being reduced to a personal attribute. Thus, population health disciplines marginalize rich traditions in Marxist theory whereby 'class' is understood as a 'hidden' social mechanism such as exploitation. Yet Neo-Marxist social class has been used over the last two decades in population health research as a way of understanding how health inequalities are produced. The Neo-Marxist approach views social class in terms of class relations that give persons control over productive assets and the labour power of others (property and managerial relations). We critically appraise the contribution of the Neo-Marxist approach during the last two decades and suggest realist amendments to understand class effects on the social determinants of health and health outcomes. We argue that when social class is viewed as a social causal mechanism it can inform social change to reduce health inequalities.

Invited commentary: On the future of social epidemiology--a case for scientific realism

In their article in this issue of the Journal (Am J Epidemiol. 2013;178(6):843-849), Galea and Link identify important heuristics for our discipline. In this commentary, I build upon their ideas by arguing that (1) social epidemiology has become an Asian, European, Latin American, and African rather than just North American endeavor, (2) realism is better suited to social epidemiology than positivism, (3) more work on social mechanisms (social class relations, racial discrimination) is needed to increase the explanatory power of social epidemiology, (4) increased attention on (social) causal models will generate more innovative social interventions, and (5) social interventions should be conducted in full partnerships with affected populations.

Individual and national level associations between economic deprivation and partner violence among college students in 31 national settings

This study expands previous work by examining individual and national level effects of economic deprivation on partner violence among college students. Three main hypotheses were tested: (1) individual level economic deprivation (i.e., ability to meet daily needs and family income) is associated with partner violence, (2) gross national income is associated with the mean rates of partner violence across nations, and (3) the association between individual level economic deprivation and partner violence varies according to the economic national context as measured by gross national income. Data for 14,090 participants from 31 nations came from the International Dating Violence Study that queried university students about violence in their relationships and relevant risk factors. A series of overdispersed Poisson hierarchical linear regression models were specified to test the hypotheses. Ability to meet daily needs, but not family income, was associated with rates of partner violence. Gross national income was also associated with mean rates of partner violence across nations as well as the relationships between ability to meet daily and partner violence and between family income and partner violence. The findings show the importance of context, as indicated by national economic standing, on rates of partner violence. Not only do economically deprived individuals experience more partner violence, but those living in poorer nations experience more partner violence, regardless of individual economic deprivation. Limitations of the study include a non-random sample and substantial variation in the study sites beyond economic standing. Nonetheless, findings indicate efforts to confront partner violence must also call for cross-national economic development.

Social inequalities in mental health: results from the EU contribution to the World Mental Health Surveys Initiative

PURPOSE

The objective of the present study was to provide updated data from nine European countries about the impact of social inequalities in the prevalence of common mental disorders.

METHODS

Cross-sectional household survey of a representative sample of the adult general population of Belgium, Bulgaria, Germany, Italy, The Netherlands, Northern Ireland, Portugal, Romania and Spain. In total, 34,395 individuals were included. Social inequalities in 12-month mood, anxiety and alcohol-related disorders were evaluated.

RESULTS

In Europe, income seems not to be related to the prevalence of mental disorders. Unemployment and disablement are associated with mental disorders. Lower educational level augments the risk for mood disorders. Living in small (rural) areas decreases the risk for mood disorders and living in urban settings increases it. Northern Ireland, Portugal and Belgium are the countries with the highest risks for mental disorders.

CONCLUSIONS

Despite some contradictions with previous literature, in Europe there are social inequalities in the prevalence of mental disorders. However, income showed not to be associated with inequalities in mental health. Being younger, unemployed or disabled, with no education or incomplete primary studies, living in urban settings, and in Northern Ireland, Portugal or Belgium were associated to an augmented prevalence of mental disorders. Policy makers could focus on mental health promotion and mental disorders prevention programmes for risk groups such as unemployed/disabled individuals. Support to vulnerable groups (unemployed or those with less education) and mental health literacy can improve European citizens' mental health.

Racial discrimination: a continuum of violence exposure for children of color

This article reviews and examines findings on the impact of racial discrimination on the development and functioning of children of color in the US. Based on current definitions of violence and child maltreatment, exposure to racial discrimination should be considered as a form of violence that can significantly impact child outcomes and limit the ability of parents and communities to provide support that promotes resiliency and optimal child development. In this article, a conceptual model of the effects of racial discrimination in children of color is presented. The model posits that exposure to racial discrimination may be a chronic source of trauma in the lives of many children of color that negatively influences mental and physical outcomes as well as parent and community support and functioning. Concurrent exposure to other forms of violence, including domestic, interpersonal and/or community violence, may exacerbate these effects. The impact of a potential continuum of violence exposure for children of color in the US and the need for future research and theoretical models on children's exposure to violence that attend to the impact of racial discrimination on child outcomes are discussed.

Art in Mind: implementation of a community arts initiative to promote mental health

The arts and health agenda has experienced considerable expansion in the UK in recent years, against a backdrop of increasing social inequality and rising incidence of mental health problems. This paper explores the role of community arts in combating social and mental health inequalities as exemplified by one particular project, Art in Mind, in Nottingham, which is funded by England's New Deal for Communities programme and is designed to promote mental health. In describing Art in Mind's conceptualisation and implementation, attention is given to the importance of developing community networks that are designed to build social capital for participating groups and individuals, in order to combat health and social inequalities.

The troubled relationship between psychiatry and sociology

The alienated relationship between psychiatry and sociology is explored. The two disciplines largely took divergent paths after 1970. On the one side, psychiatry manifested a pre-occupation with methodological questions and sought greater medical respectability, with a biomedical approach returning to the fore. Social psychiatry and its underpinning biopsychosocial model became increasingly marginalised and weakened. On the other side, many sociologists turned away from psychiatry and the epidemiological study of mental health problems and increasingly restricted their interest to social theory and qualitative research. An interdisciplinary void ensued, to the detriment of the investigation of social aspects of mental health.

Gender, occupational, and socioeconomic correlates of alcohol and drug abuse among U.S. rural, metropolitan, and urban residents

OBJECTIVE

To estimate the prevalence and correlates of alcohol and drug abuse and dependence among rural, urban, and metropolitan U.S. residents.

METHODS

The National Comorbidity Survey (NCS) (1990-1992) yielded lifetime risks of psychiatric disorders in a probability sample of 8098 respondents in the 48 contiguous states using DSM-III-R for diagnosis. Logistic regressions of alcohol and drug disorders were performed to compare their correlates in rural, urban, and metropolitan areas after stratifying by demographic and socioeconomic variables.

RESULTS

Household income was protective only in rural areas. High occupation strata were positively associated with alcohol disorders. Urban and metropolitan women were less likely to report drug disorders. There was no gender difference in rural drug abuse and dependence. Also, high occupation strata were positively associated with drug disorders.

CONCLUSION

Lack of gender differences in rural drug disorders may indicate an increase in drug availability, access, and use among rural women. Workplace alcohol and drug disorders, especially among metropolitan sales, crafts, and service workers should be of concern to policymakers. These results underline the usefulness of using multiple indicators of socioeconomic positions in epidemiologic studies of substance use disorders.

State-event relations among indicators of susceptibility to mental distress in Wythenshawe in the UK

This paper explores the utility of concepts drawn from psychosocial theory as predictors of the proneness to mental distress among the residential population of a large suburban council estate (Wythenshawe, South Manchester). In this respect, items are selected and tested to form composite variables measuring individual ratings with regard to notions of structural risk, personal vulnerability, goal-setting behaviour, quality of life, and the frequency of life events and restricted opportunities. Mental distress is enumerated on the standard GHQ12-point scale. The design makes the distinction between composite variables that record persistent states and those which count events and aspirations immediate to the individual's present experience. To examine the consequences of this difference between indicators of prevalence and incidence, our analysis adopts a two-stage multiple regression format. The first examines these state-event interactions among the composite variables, while the second tests the separate significance of these types as predictors of GHQ12. The findings reveal significant proportions of the variation in GHQ12 are be explained either by associations with the ageing process or by those linked to subjective indicators of the quality of life. In contrast, structural deprivation correlates less significantly with the reporting of psychiatric distress in this socially homogeneous population. The discussion considers the methodological implications of these relationships for understanding common mental health problems together with their connotations for health policy.

A theoretical and empirical analysis of context: neighbourhoods, smoking and youth

Numerous studies are currently addressing the issue of contextual effects on health and disease outcomes. The majority of these studies fall short of providing a theoretical basis with which to explain what context is and how it affects individual disease outcomes. We propose a theoretical model, entitled collective lifestyles, which brings together three concepts from practice theory: social structure, social practices and agency. We do so in an attempt to move away from both behavioural and structural-functionalist explanations of the differential distribution of disease outcomes among areas by including a contextualisation of health behaviours that considers their meaning. We test the framework using the empirical example of smoking and pre-adolescents in 32 communities across Québec, Canada. Social structure is operationalised as characteristics and resources; characteristics are the socio-economic aggregate characteristics of individuals culled from the 1996 Canadian Census, and resources are what regulates and transforms smoking practices. Information about social practices was collected in focus groups with pre-adolescents from four of the participating communities. Using zero-order and partial correlations we find that a portrait of communities emerges. Where there is a high proportion of more socio-economically advantaged people, resources tend to be more smoking discouraging, with the opposite being true for disadvantaged communities. Upon analysis of the focus group material, however, we find that the social practices in communities do not necessarily reflect the "objectified" measures of social structure. We suggest that a different conceptualisation of accessibility and lifestyle in contextual studies may enable us to improve our grasp on how differential rates of disease come about in local areas.

Racial ideology and explanations for health inequalities among middle-class whites

Middle-class whites' explanations for racial inequalities in health can have a profound impact on the type of questions addressed in epidemiology and public health research. These explanations also constitute a subset of white racial ideology (i.e., racism) that in itself powerfully affects the health of non-whites. This study begins to examine the nature of attributions for racial inequalities in health among university students who by definition are likely to be involved in the research, policy, and service professions (the upper middle class). Investigation of the degree to which middle-class whites attribute racial inequalities in cardiovascular health (between themselves and African Americans, American Indians, or Asian Americans) to biological, social, or lifestyle factors reveals that whites tend to attribute their own health to lifestyle choice and to biology rather than to social factors. These results suggest that contemporary middle-class whites' "self-serving" explanations for racial inequalities in health are comprised of two beliefs: implicit biologism (race is an attribute of organisms rather than a social relation) and liberal belief in self-determination, choice, and individual responsibility--some of the core lay beliefs of the worldview that sustains neoliberal capitalism. Contemporary white middle-class explanations for racial inequalities in health appear to include assumptions that justify class inequality. Liberal approaches to racism in public health are bound to miss a key component of racial ideology that is currently used to justify racial and class inequalities.

Evaluating the impact of a locality based social policy intervention on mental health: conceptual and methodological issues

Urban regeneration initiatives provide an opportunity for examining the impact of changes in socio-economic circumstances on the mental health of different groups and individuals within localities. This paper sets out the conceptual and methodological bases for evaluating the impact of a population based social policy intervention on mental health. We suggest the need to integrate a range of disciplinary and methodological developments in research on health inequalities in exploring the impact of urban regeneration on mental health. A combination of multi-level modelling, subjective indicators and narrative accounts of individuals about mental health in the context of locality and personal changes are central for developing theories and methods appropriate for exploring the action and interaction of effects operating between structural and individual/agency levels.