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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. Levels at which social processes exert effects. Individual.

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Social Psychiatry: more than poverty and deprivation

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  1. Social Psychiatry: more than poverty and deprivation Tom Craig

  2. Social processes play a role in: • Aetiology of mental disorder • The sick role & help seeking • Diagnosis/labeling • The course of disorder • External appraisal • Stigma

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

  4. 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

  5. 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

  6. The contextual approach to measurement of ‘stress’ Short term Focus Independence Threat Long term Self Illness Loss Other Behaviour Danger Humiliation Severe Event : found to precede 90% of all onsets of depression

  7. Onset by type of severe event: (Brown et al 1994) 30% 15% 9% 4% 3%

  8. 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

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

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

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

  12. 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

  13. 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)

  14. 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

  15. Befriending Intervention Study Comparison series Effect size = 0.43

  16. 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 W/L control n=39 12 mo Follow up n =32 12 mo Follow up n=35

  17. NEWPIN 20/35 8/32

  18. 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

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

  20. 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

  21. Where next? • Repair damage from early childhood? • Parenting interventions ? • Mentorship schemes • Lay Volunteering • Social support interventions • Post-natal depression • Adult befriending programmes +/- psychological refinements?

  22. Society & severe mental illness • Control • Housing • Occupational activity • Leisure activity • Social contact

  23. 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 intervention Marwaha & Johnson 2004

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

  25. 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

  26. 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

  27. 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

  28. Closure of Mental Hospitals • Goffman and ‘institutionalisation’ • 3 hospitals study • Tooth & Brooke - 50% reduction in beds by 1975 • Enoch Powell • 1962 hospital plan

  29. 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

  30. Trans-institutionalisation? • 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? Priebe et al, 2005

  31. Social & Leisure Activity • A neglected aspect • Barriers of stigma and social exclusion • Under-resourced and diminishing • Not valued by health or social care

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