Public mental health presentation with focus on child and family
Dr Jonathan Campion
Director of Population Mental Health (UCLPartners)
Visiting Professor of Population Mental Health (UCL)
Contents
1.
2.
3.
4.
5.
6.
7.
8.
Sources and limitations
Public mental health and policy
Impact of mental disorder
Risk factors and higher risk groups
Estimating local levels of mental disorder
Mental wellbeing: levels and impact
Public mental health interventions
Public mental health intelligence on coverage, spend,
outcomes and economic impact
Summary
Acknowledgements, references and contact
Sources and limitations
• Presentation draws on public mental health commissioning
guidance endorsed by ADPH, RSPH and LGA, published in
December 2012 and updated in August 2013 at
www.jcpmh.info/resource/guidance-for-commissioning-publicmental-health-services/
• Graphs which highlight variation across London use nationally
available datasets although the quality of such datasets vary
• Highlights need to also draw on local public mental health
intelligence not available in such datasets
• Presentation includes UCLPartners preliminary work to provide
local public mental health intelligence to inform coverage of
effective treatment of mental disorder, prevention of mental
disorder and promotion of mental wellbeing
• Further information is available on request
SECTION 1: WHAT IS PUBLIC
MENTAL HEALTH?
Public health
• Addresses underlying socio-economic and wider
determinants of health and disease
• Partnerships with broad range of organisations and
agencies which contribute to and have an influence on
health of the population
What public mental health covers
•
•
•
•
Level and impact of mental disorder and well-being
Level of risk and protective factors
Higher risk groups
Interventions to promote mental well-being, prevent
and treat mental disorder
• Assessment of level of unmet need - size, impact and
cost of PMH intervention gap
• Use of PMH intelligence to inform strategic
development and commissioning
• Evaluation of impact on population outcomes
Prevention and promotion
• Mental disorder prevention - addressing risk factors for
mental disorder
• Mental health promotion – promoting protective
factors for mental health including social inclusion and
capacity to cope with adversity
Need for twin track approach to treatment
and prevention/promotion
• Population study highlighted that current levels of
treatment for mental illness reduces burden by 13%
• If all those with mental disorder received best available
treatment, burden would only be reduced by 28%
• Highlights need for prevention/promotion to
complement treatment
Source: Andrews et al, 2004
Public mental health and national policy
• In 2009, Labour cross Government mental health strategy
entitled ‘New Horizons’ (HMG, 2009) with twin aims:
 Improve quality and accessibility of services for people
with poor mental health
 Improve mental health and well-being of the population
• Cross government public mental health strategy document
‘Confident communities, brighter futures’ (HMG, 2010)
• Public health white paper (DH, 2010)
• Coalition maintained twin track approach in Cross Government
mental health strategy ‘No health without mental health’
(HMG, 2011)
SECTION 2: IMPACT OF MENTAL
DISORDER
Impact of mental disorder
Disease burden in UK caused by mental disorder (WHO, 2008)
• Underestimate
• Size of impact due to
A) Arising early in the life course
B) Broad range of impacts
C) Mental disorder being common
A. Most lifetime mental disorder arises
before adulthood
Age of onset of lifetime mental illness – predates subsequent physical illness by several decades
Source: Kim-Cohen et al, 2003; Kessler et al, 2005; Kessler et al, 2007
B. Mental disorder is common
National rates of child and adolescent mental disorder
• 10% of children and young people have a clinically recognised
mental disorder
• 6% conduct disorder
• 4% emotional disorder
• 2% hyperkinetic disorder
• 1% autism/ eating disorders, tics, selective mutism
• Co-morbidity: One third of children with conduct disorder
have another disorder most commonly anxiety and ADHD
Source: Green et al, 2005
B. Mental disorder is common
National rates of adult mental disorder
• 17.6% of adult population have at least one common mental
disorder
• 0.4% had psychosis in previous year
• 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
• Dementia:
5% of people aged over 65
20% of those aged over 80
Source: McManus et al, 2009; Knapp et al, 2007
B. Sub-threshold mental disorder is common
National rates of sub-threshold mental disorder
• Results in significant burden and also increases the risk of
threshold disorder
• 18% of 5-16 year olds have sub-threshold conduct disorder
• 17% of adults experience sub-threshold common mental
disorder
• 5% of adults have sub-threshold psychosis
• 24% hazardous drinkers
Source: Colman et al, 2009; van Os et al, 2009; McManus et al, 2009;
C. Broad range of impacts during adolescence
• Poor educational outcomes
• Health and social skills outcomes
• Self-harm and suicide
• Health risk behaviour - smoking, alcohol and drug misuse,
sexual risk, nutrition, physical activity
• Antisocial behaviour/ offending
Source: Campion et al, 2012
Impacts of emotional and conduct disorder in
adolescents in UK
Emotional
disorder (4%)
Conduct
disorder (6%)
No mental
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%
Risk Behaviour
Source: Green et al, 2005
Impact of mental disorder: Underlies large
proportion of overall health risk behaviour
Smoking as an example – the single largest cause of preventable
death
• Most smoking starts before adulthood
• 43% of under 17 year old smokers have either emotional or
conduct disorder
• 42% of adult tobacco consumption in England by people with
mental disorder
Source: Green et al, 2005; McManus et al, 2010
Impact of mental disorder during childhood and
adolescence on adult outcomes
Poor mental health in childhood and adolescence also
leads to a broad range of poor adult health outcomes
• Higher rates of adult mental disorder
Common mental disorder
Schizophrenia and mania
Substance misuse
Suicidal behaviour
Personality disorder: 40–70% of children with conduct
disorder develop antisocial personality disorder as adults
• Higher rates of health risk behaviour
• Unemployment and lower earnings
• Crime and violence
Source: Fergusson et al, 2005; Colman et al, 2009; Odgers et al, 2007; NICE, 2009; NICE, 2013
Impact of mental disorder: 10-20 year
reduced life expectancy
• Depression: 11 years (men), 7 years (women)
• Schizophrenia: 21.7 years (men), 17.5 years (women)
• Alcohol use disorder: 10.8 years (women), 17.1 years men
• Opioid use disorders: 17.3 years (women), 9.0 years (men)
• Personality disorder: 18 years
Source: Change et al, 2011; Brown et al, 2010; Hayes et al, 2011; Fok et al, 2012
Impact of mental disorder: National
annual costs
Source: CMH, 2010; NICE, 2009; SCMH, 2009
Local estimation of London’s annual cost of
mental disorder
Source: Application of national figures for cost of different mental disorder to London population size
Impact of mental disorder: key points
• Most mental disorder arises before adulthood but often
continues to impact across the life course
• Mental disorder results in broad range of adverse outcomes
and associated economic costs
• Local impacts can be estimated
• Prevention and early intervention for mental disorder
prevents a broad range of associated outcomes and
inequalities
SECTION 3: RISK FACTORS AND
HIGHER RISK GROUPS
Risk factors
• Addressing risk factors can prevent mental disorder
• Number of people who have a particular disorder is directly
related to the mean population level of the underlying
symptoms or risk factors
• Small reduction in average symptoms/risk factors within a
population can reduce number with mental disorder
• Significant opportunity during childhood/ adolescence given
most lifetime mental disorder has arisen before adulthood
Source: Rose 1992, 2008; Goodman & Goodman, 2011
Risk factors for childhood mental disorder
Household factors
• Children from lowest quintile of household income - 3 fold
increased risk of mental disorder
Pregnancy factors
• Maternal use of drugs, alcohol, tobacco
• Prenatal maternal smoking predictive of conduct problems and
criminal conviction
• Maternal stress during pregnancy - increased risk of child
behavioural problems and impaired cognitive development
• Prematurity associated with mental disorder
• Low birth weight associated with impaired cognitive and language
development
Source: Green et al, 2005; Murray et al, 2011; O’Connor et al, 2003; Nosarti et al, 2012; Colman et al, 2007
Risk factors for childhood mental disorder
Parental factors
• Poor parental mental health 4–5 fold increased rate in
mental disorder
• Parental unemployment 2–3 fold increased risk in onset of
emotional/conduct disorder in childhood
Child factors
• Age: increased rates as reach adolescence
• Sex: boys > girls
• Ethnicity: White highest, Indian lowest
• Screen time: Impact on attention, physical activity, physical
health, weight and social interaction
Source: Green et al, 2005; Meltzer et al, 2003; Murray et al, 20110
Adversity and abuse: Key risk factors for mental
disorder
Accounts for 30% of adult mental disorder
• Child abuse: increased risk of depression (OR 2.9), PTSD (OR
4.0), psychosis (OR 2.7), alcohol dependence (OR 1.8) and
drug problems (OR 2.1)
• 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) and attempted suicide (OR 9.4)
Source: Bebbington et al, 2009; Jonas et al, 2011; Kessler et al, 2010
Adversity and abuse: Key risk factors for mental
disorder
As for any risk or protective factor, important to also consider
proportion of population affected
• Child abuse: 25.3% of 18-24 year olds and 18.6% of 11-17 year
olds experienced severe maltreatment during childhood
• Sexual abuse: 2.9% of women and 0.8% of men experienced
sexual abuse in childhood (sexual intercourse)
Source: NSPCC, 2011; Bebbington et al, 2011
London borough variation of risk factors for
childhood mental disorder
• Prevalence of mental disorder associated with local levels of
risk factors which can be measured
• Borough level variation of some risk factors are highlighted on
the next slide
• Indicate local opportunities to prevent mental disorder
Borough level of risk factors associated with
mental disorder
Source: DCLG 2011, PH Outcomes, Bebbington et al 2011, DfE 2012
Child and adolescent higher risk groups
Looked after children
5 fold increased risk of mental disorder
46% of looked after children have a mental disorder
Children with learning disability
6.5 fold increased risk of mental illness
36% of children with learning disability have a mental disorder
Young men in custody aged 15–17
 18 fold increased risk of suicide
Source: Ford et al, 2007; Emerson & Hatton, 2007; Fazel et al, 2005
Adult higher risk groups
Proportion of women with depression (Gavin et al, 2005)
 12.7% during pregnancy
 6.5% at 6 months after birth
 21.9% a year after birth
BME – Schizophrenia (Kirkbride et al, 2012)
5.6 times higher in black Caribbean group
4.7 times higher in black African group
Source: Gavin et al, 2005; Kirkbride et al, 2012
Risk factors and higher risk groups: key points
• Level of risk factors for mental disorder vary by locality and
are important to address to prevent mental disorder
• Certain groups experience several fold increased risk of
mental disorder
• For different higher risk groups, important to know local
numbers and size of increased risk of mental disorder
• Enables estimation of numbers with different mental disorder
Source: Campion & Fitch, 2012
SECTION 4: ESTIMATING LOCAL
LEVELS OF MENTAL DISORDER
Estimating local levels of mental disorder
• Informs localities about numbers with different mental disorder
including from higher risk groups - important information for
commissioning and planning
• Next slides
Relationship between deprivation and estimated local level of
child/adolescent conduct disorder, emotional disorder and
ADHD
Estimated numbers of children and adolescents who have selfharmed in each borough
Borough variation in expected incidence of psychosis
Estimated local prevalence of child and
adolescent mental disorder
Source: Campion & Fitch, 2012
Estimated local number of children and
adolescents who have self-harmed
Self-harm and have an emotional disorder
Self-harm and have a conduct disorder
Self-harm and have ADHD
Source: Green et al, 2005 (assuming national 7% prevalence rates)
Estimated annual incidence of psychosis per
100,000
Source: Psymaptic, 2013
Estimating local numbers from higher risk
groups and proportion with mental disorder
• Certain groups at several fold increased risk of mental disorder
• Require targeting for both treatment, prevention and
promotion
• Service providers and commissioners require information about
numbers from higher risk groups and proportion estimated to
have mental disorder
• Subsequent slides show estimated numbers from several higher
risk groups in each borough and proportion with mental
disorder
Local number of looked after children and
proportion estimated to have mental disorder
Source: DfE 2011
Local number of new mothers and
proportion estimated to have depression
Rates of maternal depression a year after giving birth
Rates of maternal depression during pregnancy
Number of new mothers
Source: ONS 2012
SECTION 5: MENTAL WELLBEING –
IMPACT, LOCAL LEVELS AND
PROTECTIVE FACTORS
Impacts of mental wellbeing
• More than just absence of mental illness
• Improved resilience to broad range of adversity
Source: Campion et al, 2012
Health impacts of mental wellbeing
Associated with reductions in and prevention of:
• Mental disorder in children and adolescents
• Suicide in adults
• Mental disorder in adults
• Physical illness
• Associated health care utilisation
• Mortality
Source: Campion et al, 2012
Impacts of mental wellbeing outside health
• Improved educational outcomes
• Healthier lifestyle
• Reduced health risk behaviour - smoking, alcohol, drug
misuse, physical inactivity, diet
• Increased productivity at work, fewer missed days off work
• Social/ more positive relationships
• Higher income
• Reduced anti-social behaviour, crime and violence
Source: Campion et al, 2012
Local levels of mental wellbeing
• UK ranked 16th out of 29 countries in 2013 (UNICEF, 2013)
• Levels vary between and within boroughs
• ONS measures for adult wellbeing available at borough level
(ONS, 2013)
28.4% - low happiness score
23.0% - low satisfaction score
19.3% - low worthwhile score
• Range of protective factors – proxy indicators
Protective factors for mental wellbeing
• genetic background, maternal (ante-natal and post-natal) care,
early upbringing and early experiences including attachment
patterns
• personality traits
• age, gender and marital status
• relationships, strong social support and networks
• socio-economic factors
• access to resources and reduced inequality
• employment and other purposeful activity
• community factors such as levels of trust and participation
• self-esteem, autonomy, values such as altruism
• emotional and social literacy
• physical health
Source: Campion et al, 2012
Protective factors for wellbeing
Young children
• Primary school context/ friendships
• Home life and family relationships
• Less deprived neighbourhood
School teenage years
• School environment free from bullying and classroom disruption
• Feeling supported
• Sharing meals
Adulthood
• Good employment
• Conditions of home
Source: Chanfreau et al, 2013
Risk factors for poor wellbeing
School and teenage years
• Substance misuse
• Excessive computer gaming
• Disruptive behaviour at school
Adulthood
• Deprivation
• Fuel poverty
• Poor state of repair of housing
• Stressful job
• Mental disorder
Source: Chanfreau et al, 2013
Risk of lower wellbeing at certain ages
 Falls during teenage years (proportion with high levels of
wellbeing)
Age 11: 24%
Age 12: 18%
Age 13: 14%
Age 14: 11%
Age 15: 8%
 Dips between ages of 33-54
 Lowest in older women
Source: Chanfreau et al, 2008; HSE, 2010
Key points
• Improved mental wellbeing have a similar broad range of
impacts to mental disorder
• Particular groups at higher risk of poor mental wellbeing
• Note that largest single group with poor wellbeing are people
with mental disorder
• Interventions to promote mental wellbeing need to target
higher risk groups and coordinate with services providing
treatment for mental disorder
SECTION 6: PUBLIC MENTAL
HEALTH INTERVENTIONS
Effective interventions exist
• Cross Government public mental health strategy ‘Confident
Communities, Brighter Futures’ (HMG, 2010)
• Royal College of Psychiatrists position statement on public
mental health (RCPsych, 2010)
• Cross Government mental health strategy ‘No health without
mental health’ (HMG, 2011)
• Joint Commissioning Panel guidance on public mental health
(Campion & Fitch, 2012)
Effective interventions exist
• Prevention of mental disorder (primary prevention)
• Treatment of mental disorder (secondary and tertiary
prevention)
• Promotion of mental wellbeing (primary promotion focusing
on whole population with secondary and tertiary promotion
targeting groups with low wellbeing including those with
mental disorder
Interventions from range of organisations
including from outside health
Highlights importance of knowledge of activities of different
organisations to facilitate cross-sector coordination:
• Primary and secondary care
• Local government
• Public health
• Social care service providers
• Third sector social inclusion providers
• Education providers
• Employers
• Criminal justice services
PRIMARY PREVENTION AND
PROMOTION
Primary prevention and promotion
• Address risk factors for mental disorder and promotes
protective factors for mental wellbeing
• Particularly
Inequalities and deprivation
Violence and abuse in childhood and adolescence
Discrimination and stigma
• Targeting groups at higher risk
• Important part of sustainable reduction in burden of mental
disorder
• Area usually outside remit of ‘health’ but within remit of
public health
Primary prevention and promotion
• Childhood and adolescence particularly important opportunity –
family approach including parents
• Place based approaches (e.g. child centres/schools/ workplace)
Cover a large number of population at one time
Improve literacy about mental wellbeing and disorder
• Campaigns or social marketing of resources which improve
mental health literacy and outline what people can do to
promote their wellbeing
’10 Actions for Happiness’
‘5 ways to wellbeing’
Promotion of parental mental and physical
health
• Programmes to support secure attachment with parents and
carers
• Breastfeeding support
• Supporting good parenting skills
• Home visiting programmes
• Preschool programmes
Source: Campion & Fitch, 2012
Parenting support programmes
• Improved parental efficacy and practice
• Improved maternal sensitivity
• Improved child emotional/behavioural adjustment in 0-3 years
• Improved behaviour in high risk children and those with conduct
problems
• Improved safety at home
• Reduced antisocial behaviour
• Reduced re-offending
Source: Campion & Fitch, 2012
Home visiting programmes
• Improve child functioning and reduce behavioural problems
• Reduced maternal depression
Source: Elkan et al, 2000; Bull et al, 2004
Addressing parental risk factors
• Maternal smoking during pregnancy (PH outcome)
• Post-partum support
• Parental mental disorder
• Violence/ abuse
Source: Campion & Fitch, 2012
Prevention of child abuse
• Adverse child experiences single largest risk factor for mental
disorder (30%)
• Child abuse associated with several fold increased risk of
mental disorder, suicide and self-harm
• Nationally, 19% of 11-17 year olds estimated to experience
severe maltreatment during childhood
• 3% of women and 1% of men experience sexual intercourse
during childhood
Source: Campion & Fitch, 2012; Bebbington et al, 2011
Prevention of child abuse
• Parent training programmes result in reduced aggression,
violence, offending, antisocial behaviour, and bullying
• Nurse Family Partnerships
• School based:
violence prevention programmes
sexual abuse prevention programmes
bullying prevention programmes
date violence prevention programmes
• Also addressing abuse when identified e.g. CPP
Source: Campion & Fitch, 2012
Preschool and early education programmes
Result in improved:
• cognitive skills
• school readiness
• improved academic achievement
• positive effect on family outcomes including for siblings
• prevention of emotional and conduct disorder
Combined programmes for preschool children from
disadvantaged areas - improved parent and family wellbeing
Source: Campion & Fitch, 2012; Anderson et al, 2003; Nelson et al, 2003; Sylva et al, 2007; Tennant et al, 2007
School based mental health promotion/
prevention programmes
• Improved wellbeing associated with:
Improved academic performance, social and emotional
skills, and classroom misbehaviour (NICE, 2008; NICE,
2009)
Reduced conduct problems and emotional distress
(Stewart-Brown, 2006; Adi et al, 2007)
• Long term, whole school, focusing on promotion and including
teacher training and parental participation – more effective
(Durlak et al, 2011; Weare & Nind, 2011)
Source: Campion & Fitch, 2012
School based social and emotional learning
programmes
Meta-analysis of more than 270,000 students from
US social and emotional programme
• reduced conduct problems and emotional distress
• improved social and emotional skills, attitude about self
• improved social behaviour
• 11% improved academic performance
• cost savings of reduced conduct disorder are £84 for each
pound invested
Source: Durlak et al, 2011; Knapp et al, 2011
School based social programmes
• Peer mediation effective in promoting pro-social and
behavioural skills in the long term (Blank et al, 2009)
• Secondary school curriculum approaches to promote prosocial behaviours and skills can also prevent development of
anxiety and depression (NICE, 2009)
• TaMHS incorporates a number of different programmes
 Bullying prevention (£14 net savings for each £ spent)
(Knapp et al, 2011)
 Violence prevention programmes
 Addressing domestic violence
 Loss, separation and bereavement
 Stigma prevention
Elements of TaMHS programmes
Targeted Mental Health in Schools
‘Drawing and
Talking’
KS1-4
Emotional Health /
Wellbeing Team – to
support students in
KS3&4
Home-Focused
Practitioner Trained
in ASD, 123 Magic,
Solihull Approach
Parenting
More Targeted
Programmes or Support
- Wave 3 focused
Targeted Programmes
Peer Support CBT based Group
Support for child
or Support
KS1&2
Work e.g.
experiencing Loss,
- Wave 2 focused
Peer
‘Growing
Bereavement, Separation,
Mentoring
Optimism’ or
ADHD, ASD, Self-harm &
Universal
KS3&4
‘RESPECT’
Domestic Abuse
Whole-School
Building
Resilience
Peer
Massage
Well-Being
Programmes or
Behaviour
thru:
or
Wheels Management Approach Support- Wave 1
Relaxation
‘Zippy’s Friends’ KS1
interactive
focused
e.g. 123 Magic
‘FRIENDS’ KS2/3/4
Techniques
resource
Essential
Shoe
Headteache Solihull
Solution Mental
Family
Parent
Box &
r & Staff
Approach
Focused Health Team
SEAL
Engagement
Foundation
Mental
Well-being
& or
Approac or Lead
– Best
Programmes
Health
Programme Protective
h
Person in
Practice
&
s ProgrammeBehaviour
MentalHandboo
Health Stigma
(MHSP) inc ParticipationSchool
of Children & Young People
Approaches
k
s
Children’s Workforce Core Competencies (from DCSF, ECM 2005)
Essential Underpinnings
for work with children
Prevention of conduct and emotional
disorder
• Reduced maternal smoking
• Home visiting programmes , Nurse Family Partnership ,
Surestart
• Parenting programmes (NICE, 2013)
• Pre-school programmes (Tennant et al, 2007)
• Universal and targeted school programmes (Horowitz and
Garber, 2006; Merry et al, 2004)
• Penn Resiliency programme (Brunwasser & Gilham, 2008)
Prevention of alcohol, smoking and drug
misuse
• School based mental health promotion can reduce range of
health risk behaviours (WHO, 2006)
• Price and availability of alcohol (NICE, 2010)
• Alcohol; guidelines exist for prevention and reduction of
alcohol use in children and young people (NICE, 2007)
• Prevention of uptake of smoking in children/ young people
(NICE, 2008, 2010)
• Drug misuse; NICE reviews exist for prevention and reduction
of substance misuse among young people (McGrath et al,
2006; Jones et al, 2006)
Note several fold increased level of substance misuse in
children/ adolescents with mental disorder (Green et al, 2005)
Screen time prevention
• Screen time associated with poor wellbeing (Sigman, 2012)
• Daily average of more than 6 hours outside school (Ofcom,
2012)
• Advice/ information to parents:
Encourage no screens in children’s bedrooms
Advice to parents of younger children to choose screen
material with a slower pace, less novelty and more of a
single narrative quality
Monitor and control the time their children spend on
hand-held computer games/media
Work and social promotion interventions
• Important impact on parents which impact on family
• Work based mental health promotion programmes result in
net savings of £10 for each £ spent
• Social relationships important protective factor for wellbeing.
Interventions to enhance social capital include:
Mentoring
Timebanks
Adult education
Volunteering
Art
Mindfulness/ spiritual/ religious
Physical activity
Source: Campion & Fitch, 2012; Knapp et al, 2011
Living well interventions
• Good housing and supported housing
• Interventions to ensure adequate heating
• Physical activity - improves depression and well-being (NICE,
2009), cognitive performance in children (Sibley and Etnier,
2003)
• Active travel
• Neighbourhood interventions
• Safe green community space
• Activities including learning, active leisure, volunteering, arts
• Positive psychology interventions
• Mindfulness interventions
Source: Campion & Fitch, 2012
SECONDARY/ TERTIARY
PREVENTION AND PROMOTION
Secondary/ tertiary prevention and promotion
• Adolescence particularly important opportunity since half of
lifetime mental illness has arisen by 14
• Intervention for mental disorder supported by NICE guidance
• Early intervention for mental disorder results in improved
outcomes and prevents a range of subsequent impacts. Also
addresses underlying cause of poor wellbeing
• Need for targeting of groups at higher risk
Source: Campion & Fitch, 2012
SECTION 7: PUBLIC MENTAL HEALTH
INTELLIGENCE ON
A) COVERAGE
B) SPEND
C) OUTCOMES
D) ECONOMIC IMPACT
Limitations of intelligence
• Quality and how recent
• Lack of national data sets for certain risk/protective factors
• Lack of national data sets for coverage of certain
interventions
• Lack of data on outcomes of interventions
• Certain data can be collected at locality level to fill gaps in
national dataset coverage
A) COVERAGE OF INTERVENTIONS
Coverage of primary promotion/ prevention
• Lack of provision of primary prevention of mental disorder or
promotion of mental wellbeing
• 0.03% of mental health budget spent on adult mental health
promotion (DH, 2012)
• Lack of data for coverage including for higher risk groups
• Opportunity for improved action on primary level of
intervention through coordinated working
Next slide highlights example of child abuse
• Could be addressed through more coordinated action
between interventions from schools and social services
• Only a minority of children experience sexual abuse receive
any intervention
Proportion of children being abused who
receive intervention for sexual abuse
Source: DCLG 2011, PH Outcomes, Bebbington et 2011 and DfE 2012
COVERAGE OF TREATMENT FOR
MENTAL DISORDER
Coverage of treatment
• In UK, majority of people with mental disorder (except
psychosis) receive no intervention despite impact of mental
disorder and availability of evidence based interventions
• Nationally, less than 3% of adults see secondary care
• Variation in treatment coverage within and between
boroughs
• Lack of data for coverage of higher risk groups
• Primary care – opportunity for detection /intervention and
subsequent referral to secondary care if required
• Highlights need to improve recognition of mental disorder by
both primary care staff and general population
Source: Green et al, 2005; McManus et al, 2009; HSCIC, 2013
National proportion of children and adolescents
receiving any intervention for mental disorder
Conduct disorder
• 28% parents - advice from mental health specialist
• 24% from special educational services such as psychologists
Emotional disorder: 64% of parents had contacted a
professional source usually a teacher
Symptoms/ impairment undetected in
• 55% of children with autism
• 57% of Aspergers
Source: Green et al, 2005 ; Russell et al, 2010
National proportion of adults who receive no
intervention for mental disorder
•
•
•
•
•
•
•
Common mental disorder 76%
Probable psychosis 19%
Psychosis in past year 35%
Alcohol dependency 86%
Cannabis dependency 86%
Other drug dependency 64%
Older people with depression 90%
Source: McManus et al, 2009; Chew-Graham et al, 2004
Coverage of treatment for self-harm in
children and adolescents
• No nationally collected information on numbers of children
and adolescents receiving treatment for mental disorder
available at present despite majority of lifetime mental
disorder arising before adulthood
• Following two slides show:
 Borough level variation of child/ adolescent admissions due
to self-harm
 Lack of association between self-harm admissions and
deprivation
Child and adolescent admission due to self
harm per 100,000
Source: HES, 2012
Child and adolescent admission due to self
harm per 100,000 vs. IMD rank
Source: HES, 2012; DCLG, 2011
B) SPEND ON MENTAL HEALTH
Resource allocation for mental health
• In 2010/11, NHS spent 11.1% of annual budget on mental health
services = £12 billion (DH, 2012) - note mental disorder 23% of
total burden of disease
• 6.8% of mental health budget spent on child and adolescent
services despite half of lifetime mental disorder arising by age
14
• In 2011/12, estimated national spend on adult mental health
promotion = £3 million (DH, 2013)
• 2% cut in mental health budget announced in December 2013
Spend on personal social services for adult
mental disorder
• Next two slides highlight borough variation in levels of social
care spending for people with mental disorder
• While spending tends to be higher in more deprived boroughs,
some boroughs spend considerably more or less than would be
expected
Spend on personal social services for
adult mental disorder
Source: HSCIC, 2013
Spend on personal social services for adult
mental disorder
Source: HSCIC, 2013
C) OUTCOMES
C) Outcomes
• Includes
Intelligence about outcomes of interventions
Information on outcomes of different interventions for
different groups
Range of measures including experience
• Note general lack of nationally available data particularly for
higher risk groups
C) Outcomes
Following two slides show borough level variation in
• Level of emotional wellbeing of looked after children highlights wide variation of wellbeing in more deprived
boroughs
• SMI excess mortality rate - this is higher in less deprived
boroughs
Emotional wellbeing of looked after children
Source: DfE 2013; DCLG, 2011
SMI excess mortality rate vs. IMD Rank
Source: DCLG, 2011; HSCIC 2010-2011
D) ESTIMATING ECONOMIC
IMPACT OF INTERVENTIONS
Economic impact of primary prevention
Figures in red are examples of net savings for each £ spent
outlined in the mental health strategy economic modelling
paper by Knapp et al, 2011
• School based social emotional learning programmes to
prevent conduct disorder - £84 net savings for each £ spent
• School based bullying prevention £14
Size of local savings depend on coverage and outcomes which
are associated with quality of implementation
Source: Knapp et al, 2011
Economic impact of secondary prevention
• Parenting interventions for children with conduct disorder £8
• Multi-dimensional treatment foster care reduces crime by
17.9% - net savings of $88,953 per participant
• Early detection and treatment of depression at work £5
• First episode psychosis £18
• Early intervention for the stage which precedes psychosis
(Clinical High Risk State) £10
• Screening and brief interventions in primary care for alcohol
misuse £12
Source: Knapp et al, 2011; Drake et al, 2009
Local net savings if all parents of children with
conduct disorder received parenting interventions
Source: Knapp et al, 2011; Friedli & Parsonage, 2008; Campion & Fitch, 2012
New commissioning landscape
• CCGs and LA’s jointly leading local healthcare system through
H&WBs in collaboration with their communities (DH, 2011)
• Integration of public health into LA’s
• Information required for Joint H&WB strategies and
commissioners to inform about required level of PMH
interventions
JSNA key vehicle for provision of relevant
public mental health information
•
•
•
•
Level of risk and protective factors across the population
Numbers from higher risk groups
Local levels of well-being and mental disorder
Proportion receiving intervention including from high-risk
groups
• Current levels of provision of cost-effective public mental
health interventions
• Joint Strategic Asset Assessments augment JSNAs and identify
local assets to improve health and social outcomes
Good public mental health commissioning
• Prevents large proportion of mental disorder and promotes
population wellbeing/ resilience
• Enhances coverage of effective intervention to treat mental
disorder, prevent mental disorder and promote mental health
• Focuses on children and families
• Effectively targets higher risk groups to prevent widening of
inequality
• Results in significant improvements in NHS, public health and
social care outcomes
• Facilitates joined up and collaborative working between
different service providers
SECTION 8: SUMMARY
Summary
Various policy documents highlight compelling evidence for public
mental health interventions to:
• Improve healthy lifestyles, improve physical health, life
expectancy
• Improve resilience, social functioning and quality of life
• Reduce burden of mental disorder
• Reduce economic costs of mental disorder
• Reduce inequalities
• Reduce associated health risk behaviour, crime, violence
Summary
• Greater coverage of early intervention and prevention can
reduce burden and cost of mental disorder as well as
associated physical illness
• Significant personal, social and economic savings result from
such investment across a range of area even in the short term
• Significant costs arise from lack of such investment
• Balancing resources with early treatment of mental disorder
particularly before adulthood
Summary
• Public mental health intelligence includes local:
 Level of risk and protective factors
 Numbers from higher risk groups
 Level of mental disorder and poor wellbeing
 Coverage of public mental health interventions
 Outcomes of interventions across a range of areas
• Important intelligence not available as national datasets
which needs to be collected locally
• Public mental health intelligence
Supports integrated strategic development
Supports collaboration with a range of sectors whose
priorities benefit from public mental health intervention
Facilitates improved coverage of interventions
Summary
• Since majority of mental disorder arises before adulthood,
greatest opportunity to both prevent and intervene early
during this period
• Sustained, systematic and coordinated commissioning in
partnership with range of different organisations and service
providers is achievable
• Requires universal interventions, applied to the entire
population and targeted interventions for those at higher risk
• UCLPartners currently bringing all public mental health
intelligence together
Acknowledgements
• Peter Fonagy: Programme Director, Integrated Mental Health
Programme (UCLPartners)
• Anna Moore: Director, Integrated Mental Health Programme
(UCLPartners)
• Chris Houghton: Consulting Manager (Concentra)
References and contact
• Campion J, Fitch C (2012) Guidance for the commissioning of
public mental health services. Joint Commissioning Panel for
Mental Health www.jcpmh.info/resource/guidance-forcommissioning-public-mental-health-services/
• Campion J, Bhui K, Bhugra D (2012) European Psychiatric
Association (EPA) guidance on prevention of mental disorder.
European Psychiatry 27: 68-80
• Campion J (2013) Public mental health commissioning
guidance: embedding mental health in local public health
work. Perspectives in Public Health 133: 87
• Email: j.campion@ucl.ac.uk