Written evidence submitted by Centre for Mental Health (DEL0130)
Introduction and summary
- Centre for Mental Health is an independent charity with 35 years of experience delivering life changing research, policy analysis and health economics in mental health. Our work spans themes such as employment, physical health, criminal justice, wellbeing, inequality and multiple disadvantage across the life course. We work closely with NHS mental health providers, mental health and physical health charities and networks of people with lived experience of mental health problems.
- The research evidence base for the specific impact of the coronavirus outbreak on mental health and on mental health inequalities is still emerging, but we are hearing from our networks about its effects on individuals and services. These insights, alongside reflections on our own and others’ research, moves us to respond and informs our submission to the Health and Social Care Select Committee.
- Key points:
- There may be a negative long term impact of reduced support for people living with mental illness
- The health of the economy affects the health of the nation: the economic shock will disproportionately affect the mental health of people in poverty and on low incomes
- Other groups may need access to targeted services: BAME communities, survivors of intensive care, people with both physical and mental health problems, the bereaved, and women and children exposed to domestic violence or trauma at home
Balancing coronavirus and ‘ordinary’ health and care demand
- There have been reports of significant decreases in referrals to child and adolescent mental health services (CAMHS) and Improving Access to Psychological Therapies (IAPT) services.[i] This suggests that large numbers of people who would ordinarily be accessing support have not been. Left unattended, lower level mental health problems can become worse and require more acute treatment. This is especially concerning considering recent survey evidence of increasing levels of anxiety across the population. It is important that the message of mental health services being ‘open for business’ continues to be shared by the NHS and its partners.
Meeting demand for health and care services that have been delayed due to the coronavirus outbreak
- We are concerned that some people with mental health problems are receiving reduced support during key moments in their recovery. This includes people who have been held for longer periods in restrictive settings, who have had their freedom and personal agency reduced while in inpatient care, and those who have been discharged from services without plans in place to meet their mental health and social needs fully. As system capacity improves and some restrictions are relaxed, there should be targeted follow up work with these individuals to ensure that they are supported and that any progress made towards recovery prior to coronavirus is sustained and not unduly interrupted.
Meeting extra demand for mental health services as a result of the societal and economic impacts of lockdown
- Evidence from previous disasters, disease epidemics and crises suggests that one of the biggest factors affecting mental health will be the economic impact of lockdown. An economic shock is likely to be felt in increased mental health problems amongst people pushed further into poverty. Across the UK and Europe between 2009 and 2013, there is evidence that the prevalence of mental illness rose alongside public spending cuts, rising debt, and unemployment.[ii] A number of recent UK surveys (ONS and various charities) show rising anxiety is mostly attributed to economic concerns. Poverty intersects other inequalities, notably in health and ethnicity, where, for example, evidence demonstrates that ethnic groups with higher rates of poverty also experience higher rates of multiple physical and mental health difficulties and a heightened risk of compulsory mental health treatment in the UK.[iii] Poverty itself is a major risk factor for mental illness at any age. This is especially true for children – children from the poorest 20% of households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%.[iv]
- It is becoming clear that people from Black, Asian and minority ethnic communities in both the UK and the US face a higher risk of dying with the virus than white people. The reasons for this are still unknown but they likely include a complex intersection of social and economic factors. There is extensive evidence that mainstream statutory services fail to engage and meet the needs of some groups of people. BAME individuals are 40% more likely than white people to access mental health support via a criminal justice route rather than voluntarily seeking and accessing support.[v] People from BAME backgrounds experiencing mental distress as a result of coronavirus may be doubly disadvantaged due to economic circumstances and services which fail to respond to their needs in a timely and appropriate fashion. Many may feel a profound sense of institutional betrayal as a result of the unequal impact of the virus on their communities[vi]. It will as important as ever to ensure that responses are culturally informed and that BAME communities are not marginalised.
- People who have themselves been treated in intensive care may require psychological support. Invasive treatments (intubation, sedation) and very high mortality rates on wards can lead to a higher risk of post-traumatic stress symptoms. A recent meta-analysis of published studies established that 20% of those in critical care will suffer significant symptoms of post-traumatic stress disorder (PTSD) during the 12 months after discharge and the prevalence remains high at the 12-month point.[vii] Pre-existing anxiety or depression are major risk factors for PTSD following any episode of intensive care. [viii] This can have a serious impact on future physical health: one UK study found that survivors of critical illness who report symptoms of depression have an increased risk of dying in the two years following discharge from intensive care.[ix]
- There may also be extra demand for bereavement support. Many thousands of people have lost loved ones, often unexpectedly, and estimates suggest that over the next 12 months, thousands more will die from other causes, such as cancer, due to resources being diverted to tackle coronavirus.[x] Restrictions to stop the spread of the virus add constraint to the shock of unexpected loss: people are unable to visit loved ones in intensive care units; self-isolation and shielding can exacerbate feelings of loneliness of abandonment; and normal funeral practices are impossible.[xi] These circumstances make it more likely that individuals may experience complicated grief, or prolonged grief disorder.[xii] Symptoms of complicated grief can overlap with those of moderate to severe depression and post-traumatic stress disorder (PTSD) – it is a risk factor for and can co-occur with both, worsening symptoms and making recovery more difficult. It is also associated with suicidal ideation and sleep disturbance. There may be a growing need to equip therapists and mental health practitioners to enable them to identify complicated grief and provide appropriate support to individuals.
- The voluntary and community sector makes a substantial contribution to supporting mental health and wellbeing in communities. It is a critical counterpart to the NHS, often working in close partnership. The sector’s role in meeting increased demand over time, and supporting mental health needs below thresholds imposed by statutory services in order to avoid increased demand for acute care, will be crucial. This is particularly important in helping people stay well and in challenging health inequalities for groups who have historically been marginalised or let down by services such as some BAME communities and people with multiple and complex needs. In some areas, statutory and voluntary sector bodies have found creative and highly effective ways of working together during the crisis to meet people’s needs at a time of national emergency and reduced capacity across the system[xiii]. But this is not sustainable for many VCS organisations whose funding remains precarious and whose contractual relationships with NHS and local authority commissioners are complex at the best of times[xiv]. While some funding has been provided to help mental health charities during the crisis, it is unlikely to bridge the gap many face between higher demand for support and reduced income this year, and many are at risk of going out of business during this time as a result. There must be a review of the financial sustainability of voluntary and community sector organisations, and appropriate relief to enable them to continue to support and complement statutory services.
Meeting the needs of rapidly discharged hospital patients with a higher level of complexity
- We are concerned that easements to local authority obligations under the Care Act are leading to people with mental illness being discharged from inpatient settings without a care assessment or a care plan in place. Wraparound community support is vital in ensuring that people get the help they need to recover and live more independently. Where people are discharged without their needs being met, there is a likelihood that they will require readmission to inpatient care sooner. There needs to be clearer guidance and less variation on how people are discharged from mental health inpatient settings, including how their needs have been assessed and how decisions have been made.
- At the same time, because there is less capacity to plan for and provide complex care in the community, we have heard of cases where people with complex needs are being kept on mental health wards for longer than is beneficial to their mental health. Efforts to understand the scale of this is currently challenging due to the suspension of data collection on delayed transfers of care (DToCs).
Providing healthcare to vulnerable groups who are shielding
- People with some long term conditions, such as chronic obstructive pulmonary disease (COPD) and diabetes, have been identified as clinically vulnerable to the coronavirus, and may be more likely to self-isolate or shield. There is a bidirectional relationship between mental health and physical conditions. People with a mental illness are more likely than the generally population to suffer from most physical health problems: for example with a threefold higher risk of diabetes and double the risk of heart disease, asthma and COPD[xv]. And people with long-term physical health conditions are twice as likely to have a mental health problem at the same time. Approximately 4.6 million people have both a long-term condition and a mental health problem – this equates to 46% of those with a mental health problem and 30% of people with long term conditions.[xvi] People who are vulnerable or being shielded because of a long-term condition will be especially at risk of poorer mental health at this time. Mental health support to people with long-term conditions is still very patchy, and made all the more difficult by social distancing measures.
- Women and children exposed or at risk of experiencing domestic violence and abuse in the home are also at greater risk. Emergency measures disproportionately affect women and children by potentially exposing them to further danger and reducing their access to external support networks and vital services which keep them safe and well. For children and young people, this increases the risk of exposure to adverse experiences that can have lifelong consequences for their mental health[xvii]. Following trauma, women are more likely to suffer from eating disorders, self-harm, personality disorders and other internalising disorders.[xviii] Women are ten times as likely as men to have experienced extensive physical and sexual abuse during their lives: of those who have, 36% have attempted suicide, 22% have self-harmed and 21% have been homeless.[xix] Within the current environment, it may be difficult for services to offer choices to women and to provide access to safe physical spaces, especially when they are shielding or otherwise vulnerable to Covid-19. Services during and after lockdown must still consider how they can respond to trauma by communicating with and listening to women about their needs and responding in a holistic, tailored way.[xx]
- Social distancing and shielding many increase the likelihood that older adults experience loneliness and negative psychological effects of social isolation. Research has associated this with higher risks for a variety of conditions, including high blood pressure, heart disease, obesity, anxiety, depression, cognitive decline and Alzheimer’s disease.[xxi] Digital offers may be less appropriate for reaching this group, so – while observing necessary social distancing – opportunities for home visits or personal contact from NHS volunteers should be considered.
How to ensure that positive changes that have taken place in health and social care as a result of the pandemic are not lost as services normalise
- Advances in the use of digital technology have been cited as a key positive change for mental health services. This is promising, but digital can be a prohibitive medium for people without access to technology (for example while young people are generally very positive about digital communication, many reply on phones rather than other devices, do not have an email address and may not have sufficient data to engage online with mental health services), who aren’t physically comfortable using it (older people, people with dexterity issues), or who need a more personal approach, who may not trust remote communication or be able to use it in their homes for privacy and safety reasons. While we encourage this area to be explored, outcomes of digital support must be closely monitored, and should not be assumed that it is the most appropriate mode of intervention for everyone long-term. Digital as default will perpetuate inequalities.
- The temporary move to suspend the conditionality of benefit payments is welcome. The temporary measures put in place by DWP during the crisis are an important opportunity to assess how far the current approaches to assessing disability benefit eligibility and placing conditions on out of work benefits are actually needed. Accessing benefits can be especially hard for people with mental health problems. We know from our own research and from consulting with practitioners in mental health services that many crises relate to problems such as debt crisis, finances, housing, and relationship breakdown. Around half of all people with problem debts also have a mental health problem, compared with 14% of the population without such financial difficulties, and people with a mental health problem are roughly three times as likely to be in debt as those without – the likelihood rises to four times among people with severe mental illness.[xxii] In light of the economic aftermath of coronavirus, enabling people with mental health problems to access the financial help they need and are entitled to in a fair and transparent way should be a priority. Getting this right will also help reduce the need for mental health and other services.
[ii] Janke, K., Lee, K., Propper, C., Shields, K. and Shields, M. (2020), ‘Macroeconomic conditions
and health in Britain: aggregation, dynamics and local area heterogeneity’, Centre for
Economic Policy Research (CEPR), Discussion Paper DP14507.
[iv] Morrison Gutman, L. et al (2015) Children of the new century. London: Centre for Mental Health and University College London
[vi] Centre for Mental Health (2020) Trauma, coronavirus and mental health https://www.centreformentalhealth.org.uk/trauma-mental-health-and-coronavirus
[vii] Righy C, Rosa R, Amancio da Silva R, Kochhann R, Migliavaca C, Robinson C , Teche S, Teixeira C , Bozza F & Falavigna M (2019) Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis. Critical Care. 23:213 https://doi.org/10.1186/s13054-019-2489-3
[viii] Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–9.
[ix] Hatch, R., Young, D., Barber, V. et al. Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study. Crit Care 22, 310 (2018). https://doi.org/10.1186/s13054-018-2223-6
[x] Lai, A., Pasea, L., Denaxas, S., Chang, W.H, Pillay, D., Noursadeghi, M., Linch, D., Hughes, D., Forster, M., Turnbull, C., Boyd, K., Foster, G., Cooper, M., Pritchard-Jones, K., Sullivan, R., Davie, C. and Hall, G. (2020). Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency. 10.13140/RG.2.2.34254.82242.
[xi] Gov.UK (31 March 2020), Press release – ‘New advice for safe funerals after discussions with faith leaders’, accessed April 2020. 29. Sherwood H (4 April 2020), ‘UK councils begin to ban funeral ceremonies due to coronavirus’. The Guardian, accessed April 2020; https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Supporting%20yourself%20and%20others.pdf
[xii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990943/; https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1183832314
[xiii] Centre for Mental Health, Association of Mental Health Providers and Mental Health Network (2020) Supporting mental health in communities during the coronavirus crisis https://www.centreformentalhealth.org.uk/mental-health-communities-coronavirus
[xiv] Bell, A and Allwood, L (2019) Arm in arm https://www.centreformentalhealth.org.uk/arm-in-arm
[xvi] Naylor, C. et al (2012) Long-term conditions and mental health: the cost of co-morbidities. The King’s Fund and Centre for Mental Health.
[xx] https://www.centreformentalhealth.org.uk/sites/default/files/2019-05/CentreforMH_EngagingWithComplexity.pdf; https://www.centreformentalhealth.org.uk/sites/default/files/2019-11/CentreforMH_ASenseOfSafety_0.pdf
[xxi] https://www.ncbi.nlm.nih.gov/pubmed/23749730; Shankar, A., McMunn, A., Banks, J. and Steptoe, A. (2011), ‘Loneliness, social isolation, and behavioral and biological health indicators in older adults’, Health Psychology, 30(4), 377– 85. Steptoe, A., Shankar, A., Demakakos, P. and Wardle, J. (2013), ‘Social isolation, loneliness, and all-cause mortality in older men and women’, Proceedings of the National Academy of Sciences of the United States of America, 110(15), 5797–801.
[xxii] Jenkins, R., Bebbington, P., Brugha, T. et al. (2009) Mental disorder in people with debt in the general population. Public Health Medicine, 6(3), 88-92.