In 1958, sociologist August Hollingshead and psychiatrist Fritz Redlich wrote a pioneering book called Social Class and Mental Illness. They began the book with a memorable claim: “Americans prefer to avoid the two facts in life explored in this book: social class and mental illness.”
They were right. Of course, there were social classes in the United States during the 1950s, but this flew in the face of the American Dream that anyone—no matter their background—could become successful. And of course, there was mental illness. But no one wanted to talk about that, either.
Hollingshead and Redlich decided to study these two “facts of life” nonetheless. Both based at Yale, they used the city of New Haven as their case study. Their goal was to explore the relationship between social class and mental illness. The project was one of a number of social psychiatry studies developed during the 1950s. Social psychiatry was an interdisciplinary approach involving psychiatrists, social scientists, and other scholars, dedicated to identifying the social determinants of mental health. Ultimately, the aim of social psychiatry was to prevent mental illness. As a sociologist-psychiatrist team, Hollingshead and Redlich were well-suited for this new way of researching mental health.
New Haven was a great place to study social class. Founded in 1638 by Puritans, the city developed a rigid class system built around ancestry, wealth, ethnicity, religion, race, and education.
Hollingshead and Redlich split the class structure into five tiers, with the first being made up of wealthy New Haveners who could often date their lineage back to well before the Revolutionary War, and the fifth consisting of poor immigrants and so-called “Swamp Yankees.” They then analyzed how people in these five social strata experienced mental health and illness.
The findings were stark. First, people in lower tiers experienced far more mental illness than their higher-status compatriots. People in the fifth tier were three times more likely to be diagnosed with a mental illness than those in tiers one or two. This was despite the fact that people from lower tiers were far less likely to seek out psychiatric care. Moreover, they were more likely to be diagnosed with psychoses than neuroses. They tended to be referred for mental health services via the courts, rather than other medical services. Finally, while upper-class individuals were likely to be given psychotherapy by private psychiatrists, lower-class people were prescribed drugs, electroconvulsive therapy, or even lobotomies, usually in state hospitals. Class mattered a great deal when it came to mental health.
Despite these striking findings, Hollingshead and Redlich didn’t have much to say about what could be done. Observations made of lower-class New Haveners revealed a certain degree of apathy and even disdain about their predicament. They certainly did not recommend a redistribution of resources or improving access to the peerless educational opportunities at Yale, for instance. Although the study was initially influential, it would be forgotten by the 1970s, when biological explanations for mental illness began to predominate.
In 2009, British researchers Richard Wilkinson and Kate Pickett published The Spirit Level. Using different methods, they found pretty much the same thing: Inequality is bad for mental health. Throw in structural racism (something that did not affect the New Haven Study too much because Black American migration to New Haven accelerated in subsequent decades) and things get even worse. The situation is exacerbated even further by cuts to public health care, diminishing access to mental health care.
So, what to do? With the cost of mental illness estimated (by Yale researchers, no less) at $282 billion per year (including both the direct cost of care and lost productivity), certainly it is time to reconsider the claim that Hollingshead and Redlich began their book with: that Americans preferred to avoid talking about mental health and social class. It’s clear that Americans are quite happy talking about mental health in 2025, but have they come to terms with class? Probably not. If they want to reduce the mental illness burden, however, perhaps it’s time they should, and start thinking seriously about reducing inequality.
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