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Title: The NZ mental health plan and serious mental illness.


1
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

2
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.

3
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.

4
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

5
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

6
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

7
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

8
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.

9
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10
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11
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.

12
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.

13
Problems with definitions.
  • What is the purpose of mental health?
  • What is Serious Mental Illness?
  • Who is a mental health user?
  • What is recovery?

14
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.

15
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)

16
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)

17
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.

18
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19
  • SMI smoke more, but want to change like non SMI
  • SMI non SMI exercise little, but SMI less
    motivated to change.

20
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).

21
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
22
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
23
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
24
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.
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