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Health in Scotland 2002

CHAPTER 2

MENTAL HEALTH

"Positive mental health and well-being is important within the whole Scottish Executive agenda and will require work across the full spectrum of the health sector, education, social justice, employment, criminal justice agencies, health at work and local communities. This way we can better respond to reducing those factors that are a risk to good mental health such as poverty, poor housing or lack of employment or educational opportunities and seek to increase and sustain those factors that are protective of good mental health." Malcolm Chisholm, Minister for Health and Community Care, Well? September 2002.

A Priority for Action

Mental health problems are among the commonest causes of ill-health in Scotland.

• 30% of consultations each year in general practice are for mental health problems ¹

• In Scotland 40% more per head is spent on antidepressant prescriptions than in England ²

• Suicide is the leading cause of death among young men in Scotland and is over twice the rate in England ³

• Around 1,400 young people (under 18 years) are treated in hospital each year for deliberate self-harm ⁴

These affect not only individuals but also carers, families, communities and society as a whole. Achieving the goal of improving Scotland's health therefore means addressing not just physical health but also the mental health and wellbeing of people and the communities within which they live. This is why mental health continues to be one of the main clinical priorities for Scotland.

It is not only the absolute numbers of people with mental health problems or who are suicidal or self-harming that present a challenge but also the disproportionately higher rates of mental ill-health experienced by people living in the most deprived communities, where:

• GP consultations for anxiety and depression are twice as high as in the more affluent communities

• First admission rates to specialist psychiatric care for people with schizophrenia are higher ⁵

• Twice as many suicides occur ⁶

• Children of families in Social Class 5 are approximately three times more likely to have a mental health problem that those in Social Class 1 ⁷

• People with mental health problems have the highest rate of unemployment among people with disabilities ⁸

This relationship between deprivation and mental illness means that actions directed at improving mental health have to be integral to broader policy goals of social justice and social inclusion.

Improving Scotland's Mental Health

Aims and Objectives

• A greater awareness and understanding of mental health and mental illness

• A reduction in the incidence and prevalence of mental ill-health

• Timely access to and delivery of effective and good quality services for people

• The elimination of the stigma and discrimination associated with mental illness

• The social inclusion of people who experience mental ill-health

None of these can be delivered by a single organisation. A combined, co-ordinated effort is required with the shared objective of improving mental health in Scotland. There is national and international recognition (WHO ⁹, EU ¹⁰) that to improve individual and community mental health requires an integrated approach to the development and implementation of policy. This underlines the need for joint action aimed at

• Promoting positive mental health

• Preventing and/or reducing the influences that put mental health at risk

• Ensuring early recognition and intervention at times when individuals are vulnerable

• Providing accessible, appropriate, integrated and high quality services

• Providing the right legislative framework

• Tackling the social and economic influences that are detrimental to mental health

Last year saw an unprecedented level of activity to achieve these goals. Scotland now has in place the foundations for making significant progress in improving mental health for all and for taking forward integrated work on promotion, prevention and care.

Progress in 2002

2002 saw the beginning of an ambitious national programme aimed at improving mental health in Scotland, building on evidence that shows that achieving good mental health is more than responding to mental illness. A National Advisory Group, chaired by the Minister for Health and Community Care, has been drawn from a range of interests across Scotland to provide advice on the development of the programme.

Initial funding of 4 million was made available for this from the health improvement fund with a further commitment of 20 million from the SE for the period 2003/2006. Its first achievements include

• The launch of 'Choose Life,' the national strategy and action plan to reduce the rate of suicide in Scotland by 20% by 2013

• The development of the 'Breathing Space' advice line for people affected by low mood and depression

• The launch of Scotland's first ever anti-stigma campaign 'see me....' developed and implemented, with funding from the National Programme, by an alliance of organisations including the Royal College of Psychiatrists (Scottish Division), National Schizophrenia Fellowship (Scotland), Penumbra, Scottish Association for Mental Health (SAMH) and the Highland Users Group

• Publication of 'With Health in Mind' by the Scottish Public Mental Health Alliance to engender discussion and debate on wider mental health issues

As the programme gathers pace, the involvement of a wider range of different partners will ensure that together these far-reaching aims can be achieved.

Improving Mental Health Services

In 2001/2002 NHS Boards in Scotland spent over 558 million on mental health services, an 8% increase on the previous year. Local authorities planned direct spend on mental health, in addition to caseload expenditure, was over 52 million in 2002/2003, significantly higher than in previous years. Mental Illness Specific Grant, amounting to 19 million, funded around 400 small-scale projects for people with mental health problems in communities across Scotland.

This represents record expenditure by the statutory partners on mental health during 2002. To ensure the effective and efficient use of resources, consultations took place on how to proceed with the development of mental health services, including more effective joint working. Discussions on the details of the next steps continue with the partner care organisations, and the progress is encouraging.

Liaison Mental Health Services

A sizeable proportion of people seen in primary care and of those referred for physical investigation and treatment are also experiencing mental health problems. If these additional problems go unrecognised or untreated, it can lead to increased suffering, delayed recovery and even unnecessary investigations. In 2002 the Scottish Needs Assessment Programme (SNAP) published a report addressing this issue and will allow the commitment to liaison services made in Our National Health: A plan for action, a plan for change to be pursued further.

In cancer services in Scotland there are already welcome signs of increasing awareness of the psychological dimensions. The Alcohol Problem Support and Treatment Services Framework highlights the need for early recognition and help for people with mental health problems who present with associated physical problems.

Postnatal Depression

In 2002 the Scottish Intercollegiate Guidelines Network (SIGN) issued its guidelines on 'Postnatal Depression and Puerperal Psychosis'¹¹. This added to the available advice and invited the partner organisations to work together towards integrated services and support. The welcome suggestion was made to NHSScotland in December 2002 that further consideration be given to this important aspect through the developing arrangements for regional planning.

Child and Adolescent Mental Health Services (CAMHS)

About 125,000 young people in Scotland have mental health problems which are severe enough to interfere with their day to day life ¹². Factors known to increase children's vulnerability to mental health problems ¹³ include a learning disability, physical ill-health, physical or sexual abuse and witnessing domestic violence. A child whose parent has a serious mental health difficulty is also more likely than others to develop a mental health problem.

Numerous reports suggest that mental health problems amongst children and young people are on the increase ¹⁴ and there is clear evidence in NHS data of increasing demand for mental health services for children and young people. These changes can reflect changing prevalence, increased recognition as a result of changing awareness and attitude and even increasing availability of services. The feasibility of promoting positive mental health and preventing mental health problems has been increasingly studied in recent years. Some studies suggest that it is possible to promote resilience - the capacity to cope with stress - through school-based programmes ¹⁵.

Several Scottish initiatives have a bearing on the mental health of children and young people, including the report, 'For Scotland's Children'¹⁶ and the First Minister's declaration, in his inaugural address, of a commitment to the wellbeing of children.

In Scotland, the Mental Health and Well-being Support Group, whose primary task is to monitor the implementation of the 1997 Framework for Mental Health, hold the NHS strategic overview of child and adolescent mental health. Also the more recently established Child Health Support Group takes an interest in child and adolescent mental health service development.

A forthcoming needs assessment report from PHIS on child and adolescent mental health (originally commissioned under SNAP) will consider how to work with young people with mental health problems and the importance of developing and sustaining mental health and wellbeing. It will consider the potential benefits for young people, families and communities, when young people feel well and are emotionally fit for learning, playing, working and relating. The working group undertook an extensive surveying and consultation exercise during 2002 with the final report due in March 2003.

In December 2002, the Minister for Health and Community Care announced that mental health would be a pathfinder client group for the new initiatives on integrated workforce development. It is most timely that one of the first priorities for this initiative will be attention to the child and adolescent mental health services workforce.

Two groups with specific needs - people with Autistic Spectrum Disorder and Learning Disability - saw additional focus and commitment to improvement in services.

Needs Assessment - Autism

In January 2001, the SEHD commissioned PHIS to co-ordinate a needs assessment on Autistic Spectrum Disorders in Scotland. The project brief was for a report comprising an epidemiological review, a description of services and an assessment of the extent to which children, young people and adults with ASD, and their carers, receive appropriate and adequate support.

The process was similar to previous SNAP reports: it was developed using both epidemiological information and expert opinion by a multi-agency, multi-disciplinary group. The process was open and consultative and sought to involve as many interested parties as possible in the time available. The group worked on the report during 2001 and it was published in early 2002. The aim was to provide service commissioners in the SE and in NHS Boards with the best available information about autistic spectrum disorders and current service provision in Scotland and guidance on how services might better meet the needs of those affected.

Learning Disabilities

The Same As You? review of services for people with a learning disability was published in 2000. It is a strategy for services to support people with learning disabilities and acts as a keystone for better prospects, which aim to close the opportunity gap, over the next ten years.

Year 2 of The Same As You? implementation has featured a series of events and conferences with high levels of involvement. Delegate numbers exceeded 300 for conferences on autism, registers for data bases and hospital closure. The Same As You? Implementation Group focussed on three agreed priorities: the role of the Local Area Co-ordinator (LAC), hospital closures and prospects for employment.

LACs are an innovative proposal: a working group made recommendations on core responsibilities and job plans. Almost all local authorities have agreed to appoint LACs. Early signs are very encouraging that the co-ordinator focuses on individual needs of a small population and uses imagination, resourcefulness and professional skills to deliver the aims of people with learning disabilities and to act as advocate for improvements. LACs may mark the start of exciting developments for other groups of people with care needs.

Hospital closures and their follow-through were the second subject for priority treatment. Early signs show different levels of momentum towards closing long-stay hospitals across Scotland, with mixed stories about support that may be available in the community for former patients. The best accounts were of supported lives near family and friends with social and work opportunities. Less positive accounts included movement to other institutional care, daytime boredom and lack of opportunity. Further work is taking place to define and develop the challenge for primary care in supporting people with learning disability. A large conference in December 2002 set down themes for a forthcoming report.

The third group is addressing employment prospects for people with learning disabilities. Collecting information in this area has been a challenge. Several pieces of work have brought together a picture of low levels of employment, lack of training opportunities and many other links yet to be made. This group's report will be available later in 2003.

The Deputy Minister for Health and Community Care has taken a keen interest in the welfare of people with learning disabilities. A cross party group in the Scottish Parliament also reflects wider public concern for this client group. With broad commitment, examples of excellence and dedication in places across the country and the involvement of straight-talking users and carers, the future prospects for collaboration towards better lives are now brighter.

People with learning disabilities and mental health problems

Among people with learning disabilities there is a higher prevalence of mental illness than the general population: 30-42% of children and 40-50% of adults with learning disabilities require treatment for mental health problems. As many as 60% of older people with learning disabilities may have mental health problems, with higher than average levels of depression, psychoses and dementia ¹⁷.

PHIS was commissioned to carry out a comprehensive national assessment of the health needs of children and adults with learning disabilities. This report is due in summer 2003. The review will assist in informing the NHS and partner organisations of the measures required to ensure that in the future the physical and mental health needs of people with learning disabilities are addressed.

Specialist secure facilities for young people with severe mental health problems

There is currently no secure psychiatric provision in Scotland for adolescents with severe mental health needs. Young people with mental disorders are generally dealt with by specialist Child and Adolescent Mental Health Services and when requiring admission to secure facilities may be admitted to NHS facilities elsewhere in the UK or, inappropriately, to Adult Inpatient Units.

The stakeholders in the NHS, local authorities and existing secure care providers agree that development of secure adolescent psychiatry capacity within NHSScotland is needed and the SE will now take this forward. This should take place within the wider context of the need to strengthen CAMHS across Tiers 1-4 in community and primary care settings, as well as specialist services.

Ensuring Mental Health Service Quality

Ensuring safety, reducing risk

In August 2002 the Clinical Resource and Audit Group (CRAG) published Engaging People, ¹⁸ its revised good practice guidance on the observation of people with acute mental health problems. Describing the key standards for observation, the guidance recommends that each local service should have a system that is flexible and responsive to patient need, to help reduce the incidence of suicide and self harm among people in hospital.

Guidance was also made available in May 2002 to service providers on taking practical steps to reduce the risks to staff and others of drugs misuse and alcohol consumption within mental healthcare settings ¹⁹. A short life working group has been set up jointly by the Scottish Advisory Committee on Drug Misuse and the Scottish Advisory Committee on Alcohol Misuse to examine the need for assessment, treatment and further action, when individuals present with a history of substance misuse and a mental health problem. The group is due to report to a joint meeting of the two committees in June 2003.

Review of the Governance and Accountability of the State Hospital

In 2002 consultations on the governance and accountability of the State Hospitals Board for Scotland took place ( The Right Place, The Right Time) ²⁰. Appropriate attention is being given to these issues, with a view to achieving a service designed to deliver the most appropriate care across a range of provision and levels of security. There are also emerging (and encouraging) developments in forensic services across Scotland involving healthcare and other organisations as evidenced by the wide representation and focussed content of the Mentally Disordered Offenders Conference held in May 2002.

Mental Health and Well-Being Support Group

The Mental Health and Well-Being Support Group advises Ministers on the progress being made in local mental health services in line with the template set by The Framework for Mental Health Services in Scotland ²¹. This year, in the course of its series of annual visits, attention focused on plans for community-based care, management of change and local planning (reports of these and earlier site visits are published on the Support Group website www.show.scot.nhs.uk/mhwbsg . The Group's work is taken into account as part of the newly established Performance Assessment Framework, the basis for the annual Accountability Review between each NHS Board and the SEHD.

Clinical Standards Board for Scotland Schizophrenia Standards

Reflecting mental health's priority status, schizophrenia was selected by the Clinical Standards Board for Scotland (CSBS) for early attention. The first national report on compliance with the resulting Standards for Schizophrenia was published in 2002 ²². The report showed the standards and the associated audit tool combining to provide an effective mechanism for reflecting on local services and promoting change and improvement. It also revealed the need for continued progress across Scotland to meet and maintain the standards set.

New Clinical Effectiveness Body

The decision made in 2002 to integrate several clinical effectiveness bodies into one organisation, NHS Quality Improvement Scotland (NHS QIS), is most welcome. For mental health, the incorporation of Scottish Health Advisory Service (SHAS) within the new body is an important development and one that will see the priority attached to standards of care for mental health services maintained and developed within the overall remit for the new body.

Mental Welfare Commission for Scotland

In September 2002, a Policy and Financial Management Review of The Mental Welfare Commission for Scotland was completed. The SE will work with the Commission to help take forward the Review's recommendations in relation to the Commission's focus on users and carers, operation and management issues and partnership working.

Protecting People Through Legislation

Those who need treatment may sometimes, because of their mental disorder, not recognise their need. In these situations the law can help by providing controlled procedures under which, where strict criteria are met, individuals can be given treatment on a compulsory basis, while protecting their human rights.

Legislation can also serve a vital purpose in allowing decisions to be made on behalf of those who lack the capacity to make decisions for themselves. 2002 saw significant progress being made in relation to two pieces of legislation dealing with the rights and interests of people in these situations.

One of the first Acts to be passed by the Scottish Parliament was the Adults with Incapacity (Scotland) Act 2000. Part 5, which covers medical treatment and research, and Part 6, which makes provision for intervention and guardianship orders, came into effect in 2002. The Act provides mechanisms for safeguarding the welfare and managing the finances and property of adults who lack the capacity to make some or all decisions for themselves, because of a mental disorder or inability to communicate because of physical disability.

Last year also saw the introduction into the Parliament of a new Mental Health (Scotland) Bill. This was the product of nearly four years' work, first by the Committee chaired by Bruce Millan and subsequently by the SE, working closely with a wide range of individuals and organisations. The development of the Bill has been based squarely on the principles set out by the Millan Committee.

Within its wide-ranging provisions, the Bill

• Provides clear criteria which must be met before compulsory treatment can be permitted

• Establishes a new forum for making decisions on compulsory treatment: the Mental Health Tribunal for Scotland

• Promotes the participation of service users and carers

• Enhances the rights of people with mental disorders to services and to advocacy

• Updates and improves procedures in relation to people with mental disorder within the criminal justice system

To secure the successful implementation of the legislation, the Minister gave a commitment to undertake an assessment of current mental health services. The aim is to identify priorities for service development to ensure the availability of high quality mental health services. The new legislation is expected to be brought into effect in 2004 or 2005. The introduction of a more strongly principle-based approach, the operation of the new Tribunal system, the continuing drive towards joint working and the increased participation of service users in their own care and treatment will together have very significant implications for the way services are delivered. Only by meeting these challenges will the aspiration to have the best system of mental health law in the world become a reality.

Building on the Evidence

Ongoing monitoring, evaluation, review and research are fundamental to making sure that policy and practice rests on a firm evidence base. The Chief Scientist Office (CSO) supports a wide ranging programme of research in mental health, accounting for 14% of its total direct research spending - over 1.5 million per year. Mental health research has also been identified as one of four main priorities in the CSO's proposed research strategy for the next five years, on which consultation is currently taking place. Additionally, for the last 18 months the Mental Health Information Programme within ISD has been hosting the Improving Mental Health Information Project ( www.show.scot.nhs.uk/isd/mental_health/mhipbase.htm ). Its aims are to improve access to information and thereby to support mental health service planning, improvement and delivery.

Over the past year the SEHD's Social Research Team (formerly the Central Research Unit) has increased its capacity for mental health research. A new post of Senior Research Officer was created to develop and manage a long term programme of research to support the implementation of the proposed new mental health legislation and to monitor its operation and impact. In the broader area of health and community care policy, reports from a number of studies commissioned by the Social Research Team that were published in 2002 had relevance for the care and support of people with mental health problems, learning disabilities and dementia. These included

• A study of direct payments to mental health service users

• Users' experiences of discharge from acute psychiatric hospital care

• A review of care management

• A survey of public attitudes to community care in Scotland

A National Scottish Survey of Public Attitudes to Mental Health, Well-Being and Mental Health Problems was also commissioned and published in 2002 as part of the work of the National Programme to improve mental health and wellbeing.

The Way Ahead

Throughout the past year, policies and programmes aimed at improving both mental health and mental health services were put into effect. It is important to ensure that these different strands of activity work together to achieve the objective of improving Scotland's mental health. This requires continued partnership working to tackle the causes of mental ill-health and the social and economic impact for people who experience mental illness. Related developments are progressing to support people with autistic spectrum disorder and learning disability. Only in this way can social justice be attained for these potentially, and actually, excluded groups of people.

References

1. www.show.scot.nhs.uk/isd/CMR/index.htm

2. www.show.scot.nhs.uk/isd/mental_health/natinforeview.htm

3. GROS

4. www.show.scot.nhs.uk/isd/mental_health/mhipbase.htm

5. www.show.scot.nhs.uk/isd/scottish_health_statistics/subject/deprivation/mental.htm

6. Blamey, A., Hanlon, P., Judge, K. & Murie, J. (eds) (2002), Health Inequalities in the New Scotland, Glasgow, PHIS.

7. Meltzer, H., Gatward, R., with Goodman, R., and Ford, T. (2000), The Mental Health of Children and Adolescents in Great Britain, London, ONS.

8. ONS (1995) Surveys of psychiatric morbidity in Great Britain, Report 3: Economic activity and social functioning of adults with psychiatric disorders, London, Stationery Office.

9. www.who.int/mental_health;

10. Europa.eu.int/comm/health/ph/eu-action_/eu_action01_en.html

Figures collated for the purposes of the national review of the contribution of all nurses and midwives to the care and support of people with learning disabilities. Scottish Executive (2002), Promoting Health, Supporting Inclusion, Edinburgh, Stationery Office.

11. SIGN Guideline on Postnatal Depression and Puerperal Psychosis, June 2002 ( www.sign.ac.uk//guidelines/fulltext/60/index.html)

12. Meltzer, H et al (2001) Mental Health of Children and Adolescents in Great Britain. London, Stationery Office

13. Mental Health Foundation (1999) Bright Futures. London, Mental Health Foundation

14. Durlak, J and Wells, A (1997) Primary prevention mental health programs for children and adolescents: a meta-analytic review American Journal of Community Psychology 25, 115-151

15. Scottish Executive (2001) For Scotland's Children: Towards Better Integrated Children's Services (available at www.scotland.gov.uk/library3/education/fcsr-02.asp)

16. Scottish Office, 1997, A Framework for Mental Health Services in Scotland, Edinburgh, Scottish Office.

17. Scottish Needs Assessment Programme: Liaison Psychiatry and Psychology, May 2002 ( www.phis.org.uk)

18. CRAG Good Practice Statement: Engaging People: Observation of People with Acute Mental Health Problems, Aug 2002 ( www.show.scot.nhs.uk/crag/topics/mhealth/Obs%20report%20pagehtm.htm)

19. NHS HDL (2002) 41: Managing Incidental Drug Misuse and Alcohol Problems in Mental Health Care Settings, May 2002 ( www.show.scot.nhs.uk/sehd/mels/HDL2002_41.pdf)

20. The Right Place, The Right Time: A review of the governance and accountability of the State Hospitals Board for Scotland, May 2002 ( www.show.scot.nhs,uk/sehd/publications/DC20020517StateHosp.pdf

21. CSBS National Overview on Schizophrenia, March 2002 ( www.clinicalstandards.org/pef/natoveriew/schizophrenia.pdfCSBS)

22. CSBS Clinical Standards for Schizophrenia, January 2001 ( www.clinicalstandards.org/pdf/finalstand/Schizophrenia.pdf)

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