1. Mental Health and Physical Health & Long Term Conditions

2. Mental health problems predict physical disease (1)
People with psychotic disorders die on average 25 yrs earlier than the general population (Parks et al 2006)
Self report of depression in population studies increases mortality by 50% (Mekletun et al 2007)
Diagnosis of neurotic disorder in general practice increases mortality over next 11 years by 70% (Lloyd et al 2006)
Acknowlege Johanthon Campion
Plenty of studies showing that mental illness increases risk of death from all causes
Also plenty of studies showing that people with menta ge of Anxiety, phobias, neurotic depression, psychosomatic illnesses – tension headache, insomnia – not the sort of things you die of
External comparison in the way we have just described
Various ages at recruitment
Subjects retraced 11 years later 87% Follow-up
Number of person years in each age group
Expected death rates from general population used to work out expected deaths in this group of people
Compared with observed deaths None of the deaths related to mental health
Found to be at increased risk of death from physical causes
Those of you who are still very much on the ball will spot the fact that these individuals were not disease free at the outset: they were selected because they had neurotic disorders. Cohort studies can be used in this way

3. Mental health problems predict physical disease (2)
Depression associated with increased mortality from
cardiovascular disease
cancer
respiratory disease
nervous system disease
accidents
Plenty of studies showing that mental illness increases risk of death from all causes
Also plenty of studies showing that people with menta ge of Anxiety, phobias, neurotic depression, psychosomatic illnesses – tension headache, insomnia – not the sort of things you die of
External comparison in the way we have just described
Various ages at recruitment
Subjects retraced 11 years later 87% Follow-up
Number of person years in each age group
Expected death rates from general population used to work out expected deaths in this group of people
Compared with observed deaths None of the deaths related to mental health
Found to be at increased risk of death from physical causes
Those of you who are still very much on the ball will spot the fact that these individuals were not disease free at the outset: they were selected because they had neurotic disorders. Cohort studies can be used in this way

4. Mental health problems predict physical disease (3)
Depression associated with increased morbidity from
cardiovascular disease
back pain
irritable bowel
tension headache
insomnia
There are of course plenty of studies showing that physical health impacts on mental health
Various ages at recruitment
Subjects retraced 11 years later 87% Follow-up
Number of person years in each age group
Expected death rates from general population used to work out expected deaths in this group of people
Compared with observed deaths None of the deaths related to mental health
Found to be at increased risk of death from physical causes
Those of you who are still very much on the ball will spot the fact that these individuals were not disease free at the outset: they were selected because they had neurotic disorders. Cohort studies can be used in this way

5. Plenty of studies show that physical illness can affect mental health
Mental Illness
But the studies suggest that the mental health to physical health is stronger than the other way round
Physical Illness

6. The impact of long-term conditions (LTC) and co-morbidity
More than 15 million people in England (30% of population have one or more long-term conditions (DH 2011).
Co-morbidities are the norm in later life.
Evidence consistently demonstrates that people with LTC are two to three times more likely to experience mental health problems than the general population.
Much of the evidence relates specifically to affective disorders such as depression and anxiety, though co-morbidities are also common in dementia, cognitive decline and some other conditions.
This includes people with a range of conditions that can be managed but often not cured, such as diabetes, arthritis and asthma, or a number of cardiovascular diseases. To this we can add conditions such as HIV/AIDs and certain cancers, which have not traditionally been considered long-term conditions but which are increasingly experienced and regarded as such
The prevalence of long-term conditions rises with age, affecting about 50 per cent of people aged 50, and 80 per cent of those aged 65. Many older people have more than one chronic condition, but in absolute terms there are more people with long-term conditions under the age of 65 than in older age groups

7. The overlap between long-term conditions and mental health problems

8. Health-related quality of life scores associated with single and multiple long-term conditions

9. Mental Health and Older People-the costs
Co-existing mental health problems in people with LTC leads to significantly poorer health outcomes and reduced quality of life.
Costs to the health care system are also significant – by interacting with and exacerbating physical illness, co-morbid mental health problems raise total health care costs by at least 45% for each person with a long-term condition and co-morbid mental health problem
This suggests that between 12% and 18% of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – between £8 billion and £13 billion in England each year.
In terms of NHS spending, at least £1 in every £8 spent on long-term conditions is linked to poor mental health and wellbeing.
People with long-term conditions and co-morbid mental health problems disproportionately live in deprived areas and have access to fewer resources of all kinds. The interaction between co-morbidities and deprivation makes a significant contribution to generating and maintaining inequalities.
People with long-term physical health conditions – the most frequent users of health care services – commonly experience mental health problems such as depression and anxiety, or dementia in the case of older people.
Older people living with frailty make up between 9% and 25% of the population.
They are highest users of services across health and social care and have the highest levels of unplanned admissions to hospital.
When the NHS was founded in 1948, 48% of population died before the age of 65; that figure has now fallen to 14%
Life expectancy at 65 is now 21 years for women and 19 years for men
Health and care services have failed to keep up with this dramatic demographic shift
People over 65 account for 51% of gross local authority spending on adult social care
2/3 primary care prescribing budget
70% health and social care spend is on people with long-term conditions

10. Other costs/impact of LTC
Chronic diseases are now the most common cause of death and disability in England.
People with LTC tend to be heavy users of health care resources, accounting for:
At least 50 % of all GP appointments,
64% of outpatient appointments and
70% of all inpatient bed days
18% of people with LTC are in receipt of state-funded social care

11. Monthly costs per patient with and without mental health problems (based on client claims data from Beacon Health Strategies, prior to Beacon engagement)

12. Proportionate increase in per patient medical costs associated with depression and anxiety relative to people without a mental health problem (based on US claims data for more than 9 million people, Melek and Norris 2008)

13. A word about Medically Unexplained Symptoms (MUS)
Physical symptoms that have no currently known physical pathological cause
Studies have shown that MUS account for 20% -30% of consultations in primary care
52% in secondary care  
Up to 70% have depression and/or anxiety disorders medically unexplained symptoms

14. There may be trouble ahead..

15. King’s Fund, July 2016
‘The NHS is going through the biggest financial squeeze in its history. Since 2010, its budget has effectively been frozen, increasing by just enough to cover inflation. Increasing demand for care means that services are under huge pressure.. Looking further ahead, pressure to spend more will grow as the costs of treatment rise, public expectations increase and the population continues to age’.

16. In 2015/16, NHS is under unprecedented strain….
8% patients, more than 1.85 million, spent longer than four hours in A&E across the year, the worst performance since 2003/4
Number of patients waiting for hospital treatment has risen to 3.7 million, (increase of 17% (500,000 patients), and highest number since 2007
By March 2016, 5,700 patients were delayed in hospitals, an increase of 15% over the year and the highest number since 2008.

17. Question?
How can we address sustainability of NHS and Social Care by targeting interventions aimed at improving mental health and wellbeing in people with LTC/co-morbidity and patients with MUS?

18. LTC/Mental Health/Mental Illness: What can we do?
Growing evidence that addressing the psychological and MH needs of people with LTCs leads to improvements in both mental and physical health. Also possible to reduce the number of people with LTC who go on to develop MH problems. Psychosocial interventions effective and cost-effective in improving mental well-being and in reducing prevalence mental illness e.g. addressing the psychological needs of people with diabetes improves clinical outcomes, quality of life, relationships with health care professionals and carers, dietary control and overall prognosis

19. What can we do (2) ?
Interventions that have been shown to be cost-effective:
Reducing social isolation and loneliness
Befriending
Training in the use of the internet to increase social support
Walking and physical activity programmes
Learning and volunteering
Debt advice
Home insulation and improved central heating have resulted in 40-50% decrease in depression and anxiety
Research suggests it may be possible to reduce the number of people with LTC who go on to develop MH
A number of cost-effective interventions exist for promoting mental health and preventing the development of mental illness e.g.
providing debt advice
befriending interventions aimed at older people
Good evidence for effectiveness of a number of psycho-social interventions such as CBT, Behavioural Activation, Problem Solving Treatments
Exercise is recommended as a treatment for mild to moderate depression,
Psycho-social interventions e.g. befriending may also be useful in management of mild depression in older people.
Medication: Also good evidence base for use in depression in older people: antidepressants are effective for people with moderate to severe depression.

20. What can we do for MUS?
A recent systematic review of MUS found that interventions targeting GP’s diagnostic and patient management skills as well as CBT for patients have the potential to improve patients’ health status and to reduce costs .

21. Where best to intervene?

22. The role of Primary Care
90% of all NHS interactions take place in primary care (most depression also managed in primary care -91%)
Primary care on front-line in dealing with MH of older people, supporting families, and managing people with complex co-morbidities (including LTCs)
Services provided by GPs often highly valued by patients although access remains problematic in some/many cases
Depression is under-detected in older people, with only 1 in 6 older people with depression discussing their symptoms with their GP, and less than 1/2 of these receiving adequate treatment.
MUS account for 20% -30% of consultations in primary care
There is growing evidence that supporting the psychological and mental health needs of people with LTC more effectively can lead to improvements in both mental and physical health.
There is evidence, however, that GPs continue to refer younger rather than older people for talking treatments.

23. Social Prescribing
Involves the use of non-medical interventions, sometimes called ‘social prescribing’ or ‘community referral’, to improve mental health and wellbeing.
Provides a significant opportunity to strengthen resilience in older people and/or people with LTC
Ideally best positioned in primary care
Social prescribing supports improved access both to psychological treatments and to interventions addressing the wider determinants of mental health
Social prescribing has the potential to become fully integrated as a patient pathway for primary care practices and to strengthen the links between healthcare providers and community, voluntary and local authority services that influence public mental health. These include leisure, welfare, education, culture, employment and the environment (for example urban parks, green gyms and allotments).

24. Social prescribing