Current evidence on depression – the view from Centre for Mental Health

seandugganby Sean Duggan

Around nine out of 10 people who commit suicide suffer from a mental health problem with depression being the most common co-existing difficulty affecting 60% of those who tragically take their own lives. Nearly one-fifth of adults in the UK experience anxiety or depression. Often these problems remain unrecognised and untreated – sometimes for many years. This is despite that fact that there are effective interventions that have been proven to make a difference to those suffering with depressive illnesses.

The World Health Organisation has estimated that by 2030 more people will be affected by depression than by any other health problem. These findings reinforce the importance of treating depressive disorders as a health priority and of making available proven, cost-effective and accessible interventions to reduce their burden. Other evidence reinforces the critical importance of intervening early to improve the life chances of those facing or already suffering from mental illness.  Early intervention not only improves the prospects and life chances of those with poor mental health, it reduces the burden on families as well as broader costs to the public purse.

Yet the UK spends less than 4% of its national budget on mental healthcare with evidence pointing to a health system increasingly geared towards short term solutions (Lintern, 2012).

So what should we do?

We need to be more alert to the early signs of poor mental health.  It is particularly important to identify poor mental health early and give children a good start in life in terms of their emotional wellbeing.  Increasingly science is pointing to the damaging effects both of maternal depression and anxiety before and after the birth of a baby. This damage not only affects a mother’s wellbeing; poor maternal mental health also undermines the mental health of children.  Only a small number of mothers suffering from poor peri natal mental health get identified; even fewer get the help that can make a difference.  Simple screens used by midwives, health visitors and GPs could help identify risks and support better access to care.  The Centre is currently working with partners to improve the availability of better quality peri natal care, to assess its cost effectiveness and to support improved GP practice.

We also need to identify childhood and youth mental health problems as early as possible.  The government acknowledges that half of people with lifetime mental health difficulties first experience symptoms by the age of 14 and one in ten children aged between 5 and 16 will have a diagnosable mental health problem.  Most parents actively seek help for their children and yet only a quarter get the help they need. This is in spite of excellent evidence that effective interventions can both make a difference to children’s life chances and to the future burden on the public purse. Far too frequently, children’s needs are picked up by chance.   Teachers don’t know the symptoms of mental health problems in children (often these present as behavioural problems) and, if they do, they remain unsure where to refer them.   We need more systematic ways of picking up when children’s wellbeing moves outside healthy ranges and we need better and more accessible support with mental health and emotional wellbeing available in schools to help teachers, parents, children and young people to get prompt help when they encounter families or children distress. Furthermore, young people have often expressed significant concerns that help is not available in convenient and non-stigmatising settings, that it often feels irrelevant to their needs and that they often face a lengthy wait to access the help that they need. Young people should have a major role in shaping what prevents and helps them recover from mental health difficulties and this needs to be taken into account in the design of local support.

Early identification for adults also requires whole-system sensitivity both to the signs of poor mental health and about what to do when early signs are spotted. This includes the need to build awareness and capacity in employers, faith leaders, police custody, courts and custodial settings, voluntary and statutory sector support services and many others providers working with groups at higher risk of developing poor mental health.

It is not acceptable that people with mental health problems can expect to die 10 to 20 years earlier than those without a diagnosis (http://www.psych.ox.ac.uk/research/forensic-psychiatry). It is essential that we begin to take seriously the distressing and damaging impact that mental illness has on lives, on communities on families and on the public purse. Investment in mental health support must be increased at least to match investment in physical health and also to adequately reflect this increasing economic burden.  Most importantly it should aim to reduce the significant distress and health inequalities faced by those facing or living with poor mental health. However, increased investment needs to go hand in hand with a more creatively designed and responsive system of support which provides non stigmatising help, builds capacity in communities and in workplaces, provides easy access to help where and when people need it and which draws together what we know works and what those with lived experience know promotes their progress and recovery.

Sean Duggan is chief executive at the Centre for Mental Health

Mental health care for all stages of life must be improved for all to thrive

AndyBellby Andy Bell

This week, a new book by Lord Layard and Professor David Clark sets out a call for a transformation in the way we think about mental health and the priority mental health care is given.

Thrive: the power of evidence-based psychological therapies, argues that mental ill health causes far greater suffering than has ever been realised by policymakers and that through investment in cost-effective interventions much of that distress can be prevented or treated successfully.

Layard and Clark build a persuasive case for extending and improving mental health support at all stages of life, starting from pregnancy and early years and throughout life. They show that responding better to our mental health needs is not only just and humane but also good economics.

Much of the focus of Thrive is on the value of investing more in psychological therapies. Layard and Clark identify a wide range of therapies that have been shown to be highly cost-effective in improving people’s health: including but not only cognitive behavioural therapy. But they also look at a much wider range of interventions, for example those that will enhance resilience such as social and emotional learning in schools, parenting programmes and mindfulness.

Thrive offers a vision for the future and a case for change that no one can or should ignore. And it reminds us of our place in history; how the decisions we make today affect our future and the lives of future generations. The book concludes that:

“Future generations will be amazed at how blind we were. They will also be amazed that we were so cruel. When we ourselves look back at earlier generations, we are shocked by how they treated slaves, or women and children in the mines, or people with physical disabilities.”

We are thus at a crucial point in time. The last two decades have seen some very important developments in mental health policy and practice: the National Framework for Mental Health; the Improving Access to Psychological Therapies programme; the development of prison mental health services and of liaison and diversion; and the growing movement to put personal recovery at the heart of mental health care.

But we also face huge challenges. Three quarters of adults and children with mental health problems go without treatment. Three quarters of CCGs last year cut or froze their spending on children’s mental health services. And too many people with mental health problems are left without the help they need to pursue their personal goals.

Thrive should be required reading for any aspiring member of Parliament, for any CCG or health and wellbeing board member, and for any future government. It offers both a message of hope and a warning we should all heed and take action to support.

The Bradley report five years on – finishing the vital job

Lord_Bradley_bwby Rt Hon Lord Bradley

In the five years since I published my independent review of the support offered to people with mental health problems and people with learning difficulties in the criminal justice system, we have seen significant progress towards achieving the vision set out in that report with the clear and unambiguous support of both governments.

In looking back at what has changed over the last five years, it has been encouraging to see the development of more liaison and diversion teams, both for adults and for children and young people, offering early intervention in police stations and courts across the country. While there is a lot more to be done in making sure liaison and diversion is available everywhere, the commitment of the Department of Health, Ministry of Justice and NHS England to the successful completion of this job has been key to the continued progress we are making.

We are also now seeing the emergence of new and creative ways of supporting people with mental health problems and those with learning difficulties across the criminal justice system. Initiatives like street triage, which offers a more humane crisis response, and youth justice liaison and diversion, which provides support to children and young people when they come into contact with the police. We still have a lot to learn from these as we build the evidence of what makes the biggest difference to people’s lives and the most cost-effective use of public money.

I have been impressed ever since I began work in this area with the dedication, creativity and resilience of the people who work in it. Many have personal experience of being in the criminal justice system themselves and now try to help others going through it. Many work in voluntary and community organisations, offering credible alternatives to traditional services, while others are based in the NHS and local government, finding new ways of improving care and support despite the difficult financial climate.

Bradley_report_five_years_onThis report looks at what has been achieved so far, at what has changed in the context we work in, and at what still needs to be done. I hope that it demonstrates the value of finishing the vital job we have begun of implementing liaison and diversion nationwide as well as making further progress in less well developed actions.

Finally, I hope that in another five years’ time we are able to look back on continued progress and to say with confidence that as a society we respond more effectively and more humanely to the needs of people with mental health problems and people with learning difficulties who are at risk of offending or who come into contact with the criminal justice system.

New Mental Health Dementia and Neurology Intelligence Networks

By James SewardJames Seward

This week Public Health England launched a new Mental Health, Dementia and Neurology Intelligence Network (www.yhpho.org.uk/mhdnin). This website includes new profiling tools for Common Mental Health Disorders, Severe Mental Illness, Community Mental Health Profiles and Neurology. For the first time, these tools bring together the range of nationally reported data sources in one place, available to all, and present them by local area. People using the tools can see not only how their local area is doing in putting in place the right services to deliver the right outcomes to meet the needs of local people, but they can also compare themselves against their neighbours and other places across the country with similar needs.

This a big step forward in making this information about the state of local mental health services available in public to support local commissioners, providers and other stakeholders available to all. The aim is to work with local partners to help them use this information to make better decisions to improve outcomes for people who use services and for whole communities.

The Network will continue to develop and we will work with local partners to improve and extend the current tools and resources. The plan is to produce new profiles covering Children and Young People’s Mental Health, Co-existing mental health and addictions issues and Dementia later this year.

James Seward is National Mental Health Dementia and Neurology Intelligence Network – Programme Lead at Public Health England

Keys to Diversion

Graham-Durcan-bwDr Graham Durcan

A large proportion of people in the criminal justice system have multiple or complex needs including a range of mental health problems. Many have repeated contact with the police and a number of other public services yet rarely get the support they need to build better lives.

With funding from the LankellyChase Foundation, Centre for Mental Health has been investigating how liaison and diversion services can best identify and support people with multiple needs when they come into contact with the police and courts.

We found that successful liaison and diversion services offer immediate help with people’s basic needs, such as with housing and benefits, as well as mental health problems. They have a comprehensive knowledge of local services for people with multiple needs in order to build packages of support from a range of local agencies. They help make connections for people to other local services rather than just referring them on. And they offer ‘drop-in’ support whenever people need it long after they have been diverted.

keys_to_diversionThe services we studied for Keys to Diversion include Mo:Del in Manchester, which works with up to 150 people at a time for up to six months. Its clients are offered help to get work, to manage their finances and to learn basic skills such as cookery.

We also studied CASS, a Rethink Mental Illness drop-in service that delivers early intervention to people attending Plymouth, Bodmin and Truro Magistrates Courts. It helps to address complex needs (eg homelessness, drugs and alcohol, finance, education and employment, physical and mental health) by supporting people through Court process and also by helping them with supported referrals to agencies based in local communities.

The people we met who use these services invariably had a history of neglect, trauma, abuse and mental ill health. Many had been turned away or received only intermittent help from mental health services. Yet with consistent and coherent support, they can rebuild their lives.

Our report has major implications for national and local policy and practice. It is vital, for example, that clinical commissioning groups coordinate care across agencies for people with multiple needs so that liaison and diversion services can help them to get the support they need when they need it. This should include timely access to psychological therapy for people in contact with liaison and diversion services and for those under probation supervision.

Liaison and diversion services, meanwhile, should be able to assess for a wide range of needs, to offer immediate help with practical matters like housing and benefits if required, and to stay in touch with the people they divert rather than just referring them on to other services and losing contact.

By looking closely at four highly effective liaison and diversion services, we have been able to identify the keys to diversion for people with multiple needs. While every local area is unique, the keys to diversion can be applied universally to guide local commissioners, planners and managers to get the best value for money from their services and achieve the biggest possible improvement in people’s lives.

Mental health cost cutting is a false economy

seandugganby Sean Duggan

The NHS should be investing in interventions that improve health and wellbeing, not cutting cost effective mental health services, says Sean Duggan

The funding of mental health care has come under the microscope in recent weeks, with concerns about budget cuts and their impact on services and the people who use them.

Financial pressures are not new to mental health services; even in times of plenty, NHS investment is skewed towards physical health care, and hospital services have tended to get a bigger share of the pie than those that work less visibly in the community.

‘Investing in an otherwise missing level of mental health support can actually create savings in some of the most costly and pressured parts of the NHS’

Evidence published earlier this month by Rethink Mental Illness suggests that in about half of the country financial pressures are taking a heavy toll on some of the most effective (and cost effective) mental health services around.

It found that 55 per cent of early intervention in psychosis services had been forced to cut costs despite the savings such services generate when they are working well. Such cuts will almost certainly turn out to be a false economy, stacking up costs for individuals, families, health and care services for years to come.

Yet in some parts of the country, local commissioners are taking a more creative approach to managing scarcity. In the City of London and Hackney, for example, a group of GPs set up a new service aimed at offering better care and support to people whom neither primary nor secondary care services had previously been able to help successfully.

The primary care psychotherapy consultation service (PCPCS) supports people with medically unexplained symptoms, those with personality disorders and those with chronic mental health problems. It offers training and support to GP as well as providing a range of psychological therapies directly to people who would otherwise get little effective help from existing services.

Economic sense

The Centre for Mental Health recently carried out an economic evaluation of the PCPCS and concluded that it improved people’s quality of life at the same time as reducing the cost of GP consultations, accident and emergency attendances, outpatient appointments and hospital admissions. These savings offset more than a third of the cost of the new service within two years – and the longer term benefits may be greater still. Even on very conservative assumptions cost per quality-adjusted life-year gained is well below the National Institute for Health and Care Excellence’s threshold of £20,000-£30,000.

‘Psychological support can be beneficial to our physical and social wellbeing as well as our mental health’

This illustrates that investing in an otherwise missing level of mental health support can actually create savings in some of the most costly and pressured parts of the NHS. It can reduce the workload of GPs and, like liaison psychiatry teams, prevent expensive hospital admissions. By helping people whose physical health is often very poor, it shows that psychological support can be beneficial to our physical and social wellbeing as well as our mental health.

The NHS is likely to face many more years of austerity. Cutting cost effective services now carries big risks for the near future. Investing instead in interventions that improve health and wellbeing can help the NHS to live with the years of scarcity that are yet to come while offering better care and support to people who need it most.

Sean Duggan is chief executive at the Centre for Mental Health

An innovative approach to mental health support

James_Morris_MPby James Morris MP

As chair of the All-Party Parliamentary Group on Mental Health, I am always pleased to hear about promising new ways of helping people who have previously missed out on effective treatment and support.

A group of GPs in the City of London and Hackney have taken an innovative response to the needs of people whose mental health problems are more complex than their doctor can manage alone yet who don’t qualify for specialist services. The Primary Care Psychotherapy Consultation Service (PCPCS) is run by the Tavistock and Portman NHS Foundation Trust. It offers hope to people who would otherwise get bounced around the NHS without adequate care and support, such as people with medically unexplained symptoms, those with personality disorder and those with complex mental health problems. This ground-breaking service offers a range of therapies, close to people’s homes, often in their own GP surgeries, not a one-size-fits-all service in a remote clinic.

complex_needsCentre for Mental Health has evaluated the PCPCS and shown that it has changed people’s lives. And it shows that the service offers good value for public money – not just by improving the health of people with complex needs but by taking pressure off primary care services and local hospitals.

Many of the patients supported by the PCPCS have multiple mental and physical health problems at the same time, coupled in some cases with a history of social difficulties, isolation, neglect and trauma. Because of this complexity, patients supported by the PCPCS do not fit neatly into any single diagnostic category and by the same token their needs do not map readily on to existing structures of service provision. They are unlikely to be well supported by local IAPT services, which are mainly set up to deal with relatively straightforward cases of anxiety and depression.

The Centre’s report shows that by offering a broad range of therapies, tailored to each person, and by advising GPs on how to manage complexity, services like the PCPCS can help to extend psychological therapy provision in the NHS and improve mental health support in GP surgeries.

I am delighted to see that the NHS is taking an innovative approach to improving mental health support, achieving better care cost-effectively, and making a real difference to people’s lives. The PCPCS demonstrates to the whole system what can be achieved by opening up the NHS to high quality psychological support to people who too often get nothing. I hope it will inspire many more NHS commissioners to innovate locally and improve mental health care for all who need it.