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Adult mental health: what works and best practice

There is a vast array of National Institute for Health and Care Excellence (NICE) publications on mental health and related conditions. It is not possible to list them all here but the reader is advised to look these up at the NICE website.

However there are some key points on what works to improve mental health and wellbeing of people with mental health problems:

  • employment support for people with mental health problems
  • information and support for people with mental health problems to improve access to work and social opportunities (e.g. through day care or primary care services.
  • promotion of positive mental health in schools
  • improved diagnosis and management of common mental disorders in primary care, e.g. anxiety and depression
  • equitable access to mental health services e.g. for black, Asian and minority ethnic (BAME) communities
  • supporting community involvement for people who are at risk of social isolation or where they are disaffected.

The Department of Health published a cross-government strategy on mental health, No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages, in 2011 (the Strategy).

The Strategy focuses on six shared objectives:

  • More people will have good mental health.
  • More people with mental health problems will recover.
  • More people with mental health problems will have good physical health.
  • More people will have a positive experience of care and support.
  • Fewer people will suffer avoidable harm.
  • Fewer people will experience stigma and discrimination.

The objectives are based on three guiding principles:

  • Freedom
  • Fairness
  • Responsibility.

The strategy aims to bring about significant change in people’s lives. Bringing the changes, for everyone, across the country and in the most effective way, will mean that:

  • Mental health has ‘parity of esteem’ with physical health within the health and care system.
  • People with mental health problems, their families and carers, are involved in all aspects of service design and delivery.
  • Public services improve equality and tackle inequality.
  • More people have access to evidence-based treatments.
  • The new public health system includes mental health from day one.
  • Public services intervene early.
  • Public services work together around people’s needs and aspirations.
  • Health services tackle smoking, obesity and co-morbidity for people with mental health problems.
  • People with mental health problems have a better experience of employment.
  • We tackle the stigma and discrimination faced by people with mental health problems.

Department of Health Analysis of the Impact on Equality (AIE)

The AIE explains and analyses the impact of equality on the six shared objectives identified in the Strategy. The Equality Act 2010 covers nine protected characteristics, and there is a public sector duty to advance equality and reduce inequality for people with these protected characteristics.

There are three aspects to reduce mental health inequality:

  • tackling the inequalities that lead to poor mental health
  • tackling the inequalities that result from poor mental health – such as lower employment rates, and poorer housing, education and physical health
  • tackling the inequalities in service provision – in access, experience and outcomes.

Department of Health No Health Without Mental Health: Implementation framework

The national policy integrates mental health and physical health and suggests that there should be a collaborative programme of action to achieve the ambition that mental health is on a par with physical health:

  • Local planning and priority setting should reflect the mental health needs of the population. Mental health and wellbeing are integral to the work of CCGs, health and wellbeing boards, and other local organisations.
  • To translate the vision into reality, people with mental health, and their families and carers, should be fully involved in planning, priority setting and delivery of services.
  • Services should actively promote equality and be accessible, acceptable, and culturally appropriate to all the communities. Public bodies should meet their obligations under the Equality Act 2010. People including children, young people, older people, and people from ethnic minorities should have access to IAPT.
  • All people should receive evidence-based mental health promotion. Schools and colleges should promote good mental health for all children and young people, alongside targeted support for those at risk of mental health problems.
  • The Public Health Outcomes Framework (PHOF) includes mental health measures. Local public health services deliver clear plans for mental health.
  • All organisations should recognise the value of promoting good mental health.
  • Public services should recognise and identify people at risk of mental health problems and take appropriate, timely action, including using innovative service models. Early recognition and intervention will enable stopping serious consequences from occurring.
  • Public health campaigns should include people’s mental health as well physical health. Services tackle and support people with dual diagnosis and substance misuse to achieve better outcomes and reduce cost.
  • Services working together support people with mental health problems to maintain, or to return to employment.
  • Frontline workers, across the full range of services, are to be trained to understand better about mental health, the principles of recovery and be able to tackle any stigma related to mental health.

No health without public mental health: The case for action, Royal College of Psychiatrists (RCP), 2010

This report describes the key points and features that should be part of a public mental health strategy:

  • There is no public health without public mental health. Investment is needed to promote public mental health. This will enhance population wellbeing and resilience against illness, promote recovery, and reduce stigma and the prevalence of mental illness.
  • The Royal College of Psychiatrists strongly supports the findings of the Marmot Strategic Review of Health Inequalities in England post 2010. It recognises that inequality is a key determinant of illness, which then leads to even further inequality. Government policy and actions should effectively address inequalities to promote population mental health, prevent mental ill health and promote recovery.
  • Physical health is inextricably linked to mental health. Poor mental health is associated with other priority public health conditions, such as obesity, alcohol misuse and smoking, and with diseases such as cancer, cardiovascular disease and diabetes. Poor physical health also increases the risk of mental illness.
  • Interventions which apply across the life course need to be provided. Since the majority of mental illnesses have childhood antecedents, childhood interventions which protect health and wellbeing and promote resilience to adversity should be implemented. If mental health problems occur there should be early and appropriate intervention. Strategies to promote parental mental health and effectively treat parental mental illness are important since parental mental health has a direct influence on child mental health.
  • Older people also require targeted approaches to promote mental health and prevent mental disorder, including dementia. Action is needed to promote awareness of the importance of mental health and wellbeing in older age as well as ways to safeguard it. Ageist attitudes need to be challenged and values promoted that recognise the contributions older people make to communities, valuing unpaid, voluntary work as we do economic productivity.
  • An effective public health strategy requires both universal interventions, applied to the entire population, and interventions targeted at those people who are less likely to benefit from universal approaches and are at higher risk, including the most socially excluded groups. Such groups include children in care or subject to bullying and abuse, people of low socioeconomic status, those who are unemployed or homeless, those with addictions or intellectual disability, and other groups subject to discrimination, stigma or social exclusion. Health promotion interventions are particularly important for those recovering from mental illness or addiction problems. Those with poor mental health as well as poor physical health require effective targeted health promotion interventions.
  • The prevention of alcohol-related problems and other addictions is an important component of promoting population health and wellbeing. The RCP supports the development of a minimum alcohol pricing policy and a cross-government, evidence-based addictions policy.
  • Smoking is the largest single cause of preventable death and health inequality. It occurs at much higher rates in those with mental illness, with almost half of total tobacco consumption and smoking-related deaths occurring in those with mental disorder. Therefore, mental health needs to be mainstreamed within smoking prevention and cessation programmes.
  • A suicide prevention strategy should remain a government priority and should include strategies to address and reduce the incidence of self-harm.
  • Collaborative working is required across all government departments in view of the cross-government benefits of public mental health interventions across a range of portfolios, such as education, housing, employment, crime, social cohesion, culture, sports, environment and local government. Actions to combat stigma related to mental illness should be included in these strategies.
  • Doctors can be important leaders in facilitating local and national implementation of public mental health strategies. Many psychiatrists already adopt a public mental health approach in their work and influence national and local strategy. Psychiatrists should be supported in assessing the needs of their local population for health promotion.
  • Psychiatrists should be engaged in the commissioning process and inform commissioners of the expected prevalence of specific disorders to anticipate levels of service provision and unmet need, and to help prioritise resource allocation. Support and training are required to facilitate this.
  • Commissioners should take into account the effects of mental health and mental illness across the life course as well as the economic benefits of protecting and promoting mental health and wellbeing.
  • Commissioners should consider the existing arrangements and adequacy of services for comorbid disorders and unexplained medical symptoms where cost-effective interventions could be provided.

What works to improve mental wellbeing in older people (NICE 2008)

  • Occupational therapy involvement in the design and development of locally relevant training schemes for those working with older people.
  • Advice and support to older people and carers.
  • Regular sessions based on occupational therapy principles to aid daily routine activities.
  • Advice and information on health, personal care, safety and other issues.
  • Commissioning tailored exercise programmes.
  • Developing, organising and promoting walking schemes.

For further information see Mental wellbeing and older people overview (NICE website)

NICE Clinical Guideline CG123: Common mental health disorders: Identification and pathways to care, 2011

Common mental health disorders are depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and social anxiety disorder. Depression and anxiety disorders can have a lifelong course of relapse and remission. There is considerable variation in the severity of common mental health disorders, but all can be associated with significant long-term disability. This guideline offers best practice advice on the care of adults with a common mental health disorder.

This guideline offers advice on the identification and the care of adults who have common mental health disorders with a particular focus on primary care.

The priorities for implementation are:

  • Improving access to services: Services need to be integrated for delivery, with clear explicit criteria for entry to the services, focused on entry and not on exclusion criteria. There should be multiple ways to entry to the services including self-referral, and multiple points of access with links to wider healthcare system. People with a common mental health problem should be provided with information about services and available treatments according to their knowledge and understanding of mental health disorders appropriate to the communities. Local care pathways should promote access to the services by wider communities including socially excluded groups such as black and minority ethnic groups, older people, those in prison or in contact with the criminal justice system and ex-service personnel.
  • Stepped care: Use of the stepped-care model to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals, is the most effective way of interventions.
  • Identification and assessment: It is important to identify early possible depression particularly in people with a past history, and assessment should be done by competent staff and provide appropriate treatment and referral accordingly.
  • Treatment and referral for treatment
  • Developing local care pathways: A collaborative local care pathway needs to be developed for people with common mental health problems. The local care pathway should promote implementation of the key principles of good care. It should be negotiable, workable, accessible and acceptable by wider communities who are in need of the services. It should be outcome focused.

NICE Quality standard QS8: Depression in adults, 2011

This quality standard covers the assessment and clinical management of persistent subthreshold depressive symptoms, or mild, moderate or severe depression in adults (including people with a chronic physical health problem).

NICE Quality standard QS14: Service user Experience in adult mental health, 2011

This quality standard outlines the level of service that people using the NHS mental health services should expect to receive. It covers improving the experience of people using adult NHS mental health services. It does not cover mental health service users using NHS services for physical health problems, or the experiences of families or carers of people using NHS services specifically.