Soc. Sci. & Med.. Vol. 10. pp. 5 to 13. Pergamon Press 1976.Printedin Great Britain THE MANUFACTURE AND OBSOLESCENCE OF MADNESS: AGE, SOCIAL POLICY AND PSYCHIATRIC MORBIDITY IN A PRAIRIE PROVINCE* CARL D'ARcY~ Applied Research Unit, Psychiatric Research, University Hospital, Saskatoon S7N OW8, Saskatchewan, Canada Abstract--Societal reaction theory of mental illness posits a host of contingent factors--incidental to the ontology of psychiatric medicine--as determinants of entry into, career in, and exit from the status "mentally ill". This paper deals with the nature of these contingencies both theoretically and empirically. Initially, a six-fold typology of the contingencies in terms of socio-cultural, institutional, social structural, organizational, everyday interpersonal and personal-professional categories is pre- sented. The articulation of and interaction between the various types of contingencies is further dealt with in terms of a flow-chart and ensuing discussion. Secondly the data reported show the effects of organizational and social structural contingencies upon the rates of mental illness and kinds of persons identified as mentally ill. The introduction of a program of free hospitalization for mental illness interacting in the context of a rapidly increasing older age component in the population and the lack of facilities for the care of the aged, had the effect of dramatically increasing the rate of mental illness in the older age category. The build up of large numbers of the aged in psychiatric institutions and the problem of providing adequate care for the aged acted back as a "problem" into the social alad political milieu. Subsequent responses which saw changes in the delivery of health and welfare services resulted in a drastic decrease in the rate of mental illness in this older age category. In this sense the structure of the psychiatric care delivery system of the province acting within a social and institutional context has acted as contingent factors initially contributing and subsequently not contributing to mental illness outcomes--to the process of becoming mentally ill--in the older age category. INTRODUCTION "'When a belief in witchcraft was accepted in a disor- dered society looking for scapegoats who could be blamed for its terrors, senile women were burnt or hanged as witches. In the nineteenth century, if they were indigent they were relegated to the almshouse or the workhouse infirmary. Society had changed, not the women. Thus the key to prevention, control and therapy of mental patho- logy lies not alone in the impaired individual, but also more significantly in understanding the perceptual and social environment in which he exists." GEORGE ROSE~ [1] This paper is concerned with the psychiatric mor- bidity patterns of the older age group, 70 yr of age and over, in the Province of Saskatchewan during the period 1946--1970 and the extent to which these morbidity patterns are responsive to social policy and organizational changes with regard to the delivery of psychiatric care specifically and health and welfare services more generally. * This is a revised version of a paper read to the section on the "'Sociology of Health in Canada--Canadian Health System", at the Scientific Sessions of the Research Com- mittee on the Sociology of Medicine of the International Sociological Association. Toronto. 21 August 1974. t The continuing financial support of the Psychiatric Services Branch. of the Department of Health of the Pro- vince of Saskatchewan is gratefully acknowledged. While the problem of the aged and the delivery of psychiatric services has often been noted and is certainly not unique to the province, the level of re- sponsiveness of the psychiatric morbidity patterns of the aged probably is. This responsiveness results from some unique social and institutional aspects of the province. It is important to stress here that in order to under- stand fully the impact of these changes in the delivery of health and welfare services, it is necessary to under- stand the social and institutional context in which they occurred. More specifically, certain peculiarities of the demographic structure of the province, and the lack of facilities for the care of the aged are due both to the recency of the settlement of the province and the changes in distribution of the provincial population. Besides being of intrinsic interest in and of itself, it is felt that the material reported here has significant theoretical import. The data reported dramatically demonstrate, in a real way, the negotiated character--in a social-struc- tural and organizational sense---of deviance cate- gories in general and the phenomena of "mental ill- ness" in particular. THE THEORETICAL PERSPECTIVE The conceptual framework which is used here to help understand the phenomena of the changing mor-