Social sustainability and mental health: a threat to evidence-based practice?

The availability and use of mental health treatments are influenced by many different factors. Prominent among these are scientific evidence, cost, ethics and politics. However, the social sustainability of treatments can also have a considerable influence on their use.

Social sustainability is a relatively new concept that relates to the minimum social requirements for society to function and develop (Littig & Griessler, 2005). Given that mental illness is now the leading cause of disability worldwide (Whiteford et al, 2013) and that it can severely impact on the social functioning of those affected, it undoubtedly affects the social sustainability of communities globally.

Social sustainability in relation to mental health has two main aspects. First, it relates to the ability to restore the social capital that is lost due to mental illness, such as housing, education, employment and community connectedness (Colantonio, 2009). Second, it relates to the societal support required to continue providing care. This introduction to the issue’s thematic section considers how the latter aspect of social sustainability – societal support – affects the use of mental health treatments and how, at times, it can be more influential than a supporting scientific evidence base.

Ensuring mental health treatments are socially sustainable

Sustaining the provision of evidence-based treatments is dependent on support for their continued use from the principal groups in society that are affected by mental illness: patients, healthcare professionals and the wider public. Each of these groups differs in their experience of mental health treatments. The manner in which these groups form opinions about different treatments is complex and interdependent. For example, healthcare professionals’ engagement with treatment will be influenced by their perception of the support of the medical community and the wider public, in addition to their personal experience of the efficacy of a treatment. However, there are different factors that need to be considered to ensure that social sustainability is maintained with respect to each of these groups.

First, patients are people who are diagnosed as having a need, receive medical advice, undergo treatment first-hand and who reflect upon that entire process, from diagnosis to recovery. To ensure the ongoing support of patients, their anticipations, experiences and reflections on treatments need to be understood and evaluated. Evidence suggests that patient-reported outcome measures are less symptom-focused, and instead are based on perceived recovery of functional independence (Bellack, 2006). For mental healthcare to remain socially sustainable in the eyes of patients, services need to meet these objectives. The first of the papers in the section considers whether the new paradigm of service delivery known as recovery colleges is acceptable from a patient perspective.

Second, healthcare professionals assess, diagnose and treat patients, and have a broader responsibility to the medical community and the wider public. Healthcare professionals are also able to discriminate between treatments that are founded on solid evidence and those that may be an unsupported part of the Zeitgeist. To ensure ongoing support from healthcare professionals, two key issues are maintaining adequate recruitment and ensuring staff are engaged with training and able to work effectively. These issues are important as there is a global recruitment crisis in psychiatry (Lunn, 2011) and caring for people with mental illness can be challenging. Evidence suggests there is a high prevalence of stress in staff working in mental health settings and that as many as two out of three experience ‘burnout’ (Morse et al, 2011). For mental healthcare to remain socially sustainable in the eyes of healthcare professionals, among a myriad of other issues, services primarily need to maintain a workforce that is willing and capable of providing this care. The second paper in this thematic section considers how healthcare professionals in Nepal responded to the catastrophic earthquake in April 2015 to defend and support the provision of mental health treatments.

Third, the wider public comprises many sub-groups, members of which range from those who have immediate engagement with people receiving treatment (e.g. partners or carers of patients) to those who have influence over policy regarding treatments (e.g. elected non-specialist officials) and those who have no knowledge of treatment beyond culturally transmitted stereotypes (e.g. a large portion of the unaffected cinema-going population). Support of the wider public is an important component of the social sustainability of mental health treatments and that support is affected by stigma, perceptions about personal safety, mental health literacy levels and the provision of ethical treatments (Jorm, 2000; Saraceno et al, 2007). Mental health treatments continue to be a source of controversy in the public arena. From as far back as the asylum era, through to modern-day issues such as electroconvulsive therapy and community treatment orders, treatments provided by psychiatrists have faced strong opposition (Cooper, 2013). There remain debates about the ethics of detaining those with mental illness, particularly the detention of children (Roberts, 2013), while, contrastingly, the media fuel the perception that psychiatrists do not do enough to protect society (Stout et al, 2004). For mental healthcare to remain socially sustainable, the wider public needs to provide ongoing support for services and treatments.

The impact of social sustainability on mental health treatments

Considering the social sustainability of each of these groups is important because it has a considerable influence on the shape of services and the availability of treatments. For example, asylums initially had substantial support from all groups for managing mental illness (Burns, 2014). However, within a few decades deinstitutionalisation had occurred and the key factor in abandoning the asylum model was arguably a lack of social sustainability rather than a scientific evidence base. First, from the perspective of the patient, asylums did very little to promote recovery and the restoration of independence (Burns, 2014). Second, it was noted that working in large institutions affected care professionals in negative ways: their behaviours became less therapeutic and more punitive (Paulson, 2012). Third, public support for this form of treatment faltered (Paulson, 2012). This example serves as a reminder that society, and its subgroups, is in flux. Within society, developments are made, attitudes shift and the skills required to live independently change, such that services might begin by being socially sustainable, but then prove not to be a few years later.

A contemporary UK example of the impact of social sustainability on a new type of service is that of ‘recovery colleges’. These provide educational courses aimed at helping those with mental illness to achieve their goals and ambitions. Patients have been very supportive of recovery colleges, and mental health organisations have been very keen to develop them, with healthcare professionals independently volunteering to set up such services, without instruction from commissioners or health policy (Perkins & Slade, 2012). There has also been prominent support from the wider public for these services (Phillips et al, 2013). The number of recovery colleges has greatly increased over the past few years and, given the lack of scientific evidence to support the efficacy of the treatment (Slade et al, 2012; Phillips et al, 2013), it is our opinion that issues underpinning social sustainability have been critical in their rise.

In contrast, the use of a treatment can decrease even in the face of scientific evidence if it is not socially sustainable. For example, the third paper in this thematic section contends that the use of electroconvulsive therapy has reduced because of increasingly negative attitudes of patients and care professionals and also diminishing public support, despite the good level of evidence that supports its use in certain conditions.

Responsibilities to ensure social sustainability

The social sustainability of a treatment or service has a large influence on its availability or use. It is the responsibility of mental health organisations to address the elements underpinning social sustainability in order to ensure that treatments are evidence-based and relevant to community needs. This involves:

ensuring that treatments are evaluated on the basis of patient-reported outcomes

ensuring adequate recruitment, appropriate training and good support for staff working in mental health

publicly defending certain treatments that have a good evidence base but lack public support or, conversely, ensuring certain treatments that do have substantial public support are not provided carte blanche in the absence of evidence of patient benefit.

Greater awareness is needed about social sustainability to ensure that the use of evidence-based treatments continues into the future despite shifting patient, staff and public attitudes.