The need for a fair deal
Overall, there needs to be a
fundamental shift in understanding in the NHS about the
relationship between mental and physical health. All health
professionals have a role in addressing the mental and physical health needs of their
patients. People with certain physical illnesses often report high
levels of mental health problems.1 Conversely,
individuals who have mental illnesses, such as depression,
schizophrenia and others, have excessive rates of physical health
problems.2 Mental health problems may also present as
physical illness.
Despite this, both the mental health
needs of individuals treated for physical illness and the physical
health problems of people with mental illnesses can be undetected
and overlooked by primary care and specialist staff. This happens
because there is a lack of staff training and too little
collaboration between mental health professionals and those in
primary care and hospitals. Psychiatrists, as medical
practitioners, should play a role in the management of their
patients’ general health problems.
Professor Dame Carol
Black
‘The same standard of urgent assessment, diagnosis
and intervention should be provided for mental healthcare as is
expected for physical healthcare.’
What we are calling for
- All health professionals to have training
in mental health.
- The curricula of all doctors in training
and the continuing professional development of qualified doctors to
reflect the relationship between mental and physical health, both
in general and in specific conditions.
- National guidelines – including those
issued by the NICE and SignHealth – about conditions treated in
general hospitals to cover the mental health of individuals with
these conditions.
- Patients in acute
hospitals to have the same level of access to a consultant psychiatrist as they would have
from a consultant specialising in physical
health problems.
- All care pathways for delivering physical
healthcare to have a mental health component and pathways for
commissioning practice to ensure the services to deliver them.
- Education to be provided for service users,
carers and the public to develop community awareness of the
psychological aspects of physical conditions.
- People with learning disabilities and
people with severe mental illness to receive an annual physical
health check.
Examples of what the College will do
- The College will work with our partners in
other medical and health Colleges to improve mental health training
for health professionals.
- We will campaign for a liaison service to
be established at each health
community.
- We will develop a comprehensive set of
standards for liaison mental health services that provide advice,
assessments and care for individuals of all ages, including those
with learning disabilities.
- We will continue to promote key standards
for the physical healthcare of individuals in a range of
psychiatric services and the responsibilities of psychiatrists for
monitoring the physical health of service users.
The mental health of people with physical health problems
Mental health problems are not uncommon
among individuals with physical conditions. In hospitals, medical
and surgical wards and accident and emergency departments have high
levels of activity and encounter some of the most seriously ill
people at greatest risk. However, the current provision of mental
health services to people attending these departments is
inconsistent.
Acute services have not adequately
commissioned services of liaison psychiatrists and some existing
liaison services have been
under threat of
closure.3
Staff in general practitioners’ surgeries
and hospitals will frequently encounter individuals with
depression, particularly among those who are chronically ill.
Approximately 10% of the general population are reported to have
major depression, but among people with cerebrovascular disease
rates of major depression are twofold, threefold in individuals
with diabetes or cancer and fivefold among those with recurrent
epilepsy.2
In older people depression can often be
comorbid with chronic physical disorders. In addition to the
distress it causes, depression may hinder recovery because it
suppresses the immune system or reduces a person’s motivation to
adhere to treatment or medication.4 Some conditions,
like chronic fatigue syndrome, have both mental and physical
origins. Unexplained medical symptoms often have a psychological
component.5
Conditions such as the ones discussed
currently use a high volume of NHS resources in both primary care
and out-patient services. Although only a minority of service users
with physical health problems require referral to a psychiatrist, a
well-staffed liaison psychiatry service provides the support and
advice that health professionals in primary and secondary care need
in order to manage their patients’ mental health needs. National
standards that will inform the commissioning of services are
urgently needed. This will guarantee that people in need receive
prompt assessment and management by professionals who have been
appropriately trained.
People who have deliberately injured
themselves or taken a drug overdose are treated by staff in primary
care or hospitals – around 150 000 to 170 000 individuals who
self-harm present annually to accident and emergency departments in
the UK.6 However, these departments are not staffed to
cope well with those who are mentally distressed.
Case study
1
What the College is Doing: Physical Health in Mental Health
Scoping Group report, 2008
As doctors, psychiatrists
have a responsibility to provide their patients with good standards
of practice and care. The Royal College Scoping Group’s report sets
key standards for the physical healthcare of patients in a range of
psychiatric services and outlines the responsibilities of
psychiatrists for monitoring the physical health of patients,
including physical side-effects of psychotropic medication. The
report recommends that psychiatrists are trained and kept up to
date in relevant physical health matters. The College will continue
actively to promote these standards.
The physical health of people with mental illnesses
Mental illness is associated with poor physical health, arising in
part from the side-effects of medication7,8 and an
unhealthy lifestyle. It can occur alongside physical illness and
can lead to it. Yet people with a diagnosed mental health disorder
too often find their symptoms of physical illness dismissed as
simply being ‘all in the mind’.9
Compared with the general population,
people with depression are twice as likely to develop type 2
diabetes, three times more likely to have a stroke and five times
more likely to have a myocardial infarction.2
For individuals with schizophrenia,
life-expectancy is on average 10 years shorter that in the general
population. They also experience high rates of obesity, diabetes,
osteoporosis and cardiovascular conditions.8,10–12
People with learning disabilities have high
levels of physical and mental health needs, in particular in
epilepsy, dementia and polypharmacy.13
Individuals with eating disorders have an
increased risk of premature death, skin conditions,
gastrointestinal complications, cardiovascular and pulmonary
difficulties, osteoporosis and nutritional
problems.14
In light of this evidence, the government’s
health inequality agenda should broaden its indicators of
disadvantage to include mental illnesses and learning disability.
In particular, as recommended by the Disability Rights
Commission,9 people with learning disabilities and
mental health problems should be screened for, and receive,
appropriate physical healthcare. This includes ensuring that
current policy initiatives such as the annual physical health check for people with a learning
disability are realised in practice.
Robert Westhead, service
user
‘I have
bipolar disorder or manic depression, so as studies have shown, I’m
likely to die 10 years before people without a mental health
problem: we’re a marginalised group, doctors think we’re
hypochondriacs and standards in psychiatric services are lower than
in the rest of the NHS.
On one
occasion I went to my general practitioner with stomach pain. He
clearly thought it was ‘psychosomatic’ and did nothing. It turned
out it had been caused by an antibiotic he’d prescribed. All I ask
for from the NHS is the same treatment – as a person and a patient
– as everyone else.’
No health without mental health – the role of NHS
professionals
It is time to end dualistic thinking within
the NHS which rigidly separates mental and physical health. We need
to develop a ‘whole person’ approach to integrate mental and
physical healthcare from cradle to grave. A new approach should
incorporate and reflect the evidence base for whole-person health
and provide the training and education in order to develop it.
Service commissioning and delivery of general mainstream services
should incorporate a multidisciplinary approach and have mental
health embedded in all care pathways.
All health professionals have a role to
play in improving the mental health of their patients. This
involves being trained to understand the complex interactions
between mental health and physical health, and being familiar with
the means to address and manage these conditions. Health
professionals need knowledge of the evidence base about physical
and psychological comorbidity. They also need practical competence
in the prevention, detection and treatment (including specialist
referral) of relevant conditions.
National guidelines and health policies for
physical health conditions – including NICE and the Scottish Intercollegiate Guidelines Network
(SIGN) – should also set standards to meet the mental
health needs of these service users.
Case study
2
What the College is doing
The Academy of Medical Royal
Colleges project No Health without Mental Health aims to help
ensure that people of all ages attending general hospitals receive
the mental healthcare they require. The project aims: to produce a
report that summarises the relationship between physical and mental
health, with recommendations for hospital practice; to review the
training curricula for medical doctors and the national guidelines
on physical conditions for any gaps in mental health content; and
to produce a comprehensive set of quality standards for
liaison mental health services, which will later be used to form an
accreditation programme.
Sally
‘When
in accident and emergency, I have been kept waiting for hours in
cases of self-harm and have been discharged straight from accident
and emergency after an overdose without seeing anyone. I have been
left for more than 24 hours after an overdose in urine soaked
clothes, with a doctor telling my husband in critical tones that
I’m “going to kill myself one of these days”.’
Service user
‘My doctor struck me off her list last week
because she sent a letter saying I was upsetting her staff. I try
to put my points across clearly but none of them listens to
me…’9
The role of the psychiatrist
As doctors, psychiatrists have a key role
to play in improving and promoting the physical health of service
users and, when appropriate, referring them to other medical
specialists. However, the level and range of expertise in physical
healthcare among psychiatrists varies considerably and service
users – depending on factors such as age and existing mental health
condition – will present varying diagnostic and treatment
challenges. General health provision within psychiatric settings
needs to be improved and common standards need to be developed with
which to evaluate care.
In hospital settings, patients and staff
may benefit from specific psychiatric liaison support service to
facilitate integration of their psychological and physical care.
Standards should be developed to assess the quality of such
provision. Finally, psychiatrists and other mental health
professionals should work together with primary care professionals
to ensure a seamless and collaborative approach to the well-being
of their patients.
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