Why do we need a social psychiatry?

Human beings are social animals, and familial or social relationships can cause a variety of difficulties as well as providing support in our social functioning. The traditional way of looking at mental illness has focused on abnormal thoughts, actions and behaviours in response to internal causes (such as biological factors) as well as external ones such as social determinants and social stressors. We contend that psychiatry is social. Mental illness and interventions in psychiatry should be considered in the framework of social context where patients live and factors they face on a daily basis.

Economic development does not improve public mental health spending.

As a result of rapid globalization the Gross Domestic product of countries may have changed, but the gap between the very rich countries and poor countries has changed too, along with a change in social and economic strata within each society; although the rates of psychiatric disorders are affected by industrialization and urbanization, the financial pressures add yet another layer of burden. Global burden of disease due to mental illness is tremendously high and yet, in spite of pressures, there is no equity and increased discrimination related to mental illness. This paper presents some of the issues related to the economic state of the countries. In order to ensure that citizens receive the best treatments available it is important that socio-economic causes and gaps in treatment are identified and dealt with at national levels.

A service evaluation study of the impact of ageless policy in a London inner-city early intervention in psychosis service.

BACKGROUND: Schizophreniform disorders tend to have an early onset. Early intervention in psychosis (EIP) services aim to provide early treatment, reduce long-term morbidity and improve social functioning. In 2016, changes to mental health policy in England mandated that the primarily youth-focused model should be extended to an ageless one, to prevent ageism; however, this was without strong research evidence. AIMS AND METHOD: An inner-city London EIP service compared sociodemographic and clinical factors between the under-35 years and over-35 years caseload cohorts utilising the EIP package following the implementation of the ageless policy. RESULTS: Both groups received similar care, despite the younger group having significantly more clinical morbidity and needs. CLINICAL IMPLICATIONS: Our results may indicate that service provisions are being driven by policy rather than clinical needs, potentially diverting resources from younger patients. These findings have important implications for future provision of EIP services and would benefit from further exploration.

Synaptic Terminal Density Early in the Course of Schizophrenia: An In Vivo UCB-J Positron Emission Tomographic Imaging Study of SV2A.

BACKGROUND: The synaptic hypothesis is an influential theory of the pathoetiology of schizophrenia (SCZ), which is supported by the finding that there is lower uptake of the synaptic terminal density marker [11C]UCB-J in patients with chronic SCZ than in control participants. However, it is unclear whether these differences are present early in the illness. To address this, we investigated [11C]UCB-J volume of distribution (VT) in antipsychotic-naïve/free patients with SCZ who were recruited from first-episode services compared with healthy volunteers. METHODS: Forty-two volunteers (SCZ n = 21, healthy volunteers n = 21) underwent [11C]UCB-J positron emission tomography to index [11C]UCB-J VT and distribution volume ratio in the anterior cingulate, frontal, and dorsolateral prefrontal cortices; the temporal, parietal and occipital lobes; and the hippocampus, thalamus, and amygdala. Symptom severity was assessed in the SCZ group using the Positive and Negative Syndrome Scale. RESULTS: We found no significant effects of group on [11C]UCB-J VT or distribution volume ratio in most regions of interest (effect sizes from d = 0.0-0.7, p > .05), with two exceptions: we found lower distribution volume ratio in the temporal lobe (d = 0.7, uncorrected p < .05) and lower VT/fp in the anterior cingulate cortex in patients (d = 0.7, uncorrected p < .05). The Positive and Negative Syndrome Scale total score was negatively associated with [11C]UCB-J VT in the hippocampus in the SCZ group (r = -0.48, p = .03). CONCLUSIONS: These findings indicate that large differences in synaptic terminal density are not present early in SCZ, although there may be more subtle effects. When taken together with previous evidence of lower [11C]UCB-J VT in patients with chronic illness, this may indicate synaptic density changes during the course of SCZ.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health.

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Establishing a business case for setting up early detection services for preventing psychosis.

Under standard care, psychotic disorders can have limited response to treatments, high rates of chronicity and disability, negative impacts on families, and wider social and economic costs. In an effort to improve early detection and care of individuals developing a psychotic illness, early intervention in psychosis services and early detection services have been set up in various countries since the 1980s. In April 2016, NHS England implemented a new 'access and waiting times' standard for early intervention in psychosis to extend the prevention of psychosis across England. Unfortunately, early intervention and early detection services are still not uniformly distributed in the UK, leaving gaps in service provision. The aim of this paper is to provide a business case model that can guide clinicians and services looking to set up or expand early detection services in their area. The paper also focuses on some existing models of care within the Pan-London Network for Psychosis Prevention teams.

Use of continuation and maintenance electroconvulsive therapy: UK national trends.

BACKGROUND: Continuation and maintenance electroconvulsive therapy (ECT) have been used for prophylactic treatment of recurrent depression but are poorly researched and not recommended by the National Institute of Health and Clinical Excellence, UK. AIMS: To document the demographic, clinical, and legal characteristics of patients receiving continuation or maintenance ECT, trends in their use, and whether the 2 types could be distinguished by duration and frequency of application. METHOD: Electroconvulsive therapy specialist psychiatrists completed postal questionnaires about its current use and retrospective use over the past decade. RESULTS: Thirty-five (34%) clinics responded, with 26% currently treating patients with either treatment. Its use has declined over a 5-year period after restrictive guidance by the National Institute for Clinic Excellence. The mean age of patients was 60 years, and more women are treated. Maintenance ECT was given for a longer duration and less frequently than continuation ECT. CONCLUSIONS: Use has declined since 2001-2002. Continuation and maintenance ECT can be differentiated according to the frequency and duration of treatment.

How shrinks think: decision making in psychiatry.

OBJECTIVES: Psychiatrists use biopsychosocial models in identifying aetiological factors in assessing their patients and similar approaches in planning management. Models in decision making will be influenced by previous experience, training, age and gender, among other factors. Critical thinking and evidence base are both important components in the process of reaching clinical decisions. Expected outcome of treatment may be another factor. The way we think influences our decision making, clinical or otherwise. With patients expecting and taking larger roles in their own management, there needs to be a shift towards patient-centred care in decision making. CONCLUSIONS: Further exploration in how clinical decisions are made by psychiatrists is necessary. An understanding of the manner in which therapeutic alliances are formed between the clinician and the patient is necessary to understand decision making.

Through the prism darkly: how do others see psychiatrists?

OBJECTIVE: With changes in healthcare delivery and public expectations of psychiatry and psychiatric services changing, we set out to explore how other professions and psychiatrists themselves see their roles. In the UK and the USA, recent political imperatives have influenced training and roles of psychiatrists. We wanted to explore patient and carer perspectives as well. METHODS: We conducted two focus groups with patients and carers to explore their views about the roles of the psychiatrist. For occupational therapists and social workers, a brief questionnaire was placed on their respective professional organization's website. Psychiatric trainees and psychiatrists attending different meetings were asked to fill in the questionnaire. RESULTS: Patients and carers wanted to be more involved in planning their care. In common with other groups, being technically competent, being honest, approachable and being a good listener were general characteristics of a good psychiatrist. Occupational therapists saw psychiatrists as having a unique expertise and ability to provide leadership and also having skills in teaching, research, evaluating evidence and being respectful of other professions. Social workers would like psychiatrists to look beyond the medical model. CONCLUSIONS: In spite of different methods of collecting information, common themes emerge in what stakeholders expect from psychiatrists. As a profession, we need to respond to this.

Improving smoking cessation in first episode psychosis: a quality improvement project by the City & Hackney Early and Quick Intervention Psychosis (EQUIP).

Smoking tobacco is a major public health issue and a significant cause of increased mortality. People with a first episode of psychosis are more likely to smoke and the subgroup that goes on to have schizophrenia will have a significantly reduced life expectancy to the general population. The City & Hackney Early and Quick Intervention in Psychosis Team is a community mental health team at East London NHS Foundation Trust, providing outpatient care for adults presenting with first episode psychosis. This project aimed to increase the number of smoking cessation referrals from EQUIP to national smoking cessation services to 15% of the total team caseload over 6 months initially. A secondary measure was to complete an assessment of the smoking status for 90% of the caseload at all times. Change ideas were tested using plan-do-study-act cycles. A smoking cessation referral pathway was created and disseminated to the outpatient and inpatient services. The project was discussed at least monthly at the clinical team meeting. An education and skills building session was organised and took place at the team away day and an education drop-in session for patients was organised. The project was slow to take-off and patient participation was essential in driving progress. The aim was achieved at 23 months. A collateral benefit indicated that 25.7% of the total number of smokers had been recorded as having stopped smoking during the course of this project. This project demonstrates the effectiveness of quality improvement methodology facilitated by efficient leadership, collaborative teamwork, patient participation and persistence to address a complex problem that has significant consequences to patient health.

Psychoanalysis and the Hindi cinema.

Psychoanalysis was developed in nineteenth-century Vienna and led to a major change in thinking about emotions and feelings, and entered common parlance. Psychoanalysis raises notions of individual's growth and development, and defence mechanisms are used to suppress anxiety and stress. Portrayal of psychoanalysis in modern Hindi cinema is rare. In this paper we look at two films released in the late 1960s which dealt directly with psychoanalysis. Using these films we illustrate the relationship between males and females and the interaction between mothers and sons in the Indian context. The role of nurses as nurturing maternal figures and the role of tradition and modernity related to gender and westernization are discussed. These films represent the emergent India and its relationship with modernity and traditional values.

Pan-London Network for Psychosis-Prevention (PNP).

Background: The empirical success of the Clinical High Risk for Psychosis (CHR-P) paradigm is determined by the concurrent integration of efficient detection of cases at-risk, accurate prognosis, and effective preventive treatment within specialized clinical services. The characteristics of the CHR-P services are relatively under-investigated. Method: A Pan-London Network for psychosis prevention (PNP) was created across urban CHR-P services. These services were surveyed to collect the following: description of the service and catchment area, outreach, service users, interventions, and outcomes. The results were analyzed with descriptive statistics and Kaplan Meier failure function. Results: The PNP included five CHR-P services across two NHS Trusts: Outreach and Support In South-London (OASIS) in Lambeth and Southwark, OASIS in Croydon and Lewisham, Tower Hamlets Early Detection Service (THEDS), City & Hackney At-Risk Mental State Service (HEADS UP) and Newham Early Intervention Service (NEIS). The PNP serves a total population of 2,318,515 Londoners (830,889; age, 16-35 years), with a yearly recruitment capacity of 220 CHR-P individuals (age, 22.55 years). Standalone teams (OASIS and THEDS) are more established and successful than teams that share their resources with other mental health services (HEADS UP, NEIS). Characteristics of the catchment areas, outreach and service users, differ across PNP services; all of them offer psychotherapy to prevent psychosis. The PNP is supporting several CHR-P translational research projects. Conclusions: The PNP is the largest CHR-P clinical network in the UK; it represents a reference benchmark for implementing detection, prognosis, and care in the real-world clinical routine, as well as for translating research innovations into practice.

Alcohol-related dementia: a 21st-century silent epidemic?

Evidence suggests a J-shaped relationship between alcohol consumption and cognitive impairment and other health indicators, with low levels of consumption having better outcomes than abstention or moderate to heavy drinking. Most research to date has focused on the protective effects of drinking small amounts of alcohol. As alcohol consumption is escalating rapidly in many countries, the current cohort of young and middle-aged people may face an upsurge of alcohol-related dementia. The dangers of heavy drinking and its effect on cognition require further attention.

Efficacy of maintenance electroconvulsive therapy in recurrent depression: a naturalistic study.

BACKGROUND AND OBJECTIVE: The use of maintenance electroconvulsive therapy (mECT) in contemporary psychiatric practice is controversial. In the United Kingdom, the National Institute for Health and Clinical Excellence has recommended that mECT should not be used, although evidence underpinning this decision is lacking. Undertaking a randomized evaluation of this treatment would now be very difficult in the United Kingdom. The main aim of this study is to evaluate the efficacy of mECT in reducing recurrence in depression. METHOD: A retrospective analysis of 19 patients who had responded positively to an index and continuation course of ECT and then proceeded to receive mECT. We compared the number of hospital admissions and duration of hospital stay over 3 time periods: 2 years before ECT, during mECT, and up to 4 years after cessation of mECT. To account for secular trends in service use, we also compared the admission rates of this group with a matched sample who received successful index ECT followed by other maintenance therapies (comparison group). RESULTS: Participants received an average of 37 applications of mECT over a median period of 26 months. Inpatient hospital stay and rate of admissions to an acute psychiatric unit fell significantly during the period of mECT compared with the rates before the initiation of mECT. This reduction in bed use was maintained after termination of mECT. No reduction of service use was observed in the comparison group. CONCLUSIONS: The findings suggest that mECT may have a role in reducing the rate and duration of hospital stay of patients with major depressive disorder.

Community treatment orders in England: review of usage from national data.

Aims and methodCommunity treatment orders (CTOs) have been in used in England and Wales since November 2008; however, their effectiveness has been debated widely, as has the question of which methodology is appropriate to investigate them. This paper uses national data to explore the use of CTOs in England. RESULTS: About 5500 patients are subject to CTOs at any one time. Each year, ~4500 patients are made subject to a CTO each year and ~2500 are fully discharged, usually by the responsible clinician; fewer than half of CTO patients are recalled, and two-thirds of recalls end in revocation. The low rate of CTO discharges by mental health tribunals (below 5%) suggests that they are not used inappropriately.Clinical implicationsThe introduction of CTOs in England has coincided with a reduction in psychiatric service provision due to the economic downturn. Pressures on services might be even more severe if patients currently subject to CTOs instead needed to be detained as in-patients.Declaration of interestNone.

Geopolitical factors and mental health I.

Natural and man-made disasters carry with them major burden and very often the focus is on immediate survival and management of resulting infectious diseases. The impact of disasters directly and indirectly on the well-being and mental health of those affected often gets ignored. The reasons are often stigma and lack of attention to mental health consequences. In addition, often the focus is on preventing the spread of infectious diseases such as waterborne or airborne diseases. This is further complicated by the fact that often aid agencies in offering aid tend to focus on communicable diseases and not on mental health of populations. This focus may reflect easily to measure outcomes in comparison with mental illnesses as the global burden of disease is likely to increase in the next few decades. There is an urgent need to apply the principles of social justice on social and health care policies, which will lead to elimination of stigma. In this article, we propose that the impact of mental illness as a result of disasters needs to be taken seriously in any planning and delivery of relief. Mental health is likely to be affected both directly and indirectly as a result of disasters and also likely to be influenced by ongoing factors such as poor housing, overcrowding and other social determinants. In addition to deliver equity between physical and mental illnesses, appropriate and adequate resources are needed so that identifiable needs can be met with clear outcomes.

Geopolitical factors, foreign aid and mental health II: Value for money.

In the previous accompanying paper, we described geopolitical factors which affect mental health of individuals who suffer directly and indirectly. These disasters whether they are natural or man-made often attract significant amounts of aid and resources - financial and human. In addition, those who offer foreign aid need to be aware of where and how the aid is being spent. In this paper, we propose that aid giving agencies give due attention to the impact the aid should have on mental health of recipients. Global mental health has become a movement, but concerns remain about its efficacy. Therefore, it is imperative that any aid given is given and utilised in a culturally appropriate and culturally sensitive way. In an interconnected and interlinked world, it is likely that when one country or nation is affected by disasters or trauma, it will impact upon others around both directly and indirectly. We present a new measurement tool-CAPE Vulnerability Index which can be used to identify most vulnerable communities so that international aid may be more appropriately targeted. We believe that this index may go some way in assisting governments and policymakers in ascertaining the impact of their aid on the emotional and mental health of individuals. We suggest that their needs to be a ring-fencing of aid to ensure that population mental health is protected and enhanced with a strategic approach inbuilt into the foreign policy the focus needs to shift towards public mental health.

Improving the Physical Health Monitoring of City & Hackney Assertive Outreach Service Patients.

Improving physical healthcare to reduce premature mortality in people with SMI (Serious Mental Illness) is a priority for ELFT (East London NHS Foundation Trust) and NHS England. It is well know that people with schizophrenia have a life expectancy which is approximately 20% shorter than that of the general population and a substantial mortality difference exists between people with schizophrenia and the general community.[1-2] Among other risk factors, such as poor diet, physical inactivity, and high rates of smoking, the iatrogenic effects of anti-psychotic medications have been found to increase the risk of metabolic syndrome. This can easily be detected through regular monitoring. Through this project, it was our aim to improve the physical health monitoring of City & Hackney Assertive Outreach Service (AOS) patients with a view to decrease mortality rate, increase life expectancy, increase the quality of life, and reduce harm from medication. This was done using quality improvement methods, including several change ideas, each of which started sequentially over the course of a nine month period from November 2014. Following QI methodology, this utilised cycles of iterative learning using PDSA methods and was supported by the Trust's extensive programme of quality improvement, including training provided by the Institute for Healthcare Improvement. The project involved setting a specific aim which was improving the physical health monitoring of AOS patients to 80% by July 2015 and for our patients to have physical health checks (blood tests, weight, ECG, BP) as a minimum annually. From baseline measurements of between 50-75%, we reached our target of 80% for weight, BP and blood tests monitoring, with 89%, 91%, and 84% achieved respectively by July 2015. Further progress still needs to be made on ECGs, with 77% achieved by July 2015, although the monitoring of ECG nearly doubled from 39% in November 2014 to 77% in July 2015. This project demonstrated that effective leadership, collaborative team work, embedding the project in our daily practice, generating local solutions, and improved communication between primary and secondary care can increase the physical health monitoring of this complex and challenging patient group. The team continues to identify other areas for change that may lead to further improvement in the physical health monitoring of AOS patients while making sure that the improvement is sustained.

Randomized, double-blind, placebo-controlled clinical trial of the efficacy of treatment with zinc or vitamin A in infants and young children with severe acute lower respiratory infection.

BACKGROUND: Acute lower respiratory infection (ALRI) is a leading cause of childhood death. Zinc supplementation prevents ALRI. Vitamin A supplementation reduces childhood mortality, but its benefit concerning ALRI-specific mortality is unproven. OBJECTIVE: The objective was to evaluate the effect of zinc and vitamin A on the clinical recovery of children with severe ALRI. DESIGN: In a controlled trial with a factorial design, 153 children aged 2-24 mo who were hospitalized with severe ALRI were randomly assigned to receive 10 mg zinc as acetate (twice daily for 5 d) plus vitamin A placebo, 10 000 micro g retinol equivalents vitamin A (twice daily for 4 d) plus zinc placebo, zinc plus vitamin A, or zinc and vitamin A placebos. The main outcome variable was the time for resolution of very ill status; other outcomes were resolution of fever, tachypnea, and feeding difficulty. RESULTS: Recovery rates from very ill status and from fever in zinc-treated boys were 2.6 times (P = 0.004) and 3 times (P = 0.003) those in non-zinc-treated children; feeding difficulty and tachypnea were not significantly different between groups after an adjusted analysis. Recovery rates were not significantly different between groups on the basis of vitamin A treatment. At discharge, serum zinc was 6.06 micro mol/L higher (P = 0.001) in the zinc-treated children, and serum retinol was 0.387 micro mol/L higher (P = 0.001) in the vitamin A-treated children. CONCLUSION: Zinc treatment significantly reduces duration of fever and very ill status in boys, but not in girls, with severe ALRI. Vitamin A treatment of children with severe ALRI had no significant beneficial effect.