Esther12
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I saw ME Agenda linking to this and thought that it could be of interest to some here.
edit: Realised that this title could make this seem more important that it is, it's an NHS document, but just one of many. The forum's software limited the length of my title, so I had to cut bits out.
It's not really important though, and feel like I keep linking to frustrating things at the moment - sorry! Probably best to ignore, but I thought I'd store it here in case it's ever wanted as a historical document!
Best bit imo:
http://www.emotionalwellbeing.south...cle/368-case-for-change-physical-health-final
edit: Realised that this title could make this seem more important that it is, it's an NHS document, but just one of many. The forum's software limited the length of my title, so I had to cut bits out.
It's not really important though, and feel like I keep linking to frustrating things at the moment - sorry! Probably best to ignore, but I thought I'd store it here in case it's ever wanted as a historical document!
Best bit imo:
Medically Unexplained or Physiologically Explainable Symptoms?
Physical symptoms which are not caused by physical disease or injury are very common, and can become very distressing and disabling. They can be caused by over-use (e.g. ‘cramp’ or tiredness) or over-breathing (e.g. ‘pins and needles’ or giddiness) but are usually explained by natural physiological processes.1 They are often explainable by reference to very well established physiological explanations of stress on the body, e.g. lactate build-up in muscles with over-use or acid-base imbalances from hyperventilation causing giddiness or tingling. They can be a result of an interaction between the physical trigger for the symptoms (e.g. a virus or an acute injury) and an individual's cognitive, behavioural and emotional responses which may perpetuate these symptoms. Many patients with these symptoms meet criteria for a recognised syndrome such as chronic fatigue syndrome, irritable bowel syndrome, non-cardiac chest pain and fibromyalgia. They can also be a result of anxiety or depression which needs treatment in its own right.
Describing these symptoms as medically unexplained is incorrect, confusing and even frightening to those experiencing and not understanding them – more empowering, recovery-focused approaches are evidence-based.
Why specific symptoms occur may be explained by the context and prior experience of the person concerned - so may have psychological significance e.g. the interpretation of chest pain as due to a heart attack when a close relative has recently died of this. Persistent and more severe symptoms – often referred to as somatoform disorders - can benefit from intervention, e.g. cognitive behaviour therapy or graded exercise therapy, and even more complex ones from liaison services.
http://www.emotionalwellbeing.south...cle/368-case-for-change-physical-health-final
Emotional Wellbeing & Physical Health Care
Case for Change
1. Reduce Waste In General Hospitals By Acute Care Commissioning Of Psychiatric Liaison Services To Emergency Departments And Wards
2. Change Understanding And Practice In Primary, Community And Secondary Care Towards ‘Physiologically Explainable’ Symptoms And The Interaction Of Emotional Wellbeing With Long-term Conditions
3. Maximise Physical Health Gain In People With Severe Mental Illness Through Collaboration Between Primary, Secondary And Mental Health Services
Acute care commissioning of liaison services can reduce distress and disability whilst cutting bed usage, unnecessary investigations and hospital visits.
People with severe mental illness die early and avoidably: collaboration between primary care and mental health services to ensure regular health checks and then responsiveness when they do attend, could change this - especially with those most difficult to reach.
Medically Unexplained or Physiologically Explainable Symptoms?
Physical symptoms which are not caused by physical disease or injury are very common, and can become very distressing and disabling. They can be caused by over-use (e.g. ‘cramp’ or tiredness) or over-breathing (e.g. ‘pins and needles’ or giddiness) but are usually explained by natural physiological processes.1 They are often explainable by reference to very well established physiological explanations of stress on the body, e.g. lactate build-up in muscles with over-use or acid-base imbalances from hyperventilation causing giddiness or tingling. They can be a result of an interaction between the physical trigger for the symptoms (e.g. a virus or an acute injury) and an individual's cognitive, behavioural and emotional responses which may perpetuate these symptoms. Many patients with these symptoms meet criteria for a recognised syndrome such as chronic fatigue syndrome, irritable bowel syndrome, non-cardiac chest pain and fibromyalgia. They can also be a result of anxiety or depression which needs treatment in its own right.
Describing these symptoms as medically unexplained is incorrect, confusing and even frightening to those experiencing and not understanding them – more empowering, recovery-focused approaches are evidence-based.
Why specific symptoms occur may be explained by the context and prior experience of the person concerned - so may have psychological significance e.g. the interpretation of chest pain as due to a heart attack when a close relative has recently died of this. Persistent and more severe symptoms – often referred to as somatoform disorders - can benefit from intervention, e.g. cognitive behaviour therapy or graded exercise therapy, and even more complex ones from liaison services.
How much of a problem are physiologically explainable symptoms?
- Physical symptoms which are not caused by physical disease or injury are extremely common with many people experiencing them most days (e.g. headache, cramp, tiredness) but not normally requiring medical intervention. However quite commonly, people present and re-present to primary care or emergency departments because of concern that these physical symptoms may be caused by a physical disease.
- 19 per cent of new primary care GP appointments, especially frequent attenders, were found to be for people whose symptoms were previously described as ‘medically unexplained’ (PES (‘MUS’)) but may be better described as physiologically explainable2-3.
What works?
- In secondary care (physical health trusts/services), a number of studies in both the UK and the United States have shown that up to 50 per cent of sequential new attenders at outpatient services have PES (‘MUS’). For example, percentage with PES (‘MUS’) in new attenders at the outpatient department, King’s College Hospital, London4 by specialty were found to be:
- Chest (59%)
- Cardiology (56%)
- Gastroenterology (60%)
- Rheumatology (58%)
- Neurology (55%)
- Gynaecology (57%)
- Dental (49%)
- Analysis of 2008/2009 NHS figures shows that people with these problems account for as many as:
- one in five new consultations in primary care,
- 7 per cent of all prescriptions,
- 25 per cent of outpatient care,
- 8 per cent of inpatient bed days, often repeat admissions, and
- 5 per cent of A&E attendances,
- Women are three to four times more likely to experience PES (‘MUS’) than men.5
- What do patients and carers think?
- Management of physical symptoms which are not due to physical disease or injury can be complex but patients and carers consistently say that they want information (www.rcpsych.ac.uk/mentalhealthinfo/improvingphysicalandmh.aspx), explanation and good services.6
- ‘Symptom reattribution’ has been found to be a successful form of intervention for people with PES (‘MUS’): this is a structured consultation delivered by GPs which provides a psychological explanation to patients with somatised disorder9. However, while it does improve doctor-patient communication, it may not improve patient outcomes10.
- Identification and management of symptoms and treatment of any associated symptoms of depressionor anxiety in accordance with the relevant National Institute for Health and Clinical Excellence (NICE) guidelines can be beneficial to those disorders. However, successful psychological treatment is usually dependent on treatment models specific to the PES (‘MUS’) delivered by therapists with training in this area.
- Specialist services where persistent symptoms present are more successful where they focus on specific syndromes, e.g. chronic fatigue syndrome or irritable bowel syndrome.
- Liaison teams provide multidisciplinary care for patients presenting with more complex PES (‘MUS’) including associated high levels of disability and high levels of distress11.
- Pain, fatigue or more generic clinics, e.g. rheumatology or G-I, may have psychological intervention integrated within them; this collaborative model may be more acceptable to patients presenting and improve identification and management
- A meta-analysis of treatment for chronic fatigue syndrome suggests that both CBT and graded exercise therapy are promising treatments, with CBT possibly the more effective treatment in patients who have co-morbid anxiety and depressive symptoms12.
What is actually available?
- Positive outcomes depend on:
- Provision of empowering ‘normalising’ physiological explanations of symptoms in primary, community and secondary care16.
- Where symptoms persist, offering prompt intervention using ‘low intensity’ or ‘high intensity’ psychological interventions based on a clear biopsychosocial understanding and formulation of these conditions
- Availability of specialist services (e.g. fatigue or pain services) or psychiatric liaison teams for further care especially where physical illness complicates, restoration of function has not occurred or where substantial acute service resources being used.
- Primary care can be very effective in managing physiological explainable symptoms but unfortunately this remains very variable. Improvements in this area could be highly cost-effective17.
- Persistent symptoms can respond to NICE-approved psychological treatments available through IAPT; extension of these services will have ‘knock-on’ effects through primary, community and secondary care.
What information is there on cost?
- More complex cases are treated in specialist services where these exist. However liaison psychiatry and linked psychology service availability is uneven.
- Estimated cost to the NHS associated with PES (‘MUS’) of £3.1 billion17. However, about half the cost (£1.2 billion) was spent on the inpatient care of less than 10 per cent of people with PES (‘MUS’) – a relatively small number of people receive very expensive and inappropriate care.
- While the economic case for CBT is most compelling if resources are targeted at those with full somatoform disorders, the case for also tackling sub-threshold conditions is strong. All models are likely to be cost saving in the long-term.
- Cost models rely on evidence of effectiveness from studies in the United States, which may not be easily generalizable to an English context. However, sensitivity and threshold analyses indicate that, even assuming very limited improvements in health outcomes, investing in actions to tackle somatoform disorders remains cost-effective from a societal perspective under most scenarios.
- Pathways can be developed for 'functional/MUS/physiological explainable symptoms’ with evidence for cost savings being greatest at the severe end using collaborative care.
Impact of Emotional Wellbeing on Physical Conditions
- More information is required on the relative effectiveness of e-learning compared to face-to-face learning as a way of raising GP awareness, because costs are substantially lower.
How common a problem is this?
A recent study of frequent attenders at emergency departments in Cambridge identified at least three subgroups with mental health-related presentations:
- One in four of GP’s patients will need treatment for mental health problems at any time18.
- At least 25 per cent of patients with a physical illness admitted to hospital also have a diagnosable mental health condition;
- A further 41 per cent have sub-clinical symptoms of anxiety or depression, with rates rising to 60 per cent for the over-60s.19 Dementia is also a very important issue (see Dementia Commissioning Pack)20
- Patients with a physical illness are three to four times more likely to develop a mental illness than the rest of the population;
- Moderate frequent attenders (defined as six–20 presentations per year) with unattributed PES ('MUS' presenting with abdominal complaints in particular),
- Moderate frequent attenders with undiagnosed mental health and long-term physical health co-morbidities, and
The common problems acute liaison services address are:18 19
- Extreme frequent attenders (more than 20 presentations per year) with repeated self harm and substance misuse problems.21
- Mental disorder accounts for around five per cent of A&E attendances, 25% of primary care attendances, 30% of acute inpatient bed occupancy and 30% of acute readmissions
- Self-harm accounts for between 150,000 and 170,000 A&E attendances per year in England
- MUS may account for up to 50% of acute hospital outpatient activity
- 13–20% of all hospital admissions and up to 30% of hospital admissions via A&E at weekends are related to alcohol
- In England, alcohol-related hospital admissions doubled in the 11 years up to 2007, and alcohol-related deaths also doubled in the 15 years to 2006
- One-quarter of all patients admitted to hospital with a physical illness also have a mental health condition that, in most cases, is not treated while the patient is in hospital
- Most patients who frequently re-attend A&E departments do so because of an untreated mental health problem
- Self-harm is the third most common reason for unscheduled medical admission
Long-term conditions
- Two-thirds of NHS beds are occupied by older people, up to 60% of whom have or will develop a mental disorder during their admission
- Over 30 per cent of all people say that they suffer from a long-term condition.18
- People with one long-term condition are two to three times more likely to develop depression than the rest of the population. People with three or more conditions are seven times more likely to have depression
- Mental health problems such as depression are much more common in people with physical illness. Having co-morbid physical and mental health problems delays recovery from both
- Adults with both physical and mental health problems are much less likely to be in employment
- Depression in people with coronary heart disease (CHD) predicts further coronary events and greater impairment in health-related quality of life. Depressed individuals with CHD are more than twice as likely to die as those with CHD alone.24-25
Coronary heart disease
- Patients with chronic obstructive pulmonary disease (COPD) have a higher prevalence of anxiety and depression than the general population26-27; it is estimated that up to 40% of COPD patients have symptoms of depression and 34% anxiety.28 Psychological distress (such as anxiety and depression) can have an impact on symptoms and on how people manage their condition.29
- European guidelines on cardiovascular disease prevention41describe that
- Depression predicts cardiovascular events and worsens prognosis;
- Depression at least doubles the risk of a major cardiac event;
- In patients with CHD, depression has effects on cardiac symptoms, overall quality of life and illness behaviour including increased healthcare utilisation, low adherence to treatment and lowered rates of return to work.
- People who have suffered a heart attack, unsurprisingly, have a 30 per cent chance of developing depression – which can be helped in its own right.30
- Those with cardiac problems are approximately three times more likely to die of these causes if they also suffer from depression than if they do not.31
- Depression in people with CHD predicts further coronary events (odds ratio = 2.0) and greater impairment in health-related quality of life.24-25
- People who develop depression following acute coronary syndrome, as opposed to those with depression that pre-dates the acute coronary syndrome, may be at particularly high risk of worse cardiac outcomes.31
What do service users and carers want?
- Depressed individuals with CHD are more than twice as likely to die as those with CHD alone.24 25 The mechanisms behind the association between depression and either mortality or morbidity in physical illness are not fully understood.33 Either diminished healthcare behaviour or physiological impairment, or a combination of the two, may be important.
Service users and carers consistently say that they want:
What works?
- Good services provided in a holistic way for their emotional and physical wellbeing,
- To be listened to and treated with respect
- Effective treatments
- To be provided with information about their conditions.
In primary care, collaborative care described in the NICE guideline35 has been successful in the United States.36 It involves37:
- Multi-professional approach to patient care provided by a case manager working with the family doctor under weekly supervision from specialist mental health medical and psychological therapies clinicians
- A structured management plan of medication support and brief psychological therapy
- Scheduled patient follow-ups
In diabetes:
- Enhanced inter-professional communication patient-specific written feedback to family doctors via electronic records and personal contact.
- Addressing psychological needs has been shown to improve glycosylated haemoglobin (HbA1c) by 0.5 to 1 per cent in adults with Type 2 diabetes.38-39
With coronary heart disease:
- Improvements with psychological intervention include reduced psychological distress and anxiety; improved mood and quality of life; improved relationships with health professionals and significant others; and improved eating-related behaviours such as binge eating, purging and body image symptoms.40
- Psycho educational interventions significantly reduce angina frequency and medication use and psychological wellbeing in patients with stable angina.41
- NICE-approved psychological therapies have been shown to:
- A very recent review44 found 16 trials of psychological and pharmacological interventions for depression co-morbid with CHD. There was a small but clinically meaningful effect of psychological interventions and SSRI antidepressants on depression outcomes in CHD patients but there were no effects on mortality rates or cardiac events.
Psychological needs of patients and carers exist with other long-term conditions including, for example:
- In the year following the brief cognitive behavioural intervention for patients with chronic refractory angina43, patients exhibited 5-10 fewer inpatient bed days associated with cardiac admissions on average, and 0.75 fewer inpatient bed days associated with myocardial infarction.
- Post-stroke, neurodegeneration, epilepsy, sickle cell disease, cancer, renal disorders HIV/AIDS, gastro-intestinal conditions
In secondary care, liaison services have been shown to bring the following benefits48:
- Evaluation of the promising efficacy of psychological therapies and economic arguments of actual or potential savings associated with provision of psychological care in these areas is being developed.47
- Improved patient self-management of their care
- Assessment, engagement, formulation and treatment with reduced healthcare costs, of patients who may be reluctant to attend other mental health services and including those with physiologically explainable symptoms PES (‘MUS’)
- Support with patients admitted to medical wards with severe anorexia nervosa who are at high risk from combined physical, psychological and behavioural problems
- Improved return to independent living for the elderly52
- Reduced stigma associated with mental health care
- Advocacy directly for the physical care of those with mental health problems in acute services
- Reduction in readmissions and length of stay53
- Advice on, and where appropriate, management of complex issues to do with the Mental Health Act and Mental Capacity Act
- Reduction in subsequent healthcare utilisation, including emergency care and clinic visits51
- Improved mental health skills and wellbeing of staff in acute hospital settings
Liaison services aim to increase the detection, recognition and early treatment of impaired mental wellbeing and mental disorder to:
- Assistance in relieving the stress that staff often feel when dealing with patients with complex needs and this reducing levels of sickness absence
- Reduce excess morbidity and mortality associated with co-morbid mental and physical disorder
- Reduce excess lengths of stay in acute settings associated with co-morbid mental and physical disorder
- Reduce risk of harm to the individual and others in the acute hospital by adequate risk assessment and management
- Reduce overall costs of care by reducing time spent in A&E departments and general hospital beds, and minimising medical investigations and use of medical and surgical outpatient facilities
Priorities for development in all general hospitals are services for:
- Ensure that care is delivered in the least restrictive and disruptive manner possible.
- Acute mental health presentations to the Emergency Department including self-harm
What is actually available?
- Acute mental health issues on wards especially delaying discharge (mainly depression but also organic psychosis, personality disorders impacting on treatment, advice on capacity, complex diagnoses, and advice on the use of psychopharmacology)
In primary care:
- The impact of the care provided for people with physical conditions, especially long-term, on their emotional and physical wellbeing in hampered by lack of outcome measurement – as is the case in primary and mental health care
In secondary care, liaison teams exist in many University hospitals but are less common in other general hospital settings. Psychologists are part of multidisciplinary teams in some departments. This has tended to happen in a non-systematised way where the value of evidence-based practices is recognised by local clinicians and so may be provided by:
- IAPT services now have a focus on providing care for emotional problems comorbid with long term conditions and pathfinder sites have recently set up for PES (‘MUS’)
- Clinical and/or health psychologists embedded in medical teams, such as oncology, diabetes, renal, rheumatology or respiratory teams and providing specialist talking therapies, assessment, consultation, training and research
- Chronic pain management teams and chronic fatigue teams, operating over a wider area than a single acute hospital
- Cancer network of psychosocial support professionals, organised to support sophisticated training arrangements for medical and nursing oncology staff (and often including liaison psychiatrists)
What information is there on cost?
- Cardiac and pulmonary rehabilitation teams
Between £8 billion and £13 billion of NHS spending in England is attributable to the consequences of co-morbid mental health problems among people with long-term conditions57
Wastage includes:
- Unnecessary investigation;
- Increased presentations in primary care, emergency departments and outpatient clinics;
- Increased use of medication;
- Increased, usually unscheduled, admissions with longer lengths of stay;
- In older people, increased risk of institutionalisation.
- At least 28 per cent of patients admitted to hospital with physical illness also have a significant mental health problem, and a further 40 per cent have sub-clinical depression or anxiety.55
- This rises to at least 60 per cent for people over the age of 60.56
- Co-morbid mental health problems are a major cost driver in the care of long-term conditions35:
- Associated with a 45–75 per cent increase in service costs.
- At least £1 in every £8 spent on long-term conditions is linked to poor mental health and wellbeing, meaning that between £8 billion and £13 billion of NHS spending in England
- Majority of these costs will be associated with the most complex patients whose long-term conditions are most severe or who have multiple co-morbidities.
- There is considerable scope for NHS savings and health gains for patients through improving the care pathways and delivering appropriate psychological interventions for patients with diabetes and co-morbid common mental health problems.
Evaluation of the Rapid Assessment Interface and Discharge (RAID) liaison service in Birmingham demonstrated improvements in health and wellbeing and in cost savings.60-61 An independent economic evaluation was undertaken by the London School of Economics showing:
- Collaborative care for patients with Type 2 diabetes and co-morbid depression36:
- Delivered in a primary care setting to individuals with co morbid diabetes and depression.
- Estimate that the total cost of six months of collaborative care is £682, compared with £346 for usual care.
- A two-year evaluation in the United States found that, on average, collaborative care achieved an additional 115 depression-free days per individual; total medical costs were higher in year one, but there were cost savings in year two.36
- Investing in six months of collaborative care in England for patients with newly diagnosed cases of Type 2 diabetes who screen positive for depression, compared with care as usual. The costs associated with screening are not included in the baseline model. Existing data on the cost effectiveness of CBT were used to estimate the impact on healthcare and productivity losses.
- Estimated costs and savings for 119,150 new cases of Type 2 diabetes in England in 2009: assumed that 20 per cent of patients under collaborative care would receive CBT, compared with 15 per cent of the usual care group.
- Assuming 20 per cent screen positive for co-morbid depression, completing and successfully responding to collaborative care leads to an additional 117,850 depression-free days in Year 1 and 111,860 depression-free days in Year 2. Substantial additional net costs in Year 1 due to the costs of the treatment but in Year 2, net savings for the health and social care system due to lower costs in the intervention group, plus further benefits from reduced productivity losses.
- Using a lower 13 per cent rate of co-morbid diabetes and depression, total net costs in Year 1 would be more than £4.5 million, while net savings in Year 2 would be more than £450,000.
- In the year following a brief cognitive behavioural intervention for patients with chronic refractory angina43
- Patients exhibited 5-10 fewer inpatient bed days associated with cardiac admissions on average, and 0.75 fewer inpatient bed days associated with myocardial infarction.
- On this basis, the study demonstrates reductions in healthcare usage of approximately £2,000 per person in the year after treatment, well in excess of the cost of psychological intervention.
- Adaptive pacing therapy (APT), cognitive behaviour therapy (CBT), or graded exercise therapy (GET) for patients with chronic fatigue syndrome resulted in improvements in health-related quality of life in comparison with specialist medical care (SMC) which produced little change.
- At a threshold of £30,000 per QALY, CBT had a 62.7% likelihood of being the most cost-effective option from a healthcare perspective followed by GET at 26.8%;
- CBT had a 59.5% likelihood of being the most cost-effective option from a societal perspective.
- Demonstrated total incremental savings from RAID to be in the order of £3.55 million a year, that is 14,500 bed days saved at £245 per bed day
- In comparison with the incremental cost of RAID was £0.8 million a year.
- Benefit: cost ratio is therefore in excess of 4:1, or a saving of £4 for every £1 invested which may well be an underestimate of potential cost savings.
Commissioners are required to improve quality while at the same time increasing productivity (QIPP). Liaison services provide an excellent opportunity to do this by:
- Additional benefits may be derived from decreased health resource usage as a result of:
- Improvements in the health and quality of life of patients,
- Improvement in the identification of mental health problems,
- The signposting of patients to more appropriate mental health pathways;
- Impact on elective admissions (evaluation only considered emergency admissions);
- Increased discharge of older people to their homes
- Decreased discharge to residential or nursing homes and hence potential savings in the social care sector.60
- Improving clinical outcomes
- Reducing admissions to and lengths of stay in acute settings
- Ensuring patients with co-morbid long term conditions receive better treatment while using fewer health care resources
- Treating and reducing costs for patients with PES (‘MUS’)
Liaison services are usually commissioned by the commissioners of mental health services. However the major benefits in health gain and cost that can accrue from liaison services occur within acute services. There is therefore a case for funding of liaison services to move to become a responsibility of commissioners of acute hospital care to realise these potential cost-benefits.
- Reducing psychological distress following self-harm, and reducing suicide.
Physical Care For People With Severe Mental Illness
How much of a problem is it?
Summarised in an Academy of Royal Colleges publication66 types of physical health problems associated with mental ill health include:
- The life expectancy for a male with psychosis (schizophrenia) is 15–20 years less than average with more than 60 per cent of premature deaths not directly related to suicide.62
- There are many reasons for this high death rate but failure to prevent, diagnose and treat are included and could be remedied.
- Fifty per cent of people with mental health problems have a co morbid physical illness.
- In a study of young people (85 young people aged 16 to 27 years) treated for first episode psychosis, a third had metabolic syndrome or showed metabolic abnormalities.63
- Smoking is the main cause of preventable death in the general population.
- People with a mental disorder smoke much more than people without a mental disorder: they consume 42% of all tobacco consumed in England.
- 59% of people with a first episode of psychosis smoke – a rate 6x higher than non psychotic peers.64
- Increased smoking is responsible for most of the excess mortality of people with severe mental health problems. 62
- Obesity is of similar concern:
- It is likely to be the prime cause of higher rates of type-2 diabetes
- It is also socially excluding, greatly distresses services users especially in the early phase of rapid weight gain and contributes to treatment discontinuation.
- Having a mental health problem increases the risk of physical ill health: co-morbid depression doubles the risk of coronary heart disease in adults and increases the risk of mortality by 50 per cent.
- Medication side effects are:
- Common, e.g. metabolic syndrome and extrapyramidal side effects
- Potentially severe, e.g. neuroleptic malignant syndrome, lithium toxicity and cardiomyopathies.
- Cardiovascular risk increases after first exposure to any antipsychotic drug, 65
- In people with severe mental health problems, there is increased occurrence of:
- Diabetes (prevalence of, at least, 15 per cent in people with schizophrenia, 5 per cent in the general population). This may also be culturally influenced.
- Cardiovascular disease
- Hyperlipidaemia
- Chronic obstructive pulmonary disease (COPD)
- Bowel cancer
- Venous thrombosis and pulmonary emboli
- Major depression doubles the lifetime risk of developing Type 2 diabetes
- Standardised mortality rates for older people with depression is two to three times higher if untreated or unresolved
- People with schizophrenia are three to four times more likely to develop bowel cancer
Co-morbid health anxieties or mental health disorders are associated with:
- People with schizophrenia have a 52 per cent increased risk of developing breast cancer.
- Poorer objective health outcomes
- Poorer subjective health outcomes
- Higher use of healthcare resources
Many individuals do not have physical and psychological needs met through:
- Wider costs of, for example, lack of employment, sickness absence, informal family care and support.
- The continued stigma of mental health problems
- Physical explanations may be more acceptable and understandable
- A continued lack of expertise and training in psychological assessment, management and mindedness for many practitioners
- Inadequate service design and provision
NICE clinical guidelines for schizophrenia and bipolar disorders 67-68 include recommendations for physical healthcare, and within regular case reviews, community mental health services are expected to ensure access to regular physical health checks and healthcare.
- Lack of integrated ‘whole person’ commissioning structures and provider organisations
What do service users and carers think?
Service users and carers consistently highlight the importance of physical health needs and the relative neglect of them by services. Often this is stigma-related – assumptions are made that physical symptoms experienced are psychologically determined and screening and investigation is either not done or done inadequately.
Service user views of current medication, e.g. antipsychotics and mood stabilisers, are often negative even though they may accept the need to take them. Of those settled on the former, 70% discontinued them over an eighteen month period. There is a view that effectiveness has been over- and adverse effects under-stated and that choice of intervention needs to be widened.
What works?
The range of care across the pathway includes:
- Primary care management of ‘active monitoring’ and positive diagnosis, management of common mental health problems, guided self-help strategies and programmes, motivational interviewing.
- Psychological interventions at the primary/ secondary care interface, including integrated/stepped/collaborative care models with planned and coordinated care, interdisciplinary working and clear access points to services.
- Invitation letters for physical health checks may be responded by more than 60% of those with severe problems. 71
- Psychological care input into long-term conditions and acute hospital multidisciplinary teams.
Outcomes can be improved:
- Development of liaison psychiatry services in acute hospitals to provide assessment, treatment, advice, consultation and management of complex cases.
- If health promotion programmes specifically address the common relevant issues; poor attention, concentration and motivation, social anxiety and fear and suspicion of other people. People with mental health problems are less likely to benefit from mainstream screening and public health programmes.
- Regular health checks can also improve detection rates but those who need them most are least likely to access them. Closer links between primary and secondary care e.g. assertive outreach teams bringing service users to primary care or facilitating home visits can substantially improve detection and support intervention 72.
- Pro-active ‘recovery-focussed’ prescribing can reduce metabolic and other side effects.
- ‘Hand-held’ records shared between primary and secondary care for psychosis do not seem to work nor do primary care facilitators.
What is actually available?
- Collaborative working with secondary care mental health services has the potential to improve health care (see Case for Change: Severe Problems).
- Community mental health teams can engage with people with long-term mental health problems; care coordinators and/or Support, Treatment and Recovery workers can bring them to health centres or facilitate home visiting
- Assertive outreach teams have been shown to be able to engage the most difficult group of patients and can similarly collaborate with primary care
Good practice in managing the physical health care of people with severe mental illness abounds but falls far short of being comprehensively provided through:
- Use of effective screening tools
- Provision of extensive information
- Collaborations between primary care and mental health services
Payment-by-results
- Access to primary care in all settings including long-term, e.g. rehabilitation and forensic, facilities
- Payment-by-Results: Physical health care is relevant for all clusters.
NICE Guidelines for Mental Health & Physical Health
- PES (‘MUS’) and LTCs can present problems with ‘common mental disorders’ (Clusters 1-5) & with emotional difficulties (‘personality disorders’)(6-8). These, psychoses & bipolar disorders(10-17) can cause major complications with:
- Acceptance of illness
- Medication adherence
- Acceptance of operative procedures and aftercare
- Dietary and lifestyle adjustments
- Evidence-based treatments are defined in relevant NICE guidelines
Guide to links:
1. Homepage of the guidelines for the specific disorder
2. NICE guidelines for the disorder
3. Full guidelines for the disorder
Condition Link
Schizophrenia (CG1) (replaced by CG82)
http://guidance.nice.org.uk/CG1 /http://guidance.nice.org.uk/CG82
http://guidance.nice.org.uk/CG82/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG82/Guidance
Eating disorders (CG9)
http://guidance.nice.org.uk/CG9
http://guidance.nice.org.uk/CG9/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG9/Guidance/pdf/English
Self-harm
(Short term: CG16)
(Long term: CG133)
http://guidance.nice.org.uk/CG16
http://guidance.nice.org.uk/CG133/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG16/Guidance/pdf/English
Anxiety (CG22) (replaced by CG113)
http://guidance.nice.org.uk/CG22 /http://guidance.nice.org.uk/CG113
http://guidance.nice.org.uk/CG113/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG113/Guidance
Depression (CG23) (replaced by CG90)
http://guidance.nice.org.uk/CG23/ http://guidance.nice.org.uk/CG90
http://guidance.nice.org.uk/CG90/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG90/Guidance
Violence (CG25)
http://guidance.nice.org.uk/CG25
http://guidance.nice.org.uk/CG25/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG25/Guidance
Post-traumatic stress disorder (PTSD) (CG26)
http://guidance.nice.org.uk/CG26
http://guidance.nice.org.uk/CG26/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG26/Guidance
Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31)
http://guidance.nice.org.uk/CG31
http://guidance.nice.org.uk/CG31/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG31/Guidance
Bipolar disorder (CG38)
http://guidance.nice.org.uk/CG38
http://guidance.nice.org.uk/CG38/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG38/Guidance
Antisocial personality disorder (CG77)
http://guidance.nice.org.uk/CG77
http://guidance.nice.org.uk/CG77/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG77/Guidance
Borderline personality disorder (BPD) (CG78)
http://guidance.nice.org.uk/CG78
http://guidance.nice.org.uk/CG78/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG78/Guidance
Depression with a chronic physical health problem (CG91)
http://guidance.nice.org.uk/CG91
http://guidance.nice.org.uk/CG91/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG91/Guidance
Delirium (CG103)
http://guidance.nice.org.uk/CG103
http://guidance.nice.org.uk/CG103/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG103/NICEGuidance/pdf/English
Common mental health disorders: depression, GAD, panic disorder, OCD, PTSD, and social anxiety disorder (CG123)
http://guidance.nice.org.uk/CG123
http://guidance.nice.org.uk/CG123/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG123/Guidance
Service user experience in adult mental health (CG136)
http://guidance.nice.org.uk/CG136
http://guidance.nice.org.uk/CG136/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG136/Guidance
Autism in adults (CG142)
http://guidance.nice.org.uk/CG142
http://guidance.nice.org.uk/CG142/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG142/Guidance
Technology Appraisal Guidance
Guide to links:
1. Homepage of the topic
2. Full guidance
Topic Link
Schizophrenia - atypical antipsychotics (TA43) (replaced by CG82)
http://guidance.nice.org.uk/CG82
http://guidance.nice.org.uk/CG82/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG82/Guidance
Bipolar disorder - new drugs (TA66) (replaced by CG38)
http://guidance.nice.org.uk/TA66 / http://guidance.nice.org.uk/CG38
http://guidance.nice.org.uk/CG38/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG38/Guidance
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