Mental and behavioural disorders

Mental wellbeing is the foundation for positive health and effective functioning for individuals and communities.  One in four people will experience mental health problems at some point during their life.

Mental ill-health is common with a significant impact on individuals, their families and the whole population. 22.8% of burden of disease in UK is due to mental disorder and self-reported injury compared to 15.9% for cancer and 16.2% for cardiovascular disease (WHO 2008).

The causes of mental illness are extremely complex – physical, social, environmental and psychological causes all play their part. The problems are unevenly distributed within the population and having mental ill-health further widens existing inequalities.  The impact of mental health problems has wide-ranging and long-lasting effects, including trans-generational impacts which occur more often in groups at higher risk.

Mental health conditions are strongly associated with socioeconomic deprivation.  The connection between rates of mental illness and other factors such as poverty, unemployment and social isolation is well established.

The cost of mental health problems to the economy in England is estimated to be £105 billion, and treatment costs are expected to double in the next 20 years (DH, 2011).

Employment opportunities for people with mental health problems in Hartlepool are very limited and of those long-term unemployed people claiming incapacity benefit, two-thirds have a mental health problem.

Mental health needs in Hartlepool are higher than the national average.  The promotion and development of good mental health is essential to the human, social and economic development of the borough. The potential to promote good mental health lies with a number of agencies such as those responsible for housing, regeneration, social care, employment, leisure and health.

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Last updated: 2016-02-01 14:50:58
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1. What are the key issues?

There are higher than average levels of long-term unemployment, deprivation, drugs use and alcohol-related harm (DH, 2011b).

Hartlepool has 40% greater need in relation of mental illness compared to England and 14% higher need in relation to common mental health problems.

The number of people with a mental illness is predicted to remain at similar levels over the next 5 years, with estimates of around 4,000 people aged 18-64 likely to experience a mental health problem (PANSI, 2015) , there will also be a marked increase in the number of people with dementia.

Mental ill-health is linked with inequality (Marmot, 2010).  Addressing the wider determinants of ill-health will impact positively on both people’s mental health and their inequalities.

A ‘recovery’ approach facilitates improved physical and mental health for people by promoting social inclusion.  Being in good employment is protective of health.  Housing, employment, education and being linked to mainstream community resources and leisure activities are central objectives for mental health services.

 

Last updated: 01/02/16

2. What commissioning priorities are recommended?

Priorities for 3-5 years

2015/01
Increase the numbers of people with a mental health problem who have a personal budget
.

2015/02
Increase the numbers of people in settled employment
.

2015/03
Increase the numbers of people in their own settled accommodation
.  Commissioners in Hartlepool should consider increasing accommodation for people with mental ill-health who need supported accommodation by 2 units in the short-term.

2015/04
Ensure the priorities in the joint mental health plan are achieved
.

Long-term priorities

2015/05
Ensure physical and mental well-being are seen as equal priorities
.

2015/06
Ensure wellbeing services, psychological and family therapies are widely available
.

2015/07
Ensure people receive personalised services and plan their own outcomes
.

2015/08
Ensure people are brought home from out-of-area placements into their communities
.


Previously identified commissioning priorities

Priorities for 3-5 years

2012/01 - replaced by 2015/01
Increase the numbers of people with a mental health problem who have a personal budget.

2012/02 - replaced by 2015/02
Increase the numbers of people in settled employment.

2012/03 - replaced by 2015/03
Increase the numbers of people in their own settled accommodation.  Commissioners in Hartlepool should consider increasing accommodation for people with mental ill-health who need supported accommodation by 2 units in the short-term.

2012/04
Increase the availability of psychological therapies and early intervention services.

Long-term priorities

2012/05 - replaced by 2015/05
Ensure physical and mental well-being are seen as equal priorities.

2012/06 - replaced by 2015/06
Ensure wellbeing services, psychological and family therapies are widely available.

2012/07 - replaced by 2015/07
Ensure people receive personalised services and plan their own outcomes.

2012/08 - replaced by 2015/08
Ensure people are brought home from out-of-area placements into their communities.

 

Last updated: 01/02/16

3. Who is at risk and why?

Age
Mental health problems are more common in older people.  For older people it is estimated that 40% of GP attendees, 50% of Acute Hospital patients and 60% of care home residents have a mental health problem.

Depression affects 1 in 5 older people.  Dementia affects 5% of people aged over 65 and 20% of those aged over 80 (Mental Health Foundation, 2013)

About 10% of children have a mental health problem at any one time (Mental Health Foundation 2013b).


Gender
Women are more likely to have been treated for a mental health problem than men (29% compared to 17%) (Mental Health Foundation, 2013c).

Depression is more common in women than men. One in four women will require treatment for depression at some time, compared to 1 in 10 men (Mental Health Foundation, 2013c).

Women are twice as likely to experience anxiety as men. Of people with phobias or obsessive-compulsive disorder (OCD), about 60% are female (Mental Health Foundation, 2013c).

Boys are more likely to have a mental health problem than girls (Mental Health Foundation, 2013b).

Socioeconomic status
Unemployed people are twice as likely to have depression as those in work.  Only 24% of those with long-term mental health conditions are in work.

The Marmot Review (2010) shows the links between women who suffer from post-natal depression and those living in more deprived areas. Mothers who suffer from post-natal depression are one of the factors relating to children’s chances of doing well at school. The importance therefore of support in the early identification and support of post-natal depression and depressive illness is significant for both women and their children where deprivation is significant.


Ethnicity
Rates of mental ill-health amongst some ethnic groups are estimated to be higher than the general population.


Other risks
People with drug and alcohol problems have higher rates of mental health problems.

Mixed anxiety and depression is the most common mental disorder in Britain (Mental Health Foundation, 2013e).

The UK has one of the highest self-harm rates in Europe: 400 per 100,000 population.  People with current mental health problems are 20 times more likely than others to report having harmed themselves in the past (Mental Health Foundation, 2013f).  See the suicide and self-harm topic for further details.

National statistics show that at least 1 in 4 people will experience a mental health problem at some point in their life and one in six adults has a mental health problem at any one time (DH, 2011).

Almost half of all adults will experience at least one episode of depression during their lifetime. DH 2011.

Nine out of ten prisoners have a mental disorder.

More than 70% of the prison population has two or more mental health disorders.  The suicide rate in prisons is almost 15 times higher than in the general population (Mental Health Foundation, 2013d).


Dementia
Two-thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only one-third of GPs feel they have adequate training in diagnosis of dementia.

Two-thirds of people in care homes have dementia; dependency is increasing; more than half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs.

About 180,000 people with dementia are on antipsychotic drugs in the UK.  In only about one-third of these cases are the drugs having a beneficial effect and there are 1,800 excess deaths per year as a result of their prescription.

Forty percent of people in acute hospitals have dementia; the excess cost is estimated to be £6m per annum in an average general hospital; co-morbidity with general medical conditions is high and people with dementia stay longer in hospital than those without.

 

Last updated: 01/02/16

4. What is the level of need in the population?

In 2008 a MORI poll in Hartlepool identified subjective reports of anxiety, depression or ‘nerves’ at over 20%.

Objective studies including the mental health needs indicator and the National Psychiatric Morbidity Survey suggests Hartlepool has 4% greater needs than the national average in relation to serious mental illness and 14% higher needs for common mental health problems.

Hartlepool MIND offer Improved Access to Psychological Treatments (IAPT) services for people with anxiety and depression. Staff are trained and registered as cognitive behavioural therapists. This service is well used with a recovery rate of 79% (as measured by CORE 10, GAD 7 and PHQ9). Waiting lists are growing: in 2010 there was a 2 week wait for assessment and in 2011 this had become a 12-week wait for services with 45 people waiting for assessment and 22 people waiting for therapy.

Hartlepool PCT saw a rise of 6.6% in anti-depressant prescriptions between December 2009 and December 2010 equating to nearly 90,500 prescriptions being issued over 12 months.  Prescription of Benzodiazepine-type medications in Hartlepool is less than regional or national average: the regional standardised rate of prescribing is 1.64, the national average is 1.69 and in Hartlepool it is 0.96. 

There are forty-three people with mental ill-health in residential / nursing placements in Hartlepool with an additional 7 people placed out of the area.  The unit cost expenditure per person per week averages £530 with some of the out of area placements reaching £2,830 per week due to the nature and complexity of needs.

There are currently 53 units of accommodation-based services for people with mental ill health, homelessness complex needs and drug and/or alcohol issues.

There are no delayed discharges from hospital because of insufficient accommodation in respect of people with mental ill-health leaving hospital. 

Depression
Hartlepool data for 2010/11 shows 7,200 adults on general practice registers recorded as having depression.  In 2011/12, Hartlepool had significantly fewer adults with depression than England (10.5% and 11.7%, respectively) (NEPHO, 2013).  This is an increase from the prevalence identified in 2010/11.Prevalence of depression, Tees, 2010/11

 

Dementia
In 2010/11, there were approximately 440 people with dementia recorded on general practice registers in Hartlepool.  From being significantly below the England average in 2010/11, the prevalence of dementia in Hartlepool in 2011/12 rose to 0.54%, similar to the England average (0.53%).Prevalence of dementia, Tees, 2010/11

 

Psychoses
In 2010/11, there were 680 people on mental health registers with serious mental illness in Hartlepool.  The register includes all people with a diagnosis of schizophrenia, bipolar affective disorder and other psychoses rather than all mental health problems.  The recorded prevalence in Hartlepool is statistically significantly below the England and North East averages.Prevalence of psychoses, Tees, 2010/11

 

The North East, at 17.5%, is the only English region with an estimated prevalence of possible psychiatric disorder that is significantly higher than the England average (13.2%) (Health Survey for England). Given the pattern of risk factors for mental ill-health, the North East displays some of the highest rates of mental ill-health in England.

The data for depression, dementia and psychoses present an opposing view to the psychiatric morbidity survey (2001).  This could suggest an improvement in mental health in Hartlepool in the past decade, an under-recording of mental health issues in general practice, or a combination of these.

Community Mental Health Profiles
The North East Public Health Observatory has produced profiles covering a range of mental health indicators.  The summary below provides an overview for Hartlepool and the full profile can be found at:
http://www.nepho.org.uk/cmhp/index.php?view=E06000001.

Many of the determinants of mental health and risks for poor mental health are worse than the national average.  However, the majority of treatment indicators are similar to or better than England averages.

Mental health profile spine char, part A, Hartlepool, 2013

Mental health profile spine chart, part B, Hartlepool, 2013

Mental health profile key

In 2009/10 there were 2,274 adults accessing NHS specialist mental health services in Hartlepool.  This is an increase on the 2,090 in 2008/9 (NHS Information Centre, 2011).

Deprivation is identified as a significant indicator of risk for mental health problems.  Hartlepool is ranked 24th most deprived local authority of 326 in England (DCLG, 2010)

The National Psychiatric Morbidity Survey (2001) showed that Hartlepool has 40% greater needs than the national average in relation to mental illness and 14% higher needs for common mental health problems.  Prevalence in males is higher than females. 

Clients receiving services
The number of clients with mental health problems receiving services in Hartlepool has fluctuated considerably in recent years.  In particular there was a reduction from 495 clients receiving services in 2009/1 to 175 clients in 2010/11 (numbers are rounded to the nearest 5).  The majority of people receive community-based services, with around 15 clients receiving residential care and a similar number receiving nursing care.

Number of clients aged 18-64 receiving services, Tees Valley, 2008/09 to 2010/11Clients receiving services, Tees Valley, 2008/09 to 2010/11

Source: NASCIS Information Centre - RAP P1

Accommodation
Hartlepool has a higher proportion of adults with mental health problems in settled accommodation than elsewhere in Tees Valley.  However, one-in-five of these adults are not in settled accommodation.

Adults in contact with secondary mental health services in settled accommodation, Tees Valley, 2008/09 to 2010/11Adulth in settled accommodation, Tees Valley, 2008/09 to 2010/11

Source: NASCIS Information Centre

Employment
In Hartlepool, 8.7% of adults in contact with secondary mental health services were in employment, up from 5.2% in 2008/9.  In Darlington and Redcar & Cleveland over 10% are in employment.

Adults in contact with secondary mental health services in employment, Tees Valley, 2008/09 to 2010/11Adults with mental ill-health in employment, Tees Valley, 2008/09 to 2010/11

Source: NASCIS Information Centre


Residential and nursing homes
The number of people with mental health problems who are supported in residential and nursing homes has increased in Hartlepool from 30 in 2008/9 to 40 in 2010/11 (numbers rounded to nearest 5).

Adults with mental health problems who are supported in residential and nursing homes, Tees Valley, 2008/9 to 2010/11Adults with mental ill-health supported in nursing and residential homes, Tees Valley, 2008/09 to 2010/11

Source: NASCIS ASC-CAR S1

Self-directed support and direct payments
Self-Directed Support and Direct Payments for mental health are distributed differently in Hartlepool compared to elsewhere in Tees Valley.  In Hartlepool, fewer clients receive direct payment (not self-directed support) but more receive self-directed support than in other areas of Tees Valley.
Self-directed support and direct payments, Tees Valley, 2009/10 to 2010/11

Self-directed support and direct payments, Tees Valley, 2009/10 and 2010/11

Data Source: NASCIS RAP SD1

Incapacity benefit
Incapacity benefit levels for mental health in Hartlepool are more than 70% higher than the England average, and above the North East average.Incapacity benefit for mental illness, Tees, 2009/10
 

 

Last updated: 11/04/13

5. What services are currently provided?

Mental Health Services in Hartlepool are provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and Hartlepool Borough Council in partnership.  The Local Authority contributes approximately £2 million and TEWV £4 million (direct costs and including inpatient services).

Adult mental health services in Hartlepool cover an age range from 18 years and include people over 65 years with a functional mental illness.  Eligibility criteria are set at substantial or critical levels of need within the Fair Access to Care Services (FACS) framework for the local authority and the Care Programme Approach for specialist mental health services.

Low level interventions that can delay or prevent people having access to more costly, specialised services are supported with grants to the voluntary and community sector.
For the Child and Adolescent Mental Health Services (CAMHS), Hartlepool received nearly 600 referrals in 2010/11, a 7% increase in referrals from 2009/10. Referrals are allocated on a daily basis. CAMHS provide a range of assessments and therapies as well as training and consultation to other agencies for young people and mental health problems and the promotion of mental health.

The JSNA 2010 committed to developing services to ensure the best possible mental health and wellbeing for people:

  • Easier access to services and more choice.
  • Improved mental health and wellbeing.
  • Promoting recovery.

One way to tackle inequalities in service provision is to deliver a personalised approach that identifies the specific needs of each individual and their families and carers.  This enables people to have more control over the services they receive.

The number of people with mental-ill health who have a personal budget and therefore choosing services independently continues to grow .  A significant number of people still opt to use traditional services but increasingly people are using direct payment to commission their own support.  By 2013 all people with mental ill-health who have social care needs should be offered a personal budget.  In the future Personal Health Budgets will increase choice and control for people using mental health services.

 

Last updated: 01/02/16

6. What is the projected level of need?

The social determinants of mental ill health will impact on the projected number of people with mental ill health in future years.  The levels of deprivation and in particular poverty, unemployment, poor physical health, a lack of appropriate accommodation, homelessness, domestic violence and social exclusion all affect people adversely and undermine mental wellbeing.

Forecast number of working age adults (18-64 years) with mental health problems, Hartlepool, 2010 to 2030

 

Male

Female

Diagnosis

2010

2030

Change (%)

2010

2030

Change (%)

Common mental disorder (anxiety, depression, etc)

3438

3438

0

5615

5398

-4%

Borderline personality disorder

83

83

0

171

164

-4%

Anti-social personality disorder

165

165

0

29

27

-7%

Psychotic disorder

83

83

0

143

137

-4%

Source: www.pansi.org.uk

Note:  This table is based on the report Adult psychiatric morbidity in England, 2007: Results of a household survey, published by the Health and Social Care Information Centre in 2009.  Details of the diagnoses can be found on the PANSI website (registration needed).

People aged 18-64 predicted to have a mental health problem, projected to 2030 show an average 2% decrease in numbers.  This reflects predicted decrease in the 18-64 years population of Hartlepool, from 55,800 in 2010 to 54,900 in 2030.

Forty people with mental ill-health live in residential and nursing care (2010) and this number is not expected to change.

The number of people aged over 65 with dementia is expected to increase by 15% in the next 5 years, and by 30% within ten years.  By 2022 there is likely to be 1,300 people suffering dementia in Hartlepool, compared with 1,030 in 2012.  Similar increases are forecast for people aged over 65 with depression and severe depression.  These increases are due, in most part, to the increasing numbers of older people.

Forecast mental illness, Hartlepool, 2011 to 2030

 

Last updated: 01/02/16

7. What needs might be unmet?

There is evidence of a short waiting list (averaging 1 or 2 people) for people with mental ill-health who need supported accommodation in Hartlepool.

There are 7 people placed out of area due to their specialist / complex / dual diagnosis needs.  Further analysis should take place to determine whether it would be cost-effective to consider commissioning suitable services locally.

The numbers of people with mental ill-health who have a personal budget and use a direct payment to commission their own support services is growing. There was 1 personal budget in mental health services in 2007 and 140 in November 2011. These numbers are expected to continue to increase significantly over the next 3 years.  As these numbers increase commissioners will need to identify appropriate services for de-commissioning otherwise there will be a significant risk of double running costs.

Waiting lists for IAPT and talking therapies indicate the need for additional services to meet need. In February 2012 there were 45 people waiting for assessment and 22 people waiting for therapy with a waiting time of approximately 8 weeks. In 2010/2011 the waiting list was 2 weeks (Source: Hartlepool MIND).

The CAMHS service has seen an increase in the number of bereavement referrals over the year due to funding pressures being felt by local bereavement services. There is a need for Autistic Spectrum Disorder services in Hartlepool and a requirement for improving access to the CAMHS service through extended opening hours and alternative venues to accommodate young people and families. The current service opens 8am–6pm, Monday to Friday.

 

Last updated: 01/02/16

8. What evidence is there for effective intervention?

National Institute for Health and Care Excellence

Public Health Guidance

Social and emotional wellbeing in primary education (PH12)

Mental wellbeing and older people (PH16)

Social and emotional wellbeing in secondary education (PH20)

Promoting mental wellbeing at work (PH22)

Social and emotional wellbeing: early years (PH40)

 

Clinical Guidance

Eating disorders (CG9)

Self-harm (CG16)

Violence (CG25)

Post-traumatic stress disorder (PTSD) (CG26)

Depression in children and young people (CG28)

Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31)

Bipolar disorder (CG38)

Dementia (CG42)

Antenatal and postnatal mental health (CG45)

Attention deficit hyperactivity disorder (ADHD) (CG72)

Antisocial personality disorder (CG77)

Borderline personality disorder (BPD) (CG78)

Schizophrenia (CG82)

Depression in adults (CG90)

Depression with a chronic physical health problem (CG91)

Anxiety (CG113)

Psychosis with coexisting substance misuse (CG120)

Common mental health disorders (CG123)

Self-harm (longer term management) (CG133)

Service user experience in adult mental health (CG136)

Psychosis and schizophrenia in children and young people (CG155)

 

Quality Standards

Service user experience in adult mental health (QS14)

 

The Centre for Evidence-Based Health Care (http://cebmh.warne.ox.ac.uk) promotes the teaching and practice of evidence based health care (with emphasis on mental health) both in the UK and internationally.  The principal research groups are concerned with mood disorders, cognitive therapy, eating disorders, evidence-based medication, schizophrenia, suicide and deliberate self-harm.

The Cochrane Collaboration at (http://www.cochrane.org) provides a wealth of information on evidence-based interventions for mental health.

The Social Care Institute for Excellence (http://www.scie.org) shares knowledge about best practice and has a range of evidence-based guides on working with people who have mental ill-health.

In Control (http://www.incontrol.org.uk) has published research to show that personal budgets and direct payments improve the lives of people with mental ill health by giving them choice and control over the services they receive.

The Commissioning Friend for Mental Health Services (NMHDU, 2009) outlines the challenges that commissioners of mental health services need to note:

  • Personalisation and personal budgets;
  • Improving quality;
  • Reduced budgets;
  • Commissioning in partnership (Health and Social Care);
  • Engagement of service users, carers and their families.


In summary, to improve mental health, there is a strong evidence base for:

  • Recovery-based interventions;
  • Early interventions using talking therapies;
  • Promoting employment and good quality housing; and
  • Personal budgets.

 

Last updated: 01/02/16

9. What do people say?

A consultation event (Autumn 2009) gathered the views of 130 people who use mental health services and providers.  People said they wanted:

  • Better partnership working between service providers.
  • Treating people holistically and not just as ‘a mental health problem’.
  • More emphasis on prevention, more personalised services, more choice, more community provision and personal budgets with clear outcomes.
  • More alternatives to medication, for example, talking therapies.
  • Better information and the use of text and e-mail messages to confirm appointments.
  • Improved integrated information systems, single databases and better use of assistive technologies. 

A replacement for the Mental Health Local Implementation Team is currently in development and this body will be accountable to the Health and Wellbeing Board.

 

Last updated: 01/02/16

10. What additional needs assessment is required?

Review out of area placements to determine whether services could be developed and commissioned locally to enable people to be moved back to Hartlepool.

Review talking therapies to determine the level of additional services required.

Review the take up of Personal Budgets and Direct Payments, monitor budgets and decommission elements of traditional services appropriately to minimise the risk of double-funding services.

Evaluate the results of the CAMHS review.

 

Last updated: 01/02/16

Key contact

Name: Neil Harrison

Job Title: Head of Service – Hartlepool Borough Council

e-mail: neil.harrison_1@hartlepool.gov.uk

phone:01429 523913

 

Name: Donna Owens

Job Title:

e-mail: donna.owens@nhs.net

Phone: 0191-374-4168

 

References

 

Local strategies and plans

 

 

 

 

 

National strategies and plans

 

Department of Health (2011) No Health without Mental Health: A cross-government mental health outcomes strategy for people of all ages.

Department of Health (DH, 2011b).  No Health Without Mental Health: Across Government Mental Health Outcomes Strategy for People of all ages

Department of Health (DH, 2010a).  The vision for adult social care

Department of Health (DH, 2010b).  Confident Communities, Brighter Futures - a framework for developing well-being

Time To Change national mental health anti stigma campaign. Commencing phase 2 of the campaign following the last 4 years which have shown a decrease in discriminatory attitudes and behaviour.

National Dementia Strategy – living well with dementia 2009

National autism strategy – working together for change 2010

 

Other references

Anxiety UK

Brown et al (2010): Twenty years mortality of a community cohort with schizophrenia.  British Journal of Psychiatry 196 : 116-121

Centre for Evidence-based Health Care

Centre for Mental Health. The economic and social costs of mental illness.  Policy Paper 3 and 2009/10 update.

The Cochrane Collaboration

Department for Communities and Local Government (DCLG, 2011). Indices of Deprivation 2010.

Department of Health (2012). Dementia: News, information and conversations.

Department of Works and Pensions (2010) Statistical Summaries

In Control

Marmot Review (2010). Fair Society, Healthy Lives.

Mental Health Foundation (2007). Fundamental Facts.

Mental Health Foundation (2013). Mental Health Statistics: Older People.

Mental Health Foundation (2013b). Mental Health Statistics: Children and Young People.

Mental Health Foundation (2013c). Mental Health Statistics: Men & Women.

Mental Health Foundation (2013d). Mental Health Statistics: Prisons.

Mental Health Foundation (2013e). Mental Health Statistics: The Most Common Mental Health Problems.

Mental Health Foundation (2013f). Mental Health Statistics: Self-Harm.

Mind

NASCIS, National Social Care Information Service

National Mental Health Development Unit (NMHDU, 2009).  The Commissioning Friend for Mental Health Services: A guide for health and social care commissioners

NHS Health and Social Care Information Centre (NHSIC, 2011). Attitudes to Mental Illness - 2011, Survey report.

North East Public Health Observatory (NEPHO, 2008). Mental Health Observatory Brief 3 - Estimating the Future Numbers of Dementia.

North East Public Health Observatory (NEPHO, 2013). Community mental health profile.

PANSI (2013). Projecting Adult Needs and Service Information.

POPPI (2013). Projecting Older People Population Information System.

Social Care institute for Excellence

World Health Organisation (WHO, 2008).  The Global burden of disease.