Medical clinic referrals to psychiatric social work: review of 100 cases

This study examines 100 consecutive patient referrals from a general medical clinic to psychiatric social work. While much has been written from a theoretical or anecdotal perspective on the contribution of social work to medical care, there have been relatively few attempts to look in detail at actual practices. Of the 100 patients, 52 were referred for "concrete services," 30 for evaluation of a psychiatric disorder (such as depression or somatoform disorder), 20 for counseling, and 11 for assistance for a drug or alcohol problem. Although the most frequent referral to psychiatric social work by the medical clinic staff was for concrete services, half of these cases actually involved overlooked psychiatric problems, and no concrete service of any sort was perceived as necessary by the psychiatric social worker in 30% of these cases. Referring medical staff tended to view patient distress in terms of concrete needs and chose to refer to social work even when significant psychiatric diagnostic problems were identified. Analysis of the differences in reasons for referral versus actual clinical problems has implications not only for the training needs of social work in this setting, but also for the relationship between social work and psychiatry, and for the organizational and educational needs of ambulatory medical services.     

Psychiatric symptoms, social disablement and illness behaviour

In this paper we investigate the relationship between social performance and the use of medical services, and to what extent this is independent of clinical disorder. In a sample of adults living in Camberwell, South London, social disability and clinical disorder were both predictive of service use. Those subjects who were admitted to psychiatric day-patient or inpatient facilities were found to show the highest levels of both types of impairment, followed by psychiatric outpatients. People who had seen their general practitioner because of their 'nerves' were less impaired than those in touch with the specialist psychiatric services but had significantly poorer social performance and a higher level of clinical disorder than people not in contact with medical services at all. When the severity of clinical disorder was controlled, however, levels of social performance no longer discriminated between the different groups of service users, except that psychiatric outpatients remained significantly more socially disabled than the general practice group.     

Social welfare policy: social rehabilitation of psychiatric patients in urban China

BACKGROUND: The background of this paper is an empirical research on social rehabilitation of psychiatric patients in a large urban city in China during the post-Mao period, the Beijing Psychiatric Rehabilitation Research. Another aspect of this background is an exchange with Chen Sheying, a colleague interested in social services for the elderly in China. The underlying assumption of this paper is the multiple similarities between those two areas. OBJECTIVES: The first objective of this paper is to present a contextual analysis of the development of psychiatric rehabilitation in urban China and a second objective is to stress the similarities between psychiatric rehabilitation and social services to the elderly. MATERIAL: The material presented, while referring mainly to the general context of psychiatry and rehabilitation around that period, includes some data from the Beijing research. There are five analytical dimensions: (1) epistemological choices and research paradigms; (2) rehabilitation as an idea; (3) rehabilitation as a social, political and cultural matter; (4) factors of change in the recent history of China; and, finally, (5) mental illness as a personal experience. DISCUSSION: This presentation leads to a discussion about the multiple similarities between the social welfare of two vulnerable categories of people (i.e. psychiatric patients and the elderly). It also offers, in the specific field of mental illness, a general interpretation of the rapid social changes in urban China. CONCLUSION: The conclusion is that psychiatric and ageing services are both a product of interaction among various cultural and social-political-economic factors. Any social welfare intervention or policy should be based on a thorough understanding of the five dimensions referred to earlier, including the traditional Chinese familism and structural dimensions of the post-Mao 'economic state' orientation.     

The relationship between social functioning and psychiatric symptomatology in primary care

Summary The relationship between social functioning measured by an interview schedule, psychiatric symptoms, alcohol abuse and personality was examined in 171 patients with conspicuous psychiatric morbidity seen in primary care. Social functioning was significantly better in older patients and in those with no alcohol abuse or personality disorder. A close relationship was shown between social functioning and psychiatric diagnosis, social impairment increasing with severity of disorder. This relationship was not obtained for depressive disorders in which social functioning was similar across all diagnostic groups. There was a high correlation between social functioning score and total psychiatric symptomatology, although social functioning appeared to be a more important determinant of referral to psychiatric services than Present State Examination (PSE) total score. The results support the view that social functioning measures can convey additional useful information to that of symptom measures, and might be of use in a multiaxial classification.     

Deficient health and social services for elderly people with learning disabilities

Elderly people with learning disabilities have greater psychiatric morbidity than younger individuals, but a previous report has suggested that themajorityoftheformerdonot receive treatment All people with leaming disabilities aged 65 years and over living in Leicestershire, England (n= 134), and a random sample of adults with learning disabilities aged between 20 and 64 years (n= 73) were assessed for psychiatric disorders and service use. Elderly people received less day care, less respite care, and were less likely to have a social worker and receive input from most health services than the younger group. Chiropody was an exception. Those receiving psychiatric services did so through the leaming disabilities specialist services only. Those with an additional psychiatric disorder were more likely to receive services, but results still favoured the younger group. Services were better accessed by those living in residential care. Failure to access services may relate to carers attitudes and beliefs: in leaming disability settings, morbidity was attributed to ‘it's just old age’ in the elderly settings, morbidity was attributed to ‘it's because s/he has leaming disabilities’. The specialist health and social services need to take the lead in health promotion and education.     

Psychiatric morbidity in social workers' clients

Summary The rate of psychiatric disorder in a social services sample in a small town was compared to the rate in an inner-city sample. Nearly 40% of respondents in the small town had a positive General Health Questionnaire score and 37% had case status (ID greater than 5) on the Present State Examination. Most of these were cases of neurotic depression and were generally recognised as such by the social workers. The type of intervention undertaken by social workers differed in the two settings. Small-town social workers were more likely to offer advice, guidance, exploration and mobilisation of resources. The small-town social workers were more likely to have success in helping their clients with problems of social isolation and marital disharmony than were their inner-city counterparts. Mental illness problems, however, showed less improvement than in the inner-city sample, with over one-third of the small-town cases remaining unwell throughout the 12-month follow-up. Both previous psychiatric history and current depression were indicators of a poor outcome. The present findings provide further support for the argument that unless there is close collaboration between social workers, the medical profession, and health care teams, people who present their problems to social services are unlikely to have their mental health problems addressed adequately.     

Needs assessed by psychiatric health care and social services in a defined cohort of clients with mental disabilities

Background The identification of needs for support and service in clients with long–term mental disabilities is usually not done by staff personnel from both psychiatric care and social services. However, such a process is probably necessary in order to provide adequate psychiatric care and social services. Aims To estimate the prevalence of mentally disabled clients and investigate whether staff from psychiatric care and social services identified the same individuals and the same number of needs in the same areas. Methods Clients from a defined catchment area were identified during a three–month period. A questionnaire was developed to collect socio–demographic information and to assess needs for support and service. Results The study identified 1,290 clients with needs with a prevalence of 5.72/1000 inhabitants. More than half of the clients needed support in activities of daily living. Only 18.1% of the clients were identified by both organizations. In general, the staff from psychiatric care and social services identified the same needs at a group level. However, at the individual level, agreement was quite low. Conclusions The staffs from both psychiatric care and social services are necessary to evaluate the needs of support and services in clients with mental disabilities.     

Psychiatric morbidity in clients of social workers: Social outcome

Summary 141 clients referred to social service department local social work teams (area workers) and general practice attachments were interviewed to assess their levels of psychiatric morbidity. 101 cases received clinical and social reassessment at twelve months. A substantial proportion (63%) had a positive social outcome according to the client and social worker, a finding confirmed by an independent social assessment. Family break up, more common in the area setting, was associated with a better clinical outcome. Attachment clients had significantly higher levels of psychiatric morbidity, and in clinical terms improved more frequently than area cases, but not significantly so. Clinically improved cases had a higher number of GP-social worker contacts. Both social and clinical variables contributed to the prediction of clinical outcome. By reducing the availability of attached workers, social services departments are removing a valuable source of help for people with psychiatric disorders.     

The social functioning of older adults with schizophrenia

A cross-sectional survey of the social functioning of community dwelling older adults was undertaken. Older adults with no psychiatric morbidity, depressed older adults and older adults with schizophrenia were surveyed to see if there were differences in the level of social functioning of the three groups. The setting was two old age psychiatric services, one in an urban area of London and the other in a semi-rural area of Leicestershire. Participants consisted of depressed (n = 81) or normal (n = 101) older persons identified as part of a general practice over 75 years check and clients over 65 years with schizophrenia (n = 30) known to mental health teams for older adults. All participants were interviewed by one of two trained researchers and completed the Mini-Mental State Examination questionnaire, the 15-item Geriatric Depression Scale, a social functioning questionnaire, and the Schedules for Clinical Assessment in Neuropsychiatry or the Brief Psychiatric Rating Scale. In our sample population, community dwelling older persons without any psychiatric diagnosis were the least isolated from their local community, reported more private leisure activities, and had the least contact with professional community services. Clients with schizophrenia reported more isolation from their local community and fewer private leisure activities than clients with a diagnosis of depression.     

A European perspective on social anxiety disorder

Epidemiologic surveys conducted across Europe indicate that the lifetime prevalence of social anxiety disorder in the general population is close to 7%. The disorder in adulthood rarely presents in its `pure' form and 70–80% of patients have at least one other psychiatric disorder, most commonly depression. Social anxiety disorder is a risk factor for the development of depression and alcohol/substance use or dependence, especially in cases with an early onset (< 15 years). Individuals with social anxiety disorder have significant functional impairment, notably in the areas of initiation and maintenance of social/romantic relationships and educational and work achievement. The economic consequences of social anxiety disorder are considerable, with a high level of diminished work productivity, unemployment and an increased utilisation of medical services amongst sufferers. Effective treatment of social anxiety disorder would improve its course and its health and economic consequences.     

Role of social disadvantage in crime, joblessness, and homelessness among persons with serious mental illness

Research on mental illness in relation to social problems such as crime, unemployment, and homelessness often ignores the broader social context in which mental illness is embedded. Policy, research, and practice will be improved if greater attention is given to social context. The authors critically analyze the approach used in much of the psychiatric services literature to infer links between mental illness and social problems. They compare these studies with studies that have been more validly conceptualized to account for social context. With this broader perspective, the impact of mental illness on crime, unemployment, and homelessness appears to be much smaller than that implied by much of the psychiatric services literature. Poverty moderates the relationship between serious mental illness and social problems. Factors related to poverty include lack of education, problems with employment, substance abuse, and a low likelihood of prosocial attachments. This relationship is often complicated and is not amenable to simple explanations. Research and policy that take this complexity into account may lead to greater effectiveness in interventions for persons with serious mental illness.     

Connectedness and citizenship: redefining social integration

OBJECTIVE: Despite decades of deinstitutionalization, individuals with psychiatric disabilities living outside the hospital may be described as in the community, but not of it. To effectively address the persisting problem of social exclusion of persons with psychiatric disabilities, new conceptual tools are needed. To address this need, a new definition of social integration is offered. METHODS: The definition is based on data from a qualitative study. Data collection consisted of individual, unstructured interviews with 56 adults who have been psychiatrically disabled (N=78 interviews) as well as ethnographic visits to five service sites working to promote social integration for their users (N=8 visits). An interpretive approach was used to analyze the data. RESULTS: Social integration is defined as a process, unfolding over time, through which individuals who have been psychiatrically disabled increasingly develop and exercise their capacities for connectedness and citizenship. Connectedness denotes the construction and successful maintenance of reciprocal interpersonal relationships. Social, moral, and emotional competencies are required to sustain connectedness. Citizenship refers to the rights and privileges enjoyed by members of a democratic society and to the responsibilities these rights engender. The definition calls for full rights and responsibilities of citizenship. CONCLUSIONS: The new definition sets an ideal, but not unrealistic, standard for social integration in the context of psychiatric disability. High standards encourage mental health professionals and policy makers to rethink what is possible for mental health services and to raise expectations for connectedness and citizenship among persons once disabled by mental illness.     

Sociotherapy in German social law. Indication,contents, and aspects of public health

In German mental health services, the ill-defined term "sociotherapy" has been used to designate nonmedical, social, and work-related components of the care process. Recently, a new component of outpatient/community mental health care called "sociotherapy" (according to Paragraph 37a of the Fifth German Social Code) which is funded by the public health insurance system has been introduced and is now in the process of being implemented. The paper describes (a) patients eligible for the service and (b) the aims and scope of this case management module. The key objectives are to motivate patients with schizophrenia to utilise mental health services and antipsychotic medication and to liaise with psychosocial services. Therefore, sociotherapy is distinct from (a) multidisciplinary inpatient care for people with severe mental illness, (b) assertive community treatment, (c) community care provided by social workers or community psychiatric nurses, and (d) family interventions. So far there has been little evaluation of sociotherapy.     

Psychiatric morbidity and social functioning among adults with borderline intelligence living in private households

Background Approximately one‐eighth of the population will have DSM‐IV borderline intelligence. Various mental disorders and social disability are associated with it. Method The paper uses data (secondary analysis) from a UK‐wide cross‐sectional survey of 8450 adults living in private households. Data were collected on psychiatric disorders, intellectual level, social functioning and service use. Results In total, 12.3% of the sample had borderline intelligence. The prevalence of psychotic disorder was not significantly increased, but the group showed significant social disadvantage and increased rates of neurotic disorders, substance misuse and personality disorders when compared with their counterparts of normal intelligence. The borderline group was more likely to receive psychiatric medication, but not talking therapies. They appear to use significantly more services, including emergency services. Conclusion Adults with borderline intelligence are more likely to suffer from treatable mental disorders and an excess of substance misuse. Services should be aware of hidden morbidity in this group.     

Clinical and social determinants of a longer duration of untreated psychosis of schizophrenia in a Japanese population

Aim: To measure the duration of untreated psychosis (DUP) among patients with schizophrenia in a Japanese population and to investigate clinical and social determinants of the DUP. Methods: A multicentre, retrospective study at seven medical centres in three cities (Tokyo, Toyama and Kochi) was performed. In total, 150 consecutive patients (78 men) with neuroleptic-naïve first-episode schizophrenia were investigated; their DUP and demographic, clinical and social variables were obtained from their medical charts and analysed. Results: The intraclass correlation coefficient for the DUP was quite good (ICC = 0.849). The mean DUP of all the subjects attending the seven psychiatric services was 20.3 months, and the median DUP was 6.0 months. Fourteen patients (9.3%) had a DUP of more than 60 months, and 47 patients, or about one-third, had a DUP of more than 24 months. No significant differences in the mean DUPs were observed among the three cities. Patients who were employed or who were students had a significantly shorter DUP (14.3 months). The median DUP for those with an insidious onset of psychosis (n = 85) was 18.0 months, compared with a median of 2.0 months for those with a sudden and acute onset (n = 61). However, no other clinical or social variables examined in this study were associated with differences in the DUP. Conclusions: The DUP of patients with schizophrenia is relatively long in Japan. The provision and modification of psychiatric services for easy access and a system for the early recognition and detection of mental illness are needed.     

Commentary: The failure of social inclusion: an alternative approach through community development

Mental health services have not resulted in broad-based inclusion of people with psychiatric disabilities. Rather, many maintain their community lives only through the support of formal mental health services, which is financially unsustainable given current fiscal realities. Fundamental assumptions about sources of support for everyday life need to be reassessed. The economic and social development of the mental health recovery community provides an alternative approach to helping people maintain successful community lives and shifts some of the supports from mental health providers to business infrastructure within the mental health recovery identity community. Some projects that have utilized this approach, such as business incubators and work integration social enterprises, are described, and community development that builds on concepts of recovery is discussed.     

Japanese physicians'attitude for utilization of social support services for persons with intellectual disabilities

We assessed physicians'attitude for the utilization of social (medical, educational, and financial) support services for persons with intellectual disabilities supplied by the Japanese government. A total of 113 physicians specializing in pediatric neurology answered our mail-in questionnaire. Medical care benefits for psychiatric outpatients and short-time stay were the most common services utilized. Whereas most physicians used various public support services regardless of their experience and affiliations, the selection of services by an individual physician correlated with the number and state of patients they usually cared. Physicians were less familiar with the services regarding residential or community care and advocacy. Knowledge of the specialists on each service will enrich assistance appropriate to the life styles of each patient with intellectual disabilities.     

The dual-diagnosis concept used by Swedish social workers: limited validity upon examination using a structured diagnostic approach.

A co-existence of chemical dependence and other psychiatric syndromes is commonly referred to as "dual-diagnosis." This categorization is commonly made by social workers in several European countries assigned the primary responsibility for the care of drug and alcohol dependence. Here, we examined the validity of this categorization through systematic, structured patient evaluation following a minimum of 3 weeks of abstinence from drugs and alcohol. Less than one-third of patients originally labelled as suffering from "dual-diagnosis" by the social services did in fact obtain any Axis I DSM IIIR diagnosis, and less than half of the patients had any psychiatric diagnosis other than dependence. Syndromes commonly discussed in the context of self-medication, i.e., unipolar depression and anxiety syndromes, were not over-represented compared to a population sample, while chronic psychoses and bipolar syndromes were highly significantly more common. We conclude that the dual-diagnosis concept, unless substantiated through stringent diagnostic procedures by psychiatrically trained personnel, may be of questionable utility in caring for patients presenting with psychiatric symptoms and substance dependence. A systematic individual evaluation in an alcohol- and drug-free state of sufficient duration is necessary to obtain a basis for an adequate individual treatment plan.     

Relationship between maternal church attendance and adolescent mental health and social functioning.

OBJECTIVE: This study compared maternal attendance at religious services with standard demographic characteristics such as race, type of religion, and mother's education in terms of their relative association with the behavioral and social functioning of young adolescents. METHODS: The Child Health and Illness Profile--Adolescent Edition and the Children's Depression Inventory were used to screen 445 youths age 11 through 13 who were randomly selected from two public middle schools in Baltimore. Based on the findings, the investigators selected a sample of 143 youths in which approximately two-thirds were at risk of having a psychiatric disorder and the remaining third were unlikely to have a psychiatric disorder. The youths and their mothers were interviewed at home to determine the mothers' frequency of participation in religious services and the youths' self-reported health and mental health status and social role functioning. RESULTS: Youths whose mothers attended religious services at least once a week had greater overall satisfaction with their lives, more involvement with their families, and better skills in solving health-related problems and felt greater support from friends compared with youths whose mothers had lower levels of participation in religious services. Maternal attendance at religious services had a strong association with the youths' outcome in overall satisfaction with health and perceived social support from friends, although family income was the strongest predictor of five other aspects of functioning, including academic performance. CONCLUSIONS: Frequent maternal participation in religious services was associated with healthy functioning and well-being in this sample of young adolescents. This association is as important as or more important than associations involving other traditional demographic variables, with the exception of family income.     

Dead and forgotten--postmortem time before discovery as indicator of social isolation and inadequate mental healthcare in schizophrenia

The psychiatric care of patients with schizophrenia has changed dramatically following the "deinstitutionalization" of mental health care in many Western countries. In a study of forensic autopsies in the Swedish city of Malm? between 1952 and 2005, we found an increase over time in the number of patients with schizophrenia whose bodies were not discovered until late after death, which correlated closely with the decrease in the number of hospital beds in the psychiatric services used by this group of patients. This indicates a strong increase in the social isolation and unavailability of adequate mental health care for patients with schizophrenia.