Is depression really like diabetes? Yes – in more ways than you think

It’s often said that depression is just like diabetes.

The aim is usually to encourage people to speak up about their mental health problems, by pointing out that they’re no more worthy of shame than other illnesses.

The comparison seems to go down pretty well with most folks. But not with everyone. Some people hate it.

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So how much do the two conditions really have in common? A lot, I reckon. Their similarities run deep, but perhaps not in the ways that you’d considered.

To begin with, depression seems to me to compare more closely with Type 2 Diabetes than Type 1, for many reasons.

Whereas Type 1 always involves the same underlying problem – destruction of pancreas cells leading to a lifelong need for insulin – Type 2 is a more variable biological state, just like depression. In Type 2 Diabetes, high sugar levels are primarily caused by the body not being as responsive to insulin as it should be, but insulin levels are often low as well. Other hormones like glucagon and incretin are out of kilter too. This is akin to depression, in which we know that it’s not just serotonin that’s important at the biological level. Other neurotransmitters like noradrenalin and dopamine (and many others) are all involved.

The concept of depression sometimes gets criticised because it’s different for everyone, not like ‘real’ illnesses. But the biological state of any one person with diabetes won’t identically match that of any other any more than one depressed person’s brain will match another. They’re both illnesses with a lot of variation that we treat as one thing because the end results (high blood sugar or low mood) are relatively similar across people and treatments can be developed to tackle them.

Sure, diabetes has an objective test in blood sugar readings, whereas diagnosing depression relies heavily on rating someone’s sadness in at least a partially subjective sense, but just because mood is hard to measure doesn’t mean it’s not a real problem. And both blood sugars and mood ratings are tips of icebergs, the diagnostic variables that we choose to measure in conditions that affect much more. Diabetes will make you feel tired, give you headaches, make you drink lots and pee lots and eventually ruin your eyes and kidneys if left unchecked. Depression affects your sleep, appetite and sex drive and might lead to suicide.

Also, neither Type 2 Diabetes nor depression have one simple cause. Both are caused by a collection of individually small risk factors. With diabetes the big dangers are things like obesity, high cholesterol, poor diet and sedentary lifestyle, whereas with depression it’s things like recent adverse life events, a tough childhood and a lack of social support. Diabetes and depression both have a huge genetic component, but neither has a single-gene cause.

Taking things further, the treatment for both Type 2 Diabetes and depression is almost uncannily similar. The first step for both – and people never seem to know this – is not medication, unless the problem is severe. For diabetes it’s a change to a healthier lifestyle, whereas with depression it’s self-help and perhaps talking therapy. Both conditions can fully remit with those kinds of interventions, or partially remit, or remain a problem for life. When medication is needed it comes in the form of artificial chemicals that try to assist the body in doing what it does when it’s healthy. Drugs like metformin are first choice in Type 2 diabetes, and they certainly aren’t ‘natural’, but even injectable insulins aren’t the same as insulin produced by a real pancreas. Just like depression we don’t know who will respond to a particular diabetes treatment, how much, or why.

It’s ironic that some people think depression is something sufferers are to blame for and can fix for themselves (‘pull yourself together!’) when in reality it might be Type 2 diabetes with the risk factors and treatments that are most controllable by the person with the illness. It’s probably easier to shift your Type 2 diabetes by avoiding junk food, exercising and losing weight than it is to ease your depression by taking away life stressors like a busy job and magically undoing an abusive childhood.

So depression certainly isn’t identical to diabetes, but they do share a lot of common ground. They’re both illnesses with variable and complex biological states, tests which don’t show how widespread the problems can be, ranges of risk factors and treatments and unpredictable outcomes. Next time you hear someone say that ‘depression is just like diabetes’, you can agree with them – perhaps more than they’ll realise.

Smoking in psychiatric hospitals

Last week the Mental Elf reviewed a research paper on the effects of smoke-free policies in psychiatric hospitals. It looks like some smokers manage to stay clear of cigarettes after being admitted to a hospital with a ban.

The debate about whether such bans are fair is complex and often heated, but can usually be boiled down to an argument between freedom (to smoke) and health (of the smoker and others). Contrary to my usual mindset, which is very freedom-orientated, I actually support smoking bans in psychiatric hospitals. I’d like to discuss why, not because I’m particularly ardent in my stance (in fact I used to be against them) but because it’s a tricky area in which I value both points of view. And before you ask, yes, I’ve been a smoker.

Firstly, let’s not forget – smoking is really, really dangerous. It wrecks the human body like nothing else, with smokers dying at least ten years before non-smokers on average. Furthermore, over a third of cigarettes are sold to people with mental illness, unfairly targeting a group that are already having a hard enough time.

Second, despite how many people feel, smoking doesn’t improve mental health conditions, it makes them worse. Smoking might appear to soothe naturally occurring anxiety but in reality it probably only relieves anxiety caused by needing a cigarette (if I had a cigarette now as a non-smoker, would I feel less anxious?). Moreover, quitting smoking while being treated for a mental health problem does not appear to make it worse if you get the right help – in fact, it seems to lead to a decrease in anxiety.

So from a health perspective, smoking is something we don’t want people to be doing for any reason. But should we be able to insist that they stop when in hospital?

Informal patients should be able to nip off the ward for a fag any time they like, but patients held under section aren’t free to leave. This is the most contentious area of the debate. I see both sides of the argument, but overall I think that if someone has been sectioned for the benefit of their health, it seems farcical to facilitate their hugely harmful addiction. Plenty of other behaviours and habits are seen as unacceptable in hospital, without such fierce criticism – drinking alcohol, using illegal drugs, gambling. Even though they can be a normal part of life when well, they’re not allowed in hospital because they aren’t helpful when unwell and it certainly isn’t within the remit of staff to spend time helping patients undertake them.  As a correlate, do we insist that patients have leave from hospital to be escorted to the local betting shop or off license?

Furthermore, facilitating smoking – which often involves nurses wasting hours of each day escorting people back and forth to smoking gardens or the front gate – sends out a bad message about mental health services, I think. When someone is admitted to a general hospital, they accept that the aim of the staff is to improve their health and that although they can smoke if they can make it outside, staff aren’t going to bend over backwards to help them. Plenty of people with physical health problems can’t leave hospital, just like people under section, because they’re too unwell but they don’t tend to feel like that’s unreasonable.

On the topic of rights, non-smoking patients have a right to nurses that aren’t spending their time facilitating the addictive and harmful behaviour of other patients, who then come back onto the ward covered in dangerous chemicals. Most of us have met patients who started smoking on psychiatric wards as a result of exposure to a cigarette-friendly environment, which has to stop.

I’ve worked in psychiatric hospitals both with and without bans. In places without bans, throngs of patient spent literally all day crowding around the nursing station, asking for smoking breaks. It consumed the nurses’ time, so they couldn’t do a range of other caring tasks, and led to a number of incidents of aggression when demands couldn’t be met. In psychological terms such ‘variable reinforcement’ regimes (i.e. only letting someone have something they ask for every so often in an unpredictable way) is a recipe for frustration.

However, in places with bans, in my experience patients are usually a bit annoyed when they’re admitted but usually accept fairly quickly that it doesn’t make sense for a hospital to be condoning smoking, they accept nicotine replacement therapy (which works pretty well), and do just fine. Counter to what you might expect, violence is not increased with total bans, and in at least one instance in the UK a smoke-free policy has halved it.

In summary, there is no perfect solution. We can either help very ill people harm themselves by smoking in the name of freedom, or restrict something they want to do in the name of health. The key for me is that the freedom to smoke isn’t as simple as just letting people smoke – it’s a freedom which has to be actively supported but has negative knock-on effects on patient health and mental state, staff time (including time with other patients), the image of mental health services as pro-health, and ultimately parity. And I haven’t lost any sleep because my patients don’t have access to something that will kill them when I’m meant to be looking after them.

Foreign nurses hold the NHS together – ignore the Daily Mail

The Daily Mail has a lot in common with genital herpes. It’s seemingly permanent, an unacceptable topic in polite conversation, can go several months without causing annoyance but occasionally flares up in repulsive and virulent fashion. And so it did today. Following the (entirely justified) conviction of Victorino Chua, who poisoned at least 22 patients, the Mail saw fit to effectively brand all Filipinos as potential murderers:

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Why not just ‘Did The Nurse Murder 11 More?’

In the article itself, the linking of which to my blog makes me physically nauseous, the Mail gives details of their undercover investigation into the hiring practices of NHS organisations in the Philippines. It was possible to cheat on some entrance exams, they say. Forged copies of qualifications can be obtained in Manila, they say (though they found no proof this had happened – but their reporter did get some certificates made and stood outside the shop looking shifty for effect). The insinuations are clear – that the nurses aren’t any good but are gaming the system to steal UK taxpayer’s money and also have sinister intentions.

What a load of crap.

If some entrance exams are too easy, allowing a slim minority of underqualified nurses to gain employment in the UK then fine, look into that. Do make sure you don’t forget about the series of other rigorous process that nurses have to undergo to start and remain in work in the UK when you cast judgement.

But don’t anyone dare conflate this with foreign staff being of generally poor quality with criminal intent. I have worked in the NHS for many years, and met many foreign nurses. I’ve met so many because there are so many. One in seven trained abroad. The vast majority have been hardworking, well trained, caring and kind people who came to the UK not in pursuit of a fortune or an easy ride – who the hell would call £25,000 a year for the ridiculous hours our nurses work that – but because they felt the NHS offered them a chance to be able to care for people without having to live in poverty. Victorino Chua would not have been caught by a more demanding entrance exam or tougher document checks, just like Harold Shipman wouldn’t have been caught by compassion testing. And his crime has nothing to do with his nationality. One bad apple is no excuse to tarnish a whole culture.

Far from taking advantage of our system, foreign nurses actually make the UK money. We didn’t pay for their school or university education, and because they’re able to work they won’t be needing to claim benefits. They help return sick people to work, where they can resume paying tax. Morevoer, they pay income tax themselves.

Without foreign staff the NHS would collapse – almost literally – in a matter of minutes. Stupidly we’ve neglected our own nurse training schemes for years, leaving vast numbers of posts empty and relying on overseas staff to cover for our mistakes, leaving their own countries worse off for it. And trust me, whatever the Daily Mail says, when the inevitable day comes when you feel that twinge of chest pain, your left side going weak, or a loved one collapses, and you reach for the phone to call 999, you’ll be bloody glad they’re still here.

Where does ‘Choosing Wisely’ fit into mental health services?

Last week the Academy of Medical Royal Colleges announced that it would be bringing ‘Choosing Wisely’ to the UK. The US initiative, which has spread to more than 12 countries worldwide, encourages leading medical organisations to list tests, procedures and medications with little evidence behind them and advise doctors to think twice before using them.

This is a good thing. In many areas, medical intervention has expanded way beyond the point of usefulness, resulting in extra risk to patients for little gain.

Though the Patients Association reacted cautiously, fearing it might mark the beginning of ‘rationing’ of interventions, the reception was overwhelmingly positive. No one really buys the ‘rationing’ worry – the ethos of the campaign is openly directed at empowering choice not withholding, and you have to wonder what the harm would be in rationing ineffective treatments in any case. Atul Gawande hit the nail on the head in his utterly readable New Yorker piece ‘Overkill’, saying that these types of intervention aren’t just ‘low-value care’ but no value care.

I’ve been thinking about how this all applies to mental health services in the UK.

The Royal College of Psychiatrists has signed up for Choosing Wisely, as is right and laudable. And there definitely are interventions in psychiatry which could potentially be cut down on. Antidepressants for mild depression, for example, are next to useless but prescriptions continue to rise suspiciously. Antipsychotics for behavioural disturbance in dementia are only temporarily helpful (if at all) but result in a significantly increased risk of stroke. Antipsychotic polypharmacy for schizophrenia is poorly supported by research, associated with increased side-effect burden, but not rare.

However, we need to keep things in perspective. Unlike most other medical specialties, psychiatry faces the paradox that though we can prune a few treatments back as unhelpful, our main problem is that we’re vastly undertreating most people.

A lot of the time this is fairly convincingly not our fault, due to there not actually being a service in existence to do the treating. Only half of women in the UK have access to perinatal mental health services. Liaison psychiatry provision is so patchy that no official statistics exist, but a recent survey found that even in London only 50% of hospitals have a 24 hour service. Only 25% of people with depression or anxiety access help; the proportion of children with a mental illness in treatment is similar.

But even patients who are lucky enough to find their way to a psychiatrist can somehow avoid being offered effective treatment. Clozapine, the antipsychotic which works significantly better than all others, is meant to be offered after two failed trials of different antipsychotics lasting 6 weeks each. But recent research suggested that the average time to be offered clozapine – which is associated with vastly improved functional and symptomatic outcomes – was 4 years. Similarly, despite the fact that it probably works better than anything else for prophylaxis and suicidal prevention in bipolar disorder, lithium prescribing rates have dropped. Most likely due to the the lack of pharma interest (you can’t patent an ion) and the need for annoying blood test monitoring, patients aren’t getting the best treatment. Moreover, antidepressants aren’t increased to effective doses and aren’t switched in a timely enough fashion if they don’t work. Using an algorithm can help.

And it’s not just medications that are underprovided. According to the National Audit of Schizophrenia less than half of people with schizophrenia who aren’t in remission are offered CBT, just 59% of smokers get offered advice and a measly 25% get counseled on their high blood pressure. Doubtless this is frequently due to clinicians being pressured for time, but the facts remain.

In short, though cutting out pointless and potentially risky interventions is always desirable, in mental health it can hardly be our main focus. We’re way behind the luxurious curve that other specialties find themselves on. Managing to identify and reduce ineffective decisions while introducing effective ones will demand considerable mental dexterity and vigilance of psychiatrists. And of course, they’ll only be able to make those calls if services for them to work in are commissioned in the first place. Choosing wisely is great, but it requires having a choice to start with.

An open letter to Alistair Burt, the new Minister of State for Health

Dear Mr Burt,

Congratulations on your recent appointment as Minister of State for Health and for holding your seat as an MP in North East Bedfordshire.  I must admit, the majority your party obtained last week in the General Election was not the result I had personally wished for, but the result of a fair democratic election is not something to be sniffed at.

Forgive me if I’m wrong here, but a quick trawl of the internet suggests that this is the first time your brief has included mental health. In fact, it seems to be the first time you’ve been tasked with managing health policy of any kind. I was hoping, as a member of the mental health community that includes inordinate numbers of patients, carers and professionals who have spent their lives immersed in this complex area, that I might be able to offer you some advice.

As it turns out, you have big shoes to fill. Norman Lamb was well liked as a politician, which I am sure you’ll recognise as a rare attribute. As one of only a handful of Lib Dem MPs to survive the recent cull, the positive impact of his work over the last 5 years is beyond doubt.

How did he achieve this respect? By having the integrity and compassion to admit that the mental health system he was in charge of was critically inadequate, leading to the needless suffering of countless thousands. His Crisis Care Concordat and the Liberal Democrat’s Closing the Gap report were ample evidence of their commitment to make positive changes in mental health, and they were the only party to give a concrete funding promise (of £3.5bn over 5 years) in their manifesto.

And oh, how we needed that money. Though your colleague Mr Hunt has claimed that mental health funding went up in real terms over the last parliament, no figures in the public domain support that assertion. When corrected for inflation, official figures seem to show a minute fall. But these numbers don’t match our experience of services on the ground – Trusts have recently reported an 8% drop in funding over the last 5 years. Moreover, they expect their funding to keep on falling, by an additional 8% over the next 5 years.

The sad thing is, our services were on the ropes even before these cuts. Mental health problems account for 23% of the illness burden in the UK, but receive only 13% of the funding, an approximate annual shortfall from CCGs of £6.5bn. And during the cuts of the last 5 years, referrals to community teams actually rose by 17%, stretching us further. This pressure had to tell, and the result was agonising. We lost over 2,100 inpatient psychiatric beds. Community teams, the development of which is usually touted as an excuse for reductions in bed numbers, were cut too. Patients continue to be shipped up and down the country, away from their friends and family, just for the sake of finding a bed. Sometimes, even worse, they are sent home when a bed cannot be found or admitted to a ward but without a bed (!). At least seven patients have ended their lives by suicide as a result, just the tip of an iceberg shrouded by confidentiality and incomplete reporting. Those who somehow manage to stay alive receive a grossly and shamefully lower standard of care than their counterparts with physical health disorders. Despite the touting of increased overall nursing numbers in the pre-election period, here in mental health we’ve actually lost 3,300 nurses over the last 5 years.

As if this wasn’t hard enough to bear, the deep cuts to social care have hit people with mental health problems harder than any other group, with a staggering 48% fewer people claiming help in 2013 than they did in 2006. Because recovery in terms of mental health encompasses the whole person, this only serves to heighten the risk of needing more intensive input from mental health services, wasting money in one area by pinching pennies in another.

I could go on, detailing the desperate state of our services in detail. But that wouldn’t be as productive as telling you how to help. You see, you may have inherited nothing short of a national human rights issue, but it is a national human rights issue that you can go a seriously long way to fixing. Our services aren’t that complicated and they’re not even expensive in comparison to interventions in the rest of medicine – but the results can be incredible. Early intervention services, for example, were recently shown to be capable of saving £15 for every £1 invested. Similarly, though perinatal mental health problems costs society £8bn a year, over half the women in the UK don’t have access to a specialist perinatal mental health service. Providing cost-effective care consistent with NICE guidelines to the whole UK would set you back just £337m a year in comparison. I believe economists call this ‘low hanging fruit’. Instead of cutting your outgoings now, cut them in the future by funding these services, and save some lives to boot.

Here’s another tip. Listen to people who have lived experience of using the services that you are in charge of. Listen to them more than you listen to statistics or advisors. When they say that there is a problem, then trust me, there’s a problem. Mental health is fascinatingly complex and learning all its nuances takes years – I still learn something new every day. Genuinely hearing what these people have to say will win you supporters for life, but assumption and hubris will turn this crowd against you like no other.

As well as individuals, listen to the major organisations. They talk a lot of sense and are driven solely by wanting the best for people with mental health problems. Mind, Rethink and the Mental Health Foundation are just about as informed and influential as charities get. My own affiliation, the Royal College of Psychiatrists, regularly turns out lucid documents on topics like Parity of Esteem. They also asked for 6 things from the incoming government, including investment in (again, unbelievably cost-effective) parenting interventions and liaison psychiatry services.

As an additional note, could I implore you to bring a halt to the government’s flirtations both with putting online CBT into Job Centres and sanctioning people who refuse treatment for long term conditions. Both policies are in direct contradiction to the most basic principles of medical ethics (i.e. free consent), underestimate how difficult recovery is for people with these difficulties, discriminate against people with mental health problems and risk a dangerous conflation of unemployment with illness. The goal of recovering from a mental illness should be recovery itself, not employment. To be honest, in a general sense, I do not feel that the further fragmentation of our health services through privatisation, which brings with it the added clash of ideologies between profit and care, and a cumbersome and expensive tendering process, has any place in the NHS. But this is an issue for another day.

In summary, your new job may have more in store for you than you may have expected. You quite literally have the power to do more good, and to win more plaudits, than any other politician in the UK today. We will help you in any way we can, but only if you are eager to listen. I genuinely look forward to working with you in future.

Yours in collaboration,

Alex

CBT in Job Centres: Five Objections

In March, Nick Clegg announced his plan to improve access to mental health care for people who are out of work. It started off so well, but had a bizarre twist.

He said that he’d found an extra £25 million for mental health, to be invested over the next three years. So far so good.

And that this money might end up helping 40,000 people. Great.

And that this money would fund ‘specialists in mental health support’ to provide talking therapy in 350 Job Centres across the UK. Sorry, what?

On the face of it, you might mistake this for a good idea. Unemployed people are statistically more likely than average to have a mental health problem, and CBT can be pretty effective.

But there are at least 5 reasons why this is a disastrous plan:

  • It feeds into the belief that people with physical health problems should get better but people with mental health problems should get back to work. You won’t be seeing 350 new physiotherapists in Job Centres trying to get people with back pain back to work, even though back pain is a hugely significant cause of sickness absence. This is because we know that recovery comes first, is the primary goal, and happens in a recovery-focused setting, not a Job Centre, where the intentions of those doing the ‘treating’ become murkier.
  • There were already brewing concerns that people with mental health problems would feel coerced into accepting such treatments when the Tories simply came out and said it in their manifesto – some people will lose their benefits if they say no. This baulks against the very fundamentals of medical ethics, of being able to make an uninfluenced decision about what treatment to accept. Furthermore, doing therapy with people who simply don’t want to be there is at best a waste of money and at worst downright harmful.
  • It targets help at people who have something to offer in return, i.e. getting back to work and paying some tax. This is firmly against the principles of the NHS, which state that a person’s means (including, if you have any common sense, their potential) should have no say in their access to treatment. People with equally troublesome mental health problems but no likelihood of ever working again won’t see a penny of this £25 million.
  • What on earth are ‘specialists in mental health support’? According to these contracts for over 80% of the £25 million they appear to be online CBT assistants. These types of resources can be valuable and effective, but working in isolation, as I presume these guys will be, could be unsafe and result in downright quackery. Mental health conditions are complex and require a commensurate amount of assessment – not a quick meeting with someone who is barely qualified. Is there a chance that sub-standard assessments could diagnose problems where there are none, or worse, conclude that not being able to get back into work is a CBT-suitable problem in itself? This is a hair’s breadth from seeing unemployment as illness.
  • Despite it being sold in some articles as ‘co-location’ (i.e. multiple services working closely together in the same place), I can only see this project fragmenting services even further. It will simply add another layer of complexity and miscommunication to pathways which are already needlessly arcane and soul-destroying. Put it this way – the ‘specialist in mental health support’ isn’t going to be ringing the GP or psychiatrist with a thorough summary of treatment and progress, are they? If you want joined up services, put more employment advisors in mental health settings. Fund OT and social work better.

Clegg has been a positive figure for mental health in recent years, so I can’t be too harsh on him. But if he wants people with mental health conditions to recover and get back to work, my suggestion is simple. Fund mental health services better. Don’t create a coercive, work-orientated, untried, discriminatory and disconnected treatment model staffed by isolated and weakly trained staff.

Mental health in the manifestos: what are the parties promising?

The general election is nearly upon us.  After five years of fierce discussion, debate and dispute, we finally get a concrete chance to influence the political landscape of this country. And for the first time, mental health has been acknowledged as a key issue. Last year The Mental Health Policy Group, a collection of six leading mental health charities and organisations, published it’s own ‘Manifesto for Better Mental Health’, outlining where they felt the main political parties needed to commit their energies following this election. In summary, they lobbied for:

  • fair funding for mental health services
  • giving children a good start in life (including perinatal care and education on MH at school)
  • improving physical health care for people with mental health problems
  • improving the lives of people with mental health problems (anti-stigma and pro-employment)
  • enabling better access to mental health services

The Royal College of Psychiatrists published their own ‘6 months, 6 asks’ manifesto around the same time, detailing what they felt should be priorities for the next government:

  • tackling the mental health bed crisis
  • introducing maximum waiting times
  • improving crisis care
  • improving liaison psychiatry services
  • introducing a minimum unit price for alcohol
  • investing in parenting programmes

So let’s see how well each of the main three parties lives up to these expectations in their manifestos.

The Conservatives

The Tory manifesto is light on references to mental health. The first mention it gets is in the scandalous segment on how people with long-term but treatable conditions will be ‘helped back to work’ by having their benefits cuts if they refuse a treatment. The same segment does also offer the following rather nebulous promise, again tied in closely to being able to get back to work:

“We will also provide significant new support for mental health, benefiting thousands of people claiming out-of-work benefits or being supported by Fit for Work”

Later on in the manifesto, there are marginally more specific pledges, namely that that the Tories will ensure…

“…that there are therapists in every part of the country providing treatment for those who need it. We are increasing funding for mental health care. We will enforce the new access and waiting time standards for people experiencing mental ill-health, including children and young people. Building on our success in training thousands of nurses and midwives to become health visitors, we will ensure that women have access to mental health support during and after pregnancy, while strengthening the health visiting programme for new mothers.”
 
It should be noted that mental health nursing numbers have dropped like a rock rock over the last 5 years, and mental health funding has probably fallen too, so this passage felt a little trite. But although the promises are vague and the pledge to increase funding is unquantified, the commitments are there.
 
Finally, there is an acknowledgement of the vital need for improvement in care for people who come to the attention of the police:
 
“We will ensure proper provision of health and community-based places of safety for people suffering mental health crises – saving police time and stopping vulnerable people being detained in police custody”
 
 
 
Labour
 
In their manifesto, Labour are keen to push the fact that we need more joined-up, integrated services:
 
 
“Our health reforms will focus on prevention and early intervention, and joining up services from home to hospital. When people cannot get to see their GP, many go to A&E instead. When mental health problems are not spotted early, people can deteriorate and need more intensive support”
 
 
“The current system is too fragmented. It was not designed for the growing numbers of people living with chronic conditions or multiple needs. Rather than having three separate systems for dealing with physical, mental and social care, we will create a whole person approach: a single service to meet all of a person’s health and care needs”
 
 
And they go on to briefly mention parity and improving access to services, with a particular focus on children:
 
 
“Mental health will be given the same priority as physical health. People will have the same right to psychological therapies as they currently have to drugs and medical treatments. To help address the problem of undiagnosed mental illness, NHS staff training will include mental health. We will increase the proportion of the mental health budget that is spent on children, and make sure that teachers have training so they can identify problems early and link children up with support. To support young people’s health and wellbeing, we will encourage the development of social and emotional skills, for example through the use of mindfulness to build resilience. And we will set out a strategy with the goal of ensuring that the great majority of patients can access talking therapies within 28 days, and that all children who need it can access school- based counselling”
 
 
This, I felt, was slightly more encouraging than the Tory effort. Still no hard figures, but Labour at least seem sympathetic to the plight of people with mental illness, and aware of the inefficiency and turmoil of having such fragmented care. The nod towards funding ‘wellbeing’ interventions, which the Chief Medical Officer warned against last year due to a limited evidence base, was probably included to make the manifesto’s commitment to mental health resonate with the public at large. I also note that Labour only promise to increase the proportion of the mental health budget spent on child services, effectively committing to cuts elsewhere unless funding is increased overall. This is cheeky.
 
 
 
Liberal Democrats
 
As promised by Nick Clegg there is a pledge to ‘guarantee equal care for mental health’ on the front cover of the Lib Dem manifesto. There is also a more intentful mention of mental health in their introductory paragraph than in any of their competitor’s opening statements:
 
 
“Those facing anxiety and depression will be seen swiftly, people struggling not to harm themselves will find emergency help at A&E and teenagers suffering from eating disorders will get the help they need close to home”
 
Indeed, mental health is alluded to more frequently in this manifesto than in the others. Apprenticeships are to be tailored better for people with mental health problems, and foster carers are to be better educated on the topic. Later, in the health section, they become the only major party to offer an exact figure for investment:
 
 
“…£500m [extra per year by 2016/17] to transform mental health care with waiting time standards to match those in physical health care”
 
 
When added to previous pledges, as reported this week, that that would add up to £3.5bn extra for mental health over the next five years, to be partially paid for through changes to capital gains tax.
 
This promise is part of a solid two pages of text on mental health. Assurances given in this generous space include:
 
  • “a waiting time standard from referral of no more than six weeks for therapy for depression or anxiety and a two-week wait standard for all young people experiencing a first episode of psychosis”
  • “increased access to clinically and cost-effective talking therapies”
  • “transforming care for pregnant women, new mothers and those who have experienced miscarriage or stillbirth, and help them get the early care they need”
  • implementing the proposals outlined in the report of the Government’s Children’s Mental Health Taskforce. For example, “building better links with schools, ensuring all children develop mental resilience, and getting support and care quickly to those who are struggling”.
  • “ensure no one in crisis is turned away, with…better crisis care in A&E, in the community and via phone lines. This will enable us to end the use of police cells for people facing a mental health crisis”.
  • “extending the use of personal budgets, integrating care more fully with the rest of the NHS, introducing rigorous inspection and high-quality standards, comprehensive collection of data to monitor outcomes and waiting times and changing the way services are funded so they do not lose out in funding decisions in future”
  • “introduce care navigators so people get help finding their way around the system, and set stretching standards to improve the physical health of people with mental health problems”
  • “publish a national wellbeing strategy”, with a “public health campaign promoting the steps people can take to
    improve their own mental resilience” and “ensuring people with mental health problems get the help they need to stay in or find work”
  • “establish a world-leading mental health research fund, investing £50m to further our understanding of mental illness and develop more effective treatments”
  • “continue to support the Time to Change programme to tackle stigma against mental health”
  • “ensure all frontline public service professionals, including in schools and universities, get better training in mental health”

There’s also a vow to offer more “support for personnel and veterans with mental health problems”.

It doesn’t take a PhD in politics to work out that the Lib Dem manifesto is head and shoulders above the Conservatives and Labour in terms of engagement with the issue and promises made. They have ticked pretty much every one of the Mental Health Policy Group’s boxes for suggested improvements. Again, there is an infatuation with wellbeing, but the groundwork done by Norman Lamb with his Crisis Care Concordat has gone some way to engendering trust in the party when it comes to tackling more weighty issues. The real question is, will they have any power to implement these changes on May the 8th?
 
 

The Green Party

The Greens dedicate a generous proportion of their  to mental health, not least because one of their main focus points – equality – is tied in with it so closely. They state clearly, and in a way that no other party does, that their policies are all intertwined, for example that reducing mental ill health will have a positive knock-on effect on the economy, crime and drug use.

They pledge to ‘increase investment in mental health care’ as part of a general £12bn increase in NHS funding per year, but don’t say exactly how much of that £12bn mental health will get.

They highlight the huge disparity between the proportion of illness that is due to mental health problems (28%) in UK society and the amount of NHS funding dedicated to mental health services (23%), before going on to make a series of promises:

 

  • Ensure that no one waits more than 28 days for access to talking therapies.
  • Ensure that everyone experiencing a mental health crisis, including children and young people, should have safe and speedy access to quality care, 24 hours a day, 7 days a week.
  • The use of police cells as ‘places of safety’ for children should be eliminated by 2016, and by the end of the next Parliament should only occur for adults in exceptional circumstances.
  • Ensure that everyone who requires a mental health bed should be able to access one in their local NHS Trust area, unless they need specialist care and treatment. If specialist care is required, then this should be provided within a reasonable distance of where the patient lives.
  • Implement a campaign to end the discrimination and stigma associated with mental health through supporting the Time for Change programme and offering employment support to those with mental health problems.
  • Invest in dementia services, ensuring that support is available for all affected by this debilitating disease, including families and carers.
  • Pay special attention to any mental health issues of mothers during and after pregnancy, children and adolescents, Black and Minority Ethnic people, refugees, the LGBTIQ communities and ex-service people and their families.
  • Improve access to addiction services, including both drugs and alcohol addiction.
  • Give higher priority to the physical healthcare of those with mental health problems.

 

These are ambitious pledges, but rather unembellished ones. Such changes would take huge about of reinvestment and substantial reorganisation of services, but I haven’t seen any finer detail from the party on how this would happen. On the plus side, the manifesto has a lengthy but understandable appendix which lists every revenue and expenditure the party would implement, evidencing their financial plans.

 UKIP

To be fair to UKIP, there is a promise to ‘invest £1.5 billion into mental health and dementia services’ in the introduction to their manifesto and they do mention the need for parity. They also acknowledge how important liaison services are, pledging to end the ‘postcode lottery’ in that respect. To continue being fair to UKIP, the rest of their commitments to mental health are very dilute and feel like token statements. For example, they promise:

  • Directing patients diagnosed with a debilitating long-term condition or terminal illnesses to mental health professionals when appropriate
  • Recognising there is often a link between addiction and mental illness and offering appropriate treatment where this is the case
  • Offering direct access to specialist mental health treatment for pregnant women and mothers of children under 12 months of age
  • Fighting the stigma around mental illness and supporting those seeking to get back into work.

Hardly groundbreaking – they sound more like standard expectations of the current service.

In a bizarre move, they also pledge to bring in a ‘veteran card’ so that ex-serviceman and women can be ‘fast-tracked’ into NHS services, including when they need mental health care. There is no need for such a two-tiered system – it would surely be a better aim to make services accessible to all in a timely manner.

 
The SNP
 
The SNP manifesto notes that they would pledge and additional £100m over 5 years for mental health (in Scotland), mainly to be directed at primary care and children’s services, but doesn’t have a dedicated section on mental health. In fact, that’s pretty much the only mention of it at all. 
 
So ladies and gentlemen, if mental health is the issue dearest to your hearts, then there are your contenders. Vote for whoever you choose, but please, please, do vote.
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