Summary

Currently a detailed review of adult mental health services is under way in Merton, which includes a mental health needs assessment. The review will result in the development of an adult mental health strategy for Merton and will be used to update the mental health section of the JSNA.

Key facts on mental health

One in four people in the UK will experience a mental health problem in the course of a year. The cost of mental health problems to the economy in England has recently been estimated at £105 billion each year and treatment costs are expected to double in the next 20 years (NEPHO). In 2004, 22.8% of the total burden of disease in the UK was attributable to mental disorder (including self-inflicted injury), compared with 16.2% for cardiovascular disease and 15.9% for cancer, as measured by disability-adjusted life years (DALYs).1 Depression alone accounts for 7% of the disease burden, more than any other health condition. It is predicted that, by 2030, neuropsychiatric conditions will account for the greatest overall increase in DALYs.2

Key commissioning implications for services to support improved mental health and wellbeing

As mentioned earlier, the Merton adult mental health services review is currently under way and will help to inform future commissioning intentions. The recommendations will be included in a refresh of the mental health section of the current joint strategic needs assessment (JSNA) when it is ready and available.

With changes proposed for commissioning in the NHS, as well as changes to Public Health, and the drive to provide care in community settings, it is imperative that consideration is given to the overlap between commissioning inpatient mental healthcare for people with dual diagnosis and support in the community. Further investigation is recommended to identify the specific needs of this group of individuals to assess whether the balance of admission and community support is appropriate and to understand which services care is accessed through.

In terms of treatment services, commissioners should focus on developing a whole system approach to mental health with more joined-up services to improve experience and outcomes. They should also focus on developing better data and local information on outcomes, and on addressing health inequalities in relation to mental health. There should be further investigation into why Merton has higher rates of depression than London, in light of its wider good health, and a focus on improving recovery rates following psychological therapies. Further work is also needed to understand access by and for ethnic minorities. A health equity audit for mental health services would be useful to support this.

Commissioners need to give consideration to local data that has suggested a number of areas where mental health can reduce health costs and lead to physical and mental health gains:

  • High costs associated with unnecessary and unplanned admissions amongst people with a range of long-term conditions could be reduced with motivational work to support lifestyle change and psychological support to distinguish symptoms requiring medical attention from symptoms of anxiety or depression.
  • High numbers of young people and their families presenting frequently and unnecessarily at A&E with asthma or minor injuries could be reduced with assistance to manage anxiety and improve self-care.
  • High-cost areas (mostly associated with sheltered housing where the top 25% accounted for nearly half of cost) could be reduced with the provision of support to staff and people living in sheltered accommodation and residential care to manage difficult situations and distinguish symptoms requiring medical attention from symptoms of anxiety or depression.

Recommendations from the insight work by Resonant Media

Resonant Media has developed recommendations across three areas to address these barriers and improve the existing service provision. These will inform, encourage and support service users to access physical health services.

Involving the service users themselves in shaping and delivering services is key to all the recommendation areas. This will build trust in the services and ensure that they are genuinely shaped for their needs.

GPs

Since GP practices are so busy it can be difficult to engage with them and change their practice. The research suggested initially developing a couple of best practice pilots. One or two selected GP surgeries would act as pilot projects to implement improved services for those with SMI. Positive results from these pilots, on outcomes such as do not attends (DNAs), could then be used to encourage other GP practices to implement the improved services.

Further training on working with those with mental health problems is also suggested for all who work in GP practices. This should utilise existing training courses and times when the staff are already gathered together.

System level

To drive forward proper links locally between the physical health and mental health services, a senior level champion needs to be identified to drive this forward. This champion could help with creating specific targets around physical health for those with SMI. They would also lead on the future development of co-located services and multidisciplinary teams.

The recommendations of Resonant Media address all four of the social marketing intervention modes – support; design; inform and educate; and control – to try to increase levels of those with SMI accessing physical health and health promotion services and thus reducing their health inequalities.

Key commissioning implications for services to reduce suicide

Commissioners need to give consideration to the recommendations in the Department of Health’s National Suicide Prevention Strategy for England:

  • prevention targeted at high-risk groups e.g. those in recent contact with mental health services, those who have self-harmed, young men and those in high-risk occupations
  • reducing access to lethal methods of self-harm, such as hanging and strangulation, in wards and prisons
  • promoting positive mental health and social inclusion, particularly among the vulnerable
  • multi-faceted strategies to prevent, identify and address behaviours linked to a high risk of suicide in school.

Key facts on mental health and wellbeing

Mental illness is generally applied to conditions on a spectrum ranging from those almost entirely managed in primary care to conditions that are almost exclusively managed by specialists. The link between mental health problems and social exclusion is intricate and well documented. Mental ill health can be both the cause and the consequence of social exclusion leading to a vicious cycle of homelessness, unemployment, and worsening physical and mental health.

In the UK, 1 in 4 people will experience a mental health problem in the course of a year. The cost of mental health problems to the economy in England has recently been estimated at £105 billion each year and treatment costs are expected to double in the next 20 years (NEPHO). In 2004, 22.8% of the total burden of disease in the UK was attributable to mental disorder (including self-inflicted injury), compared with 16.2% for cardiovascular disease and 15.9% for cancer, as measured by DALYs.1Depression alone accounts for 7% of the disease burden, more than any other health condition. It is predicted that by 2030, neuropsychiatric conditions will account for the greatest overall increase in DALYs.2

In 2011, the Department of Health launched its strategy ‘No Health Without Mental Health’ (DH 2011), which takes a cross-government approach, including promoting mental wellbeing, reducing stigma and focusing on improving outcomes for people with mental illness.

The key inequalities experienced by people with mental health problems are:

  • Low levels of employment: less than 25% of people with mental ill health work although many would like to do so. Of those with severe and enduring mental illness, 58% are capable of employment. During long-term unemployment, mental health can deteriorate thus further reducing the chance of gaining work.
  • Social exclusion: this might arise through stigma, discrimination and difficulties in maintaining social and family networks.
  • Barriers to accessing health services: the Social Exclusion Report (2004) indicated that 44% of people with mental ill health were dissatisfied with their GP because their physical health problems/symptoms were dismissed as a mental health issue.
  • Poorer physical health and increased mortality from some diseases. This may result from misdiagnosis of physical ailments; reluctance or inability to access health services; and unhealthier lifestyles e.g. poor diet, less exercise and higher levels of smoking.

Key inequalities in physical health for people with serious mental health problems are:

  • A person with schizophrenia is at risk of dying on average 20 years prematurely.
  • Around 50% of people with mental ill health smoke (this varies with the type of mental illness and gender), compared with around 27% of the general population.
  • Approximately 30% of people misusing drugs have mental health problems. In one study, half of alcohol-dependent adults said they had a mental health problem.
  • People with serious mental illnesses have twice the risk of developing diabetes compared with the general population,5 2-3 times the risk of hypertension and 3 times the risk of dying from coronary heart disease.

The inequalities described above are present and often more severe amongst people in BAME groups with mental health problems. Additional inequalities include:

  • increased risk of hospital admission and coercive care under the provisions of the Mental Health Act 1983
  • greater difficulty accessing mental health assessment and treatment
  • higher levels of dissatisfaction with mental health services
  • greater likelihood of considering their diagnosis inappropriate
  • greater likelihood of having medical problems misattributed to mental health.

A recent report by Rethink, ‘Lethal Discrimination’, published in September 2013,7found that:

  • more than 40% of all tobacco is smoked by people with mental illness, but they are less likely to be given support to quit
  • fewer than 30% of people with schizophrenia are being given a basic annual physical health check
  • people gain an average of 13lbs in the first two months of taking antipsychotic medication and this continues over the first year. Despite this, in some areas 70% of people in this group are not having their weight monitored
  • many health professionals are failing to take people with mental illness seriously when they raise concerns about their physical health.

Locally there is limited definitive data on prevalence and incidence of mental health conditions. The local Mental Health Strategy included a basic review of expected mental health needs in Merton, based on national evidence. This estimated that overall 15,800 adults have depression and/or anxiety, 2,600 adults have bipolar disorder and 900 adults have schizophrenia (2010).

However currently a detailed review of adult mental health services is under way in Merton, which includes a mental health needs assessment. The review will result in the development of an adult mental health strategy for Merton and will be used to update the mental health section of the JSNA.

Expected prevalence of mental health conditions in working age adults (18-64) in Merton, London and England in 2012 and 2018. The table shows the modelled prevalence for mental health conditions in Merton, London and England for two periods 2012 and 2018. The figures show that the prevalence increases in time at all administrative levels and for all conditions.

Source: Projecting Adult Needs and Service Information (PANSI) website 08.10.2013

Based on the Adult psychiatric morbidity in England, 2007: Results of a household survey, published by the Health and Social Care Information Centre in 2009.

Expected prevalence of depression and severe depression in older people (65+) in Merton, London and England in 2012 and 2018.

The table shows the modelled prevalence in Merton, London and England for two periods 2012 and 2018. The figures show that the prevalence increases in time at all administrative levels and for all conditions.

Source: Projecting Older People Information System (POPPI) web site 08.10.2013

Estimated prevalence of depression in men and women (65+) in England.

Estimated prevalence of mental health conditions in Merton compared with other London boroughs, NEPHO 2006.

Estimated numbers of people in Merton predicted* to have a common mental disorder or two or more psychiatric disorders projected from 2012 to 2020.

Prevalence % Males % Females
Common mental disorder 12.5 19.7
Two or more psychiatric disorders 6.9 7.5

Common mental disorders (CMD's)cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. They include depression, anxiety, and obsessive compulsive disorder. The report found that 19.7% of women and 12.5% of men surveyed met the diagnostic criteria for at least one CMD.

Psychiatric comorbidity – or meeting the diagnostic criteria for two or more psychiatric disorders – is known to be associated with increased severity of symptoms, longer duration, greater functional disability and increased use of health services. Disorders include the most common mental disorders (namely anxiety and depressive disorders) as well as: psychotic disorder; anti-social and borderline personality disorders; eating disorder; post-traumatic stress disorder (PTSD); attention deficit hyperactivity disorder (ADHD); alcohol and drug dependency; and problem behaviours such as problem gambling and suicide attempts. Just under a quarter of adults (23.0%) met the criteria or screened positive for at least one of the psychiatric conditions under study. Of those with at least one condition: 68.7% met the criteria for only one condition, 19.1% met the criteria for two conditions and 12.2% met the criteria for three or more conditions. Numbers of identified conditions were not significantly different for men and women.

Estimated numbers of working age people in Merton predicted* to have a personality or psychotic disorder projected from 2012 to 2020.

Prevalence % Males % Females
Borderline personality disorder 0.3 0.6
Anti-social personality disorder 0.6 0.1
Psychotic disorder 0.3 0.5

Personality disorders are long-standing, ingrained distortions of personality interfering with the ability to make and sustain relationships. Anti-social personality disorder (ASPD) and borderline personality disorder (BPD) are two types with particular public and mental health policy relevance.

ASPD is characterised by disregard for and violation of the rights of others. People with ASPD have a pattern of aggressive and irresponsible behaviour which emerges in childhood or early adolescence. They account for a disproportionately large proportion of crime and violence committed. ASPD was present in 0.3% of adults aged 18 or over (0.6% of men and 0.1% of women).

BPD is characterised by high levels of personal and emotional instability associated with significant impairment. People with BPD have severe difficulties with sustaining relationships, and self-harm and suicidal behaviour are common. The overall prevalence of BPD was similar to that of ASPD, at 0.4% of adults aged 16 or over (0.3% of men, 0.6% of women).

Psychoses are disorders that produce disturbances in thinking and perception severe enough to distort perception of reality. The main types are schizophrenia and affective psychosis, such as bipolar disorder. The overall prevalence of psychotic disorder was found to be 0.4% [of adults aged 18 or over] (0.3% of men, 0.5% of women). In both men and women the highest prevalence was observed in those aged 35 to 44 years (0.7% and 1.1% respectively). The age standardised prevalence of psychotic disorder was significantly higher among black men (3.1%) than men from other ethnic groups (0.2%of white men, no cases observed among men in the South Asian or 'other' ethnic group). There was no significant variation by ethnicity among women.

Mental wellbeing

Having good mental health and wellbeing is of vital importance for long-term physical health. The Foresight Report published in 2008 highlights the link between long-term stress and poorer physical health. Until recent years there has been much less focus on mental wellbeing compared with mental health but the evidence emerging from the Foresight Report and the WHO has put an emphasis on both local authority and Health Services working together to tackle wellbeing, not only for the population they cover but also for the workforce.

The five factors identified as key in achieving mental wellbeing are:

  • Connecting – creating strong social networks
  • Physical activity
  • Taking notice – noticing not only what is happening around you but also noticing your own feelings
  • Lifelong learning
  • Giving – supporting family and friends and volunteering in the community.

The Office for National Statistics (ONS) is leading a programme of work to develop new measures of national wellbeing. Based on estimates of subjective wellbeing (2012) in Merton:

  • 27% of adults reported low satisfaction with their lives, higher than for England (24%).
  • 22% of adults reported a low score for feeling the things they do in life are worthwhile, similar to England (20%).
  • 30% of adults reported low levels of happiness, similar to England (29%)
  • 43% of adults reported a high anxiety score, higher than England (40%).

Mental ill health and physical ill health

There is a significant link between mental ill health and physical ill health, not only from the perspective that poor mental health and wellbeing can lead to poor physical health but also that people who have poor mental health can have physical health problems that often go undetected.

A briefing document by South-West London and St. George’s NHS Mental Health Trust summarised recent evidence to highlight these issues. It found people with mental health and physical health needs often find it difficult to access services for their physical health concerns for a variety of reasons. These include:

  • few mental health inpatient units have GPs attached to them
  • for many people with mental health needs, especially secondary care mental health needs, GP practices often seem unwelcoming or unsupportive environments
  • when such a person approaches physical health services the clinician may well perceive their physical health needs as being a construction of their patient’s mental health – ‘diagnostic overshadowing.

This situation can have a very severe impact on the health and wellbeing of those people as it decreases the opportunities for prevention and early intervention. As a consequence, those individuals may only access physical health services through A&E or when their physical health needs have reached a very developed state.

A range of research indicates that the reasons for health inequalities among people with severe mental illness are complex and likely to include poverty, lifestyle, access to health assessments and treatments, and the side effects of antipsychotic and mood stabiliser medication. These inequalities cannot be explained by the mental health problem alone.

The GP consultation rate for people who use mental health services is much higher than average: 13-14 times per year compared with 3-4 times for the general population.

The landmark 1980 study by Richard Hall et al found that 46% of the psychiatric patients thoroughly examined had physical ailments causing or exacerbating their mental symptoms.

A significant proportion of people with a range of physical health needs also have co-existing mental health needs or their mental state is made worse by their physical condition.

Examples of this are:

  • A serious physical illness can affect every area of life, such as relationships, work, spiritual beliefs and how people socialise. This can result in increased levels of anxiety and depression.
  • Some drug treatments, such as steroids, affect the way the brain works and so cause anxiety and depression directly.
  • Some physical illnesses, such as an underactive thyroid, affect the way the brain works. They cause anxiety and depression directly.
  • Recent research has shown that a history of celiac disease makes the risk of developing schizophrenia 3.2 times higher.
  • Cancer – 33% of patients suffer depression and these patients remain in hospital 40% longer, resulting in 35% more costs. Meta-analysis of PCTs revealed sustained beneficial gain from short-focused cognitive behavioural therapy (CBT) in terms of mental health, functional adjustment (return to work), and physical symptoms. There is also evidence of increased survival rates and increased coping and quality of life-years.

Many long-term conditions (LTCs) are associated with elevated rates of mental ill health e.g. anxiety and depression are 2-3 times more common in people with diabetes compared with general population, at 4 times the health cost of diabetes without an LTC.

References

1.^ World Health Organization (2008). The global burden of disease. WHO.

2.^ World Health Organization (2004). Projections of mortality and burden of disease2004-2030. WHO.

3.^ Brown, S., Kim, M., Mitchell, C. and Inskip, H. (2010). Twenty-five year mortality of a community cohort with schizophrenia. British Journal of Psychiatry 196 pp. 116-121.

4.^ Parks, J., Svendsen, D., Singer, P. et al. (2006). Morbidity and Mortality in People with Serious Mental Illness. 13th technical report. Alexandria, Virginia: National Association of State Mental Health Program Directors.

5.^ Royal College of Psychiatrists (2013). Whole person care: from rhetoric to reality. Achieving parity between mental and physical health. Occasional paper OP88.

6.^ Osborn, D.P.J. (2007). Physical activity, dietary habits and coronary heart disease risk factor knowledge amongst people with severe mental illness: a cross sectional comparative study in primary care. Social Psychiatry Psychiatric Epidemiology pp. 787-93.

7.^ Rethink (2013). Lethal Discrimination

8.^ Rethink Briefing: Physical health and mental health accessed on 07/06/2011.

9.^ DH (2006). Choosing Health: Supporting the physical health needs of people with severe mental illness. Commissioning framework, August 2006. Department of Health, London.

10.^  Hall, R., et al. (1980). Physical illness manifesting as psychiatric disease: II. Analysis of a state hospital inpatient population. Archives of General Psychiatry, Vol 37(9), Sep 1980, 989-995.

11.^ Royal College of Psychiatrists Physical Illness and Mental Health.

12.^ Eaton,W., Mortensen, P.B., Agerbo, E., Byrne, M., Mors, O. and Ewald, H. (2004). Coeliac disease and schizophrenia: population based case control study with linkage of Danish national registers. British Medical Journal 328 438-439.