Guidance

6. Working age adults

Updated 25 October 2019

© Crown copyright 2019

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1. Introduction

The purpose of this chapter, and the mental health and wellbeing JSNA toolkit overall, is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

There are a wide range of mental health conditions and materials to cover when considering the needs of the working age population. Within this document we cover this under two broad categories; common mental health conditions and severe mental illness (SMI). Extra detail on specific conditions is available through the links provided.

The focus of this document is the treatment of mental health problems. Opportunities to promote healthy behaviours, prevent mental ill health and develop community resilience are covered in Mental health: environmental factors and Mental health: population factors.

For working age adults low educational attainment, material disadvantage and unemployment are particularly strong factors affecting mental health and wellbeing[footnote 1]. Cost-effective interventions exist to promote and protect employee mental health[footnote 2].

There are some conditions which often begin in childhood but can persist into or develop in adulthood, such as eating disorders. It is important to be aware that parts of NICE guidance are age specific and differing treatments and approaches may be recommended for the adult population[footnote 3]. These conditions are covered in Children and young people as well as other important issues such as transition between children and young people’s services and adult services.

Specific older age considerations are detailed in Living well in older years. However, when focussing on older adults it is important to consider the all age adult aspects included within this document which also relate to the older population (aged 65 and over).

One of the aims of JSNA is to assess if the local population are accessing services in line with identified need and if, following treatment, the services available are helping people to recover and stay well. The following questions may be helpful to consider:

  • what are the known social determinants of good mental health in your area?
  • what are the social, economic and other factors that could make working age adults more vulnerable to developing a mental health problem?
  • what community assets are in place to support prevention of, and provide resilience to, working age adult mental health problems?
  • what is the local prevalence and incidence of working age mental health conditions?
  • are preventive interventions available and used by those who need them?
  • how many adults are in demographic groups that often have complex or extra mental health needs?
  • what enhanced primary care mental health services are available for adults?
  • how are the different adult mental health services used currently and how does this use compare with expected need?
  • what is the impact of parental mental health on children and young people, and the impact of children or young people with mental health problems on their parents?

2. Common mental health problems

2.1 Overview

The prevalence of common mental health problems (CMHPs) is influenced by social determinants. Poor and disadvantaged people suffer disproportionately more CMHPs. The more debt people have, the more likely they are to have some form of mental health problem. CMHPs lead to reduced income and employment, which entrenches poverty and increases the risk of mental health problems. High rates of CMHPs are associated with low educational attainment[footnote 1]. These factors are considered in more detail in Mental health: environmental factors and Mental health: population factors.

There are a range of mental health conditions covered within this section, these include:

Depression

A mental health problem characterised by persistent low mood and a loss of interest and enjoyment in ordinary things. A range of emotional, physical and behavioural symptoms are likely such as sleep disturbance, change in appetite, loss of energy, poor concentration, low feelings of self-worth and thoughts of suicide. Depressive episodes can range from mild to severe[footnote 4]. Condition specific NICE guidance is available.

Generalised anxiety disorder (GAD)

An anxiety disorder characterised by excessive worry about many different things and difficulty controlling that worry. This is often accompanied by restlessness, difficulties with concentration, irritability, muscular tension and disturbed sleep[footnote 5]. Condition specific NICE guidance is available.

Social anxiety disorder (social phobia)

A persistent and overwhelming fear of a social situation, such as shopping or speaking on the phone which impacts on a person’s ability to function effectively in aspects of their daily life.. People with social anxiety will fear doing or saying something that will lead to being judged by others and being embarrassed or humiliated. Feared situations are avoided or endured with intense distress[footnote 6]. Condition specific NICE guidance is available.

Panic disorder

People with panic disorder experience repeated and unexpected attacks of intense anxiety. There is a marked fear of future attacks and this can result in avoidance of situations that may provoke a panic attack. Symptoms include a feeling of overwhelming fear and apprehension often accompanied by physical symptoms such as nausea, sweating, heart palpitations and trembling[footnote 7]. Condition specific NICE guidance is available.

Agoraphobia

Characterised by fear or avoidance of specific situations or activities that the person fears will trigger panic-like symptoms, or be difficult or embarrassing to escape from, or where help may not be available. Specific feared situations can include leaving the house, being in open or crowded places, or using public transport[footnote 8].

Obsessive-compulsive disorder (OCD)

An anxiety condition characterised by the presence of either obsessions (repetitive, intrusive and unwanted thoughts, images or urges) or compulsions (repetitive behaviours or mental acts that a person feels driven to perform), or both[footnote 9]. Condition specific NICE guidance is available.

Specific phobia

An overwhelming and debilitating fear of an object, place, situation, feeling or animal. This can include a fear of heights, flying, particular animals, seeing blood or receiving an injection. Phobias can have a significant impact on day to day life and cause significant distress[footnote 10].

Post-traumatic stress disorder (PTSD)

A set of psychological and physical problems that can develop in response to threatening or distressing events, such as physical, sexual or emotional abuse, severe accidents, disasters and military action. Typical features of PTSD include repeated and intrusive distressing memories that can cause a feeling of ‘reliving or re-experiencing’ the trauma. PTSD is often comorbid with other mental health conditions such as depression[footnote 11]. Condition specific NICE guidance is available.

Health anxiety (hypochondriasis)

A central feature is a persistent preoccupation with the possibility that the person has, or will have, a serious physical health problem. Normal or commonplace physical symptoms are often interpreted as abnormal and distressing, or as indicators of serious illness[footnote 12].

Common mental health problems cause distress and interfere with normal everyday life. Parenting, caring, going to work and socialising can all suffer. The large numbers of people experiencing these conditions at any one time has a significant cost to society[footnote 11].

Prevention and treatment of CMHPs should follow the stepped model of care, where the most effective yet least resource intensive form of support is provided in the first instance[footnote 4].

General population level support measures should be considered as part of the stepped care approach[footnote 13]. These should focus on enhancing community assets to prevent mental health problems and promote healthy behaviours. This may include, amongst others, providing support around:

  • housing
  • relationships
  • access to education
  • employment
  • discrimination
  • welfare rights
  • carer support
  • crime

Developing social capital through community engagement can help to build resilience and increase a sense of belonging which is beneficial to adult wellbeing[footnote 14].

At the initial steps of the model, primary care workers should be alert to the presenting symptoms of CMHPs and have a clear understanding of the best practice protocols they can put in place and the onward referral routes available[footnote 15]. This includes social prescribing to community resources such as volunteering opportunities, physical activity programmes and befriending services[footnote 16].

This form of prescribing is likely to increase confidence, build social networks and develop self-efficacy[footnote 16],[footnote 17]. Medication should not routinely be prescribed at the lower steps for recent onset mild to moderate CMHPs, although NICE guidelines are clear about the risks and exceptions do apply[footnote 4],[footnote 18].

At the higher steps of the model, treatment for identified CMHPs should be provided by Improving Access to Psychological Therapies (IAPT) services[footnote 15]. Provision of these services is increasing, but currently less than a half of those who need access to services get it[footnote 19].

The aim of IAPT is to provide evidenced based treatment at a level appropriate to an individual’s condition. In 2015 to 2016 almost 1 million people in England entered IAPT treatment with almost half moving to recovery (according to a range of clinical measures which monitor symptom frequency and severity)[footnote 20].

For mild to moderate CMHPs the following interventions should be available[footnote 4],[footnote 18]:

  • individual facilitated self-help based on the principles of cognitive behavioural therapy (CBT)
  • computerised CBT
  • structured group physical activity programmes
  • group-based peer support (self-help) programmes (for those who also have a chronic physical health problem)
  • non-directive counselling for depression delivered at home (for women during pregnancy or the postnatal period)

People who present with more severe CMHPs, or who fail to respond to the above treatments, should be offered one of a range of more intense psychological therapies (such as face to face CBT or couples therapy), or a suitable medication, or both[footnote 4],[footnote 18]. As mentioned previously, social factors contributing to the depression should also be addressed[footnote 16].

Whilst CMHPs respond well to evidence based interventions, there is a known high level of relapse. Services should ensure that relapse prevention approaches are included in treatment episodes as identified by the condition specific NICE guidance[footnote 18].

The Five Year Forward View for Mental Health[footnote 19] and subsequent implementation guidance[footnote 21] set out new ambitions for the delivery of services for CMHPs:

  • at least 25% of people with CMHPs access appropriate services each year (an increase from the current 15% ambition).
  • 75% of people referred to IAPT services should start treatment within 6 weeks and 95% within 18 weeks.
  • 50% of people entering IAPT treatments achieve clinical recovery.
  • in relation to post-traumatic stress disorder in veterans, all NHS-commissioned mental health providers will have armed forces champions and a specific named clinician with an expertise in military trauma.

2.2 Data Sources

Examples of metrics relating to the common mental health problems of working age adults in the profile include:

In prevalence and incidence:

  • estimated prevalence of common mental health disorders (CCG, STP)
  • depression recorded prevalence (QOF) (County & UA, CCG, STP, GP)

In risk factors and protective factors a range of metrics on known risk and protective factors for mental health problems are included. As risk of developing mental ill-health develops across the life course, the broad spectrum of risk and protective factors should be considered.

In services:

  • referral, access, entering recovery and completing IAPT treatment, referred to IAPT (CCG, STP)

In quality and outcomes:

  • primary care reviews of depression (CCG, STP, GP)

For a detailed consideration of available metrics relating to adult common mental health conditions go to the common mental health disorders profile.

Adult psychiatric morbidity survey 2014 provides further data at a national and regional level on prevalence of specific common mental health conditions and psychoses by age, gender and other demographic analyses.

The RightCare commissioning for value packs contain data across a range of mental health services, including IAPT.

NHS Digital produces reports from the IAPT Dataset and the Mental Health Services Dataset. These provide a source of information on CMHPs treated by primary and specialist care services.

Local data

Further consideration of prevention strategies and treatment and support services for specific conditions and population groups will require local action. Sources of data that areas can access locally include:

  • data from mental health service providers on number of referrals by type and demographics, diagnosis, types of interventions and outcomes.
  • data from third sector and community services which provide targeted interventions.
  • engagement with service users through focus groups and surveys and working with service user advocacy groups.
  • engagement with professionals across the range of organisations that work with people with mental health conditions.

2.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

NHS: Adult Improving Access to Psychological Therapies programme: overview of the IAPT programme, priorities for development and a range of links to service standards and workforce requirements.

NICE: Common mental health disorders: identifies common mental health disorders in people aged 18 and over in primary care and the principles for treatment and referral. From this pathway it is possible to access specific guidance on depression, generalised anxiety, PTSD, OCD, social anxiety and panic disorder.

PHE: Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill Health information on interventions that address loneliness to protect the mental health of older people.

3. Integrating physical and mental health

The relationship between physical and mental health is complex. There are high rates of mental health problems among people with long-term physical conditions (LTC) and within this group the associated healthcare costs are 45% higher. 46% of people with a mental health problem have a LTC and 30% of people with LTC have a mental health problem[footnote 22].

There is likely to be a two-way causal relationship; people with LTC are two to three times more likely to experience mental health problems than the general population[footnote 23]. Co-existing mental health problems can lead to:

  • increased hospitalisation rates - patients with chronic lung disease spend twice as long in hospital if they also have a mental health problem.
  • increased outpatient service use - diabetes sufferers with mental health problems access double the amount of outpatient services as those with diabetes alone.
  • less effective self-management - poor mental health means that people with heart disease or other long-term conditions are less likely to look after their physical health, take medication as intended and attend medical appointments.

Physical and mental health problems should be supported in an integrated way across all aspects of the health system, from public health and prevention initiatives to the care provided by GPs, hospitals and the social care sector[footnote 22]. Cost-effective interventions which protect the mental health of people with long term conditions are available[footnote 2].

3.1 Medically unexplained symptoms

More than a quarter of primary care patients in England have unexplained chronic pain, irritable bowel syndrome, or chronic fatigue. In secondary and tertiary care, around a third of new neurological outpatients have symptoms thought by neurologists to be ‘not at all’ or only ‘somewhat’ explained by disease[footnote 24].

Persistent physical medically unexplained symptoms (MUS) account for up to a fifth of all GP consultations in the UK[footnote 25] and are generally managed with limited psychological support[footnote 22]. Without appropriate treatment, outcomes for many patients with MUS are poor.

Evidence-based treatments for MUS exist but have limited availability[footnote 26]. Patients are often subjected to repeated diagnostic investigations, and unnecessary and costly referrals and interventions[footnote 26]. Healthcare costs incurred by patients with MUS are estimated to be £3 billion, representing approximately 10% of total NHS expenditure on services for the working‐age population. The resulting cost of sickness and decreased quality of life is estimated to cost over £14 billion[footnote 27].

Appropriate multi-disciplinary services for people with MUS should be commissioned in primary care, community, day services, A&E departments and inpatient facilities. This will enable people to access the services most appropriate for their problems, resulting in improved outcomes for patients and substantial cost-savings for the healthcare system[footnote 26].

3.2 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

King’s Fund: Bringing together physical and mental health: integration of physical and mental health assessments, treatments, care pathways and services.

Institute for Public Policy Research: Patients in control: why people with long-term conditions must be empowered: overview of self-management and peer support in long term conditions.

JCPMH: Guidance for commissioners of services for people with medically unexplained symptoms: commissioning of comprehensive MUS services across the healthcare system. In developing this guide, we recognise that ‘medically unexplained symptoms’ is an unsatisfactory term for a complex range of conditions.

PHE: Wellbeing in mental health: applying All Our Health: examples to help healthcare professionals make interventions to promote physical health and wellbeing in mental health.

4. Severe mental illness

4.1 Overview

There are well established NICE standards and guidelines for SMI which cover a wide range of conditions:

Psychosis and Schizophrenia in adults: Prevention and management (2014): sets out the evidence base for the recognition and management of psychosis and schizophrenia in adults at each stage in the pathway from early recognition and treatment, through to rehabilitation and recovery and primary care continuing care and recommends checking for coexisting health problems and providing support for family members and carers.

NICE Bipolar assessment and management (2014): recognising, assessing and treating bipolar disorder (formerly known as manic depression) in children, young people and adults. It aims to improve access to treatment and quality of life in people with bipolar disorder.

Severe depression (updated April 2016): describes the presentation and impact of severe depression and the range of social, psychological, medication and other interventions. Suicidal ideation is more common with this conditions and in some cases people will experience psychotic symptoms[footnote 28].

NICE Personality disorders overview: overview of personality disorder, conditions in which an individual differs significantly from an average person in terms of how they think, perceive, feel or relate to others. Experiences of distress or fear during childhood, such as neglect or abuse, are common[footnote 29].

These standards and guidelines stress that early recognition and rapid access to biopsychosocial effective care provides the best outcomes. However, the commissioning and implementation of these services is more variable than for comparable physical health conditions[footnote 30].

Variation is seen in the duration of untreated mental health problems, access to full, rather than just partial effective interventions and in levels of resourcing. The national policy and plans seek to transform this pattern of care.

4.2 Models of care

People need expert, evidence based services at all stages of the pathway. This includes services that provide[footnote 19]:

  • early intervention for first episode psychosis
  • rapid access to urgent and emergency care when in crisis
  • coordinated case management, rehabilitation and recovery for on-going needs
  • enhanced secure care when risk is high
  • physical health care to reduce the 20 year premature mortality gap
  • suicide prevention
  • recovery to social inclusion, stable housing and employment

The Five year Forward View for mental health[footnote 19] and implementation guide[footnote 21] set out the principles, models of care and timescales for implementation of services that will deliver standards of care equal to those provided for physical conditions. They aim to deliver improved benefits for people’s mental, social and physical health, and major economic value to the wider health and social care system.

Designed by users, carers, and professional experts, a series of detailed guides are being produced to support commissioning, service delivery, benchmarking and continuous quality improvement, routine outcome monitoring and workforce training for each pathway. The timescales for the production of these support tools spans 2015 to 2020. Guidance for people with a first episode psychosis is already available and further publications will follow.

The model of mental health care has transformed from a hospital-based speciality to one where 89% of contacts take place in the community[footnote 31]. Community based mental health services should support people with mental health conditions in their journey from referral to longer term recovery. A service should be commissioned to consistently provide rapid access to a full NICE-recommended package of care, delivered in a person-centred and values based way, which includes[footnote 32],[footnote 33],[footnote 34],[footnote 35],[footnote 36]:

  • a person-centred and co- produced approach to the formulation, delivery and review of care planning
  • psychosocial and psychological therapy interventions for individuals and their families
  • optimisation of medication and regular medication review
  • physical health assessment and required interventions, including dental and ophthalmologic and healthy lifestyle promotion
  • effective recovery and rehabilitation in home and community settings including support with finding and maintaining stable housing, employment, financial wellbeing and social networks

Services should help people achieve and maintain recovery by providing:

  • rapid referral for assessment and secondary care treatment and support where required
  • enhanced primary care step-down support to maintain recovery following discharge from secondary mental health services
  • rapid access to care to enable service users to step-up their care as required, or self-refer for re-assessment
  • routinely record & publish patient and carer experience and outcome measures

4.3 Early intervention in psychosis (EIP)

EIP services are multidisciplinary community mental health services that provide treatment and support to people experiencing or at high risk of developing psychosis, typically for a three year period[footnote 36]. EIP services have a strong ethos of hope and whole-team commitment to enabling recovery through the provision of individually tailored, evidence-based interventions and support to service users and their families/carers.

The short and longer-term economic benefits of EIP services are significant[footnote 36]. The net cost savings per person after the first four years is £7,972, with a further £6,780 saving per person in the next four to 10 years if full EIP provisions are provided. Over a 10-year period this would result in £15 of costs saved for every £1 invested in EIP services. The majority of these cost savings can be attributed to:

  • the reduction in use of crisis and inpatient services
  • improved employment outcomes
  • the reduction in risk of future hospitalisation as a result of improved management and reduced risk of relapse

4.4 Enhanced rehabilitation, recovery and secure care

For people with continuing and rehabilitation needs, there is a range of service models with the emphasis on 24/7 community based recovery focussed care.

NHS England is leading the work to increase access to high quality care[footnote 21] which prevents avoidable admissions, supports recovery for people who have longer term SMI, and is available in the least restrictive setting and as close to home as possible. The aim is to increase provision of integrated health and social care community-based services and trial new co-commissioning funding and service models.

Secure (or ‘forensic’) mental health services provide accommodation, treatment and support for people with SMI who pose a risk to themselves and at times, the public[footnote 38]. There is a major service transformation programme in place.

NHS England has committed to achieving the following objectives to improve the quality of community based mental health provision[footnote 19]:

  • at least 60% of people with first episode psychosis start treatment with a NICE-recommended package of care with a EIP service within two weeks of referral
  • increasing access to integrated evidence-based psychological therapies for people with psychosis, bipolar disorder and personality disorder
  • doubling the numbers who access Individual Placement and Support (IPS), which enables people with SMI to find and retain employment

Additionally to the above, along with NHS Improvement, ensure that use of the Mental Health Act is closely monitored at both local and national level, and by 2020 to 2021, through the provision of earlier intervention, reduce the rates of detention. Plans should include specific actions to substantially reduce avoidable Mental Health Act detentions and targeted work should be undertaken to reduce the current over-representation of BAME and any other disadvantaged groups in acute and forensic care.

4.5 Urgent, emergency and acute mental health care

Urgent, emergency and acute mental health care is provided by a range of teams and services:

Crisis response and home treatment teams

Based in a community setting, these services aim to assess and manage all patients in a mental health crisis and those also being considered for acute hospital admission. They offer intensive home treatment rather than hospital admission if safe and feasible. They also work to facilitate early discharge from hospital where possible and appropriate[footnote 39]. They are optimal when the model used meets the evidence based fidelity processes.

Mental health liaison services

Situated in general hospitals, for example in the emergency department or in-patient wards, these services aim to provide psychiatric assessment and treatment to patients who may be experiencing distress whilst in hospital. They provide a valuable interface between mental and physical health. There is evidence that medical patients have a high rate of psychiatric disorder, but can respond positively to psychological or drug treatments. Psychiatric liaison teams are helpful in detecting these psychiatric disorders, such as depression or anxiety, and improving patient outcomes[footnote 40].

Acute inpatient services

Providing treatment when a person’s mental health condition cannot be managed in the community, and where the situation is so severe that specialist care is required in a safe and therapeutic space. Admissions should be purposeful, integrated with other services, open and transparent, and as local and short as possible[footnote 41].

The current commissioning and provision of crisis care is variable with:

  • only 14% of people report a positive experience of crisis care[footnote 42]
  • many Crisis Resolution and Home Treatment teams (CRHTTs) being unable to offer the full range of community based treatment due to caseload capacity[footnote 41]
  • only 36% of people reporting a positive experience in A&E during a mental health crisis[footnote 42]

People are routinely sent out of area for acute care due to a lack of bed capacity. Delays in the transfer of care are a major issue in mental health providers, with a lack of housing and capacity in community mental service as the main causes[footnote 43].

The following recommendations and investment initiatives have been set out to address aspects of urgent, emergency and acute mental health care[footnote 19]:

  • introduce a range of access and quality standards, including recommended response times and interventions for urgent, emergency and acute mental health care
  • eliminate the practice of sending people out of area for acute inpatient care as a result of local acute bed pressures by no later than 2020 to 2021
  • by 2020 to 2021 24/7 community crisis response across all areas that are adequately resourced to offer intensive home treatment, backed by investment in crisis resolution and home treatment teams, with an equivalent model to be developed for children and young people
  • by 2020 to 2021, no acute hospital is without all-age mental health liaison services in emergency departments and inpatient wards, with at least 50% of acute hospitals meeting the ‘core 24’[footnote 33] service standard for adults and older adults
  • new investment over four years from April 2017, with £400m for CRHTTs, and £249m in adult and older adult mental health liaison in A&E and acute hospital wards

4.6 Data sources

In prevalence and incidence:

  • new cases of psychosis (District & UA, County & UA, CCG, STP)
  • SMI recorded prevalence (QOF) (County & UA, CCG, STP, GP)

In risk factors and protective factors a range of metrics on known risk and protective factors for mental health problems are included. As risk of developing mental ill-health develops across the life course, the broad spectrum of risk and protective factors should be considered.

Other available data in the profile include:

In services:

  • contact with mental health or learning disability services (County & UA, GP)

In quality and outcomes:

  • stable and appropriate accommodation for adults in contact with mental health services (County & UA)

Metrics relating to addressing the physical health needs of people with SMI are included in quality and outcomes:

  • smoking prevalence in people with SMI (District & UA, County & UA, Region)
  • people with SMI who have received the complete physical health checks (CCG, STP)

For a detailed consideration of available metrics relating to adult mental health go to the severe mental illness profile. For metrics specifically focussed on assessment of mental health crisis care go to the crisis care profile.

Additional sources of data relating to adult mental health services include:

Local data

Further consideration of prevention strategies and treatment and support services for specific conditions and population groups will require local action. This is likely to require working with third sector and community services which provide targeted interventions. More detailed assessment of local support services will require direct contact with providers (social care, NHS and private specialist mental health services).

4.7 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Care Quality Commission: Right Here Right Now: review of the quality, safety and effectiveness of care provided to those experiencing a mental health crisis.

Centre for Mental Health: IPS Resources: collection of materials brought together from the IPS Centres of Excellence to help services develop IPS supported employment or vocational services.

Commission on Acute Adult Psychiatric Care: Old Problems, New Solutions (2016): describes the problems with finding care beds or receiving good home treatment and points to the improvements that can be made. It gives examples where people are being well cared for in good services.

JCPMH: Rehabilitation services for people with complex mental health needs: the commissioning of good quality mental health interventions and services for people with complex and longer term problems to support them in their recovery.

NICE/NHS England: Achieving Better Access to 24/7 Urgent and Emergency Mental Health Care – Part 2: Implementing the Evidence-based Treatment Pathway for Urgent and Emergency Liaison Mental Health Services for Adults and Older Adults – Guidance: guidance on establishing, developing and maintaining urgent and emergency liaison mental health services for adults and older adults in emergency departments (EDs) and general hospital wards. The appendices provide examples of successful implementation and useful resources to share learning.

NICE/NHS England: Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance: provides support to local commissioners and providers in implementing the standard. An information pack accompanies this publication to provide commissioners and providers with helpful resources to support implementation.

NICE: Transition between inpatient mental health settings and community or care home settings: covers the period before, during and after a person is admitted to, and discharged from, a mental health hospital.

5. Reducing premature mortality

5.1 Suicide and self-harm

In 2015 there were over 6000 suicides recorded in the UK[footnote 44]. People under the care of mental health services have been identified as a high risk group for suicide and self-harm[footnote 45]. For a more detailed overview of what can be done for people who present with significant risk or safety issues, please see suicide and self-harm in Mental health: population factors.

Severe mental health problems and poor physical health

On average, men with SMI die 20 years earlier, and women die 15 years earlier, than the general population[footnote 19]. Two thirds of people with serious mental health problems will die prematurely due to treatable cardiovascular, pulmonary and infectious diseases[footnote 46]. Compared to the general population people in contact with specialist mental health services have:

  • nearly four times the rate of deaths from diseases of the respiratory system
  • just over four times the rate of deaths from diseases of the digestive system
  • nearly three times the rate of deaths from diseases of the circulatory system

Much of the poor physical health amongst those with mental health problems can be explained by peoples behaviour, for example, excessive smoking and alcohol use (see Mental health: population factors). However, other important factors also play a part. Less than a third of people with schizophrenia in hospital received the recommended assessment of cardiovascular risk in the previous 12 months[footnote 19].

The Five Year Forward View for Mental Health[footnote 19] calls for greater integration of physical and mental health care and sets out a particular ambition that the premature mortality of people living with SMI is reduced. NHS England are leading work to ensure that by 2020 to 2021, 280,000 more people living with SMI have their physical health needs met by increasing early detection and expanding access to evidence based physical care assessment and intervention each year.

5.2 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Academy of Medical Royal Colleges: Improving the physical health of adults with severe mental illness: essential actions: recommends practical ways to improve physical healthcare services for people with psychoses and those on antipsychotic medications.

Department of Health: Improving the physical health of people with mental health problems: Actions for mental health nurses: draws on the available evidence to improve the monitoring of and reduction of the risk factors that have a detrimental effect on people’s physical health and ultimately reduce health inequalities.

6. References

  1. WHO, Calouste Gulbenkian Foundation. Social determinants of mental health (2014). ↩ ↩2

  2. PHE. Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill Health September 2017. ↩ ↩2

  3. NICE. Eating disorders: recognition and treatment: NICE guideline (NG69) (2017). ↩

  4. NICE. Depression in adults: recognition and management (CG90) (2009). ↩ ↩2 ↩3 ↩4 ↩5

  5. NHS Choices. Generalised anxiety disorder in adults. ↩

  6. NHS Choices. Social anxiety disorder (social phobia). ↩

  7. NHS Choices. Panic disorder. ↩

  8. NHS Choices. Agoraphobia. ↩

  9. NICE. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Clinical guideline (CG31) 2005. ↩

  10. NHS Choices. Phobias. ↩

  11. NHS Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014 (2016) ↩ ↩2

  12. NHS Choices. Health anxiety (hypochondria). ↩

  13. Bower P, Gilbody S. Stepped care in psychological therapies: access, effectiveness and efficiency. The British Journal of Psychiatry (2005)186:11-7 ↩

  14. Chanfreau J, Lloyd C, Byron C, Roberts C, Craig R, De Feo D, et al. Predicting wellbeing - NatCen Social Research (2008). ↩

  15. NHS England. Adult Improving Access to Psychological Therapies programme. ↩ ↩2

  16. NESTA. More than medicine: New services for people powered health (2013). ↩ ↩2 ↩3

  17. Brandling J, House W. Social prescribing in general practice: adding meaning to medicine. The British Journal of General Practice (2009) 59(563):454-6 ↩

  18. NICE. Common mental health problems: identification and pathways to care (CG123) (2011) ↩ ↩2 ↩3 ↩4

  19. NHS England. Five Year Forward View for Mental Health (2016) ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9

  20. NHS Digital. Psychological Therapies: Annual report on the use of IAPT services, England 2015-16 (2016) ↩

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