Evidence-based mental health policy
Posted on 8th April 2015 by Alice Buchan
Mental health comprises a huge proportion of visits to GPs in the UK, and is also one of the biggest causes of disability in the developed world. In spite of this, it does not have parity of esteem or of funding with physical health.
In September 2014, Prof Dame Sally Davies, the UK government’s Chief Medical Officer, published her 2013 annual report; the topic is mental health. Entitled “Public Mental Health Priorities: Investing in the Evidence”, this report promotes parity of esteem for mental health, and evidence-based interventions for prevention, promotion, and treatment in mental health. Much of the evidence cited in this report comes from Cochrane reviews, of which 18 are featured. It makes 14 recommendations for evidence-based improvement of mental health services. I have looked at some of the recommendations and points in this report, and looked back at the review from which that evidence came.
The first review cited uses the Cochrane review as an example of one of the most robust reviews related to well-being and mental health, to point out that many of these robust sources of evidence mention many caveats, and critique the quality of the evidence base.
Mental health in older adults – chapter 8
The mental health of older adults is featured as part of the report’s section on a life-course approach to mental health. This Cochrane review looks at treatments for late-onset schizophrenia.
What the review says: “There is no trial-based evidence upon which to base guidelines for the treatment of late-onset schizophrenia. There is a need for good quality-controlled clinical trials into the effects of antipsychotics for this group. Such trials are possible. Until they are undertaken, people with late-onset schizophrenia will be treated by doctors using clinical judgement and habit to guide prescribing.”
What the report says: “A Cochrane review cited an inadequate evidence base around antipsychotic treatments” (p134)
There are no specific policy recommendations about psychosis in older adults, however the authors do recommend that mental health services for older adults remain a separate specialty to general adult psychiatry, as the needs of older people were previously not well catered for by all-ages services.
The economic case for better mental health – chapter 9
This chapter looks at the economic consequences of poor mental health in the population, as well as exploring how to use NHS resources to their best effect in improving mental health. It includes two Cochrane reviews: one looking at family-based interventions for patients with schizophrenia (found here), and the other looking at consumer-providers (past or current users of mental health services providing those services to others) in mental health (found here).
Family-based interventions aim to reduce “expressed emotion” or hostility and criticism in families of patients with schizophrenia, with the aim of reducing the frequency of relapses in these patients.
What the review says: “Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality.”
What the report says: “Interventions can be targeted on family members or intra-family relations, as with family therapy for schizophrenia, for which there is both a clinical and an economic case”
Employing past or present consumers of mental health services is common in services that aim to support people living with mental illness.
What the review says: “Involving consumer-providers in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that were no better or worse than those achieved by professionals employed in similar roles, particularly for case management services. There is low quality evidence that involving consumer-providers in mental health teams results in a small reduction in clients’ use of crisis or emergency services. The nature of the consumer-providers’ involvement differs compared to professionals, as do the resources required to support their involvement. The overall quality of the evidence is moderate to low. There is no evidence of harm associated with involving consumer-providers in mental health teams.”
What the report says: “There are also interventions that build explicitly on community assets, as with befriending programmes, and interventions that can employ people with lived experience of mental illness to deliver support, as with peer workers.”
The policy suggestions from this section of the report include better integration of physical and mental health services, reducing stigma attached to mental illness, reducing inequalities in terms of access to mental health services, and “long-term strategic action” to improve outcomes for people with mental illness.
Physical health and mental illness – Chapter 13
This chapter is in the section about parity of esteem between mental and physical health. It also serves to highlight that physical and mental health problems do not occur in isolation, but each is more common in people with the other. The two Cochrane reviews in this chapter look at psychological treatments for physical pain (review here), and treating depression in people who also have a physical illness (review here). Psychological problems are very common in the physically ill, and some hospitals now have dedicated liaison psychiatry/psychological medicine teams to treat these patients. In addition to the impact on their mood or mental health, mental illness can be associated with worse outcomes in physical illness.
What the review says: Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list… CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.”
What the report says: “Certainly high-intensity treatments, such as those including combinations of physical exercise and psychosocial methods, are shown to improve anxiety, depression and quality of life in people with COPD, and to produce similar results for people with chronic pain.”
Whilst many studies and systematic reviews have shown that antidepressants can help in depression in the general population, this systematic review included only trials in patients with physical illnesses as well as depression.
What the review says: “This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.”
What the report says: “Similarly, there is substantial evidence that antidepressants are effective in depression associated with physical illness, although current guidance restricts their use to those with a history of more severe depression, in whom the depression is complicating other treatments or is highly persistent.”
This chapter did not make any specific policy recommendations, but emphasised the need for joined-up care for the large number of patients with both physical and mental conditions, and notes that the way we choose to term conditions as either physical or mental may itself be unhelpful.
Violence and mental health – chapter 14
In terms of public perceptions of mental illness, violence is always a concern; however, the vast majority of people with mental illness are not violent. In combination with other risk factors, mental illness may contribute to violence and risk. People with mental health problems may also be at increased risk of being victims of violence. This chapter of the report cited two Cochrane reviews: one looking at compulsory treatment as an outpatient or in the community (i.e. not in a hospital) for people with severe mental disorders (review here). The other reviewed advocacy interventions and whether they could reduce the risk of violence (review here). This second review was not discussed in the report.
What the review says: “Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature.”
What the report says: “Key modifiable risk factors of relevance to clinical practice include substance misuse and poor service engagement, while key factors of relevance to public health include social exclusion, stigma, homelessness and unemployment.”
Some of the policy recommendations made in this chapter are:
- To reduce experience of violence – as experiencing violence is a risk factor for going on to be violent
- Violence against people with mental illness needs to be better identified and addressed by the healthcare system – and that healthcare staff need be to trained to identify and manage people with mental illness who have been victims of violence
- The use of alcohol in particular, but also other substances, needs to be addressed as a modifiable risk factor for violence, as intervening in patients with mental illness and substance misuse may reduce their risk of violence
Addictions, dependence, and substance abuse – Chapter 16
This chapter is the one that relies most on Cochrane evidence – citing several Cochrane reviews related to smoking cessation, and treatments for substance dependency.
What the review says:
Review on physician advice for smoking cessation (here) (NB this is the 2008 version as used in the report, a newer one is available): “Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1to 3%.”
Review on individual behavioural interventions for smoking cessation (here): “The review found that individual counselling could help smokers quit, but there was not enough evidence about whether more intensive counselling was better.”
Review on group behaviour therapy programmes for smoking cessation (here): “Group programmes are more effective for helping people to stop smoking than being given self-help materials without face-to-face instruction and group support. The chances of quitting are approximately doubled. It is unclear whether groups are better than individual counselling or other advice, but they are more effective than no treatment. Not all smokers making a quit attempt want to attend group meetings, but for those who do they are likely to be helpful.”
Review on telephone counselling for smoking cessation (here) (NB this is the version cited but a newer one is available): “Proactive telephone counselling helps smokers interested in quitting. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, brief advice, or compared to pharmacotherapy alone. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness.”
What the report says:
“Brief interventions for reducing excessive alcohol use and helping patients quit smoking can be delivered effectively in the primary care setting.”
“Brief advice from health professionals can trigger successful quit attempts. Behavioural support includes strategies to manage cravings and withdrawal symptoms, and guidance on the use of pharmacological treatments. Group support is more effective than individual support, with specialist advisers being more effective than those delivering cessation support alongside other clinical duties. Behavioural support can also be delivered via telephone, text messaging or the Internet.”
In terms of opiate use, the report cites Cochrane reviews regarding harm minimisation for opiate users, ranging from oral substitutes such as buprenorphine and methadone to supervised heroin use.
What the reviews say:
Methadone maintenance for opioid dependence:
“Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity or mortality.” (link here)
“Methadone dosages ranging from 60 to 100 mg/day are more effective than lower dosages in retaining patients and in reducing use of heroin and cocaine during treatment. To find the optimal dose is a clinical ability, but clinician must consider these conclusions in treatment strategies.” (link here)
Oral treatments for prevention of HIV infection
“Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review” (link here)
Oral treatments- comparison of methadone, buprenorphine, and placebo
“Buprenorphine appears to be less effective than methadone in retaining people in treatment, if prescribed in a flexible dose regimen or at a fixed and low dose (2 – 6 mg per day). Buprenorphine prescribed at fixed doses (above 7 mg per day) was not different from methadone prescribed at fixed doses (40 mg or more per day) in retaining people in treatment or in suppression of illicit opioid use.” (link here)
What the report says: “Heroin/opiate addiction is notable for several evidence-based interventions that exist at public health and individual health levels, which can produce major health benefits.
Opiate Substitution Treatment (OST) has been extensively studied and reviewed by Cochrane and NICE and comprises supervised daily methadone (a long-acting oral opioid) or sublingual buprenorphine, moving to unsupervised dosing when good adherence and drug-free behaviour are achieved.”
Supervised heroin use
What the review says: (link here)“The available evidence suggests an added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment refractory, opioid users, to reach a decrease in the use of illicit substances, involvement in criminal activity and incarceration, a possible reduction in mortaliity; and an increase in retention in treatment. Due to the higher rate of serious adverse events, heroin prescription should remain a treatment for people who are currently or have in the past failed maintenance treatment, and it should be provided in clinical settings where proper follow-up is ensured.”
What the report says:“While methadone and buprenorphine are the front-line medication-assisted treatments for opioid addiction, a small sub-set of entrenched heroin addicts exists who appear treatment resistant and for whom intensive treatment with supervised heroin maintenance has shown good benefits and is a necessary second-line treatment.”
Therapeutic communities for substance misuse
Whether patients with addictions benefit from ‘rehab’ – in other words a therapeutic community in which they do not have access to drugs, is a contentious issue. A 2006 Cochrane review (here) has looked at the topic, but has not been updated since them.
What the review says: “There is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another. Prison TC may be better than prison on it’s own or Mental Health Treatment Programmes to prevent re-offending post-release for in-mates. However, methodological limitations of the studies may have introduced bias and firm conclusions cannot be drawn due to limitations of the existing evidence.”
What the report says: “Drug-free residential rehabilitation has attracted criticism from Cochrane for a lack of randomised controlled trial-type evidence, but is important for those for whom OST is not appropriate, does not deliver benefits or is not acceptable.”
Some of the key recommendations from this chapter, on the basis of evidence from Cochrane and other systematic reviews and meta-analyses are a continued emphasis on smoking cessation, including interventions such as plain packaging, and a smoke-free health service. In terms of opiates, they concern optimising both the drug and non-drug aspects of care to ensure the best possible outcomes.
As the report suggests, there is much to be done in the field of mental health. There are of course still areas in which evidence is lacking, or does not fit the population of patients whom we are treating, but the vast amounts of evidence cited in this report show just how much there is. In mental health, the aim should still be to treat people in an evidence-based way, just as in physical conditions.