The heart of the matter: Social and cultural factors impacting mental health

In his Retrospective, Scott Henderson (this issue) states his belief that academic psychiatry should focus on the core of our discipline, namely, mental disorders that are severely disabling. This month, the ANZJP takes up his plea with a comprehensive update from the Survey of High Impact Psychosis (SHIP) by Morgan et al. (this issue). The authors report that over 60 papers have now been published from the survey covering key challenges reported by participants. These challenges are, to put it simply, money, employment and social engagement. Most (85%) of the participants receive a government benefit and are relatively poor. Only one-third are employed, and most of these are employed part-time (only 4.1% of all participants have full-time employment).

While these findings are expected, of equal concern are the high rates of loneliness and social isolation. Self-reported rates of loneliness are around 80%. The consequences of loneliness impact physical health, morbidity and mortality as well as inpatient admissions in emergency presentations. The importance of factors outside the delivery of good clinical practice for those suffering from severe mental illness is a major issue. The repeated finding that outcomes for serious mental disorders may be better in low-income countries (Mulder et al., 2016) suggests, as Morgan and colleagues note, that something essential to recovery is missing in the social fabric of high-income countries, despite access to costly biomedical treatment. Consequently, they advocate that services adopt a multifaceted approach, which extends beyond the delivery of good clinical practice and ‘includes strategies aimed at improving socio-structural and socio-demographic circumstances, including the provision of basic necessities of everyday living’ (Morgan et al., this issue).

The importance of sociocultural factors in mental health is reinforced by Myles and colleagues (this issue) in their paper on unemployment. They conclude that unemployment results in an approximate doubling of psychological distress. Literature pertinent to closures of manufacturing/industry resulting in unemployment en masse points to a potential doubling of suicide mortality in the 4 years following such an event.

Predictive factors for self-harm are also largely sociocultural (Stanford et al., this issue), and while suffering from depression is a significant predictor of self-harm, the magnitude of the relationship is modest. Notable predictive factors include physical abuse, sexual abuse, stress, difficulty in relationships and dieting behaviours. Interestingly, many who self-harm do not seek help, suggesting perhaps that strategies at the community level, rather than the individual clinical level, are likely to be more effective.

Remaining with the theme of stress, the stressful period of late pregnancy is examined in a paper by Signal et al. (this issue). In the introduction of their article, they note the disturbing fact that currently in New Zealand, suicide is the leading cause of maternal deaths and that rates are seven times higher than those in the United Kingdom! The authors go on to report that depressive symptoms, anxiety symptoms, significant life stress and a period of poor mood during the current pregnancy are all more prevalent in Maori versus non-Maori populations. But these differences are not all due to ethnicity per se. Maori women were more likely to have children at a younger age, and to have multiple children, and these factors were associated with higher rates of depression; thus, Maori women also had higher rates of depression. This once again points to a mixture of clinical symptoms and social and cultural variables existing at the heart of the matter.

In a prospective multi-site treatment study on substance abuse outcomes, Manning et al. (this issue) report that just over half of the participants showed reliable reduction in the use of, or abstinence from, their primary drug of concern. Interestingly, this was highest in those using meth/amphetamine (66%) and lowest in those using alcohol (47%). It also suggested that clients may need different treatment pathways and that community service engagement and mutual aid attendance were particularly important in those where alcohol was the primary drug of concern. The authors speculate that these approaches may offer the necessary support mechanisms to help safeguard against the ubiquitous opportunities to consume alcohol in Australian society.

In summary, along with other important themes, this month the Journal features the importance of sociocultural factors affecting quality of life in patients. These factors appear most important in the severely disabling mental disorders and, as Morgan and colleagues note, they challenge psychiatry to improve service integration between mental health and other services, especially employment, education, family, housing and primary care services. Hopefully, the roll-out of Primary Health Networks and the National Disability Insurance Scheme may help people with severe mental illness by improving referral pathways and therefore high-quality care coordination.