Social Psychiatry: more than poverty and deprivation

Tom Craig

Social processes play a role in:

• Aetiology of mental disorder• The sick role & help seeking• Diagnosis/labeling• The course of disorder• External appraisal– Stigma

Individual

Family

Neighbourhood

Wider society; urban/rural; region; country etc

Levels at which social processes exert effects

Depression & the Wider Social Arena

• Female excess– Not pre-adolescent or elderly– Mostly in young adulthood

• Higher rates in lower SES; Urban excess• No evidence for higher rates in ethnic group or

religious affiliation• Married men < single men without children <married

women < lone mothers

Measuring the Social Environment

• What constitutes a stressor?– Who defines it?

• The subject or the investigator?– Events only or ongoing difficulties as well?– Separating cause and effect

• Problem of effort after meaning• Independence

– Measuring meaning• Personal meaning• Dictionary approaches• The contextual approach

The contextual approach to measurement of ‘stress’

Threat

Short term

Long term

Loss

Danger

Humiliation

Self

Other

Focus Independence

Illness

Behaviour

Severe Event : found to precede 90% of all onsets of depression

Onset by type of severe event: (Brown et al 1994)

0

10

20

30

40

% onset depression

Humiliation Loss Danger Any SE None

30%

9%

3%

15%

4%

Vulnerability

• If properly enquired about, the majority of new onsets of depression are preceded by severely threatening life events

But• Only about 1:25 of all those experiencing one of these

events in any year will go on to develop depressionTherefore• There must be something else that makes people specially

vulnerable to the impact of severe events.– Other social conditions?– Constitutional factors including genetics

Stress & Vulnerability 1.Social Support Can Be Protective……

High

Medium

Low

Stressful Experience

10 (9/88) 26 (12/47) 41 (12/29)

No stressful Experience

1 (2/193) 3 (1/39) 4 (1/23)

Intimacy

……. If you get it at the right time

Good/AverageMarriage

The Life-span Model (Brown & Harris)

Childhood Neglect & Abuse

Early adult adversity

Precipitating stressors

Poor Support

Low Self Esteem

Attachment problems

Low Self Esteem

DEPRESSION

Recovery from chronic (>1yr) depression

• Fresh Start: a new turning point in life in which there is a chance to restore something lost

• Not necessarily ‘positive’ or pleasant - 20% were severe events

• Diff reduction = change from severe to non severe

Brown et al 1988

Befriending Intervention (Harris et al 1999)

• Volunteer befriender (n =43)– Meeting, talking and practical support for a min of 1 hour per week– Confiding– Practical support (difficulty reduction)– Encourage fresh starts

• Target women (n = 86)– Willing to consent to randomisation– Chronic depression– General Population sample– Not recently started other treatment

• Non intervention comparison series (pop. Cases n= 35 and patients n = 18)

Befriending Intervention (Harris et al 1999)

Depression n = 606

Express interest n = 111

Not chronic /other disorder 291

Randomised n =86

Chronic Depression n = 315

Refused/ in therapy n= 204

Withdrew/lost n=25

Befriending n=43 Control n = 43

Befriending Intervention

Study Comparison series

Effect size = 0.43

NEWPIN StudyAntenatal Screen n = 2,600

Vulnerable to depression n= 442

Agree to take part n= 71

VDQ

Out of area n=151Refuse n = 220

NEWPIN n= 32 W/L control n=39

12 mo Follow up n=35 12 mo Follow up n =32

NEWPIN

0

10

20

30

40

50

60

Onset depression %

NEWPIN Control

Onset of depression in post natal year

20/35

8/32

Dr Dele Olajide of Cares of Life at Redeemed Church of Christ

• High rates of common mental disorder in black community

•But less likely to access psychological therapy (Bhui & Bahl 1999)

•Lay Health Volunteers to outreach black churches, barber shops, CoLP Bus etc

•Community Health Workers provide support, practical advice and problem solving

•RCT evaluation

CoLP Evaluation: Clinical Trial DesignAll Referrals N = 69

Eligible N = 40Not seen N = 19 Not Eligible N= 10

Consent N = 40

CoLP = 20 W/L = 20

FU = 16 FU = 16

CoLP: improvement in GHQ-28

• Fresh start in FU associated with remission

• 7 of the 11 women fresh start events had at least 1 attributable to the worker

• Assignment (B=7.36, p=.04) and fresh start (B=2.58, p= .04) make independent contributions to remission

0

10

20

COLP Control

Baseline 3 months

Where next?

• Repair damage from early childhood?– Parenting interventions ?– Mentorship schemes– Lay Volunteering

• Social support interventions– Post-natal depression– Adult befriending programmes +/- psychological

refinements?

Society & severe mental illness

• Control• Housing• Occupational activity• Leisure activity• Social contact

Employment in UK:Gen Pop Vs. Schizophrenia

• N. Italy 50% working 20% FT• USA as many as 60% achieve

competitive work• Chennai India 67% Why?• Benefits

– Italy have to be 80% disabled to get any but this system only works because 80% live with families

– Benefit ‘traps’• Type of occupational

interventionMarwaha & Johnson 2004

Industrial Therapy 1960s

• By 1967 most hospitals have an ITU.

• Wide range of products.

• Simple repetitive work replaces simple repetitive sitting.

Sheltered Work to Social Firm 1980s

• Over 1/3 employees are people with SMI

• Every worker paid a fair market wage

• Business works subsidy free

• In practice most have subsidy• 8000 in Europe by 2005• Catering / horticulture / small

industry• Vulnerable to market

conditions

Clubhouse & TEP 1980s

• Fountain House and the work ordered day

• TEP :– Job coach locates job– Trains client(s)– Placements for 6/12

• TEP alone now criticised as discredited train & place

• Most Clubhouse models now combine TEP with permanent job placement

Individual Placement and Support 2000’s

• Eligibility on consumer choice. • No exclusion because of poor

work record or lack of work readiness

• Rapid ‘Place then Train’• At 18 months IPS vs

prevocational ‘not in work’ RR 0.82 [0.77 to 0.88] NNT 7

• Mainly entry-level jobs• Relatively short tenure and

ongoing support is crucial• Variable UK results

Closure of Mental Hospitals

• Goffman and ‘institutionalisation’

• 3 hospitals study• Tooth & Brooke - 50%

reduction in beds by 1975

• Enoch Powell• 1962 hospital plan

0

20

40

60

80

100

120

140

160

1900 1940 1960 1980 200

MH Pop

TAPS & Friern Barnet

– 671 patients discharged to community homes with 5 year follow-up

– 126 died in subsequent 5 years

– Only 3 became homeless– Just over 1:3 readmitted at

some point– Patients made more

friends, greater use of community facilities

– No overall worsening in symptoms or social behaviour

– Cost-neutral

• Ideal:– Ordinary housing– Tenancy support – Practical help with ADL– Core & Cluster models

• Reality:– As many beds in

residential settings now as in 1950s

– Are we entering an era of greater segregation of the mentally ill again?

Beds / 100,000 population

1991 2001 Change %

Hospital 131.8 62.8 -52

Forensic 1.3 1.8 +38

Group Homes 15.9 22.3 +40

Trans-institutionalisation?

Priebe et al, 2005

Social & Leisure Activity

• A neglected aspect• Barriers of stigma and

social exclusion• Under-resourced and

diminishing• Not valued by health

or social care