Social Capital and Psychiatry: Review of the Literature

REVIEW

Social Capital and Psychiatry:Review of the Literature

Rob Whitley, PhD, and Kwame McKenzie, MD, MRCPsych

Social capital is an umbrella term used to describe aspects of social networks, relations, trust, andpower, as a function of either the individual or a geographical entity (e.g., a city neighborhood).Increased attention is being paid to the role that social capital can play in determining a varietyof physical health outcomes, though less attention has been paid to its role in determining mentalhealth outcomes. This relative inattention continues despite a long historical tradition in psychiatryof exploring the role that socio-environmental factors can play in the etiology and course of mentalillness. In this review, we begin by tracing the historical development of the concept of social capital,describing and analyzing competing definitions. We then proceed to review the published studies thatexamine the relationship between social capital and mental health—looking first at studies that focuson depression and anxiety, and second at studies that focus on psychoses. After briefly exploringwhether social capital can have a detrimental effect on mental health, we discuss how knowledgeregarding social capital may aid the clinician and mental health services. We go on to make anumber of suggestions relevant to methodological, theoretical, and empirical advancement. Thesesuggestions include refining the definitions of social capital, paying attention to communities withoutpropinquity, and constructing contextual indicators of social capital. We conclude by remarking thatsocial capital may be a promising heuristic for studies in community psychiatry and may even helpindividual clinicians in designing treatment plans. Despite all this promise, however, there is a lackof strong evidence supporting the hypothesis that social capital protects mental health. (HARV REV

PSYCHIATRY 2005;13:71–84.)

Keywords: epidemiology, mental health, psychiatry, social anthropology, social capital, social andpolitical issues, stress

From the Division of Social and Trans-cultural Psychiatry, Depart-ment of Psychiatry, McGill University, and Division of Psycholog-ical Medicine, Institute of Psychiatry, King’s College London (Dr.Whitley); Department of Psychiatry and Behavioural Sciences, RoyalFree and University College Medical School, London (Dr. McKenzie).

Supported by a grant from the Leverhulme Trust (Dr. Whitley).

Original manuscript received 3 April 2004; revised manuscript re-ceived 14 September 2004, accepted for publication 23 September2004.

Correspondence: Rob Whitley, PhD, Division of Social and Trans-cultural Psychiatry, Department of Psychiatry, McGill University,1033 Pine Ave. West, Montreal, PQ, Canada H3A 1A1. Email:[email protected]

©c 2005 President and Fellows of Harvard College

DOI: 10.1080/10673220590956474

Social capital is a concept developed in disciplines as di-verse as criminology,1 political science,2 and internationaldevelopment.3 Researchers involved in the health sciencesare showing an increasing interest in the concept as a possi-ble explanatory factor for group and individual variations inhealth and as a potential target for interventions. The inter-est in social capital and health is characteristic of a revivedgeneral interest in social factors in the causation of healthand illness. The World Health Organization has stated thatthe fundamental causes of health and illness have a strongsocial and environmental component.4 Numerous articleshave suggested that geographical units (ranging from smallneighborhoods to American states) with “high levels” of so-cial capital have lower suicide rates, lower overall mortality,and longer life expectancy.5 It has also been argued that lev-els of income inequality within a nation determine healthindicators such as life expectancy: the more inequality, thelower life expectancy.6 Increased income inequality has beenposited to lead to lower levels of social cohesion and trust

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(key components of social capital), deterring investment incommunity life—which may have deleterious effects on pub-lic health.

Henderson and Whiteford7 have commented on thedearth of robust theory and evidence for posited links be-tween social capital and mental health. Even if they arecorrect, however, there is a strong tradition of ecologicalthinking in psychiatric epidemiology that suggests that so-cial factors play a strong role in the etiology and courseof mental illness. For example, Faris and Dunham8 ar-gued in the 1930s that the level of “disorganization” withina neighborhood was a factor that could explain differen-tial rates of mental disorders within the City of Chicago.Since then, other psychiatric researchers such as Leighton9

and Freeman10 have shown a relationship between socio-environmental variables and mental health. Such findingsled an American Psychiatric Association task force to cointhe term “ecopsychiatry” in the early 1980s.11 Current psy-chiatric interest in social capital may thus be seen as a con-tinuation or revival of this interest, rather than as a devel-opment de novo.

WHAT IS SOCIAL CAPITAL?

As will be explored later in the literature review, most em-pirical studies in public health anchor the concept of socialcapital around levels of trust, community participation, andcommunity/individual networks. Just how to define socialcapital is a matter of ongoing, critical debate, however, andwithin the social sciences, there are various other, compet-ing definitions of social capital—ones often overlooked in thehealth sciences.

Jane Jacobs12 is often credited with being the first personto present a sociological definition of the term social capital:“Underlying any float of population must be a continuityof people who have forged neighbourhood networks. Theseare a City’s irreplaceable social capital.” Since then, othersocial scientists have tried to define social capital more pre-cisely. Bourdieu13−15 defined social capital as the sum of anindividual’s social relationships—which were perceived asassets that allowed differential access to societal resourcessuch as employment and educational opportunities. Theserelationships defined social capital as both mirroring andreproducing existing class and structural inequalities in so-cieties. Social capital was therefore primarily a property ofindividuals.

Coleman, also considered a “founding father” of socialcapital theory, gave more emphasis to the supra-individualnature of social capital, though he also posited a strong re-lational aspect to the concept, stating that “social capital islodged neither in individuals nor in physical implementsof production.”16 Social capital was embodied in relation-

ships between individuals, between groups, and betweengroups and abstract bodies such as the state. This defini-tion, unlike Bourdieu’s, thus transcended conventional so-cial network/social support theory—which concentrates ex-clusively on an individual’s social relationships as the vari-able of interest—by focusing on the role of group values andnorms.

The most common definition of social capital used inthe health sciences originates with Putnam. This definitionarose out of empirical studies of the performance of regionalgovernment in Italy.2 Putnam defined social capital as con-sisting of five principal characteristics, namely:

1. Community networks: number and density of volun-tary, state, and personal networks

2. Civic engagement: participation and use of civicnetworks

3. Local civic identity: sense of belonging, of solidarity,and of equality with other members of the community

4. Reciprocity and norms of cooperation: a sense of obli-gation to help others, along with a confidence that suchassistance will be returned

5. Trust in the community

A key point of Putnam’s work is that while social capital isoften measured by gathering data at the individual level,its impact is hypothesized to be collective. All individualsliving in neighborhoods where there are high levels of trustand civic engagement are posited to benefit from these com-munity characteristics—even the individuals who are suspi-cious of others and engage in no civic activity. For example,any resident in a high social capital neighborhood will beless likely to be a victim of crime and will be able to accessa comprehensive social safety net in times of need, regard-less of the person’s civic contribution. There is thus a com-plex relationship between individual- and group-level fac-tors in social capital (discussed in more detail in the nextsection)—which raises important questions about measure-ment, another issue of critical debate in social capital re-search. For example, civic identity can be measured at theindividual level by collecting data from individuals throughquestionnaires or semi-structured interviews. The same fac-tor can also be modeled, however, as having supra-individualcomponents better measured by collecting independent dataabout the neighborhood or community under question—for example, the number of shared community facilitiessuch as sports fields, parks, community centers, and publiclibraries.

It should be noted that the various conceptions of so-cial capital described above, though interesting and likelyto drive further research, have not been widely embraced inthe existing literature involving social capital and psychia-try. That particular literature has generally relied on ver-sions of Putnam’s five-point definition, as discussed above,

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with particular emphasis on the role of relationships, net-works, trust, and norms.

Ecological and Individual Social Capital

One area of ongoing debate, which much of the empirical andtheoretical literature has not quite confronted, regards thequestion of whether social capital should be conceptualizedas primarily a property of neighborhoods and groups (eco-logical social capital) or primarily a property of individuals.Commitment to one view or the other does not necessarilypresume that there is no validity in the other mode of concep-tualization. Similarly, it has been convincingly argued thata distinction between ecological and individual social capitalmay well be artificial. Ecological social capital is often mea-sured by aggregating individual social capital at a particularspatial level such as a city neighborhood—and, in fact, thesetwo are often linked. For example, some studies have found aclear interaction between individual trust and collective no-tions of trust,17,18 which suggests that the actions, choices,and thoughts of the individuals who make up a group havea major impact on ecological social capital. Conversely, oth-ers have rightly emphasized that so-called individual-levelfactors (e.g., low income) are often partially determined bygroup or place-level dynamics and identity.19 Still, questionsremain as to whether aggregating the views of individualsproduces an accurate measure of social context and, con-versely, whether the ecological measurement of social con-text captures the day-to-day experience of individuals.

Most ongoing thought in social science suggeststhat neighborhoods and groups are synergistic, complexrealities—that is, they are more than simply the sum of theindividuals contained therein—and that, conversely, indi-vidual members of a group do not necessarily reflect dom-inant group characteristics. This theorizing has led to thedevelopment of well-known concepts such as the atomisticand ecological fallacies.20

Research that aggregates from individuals to groups maycommit the atomistic fallacy (depending, of course, on the in-ferences one attempts to draw from the aggregated data)—which Durkheim neatly illustrated as follows: from the factthat cells are made exclusively of inanimate atoms, one can-not conclude that the cell itself is inanimate.21 By contrast,the ecological fallacy involves drawing inferences about indi-viduals based on data gathered at an ecological level. Again,Durkheim neatly remarks that one cannot conclude Protes-tants have a higher rate of suicide than Catholics simply be-cause predominantly Protestant regions have higher ratesof suicide than predominantly Catholic regions. It could bethat more Catholics within Protestant regions are commit-ting suicide and are thus responsible for the elevated rates.

Complex epistemological debate regarding the meaningand applicability of these issues in contemporary public

health is ongoing.20 Without wishing to embroil ourselvesin this specialist debate, it is worth noting at this stage thatmany studies of “ecological” social capital and public healthrely on the aggregation of data collected from individuals asa measurement of “ecological” social context. Aggregatingdata from individuals to groups in this manner does not nec-essarily produce fallacy, as long as consequent explanationsand conclusions do not cross levels. Thus, unemploymentrates in a neighborhood are validly measured by aggregatingdata collected from individuals regarding their employmentstatus. Unemployment will have different health effects atthe individual and neighborhood levels, however, and boththe atomistic and ecological fallacies come into play whenthese differences are overlooked and inferences are drawnacross levels. Consider the case of a high neighorhood un-employment rate that results from the closure of a localindustry known to be injurious to health, such as mining.While this closure may have a negative impact on commu-nity health because of decreasing general incomes, weak-ening of social infrastructure, and disinvestment, it mayhave a positive impact on the health of individuals who werepreviously employed in the health-damaging occupation ofminer. In this instance, extrapolating from the effect of un-employment at the individual level to the effect of unem-ployment at the neighborhood level (or vice versa) would befallacious.

As will be seen, studies vary in how they deal with theseissues of measurement and fallacy. It is sometimes difficultto discern a difference between research claiming to mea-sure social capital based on aggregated data collected fromindividuals and research claiming to measure individual so-cial support or social networks. In the long term, if the con-cept of social capital is to drive forward new and better re-search in psychiatry, it may be more fruitful to conceptualizesocial capital as being primarily, though not exclusively, agroup-level variable that should be measured as such. Thisconception clearly differentiates social capital theory fromsocial support/network theory and, by the same token, con-stitutes a distinct theoretical approach. Nevertheless, theindividualistic conception of social capital—inspired primar-ily by Bourdieu’s definition—has much to offer, for it revealsimportant processes often ignored by social support theory,such as the role of an individual’s societal status, power, andconnections.

Taking all of the above considerations into account,though there are obviously methodological and conceptualconnections between ecological and individual-level socialcapital, we believe that at present it may be more helpfulto conceptualize “social capitals” in the plural rather thanas a single ontological entity. While related, individual-leveland ecological-level social capital may capture separate pro-cesses that differentially affect everyday experience—andultimately, individuals’ mental health and well-being. Since

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the concept is still in its infancy, conceptualization of “so-cial capitals” in the plural would validate studies that areeither individually or ecologically orientated, thereby allow-ing for further theoretical development and a more in-depthdescription of different types of social capital. There are par-allels to this pluralization in other public health literature—for example, with regard to air quality. Both indoor andoutdoor air quality are known to contribute to respiratoryproblems. Though there may be a link between these tworelated exposure variables, both are worthy areas of inves-tigation, and inquiry into the one does not preclude or inval-idate inquiry into the other.

Structural and Cognitive Social Capital

Uphoff 22 defines social capital as consisting of twodimensions—structural and cognitive—and in a way thattranscends some of the ongoing debates discussed above.Both cognitive and structural social capital are conceptu-alized primarily as properties of collective entities (e.g.,neighborhoods) rather than of individuals. Structural socialcapital is seen as consisting of relationships, networks, as-sociations, and institutional structures that link people andgroups together. These factors can thus be crudely measurednumerically through an analysis of linkages and networkdensity at a community level. This direct observation andenumeration will not be influenced by the perceptions of in-dividuals within the sample—thus leading to some form ofindependent assessment.

Cognitive social capital consists of values, norms, reci-procity, altruism, and civic responsibility. It thus taps intoshared patterns of cognition and subsequent social behavior,and explicitly attempts to describe what Uphoff calls “collec-tive moral resources.”

Though the conceptualization of social capital underlyingthese two components—one structural and one cognitive—isprimarily ecological rather than individual, this model givessome credence to the argument previously espoused thatindividual and ecological social capital are closely linked.For example, neighborhood values, norms, and structureswould be expected to perpetuate themselves by selectivelyattracting certain individuals willing and able to contributeto their continuity. Similarly, those individuals likely to dis-rupt neighborhood values and norms may be repulsed bythe obvious disjunction between their own values and thoseof the community. An obvious dialectical relationship be-tween individual and ecological social capital can thus bediscerned, supporting the view that there is an interpen-etration between the two. As Giddens23 aptly observes inthis context, “structure makes agency and agency makesstructure”—a recognition of the mutually dependent rela-tionship between societal structural variables and individ-ual outcomes.

Cognitive social capital could be pictured as being morepsychological in nature, whereas structural social capitalcould be seen as more ontologically concrete. The etherealnature of cognitive social capital therefore poses more diffi-culties with regard to measurement. For example, althoughit is common to aggregate self-reported individual values(such as trust) as a measure of cognitive social capital,this method may not accurately measure trust at the eco-logical level—and not just because of the epistemologicalrisks associated with making inferences about ecologicalproperties from aggregated data collected from individuals.There is also a potential response bias; individuals’ socio-demographic, economic, and cultural backgrounds will colorthe way in which they describe their community. Indeed, re-cent research has demonstrated that the reporting of trust inthe same neighborhood is affected by respondents’ socioeco-nomic status, age, marital status, and ethnicity, even thoughthere was an ecological association between community so-cial trust and self-reported health.18 Thus, linkages betweenmeasures at the individual and the ecological level can easilyvary—again raising the question of the validity of using ag-gregated data collected from individuals to make inferencesregarding collectivities.

Bonding and Bridging Social Capital

Putnam rarely discusses issues of power relationships in hiswork, which has led to criticisms that his general approachto social capital is selectively myopic and simplistic, and ig-nores the important role of individual and group power—something highlighted by Bourdieu and others in their con-sideration of social capital (see, e.g., articles by Muntaneret al.24 and Lynch et al.).25 Perhaps in an effort to overcomesome of these criticisms regarding the alleged thinness ofhis analysis, Putnam has recently theorized about two di-mensions of social capital: bridging (inclusive) and bonding(exclusive).26 Bonding social capital is defined as inwardlyfocused and characterized by homogeneity, strong norms,loyalty, exclusivity, and a reliance on solid intra-group ties.Bridging social capital is defined as outwardly focused, link-ing diverse groups and people. It is intergroup and charac-terized by weaker ties. Putnam notes that bonding socialcapital can be negative and uses the Ku Klux Klan as an ex-ample. It can also be positive, however—for example, whendense ethnic groups of well-established immigrants providesupport for newer immigrants.27 By contrast, Putnam ar-gues that bridging social capital is generally positive—“a so-ciological superglue”—and gives examples of organizations(e.g., fraternal organizations such as the Elks and RotaryClubs, and parent-teacher associations) that regularly bringdiverse groups of people together.

Though this distinction between bonding and bridgingsocial capital is theoretically interesting and intuitively

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attractive, it has rarely been empirically employed as aframework in studies of social capital and health. There arestill numerous question marks regarding how this divisioncould be utilized or even measured empirically. Furthermorethough this distinction stimulates further thought regard-ing social capital, it still does not address issues of power andstructural inequality. It has been argued by some that theseelements, which were inherent in Bourdieu’s definition ofsocial capital14,15 but have been overlooked by Putnam andhis followers,24,25 are the most important aspects of socialcapital as related to public health.

Horizontal and Vertical Social Capital

Woolcock28 argues that it is important to distinguish be-tween social capital at the micro level and social capitalthat maintains and provides institutional integration at themacro level. The latter is usually hypothesized as applyingto groups but can be equally applied to individuals. Collettaand Cullen3 come closest to formulating such a distinctionby defining social capital as consisting of two dimensions;horizontal and vertical. Horizontal social capital is definedas the number and extent of linkages between groups of anequal standing in society. Vertical social capital can be seenas the degree of integration and social efficacy of groupswithin a hierarchical society. Vertical social capital can beused by entities such as neighborhoods (or individuals) toinfluence policy, to ensure fair treatment by the legal sys-tem, and obtain resources from those in power. Woolcock28

argues that vertical social capital is a function of the organi-zational integrity, penetration, and effectiveness of the stateand, to a lesser extent, of the market. Colletta and Cullen3

equate horizontal bridging social capital and vertical inte-gration with an inclusive, cohesive society. Through this def-inition of social capital, extra-community integration andsocial efficacy of groups are seen as being just as importantas intra-community cohesion. This refinement of definitionsovercomes the critique, often leveled against Putnam’s con-ceptualization, that social capital ignores important powerrelations that may have detrimental effects on individualand group health outcomes.29 The model of vertical socialcapital may thus be considered progressive for two reasons.First, it widens the researcher’s lens by examining macro-level structures in the social and political world, and howthese structures affect group outcomes. Second, it implic-itly acknowledges the incomplete nature of any approach inwhich the characteristics of neighborhoods or groups are ex-amined in isolation—without reference to the wider social,economic, and political environment.

Furthermore, if the theory of vertical integration is ac-cepted, it has implications for what kinds of interventionsare appropriate and likely to obtain results. Efforts simplyto increase within-group “community spirit” in an econom-

ically deprived immigrant neighborhood—for example, bythe building of a community center—may be insufficient ifthe immigrant group still has unequal access to employ-ment, education, lobbying power, and other important re-sources that may have just as much bearing on social capi-tal (broadly defined). The same level of attention may haveto be given to restructuring vertical relations, such as thegroup’s relations with local government, employers, law en-forcement agencies, and educators.

Social Support and Social Capital

As we have already mentioned, there is some conceptualoverlap between social support/network theory and socialcapital work that is individually oriented. This overlapmakes it difficult for us as reviewers to create valid ex-clusion/inclusion criteria for articles to be discussed in thisoverview, especially in light of the extensive literature inves-tigating the relationship between social support/networksand mental health. We will therefore briefly discuss someof the key findings regarding social support/networks be-fore exploring in depth the empirical studies that have at-tempted to relate mental health to social capital, whetherconceptualized individually or ecologically. We also directthe interested reader to more comprehensive overviews ofsocial support/networks and mental health (e.g., the one byKawachi & Berkman).30

Social support has been consistently shown to act as aprotective factor for a variety of health outcomes.31 Throughlongitudinal analysis it has been shown that low social net-works are correlated with increased risk of mortality, acci-dents, suicides, and cardiovascular disease.32,33 It has beenargued that social networks and supports provide emotionalsustenance and instrumental aid that play a major rolein maintaining an individual’s mental health.34 Empiricalwork in London, England, supported this argument, findingthat lack of social support was a vulnerability factor thatcould predispose certain people to depression.35 The samestudy also found that social support, as indicated by thepresence of a significant other, lowered risk of depression.

Existing studies thus suggest that the provision ofemotional, informational, and instrumental social sup-port buffers individuals against both chronic and acutestress.36,37 The socially isolated individual lacks support andsuffers the consequent disadvantages. Social capital could behypothesized as acting in a similar manner, though describ-ing the character of neighborhoods or groups rather thanindividuals. Like individuals, neighborhood or other groupsmay be isolated, alienated, powerless, or lacking in socialefficacy. They may lack formal and voluntary societal safetynets and access to health care, just as the isolated individuallacks informal safety nets and friendship networks that canpoint in the direction of (or finance) appropriate facilities or

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services. This communal isolation and alienation could exerta collective effect on mental health, especially with respectto persons who are otherwise already at risk.

To summarize the material presented so far, it is truethat, like other sociological concepts such as social classor ethnicity, the variety of approaches to the definitionand measurement of social capital may appear bewilder-ingly complex. This complexity, however, reflects real dif-ferences of opinion within the social sciences that cannotbe ignored. Having said that, there are a number of com-mon themes and trends underlying social capital researchthat can be usefully summarized at this point and that setthe stage for the rest of our discussion. First, most theo-rists agree that social capital relies on four principal fac-tors: networks, relationships, norms, and trust, with differ-ent theorists placing more or less emphasis on each separatecomponent. Second, some argue that social capital can bedefined and measured as a property of individuals, whereasothers see it as a property of an ecological unit (typically,a city neighborhood or a larger unit such as an Americanstate). We take the position that treating social capital atan ecological level is the way forward if social capital is tobe distinguished from conventional social support/networktheory. We acknowledge, however, that some researchersprefer to consider social capital as an individual-level fac-tor. Finally, a number of different conceptions of social capi-tal (e.g., cognitive, structural, bridging, bonding, horizontal,and vertical) have emerged as theories have become morecomplex. While these conceptions merit inclusion in anyarticle endeavoring to provide an introduction to social cap-ital (which is, in part, our goal here), they have yet to havea significant impact on the design of empirical research inpsychiatry.

SOCIAL CAPITAL AND PSYCHIATRIC ILLNESS

In this new section of our review, we move away from generaland complex considerations of theory, definition, and mea-surement in social capital research to a review of the em-pirical work exploring the relationship between social capi-tal and psychiatric outcomes. Toward the very beginning ofthis article, we noted that some leading commentators havestated that there is a dearth of research and robust theoryon social capital and mental health.7 Most work investigat-ing social capital and psychiatry has been general in natureand has employed off-the-shelf definitions—usually similarto Putnam’s five-point formulation of social capital—ratherthan developing the concept with special reference to psy-chiatry. Because of this lack of robust theory, the impact ofsocial capital on any specific psychiatric disorder is difficultto assess—though it could be hypothesized that the impactwould vary with the disorder in question.

Our own view is that the genesis, treatment, and courseof most psychiatric illnesses are influenced by social con-text. From alcohol and drug abuse, to common mood disor-ders such as depression and anxiety, to severe mental illnesssuch as schizophrenia, the social world is important. Therelative contributions of genetic and environmental vulner-ability will differ, but it is rare for one to be entirely absent.For example, the social world influences the type and ex-tent of vulnerability factors, precipitating factors, and per-petuating factors known to be associated with most mentalillnesses.30,34,35 Even in the case of Huntington’s chorea, adisease that is usually considered purely genetic, the socialand medical safety net required to care properly for sufferersmay depend on a neighborhood’s, or on society’s, willingnessto finance community care and on the patient’s access tovoluntary or statutory supportive institutions.

As stated throughout this article, there have been fewempirical studies directly investigating the relationship be-tween social capital and mental health outcomes. The dis-cipline of psychiatry is thus just beginning to understandthe relationship between these two factors. For both practi-cal and theoretical reasons, we have divided our review intotwo parts—the first to empirical studies dealing primarilywith depression and anxiety, the second to those dealing withpsychoses. To our knowledge, in all of the empirical inves-tigations of the relationship between social capital and psy-chiatric illness, all of the illnesses studied have been onesthat fit neatly into this dichotomy. In fact, almost all of theresearch reviewed here conceptualizes mental health in ageneral manner without reference to DSM-IV criteria. Whileit is tempting to discuss the possible effect of social capi-tal on rarer psychiatric illnesses or on illnesses commonlyencountered in subfields (such as geriatrics or learning dis-abilities), we have decided to eschew this option in order tofocus on the existing empirical literature. This literature ismostly general in orientation and includes only broad cate-gories such as depression or psychoses. Our approach leavesmany pertinent questions unanswered (some of which wereturn to at the end of the article), but more specialized dis-cussion would be mere speculation in the absence of anyform of peer-reviewed literature. By discussing in depth thework on depression and anxiety and on psychoses, we hopeat least to summarize and synthesize important informationon debilitating mental illnesses frequently encountered bycommunity and hospital psychiatrists.

Social Capital and Depression/Anxiety

Putnam has promulgated the idea that strong communi-ties (especially those of a religious persuasion) protect in-dividual members from depression.26 In discussing whatSeligman referred to as the “depression epidemic” in theUnited States, Putnam notes that it may have spared the

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Amish community in Pennsylvania—precisely because it isclose-knit with strong norms of trust. This view is in the tra-dition of Durkheim, who found that suicide was less preva-lent among groups having potentially high degrees of bond-ing social capital, such as practicing Catholics or Jews.21

A number of recent studies have attempted to measurewhether social capital is associated with depression or anxi-ety. One of the first quantitative studies of social capital andmental health in the United States surveyed 700 African-American mothers of 10- to 12-year-olds from 31 areas, madeup of 259 census blocks.38 Using multilevel analysis, per-ceived social cohesion (aggregated to the area level from in-dividual responses within each area) was nonsignificantlyassociated with anxiety and depression measured using 8items designed to assess nonspecific symptoms of depressionand 10 items relatively specific to anxiety, such as shakiness,dizziness, or sensations of being short of breath, from theMini-Mood and Anxiety Symptom Questionnaire.38 In thisstudy, social capital was modeled as “social cohesion” andtherefore accessed respondents’ views on trust and neigh-borhood relations (close to Putnam’s formulation). Thoughsocial capital was modeled ecologically in this study, the con-textual indicators were nevertheless arrived at through theaggregation of individual responses; as noted earlier in thereview, this type of aggregation may bias results or gener-ate an incomplete picture of whatever is being investigated.Another weakness of this study is that the particular geo-graphical areas delineated as targets for research may nothave been meaningful reflections of the individuals’ day-to-day environment. The authors conceptualized a neighbor-hood as clusters of blocks that had similar socioeconomicstatus but were not necessarily adjacent to each other. Thistype of problem is common to many studies of social capitalsince the choice of contextual unit is often based on practical,rather than theoretical, reasons.

A similar methodology was employed by a study in theNetherlands of 10- to 12-year-old children.39 Almost 600children from 36 neighborhoods participated, with mentalhealth status being assessed by scores on the mental illnessand behavior subscales of the Child Health Questionnaire.Social capital was measured from responses to a communitysurvey accessing information about trust, relationships, andcivic identity, aggregated to a neighborhood level. No sig-nificant associations between mental health status and so-cial capital were reported using multilevel analyses, thougha low response rate to the questionnaire measuring socialcapital may have led to response bias. This study, like manyothers, relied on aggregated data collected from individualsto indicate social capital, with no independent data beinggathered regarding neighborhood context.

Another study examining social capital and mentalhealth relied on a cross-sectional survey collected from arandom sample of almost 2,000 Russians participating in the

1998 New Russia Barometer questionnaire.40 Social capitalwas the exposure variable measured by responses to 18 ques-tions in the survey, most of which concerned involvement informal and informal networks, trust in people, and situation-specific responses. This study thus collected data on aspectsof social capital common across the various definitions de-scribed in the preliminary section of this article, though thestudy’s orientation was primarily individual rather than eco-logical. A five-point self-report scale asking individuals toassess their health in the past 12 months was used to mea-sure physical and “emotional” health. Individuals scoringhigh in the measures of social capital had notably betterphysical health. A similar relationship was found betweensocial capital and “emotional health”—explaining 15.7% ofthe variance in emotional health. One important finding wasthat those individuals most reliant on informal networkshad worse emotional health than those relying on more for-mal networks. Involvement in informal community life wasthus of less importance than knowledge and utilization offormal networks. This result could be interpreted as sup-porting Bourdieu’s view that social capital is a resource tobe exploited, and as highlighting the importance of verticalsocial capital—issues usually not explored in the literatureon social capital and psychiatry. It must be noted, however,that there are limitations to this study. First, the conceptof “emotional health” is hazy and does not closely corre-late to any conventional nosological category or concept inpsychiatry (though it may capture aspects of common men-tal disorders such as depression and anxiety). Second, likemany other studies that explore the relationship betweensocial capital and physical health, the question is addressedat an individual, rather than an ecological, level—with nosupra-individual data being collected (see, e.g., the study byVeenstra).41 Thus it could be argued that the measures em-ployed are better construed as describing social networks,individual ideology, and individual support. There is also theissue of response bias and reverse causation since this studyis cross-sectional in character; although people with worsemental health reported less involvement, this relative lackof involvement may itself be a reflection of their own mentalhealth (and therefore unconnected with social capital).

A similar study, conducted in the United Kingdom, used apopulation survey to measure the association between socialcapital, on the one hand, and depression and anxiety, on theother.42 Social capital was measured by asking respondentsgeneral questions about their neighborhoods, thus tappinginto a definition of social capital close to that formulated byPutnam. Anxiety and depression were assessed using the12-item General Health Questionnaire, a commonly usedscreening tool in surveys. Those with a score of 3 or morewere considered likely cases of anxiety or depression. It wasfound that people characterizing their neighborhoods as lowin social capital were nearly twice as likely to screen positive

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as those reporting their neighborhoods to be highest in socialcapital. This study suffers, however, from problems similarto those of the above Russian study. First, like the Russianstudy, it is cross-sectional, so reverse causation cannot beruled out; lack of social integration and a negative opinionregarding the local environment can be a consequence, aswell as a cause, of depressive symptoms. The attempt tomeasure ecological social capital through asking questionsabout the organization, quality, and state of the neighbor-hood to individuals also potentially suffers from the limita-tions and biases inherent in any study that attempts to drawinferences about the overall setting from data collected fromindividuals living within that setting.

In fact, all of the above studies gather data from individu-als living in neighborhoods and then sum that data to arriveat a measure of ecological social capital. This approach maymiss important dimensions of community life that cannot bemeasured by individual responses.

In an effort to overcome this deficiency, collaboration be-tween social scientists, psychiatrists, and epidemiologistsmay prove fruitful. One recent qualitative case study (byRW)43 in a neighborhood known to have high rates ofdepression37 used just such an approach. Data were col-lected on the main, commonly defined elements of socialcapital (trust, relationships, networks, and norms) throughin-depth interviews and focus groups with a stratified sam-ple of residents with and without a psychiatric illness.The goal was to determine whether lack of social capitalcould be linked to high rates of depression. These datawere complemented by data collected through anthropo-logically informed participant observation in the day-to-day life of the neighborhood, thus adding an element ofindependent-observer assessment. Since most participants,even those with a psychiatric disorder, showed a high levelof satisfaction with components of social capital in theneighborhood—which correlated with the observer’s inde-pendent assessment—the results were not subject to thesame ambiguity as the previous studies. The data thereforedid not support the hypothesis that lack of social capitalcould be a factor linked to the neighborhood’s high rate ofdepression.

Social Capital and Psychosis

It is often assumed that psychotic disorders are less stronglyassociated with social factors than are mood disorders suchas anxiety and depression. A number of recent studies havecontinued to suggest, however—in the tradition of Faris andDunham,8 discussed earlier—that some social factors maybe linked to the incidence and course of psychotic illness.44,45

Still, there have been few direct studies investigatingthe relationship between social capital and psychosis. Oneof the few longitudinal studies investigating social capital

and mental health investigated the rates of psychotic ill-ness, as well as anxiety, depression, and drug and alco-hol abuse, in over 3,000 homeless people with mental ill-ness in the United States.46 Social capital was measuredat the county level using survey information on trust, vol-unteering, community-project involvement, club meetingsattended (e.g., fraternal organizations; sports, youth, andchurch clubs; and parent-teacher associations), and propor-tion of adults who voted. This conceptualization of socialcapital was much in line with Putnam’s definition. Usingmultilevel analyses, there was no significant relationship be-tween the incidence of psychotic illnesses and social capital.High levels of social capital were associated, however, withhigher rates of alcohol abuse. A possible problem with thisstudy is that the population survey used to measure socialcapital was performed years before the survey of the home-less. Consequently, the measures of social capital do not nec-essarily reflect the later social ambience of the counties.It should be noted, too, that the earlier population surveywas an opportunistic analysis not set up to measure socialcapital.

Another study examined the relationship between socialcapital and the incidence of schizophrenia in electoral wardsin south London.47 Social capital in electoral wards was mea-sured by aggregate responses to a questionnaire—modifiedfrom one originally developed in the United States1—thatwas mailed to randomly selected electoral ward residents.Social capital was conceptualized as social cohesion andneighborhood efficacy. Incident rates of schizophrenia weremeasured using psychiatric case notes. Bivariate anal-ysis indicated that electoral wards with high levels ofsocial capital had lower incidence rates of schizophre-nia. This small pilot study had little ability to control,however, for confounding factors such as population com-position or selective migration—which may have playedan important role. There was also a relatively low re-sponse rate to the postal survey, raising the question ofwhether there was also some form of response bias. Fur-thermore, as in many of the studies, the contextual unitof analysis was chosen for practical, not theoretical, rea-sons; it is unclear whether electoral wards in the UnitedKingdom—administrative units of six to ten thousandresidents—equate to what the residents would perceive as acommunity.

Social Capital: A Risk Factor?

A commonly asked question is whether living in a neighbor-hood rich in social capital can have a negative effect on men-tal health for some people.29 For example, a well-functioning,integrated, cohesive community may serve a utilitarian pur-pose for the majority of the population. This kind of commu-nity may be dependent upon homogeneity and obedience to

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social norms—which may themselves be related to high lev-els of social capital.48 It may be wrong to assume, however,that all subgroups of the population will experience the samepositive effect from the existing high level of social capital.To take one such case, people suffering from, or vulnerableto, anxiety disorders may wish to blend unobtrusively intotheir surroundings and feel protected by anonymity, but thisoption may not be available in communities with a strong,but asphyxiating, social ambience.

There has been little empirical research exploringwhether social capital can have a negative effect on men-tal health. Coleman16 has stated, however, that social capi-tal not only facilitates certain actions, but also constrainsothers, with an inverse relationship between freedom todeviate and group solidarity—the more solidarity, the lessfreedom. In the general literature, there are numerous ex-amples of these processes in action. It has been reportedthat Andean entrepreneurs convert to Protestantism fromtheir native Roman Catholicism in order to free themselvesfrom what they perceive as constraining and heavy groupdemands—associated with their Catholicism—that restrictautonomy and financial freedom.48 Some members of eth-nic communities in the United States use a similar tech-nique by anglicizing their names in order to escape perceivedresponsibilities to their own ethnic groups, as well as re-duce potential discrimination by the majority population.27

Related research in psychiatry has indicated that the riskof schizophrenia increases among ethnic minority individ-uals who are living in neighborhoods where they make upa lower proportion of the population.49 One interpretationof these results, in line with Durkheim’s writings on grouprelations,21 is that social capital in white neighborhoods notonly is inaccessible to ethnic minority individuals, but alsohas a negative impact in terms of intensifying their isola-tion and alienation. In contrast, ethnic minority individu-als in places where they make up a greater proportion ofthe population may be able to access protective social cap-ital with more ease. This neatly illustrates the potentialupsides and downsides of social capital’s impact on mentalhealth.

There may consequently be costs, as well as benefits, tostrong levels of social capital. High levels of social capitalcould alienate those who are different from the norm, andheighten their exclusion. More research is needed to clarifythese matters.

Social Capital and the Clinician

The level of social capital in an area may be associated withthe risk of mental illness and other outcomes relating tohealth and well-being. Consequently, increasing the levelof social capital in an area may be considered, by some, alegitimate public health intervention. In addition, it is con-

ceivable that individual psychiatrists may be encouraged toutilize the concept in their assessment and treatment of pa-tients. Presently, however, the research base is so underde-veloped that we can only offer ideas that may be of value forfurther discussion.

A clinician’s assessment of a patient could take accountof both individual and ecological levels of social capital rel-evant to the patient. In terms of individual-level social cap-ital, knowledge about social supports and social contactscould indicate likeliness to adhere to treatment plans or toutilize health-promoting facilities such as psychiatric day-care or rehabilitation centers. In terms of ecological socialcapital, it may be useful for clinicians to know the capac-ity of a community to absorb and support the patient dur-ing the recovery period. For example, in an effort to deter-mine the level of ecological social capital, the clinical teamcould consider the number of nonprofit resources, such aspatient groups or religious organizations, within a neigh-borhood. This information, which could then be incorporatedinto the development of the therapeutic plan, might be es-pecially useful in determining how and when to dischargea patient who is returning to a neighborhood or communitythat may have contributed in some way to onset or exacer-bation of the patient’s disorder. In extreme cases, the clinicalteam could advise a temporary or permanent removal froma community, or delay discharge based on assessment of acommunity.

Individual and ecological social capital could also par-tially determine whether affective or psychotic disordersbecome chronic after their initial onset. That is, a highlevel of input from the local social network, coupledwith quality health and social services, could help stabi-lize a patient during early onset, preventing the devel-opment of chronic disease. Though sometimes consideredoutside his or her purview, a psychiatrist could act tomobilize these social resources in an attempt to preventdeterioration.

Another scenario where knowledge of social capital canhelp mental health professionals is in the case of deci-sions regarding the sites of new halfway houses, rehabili-tation/crisis centers, or similar community facilities. In con-sidering such questions concerning the social capital of thecommunity, it would be advisable for decision makers to takeinto account the likely impact on patients of the surroundingsocial ambience.

It should be borne in mind that contrary to some popu-lar belief, the existing literature on social capital does notindicate a simple linear relationship between higher so-cial capital and better mental or physical health.17,46 Com-plex individual-environment interactions may be at play,and further work needs to be done to help practitionerseffectively factor social capital into their decision-makingprocesses.

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ADVANCING THE STUDY OF SOCIAL CAPITALAND PSYCHIATRY

As we have already discussed, the study of social capitaland health—let alone the relationship between social capi-tal and mental health—is relatively new. There are conse-quently many general and specific challenges regarding the-oretical and empirical advancement. We will discuss thesechallenges in this final section. Throughout this section, weattempt to focus on issues relevant specifically to psychia-try, though many of the issues discussed concern the moregeneral relationship between social capital and outcomes re-lating to (general) health and well-being. We hope that theanalysis presented will serve as an early, but helpful, stepin the development of productive future research on socialcapital and mental health.

Validation and Further Exploration of Concepts

Validation and refinement of concepts are generally takenas prerequisites for empirical testing. Otherwise, there canbe no certainty that the same phenomenon is under observa-tion. Similarly, terminological precision is usually a precon-dition for the building of effective theory.50 As we stated inthe introduction, there are various definitions of social cap-ital, and we agree with one commentator’s remark that “noclear shared definition exists about what the concepts ac-tually mean.”25 Consequently, we reemphasize that, in theshort term, the best way of dealing with this definitionalhaze is to speak of “social capitals” rather than “social capi-tal.” We believe that the use of differing orientations, rang-ing from an individual to an ecological outlook, can onlybroaden, and thus strengthen, the literature—as long asresearchers are careful to explain their particular orienta-tion and its rationale, and to utilize appropriate methodol-ogy in answering their research questions. While the bulkof research examining social capital and mental health hasbeen quantitative in nature, qualitative methodology mayprove to be useful for the in-depth exploration of certainkey issues. For example, the literature leaves unansweredthe question of which component parts of social capital havethe greatest impact on mental health and well-being. Ex-ploration of the qualitative differences between aspects ofsocial support, social networks, and social capital may beable to assess the phenomenological impact of these differentcomponents on mental health. These results could then beused to clarify which factors are most effective in promotingmental health—which would have important consequencesregarding the development and execution of interventions.

Research Design

It is an accepted tenet of the hypothetico-deductive methodthat the strongest science occurs when a hypothesis is de-

veloped from theory and when data are then collected totest that hypothesis, in that temporal order.50 Basic sci-entific theory states that prospective, longitudinal studiesdesigned to test specific hypotheses are far stronger thanretrospective studies. As was apparent in the preceding lit-erature review, most of the present studies on social capitaland mental health have been either cross-sectional or ret-rospective (relying on secondary data). Longitudinal stud-ies may decrease the chance of reverse causation, and sincemental illnesses are often the culmination of insults overthe life span, these studies can better account for length ofexposure to a particular social-capital environment (a timeperiod that is rarely stated or investigated in cross-sectionalor retrospective studies of social capital and mental health).Research on mental health and social capital should ide-ally overcome this reliance on secondary data, retrospectivehypothesis testing, and cross-sectional analysis. The collec-tion of prospective data to test hypotheses particular to so-cial capital and mental health would add rigor to the fieldand create a methodological gold standard for the developingdata on social capital and psychiatry. Having said that, somequestions would take decades to answer through prospectivecohort studies taking a life-course orientation. In the mean-time, more expedient alternatives could include, for exam-ple, multiple cohort studies in which a series of age cohorts(with different starting ages) could be followed for a shorterperiod of time, thus providing life-span data related to socialcapital and mental health.

Measurement Issues

The general social capital literature needs to develop andvalidate measures and indicators of social capital thatcapture the true contextual, dimensional elements of theconcept, such as vertical integration, state-society rela-tions, linkages between groups, and social inclusion. Manyexisting studies in psychiatry and other fields rely on mea-suring and aggregating individuals’ perceptions of socialcapital. This measure is inadequate if one considers so-cial capital to be primarily a property of geographical en-tities; as frequently mentioned in this article, aggregatedresponses gathered from individuals are, in this context,subject to response bias. Such bias may be a problem whendealing with a mentally ill sample if the particular illnessleads to a negative global outlook. Similarly, aggregateddata does not give a holistic, independent description of aneighborhood.

It is impossible to effectively measure vertical and struc-tural social capital at the individual level. Contextual, multi-dimensional indicators should ideally measure a contextual,multidimensional concept such as social capital. Lochnerand colleagues51 have therefore proposed a model for mea-suring overlapping ecological components of social capital.

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Four constructs are suggested that can be used as indica-tors of social capital: collective efficacy, psychological senseof community, neighborhood cohesion, and community com-petence. Some of these elements can be measured by collect-ing data from individuals, though other elements, such ascollective efficacy, demand supra-individual measurement.Imaginative non-individual indicators of these constructshave been suggested—for example, determining whether lo-cal gas stations demand prepayment before motorists filltheir tanks. We would also suggest several additional pos-sible indicators for capturing non-individual elements ofsocial capital—some of which have been occasionally usedin existing work: differential turnouts in elections, popula-tion turnover, success/failure of lobbying, capital flows intoneighborhoods, and levels of media/communications withincommunities.

While issues of measurement of social capital may bemore fully discussed in disciplines such as sociology andpolitical science, we believe it is important that social psy-chiatrists and psychiatric epidemiologists contribute to thisdebate. For example, issues of measurement are crucial if so-cial capital is to be integrated into the therapeutic plan forpatients. The psychiatrist might like to know about certaincharacteristics of a community that could be relevant to hisor her patient—such as the likely occurrence (or recurrence)of life events, or the extent of formal and informal supportgroups.

Having this information clearly and unambiguously attheir fingertips may aid mental health professionals in aholistic assessment of their patients’ options. It is thus vitalthat individuals within the discipline of psychiatry monitorand contribute to the discussion of measurement and socialcapital. On the plus side there are ongoing efforts to resolvethese issues of measurement in the general health sciences,to which people working in the field of mental health arecontinuing to contribute.52,53

Community Without Propinquity

It has been stated that “concepts like social capital are inher-ently ecological, that is they are characteristics of places notpeople,”54 and that neighborhood cohesion is one of the fourecological constructs of social capital.51 This belief that socialcapital primarily resides in the neighborhood is embedded inthe empirical work, following a long tradition of area-basedstudies in social epidemiology, such as the Alemeda County33

and Roseto studies.55

This assumption that communities are generally place-based may nevertheless be outdated; some sociologists haveclaimed that the current era of post- (or late) moder-nity is characterized by constant change, with individualsconstantly constructing and reconstructing their commu-nal belongings and relation to others.56 What makes this

possible is the vast, indeterminate range of choices and“lifestyles” available in the modern world—due to a com-bination of globalization, demographic change, technology,and infrastructural developments. Present-day society maybe markedly different—in parts of the globe—from the worldof self-contained homogenous and stable neighborhoods of-ten found in earlier eras. In the present social milieu, non-spatial communities—which may be based on such com-monalities as religion (e.g., Jehovah’s Witnesses)—may, forcertain individuals, dwarf the neighborhood community inimportance.57 These new types of community have not comeunder the spotlight in studies of social capital, despite op-portunities offered by multilevel modeling and qualitativeresearch.

These cross-spatial communities may be especially im-portant in promoting some people’s mental health. For exam-ple, a Puerto Rican living in a white neighborhood of a largecity may find the citywide Puerto Rican (or Hispanic) com-munity to be of far more psychological and social importancethan the immediate neighborhood community. It may be inthis broader community that an individual borrows money,finds work, and makes meaningful friendships. It is unclearwhether social capital in these communities should be con-ceptualized in the same way as in neighborhood-based com-munities, and also what kind of impact such cross-spatialcommunities have on their members, but it is at least worthyof further inquiry and theoretical speculation. It is conceiv-able that membership in such groups may protect mentalhealth.

Similarly, groups of specific interest to psychiatrists—such as persons known to be at risk of mental illness (e.g., on-cology patients) or current psychiatric outpatients (e.g., onesdiagnosed with obsessive-compulsive disorder)—will be geo-graphically dispersed. Through the Internet or centralizedsupport groups, however, they may find solace, identity, lob-bying power, and social support, all of which could protecttheir mental health from further deterioration. Due to their“otherness,” such people may not desire to participate in lo-cal activities but may prefer to interact with people havingcommon problems. There is a need for further research intothe nexus between individuals, neighborhood communities,and nonspatial communities.

Scale of Effect and Interventions

Even if place is accepted as a primary source of social capi-tal, there are current theoretical limitations in the existingliterature. For example, as previously outlined, place-basedstudies vary in their ecological units of analysis and thusin their assumptions about the appropriate unit of analysisregarding social context. A study of crime in Chicago mea-sured social capital at the level of the urban neighborhood;1

the Roseto study looked at a number of small towns in

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Pennsylvania;55 other studies have compared areas as vastas nation-states.6

There has been little theoretical discussion, however, ofthe appropriate contextual unit in which to conceptualize so-cial capital, and the causal pathways from the ecological unitto individual pathology are rarely discussed in depth. Again,there is a need for further theoretical and empirical explo-ration to clarify these issues. Some research suggests that,for the person suffering from, or at risk of, mental illness, itcould be the immediate neighborhood that contributes mostto etiological pathways.49 Not only is that neighborhood thesite of salient social and other day-to-day interactions of onekind or another, but it is also where recovery, support, andpreventive services may be located. More-specialized ser-vices, however, and wider factors such as job opportunitiesmay be situated over a broader geographical level. Both ofthese levels may be critical in the development or exacerba-tion of psychological distress, but we suggest, in line withrecent studies in social psychiatry, that smaller contextualunits should be considered the preferred starting points forfuture research.

Understanding both the role of place and scale of ef-fects is crucially important for the development of effec-tive interventions—which could be area based (at any ofthe geographical levels discussed) or cross-spatially based(i.e., aimed at geographically dispersed target groups suchas ethnic minorities in a rural county). At present, how-ever, the literature gives little indication as to what formsof social capital intervention could help promote communalor individual mental health. One recent qualitative studyfound that social capital appeared to flourish in a web ofcore community spaces such as libraries, community cen-ters, and local shops—facilities particularly valued for theirstabilizing effect by study participants with existing psychi-atric disorders.43 It may be too early to state confidently thatthese local facilities can be considered the site of effective in-terventions to promote mental health. We would encouragefuture research in this direction, however, especially con-sidering the ongoing trend in world psychiatry away frominstitutional, and toward community, care.

Subgroup Analysis

The differential impact of social capital on particular sub-groups could potentially be vitally important in terms ofmental health and must be carefully measured; all of thedifferent dimensions of social capital discussed earlier couldvary according to the group in question. Relatively immo-bile groups—for example, the elderly and children—may bemore affected by neighborhood social capital than groupsthat are more mobile. The relative lack of mobility wouldproduce both greater exposure to social context and less ac-cess to cross-spatial communities. Consequently, specialists

such as geriatric or child psychiatrists may need to pay spe-cial attention to the neighborhood context of their patients’everyday lives. Similarly, ethnic minorities may find somestrong forms of social capital impenetrable and exclusion-ary in nature. Future study designs need to address suchproblems by sampling respondents and analyzing data todescribe and account for possible subgroup variations.

Exposures and Outcomes

In this concluding section of our review, we have eschewedspecific discussion of how advances can be made in the studyof specific psychiatric outcomes. We believe, instead, that itis vitally important for mental health researchers and prac-titioners to focus primarily on general methodological andconceptual issues—since applied research in the field of so-cial capital (as such) is still in its infancy. This emphasisnot only aids evaluation of current research regarding so-cial capital and mental health, but helps potential psychi-atric researchers, regardless of their fields of specialization,to become aware of the stumbling blocks and key issues thatmust be considered in future work.

There are other reasons why we have not engaged in in-depth discussion of specific outcomes. The purpose of thisarticle is to provide a descriptive and analytical overview,rather than a detailed manual on social capital’s relation-ship to specific illnesses. We have argued throughout thearticle that almost all psychiatric disorders have a socialcomponent. Furthermore, some evidence suggests that dif-ferent psychiatric outcomes may share the same social eti-ological pathways.34,36 For example, while severe life eventsincrease the rate of depression, they are also associated withpsychotic episodes.35,58

Still, we acknowledge that social capital may be moreclosely related to certain mental health outcomes than oth-ers. By recognizing this possible heterogeneity of effect, wesimply encourage further investigation of the relationshipbetween specific psychiatric disorders and social capital (as-suming that such future studies address the fundamentalissues raised elsewhere in this article). These studies willhelp fill in the considerable voids that are presently beingoccupied by speculation.

CONCLUSION

Social capital is a promising heuristic for the study of so-cial forces in psychiatry. It is of relevance and importance topsychiatric epidemiologists and also to individual clinicians.Though theoretical speculation has suggested that both in-dividual and ecological social capital can promote mentalhealth, existing studies do not offer strong evidence for oragainst any association between social capital and mentalhealth. As discussed, there are, at present, few direct studies

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of social capital and mental health, and all of them haveacknowledged flaws—which is to be expected, as investi-gators are working with a new concept that has a varietyof definitions. Furthermore, there are no validated screen-ing instruments by which to measure social capital. At thisearly stage, it is understandable that investigators have re-lied on cross-sectional and retrospective studies, frequentlyutilizing secondary data tapping into exposures and out-comes that may seem hazy to those working in precise, well-established fields in psychiatry. Nevertheless, as time pro-gresses, it is to be hoped that researchers will take up someof the suggestions we have made concerning directions forfurther research, adding precision and refinement to whatis still an emerging field of inquiry. In the light of our reviewof the literature, it would be premature to state definitivelythat social capital protects mental health; instead, the indi-cations are that whatever relationships exist between thesefactors, they are almost surely complex. We close by statingour belief that the jury is still out; we are a long way fromknowing the exact impact that social capital has on mentalhealth.

We would like to thank Professors Martin Prince and Scott Weichfor commenting on earlier drafts of this article. We would also liketo thank the editors of the Review and two anonymous reviewersfor their helpful suggestions.

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Social Capital and Psychiatry: Review of the Literature

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