Mental Health: Concepts of Race and Gender

Mental distress/disorder as a function of the society we live in: implications for the practice of mental health social work in terms of gender and race

Introduction

Mental illness/disorder/distress is a rather ambiguous umbrella term for describing a wide range of diverse disorders of the mind. According to the Oxford Medical Dictionary, mental illness is “a disorder of one or more of the functions of the mind (such as emotion, perception, memory, or thought), which causes suffering to the patient or others” (Oxford Medical Dictionary, 2007). The global burden of mental illness was estimated at 12.3% at the beginning of the millennium and is expected to rise even further in the next decade (Murray and Lopez, 1997; Patel et al, 2006).

Critical perspectives that refute the biological definitions of mental illness started to arise in the 1960s. Szasz (1961) and other critical theorists have continually challenged the classification of normal and abnormal behavioural categories, and focused instead on the role of social factors on the development of mental illness (Martin, 2003). Key among these factors are gender, race and ethnicity, sexual preference, age and class.

Apart from several medical theories that explain the aetiology of mental illness with neurological chemical imbalances, the actual causes of such psychological disorders are largely unknown. However, as outlined above, there are myriad known factors that trigger or prompt such mental impairment. Work stress and work-related psychosocial conditions, for example, plays an important role in self-reported mental health (Kopp M et al, 2008).

Furthermore, gender is generally accepted as a significant risk factor for the development of mental distress. The World Health Organization acknowledges that a large majority of common mental health diseases are more frequently reported in the female gender than in their male counterparts. As an example – common psychological disorders such as depression and anxiety are predominant in women. Conversely, there are other disorders of the mind that are more common in men. These include, but are not limited to, substance misuse (including alcohol dependence) and antisocial personality disorder (The World Health Organization). Nevertheless, there are no reported differences in the incidence of some severe mental disorders, like schizophrenia, in men and women. In addition to the gender-related differences documented in the incidence of these disorders, there have also been reported differences in terms of the epidemiology and severity – age of onset, symptom frequency, social adjustment, prognosis and trajectory of the illness.

The World Health Organization proffers possible explanation for the observed differences between genders – men and women have differential withstanding power over socioeconomic determinants of their mental health, social position, status and treatment in society and their susceptibility and exposure to specific mental health risks (The World Health Organization).

Similarly, race could also be a determining factor for the development of mental illness. In addition, mental illness in some races, e.g. black and minority ethnic (BME) groups can be further exacerbated by alleged discrepancies in the mental health services available to this potentially vulnerable groups of patients (Ferns P, 2008). A possibly rational explanation for the reason behind any disparities in mental health across diverse races could be the societal differences that are inherent to various cultural backgrounds.

The main objective of this paper is to analyse the social factors that can prompt mental distress, especially in women and people from BME populations, and to rationalise how these factors may actually pathologise the discourse of mental health.

Mental Illness in Women

The natural subordinate role of women and gender stereotypes in most societies makes them prone to disorders of the mind. Psychoanalytic theories believe that patriarchy-based communities are associated with a higher rate of mental illness in women (Olfman S, 1994). These supremacy-governed organisations in which men are largely in control leave women with a consistent feeling of repression, which could culminate in mental distress. Indeed, in some extreme societies, women with more independent views who express anger or dissatisfaction with the standard patriarchal social structure are often seen as having psychological problems (Martin, 2003).

According to The World Health Organization, gender-specific roles, negative life occurrences and stressors can adversely affect mental health. Clearly the impact of the latter factors (i.e. life experiences and stressors) is in no way exclusive to the female gender. However, it is the nature of some events that are sometimes commonplace in women’s lives that could account for the documented gender-related differences. Risk factors for mental illness that mainly affect women include women-targeted violence, financial difficulties, inequality at work and in the society, burdensome responsibility, pregnancy-related issues, oppression, discrimination, and abuse. There is a linear correlation between the frequency and severity of such social factors and the frequency and severity of female mental health problems. Adverse life events that initiate a sense of loss, inferiority, or entrapment can also predict depression (The World Health Organization).

Furthermore, in a domino-effect way some female factors can also lead to mental illness, not just in the individual concerned, but also in subsequent generations and/ or interacting family and friends. For example – maternal depression has been shown to be associated with failure of children to strive in the community, which in turn could culminate in delays in the developmental process and subsequent psychological or psychiatric problems (Patel et al, 2004).

In the past three decades, the debate of women and mental health illness and their treatment in mental health services has been quite controversial (Martin J, 2003). From a social constructionist point of view, it is believed that some women are wrongly labelled as ‘mentally ill’ merely because they do not accept certain (usually unfair and unfounded) gender-related stereotypical placement in the society. In this often-cited and somewhat controversial book chapter by Jennifer Martin (Mental health: rethinking practices with women) she expresses great concern for the biological explanations of mental health which have the tendency to lay undue emphasis on the female reproductive biology that supposedly leads to a predisposition to mental illness. Such sexist notions tend to disproportionately highlight female conditions such as pre-menstrual tension, post-natal depression and menopause, in a bid to foster the notion that women are at higher risk of developing mental distress (Martin J, 2003).

Instead of this allegedly short-sighted approach to the medicalisation of mental health in women, feminist theorists focus on female mental illness as a function of the lives they are made to live within patriarchal, and often oppressive, societies. Women are disadvantaged – both socially and psychologically – by these unreasonably subservient role expectations (Martin J, 2003).

Mental Illness and Race

The United Kingdom (UK) is a home to a very diverse and multicultural population, and BME communities make up approximately 7.8% of the total UK population (Fernando S, 2005). There are innate differences in the presentation, management and outcome of mental illness between the different races and ethnic groups (Cochrane R and Sashidharan S, 1996; Coid J et al, 2002; Bhui K et al, 2003).

In a recent policy report for the UK Government Office of Science, Jenkins R et al, (2008) explained that while some mental disorders appear to be more common in the BME populations, others are not. In addition, incidence rates of different mental disorders also vary among different ethnic groups within the BME populations. For example, depression is increasingly common in the Irish and Black Caribbeans, but not necessarily in the Indian, Pakistani and Bangladeshi sub-populations (Jenkins R et al, 2008). In the UK, the risk of suicide also varies by gender as well as ethnicity, with Asian men and Black Carribeans having lower rates than the general UK population, and Asian women having higher rates. Similarly, the incidence of psychoses is not uniformly elevated in all BME groups – the highest incidence is seen in Black Caribbean and Black African groups in the UK, (4 – 10 times the normal rates seen in the White British group) (Jenkins R et al, 2008).

In a retrospective case-control study of a representative sample of more than 22,000 deceased individuals, Kung et al (2005) highlighted important disparities in mental health disorders, such as substance misuse, depressive symptoms and mental health service utilisation as possible determinants of suicidal behaviours and/ or attempts. Also, clear associations have been demonstrated between racism and the higher rates of mental illness among BME groups (McKenzie K, 2004). The rising incidence of suicides in some developing countries, as seen with Indian farmers, South American indigenes, alcohol-related deaths in Eastern Europe, and young women in rural China, can be partly attributed to economic and social change in these nations (Sundar M, 1999; Phillips M et al, 1999).

Pre-, peri- and post-migratory experiences can be major stressor determinants for the development of mental health illness (Jenkins R et al, 2008). Therefore, in order to understand the differences in these populations, it is of utmost importance to gain some insight into their cultural backgrounds and the happenings in their countries of origin all of which could be determinants of mental health.

There is a direct relationship between social change and mental health and, in the recent past, many developing countries have undergone incomparable, fast-paced social and economic changes. As Patel et al (2006) have pointed out, such economic upheavals commonly go hand-in-hand with ruralurban migration and disruptive social and economic networks. Furthermore, it is noteworthy that The World Health Organization has acknowledged that such changes can cause sudden disruptive changes to social factors, such as income and employment, which can directly affect individuals and ultimately lead to an increased rate of mental disorders.

Also Alean Al-Krenawi of the Ben-Gurion University of the Negev has extensively explored how exposure to political violence has influenced the mental health of Palestinian and Israeli teenagers (Al-Krenawi A, 2005). Al-Krenawi goes on to emphasise that the concept of mental health in the Arab world is a multi-faceted one and is often shaped not only by the socio-cultural-political aspects of the society, but also by the spiritual and religious beliefs.

In addition, the perception of racial discrimination has been identified as a significant contributory factor to poor mental and overall health in BME groups – even more important that the contribution of socio-economic factors (Jenkins R et al, 2008). It is disheartening to note that institutionalised and/ or constitutional racism is rife in the conceptual systems that are employed in the provision of mental health services (Wade J, 1993; Timimi S, 2005).

Implications for the Practice of Mental Health Social Work

In general, people suffering from mental illnesses receive substandard treatment from medical practitioners both in the emergency room and in general treatment, and insurance coverage policies are usually unequal compared with their mentally balanced counterparts (McNulty J, 2004).

For BME populations, especially Black and Asians, access and utilisation of mental health services are very different from those recorded for White people (Lloyd P and Moodley P, 1992; Bhui K, 1997). Exploring the pathway to care in mental health services, Bhui K and Bhugra D (2002) highlight that the most common point of access to mental health services for some BME groups is through the criminal justice system, instead of their general practitioner, as would be the case in their White counterparts.

Major areas in which institutional racism is rife in the provision of mental health services to BME patients include mental health policy, diagnosis and treatment (Wade J, 1993). For example, Black patients with mental illness are more likely to be treated among forensic, psychiatric and detained populations (Coid J et al, 2002; Bhui K et al, 2003) and are also disproportionately treated with antipsychotic medication than psychotherapy (McKenzie K et al, 2001). Having said this, it is important to differentiate between racial bias and the consideration of racial and ethnic differences. In fact, ignoring these essential differences could actually be seen as a different type of bias (Snowden L, 2003).

Already, members of the BME population face prejudice and discrimination; this is doubled when there is the additional burden of mental illness, and is one of the major reasons why some of these patients choose not to seek adequate treatment (Gary F, 2005). As such, stigma arising from racism can be a significant barrier to treatment and well-being, and interventions to prevent this should be prioritised. It is therefore also of utmost importance that institutional racism be eliminated.

As far back as 1977, Rack described some of the practical problems that arise in providing mental health care in a multicultural society. These include, but are not limited to: language, diagnostic differences, treatment expectations and acceptability. Some effort has been made to address some of these problems in England, by the development of projects for minority ethnic communities both within the statutory mental health services and in non-governmental sector (Fernando S, 2005). In addition, overcoming language barriers should help in eliminating racial and ethnic disparities towards achieving equal access and quality mental health care for all (Snowden L et al, 2007).

The World Health Organization also draws attention to similar bias against the female gender in the treatment of mental disorders. Doctors are generally more likely to diagnose depression in women than in men, even with patients that present with similar symptoms and Diagnostic and Statistical Manual of Mental Disorders (DSM) scores. Probably as a result of this bias, doctors are also more likely to prescribe mood-altering psychotropic drugs to women.

Considering that immigrants and women separately face challenges with the provision of mental health care, it is expected that immigrant women would have even more setbacks, owing to their double risk status. Using Kleinman’s explanatory model, O’Mahony J and Donnelly T (2007) found that this unfortunate patient group face many obstacles due to cultural differences, social stigma spiritual and religious beliefs and practices, and unfamiliarity with Western medicine. However, the study did also highlight some positive influences of immigrant women’s cultural backgrounds, which could be harnessed in the management of these patients.

To effectively target and treat the diverse population that commonly present with mental illness in the UK, it is necessary to promote interculturalisation, i.e. “the adaptation of mental health services to suit patients from different cultures” (De Jong J and Van Ommeren M, 2005). Hollar M (2001) has developed an outline for the use of cultural formulations in psychiatric diagnosis, and advocates for the inclusion of the legacy of slavery and the history of racism to help understand the current healthcare crisis, especially in the Black population.

Conclusion

As we have discussed extensively in this paper, females and patients of BME origin are commonly disadvantaged in the treatment of mental illnesses. Mental healthcare professionals need to eliminate all bias in the treatment of these patients, while at the same time, taking into consideration their inherent differences to ensure that mental health services provided are personalised to suit the individual patient.

References

Al-Krenawi A. Editorial: mental health issues in Arab society. Israeli Journal of Psychiatry and Related Sciences 2005; 42 (2): 71.

Bhui K. Service provision for London’s ethnic minorities. In London’s Mental Health, London: King’s Fund (1997).

Bhui K and Bhugra D. Mental illness in Black and Asian ethnic minorities: pathways to care and outcomes. Advances in Psychiatric Treatment 2002; 8: 26 – 33.

Bhui K, Stansfeld S, Hull S, Priebe S, Mole F, Feder G. Ethnic variations in pathways to specialist mental health care: a systematic review. The British Journal of Psychiatry 2003; 182: 5 – 16.

Cochrane R and Sashidharan S. Ethnicity and health: reviews of the literature and guidance for purchasers in the areas of cardiovascular disease, mental health, and haemoglobinopathies. York: University of York, 1996: 105 – 126 (part 3).

Coid J, Petruckevitch A, Bebbington P, Brugha T, Brugha D, Jenkins R, et al. Ethnic differences in prisoners. 1: criminality and psychiatric morbidity. The British Journal of Psychiatry 2002; 181: 473 – 480.

De Jong J and Van Ommeren M. Mental health services in a multicultural society: interculturalisation and its quality surveillance. Transcultural Psychiatry 2005; 42 (3): 437 – 456.

Fernando S. Multicultural mental health services: projects for minority ethnic communities in England. Transcultural Psychiatry 2005; 42 (3): 420 – 436.

Ferns P. The bigger picture. If racism exists in society, then surely it must influence mental health services. Mental Health Today 2008 March; 20.

Gary F. Stigma: barrier to mental health care among ethnic minorities. Issues in Mental Health Nursing 2005; 26 (10): 979 – 999.

Hollar M. The impact o0f racism on the delivery of healthcare and mental services. Psychiatric Quarterly 2001 Winter; 72 (4): 337 – 345.

Jenkins R, Meltzer H, Jones P, Brugha T, Bebbington P, Farrell M, Crepaz-Keay D and Knapp M. Foresight Mental Capital and Wellbeing Project. Mental health: Future challenges. The Government Office for Science, London (2008).

Kopp M, Stauder A, Purebl G, Janszky I, Skrbski A. Work stress and mental health in a changing society. European Journal of Public Health 2008; 18(3): 238 – 244.

Kung H, Pearson J, Wei R. Substance use, firearm availability, depressive symptoms, and mental health service utilization among white and Africa-American suicide decedents aged 15 to 64 years. Annals of Epidemiology 2005; 15 (8); 614 – 621.

Lloyd P and Moodley P. Psychotropic medication and ethnicity: an inpatient survey. Social Psychiatry and Psychiatric Epidemiology 1997; 27: 95 – 101.

Martin E ed. (2007). Oxford Concise Colour Medical Dictionary. Oxford University Press; 4th edition, page 445.

Martin J (2003). Mental health: rethinking practices with women in Critical social work: an introduction to theories and practices. By Bob Pease, June Allan, Linda Briskman. Published by Allen & Unwin, 2003 ISBN 1865089079, 9781865089072.

McKenzie K, Samele C, Van Horn E, Tattan T, Van Os J, Murray R. Comparison of the outcome and treatment of psychosis in people of Carribean origin living in the UK and British Whites. Report from the UK700 trial. The British Journal of Psychiatry 2001; 178: 160 – 165.

McKenzie K. Tackling the root cause: there are clear links between racism and the higher rates of mental illness among ethnic minority groups. Mental Health Today 2004; 30 – 32.

McNulty J. Commentary: mental illness, society, stigma and research. Schizophrenia Bulletin 2004; 30 (3): 573 – 575.

Murray C, Lopez A. Alternative projections of mortality and disability by cause 1990 – 2020: global burden of disease study. The Lancet 1997; 349: 1498 – 1504.

O’Mahony J and Donnelly T. The influence of culture on immigrant women’s mental health care experiences from the perspectives of health care providers. Issues in Mental Health Nursing 2007; 28 (5): 453 – 471.

Olfman S. Gender, patriarchy, and women’s mental health: psychoanalytic perspectives. The Journal of the American Academy of Psychoanalysis 1994; 22: 259  271.

Patel V, Rahman A, Jacob K, Hughes M. Effect of maternal mental health in infant growth in low income countries: new evidence from South Asia. The British Medical Journal 2004; 328: 820  823.

Patel V, Saraceno B, Kleinman A. Beyond evidence: the moral case for international mental health. The American Journal of Psychiatry 163: 8; 1312 – 1315.

Phillips M, Liu H, Zhang Y. Suicide and social change in China. Cultural Medical Psychiatry 1999; 23: 25 – 50.

Rack P. Some practical problems in providing a psychiatric service for immigrants. Mental Health Soc 1977; 4 (34): 144 – 151.

Snowden L. Bias in mental health assessment and intervention: theory and evidence. American Journal of Public Health 2003; 93 (2): 239 – 243.

Snowden L, Masland M, Guerrero R. Federal civil rights policy and mental health treatment access for persons with limited English proficiency. American Psychology 2007; 62 (2): 109 – 117.

Szasz (1961) in Martin J (2003). Mental health: rethinking practices with women in Critical social work: an introduction to theories and practices. By Bob Pease, June Allan, Linda Briskman. Published by Allen & Unwin, 2003 ISBN 1865089079, 9781865089072.

Sundar M. Suicide in farmers in India. The British Journal of Psychiatry 1999; 175: 585 – 586.

The World Health Organization. Gender and women’s mental health: Gender disparities and mental health: The Facts. [WWW] Available online at http://www.who.int/mental_health/prevention/genderwomen/en/ (Accessed Friday November 15^th 2008).

Timimi S. Institutionalised racism lies at the heart of the conceptual systems we use in psychiatry. Mental Health Today 2005; 21.

Wade J. Institutional racism: an analysis of the mental health system. The American Journal of Orthopsychiatry 1993; 63 (4): 536 – 544.