Challenges for social psychiatry in a changing world

Legal and administrative changes and a radical reform in training for all stakeholders in mental healthcare are needed to meet current challenges and address the shifting priorities for psychiatric practice, said Professor Norman Sartorius, a former director of the World Health Organization and former president of the World Psychiatric Association. The shifting priorities include:

• provision of collaborative care to include people with comorbid mental and physical disorders
• a focus on care for the patient and the family
• fighting discrimination and stigma

Changes and training are needed to address the shifting priorities in psychiatric practice

What are the modern social risk factors for psychosis?

Epidemiological risk groups for psychotic disorders include young men, urban populations, ethnic minority groups, and black African and Caribbean descent in Europe. However, the determinants of the increased risks are unknown, said Dr Ka-Young Ban, University College London (UCL), UK.

Dr Ban and her colleagues have therefore investigated the influence of social risk factors for psychosis over the life course by reviewing epidemiological data from the PsyLife group at UCL. The data were derived from the Social Epidemiology of Psychosis in East Anglia (SEPEA) study, the Avon Longitudinal Study of Parents and Children (ALSPAC) study, EU-GEI (the European Network of National Schizophrenia Networks studying Gene-Environment Interactions) and Psychiatry Sweden, a large longitudinal population register linkage of psychiatric disorders in Sweden.

Risk for psychosis is increased by social disadvantage and migration

These real-world data reveal that the risk for psychosis is increased by:

• social disadvantage in both rural and urban communities
• migratory factors before, during and after migration among migrant groups^1,2

Residential instability may also increase the risk.

The group concluded that their findings cannot be attributed to polygenic risk for schizophrenia, and do not support the possibility that social drift is the sole cause. They highlighted the need for more epidemiological studies to focus on the causal mechanisms linking the social environment to psychosis.

Can an intensive lifestyle intervention program improve the physical health and outcomes for patients with severe mental disorders?

Multiple factors contribute to the poor physical health of patients with psychiatric disorders

Patients with schizophrenia die on average 20 years earlier than the general population and have a significantly higher risk of obesity, hyperglycaemia and metabolic syndrome.1 Dr Mario Luciano, University of Campania L. Vanvitelli, Italy, added that these risk factors are compounded by:

• the adverse effects of some antipsychotic therapies
• restricted access to healthcare for a variety of reasons
• poor collaboration between psychiatrists and other medical specialties
• general disease-related factors such as cognitive impairment and lifestyle choices

Effective strategies are needed to improve the physical health of patients

Dr Luciano and his colleagues are therefore evaluating the efficacy of a large-scale 2-year intensive lifestyle intervention program for use in routine care to improve the physical health of their patients. They are enrolling 420 patients with psychotic, bipolar or depressive disorder aged 18–65 years with a body mass index over 25:

• 210 patients are taking part in the intensive lifestyle intervention comprising educational sessions, motivational interviewing and problem-solving focused on a healthy diet, physical activity, smoking cessation, drug/alcohol use, risky sexual behaviors, sleep hygiene and adherence to pharmacological treatments and management of adverse effects
• 210 patients (the control group) are taking part in a brief psychoeducational intervention on the treatment of psychiatric illness, management of the adverse effects of therapy and early warning signs

Dr Luciano concluded that it is a moral and clinical priority for psychiatrists to develop and implement effective strategies to modify and eliminate the risk factors contributing to the poor physical health of their patients.