Public mental health: required actions to address implementation failure in the context of COVID-19.

Mental disorders account for at least 18% of global disease burden, and the associated annual global costs are projected to be US$6 trillion by 2030. Evidence-based, cost-effective public mental health (PMH) interventions exist to prevent mental disorders from arising, prevent associated impacts of mental disorders (including through treatment), and promote mental wellbeing and resilience. However, only a small proportion of people with mental disorders receive minimally adequate treatment. Compared with treatment, there is even less coverage of interventions to prevent the associated impacts of mental disorders, prevent mental disorders from arising, or promote mental wellbeing and resilience. This implementation failure breaches the right to health, has increased during the COVID-19 pandemic, and results in preventable suffering, broad impacts, and associated economic costs. In this Health Policy paper, we outline specific actions to improve the coverage of PMH interventions, including PMH needs assessments, collaborative advocacy and leadership, PMH practice to inform policy and implementation, training and improvement of population literacy, settings-based and integrated approaches, use of digital technology, maximising existing resources, focus on high-return interventions, human rights approaches, legislation, and implementation research. Increased interest in PMH in populations and governments since the onset of the COVID-19 pandemic supports these actions. Improved implementation of PMH interventions can result in broad health, social, and economic impacts, even in the short-term, which support the achievement of a range of policy objectives, sustainable economic development, and recovery.

Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis.

AIM: Early Intervention Psychosis Services (EIPS) for people experiencing First Episode Psychosis (FEP) offer important clinical and non-clinical benefits over standard care. Similarly, intervention for Clinical High Risk for Psychosis state (CHR-P) can prevent psychosis, ameliorate symptoms and have non-clinical benefits. This study aimed to estimate associated local economic benefits of FEP and CHR-P services compared with standard care. METHODS: Across four south London boroughs, proportion of annual number of new cases of FEP and CHR-P seen by early intervention services was estimated. Economic modelling conducted for England's mental health strategy was applied to estimate local economic impacts of current and improved service provision. RESULTS: Across four London boroughs during 2011/2012, proportion of 15-34 year olds with FEP seen by EIPS was 100.2% assuming 80/100 000 annual incidence whereas proportion with CHR-P seen by CHR-P services was 4.1% assuming 200/100 000 annual incidence. Application of economic modelling suggests that provision of EIPS to reach all new FEP cases each year would free up resources of £13.1m over 10 years including £2.0m to National Health Service (NHS) after the first year. Scaling up to reach all new CHR-P cases each year would free up resources of £19.7m over 10 years with an estimated 10-year cost of implementation gap for each 1 year cohort of £18.9m. An earlier related briefing resulted in increased funding for EIPS and new CHR-P services despite overall cuts to mental health services. CONCLUSIONS: Estimation of local economic impacts of FEP and CHR-P services was associated with improved investment in such services.

Public mental health: key challenges and opportunities.

Public mental health involves a population approach to mental health, and includes treatment of mental disorder, prevention of associated impacts, prevention of mental disorder and promotion of mental well-being, including for those people recovering from mental disorder. Such interventions can result in a broad range of impacts and associated economic savings even in the short term. However, even in high-income countries only a minority of people with mental disorder receive any treatment, while provision is far less in low- and middle-income countries. Coverage of interventions to prevent mental disorder and promote mental well-being is far less even in high-income countries, despite such interventions being required for sustainable reduction in the burden of mental disorder. This implementation gap results in a broad set of impacts and associated economic costs. Mental health needs assessments represent an important framework and mechanism to address this implementation gap - in low- and middle-income as well as high-income countries. Training and support to perform mental health needs assessments is important, as is the use of information derived from such assessments to more effectively advocate for the required level of resources to address the implementation gap. Such a public health approach to mental health represents an opportunity for psychiatrists to advocate more effectively for resources at both the local and national level. This can improve the coverage and outcomes of a range of public mental health interventions that result in broad impacts and associated economic savings, which can be estimated.

Mental health coverage in needs assessments and associated opportunities.

Background: Mental disorders account for almost a third of UK disease burden. Cost effective public mental health interventions have broad public health relevant impacts. Since coverage of such interventions is low, assessment of local coverage is important. Methods: A total of 23 Joint Strategic Needs Assessments (JSNAs) around London were assessed for different mental health intelligence. Results: Mental health was poorly covered and difficult to locate in JSNAs. Only a minority of JSNAs mentioned most mental disorders while far fewer JSNAs provided local prevalence estimates or numbers receiving treatment. Only 6% JSNAs included local wellbeing levels and any mental wellbeing promotion initiative mentioned included no information about coverage. Most JSNAs provided little information about impact of mental disorder or broader determinants on mental health. No JSNAs included associated economic implications or information about size of mental health unmet need. Conclusions: Lack of mental health representation in JSNAs means local authorities and clinical commissioning groups cannot perform statutory duties to assess local health needs to inform strategic development and commissioning. This perpetuates poor coverage of public mental health interventions. Actions to improve mental health representation in JSNAs are suggested. Improved coverage of such interventions will result in broad public health relevant impacts and associated economic savings.

Health inequalities and psychosis: time for action.

People with psychosis face a life-restricting and life-shortening epidemic of obesity, diabetes and cardiovascular disease. This can be predicted by the associated antecedent risk factors evident from early in psychosis, yet remain largely ignored. Greater coordination between primary care, secondary care and public health to systematically prevent and intervene earlier for these physical illnesses offers a realistic solution to reduce this health inequality.

Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England.

BACKGROUND: Globally, smoking remains a significant issue for mental health populations. Many mental health trusts in England are facing challenges of implementing the National Institute for Health and Care Excellence guidance according to which all mental health settings, no matter the type, should be entirely smoke-free and provide comprehensive smoking cessation support. AIM: The aim of this paper was to determine if unit type and unit manager smoking status influence mental health smoke-free policy implementation. METHOD: This paper reports on the secondary analysis of data from a cross-sectional survey of 147 mental health inpatient settings in England, in 2010. The original study's main aim was to understand unit managers' perceived reasons for success or failure of smoke-free policy. RESULTS: Unit managers (n = 131) held a positive stance towards supporting smoke-free policy and most perceived that the policy was successful. Non-smoker unit managers were more likely to adopt complete bans than smoker unit managers, whereas smoker unit managers were more likely than non-smoker unit managers to think that stopping smoking aggravated patients' mental illness. Smoking rates for staff and patients remain high, as perceived by unit managers, regardless of unit type. Proportion of units offering nicotine replacement therapy and peer support to patients was significantly higher in locked units compared to semi-locked or residential rehabilitation. Applied strategies significantly vary by type of unit, whereas unit managers' knowledge, attitude and practices vary by their smoking status. DISCUSSION: There are nuanced differences in how smoke-free policy is enacted which vary by unit type. These variations recognise the differing contexts of care provision in different types of units serving different patient groups. Addressing staff smoking rates, promoting consistency of staff response to patients' smoking and providing staff education and support continue to be key strategies to successful smoke-free policy. CONCLUSIONS: Our results demonstrate the importance of taking into account the type of unit and acuity of patients when enacting smoke-free policy and addressing staff smoking.

Mental health professionals' perspectives on the implementation of smoke-free policies in psychiatric units across England.

BACKGROUND: The original audit on which this 2013 secondary analysis is based, was conducted in 2010. It explored implementation of smoke-free policies from the perspective of unit managers in 147 psychiatric units across England comprising a randomly selected sample of nine different unit types. MATERIAL: Two main themes are presented: positive perspectives of smoke-free policy implementation, and barriers and problems with smoke-free policy implementation. Analysis of unit managers' experiences and perspectives found that 96% of participants thought smoke-free policy had achieved positive outcomes for staff, patients, services and care. DISCUSSION: Consistency of response was the most prominent factor associated with policy success. Quality of the physical environment and care delivery were clear positive outcomes which enabled the environment to be more conducive to supporting staffs' and patients' quit attempts. Lack of consistency and a prevailing culture of acceptance of smoking were identified as some of the most reported perceived continuing problems. Solutions included the need to acknowledge that this type of complex systems change takes time and ongoing staff education and training. CONCLUSION: Our results demonstrate the importance of taking into account the experiences and attitudes of staff responsible for enacting smoke-free policy.

Achieving smoke-free mental health services: lessons from the past decade of implementation research.

The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from smoke-free policy because of complex held views about the capacity of people with mental disorder to tolerate such policy whilst they are acutely unwell, with stakeholders' continuing fierce debate about rights, choice and duty of care. This culture has played a significant role in perpetuating physical, social and economic smoking associated impacts experienced by people with mental disorder who receive care within mental health care settings. The past decade has seen a clear policy shift towards smoke-free mental health settings in several countries. While many services have been successful in implementing this change, many issues remain to be resolved for genuine smoke-free policy in mental health settings to be realized. This literature review draws on evidence from the international published research, including national audits of smoke-free policy implementation in mental health units in Australia and England, in order to synthesise what we know works, why it works, and the remaining barriers to smoke-free policy and how appropriate interventions are provided to people with mental disorder.

Factors associated with success of smoke-free initiatives in Australian psychiatric inpatient units.

OBJECTIVE: Smoking is the largest cause of preventable illness in the United States, the United Kingdom, Canada, Australia, and many other countries. Smokers with mental illness smoke significantly more than those without mental illness and therefore experience even greater smoke-related harm. Internationally, there is increasing pressure on psychiatric inpatient settings to adopt smoke-free policies. This study examined smoke-free policies across psychiatric inpatient settings in Australia and thereby identified factors that may contribute to the success or failure of smoke-free initiatives in order to better inform best practice in this important area. METHODS: Semistructured in-depth telephone interviews were conducted with 60 senior administrators and clinical staff with direct day-to-day experience with smoking activities in 99 adult psychiatric inpatient settings across Australia. Quantitative data were analyzed using descriptive statistical analysis and Pearson's chi square correlations measure of association. RESULTS: Factors associated with greater success of smoke-free initiatives were clear, consistent, and visible leadership; cohesive teamwork; extensive training opportunities for clinical staff; fewer staff smokers; adequate planning time; effective use of nicotine replacement therapies; and consistent enforcement of a smoke-free policy. CONCLUSIONS: A smoke-free policy is possible within psychiatric inpatient settings, but a number of core interlinking features are important for success and ongoing sustainability.