Social Psychiatry more than poverty and deprivation Tom

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

Levels at which social processes exert effects Individual Family Neighbourhood Wider society; urban/rural; region; country etc

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

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’ Short term Focus Independence Threat Long term Self Other Illness Behaviour Loss Danger Humiliation Severe Event : found to precede 90% of all onsets of depression

Onset by type of severe event: (Brown et al 1994) 30% 15% 9% 3% 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 depression Therefore • 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…… Intimacy

……. If you get it at the right time Good/Average Marriage

The Life-span Model (Brown & Harris) Childhood Neglect & Abuse Early adult adversity Precipitating stressors Poor Support DEPRESSION Attachment problems Low Self Esteem

Recovery from chronic (>1 yr) 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 Not chronic /other disorder 291 Chronic Depression n = 315 Refused/ in therapy n= 204 Express interest n = 111 Withdrew/lost n=25 Randomised n =86 Befriending n=43 Control n = 43

Befriending Intervention Study Effect size = 0. 43 Comparison series

NEWPIN Study Antenatal Screen n = 2, 600 VDQ Vulnerable to depression n= 442 Out of area n=151 Refuse n = 220 Agree to take part n= 71 NEWPIN n= 32 12 mo Follow up n =32 W/L control n=39 12 mo Follow up n=35

NEWPIN 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, Co. LP Bus etc • Community Health Workers provide support, practical advice and problem solving • RCT evaluation

Co. LP Evaluation: Clinical Trial Design All Referrals N = 69 Not seen N = 19 Eligible N = 40 Not Eligible N= 10 Consent N = 40 Co. LP = 20 W/L = 20 FU = 16

Co. LP: 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

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’ Marwaha & Johnson 2004 • Type of occupational intervention

Industrial Therapy 1960 s • By 1967 most hospitals have an ITU. • Wide range of products. • Simple repetitive work replaces simple repetitive sitting.

Sheltered Work to Social Firm 1980 s • 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 1980 s • 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

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

Trans-institutionalisation? • Ideal: – – Ordinary housing Tenancy support Practical help with ADL Core & Cluster models • Reality: – As many beds in residential settings now as in 1950 s – 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 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