Mental health

‘Good’ or ‘positive’ mental health is fundamental to our physical health, our relationships, our education, our training, our work, our ability to cope with life’s problems and make the most of life’s opportunities, and to achieving our potential. It is the foundation for wellbeing and for functioning effectively, both as individuals and as communities. Positive mental health is influenced by, and influences, improved physical health and life expectancy, increased skills, reduced health-risk behaviours, reduced risk of mental health issues and suicide, improved employment rates and productivity, reduced anti-social behaviour, and higher levels of social interaction.

The term ‘mental health issue’ is an umbrella term to cover the full range of mental illnesses and conditions, including personality disorder. Mental health issues may be more or less common, and acute or longer lasting. They may vary in severity. Mental illness is a term generally used to refer to more serious mental health issues that often require treatment by primary care or specialist services, such as depression or anxiety (also called common mental health issues), as well as schizophrenia and bipolar disorder (sometimes referred to as severe mental illness). Some mental health issues can significantly affect the quality of people’s lives.

Mental health accounts for 23% of the total burden of disease in the UK, compared to about 16% each for cancer and cardiovascular disease (Department of Health (DH): Mental health promotion and mental illness prevention: the economic case , April 2011). However, only 13% of NHS health expenditure is dedicated to treating mental illness (London school of economic and political science / Centre for economic performance: How mental illness loses out in the NHS ). There is a national drive to create greater equality in how mental and physical health services are valued within the health and care system, termed ‘Parity of Esteem’ (Department of Health: No health without mental health: a cross-government mental health outcomes strategy for people of all ages ). All the evidence suggests that a real difference can be made to people’s lives by commissioning effective, early interventions and treatments. There is a strong association between mental health needs, and drug and alcohol misuse. Alcohol and drug misuse is dealt with in a separate part of the Joint Strategic Needs Assessment (JSNA).

It is estimated that one in four people in the UK experience a mental health issue each year(NHS England: The five year forward view for mental health: a report from the independent Mental health taskforce to the NHS in England ), and treatment costs are expected to double in the next 20 years. The direct financial cost to the state of treating people with mental health issues is however the tip of an iceberg when it comes to the impact of mental health issues. Most of those experiencing issues are adults of working age, who have caring and family responsibilities. The economic and emotional impact on families when a main earner and carer experiences mental health issues can impact across generations.

Some key cost implications to the economy of mental ill-health issues include:

Mental health is high on the government's agenda and the cross-government strategy, ' No health without mental health: a cross-government mental health outcomes strategy for people of all ages ' was published by the Department of Health in 2013. This strategy recognises the importance of social determinants of mental health, and that socio-economic deprivation and social isolation can both contribute to the development of mental health issues and result from them.

A more recent strategy ‘ The five year forward view for mental health: a report from the independent Mental health taskforce to the NHS in England ’ was published in February 2016. This report sets out the government response to the work of the Mental Health Taskforce.

The key aims from this report are:

  • making it easier for everyone to access high quality services
  • bringing mental health care and physical health care together;
  • promoting good mental health and stopping people from having mental health issues

The local picture

Positive mental wellbeing / health

An estimated 81.2% of the England population reports having high satisfaction with life, and 74.7% report having high happiness in 2015/16. Self-reported wellbeing is associated with income, with people with lower incomes less likely to report positive wellbeing than those with higher incomes (NHS Digital: Health survey for England 2015 ). The Public Health Outcome Framework (PHOF) provides a number of indicators available for measuring wellbeing. These include percentages of people scoring themselves low values for satisfaction, worthwhile and happiness. These are as follows:

  • Calderdale low satisfaction score 5.5% (Yorkshire and the Humber 4.8%, England 4.6%);
  • Calderdale low worthwhile score 4.5% (Yorkshire and the Humber 3.9%, England 3.6%);
  • Calderdale low happiness score 10.5% (Yorkshire and the Humber 9.9%, England 8.8%).

Loneliness and social isolation

There is a strong link between social isolation, loneliness, and poorer mental and physical health. The poorer impact on health includes increasing self-harming behaviours (such as over-eating, greater alcohol consumption and smoking), increased exposure to stress and an increased likelihood of people withdrawing and not seeking emotional support. It can also be a factor in depression and suicide. Loneliness affects the immune and cardiovascular systems and can result in sleeping difficulties, which in turn have negative effects on metabolic, neural and hormonal regulations. Research suggests that approximately 14% of those aged 65-79 years are likely to report feeling lonely, and 29% of those aged 80 years and over ( Mental health promotion and mental illness prevention: the economic case ).

Common mental health conditions

Common mental health conditions are those mental conditions that cause clear emotional distress and interfere with daily living, but do not usually affect people’s insight or cognition. They include different types of depression and anxiety, and obsessive compulsive disorder. It is estimated that common mental health conditions may affect up to 15% (12.5% males and 19.7% females) of the population at any one time (Centre for economic performance / London school of economic and political science: How mental illness loses out in the NHS ). There is great variation in the severity of different common mental health conditions, but all of them are linked with significant long-term disability. Depression and anxiety can follow a pattern of relapse and remission throughout life. The vast majority of people with depression are diagnosed and treated in primary care. Depression is the most common condition associated with suicide ( How mental illness loses out in the NHS ).

In Calderdale:

  • using national prevalence data, there were an estimated 25,922 adults in 2014/15 aged 16 to 74 years in Calderdale with a common mental condition ( Projecting adult needs and service information system ). Of these people, an estimated:
    • 76% (19,701) received no treatment for their condition;
    • 14% (3,629 people) received psychoactive medication only;
    • 5% (1,296 people) received counselling or therapy;
    • 5% (1,296) received both medication and therapy;
  • the prevalence of depression in Calderdale is 10.7% (2015/16) as stated from Quality and Outcomes Framework (QOF) registers. This was statistically higher than the England value of 8.3% (PHE Fingertips: Depression: Recorded prevalence ). This figure is likely to be an underestimate of the proportion of people with depression, as many people do not seek treatment so are not diagnosed. Data from the national General Practioner (GP) survey is more robust and predicts the actual prevalence to be 12.9% in Calderdale and 12.7% nationally;
  • 3,210 adults aged 65 years and older were predicted to have depression in 2015 ( Projecting older people population information system ).

More severe mental health conditions

More severe mental health conditions include psychoses and personality conditions. Psychoses are conditions that produce disturbances in thinking and perception, severe enough to distort people’s perception of reality. The main types of psychoses are schizophrenia and affective psychosis such as bi-polar condition.

Antisocial personality disorder (ASPD) is characterised by a clear pattern of disregard and violation of the rights of others. People with ASPD account for a disproportionately large proportion of crime and violence that is committed ( Adult psychiatric morbidity survey ). Borderline personality disorder (BPD) is characterised by high levels of personal and emotional instability associated with significant impairment. People with BPD can have severe difficulties with sustaining relationships. They are more likely to self-harm and attempt suicide at some point in their lives. The outlook for many people with BPD is reasonably good over time, and psychological or medical treatment can help.

In Calderdale:

Table 1: Estimated number of Calderdale residents with psychosis in 2015

  National prevalence % Estimated number of Calderdale residents affected
Calderdale residents with psychotic disorders 0.4 834
Calderdale male residents with psychotic disorders 0.3 307
Calderdale male residents (35 to 44 years) with psychotic disorders 0.7 94
Calderdale female residents with psychotic disorders 0.5 531
Calderdale female residents (35 to 44 years) with psychotic disorders 1.1 150
Calderdale residents with probable psychosis receiving treatment for psychotic disorders (medication or counselling) 80.0 667
Calderdale residents with probable psychosis not receiving treatment (medication or counselling) 20.0 167

(Note: figures might not reconcile because of rounding)

Suicide

Suicide is a leading cause of years of life lost. The number of deaths by suicide in Calderdale is relatively small compared to the number of all deaths in the area. However most deaths by suicide are preventable and have a wide and usually long-lasting impact to family and friends, and sometimes witnesses.

In 2014, a 2012-2014 retrospective suicide audit was undertaken for Calderdale using this and other available data (Audit of suicides in Calderdale). Table 2: Calderdale Suicide rate - suicide frequency by gender ( Mental health dementia and neurology ) gives all deaths by suicide in Calderdale. The audit concluded that while Calderdale was on target to achieve the national target for suicide reduction, the evidence of a consistent decline nationally in rates was not strong locally, and that there was scope for some prioritisation in respect of employment sectors and improvements to safety in specific environments. The audit also considered data by locality information but concluded that there were no geographical ‘hot spots’ during the three years studied.

Table 2: Calderdale suicide rate – suicide frequency by gender

Period Female Male Total
2001 - 03 18 37 55
2002 - 04 13 36 49
2003 - 05 16 45 61
2004 - 06 15 47 62
2005 - 07 11 41 52
2006 - 08 9 32 41
2007 - 09 14 35 49
2008 - 10 15 41 56
2009 - 11 13 52 65
2010 - 12 5 51 56
2011 - 13 6 57 63
2012 - 14 11 53 64
2013 - 15 19 52 71

 

Figure 1: Suicide rate (persons) per 100,000 (Directly Standardised Rate (DSR))

Suicide rate (persons)

Source: Public Health Outcome Framework  Suicide rate (person) for Calderdale

Inequalities

Lesbian, gay, bisexual and transgender groups (LGBT)

Mental ill-health is more prevalent among LGBT people than in the wider population, although due to a lack of sexual orientation and gender-identity monitoring, there is little data on LGBT people’s access of secondary mental health services. There is evidence to suggest that LGBT people experience poor care in mental health services.

Research shows that LGBT people are more likely to attempt suicide compared to the wider population, with a two-fold increase in suicide attempts by LGB people. More than one in three people who are described by the Equality Act 2010 definition of gender reassignment have attempted suicide. The Department of Health’s Suicide Prevention Strategy (2012) identified LGBT people as a high-risk group. In our local audit, this information did not usually appear in the Coroner’s records.

Older people and mental health

Certain groups of older people can be at risk of poorer mental health. For example, as many as 40% of older people in care homes experience depression (National institute for mental health in England: Facts for champions (2005)). Social isolation is a key contributory factor in depression in older people. Although less common than depression, dementia is a key issue for the older age group. The mental health needs of older people from Black and minority ethnic (BME) communities can be difficult to identify and diagnose – especially in the case of dementia. The stigma associated with the condition means that few people from BME communities may come forward for diagnosis ( Projecting older people population information system ).

Gender and mental health

Women between the ages of 16 and 24 years are almost three times as likely (26%) to experience a common mental health issue as males (9%), and have higher rates of anxiety conditions, eating conditions, self-harm and sexual, emotional or physical violence, which are associated with higher rates of mental health issues. One in four women requires treatment for depression at some time. Post-natal depression affects a significant minority of women. If it is left undiagnosed and untreated, it can result in significant harm not just to women, but also to their children and wider families.

Fewer men seek treatment for depression, which may in part reflect men’s fear of stigmatisation than be an accurate indicator of the incidence of male depression. Male mental distress is more likely to result in violent behaviours towards self and others, so that men are three times more likely to die from suicide than women.

  • Common mental condition is 2.7 times more common in men and 1.4 times more common in women from the lowest 20% household income compared to highest 20% household income ( Adult psychiatric morbidity survey );
  • post-traumatic stress disorder is 3.3 times more common in men and 2.3 times more common in women from the lowest 20% household income compared to top 20%;
  • self-harm is 3.2 times more common in men and 2.5 times more common in women from the lowest 20% household income compared to the highest 20%;
  • suicide attempts are five times more common in men and 3.2 times more common in women from the lowest 20% household income compared to the highest 20%;
  • psychotic conditions are nine times more common in adults from the lowest 20% household income compared to the highest 20%;
  • eating conditions in the past year is 1.7 times more common in men and 1.2 more common in women from the lowest 20% household income compared to the highest 20% ( Projecting older people population information system ).

Asian, and Black and minority ethnic (BME) communities and mental health

Incidence of mental health issues in BME groups is complex. Some Black groups have admission rates around three times higher than average. African-Caribbean people are particularly likely to be subject to compulsory treatment under the Mental Health Act. South-East Asian women are less likely to receive timely, appropriate mental health services, even for severe mental health conditions. There is little difference between white, Black and South Asian men in the rates of common mental health issues. Rates of all common mental health issues are higher among South Asian women.

Care Quality Commission (CQC) ethnicity counts, in the census reports of 2009 and 2010, confirms that some BME groups are accessing mental health services at crisis point rather than accessing preventative services. The average length of stay in hospital is higher in some BME groups, in particular in the African and Caribbean communities, who have rates two to six times higher than average.

Gypsies and Travellers are nearly three times more likely to experience anxiety than average and just over twice as likely to be depressed. Women in these communities are twice as likely to experience mental health issues as men. This group is extremely vulnerable due to social exclusion, poor literacy levels, low life expectancy and a high risk group in terms of self-harm and suicide ( No health without mental health: a cross-government mental health outcomes strategy for people of all ages ).

Low income families and mental health

There is overwhelming evidence that the key factors which increase the risk of developing mental illness are inequality and poor mental wellbeing, and that these have a mutually reinforcing effect. For example, children and adults living in households in the lowest 20% income bracket in Great Britain are two to three times more likely to develop mental health issues than those in the highest ( Mental health promotion and mental illness prevention: the economic case ). Analysis of data from the Millennium Cohort Study in 2012 found children in the lowest income quintile to be 4.5 times more likely to experience severe mental health issues than those in the highest quintile, suggesting that the income gradient in young people’s mental health has worsened considerably over the last decade.

Stigma and mental illness

A key source of discrimination and unfair treatment faced by people with mental health issues is the stigma that they face from society because of misconceptions about mental illness.

One of the harms caused by stigma is the adverse impact on people’s human rights, through denying them the right to fair and dignified treatment. Other harms include social and economic effects, such as the lowering of people’s self-esteem, or disadvantaged when applying for jobs. This can lead to increased isolation, reduced employment opportunities and other material disadvantage.

Moreover, stigmatising attitudes by authorities and service providers can result in restrictions on the civil liberties and human rights of people with mental health issues. Stigma can result in discrimination against people with poor mental health, across a range of areas including housing, education and employment.

Stigma contributes to worsening the prognosis for recovery from mental illness. The national strategy and local programme notes that worry about stigma can trigger a destructive spiral of behaviours in people with poor mental health, such as a refusal to accept their condition and treatment avoidance.

The harm caused by stigmatisation of mental illness extends more widely than just people with poor mental health. Family, friends and carers of people with mental health issues often face stigma by association, with similar consequences for their own wellbeing and human rights.

People from BME groups may also suffer stigma and discrimination, which can increase their risk of developing mental health issues. They can then experience additional stigma and discrimination.

The stigma attached to mental health issues within some groups and cultures may result in people avoiding acknowledging their mental health issues and seeking help, eg Asian, and Gypsy and Travelling communities. This can result in under-diagnosis, under-treatment and poorer prognosis for recovery ( No health without mental health: a cross-government mental health outcomes strategy for people of all ages ).

Current provision

At present, there is no current provision

User views

Commissioners and providers of mental health in Calderdale are committed to service user involvement and value the opinions of people who use mental health services. Health and social care commissioners have recently commissioned a two-year project: a mental health recovery network to Healthy Minds, which is a local service-user-led mental health charity in Calderdale. The aim of the recovery network is to develop service user-led approaches to recovery such as volunteering, peer support groups, and have your say forums.

Calderdale Council has commissioned a similar project to the National Autistic Society, to deliver a Calderdale autism development project. The aim of this project is to raise the profile of autism through developing co-production activities with people on the autism spectrum disorder and their carers.

Calderdale Council has also established a Mental health partnership board. Service users and carers have been recruited to become members of the Board, and represent service user and carer views and experiences of mental health services.

South West Yorkshire Partnership NHS foundation trust have long-standing service user and carer dialogue groups. The work of these dialogue groups are then reported to the mental health partnership board.

A joint mental health programme for Calderdale was developed in 2011 to support the implementation of the national mental health strategy ' No health without mental health: a cross-government mental health outcomes strategy for people of all ages '. Due to the recent changes in the NHS and the council, a new mental health commissioning strategy will be developed to deliver the key messages outlined in the national mental health strategy.

Unmet need

Prevalence

Mental health needs and access to services in Calderdale do broadly mirror those nationally, and there is no evidence to suggest otherwise. The prevalence of depression using data from the QOF register shows Calderdale to have a higher than national average prevalence (Calderdale 10.7%, England 8.3%). However, when this data is compared to the GP national survey data, the prevalence is not statistically different (Calderdale 12.9%, England 12.7%). This implies the prevalence is not different, but that Calderdale GPs are better at detecting and diagnosing it ( Mental health dementia and neurology ). Depression is common and disabling. The estimated prevalence of major depression among 16 to 65 year olds in the UK is 21 per 1,000 population (males 17, females 25).

Access

Hospital admission rates for mental health conditions can be reduced if there are adequate mental health services available in the community. Calderdale admission rates were significantly lower than the national average (Calderdale 25.5 per 100,000 population, England 87.4 per 100,000 population, 2014/15)( Mental health dementia and neurology ). This however, is different from the attendance rate at Accident and Emergency for a psychiatric disorder, which is much higher in Calderdale than nationally (Calderdale 665.4 per 100,000 population, England 243.5 per 100,000 population, 2012/13). It may be compared to the data for mental health service users with a crisis plan who are in contact with services in place, which is significantly lower in Calderdale (Calderdale 4.8%, England 13.3%, 2015/16). Access to psychological services in Calderdale is significantly better than the national average with patients receiving more referrals and waiting a lot less than nationally( Joseph Rowntree Foundation: Neighbourhood approaches to Loneliness ).

Treatment

The percentage of those entering treatment for Improving access to psychological therapies (IAPT) in the second quarter of 2016/17 in Calderdale is significantly better than the national average (Calderdale 751 per 100,00 population, England 540, per 100,000 population)( Mental health dementia and neurology ).

Outcomes

  • Improving access to psychological therapies – recovery rate, September 2016: in terms of recovery rate from talking therapies, Calderdale scores significantly better than the national average (Calderdale 51.2, England 48.4);
  • Emergency hospital admissions for self-harm 2011/2012: Calderdale scores significantly worse than England;
  • Hospital admissions caused by unintentional and deliberate injuries under-18s 2009/10: Calderdale scores significantly worse than England.

Projected future need

Changes in the Calderdale population size and structure are predicted to lead to the following by 2020:

  • 3,519 adults aged 65 years and over predicted to have depression (compared with 3,210 in 2015);
  • 1,099 adults aged 65 years and over predicted to have severe depression (compared with 1,006 in 2012);
  • 9,145 adults aged 18 to 64 predicted to have two or more psychiatric disorders (compared with 9,073 in 2015).

Key considerations linked to the known evidence base (what works?)

National Institute for Clinical Excellence (NICE) guidelines:

Other national guidelines and reports

References and further information

References

Further information

Always open first panel: 

Author

Caron Walker, Public health consultant, Public health, Calderdale Council (July 2017).