Using population mental health data to inform commissioning across health, public health

1. Using population mental health data to inform commissioning across health, public health • and social care • Dr Jonathan Campion • Director of Population Mental Health (UCLPartners) • Visiting Professor of Population Mental Health(UCL) • Director for Public Mental Health& Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust • London 20thNovember 2013

2. Presentation outline • Types of public mental health data to inform commissioning • Impact of mental disorder • Risk factors and higher risk groups • Estimating local levels of mental disorder • Mental wellbeing: levels and impact • Public mental health interventions • Data on coverage, spend, outcomes and economic impact of public mental health interventions • Summary • References and contact

3. Sources • Presentation draws on public mental health commissioning guidance endorsed by ADPH, RSPH and LGA, published in December 2012 and updated in August 2013 • Graphs which highlight variation across London use nationally available datasets although the quality of such datasets vary • Highlights importance of drawing on local public mental health data not available in such datasets • Includes preliminary work to provide local public mental health data to inform coverage of effective treatment of mental disorder, prevention of mental disorder and promotion of mental wellbeing

4. 1. Different types of public mental health data • Level and impact of mental disorder and well-being • Level of risk and protective factors • Numbers from higher risk groups and size of increased risk • Coverage of interventions to treat mental disorder, prevent mental disorder and promote mental well-being • Level of unmet need: size, impact and cost of public mental health intervention gap • Data on impact on outcomes • Using data to inform strategic development and commissioning • Problem that usually not integrated into JSNAs

5. 2: IMPACT OF mental Disorder

6. Impact of mental disorder Disease burden in UK caused by Mental Disorder (WHO, 2008) • Underestimate • Size of impact due to • A) Arising early in the life courseB) Broad range of impactsC) Mental disorder being common

7. A. Most lifetime mental disorder arises before adulthood Age of onset of lifetime mental illness – predates subsequent physical illness by several decades Source: Kim-Cohen et al, 2003; Kessler et al, 2005; Kessler et al, 2007

8. B. Mental disorder is common National rates of mental disorders National rates of sub-threshold mental disorder Source: McManus et al, 2009; Knapp et al, 2007

9. C. Broad range of impacts • Self-harm and suicide • Health risk behaviour - smoking,alcohol and drug misuse, sexual risk, nutrition, physical activity • Physical illness, long term (physical) conditions and premature death • Educational outcomes • Employment • Antisocial behaviour/ offending • Social skills Source: Campion et al, 2012

10. Impacts of emotional and conduct disorder in adolescents in UK Source: Green et al, 2005

11. Impact of mental disorder: Underlies large proportion of overall health risk behaviour Smoking as an example – the single largest cause of preventable death • 42%of adult tobacco consumption in England by people with mental disorder (McManus et al, 2010) • 43%of under 17 year old smokers have either emotional or conduct disorder (Green et al, 2005)

12. Impact of mental disorder: 10-20 year reduced life expectancy • Depression: 11 years (men), 7 years (women) (Chang et al, 2011) • Schizophrenia: 20.5 year (men), 16.4 year (women) (Brown et al, 2010) • Alcohol use disorder: 10.8 years (women), 17.1 years men (Hayes et al, 2011) • Opioid use disorders: 17.3 years (women), 9.0 years (men) (Hayes et al, 2011) • Personality disorder: 18 years (Fok et al, 2012)

13. Impact of mental disorder: National annual costs Source: CMH, 2010; NICE, 2009; SCMH, 2009

14. Local estimation of London’s annual cost of mental disorder Source: Application of national figures for cost of different mental disorder to London population size

15. Impact of mental disorder: key points • Most mental disorder arises before adulthood but often continues to impact across the life course • Mental disorder results in broad range of adverse (public health related) outcomes and associated economic costs • Local impacts can be estimated • Prevention and early intervention for mental disorder prevents a broad range of associated outcomes and inequalities

16. 3: Data about RISK FACTORS AND HIGHER RISK GROUPS

17. Risk factors for mental disorder • Prevalence of mental disorder associated with local levels of risk factors which can be measured and include: • deprivation/ inequalities (Green et al, McManus et al, 2009) • smoking/ alcohol use during pregnancy • parental mental disorder • poor parenting • childhood adversity/ abuse accounts for 30% of mental disorder (Kessler et al, 2010) • Indicates opportunities to prevent mental disorder

18. Borough level of risk factors associated with mental disorder Source: DCLG 2011, PH Outcomes, Bebbington et al 2011, DfE 2012

19. Higher risk groups • Looked after children (Ford et al, 2007) • 5-fold increased risk of mental disorder • 46% of looked after children have a mental disorder • Long term physical conditions (NICE (2009) • 2–3fold increased risk of depression • >7 fold increase with two or more LTCs • BME – Schizophrenia(Kirkbrideet al, 2012) • 5.6 times higher in black Caribbean group • 4.7 times higher in black African group

20. Risk factors and higher risk groups: key points • Level of risk factors for mental disorder vary by locality and are important to address to prevent mental disorder • Certain groups experience several fold increased risk of mental disorder (Campion & Fitch, 2012) • For different higher risk groups, important to know local numbers and size of increased risk of mental disorder - enables estimation of numbers with different mental disorder

21. 4: ESTIMATING Local Levels of mental Disorder

22. Estimating local levels of mental disorder • Informs localities about numbers with different mental disorder including from higher risk groups • Such data important for commissioning and planning

23. Estimated local prevalence of child and adolescent mental disorder Source: Campion & Fitch, 2012

24. Estimated local number of children and adolescents who have self-harmed Self-harm and have an emotional disorder Self-harm and have a conduct disorder Self-harm and have ADHD Source: Green et al, 2005 (assuming national 7% prevalence rates)

25. Estimated annual incidence of psychosis per 100,000 Source: Psymaptic, 2013

26. Estimating local numbers from higher risk groups and proportion with mental disorder • Particular groups have several fold increased levels of mental disorder (Campion, 2013) • Such groups require targeting for both treatment, prevention and promotion • Service providers and commissioners require data about numbers from higher risk groups and proportion estimated to have mental disorder • Subsequent slides show estimated numbers from several higher risk groups in each borough and proportion with mental disorder

27. Local number of looked after children and proportion estimated to have mental disorder Source: DfE 2011

28. Local number of new mothers and proportion estimated to have depression Rates of maternal depression a year after giving birth Rates of maternal depression during pregnancy Number of new mothers Source: ONS 2012

29. Local numbers with long term limiting illness – a high risk group for depression Source: ONS, 2012

30. 5: MENTAL WELLBEING - IMPACT AND LOCAL LEVELS

31. Health impacts of mental wellbeing • Associated with reductions in and prevention of: • Mental disorder in children and adolescents • Suicide in adults • Mental disorder in adults • Physical illness • Associated health care utilisation • Mortality Source: Campion et al, 2012

32. Impacts of mental wellbeing outside health • Improved educational outcomes • Healthier lifestyle • Reduced health risk behaviour - smoking, alcohol, drug misuse, physical inactivity, diet • Increased productivity at work, fewer missed days off work • Social/ more positive relationships • Higher income • Reduced anti-social behaviour, crime and violence Source: Campion et al, 2012

33. Local levels of mental wellbeing • ONS measures available at borough level for England (ONS, 2013) • 28.4% have a low happiness score • 23.0% adults have a low satisfaction score • 19.3% have a low worthwhile score • Levels vary between and within boroughs • Range of protective factors – proxy indicators • Single largest group with poor wellbeing are those with mental disorder

34. Key points • Improved mental wellbeing have a similar broad range of impacts to mental disorder • Particular groups at higher risk of poor mental wellbeing • Largest single group with poor wellbeing are people with mental disorder • Interventions to promote mental wellbeing need to target higher risk groups and coordinate with services providing treatment for mental disorder

35. 6: PUBLIC MENTAL HEALTH INTERVENTIONS

36. Effective interventions exist • Range of cost effective interventions (HMG, 2010; Campion & Fitch, 2012) which health professionals and commissioners require information about • Can be categorised as • Treatment of mental disorder (secondary and tertiary prevention) • Prevention of mental disorder (primary prevention) • Promotion of mental wellbeing • primary promotion focusing on whole population • secondary and tertiary promotion targeting groups with low wellbeing including those with mental disorder

37. Interventions provided by range of organisations including from outside health • Highlights importance of data about size/ impact of activities of different organisations to facilitate cross-sector coordination: • Primary and secondary care • Local government • Public health • Social care service providers • Third sector social inclusion providers • Education providers • Employers • Criminal justice services

38. Primary prevention and promotion

39. Primary prevention and promotion • Addresses risk factors for mental disorder and promotes protective factors for mental wellbeing • Childhood and adolescence particularly important opportunity – family approach including parents • Targeting groups at higher risk • Important part of sustainable reduction in burden of mental disorder • Area outside remit of ‘health’ and within remit of public health/ LA

40. Mental wellbeing promotion interventions • Promote protective factors • Place based approaches (e.g. schools/ workplace/ libraries/ nursing homes) • Cover a large number of population at one time • Improve literacy about mental wellbeing and disorder • Campaigns or social marketing of resources such as ’10 Actions for Happiness’ or ‘5 ways to wellbeing’ which outline what people can do to promote their wellbeing

41. Wellbeing promotion for parents and infants • Programmes to support secure attachment with parents and carers • Breastfeeding support • Supporting good parenting skills • Preschool programmes Source: Campion & Fitch, 2012

42. School based mental health promotion interventions • Whole school mental health promotion • Targeted Mental Health in Schools Programme (TaMHS) Source: Campion & Fitch, 2012

43. Work and social promotion interventions • Work based mental health promotion programmes result in net savings of £10 for each £ spent (Knapp et al, 2011) • Social relationships important protective factor for wellbeing. Interventions to enhance social capital include: • Mentoring • Timebanks • Adult education • Volunteering • Art • Mindfulness/ spiritual/ religious • Physical activity Source: Campion & Fitch, 2012

44. Primary prevention of mental disorder • Interventions addressing risk factors for mental disorder which include: • Inequalities and deprivation • Maternal smoking during pregnancy (PH outcome) • Parental mental disorder • Violence and abuse particularly during childhood and adolescence • Discrimination and stigma Source: Campion & Fitch, 2012

45. Prevention of child abuse • Adverse child experiences single largest risk factor for mental disorder (30%) • Child abuse associated with several fold increased risk of mental disorder, suicide and self-harm • Nationally, 19% of 11-17 year olds estimated to experience severe maltreatment during childhood • 3% of women and 1% of men experience sexual intercourse during childhood (Bebbington et al, 2011) • Interventions to • Prevent child abuse including parenting programmes and school based interventions • Address abuse early e.g. Child Protection Plans Source: Campion & Fitch, 2012

46. School based prevention interventions • Social emotional programmes to prevent conduct disorder result in net savings of £84for each £ spent (Knapp et al, 2011) • Bullying prevention (£14 net savings for each £ spent) (Knapp et al, 2011) • Violence prevention programmes • Domestic violence (TaMHS) • Loss, separation and bereavement • Stigma prevention Source: Campion & Fitch, 2012

47. Other prevention interventions • Debt advice(£4 net savings for each £ spent) (Knapp et al, 2011) • Work place stress reduction • Targeted smoking cessation for people with mental disorder which prevents physical illness and premature mortality Source: Campion & Fitch, 2012

48. Secondary/ tertiary prevention and promotion • Adolescence particularly important opportunity since half of lifetime mental illness has arisen by 14 • Treatment interventionssupported by NICE guidance • Early intervention for mental disorder results in improved outcomes and prevents a range of subsequent impacts - also addresses underlying cause of poor wellbeing • Need for targeting of groups at higher risk Source: Campion & Fitch, 2012

49. Section 7: PUBLIC MENTAL HEALTH DATA on a) coverageB) spendc) outcomes d) economic impact

50. Limitations of data • Quality and how recent • Lack of national data sets for certain risk/protective factors • Lack of national data sets for coverage of certain interventions • Lack of data on outcomes of interventions • Certain data can be collected at locality level to fill gaps in national dataset coverage