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No health without mental health

Almost a billion pounds of investment have been pledged by the Government to improve mental health services in the UK. Sophie Goodchild looks at how customising approaches could lead to better outcomes.

Lonely boy looking outIt has long been acknowledged that mental health is a 'Cinderella service' within the NHS. Representing just 13 per cent of the public health budget, mental healthcare still fights for equal priority with physical health despite government moves to address this inequality. Not only does it affect the life expectancy and chances of patients, this lack of parity serves to increase the social burden of mental health problems including anxiety, depression and self-harm that the Centre for Mental Healthestimates to cost £100 billion a year.

This is not to say attempts have not been made at reforming mental health support and treatment. A national agreement between local care agencies and services – theCrisis Care Concordat – now exists to help people get the support they need when they need it. In addition, waiting times have been introduced for the first time – people needing therapy for depression, for example, will get guaranteed treatment within six weeks.

But the current reality is that services are underfunded and beds are in short supply, which means patients end up in treatment far from home – or not receiving care at all. Crisis care too often falls short with police left as the first line of support instead of trained NHS staff.

To tackle mental illness in Britain, it is essential to address the societal causes – which are numerous and complex. Living in poverty, social isolation or in a violent or abusive family are all contributing factors along with unemployment, bullying and pressures on young people such as school performance.

Louise Arseneault from King's College London, who is heading the part ESRC-funded project The Environmental Risk (E-Risk) Longitudinal Twin Study, says that victims of domestic violence, for example, are at greater risk of mental health problems including depression and psychotic symptoms, and health professionals need to be aware that women who experience mental health problems may also be domestic violence victims and vice versa.

"Given the prevalence of depression in these victims, we need to prevent these situations and take action – early childhood abuse also increases their risk of being exposed to violent relationships in adulthood and domestic violence in turn increases their risk of depression," she states.

Early anxieties

There is growing evidence that mental health starts in the womb because an anxious mother-to-be will produce stress hormones that affect the developing foetus. Also, the critical 'window' for mental health problems typically to develop is between 12 and 25 years, so it is a matter of growing concern how to meet the needs of young people as well as adults.

Professor Arseneault says that nearly two thirds (60 per cent) of young people not in education, employment or training (NEET) have already experienced more than one mental health problem in childhood or adolescence. Therefore, unemployment takes an additional toll on those who are already vulnerable.

As a result of these psychological problems and a lack of 'soft' skills such as time management, NEETs are already at a "disadvantage" in the jobs market despite a commitment to working, says Professor Arseneault. "It's crucial that young people are better supported by mental health services as they make this transition from school to employment."

This need for more 'youth-friendly' or youth-appropriate services is a theme being explored by Maria Michail and colleagues at the University of Nottingham in a three-year ESRC-funded programme ending in 2017 (Youth Mental Health and Wellbeing). Under current provision, children receive assistance from the Children and Adolescent Mental Health Services (CAMHS) until the age of 18. But Dr Michail argues that teenagers can struggle making the transition to adult services because support at this crucial crossroads is fragmented. Her research findings suggest that continuity of care for young people could be achieved by not stopping at 18 but instead extending them from age zero to 25.

Digital technology may also maximise how young people access services given that, as Dr Michail points out, more than 90 per cent of young people use the internet daily: "There are lots of pressures on young people to perform, achieve and improve themselves, but the way our mental health services are set up is not addressing the needs of young people. It's very unlikely a 22-year-old (man) with depression, anxiety and thoughts of suicide will go knocking on their GP's door. Digital technology may be a better way of communicating – it should complement face-to-face therapy, not replace it." 

Her view is that a national framework for E-mental health is needed, which would integrate digital technology – including apps to improve mood and online talking therapies – into the existing system of healthcare and use this technology as a tool for communicating what support is available.

Breaking down barriers

Stigma surrounding mental health is still an obstacle to patients seeking out help. Public figures such as actor Stephen Fry and Alastair Campbell, the former political aide and author, speaking out in recent times about their own struggles with mental ill health, have changed attitudes on one level. On another, though, mental illness is not met with the same understanding and sympathy as, say, a broken leg or cancer.

Dr Michail says stigma is still rooted in a perception that people are "unpredictable or violent even", and this means those with a mental illness will try and hide their symptoms from friends, family and medical professionals for fear of affecting their life chances. "With young people it's the perceived impact of that disclosure, such as ‘How will this affect my future job prospects?'" 

She commends the work of Time to Change, a nationwide campaign aimed at ending discrimination faced by people with mental health problems, but echoes the concerns of charities such as Young Minds that there is "still a long way to go" in changing attitudes.

Attitudes also need to change among those working in health and social care services says Dr Iris Elliott, head of policy and research at the Mental Health Foundation. Social workers and midwives without mental health training, she argues, can make new mothers and pregnant women with a history of mental illness worried that their child "will be taken into care". Better training is essential, she says, as well as improved service provision for adults and children.

However, the Mental Health Foundation also wants a national prevention strategy to reduce the risk of people experiencing mental illness and to equip people with tools at an early age. Says Dr Elliott: "Mental health should be an integral experience, part of pre- and secondary-school learning in order to build resilience skills in children, and we should be creating mentally healthy workplaces too."

This is a view shared by Lord Victor Adebowale, chief executive of social care organisation Turning Point and a member of a new mental health task force set up by NHS England. In his opinion, having mental health challenges should be seen as "perfectly normal for young people" and that can only be achieved if services are integrated into schools, instead of being ‘special’. "No child I know is going to walk into a service called ‘mental health’. Resilience training, for example, should be part of growing up, and teachers trained to identify, understand and intervene," he says.

There is agreement among experts that a more targeted and tailored approach is needed that starts early in life. The consensus too is that there is "no health without mental health", to quote the government's own mantra on achieving parity of esteem.

Sophie Goodchild is an award-winning health and social affairs journalist who was previously Health Editor on the Evening Standard and Chief Reporter on The Independent on Sunday.

This article features in our newsstand magazine Britain in 2016.

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