1. The Contribution of Mental Health Services to Tackling Health Inequalities Dr Alastair Cook Chair RCPsych in Scotland

2. Outline The health of people with mental health problems The impact of having a mental health problem as well as other long term conditions Mental health services and early years What do we need to do?

3. People with severe mental illness Die early – Life expectancy for men 20 years less than average – Life expectancy for women 15 years less Are more likely to have physical illness – Under 50s are 3x more likely to die from coronary heart disease Are less likely to receive interventions

4. Health-risk behaviours Smoking In England – 21% of population smoke – 44% of people with common mental health disorders – 64% of people with probable psychosis – 70% of mental health inpatients 42% of tobacco consumption by people with MH problems http://www.natcen.ac.uk/our-research/research/cigarette-smoking-and-mental-health-in-england

5. Other factors Obesity ‘Obese persons had a 55% increased risk of developing depression over time, whereas depressed persons had a 58% increased risk of becoming obese’ Diagnostic overshadowing – Patients with CHD or diabetes less likely to receive effective treatment if they had a mental illness

6. Example of inpatient data Local study in Lanarkshire (Wishaw) – All admissions from Jan 2005 – December 2007 – 1199 people admitted – 1688 admissions 5 year follow up period – 100 deaths (8.3%) – 66 male, 34 female – 87 had substance misuse as primary or secondary diagnosis Data & slides from McLaughlin et al WGH

7. Life expectancy (1) Females (n=34) Study population 49.9 years [45.8-54.0]* North Lanarkshire 78.8 Scotland average 80.4 Males (n=66) Study population 43.8 years [41.4-46.3]* North Lanarkshire 74.3 Scotland average 75.8 2008-2010 figures from National Records of Scotland http://www.gro-scotland.gov.uk/files2/stats/council-area-data-sheets/north-lanarkshire-factsheet.pdf *[95% confidence interval]

8. Life expectancy (2) History of alcohol or substance misuse in primary or secondary diagnosis 44.4 years [42.2-46.7]* *[95% confidence interval] NO history of alcohol or substance misuse in primary or secondary diagnosis 55.3 years [49.5-61.0]* *[95% confidence interval]

9. Cause of death (n=100) Number (=%)Mean age at death Chronic liver disease25 Cardiovascular disease11 48.3 Upper & lower respiratory disease12 Other physical illness21 Accidental/undetermined1842.6 Suicides1337.2

10. Alcohol consumption (1) Females Study population n=34 Known alcohol history n=26 Unknown quantity n=8 Mean consumption (of those who drank alcohol) = 204u/week [154-254]* (14x) Safe limit =14u/week Males Study population n=66 Known alcohol history n=55 Unknown quantity n= 11 Mean consumption (of those who drank alcohol) = 285u/week [240-331]* (14x) Safe limit =21u/week *[95% confidence interval]

11. Life expectancy varies with Scottish Multiple Index of Deprivation *t=-1.93, df=96, p=0.055 http://www.scotland.gov.uk/Publications/2009/10/28104046/14 Less deprived (includes n=1 from q5) Most deprived 52.5 [47.3-57.7]* 45.0 [39.7-50.2] 45.4 [40.8-50.0] 45.0 [41.4-48.5]* Life expectancy (years)

12. The impact of having a mental health problem as well as other long term conditions Depression is – 3x more likely in CHD – 2-3x more likely in diabetes – 3x more likely in COPD – Common (33 % of women and 20% of men) in arthritis

13. Impact of this Somebody with depression is 3.5 times more likely to die after a heart attack Poor outcomes in diabetes 50% more acute exacerbations in COPD

14. Economic impact 12 – 18% of all spend on long term conditions is due to the effect of mental health problems Healthcare costs increased by 45% Increased lengths of stay in hospital

15. Mental Health Services and Early Years Impact of adverse childhood experience on physical and mental health in later years Need for a life-course approach

16. CDC ACE Study http://www.cdc.gov/ace/index.htm

17. The range of mental health services Perinatal services Child and Adolescent services Addiction services Adult (parental) mental health Intellectual Disability services Psychotherapy services Interaction with Criminal Justice

18. What do we need to do? Acknowledge and recognise that poor mental health makes a significant contribution to the health inequalities in our society Improve physical care of those with severe mental illness – Earlier recognition – More proactive / assertive health promotion

19. What do we need to do? Improve mental health liaison services in Primary and Acute care Develop clinical pathways that support managing multiple diagnoses including mental health Be prepared to take a whole system approach (MH investment will save acute care costs)

20. What do we need to do? Review the roles of mental health services in supporting families – Earlier recognition and intervention – Role of adult services in supporting parents Recognise that resources need to be targeted to where the greatest need is known to exist.

21. Summary People with severe mental illness are more unequal than others! Mental health conditions make a significant contribution to all health inequalities Earlier, better co-ordinated interventions can make a difference but need to be prioritised