Encyclopedia of Sociology Vol

Americans was fully 43.4 million, or 16.1 percent of the population in 1997—the highest level in a decade (Kuttner 1999). Moreover, there are alarming increases in the uninsured population among African-Americans, Latinos, and the middle class (Carrasquillo et al. 1999). Of those Americans who do have insurance, a recent study found that the number of persons insured by the private sector is much less than previously believed. While many studies had estimated that 61 percent of the insured received coverage through the private sector, Carrasquillo and colleagues (1999) found that the public sector subsidizes much of this coverage so that, in fact, only 43 percent of the population receives insurance through the private sector. Thus, not only is the burden on the state greater than previously thought because of this subsidy to the private sector, but the general decline in private insurance coverage will also produce further strains on the government’s budget.

The rapidly growing health care industry is creating strains on the economic system while it also is creating a financial burden on government, business, and individuals through their payments for health services. These strains are occurring simultaneously when, in 1999, a huge federal deficit has been turned into a surplus, an event of historic significance. The budget surplus has produced a combination of euphoria and vigorous debate over what the government should do with it. This surplus emerged against the backdrop of an unusually high economic growth rate and strong general U.S. economy as we enter the new millennium. Responses to these deficit strains and fluctuations have included cutbacks in services and reimbursements; cost shifts onto consumers; and alterations in the structure of the health care system itself to accord better with a competitive, for-profit model. The competition model as a prescription for the nation’s health-care woes has restricted access to health care and raised questions of quality of care (Bond and Weissman 1997; Harrington 1996; Kassirer 1997). Cost shifting to consumers is increasingly limiting access to needed services for those with less ability to pay. Managed care has not delivered the cost savings it promised, and the Health Care Financing Administration acknowledges that Medicare does not benefit from cost reductions from HMO enrollment of elders due to continuing adverse risk selection (DePearl 1999).

The juxtaposition of the commercial ethos familiar in fast-food chains with health care collides with traditional images of medicine as the embodiment of humane service. Investor-owned health care enterprises have elicited a number of specific criticisms. It has been argued that commercial considerations can undermine the responsibility of doctors toward their patients; can lead to unnecessary tests and procedures; and, given other financial incentives, can lead to inadequate treatment. The interrelationships among physicians and the private health care sector, particularly forprofit corporations, raises many issues about the effects on quality of care and health care utilization and expenditures. Many have argued that the potential for abuse, exploitation, unethical practices, and disregard of fiduciary responsibilities to patients is pervasive (Iglehart 1989). Legislation has even been introduced in Congress that would prohibit physicians from referring patients to entities in which they hold a financial interest and from receiving compensation from entities to which they refer patients (Iglehart 1989). In the late 1990s several versions of a ‘‘patient’s bill of rights’’ were considered at the state and federal levels of government.

Critics of for-profits argue that such ownership drives up the cost of health care, reduces quality, neglects teaching and research, and excludes those who cannot pay for treatment. Opponents of the market model for health care reflect diverse interests, including members of the medical profession seeking to preserve their professional autonomy, advocates for access to health care for the poor and uninsured, those concerned about the impact of profit seeking on quality of care, and many others. As government and business attempt to restrain health care spending, cutting into profits and forcing cost reductions, these concerns intensify.

The medical-industrial complex is an inherently fascinating topic for sociological analysis because it underscores many of the less obvious dimensions of health care. Profits, power, and market control are not terms that have traditionally come to mind when the average person in the United States talked about their health care provider (although this is changing as we observe the managed-care ‘‘backlash’’). Yet, these are some of the primary goals of those organizations administering our medical care. Sociology itself arose as

an effort to wrestle with the myriad social impacts of nineteenth century industrialization (Durkheim [1893] 1984; Marx [1867] 1976). Early sociologists were especially concerned about how changes in communities were created by industrial production. Over the last century, sociologists have maintained a particular interest in the connection between advanced capitalism and the emergence of specific types of work, formal organizations, political systems, families, and cultural beliefs. An examination of the medical-industrial complex is therefore one of the more recent attempts to refocus core sociological questions about community, power, stratification, and social change.

Underlying this early sociological research on the impact of industrialization was an interest in power. How does power get accumulated and applied in a market-based society? How does it get distributed unevenly to social groups? To what ends do empowered social groups apply their power? One school of thought has been that industrial production skews power to an elite class (Domhoff 1998; Gramsci [1933] 1971). Max Weber’s theory of bureaucracy, for example, suggested that this was an organizational form that pervades all social institutions. Its emphases on rationality, efficiency, predictability, calculability, and control (Weber [1921] 1961) were in part seen as a social advance over arbitrary religious, charismatic, and personalized forms of authority. Later analysts of bureaucracy, in contrast, saw this formalization of organizations as a dehumanizing and antisocial mechanism.

Issues for sociological investigation include the systematic identification of the ways in which the new commercial practices and organization of health care affect health care delivery. Organizational studies are needed to disentangle the effects of organizational characteristics (e.g., tax status and system affiliation) on the outcomes of equity, access, utilization, cost, and quality of care. The effects on provider-patient interactions of these structural and normative changes in health care require investigation as well. A general sociological theory of the professions will emerge from understanding the ways in which the dominant medical profession responds to the ongoing restructuring of health care and accompanying challenges to its ability to control the substance of its own work, erosions in its monopoly over medical knowledge, diminishing authority over patients

resulting from health policy changes, major technological and economic developments, and changes in the medical-industrial complex. Finally, sociologists must confront the coming biotechnological revolution and its impacts on society, human health, and the environment. The corporatization of health care and health-related research and the medical industrial complex are topics of great interest to scholars studying social movements, organization behavior, stratification, health and illness, and science and technology.

(SEE ALSO: Health Care Financing; Health Policy Analysis;

Health Services Utilization; Medical Sociology)

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CARROLL L. ESTES

CHARLENE HARRINGTON

DAVID N. PELLOW

MENTAL HEALTH

See Positive Mental Health.

MENTAL ILLNESS AND MENTAL DISORDERS

After years of empirical research and theoretical activity, social scientists still do not agree about what mental illness actually is, let alone about what its primary causes are or about the efficacy of various treatments. Sociologists disagree about whether or not mental disorder is truly a disease that some people have and other people do not have, thus fitting a medical model of health and illness. They disagree about the relative importance of genetics, biochemical abnormalities, personality characteristics, and stress in the onset and course of psychiatric impairment. Most sociologists do, however, agree that definitions of mental illness are shaped by the historical, cultural, and interpersonal contexts within which they occur. They argue that the significance of any particular set of psychological or behavioral symptoms to a diagnosis of mental disorder lies in part with the actor and in part with the audience. Given this understanding of mental illness, sociologists are often as interested in understanding the consequences of being labeled mentally ill as they are in understanding the causes. Sociologists do, indeed,

study the social distribution and determinants of mental disorder. However, they also study social reactions to mental illness and the mentally ill and investigate ways in which mental health professionals and institutions can come to serve as agents of social control.

CLASSIFICATION AND DIAGNOSIS

Although psychiatrists themselves have difficulty defining mental illness, the official system for classifying and diagnosing mental disorder in the United States is produced by the American Psychiatric Association (APA). It is known as the Diagnostic and Statistical Manual of Mental Disorder (DSM) and was first published in 1952. In its earliest form, DSM-I included a list of 60 separate mental illnesses. By the second edition in 1968, psychiatric definitions of mental illness had changed so markedly that 145 different types of mental disorder were included. Despite the attempt in DSM-II to define the parameters of mental illness more precisely, critics from inside and outside psychiatry pointed out that diagnoses of mental disorder were extremely unreliable. When different psychiatrists independently used DSM-II to diagnose the same patients, they did so with substantially different results. Studies conducted during the 1960s and 1970s indicated that there was poor agreement about what disease classification was appropriate for any given patient; studies also found that clinicians had difficulty in differentiating normal persons from mental patients and that they frequently disagreed about prognosis and the clinical significance of particular symptom patterns (Loring and Powell 1988).

After years of debate, some of which was quite heated, the APA published a third edition of DSM in 1980. Mental disorder was defined in DSM-III as ‘‘a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with either a painful symptom (distress) or impairment in one or more areas of functioning (disability)’’ (APA 1980, p. 6); deviant behaviors and conflicts between individuals and society were specifically excluded from this definition unless they were symptoms of another diagnosable disorder. DSM-III took a purely descriptive approach to diagnosis, outlining the essential and associated features of each disorder but making no attempt to explain the etiology of

either symptoms or illnesses. At the time of the most recent revision (DSM-IV) in 1994, there was considerable debate about whether or not to actually retain the phrase ‘‘mental disorder’’ in the title of the DSM. The argument was that doing so implied a false distinction between mind and body, and between mental disorders and physical or general medical conditions. For lack of a better term, however, DSM-IV retained the same terminology and definition of mental disorder that had been used in DSM-III. DSM-IV contains hundreds of mental diagnoses, including such disorders as caffeine intoxication, circadian rhythm sleep disorder, and hypoactive sexual desire disorder. It also contains a section on ‘‘other conditions that may be a focus of clinical attention’’ but that are not mental disorders themselves. Included here are such conditions as relational problems connected with a family member’s mental disorder, noncompliance with treatment, religious or spiritual, academic, occupational, acculturative, and phase-of-life problems.

The use of DSM-III and DSM-IV criteria has vastly improved the overall reliability of psychiatric diagnoses, thereby enabling psychiatry to meet one of the major criticisms of the medical model of mental disorder. The inclusion of more and more categories of illness in each succeeding version of DSM has led to more precise and consequently more reliable diagnoses. However, some scholars have argued that this expansion of mental diagnoses has less to do with problems of disease classification than with ‘‘problems’’ of third-party reimbursement (Kirk and Kutchins 1992; Mirowsky and Ross 1989). Each increase in the number of disorders listed in DSM has increased the scope of psychiatric practice. As the number of patients with recognized illnesses increases, so too does the amount of compensation that psychiatrists receive from insurance companies.

Even the firmest supporters of DSM-IV recognize that the classification of mental disorder is influenced by nonmedical considerations. In fact, DSM-IV itself includes a discussion of specific culture, age, and gender features which should be taken into account for each diagnosis. Pressures from outside psychiatry also influence diagnostic classifications. In order to reduce their payment liabilities, insurance companies have lobbied the APA to reduce the number of diagnoses. Changes in public attitudes toward sexual preference issues

led, in 1974, to dropping homosexuality from the list of mental disorders, and veterans’ groups successfully pressed for the inclusion of posttraumatic stress syndrome (Scott 1990). The storm of controversy that surrounds the issue of whether premenstrual syndrome is a medical or a psychological condition, or whether it is socially unacceptable behavior, is another example of the intersection of political, social, economic, and diagnostic concerns (Figert 1994); at the insistence of feminists inside and outside psychiatry, premenstrual dysphoric disorder has been relegated to an appendix of DSM-IV on the basis that there is currently little scholarly evidence to support such a diagnosis and that its social implications dangerously feed ‘‘the prejudice that women’s hormones are a cause of mental illness’’ (Tavris 1993, p. 172). In sum, there is a less than perfect correspondence between some disease-producing entity or syndrome and the diagnosis of mental disorder; psychiatric diagnosis is based partly in the reality of disordered behavior and emotional pain, and partly in the evaluations that society makes of that behavior and pain. Thus, questions about the validity of psychiatric diagnosis are as troubling for DSM-IV as they were for DSM-I. As one observer has noted, ‘‘We have learned how to make reliable diagnoses, but we still have no adequate criterion of their validity’’ (Kendell 1988, p. 374). Given the problems scholars have in defining ‘‘mental disorder’’ and given the validity problems that ensue, it is not surprising that epidemiologists have used a number of different strategies to estimate rates of psychiatric impairment. These different research methodologies often have led to quite different interpretations of the role of social factors in the etiology of mental illness.

MEASUREMENT

The earliest sociological research on mental disorder relied on data from individuals receiving psychiatric care. In a classic epidemiological study, Faris and Dunham (1939) reviewed the records of all patients admitted to Chicago’s public and private mental hospitals between 1922 and 1934. They found that admission rates for psychosis were highest among individuals living in the inner city. Several years later, researchers used a similar design to study the social class distribution of mental disorder in New Haven. In contrast to the

Chicago study, which focused only on individuals who had been hospitalized, Hollingshead and Redlich (1958) included individuals receiving outpatient care from private psychiatrists in their study. Results from the New Haven study confirmed the earlier findings; the lower the social class, the higher the rate of mental disorder. More recent studies have also used information on treated populations. Studies of patient populations provide useful information to be sure; findings shed light on the social factors that influence the course of mental health treatment. Individuals receiving treatment for mental disorder, however, are not a random subset of the population of individuals experiencing psychological distress. Everybody who has potentially diagnosable mental disorder does not receive treatment. Furthermore, pathways to mental health care may be systematically different for individuals with different social characteristics. Consequently, research based on treated rates of mental disorder seriously underestimates the true rate of mental illness in a population. (In 1994 the Institute of Medicine Committee on the Prevention of Mental Disorders estimated, for instance, that only 10–30 percent of those with a mental disorder receive any treatment.) Furthermore, such research may confuse the effects of variables such as social class, gender, place of residence, and age on psychiatric treatment with the impact of those same variables on the development of psychiatric impairment.

An alternative strategy for studying the epidemiology of mental disorder is the community survey. Early studies such as the Midtown Manhattan study (Srole et al. 1962) used symptom checklists with large random samples to estimate the amount of psychiatric impairment in the general population. Although such studies provided less biased estimates of the prevalence of psychological distress than did research on patient populations, they were subject to a different set of criticisms. The most serious limitation of the early community studies was that they used impairment scales that measured global mental health. Not only did the scales fail to distinguish different types of disorders, they confounded symptoms of physical and psychological disorder (Crandall and Dohrenwend 1967), measured relatively minor forms of psychiatric impairment, and frequently failed to identify the most serious forms of mental illness (Dohrenwend and Crandall 1970). Since it

was not clear what relationship psychological symptom scales bore to cases of actual psychiatric disorder, it was also not clear how results from those studies contributed to an understanding of the social causes of mental illness.

Since the early 1980s, symptom scales that measure specific forms of impairment have largely replaced the early global scales with the consequence that the reliability and validity of community survey research has been vastly improved. The CES-D, for instance, is a twenty-item depression scale that can accurately distinguish clinical from normal populations and depression from other psychiatric diagnoses (Weissman et al. 1977). Consistently with the overall improvement in diagnostic reliability that has accompanied the development of DSM-III and DSM-IV, methods have been developed that provide reliable psychiatric diagnoses of many disorders among community residents. The most widely used diagnostic instrument of this sort was developed by a team of researchers at Washington University as part of the National Institute of Mental Health (NIMH) Division of Biometry and Epidemiology’s Catchment Area Program. Called the Diagnostic Interview Schedule (DIS), the instrument can be administered by nonpsychiatrists doing interviews with the general population. Using DSM-IV criteria, it provides both current and lifetime diagnoses for many adult psychiatric disorders (Eaton et al. 1985). Enormous amounts of time and money have been devoted to the development of the DIS, and research that makes use of it promises to provide a vital link between studies of clinical and community populations. Nevertheless, even instruments like the DIS have shortcomings.

Mirowsky and Ross (1989) have challenged the DIS and the DSM upon which it is based on the grounds that psychiatric diagnosis is a weak form of measurement and that it is of questionable validity. These authors claim that psychiatric disorders are dimensional, not categoric. By collapsing a pattern of symptoms into a single diagnostic case, valuable information is lost about the nature of the disorder. As a result, the causes of mental, emotional, and behavioral problems are obscured. Mirowsky and Ross go on to suggest that the reliance on diagnosis does not give a true, that is, a valid, picture of psychiatric distress. Instead, psychiatrists use diagnosis because it allows them to

receive payment from insurance companies who will pay only for cases and because it establishes mental distress as a problem that can be treated only by a physician. Although their criticisms are harsh, these authors reestablish the important distinction between the social construction of psychiatric diagnoses and the social causes of psychological pain. It is the latter issue, however, that most sociological research has addressed.

THE EPIDEMIOLOGY OF MENTAL

DISORDER

Socioeconomic Status. The inverse relationship between socioeconomic status and mental disorder is now so well established that it has almost acquired the status of a sociological law. The relationship is surprisingly robust; it holds for most forms of mental disorder, no matter how socioeconomic status is measured, and for both patient populations and community samples. The relationship is strongest and most consistent for schizophrenia, personality disorders, and medically based syndromes. Findings for the major affective disorders are somewhat less consistent. Studies tend to report weak to moderate inverse relationships between social class and the incidence of major affective disorders such as anxiety and depression (Kessler et al. 1994). However, studies sometimes report no relationship (Weissman et al. 1991) or a positive class gradient (Weissman and Myers 1978). Evidence on the class distribution of minor depression is more clear-cut, with studies almost universally showing higher levels of depressive symptomatology among the lower strata. Similarly, research consistently shows that the highest levels of general distress are also found among those with the lowest income, education, or occupational status.

There are two general qualifications to the pattern outlined above. First, even though socioeconomic status is negatively associated with most types of mental disorder, the relationship is probably not linear. Extremely high rates of disorder are typically found in the lowest stratum. Higher strata do have progressively lower rates, but variation is considerably less between them than between the lowest and next-to-lowest tier. Some scholars have claimed, therefore, that serious mental illness is primarily an underclass phenomenon. Second, the inverse relationship between social

class and mental disorder may be stronger in urban than in rural areas and is probably stronger in the United States than in other societies. (For a comprehensive review of this literature, see Ortega and Corzine 1990.)

Most, if not all, of the major sociological theories of mental illness begin with the empirical observation that psychological disorder is most prevalent among those individuals with the fewest resources and the least social power. Until recently, researchers focused almost exclusively on one dimension of inequality—social class. Indeed, the dominant paradigms in the sociology of mental health have derived primarily from the attempt to explain this relationship; hypotheses regarding the effects of gender, age, or marital status on psychological distress are often simple elaborations of models derived from the study of social class and mental disorder. Three general models of the relationship between social resources and mental illness have been suggested. These are (1) the ‘‘social causation’’ hypothesis; (2) the ‘‘social selection’’ or ‘‘drift’’ hypothesis; and (3) the ‘‘labeling’’ or ‘‘societal reaction’’ approach.

Social Causation. Social causation is a general term used to encompass a number of specific theories about the class-linked causes of mental disorder. Perhaps the most common version of social causation explains the higher rates of mental disorder among the lowest socioeconomic strata in terms of greater exposure to stress. According to this perspective, members of the lower class experience more stressful life events and more chronic strains (Turner et al. 1995). In addition, they are more likely to experience physical hazards in the environment, blocked aspirations, and status frustration (Cockerham 1996). Taken together, these stresses produce elevated rates of psychiatric impairment. In another version of social causation, scholars have argued that class differences in coping resources and coping styles are at least as important in the etiology of mental disorder as are class differences in exposure to stress (Pearlin and Schooler 1978). In this view, poverty increases the likelihood of mental illness because it (1) disrupts precisely those social networks that might effectively buffer the effects of stressful events and (2) inhibits the development of an active, flexible approach to dealing with problems. For both social and psychological reasons, then,

the lower classes make use of less effective coping strategies. Finally, part of the class difference in mental disorder, especially rates of treated disorder, may stem from class differences in attitudes toward mental illness and psychiatric care. Because of more negative attitudes toward mental illness and because of inadequate access to appropriate psychiatric care, the lower classes may be more seriously ill when they first come in contact with the mental health care system, and thus they may be more likely to be hospitalized (Rushing and Ortega 1979).

Social Selection and Drift. This perspective implies that, rather than causing mental disorder, low socioeconomic status is a result of psychological impairment. Two mobility processes can be involved. According to the drift hypothesis, the onset of mental disorder adversely affects an individual’s ability to hold a job and generate income. As a result of psychological disorder, then, individuals experience downward intragenerational mobility and physical relocation to less socially desirable neighborhoods (Eaton 1980). Social selection, on the other hand, occurs when premorbid characteristics of the mentally disordered individual prevent him or her attaining as high a social status as would be expected of similar individuals in the general population. Here, the focus is on intergenerational mobility (Kendler et al. 1995).

Labeling or Societal Reaction. Based on the work of Thomas Scheff (1966), this approach holds that much of the class difference in mental disorder stems not from any real difference in mental illness but rather from a tendency to diagnose or label a disproportionate number of lower-class individuals as psychologically impaired. According to Scheff, the process works as follows. Psychiatric symptoms have many different causes and many people experience them. Only a few individuals, however, are ever labeled as mentally ill. People who are so labeled are drawn from the ranks of those least able to resist the imputation of deviance. Once an individual is identified as mentally ill, a number of forces work to reinforce and solidify a mentally ill self-identity. Once labeled, individuals are encouraged by family and mental health professionals to acknowledge their illness. They are rewarded for behaving as ‘‘good’’ patients should, a task made easier by virtue of the fact that individuals learn the stereotypes of mental illness in early childhood. When individuals are

discharged from the mental hospital, or when they otherwise terminate treatment, they may be rejected by others. This rejection has psychological consequences that simply reinforce a mentally ill identity. The process is self-fulfilling, leading Scheff to conclude that attachment of the mentally ill label is the single most important factor in the development of chronic mental disorder.

An Assessment. After two decades or more of acrimonious debate, the search for unitary explanations of the relationship between mental disorder and social class has largely been abandoned. Sociologists seldom claim that mental illness is derived only from medical factors, is caused only by features of the social environment, or stems purely from societal reaction. Most scholars now believe that different types of disorders require different types of explanations. Genetic and other biomedical factors are clearly involved in schizophrenia, and certain forms of depression. However, genetics, brain chemistry, and other medical factors do not provide the entire answer since, even among identical twins, concordance rates for mental illness fall only in the range of 30 to 50 percent. Thus, the causes of mental disorder must also be sought in the social environment. Research does suggest a modest relationship between the social stressors attendant to lower-class status and the onset of some forms of mental disorder. The evidence is clearest, however, for anxiety, substance abuse, and relatively minor forms of depression or psychological distress. For the more severe forms of mental illness and for conduct disorders, the drift and selection hypothesis appears to have the most empirical support. (See Miech et al. 1999 for a comprehensive review and data bearing on these points.) Although labeling is not the only cause of chronic mental illness, it is clear that the mental illness label does have negative consequences. In what has come to be called modified labeling theory, researchers have demonstrated that the status of ex-mental patient and the discrimination that follows from it, coupled with the ex-patient’s expectation of rejection by others, adversely affects earnings, work status, and subsequent mental health (Link 1987; Markowitz 1998). Thus, labeling is one of the processes through which drift occurs. As researchers continue to refine the definitions and measurement of various mental disorders and as they more clearly delineate the processes of social causation, drift, and

labeling, it is likely that further theoretical convergences will be identified.

Gender. It is not yet clear whether there are significant gender differences in overall rates of mental illness. There is little doubt, however, that certain types of disorders occur more frequently among women than among men. Research clearly shows that women are more likely to suffer from major and minor depression and anxiety than are men (Kessler et al. 1994); men, however, are usually found to have higher rates of antisocial personality disorders and the various forms of substance abuse and dependence (Aneshensel et al. 1991). The sex ratio for some forms of mental disorder may be age dependent; males have higher rates of schizophrenia prior to adolescence and females have higher rates in later adulthood (Loring and Powell 1988). Studies also find that male-female differences in levels of depression are most pronounced among young adults (Dean and Ensel 1983). Furthermore, gender effects appear to interact with those of marital, occupational, and parental roles.

Scholars continue to disagree about the precise form of the interaction effects of gender and marital status on mental illness. Virtually all studies report that gender differences are most pronounced among married persons; married women consistently show higher levels of depression and anxiety than married men. Evidence on the unmarried, however, is mixed. Research based on treated populations often finds higher rates of disorder among single men. Studies based on community samples more frequently report higher distress levels among unmarried women. The interaction between gender and marital status is further complicated by the presence of children, work outside the home, or both.

Some research on married persons finds that gender differences are reduced when both husbands and wives are employed. Studies comparing groups of women often find that employment has modest, positive effects on mental health. However, other studies report no difference between employed women and housewives (Carr 1997) and a few report that married, full-time homemakers with children have fewer worries and more life satisfaction (Veroff et al. 1981). These apparently contradictory findings stem, in part, from the

different measures of mental health and illness used. It is possible, for instance, that small children can simultaneously increase their mothers’ life satisfaction and their overall levels of anxiety and distress. However, two substantive factors also appear to be involved. First, it is the demands created by children and employment, rather than by parental or employment status per se, that cause elevated levels of distress among married women (Rosenfeld 1989). The level of demands varies, of course, depending upon the level of male responsibility for child care and housework. Second, employment decreases gender differences in distress only when it is consistent with both the husband’s and the wife’s desires. Married men’s distress levels may, in fact, surpass married women’s when wives work but their husbands prefer them not to (Ross et al. 1983).

As is true for social class, explanations for gender differences in mental disorder fall into three broad classes: social causation, social selection, and labeling. Because of the consistency of gender effects (at least for depression and anxiety) and improvements in the reliability of psychiatric diagnoses, most recent work has focused on the ways in which the social and psychological correlates of male and female roles cause variation in rates of mental disorder. Some have argued that differences in sex-role socialization make females more likely to direct frustration inward, toward themselves, rather than towards others, as males might. Thus, women are more likely to develop intropunitive disorders, whereas men are more likely to behave in antisocial ways (Loring and Powell 1988). Others have argued that women are more attached to others and are more sensitive to others’ needs than are men. As a result, not only is women’s mental health influenced by their own experiences but, also in contrast to men, they are more psychologically vulnerable to the stresses or losses of loved ones (Kessler and McLeod 1984). Although the empirical literature is far from clear on this point (cf. Umberson et al. 1996), according to this perspective, women experience more stressful events and are more psychologically reactive to them than are men. Other explanations—for both direct and interactive effects—of gender on mental illness have focused on male-female differences in power, resources, demands, and personal control. Insofar as employment increases women’s