Transcript Public mental health

Public mental health
Peter Byrne,
Consultant liaison psychiatrist at Homerton Hospital
Assoc Registrar / Public mental health lead, RCPsych &
Visiting Professor, University of Strathclyde, Glasgow
@pubmentalhealth
[email protected]
Content
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Why and How of Public Mental Health
Big 4: our services, stolen years, lifestyle, EI
Early intervention: think children and elders
Chief Medical Officer (E&W) 2014 Report
Inequalities
Debates: smoking, vaping & abstaining
Start a debate with users, carers & others: the
What (to prioritise) of Public Mental Health
Public
Education
Psychoeducation
Public
Engagement
Public Mental Health
Davies & Mehta,
2014: as quoted
by CMO England
Public mental health (PMH) definition
1. Mental health prevention: e.g. CMO Report of
2012 on children, Prevention Pays …(women 2015)
2. Mental health promotion: often this involves
NOT doing things (alcohol, drug misuse) as
well as proven (exercise, MH first aid) and the
not-so-proven (well being promotion)
3. Treatment, recovery, rehabilitation (overlap):
this is what MH clinicians spend all time on
What’s the evidence for PMH?
• Epidemiology: RCPsych “1
in 4” tag apples to people
who have common mental
disorders (depr +/- anxiety):
60% of these are working.
• Economic: £70-100b/ year
equal to 4.5% LOST to GNP
• Both: since 2008 crash,
suicide rates rose by 4%...
Self harm rates increasing
• Special challenges:
alcohol misuse in over 65s
men ↑ by 60% in 20 years;
↑ by 100% in older women
• Premature mortality gap
= “Stolen years”: why do
people with SMI die >15
years before the rest of the
(matched) population?
Glasgow man with SZ loses
26 years; women lose 23 yrs
Start at the beginning: challenges
• There are lots of people out there who have
MH problems (CMD… alcohol… eating ds…SMI)
but are not engaged in any treatment for this
We call this the Treatment gap: 75%
• Access to services blocked by stigma (incl
internalised stigma), gatekeepers, lack of funds
• Parity of esteem: MH = 28% of morbidity, but
gets 13% of UK health spending, falling slowly
But that is NOT the beginning
• Genetic associations with MH disorders
• Perinatal interventions protect M and child
• Children’s lives ruined by parental alcohol and
drug misuse: services cut, alcohol cheaper
• Inequalities → MH probs, self harm, stolen years
• Current disinvestment in children’s services
• Early Intervention: lip service, pilots, or nothing
• Evidence-based parenting programmes: no £
Parenting Skills Training
Systematic reviews have shown that parenting interventions are effective in
improving maternal psychosocial health,(77) reducing child behavioural
problems in infants and toddlers,(78) and in children aged 3 to 10 years
old,(79) reducing unintentional injuries in children aged 18 years and
younger(80) and improving the mental health of families with children with
conduct disorders (NICE, 2006). These programmes also reduce antisocial
behaviour and offending.(81-83)
RCPsych Response to Marmot (Inequalities) Review, 2010
(77) Barlow J, Coren E, Stewart-Brown S. Parent-training programmes for improving maternal psychosocial health. Cochrane
Database of Systematic Reviews 2003;(4).
(78) Barlow J, Parsons J. Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3
year old children. Cochrane Database of Systematic Reviews 2003 2003;(2).
(79) Barlow J, Stewart-Brown SL. Review article: behavior problems and parent-training programs. Journal of Developmental and
Behavioral Pediatrics 2000;21(5):356-70. (80) Kendrick D, Barlow J, Hampshire A, Polnay L, Stewart-Brown S. Parenting
interventions for the prevention of unintentional injuries in childhood. CochraneDatabase of Systematic Reviews 2007;(4).
(81) Hutchings J, et al. Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic
randomised controlled trial. BMJ 2007;334:7595. (82) Scott S. An update on interventions for conduct disorder. Advances in
Psychiatric Treatment 2008;14(61):70. Page 52 of 52
(83) Woolfenden SR, Williams K, Peat J. Family and parenting interventions in children and adolescents with conduct disorder and
delinquency aged 10-17. The Cochrane Database of Systematic Reviews, 2006; 2006.
Concepts and slogans
• Cartesian dualism: the separation of diseases
of the mind from diseases of the body (misQ)
• Separation of physical health services from
mental health services
• No health without mental health
• Parity of esteem
• No mental health without physical health:
mens sano in corpore sano
Two questions
• Number One preventable cause of cancer?
In reality, the Number
One Cause of cancer.
• Number 2 preventable cause of cancer?
Neuropsychiatric sequelae Alcohol
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Amnesias (e.g. blackouts)
Withdrawal seizures
Confusion (acute / chronic)
Head injury / subdural
Cerebellar damage
Peripheral neuropathy
Depression & anxiety
↑self-harm, ↑suicide
Hallucinosis, psychosis
Impotence / libido probs
Evidence based measures: 7
Babor et al, 2010: Alcohol - no ordinary commodity
• Pricing: alcohol taxes
• Regulate availability:
minimum age, licencing
hours, no. of outlets
• Modify drinking environ:
server liability, enforce on
premises laws, train staff
• Drink driving: best evidence
- some behaviours can &
need to be stigmatised
• Early intervention: selfhelp, mutual help, IBA,
medical detox IF linked
with talking therapies,
weak evid for pharmacol
• Restrict marketing: laws
work, less so vol codes
• Educ & Persuasion: labels,
classroom, mass media –
less strong evidence
The Great Lie: we need more evidence
Alcohol Minimum Pricing Act
(Scotland), June 2012
The Chief Medical Officer believes that like the smoking ban - minimum price
would save lives within a year. Research
by the University of Sheffield estimated
that the proposed minimum price of
50p per unit would result in the
following benefits:
• Alcohol related deaths would fall by
about 60 in the first year and 318 by
year ten of the policy
• A fall in hospital admission of 1,600
in year 1, and 6,500 per year by year
ten of the policy
• A fall in crime volumes by around
3,500 offences per year
• A financial saving from harm
reduction (health, employment,
crime etc) of £942m over ten years
Inequalities
Cigarettes
Mental illness
Low income, U/E, low
education, poor
health, health risks
Worst possible
outcomes
X 3 fold differences in
MH probs and DSH
between top 20% and
bottom 20% incomes
Obesity
Alcohol
misuse
Self-harm and Suicide
• Up to 10% of young people have self harmed,
of which 1 in 8 have sought treatment
• <65: 30-40 hosp DSH for each suicide; >65: 10
• Suicide rates fell until 2008: since then 4% rise
• 28% of suicides had contact with MH services
in previous year; ½ of these contact that week
• Hanging in 2/3 men & > 1/3 women who die
• Prevention: access to method, alcohol, services
RCPsych Manifesto
Sept 12, 2014. The manifesto has six key asks:
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Everyone who requires a mental health bed should be able to access
one in their local NHS Trust area, unless they need specialist care and
treatment. If specialist care is required, then this should be provided within a
reasonable distance of where the patient lives.
2.
No-one should wait longer than 18 weeks to receive treatment for a
mental health problem, if the treatment has been recommended by NICE
guidelines and the patient’s doctor.
3.
Everyone experiencing a mental health crisis, including children and
young people, should have safe and speedy access to quality care, 24 hours a
day, 7 days a week. The use of police cells as ‘places of safety’ for children
should be eliminated by 2016, and by the end of the next Parliament occur
only in exceptional circumstances for adults.
…/ RCPsych manifesto
4.
Every acute hospital should have a liaison psychiatry
service which is available seven days a week, for at least 12
hours per day. This service should be available to patients across
all ages. Emergency referrals should be seen within one hour,
and urgent referrals within five working hours.
5.
A minimum price for alcohol of 50p per unit should be
introduced. This will reduce the physical, psychological and social
harm associated with problem drinking, and will only have a
negligible impact on those who drink in moderation.
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There should be national investment in evidence-based
parenting programmes, in order to improve the life chances of
children and the well-being of families.
CMO Report
• “more accurate data”, “more research needed”
• Some use in collecting well-being data
• Questions Rose hypothesis: “better well-being
leads to less mental disorders”
• Advising commissioners NOT to invest in wellbeing promotion unless (new) evidence
• Recommendations limited or obvious (data
and training) but highly quotable text
Where else should we go?
• Some role in MH Promotion: Director of Public
Education → Director of Public Engagement
• Until recently, www.rcpsych.ac.uk was the
number 2 site (to APA) for MH information
• By speciality (MH cannot be ageless), MH
prevention: primary “vague”; secondary = EI
• Branding: gen hosp / “liaison” psychiatry,
psychological medicine, EI in a general hosp
Older adults
• Specialist MH services: <65 16% of population,
>65 34% of this age group use these services
• Multimorbidity, poorer outcomes, less £
• Depression in 10-20% of community >65, but
20-30% of gen hospital / care home >65
• Older people in general hosp: 1/5 delirium, 2/3
have a treatable MH disorder… RAID investment
• To achieve parity with 35-55 y.o. +24% increase
Smoking cessation
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Now 18% smoking rates, England
Anti-smoking messages work (middle class)
>50% mortality differences rich / poor = cigs
THESE ARE GETTING WORSE…
NHS smoking cess reverses these inequalities
People with SMI just as likely to quit cigs BUT
programmes will have to be brought to them
• Possible TCO = Tobacco Company Obligation
Are new things always good?
PRO eCigarettes
(think of a Nuclear conflict, and a
conventional war seems rather nice)
• Rising use in ex-smokers
• Far less carcinogens
• eCigs help people quit, but
most “vapers” still smoke
• Not seen as treatment
• Second hand smoke less bad
• Public attitudes: want same
ban in public places
ANTI / Caution eCigarettes
• Significant uptake among
young / new “vapers”
• Flavours, marketing
• Big tobacco investing
• Facilitate nicotine delivery
and therefore addiction
• Nicotine harmful in preg,
might also be carcinogenic
• Other drugs delivered…
Stolen years
• The ultimate case for Parity of Esteem is that
our patients with SMI die 15-20 years early
• We know it’s Inequalities + cigs / alcohol
• Final common pathway: cardiovasc disease,
cancer, victims of violence, untreated disease
• Medical response: can’t someone else do it?
• Evidence is there already: cigs; min pricing;
safer prescribing of APs; Lester Adaptation
PMH: conclusions
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Promotion, Prevention, Treatment
Big 4: our services, stolen years, alcohol, EI
Get Psychiatry’s (& specialities’) voice heard
Opportunities to engage new people, ££s
Hardest bits: inequalities, stigma, people at
the margins - collaborate to advocate
• Talk to us: [email protected]
[email protected]