Social psychiatry – new directions The way forward?

1. Social psychiatry – new directionsThe way forward? Prof. Stefan Priebe Queen Mary, University of London

2. Social Psychiatry • Social: everything that happens between people • A social perspective of mental health and mental disorders: a) A societal movementb) A form of practicec) A field of research

3. Social factors in mental health • Social inequality • Poverty • Unemployment • Social isolation • War

4. Psychiatry in crisis? • Problems with recruitment • Complaints about burn out and stigmatisation • Calls for - stronger medical orientation, - focus on neuro-biological knowledge, and - emphasis on research basis • Consistent for about 150 years

5. Progress in last 30 years • More staff for more patients • Better qualified staff (e.g. clinical psychologists) • Better facilities • More attention in society • More investment

6. Why? • Different attitude to health and mental health in society • Mental health reforms • Linked to values • More dignified care for people with severe mental disorders • Threatened with profit orientation of provider organisations and social inequality

7. Contribution of research discoveries • Billions of investment worldwide • Decade of the brain (1990s) • But: • No new and more effective drugs • Hardly any new psychotherapeutic school • No new social interventions • No new service types

8. Treatment of severe mental illness • No advantage of new antipsychotics • Antidepressants effective only in severe depression • Hardly any difference between drugs • Hardly any difference between psychological treatments • Limited effect sizes • Hardly any predictors for individual treatment response

9. Cochrane: CBT in schizophrenia • 2000: For those with schizophrenia …. access to CBT is associated with a substantially reduced risk of relapse • 2004: Trial based data supporting the wide use of CBT for people with schizophrenia are far from conclusive. • 2011: Trial based evidence suggests no clear and convincing advantagefor CBT over much less sophisticated therapies for schizophrenia

10. Methods • Similar types of psychometric scales (some even identical) • Randomised controlled trials as gold standard for evaluating treatments • Systematic reviews and meta-analysis for reaching consensus

11. Why no progress? (I) • Rules of academic success • Opportunism and short term planning • Drive towards mainstream and fashion –search for external funding, impact factor points and citations; peer review process • Yet, the same rules across medicine

12. Why no progress? (II) • The paradigm • Disorders are based on operationalised criteria, detached from biography and context • Concept of fundamental research leading to application

13. Paradigm Real cause Expression Consequence Social - relationship- social function Psychological - experience - symptoms Neuro-biological - genetic disposition - physiological processes Social management Psychological modification Real treatment

14. Mental disorders as social phenomena • Defined in social interactions, e.g. cultural and societal norms • Occurring in interactions • Related to interactions • Diagnosed in interactions • Treated in interactions

15. Alternative paradigm of mental disorder Psychological Societal Neuro- biological Social phenomenon

16. New directions – research (I) • Assessment of interactions in natural relationships, e.g. families • Assessments of interactions in therapeutic groups • Assessment of ‘real life ‘, e.g. for evaluating interventions

17. New directions – research (II) • Analysis of therapeutic interactions and their role in social context of the patient • Exploring the potentials of new communication technologies for patients social life and for novel treatments • Understanding of non-specific treatment effects

18. Non-specific effects? TAU or placebo Non-specific or placebo effect symptom levels real treatment treatment effect baseline end of treatment

19. New directions - practice • Focus on social roles, friendships, societal purpose • Generic socio-therapeutic approaches, e.g. therapeutic communities • Specific socio-therapeutic approaches, e.g. groups using creative activities and body experiences • Emphasis on therapeutic relationship and communication

20. Individual vs social solutions • Very active children have ADHD and receive medication • Old people with cognitive decline have beginning dementia and receive memory training or medication • Playing with children may stem cognitive decline in old people and help children and increase social cohesion/capital

21. New directions – concepts • Facilitating improvement in a social context instead of ‘treating’ a patient or a disorder • Resource orientated models of interventions • Considering the role of societal role of psychiatry and psychiatrists • Implications for concepts of neurobiological and psychological dimensions of psychiatry

22. The way forward? • Different definitions of fundamental and applied research • New perspective in research with unclear outcomes • Focus on psychiatrists as agents in a societal context • Profession based on skills and competence as much as on knowledge • More fascinating job and more impact