Recovery From Schizophrenia: Psychiatry And Political Economy

32 BACKGROUNDschizophrenia, were concentrated in centrally located, low socio-economicdistricts in many American and European cities - Peoria, Illinois; Kansas City,Missouri; St Louis, Missouri; Milwaukee, Wisconsin; Omaha, Nebraska; 21Worcester, Massachusetts; 22 Rochester, New York; 23 Baltimore, Maryland; 24Oslo, Norway; 25 and Bristol, England. 26Sociologist Robert Clark demonstrated in the 1940s that Chicago residents inlow-status and low-income occupations had a higher incidence of treatedschizophrenia than higher-status workers. 27 This observation has also beenconfirmed by a number of studies. In their survey of New Haven, Connecticut,in the 1950s, August Hollingshead and Frederick Redlich revealed a gradient ofprogressively greater prevalence of treated schizophrenia in the lower socioeconomicclasses. The prevalence of the illness was 11 times greater in the lowestclass compared with the highest class. 28 Leo Srole and his associates, in acommunity survey of midtown Manhattan in New York City, which locatedboth treated and untreated cases, found mental disorder to be more common inthe lower classes than in the upper classes and more prevalent in those whoremained at the same socio-economic level than in the upwardly mobile. 29Dorothea Leighton and her colleagues found mental disorder to be most frequentin the lowest social class in their comprehensive survey of a rural area of NovaScotia. 30 Social psychiatrist Örnulv Ödegard demonstrated that first admissions forschizophrenia to all psychiatric hospitals in Norway were most common amonglow-status workers, such as ordinary seamen and farm laborers and one-third asfrequent among the owners and managers of businesses and others in high-statusoccupations. 31 In London, Lilli Stein showed that there existed a social-classgradient in the incidence and prevalence of mental illness (with the highest ratesin the lowest classes) that was particularly marked for schizophrenia. 32 Reviewingthese data, epidemiologist William Eaton concluded that, if we divide thepopulation into three social classes, it is common to find a three-to-one differencein rates of schizophrenia between the lowest and highest classes. 33SOCIAL DRIFT OR SOCIAL STRESS?A reasonable explanation for the social-class gradient in schizophrenia, and onewhich is commonly given, is that people with the greatest risk of developing theillness drift into lower-status occupations and low-income city areas as a result oftheir marginal, pre-psychotic levels of functioning. This is known as the socialdrifthypothesis. Support for the social drift theory came from a study conductedin Britain in 1963 demonstrating that, although males with schizophrenia wereover-represented in the lowest socio-economic class, the social class of theirfathers and other male family members was distributed much as in the generalpopulation. 34 Similar findings came from the US. 35 An alternative explanationwould be that the stresses of lower-class living, including labor-market stresses andclass-related effects on fetal development and birth complications, increase the riskof developing schizophrenia. A final, theoretical possibility is that there exists an