Summary of main evidence
Centre for Mental Health and Society, Bangor University
Senedd Cymru Health and Social Care Committee
4th May 2022.
The main points that we want to draw to the committee’s attention fall under five headings:
· Prevention
· Evidence
· Access to Services
· Social Outcomes
· Relationships
1. Prevention. Prevention of mental health problems is possible without either utopian social change or mass programmes of individual intervention. Like almost all health difficulties, mental illness has social determinants. High rates of mental illness are seen in the poorest, most marginalised parts of the population, and they also experience the worst outcomes from episodes of mental ill health.
a. Primary prevention means taking steps to avoid people becoming unwell in the first place through measures that affect the whole population. For example, in the 19th Century, recurrent epidemics of cholera and typhoid affecting poor areas of London stopped happening when clean water and sanitation became available for everyone. In mental health, the biggest positive effects are seen from measures affecting children. Children are known to be placed at high risk of serious mental illness in adulthood if they grow up in impoverished inner-city environments, in families on low incomes with poor educational opportunities. Growing up with racial disadvantage and racism has an additional major impact. The latter is true both in cities, where numbers of Black people are high, but also in rural areas. Long term strategies to reduce rates of mental illness should include measures to reduce the gap in income between the richest and the poorest; measures to improve the quality of social infrastructure in poor areas; and equitable welfare benefits that do not penalise children who grow up in large families. There is evidence that schemes such as Sure Start have an impact into adulthood, provide they are sustained over many years. Specific recommendation: The Welsh Government should reintroduce Sure Start, which has a good evidence base as prevention in mental health, alongside other benefits.
b. Secondary prevention involves early detection of mental illness as it emerges. Appropriate measures are set out below under Access
c. Tertiary prevention means providing adequate support for people with established conditions to prevent relapse and long term disability. The key point to understand is that every successful scheme that has been properly evaluated has included long term support for people rather than transient intervention. There is good evidence for Individual Placement and Support in employment, which has been demonstrated to help people to re-enter and remain within open employment provided support remains available in the long-term. Further measures include availability of professional legal support in the civil justice system and access to debt counselling. The harsh and inefficient nature of benefits assessments outsourced from the Department of Work and Pensions are a known cause of relapse of mental illness. We suggest that it might be possible for the Welsh Government to negotiate devolution of the commissioning of assessments, which would allow specification of a more humane and efficient process.
Specific recommendations: Provide long term funding for evidence based Individual Placement Support in employment; provide support for people with mental health problems In the civil justice system; seek devolution of commissioning of DWP benefits assessments.
2. Evidence. The history of mental health services has been marred by imposition of models that have been driven by political or professional ideology rather than evidence. One UK example was the imposition of Assertive Outreach Teams in the face of the evidence that they were more expensive, but no more effective, than standard care. A number of new models of care are currently being promoted by a variety of interest groups. We strongly recommend that they should only be adopted where there is a rigorous evidence base to support this. Where no evidence exists, the Welsh Government should facilitate research ahead of adoption.
Specific recommendation: focus on evidence prior to adoption of new models of help in mental health, and, where there is no evidence, commission research
3. Access. Timely access to good quality services is essential to prevent mental health problems becoming chronic and more difficult to treat. Unfortunately, one the unforeseen consequences of the Welsh Mental Health Measure has been an increase in severity threshold for access to secondary mental health care. We have evidence that has been submitted for publication that suggests that the quality of mental health services deteriorated during the pandemic. There are significant barriers created by waiting lists, especially for children’s services.
4. Social outcomes. There is good evidence that patients with mental health problems are more concerned about social outcomes, such as return to employment, than they are about complete symptom relief. Wales should develop better assessment of social outcomes. This would require a move away from an emphasis on patient turnover, and would probably require longer periods of involvement with services in the community. We have recently published evidence that shows that outcomes for people diagnosed with relapsing schizophrenia have worsened over the past 20 years. Whilst this is in part due to increases in social inequality, there is indirect evidence that it is also due to drawing funds away from people with long term mental illness.
Specific recommendation: Wales should develop a national strategy to improve the care of people with chronic psychosis
5. Relationships. For a variety of reasons, there has been a sharp reduction within mental health services in the emphasis on therapeutic relationships. Services tend to regard any degree of “dependency” by patients as a very bad thing. However, there is a mass of research evidence that shows that the quality of the therapeutic relationship is critical to the effectiveness of all treatments, both psychotherapeutic and pharmacological. Furthermore, the wealthiest parts of the population are able to purchase good quality therapeutic relationships in the private health market. The poorest section of the community cannot do this and are therefore especially disadvantaged in this regard. Community mental health teams need to form close relationships with the communities that they work within, which means that stable groups of staff need to work within relatively small natural communities. Pooled or county-wide services militate against this and lead to poor relationships between services and the communities they serve.
Specific recommendation: Wales should review the role and nature of Community Mental Health Teams, with increased focus on sustained therapeutic relationships, and interactions with local minority communities.
Summary of specific recommendations:
The Welsh Government should:
· Reintroduce Sure Start
· Provide long term funding for Individual Placement Support in employment
· Provide support for people with mental health problems in the civil justice system
· Seek devolution of commissioning of DWP benefits assessments
· Focus on evidence prior to adoption of new models of help in mental health
· Where there is no evidence, commission research
· Develop a national strategy to improve the care of people with chronic psychosis
· Review the role and nature of Community Mental Health Teams with increased focus on sustained therapeutic relationships
Professor Rob Poole
Professor Peter Huxley
Dr Robert Higgo
Centre for Mental Health and Society,
Bangor University
13th May 2022
Selected Bibliography
Evidence for Individual Placement Support in employment:
Suijkerbuijk YB, Schaafsma FG, van Mechelen JC, Ojajärvi A, Corbière M, Anema JR. Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta‐analysis. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD011867. DOI: 10.1002/14651858.CD011867.pub2. Accessed 13 May 2022.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011867.pub2/full
Kinoshita Y, Furukawa TA, Kinoshita K, Honyashiki M, Omori IM, Marshall M, Bond GR, Huxley P, Amano N, Kingdon D. Supported employment for adults with severe mental illness. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD008297. DOI: 10.1002/14651858.CD008297.pub2. Accessed 13 May 2022.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008297.pub2/full
Evidence for social interventions in serious mental illness
Barnett, P., Steare, T., Dedat, Z. et al. Interventions to improve social circumstances of people with mental health conditions: a rapid evidence synthesis. BMC Psychiatry 22, 302 (2022). https://doi.org/10.1186/s12888-022-03864-9
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-03864-9
Evidence for worsening outcomes for people with recurrent episodes of schizophrenia
Huxley, P., Krayer, A., Poole, R., Prendergast, L., Aryal, S., & Warner, R. (2021). Schizophrenia outcomes in the 21st century: A systematic review. Brain and behavior, 11(6), e02172. https://doi.org/10.1002/brb3.2172
Overall evidence on mental health and poverty
Poole R, Higgo R, Robinson C (2014) Mental Health and Poverty. Cambridge: Cambridge University Press ISBN 0521143969