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The Royal College of Psychiatrists Improving the lives of people with mental illness

Update from Alistair Burns, NHS England’s National Clinical Director for Dementia and Older People’s Mental Health.

There have been some developments in the last few months which I think will be of interest to readers of the newsletter.

The Mental Health Task Force is due to publish its findings in the next few weeks (by the time you read this, it should have been published) and the work of the Task Force has explicitly been across the life course. The Mental Health Task Force reports for all Arm’s Length Bodies and so not only includes NHS England but also Health Education England, Public Health England, NHS Improvement and the Care Quality Commission. 

There was a wide consultation to the task force’s call for comments, with some 20,000 people responding. The generic issues from the consultation will be familiar to everyone and are around things like skills of staff, access to services and equality of provision. Many of the issues raised in terms of general psychiatry, are equally applicable to older people.  We await the publication of the report with interest.

Aside from the work of the Task Force, there are three issues which are currently foremost in my mind, and I would consider important for us as a profession to tackle.  First, the clinical rationale and evidence base for the recognition and treatment of depression in older people. I think it is fair to reflect that the therapeutic nihilism which often accompanies depression in older people among some professionals is not dissimilar to that which can surround dementia. The assumption  that depressive symptoms in the presence of physical ill health or impoverished social circumstances is understandable and, therefore, that they do not merit treatment is still prevalent.  Identifying people with depression is crucial and there has been a suggestion that there be an older person’s depression CQUIN in general hospitals similar to the dementia CQUIN. Even its critics would acknowledge that this has garnered support and has raised the profile of Dementia.   It could be that a similar three stage approach of identifying depression, assessment and then treatment and referral could be helpful.

Second,  loneliness. We all know that loneliness and isolation, although strongly associated, are not the same; the former referring to separation from contact, with the latter representing the subjective experience (Age UK). Around 10% of older people feel lonely but up to three times that figure will experience loneliness some of the time. It has been said that loneliness has the same effect on your health as smoking 15 cigarettes a day. Loneliness increases with age and to have children but no contact with them makes you feel more lonely than having no children at all.

Third, the issue of ageless mental health services for older people.  James Warner and I have suggested that this is an important issue and have recently written something and quoted some of the facts about mental health in older people (NHS England).

  • In a 500 bed general hospital, on an average day, 330 beds will be occupied by older people of whom 220 will have a mental disorder, 100 each will have dementia and depression and 66 will have delirium.
  • For every 1,000 people over the age of 65, 250 will have a mental illness, 135 will have depression, of which 115 will have no treatment.
  • 85% of older people with depression receive no help from the NHS, and older people are a fifth as likely as younger age groups to have access to talking therapies but six times as likely to be on medication.
  • The number of older people being treated in the improving access to psychological therapies (IAPT) programme rose from 4% to 6.5% (2008/9-2013/14), still short of the articulated goal.
  • While 50% of younger people with depression are referred to mental health services, only 6% of older people are.
  • Around 10% of older people experience loneliness which can be a symptom course of depression – loneliness has the same health effects as smoking 15 cigarettes a day.
  • 20% of men and 10% of women are drinking alcohol in harmful amounts – the latter is a 100% increase over the past twenty years.

We have addressed the recent study  which showed that older people’s needs are not met as well in generic services making the case for a specialist old age provision (British Journal of Psychiatry). 

In terms of dementia, we have now, to all intents and purposes, achieved the two thirds diagnosis admission nationally, which is great news (the current figure is 66.5%).  Thank you to everyone who has contributed to this significant piece of work. It allows us now to adapt the conversations about dementia towards looking at diagnostic support and the benefits that brings. I am sure everyone would agree that should be a priority for us and that post-diagnostic support makes the big difference to people with dementia and their carers.

Along with that we have the opportunity to look in a slightly different way at what we are doing in dementia and we have begun to socialise the idea of the wellbeing pathway i.e. if we started with one of the five things we could do with dementia and their carers we have developed the ideas of:

  • preventing well
  • diagnosing well
  • supporting well
  • living well
  • dying well

These align neatly with the dementia ‘I’ statements and the various NICE guidelines and quality standards and also the Prime Minister’s challenge on dementia and the OECD (The Organisation for Economic Co-operation and Development) which has taken an international interest in dementia.

Finally, I am a bit short of pictures these days (for a number of reasons) but found this one on my phone. It is clearly from a country railway station in a place that I was visiting but I have forgotten where. Does anyone recognise it or has the pictorial forensic skills to identify it?

 

Click on the image for a larger version

 A country railway station in a place that I was visiting but I have forgotten where. Does anyone recognise it or has the pictorial forensic skills to identify it?

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