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17th April 2024
NHS England has U-turned on plans to cut funding for a mental health support service following strong criticism from the profession, and will allow new registrations from hospital clinicians for another year.
Earlier this month, the NHS Practitioner Health service said NHS England was ‘undertaking a review’ for the support offer across all NHS staff groups, to consider ‘long term sustainable options’.
This meant that the service would not accept any new registrations from secondary care staff from 15 April, but would continue to treat existing patients, with new patients being ‘signposted’ to other services such as their GP, it said.
Justifying the decision, NHS England chief strategy officer Chris Hopson said the ‘vast majority’ of mental health support for NHS staff ‘is, and always has been, via their employer’s health and wellbeing schemes’.
However, the decision was strongly criticised by doctors, including the BMA and the Doctors’ Association UK, who said it was ‘short-sighted’ and ‘cruel’.
Now, NHS England has agreed to ‘extend the service’ for secondary care health professionals by 12 months while a review is carried out.
It confirmed that the service will remain in place for GPs and other primary care staff for another 12 months until the end of March next year.
NHS England chief workforce officer Dr Navina Evans said: ‘Following discussions with Practitioner Health on their current service for secondary care doctors, dentists and senior staff, we have jointly agreed to extend the service by 12 months, for both existing and new service users, while we carry out a wider review to ensure that all NHS staff groups have the mental health support they need.’
Professor Dame Clare Gerada, an ambassador for NHS Practitioner Health who is also a GP, said she was ‘delighted’ that the extension was agreed and that the service will ‘work closely’ with NHS England on the review.
The Royal College of Physicians (RCP) has welcomed the announcement and said it will ‘take an active interest in [the new review] process, recommending that any new solution must be either equal to or better than the current situation‘.
The RCP added: ‘All NHS staff groups must have the mental health support they need.‘
NHS Practitioner Health provides mental health and addiction support for healthcare professionals so that they are able to remain in, or return safely to, work.
According to figures for 2022/23, 6,741 new patients registered with the service, with average registrations per month at 562, up from 225 before the pandemic.
Prior to the reversal of the decision, in a post on X (formerly Twitter), Professor Dame Gerada said: ‘To remind, [NHS Practitioner Health] was established following suicide of a psychiatrist who also killed her baby and highlighted the barriers doctors have in accessing mental health care.’
She added: ‘I am so proud of the 32,000 doctors/dentists/nurses/paramedics/and others who have sought our help.‘
BMA workforce lead Dr Latifa Patel said doctors are ‘more burnt-out’ than ever‘, and described NHS England’s withdrawal of funding as a ‘short-sighted financial decision with potentially harmful consequences for both doctors and patients’.
She added: ‘We need to have assurances that its review of services will lead to equal or better provision of mental health support in the future.’
In December 2023, a report from the British Psychological Society called for priority long-term investment in NHS staff mental health and wellbeing.
An earlier survey showed that health professionals ranked work-related stress, workload intensity and staffing levels as the primary ‘push factors’ underpinning decisions to leave the NHS.
A version of this story was originally published by our sister publication Pulse.
6th February 2024
The role of paediatricians in the prevention, early recognition and holistic care of mental health problems in children has been outlined in a new position statement from the Royal College of Paediatrics and Child Health (RCPCH).
The position statement follows an ‘unprecedented rise in demand for children’s mental health services’ as more ‘paediatricians are upskilling and expanding their role to care for and treat their young patients’, the RCPCH said.
Indeed, recent data from NHS Digital shows that one in five (20.3%) children aged 8-16 had a probable mental disorder in 2023, rising from 12.5% in 2017.
What’s more, the number of open referrals to Children and Young People’s Mental Health Services reached the highest on record with 496,897 referred to services in November 2023, an increase from 493,434 in October 2023.
The data also showed the number of urgent referrals – where crisis support is required – among under-18s reached a record high of 4,032 for November 2023. This was up from 3,355 the previous month.
Rates of self-harm remain high for young people, with almost a quarter (24%) of 17-year-olds self-harming each year. Suicide remains the leading cause of death for young people in the UK, according to the charity Papyrus.
According to the RCPCH, a lack of staff and resources mean young people are being placed on long waiting lists, which can lead to more serious symptoms developing and an increased the likelihood of them presenting to emergency departments and paediatric settings in crisis.
‘It has never been more important for paediatricians to recognise that the mental health of our patients is our business,’ it said.
As part of its position statement, the RCPCH recommends paediatricians promote positive mental health in all their interactions and provide a safe environment for children in paediatric wards and emergency departments, by having appropriate staffing levels, and necessary training for managing acute distress.
The position statement also includes key policy recommendations to support effective joint working and integrated pathways with mental health services.
Improved support, training and increased capacity across the paediatric workforce is also a priority to support early recognition of and intervention for common mental health problems, the RCPCH said.
It is also calling for increased funding and capacity for community based mental health services so children can access quality and timely support before reaching extreme distress.
RCPCH officer for mental health Dr Karen Street said: ‘The entire children’s workforce has a role to play in tackling the current crisis in children’s mental health, but as paediatricians we are particularly well placed to make a difference. Research shows paediatricians are the most trusted profession for secondary school children, across all ethnicities and backgrounds and that children see doctors as a key group to support their mental health.
She added: ‘The paediatric profession is committed to holistic care for children and young people, which necessarily includes both their physical and mental health, and adapting to the changing challenges for children and young people to give our patients the best quality care and support – we now need Government to follow suit.
‘If we are ever to get out of this dire situation then we need meaningful support for health services and staff, as well as child focused polices that can improve the physical, emotional, social and educational wellbeing of young people. The responsibility to tackle this growing mental health emergency cannot be left to healthcare professionals alone.’
Dr Elaine Lockhart, chair of Royal College of Psychiatrists Child and Adolescent Faculty, added: ‘We fully support the work our paediatric colleagues bring to earlier identification and support of mental health difficulties in children seen within their services.
‘We also support their call for increased focus and funding of children’s mental health services so that there are well trained and resourced teams across the country who can meet the full spectrum of need from mild difficulties to severe mental illness.’
29th January 2024
People with obsessive-compulsive disorder (OCD) have an increased risk of death than those who are not affected by it, Swedish research suggests.
An analysis of more than 61,000 people with OCD and 10 times as many unaffected people from the general population found an increased risk of death associated with both natural and unnatural causes.
As part of the research, the team also compared patient records from a group of 34,000 people with OCD with almost 48,000 unaffected siblings over an eight-year period where they found similar increased risks to the general population.
Writing in the BMJ, the researchers said previous studies had focused on unnatural causes of death including suicide.
Their research suggested that after taking into account potentially influential factors such as birth year, sex, county, migrant status, education and family income, people with OCD had an 82% increased risk of death from any cause.
The excess risk of death was 31% higher for natural causes and three times higher for unnatural causes of death, they reported.
Among the natural causes of death, people with OCD had increased risks of death due to respiratory system diseases (73%), mental and behavioural disorders (58%), diseases of the genitourinary system (55%), endocrine, nutritional, and metabolic diseases (47%), diseases of the circulatory system (33%), nervous system (21%), and digestive system (20%), the analysis showed.
For unnatural causes, suicide was by far the biggest factor with an almost five-fold increased risk of death followed by accidents with a 92% increased risk.
Overall, the risk was similar for both men and women with OCD, although women did have a higher risk of dying due to unnatural causes. That could be explained by their lower baseline risk in the general population, the researchers explained.
But people with OCD had a 10% lower risk of death due to tumours, they noted.
‘Non-communicable diseases and external causes of death, including suicides and accidents, were major contributors to the risk of mortality in people with OCD.
‘Better surveillance, prevention, and early intervention strategies should be implemented to reduce the risk of fatal outcomes in people with OCD,’ they concluded.
They added that ‘significant efforts’ should also be made to promote early detection and improve access to specialist treatment for people with OCD.
‘People with psychiatric disorders are known to be less likely to seek help for health related problems and to attend medical check-ups, and they are also less likely to receive health interventions and prescriptions for non-psychiatric drugs, potentially leading to delays in the detection and treatment of diseases,’ they noted.
A version of this article was originally published by our sister publication Pulse.
11th December 2023
A new report from the British Psychological Society (BPS) is urging the Government to commit to further long-term funding for NHS staff mental health and wellbeing services, calling it ‘fundamental‘ for workforce retention, the delivery of the NHS Long Term Workforce Plan, and protecting patient care.
The BPS ‘Learning from the NHS Staff Mental Health and Wellbeing Hubs‘ report highlights the need for standards for staff mental health provision, amid concerns that staff struggling with their mental health could face a postcode lottery to access the support they need from a dwindling number of NHS Staff Mental Health and Wellbeing Hubs.
Set up in February 2021 to provide health and social care staff with rapid access to mental health support, ring-fenced Government funding for NHS Staff Mental Health and Wellbeing Hubs ended in March 2023, with integrated care systems (ICSs) either identifying short-term interim funding for their Hub for a defined period of time, or closing them.
The report highlights a data analysis from the Nuffield Trust showing six million sick days recorded for NHS staff due to anxiety, stress, depression and other psychiatric illnesses in 2022, with sickness absence associated with a higher likelihood of staff leaving the NHS.
And the same Nuffield analysis revealed that a consultant missing three days of work for mental health reasons is 58% more likely to leave three months later.
Further figures outlined in the BPS report showed demand for NHS Staff Mental Health and Wellbeing services is increasing.
Data from one hub recorded 404 people registering for one-to-one support between July 2023 and September 2023 – a 65% increase on the same period in the previous year during which 245 referrals were made – with one in five of those accessing one-to-one support identified as senior leaders.
BPS says its report aims to support health and care leaders make ‘crucial decisions‘ about future investment in local mental health and wellbeing services for their teams.
It cites evidence of the cost benefits for investment in mental health and wellbeing that shows an investment of £80 per member of staff in mental health support can achieve net gains of £855 a year through savings from absenteeism and presenteeism.
Noting ‘more than 121,000 unfilled jobs across the NHS in England today‘, Saffron Cordery, deputy chief executive of NHS Providers, said: ‘Heavy workloads and huge pressure on stretched services are leading to lots of staff feeling worn out. The effects of financial pressures on trusts and the cost of living crisis on staff amid the longest period of industrial action in the history of the NHS’ history have compounded problems of high staff turnover.‘
As a result, the report makes a series of recommendations, including that:
Dr Roman Raczka, president-elect of the BPS, said: ‘The ambitious measures set out in the NHS Long Term Workforce Plan are not a quick fix.
‘Existing and future staff members deserve to work in an environment that gives them the support they need, to provide the safe, high-quality care they as health and care professionals are proud to give.
‘Put simply, NHS and social care employers cannot afford to ignore the mental health needs of their workforce, if they wish to create a system that’s fit for the future.‘
4th September 2023
The use of postnatal selective serotonin reuptake inhibitor (SSRI) treatment is associated with a lower risk of postnatal depression-associated maternal mental health problems and child externalising behaviours, up to five years after childbirth, according to a recent study.
Published in the journal JAMA Network Open, the study sought to examine whether postnatal SSRI treatment moderated postnatal depression-associated maternal and child outcomes across early childhood years.
The UK and Norwegian researchers used longitudinal data from the Norwegian Mother, Father and Child Cohort Study, which recruited women during weeks 17 to 18 of their pregnancy and prospectively followed them after childbirth.
Mothers were asked to report any medications they had taken at postpartum month six. As SSRIs are commonly used for postnatal depression, the study focused exclusively on this class of drugs.
The outcomes of interest were self-reported maternal depression symptomology and relationship satisfaction from childbirth to five years after giving birth. In addition, child outcomes included emotional and behavioural problems such as internalising and externalising behaviours, attention deficit hyperactivity disorder (ADHD) symptoms, together with motor and language development at ages 18 months, three and five years.
A total of 61,081 mother-child dyads met the criteria for a postnatal depression diagnosis. The analysis revealed that the severity was associated with higher levels of maternal depression across postpartum years 1.5 to five. There was also poorer relationship satisfaction between postpartum month six and year three.
Furthermore, postnatal depression severity was associated with higher levels of child internalising and externalising behaviours as measured across ages 18 months to five years, poorer motor and language development at years 18 months and three, as well as and ADHD symptoms at age five years.
In further analysis, the researchers observed postnatal SSRI treatment moderated associations between postnatal depression and maternal depression at postpartum year 1.5 and year five, together with better relationship satisfaction at both six months and three years after birth.
However, postnatal SSRI use also moderated the associations between postnatal depression and child externalising behaviours at ages 18 months and five years, as well as ADHD at age five years.
Dr Tom McAdams, senior author of the study and Wellcome Trust senior research fellow at King’s Institute of Psychiatry, Psychology and Neuroscience, said: ‘Postnatal depression is under-recognised and under-treated. It‘s critical that we view it as the severe mental illness that it is and ensure it is treated properly to mitigate some of the associated negative outcomes in mothers, children and wider family.
‘Our study found no evidence that SSRI treatment for mothers affected by postnatal depression was linked with an increased risk for childhood emotional difficulties, behavioural problems or motor and language delay.‘
SSRIs are designed to increase levels of the neurotransmitter serotonin, though, in recent years, this purported mode of action has been questioned.
3rd February 2023
Andreas Reif is Head of the Department of Psychiatry, Psychosomatic Medicine and Psychotherapy at the University Hospital, Frankfurt. He spoke to Hospital Healthcare Europe about treatment-resistant depression and innovations in the management of the condition.
Andreas Reif’s main clinical areas of interest are mood disorders with a focus on bipolar disorders, suicidality, therapy-resistant depression and adult ADHD. From a research perspective, he is interested in personalised medicine in psychiatry as well as the neurobiology of mental disorders, with a focus on improving diagnosis and treatment. He was involved in establishing the German National Centre for Affective Disorders and sits on its board of directors.
Professor Reif described how the main reason for establishing the national centre (along with seven other institutions in Germany) was to ‘create a research and clinical studies network of centres of excellence for mood disorders.’ He believed that such a network was lacking in Germany, especially considering how ‘depression is the most prevalent disorder in the field of psychiatry and there are only a few hospitals that really specialise in mood disorders.’
The overarching aim he felt, was really to bring together existing expertise in the fields of neurostimulation, neuroimaging, genetics and psychopharmacology and therefore ‘create a network that leverages existing studies that are able to build up cohorts for research purposes as well as providing an existing network for both academic and industry sponsored studies on mood disorders in a larger network.’
Professor Reif described how unfortunately there is no single universally accepted definition, though existing ones are similar and vary slightly. He mentioned that the current definition used for regulatory purposes is ‘the failure of two antidepressant treatments that have been provided with an adequate dose and duration.’ This he explained was a rephrasing of the criteria for treatment-resistant schizophrenia which was used after the introduction of clozapine.
Despite this somewhat straight forward definition, Professor Reif noted that in practice, it was more difficult to interpret. For instance, non-medical treatments such as psychotherapy, and CBT are not included and there was some uncertainty over what constituted an adequate dose and duration of treatment. As he said, the current definition ‘gets messier and messier the longer you think about it.’ Nevertheless, he feels that at least two-thirds of the patients he sees in outpatient clinics have treatment-resistant depression.
In contrast, there are others who have been suboptimally managed with either an inadequate dose of treatment or the way in which the drug had been used was not guideline compliant. Fortunately, in such cases, treatment could be easily modified and patients discharged back into primary care.
Professor Reif thinks that there is still much to be learnt about the underlying causes of treatment-resistant depression. He mentioned how there was a known relationship with certain factors such as ‘co-morbidity with anxiety disorder, ADHD, early onset depression, melancholic features such as early suicide attempts,’ however, but these were merely associated risk factors and not causative.
Delving into the neurobiology has also failed to provide satisfactory explanations, particularly in relation to genetics, with no obvious differences between those who have can be considered to have regular depression and those who eventually display treatment-resistant depression. It has been postulated that there is some degree of neurological imbalance between pro-inflammatory and anti-inflammatory markers or a disturbance in the connections between the limbic system and the prefrontal cortex.
Nevertheless, he thinks that a better understanding of possible mechanisms would arise from prospective studies that followed up on depressed patients and to identify those who enter remission and those who go on to become treatment-resistant, though sadly, there is an absence of such studies. Although inadequate adherence may be a factor in treatment-resistant depression, this could easily be identified with therapeutic drug monitoring.
Professor Reif feels that the burden upon both the individual and healthcare systems is enormous. Treatment-resistant patients have a higher level of hospitalisations and suicide attempts but there is also an economic impact. As he said, ‘individually, often these patients are unable to work or work with reduced ability’ and there is a high level of unemployment combined with a huge negative impact on their quality of life.
Currently, there are several recommended approaches. First, the patient’s existing therapy can be augmented with an atypical antipsychotic such as quetiapine or lithium. Another approach is to combine an SSRI or SNRI or a tricyclic with mirtazapine or trazadone. Treatment switches can also be effective but this is only recommended once. For instance, if patients have already been changed from an SSRI to a SNRI, there is no benefit from any further switches. Both transcranial magnetic stimulation or ECT have also been used and in some cases prove to be very effective. Finally, the addition of psychotherapy to the current medical treatment can also be tried.
Professor Reif said that the efficacy of these approaches, at least from an examination of the current evidence, is that between 20% to a third of patients should be helped. He is not overly convinced by these figures but this probably reflects how in practice he deals with more severely ill patients. Despite this, he does believe that with the combination of high-density psychotherapy, optimised medical treatment and neuro-stimulatory techniques, ‘over 90% of patients will ultimately remit.’ For those patients who fail to remit with such combination therapy, he thinks that experimental approaches such as deep brain stimulation or invasive vagus nerve stimulation are likely to be more successful.
Professor Reif mentioned the ESCAPE-TRD study in which nasal esketamine was compared to augmentation therapy with extended-release quetiapine in patients with treatment-resistant depression. Esketamine represents a first-in-class treatment targeting the glutamate system although Professor Reif had already been using the drug experimentally at his centre for severely ill patients and found it to be very effective.
While there were studies demonstrating that esketamine was effective, esketamine had only been compared to placebo plus newly initiated oral antidepressants, hence it has not been possible to determine whether it is more effective than any of the existing therapies. As he said, ESCAPE-TRD was really the first head-to-head study comparing esketamine with an active treatment, a move he thinks was ‘quite brave for Janssen because they could have failed.’ ESCAPE-TRD was conducted over 32 weeks and which he says, was a sufficiently long time to determine its effectiveness.
He described how the study found that ‘esketamine was significantly better in all outcomes but most importantly, met its primary outcome of remission at week eight in an acute setting.’ In fact, there was an almost 10% difference in the remission rate compared to quetiapine.
A further and relevant finding was in relation to the main secondary outcome, which found that a significantly higher proportion of patients given esketamine, who achieved remission achieved at week eight, maintained relapse free through to week 32. When asked to summarise the findings, he said that the overall conclusion was that ‘esketamine was superior to quetiapine in achieving remission in treatment-resistant depression.’
Professor Reif thinks that much more needs to be achieved in the management of treatment-resistant depression and believes that there are at least three initial steps required. Perhaps the immediate priority, he feels, is to ensure access to esketamine given how currently, few centres provide the drug.
Secondly, with only around a quarter of patients achieving remission after eight weeks, it was necessary to explore the development of relevant biomarkers, to identify those patients likely to respond, since this was impossible from a clinical perspective.
Thirdly, is the acknowledgement that depression is actually a heterogenous disorder with many underlying pathologies and the introduction of a wide range of therapies, affecting different biochemical pathways, would enable the treatment of a higher number of patients.
Finally, Professor Reif believes that a wider adoption of esketamine is needed, together with its incorporation into management algorithms. While accepting that the drug is not a panacea, he says that it represents a valuable addition to psychiatry’s therapeutic armamentarium and is hopeful that because of this innovation, the pharmaceutical industry will be spurred on to develop more effective treatments in psychiatry.
31st January 2023
The UK Government said that urgent care provided in the community will be expanded to ensure ‘people can get the care they need at home,’ without the need for a hospital admission and that the measures will be ‘aligned with priorities for primary care,’ including the forthcoming GP access recovery plan and the implementation of the Fuller stocktake report.
The two-year delivery plan for recovery announced today comes amid ‘record demand for NHS services’ and promises ‘boosted frontline capacity’, with 800 new ambulances, including 100 mental health vehicles and 5,000 more hospital beds, backed by a £1bn fund.
The new plans will see an increased number of clinicians – including retired staff and returners – working in NHS 111.
The services will run for at least 12 hours a day – responding to calls normally requiring an ambulance crew – and will mean people who have fallen or are injured can get care and treatment at home within two hours.
Parents and carers seeking health advice for children and young people using NHS 111 will have increased access to specialist advice, including support from paediatric clinicians who can help them manage illness at home or decide the best route for their care.
This will see some children referred directly to a same-day appointment with a specialist rather than attending A&E, which NHS England said would avoid unnecessary hospital admissions.
Direct access to urgent mental health support using NHS 111 is also being rolled out with people being able to select the mental health option when they call up for help.
NHS 111 will also be integrated into the NHS app to make it even easier for people to use, the plan said.
Same day emergency care units, staffed by consultants and nurses, will be open in every hospital with a major A&E, allowing thousands of people to avoid an overnight hospital stay.
The plans will also see a new scheme embedding family support workers across selected A&E sites – with at least one in every region – to provide support to children with non-urgent issues.
Amanda Pritchard, the NHS chief executive, said: ‘The NHS has experienced the start of a winter like no other – the threat of the flu and covid ‘twindemic’ became a reality and that was alongside huge demand for all services – from ambulance and A&E services to mental health and GP appointments.
Health secretary Steve Barclay said: ‘Every day of every week, tens of thousands of people receive safe, high-quality urgent and emergency care. However, with the NHS under unprecedented pressure from high Covid and flu cases and the backlog from the pandemic, too many people are waiting too long in A&E or for ambulances. ‘Today’s plan which is backed by record investment aims to rapidly cut waiting times, helping to deliver on one of the Government’s five priorities, while giving patients the confidence that health and social care services will be there for them when they need them.
This article first appeared in our sister publication Pulse.
19th May 2022
The ENO Breathe programme used by patients experiencing long COVID symptoms has been found to improve mental health scores and elements of breathlessness compared to usual care. This was the conclusion from the first randomised trial to evaluate interventions for patients with long COVID by a UK team of researchers from London.
A recognised consequence for some patients after an acute infection with COVID-19 is long COVID and which has been defined as new or ongoing symptoms 4 weeks or more after the start of acute COVID-19. A wide range of symptoms experienced by those with long COVID have been documented with the most frequently reported including breathing problems, fatigue, muscle weakness or joint stiffness, sleep disturbances, problems with mental abilities, and mood changes such as anxiety or depression.
In a systematic review, researchers identified how music interventions were associated with clinically meaningful improvements in health-related quality of life.
The English National Opera has created the ENO Breathe programme, to help patients recovering from the effects of COVID-19 an,d for the present study, the UK researchers set out to determine whether the programme could improve both mental and physical aspects of health-related quality of life, as well as breathlessness, in patients with long COVID.
They conducted a parallel-group, single-blinded, randomised trial to compare the ENO programme with usual care. Eligible patients were adults (> 18 years of age) and who were recovering from COVID-19 with ongoing breathlessness with or without anxiety for at least 4 weeks after their acute onset of symptoms. Individuals were randomised 1:1 to the ENO Breathe programme or usual care.
The programme was individualised and designed to support people with breathlessness and/or anxiety by focusing on breathing, retraining through singing techniques and delivered online. It consisted of an introductory session followed by 6, once weekly sessions.
The primary outcome of interest was a change in health-related quality of life (HRQoL) from baseline to the end of the 6-week programme and which was assessed using the RAND 36-item short form survey instrument and in particular two summary measures, the mental health (MHC) and physical health components (PHC).
A number of secondary outcomes were used including a visual analogue scale (VAS) for breathlessness on rest, walking, climbing stairs and running.
ENO Breathe programme and HRQoL
A total of 150 participants with a mean age of 49 (81% female) were randomised to either the ENO programme or usual care. Across the two groups, there was a mean of 320 days since the onset of their initial COVID-19 symptoms.
Compared to usual care, those allocated to the ENO Breathe programme had a greater improvement in the MHC (regression coefficient = 2.42, 95% CI 0.03 – 4.80, p = 0.047). However, there was no significant difference between groups for the PHC component (p = 0.54).
With respect to breathlessness, the only self-reported measure to significantly reduce was based on running (p = 0.0026).
The authors concluded that the ENO Breathe intervention could improve mental health wellbeing and one aspect of breathlessness and suggested that the programme might have a role in supporting patients with persisting long COVID symptoms.
Citation
Philip KEJ et al. An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial Lancet Respir Med 2022
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