Two pressing needs: to measure social integration and to re-orient mental health services towards social integration

Social integration is now regarded as an important outcome of mental health care. It is achieved through the provision of psychosocial interventions, for example, by long-term community-based residential care or supported employment programmes. These interventions help to avoid negative outcomes for people with severe mental disorders, such as suicide, poverty, human rights violations and incarceration, which are all linked to social marginalization and lack of support and care. However, even if it is generally accepted that psychosocial interventions contribute to facilitate the social integration, the evidence about the effectiveness of those interventions remain largely insufficient. In 2010, WHO launched the mhGAP Intervention ‘Guide for mental, neurological and substance use disorders in non-specialized health settings’ (World Health Organization, 2010). The guide was developed following a rigorous process that included a systematic review of the available evidence for mental health interventions. The review reinforced the fact that there were far fewer studies examining the effectiveness of psychosocial interventions and rehabilitation programmes compared with pharmacological interventions. In addition, the former tended to be of lower quality. It is, thus, obvious that in order to improve the evidencebase around psychosocial and rehabilitation programmes, we need to better define the concept of social integration and devise more reliable ways to measure it. The article by Baumgartner and Susser examines the notion of social integration and its measurement, and calls for the development of measures for crosscultural use. Unquestionably, the authors have identified an important issue. Indeed, the definition of social integration remains rather vague among psychiatrists, and even more so when mental health workers come from different disciplinary perspectives: the same word is used with different meanings and with a different emphasis. For example, Berger-Schmitt and Noll from the German Centre for Survey Research and Methodology on Social Indicator Development (Berger-Schmitt & Noll, 2000) consider that social integration has to do with the dynamics between social exclusion and social inclusion. Others emphasize poverty as the key element of poor social integration (Atkinson & Marlier, 2009). Ware et al. (2008), from the Harvard Department of Social Medicine, identify social integration with quality of life. This article by Baumgartner and Susser provides a conceptual framework for social integration based on four perspectives: (i) the disability framework promoted by the WHO through the International Classification of Functioning, Disability and Health (ICF) and related disability assessment instruments; (ii) the US mental health service literature; (iii) Amartya Sen’s notions of Capabilities and Commodities; and (iv) the notion of sub-communities as a potential framework for social inclusion of people with severe mental disorders. These perspectives may be useful for a better articulation of the notion of social integration, but Baumgartner and Susser do not provide any rationale for adopting these four perspectives over others as a framework for defining social integration. Furthermore, they do not explain why the ‘US mental health service literature’ should become a reference to define the notion of social integration which, in their view, should have ‘global’ relevance. Address for correspondence: Professor B. Saraceno, Calouste Gulbenkian Professor of Global Health at the University Nova of Lisbon, Portugal. 70 C rue du Grand Pré, CH 1202 Genève, Switzerland. (Email: benedetto.saraceno@gmail.com) Epidemiology and Psychiatric Sciences (2013), 22, 39–41. © Cambridge University Press 2012 COMMENTARY doi:10.1017/S2045796012000297