ECONOMIC CRISIS AS A SOCIAL PATHOLOGY: CRISIS-RELATED PATIENTS AND CLINICAL ASSESSMENT.

Rossi, Alessandro ; Frera, Fernanda ; Giannelli, Andrea 等

The recent socioeconomic crisis has left deep scars on people's everyday life. Reduction in incomes (Katz, 2010), debts (Brown, Taylor, & Price, 2005), job losing and poverty (Jahoda, 1988) are among the adverse ramifications of economic downturn (World Health Organization, 2011). Even today, the financial depression is still overwhelming Europe: Spain, Greece and Italy are among the worst affected (de Belvis, Ferre, Specchia, Valerio, Fattore & Ricciardi, 2012; Conti, 2012). Thus, economic crisis could be considered the trigger of a wasting social pathology (Jahoda, 1988; Brenner, 1976) that undermines the Self (Jahoda, 1988)--or identity (Schob, 2013)--and provokes the onset of "crisis-related" (Rossi, D'Oronzio, Porta, Soldatesca & Giannelli, 2014; Rossi, Frera, Cavedoni & Giannelli, 2015a; Rossi, Frera, Cavedoni & Giannelli, 2015b;Giannelli, Frera, Cavedoni & Rossi, 2015a;Giannelli, Frera, Cavedoni & Rossi; 2015b) severe mental health disorders (World Health Organization, 2011, Uutela, 2010, Karanikoloset al.,2008).

Individual's sense of the Self could allow getting a new view of coping strategies of many economic difficulties (Akerlof & Kranton, 2000). At the same time, on the conceptual level, economic depression is strictly associated to a variety of indicators of social pathology (Brenner, 1976), derived from the fit or misfit between socially imposed experiences and human needs (Jahoda, 1982; 1988). This issue suggests that the manifestations of mental (un)health should not be assessed exclusively from an individual perspective but should be necessarily considered in conjunction with a social and psychological one (Jahoda, 1988).For instance, economic uncertainties often drag people down to social withdrawal and isolation (Brennan & McHugh, 1993;McHugh & Brennan, 1993; Pollack, Vanepps & Hayes, 2012).These situations often lead to perceive a lack of social support (Giannelli et al.,2015a;Giannelli et al.,2015b;World Health Organization, 2011;Economou, Madianos, Peppou, Patelakis & Stefanis, 2013), which in turn could ravage individual's identity (Jahoda, 1988). There is no doubt that the Self is fundamental to behavior, as it is the spark that ignites motivational drive to act (e.i.: Akerlof & Kranton, 2000; Deci & Ryan, 1985; Dweck, 1986; Elliott & Dweck, 1988; Hogg, 2000;Markus & Wurf, 1987; Nicholls 1984) and--often--is strongly associated to the social setting (Brown, 1986; Tajfel & Turner, 1979;Wetherell,1996).

Workplace and employment latently define aspects of personal status and identity (Jahoda, 1981; 1982); instead, job losing haul individuals from a social institution that had previously dominated their lives (Jahoda, 1988). Thus, besides the manifest function to produce an income, employment imposes a strong structuration of time, status and identity, involves social contacts (Jahoda, 1981) and is psychologically supportive (Jahoda, 1979; 1981; 1982; Fryer & Payne, 1984). Moreover, job could be people's strongest tie to reality (Freud, 1930) that protects them against negative emotions and/or hopelessness (Jahoda, 1981).

So, regardless of the level of poverty (Jahoda, 1988; Fineman, 1983; Fryer & Payne, 1984), a break in the latent function of employment in conjunction with a rifted sense of the Self may explain why the impact of economic crisis-related unemployment and hopelessness is so psychologically destructive(Jahoda, 1981).As a result, this crisis-related impact is associated with a worsening in health self-perception (Kentikelenis, Karanikolos, Papanicolas, Basu, McKee & Stuckler, 2011),which in turn is linked to an increased demand for medical and psychological support to public health services (Catalano, 2009; Kentikelenis et al., 2011; Lusardi, 2010) with a help request for the resolution of a suffering triggered by 2008 economic crisis(Gili, Roca, Basu, McKee & Stuckler, 2013). Consistently, this leads one to assume that this kind of individuals--who experience psychological and/or psychiatric suffering strictly related to that financial crisis--are "crisis-related" patients (Rossi et al., 2014; Rossi et al., 2015a; Rossi, et al, 2015b; Giannelli et al., 2015a; Giannelli et al., 2015b).

However, individuals hit by the impact of economic depression are not a homogeneous mass (Jahoda, 1981; 1988; Brenner, 1976). Several studies have demonstrated that this crisis-related population reports physical (Catalano, 2009; Marmot& Bell, 2009) and mental health problems (World Health Organization, 2011) such as ordinary psychiatric patients do. Indeed, people who are forced to cope with the economic-crisis-related effects are at higher risk (Uutela, 2010) for a critical intensification or even an explosive onset of psychiatric morbidity (Rossi et al., 2015b; Ferrie, 2005) and psychological disorders than their counterparts (Jerkins et al., 2008). In particular, financial-crisis-related subjects are much more vulnerable to experience serious clinical anxiety (Kessler, Turner, & House, 1987), major depression syndrome (Uutela, 2010), alcohol use disorders (Browning & Heinesen, 2012; Eliason & Storrie, 2009) and--at least--negative emotions (Fryer & Payne, 1986) as stronger feelings of hopelessness (Rossi et al., 2015a; Rossi et al., 2015b; Meltzer, Bebbington, Brugha, Jenkins, McManus & Dennis, 2011; Moorhouse & Caltabiano, 2007).

Unfortunately, this parallelism in psychiatric symptomatology does not allow to distinguish--quickly and correctly--which one causes the onset of the disease; that is, if the subject's psychological suffering was caused by the impact of the economic crisis, or if it is independent. To date, into Italian public service only the psychiatric interview is commonly used in order to detect crisis-related patients from ordinary ones. To our knowledge, no other study has investigated whether the only clinical examination is a sufficient and reliable approach to identify correctly this kind of patients in order to provide them better solutions for their specific help request in Italian public health services. Thus, the aim of the study was to test whether a clinical interview-based approach could correctly identify crisis-related subjects.

METHODS

Sample: Participants were 103 (48 females[46.6%] and 55 males [53.4%]; mean age = 47.58, SD = 11.22) consecutively enrolled to the Public Mental Health Care Service (CPS--via Fantoli 7) of Ospedale Maggiore Policlinico of Milan, Italy; with the following exclusion criteria. None of the subjects met any of the following exclusion criteria: (A) supposed IQ less than 75, (B) diagnosis of psychotic and/or delusional disorder according to ICD-10, (C) diagnosis of dementia or other organic mental disorder according to ICD-10 and (D) older than 80 years old. Written informed consent was obtained from all participants.

Procedure: In order to realize this study, we used a double-blind correlational design. First of all, upon arrival to the Mental Health Care Service, patients completed a check list in the presence of a psychologist. In this preliminary part were not foreseen psychological interventions. The psychologist inquired medical information, presence of psychological and/or psychiatric disorders. Subsequently, the participants came to support the psychiatric examination. Subjects were randomly assigned to one of two different psychiatrists; at the same time, the psychiatrists were in a blind condition about checklist results and the motivation of the help request. Finally, depending on the demand analysis, the psychiatrist split participants into: crisis-related (psychiatric and/or psychological disorders exclusively related to the economic crisis) or non-crisis-related patients (mental health problems/diseases not associated to the economic difficulties).

Measures. CPS Checklist: This preliminary version of the checklist is a 9 items instrument specifically developed to promote the screening of crisis-related patients. It aims to investigate two different kinds that we supposed to be the antecedents of crisis-related mental health disorders (Jahoda, 1988). In particular, the first area surveyed refers to crisis-related worries and uncertainties, such as: job insecurity, work demotion and professional failure (Kuder-Richardson's alpha was 0.72). The second area detected refers to negative economic changes related to the income; as job loss, heavy debts or loss of welfare support (Kuder-Richardson's alpha was 0.63).

RESULTS

Preliminary Analysis: Using M plus software (version 7., Muthen, L. K., & Muthen, B. O., 1998-2013), an exploratory factor analysis for categorical data (estimator: Robust Weighted Least Squares, WLSMV) with oblimin rotation was conducted to explore the factorial structure of the proposed checklist. A two factor solution emerged has been suggested by two eigen values higher than 1. Results from the EFA seemed to strongly confirm the two-factor solution. Indeed, the chi-square for model fit did not result statistically significant ([[chi].sup.2](19) = 25.484, p= 0.145), the Root-Mean Square Error of Approximation and the Comparative Fit Index showed adequate fit indices: RMSEA = 0.058 (90% CI: from 0.000 to 0.110), p(RMSEA < 0.05) = 0.379; in line with the CFI = 0.970 and the TLI = 0.943. The two factors were related to specific components of economic-crisis impact on mental health. Specifically, the first represents economic uncertainty related to worries about the financial situation (item 2, 4, 6, 9); while, the second factor stand for negative changes related to the income (item 1, 3, 5, 7, 8). Taking account of this, the first factor loadings ranged from 0.91 to 0.59; and the second factor loadings ranged from 0.91 to 0.31.

Principal analysis: Statistical analyses were conducted using the SPSS 20. For this first analysis we relied on the division made during the psychiatric interview. A One-Way ANOVA was used to test if the CPS checklist could help the psychiatrist to distinguish crisis-related patients into the clinical examination. As hypothesized for the first factor--negative changes in income -crisis-related patients showed a significantly higher number of negative changes occurred (M = 1.34; SD = 1.19) than ordinary patients (M = 0.25; SD= 0.52); F (1,102) = 35.87, p <.001. Even for the second factor--economic crisis worries--crisis-related patients showed a higher number of worries (M = 1.15; SD= 1.43) than ordinary patients (M = 0.59; SD= 0.91); F (1,102) = 5.63, p = .020.

Moreover, in order to test whether a sharable split in the two groups of the participants (crisis-related vs. non-crisis-related) were made, the most important parts of psychiatric interview were transcribed and submitted to the judgment of 10 judges (5 expert psychologists, 3 psychology students, 2 other professionals). The agreement between judges was tested by Krippendorffs Alpha (Hayes &Krippendorff, 2007; Krippendorff, 2011) that showed good values of concordance--based on 5000 bootstrap resampling. In particular, the experts agreement was: Alpha =.88 (CI95%: 0.78 to 0.96); the agreement of psychology students was: Alpha = .85 (CI95%: 0.76 to 0.94), the non-expert agreement was: Alpha = .72 (CI95%: 0.58 to 0.86) and the agreement between all judges revealed a good concordance: Alpha = .85 (CI95%: 0.74 to 0.94). Finally, the overall Krippendorffs Alpha revealed a good concordance between judges and psychiatrists: Alpha = .87 (CI95%: 0.76 to 0.96) and a chi-square analysis was performed to test whether judges' split could have been as same as those made by psychiatrists. Results confirmed our hypothesis: [[chi].sup.2] (6) = 103, p< 0.001. The clinical interview could be considered a sufficient and reliable method in order to distinguish "crisis-related" patients.

DISCUSSION

The aim of the present research was to test whether the clinical interview could be considered sufficient and reliable in order to distinguish--in a mental health care centre setting--crisis-related patients from the ordinary ones. Results seem to be encouraging, confirming our hypothesis. This study showed that clinical examination could be appropriate in order to discriminate crisis-related patients from the ordinary ones. In other words, the psychiatric interview could correctly establish if the onset of psychiatric symptomatology is strictly related to the impact of the 2008 economic depression or if it is independent. Moreover, this split of patients has been widely supported by both the judgment of ten independent judges and through a checklist ad hoc developed. In particular, the earlier showed a high agreement across participants with different degree of expertise, while the latter besides revealing good psychometric properties also reflected previous literature.

To date, 2008 recession is still wasting Europe (de Belvis, et al., 2012; Conti, 2012). Consistently, it could be considered the spark of a social pathology (Jahoda, 1988; Brenner, 1976) that destabilizes the individual's sense of Self (Jahoda, 1988, Schob, 2013) and leads to experience mental health suffering strictly related to that financial crisis--"crisis-related" patients (Rossi et al., 2014). This kind of individuals, hit by the impact of economic depression, show a variety of psychological or psychiatric disorders as ordinary psychiatric patients do. Crisis-related symptomatology such as anxiety (Kessler, Turner, & House, 1987), depression (Uutela, 2010), alcohol abuse disorders (Browning & Heinesen, 2012; Eliason & Storrie, 2009) and heavy feelings of hopelessness (Meltzer et al., 2011; Moorhouse & Caltabiano, 2007). However, this similarity--between crisis-related patients and ordinary ones--in the psychiatric symptomatology could lead to distinguish incorrectly the cause of their psychological suffering. In this confused context, this study provides support to the clinician's ability to detect differences in the onset of psychological disorders. Furthermore, it shows that psychiatric interview could be considered sharable, reliable and appropriate in order to understand which kind of patients he/she has in front of him/her.

Despite the strength of the results just shown, there are limits that have to be acknowledged. One of them is the small sample size used to conduct our hypotheses tests; in addition, the results are based on a convenience sample. However, in spite of limitations, these findings could be used to create and/or improve specific mental health supportive therapies based on the different source of the onset of symptomatology.

While ordinary patients could be treated with standardized therapies, these treatments are often ineffective for individuals that have developed a psychiatric disorder exclusively related to the impact of economic depression. Indeed, for crisis-related patients the 2008 recession means an enforced radical change in their way of living and often implies financial dependence from the public purse, which is not always sufficiently provided (Jahoda, 1988). This is the real difference between ordinary patients and crisis-related ones which have no the institutional support. Therefore, their mental state may be not so compromised if they found an institutional support that could give them a workplace (Brenner, 1976; Jahoda, 1988), which in turn could satisfy some of their basic needs. Consequently, for crisis-related patients, the cure may lie not only in individual psychological therapy but also in the creation of organized social support and jobs workplaces (Jahoda, 1987; 1988; Darwin, Fitter, Fryer, & Smith, 1987) that could make their psychological burden more bearable (Jahoda, 1988). Despite of limitations, these results seem to be encouraging and suggest improvements in the research in crisis-related field.

APPENDIX

CPS--Checklist

ISTRUZIONI:

Di seguito sono elencate alcuni avvenimenti che possono capitare nella vita ci ciascuno; per ognuna di esse vi e un gran numero di persone per le quali potrebbe essersi verificate e un altrettanto ampio numero di persone alle quali non sono mai successe.

La preghiamo di segnare per tutti gli avvenimenti di vita qui descritti se questi Le sono capitati (Si) OPPURE,se NON Le sono capitati (No) nell'ultimo anno di vita 1 Perdita dei sostegni socio-assistenziali (pensione, No Si sussidi, case popolari, ecc.) 2 Provvedimenti sul posto di lavoro come mobilita, cassa No Si integrazione, precarizzazione, ecc 3 Perdita del posto di lavoro No Si 4 Importante demansionamento e/o cambiamenti della No Si posizione lavorativa 5 Rilevanti e negativi cambiamenti del legislatore in No Si materia regolamentare (tassazione, procedure burocratiche, mancata riscossione di crediti, modificazione di regolamentari) tali da rendere difficoltosa la prosecuzione dell'attivita lavorativa 6 Rilevante insuccesso professionale No Si 7 Presenza rilevante di debito economico e/o grave No Si insolvibilita 8 Cambiamenti importanti e negativi della situazione No Si economica 9 Stressors lavorativi continui o sub-continui No Si (contenziosi in corso, ad esempio, per mobbing)

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Alessandro Rossi (1,2,3); Fernanda Frera(1); Andrea Giannelli (1)

(1) Department of Psychiatry, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy;

(2) Psychology Research Laboratory, IRCCS Istituto Auxologico Italiano, Ospedale San Giuseppe, Oggebbio (VCO), Italy

(3) Department of Medical Oncology, ASST Valle Olona, Presidio Ospedaliero di Saronno, Saronno (VA) Italy; rossi.alessandro.alberto@gmail.com