All aboard the public mental health train: mainstreaming public mental health training

The monthly blog of the Public Mental Health Implementation Centre (PMHIC), 'Perspectives on public mental health', aims to highlight the voices of practitioners, patients, carers, and public health experts.

In this blog post, Hanna Tu (a CT-3 in psychiatry) tells us how she discovered that public mental health training is essential for trainee psychiatrists – and for other healthcare professions.

“30% of your training this year may be spent on public mental health”, I was told by my coordinating supervisors. As a trainee in psychiatry coming from Belgium, doing a placement in London already felt like a small victory. Public mental health (PMH) was the reason I had wanted to go to London in the first place, so this opportunity to discover PMH as part of my training only added to my enthusiasm. Now that my year of training in London is coming to an end, I can safely say that PMH has become an essential part of my training. One I strongly hope can become an integrated part of medical and psychiatry training.

Discovering a population approach to mental health

During medical school and my first years of psychiatry training, I found that the teaching was mainly focused on clinical work and neuro- and pharmacobiology. Although they are important parts of medical education, this seemed to restrict practice to seeing patients only on an individual level. While I take pride in my efforts to become a good clinician, I also wondered, where was clinical work situated on a population level? Was my practice was targeting the right people and the right aspects of their care? I missed a population approach as part of my education and wanted to learn. After a long search, I found a supervisor in Dr Jonathan Campion, one of the co-directors of the new PMH Implementation Centre at the RCPsych, who has several other PMH roles.

Prevention and treatment of mental disorders through public mental health

From there, I came to really comprehend what PMH is: a dynamic field that is continually shaped by the existing healthcare and public health systems as well as by the societies we live in. I learned about the large impact of mental disorder on the general population, and about risk and protective factors that contribute to developing mental disorders. I learned that there are higher-risk groups in which several risk factors congregate. There is an abundance of evidence-based interventions that prevent and treat mental disorder, prevent associated impacts and promote wellbeing. They can be provided by different sectors ranging from schools to hospitals. I learned about the importance of prevention, as treatment alone is not enough. I learned about the implementation gap, meaning that all the excellent research on interventions is not being implemented. This gap is a global problem, but even more so in low- and middle-income countries. I learned that the implementation gap can be identified by carrying out a needs assessment, determining which groups are at higher risk and which interventions could have the biggest impact. Structural policy change, broad implementation work, and coordination between mental health services and a wide array of other services are needed to help close this gap. So how, as a trainee, could I integrate PMH in my own work and training?

Public mental health in clinical work and training

I learned about the interplay between smoking and mental health, where people with mental disorder are at much higher risk of smoking. Smoking, in turn, has significant negative impacts on mental and physical health as well as the metabolism of medications. Despite smoking being the single largest cause of preventable death, my training did not cover this vast impact nor any practical sessions in offering advice and treatment for smoking cessation. I felt complicit in the poor provision of smoking cessation interventions for people with mental disorder, as I hadn’t considered the impact of smoking on my patients’ health and never took the time to talk it through with them. I felt inspired, and turned this experience into a service evaluation project on smoking cessation in the community mental health service I worked at. For this project, I mapped the impact of smoking on our caseload, conducted patient and staff surveys and assessed the implementation gap of smoking cessation interventions by both my team as well as primary care and specialised stop smoking services. I found that my caseload had a threefold higher risk of smoking compared to the general population. Although 63% of smokers wanted to quit or reduce, only a fraction was offered advice or support. The project led to discussions to improve coverage of stop smoking interventions within my service and reaching a broader audience with a poster presentation at the RCPsych International Congress. It informed our Trust’s Population Strategy Group and the local Council responsible for specialised stop smoking services. It highlighted a gap in training not only for psychiatrists but for all healthcare workers, where an evidence-based intervention with big potential impact was not prioritized in training and not being implemented. The project has changed my own clinical practice for the better: I will never again pass on the opportunity to offer patients brief advice on smoking cessation and provide them with the necessary support to quit or reduce. I will also advocate for stop smoking interventions in my future work to improve coverage.

This is an example of local PMH work that can be done by any trainee in any Trust or country. It illustrates that as trainees, we can do our own part to have an impact on a population level as well as improve clinical practice. PMH has the advantage of being widely applicable to any field of interest to improve coverage of treatment, prevention of associated impacts, mental disorder prevention and to promote mental wellbeing. Encouraging trainees to use this population approach will have significant direct impacts but would also improve how psychiatrists address need at a population level. Although trainees can seek out these projects, organisation of PMH training by educational institutions is paramount. Integrating PMH in medical and psychiatry training not as a fragmented subject, but as part of every mental health area would spark interest and improve implementation.

Furthermore, addressing PMH in undergraduate medical training will not only facilitate a more holistic approach to our patients but will also help young doctors to understand the importance of systemic interventions at every level of prevention and treatment of mental disorders. Training can encourage the psychiatrists of tomorrow to look beyond their clinic room to the societies that perpetually influence their patients’ lives, and to recognise their own part in advocating and influencing change.

It’s an exciting time for PMH, which is being championed by the RCPsych, the European Psychiatric Association and the World Psychiatric Association. The RCPsych is working towards certified training in PMH, led by the College Dean, Professor Subodh Dave. I hope this momentum will be used to acknowledge PMH as an indispensable part of undergraduate and postgraduate psychiatry training, as well as being integrated into training for nurses, psychologists, social workers, public health workers and many other relevant professions. PMH, much like psychiatrists, cannot exist on a deserted island. It needs to be fueled by appropriate training, collaboration and a broad network to become the high speed train to support universal coverage of PMH interventions.

Dr Hanna Tu

Hanna is a CT-3 in Psychiatry at the South London and Maudsley NHS Foundation Trust, on a 1- year secondment from Psychiatry Training Scheme, Catholic University of Louvain, Belgium.