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Being Sad makes me ill Dr Geraldine Strathdee, National Clinical Director for Mental Health. Stadium of Light 15 October 2014 The interaction between mental & physical ill health The challenges: • • • • Physical ill health & premature mortality in people with psychosis & SMI Depression as a major risk factor for physical ill health Mental ill-health and premature mortality people with long term physical illnesses Baseline data for the North from MH Intelligence network & NAS, Oct 10th The start of the solutions • • • The national physical cardiometabolic and care CQUIN Moving to action ASAP for improvement in SMI Call for examples of evaluated ‘what good looks like’ The enabling role of the SCN & AHSNs • • • • • Bringing every possible local network together for action Focus on the life saving clinical priorities Support new collaborative relationships between users & carers, primary and specialist care Disseminate at pace the fastest ways to implementation Save lives and have fun in the North Culture change! Reversing the damage of the separation of physical & mental health practice Chris Manning, extraordinary thinker 1. Premature mortality in people with psychosis People with mental ill health are more likely to have poor physical health Mental illness has a similar effect on life-expectancy to smoking, reducing life expectancy by: • 7 to 10 years: in people with depression • 10 to 15 years: in those with schizophrenia • Almost 15 years: in those who misuse drugs or alcohol Smoking General Population This used to be the prevalence in general population 30 years ago! Alcohol misuse General Population Common mental health problems Common mental health problems Long Term Mental Health Problems Long Term Mental Health Problems Psychotic disorder Psychotic disorder 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 1. Source: Health Survey for England (2010), those with common mental health problems are identified by scoring 4 or more on the GHQ12 questionnaire; 2. Source: Adult Psychiatric Morbidity Survey (2007). Note that those with psychotic disorders are also likely to be included among those with Long term mental health problems and those with severe depression may be included among those with Common mental health problems and those with Long term mental health problems. 3. Answers positively to “Whether smokes cigarettes nowadays?” question; 2. Weekly alcohol consumption >21 units (men), >14 units (women); 3. Body Mass Index >30; 4. Weekly physical exercise does not exceed 30 minutes on five days. 60% 2. Premature deaths due to untreated depression & anxiety In long term condition - Those with long term physical health conditions are at higher risk of experiencing mental health problems…especially depression / anxiety % of people affected by depression People who experience persistent pain are four times as likely to have an anxiety or depressive order as the general population Integrated physical and mental health care for long term conditions in primary, acute care and community services Depression & anxiety is common in long term conditions & is associated with: • that co-morbid MH problems are -Higher rates of cardiovascular, diabetes & cancer, liver, renal disease -Higher rates of suicide -Higher rates of service use in primary care, A/E, LTC outpatient clinics -Premature mortality & reduced treatment adherence associated with a 45-75% increase in service costs per patient (after controlling for severity of physical illness) -45-75% increase in service costs per patient (after controlling for severity of physical illness) % increase in annual per patient costs (excluding costs of MH care) Overall, international research finds • Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and 180% wellbeing – at least £1 in every £8 160% spent on long-term conditions. 140% • 120% therapy into LTC care pathways and 100% 80% 60% 40% 20% 0% Provision of integrated psychological tariffs offers value and reduces Depression premature mortality, disability and Anxiety improves Quality of life & reduces crisis presentations, admissions and increases employment rates. 6 The interaction between mental and physical ill health Moving to solutions SMI: immediate action needed • The national physical cardiometabolic and care CQUIN • 5 top tips for fast tracking action for CQUIN implementation Access to treatment for common mental health conditions • New era progressing for – Integrated physical and mental assessment & treatment in primary care, acute care & community providers – Access standards set for treatment – New commissioning guidance The target causes that can be addressed to reduce premature mortality : the patients Lifestyle Food & exercise Smoking Access to early identification & timely treatment Lack of exercise: due to negative symptoms & sedating medicines Increased smoking causes much of the excess mortality of people with mental health problems. 76% of those in their first episode of psychosis are smoking regularly Diet: Less likely to eat fruit and vegetables (high cost of healthier foods, lack of nutritional knowledge or cooking skills). Those with schizophrenia have a 10 fold increased death rate from respiratory disease. Lowered reporting of physical symptoms: People with schizophrenia are less likely than healthy controls to report physical symptoms 2-3 times more likely to be obese which is linked to raised cardiovascular mortality Drug Interactions Smoking induces metabolism of some antipsychotic medication, resulting in smokers requiring increased doses which can be reduced by up to half following smoking cessation. The suffering of untreated illness leads to self medication with drugs, alcohol, smoking NAS 2 (blue) v NAS – Physical Health monitoring Standard 4 – monitoring of physical health risk factors Monitoring of five risk factors (family history 33% 29% Monitoring of smoking 89% 88% Monitoring of BMI 52% 51% 5– 27 – excluded) Range across Trusts for monitoring of BMI 92% 87% Monitoring of glucose control 57% 50% Range across Trusts for monitoring glucose 16 – 25 – control 99% 83% Monitoring of lipids 57% 47% Monitoring of blood pressure 61% 56% Monitoring of five risk factors in those with 37% 37% 70% 69% established cardiovascular disease Monitoring of alcohol consumption This outlines practical actions for Board Executive team Learning and development dept. Operational management Clinical team Every clinician 5 fast track proven innovations for CQUIN physical health Clinical decision support templates for GP & MHT clinicians Bradford MHT & CCG MH lead has implemented a brilliant template for primary care clinicians & for secondary care which guides the physical examination, estimates Q risk, and prints off as an instant report for the patient GP practices commissioned for wards GP practice commissioned to provide care, training, supervision & skill share on wards in Broadmoor Rampton, several MSU & LSUs & some rehab units leading to smoke free units 2.5 hour Master class training for practice & MH nurses Sheila Hardy’s cascade master class training has resulted hundreds of practice nurses and mental health nurses working together to skill share Football, aerobics, recovery programmes, 7 day outreach, fun!! Using staff & service user skills Physical health can be fun if staff & SUs join in Coaching, football, sports, aerobics, dance Safer medicines prescribing & administration within MH services Never start a medication without education re the lifestyle changes needed to reduce the likelihood of obesity and diabetes Always assess and address side effects Other first world countries modern healthcare systems are acting on the facts………. If a person has a ‘physical’ health major illness, 40% will have a depression and anxiety as a result & if that is not treated they will die earlier, have more disability and use a lot of health care services …….it just does not make economic let alone clinical sense to Mental health is the commonest comorbidity and raises costs in all sectors 180% • Overall, international research finds that co-morbid MH problems are associated with a 45-75% increase in service costs per patient (after controlling for severity of physical illness) Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term conditions. 160% % increase in annual per patient costs (excluding costs of MH care) • 140% 120% 100% 80% Depression Anxiety 60% 40% 20% 0% successful outcome. The second point is the level of cost-effectiveness as measured by cost per QALY. This involves two further factors. First there is the severity of the condition which is averted, and second the cost per case treated. The concept of severity used by NICE is that each medical condition involves a reduction in the quality of life, and a successful treatment thus increases the number of Quality Adjusted Life Years (QALYs). The cost per QALY is then the (inverse) measure of the cost-effectiveness of the treatment. The informal cut-off The availability of treatment & the costs of effective treatment 22 Annex B: Prevalence of adult mental health conditions and % in treatment, England 2007 % of adults diagnosable (1) % of (1) in treatment (2) % of (1) receiving counselling or therapy 15.0 24 10 PTSD 3.0 28 10 Psychosis 0.4 80 43 Personality Disorder* 0.7 34 ADHD 0.6 25 4 Eating disorders 1.6 23 15 Alcohol dependence 5.9 14 6 Drug dependence 3.4 Anxiety and/or depression Cannabis only 2.5 14 7 Other 0.9 36 22 Any condition 23.0 * Includes Anti-social P.D. and Borderline P.D. Note: The conditions are not mutually exclusive. 18 Table 5: Cost-effectiveness of some treatments for mental and physical illnesses Mental illness Depression Social anxiety disorder Post-natal depression Obsessive-Compulsive Disorder Physical illness Diabetes Asthma COPD Cardio-vascular Epilepsy Arthritis Treatment Numbers Needed to Treat Cost per additional QALY CBT v Placebo CBT v Treatment As Usual (TAU) Interpersonal therapy v TAU CBT v TAU 2 2 5 3 £6,700 £9,600 £4,500 £21,000 Metformin v Insulin Beta-agonists + Steroids v Steroids Ditto Statins v Placebo Topirimate v Placebo Cox-2 inhibitors v Placebo 14 73 17 95 3 5 £6,000 £11,600 £41,700 £14,000 £900 £30,000 NICE guidelines for the treatment of depression in LTCs show stepped care model 2012 publication Compendium of examples of cost effective programmes for people with physical illnesses in acute trust, primary care settings Additional slides with details if asked to show What does every clinical team need to do & what support do they need to do it Template Letter to GP to get the summary record with Reed/ICD codes, medications, physical blood etc results Mental health & Lester plus cardiometabolic physical assessments Coproduced formulation with service user ICD physical & MH codes recorded on ECR Co produced Care Plan with the 7 core components of NICE/SCIE effective care : 1. Information 2.healthy lifestyle & physical health rx ,3. Psychological therapies 4. Safe medicines and routine GASS 5. Recovery social, training & employment plans , 6. Carer education & support; 7 what to do in crisis NAS 2 (blue) v NAS – Physical Health interventions Standard 5 – intervention offered for identified physical health risks Intervention for BMI > or = 25kg/m2 71% 76% Intervention for abnormal glucose control 36% 53% Intervention for elevated blood pressure 25% 25% Intervention for alcohol misuse 74% 72% NAS 2 (blue) v NAS Antipsychotic prescribing Standard / Indicator NAS2 NAS1 (%) (%) 11% 11% 1-24% 3-30% 10% 10% 1-22% 1-24% 37% 25% Standard 8 – antipsychotic monotherapy Frequency of polypharmacy Range across Trusts Standard 9 – dose within BNF maximum Frequency of high dose (>100% BNF) Range across Trusts Rationale documented for high dose Standard 10 – investigation of alcohol and substance misuse in those with poor symptom response Frequency in cases not on clozapine 62% 78% Frequency in cases on clozapine 56% 81% 27% 40% 26% 22% Standard 11 – medication changed if poor response Direct comparison not possible as Standard was amended Standard 12 – pathway to clozapine Service users not in remission and not on clozapine without a reason normally considered as appropriate Standard 13 – augmentation of clozapine Frequency of use of augmentation strategy in service users on clozapine Indicator 1: 65 % funding for demonstrating, through the National Audit of Schizophrenia, full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in patients with psychoses, including schizophrenia. The following cardio metabolic parameters (as per the 'Lester tool' and the cardiovascular outcome framework) are assessed; • • • • • • • Smoking status Lifestyle (inc. exercise, diet, alcohol and drugs) Body Mass Index Blood pressure Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate) Blood lipids Hepatitis C The results recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a record of associated interventions according to NICE guidelines or onward referral to another clinician for assessment, diagnosis, and treatment eg smoking cessation programme, lifestyle advice and medication review. Indicator 2: 35% funding for completion of a programme of local audit of communication with patients’ GPs, focusing on patients on the CPA, demonstrating by Quarter 4 that, for 90 per cent of patients, an up-to-date care plan has been shared with the GP, including the holistic components set out in the CPA guidance: • ICD codes for all primary and secondary mental and physical health diagnoses. • Medications prescribed and monitoring and adherence support plans. • Physical health condition(s) and ongoing monitoring and treatment needs. • Recovery interventions including lifestyle, social, employment and accommodation plans where necessary for physical health improvement. • The local audit will cover a sample of patients in contact with all specified services for more than 100 days and who are on the CPA. Primary care innovations learning from the best of international primary care MH leaders & role modeling collaborative partnerships Registration & annual checks: – include 1 min self completion behavioural health assessment Primary care team skillmix – 30% of the work. – ? % of staff with NICE training psychological health training Supporting hard pressed primary care : the basics – – – Clinicians decision support templates Annual checks : zero exclusion of SMI Family and 3rd sector outreach Primary care at scale initiatives – – integrated ‘Living well’ care stroke, diabetes, pain, COPD, bariatric surgery care Named workers in primary care Population based focus based on local need – – – – Enhanced SMI care in inner cities ? Enhanced MUS care Enhanced SMI care Alliance commissioning models Psychosis: National audit of Schizophrenia 2013 and 2014 show the gap between the standards and the current pattern of care in England –Current services: –- Standard care means that duration of untreated psychosis is now 8-30 months: with lifelong poor outcomes –- Only 29% receive Cardio metabolic assessment & only 25% receive treatment –- 34% do not have NICE psychological therapies –- 16% of medicines prescribed do not adhere to guidelines. –- The Variation ranges from 0-70% across England Future services: - Early intervention psychosis teams which: Treatment in the first critical 8 weeks -full NICE compliance -home based care -recovery to employment