The NZ mental health plan and serious mental illness.

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The NZ mental health plan and serious mental
illness.

• Serious Mental Illness module
• Lecture I
• Chris Gale
• Department of Psychological Medicine,
• Dunedin School of Medicine.
• University of Otago

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New Zealand Mental Health Plan.

• Official documents Te Tahuhu
• Te Tahuhu is the ridgepole that provides
  essential support.
• Full document emphasisies that all these issues
  need to be implemented by the collective of
  people.
• Language remains politically correct, without
  good definitions (particularly of recovery), and
  does not consider evidence base around treatment.
• Services are left with multiple goals, at times
  conflicted. This has led to this document being
  of limited utility to clinicians.
• The following text is taken from the website.

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Te Tahuhu Improving Mental health 2005-2015

• Te Tahuhu Improving Mental Health outlines
  Government policy and priorities for mental
  health and addiction for the 10 years between
  2005 and 2015, and provides an overall direction
  for investment in mental health and addiction. It
  builds on the current Mental Health Strategy
  contained in Looking Forward (1994) and Moving
  Forward (1997), and the Mental Health
  Commissions Blueprint for Mental Health Services
  (1998).
• Te Tahuhu Improving Mental Health has been
  informed by extensive public consultation and
  consultation with the health sector over the past
  18 months and responds, in particular to the
  calls from the sector for a more strategic and
  over-arching plan. It is based on an outcomes
  framework and describes ten leading challenges
  that need to be addressed in order for government
  outcomes for mental health and addiction to be
  achieved.

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All New Zealanders in their communities

• People
• make informed decisions to promote their mental
  health and wellbeing
• value diversity and support and enable people
  with experience of mental illness and addiction
  to fully participate in society and in the
  everyday life of their communities and whanau
• Service
• see a trusted and high-performing mental health
  and addiction sector, and have confidence that if
  they need them, they can access high-quality
  mental health and addiction services

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People with experience of mental illness and
addiction

• Person
• have the same opportunities as everyone else to
  fully participate in society and in the everyday
  life of their communities and whanau
• Service
• experience trustworthy agencies that work across
  boundaries and enable service users to lead their
  own recovery
• experience recovery-focused mental health
  services that provide choice, promote
  independence, and are effective, efficient,
  responsive and timely

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Whanau and friends who support and who are
affected by people with experience of mental
illness and addiction

• Person
• maintain their own wellbeing and participate in
  society and in the everyday life of their
  communities and whanau
• Service
• experience agencies that operate in a way which
  enables them to support their family members
  recovery and maintain their own wellbeing

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Leading Challenges.

• Promotion and prevention
• Promote mental health and wellbeing and prevent
  mental illness and addiction
• Building mental health services
• Build and broaden the range and choice of
  services and supports, which are funded for
  people who are severely affected by mental
  illness
• Responsiveness
• Build responsive services for people who are
  severely affected by mental illness and/or
  addiction
• Workforce and culture for recovery
• Build a mental health and addiction workforce --
  and foster a culture amongst providers -- that
  supports recovery, is person centred, culturally
  capable, and delivers an ongoing commitment to
  assure and improve the quality of services for
  people
• Maori mental health
• Continue to broaden the range, quality and choice
  of mental health and addiction services for Maori
• Primary health care
• Build and strengthen the capability of the
  primary health care sector to promote mental
  health and wellbeing and to respond to the needs
  of people with mental illness and addiction
• Addiction
• Improve the availability of and access to quality
  addiction services, and strengthen the alignment
  between addiction services and services for
  people with mental illness
• Funding mechanisms for recovery
• Develop and implement funding mechanisms for
  mental health and addiction that support
  recovery, advance best practice and enable
  collaboration
• Transparency and trust
• Strengthen trust in services and accountability
  and information systems
• Working together

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Te Kokiri The Mental Health and Addiction Action
Plan 2006-2015

• Te Kokiri The Mental Health and Addiction Action
  Plan has been developed to directly implement Te
  Tahuhu Improving Mental Health 2005-2015 The
  Second New Zealand Mental Health and Addiction
  Plan.
• Te Kokiri is the result of extensive consultation
  with the mental health and addiction sector over
  the past two years.
• The Ministry of Health and District Health Boards
  jointly developed the action plan and undertook a
  comprehensive approach to its development.
• An Advisory Group was established in August 2005
  made up of representatives of the Mental Health
  Commission and District Health Boards, along with
  individuals selected on the basis of their
  expertise, skills and knowledge. A process of
  pre-consultation on a draft to elicit broader
  sector feedback included
• senior peer reviewers
• feedback on a draft from key stakeholders
• presentations to key groups.
• This was followed by a formal consultation period
  and analysis of submissions, in March/April 2006.
• Te Kokiri is a high-level document that takes a
  comprehensive approach, and like Te Tahuhu
  Improving Mental Health includes a mix of both
  high-level initiatives and specific operational
  actions. In relation to specific actions, key
  stakeholders and milestones/measures are
  identified. Timeframes are set and clustered
  around three time periods, 1-3 years, 3-5 years
  and 5-10 years.
• The action plan also clearly defines the
  responsibilities of the Ministry of Health and
  District Health Boards, the two agencies with
  stewardship responsibilities for implementing the
  action plan.

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Te Kokori as a centrally directed document..

• Long.
• Detailed, but without hard outcomes.
• Over emphasis political needs not research base
• Sense that the government can manage research and
  determine outcomes.
• Directions towards recovery, inclusiveness.
• Lack of ethical considerations (lost in
  postmodern sense of silence).
• Driven by ministry and managerial clinicians.
• Important for DHBs as the government is the
  monopoly funder.

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Consequences of the national guidelines.

• One size fits all outcomes.
• Denigration of professional skills.
• Elevation of central planners and managers.
• Paradoxically, a loss of political power by
  consumers who are now subsumed into the
  ministerial discourse.
• Use of terms without clear definitions or not
  needed
• Tanagata Whaiora.
• Recovery.

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Problems with definitions.

• What is the purpose of mental health?
• What is Serious Mental Illness?
• Who is a mental health user?
• What is recovery?

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Psychiatry vs mental health.

• Psychiatry is part of medicine.
• We treat diseases cure, control, comfort.
• We deal with people who have illnesses, within
  the ethical bases and boundaries of medicine.
• We use a clinical and scientific evidence base to
  do this.
• Mental Health is wholistic.
• Not just the absence of disease, but wellbeing.
• Based on populations
• Paradoxically, easy to measure, and general
  approach is taken from a political or public
  health paradigm.
• This can and has been subverted during the
  neoliberal (Thatcherite in UK) move to all
  aspects of government being run by technocratic
  managers, as if in a market.

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What is Serious Mental Illness

• USA
• The definition of SMI stipulated in PL 102-321
  requires the person to have at least one 12-month
  DSM disorder, other than a substance use
  disorder, and to have "serious impairment."
  Subsequently, SAMHSA decided that "serious
  impairment" should be defined as a Global
  Assessment of Functioning (GAF) score of less
  than 60.
• (Kessler, Arch Gen Psych, 2003)
• UK
• For 25 years the care of serious mental illness
  (SMI which usually denotes schizophrenia, severe
  depression, and mania)...
• (Marks, Brit J Psych, 1994)

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What is recovery?

• Abscence of disease equivelant to remission
  (which we can measure eg. HAM-A less than seven
  for GAD).
• Living well with a disability (or by extension, a
  disease).
• Taking the symptoms of mental illness and turning
  remission into a form of spiritual growth.
• A form of political empowerment for people who
  have been in the psychiatric system. (Often
  associated with antipsychiatry)

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Who has SMI? Buhagiar K, Parsonage L, Osborn DP.
BMC Psychiatry 2011 Jun 24

• People with SMI and non-psychotic mental illness
  were recruited from an out-patient adult mental
  health service in London.
• Cross-sectional comparison between the two groups
  was conducted by means of a self-completed
  questionnaire.
• A total of 146 people participated in the study,
  52 with SMI and 94 with non-psychotic mental
  illness. There was no statistical difference
  between the two groups with respect to the
  perception of global physical health.
• However, physical health was considered to be a
  less important priority in life by people with
  SMI (OR 0.5, 95 CI 0.2-0.9, p 0.029). There
  was no difference between the two groups in their
  desire to change high risk behaviours.
• People with SMI are more likely to have a health
  locus of control determined by powerful others (p
  lt 0.001) and chance (p 0.006).
• People with SMI appear to give less priority to
  their physical health needs. Health promotion for
  people with SMI should aim to raise awareness of
  modifiable high-risk lifestyle factors. Findings
  related to locus of control may provide a
  theoretical focus for clinical intervention in
  order to promote a much needed behavioural change
  in this marginalised group of people.

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• SMI smoke more, but want to change like non SMI
• SMI non SMI exercise little, but SMI less
  motivated to change.

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Does SMI Matter. (Hayes, Cheung et al, J Psychom
Res. Feb 2012)

• Aim to see if aggression, hallucinations,
  delusions or other factors contribute to excess
  mortalility in SMI.
• SMI cases gt 15 years in large mental healthcare
  case register (South London and Maudsley Trust
  (SLaM), 2007 2010
• 6880 cases, 242 deaths
• Bipolar disorder was associated with reduced
  mortality risk compared to schizophrenia (HR 0.7
  95 CI 0.40.96 p 0.028).
• Mortality was not significantly associated with
  hallucinations and delusions or
  overactiveaggressive behaviour, but was
  associated with physical illness/disability.
• There was a positive association between
  mortality and subclinical depression among
  individuals with schizophrenia (HR 1.5 1.12.2
  p 0.019) but a negative association with
  subclinical and more severe depression among
  those with schizoaffective disorder (HR 0.1
  0.020.4 p 0.001 and 0.3 0.10.8 p 0.021,
  respectively).

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Cox regression analyses of factors associated
with all cause mortality in the cohort (6880
individuals with schizophrenia, schizoaffective
and bipolar affective disorder). Hayes, Chang et
al. J PsychoSom Res Feb 2012
Variables Crude hazard ratio (95 CI) Adjusted hazard ratio (95 CI) Adjusted P value
Overactivity and aggression Overactivity and aggression Overactivity and aggression Overactivity and aggression
 Not a problem Referent Referent
 Subclinical, minor problem requiring no action 1.0 (0.71.4) 0.8 (0.61.2) 0.333
 Mild to very severe problem 1.2 (0.91.6) 1.1 (0.81.6) 0.604
Hallucinations and delusions Hallucinations and delusions Hallucinations and delusions Hallucinations and delusions
 Not a problem Referent Referent
 Subclinical, minor problem requiring no action 1.2 (0.81.8) 1.1 (0.71.6) 0.773
 Mild to very severe problem 1.2 (0.91.6) 1.0 (0.71.4) 0.99
Depressed mood Depressed mood Depressed mood Depressed mood
 Not a problem Referent Referent
 Subclinical, minor problem requiring no action 1.2 (0.91.6) 1.2 (0.91.7) 0.174
 Mild to very severe problem 0.9 (0.61.2) 0.9 (0.61.3) 0.534
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Variables Crude hazard ratio (95 CI) Adjusted hazard ratio (95 CI) Adjusted P value
Diagnosis Diagnosis Diagnosis Diagnosis
Schizophrenia Referent Referent
Schizoaffective disorder 0.9 (0.61.3) 1.0 (0.61.5) 0.927
Bipolar disorder 0.6 (0.50.9) 0.7 (0.40.96) 0.028
Physical illness or disability Physical illness or disability Physical illness or disability Physical illness or disability
 Not a problem Referent Referent
 Subclinical, 2.9 (2.14.1) 1.9 (1.32.7) 0.001
 Mild to very severe problem 5.3 (3.97.1) 3.0 (2.14.1) lt 0.001
Non-accidental selfinjury Non-accidental selfinjury Non-accidental selfinjury Non-accidental selfinjury
 Not a problem Referent Referent
 Subclinical, 1.3 (0.82.1) 1.4 (0.82.2) 0.227
 Mild to very severe problem 1.0 (0.51.8) 1.0 (0.52.0) 0.969
Problem-drinking or drug taking Problem-drinking or drug taking Problem-drinking or drug taking Problem-drinking or drug taking
 Not a problem Referent Referent
 Subclinical, 1.0 (0.71.6) 1.5 (1.02.3) 0.066
 Mild to very severe problem 0.9 (0.61.3) 1.2 (0.81.8) 0.444
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Variables Crude hazard ratio (95 CI) Adjusted hazard ratio (95 CI) Adjusted P value
Deprivation in area of residence (in tertiles) Deprivation in area of residence (in tertiles) Deprivation in area of residence (in tertiles) Deprivation in area of residence (in tertiles)
 Low levels of deprivation Referent Referent
 Medium levels of deprivation 0.9 (0.71.2) 1.0(0.81.4) 0.842
 High levels of deprivation 0.7 (0.51.0) 0.8 (0.51.1) 0.106
 Homeless 0.7 (0.31.9) 0.7 (0.32.0) 0.507
Level of face to face contact with SLaM services (in tertiles) Level of face to face contact with SLaM services (in tertiles) Level of face to face contact with SLaM services (in tertiles) Level of face to face contact with SLaM services (in tertiles)
 Low level of contact Referent Referent
 Medium level of contact 1.0 (0.71.4) 1.0 (0.71.5) 0.831
 High level of contact 1.1 (0.81.5) 1.5 (1.012.1) 0.043
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Comments SMI.

• SMI is best seen as following diagnoses.
• Level of disability is high.
• SMI are different from non SMI in clinical
  populations.
• SMI may not predict premature death,
• but a diagnosis of schizophrenia does.
• Comorbid physical problems are highly
  significant.
• In South London, those in contact MHS were those
  at highest risk.