Social Psychiatry

'Social Psychiatry is concerned with the relationship between disorders of the mind and the human environment. It studies the forces which act at the interface between individuals and those around the; and which may contribute to the onset, or influence the course of mental disorders'.

The broad focus of Social Psychiatry has shifted and generally become narrower during the last four decades. It has covered the

following area in its time:

Therapeutic Communities (Maxwell Jones)

Crisis Intervention (Caplan)

Both are areas of psychiatry which draw on the powerful effects of interpersonal forces (i.e. human relationships) to explain the

development of emotional disorders and which rely on them to construct treatment strategies. It will be obvious that social

psychiatry stretches from pure epidemiological work on the one hand to an indistinct boundary with psychotherapy.

Epidemiological Aspects

The relationship between social factors and mental illness has always been suspected and was demonstrated powerfully by the early work of Hollingshead and Readlich in Chicago in the 1930s. The high concentration of schizophrenic in dilapidated areas of the city has been replicated numerous times throughout the world. Controversy still exists about its cause - drift of vulnerable individuals to these areas or a high incidence of disorder in the social advantaged. Various epidemiological studies have highlighted the international consistency of incidence rates for the major mental illnesses. These studies have become possible over the last four decades because of the development of reliable and valid diagnostic and screening instruments (e.g. Feighners Research Criteria, PSE, GHQ, etc). These allow caseness to be reliably established and correlated with relevant factors. The Jarman Indices are commonly used to measure the level of social deprivation (Identification of underprivileged areas, 1983, BMJ, 286, 1705 - 1709). This index is composed of eight factors of which unemployment, overcrowding and single parent families are the most significantly related to mental illness. The Jarman Indices (or some similar measure of social deprivation) are necessary to adjust norms for service planning.

Needs Assessment

Psychiatry, like most medicine, is essentially demand-lead rather than needs-lead, perhaps even more so because of stigma and diffidence in psychiatric patients. The gross variations in morbidity demonstrated by epidemiological studies has stimulated the growth of Needs Assessment procedures in Psychiatry (e.g. The Camberwell High Contact Study, 1988, Psychological Medicine, 18, 443-456) .

Pathways to Care

The work by Goldberg and Hurley (Mental illness in the Community, 1950, Tavistock) is of crucial importance. This identifies a series of Filters and Levels of Care. And draws attention to the significance of skills recognising mental illness displayed by General Practitioners. This book has recently come out in its second edition and examiners would normally expect you to be familiar with the various filters and levels of care and even to have a rough idea of the numbers involved.

The Impact of the Social Environment

The Three Hospitals Study (Wing JK and Brown GW, 1970, Institutionalism and Schizophrenia, Cambridge University Press,

or 1961 Social Treatments of Chronic Schizophrenia: a comparative survey of time mental hospitals, 1961, Journal of Mental

Science, 107, 874-861). This very influential work has recently been replicated. It demonstrated forcefully that the poverty of

the environment in poor mental hospitals lead to greater handicaps in the patients. It lent credence to Russet Batons concept of Institutional Neurosis.

Life Events

The study of Life Events has demonstrated the obvious (something which must be undertaken because the obvious is not always so)

namely that most psychiatric disorders have precipitants. The original work was done by American Navy Psychiatrists Holmes and

Rahe. They drew up a list of life events which were more often associated with the onset of a disorder. The list is well known

and indeed their ranking of events well discussed (from bereavement, promotion, moving house, having a child, etc).

Life event work and social network theories have lead to the tendency to attempt to identify

Predisposing Factors

Precipitating Factors

Maintaining Factors

for all psychiatric disorders, especially chronic or resistant forms.

George Brown and the Bedford College group are now usually associated with this work because of their research into depression in working class women (Brown GW, Hams TO, 1978, The Social Origins of Depression, Tavistock).

This work is central for its identification of Vulnerability Factors in these women. The most widely known area

No Confiding Relationship No Job 3+ Children Poor Marriage

In addition, the loss of mother before the age of 11 was found to be related to risk for depression. The factors are not replicated in all studies and are markers for a more central vulnerability Low Self Esteem. Brown hypothesizes that this low self esteem la result of deficient parenting) may lead to increased risk through poor decision making (poor choice of marital partner and early pregnancy).

In analysis of the Life Events data he has developed a concept of Contextual Threat which evaluates the life event in the light of the woman's self image. He has also focused on on-going difficulties (Social Adversity) and developed a schedule for measuring them (LEDS - Bedford College Life Events and Difficulty schedule) .