Social Psychiatry: more than poverty and deprivation
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Transcript of Social Psychiatry: more than poverty and deprivation
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