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In Relation to Psychiatric Epidemiology Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from POSTGRAD. MED. J. (1965), 41, 401 STUDIES OF SOCIAL ATTITUDES AND VALUES IN RELATION TO PSYCHIATRIC EPIDEMIOLOGY K. RAWNSLEY, M.B., M.R.C.P., D.P.M. Professor of Psychological Medicine, Welsh National School of Medicine, (formerly member of scientific staff, M.R.C. Social Psychiatry Research Unit, Llandough, Penarth, S. Wales). FOR MANY years the annual rate of first admis- cases are defined in the community, recognised sions to psychiatric hospitals in England and by community members and by medical and Wales has shown a steady rise (Registrar social agencies, and dealt with by one means General 1964). Changes in the legal and ad- or other. Studies of this kind are very relevant ministrative arrangements for the care and treat- to the epidemiology of mental disorder since, ment of mental disorders are probably account- by the nature of such illness, the detection and able for the greater part of this rising influx. The enumeration of cases is intimately linked with Mental Treatment Act 1930 established volun- prevailing social "yardsticks" pertaining to the tary admission and enabled local authorities to acceptable bounds of "normal' behaviour and set up out-patient clinics. The development of experience and also to the categorisation of the National Health Service brought a sub- deviant behaviour as falling within the doctors' stantial enlargement of the specialist establish- province. by copyright. ment in psychiatry. More recently the Mental Health Act 1959 has abolished the special status Attitudes to the Psychiatric In-patient of psychiatric hospitals and has removed all A feature of post-war British psychiatry has formality from the admission procedure for all been the mobilisation and rehabilitation of except a minority of patients. many long-stay patients in mental hospitals. These changes in social policy towards the The increasing number of cases with residual mentally ill may arise in part out of rather symptoms living either with their families, or at widespread changes in attitudes towards mental institutions in closer proximity to the local illness among the general population. Imple- population than traditional mental hospitals, http://pmj.bmj.com/ mentation of the policies must, in turn, serve demands much tolerance and sympathy from to generate modifications in social attitudes. relatives, friends, neighbours and members of The passage of patients into and out of the the general public. The Mental Health Act specialist mental health services and the factors 1959 emphasised the desirability of developing which play upon and determine this movement a comprehensive scheme of care and treatment represent one stage of a cycle which begins in the The success of this with the earliest the individual community. policy recognition by will depend, in part, on the attitudes which on September 29, 2021 by guest. Protected patient (or by his relatives) that something is prevail towards mental disorder in the wrong. The process continues when the abnor- community. mality is reckoned by the patient, or by his An enquiry was carried out in S. Wales to family, to have medical significance, and when examine the attitudes of relatives to a family a decision is made to seek advice, usually from member in a mental hospital and especially the general practitioner. A further stage is those attitudes which may influence family encountered in the appraisal of the case by behaviour if and when the time comes for the the G.P. and in his diagnosis and treatment, patient to leave hospital (Rawnsley, Loudon and in his decision whether to handle the case and Miles, 1962). The survey was based himself or to refer the patient for a psychiatric upon all patients, 230 in number, who were in opinion. mental hospitals at the time of the enquiry Part of the work of the M.R.C. Social and those whose home addresses on admission Psychiatry Research Unit (S. Wales detach- lay in one of three defined areas in S.E. Wales ment) has been to examine certain aspects of -a mining valley, a rural area, and a small the elaborate social process whereby psychiatric town. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from 402 POSTGRADUATE MEDICAL JOURNAL July, 1965 Patients were assessed by the hospital staff in better prospects of accommodation on discharge terms of their social capabilities and poten- than do single schizophrenics. This finding tialities. Attitudes of relatives were studied illuminates earlier statistical enquiries into the principally by home interviews conducted with differential probability of discharge for single a sample of relatives from each family and by and married patients. Thus Norris (1956) the examination of records of contacts-visits, showed that amongst schizophrenic admissions letters, parcels--between relatives and patients. in 1947-49 to some London hospitals, single Twenty per cent of the patients, many of patients had the greatest chance of retention them with very long hospital stay, were found for two years and that the married had least, to lack any contact with their families for the with the widowed and divorced occupying an past year or more. It was a little surprising, intermediate position. Brooke (1959) showed therefore, to discover relatives of these that 19%/ of single schizophrenic first admis- patients-usually close relatives-living locally. sions in England and Wales in 1954-56 were Furthermore, offers of accommodation in the still alive and in hospital two years later, while event of discharge were forthcoming in a 12% of the patients who had been married at quarter of the cases where contact had been some time were likewise retained. Wing, lost for so long. Denham and Monro (1959) found that single 6.1% of the patient sample had been con- schizophrenic patients in two cohorts of admis- tinuously in hospital for a year or more, were sion to Long Grove Hospital had a worse fit to live at home (according to the hospital prognosis for discharge within two years than staff) and had a home waiting for them (accord- married patients. ing to the family). Although on the face of it Comparison of the attitudes of relatives to these patients would appear to be promising patients from the three geographical areas in candidates for rehabilitation, certain reserva- S. Wales indicates that despite equivalence of tions must be entered. There is evidence that "active interest" revealed through visiting,by copyright. contact with close relatives at home may have patients from the town have a substantially a deleterious effect upon schizophrenics lower proportion of relatives willing to house (Brown, Carstairs and Topping, 1958). Disquiet- them on discharge than have patients from the ing reports have also been published of the dis- rural area. Patients from the mining valley are rupting effects on the family of the returning intermediate in this respect. patient with residual disability (Wing, Monck, One important factor not systematically ex- Brown and Carstairs, 1964). amined in this study is the attitude of the These studies, carried out in an area where patients themselves to their future and, in the community aftercare services were inade- to the of particular, prospect leaving hospital.http://pmj.bmj.com/ quate, indicate very plainly the need for inten- Although many patients would undoubtedly sive supervision of the partially remitted prefer an early discharge, others are too appre- schizophrenic after leaving hospital. hensive or too settled to want it. Folkard In the S. Wales investigation, analysis of (1960) found that the expectations of a group frequency of visits by relatives and of their of selected chronic patients regarding prospects willingness to accommodate patients in the of discharge and level of performance after event of discharge by age of patient and by discharge, were more optimistic than those duration of stay in hospital indicates that, expressed by their relatives. Wing, Bennett and on September 29, 2021 by guest. Protected although interest expressed through visiting is Denham (1964) have shown that the desire of sustained in the elderly group of patients, this is some chronic male schizophrenics to leave not matched by willingness to house them. hospital can be substantially sharpened by Judging by the response of relatives, it is clear exposing them to an Industrial Rehabilitation that a policy which seeks to discharge long-stay Course at a of Labour Unit. elderly patients of either sex must look for Ministry accommodation outside the family. The pro- The General Practitioner vision of special hostels for the elderly long-stay Patients with psychiatric illness form a subs- patient with mild symptoms is an obvious tantial fraction of the G.P.'s case load. In a solution. Social work with families would be survey carried out by the General Register best reserved for the younger group whatever Office in collaboration with the College of their length of stay in hospital. General Practitioners (Logan and Cushion, Married schizophrenics of less than two- 1958) 171 volunteer G.P.s kept an account of years' stay command a higher level of active their contacts with patients, including a record interest (as judged by visiting frequency) and of the nature of the illness, for one year. Postgrad Med J: first published as 10.1136/pgmj.41.477.401 on 1 July 1965. Downloaded from July, 1965 RAWNSLEY: Social Attitudes and Psychiatric Epidemiology 403 During the year, 5% of all patients on the positive association was found between level practice lists consulted their doctors for an of interest and the proportion of patients placed ailment regarded as psychiatric. This is an in each of the categories 2, 3 and 4 separately. average value for a large number of practices.
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