7 Jul, 09 | by Steven Reid, Evidence-Based Mental Health
9 Jun, 09 | by Steven Reid, Evidence-Based Mental Health
After a bloodbath at the ballot box, the knives are out for the party leader. Media commentary is awash with Shakespearean allusions, although a more apt reference would be ‘The Tragical Comedy of Punch & Judy’. As past slights and feuds come back to haunt Mr Brown here is a timely article on the psychology of retribution in the journal Monitor on Psychology. It appears that revenge may not be as sweet as we think.
17 May, 09 | by Steven Reid, Evidence-Based Mental Health
Last week NHS Yorkshire and Humber released the findings of an external investigation into the care and treatment of Benjamin Holiday. You can find the report here. In January 2005 Holiday, a young man with schizophrenia, killed a pregnant woman, Tina Stevenson, stabbing her in the street close to her home. He was under the care of a community mental health team and living at home with his mother. Having no recollection of the attack he pleaded guilty to manslaughter with diminished responsibility and has been detained indefinitely in a special hospital.
Department of Health guidelines (shouldn’t that be directives?) call for a series of reviews when a homicide has been committed by a person who has been in contact with mental health services:
1) A fast-track (72 hours) investigation to identify any necessary immediate action
2) An internal mental health trust investigation (within 3 months)
3) And finally, an independent investigation commissioned by the Strategic Health Authority.
The reasons for an external investigation are obvious: lessons must be learned to prevent such events happening again. But do they work? They certainly provide a revealing insight into the day to day care of someone living with a severe mental illness, affording a degree of transparency for relatives and carers that is rarely available elsewhere. And outcomes? There have been at least 400 homicide inquiries in the last 15 years yet the rates of homicide by people with mental disorder remains unchanged: 30-50 from 800 homicides annually, with fewer than 10 committed by people with a psychotic illness (the remainder largely related to personality disorder and drug misuse). The recommendations have become familiar too: improved risk assessment, better communication and better record-keeping. Another report isn’t needed to tell us that. The Holiday Inquiry illustrates their inefficiency. Tina Stevenson was killed in 2005; the inquiry reports four years later in which time things have changed. We have a new Mental Health Act, community treatment orders, crisis resolution teams and I’m sure that like elsewhere, services in Hull have been completely reorganised. The authors acknowledge that much of what they say was reported in 2006 by the mental health trust’s internal review.
Much has been made of bringing an end to the ‘blame culture’ in the NHS which encourages staff to cover up errors for fear of retribution. The new focus is on systematic factors that allow such errors to be made. It is human nature, however, to search for a scapegoat and in this inquiry: “…if we are allowed to indulge in one piece of viewing this investigation through a ‘retrospective-scope’ we would conclude this was a missed opportunity to possibly break into the cycle”. What they are referring to here is the decision by a social worker not to complete an application to detain Holiday under Section 3 of the Mental Health Act two months before the homicide. At the time however, he was agreeing to an informal admission, and following his discharge one month later he was seen by a nurse on two occasions and given his depot antipsychotic injection. It is just as plausible that by detaining him at that time he may have become less cooperative with treatment and disengaged completely – a classic example of hindsight bias.
Of course these points have been made before. In 1999 the DoH’s Safer Services report recommended that homicide inquiries be scrapped but they keep on coming. Clearly they fulfil a social need. The Department of Health guidelines state that mental health services must ‘be seen to investigate’ any serious incident and though not explicit, the allaying of the publics’ anxiety about the mentally ill is key. We used to have asylums to contain the mad, but now we have community care – an idea that now attracts as much vilification as political correctness. The fear of mental illness is as potent as ever and homicide inquiries serve to remind us that whilst they may live among us, they remain alien and dangerous – as illustrated by headlines such as this: Crazed Killers – trust’s failings exposed.
26 Mar, 09 | by Steven Reid, Evidence-Based Mental Health
With free market capitalism seemingly spinning off into oblivion, despite the best efforts of our Supreme Leader and his G20 disciples, the benefits of globalisation for the world economy are looking a little shaky at the moment. Whilst it has brought an unprecedented increase in prosperity for some, for others low wages and an economy underpinned by massive debt mean that the world seems a more unequal place than ever before. These inequalities are of course not just international but intranational: countries are made up of classes.
In 2004 Michael Marmot charted the impact of inequality on health in The Status Syndrome. This month his text is joined on the shelf by The Spirit Level (Richard Wilkinson and Kate Pickett). Both books marshal an array of epidemiological studies to present a robust bottom line: there is a strong correlation between a country’s level of economic inequality and its social and environmental problems. What’s more, it isn’t just the poorest in the most unequal societies that suffer but the richest too. So according to Wilkinson, “countries such as the US, the UK and Portugal, where the top 20% earn seven, eight or nine times more than the lowest 20%, scored noticeably higher on all social problems at every level of society than in countries such as Sweden and Japan, where the differential is only two or three times higher at the top.” And those social problems range from obesity to big prison populations, from teenage pregnancy rates to, of course, mental illness.
That an unequal society leads to more mental distress may seem self-evident but a study recently published by the World Health Organisation – Mental health, resilience and inequalities – amasses a broad range of evidence to show that mental health problems are not only more pronounced in unequal societies, but that mental health is also key to understanding the impact of inequality on a range of other health outcomes. Dr Lynne Friedli, the report’s author, maintains that the chronic stress of struggling with material disadvantage is intensified by doing so in more unequal societies. In turn chronic stress has a deleterious effect on the neuroendocrine, cardiovascular and immune systems increasing the risk of disorders such as coronary heart disease and metabolic syndrome. Maybe so, although the strength of the evidence is contestable. But what’s to be done? Dr Friedli’s wish list seems rather optimistic:
• social, cultural and economic conditions that support family and community life
• education that equips children to flourish both economically and emotionally
• employment opportunities and workplace pay and conditions that promote and protect mental health
• partnerships between health and other sectors to address social and economic problems that are a catalyst for psychological distress
• reducing policy and environmental barriers to social contact
This sounds too much like ‘motherhood and apple pie’ to me, although a strident call for wealth redistribution would probably be asking a lot of WHO. Of course, the UK government would claim that they have made considerable progress in all of these areas over the last decade. If that is the case, why is there a need to convene a new National Equality Panel to show how your chances in life are influenced by, among other things, ‘how much money you earn’? We are also awaiting another review of Health Inequalities in England to show us the way.
Gordon Brown is busy trumpeting the need for economic and financial reforms ahead of the G20 meeting, or as it has now been rebranded: the London Summit. An opportunity to redress global imbalances? Not bloody likely. I’m more inclined to believe this pithy observation from the Financial Times: “A crisis-torn world is in no mood for the heavy lifting of global rebalancing. Policies are being framed with an aim towards recreating the boom. Washington wants to get credit flowing again to indebted US consumers. And exporters – especially in Asia – would like nothing better than a renewal of demand led by the world’s biggest consumer. It is a recipe for disaster.”
27 Nov, 08 | by Steven Reid, Evidence-Based Mental Health
That’s not exactly what he said but Andrew Lansley, the Conservative Party’s shadow health secretary, has been slapped down by the party leadership for suggesting that the economic recession may bring health benefits. This is what he did actually say on his blog:
I’ve been reading up on the impact of previous economic downturns on our health. Interestingly on many counts, recession can be good for us. People tend to smoke less, drink less alcohol, eat less rich food and spend more time at home with their families.
You can’t read this now as the post was swiftly removed from the Conservative Party website but to be fair he prefaced his statement by emphasising that for many the everyday reality of recession does mean human misery. Furthermore it certainly is the case, as he reports, that some economists have identified a variety of health indicators that improve during a depression, a notable exception being that of mental health. His comments have caused the inevitable political spat with calls for his head and Mr Lansley has apologised (presumably through gritted teeth).
What does this rumpus have to do with mental health? Well, Lansley was actually trying to highlight the impact of a recession on mental health. He suggests that the recession may lead to a 26% rise in the number of people suffering with mental health disorders by 2010. I’m not sure where those figures come from – they sound rather speculative to me – but what is clear is that debt and mental health are inextricably linked. Seemingly self-evident, it is a point reinforced by good epidemiological data. A study by Rachel Jenkins and colleagues using data from a national cross-sectional survey demonstrated this association, showing that one quarter of people with mental health problems are living with debt or arrears (compared to one tenth of the general population) and 10% have had a domestic utility disconnected. A timely joint initiative has just been launched by the Royal College of Psychiatrists and the First Step Trust. The aim is to provide guidance on supporting patients with debt and mental health problems, an area of ignorance for many health care professionals. The leaflet ‘Final demand – Debt and Mental Health’ can be accessed here and is informative whether you have mental health problems or not. So Mr Lansley’s comments, deemed nonsensical by many, are actually noteworthy. It’s a pity that they will be lost amidst the shrill cacophony emanating from the Westminster village.
30 Sep, 08 | by Steven Reid, Evidence-Based Mental Health
No, it didn’t crop up in the first presidential debate – arguably there were more pressing issues to deal with. But the National Alliance on Mental Illness, a US advocacy group, has posted the replies to a questionnaire on mental health care sent to both Barack Obama and John McCain. Unsurprisingly, health care reform features prominently in the campaign platforms of both candidates. The problems are well known: the US has the most expensive health care system in the world, but 47 million Americans remain uninsured with both life expectancy and infant mortality falling well short compared to other developed nations. Dissatisfaction with the status quo is widespread but there is little agreement about how to change it. Mental health care always struggles to get attention until, of course, cases of gross neglect such as that of Esmin Green come to light. So that NAMI were able to get detailed responses from the two presidential candidates is noteworthy, whatever you think of the responses themselves.
Unlike McCain, Obama did answer all 24 questions that were submitted. In fact he responded by “strongly supporting” every point raised by NAMI: he’s all for guaranteeing comprehensive coverage, improving access to services, increasing funding for all, and awarding all of those living with mental illness a $1 million dollar tax-free lump sum (that last part is fiction, but you get the idea). In other words, an adroit political response: overwhelmingly supportive, but promising nothing too specific.
Although John McCain responded with his own statement (his campaign doesn’t do questionnaires), his comments are certainly more revealing than those made by Obama. Firstly, a positive: he recognises the importance of co-existing psychological disorder in chronic medical illness, stating that untreated depression raises dramatically the costs of treating the physical ailments such as diabetes. Let’s integrate psychological care into general medical practice: not much to argue with there. I’m not so sure about his emphasis on “the central role of personal responsibility” which sounds like a rerun of the ‘mental illness equals lack of moral fibre’ argument. What comes across most clearly, however, is his enthusiasm for cutting costs, mentioned four times here. At least that’s consistent with his overall approach to health care reform: “Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.” Oh dear.
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