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From the Editor's desk

Published online by Cambridge University Press:  02 January 2018

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Copyright © Royal College of Psychiatrists, 2007 

INEQUALITY, STIGMA AND MENTAL HEALTH

Society is unfair and discriminatory. Last month I was trying to improve a patient's home environment as part of the treatment called nidotherapy (Reference Tyrer, Kramo and MiloseskaTyrer et al, 2007) and was attempting to talk to a well-built neighbour whom my patient had identified as difficult and interfering. She did not particularly want to engage with me and after a few minutes, in what I remember as an unnecessarily loud voice, threatened to ‘knock me down’. I agreed with her that I was being just a little irritating but added that, while her proposed behaviour might seem justified to her at that moment, ‘unfortunately it would have a more serious consequence than if you knocked someone else down. Knocking a senior doctor down in the course of his community duties would be judged harshly by the courts and you may, quite unfairly in my opinion but society is like that, receive a long custodial sentence’. This made her pause and we ended our conversation on reasonably good terms with a promise to work hard on less aggravating behaviour.

Inequalities in society feed mental ill-health (Reference Skapinakis, Lewis and ArayaSkapinakis et al, 2005) through a variety of means, including both societal and familial stigma (Reference Lee, Lee and ChiuLee et al, 2005), and are likely to be heavily involved in premature mortality (Ran et al, pp. ). Stigma is a fuzzy term that needs a good deconstructor, and we make a fine start with Thornicroft et al (pp. ), who note that we have for too long confined it to attitudes (where we can keep it at arm's length) and not focused enough on behaviour (which makes it happen) and which, they argue, makes stigma into discrimination. Nevertheless, I hasten to add, this does not mean that the stigma scale developed by King et al (pp. ) is redundant, and the authors make a distinction between ‘felt’ and ‘enacted’ stigma that deals with the same concept. These papers will help in bringing stigma and all its nasty associations out into the spotlight of open enquiry. Unfortunately, psychiatric diagnosis shows equal evidence of stigma, inequality and, indeed, inefficiency, despite being much more exposed to scrutiny, and Baca-Garcia et al (pp. ) demonstrate in their commendably large sample just how often the labels we pin to our patients get changed over time, rather like the prices of goods in a supermarket altering with the weather.

We have always lived in an Orwellian society where some are ‘more equal than others’ and, in the case of severe mental illness, resources have been shifted from relatively expensive neglect in hospital to (equally expensive) intensive treatment in the community. Assertive outreach teams are more equal than community mental health teams as they are much better resourced and there have long been grumblings of inequity; the findings of Burns et al (pp. ) support both camps, as there seems to be no fundamental difference between assertive outreach and other community teams, although assertive teams do provide more comprehensive care as they reduce their case-load size. And so the unequal dance goes on, with odd penetrant genes in schizophrenia (McClellan et al, pp. ), selection of controls in case–control studies (Lee et al, pp. ), and the allocation of consultant care (Taylor et al, pp. ) all subject to the same lottery of variation. As for me, in my travels through the geographical inequality of London, I can give some comfort to the angry neighbour when I next see her. If she does knock me down and goes to a medium secure unit for her heinous offence, her chances of reconviction are much less than if she were a man (Coid et al, pp. ).

AN EDITOR DEPARTS

This month marks the retirement of Alan Lee, the second editor of Advances in Psychiatric Treatment, who took over from the founding editor Andrew Sims in 2003, after co-editing the journal since March 2002. At a moving farewell reception Alan explained the reasons for his departing this post in the prime of his prestige. He confessed openly his secret, hidden to all until now. He was a workaholic – he did not mind who knew as disclosure was his only hope. He asked those present, quietly but firmly, not to tempt him by little offers of work after he retired. He had continued craving for tasks of all sorts and even a small degree of re-exposure to them would quickly send him on a downward path. I promised to promulgate the message so that all others in the College and its wider community would be aware and help him to avoid temptation.

He leaves a journal in rude health and with great prospects; it is just about to be launched in North America as a major educational initiative, and its combination of independent thought, pertinent advice and clear exposition will go down well there. We welcome Joe Bouch as the new Editor, who has a gardening job on his hands, indicated by a verse from the departing doggerel I gave to Alan as he left with only idleness on his mind.

So how will we do without him

Now he's decided to hang up his boots

We'll just have to weed round his plants grown from seed

And make sure we look after the shoots

References

Lee, S., Lee, M. T. Y., Chiu, M. Y. L., et al (2005) Experience of social stigma by people with schizophrenia in Hong Kong. British Journal of Psychiatry, 186, 153157.CrossRefGoogle ScholarPubMed
Skapinakis, P., Lewis, G., Araya, R., et al (2005) Mental health inequalities in Wales, UK: multi-level investigation of the effect of area deprivation. British Journal of Psychiatry, 186, 417422.CrossRefGoogle ScholarPubMed
Tyrer, P., Kramo, K., Miloseska, K., et al (2007) The place for nidotherapy in psychiatric practice. Psychiatric Bulletin, 31, 13.CrossRefGoogle Scholar
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