Presentation on theme: "Public mental Peter Byrne,"— Presentation transcript:
1Public mental health @pubmentalhealth Peter Byrne, Consultant liaison psychiatrist at Homerton HospitalAssoc Registrar / Public mental health lead, RCPsych &Visiting Professor, University of Strathclyde, Glasgow@pubmentalhealth
2Content Why and How of Public Mental Health Big 4: our services, stolen years, lifestyle, EIEarly intervention: think children and eldersChief Medical Officer (E&W) 2014 ReportInequalitiesDebates: smoking, vaping & abstainingStart a debate with users, carers & others: the What (to prioritise) of Public Mental Health
3Psycho-education Public Mental Health Public Engagement Public EducationPsycho-education
5Public mental health (PMH) definition Mental health prevention: e.g. CMO Report of 2012 on children, Prevention Pays …(women 2015)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)Treatment, recovery, rehabilitation (overlap): this is what MH clinicians spend all time on
8What’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 GNPBoth: since 2008 crash, suicide rates rose by 4%... Self harm rates increasingSpecial challenges: alcohol misuse in over 65s men ↑ by 60% in 20 years; ↑ by 100% in older womenPremature 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
9Start 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 thisWe call this the Treatment gap: 75%Access to services blocked by stigma (incl internalised stigma), gatekeepers, lack of fundsParity of esteem: MH = 28% of morbidity, but gets 13% of UK health spending, falling slowly
10But that is NOT the beginning Genetic associations with MH disordersPerinatal interventions protect M and childChildren’s lives ruined by parental alcohol and drug misuse: services cut, alcohol cheaperInequalities → MH probs, self harm, stolen yearsCurrent disinvestment in children’s servicesEarly Intervention: lip service, pilots, or nothingEvidence-based parenting programmes: no £
11Parenting 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 ;(2). (79) Barlow J, Stewart-Brown SL. Review article: behavior problems and parent-training programs. Journal of Developmental and Behavioral Pediatrics 2000;21(5): (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 The Cochrane Database of Systematic Reviews, 2006; 2006.
12Concepts and slogansCartesian dualism: the separation of diseases of the mind from diseases of the body (misQ)Separation of physical health services from mental health servicesNo health without mental healthParity of esteemNo mental health without physical health: mens sano in corpore sano
13Two questions Number One preventable cause of cancer? In reality, the NumberOne Cause of cancer.Number 2 preventable cause of cancer?
16Evidence based measures: 7 Babor et al, 2010: Alcohol - no ordinary commodity Pricing: alcohol taxesRegulate availability: minimum age, licencing hours, no. of outletsModify drinking environ: server liability, enforce on premises laws, train staffDrink driving: best evidence - some behaviours can & need to be stigmatisedEarly intervention: self-help, mutual help, IBA, medical detox IF linked with talking therapies, weak evid for pharmacolRestrict marketing: laws work, less so vol codesEduc & Persuasion: labels, classroom, mass media – less strong evidence
19Alcohol 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 policyA fall in hospital admission of 1,600 in year 1, and 6,500 per year by year ten of the policyA fall in crime volumes by around 3,500 offences per yearA financial saving from harm reduction (health, employment, crime etc) of £942m over ten years
21Low income, U/E, low education, poor health, health risks InequalitiesMental illnessLow income, U/E, low education, poor health, health risksX 3 fold differences in MH probs and DSH between top 20% and bottom 20% incomesCigarettesObesityAlcohol misuseWorst possible outcomes
22Self-harm and SuicideUp to 10% of young people have self harmed, of which 1 in 8 have sought treatment<65: hosp DSH for each suicide; >65: 10Suicide rates fell until 2008: since then 4% rise28% of suicides had contact with MH services in previous year; ½ of these contact that weekHanging in 2/3 men & > 1/3 women who diePrevention: access to method, alcohol, services
24RCPsych Manifesto Sept 12, 2014. The manifesto has six key asks: 1. 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.
25…/ RCPsych manifesto4. 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. 6. 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.
26CMO Report Some use in collecting well-being data “more accurate data”, “more research needed”Some use in collecting well-being dataQuestions Rose hypothesis: “better well-being leads to less mental disorders”Advising commissioners NOT to invest in well-being promotion unless (new) evidenceRecommendations limited or obvious (data and training) but highly quotable text
27Where else should we go?Some role in MH Promotion: Director of Public Education → Director of Public EngagementUntil recently, was the number 2 site (to APA) for MH informationBy speciality (MH cannot be ageless), MH prevention: primary “vague”; secondary = EIBranding: gen hosp / “liaison” psychiatry, psychological medicine, EI in a general hosp
29Older adultsSpecialist MH services: <65 16% of population, >65 34% of this age group use these servicesMultimorbidity, poorer outcomes, less £Depression in 10-20% of community >65, but 20-30% of gen hospital / care home >65Older people in general hosp: 1/5 delirium, 2/3 have a treatable MH disorder… RAID investmentTo achieve parity with y.o. +24% increase
30Smoking cessation Now 18% smoking rates, England Anti-smoking messages work (middle class)>50% mortality differences rich / poor = cigsTHESE ARE GETTING WORSE…NHS smoking cess reverses these inequalitiesPeople with SMI just as likely to quit cigs BUT programmes will have to be brought to themPossible TCO = Tobacco Company Obligation
31Are new things always good? PRO eCigarettesANTI / Caution eCigarettes(think of a Nuclear conflict, and a conventional war seems rather nice)Rising use in ex-smokersFar less carcinogenseCigs help people quit, but most “vapers” still smokeNot seen as treatmentSecond hand smoke less badPublic attitudes: want same ban in public placesSignificant uptake among young / new “vapers”Flavours, marketingBig tobacco investingFacilitate nicotine delivery and therefore addictionNicotine harmful in preg, might also be carcinogenicOther drugs delivered…
34Stolen yearsThe ultimate case for Parity of Esteem is that our patients with SMI die years earlyWe know it’s Inequalities + cigs / alcoholFinal common pathway: cardiovasc disease, cancer, victims of violence, untreated diseaseMedical response: can’t someone else do it?Evidence is there already: cigs; min pricing; safer prescribing of APs; Lester Adaptation
36PMH: conclusions Promotion, Prevention, Treatment Big 4: our services, stolen years, alcohol, EIGet Psychiatry’s (& specialities’) voice heardOpportunities to engage new people, ££sHardest bits: inequalities, stigma, people at the margins - collaborate to advocateTalk to us: