Dr Geraldine Strathdee, National Clinical Director for Mental Health.

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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
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