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From the Editor's desk

Published online by Cambridge University Press:  02 January 2018

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Copyright © The Royal College of Psychiatrists 2017 

Pride, stigma and discrimination

Proud elitism will help us recruit more psychiatrists, reduce self-stigma and eschew apologetic and unconfident portrayals of psychiatric practice, say Crabb and colleagues (pp. ) in a bold editorial on branding psychiatry. Apart from presenting a progressive and enriching account of the achievements of psychiatric practice through the expert eyes of a branding company, there are some enticing one-liners with which to impress your friends, family, social and professional networks: psychiatrists wish to think and act differently; and the profession is of the moment for the moment. Such an approach may also mitigate the self-stigma faced by psychiatrists and mental health professionals who symbolise for the public popular myths about mental illness. Anti-stigma campaigns appear to encourage more comfortable disclosures of mental illness to family, friends and employers; and such campaigns are associated with more intention to seek help (Henderson et al, pp. ). Stigma is known to deter help-seeking Reference Maulik, Devarapalli, Kallakuri, Tewari, Chilappagari and Koschorke1,Reference Evans-Lacko, Kohrt, Henderson and Thornicroft2 and as a stressor may contribution to greater chances of suicidal behaviours Reference Schomerus, Evans-Lacko, Rusch, Mojtabai, Angermeyer and Thornicroft3 yet interventions appear only to be effective for shorter periods and so need to be sustained. Reference Mehta, Clement, Marcus, Stona, Bezborodovs and Evans-Lacko4 Stigma felt by healthcare staff is not much discussed; could this in part explain the higher rates of work-related ill health among ambulance staff and nurses, and then the rising levels among doctors, especially women doctors (Zhou et al, pp. )?

Despite entrenched attitudes towards mental illness, the recognition of mental health and psychiatric research as challenging, important and a valuable societal good is heartening to see captured in two new initiatives. First, there is a new UK Research Councils' forward-thinking research strategy. 5 The areas of importance include a better understanding of patient experience and aetiology, the physical–mental interface, public health interventions and recovery-oriented interventions. Cross-cutting themes include research that is interdisciplinary, that seeks effective interventions, makes best use of technology and data, improves lifestyle and behavioural treatments, reduces health inequalities; and studies on empowerment, ethics, confidentiality and trust. 5 Second, the relationship between stigma and discrimination is well established, but not easily isolated to a single or simple pathway, as there are multiple interactions between gender, race, ethnicity and other markers of identity. Reference Sanchez, Chaney, Manuel, Wilton and Remedios6,Reference Hogan, de Araujo, Caldwell, Gonzalez-Nahm and Black7 Concerns have also been raised about the Mental Health Act in England and Wales leading to discriminatory outcomes. Reference Szmukler8Reference Szmukler10 The UK Prime Minister has just announced (4 October) a commitment to a better and fairer society, race equality in public services, and the resolve to reform mental health legislation that is deemed to be discriminatory. The interactions between professional standards, empowering evidence-based practice, legal and ethical options, and a contract with society will be challenging to negotiate and necessitate sophisticated and robust and carefully marshalled evidence considered alongside patient voices.

Resonating with future ambitions for psychiatric research as a core societal good, this month's BJPsych shares substantive findings that capture the excitement of searching for new and more effective interventions.

Preventive epidemiology

Schizophrenia appears to present with a prodromal anxiety, which may constitute a useful screening target for early recognition and intervention (Hall, pp. ). Global efforts to tackle suicidal thinking and behaviours need to focus on social and economic conditions (Jacob, pp. ) rather than only on the presence of mental illness and related treatments. Childhood trauma is shown in the World Mental Health Surveys to be associated with post-traumatic disorders (McLaughlin et al, pp. ); surprisingly, parental mental illness is experienced as a trauma alongside physical, sexual and emotional abuse, making parental mental illness an important preventive target. There is much concern about young people in care and the impact on their mental health. Contrary to expectations, disinhibited social engagement due to early institutional deprivation appears to be relatively benign and not associated with other mental illnesses (Kennedy et al, pp. ).

Orgeta et al (pp. ) find that behavioural activation helpfully reduces depression in older adults living in the community; however, the evidence base is weak and more studies are needed. Similar concerns are raised about cognitive bias interventions for anxiety and depression. Reference Cristea, Kok and Cuijpers11,Reference Cuijpers, Cristea, Karyotaki, Reijnders and Huibers12 Cristea et al (pp. ) and Grafton et al (pp. ) consider methodological advances to better design cognitive bias interventions in order to not over- or under-estimate the benefits to patients.

Mind-body mortality inequalities

Inequalities were mentioned in the new UK Research Councils' strategy for forward-thinking mental health research and are of relevance to the review of mental health legislation in the UK. Another major health inequality is the premature mortality facing people with severe mental illness. Reference Baxter, Harris, Khatib, Brugha, Bien and Bhui13 Previous systematic reviews show that cancer mortality is higher among people with schizophrenia because of late and less-aggressive treatment. Reference Zhuo, Tao, Jiang, Lin and Shao14,Reference Kisely, Forsyth and Lawrence15 In contrast, a Finnish study shows higher mortality in people with psychoses and substance misuse, but this was not explained by cancer staging and treatment (Manderbacka et al, pp. ) so posing questions about which forms of psychosis and which aetiological pathways are implicated. Severe mental illness is associated with a higher cardiac mortality due to poorer care. Reference Mitchell and Lord16 Looijmans et al (pp. ) demonstrate that lifestyle interventions in people with severe mental illness who are institutionalised can reduce abdominal adiposity and cardiovascular risk, but only in the short term. Institutionalised and detained patients should be provided with healthier and health-promoting options and environments.

References

1 Maulik, PK, Devarapalli, S, Kallakuri, S, Tewari, A, Chilappagari, S, Koschorke, M, et al. Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med 2017; 47: 565–75.Google Scholar
2 Evans-Lacko, S, Kohrt, B, Henderson, C, Thornicroft, G. Public anti-stigma programmes might impove help-seeking. Br J Psychiatry 2017; 211: 182.Google Scholar
3 Schomerus, G, Evans-Lacko, S, Rusch, N, Mojtabai, R, Angermeyer, MC, Thornicroft, G. Collective levels of stigma and national suicide rates in 25 European countries. Epidemiol Psychiatr Sci 2015; 24: 166–71.Google Scholar
4 Mehta, N, Clement, S, Marcus, E, Stona, AC, Bezborodovs, N, Evans-Lacko, S, et al. Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review. Br J Psychiatry 2015; 207: 377–84.Google Scholar
5 Research Councils UK. Widening Cross-Disciplinary Research for Mental Health (http://www.rcuk.ac.uk/documents/documents/cross-disciplinary-mental-health-research-agenda-pdf/). RCUK, 2017.Google Scholar
6 Sanchez, DT, Chaney, KE, Manuel, SK, Wilton, LS, Remedios, JD. Stigma by prejudice transfer: racism threatens white women and sexism threatens men of color. Psychol Sci 2017; 28: 445–61.Google Scholar
7 Hogan, VK, de Araujo, EM, Caldwell, KL, Gonzalez-Nahm, SN, Black, KZ. “We black women have to kill a lion everyday”: An intersectional analysis of racism and social determinants of health in Brazil. Soc Sci Med 14 Jul 2017 (https://doi.org/10.1016/j.socscimed.2017.07.008).CrossRefGoogle Scholar
8 Szmukler, G. The UN Convention on the Rights of Persons with Disabilities: ‘Rights, will and preferences’ in relation to mental health disabilities. Int J Law Psychiatry 2017; 54: 90–7.Google Scholar
9 Szmukler, G, Kelly, BD. We should replace conventional mental health law with capacity-based law. Br J Psychiatry 2016; 209: 449–53.Google Scholar
10 Szmukler, G. How mental health law discriminates unfairly against people with mental illness. Gresham College lecture, 15 Nov 2010 (https://www.gresham.ac.uk/lectures-and-events/how-mental-health-law-discriminates-unfairly-against-people-with-mental-illness).Google Scholar
11 Cristea, IA, Kok, RN, Cuijpers, P. Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis. Br J Psychiatry 2015; 206: 716.Google Scholar
12 Cuijpers, P, Cristea, IA, Karyotaki, E, Reijnders, M, Huibers, MJ. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry 2016; 15: 245–58.Google Scholar
13 Baxter, AJ, Harris, MG, Khatib, Y, Brugha, TS, Bien, H, Bhui, K. Reducing excess mortality due to chronic disease in people with severe mental illness: meta-review of health interventions. Br J Psychiatry 2016; 208: 322–9.Google Scholar
14 Zhuo, C, Tao, R, Jiang, R, Lin, X, Shao, M. Cancer mortality in patients with schizophrenia: systematic review and meta-analysis. Br J Psychiatry 2017; 211: 713.Google Scholar
15 Kisely, S, Forsyth, S, Lawrence, D. Why do psychiatric patients have higher cancer mortality rates when cancer incidence is the same or lower? Aust NZ J Psychiatry 2016; 50: 254–63.Google Scholar
16 Mitchell, AJ, Lord, O. Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis. J Psychopharmacol 2010; 24 (4 Suppl): 69–80.Google Scholar
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