A teenage boy with a mild form of autism recently jubilantly explained that the lockdown ‘was the best thing that had ever happened to him… exams called off, not meeting anyone apart from family, no pressure’. I could sense that he had been looking forward to telling me, and we both had a good laugh.
Overall, the situation has in my mental health unit been surprisingly quiet during the lockdown. The picture is admittedly mixed around the country, but anecdotally there has been a decrease in demand. There can only be one of two explanations; the need for mental health input has dropped, or professionals, patients and carers do not feel that services will be able to cope with their needs under the current circumstances. While there may be some truth to the former explanation as people are confronted with a palpable, external threat and therefore find new resilience, the latter cause is sadly the more rational explanation.
But this is likely to be the quiet before the storm. The health economic decisions taken across the world in the last months to stop the spread of the virus, could have untold consequences for society… and as per usual, mainly for the most vulnerable, the poor, the marginalised and, not to forget, children and young people. If previous financial crises have taught us anything, it is that mental health deteriorates dramatically in their wake resulting in more morbidity overall along with increases in addictions, violence and suicide rates. The current provision for mental health – in spite of lots of talk of parity between mental and physical health – is a world away from what is needed for the deluge coming our way.
But this is actually not a battle cry for more resources, but rather a call for a radical rethink of how we as a society provide for people with mental health needs. Churchill’s idea of ‘never letting a good crisis go to waste’ is more apt than ever. This may be a unique opportunity to construct a healthier, happier service more fit for 2020 than what we have now. There are without question dedicated mental health staff working themselves into the ground all around the country extending gestures of kindness and good intentions to long suffering patients. But have we been barking up the wrong tree for a very, very long time?
Our NHS services are only geared towards people that are already ill, ‘sick care’ rather than healthcare… in fact, only towards the ones that suffer from a so called ‘severe mental illness’ … whatever that means. Many are left feeling frustrated and helpless, trying to find support either privately, if they can afford it, or relying on what is offered as support through charities and other third sector organisations. The traditional ‘sick care’ approach pacifies and stigmatises.
There is little talk, let alone action, about preventing mental illness, or even building up resilience against the inevitable struggles of human life in the population at large. With data suggesting 50% of all mental illness starts before the age of 14 years preventive solutions have to become a focus if we are to make any serious inroads.
Some hope is provided in the Government’s Green Paper on bringing prevention and early intervention support into schools, though we are still a long way off from what is needed across all demographic groups.
We as a service remain exclusively reactive rather than proactive - endless firefighting, rather than gently removing the matches and petrol before it is too late. The majority of research money goes into biological aspects of psychiatry. Though fascinating and necessary, it has so far had limited impact on the long-term outcomes of our patients. Why prevention? Because of the huge financial loss from the consequences of mental illness to society, but for all, because prevention reduces unnecessary human suffering.
I am not for a moment saying that we should not cater of people that have already fallen ill and attempt to understand the biological underpinnings of mental health problems. But I am certainly saying that we are neglecting a seemingly obvious way to reduce - or perhaps in some cases all together bypass - a lot of problems for society as well as for the individual. I have heard important psychiatrists stating that we do not have the evidence to say that prevention works… no, but why not try to investigate? Why should psychiatry in this aspect be so radically different from, say, cardiology that over the last 50 years has been what can only be termed as unimaginably successful in reducing people dying from cardiovascular problems? Sure, interventions in cardiology have improved, but smoking cessation, exercise advice have played a major role in these improvements.
What have we done in psychiatry? Continued to dish out in principal the same medications that we have had for the last 70 years (antidepressants, anti-psychotics and mood-stabilisers) along with out-patient appointments (psychiatrists, psychologists and other mental health practitioners) and the occasional admission. DNA (did not attend) appointment rates remain disappointingly high. Medication helps some, but in reality, psychiatric patients, more than in other branches of medicine, vote with their feet by being non-compliant (meaning not taken their medication as prescribed). In practice, our over-reliance on medications rumbles on seemingly unaffected by the patient’s consistent verbal and non-verbal feedback.
The last weeks during the Corona crisis have shown that we as a society can adapt very fast – a decade worth of change squeezed into a few weeks. Suddenly everybody is using Zoom, Microsoft Teams and other measures to stay connected. Patients have by and large taken well to the digital offers, and DNA rates have if anything improved. With digital solutions the care is brought right into the home of the patient, less stigma, no travelling, no anxiety about the waiting room or perhaps being detained by the doctor. No risk of Covid! Though solid scientific and real-world evidence for using technology in psychiatry has existed for a while, it took an unwelcome crisis to demonstrate that things can be turned on their head fast without much fallout.
Going forward we have clear choices – we can continue to push the mountain of psychiatric morbidity in front of us by doing what we’ve always done in delivery of care, or, we can modernise services with new technologies available closely monitoring outcomes, satisfaction rates and service operational indicators in the process.
We mustn’t lose this opportunity now to extract the learnings from the last weeks of mental health services forced to rapidly adopt and implement digital solutions to maintain some level of service provision. This period should provide the natural springboard to continue the momentum of a broader service transformation. A correct implementation of new scalable technology gives unprecedented opportunities to reach large swathes of the population with low-key psycho-educational approaches that could strengthen general resilience, treat early symptoms and reduce overall morbidity in a cost-effective and humane manner. Additionally, people needing further input could seamlessly, and without delay, be moved on in a hybrid pathway from digital solutions to personalised face-to-face interventions. In a post-pandemic world, with the predictable surge of mental health problems coming our way, we have to ask ourselves, are we ready?
For our patients’ sake, we really should be ready.
Dr Lars Hansen
NHS consultant psychiatrist and Chief Medical Officer, Healios