Social causes and solutions for mental health: towards equity in recoveryDr Kwame McKenzie Professor of Psychiatry U of TSenior Scientist CAMH

*OutlineSocial causation evidence

A new model for considering social causation

Implication for developing equitable solutions and recovery

*What we know about social causation

*Events in society interact with community to change risk

**GeneticmolecularIndividualInterpersonalEnvironmentalMultilevel causation of psychosisPro and anti psychotic factors at each levelEach level different scientific rulesImpact at any level confined by higher levelStudying interaction vitally importantMulti-level modelling may disentangle sub and supra level effects After Susser and Susser

**Individual factors in psychosis Obstetric complicationsViruses (flu?)City birthChildhood adversity (separation / abuse)Substance misuse (cannabis)Adult adversity (daily problems)MigrationRacism

**Migration meta- analysis schizophrenia incidence Selten & Cantor Graae Am J Psychiatry. 2005 Jan;162(1):12-24.

**Racism psychosis risk factor cross sectional Karlsenn et al Psychological Medicine 2005 Sept 29-1-9

Estimated prevalence of psychosis

Racial harassment

British employers discriminate

*Swedish study

**Ecological factors in psychosisUrban environmentSocial fragmentationPovertyAlienating environments (population density)Work availabilityIncome inequalitySocial capital

**Incidence rates of psychosis and social cohesion

*Causation of what?

PredispositionOnsetCourse / recoveryIndividualcannabiscannabisEnvironmentalsocial cohesionsocial cohesion

*Problems have a social cause but a social course

Recovery depends on the social situation and community

Individuals live in communities

Should we spend more time thinking about communities?

*A new model

*4 determinants of impact of a factorStrength of the factor in increasing riskAmount of exposure When the person or group are exposedHow it interacts with other factors

*4 D modelThere are 4 dimensions for working out social risk

Exposure to individual risksExposure to ecological risksInteraction between the different risk factorsWhen and how long you are exposed

*

*4 d model of risk indicative findings

Chart3

10008

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1.51229

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cannabis

city

cannabis and city

cannabis city and early use

continued use and residence

exposure

risk

Sheet1

cannabiscitycannabis and citycannabis city and early usecontinued use and residence

10008

10118

10218

1.51229

1.51329

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Sheet1

cannabis

city

cannabis and city

cannabis city and early use

exposure

risk of psychosis

4 d effect (hypothetical)

Sheet2

cannabis

city

cannabis and city

cannabis city and early use

continued use and residence

exposure

risk

Sheet3

What of recovery and equity

*Options for service improvement based on theory of health equityDifferent groups may have different needs. The issue not just different needs but what we do about different needsHealth inequities = differences in access, use or outcome because of an interaction between community need and service response

*Who can offer interventions for what type of need

Differential need of community or groupInequitable service responseSocietal context in which communities and societies existClinicians and teamsXOrganisationXXService systemXXXXSocietal / legislativeXXXX

*The best interventions target the problemSocial causes multi-level Social course and recovery depend on communityCommunity recovery requiresAcknowledgement of historyPolicies that promote healing and community developmentGood public services, housing, schools and jobsCommunity cohesion, self determination and efficacyAttachment to power structures

Thank you