TRADITIONALLY, HEALTH pro-motion and illness prevention is divided into primary care – the avoidance of illness amongst the general community, and secondary care – reducing relapse and complications amongst people who have already presented with symptoms. In mental health, there is much more evidence for effective secondary prevention compared to primary prevention. Unlike general medicine, there is no obvious toxic agent (such as cigarettes) involved so that general advice and preventative measures such as taxation can be applied.
However, mental illness costs the economy billions of pounds and, with increasing prevalence of dementia in the elderly, resulting in escalating costs to NHS services. The main reason for blocked beds in acute medical and surgical wards remains dementia. Similarly, at least 20 per cent of emergency admissions to general hospitals are due to self-inflicted injury – usually ingestion of pharmaceutical drugs, often as a mixture of medications or with alcohol. Alcohol related medical and surgical problems account for at least 25 per cent of acute inpatient bed use. Often these people are binge drinkers who also engage in other risky behaviour.
The traditional marker of mental illness has been suicide rates amongst the general population and specific groups such as people with previous or ongoing contact with psychiatric services. The most effective way to prevent suicide remains restricting the various physical means of harm (including toxic drugs) instead of psychological treatment – although there is some evidence for suicide and self-harm reduction by using clozapine in schizophrenia and lithium in bipolar disorder.
Compared to suicide, twice as many people with serious mental illness (such as schizophrenia, mood disorders and dementia) die of cardiovascular events. This may be due to some of the newer “atypical” an-tipsychotic drugs, that might well increase cardiovascular problems such as stroke and diabetes. Clearly these findings are relevant to psychiatrists who are considering health promotion amongst their clients. There has been recent interest in setting up healthy living groups, concentrating on exercise, diet and stopping smoking.
The main choice to be made on mental health promotion is whether efforts should be directed at primary care – early detection of dementia, depression and alcohol misuse – or, alternatively, directed at detecting these problems at the general hospital level, preferably at the point of ad-mission, so that necessary psychiatric input could be incorporated as soon as possible. Ethically, primary care is the better option, particularly with regard to preventing stigma. However, to provide a detectable benefit, general practitioner services will need to be integrated with police and social services, local employers and schools. This raises further questions with regards to practicality and confidentiality.
Screening in secondary care would consequently be the easier option to set and up and measure – especially amongst inpatients. With the growth of foundation hospital trusts, there will be a financial incentive for picking up mental health problems at an early stage. There would, however, be an equal financial incentive if fund holding were to be returned to primary care in some form.
In either case, an emphasis on mental health promotion would demand major changes in mental health care delivery. Community-based crisis resolution teams would have to consider expanding into general hospitals to accommodate self-harm management, advice on dementia care and alcohol-related difficulties. Alternatively, an expansion in general hospital-based liaison psychiatry services would be needed, most likely led by nurse practitioners. A nurse-led service would question the need for the traditional “doctor-to-doctor” referral in hospital practice. Often a nurse-to-nurse referral provides greater quality and relevance.
Liaison psychiatry – specialist mental health staff collaborating with general staff – can be practised in primary care, but involves a gradual build up of trust between GPs, practice staff and the community mental health team (CMHT). In Whitby we have used joint multidisciplinary assessment of referrals, and joint consultations with GPs. We find these procedures effective and acceptable to both clients and GPs. Most referrals can be returned to primary care with a care plan negotiated with the client and carer. Consequently, more time can be allocated by the CMHT to avoid unnecessary admissions to acute psychiatry wards. Prompt comprehensive assessment of routine referrals appears to be associated with reduced crisis referrals/admissions.
Liaison psychiatry work practices could be used in general hospitals and in primary care for effective mental health promotion. Foundation hospitals and the expectations of primary care would shape psychiatric services and influence priority, unless centrally guided. Clinical governance on the use of psychiatric medication complements restricting methods in suicide prevention.
Primary mental health promotion remains a somewhat theoretical subject, although recent interest in concepts such as “work-life balance”, and collaboration between psychiatry and chaplaincy services could provide some pragmatic inroads.
As regards secondary promotion, there has been an increasing emphasis on collaborative working with carers and users. In particular, patients with chronic relapsing mental illness are encouraged to formulate relapse managements plans otherwise known as advanced directives (although evaluation of these documents in clinical practice is needed).
Finally, the issue of equitable researching needs to be addressed. In effect, 13 per cent of NHS funding is used to pay for around 20 per cent of NHS clinical activity – the proportion accounted for by mental health problems. Further improvements in work practices will not cover this funding gap, which remains largely unquestioned.
