Adult Mental Health Introduction Positive mental health is more than the absence of mental illness. Mental wellbeing can be defined as “a dynamic state, in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their communities” Foresight (2008) One in four adults experience mental illness at some point in their lifetime and one in six are experiencing mental illness at one time This makes mental illness the largest cause of disability in society today. There are several complex reasons why individuals develop a mental illness: It can be inherited It could be caused by lifestyle Or it could be linked to events that have happened in the past Usually it is caused by a combination of all of the above. The reasons can be broken down further into groups: Social Environmental Physical Psychological Although the causes of mental health are complex, their impact can be reduced by intervening early; as soon as an individual starts to display signs of ill health. Mental illness in adults can be classified as: Common mental disorders Personality disorders Psychoses Eating disorders Disorders related to substance misuse There is a clear link between mental and physical health and an urgent need to strengthen both the provision of mental health care to people with physical illness and the quality of physical health care provided to people with mental health problems in general hospitals and primary care. 1 What do we know? Facts, Figures, Trends Many mental health problems start early in life; half of those with lifetime mental health problems first experience symptoms by the age of 14 (Kim-Cohen 2003) Almost half of all adults will experience at least one episode of depression during their life time (Andrews 2005) One if four adults experience mental illness at some point in their life and one in six are experiencing mental illness at one time – this makes mental illness the largest single cause of disability in society today Common mental health problems (such as depression, anxiety, phobias and obsessive compulsive disorder) are very common with a prevalence rate in adults in England of 17.6% The most recent psychiatric morbidity in England study (2007) found that more than half of those with a common mental disorder presented with mixed anxiety and depressive disorders (9%) The largest increase in rate of common mental disorders between 1993 and 2007 was observed in women aged 45-64 among whom the rate rose by a fifth Depression is approximately two to three times more common in patients with a chronic physical health problem Mental health is affected by a wide range of determinants, requiring intervention and support further than the scope of health services. The environment, education, housing, and the financial climate all affect an individual’s mental wellbeing. Poor mental health is a key factor that underpins many physical health problems and acts as an underlying driver for much health risk behaviour, including smoking, substance misuse and obesity. To the period 2016, the largest absolute increase is in neurotic disorders where it is estimated that 1 in 6 adults experience some sort of neurotic disorder, the most prevalent being mixed anxiety and depression. Demand for mental health services is likely to increase as a result of unemployment, personal debt, home repossession and other fallout from the recession Approximately 2% of the NHS expenditure goes on dealing with depression and anxiety Psychosis affects 0.5% of adults in England (Manus 2009) Women have a slightly higher prevalence of probable psychosis than men (0.5% and 0.4% respectively), with the highest prevalence amongst those aged 16-44 years. The coalition government has recently published its national mental health strategy ‘No health without mental health’ (HM Government 2011) The strategy encourages taking a life course perspective; laying down the foundations of good mental wellbeing in childhood, continuing wellbeing in adulthood and maintaining resilience in older age. Key to this approach is the promotion of positive mental health to prevent mental illness, early intervention, and to ensure everyone sees mental health in the same importance as physical health. 2 Mental health is an essential part of overall health, and is fundamentally related to physical health with poor mental health increasing the risk of poor physical health and vice versa. Depression increases the risk of mortality by 50% and doubles the risk of heart disease in adults (HM Government 2011) It is estimated that better mental health care would save the government £3.1 billion a year (Wanless, 2004). This does not take in to account the saving promoting health and prevention. Changing people’s health-related behaviour, promoting factors to protect mental health including improving social support and work life balance can have a major impact on some of the main causes of mortality and morbidity (NICE, 2008). Table 1: Population aged 18-64 predicted to have a mental health problem in England projected to 2030 People aged 18-64 predicted to have a mental problem projected to 2030 - England 2011 2015 2020 2025 2030 People aged 18-64 predicted to have a common mental disorder 5,278,168 5,333,570 5,424,756 5,505,735 5,556,352 People aged 18-64 predicted to have a borderline personality disorder 147,522 149,038 151,553 153,721 155,137 People aged 18-64 predicted to have an antisocial personality disorder 114,774 116,191 118,400 120,379 121,888 People aged 18-64 predicted to have psychotic disorder 131,134 132,503 134,761 136,715 138,011 People aged 18-64 predicted to have two or more psychiatric disorders 2,360,549 2,386,174 2,427,856 2464,222 2,489,210 Source: PANSI 3 Table 2: Population aged 18-64 predicted to have a mental health problem in The East of England projected to 2030 People aged 18-64 predicted to have a mental problem projected to 2030 – East of England 2011 2015 2020 2025 2030 People aged 18-64 predicted to have a common mental disorder 578,540 589,024 606,563 622,499 633,222 People aged 18-64 predicted to have a borderline personality disorder 16,172 16,463 16,951 17,395 17,692 People aged 18-64 predicted to have an antisocial personality disorder 12,564 12,809 13,204 13,558 13,813 People aged 18-64 predicted to have psychotic disorder 14,374 14,634 15,069 15,465 15,731 People aged 18-64 predicted to have two or more psychiatric disorders Source: PANSI 258,672 263,430 271,330 278,487 283,370 Table 3: Population aged 18-64 predicted to have a mental health problem in Central Bedfordshire projected to 2030 People aged 18-64 predicted to have a mental problem projected to 2030 – Central Bedfordshire 2011 2015 2020 2025 2030 People aged 18-64 predicted to have a common mental disorder 25,985 26,370 27,118 27,680 27,883 People aged 18-64 predicted to have a borderline personality disorder 726 737 758 774 779 People aged 18-64 predicted to have an antisocial personality disorder 565 575 591 601 608 People aged 18-64 predicted to have psychotic disorder 646 655 674 688 693 People aged 18-64 predicted to have two or more psychiatric disorders Source: PANSI 11,621 11,799 12,131 12,377 12,476 4 Local Picture The number of people with a mental health condition in Central Bedfordshire is predicted to rise, primarily as a result of the changing population structure. To the period 2016, the largest absolute increase is in neurotic disorders where it is estimated that 1 in 6 adults experience some sort of neurotic disorder over their lifetime, the most prevalent type being mixed anxiety and depression. In England, one person dies every two hours as a result of suicide. There were 11 suicides in Central Bedfordshire in 2010-2011 Figure 1: QMAS data by GP practices for Central Bedfordshire for mental health conditions Source: Produced by Public Health Intelligence The practice with the highest mental health QMAS data has traditionally high numbers of homeless, drug users and mental health patients. 5 Figure 2: QMAS data by Bedfordshire Localities for all mental health conditions Source: Produced by Public Health Intelligence Figure 3: Mini Mental Needs Index – Central Bedfordshire Source: Public Health Intelligence 6 Figure 3 shows that that Manshead Ward recorded the highest MINI score greater than both Central Bedfordshire and England. There are strong links between social deprivation and mental ill health, therefore service provision and treatment should be focused towards the more deprived areas of Central Bedfordshire. In terms of deprivation, no areas are within the 20% most deprived nationally, however, if deprivation is assessed at a small area level (known as Lower Super Output Areas – LSOAs) and compared with the East of England, there are nine LSOAs which fall within the 20% most deprived regionally; these are Sandy Pinnacle, All Saints, Parkside, Chiltern, Dunstable Central, Tithe Farm, Northfield, Stotfold and Manshead. Compared with people with no mental health problems, men with mental illness live 20 years less and women 15 year less. A combination of lifestyle risk factors such as smoking and diet, higher rates of unnatural deaths such as suicide and accidents and poorer physical health contribute to premature mortality (Wahlbeck 2001). Current activity & services Both Central Bedfordshire Council and NHS Bedfordshire commission mental health services in Central Bedfordshire. The main provider is South Essex Partnership Trust (SEPT), although mental health services are provided in Milton Keynes and Cambridge. The third sector also provides service in the community. Primary Care Mental Health Services Most general mental health services are provided in primary care by GP’s, the Psychological Therapy Services, The Primary Care Counselling Service and the Improving Access to Psychological Therapies (IAPT) service know as Step by Step. Within a stepped model of care, a range of individual and group psychological therapies are offered to treat common mental health problems. Employment Support Service in Primary Care The Richmond Fellowship, a specialist provider of mental health services offer vocational advice and support for clients experiencing stress, anxiety, depression or other common mental health conditions to those who are at risk of loosing their jobs or who wish to return to work after a period of sickness absence or unemployment. South Essex Partnership University NHS Foundation Trust (SEPT) is commissioned to deliver care and support to people in their own home and from a number of hospital and community settings: Acute and Crisis Service / Acute Assessment Unit (AAU) – Located at Bedford Hospital. The Trust’s Assessment Units work closely with Crisis Resolution Home Treatment Teams to offer service users an alternative to admission or to reduce length of stay for those who require admission. 7 It is a 24-hour dedicated inpatient unit. All patients that are referred from Accident and Emergency Departments are sent to the unit for consultation and referral. Crisis Resolution and Home Treatment team (CRHT) – Multi-disciplinary team of doctors, clinical psychologists, psychiatric nurses, social workers and support workers for those whose needs cannot be met in primary care and who require targeted clinical interventions. Assertive Outreach Team (AOT) - Multi-disciplinary team of doctors, clinical psychologists, psychiatric nurses, social workers, occupational therapists and support workers who support people with severe and enduring mental health conditions. The Complex Needs Service works closely with the community and specialist mental health teams to improve the care delivered to service users with personality disorders and their families and carers. B: DAT, Bedfordshire Drug and Alcohol Action Team oversees and monitors the local drug and alcohol treatment services in Bedfordshire. Care Co-ordination support people with a dual diagnosis (mental health problem and substance misuse). Psychiatric Intensive Care Unit (PICU) is located in Luton. The Robin Pinto Unit is a low secure environment which provides intensive psychiatric care. The Prison In-Reach Team – Support prisoners in Bedford Prison with mental health problems. Empowa – provides specialist support for people with mental health problems Specialist services for people of working age include: Eating Disorder Service Electro-Convulsive Therapy (ECT) Direct Access Psychology Service Clinical Health Psychology Service Acquired Brain Injury Psychology Service MIND Bedfordshire and Luton Mind provides mental health, wellbeing and social care services across Bedfordshire in partnership with other local service providers and mental health service users. Services include: Step 2 IAPT Wellbeing Centres providing supported access to a wide range of services Volunteering and mentoring, using the Recovery Star Model Social Groups 8 Therapeutic Groups including stress/anxiety management and mental wellbeing Youth in Mind Service working with young people aged 14-25 using motivational and solution focused mentoring Training – anxiety management, self esteem and assertiveness, understanding anger, sleep, stress, mental health first aid and mental health awareness Support and access to exercise and health living options Carers Services Services are available for the carers of individuals with mental health conditions within Central Bedfordshire. Rethink Services are available to help everyone affected by severe mental illness recover a better quality of life. Local Views In February 2010 an event was held by Central Bedfordshire Council, Bedford Borough Council and Luton Borough Council to consult with service users, carers and stakeholders on the proposed Mental Health Section 75 Agreement which was being developed with South Essex Partnership Trust for the provision of specialist mental health services. Priorities for the service users and carers were: Information and guidance to be easily available Employment Housing National & Local Strategies (Best Practices) Clinical Guidelines Promoting mental wellbeing at work (PH22) (2009) Eating disorders (CG9) (2004) Self Harm (CG16) (2004) Anxiety (CG22) (2007) Post Traumatic Stress Disorder (CG26) (2005) Obsessive Compulsive Disorder (OCD) and Body Dismorphic Disorder (BDD) (CG31) (2005) Bipolar disorder (CG38) (2006) Antenatal and Postnatal mental health (CG45) (2007) Antisocial Personality Disorder (CG77) (2009) Schizophrenia (CG82) (2009) 9 Depression in Adults (CG90) (2009) Borderline Personality Disorder (CG78) (2009) Public Health Guidelines HM Government (2011) No health without mental health; A cross-government mental health outcomes strategy for people of all ages. Foresight – Mental Capital and Wellbeing: making the most of ourselves in the 21st century. The Government Office for Science, 2008. Five ways to wellbeing. NEF, NMHDU, NHS Confederation, 2011. Marmot M. 2010: Fair society, healthy lives: The Marmot Review. Strategic Review of Health inequalities in England post – 2010 Mental Health and the economic downturn: national priorities and NHS solutions. R.C.psych, NHS Confederation, LSE, 2009 New Horizons: a shared vision for mental health Public Health White Paper: Healthy Lives, healthy people (2010) Joint Commissioning Strategy for Mental Health Services 2010-2013 Public Health Report 2012 – Adult Mental Health in Central Bedfordshire- Suneela Sajjad What is this telling us? What are the key inequalities? Mental health is influenced by diverse biological and social risk factors, including fixed factors such as genetic factors and biographic characteristics (age and sex) and modifiable factors such as family and socio-economic characteristics (marital status, number of children, employment), individual circumstances (life events, social supports, immigrant status, debt), household characteristics (accommodation type, housing tenure) geography (urban, rural, region) and societal factors (crime, deprivation index) (Foresight Mental capital and Wellbeing Project 2008) 10 Black and minority ethnic (BME) people with mental health problems People from BME groups often have different presentations of problems and different relationships with health services. Some black groups have admission rates around three times higher than average, with some research indicating that this is an illustration of need. The rates of mental health problems in particular migrant groups, and subsequent generations are also sometimes higher. African –Caribbean people are particularly likely to be subject to compulsory treatment under the Mental Health Act. South East Asian women are less likely to receive timely, and appropriate mental health services. Black men are 3 times more likely to be represented on a psychiatric ward and up to six times more likely to be detained under the Mental Health Act Community and inpatient caseload by ethnicity in NHS Bedfordshire Service White Black Asian Mixed Chinese/ Unknown other 2369 56 139 33 120 <5 218 9 15 <5 10 <5 Adult CMHT Adult inpatient Source: SEPT data for October 2011 People with other disabilities and mental health problems Disabled people with mental health problems may face either barriers to physical access or communication barriers (deaf people in particular). This is critical in mental health provision, which relies on communication. An estimated 25-40% of people with learning disabilities have mental health problems. 11 People with autism may be refused support because they do not fit easily into mental health and learning disabilities services. Lesbian, gay and bisexual people with mental health problems People from this group are at higher risk of mental health problems and of self harm. Monitoring of sexual orientation is patchy, making it less easy to develop tailored services Gender inequality There are differences in the rates and presentations of mental health problems between men and women. Women Recorded rates of depression and anxiety are between one and a half and two times higher for women than for men. Rates of deliberate self-injury are two to three times higher in women than men. Women are at greater risk of factors linked to poor mental health, such as child sexual abuse and sexual violence – an estimated 7–30% of girls (3–13% of boys) have experienced childhood sexual abuse. Around one in ten women have experienced some form of sexual victimisation, including rape. Studies have shown that around half of the women in psychiatric wards have experienced sexual abuse. Men Three-quarters of people who commit suicide are men. Men are three times more likely than women to be dependent on alcohol and more than twice as many men in psychiatric units are compulsorily detained. Gender Reassignment People who have undergone gender reassignment can be subject to discrimination in our society. They are at an increased risk of alcohol and substance misuse, suicide and selfharm. It is important that staff in health, social and education services are aware of the raised risks in these groups. Lesbian, gay, bisexual or transgender adults have a 4-fold increased risk of suicide Effective approaches to reducing differences in access, experience and mental 12 health outcomes are built from the best available evidence in why and how these variations occur. Unemployment Research shows that a total of 2.3 million people with a mental health condition are on benefits or out of work (HM Government, 2009) Unemployed adults have a 5.6 fold increased risk of developing a mental health problem In May 2009, there were 2,080 people claiming incapacity benefit as a result of mental health or behaviour disorders in Central Bedfordshire Drugs and alcohol The 2010 Drug Strategy shifts the focus for substance misuse services towards recovery, and not just harm-reduction, as was previously the case. The strategy recognises the importance of tackling the causes of drug and alcohol use and the clear association between mental ill health and substance misuse. The need for this locally is highlighted by the fact that less than 1 in 10 of those in treatment in Bedfordshire exited successfully in 2010, and around 1 in 3 of those on prescribing interventions have been on these for 3 years or more, with very few prescribing interventions being complimented by psychosocial intervention. Prisoners Offenders have a 5-fold increased risk of suicide (with an 18-fold increased risk amongst young offenders, a 35.8-fold increased risk amongst female offenders and an 8.3-fold increased risk for recently released offenders) Homeless Research indicates that 43% of those accessing homelessness projects in England suffer from a mental health condition The homeless have a 5.3-fold increased risk of developing a mental health problem Carers The majority of people with a mental health diagnosis live in the community with family, partners providing the bulk of their informal care. 13 Veterans In May 2010, the Coalition Government acknowledged that action need to be taken when it promised to “…rebuild the Military Covenant by…providing extra support for veterans’ mental health Health Outcomes January 2009 analysis by the Eastern Region Public Health Observatory (ERPHO) (currently only available at Bedfordshire level) showed Bedfordshire to be significantly higher than average for hospital admissions for self harm and for persons on enhanced and standard care. In all other measures Bedfordshire was significantly lower than the England average. Source: ERPHO 14 What are the unmet needs/ service gaps? There has not been enough focus on the root causes of ill health. Mental and physical health and wellbeing interact and are affected by a wide range of influences throughout life. Mental wellbeing promotion Increase in mental health issues being managed in primary care Supported housing Key areas for action: Improving mental health through wellbeing and prevention services Reducing waiting times for assessment and treatment Maintain people’s mental health post-treatment through better primary and community care services. The costs of the intervention are more than outweighed by gains to business due to a reduction in both presenteeism and levels of absenteeism. Economic driver: Possible saving from wellbeing interventions Life Course Subject Intervention Economic Advantage Adults Risk of depression Workplace Financial returns screening and almost five times early intervention the annual for depression. programme costs Targeted from increased employment productivity support for those (Foresight (2008). recovering from Three fold mental illness. increased rates of employment (Bond 2008) and saving of £6000 per client due to reduced inpatient costs over an 18month period (Burns 2009) There is reasonable evidence base to support the use of collaborative care in people with moderate to severe depression and a chromic physical health problem. Improved depression care is thought to produce other health benefits, such as improved functioning and physical outcomes (Katon 2006); this may be particularly significant for people with 15 depression and a chronic physical health problems. This means that interventions which improve physical health should result in substantial increases in utility and subsequently result in quality-adjusted life year (QALY) gains. It is estimated that improved early intervention could save the NHS up to £38 million per year (NHS West Midlands, 2010) Recommendations for consideration Ensure services are commissioned that are assessable to all, including those at highest risk. Emphasis should be on promoting recovery, and considering an individual’s mental health needs as well as their physical health needs and vice versa. Personalised care or personalisation is essential to ensue people with mental health problems can take as much control as possible over their support arrangements, to pursue their recovery and social inclusion. Commission initiatives that address the employment and accommodation needs of adults with mental health problems. Local Authorities and Mental Health Trusts could identify volunteer advocates to give practical assistance with housing, finding employment/education or helping with debt. Local authorities could also help by highlighting and promoting services available in the community Acute mental health services should ensure that individuals are not discharged with no where to go. Secure housing facilitates recovery and independence. Individuals can often find themselves in inappropriate residential care or their discharge is delayed because of lack of appropriate housing. Mental Health Trusts should provide a housing support officer to maintain close links with the housing department. Support models which work to help individuals to remain in their own homes. For example: o Supported Housing o Provision of telecare and telehealth equipment o Community aids and adaptations o Community alarms o Floating support o The use of third sector services such as the Village care Schemes Employers in all sectors, including the public sector, can play an important role in supporting the health and wellbeing of their staff by providing healthy work places which support mental wellbeing. Promoting well-being in the workplace can reduce 16 staff absences, benefit productivity and increase performance enhancing work morale and efficiency. Educate people regarding the causes and symptoms of poor mental health; this can be a way of preventing mental health problems. Introduce wellbeing self help workshops in the community and promote the books on prescription scheme. Raise awareness of mental health and the link to physical health, in mental health settings and physical health settings. Early intervention – Commission mental health/wellbeing training for front line staff to identify and signpost individuals. Tackle risk factors with an emphasis on promoting protective factors – especially for those at risk of mental health problems – including addressing alcohol, drug and tobacco use, and promote social and life skills, healthy eating and keeping physically active. Universal services provide by GP’s, hospitals, midwives, health visitors, schools and housing organisations have been shown to be effective in raising standards of physical health – they should be now be clearly charged with the responsibility for improving standards of emotional wellbeing Ensure Central Bedfordshire workplaces are exemplars of healthy working environments – The workplace provides a convenient location for addressing the physical and mental health of a large proportion of the adult population. Problems inside and beyond work can be identified and tackled, and there is also scope for general health promotion. Targeted programmes tend to be more effective. Methods for changing behaviour need to be aligned with cultures, cognitive styles and social contexts. A mental wellbeing programme can assist in reducing health inequalities and thus: Reduce morbidity and mortality from common disorders (e.g. CHD, diabetes) Reduce demand on NHS and social care Integrate approaches to mental health and substance misuse by developing joint protocols, training of staff in mental health trusts on substance misuse and training of staff in substance misuse services in mental health problems. Challenge stigma and discrimination – The provision of accurate public information is needed to combat the stigma of mental health issues. By improving the understanding of mental health, negative attitudes and behaviours to people with mental health will decrease. 17 The stigma associated with mental health is more strongly felt by men. This is said to be because men are more concerned than women about appearing ‘capable’. The stigma surrounding mental health problems within the veteran community is very strong (the average delay between becoming ill with psychological problems associated with active service and seeking help is ten years). Men are more likely than women to express psychological distress through behaviours such as aggression and substance misuse. Nationally and locally gender is the biggest risk factor for suicide. Gender-specific, anti-stigma and wellbeing campaigns should be developed, using male specific (and female specific) materials instead of, or in addition to, materials aimed at the whole population. Men’s support groups and service user champions should be encouraged and developed. Men prefer non talking social interventions such as physical exercise in team sports, making music together and allotments, which increase social networks. Homeless people have 40 to 50 time’s higher rates of mental health problems than the general population and 40 times less likely to be registered with a GP and five times more likely to use A&E (Department of Health 2010). Improving access to primary care by using innovative approaches such as running primary care services in hostels and offering flexible appointments or outreach. Improve maternal health - the health of women before, during and after pregnancy is a critical factor in giving children a healthy start in life and for laying the foundation for good health and well being in later life. Pregnancy and the postnatal period are key times for early interventions. It is when expectant mothers are motivated to learn what is best for their child. 18 References: Foresight (2008). 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Br J Psychiatry 2011; 199(6):453-458 Marmot M. 2010: Fair society, healthy lives: The Marmot Review. Strategic Review of Health inequalities in England post – 2010 Bond G, Drake R and Becker D (2008) An update on randomised controlled trails of evidence-based supported employment. Psychiatric Rehabilitation Journal 31(4): 280-290. Burns T, Catty J, White S (2009) The impact of supported employment and working on clinical and social functioning: results of an international study of Individual Placement and Support. Schizophrenia Bulletin 35@949-958. Katon W, Unutzer J, Fan MY et al. (2006) Cost effectiveness and net benefit of enhanced treatment for depression for older adults with diabetes and depression. Diabetes Care 29: 265-70 QIPP Workstream (early intervention and community teams) version 2, NHS West Midlands, 2010 19
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