Stressful Life Events
The most common psychological and social stressors in adult life include the breakup of intimate romantic relationships, death of a family member or friend, economic hardships, racism and discrimination, poor physical health, and accidental and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Although some stressors are so powerful that they would evoke significant emotional distress in most otherwise mentally healthy people, the majority of stressful life events do not invariably trigger mental disorders. Rather, they are more likely to spawn mental disorders in people who are vulnerable biologically, socially, and/or psychologically (Lazarus & Folkman, 1984; Brown & Harris, 1989; Kendler et al., 1995). Understanding variability among individuals to a stressful life event is a major challenge to research. Groups at greater statistical risk include women, young and unmarried people, African Americans, and individuals with lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999).
Divorce is a common example. Approximately one-half of all marriages now end in divorce, and about 30 to 40 percent of those undergoing divorce report a significant increase in symptoms of depression and anxiety (Brown & Harris, 1989). Vulnerability to depression and anxiety is greater among those with a personal history of mental disorders earlier in life and is lessened by strong social support. For many, divorce conveys additional economic adversities and the stress of single parenting. Single mothers face twice the risk of depression as do married mothers (Brown & Moran, 1997).
The death of a child or spouse during early or midadult life is much less common than divorce but generally is of greater potency in provoking emotional distress (Kim & Jacobs, 1995). Rates of diagnosable mental disorders during periods of grief are attenuated by the convention not to diagnose depression during the first 2 months of bereavement (Clayton & Darvish, 1979). In fact, people are generally unlikely to seek professional treatment during bereavement unless the severity of the emotional and behavioral disturbance is incapacitating.
A majority of Americans never will confront the stress of surviving a severe, life-threatening accident or physical assault (e.g., mugging, robbery, rape); however, some segments of the population, particularly urban youths and young adults, have exposure rates as high as 25 to 30 percent (Helzer et al., 1987; Breslau et al., 1991). Life-threatening trauma frequently provokes emotional and behavioral reactions that jeopardize mental health. In the most fully developed form, this syndrome is called post-traumatic stress disorder (DSM-IV), which is described later in this chapter. Women are twice as likely as men to develop post-traumatic stress disorder following exposure to life-threatening trauma (Breslau et al., 1998.)
More familiar to many Americans is the chronic strain that poor physical health and relationship problems place on day-to-day well-being. Relationship problems include unsatisfactory intimate relationships; conflicted relationships with parents, siblings, and children; and “falling-out” with coworkers, friends, and neighbors. In mid-adult life, the stress of caretaking for elderly parents also becomes more common.
Relationship problems at least double the risk of developing a mental disorder, although they are less immediately threatening or potentially cataclysmic than divorce or the death of a spouse or child (Brown & Harris, 1989). Finally, cumulative adversity appears to be more potent than stressful events in isolation as a predictor of psychological distress and mental disorders (Turner & Lloyd, 1995).
Past Trauma and Child Sexual Abuse
Severe trauma in childhood may have enduring effects into adulthood (Browne & Finkelhor, 1986). Past trauma includes sexual and physical abuse, and parental death, divorce, psychopathology, and substance abuse (reviewed in Turner & Lloyd, 1995).
Child sexual abuse is one of the most common stressors, with effects that persist into adulthood. It disproportionately affects females. Although definitions are still evolving, child sexual abuse is often defined as forcible touching of breasts or genitals or forcible intercourse (including anal, oral, or vaginal sex) before the age of 16 or 18 (Goodman et al., 1997). Epidemiology studies of adults in varying segments of the community have found that 15 to 33 percent of females and 13 to 16 percent of males were sexually abused in childhood (Polusny & Follette, 1995). A recent, large epidemiological study of adults in the general community found a lower prevalence (12.8 percent for females and 4.3 percent for males); however, the definition of sexual abuse was more restricted than in past studies (MacMillan et al., 1997). Sexual abuse in childhood has a mean age of onset estimated at 7 to 9 years of age (Polusny & Follette, 1995). In over 25 percent of cases of child sexual abuse, the offense was committed by a parent or parent substitute (Sedlak & Broadhurst, 1996).
The long-term consequences of past childhood sexual abuse are profound, yet vary in expression. They range from depression and anxiety to problems with social functioning and adult interpersonal relationships (Polusny & Follette, 1995). Post-traumatic stress disorder is a common sequela, found in 33 to 86 percent of adult survivors of child sexual abuse (Polusny & Follette, 1995). In a recent review, Weiss et al. (1999) found that sexual abuse was a specific risk factor for adult-onset depression and twice as many women as men reported a history of abuse. Other long-term effects include self-destructive behavior, social isolation, poor sexual adjustment, substance abuse, and increased risk of revictimization (Browne & Finkelhor, 1986; Briere, 1992).
Very few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials (IOM, 1998). Group therapy and Interpersonal Transaction group therapy were found to be more effective for female survivors than an experimental control condition that offered a less appropriate intervention (Alexander et al., 1989, 1991). In the practice setting, most psychosocial and pharmacological treatments are tailored to the primary diagnosis, which, as noted above, varies widely and may not attend to the special needs of those also reporting abuse history.
Domestic Violence
Domestic violence is a serious and startlingly common public health problem with mental health consequences for victims, who are overwhelmingly female, and for children who witness the violence. Domestic violence (also known as intimate partner violence) features a pattern of physical and sexual abuse, psychological abuse with verbal intimidation, and/or social isolation or deprivation. Estimates are that 8 to 17 percent of women are victimized annually in the United States (Wilt & Olsen, 1996). Pinpointing the prevalence is hindered by variations in the way domestic violence is defined and by problems in detection and underreporting. Women are often fearful that their reporting of domestic violence will precipitate retaliation by the batterer, a fear that is not unwarranted (Sisley et al., 1999).
Victims of domestic violence are at increased risk for mental health problems and disorders as well as physical injury and death. Domestic violence is considered one of the foremost causes of serious injury to women ages 15 to 44, accounting for about 30 percent of all acute injuries to women seen in emergency departments (Wilt & Olsen, 1996). According to the U.S. Department of Justice, females were victims in about 75 percent of the almost 2,000 homicides between intimates in 1996 (cited in Sisley et al., 1999). The mental health consequences of domestic violence include depression, anxiety disorders (e.g., post-traumatic stress disorder), suicide, eating disorders, and substance abuse (IOM, 1998; Eisenstat & Bancroft, 1999). Children who witness domestic violence may suffer acute and long-term emotional disturbances, including nightmares, depression, learning difficulties, and aggressive behavior. Children also become at risk for subsequent use of violence against their dating partners and wives (el-Bayoumi et al., 1998; NRC, 1998; Sisley et al., 1999).
Mental health interventions for victims, children, and batterers are highly important. Individual counseling and peer support groups are the interventions most frequently used by battered women. However, there is a lack of carefully controlled, methodologically robust studies of interventions and their outcomes, according to a report by the Institute of Medicine and National Research Council (IOM, 1998). A research agenda for violence against women was developed (IOM, 1996) and has served as an impetus for an ongoing research program sponsored by the U.S. Departments of Justice and Health and Human Services. Clearly, there is an urgent need for development and rigorous evaluation of prevention programs to safeguard against intimate partner violence and its impact on children.
Interventions for Stressful Life Events
Stressful life events, even for those at the peak of mental health, erode quality of life and place people at risk for symptoms and signs of mental disorders. There is an ever-expanding list of formal and informal interventions to aid individuals coping with adversity. Sources of informal interventions include family and friends, education, community services, self-help groups, social support networks, religious and spiritual endeavors, complementary healers, and physical activities. As valuable as these activities may be for promoting mental health, they have received less research attention than have interventions for mental disorders. Nevertheless, there are selected interventions to help people cope with stressors, such as bereavement programs and programs for caregivers (see Chapter 5) as well as couples therapy and physical activity.
Couples therapy is the umbrella term applied to interventions that aid couples in distress. The best studied interventions are behavioral couples therapy, cognitive-behavioral couples therapy, and emotion-focused couples therapy. A recent review article evaluated the body of evidence on the effectiveness of couples therapy and programs to prevent marital discord (Christensen & Heavey, 1999). The review found that about 65 percent of couples in therapy did improve, whereas 35 percent of control couples also improved. Couples therapy ameliorates relationship distress and appears to alleviate depression. The gains from couples therapy generally last through 6 months, but there are few long-term assessments (Christensen & Heavey, 1999). Similarly, interventions to prevent marital discord yield short-term improvements in marital adjustment and stability, but there is insufficient study of long-term outcomes. The prevention programs receiving the most study are the Couple Communication Program, Relationship Enhancement, and the Prevention and Relationship Enhancement Program (Christensen & Heavey, 1999). Greater research is needed to overcome gaps in knowledge and to extend findings to a broader array of programs, to diverse populations of couples, and to a wider set of outcomes, including effects on children.
Physical activities are a means to enhance somatic health as well as to deal with stress. A recent Surgeon General’s Report on Physical Activity and Health evaluated the evidence for physical activities serving to enhance mental health (U.S. Department of Health and Human Services [DHHS], 1996). Aerobic physical activities, such as brisk walking and running, were found to improve mental health for people who report symptoms of anxiety and depression and for those who are diagnosed with some forms of depression. The mental health benefits of physical activity for individuals in relatively good physical and mental health were not as evident, but the studies did not have sufficient rigor from which to draw unequivocal conclusions (DHHS, 1996).
Prevention of Mental Disorders
A promising development in prevention of a specific mental disorder in adults occurred with the publication of results from the San Francisco Depression Research Project (Munoz et al., 1995). This study investigated 150 primary care patients who did not meet diagnostic criteria for depression and who were being seen in a public clinic for other problems. They were randomized to either psychoeducation—an 8-week cognitive behavioral course to help them control and manage moods—or to a control condition. One year later, those who received psychoeducation were found to have developed significantly fewer depression symptoms than members of the control group. This trial is noteworthy in two major respects: it was a randomized controlled trial and its participants were low-income individuals, with high representation of all major minority groups. Low-income individuals are considered a high-risk population because of studies documenting their higher prevalence of mental disorders. This study demonstrated in a methodologically rigorous fashion that depression may be preventable in some cases. It serves as a model for extending the concept of prevention to many mental disorders. Prevention research is vitally important and needs to be enhanced.
