Adult Mental Health Introduction

Adult Mental Health
Introduction
Positive mental health is more than the absence of mental illness. Mental wellbeing can be
defined as “a dynamic state, in which the individual is able to develop their potential, work
productively and creatively, build strong and positive relationships with others and
contribute to their communities” Foresight (2008)
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One in four adults experience mental illness at some point in their lifetime and one in
six are experiencing mental illness at one time
This makes mental illness the largest cause of disability in society today.
There are several complex reasons why individuals develop a mental illness:
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It can be inherited
It could be caused by lifestyle
Or it could be linked to events that have happened in the past
Usually it is caused by a combination of all of the above. The reasons can be broken down
further into groups:
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Social
Environmental
Physical
Psychological
Although the causes of mental health are complex, their impact can be reduced by
intervening early; as soon as an individual starts to display signs of ill health.
Mental illness in adults can be classified as:
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Common mental disorders
Personality disorders
Psychoses
Eating disorders
Disorders related to substance misuse
There is a clear link between mental and physical health and an urgent need to strengthen
both the provision of mental health care to people with physical illness and the quality of
physical health care provided to people with mental health problems in general hospitals
and primary care.
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What do we know?
Facts, Figures, Trends
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Many mental health problems start early in life; half of those with lifetime mental
health problems first experience symptoms by the age of 14 (Kim-Cohen 2003)
Almost half of all adults will experience at least one episode of depression during
their life time (Andrews 2005)
One if four adults experience mental illness at some point in their life and one in six
are experiencing mental illness at one time – this makes mental illness the largest
single cause of disability in society today
Common mental health problems (such as depression, anxiety, phobias and
obsessive compulsive disorder) are very common with a prevalence rate in adults in
England of 17.6%
The most recent psychiatric morbidity in England study (2007) found that more than
half of those with a common mental disorder presented with mixed anxiety and
depressive disorders (9%)
The largest increase in rate of common mental disorders between 1993 and 2007
was observed in women aged 45-64 among whom the rate rose by a fifth
Depression is approximately two to three times more common in patients with a
chronic physical health problem
Mental health is affected by a wide range of determinants, requiring intervention and
support further than the scope of health services. The environment, education,
housing, and the financial climate all affect an individual’s mental wellbeing.
Poor mental health is a key factor that underpins many physical health problems and
acts as an underlying driver for much health risk behaviour, including smoking,
substance misuse and obesity.
To the period 2016, the largest absolute increase is in neurotic disorders where it is
estimated that 1 in 6 adults experience some sort of neurotic disorder, the most
prevalent being mixed anxiety and depression.
Demand for mental health services is likely to increase as a result of unemployment,
personal debt, home repossession and other fallout from the recession
Approximately 2% of the NHS expenditure goes on dealing with depression and
anxiety
Psychosis affects 0.5% of adults in England (Manus 2009)
Women have a slightly higher prevalence of probable psychosis than men (0.5% and
0.4% respectively), with the highest prevalence amongst those aged 16-44 years.
The coalition government has recently published its national mental health strategy
‘No health without mental health’ (HM Government 2011)
The strategy encourages taking a life course perspective; laying down the
foundations of good mental wellbeing in childhood, continuing wellbeing in adulthood
and maintaining resilience in older age. Key to this approach is the promotion of
positive mental health to prevent mental illness, early intervention, and to ensure
everyone sees mental health in the same importance as physical health.
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Mental health is an essential part of overall health, and is fundamentally related to
physical health with poor mental health increasing the risk of poor physical health
and vice versa. Depression increases the risk of mortality by 50% and doubles the
risk of heart disease in adults (HM Government 2011)
It is estimated that better mental health care would save the government £3.1 billion
a year (Wanless, 2004). This does not take in to account the saving promoting
health and prevention. Changing people’s health-related behaviour, promoting
factors to protect mental health including improving social support and work life
balance can have a major impact on some of the main causes of mortality and
morbidity (NICE, 2008).
Table 1: Population aged 18-64 predicted to have a mental health problem in England
projected to 2030
People aged 18-64
predicted to have a mental
problem projected to 2030
- England
2011
2015
2020
2025
2030
People aged 18-64
predicted to have a
common mental disorder
5,278,168
5,333,570
5,424,756
5,505,735
5,556,352
People aged 18-64
predicted to have a
borderline personality
disorder
147,522
149,038
151,553
153,721
155,137
People aged 18-64
predicted to have an
antisocial personality
disorder
114,774
116,191
118,400
120,379
121,888
People aged 18-64
predicted to have psychotic
disorder
131,134
132,503
134,761
136,715
138,011
People aged 18-64
predicted to have two or
more psychiatric disorders
2,360,549
2,386,174
2,427,856
2464,222
2,489,210
Source: PANSI
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Table 2: Population aged 18-64 predicted to have a mental health problem in The East of
England projected to 2030
People aged 18-64 predicted to have
a mental problem projected to 2030 –
East of England
2011
2015
2020
2025
2030
People aged 18-64 predicted to have
a common mental disorder
578,540
589,024
606,563
622,499
633,222
People aged 18-64 predicted to have
a borderline personality disorder
16,172
16,463
16,951
17,395
17,692
People aged 18-64 predicted to have
an antisocial personality disorder
12,564
12,809
13,204
13,558
13,813
People aged 18-64 predicted to have
psychotic disorder
14,374
14,634
15,069
15,465
15,731
People aged 18-64 predicted to have
two or more psychiatric disorders
Source: PANSI
258,672
263,430
271,330
278,487
283,370
Table 3: Population aged 18-64 predicted to have a mental health problem in Central
Bedfordshire projected to 2030
People aged 18-64 predicted to have a
mental problem projected to 2030 – Central
Bedfordshire
2011
2015
2020
2025
2030
People aged 18-64 predicted to have a
common mental disorder
25,985
26,370
27,118
27,680
27,883
People aged 18-64 predicted to have a
borderline personality disorder
726
737
758
774
779
People aged 18-64 predicted to have an
antisocial personality disorder
565
575
591
601
608
People aged 18-64 predicted to have
psychotic disorder
646
655
674
688
693
People aged 18-64 predicted to have two or
more psychiatric disorders
Source: PANSI
11,621
11,799
12,131
12,377
12,476
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Local Picture
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The number of people with a mental health condition in Central Bedfordshire is
predicted to rise, primarily as a result of the changing population structure.
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To the period 2016, the largest absolute increase is in neurotic disorders where it is
estimated that 1 in 6 adults experience some sort of neurotic disorder over their
lifetime, the most prevalent type being mixed anxiety and depression.
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In England, one person dies every two hours as a result of suicide. There were 11
suicides in Central Bedfordshire in 2010-2011
Figure 1: QMAS data by GP practices for Central Bedfordshire for mental health conditions
Source: Produced by Public Health Intelligence
The practice with the highest mental health QMAS data has traditionally high numbers of
homeless, drug users and mental health patients.
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Figure 2: QMAS data by Bedfordshire Localities for all mental health conditions
Source: Produced by Public Health Intelligence
Figure 3: Mini Mental Needs Index – Central Bedfordshire
Source: Public Health Intelligence
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Figure 3 shows that that Manshead Ward recorded the highest MINI score greater than
both Central Bedfordshire and England.
There are strong links between social deprivation and mental ill health, therefore service
provision and treatment should be focused towards the more deprived areas of Central
Bedfordshire. In terms of deprivation, no areas are within the 20% most deprived nationally,
however, if deprivation is assessed at a small area level (known as Lower Super Output
Areas – LSOAs) and compared with the East of England, there are nine LSOAs which fall
within the 20% most deprived regionally; these are Sandy Pinnacle, All Saints, Parkside,
Chiltern, Dunstable Central, Tithe Farm, Northfield, Stotfold and Manshead.
Compared with people with no mental health problems, men with mental illness live 20
years less and women 15 year less. A combination of lifestyle risk factors such as smoking
and diet, higher rates of unnatural deaths such as suicide and accidents and poorer
physical health contribute to premature mortality (Wahlbeck 2001).
Current activity & services
Both Central Bedfordshire Council and NHS Bedfordshire commission mental health
services in Central Bedfordshire. The main provider is South Essex Partnership Trust
(SEPT), although mental health services are provided in Milton Keynes and Cambridge.
The third sector also provides service in the community.
Primary Care Mental Health Services
Most general mental health services are provided in primary care by GP’s, the
Psychological Therapy Services, The Primary Care Counselling Service and the Improving
Access to Psychological Therapies (IAPT) service know as Step by Step. Within a stepped
model of care, a range of individual and group psychological therapies are offered to treat
common mental health problems.
Employment Support Service in Primary Care
The Richmond Fellowship, a specialist provider of mental health services offer vocational
advice and support for clients experiencing stress, anxiety, depression or other common
mental health conditions to those who are at risk of loosing their jobs or who wish to return
to work after a period of sickness absence or unemployment.
South Essex Partnership University NHS Foundation Trust (SEPT) is commissioned to
deliver care and support to people in their own home and from a number of hospital and
community settings:
Acute and Crisis Service / Acute Assessment Unit (AAU) – Located at Bedford Hospital.
The Trust’s Assessment Units work closely with Crisis Resolution Home Treatment Teams
to offer service users an alternative to admission or to reduce length of stay for those who
require admission.
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It is a 24-hour dedicated inpatient unit. All patients that are referred from Accident and
Emergency Departments are sent to the unit for consultation and referral.
Crisis Resolution and Home Treatment team (CRHT) – Multi-disciplinary team of
doctors, clinical psychologists, psychiatric nurses, social workers and support workers for
those whose needs cannot be met in primary care and who require targeted clinical
interventions.
Assertive Outreach Team (AOT) - Multi-disciplinary team of doctors, clinical
psychologists, psychiatric nurses, social workers, occupational therapists and support
workers who support people with severe and enduring mental health conditions.
The Complex Needs Service works closely with the community and specialist mental
health teams to improve the care delivered to service users with personality disorders and
their families and carers.
B: DAT, Bedfordshire Drug and Alcohol Action Team oversees and monitors the local
drug and alcohol treatment services in Bedfordshire. Care Co-ordination support people
with a dual diagnosis (mental health problem and substance misuse).
Psychiatric Intensive Care Unit (PICU) is located in Luton. The Robin Pinto Unit is a low
secure environment which provides intensive psychiatric care.
The Prison In-Reach Team – Support prisoners in Bedford Prison with mental health
problems.
Empowa – provides specialist support for people with mental health problems
Specialist services for people of working age include:
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Eating Disorder Service
Electro-Convulsive Therapy (ECT)
Direct Access Psychology Service
Clinical Health Psychology Service
Acquired Brain Injury Psychology Service
MIND
Bedfordshire and Luton Mind provides mental health, wellbeing and social care services
across Bedfordshire in partnership with other local service providers and mental health
service users. Services include:
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Step 2 IAPT
Wellbeing Centres providing supported access to a wide range of services
Volunteering and mentoring, using the Recovery Star Model
Social Groups
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Therapeutic Groups including stress/anxiety management and mental wellbeing
Youth in Mind Service working with young people aged 14-25 using motivational and
solution focused mentoring
Training – anxiety management, self esteem and assertiveness, understanding
anger, sleep, stress, mental health first aid and mental health awareness
Support and access to exercise and health living options
Carers Services
Services are available for the carers of individuals with mental health conditions within
Central Bedfordshire.
Rethink
Services are available to help everyone affected by severe mental illness recover a better
quality of life.
Local Views
In February 2010 an event was held by Central Bedfordshire Council, Bedford Borough
Council and Luton Borough Council to consult with service users, carers and stakeholders
on the proposed Mental Health Section 75 Agreement which was being developed with
South Essex Partnership Trust for the provision of specialist mental health services.
Priorities for the service users and carers were:
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Information and guidance to be easily available
Employment
Housing
National & Local Strategies (Best Practices)
Clinical Guidelines
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Promoting mental wellbeing at work (PH22) (2009)
Eating disorders (CG9) (2004)
Self Harm (CG16) (2004)
Anxiety (CG22) (2007)
Post Traumatic Stress Disorder (CG26) (2005)
Obsessive Compulsive Disorder (OCD) and Body Dismorphic Disorder (BDD)
(CG31) (2005)
Bipolar disorder (CG38) (2006)
Antenatal and Postnatal mental health (CG45) (2007)
Antisocial Personality Disorder (CG77) (2009)
Schizophrenia (CG82) (2009)
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Depression in Adults (CG90) (2009)
Borderline Personality Disorder (CG78) (2009)
Public Health Guidelines
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HM Government (2011) No health without mental health; A cross-government mental
health outcomes strategy for people of all ages.
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Foresight – Mental Capital and Wellbeing: making the most of ourselves in the 21st
century. The Government Office for Science, 2008.
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Five ways to wellbeing. NEF, NMHDU, NHS Confederation, 2011.
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Marmot M. 2010: Fair society, healthy lives: The Marmot Review. Strategic Review
of Health inequalities in England post – 2010
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Mental Health and the economic downturn: national priorities and NHS solutions.
R.C.psych, NHS Confederation, LSE, 2009
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New Horizons: a shared vision for mental health
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Public Health White Paper: Healthy Lives, healthy people (2010)
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Joint Commissioning Strategy for Mental Health Services 2010-2013
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Public Health Report 2012 – Adult Mental Health in Central Bedfordshire- Suneela
Sajjad
What is this telling us?
What are the key inequalities?
Mental health is influenced by diverse biological and social risk factors, including fixed
factors such as genetic factors and biographic characteristics (age and sex) and modifiable
factors such as family and socio-economic characteristics (marital status, number of
children, employment), individual circumstances (life events, social supports, immigrant
status, debt), household characteristics (accommodation type, housing tenure) geography
(urban, rural, region) and societal factors (crime, deprivation index) (Foresight Mental
capital and Wellbeing Project 2008)
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Black and minority ethnic (BME) people with mental health problems
 People from BME groups often have different presentations of problems and different
relationships with health services. Some black groups have admission rates around
three times higher than average, with some research indicating that this is an
illustration of need.
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The rates of mental health problems in particular migrant groups, and subsequent
generations are also sometimes higher.
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African –Caribbean people are particularly likely to be subject to compulsory
treatment under the Mental Health Act.
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South East Asian women are less likely to receive timely, and appropriate mental
health services.
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Black men are 3 times more likely to be represented on a psychiatric ward and up to
six times more likely to be detained under the Mental Health Act
Community and inpatient caseload by ethnicity in NHS Bedfordshire
Service
White
Black
Asian
Mixed
Chinese/
Unknown
other
2369
56
139
33
120
<5
218
9
15
<5
10
<5
Adult CMHT
Adult inpatient
Source: SEPT data for October 2011
People with other disabilities and mental health problems
Disabled people with mental health problems may face either barriers to physical access or
communication barriers (deaf people in particular). This is critical in mental health provision,
which relies on communication. An estimated 25-40% of people with learning disabilities
have mental health problems.
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People with autism may be refused support because they do not fit easily into mental
health and learning disabilities services.
Lesbian, gay and bisexual people with mental health problems
People from this group are at higher risk of mental health problems and of self harm.
Monitoring of sexual orientation is patchy, making it less easy to develop tailored services
Gender inequality
There are differences in the rates and presentations of mental health problems between
men and women.
Women
Recorded rates of depression and anxiety are between one and a half and two times higher
for women than for men.
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Rates of deliberate self-injury are two to three times higher in women than men.
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Women are at greater risk of factors linked to poor mental health, such as child
sexual abuse and sexual violence – an estimated 7–30% of girls (3–13% of boys)
have experienced childhood sexual abuse.
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Around one in ten women have experienced some form of sexual victimisation,
including rape.
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Studies have shown that around half of the women in psychiatric wards have
experienced sexual abuse.
Men
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Three-quarters of people who commit suicide are men.
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Men are three times more likely than women to be dependent on alcohol and more
than twice as many men in psychiatric units are compulsorily detained.
Gender Reassignment
People who have undergone gender reassignment can be subject to discrimination in our
society. They are at an increased risk of alcohol and substance misuse, suicide and selfharm. It is important that staff in health, social and education services are aware of the
raised risks in these groups.
 Lesbian, gay, bisexual or transgender adults have a 4-fold increased risk of suicide
 Effective approaches to reducing differences in access, experience and mental
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health outcomes are built from the best available evidence in why and how these
variations occur.
Unemployment
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Research shows that a total of 2.3 million people with a mental health condition are
on benefits or out of work (HM Government, 2009)
Unemployed adults have a 5.6 fold increased risk of developing a mental health
problem
In May 2009, there were 2,080 people claiming incapacity benefit as a result of
mental health or behaviour disorders in Central Bedfordshire
Drugs and alcohol
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The 2010 Drug Strategy shifts the focus for substance misuse services towards
recovery, and not just harm-reduction, as was previously the case.
The strategy recognises the importance of tackling the causes of drug and alcohol
use and the clear association between mental ill health and substance misuse.
The need for this locally is highlighted by the fact that less than 1 in 10 of those in
treatment in Bedfordshire exited successfully in 2010, and around 1 in 3 of those on
prescribing interventions have been on these for 3 years or more, with very few
prescribing interventions being complimented by psychosocial intervention.
Prisoners
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Offenders have a 5-fold increased risk of suicide (with an 18-fold increased risk
amongst young offenders, a 35.8-fold increased risk amongst female offenders and
an 8.3-fold increased risk for recently released offenders)
Homeless
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Research indicates that 43% of those accessing homelessness projects in England
suffer from a mental health condition
The homeless have a 5.3-fold increased risk of developing a mental health problem
Carers
 The majority of people with a mental health diagnosis live in the community with
family, partners providing the bulk of their informal care.
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Veterans
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In May 2010, the Coalition Government acknowledged that action need to be taken
when it promised to “…rebuild the Military Covenant by…providing extra support for
veterans’ mental health
Health Outcomes
January 2009 analysis by the Eastern Region Public Health Observatory (ERPHO)
(currently only available at Bedfordshire level) showed Bedfordshire to be significantly
higher than average for hospital admissions for self harm and for persons on enhanced and
standard care. In all other measures Bedfordshire was significantly lower than the England
average.
Source: ERPHO
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What are the unmet needs/ service gaps?
There has not been enough focus on the root causes of ill health. Mental and physical
health and wellbeing interact and are affected by a wide range of influences throughout life.
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Mental wellbeing promotion
Increase in mental health issues being managed in primary care
Supported housing
Key areas for action:
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Improving mental health through wellbeing and prevention services
Reducing waiting times for assessment and treatment
Maintain people’s mental health post-treatment through better primary and
community care services.
The costs of the intervention are more than outweighed by gains to business due to
a reduction in both presenteeism and levels of absenteeism.
Economic driver: Possible saving from wellbeing interventions
Life Course
Subject
Intervention
Economic
Advantage
Adults
Risk of depression Workplace
Financial returns
screening
and almost five times
early intervention the
annual
for depression.
programme costs
Targeted
from
increased
employment
productivity
support for those (Foresight (2008).
recovering
from Three
fold
mental illness.
increased rates of
employment
(Bond 2008) and
saving of £6000
per client due to
reduced inpatient
costs over an 18month
period
(Burns 2009)
There is reasonable evidence base to support the use of collaborative care in people with
moderate to severe depression and a chromic physical health problem. Improved
depression care is thought to produce other health benefits, such as improved functioning
and physical outcomes (Katon 2006); this may be particularly significant for people with
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depression and a chronic physical health problems. This means that interventions which
improve physical health should result in substantial increases in utility and subsequently
result in quality-adjusted life year (QALY) gains.
It is estimated that improved early intervention could save the NHS up to £38 million per
year (NHS West Midlands, 2010)
Recommendations for consideration
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Ensure services are commissioned that are assessable to all, including those at
highest risk. Emphasis should be on promoting recovery, and considering an
individual’s mental health needs as well as their physical health needs and vice
versa.
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Personalised care or personalisation is essential to ensue people with mental health
problems can take as much control as possible over their support arrangements, to
pursue their recovery and social inclusion.
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Commission initiatives that address the employment and accommodation needs of
adults with mental health problems.
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Local Authorities and Mental Health Trusts could identify volunteer advocates to give
practical assistance with housing, finding employment/education or helping with debt.
Local authorities could also help by highlighting and promoting services available in
the community
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Acute mental health services should ensure that individuals are not discharged with
no where to go. Secure housing facilitates recovery and independence. Individuals
can often find themselves in inappropriate residential care or their discharge is
delayed because of lack of appropriate housing. Mental Health Trusts should provide
a housing support officer to maintain close links with the housing department.
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Support models which work to help individuals to remain in their own homes. For
example:
o Supported Housing
o Provision of telecare and telehealth equipment
o Community aids and adaptations
o Community alarms
o Floating support
o The use of third sector services such as the Village care Schemes
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Employers in all sectors, including the public sector, can play an important role in
supporting the health and wellbeing of their staff by providing healthy work places
which support mental wellbeing. Promoting well-being in the workplace can reduce
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staff absences, benefit productivity and increase performance enhancing work
morale and efficiency.
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Educate people regarding the causes and symptoms of poor mental health; this can
be a way of preventing mental health problems. Introduce wellbeing self help
workshops in the community and promote the books on prescription scheme.
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Raise awareness of mental health and the link to physical health, in mental health
settings and physical health settings.
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Early intervention – Commission mental health/wellbeing training for front line staff to
identify and signpost individuals.
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Tackle risk factors with an emphasis on promoting protective factors – especially for
those at risk of mental health problems – including addressing alcohol, drug and
tobacco use, and promote social and life skills, healthy eating and keeping physically
active.
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Universal services provide by GP’s, hospitals, midwives, health visitors, schools and
housing organisations have been shown to be effective in raising standards of
physical health – they should be now be clearly charged with the responsibility for
improving standards of emotional wellbeing
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Ensure Central Bedfordshire workplaces are exemplars of healthy working
environments – The workplace provides a convenient location for addressing the
physical and mental health of a large proportion of the adult population. Problems
inside and beyond work can be identified and tackled, and there is also scope for
general health promotion. Targeted programmes tend to be more effective.
Methods for changing behaviour need to be aligned with cultures, cognitive styles
and social contexts. A mental wellbeing programme can assist in reducing health
inequalities and thus:
 Reduce morbidity and mortality from common disorders (e.g. CHD,
diabetes)
 Reduce demand on NHS and social care

Integrate approaches to mental health and substance misuse by developing joint
protocols, training of staff in mental health trusts on substance misuse and training of
staff in substance misuse services in mental health problems.

Challenge stigma and discrimination – The provision of accurate public information is
needed to combat the stigma of mental health issues. By improving the
understanding of mental health, negative attitudes and behaviours to people with
mental health will decrease.
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The stigma associated with mental health is more strongly felt by men. This is said to
be because men are more concerned than women about appearing ‘capable’. The
stigma surrounding mental health problems within the veteran community is very
strong (the average delay between becoming ill with psychological problems
associated with active service and seeking help is ten years). Men are more likely
than women to express psychological distress through behaviours such as
aggression and substance misuse. Nationally and locally gender is the biggest risk
factor for suicide. Gender-specific, anti-stigma and wellbeing campaigns should be
developed, using male specific (and female specific) materials instead of, or in
addition to, materials aimed at the whole population. Men’s support groups and
service user champions should be encouraged and developed. Men prefer non
talking social interventions such as physical exercise in team sports, making music
together and allotments, which increase social networks.
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Homeless people have 40 to 50 time’s higher rates of mental health problems than
the general population and 40 times less likely to be registered with a GP and five
times more likely to use A&E (Department of Health 2010). Improving access to
primary care by using innovative approaches such as running primary care services
in hostels and offering flexible appointments or outreach.
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Improve maternal health - the health of women before, during and after pregnancy is
a critical factor in giving children a healthy start in life and for laying the foundation
for good health and well being in later life. Pregnancy and the postnatal period are
key times for early interventions. It is when expectant mothers are motivated to learn
what is best for their child.
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References:
 Foresight (2008). Mental Capital and Wellbeing Project (2008) Final Project Report
The Government Office for Science, London
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Kim-Cohen j, Caspi A, Moffitt T (2003) Prior juvenile diagnosis in adults with mental
disorder. Archives of General Psychiatry 60:709-717

Andrews G, Poulton R and Skoog I (2005) Lifetime risk of depression: restricted to a
minority or waiting for most? British Journal of Psychiatry 187: 495-496

McManus, S., Meltzer, H., Brugha, T., Bebbington, P. and Jenkins, R. (2009) Adult
psychiatric morbidity in England, 2007. Results of a Household Survey, The NHS
Information Centre, Leeds

HM Government (2011) No health without mental health; A cross-government mental
health outcomes strategy for people of all ages.

Wanless D (2004) Securing Good Health for the Whole Population: Final Report.
London: HM Treasury

NICE Guidelines CG91/5

Wahlbeck K, Westham J, Nordentoft M, Gissler M, Laursen TM, Outcome of Nordic
Mental Health Systems: Life expectancy of patients with mental disorder. Br J
Psychiatry 2011; 199(6):453-458

Marmot M. 2010: Fair society, healthy lives: The Marmot Review. Strategic Review
of Health inequalities in England post – 2010

Bond G, Drake R and Becker D (2008) An update on randomised controlled trails of
evidence-based supported employment. Psychiatric Rehabilitation Journal 31(4):
280-290.

Burns T, Catty J, White S (2009) The impact of supported employment and working
on clinical and social functioning: results of an international study of Individual
Placement and Support. Schizophrenia Bulletin 35@949-958.
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Katon W, Unutzer J, Fan MY et al. (2006) Cost effectiveness and net benefit of
enhanced treatment for depression for older adults with diabetes and depression.
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