Public mental health: An overview


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In this presentation Dr Jonathan Campion, Director of Public Mental Health and Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust, explains the role of public mental health in promoting wellbeing and improving outcomes for services and the people who use them.

Jonathan covers:

What is public mental health
PMH intelligence informs local JSNA and outcomes
Impacts of mental disorder and wellbeing
Risk and protective factors
Higher risk groups
Public mental health interventions
Intervention gap

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Public mental health: An overview

  1. 1. Public mental health: An overview Dr Jonathan Campion Visiting Professor of Population Mental Health, University College London Director of Public Mental Health, South London and Maudsley NHS Foundation Trust 11th July 2013
  2. 2. Outline for presentation • • • • • • • • What is public mental health PMH intelligence informs local JSNA and outcomes Impacts of mental disorder and wellbeing Risk and protective factors Higher risk groups Public mental health interventions Intervention gap Summary
  3. 3. What is public mental health? • Intelligence on level and impact of mental disorder and well-being across populations • Intelligence on risk factors for mental disorder (including inequalities) and protective factors for mental wellbeing • Interventions to promote well-being, prevent mental disorder and intervene as soon as it arises
  4. 4. Policy context of public mental health • Twin track approach of mental health strategy (HMG, 2011): Early treatment for people with mental disorder Population approach to promote mental wellbeing and prevent mental disorder • Public Health White Paper (DH, 2010) signals new approach which places mental health 'at the heart' of the new system and highlights key role of DsPH in public mental health
  5. 5. Public mental health intelligence informs local JSNA and commissioning to improve outcomes • JSNA informs both the Health & Wellbeing Strategy and commissioning • Mental health poorly covered in JSNA perpetuating poor coverage of public mental health interventions
  6. 6. Public mental health commissioning guidance Informs JSNA with local levels of: • Risk and protective factors • Higher risk groups • Mental disorder and well-being including in higher risk groups • Proportion population receiving treatment of mental disorder, prevention and promotion of mental health • Outstanding need
  7. 7. Enables assessment of local • Impact of public mental health interventions on outcomes • Associated economic savings • Size, impact and cost of public mental health intervention need Transparency about level of coverage of interventions which commissioners decide acceptable Translation  in  Northamptonshire’s  700,000  population Thereby informs local strategic planning
  8. 8. Public mental health intelligence informs outcomes Public mental health relevant outcomes in each of the following sets of outcomes frameworks (incorporated in JCPMH public mental health commissioning guidance) • Public health outcomes (PH) • NHS outcomes (NHS) • Social care outcomes (SC) • CCG outcome indicator set (CCG) • Child outcomes (Child)
  9. 9. Impacts of mental disorder
  10. 10. Impacts of mental disorder • At least 23% of burden of disease in UK compared to 16% for cancer and 16% for cardiovascular disease (WHO, 2008) • Size of impact due to a) Arising early in the life course b) Broad range of impacts/ outcomes c) High prevalence of mental disorder • Local impacts of mental disorder can be estimated
  11. 11. a) Early onset of mental disorder • Key reason for size of burden • 50% of lifetime mental illness (excluding dementia) starts by age 14 (Kim-Cohen et al. 2003; Kessler et al, 2005) • 75% by mid twenties (Kessler et al, 2007) • Several decades before physical illness
  12. 12. b) Broad impacts/ outcomes of mental disorder
  13. 13. Impacts/ outcomes during childhood and adolescence • • • • • • health outcomes self-harm and suicide (PH) educational outcomes (PH: pupil absence) antisocial behaviour and offending (PH) social skills outcomes health risk behaviour - smoking (PH), alcohol and drug misuse, sexual risk, nutrition, physical activity • teenage parenthood (PH)
  14. 14. Impacts and outcomes of emotional and conduct disorder in children and young people in UK (Green et al, 2005) Risk Behaviour Emotional Disorder (6%) Conduct Disorder (4%) No Disorder Smoke Regularly (age 11- 16) 19% 30% 5% Drink at least twice a week (age 11- 16) 5% 12% 3% Ever Used Hard Drugs (age 11- 16 6% 12% 1% Have ever self harmed (self report) 21% 19% 4% Have no friends 6% 8% 1% Have ever been excluded from school 12% 34% 4%
  15. 15. Increased risk of poor adult outcomes Poor mental health in childhood and adolescence also associated with inequalities during adulthood including higher rates of: • adult mental disorder • health risk behaviour including smoking (PH) • physical illness • suicide (PH) • unemployment and lower earnings • crime and violence (PH)
  16. 16. Impacts of poor mental health in adulthood • • • • Physical illness Reduced life expectancy (PH) Suicide and self harm (PH) Range of health risk behaviour including alcohol, drug misuse and smoking (PH) • Unemployment • Homelessness (PH) • Stigma and discrimination
  17. 17. Economic impact of mental disorder • To UK economy: £105 billion annual cost of mental illness in England (CMH, 2010) • To UK employers: £28 billion annually (NICE, 2009) • Crime: £60 billion annual cost of crime in England and Wales by adults who had conduct problems during childhood and adolescence (SCMH, 2009) • Significant local health and non-health impacts have significant local costs
  18. 18. Mental disorder underlies a large proportion of health risk behaviour Smoking as an example • Largest single preventable cause of death • 42% of adult tobacco consumption in England is by those with mental disorder (McManus et al, 2010) • At least 33,222 of 79,100 smoking related deaths in England (NHSIC, 2012) • 43% of under 17 year old smokers have either emotional or conduct disorder (Green et al, 2005) Particularly important opportunity to prevent physical illness and premature mortality
  19. 19. Impact of mental disorder on physical illness
  20. 20. Mental disorder increases risk of physical illness and associated premature mortality Depression associated with 50% increased mortality from all disease (Mykletun et al, 2009) Schizophrenia associated with 20.5 year reduced life expectancy for men and 16.4 year reduced life expectancy for women (Brown et al, 2010) (PH)
  21. 21. c) Mental disorder is common Proportionately increase with level of deprivation • 10% of children and young people (Green et al, 2005) • 17.6% adults at least one CMD (McManus et al, 2009) • 0.4% adults have psychosis • 6% alcohol dependent, 3% dependent on illegal drugs, 21% dependent on tobacco • 5.4% of men and 3.4% of women have diagnosable personality disorder (Singleton et al, 2001) • Dementia: 5% of people aged over 65 20% of those aged over 80
  22. 22. Local estimation of levels of mental disorder • Levels of mental disorder vary by locality depending on levels of risk/protective factors and numbers from higher risk groups • JCPMH guidance enables estimation of local numbers with different mental disorder
  23. 23. Estimated numbers of children and adolescents with mental disorder in Northamptonshire (JCPMH) • • • • • 3351 have emotional disorder 5299 have conduct disorder 2049 have hyperkinetic disorder 2940 11-16 year olds report self harm 5040 of 11-15 year olds reported drinking alcohol in the previous week • 5040 of 11-15 year olds used illegal drugs in the past year and 2540 in the previous month • 2100 of 11-15 year olds were regular smokers • 3360 of 11-15 year olds smoked in previous week
  24. 24. Estimated numbers of adults with mental disorder in Northamptonshire (JCPMH guidance) • Common mental disorder 86,888 • Psychosis: each year 2145 in Northamptonshire experience a psychotic disorder with 171 new cases • Alcohol dependence: 31,645 • Drug misuse in 2011/12: 39,876 used an illegal drug 13,441 used class A drugs 15,073 taken an illicit drug Tobacco smokers 107,270 Personality disorder: 23,475 (1609 people ASPD) Dementia: 5302 people
  25. 25. Examples of local variation of substance misuse across Northamptonshire • Rate of opiate or crack use per 1000 Corby 12.8 South Northamptonshire 2.0 England 8.9 • Tobacco dependence South Northamptonshire 11.2% Corby 25.5% England 20.0%
  26. 26. Level of sub-threshold mental disorder • 18% of 5-16 year olds have sub-threshold conduct disorder (Colman et al, 2009) • 17% of adults experience sub-threshold common mental disorder (McManus et al, 2009) • 5% of adults have sub-threshold psychosis (van Os et al, 2009) • 24% hazardous drinkers (McManus et al, 2009) • Impacts on quality of life and also increases the risk of threshold disorder
  27. 27. Impact of mental health/ wellbeing
  28. 28. Impact of mental health/ wellbeing • More than just absence of mental disorder • Improved resilience to broad range of adversity • Important in prevention of mental disorder
  29. 29. Health benefits of mental wellbeing Associated with reductions in and prevention of: • Mental disorder in children and adolescents including persistence • Mental disorder and suicide in adults (PH) • Physical illness • Associated health care utilisation (PH) • Mortality (PH)
  30. 30. Benefits outside health • Improved educational outcomes (PH) • Healthier lifestyle/ reduced risk taking (PH) • Increased productivity at work, fewer missed days off work (PH) • Higher income • Social relationships/ contentedness (PH) • Reduced anti-social behaviour, crime and violence (PH) • Reduced smoking/ alcohol/ drug misuse (PH)
  31. 31. Impact depends on wellbeing levels ONS (2012) UK survey of 165,000 adults • Life satisfaction: 76% scored 7/10 or more 7% scored less than 5/10 • Life worthwhile 80% scored 7/10 or more 5% scored less than 5/10 • Happiness yesterday: 78% scored 7/10 or more 11% scored less than 5/10 • Local level of wellbeing (PH outcome)/ social carerelated quality of life (SC)
  32. 32. Relationship between mental disorder and wellbeing • Wellbeing reduces risk of mental disorder • Mental disorder reduces wellbeing. • Single largest group with poor wellbeing are those with mental disorder. • Number of other groups are at increased risk of both mental disorder and reduced wellbeing • Higher risk groups disproportionately benefit from public mental health interventions
  33. 33. Risk factors for mental disorder, protective factors for wellbeing
  34. 34. Risk and protective factors • Public health approach recognises wider determinants and lifelong impact of mental health • Addressing determinants important to prevent mental illness and promote wellbeing • Public health outcomes framework identifies local level of risk and protective factors as outcomes
  35. 35. Inequality underpins many of the risk factors for mental disorder and poor wellbeing
  36. 36. Inequality - a key underlying factor • Inequality underlies most risk factors – key outcome to address to prevent mental disorder • Mental disorder then further increases inequality which can also be prevented • Higher risk groups benefit more from intervention to both prevent and treat mental disorder
  37. 37. Inequality as a key risk factor for mental disorder and poor wellbeing Index Multiple Deprivation gives measure of deprivation: Most deprived area scores 1, least deprived area scores 326 • Northamptonshire overall 102 • Corby 57 • Northampton 119 • Wellingborough 133 • Kettering 164 • East Northamptonshire 225 • Daventry 248 • South Northamptonshire 323
  38. 38. Inequality as a key risk factor for mental disorder and poor wellbeing (JCPMH guidance) • % of under 16s living in low income households: 7.1% in South Northamptonshire 22.5% in Northampton 21.9% in England • % population living in most deprived quintile: 19.8% in England 13.0% Northamptonshire 0 in South and East Northamptonshire 31.1% in Corby
  39. 39. Risk factors for mental disorder during childhood • Pregnancy and birth: Smoking (PH), alcohol, prematurity (Nosarti et al, 2012), birth weight (PH ) • Socioeconomic: Children from lowest quintile of household income - 3 fold increased risk of mental health problems (Green et al, 2005) (PH) • Parental factors Poor parental mental health - 4–5 fold increased rate in onset of mental disorder Parenting • Child factors: Sex, age, ethnicity, screen time
  40. 40. Childhood adversity • Childhood adversities strongest predictors of mental disorder (Kessler et al, 2010) • Child abuse: several fold increased of all mental disorder (Jonas et al, 2011) • Sexual abuse: increased rates of adult: depressive disorder (OR 6.2) PTSD (OR 6.8) probable psychosis (OR 15.3) alcohol dependence (OR 5.2) eating disorder (OR 11.7) (Jonas et al, 2011) attempted suicide (OR 9.4) (Bebbington et al. 2009)
  41. 41. Risk factors in adulthood Include • Socioeconomic inequality • Unemployment (2.7 fold increase in CMD) • Debt (3 fold increase in CMD) • Violence and abuse (PHs: violent crime/ domestic violence) • Stressful life events • Inadequate housing/ homelessness (PH) • Fuel poverty (1.7 fold increased risk of CMD) (PH)
  42. 42. Population level of risk factors • Child abuse in UK: 25.3% of 18-24 year olds and 18.6% of 11-17 year olds experienced severe maltreatment during childhood (NSPCC, 2011) • Sexual abuse in England: 2.9% of women and 0.8% of men experienced sexual abuse in childhood (sexual intercourse) (Bebbington et al, 2011)
  43. 43. Estimation of local numbers experiencing different types of violence and abuse (JCPMH guidance) In Northamptonshire • 15,020 of 11-17 year olds experience severe maltreatment during childhood • 4206 of 11-17 year olds and 6725 of 18-24 year olds experience physical violence by an adult • Sexual abuse in under 18s, 12,300 experience sexual touching and 3100 experience sexual intercourse
  44. 44. Protective factors for wellbeing • Genetic background, maternal (ante-natal and postnatal) care, early upbringing and early experiences • Socio-economic factors including access to resources and inequality (PH) • Emotional and social literacy • Education (JCP) • Employment (JCP) • Physical activity (JCP) • Physical health/ healthy life expectancy (JCP) • Community trust and participation (PH) • Spirituality/ meaning
  45. 45. Higher risk groups
  46. 46. Certain groups at much higher risk of mental disorder and low wellbeing • Benefit proportionately more from intervention to promote wellbeing, prevent mental disorder and treat mental disorder if it arises • Proportionate universalism • Need for information about numbers from higher risk groups (Campion & Fitch, 2012)
  47. 47. Children and adolescent higher risk groups • Looked after children - 5 fold increased risk of mental disorder (Meltzer et al, 2003) (PH) • Children with learning disability - 6.5 fold increased risk of mental illness (Emerson and Hatton, 2007) • Young offenders: 18 fold increased risk of suicide for men in custody age 15–17 (Fazel et al, 2005) (PH)
  48. 48. Estimated local numbers from higher risk groups (JCPMH guidance) • • • • • 735 looked after children 1070 primary school children with statements 1275 secondary school children with statements 3590 children with Special Educational Needs 916 children with Autistic Spectrum Disorder known to schools • 2442 children with learning difficulties known to schools
  49. 49. Numbers of child and adolescent from higher risk groups estimated to have mental disorder in Northamptonshire (JCPMH guidance) • • • • • 331 looked after children 1580 children with Special Education Needs 879 children with learning difficulties 3324 children from one parent families 4058 children living in poverty
  50. 50. Adult higher risk groups • BME groups (7.9% of UK population) Rates of schizophrenia (Kirkbride et al, 2012) 5.6 times higher in the black Caribbean group 4.7 times higher in black African group 2.4 times higher in Asian groups (CCG) Prisoners - higher risk of all mental disorder psychosis (20 fold) (Stewart, 2008) and ASPD (130 fold) (NICE, 2009) (PH) Learning disability – 3 fold increased risk of schizophrenia (PH)
  51. 51. • Homeless people (Bebbington et al, 2004) (PH) 11.3 fold increased risk of probable psychosis 5.5 fold increased alcohol dependence • Long term physical conditions 2–3 times increased risk of depression (NICE, 2009), 7 times increased risk of depression in people with two or more chronic physical conditions (NHS – improved QoL) • Possible to estimate local numbers from higher risk groups
  52. 52. Interventions to promote wellbeing, prevent mental disorder and treat mental disorder
  53. 53. Different levels of prevention and promotion Primary: Wider determinants across whole populations. Selective prevention - targeting groups at  higher  risk  e.g.  LTC’s  ,  certain  child/  adolescent/   adult group Secondary (indicated): Early detection of risk factors/ illness and intervention . Half of lifetime mental disorder  arises  by  age  14  ,  three  quarters  by  mid  20’s Tertiary: People with established disease to promote recovery and reduce risk of relapse.
  54. 54. Interventions to promote wellbeing, prevent mental disorder and treat mental disorder Good evidence exists for a range of public mental health interventions across the life course which reduce associated inequalities (RCPsych, 2010; Campion & Fitch, 2012) • Intervention for mental disorder and associated inequalities • Prevention of mental disorder • Promotion of mental health
  55. 55. Interventions from a range of service providers Include: • Primary and secondary care • Public Health service providers • Local authorities • Social care service providers • Third sector social inclusion providers • Education providers • Employers • Criminal justice services
  56. 56. Early intervention for mental disorder • Associated with better outcomes • Time between onset and access • Improved through better recognition of mental disorder through: improved detection and treatment by health professionals improved mental health literacy among the population to facilitate prompt help seeking including higher risk groups such as BME (CCG)
  57. 57. Example of conduct disorder • Affects 6% of 5-16 year olds • Precedes different adult mental disorder (NICE, 2013) • £795 million - lifetime cost of each one year cohort of 516 year olds with conduct disorder in Northamptonshire • Parenting interventions are NICE first line treatments for conduct disorder and ADHD • Prevents antisocial personality disorder in adulthood (NICE, 2009) • Lack of provision of parenting interventions
  58. 58. Early recovery and intervention for physical health • Early promotion of recovery through early provision of activities such as supported employment (PH/ NHS/SC) and settled accommodation (PH/SC) • Early intervention to promote physical health to prevent physical illness and premature mortality (PH/NHS): early promotion of physical health physical health checks (CCG) Intervention for health risk behaviour such as smoking
  59. 59. Early intervention results in net savings per £ invested (DH/Knapp et al, 2011) • Treatment of conduct disorder with parenting interventions £8 • Early detection and treatment of depression at work £5 • Early intervention for the stage which precedes psychosis £10 • First episode psychosis £18 • Screening and brief interventions in primary care for alcohol misuse £12
  60. 60. Prevention interventions Prevention of • mental illness and dementia • health risk behaviours including smoking, alcohol and drug misuse • inequalities • discrimination and stigma • suicide (PH) • violence and abuse (PH)
  61. 61. Preventing inequalities • Inequalities increase risk of mental disorder/ poor wellbeing and underlie many other risk factors • Addressing inequalities - important intervention to prevent mental disorder and promote mental health • Mental disorder results in a further range of inequalities which can also be prevented by early: treatment of mental disorder interventions for health risk behaviours treatment of physical illness targeted wellbeing promotion to facilitate recovery
  62. 62. Prevention interventions Cost effective interventions: • school based bullying prevention (£14) • prevention and addressing child abuse • prevention of conduct disorder through school based social emotional programmes (£84) • school based violence prevention programmes • suicide prevention (£44) • smoking cessation prevents premature mortality particularly in people with mental disorder
  63. 63. Mental health promotion interventions • Starting well (PH – breast feeding; child development age 2-2.5 years) • Developing well (PH - school readiness) • Living well (PH/NHS/SC - LD/ stable accommodation; PH use of green space for health/ exercise; PH – social contentedness) • Working well (PH/SC: LD/ paid employment) • Ageing well (PH:  older  people’s  perception  of  community   safety) • Caring well (NHS/ SC: Carer QoL)
  64. 64. Economics of interventions to promote wellbeing • School based social emotional learning programmes result in net savings of £84 for each £ spent (DH, 2011) • Work based mental health promotion programmes result in net savings of £10 for each £ spent (DH, 2011) • Other cost effective interventions include debt advice (£4) services, physical activity, befriending services, timebanks and community navigators • Cost effective targeted promotion interventions for those recovering from mental disorder include supported employment and supported housing
  65. 65. Result in range of improved health/ other outcomes • Reflects broad impacts of mental disorder and wellbeing • Improved mental health and resilience, physical health, life expectancy, healthy lifestyles, economic productivity, social functioning and quality of life • Reduced Burden of mental ill-health Economic costs of mental ill-health (Knapp et al, 2011) Inequalities Health risk behaviour (PH) Crime, violence (PH) • Economic savings
  66. 66. Intervention gap
  67. 67. Intervention gap • Despite evidence based interventions, only a minority with mental disorder except psychosis receive treatment • Parity gap • Compare to cancer where almost all receive intervention
  68. 68. Proportion with mental disorder in UK receiving any intervention (Green et al, 2005; McManus et al, 2009) • • • • • • • • • 28% of parents of children with conduct disorder 24% of adults with common mental disorder 28% of adults screening positive for PTSD 81% of adults with probable psychosis received some form of treatment compared to 85% in 2000. 65% of  adults  with  ‘psychotic  disorder’  in  past  year     14% of adults dependent on alcohol 14% of adults dependent on cannabis only 36% of adults dependent on other drugs Less than 10% of older people with depression receive adequate treatment
  69. 69. Intervention gap • In UK, 11% of NHS budget spent on treatment vs 23% burden of disease • People with mental disorder lack access to physical health care despite... access to interventions for health risk behaviour • Even greater lack of access to interventions to prevent mental disorder and promote mental health despite.... virtually no spend in UK
  70. 70. Size and impact of intervention gap • Results in broad range of associated outcomes and costs • Since majority of life time mental disorder arises by mid 20's, these impacts continue over a large part of life course • JSNA requires information on size, impact and cost of public mental health intervention gap
  71. 71. Public Mental Health commissioning guidance Enables local estimation of numbers/ proportion including from higher risk groups with: • risk factors for mental disorder • risk/protective factors for wellbeing • mental disorder and poor wellbeing • receiving interventions for treatment, prevention and promotion Enables estimation of local • Impact and savings of current service provision • Impact and cost of current lack of provision
  72. 72. Broader public mental health outcomes Facilitates • Early treatment of mental disorder to: Improve recovery outcomes for mental disorder Reduce associated health risk behaviour Reduce associated physical illness and premature mortality Reduce suicide • Prevent mental disorder by addressing risk factors • Promote population mental health by enhancing protective factors
  73. 73. Summary Public mental health intelligence facilitates : • Coverage of a key area in the local JSNA • Assessment of size, impact and cost of local public mental health intervention gap • Proportionate local targeting and monitoring of access/ outcomes for higher risk groups • Informs local Health and Wellbeing Board Strategy and commissioning
  74. 74. Public mental health • Central part and solution to local issues due to broad range of impacts • Can prevent large proportion of mental disorder and promote population wellbeing • Can facilitate early intervention for mental disorder and reduced treatment gap • Results in significant improvements in NHS, public health, social care and other outcomes
  75. 75. References and contact • Campion J, Fitch C (2012) Guidance for the commissioning of public mental health services. Joint Commissioning Panel for Mental Health. • Campion J, Bhui K, Bhugra D (2012). European Psychiatric Association guidance on prevention of mental disorder. European Psychiatry 27: 68-80. • Campion (2013) Public mental health: The local tangibles. The Psychiatrist 37: 238-243 • Email:
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