Principles of Social Psychiatry

SOCIAL PSYCHIATRY IN INDIA 533 Certification of disability of mental disorders is not India has shown that schizophrenia is the most dis- regularly carried out and as a result many disabled abling of all conditions and certainly qualifies for persons do not get the benefits they are eligible to support from the state. Chaudhury et al. [14] com- obtain. This lack of support by the state increases pared the disability of seven conditions using IDEAS further the burden on families. in the north-western state of Assam and found that The common tools to measure disability in India are while schizophrenia was most disabling, it was closely the World Health Organization Disability Assessment followed by alcohol abuse and OCD. Disability in the Schedule (WHO-DAS) and the Schedule for the occupational sphere is by far of most concern to the Assessment of Psychiatric Disability [13]. The Indian patient and the family since a job not only provides Disability Evaluation and Assessment Scale (IDEAS), self-respect and self-esteem, but is also a means of developed by the Indian Psychiatric Society, has been augmenting the family income. Many rehabilitation gazetted by the government of India as the official programmes in India are therefore geared towards instrument for the measurement and certification increasing work-related skills and job placement of disability for official purposes. Most research in efforts. 40.4 STIGMA OF MENTAL DISORDERS Stigma is the social devaluation of a person because of assumesoverpowering importancewhen a girlreaches some personal attribute, leading to a sense of shame, adolescence. If the fact of mental illness in a family is disgrace and social isolation (see also Chapter 26). knowntoothers,itcouldalsojeopardizethechancesof Many health conditions have been stigmatized, from other members in the family getting married. This leprosy in biblical times to HIV in this century. The induces a lot of anxiety in parents who are seeking stigma of mental illness is as old as the disorder itself marriage proposals for their childrenyet to be married. and its negative consequences seem to play a role in Gender is also important. In the study noted above the outcome of many disorders. It is still unclear in Chennai, stigma was higher if the patient was whether the plethora of pharmacological and psycho- female and women carers perceived more stigma. social interventions in clinics and in the community Attribution of the cause of mental disorders did not have had anyimpact on stigma. While Rabkin [15] and seem to be related to stigma since more than a third of Bhugra [16] have stated that people are better the sample of carers had no explanation to offer as to informed about mental illness, it is again to be tested what caused mental illness in their relative. Another whether this has a lasting effect on perception and study [18,19], completed at the same centre, on experience of stigma. women with schizophrenia whose marriages had been In India and in many developing countries, care- broken revealed that families perceived this as a ‘dual giversandfamilymembersaresubjecttoasmuch,ifnot tragedy’ and felt very stigmatized. Very few of these greater,stigmaasthepatients.Thenatureanddegreeof women received any support from their husbands after stigmaexperiencedbypersonswithschizophreniawas the onset of illness, and many were sent back to their studied in 159 urban patients of the Schizophrenia parental families. Qualitative interviews held with Research Foundation in Chennai [17]. Using the these women and their primary caregivers brought up Family Interview Schedule of the International Study a lot of issues. One of them was that many women ofSchizophrenia,stigmaexperiencedbyprimarycare- considered the break in marriage more stigmatizing givers was computed and divided into high and low than schizophrenia since they felt socially ostracized stigma groups. Marriage, fear that neighbours would because of the failure of their marriage. Many hoped treat them differently and the extra efforts they had to that some day the husband would take them back. The maketohidethefactofmentalillnessfromotherswere stigma of mental illness can therefore be compounded the predominant concerns. With 90% of marriages in by social factors such as marital separation, infertility India still being ‘arranged’ by the families, this and childlessness.

534 GLOBAL MENTAL HEALTH Stigma isnot confinedto urban areas. An interesting from that, helped reduce reluctance to disclose pro- ethnographic piece of work by Jadhav et al. [20] has blems and seek help [21]. Indian families have been broken the myth that stigma of mental disorders is less typically described as often believing in causes like in rural areas. An ethnographically derived and vign- supernatural forces and therefore seeking help from ette-based stigmatization scale was administered to a magicoreligious healers. In the changing mental general community sample comprising two rural and health scenario in India, this impression may require one urban sites in India. Rural Indians showed sig- further study. Thara and Srinivasan [22] interviewed nificantly higher stigma scores, especially thosewith a key relatives living with 254 chronic schizophrenia manual occupation, and many appeared to deploy a patients and asked them to name the causes they punitive model towards the severely mentally ill. The believed were responsible for the illness in their urban group, in contrast, expressed a more liberal view family member. A supernatural cause was named by of severe mental illness. That said, urban Indians only 12% of families and as the only cause by 5%. strongly expressed a reluctance to work with someone Psychosocial stress was the most commonly cited with a mental disorder; such views were rare among cause, followed by personality defects and heredity. rural Indians. The authors conclude that the findings A small number of families (14%) could not name any from this study do not fully support the industrializa- cause and 39% named more than one cause. Patient tion hypothesis that is sometimes used to explain gender and education, duration of illness and the key better outcomes of severe mental illness in low- relative’s education, and the nature of the relationship income countries; rather, the lack of a link between were related to the type of causal attributions made. In stigma and work attitudes in rural areas may (the addition, it seems that urban families of patients authors suggest) contribute to the reported better out- suffering from chronic schizophrenia rarely subscribe comes. Loganathan and Murthy [5] also report stigma to the idea of supernatural causation of the illness. of mental illness in rural areas. The authors found in Rather, their causal attributions tend to be more their sample that, while urban respondents of Karna- biological and psychological. taka (in southern India) felt the need to hide their Charles et al. [23] in Vellore observed that patients illness and avoided illness histories in job applica- and families simultaneously held multiple and contra- tions, rural respondents experienced more ridicule, dictory beliefs about the causation of illness and its shame and discrimination. treatment. A majority of respondents in this study had Beliefs about the causation of schizophrenia can used at least two systems of healing, which included clearly influence the attitudes that families adopt allopathic and traditional/magicoreligious/religious towards patients and their help-seeking behaviour. modes. Stigma scores of patients were associated with A fairly recent study of the cultural epidemiology of a belief in disease models, as well as karma and evil schizophrenia and stigma in Bangalore, involving spirits as a cause of illness. The authors argue that detailed interviews with family caretakers of 60 holding specific beliefs can either increase or help patients, demonstrated how stigma, beliefs about ill- individuals cope with stigma. While planning mental ness and experiences of care all intertwine in shaping health services, it should be kept in mind that beliefs responses to illness and help seeking. The authors regarding attributions, explanatory models and stigma found, for example, that positive experiences of allo- play no small role in the help-seeking pattern of pathic care for mental illness minimized stigma and, patients with mental disorders. 40.5 SUICIDE IN INDIA 40.5.1 Rates of suicide the country according to the latest figures of the National Crime Records Bureau (NCRB) in 2007. Suicide is one of the leading public health problems in The fact that attempted and completed suicide is still India. Fourteen people commit suicide every hour in held to be a crime by an antiquated Indian law is the

SOCIAL PSYCHIATRY IN INDIA 535 reason why this department deals with suicide figures. example, found this form of abuse was a contributory In the last two decades, the suicide rate has increased factor for 64% of Indian women expressing suicidal from 7.9 to 10.8 per 100 000. There is a wide variation ideation [27]. in the suicide rates within the country. The southern states of Kerala, Karnataka, Andhra Pradesh and Tamil Nadu have a suicide rate of >15 per 100 000 40.5.3 Mental disorders and suicide while in the northern states of Punjab, Uttar Pradesh, Bihar and Jammu and Kashmir, the suicide rate is <3 The risk factors noted above may link to suicide per 100 000. The former French colonyof Pondicherry through their impact on mental health. Poor mental in south India has the highest suicide rate, followed by health is a major risk factor for suicide. However, Andaman and Nicobar islands. These official figures there are few Indian studies that have carefully may underestimate true rates. Two large epidemiolo- addressed this issue. What research has been done gical verbal autopsy studies in rural Tamil Nadu, for does confirm the link between mental disorder and example, reveal that the annual suicide rate is six to suicide. For example, in a case-control study con- nine times the official rate [24,25]. The most common ducted in Chennai using verbal autopsy, Vijaykumar modes of suicide seem to be poisoning, hanging and and Rajkumar [28] found strong associations between self-immolation. suicide and any Axis I disorder: depression and alcohol abuse were the main reasons for suicide. In a further study by Vijaykumar [29], personality dis- 40.5.2 Risk factors for suicide order was diagnosed in 20% of completed suicides, a rate that was around nine times greater than in con- Multiple factors impinge on the risk of suicide. The trols. More specifically, Cluster B personality disor- NCRB report cites, as the major causes of suicide: der was found in 12% of suicides and comorbid family problems; illness such as HIV/AIDS, cancers diagnoses were found in 30% of suicides. Chavan and strokes; and economic factors, such as bank- et al. [30], in a psychological autopsy study of 101 ruptcy andfailure torepayloans.Inaddition,the suicide cases in the north-west of India, found that young are particularly vulnerable, with many Indian 34% had a psychiatric diagnosis. Within these, studies finding higher rates in persons in the second, depression, alcohol-related disorders and epilepsy third and fourth decade of life. Ponnudurai and were the most common diagnoses. While as many Jayakar [26], after reviewing 12 studies on suicides as 57% of the subjects had shown behavioural change from different parts of India, concluded that the before the suicidal act, less than 12% sought treatment second and third decades of life seem to be the most from mental health professionals. susceptible period for Indian suicides. This imposes a Social factors and mental health appear linked in huge social, emotional and economic burden on our increasing the risk of suicide. For example, unem- society. The near-equal suicide rates of young men ployment appears relevant, as shown by figures from and women and the consistently narrow male- the study by Chavan et al. [30].Overhalfthe number to-female ratio of 1.4: 1 denotes that relatively more of suicide victims (57%) were not permanent resi- Indian women die by suicide than their Western dents of the main city covered (Chandigarh) and had counterparts. migrated from other states to eke out a living. They There appears to be gender differences in the were living on the outskirts of Chandigarh in slum relevant risk factors. Divorce,harassment byhusbands colonies and often had to change their homes. Migra- and their families for more dowry, failure in romantic tion, urbanization and the unhappy job scenario have relationships, difficulties in getting married and ille- all contributed substantially to suicides. The break- gitimate pregnancy seem to be particularly important down of the joint family system that had previously in the histories of women who commit suicide. A provided emotional support and stability may also be population-based study of domestic violence, for relevant.

536 GLOBAL MENTAL HEALTH 40.5.4 Farmer suicides Altruistic suicide has a long history in India, even being noted in the Dharmashastras, an ancient reli- Rates of suicide in farmers has been an area of gious text. In ancient India, two forms of altruistic immense concern, not just for mental health profes- suicide were practised. One was Jauhar, a kind of sionals but also for the government of India and mass suicide by women of a community when their economists and sociologists. In Maharashtra alone, menfolk suffered defeat in battle; the other was Sati, suicide by farmers crossed the 4000 annual mark for the suicide of a widow on the funeral pyre of her the third year in succession (NCRB). Since 1997 a husband. The practice of Jauhar ended with the fall total of 182 936 farmers have killed themselves. of the Muslim rule and the practice of Sati is against Chowdhury et al. [31], in their effort to identify the the law, although stray cases are still reported. The modus operandi in non-fatal deliberate self-harm act of Sati is now seen as suicide, not as an altruistic (DSH) in the eastern state of west Bengal, found that act, and there are laws against abetment and a total of 5178 (1887 male and 3291 female) subjects glorification. were admitted to the Primary Health Centres during The WHO’s suicide prevention multisite interven- the study period from 1999 to 2001. Organophosphor- tion study on suicidal behaviours (SUPRE-MISS) ous pesticide poisoning was found to be the most has revealed that it is possible to reduce suicide common method (85.1%) in DSH. mortality through brief, low-cost intervention in developing countries. The need for a national plan and strategy to raise suicide awareness and work 40.5.5 Religion, spirituality and suicide towards its prevention cannot be overemphasized. Programmes for suicide prevention for the Indian Religion seems to be a protective factor both at the context will have to be designed, implemented and individual and societal levels. The psychological evaluated on a mass scal,e which will be applicable autopsy study in Chennai by Vijaykumar and Rajku- and effective in urban and rural areas. This would mar[28]foundthatthelackofbeliefinGodwasoversix involve coordinated action by many players in the times more common in cases (i.e. completed suicides) field, such as educationists, primary care doctors, than controls. Those who committed suicide had less mental health professionals, government bodies and belief in God, changed their religious affiliation and nongovernmental organizations. Changes in the law rarelyvisitedplacesofworship.Elevenpercenthadlost are imperative and these have to be in keeping with their faith in the three months prior to suicide [32]. This international practices. Special attention needs to be finding was replicated by Gururaj et al. [33] in their given to young migrants, the elderly, victims of psychological autopsy study in Bangalore. domestic violence and farmers. 40.6 MENTAL HEALTH, RELIGION AND HELP SEEKING Religion and religious practices play a very important like temples, durghas and churches to the ubiquitous role in every aspect of life in Asia, as in many cultures roadside indigenous faith healer. across the world. Seeking help from a religious setting Explanatory models of mental illness play no small or faith healers is a common behaviour pattern among role in the choice and continuation of treatment. Over those suffering from any form of illness, particularly several decades, studies exploring treatment-seeking mental illness [34–37]. The variety and diversity of behaviours for mental illnesses have discussed the traditional health care practices is an indication of the relationship between attributions of cause for abnor- great influence that sociocultural practices have on mal behaviour and source of treatment sought. Weiss healing systems. The several sources of traditional and et al. [38] explored this issue by studying patients religious help available range from places of worship presenting to allopathic psychiatric centres in India.

SOCIAL PSYCHIATRY IN INDIA 537 The authors sought to determine whether patterns of a scientifically detailed explanation of causation by help seeking could be predicted from the conceptual medical professionals. At least four motivational fac- model by which they understood their illness. History tors appear to determine decision making [44]. These of prior consultations to other types of healers and are: (1) strong belief of the decision maker on faith explanatory models were obtained from the patients. healing; (2) easy approachability; (3) social stigma Preliminary findings were notable for the pervasive- associated with psychiatric consultation; and (4) the ness of prior use of folk healers and the prominence of belief system about the causation of mental illness. A somatic symptoms among patients presenting to these shared belief system and a common understanding of allopathic physicians. A methodologically rigorous the illness facilitate communication between the study in a rural population in south India [39] found patient, family and the healer, thereby increasing the that the explanations offered for psychoses, depres- cooperation required for the efficacy of therapy. sion and hysteria were possessions by evil spirits, A common finding across studies has been the devils or a curse of God, warranting a religious or parallel access to various forms of care resources. traditional mode of treatment. On the other hand, This has involved not only religious/traditional and epilepsy and mental retardation were understood as medical but also various forms of other medical having an organic basis. A more recent general popu- systems, such as allopathy, ayurveda, unani, siddha lation study [37], conducted in a rural area in northern and homeopathy. Studies have shown that the majority India, found that magicoreligious systems were uti- of the patients and families use multimodal thera- lized by a substantial number of persons who attrib- pies [39,45]. The interlink between various resources uted the illness to supernatural causes. accessed for help seeking is informal, with no pattern The coexistence of several kinds of healers treating or system for the vacillations between the resources. mental illness has been well documented in The persons using various systems do not appear to be India [37,40]. Healing methods included penance, destabilized by the different epistemologies and their visits to a shrine, astrology and spirit possession to components. The effectiveness of these modalities, negotiatewith the evil spirit. The choice of a particular together or alone, has also been described. A study healer is often made because of the perceived effec- from Kerala in south India, for example, examined tiveness of the healers in dealing with mental illness. reports of improvement and decline in short-term This choice may be independent of the level of follow-up interviews and long-term recollections educationorpatient’sbeliefinthecauseofillness[41]. among patients in three forms of therapy for mental Religious and traditional modes of treatment are illness: ayurveda (indigenous), allopathic psychiatric adopted for a wide variety of psychiatric problems (Western) and religious healing. The qualitative inter- including anxiety states, depression, dissociative views indicated that the patients of all three therapeu- states and chronic psychoses [34,39]. tic systems showed improvement after the assess- Interestingly, across most of these studies, one is ments and several patients had radically divergent aware of the influence of sociocultural milieu on help- experiences with each of the three therapies. seeking behaviour patterns. The interconnectedness Each therapy was found by some to be helpful of social networks influencing treatment-seeking and ineffective by others. Based on these findings, behaviour is evidenced by the fact that the main Halliburton [46] proposed that the reported better sources of information about causes of mental ill- outcomes of mental disorders in ‘developing’ coun- nesses and resources for help tend to be from tradi- tries may be accounted for by the greater availability tional healers, friends or relatives, astrologers or sig- of diverse forms of therapy that makes it more likely nificant persons in the community [36,41–43]. In that an individual will find a therapy to which he/she addition, help seeking for managing abnormal beha- responds well. viours is usually a collective decision taken by The effectiveness of healing sites has been families [39]. Suggestions from significant others in described in ethnographic studies. Raghuram the community appear to be more easily accepted than et al. [47] used standardized clinical assessments of

538 GLOBAL MENTAL HEALTH psychopathology in a temple in south India. A near cotherapy, rehabilitation strategies and spiritual 20% reduction in observed psychopathology scores (ritualistic) strategies (which have been followed as was noted. Family caregivers also thought that most of part of the temple’s healing practices). Assessments of the subjects had improved during their stay in the psychopathology, family burden and quality of life of temple. The cultural power of residency in the temple, caregivers indicated an improvement after the inter- known for its healing potency, may have played a part ventions. The authors hypothesized that the improve- in reducing the severe psychotic symptoms of the ment may have been the result of a combination of subjects. In another study [43], several ritualistic psychiatric interventions with the existing spiritual practices employed at various centres were documen- and ritualistic strategies [49]. ted. These included making offerings (money, in Religious or traditional treatment options for per- kind), engaging in physical acts like going around sons with abnormal behaviours in the help-seeking the place of worship, fasting, eating raw fruits like trajectory for mentally ill patients has been repeatedly lime or letting oneself be chained. These rituals were documented through several years of research. The viewed as necessary for recovery. These ritualistic underpinning of such help-seeking behaviours lies in practices appear to have a wide framework, incorpor- the sociocultural explanatory system, which allows ating social, religious and mythical domains, allowing for the coexistence of several explanations at a point in the patients to express and resolve social and psychic time or for the evolution of explanations through time. suffering [48]. The choice of the modality of treatment goes beyond The pattern of utilization of traditional and indi- the boundaries of religious faith. Ritualistic beha- genous systems has prompted the initiative of a formal viours and their symbolic meanings are readily collaboration between religious systems and the for- accepted and have a social sanction. Interlinks mal psychiatric care system. A rehabilitation centre between various resources accessed for help is infor- was established in a place called Gunaseelam in south mal, with no specific overlaps between systems. Over India, within the premises of a Hindu temple known time, a more formal collaboration between religious for its religious healing of the mentally ill for over 200 systems and more formal psychiatric care systems years. A quasi-experimental integrated intervention appears to be evolving, although the effectiveness of programme was designed incorporating pharma- this collaboration would need to be studied. 40.7 CONCLUSION Wehavehereprovidedabriefoverviewofkeyissuesfor itudinal study. Acta Psychiatrica Scandinavica, 90, social psychiatry in India, focusing on the role of 329–336. families,thespecificproblemofsuicideandtheplurality 2. Wig, N. N., Menon, D. K., Bedi, H. et al. (1987) ofhelp-seekingresponsesandresources.Inthis,manyof Expressed emotion and schizophrenia in north India. the themes resonate with those evident in other con- II. Distribution of expressed emotion components texts [40–43]. However, in India these find particular among relatives of schizophrenic patients in Aarhus and Chandigarh. British Journal of Psychiatry, 151, expression and pose specific challenges. Understanding 870. and meeting these requires a social psychiatry perspec- 3. Pai, S. and Kapur,R. L. (1981) The burdenon the family tive, both in research and in the delivery of care to those of a psychiatric patient: development of an interview with a mental illness and their families. schedule. British Journal of Psychiatry, 138, 332–335. 4. Thara, R., Padmavati, R., Kumar, S. and Srinivasan, L. REFERENCES (1998) Burden assessment schedule. Indian Journal of Psychiatry, 40, 21–29. 1. Thara, R., Henrietta, M., Joseph, A. et al. (1994) 5. Loganathan, S. and Murthy, S. R. (2008) Experience of Ten year course of schizophrenia – the Madras long- stigma and discrimination endured by people suffering

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41 Social psychiatry in Africa: Evidence and Challenges Oye Gureje and Victor Makanjuola Department of Psychiatry, University of Ibadan and University College Hospital, Ibadan, Nigeria 41.1 INTRODUCTION Africa, regarded as the cradle of the human race [1], economic fortunes of most of the countries in Africa. is the second-largest continent on earth. With an The continent is home to some of the poorest countries estimated 922 million people, it is also the second in the world. Over 70% of sub-Saharan African popu- most populous continent [2]. Africa is the only lations live in slums [4]. The United Nations human continentthatextends from the northern temperate development report in 2003, in its rankings based on to the southern temperate zones, encompassing the Human Development Index (HDI), had African numerous climate areas [3]. One-fifth of the earth’s countries occupying the bottom 25 positions [5]. Only land area is in Africa, covering 6% of the earth’s a few of the countries on the continent achieve the total surface area. Almost all of its 53 component status of ‘upper middle income’ in the World Bank countries are multiethnic, and a variety of colonial classification of the economic well-being of countries. experiences, with associated cultural and linguistic This widespread poverty means that resource con- influences, further deepens the diversity. straints run through the health care systems of most of In contrast to the ethnic, cultural and linguistic the countries, with only marginal variations in the diversity, there is a striking similarity in the current range of services available to their peoples. 41.2 EPIDEMIOLOGY OF MENTAL DISORDERS Misconceptions about the prevalence of psychiatric colonial political interests and often betrayed a lack of disorders among Africans were rife in the colonial sensitivitytothecultureandtraditionsoftheindigenous period. These early views were often influenced by people. For example, Carothers, one of the prominent Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

542 GLOBAL MENTAL HEALTH researchers of that era, reported that Africans lacked central finding of much of this work was the remark- ambition and often exercised poor judgement and were able similarity in the profile of psychiatric disorders in therefore unlikely to be capable of governing them- the African samples compared with their European selves. To buttress his point, he gave the example of a and American counterparts, a striking difference from ‘certaingoodmentalhealthattendantwhouponresum- the findings of some of the earlier studies. The ing from his usual home leave got a message that a Cornell-Aro study perhaps best exemplifies the mes- distant relation of his was very ill; he requested leave to sage of this early generation of epidemiological sur- attendtotheillrelativebuthewasdeniedwithawarning veys [9]. Conducted as a comparative study in Stirling that if he should leave his post to attend to the relative’s County in Canada and a community in Abeokuta need, he would have to forfeit his current exalted post in Nigeria, with the use of similar methodologies, and his gratuity for which he was qualified having the major findings included a high rate of worked for more than 15 years. Undeterred, he was ‘psychophysiologic and psychoneurotic symptoms’ reported to have gone to attend to the needs of the at both sites, similar patterns and distributions of relative and came back to restart his career from the symptoms, but a higher symptom level in Yoruba men bottom’ without an apparent regret of his action. This than women, unlike the reverse among the Canadians. was interpreted by Carothers as absolute lack of ambi- Even at that time, social factors were already found to tion in the African, unmindful of the strength of social be important in the occurrence of mental disorders integration and connectedness that made it imperative with community disintegration, suggested by poverty, for the man in question to respond to the needs of a ineffective leadership and broken homes, being com- relative. Writing mainly from his experience in Kenya, mon among symptomatic Yoruba respondents. Carothers concluded that the incidence of insanity In general, it is now accepted that the burden of among Africans in their ‘primitive state’ was exceed- mental disorders is no less important in Africa than it inglylowandthatthemorecontacttheAfricanhadwith is in other parts of the world. Even though commu- Europeans the higher the rates of psychiatric disorders nicable, maternal, perinatal and nutritional disorders inthem[6,7].Amongseveralothercontroversialclaims continue to constitute the greatest disease burden in made by Carothers were that the normal African men- much of Africa, neuropsychiatric disorders neverthe- tality resembled that of European psychopaths and that less accounted for about 10% of the total disability Africans lacked foresight, their behaviour being gov- adjusted life years (DALYs) in 2005 and more than erned by passing emotions. However, not all colonial 25% of the DALYs due to noncommunicable disease researchershadthesameviewsasCarothers.Forexam- in the same year [12,13]. When specific contextuali- ple, Tooth [8], working in West Africa (Gold Coast), zation of the global burden of disease methodology examined 173 patients and described disorders pre- has been attempted in Africa, the impact of mental viously reported in European populations. He also disorders has been shown to be considerable. In South found no evidence of a higher prevalence of psychosis Africa, for example, neuropsychiatric disorders among those exposed to Western influence and educa- account for a significant proportion of years lost due tion compared with the rest of the population. to disability, second only to the years lost due to HIV/ The common and obvious critique of these early AIDS [14,15]. The recent advent of new ascertain- works is the use of observations made on hospitalized ment tools, with some being applicable by trained lay patients to draw conclusions that were then general- interviewers, has led to increasingly more sophisti- ized to the rest of the population. By the 1960s, the cated epidemiological surveys from Africa. Today, decade during which most African countries gained several studies in primary care [16–18] and in the independence, efforts had begun to improve on these general adult population [9,19–21] have provided earlier studies with the advent of major community- estimates of the extent of mental disorders in several based epidemiological surveys. Examples of such African countries. Even though concerns about the studies include those conducted among the Yorubas applicability of some measures in the various African of south-west Nigeria [9], among the ‘coloured’ peo- cultures remain, there is now no doubt that most ple of the Cape Peninsula and in Ethiopia [10,11]. The commonly reported mental disorders in other racial

SOCIAL PSYCHIATRY IN AFRICA: EVIDENCE AND CHALLENGES 543 groups are present among African peoples. The earlier disorders are, however, recognized [26,28,29]. On the claims that some conditions were either not present or other hand, where differences in rates have been were so different in their presentations as to question empirically shown to occur, suggestions have been their equivalent identity with similar conditions in made that such differences may offer opportunities for Western Europe or North America now seem substan- examining possible lifestyle or genetic factors that tially repudiated [22–27]. Differences in the phenom- may predispose to the development of mental enology and explanatory models of common mental disorders [30,31]. 41.3 THE SOCIAL AND CULTURAL CONTEXT IN WHICH MENTAL ILLNESS IS EXPERIENCED The assessment of mental disorders can be influenced of somatization or medically unexplained symptoms, by cultural differences between the patient and the is often suggested to be associated with less psycho- physician. When the cultural idioms of expression of a logical sophistication or a lack of adequate psycho- syndrome by a patient are alien to the clinician, logical language to describe emotional distress on the significant error can occur in the evaluation of what part of its sufferers. There has, however, been no the patient suffers from. The result of such differences convincing demonstration of this ‘lack of psycholo- is exemplified by the literature on the occurrence and gical sophistication’ among somatizers. Studies in presentation of depression among Africans. Other many parts of the world show that somatization, than pronouncements made on the rarity of depres- irrespective of the way it is defined, is common in sion,early psychiatrists workingin the continent, most every culture [37]. Nevertheless, the myth about of them being from Western Europe, also suggested higher rates of somatization by Africans, or in some that guilt feelings, self-deprecation, psychomotor instances ‘patients from developing countries’, per- retardation and associated suicidal behaviours were sists. Even though several studies have shown that far less prevalent in Africa than in the West. More patients with psychological illness in general, and recent studies, conducted by African psychiatrists, those with depression in particular, often present with have found that not only is depression a common multiple bodily symptoms everywhere, the question psychiatric disorder in Africa but that the core symp- about whether Africans do so more than other racial toms of the illness can be elicited with culturally groups can only be addressed in a cross-cultural sensitive assessments [22,24,25,32–34]. Likewise, comparative study. Such a study will have to be there are now simple interpretations for some of the conducted in similar settings, use identical ascertain- so-called culture-bound syndromes that were reported ment procedures and elicit a broad array of symptoms in Africa in the 1960s and 1970s. For example, in his including those that are likely to be peculiar to the study of patients in rural Accra, Field [35] described participating cultures. spontaneous self-accusation of witchcraft by women. The research project ‘Psychological Problems in A similar feature, called jasfur, was reported by General Health Care’ (PPGHC), a WHO collaborative Diop [36] and described as a firm but false belief by study conducted in general health care settings in 14 patients that they had eaten human flesh. However, it is countries, fulfilled such characteristics and provided a nowcommonlyunderstoodthattheseare indeedforms good basis for examining the claim about the differ- of delusions of guilt in the context of depression. ential occurrence of somatization [38]. Conducted in One common misconception that has persisted Ankara, Turkey; Athens, Greece; Bangalore, India; despite empirical evidence to the contrary is that Berlin and Mainz, Germany; Groningen, the Nether- Africans are more likely to somatize [37]. The expres- lands; Ibadan, Nigeria; Manchester, UK; Nagasaki, sion of psychological distress in the idiom of bodily Japan; Paris, France; Rio de Janeiro, Brazil; Santiago, language, which is presumed to underpin the concept Chile; Seattle, USA; Shanghai, China; and Verona,

544 GLOBAL MENTAL HEALTH Italy, the project utilized similar ascertainment pro- care [42,43]. Patients were more likely to somatize cedures across the sites, thus facilitating the cross- when they attended clinics in which personalized cultural comparability of rates of several possible care, such as the receipt of follow-up from the same definitions of somatization. Reports of estimates of clinicians and documentation of clinical consultation DSM-IV-defined categories of somatization and in a personal file, was less common. Many clinics in hypochondriasis and of subthreshold forms of these sites from developing countries provided less perso- disorders as well as syndromes of pain disorder have nalized care than those from developed countries, been published [39–42]. A central finding of these even though this difference was not without excep- reports is that, irrespective of the definitions used, tion. Nevertheless, on the basis of the results of this somatization is common across diverse cultural set- large cross-cultural study in primary care, there was tings and that, even though variations in rates are no empirical support for the suggestion that African evident, Africans are no more (or, indeed, less) likely patients with psychological problems somatize more to somatize than patients from other racial and than those from other parts of the world. The study cultural groups. An interesting observation was that also suggests that the context in which care is sought the tendency to somatize was associated with some and received is important in the way psychological attributes of the clinics where patients had sought distress is expressed. 41.4 MODELS OF MENTAL ILLNESS Does the African model of mental illness bear any and Botswana who specialize in the treatment of resemblance to that of other cultures, especially the mental disorders alone [45–48]. Indeed, the complex- Western biomedical model? Patel et al. [26] in a ity of some of the traditional African beliefs concern- review of explanatory models of mental illness in ing psychic functioning is demonstrated by the obser- sub-Saharan African (which includes publications vation that the Shona people of Zimbabwe’s concept from 11 sub-Saharan African countries) examined of mankind has been likened to the three components the African concepts of the mind, the classification in Sigmund Freud’s conceptualization of the structure and aetiological models of mental illness and the of the mind [49]. phenomenology of mental illness. He concluded that Prior to the advent of Western medical practice, sub-Saharan African cultures do distinguish between indigenous African people had recognized the the mind and the body, as far as illness experiences features of mental illness. Furthermore, African tradi- were concerned. Some evidence in support of this tional mental health experts had a system of categor- comes from studies in Guinea showing that respon- ization or classification of mental disorders that dents were able to distinguish between major mental probably facilitated discussion among them and disorders and somatic illness [43]. Also, Beiser between them and their clients. In sub-Saharan Africa, et al. [44], working in Senegal, showed that the Serer mental illness is often classified on both an aetiolo- people did differentiate ‘illness of the spirit’, which is gical and phenomenological basis. Studies conducted analogous to mental disorders, from purely somatic in Nigeria among traditional healers revealed that the illness. These observations were contrary to earlier healers commonly classify mental disorders into three suggestions that the African concept of health did not major phenomenological groups [50]: a group broadly differentiate mental from physical illness. Further encompassing psychotic disorders, a less severe group evidence in support of the fact that traditional views of disorders often characterized by the presence of of ill-health in Africa make a distinction between somatic symptoms and mental retardation. Possible mental and somatic illness is providedbythe existence aetiological factors included supernatural affliction of traditional healers in Nigeria, Zimbabwe, Kenya from enemies, substance abuse (including misuse of

SOCIAL PSYCHIATRY IN AFRICA: EVIDENCE AND CHALLENGES 545 cannabis and alcohol), hereditary influences, epilepsy, Africa [53] and among the Shona people of Zimbabwe breakingofsocialtaboos, being breastfed bya mentally [49,54,55]. An interesting finding in the Kenyan ill woman, severe fever, head injuries and infections. study was that urban traditional healers placed less Somewhat similar categories and indigenous classifi- emphasis on spirit-related causes compared with catory systems have been described in Ethiopia [51], rural healers, reflecting a possible diminishing con- among the people of Berekuso in Ghana [52], in cern with ancestral spirits among the more educated Kenya [46], among Amaxhosa people of southern urban population [46]. 41.5 SOCIAL DETERMINANTS OF MENTAL DISORDER Patel and Kleinman [56], in a discussion of poverty documented a higher prevalence of disorders in and common mental disorders in developing coun- groups of lower socioeconomic class [60–62]. Find- tries, identified low income, poverty, insecurity, hope- ings from Africa are equivocal. Gureje and Jen- lessness, social change, education, female gender, kins [63] found a lower prevalence of mental disorders medical morbidities, and malnutrition and poor envir- in low-income households (one of the measures of onment as key social determinants of mental health socioeconomic class) while Myer et al. [64], using a and illness. That social factors play a major role in the comprehensive method of assessing socioeconomic genesis of mental disorders in Europe and America status, which incorporated an asset index reflecting has long been established [57,58]. Africa, with per- both individual and household wealth in addition to vasive poverty (over 50% live on less than 1 dollar per the traditional indicators of socioeconomic class, day), widespread social inequalities and frequent found that the lower the socioeconomic class, the social upheavals, on the one hand, and a complex, greater the likelihood of reporting nonspecific psy- robust, culturally ingrained social support and net- chological distress in an adult South African popula- working system, on the other hand, provides a unique tion (76% of respondents were black Africans). This opportunity for investigating the impact of social relationship was found to follow a dose-–response factors on mental health. This is particularly so as pattern. some reports have suggested that social determinants An emerging concept in mental health research is of mental health may vary between developed and that of social capital. Simply put, social capital is a developing countries [59]. The relationship between concept that refers to connections within and between poverty and mental illness in an African setting may social networks as well as connections among indi- indeed be complex. The traditional support systems viduals. Recent studies have suggested there may be that may offer protection against mental illness is some qualities of communities and neighbourhoods breaking down in large towns and cities but is still that may contribute to or protect against the develop- relatively intact in the villages. On the other hand, ment of common mental disorder [65]. One study socioeconomic difficulties are more prevalent in the reported that membership of community groups (in rural areas compared with urban settings. Also, there this study, primarily church groups) of women in may be differential effects on mental health between Lusaka, Zambia and Durban, South Africa, was asso- living in a community where everyone is poor and ciated with better self-rated mental health [66]. A living in one where one’s perception is that of eco- similar finding was reported in a survey of a nationally nomic disadvantage relative to others. In this regard, it representative sample of adult South Africans, despite probably cannot be assumed that absolute poverty is an inverse relationship between bonding social capital more likely to be associated with mental illness than and socioeconomic class [64]. This has led to sugges- relative (or subjective) poverty. tions of a probable mitigating effect of social capital Research into the distribution of mental disorders on the negative effects of lower socioeconomic class in European and North American populations has on mental health [66].

546 GLOBAL MENTAL HEALTH 41.6 STIGMA AND SOCIAL DISTANCE There has been a suggestion that stigmatization of the mental illness have cast doubts over these claims. In mentally ill is rare among Africans [67]. Indeed, a community survey of attitudes towards mental ill- Carothers [6,7] had asserted that ‘Every individual in ness and the mentally ill in south west Nigeria, Gureje an African community ... is regarded as a valuable et al. [70] reported widespread negativeattitudes, with asset by his clan ... (and) unlike in civilized commu- less than 4% of the respondents saying they would nities, the unwanted individual hardly occurs.’ Prob- consider marrying someone with mental illness. Simi- ably, these suggestions by earlier workers were the larly, Adewuya and Makanjuola [71] reported a high basis of the claim that a more positive, accommodat- degree of social distancing from the mentally ill in ing, supportive and less stigmatizing attitude towards three different communities in the south-west of the mentally ill could have been responsible for the Nigeria. Such negative societal attitudes have some- observation that patients in developing countries suf- times been extended to the members of their immedi- fering from severe mental illness appeared to have ate families [72]. Not surprisingly, beliefs in the better outcomes than their counterparts in the devel- supernatural causation of mental illness and that oped nations [66,68,69]. However, more recent stu- sufferers are in some way deserving of their lot often dies focusing on the attitude of Africans towards lie at the root of such negative attitudes [73]. 41.7 PROFILE OF MENTAL HEALTH SERVICES Early psychiatricserviceswere offered in asylums that most African countries are yet to have a fully main- were commonly established by colonial administra- streamed mental health service, in which patients with tions. For example, in Nigeria, the first asylum was mental disorders are treated in the same facility as established in Calabar in 1904, while in Nairobi, those with physical illnesses. In particular, effective Kenya, the Mathari hospital started functioning in community services are yet to be fully developed in 1910. Much of modern mental health care is still Africa. Even in Nigeria where Adeoye Lambo, the offered in these standalone mental hospitals. In many country’s first indigenous psychiatrist, pioneered the countries on the continent the great proportion of village community treatment programme [76], formal available psychiatric beds are located in these hospi- community mental health programmes are still rudi- tals. For example, more than 90% of the total psychia- mentary.Inotherpartsofthecontinent,therearesmall- tric beds in Nigeria are located in the eight psychiatric scale programmes that could provide models for effec- hospitals in the country. Mental health services in tive integration of mental health services into primary Egypt are provided predominantly by the four public care, as has been shown in Guinea-Bissau [77], and for psychiatric hospitals with a total of 5800 beds in Cairo comprehensive culturally applicable rehabilitation for andafurther1200psychiatricbedsdistributedoverthe persons with severe mental illness, as demonstrated in rest of the country [74]. Psychiatric services in South Tanzania [78]. Africa are providedby 24registered public psychiatric In pioneering the Aro Village system in Nigeria, hospitalsaccommodatingsome14000acuteandlong- Lambo sought to integrate a Western medical term care patients [75]. To varying degrees, services approach with traditional support systems of the provided by psychiatric hospitals are complemented Yoruba. He encouraged patients to live in their tradi- by psychiatry units of teaching hospitals and in coun- tional village setting, receiving the care and support tries such as Kenya by provincial or general hospitals. of their relatives, while obtaining orthodox medical In South Africa, public psychiatric facilities provide treatment provided by health professionals with Wes- careforabout80%ofpatients,withtheremaining20% tern medical training and expertise. It was an inno- receiving care from private practice [75]. In general, vative attempt to integrate traditional support systems

SOCIAL PSYCHIATRY IN AFRICA: EVIDENCE AND CHALLENGES 547 with modern medical care. It had the potential to help known. A community-based survey in Nigeria sug- patients recover quicker, minimize the disruptive gests that only a minority of persons with common effect of hospital admission and help improve com- mental disorders have consulted traditional healers munity attitudes towards mental illness and the men- and that the majority of those who have received any tally ill. Unfortunately, the approach did not go care have done so from general health practi- beyond the experimental stage as no structure was tioners [19]. As in other parts of the world, most developed to ensure its scaling up or adoption at the people with common mental disorders in Africa who national level. receive any mental health care probably do so from In most African countries, traditional healers are general health care or primary health care providers. A frequently consulted for mental disorders [79]. A major problem with calls for the integration of tradi- substantial proportion of persons who seek care in tional healers into the formal mental health service is formal health sectors may have also consulted tradi- that the scientific base of the practice is still poorly tional healers along their pathway to care [80,81]. understood even though a few researchers have shown However, the proportions of persons with need who interest in the practice and status of traditional actually seek care from traditional healers is not healing [50,82]. 41.8 CONCLUSION There have been many misconceptions about the 5. United Nations (UN) (2003) United Nations Develop- nature and distribution of mental disorder in Africa. ment Programme, Human Development Report, Over time, evidence has accrued that demonstrates Oxford University Press, New York. beyond doubt that the need for mental health care is 6. Carothers, J. C. (1953) The African Mind in Health and substantial. At present, such care remains primarily Disease: A Study of Ethnopsychiatry, World Health Organization, Geneva. centred in psychiatric hospitals and is unevenly dis- tributed within and across African countries. The 7. Carothers, J. C. (1948) A study of mental derangement ‘scaling-up’ of mental health services in Africa, and in Africans, and an attempt to explain its peculiarities, more especially in relation to the African attitude to life. indeed across the developing world, to deliver effec- Journal of Medical Science, 93, 548–596. tive interventions at relatively low cost has enormous 8. Tooth, G. (1950) Studies in Mental Illness in the Gold potential to relieve what is a major cause of suffering Coast, HMSO, London. and disability. 9. Leighton, A. H., Lambo, T. A., Hughes, C. C. et al. (1963) Psychiatric Disorders among the Yoruba, Cornell University Press, New York. REFERENCES 10. Giel, R. and Van Luigle, J. N. (1969) Psychiatric morbidity in a small Ethiopian town. British Journal 1. McDougall, I., Brown, F. H. and Fleagle, J. G. (2005) of Psychiatry, 115, 149–162. Stratigraphic placement and age of modern humans 11. Gillis, L. S., Lewis, J. B. and Slabbert, M. (1968) from Kibish, Ethiopia. Nature, 433, 733–736. Psychiatric disorder amongst the coloured people of 2. United Nations (UN) (2006) World Population Pro- the Cape Penninsula. An epidemiologic study. British spects: The 2006 Remission, United Nations (Depart- Journal of Psychiatry, 114, 1575–1587. ment of Economic and Social, Affairs, Population 12. Murray, C. and Lopez, A. (1996) The Global Burden of Division), New York Diseases: A Comprehensive Assessment of Mortality 3. Visual Geography (2008) Africa. General Info. and Disability from Diseases, Injuries andRisk Factors 4. United Nations (UN) (2003) Population, Health, and in 1990 and Projected to 2020. World Health Organi- Human Well-Being: Nigeria, United Nations (Popula- zation and World Bank, Harvard School of Public tion Division), New York. Health, Boston, Massachusetts.

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42 Social psychiatry in the Americas Pedro Ruiz Department of Psychiatry and Behavioral Sciences, University of Texas Medical School at Houston, Houston, Texas, USA 42.1 INTRODUCTION A chapter focusing on Social Psychiatry in the Amer- States have met with little consensus; additionally, icas must, first of all, establish a clear concept and Barach emphasizes that Social Psychiatry in the Uni- definition of what Social Psychiatry is. In the first ted States is sometimes interchangeable with commu- edition of Principles of Social Psychiatry, Dr Julian P. nity psychiatry. Dr Eliot Sorel in his book Social Leff defined Social Psychiatry as ‘being concerned Psychiatry in the Late Twentieth Century [3] presents with the effects of the social environment on the a set of selected proceedings from the XII World mental health of the individual, and with the effects Congress of Social Psychiatry. Despite the outstand- of the mentally ill person on his/her social ing set of papers included in this text, no clear defini- environment’ [1]. Dr Leona L. Barach [2] states that tion of what Social Psychiatry means to the field of attempts to define Social Psychiatry in the United psychiatry at large is described. 42.2 THE PRESENCE OF SOCIAL PSYCHIATRY IN THE AMERICAS In order to understand the evolution and presence of development and environmental conditions such as social psychiatry in the Americas, we need to focus on poverty or famine, as these relate to the incidence and the experiences and models of social psychiatry in prevalence of mental disorder [4]. In this context, Europe, particularly in England, and its underpinnings ‘Social Psychiatry focuses on relationships that start across the Americas, especially in North America. In with intra-uterine life, as well as on the macro-social the Americas, social psychiatry can be understood as conditions as they impact on personal development, primarily concerned with the patient and the contextin the family, groups, and communities concerning which he/she lives and works. In this regard, social health or illness’. In addition, social psychiatry is psychiatry addresses the contextual factors and forces concerned with treatment contexts, in institutions and that affect human development, especially aberrant the community [4,5]. When perceived in this way, one Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

552 GLOBAL MENTAL HEALTH can understand the unique connection between social American Association of Community Psychiatrists. psychiatry and community psychiatry across the It should also be noted that on different occasions both Americas; in other words, community psychiatry can Associations have considered merging with each be understood as the ‘clinical arm’ of social psychia- other. In contrast, in South and Central America and try [3]. For many, social psychiatry and community the Caribbean ‘social’ and ‘community’ activities psychiatry are not perceived as two different fields. I tend to be perceived as two integrated concepts should, however, underline the fact that in the United within the field of psychiatry at large, or as States these are two different Associations: the ‘specific ideological movements’ within the field of American Association for Social Psychiatry and the psychiatry. 42.3 FOCUSING ON LATIN AMERICA In order to understand the role of social psychiatry in many countries across Latin America but also among Latin America, we must also focus on the role of the Latin/Hispanic migrants who reside in the United cultural psychiatry. In Latin America, therewere more States and Canada and in countries of the European than 200 different ‘Indian groups’ during the ‘pre- union as well [9–11]. Columbian period’ [6]. Their cultural diversity During the colonial period, Spain and Portugal extended from small tribes who lived in a primitive greatly influenced the social aspects of the practice of state to great Indian empires that attained high levels psychiatry in Latin America. It should be noted, how- of sociocultural development such as the Mayas, the ever, thatthe new ideasandpracticesthatwereinitiated Aztecs and the Incas. During this period, aboriginal and/or implemented in Latin America were far more medical/psychiatric practices included magical and advanced than the ones that were taking place in the shamanistic medicine, priestly rituals and a large state Iberian Region of Europe. For instance, the concept of of botanical knowledge and experience. Still today, ‘moral treatment’ that prevailed in some regions of the fields of medicine and psychiatry are impacted by Latin America, as well as the development of hospitals the influence of these types of alternative medicine with a humane and social orientation in Mexico, Peru practices. They are also, in many ways, a good exam- and other countries of Latin America. To me, this ple of the ‘social’ and ‘community’ based practices ‘social’ and ‘humanistic’ trend in the field of psychia- within the field of psychiatry. Any socially oriented try in Latin America is quite unique and well rooted in psychiatrist must understand these practices, respect this part of the American continent. There has been and them and/or incorporate some of them, when appro- there is still so much poverty and neglect across Latin priate, to their medical/psychiatry armamentarium. To America that some sectors of society, especially the ignore them or reject them from the start will certainly psychiatric sector, is, perhaps, saying ‘enough is lead to frustration, noncompliance with treatment, enough’ and ‘we must do something positive about aggravation of the illness and in certain occasions to it’. Hopefully, this socially-oriented and humanistic- patient harm. In other words, the social context and/or oriented movement and/or trend might influence other culture of the physician/psychiatrist cannot be regions of the world as well and, in particular, the imposed on the patient’s culture; to do it can lead to United States. serious negative consequences to the patient, as well In this context, however, it has been said that as frustration and alienation to both the patient and the comprehensive mental health services are lacking in physician/psychiatrist [7,8]. Latin America and often have the lowest priority both Within these contexts mental and physical illnesses politically and socially [12]. In this respect, there is were often attributed to culturally driven aetiological currently a trend, primarily in South America, to move factors and, as such, were also classified in accordance away from the use of large urban psychiatric hospitals, with the cultural beliefs that existed at that time. These as well as towards establishing psychiatric units concepts and models can still be seen, not only in in general hospitals and towards the integration of

SOCIAL PSYCHIATRY IN THE AMERICAS 553 mental health care with primary health care; unfortu- about 45–50 million persons; the countries with the nately, however, the indigenous sectors of the popula- largest indigenous populations are Bolivia, Ecuador, tion tend to be neglected and not well attended to. Guatemala and Peru [14]. In 1990, neuropsychiatric Obviously, poverty has to do with this disparity. It is, conditions were estimated to account for around 9% of therefore, incumbent on socially-oriented psychia- disability-adjusted life years (DALYs) [15]. trists, as well as organizations such as the World Neuropsychiatric disorders account for 40% of all Psychiatric Association, to advocate and positively years lived with disability (YLD) irrespective of age address those inequalities and disparities in mental and 47% among those aged 15–59 years. Unipolar disorder and treatment that still exist among the depressive disorders account for 13% of all YLDs and poorest and most needy populations in Latin America. 17% among those aged 15–59. Unipolar depressive In this context, we cannot ignore the fact that about disorder, schizophrenia and alcohol use disorders are 30 million indigenous persons in South America, or the three top causes of YLD in women aged 15–59. about 10% of the general population in this region of For men aged 15–59 it is alcohol use disorders, Latin America, live in outrageous conditions of unipolar depressive disorders and violence [15]. human misery and neglect [12]. In some of these Obviously, indigenous populations and poverty-dri- poverty stricken regions the poverty rates are about ven populations in Latin America are at very high risk three to four times the national average [12]. Latin for psychiatric disorders and shorter life expectancy. America in general, and South America in particular, In this context, we should also note that suicide in depicts the highest disparities in income, as well as Latin America is becoming more frequent among other socioeconomic determinants of health and men- females than among males in some countries. Female tal health, in the world [13]. adolescent suicide rates are higher than male adoles- Sometimes, the psychiatric manpower available to cent suicide rates in Ecuador, El Salvador and Nicar- treat the indigenous populations who suffer from agua [15]. Among 10–19-year-old adolescents, the mental disorder in certain regions of Latin America leading causes of death in most of Latin America are is just abysmal; for instance, in Ecuador there is only external, i.e. caused by violence and homicide [16]. one Quichua psychiatrist for 5 million indigenous Domestic violence against women is highly prevalent persons [12]. It is also important to note in this regard in many Latin American countries, particularly in that traditional healers using ‘alternative medicine Colombia, Nicaragua, Chile and Peru [17]. Forced practices’ are helping to reduce the disparities in life sex in some regions of Latin America is culturally expectancy and the health disparities among indigen- considered to be a part of women’s domestic obliga- ous populations from South America [12]. tions [18]. In some regions of Latin America, such as In Latin America, all countries with the exception in Embu in Brazil, infant malnutrition has been linked of Argentina and Costa Rica currently have a negative to maternal mental health problems [19]. With respect migratory balance [14]. Mexico lost 300 000 persons to substance abuse, in Brazil, among the population to migration to the United States in 2002 [14]. Latin between 12 and 64 years old, 69% had a lifetime use of America has an indigenous population estimated to be alcohol and 41% of tobacco [20]. 42.4 FOCUSING ON THE CARIBBEAN The Caribbean (also known as the West Indies) is the territories in this region vary widely; thus, the con- region of the Americas encompassing the Caribbean tribution of mental disorders in this region to DALYs Sea and its Islands. The Caribbean comprises 28 also varies; for instance, in Haiti, which is the poorest territories, including some sovereign states, and over- country in the region, it is 9% and in Jamaica it is 26%. seas departments and dependencies. In these terri- The differences may be a function of the high pre- tories, several languages are spoken (English, Span- valence of infections diseases, such as HIV/ ish, French and Dutch) [21]. The economies of the AIDS [21].

554 GLOBAL MENTAL HEALTH Among children, based on the only study ever studies have been conducted suggest rates broadly conducted in this region in Puerto Rico of children similar to what have been reported in other parts of the aged 4–17 years, the most prevalent mental disorders world [28]. Suicide rates among the multiethnic Car- are attention-deficit hyperactivity disorder (8%) and ibbean countries such as Trinidad and Tobago, oppositional defiant disorder (5.5%) [22]. In another Guyana and Suriname remains a major problem, given classroom study in nine Caribbean countries (Antigua, the relatively high numbers of Hindu religious fol- the Bahamas, Barbados, British Virgin Islands, lowers in these countries [28]. Likewise, homicide is Dominica, Grenada, Guyana, Jamaica and Saint also a growing problem throughout the Caribbean, Lucia) it was found that 11% of males and 13% of given the easy access to guns in this region [28]. Along females had attempted suicide; physical abuse was these lines, substance abuse remains the single great- reported among 16% of adolescents; exposure to est contributor to psychosocial morbidity in this violence was also common with 20% of male adoles- region [28]. With rates of HIV infection in the Car- cents carrying weapons in school; and two out of five ibbean only second to sub-Saharan Africa, there is a had thoughts of hurting or killing someone. This study major relationship between HIV infection and mental encompassed 15 695 adolescents between the ages of health problems [29]. 10–18 years old [23]. As was obvious in Central America and South In terms of mental health service utilization, a study America, in the Caribbean region of Latin America conducted in Trinidad and Tobago found that psychia- mental disorder is related to poverty, neglect and trists were not using newer psychotropic medications, poor overall social conditions. This situation may in particular serotonin reuptake inhibitors to treat well lead to an increase in incidence and prevalence depression [24]. In Puerto Rico, however, where there of mental health disorders and conditions, as well is awell-established mental health care system, 76% of as aggravation of the severity of such disorders. persons with alcohol use disorders, 70% with major In turn, the challenges for mental health profes- depression and 10% with nonaffective disorders did sionals increase, and frustration ensues given the not receive any treatment for these conditions [25]. In limited resources to effectively treat these condi- addition, serious natural disasters, which occur quite tions. It is, therefore, a necessity for mental health often in the Caribbean region, can certainly increase professionals to become agents of social change; the incidence and prevalence of mental disorders, as i.e. socially-oriented mental health professionals, well as the severity of these conditions [26,27]. especially social psychiatrists, are expected to With regard to rates of disorder, little is known address and solve these health and mental health about rates of schizophrenia in the Caribbean. What challenges. 42.5 FOCUSING ON NORTH AMERICA The status of social psychiatry in North America, further states: ‘The current applications of Social especially the United States, is very nicely described Psychiatry have been extended from the individual by the late Dr Harold M. Visotsky in his introduction and the family to include the dimensions of culture, to ‘Section VIII: Social Profilaxis and Social Psy- religion, philosophy, and shared ideals. It further chotherapy’ for the previously cited book on Social relates to more abstract levels than the individual to Psychiatry in the Late Twentieth Century, edited by economic, political, and international interests’ [30]. Dr Eliot Sorel [3]. In his introduction to Section VIII, Within this context elements such as: culture, religion, Dr Visotskystates [30] ‘Psychiatry has approached the ethnicity, race, economic conditions, language, poli- treatment of all illnesses in medicine by not only tical ideologies, family system, work settings, educa- relating the psychological and the psychobiological tional levels, philosophical and ideological aspects, dynamics and interactions, but by also applying the environmental conditions, and other related aspects studies of the social components’ [30]. Dr Visotsky are all integral parts of social psychiatry. Social

SOCIAL PSYCHIATRY IN THE AMERICAS 555 psychiatrists need, by necessity, to pay attention to all if you own a house, have a car, a computer and a of these considerations if they want to be effective in cellular phone, you are ‘somebody’, but if you develop understanding, assessing, preventing and successfully a serious mental illness society sends you to prison, to treating mental disorders. The North American region live under bridges as a homeless person or to commit of the world has achieved a level of sophistication and suicide as the only other option that a mentally ill knowledge never secured in the past. When I discuss person has to stop this inhumane process. It is not my and address the most complex issues pertaining to the intention to be unthinkingly critical of the current state field of social psychiatry with many of my colleagues of affairs of the mental health system of the United from the American Association for Social Psychiatry, States; however, these days this system has hit the or from the Association of Community Psychiatrists, bottom in a way that has never happened before. or the American Psychiatric Association, as well as Several decades ago there were some very promis- from many other professional mental health societies ing initiatives that made us feel that something good from the United States and Canada, I always feel was taking place in the mental health care system of reassured and pleased with the social commitment, the United States. There was the Mental Health Center the social knowledge, their professional ideals, their Act that was initiated under the Kennedy administra- understanding of the problems and barriers faced by tion in 1963; there were the catchment area mental the health/mental health care systems of Canada and health centers that were going to address all of the the United States, and yet, with respect to the United problems of a given population in each catchment area States, this nation is facing a major challenge in the of the United States. I trained in psychiatry under this field of social medicine, and of social psychiatry in system; I decided to become a social and community particular. The United States is, without any doubt, the psychiatrist during this period. I had the opportunity to most economically powerful country in the world. direct one of these mental health centres: The Lincoln Right where I work, in the Texas Medical Centre, we Hospital Community Mental Health Center. We can offer the most sophisticated and effective health opened store-front mental health clinics in the South and mental health care in the world and yet about 47 Bronx area of the New York City catchment area million Americans do not have health and/or mental where our mental health center was located [31–33]. health insurance coverage; another 10–15 million New programmes were initiated to avoid unnecessary Americans have insufficient health/mental health hospitalization for the mentally ill and to treat men- insurance coverage; thousands and thousands of tally ill patients in their own communities in order that Americansarehomelessandhavetoliveunderbridges, they could fully utilize their own cultural resources for on highways or in parks, and about 60% of them are treatment and prevention purposes [34–36]. mentally ill; about 15–20% of Americans in the State During this golden period for social psychiatry and prison systems are mentally ill persons who should be community psychiatry genuine attempts were also housed and treated in psychiatric facilities and pro- made to involve patients/consumers in the mental grammes rather than inhumanely kept in prisons. How health delivery system that treated them, and excellent cananationliketheUnitedStateshavesuchanabysmal outcomes were obtained with these efforts [37,38]. mental healthcare system? I cannotfindany answers to A couple of decades later, almost all community- this question other than the fact that the United States based mental health centers are closed or permanently has lost its sense of social responsibility, its sense of impaired; no longer is the federal government inter- social commitment and its humanitarian perspective. ested in helping financially or morally the mentally ill Currently, this lack of social responsibility, which – particularly, the chronic mentally ill. State govern- prevails in many sectors of the United States, has ments decided to close or reduce the capacity of their negatively impacted on the health and mental health psychiatric hospitals; however, state governments also care system of this country. In the United States, today, decided not to transfer the necessary funds to the local you must have a ‘car’, a ‘computer’ and a ‘cellular or county governments. This ‘black’ period in the phone’, but under no circumstances can you get history of the mentally ill in the United States slowly ‘physically ill or mentally ill’. In the United States, evolved into the chaos that prevails today [39–41].

556 GLOBAL MENTAL HEALTH Not only did the opportunities to treat the mentally ill country’s government. Today, the mentally ill in the within their own community, and with the respect and United States are the victims of our failures to dignity that is required, fade away in the late 1970s, implement social psychiatry in the form of services but so too did the opportunities to train psychiatric and agency networks on behalf of the mentally ill residents within a community-based environment in patients’ welfare and treatment [45]. Comprehensive which the patient’s culture and human dignity community care has been shown to work effectively – received the highest priority [42–44]. for instance, in the Maudsley sponsored programmes The failures of community-based psychiatric care in Camberwell (South London), and also elsewhere. are clearly illustrated by the many homeless mentally However, for the most part, especially in the United ill persons, the frequency of rehospitalizations and States, it has not been tried [46]. It is certainly the high prevalence of chronicity among the mentally expensive, more expensive than poor hospital ill persons in this country. These conditions have care [47], but in the long run it could produce many sources: socioeconomic, political, budgetary, self-supporting citizens, as well as relieving human as well as prejudices and discrimination against the suffering and misery [4]. One of the major focuses mentally ill [4], but above all is the lack of social of social psychiatry is the development of competent commitment vis- a-vis the mentally ill that currently systems of care, i.e. clinicians who can work with prevails in the federal, state and local governments, patients’ families and in other relevant contexts. We and in the current lack of humanism that is frequently can no longer afford to limit our work based on the observed among the mental health policies of this dyadic doctor–patient field [4]. 42.6 CONCLUSION Despite the major challenges that have faced the field and greatly influence public policy all over the of social psychiatry in the last three decades, the core Americas especially in Latin America. philosophy and principles of this field are still present among many psychiatrists in the Americas, including REFERENCES Latin America and the Caribbean. The steady increases in the strength of the ‘consumer-orientated 1. Leff, J. P. (1993) Principles of social psychiatry, in movements’ in the Americas, especially in North Principles of Social Psychiatry, 1st edn (eds D. Bhugra America, is very visible and palpable [48]. The pas- and J. Leff), Blackwell Scientific Publications, Oxford, sage of the recent law on parity of psychiatric services pp. 3–11. with the medical/surgical services by the federal 2. Barach, L. L. (1993) American experience in social government is in many ways a result of the strength psychiatry, in Principles of Social Psychiatry, 1st edn of the consumer-orientated movement and the strong (eds D. Bhugra and J. Leff), Blackwell Scientific Pub- advocacy efforts of the mental health/psychiatry lications, Oxford, pp. 534–548. profession. 3. Sorel, E. (ed.) (1993) Social Psychiatry in the Late Today in the Americas, especially in the United Twentieth Century, Legas, New York. States, social psychiatry as conceived in the last 4. Fleck, S. (1990) Social psychiatry – an overview. Social several decades in Germany, France, Italy and the Psychiatry and Psychiatric Epidemiology, 25, 48–55. United Kingdom has had a declining influence [49]. 5. Schwab, J. J. (1993) The family: introduction, in Social Likewise, the late-century rise of biological psychia- Psychiatry in the Late Twentieth Century (ed. E. Sorel), try in the United States has also reduced the research Legas, New York, pp. 16–21. emphasis on cross-cultural psychiatry, which peaked 6. Leon, C. A. and Roselli, H. (1975) Latin America, in in the 1970s and 1980s. I think, however, that the basic World History of Psychiatry (ed. J. G. Howells), Brun- principles of social psychiatry will eventually resurge, ner/Mazel Publisher, New York, pp. 476–506.

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Epilogue



43 Where next for social psychiatry? Dinesh Bhugra and Craig Morgan NIH Biomedical Research Centre and Institute of Psychiatry, King's College London, London, UK Lauber [1] recently asked: ‘Why is social psychiatry mental hygiene movement, through deinstitutionali- still alive?’ Before pondering an answer, we might zation and the study of life events and family contexts, wonder why such a question is even being posed. In to the growth of community psychiatry, health ser- so far as mental disorder is an intrinsically social vices research and more recently global and public phenomenon, which is shaped by, and in turn shapes, mental health [2]. Throughout, social psychiatry has social contexts and experiences, such a question does provided a framework for understanding the indivi- not arise. Without research and other activities dedi- dual and his/her ‘private troubles’ [3] within a wider cated to investigating these core aspects of mental context, and in doing so has considerably enhanced disorder, there is no possibility of achieving a full our understanding of many facets of mental disorder – understanding nor of responding effectively and of how society draws the boundaries between normal- humanely. In part, the posing of such a question ity and abnormality; of how social contexts and reflects insecurity in the face of rapid advances in experiences impact on the onset, course and outcome genetics and neuroscience, as noted in the Preface. of disorder; and of how culture shapes the manifesta- Ironically, such advances – in showing how the social tion of, and responses to, disorder. These insights have and biological interact – have helped reinvigorate been crucial in informing the development and imple- areas of social research in psychiatry. This is evident mentation of complex social interventions and sys- in many of the contributions in this edition, especially tems of service delivery. In each of these areas, social in relation to the aetiology of psychosis (an area that, psychiatry can, and no doubt will, continue to make a until recently, was considered largely off-bounds for significant contribution. However, just as it has social psychiatry) (see Chapter 15). Indeed, all the evolved in the past in response to wider social and essays brought together here clearly illustrate the economic pressures, so now social psychiatry will relevance, necessity and vibrancy of current research need to be flexible in responding to the many chal- in social psychiatry. Any lack of confidence is evi- lenges posed by the ever-increasing pace of social dently ill-founded. change throughout the world. The nature and scope of social psychiatry has Indeed, the pace of social change appears to undergone tremendous changes over time – from the increase exponentially year on year under a multitude Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

562 EPILOGUE of pressures, including economic developments, mass their impact on individual biology with manyresulting migration, and technological and telecommunications fruitful collaborations between social and biological revolutions. The resulting transformations in social psychiatry. This blurring of disciplinary boundaries is relations and patterns of communication are no more to be welcomed. clearly illustrated than in the development of the Having said this, a final observation is worth noting. Internet and, with it, the emergence of myriad oppor- In the past, social psychiatry has been criticized for tunities for online ‘social’ networking. We now have leaving uncontested the basic diagnostic concepts entirely novel ways of forming relationships, seeking used in psychiatry and enshrined in DSM [4]. This support and of accessing information on most any may have been a necessity, the only basis on which to topic, all of which have important implications for work with others within the profession. Less chari- mental health and mental health care. As Chapter 36 tably, this can be construed as reflecting what might be illustrates, there is an urgent need for research to termed the absence (or loss) of a critical edge in social understand the positive and negative ways in which psychiatry. As the range of experiences being brought these new media affect mental health, help seeking under the umbrella of ‘mental disorder’ expands at a and interactions with mental health services. If seemingly exponential rate [5], there is a role for ‘social’ networking provides opportunities for social social psychiatry in reflecting back how the dividing engagement, it equally carries risks (e.g. ‘cyber- line between normality and abnormality is socially bullying’, websites promoting suicide, etc.). This is determined and changeable over time. Just as social just one example; there are many others. At the time of psychiatry can contribute to understanding the social preparing this edition, the world economy is in the dimensions of mental distress, so it can challenge the midst of a severe recession, with the inevitable con- reduction of understandable and normal responses to sequences of increasing unemployment, poverty adversity (in all its forms) to clinical diagnoses. This is and general uncertainty. International and internal a major challenge, and in responding to this there is migration now occurs at unprecedented levels and is much that can be drawn from historical and socio- driven by diverse forces, from the desire for economic logical studies of how certain experiences come to fall betterment to the seeking of refuge from war and within the ambit of psychiatry [6,7]. natural disaster to the trafficking of women for profit. There are then multiple challenges that social psy- As the research presented in many of these chapters chiatry is well placed to meet. Here we have given a highlights, these developments will have far-reaching small number of highly select examples, and others (and mainly negative) consequences for public and would no doubt highlight further areas. We have not, global mental health. As societies transform, so too do for instance, mentioned the critical role that social the contexts and questions that social psychiatry will psychiatrists can and are playing in combating the be challenged to address. widespread stigma and discrimination that continues Of course, social psychiatry does not stand in to restrict opportunities for recovery and reintegration isolation from the rest of psychiatry; the challenges for those with a mental disorder. When considered in noted in the preceding paragraph are ones that need this way, do we really need to wonder why social to be faced by all those charged with understanding psychiatry is still alive? If it were not, there would be and responding to mental disorder. However, social little hope for psychiatry as a whole. psychiatry may well be uniquely placed to provide the focal point for research that integrates the biological, psychological and social, given its foothold both in the REFERENCES social sciences (including sociology and psychology) and, as a psychiatric subdiscipline, in the medical and 1. Lauber, C. (2008) Editorial. International Review of biological sciences. Nowhere is this better illustrated Psychiatry, 20, 489–491. than in recent trends in psychosis research, in which 2. Uchtenhagen, A. A. (2008) Which future for social there is a growing consensus that social contexts and psychiatry? International Review of Psychiatry, 20, experiences can increase risk for disorder through 535–539.

WHERE NEXT FOR SOCIAL PSYCHIATRY? 563 3. Scheper-Hughes, N. (2001) Saints, Scholars and Schizo- into Depressive Disorder, Oxford University Press, phrenics: Mental Illness in Rural Ireland, Twentieth Oxford. Anniversary Edition, University of California Press, Los 6. Horwitz, A. (2004) Creating Mental Illness, 2nd edn, Angeles, California. Chicago University Press, Chicago, Illinois. 4. Cooper, B. (1992) Sociology in the context of social 7. Hacking, I. (1999) Mad Travellers: Reflections on the psychiatry. British Journal of Psychiatry, 161, 594–598. Reality of Transient Mental Illness, Free Association 5. Horwitz, A. and Wakefield, J. (2007) The Loss of Books, New York. Sadness: How Psychiatry Transformed Normal Sorrow



Index Locators in bold refer to main entries Locators in italic refer to figures/tables Locators for main headings which also have subheadings refer to general aspects of that topic AA (Alcoholics Anonymous) 267–8 aetiology abortion 321–2; see also pregnancy depression 216–20 abuse, childhood; see also child protection personality disorder 253–5 child mental health 289 Aetiology and Ethnicity in Schizophrenia and other child protection-psychiatric interface 486–7 Psychoses (AESOP) 135, 138, 199 and depression 218, 219, 220 affect recognition 23 extra-family abuse 490 affective bias 206–7, 207 parental mental health 490–1 Africa 541, 547 prevention strategies 400 epidemiology of mental disorders 541–3 as risk factor for becoming an abuser 488–9 mental health services 546–7 as risk factor for psychosis 200–1 models of mental illness 544–5 and trauma 18–19 social determinants of mental illness 545 within-family abuse 489–90 social/cultural contexts of mental illness accommodation 543–4 homelessness 260–1, 292, 351–5 stigma 546 instability 351–5 African-Carribeans see black/minority ethnic groups interventions 426, 428 age factors 95–6, 228–9; see also later life disorders rehabilitation houses 268–9 AJP (American Journal of Psychiatry) 9, 9–10 acculturation 123, 126, 134, 147 alcohol use/abuse 230, 252, 260, 334, 525; see also ACT (assertive community treatment) 390–3, 415, 428 binge drinking acute stress disorder (ASD) 157 Alcoholics Anonymous (AA) 267–8 adaptation to stress/trauma 58,157, 160, 165,166;see also alienation 146 coping alternative therapy 127, 128, 309 addiction to virtual reality worlds 480; see also drug use Alzheimer’s disease 33, 299; see also dementia ADHD (attention-deficit hyperactivity disorder) 42, 56, American Association for Social Psychiatry 552 93, 149, 554 American Association of Community Psychiatrists adolescence, prevention strategies 400–1 552 adulthood American Journal of Psychiatry (AJP) 9, 9–10 prevention strategies 401–2 American Psychiatric Association 41 sociodevelopmental origins of psychosis 202–3 Americans View Their Mental Health study 310 Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

566 INDEX Americas 551, 556; see also United States associations/societies, European mental health Caribbean 553–4 services 512–13 Latin America 552–3 asylums 56, 412–13; see also coercion; hospitalization North America 554–6 At Risk of Abuse Register (ARAR) 489–90 social psychiatry 551–2 attachment 222, 254–5, 287, 469, 485 Amnesty International 143 attention-deficit hyperactivity disorder (ADHD) 42, 56, amok 119 93, 149, 554 amphetamines 524 Australia 241, 428 animal studies of dopamine metabolism 204–5 Australian Triple P Positive Parenting Programme anomalous experiences 17–18, 20, 20, 194, 195; see also 400 delusions; hallucinations authoritarian parenting 287, 287 anomie 56, 150, 196, 204, 206 authoritative parenting 286–7, 287 and schizophrenia 198–200, 199 autistic spectrum disorders 463 anonymity 480 autonomy, patient 417, 420 anorexia 278; see also eating disorders avoidant behaviour 333–4, 335 anthropology 118 avoidant coping styles 105, 420, 453 antidepresssants 167 avoidant personality disorder 451, 454 antioxidants 403 antipsychotic medication 323, 413 BAS (Burden Assessment Scale) 532 antisocial behaviour 45, 47; see also deviance BCS (British Crime Survey) 260 antisocial personality disorder (APD) 41, 251, 253, Bebo (social networking site) 478–9 451, 454 Beck Depression Inventory 443 anxiety; see also common mental disorders; generalized behaviour anxiety disorder illness see illness behaviour and depression 217 medicalization of 149 and disasters 159 rejecting 333–4, 335 and expressed emotion 107 Belmont Hospital 3–4 and globalization 146 beta-blockers 167 and parenting styles 287, 288 Bhopal disaster 161 prevalence 93, 94 bibliotherapy 441–3, 442 psychoeducation 443–4 biculturalism 134–5 self-help 442 binge drinking, cultural influences 119, 120; see also and social support 462 alcohol use/abuse sociodevelopmental origins 193 biological model see biomedical model and suicide 241 biological vulnerability 218–20, 219 and torture 164 biomedical model of mental illness 7–8, 9, 13–14, APD (antisocial personality disorder) 41, 251, 253, 157, 544 451, 454 constructions of mental illness 40–1 ARAR (At Risk of Abuse Register) 489–90 and diagnosis 31 area-level factors, social environment 69–71 bipolar disorder 94, 323–4 ASD (acute stress disorder) 157 birth weight, and depression 399 Asperger’s syndrome 469 BJP (British Journal of Psychiatry) 9, 9–10 aspirin, and dementia 402 black/minority ethnic groups; see also cultural identity; assertive community treatment (ACT) 390–3, ethnicity; race 415, 428 cultural identity 134 assessment mental illness 135–6, 136–8 post-traumatic stress disorder 169 qualitative research 82–3 community mental health team structures schizophrenia 197–200, 199 389, 393–4 blogs 478 Association of European Psychiatry, Section of blood-brain barrier 299 Epidemiology and Social Psychiatry 512 body shape, cultural influences 119

INDEX 567 bonding ties 221 CBA (cost-benefit analysis) 379; see also books, self-help 441–3, 442 cost-effectiveness; efficiency, economic borderline personality disorder (BPD) 251–5, CD (conduct disorder) 93 454, 487 CEACs (cost-effectiveness acceptability curves) 378 bottom-up research 78–9; see also qualitative research ‘Changing Minds’ campaign 335 boundaries of mental illness 39–42,46 chatrooms 478 brain cancer, mortality rates 186, 188 Chernobyl disaster 161 Brazil 231–2, 280 cherry picking 83 Brent Woods Conference 143 child custody 324–5 bridging ties 221 child protection 483, 489, 491–2; see also abuse British Crime Survey (BCS) 260 attachment 485 British Journal of Psychiatry (BJP) 9, 9–10 background information 484 British Psychiatric Morbidity Survey 57 case example 483–4 Buddhism 238, 241 extra-family abuse 490 Buffalo Creek flood 156 neurodevelopment 485 bulimia 278; see also eating disorders parental mental health 490–1 bullying 291 parents, mental health 485–6 Burden Assessment Scale (BAS) 532 personality disorders 487–8 burden of care 104–5, 531–2; see also carers; families psychosocial factors 485 within-family abuse 489–90 Cache County Study on Memory Health and Aging childhood adversity 401; see also children’s mental 402, 403 health; developmental perspectives; poverty; stress call-centres 145 and dementia 298–9 CAM (complementary alternative medicine) 127, effects in later life 346 128, 309 and personality disorder 254 Canada 440, 554–6; see also Americas and psychosis 200–2, 207 cancer children’s mental health 285, 292; see also childhood mortality rates 186, 187, 188 adversity population level health improvements 182–3 abuse, childhood 289 CANDID 1 (Culture and Identity Schedule) 135–9 cross-sample variations 287 cannabis 205 family environments 286–90 cardiovascular factors, and dementia 299 family function/parental discord 289 Care Programme Approach (CPA) 389 homelessness 292 carers 463–4; see also burden of care; community-based life events 292 treatment; families neighbourhood influences 292 coping styles 105–6 parental illness 288–9 in India 531–2 parenting styles 286–8, 287 Caribbean 553–4 poverty 291 cartesian dualism 15–16 prevention strategies 399–401 case examples 52–3, 483–4 religious beliefs 290 case management 389–93 school environments 290–1 catechol-O-methyl-transferase (COMT) gene 205–6 sibling illness/disability 289–90 categorization of mental illnesses see classification/ social contexts 285–6 categorization socioeconomic factors 291–2 Catholicism 238 Chile 280 causation models China 517–18, 526 cultural influences 124–5, 126 addiction 524–5 health inequalities 184–5 alcohol use/abuse 525 psychiatric illness 188–90 depression 521–3 psychosis 204–7, 207 eating disorders 280 stress/depression 215 family interventions 431

568 INDEX China (Continued ) comorbidity 229–30 health care provision 519–20 definitions 227 mental health burden 518 economic impact 231 migrant workers 525–6 education/employment 232, 233 psychiatric services 519 epidemiology 227–8 psychoses 523–4 future research 233–4 social fragmentation/loss of cultural values 520–1 health service use 230–1 suicide 238, 239, 241, 520–1 public health implications 232–4 choice, treatment 312, 313, 433–4; see also coercion risk factors 228–30 Christian houses 268 social environment 232 CIDI (Composite International Diagnostic Interview) sociocultural factors 231–2 91–2, 93–4 socioeconomic factors 229, 231, 233 Civil Rights Movement 8, 9–10 special needs groups 233 classification/categorization 31–2 communication underclass 480 clinical utility 35, 35 community involvement 417–18 diagnostic categories/continuums 32, 32, 34, 34–5, 35 Community Mental Health Centres Act 8 perinatal mental disorders 326 community-based treatment 416–17; see also personality disorder 250–1 deinstitutionalization; therapeutic communities quotation 51 drug use/addiction 266–7, 268–9 reliability/validity 33–4, 34 social support 427–8, 467–9 social psychiatry applications 36 community mental health teams (CMHTs) 392, 394–5, clients 427–8 carer relationships 108 assessments/reviews 389, 393–4 communities 419–20 case management/assertive community treatment 389, participation in treatment 108–9, 416, 417 390–3 reluctant 46–7; see also choice; coercion characteristics, team 391–3, 392 self-control/autonomy 417, 420 continuity, in/out-patient care 393 symptoms, and burden of care 105 current developments 393–4 climate, and schizophrenia 197 early history 388 clinical evidence-based care 394 approaches to social support 469–72 governance 393–4 iceberg model 310–11 meta-regression of home-based care 390–1, 391, 392 utility, classification/categorization 35, 35 research 389–90 clubhouses 414, 428 specialization 393, 394 CMDs see common mental disorders staffing 388 CMHTs see community mental health teams team structures 387–8 cocaine 147 triage/allocation/zoning 389 Coconut Grove nightclub fire 156 community psychiatric nurses (CPNs) 388 coercion, medical 46–7, 312, 313, 417, 419; see also community psychiatry 552 choice; hospitalization community workers 469 cognitive behaviour therapy 1, 20, 167, 450–1, 466 comorbidity, mental disorders 97, 229–30 cognitive bias, and psychosis 206–7, 207 competing risks model 188 cognitive stimulation therapy (CST) 378 competitiveness 464, 470 colds/fevers 59–60 complementary alternative medicine (CAM) 127, Collaborative Study on Strategies for Extending Mental 128, 309 Health Care 532 complex emergencies 157; see also trauma collectivist societies 238–9 Composite International Diagnostic Interview (CIDI) colon cancer, mortality rates 188 91–2, 93–4 commodification of health 147 COMT (catechol-O-methyl-transferase) gene 205–6 common mental disorders (CMDs); see also anxiety; Concept Houses 268–9 depression conduct disorder (CD) 93

INDEX 569 confabulation 17 definitions 118–19 Confucianism 238, 241 depression 522–3 consensual verification 15 disease/illness distinctions 125 conservation of resources (COR) theory 159 and distress 119 constraints 313 eating disorders 278–80, 280, 282 consumers of mental health services see clients ethnicity 120 contextual measures, depression 216 and food 277 contingency management 451 life events/psychiatric morbidity 122–3 continuity, in/out-patient care 393 mental disorders 93, 119–20 continuums, illness/health 32, 32, 34, 34–5, 35; see also migration 121–2, 122 classification/categorization organizational culture 125 Convention on Prevention and Punishment of the Crime of pharmacotherapy 127, 128 Genocide (CPPCS) 164 psychotherapy 127–8 coping styles 470; see also adaptation to trauma race/racism 120–1 avoidant 105, 420, 453 relationships with clinicians 124–5, 126 carers 105–6 suicide 520–1 and disasters 159–60 cultural identity 123–4, 133, 139; see also black/minority illness behaviour 308, 310, 311 ethnic groups; ethnicity; race and migration 122 comparison of cases/controls 137–8 COR (conservation of resources) theory 159 comparison of control subjects across ethnic cortisol 219–20 groups 136–7 cost-benefit analysis (CBA) 379; see also efficiency; Culture and Identity Schedule (CANDID 1) 135–9 funding and eating disorders 279 cost-effectiveness eating disorders 281 acceptability curves 378 and globalization 146–7 analysis 378–9 measurement 133–5 definitions 374–5 study background 135–6 health care 371–2 Culture and Identity Schedule (CANDID 1) 135–9 cost functions 380 cyberbullying 480 cost-offset calculations 379 Cyprus 240 cost-utility analysis (CUA) 379–80 Czech Republic 280 costly signalling 345 course of illnesses danger, and depression 217 dementia 300 data analysis, qualitative research 78, 83–4 epidemiology of mental disorders 96 day care interventions for psychosis 428–9 personality disorder 252 DBT (dialectical behaviour therapy) 451 CPA (Care Programme Approach) 389 death, parental 401; see also childhood adversity CPNs (community psychiatric nurses) 388 debriefing, trauma 168 CPPCS (Convention on Prevention and Punishment of the decade of the brain 8 Crime of Genocide) 164 decision-making 455 creolizing world 146 defeat, social 204–5, 217, 243, 345 cross-cultural validity 1, 138–9, 149 definitions cross-fertilization of ideas 7; see also multidisciplinary common mental disorders 227, 440 services coping 308 CST (cognitive stimulation therapy) 378 culture 118–19 cue perception 23 drug use/addiction 259–60 cultural contexts of mental illness 117–18, 129, 231–2 effectiveness 374–5 acculturation 123, 126 efficiency 373–5 Africa 543–4 ethnicity 120 clinician culture 125–7, 126 of health/illness 40, 42, 43 culture of the individual 125 illness/health/sickness behaviour 307

570 INDEX definitions (Continued ) life events 216–17 later life disorders 297 and migration 122, 145 social determinants of mental illness 398 and parenting styles 289 social management 439–40 pharmacotherapy 190 social psychiatry 3, 5–6, 551 and pregnancy 322 support networks/social support 461–2 prevention 402–3 trauma/disasters 156–7 Problem-Solving Treatment in Primary Care 467 deinstitutionalization 351, 387; see also psychoeducation 443–4 community-based treatment qualitative research 82 delays in treatment 311–12 resilience enhancement 445–6 delusions; see also religious beliefs school environments 291 and childhood adversity 201 self-help 442 in non-clinical populations 19–20 social capital 220–2 social nature of psychiatry 20 and social defeat 205 dementia 56, 296, 297; see also Alzheimer’s disease social science perspectives 58, 59 cardiovascular factors 299 and social skills 471 classification/categorization 33 and social support 462, 463 course of illnesses/prognosis 300 sociodevelopmental origins 193 education/childhood adversity 298–9 and socioeconomic status 346–8 prevention 402–3 stigma 333, 334 social determinants 297–8, 299–301 and stress/strain 205, 215–16, 303, 462 demoralization 159, 160 and suicide 241, 404 denial coping style 105 and torture 164 dependence 463 and trauma 157, 158, 159 depression 215, 222; see also common mental disorders; vulnerability factors 218 postnatal depression Determinants of Outcomes of Severe Mental Disorder and abuse, childhood 486 (DOSMeD) 194, 531 adolescence 401 detoxification 270 adulthood 401 developmental perspectives 69, 485, 487–8; see also aetiological model 216–20 childhood adversity; sociodevelopmental origins of Africa 543 psychosis and birth weight 399 deviance, social 41, 54–6, 345; see also antisocial China 521–3 behaviour comorbidity 97 DHEA (dehydroepiandrosterone) 220 constructions of mental illness 42 diabetes 185 and cultural factors 522–3 diagnosis; see also misdiagnosis and cultural identity 135 categories/continuums 32, 32, 34, 34–5, 35; see also diagnostic categories/continuums 32, 32,35 classification/categorization and disasters 159, 160 constructions of mental illness 41, 42 dynamics of social environment 69, 70 controversy, personality disorder 249–50 exercise 403 cultural influences see cultural contexts of mental illness and expressed emotion 107 epidemiology of mental disorders 91–2, 93 family therapy 440–1 social science perspectives 57–8 gene-environment interactions 218–20, 219 Diagnostic and Statistical Manual of Mental Disorders and globalization 145 (DSM) 33–4, 41, 53 and homelessness 355 cross-cultural validity of diagnosis 149 income/social class 301 cultural influences 118 internet-based interventions 444–5 depression 466 interpersonal psychotherapy 465–6 drug use/addiction 261 intervention studies 465 epidemiology of mental disorders 91, 94, 97 later life disorders 300–3 perinatal mental disorders 326

INDEX 571 personality disorder 250, 449, 450 drug use (illicit) 147–8, 259, 272, 353, 354; see also and social psychiatry 562 pharmacotherapy trauma 157 and abuse, childhood 486 Diagnostic Interview Schedule (DIS) 91, 261 Africa 544–5 dialectical behaviour therapy (DBT) 451 amongst medical staff 264 diet; see also eating disorders; food career of 265–6 and pharmacotherapy 128 China 524–5 in pregnancy 399 community-based treatment 266–7 prevention 403 and cultural identity 135 dimensional classifications, personality definitions/terminology 259–60 disorder 250 environmental manipulations 271 direct payments 429–30 epidemiology 260–1 DIS (Diagnostic Interview Schedule) 91, 261 gender 265 disability; see also physical health and globalization 145 constructions of mental illness 42 narcotics anonymous 267–8 India 532–3 National Treatment Outcome Research Study 262–3 sibling 289–90 natural history of 265–6 Disability Assessment Schedule (WHO-DAS) 533 neighbourhood influences 271–2 Disability Discrimination Act 433 in pregnancy 399 disadvantage, and schizophrenia 198–200, 199; see also prison release 264 childhood adversity; stress relapse 269–70 disasters 159–62; see also trauma spontaneous/natural recovery 270 disclosure of symptoms 80 therapeutic communities/rehabilitation houses 268–9 discrimination 333–4 treatment policy 266 global patterns 334–5 UK studies 263–4 and schizophrenia 198–200, 199 Vietnam Study 261–2 Discrimination and Stigma Scale (DISC) 335 DSM see Diagnostic and Statistical Manual of Mental Disorders disease/illness distinctions 125 Dunedin longitudinal study 205, 220 disgrace 533 Durkheim, Emile 341–2, 520 displacement 351–5 dynamics of social environment 66–9; see also dissociation 19, 157 environmental dynamics distress; see also stress; trauma dysfunction, mental illness constructions 43–5, 46 cultural influences 119 dysthymia 97 epidemiology of mental disorders 97 and genocide 165 EAAD (European Alliance Against Depression) 513 and globalization 143, 145 early intervention (EI) 379 divorce Eastern cultural traditions 238, 241, 279–80; see also effects on children 401 China; Japan life events 346 Eating Attitude Test Questionnaire (EATS) 279 and mental health 533 eating disorders 278; see also diet; food stigma/discrimination 335 cross-cultural risks/global trends 279–80, 280 and suicide 237–9, 520 cultural identity 281 doctors, drug use/addiction 264 food/culture/society 277 Doctors Without Borders 143 gender 278 domestic violence 325–6; see also abuse; child protection interventions/prevention 281–2 dominance 464 and self-esteem 149 dopamine metabolism 23, 204–5 sociocultural factors 278–80 DOSMeD (Determinants of Outcomes of Severe Mental sociocultural model 282 Disorder) 194, 531 spectrum hypothesis 278 double-binds 54 thinness ideal 278 doubling up 352 urbanicity 279

572 INDEX economic development 562 environmental dynamics 65–6, 73, 440 economic impact of mental disorders see cost-benefit; cost- area-level factors 69–71 effectiveness; efficiency; funding/costs and common mental disorders 232 EDEN (European Day Hospital Evaluation) study 510 mobility, social/geographic 72–3 Edinburgh Post Natal Depression Screen 399 social capital 71–2 education/schools 68 social structure 66–9 common mental disorders 232, 233 socialization processes 66–8 and dementia 298–9 environmental interventions 271, 467; see also internet 480 interventions, social psychoeducation 167, 168, 443–4, 455 Epidemiological Catchment Area Study 57, 228, school-based programmes 400–1, 404 229, 440 school environments, and child mental health 290–1 epidemiology 5, 6, 91, 99 EE see expressed emotion Aetiology and Ethnicity in Schizophrenia and other effectiveness, definition 374–5 Psychoses 135 efficiency, economic 371–2 ; see also cost-benefit; Africa 541–3 cost-effectiveness; efficiency; funding age of onset distributions 95–6 cost functions 380 assessment methodology 91–2 cost-benefit analysis 379 common mental disorders 227–8, 440 cost-effectiveness analysis 378–9 comorbidity 97 costs 377 course of illness 96 cost-utility analysis 379–80 depression 521–2 definitions 373–5 and diagnosis 33 measurement/analysis 376–80 drug use/addiction 260–1 outcomes 376–7 personality disorder 252 pursuit of 380–1 prevalence 93–4 theoretical framework 373–4 and qualitative research 85 Effort Syndrome Unit 3 refugees 163 EI (early intervention) 379 social factors 343–4, 345 elderly people see later life disorders societal costs 97–8 EMDR (eye-movement desensitization and sociodevelopmental origins of psychosis 194–5 reprocessing) 167 treatment 98 emotional bias, and psychosis 206–7, 207 episodes of illness see network-episode model emotional hurt 238 EPSILON (European Psychiatric Services) study 510 emotion-focused coping 105; see also expressed emotion EQ-5D (Euro-Qol ) 376, 380 empirical studies see evidence-based strategies; EQOLISE (Enhancing Quality of Life and Independence experimental studies through Supported Employment) trial) 510 employment/unemployment 349–51; see also meaningful ESTSS (European Society for Traumatic Stress activity Studies) 513 common mental disorders 232 ethics of qualitative research 82 importance of 402, 414, 420–1, 433, 469 ethnic density 138 and suicide 237–9 ethnic identity 67 vocational rehabilitation 429 Ethnicity and Psychosis Study (EPS) 136, 138 empowerment 413, 414, 420 ethnicity; see also black/minority ethnic groups; cultural endophenotypes 22–3 identity; race Enhancing Quality of Life and Independence through common mental disorders (CMDs) 229 Supported Employment (EQOLISE) trial 510 and culture 120 ENMESH (European Network for Mental Health Service and health/mortality 181–2 Evaluation) 512–13 and schizophrenia 197–200, 199 entrapment 217 ethnography 81–2 environment-gene interactions see gene-environment European Alliance Against Depression (EAAD) 513 interactions European Day Hospital Evaluation (EDEN) study 510

INDEX 573 European Federation of Associations of Families of People Facebook 478–9 with Mental Illness (EUFAMI) 513 face-to-face contact 480 European mental health services 501–2, 508 facial affect recognition 23 associations/societies 512–13 families 103, 109–10; see also burden of care; carers; experimental studies 510 expressed emotion funding/costs 502–7, 503, 504, 505, 506, 507 burden of care/patient symptoms 105 naturalistic studies 510 caregiving impacts 104–5 North European social psychiatry revolution 413 carer coping styles 105–6 policies/legislation/mental health care models child mental health 286–90 507–8, 508 India 531–2 prevention/health promotion issues 511–12 interventions 430–1, 439, 467 scope/future of 514–15 patient perceptions 108 service provision/outcomes 509–10 positive family relationships 107–8 European Network for Mental Health Service Evaluation prevention strategies 401 (ENMESH) 512–13 as resource 103–4 European Pact for Mental Health (EC) 502 and suicide 242–3 European Psychiatric Services (EPSILON) therapy 440–1 study 510 working with 108–9 European social psychiatry revolution 413 Family Burden Scale of Reference 532 European Society for Traumatic Stress Studies farmers, suicide 536 (ESTSS) 513 fatalism 241 Euro-Qol (EQ-5D) 376, 380 fathers 326–7 EuroSC (European Schizophrenia Cohort) 510 fear conditioning 158; see also post-traumatic stress Every Child Matters agenda 485 disorder; trauma evidence-based strategies 6, 426; see also fear disorders 97; see also anxiety experimental studies Feminism 8, 9 community mental health teams 394 fevers 59–60 prevention 399–403 financial support, social interventions 429–30 evolutionary naturalism 40, 42, 43, 45, 46, 47 Finland 238, 504, 507 evolutionary theory 40, 43–5, 157 flooding 161 exercise, and dementia/depression 403 focus groups 80–1 exosystem model of child mental health 286 food; see also diet; eating disorders experience sampling 203 and culture 277 experimental studies; see also evidence-based strategies insecurity 233 European mental health services 510 Foucault, M. 40, 41, 53 social support 464–5 Fountain House 414 explanatory models see causation models fragmentation, social 196, 520–1; see also isolation exposure therapy 167–8 fresh-start experiences 222, 446 expressed emotion (EE) 430–1, 439, 441, 464 Freud, Sigmund 7 families and psychosis 106 funding mental health services; see also cost-benefit; and patient outcomes 106–7 cost-effectiveness; efficiency patient perceptions 108 common mental disorders 23, 197–8 as risk factor for psychosis 200 Europe 502–7, 503, 504, 505, 506, 507 schizophrenia 468 externalizing behaviour 69, 354 gaming 479 extinction learning 158 GATT (General Agreement on Tariffs and Trade) 143 extraversion personality trait 250 gender Exxon Valdez oil spill 162 and common mental disorders 228 eye contact, and culture 126 and depression 215 eye-movement desensitization and reprocessing drug use/addiction 265 (EMDR) 167 eating disorders 278

574 INDEX gender (Continued ) social inequality 145, 150 and marriage cost-benefits 463 training/research 150 and parenting styles 288 goal setting 455 and personality disorders 487 governance, community mental health team social determinants of mental illness 398 structures 393–4 socialization 69 Green Paper on Mental Health 511 and stigma 533 Gross Domestic Product, European countries 503 and suicide 244 grounded theory, qualitative research 84 gene-environment interactions 203, 205–6; see also group therapy 3–4, 80–1, 467, 468 genetics Guidelines, Schizophrenia 109 child mental health 285–6 guilt 164, 238 depression 218–20, 219 later life disorders 303 habitus 66, 67, 72, 73, 344 mental health 464 hallucinations 17–18 personality disorders 487 case studies 52–3 general adaptation theory 58; see also adaptation and childhood adversity 201 to stress/trauma mental nature of symptoms 15, 16 General Agreement on Tariffs and Trade (GATT) 143 in non-clinical populations 20,20 General Health Questionnaire (GHQ) 443 and trauma 18–19 General Motors 143 harm to others see violence generalizability of research 83 health; see also disability; mental health; physical health generalized anxiety disorder (GAD) 94, 95, 96, 97, 159; advisors 308–10, 309, 310 see also anxiety behaviour, definition 307 generation of alternatives 455 belief model 307, 314 genetics; see also gene-environment interactions care domain 45–7 fundamental causes of psychiatric illness 189 care provision, China 519–20 and health/mortality 182 economics see efficiency, economic and population level health improvements 183 seeking behaviour 6 and psychosis 202 service use, common mental disorders 230–1 schizophrenia 21, 22, 193, 194, 198 tourism 147 genocide 164–5 health inequality 181, 341–3; see also socioeconomic geographical mobility 72–3, 301–2 status George III 412 causality 184–5, 188–90 Germany 241–2, 504, 507, 510 changes over time 186, 186–8, 187, 188 GHQ (General Health Questionnaire) 443 core proposition 184 Global Burden of Disease Study 518 displacement/residential instability 351–5 global patterns empirical evidence 185–8 eating disorders 279–80, 280 and globalization 150 stigma/discrimination 334–5 and health/mortality 181–2, 182 global warming 171 and mental health 145, 343–4 globalization 141–2, 151, 342 population level health improvements 182–3, 183 changing perceptions of mental disorders poverty, rethinking 355–6 145–6 preventable causes of death 185–6 cultural identity 146–7 social class/life stress 344–9 health as commodity 147 unemployment 349–51 historical development 142–4 Health Utilities Index 376 impact of 142 heart disease 182–3, 187 information sharing 148 hepatitis C 267 and mental health 149 heritability see genetics migration 148–9 heroin 147, 263 pharmacotherapy 147–8 hierarchy stress 346–7

INDEX 575 high-risk situations 398 sociodemographic characteristics 314 Hispanic societies 240 theoretical models 314–16, 315 historical developments 3–5, 9 treatment choice/coercion 312, 313 biological psychiatry, rise of 7–8 treatment uptake improvements 311 China 517 understanding 316 community mental health teams 388 uptake of mental health services 310–11 cross-fertilization 7 illness/disease distinctions 125 definition 3, 5–6 image matrices, illness behaviour 309, 310 globalization 142–4 IMF (International Monetary Fund) 143 social interventions 411–13 IMPACT programme 418 United States 8–11 Implementing Mental Health Promotion Action HIV/AIDS 183, 263–4, 535, 542, 553 (IMHPA) 511, 513 Hodgkin disease 183 Improving Access to Psychological Therapies (IAPT) 379 Holocaust 165 impulsive personality disorder 251 home-based care, meta-regression of 390–1, 391, 392; impulsivity 453, 454 see also community mental health team structures inclusion, social 36, 432–4, 433, 434 homelessness 260–1, 292, 351–5 income, later life disorders 301; see also homosexuality 41, 42 socioeconomic status Hong Kong 519–20 India 145, 531, 538 hope 420 burden of care 531–2 hopelessness, and suicide 238, 240, 241 disability 532–3 hospitalization 426–7; see also coercion; mental help seeking 536–8 institutions religious beliefs/spirituality 536–8 housing see accommodation stigma of mental disorders 533–4 HPA (hypothalamic-pituitary-adrenal) axis 204–5, suicide 534–6 219–20 Indian Disability and Psychiatric Assessment Scale HRT, and dementia 403 (IDEAS) 533 human rights, respect for 419 Indian Persons with Disabilities Act 532 humanitarian values 4 indicated interventions 397 humiliation 217 individual interviews 79 hurricane Katrina 161 individual placement and support (IPS) 414, 419, 510 5-HTP (5-hydroxytryptamine) 220, 303 individualistic societies 238–9 hypothalamic-pituitary-adrenal (HPA) axis 204–5, inequality see health inequality; socioeconomic status 219–20 infancy, prevention strategies 399–400 infanticide 326 IAPT (Improving Access to Psychological Therapies) 379 Infanticide Act 484 IASC (Inter-Agency Standing Committee) 167 infectious disease, population level health IDEAS (Indian Disability and Psychiatric Assessment improvements 182–3; see also HIV/AIDS Scale) 533 information sharing identity, cultural see cultural identity health 148 IED (intermittent explosive disorder) 93 internet 480 ignorance, and stigma 333, 335, 335 internet-based, concerns/issues 480 illicit drugs see drug use stigma 333 illness behaviour 6, 307–8 information technology, and eating disorders 281–2 constraints 313 in/out-patient care, continuity 393 coping styles 308, 310, 311 insider perspectives 85 factors shaping 314 insight 17 health advisors/patterns of response 308–10, 309, 310 institutional racism 120–1 public perceptions of mental health problems 311 integration, social 342, 345 seriousness of illness/treatment needs 311–12 important elements to change 463 seriousness of illness/treatment use 312 and suicide 237–9, 240–1

576 INDEX intentionality 16 iodine supplements 399 Inter-Agency Standing Committee (IASC) 167 IPA (interpretive phenomenological analysis) 83–4 intermittent explosive disorder (IED) 93 IPS (individual placement and support) 414, 419, 510 internal markets 381 IPT (interpersonal psychotherapy) 465–6 International Center for Clubhouse Development 414 Islington study of depression 216, 217, 218 International Monetary Fund (IMF) 143 isolation, social 204 International Study of Schizophrenia 431 and eating disorders 282 internet 148, 444–5, 479–81; see also websites and globalization 146 interpersonal psychotherapy (IPT) 465–6 important elements to change 463 interpretive phenomenological analysis (IPA) 83–4 and insight 17 interventions, social 387, 411, 412, 425, 426; see also mothers with severe mental problems 324 treatment interventions and psychosis 202, 203 accommodation 426, 428 and schizophrenia 196, 197 client communities 419–20 stigma of mental disorders 533 coercion, avoiding 417 and suicide 240 collaboration with social agencies 418 ISSI (Interview Schedule for Social interaction) 464 community-based treatment 416–18, 427–8 Italy 510 current developments 431–4 day care 428–9 Japan 238, 280, 335 employment 420–1 Jones, Maxwell 3, 5 empowerment 413, 414, 420 journal articles, psychosocial 9, 9–10 evidence-based strategies 426 family interventions 108–9, 430–1 karma 161 financial support 429–30 khat 148 hospitalization 426–7 Korsakoff syndrome 17 meaningful activity 428–9 historical precedents 411–13 labelling 31; see also classification/categorization; stigma individual self-control/autonomy 417 labelling theory 51, 54–6 mental hygiene movement 412–13 later life disorders 303; see also dementia modern rehabilitation models 414–15 definitions 297 moral treatment 411–12 depression/mental disorders 300–3 multidisciplinary services 415–16, 421 geographical mobility 301–2 North European social psychiatry revolution 413 income/social class 301 optimism, therapeutic 421 life events 301 and pharmacotherapy 416 modifying factors 302–3 political advocacy 418–19 physical health/disability 296, 301 recovery model 415, 431–2 prevention 402–3 relationships 430–1 problems of later life 295–7 respect for human rights 419 social support 302 social inclusion 432–4, 433, 434 Latin America 552–3 social skills training 430 lay systems of care 308–9 social support 464–5, 470–1 layered contexts model 286 stigma, fighting 418 LEDS (Life Events and Difficulties Schedule) 216, treatment location/settings 416–17 217, 348 user/consumer participation in treatment 416 legislation 507–8, 508 vocational rehabilitation 429 leucotomy 7 interview methodology 79 life course trajectories 67 Interview Schedule for Social interaction (ISSI) 464 life events; see also stress intrusiveness 24 child mental health 292 involuntary/reluctant patients 46–7; see also choice; and culture/race 122–3 coercion and depression 216–17, 465

INDEX 577 fundamental causes of psychiatric illness 189 medication, psychotropic see pharmacotherapy; see also later life disorders 301 drug use (illicit) and psychosis 202–3 mental health; see also services, mental health research 6, 23–4 and migration 148–9 and social class 344–9 conceptualizations 39–42 and suicide 243 evolutionary/social/personal norms 43–5 vulnerability factors 218 health care domain 45–7 Life Events and Difficulties Schedule (LEDS) 216, research 68–9 217, 348 social construction 54–6 life expectancy rates, US 183 and suicide 535 living circumstances, and common mental Mental Health Action Plan for Europe (WHO) 502 disorders 229 Mental Health Declaration for Europe (WHO) 502 lobotomy 7 Mental Health in Emergencies (WHO) 167 local treatment centres 416 Mental Health: New Understanding, New Hope locus of control 420 (WHO) 501 loss mental hygiene movement 412–13 and depression 217 mental institutions 56, 412–13; see also coercion; and genocide 165 hospitalization social science perspectives 59 mesosystem model of child mental health 286 and suicide 520–1 meta-regression of home-based care 390–1, 391, 392 loud thoughts 18 methadone treatment 267, 270 lung cancer mortality rates 187, 188 Microsoft 143 microsystem model of child mental health 286 macrosystem model of child mental health 286 Midtown Manhattan Study 189 Maine, Tom 3, 4, 5 migrant workers, Chinese 525–6 maintenance interventions 397 migration 72–3, 121–2, 122 major depressive disorder (MDD) 94; see also depression common mental disorders 232 making sense of the world 16–17 and cultural identity 133–4 Malaysia 119 and globalization 143 mania, and cultural identity 135 and mental health 145, 146, 148–9 marginalization and schizophrenia 197–200, 199 black/minority ethnic groups 138 and social psychiatry 562 and globalization 142, 146, 148 and suicide 241–2 school environments 290 Mill Hill Emergency Hospital 3 marriage A Mind That Found Itself (Beers) 412–13 and depression 215 minority ethnic groups see black/minority ethnic groups discord, and child mental health 289 mirroring 15 and gender 463 misdiagnosis therapy 467 personality disorder 249–50 mastery coping style 308 psychosis 55 maturing out process 270 mixed methods research Maudsley Hospital 3 mobility, social/geographic 72–3 Mauritius 255 models McDonalds 142, 143 child mental health 286 MDD (major depressive disorder) 94; see also depression mental health care 507–8, 508 meaningful activity 428–9; see also employment/ of mental illness 544–5 unemployment recovery 415, 431–2 media influences 190, 244–5 rehabilitation 414–15 medical model see biomedical model of mental illness modernity 342 medical staff, drug use/addiction 264 mood disorders, age of onset distributions 95–6; see also medicalization of behaviour 149 depression

578 INDEX moral career of the mental patient 55 Netley Hospital 4 moral theory 56 network-episode model (NEM) 315, 315, 316 moral treatment 411–12, 420 neurasthenia 522 mortality rates neurocognitive correlates of schizophrenia 22, 23 brain cancer 186 neurodevelopment 485 personality disorder 252–3 neuroticism personality trait 218–19, 250, 462 and social inequality 181–2, 182 New Zealand 432, 440 and socioeconomic status 187–8 newborn infants, prevention strategies 399–400 United States 187 NICE (National Institute for Clinical Excellence) 109, mother and baby psychiatric units 324 380, 442 motherhood; see also postnatal depression NLMS (National Longitudinal Mortality Study) and schizophrenia 323 185, 188 and severe mental problems 324–5 nonaffective psychoses (NAPs) 93–4, 95, 96 and socioeconomic status (SES) 348 nonresource inputs, definitions 374 moving house 351–5 Nordic Association for Psychiatric Epidemiology multidisciplinary services 415–16, 421 (NAPE) 512 Munchausen syndrome by proxy 491 norms, cultural 125, 145, 149, 561 MySpace 478–9 norms, social/personal 43–5 North America 554–6 NAPs (nonaffective psychoses) 93–4, 95, 96 North European social psychiatry revolution 413 NAPE (Nordic Association for Psychiatric Norway 240, 505, 508 Epidemiology) 512 nose design function analogy 43–4 Narcotics Anonymous (NA) 267–8 NSAIDs (non-steroidal anti-inflammatory drugs) 402 narrative exposure therapy 167–8 NTORS (National Treatment Outcome Research National Association for Mental Health 413 Study) 262–3 National Comorbidity Survey (NCS) 57, 230, 346, 440 nutrition see diet; food; see also eating disorders common mental disorders 228, 229 uptake of mental health services 310 objective/subjective burden of care 104–5 National Health Service, UK 381 obsessive compulsive disorder (OCD) 94, 230 National Household Survey of Britain 440 ODD (oppositional defiant disorder) 93, 554 National Institute for Clinical Excellence (NICE) 109, ODIN (Outcomes of Depression International 380, 442 Network) 440, 510 National Institute for Mental Health 8, 432, 466 Office of Population Censuses and Surveys (OPCS) 260 National Longitudinal Mortality Study (NLMS) 185, 188 older adults see later life disorders National Social Inclusion Programme 432 Open Society for Mental Health Initiative (OSMHI) 513 National Treatment Drug Monitoring System openness personality trait 250 (NDTMS) 260 oppositional defiant disorder (ODD) 93, 554 National Treatment Outcome Research Study optimism, therapeutic 412, 421 (NTORS) 262–3 organic brain syndromes 296 natural disasters see disasters; trauma organizational culture 125 naturalism 40, 42, 43, 45, 46, 47 OSMHI (Open Society for Mental Health Initiative) 513 naturalistic studies, European mental health services 510 otherness 120 NCS see National Comorbidity Survey Outcome of Depression International Network NDTMS (National Treatment Drug Monitoring (ODIN) 440, 510 System) 260 outcomes needle/syringe exchange schemes 266–7 definitions 374 needs, treatment 311–12, 374 evaluation/maintenance, social support negative symptoms, mental nature 22–3 471–2 neighbourhood influences 271–2, 292, 344 measurement/analysis 376–7 NEM (network-episode model) 315, 315, 316 out/in-patient care, continuity 393 Netherlands 510 ovarian cancer, mortality rates 186, 188

INDEX 579 PACE (Personal Assistance in Community Living) diagnostic issues 41, 249–50 teams 418, 431 harm to others 253 panic disorder 159, 444–5 impact of 252–3 paranoia 20, 24, 196 intervention studies 255 Paranoia Checklist 20 mortality, premature 252–3 parent-child relationships 69 and parenting styles 487–8 parental mental health prevalence 251 impact on child 485–6 problems of later life 297 and child protection 490–1 psychiatric perspectives 487 prevention strategies 399–400, 400 psychological treatments 450–1 parenting styles social construction of mental illness 56, 149 and child mental health 286–9, 287 treatment of 255, 450 and personality disorder 254–5, 487–8 pessimistic thinking styles 24, 56 participant observation studies 81–2 pharmacotherapy 7; see also drug use (illicit) passivity experiences 17–18 antidepresssants 167 patients see clients antipsychotics 323, 413 PCGMHW (primary care graduate mental health and culture 127, 128 worker) 442, 443 and dementia 402–3 peer groups 68, 243–4 depression 222, 440–1 peer pressure 146 and globalization 147 perceptions of mental disorders NSAIDs (non-steroidal anti-inflammatory drugs) 402 Africa 544–5 and pregnancy 323–4 client 108 and prevalence of mental illness 190 and globalization 145–6 reducing reliance on 416 India 534 trauma/disasters 167 media role 190 phobias 94, 230 public 311 physical health; see also disability perfectionism, and suicide 239–40 later life disorders 296, 301 perinatal prevention strategies 399–400 and personality disorder 252 perinatal mental disorders 321, 327 pluralism 151; see also globalization abortion 321–2 PMS see Psychiatric Morbidity Survey classification/categorization 326 policies, mental health 507–8, 508 domestic violence 325–6 political advocacy 418–19 fathers 326–7 political violence 162 infanticide 326 population level health improvements 182–3, 183 mothers with severe mental problems 324–5 Positive and Negative Symptoms Scale 376, 432 pregnancy 322–4 positive problem orientation 452–3 permissive parenting 287, 288 positive symptoms, mental nature 22–3 Personal Assistance in Community Living (PACE) postnatal depression 322–4, 399–400 teams 418, 431 infanticide 326 personal norms 43–5 and social support 464–5 personality disorder 35, 249; see also problem-solving post-traumatic stress disorder (PTSD) 157–9; see also therapy for personality disorder; and see specific trauma disorders by name age of onset distributions 95, 96 aetiology 253–5 comorbidity 97 attachment/parenting 254–5 controversies surrounding 168–70 child protection-psychiatric interface 487–8 cultural influences 119 childhood trauma 254 and disasters 160–1 classification/categorization 33, 250–1 and genocide 165 course of illnesses 252 internet-based interventions 444–5 developmental perspectives 487–8 interventions 167

580 INDEX post-traumatic stress disorder (PTSD) (Continued ) focused coping 105 prevalence 94 orientation 452 refugees 163 solving style 453 social construction of mental illness 56 problem-solving therapy for personality disorder 449, and torture 164 450, 452, 456, 456–7 and trauma 18–19 social problem solving 452–3, 453–5, 454 war/political violence 162 Stop & Think! 451, 455–6 poverty; see also childhood adversity; socioeconomic status Problem-Solving Treatment in Primary Care 467 child mental health 291 prodromal phases 312, 431 common mental disorders 231, 233 production of welfare perspective 374 disorder 342 productivity, definitions 375 global distributions 144, 150 prognosis, dementia 300 rethinking 355–6 projection, thoughts 15, 18 social determinants of mental illness 398 prolactin 323 and suicide 342 prolonged exposure therapy 167–8 PPGHC (Psychological Problems in General Health protestant work ethic 142 Care) 543 pseudo-patient experiment 55 precipitating factors 398 Psychiatric Morbidity Survey (PMS) 228, 230 predisposing factors 398 common mental disorders 229 pregnancy, and mental health 322–4; see also perinatal personality disorder 253 mental disorders psychiatric services see mental health services prejudice 333, 480; see also stigma psychiatry premature mortality, and personality disorder 252–3 biological 7–8 prevalence and psychotherapy 6 mental disorders 93–4 social science perspectives 54 personality disorder 251 psychoanalysis 8 prevention 4–5, 397, 404 psychodynamic therapy 155–6, 450–1 in adulthood 401–2 psychoeducation 167, 168, 443–4, 455 in childhood/adolescence 400–1 psychological debriefing 168 eating disorders 281–2 Psychological Problems in General Health Care European mental health services 511–12 (PPGHC) 543 evidence-based strategies 399–403 psychological treatments, personality disorder interventions 397 450–1 older adults 402–3 psychosis; see also sociodevelopmental origins of paradox 397 psychosis; schizophrenia perinatal/infancy 399–400 and childhood adversity 207 processes at onset of mental disorder 398 China 523–4 resilience 400–1 dynamics of social environment 70 strategies 398, 398–9 misdiagnosis 55 suicide 403–4 and mobility, social/geographic 72–3 targets 398 social science perspectives 58 price efficiency 375; see also cost-benefit; cost- and trauma 18–19 effectiveness; efficiency; funding/costs psychosocial primary care graduate mental health worker conceptions of 23–4 (PCGMHW) 442, 443 factors 485 primary prevention see prevention journal articles 9, 9–10 primate studies, dopamine metabolism 204 management principles 462–3 Principles of Social Psychiatry (Leff) 551 psychotherapy prison release 264 and culture 127–8 problem and prevalence of mental illness 190 definition 455 principles 462–3

INDEX 581 and psychiatry 6 interventions, social 430–1 social support 465–7 and mental health 6, 387 psychotic experiences 17–18 mother-infant 160 PTSD see post-traumatic stress disorder parent-child 69 public health implications, common mental positive family relationships 107–8 disorders 232–4 therapeutic 6 public perceptions of mental health problems 311 reliability, classification/categorization 33–4, 34 religious beliefs 19–20 qualitative research 77–8, 79, 86, 431 child mental health 290 approaches to 78–9 and delusions 119 critical appraisal 85–6 and mental health 536–8 data analysis, approaches 83–4 and suicide 237–9, 536 data analysis, preliminary 83 reluctant patients 46–7; see also choice; coercion focus group discussions 80–1 reminiscence therapy 403 individual interviews 79 representations of mental illness 39, 40 mixed methodology 84–5 research participant observation 81–2 and globalization 150 study design 82–3 stigma 331–3 quality adjusted life years (QALYs) 376, 380 residential instability 351–5; see also accommodation quality of life studies 510 resilience 159, 341, 342, 356, 398 Quatro (Quality of Life following Adherence Therapy) enhancement 400–1, 445–6 Study 510 and homelessness 354 questionnaires 216 resource inputs 374, 377 respect 412, 419 race; see also black/minority ethnic groups; cultural responses to mental illness 59–61, 308–10, 309, 310 identity; ethnicity reviews, community mental health teams 389 and culture 120–1 risk factors and health/mortality 181–2 common mental disorders 228–30 racial identity see cultural identity suicide 535 racism 120–1, 148 rodent studies, dopamine metabolism 204 randomized controlled trials (RCTs) 426 role reversal 485–6 rape 164 Royal College of Psychiatrists 4 rational choice theory 71 Royal Medico-Psychological Association (RMPA) 3, 4, rational problem solving 453 5, 6 rationing, health service use 314 Rwanda 165 recovery models 415, 431–2 reductionism 15 sampling methodology 78 reflexivity 84, 85 SCARF (Schizophrenia Research Foundation) 532 reforms, mental institutions 412–13 Schedule for the Assessment of Psychiatric Disability 533 Refugee Convention 162–3 Schedule of Recent Experiences 345 refugees 158–9, 162–3 schizophrenia 15; see also psychosis; sociodevelopmental rehabilitation origins of psychosis houses 268–9 China 523–4 models, rehabilitation 414–15 community-based treatment 416–17 after torture 164 and cultural identity 135, 137–8 vocational 429; see also employment/unemployment delusions 19–20 rejecting behaviour 333–4, 335 epidemiology 194 relapse 109–10, 269–70 expressed emotion 439, 441, 468 relationships families of patients see families client perceptions 108 fundamental causes 189 with clinicians see therapeutic relationship genetics of 21,22

582 INDEX schizophrenia (Continued ) gaps 310–11 and globalization 150 uptake 311, 312 impact on child of parents with 486 SES see socioeconomic status importance of work 420 SFQ (Social Functioning Questionnaire) 455–6 India 531–2 shame 164, 238, 335, 533 and migration/ethnicity 197–200, 199 sibling illness/disability, and child mental health 289–90 and mobility, social/geographic 72–3 sick role 7, 60 and mother-infant relationships 323 sickness behaviour, definitions 307 mothers with severe mental problems smoking in pregnancy 399 324, 325 Social and Community Psychiatry Group, Royal College of and post-traumatic stress disorder 18–19 Psychiatrists 4–5 prevalence of 93 social anxiety disorder 444–5 social construction of 56 social capital 57, 69, 71–2, 220–2 social determinants of 56 social class see socioeconomic status sociodevelopmental origins of 193 Social Class and Mental Illness (Hollingshead and stigma/discrimination 334–5, 533 Redlich) 188–9 and suicide 404 social cognition, and schizophrenia 22–3 symptoms, mental nature 15, 16 social cohesion 520 therapeutic optimism 412 social construction of mental illness 54–6 treatment interventions 524 social costs of mental disorders 97–8; see also and urbanicity 195–7 funding/costs Schizophrenia Research Foundation (SCARF) 532 social cue perception 23 schizophrenogenic mother 54, 200 social defeat 204–5, 217, 243, 345 schools see education/schools social determinants of mental illness 56–9, 343–4 Second Life 479 Africa 545 secure attachment 287 definitions 398 ‘see Me’ campaign 335 dementia 299–301 selection, genetic 182, 189 social deviance 41, 54–6, 345; see also antisocial selective interventions 397 behaviour self-control/autonomy 417, 420 social disorders 207 self-esteem 420 social disorganization theory 69 and depression 446 social distance 546 and eating disorders 149 social ecological positioning 160 importance of work 421 social efficiency 375 loss 217 social environment see environmental dynamics and mental health 335 social exclusion 72 and migration 122 social firms 414 moral treatment 412 social fragmentation 196, 520–1; see also isolation self-harming behaviour 47, 120, 145 Social Functioning Questionnaire (SFQ) 455–6 self-help books 441–3, 442 social inclusion 36, 432–4, 433, 434 self-help groups 468 social inequality see health inequality; socioeconomic status semi-structured interviews 216, 217 social integration see integration sensitization processes 204 social interventions see interventions, social sensory experiences 16–17 social isolation see isolation SEPRATE (structured events probe and narratives rating social management of common mental disorders 439, 446 method) 349 bibliotherapy 441–3, 442 seriousness of illness, and illness behaviour 311–12 definitions 439–40 services, mental health family therapy 440–1 Africa 546–7 internet-based 444–5 China 519 psychoeducation 443–4 European 509–10 resilience enhancement 445–6