Mental ill-health - From the front line of health challenges 3

Mental health - credit Dierk Schaefer

Much progress has been made in tackling Scotland’s biggest killers: heart and lung disease and cancer. Meanwhile, other leading causes of mortality have been more stubborn to shift. 

Holyrood approached leading clinicians from the front line to examine why, and what policy makers could do to help.

The third of our Q&A with clinicians facing Scotland's persistent health challenges is with Professor Stephen Lawrie, director of PsySTAR, director of the Scottish Mental Health Research Network and honorary consultant psychiatrist with NHS Lothian.

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Is there a typical patient that you see, and if so, what are they like?

I am a general adult psychiatrist working in outpatient and community setting, so I can see almost every kind of psychiatric patient.  They are, however, usually between the ages of 18 and 65 years old and suffering from schizophrenia, bipolar disorder, depression or anxiety.  Some have alcohol or drug problems as well, either as a cause or a consequence of their illness.  I also see quite a number of outpatients with autism or Asperger syndrome because I used to run the regional service up until a year or so ago.  

There isn’t really a typical psychiatric patient as their personalities and characters are just as variable as in the general population, but the majority of patients I see tend to have shown great fortitude and strength of character in dealing with schizophrenia or bipolar disorder for 10 or more years.  If I had to generalise about them, I would say that the average psychiatric patient is perhaps a bit kinder and more sensitive than most other people. 

Despite advancements in tackling Scotland’s biggest killers, deaths related to mental and behavioural disorders have been rising. What are we missing in Scotland? 

Many mental illnesses are associated with an increased mortality rate and suicide only accounts for about 5-10 per cent of early deaths.  The illnesses that kill people with mental illnesses are the same illnesses that kill the rest of us, i.e. heart attacks, strokes and cancer. The reasons for these conditions being ever increasing killers in those with mental illness are complex and multifactorial, but include smoking, drinking, poor diet and inactivity.

There is also evidence that patients with schizophrenia and some other mental illnesses have not had the same benefits from recent advances in managing cancer and heart disease. This is probably because of a lack of access to and uptake of screening and preventative measures through general medical services.  Some of this is because of patients’ lack of engagement but there is also some evidence that medical services are less likely to refer or treat people with illnesses like schizophrenia than the rest of the population, presumably because of some stigmatisation of mental illness. 

What work you and colleagues have done to tackle the problem are you most proud of?

Clinically, I like to think I work well with patients and their GPs, and any medical specialist that may be involved, to ensure they get the medical care they require. In research terms, I have been involved for many years in developing brain imaging and other tools that can try to predict illnesses at the earliest possible stage and that could lead onto earlier treatments and better responses in the longer term.  

More specifically, one of my PhD students, Lily Macnamee, has been working with myself and Professor Gillian Mead, sponsored by the CSO, to develop a novel intervention to increase physical activity in people with schizophrenia and the early pilot results of this intervention look very promising. We hope to get monies to evaluate the intervention in a rigorous clinical trial and then roll out the intervention if appropriate as soon as possible afterwards.

The new mental health strategy consultation talks about prevention. How could people be supported better to live healthier and take more preventative measures?

Prevention is always better than cure but the evidence base for preventing mental illness is very limited. We have generally very good evidence for a range of interventions in most established illnesses, but very little is known about how to promote mental health. In general terms, one can reasonably expect that a good diet, favouring fruit and vegetables in the Mediterranean style, limited alcohol consumption, not smoking, and doing regular physical activity would all benefit general physical and mental health. More specifically, techniques such as stress management and mindfulness are undoubtedly effective in treating anxiety and depression, and may well have a role in generally increasing mental health and reducing the chances that people will develop such conditions, but this is yet to be shown in clinical trials.

What could policymakers do to better support your work? 

Tackling complex and multifactorial problems requires systematic and nuanced approaches.  The single best thing that policymakers could do to support mental health services and research is to establish and ensure parity with physical health services and research. Most health boards in Scotland aim to spend approximately 11 per cent of their budget on mental health services, which is the figure given by the World Health Organisation for ‘disability adjusted life years’ attributable to mental and behavioural disorders.

Many health boards, however, do not even manage this. And yet, because we have effective treatments for most mental illnesses, the figure could be much higher and probably have general benefits for society. A lot more money should be made available for mental health services, especially in younger people. 

The same argument of parity applies, but even more so to mental health research, which is grossly underfunded compared to medical research generally, both by governments and charities. I think the priorities are to see what helps promote mental health and to develop and test novel interventions that prevent mental illness.  

What is the landscape likely to look like in 10 or 20 years’ time?

It is difficult to predict the future, but there are several trends evident in recent years which are likely to continue. More and more money is being spent on community care, and greater integration between health and social care offers great opportunities but there is also a major risk that adequate support of people with mental illnesses in the community does not get the funding it deserves.  

My best bets for how things might improve over the next 10-20 years are that the increasing recognition of the prevalence of mental illness in children and adolescents lead to better services, including preventative and early intervention measures that could be partly based in schools and higher education institutions. There is, for example, good evidence that interventions to treat conduct disorder in boys and psychosis in adolescents is cost-effective for society as a whole.