In this presentation Dr Jonathan Campion, Director of Public Mental Health and Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust, explains the role of public mental health in promoting wellbeing and improving outcomes for services and the people who use them. Jonathan covers: What is public mental health PMH intelligence informs local JSNA and outcomes Impacts of mental disorder and wellbeing Risk and protective factors Higher risk groups Public mental health interventions Intervention gap Summary

1. Public mental health: An overview
Dr Jonathan Campion
Visiting Professor of Population Mental Health,
University College London
Director of Public Mental Health, South London
and Maudsley NHS Foundation Trust
11th July 2013

2. Outline for presentation
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What is public mental health
PMH intelligence informs local JSNA and outcomes
Impacts of mental disorder and wellbeing
Risk and protective factors
Higher risk groups
Public mental health interventions
Intervention gap
Summary

3. What is public mental health?
• Intelligence on level and impact of mental disorder
and well-being across populations
• Intelligence on risk factors for mental disorder
(including inequalities) and protective factors for
mental wellbeing
• Interventions to promote well-being, prevent mental
disorder and intervene as soon as it arises

4. Policy context of public mental health
• Twin track approach of mental health strategy (HMG,
2011):
Early treatment for people with mental disorder
Population approach to promote mental wellbeing
and prevent mental disorder
• Public Health White Paper (DH, 2010) signals new
approach which places mental health 'at the heart' of
the new system and highlights key role of DsPH in
public mental health

5. Public mental health intelligence informs local
JSNA and commissioning to improve outcomes
• JSNA informs both the Health & Wellbeing Strategy
and commissioning
• Mental health poorly covered in JSNA perpetuating
poor coverage of public mental health interventions

6. Public mental health commissioning guidance
www.jcpmh.info
Informs JSNA with local levels of:
• Risk and protective factors
• Higher risk groups
• Mental disorder and well-being including in higher
risk groups
• Proportion population receiving treatment of mental
disorder, prevention and promotion of mental health
• Outstanding need

7. Enables assessment of local
• Impact of public mental health interventions on
outcomes
• Associated economic savings
• Size, impact and cost of public mental health
intervention need
Transparency about level of coverage of interventions
which commissioners decide acceptable
Translation in Northamptonshire’s 700,000 population
Thereby informs local strategic planning

8. Public mental health intelligence informs outcomes
Public mental health relevant outcomes in each of
the following sets of outcomes frameworks
(incorporated in JCPMH public mental health
commissioning guidance)
• Public health outcomes (PH)
• NHS outcomes (NHS)
• Social care outcomes (SC)
• CCG outcome indicator set (CCG)
• Child outcomes (Child)

9. Impacts of mental disorder

10. Impacts of mental disorder
• At least 23% of burden of disease in UK compared to
16% for cancer and 16% for cardiovascular disease
(WHO, 2008)
• Size of impact due to
a) Arising early in the life course
b) Broad range of impacts/ outcomes
c) High prevalence of mental disorder
• Local impacts of mental disorder can be estimated

11. a) Early onset of mental disorder
• Key reason for size of burden
• 50% of lifetime mental illness (excluding dementia)
starts by age 14 (Kim-Cohen et al. 2003; Kessler et
al, 2005)
• 75% by mid twenties (Kessler et al, 2007)
• Several decades before physical illness

12. b) Broad impacts/ outcomes of mental disorder

13. Impacts/ outcomes during childhood and
adolescence
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health outcomes
self-harm and suicide (PH)
educational outcomes (PH: pupil absence)
antisocial behaviour and offending (PH)
social skills outcomes
health risk behaviour - smoking (PH), alcohol and
drug misuse, sexual risk, nutrition, physical activity
• teenage parenthood (PH)

14. Impacts and outcomes of emotional and conduct disorder in
children and young people in UK (Green et al, 2005)
Risk Behaviour
Emotional
Disorder (6%)
Conduct
Disorder (4%)
No Disorder
Smoke Regularly
(age 11- 16)
19%
30%
5%
Drink at least twice
a week (age 11- 16)
5%
12%
3%
Ever Used Hard
Drugs (age 11- 16
6%
12%
1%
Have ever self
harmed (self report)
21%
19%
4%
Have no friends
6%
8%
1%
Have ever been
excluded from
school
12%
34%
4%

15. Increased risk of poor adult outcomes
Poor mental health in childhood and adolescence also
associated with inequalities during adulthood
including higher rates of:
• adult mental disorder
• health risk behaviour including smoking (PH)
• physical illness
• suicide (PH)
• unemployment and lower earnings
• crime and violence (PH)

16. Impacts of poor mental health in adulthood
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Physical illness
Reduced life expectancy (PH)
Suicide and self harm (PH)
Range of health risk behaviour including alcohol,
drug misuse and smoking (PH)
• Unemployment
• Homelessness (PH)
• Stigma and discrimination

17. Economic impact of mental disorder
• To UK economy: £105 billion annual cost of mental
illness in England (CMH, 2010)
• To UK employers: £28 billion annually (NICE, 2009)
• Crime: £60 billion annual cost of crime in England
and Wales by adults who had conduct problems
during childhood and adolescence (SCMH, 2009)
• Significant local health and non-health impacts have
significant local costs

18. Mental disorder underlies a large proportion of
health risk behaviour
Smoking as an example
• Largest single preventable cause of death
• 42% of adult tobacco consumption in England is by
those with mental disorder (McManus et al, 2010)
• At least 33,222 of 79,100 smoking related deaths in
England (NHSIC, 2012)
• 43% of under 17 year old smokers have either
emotional or conduct disorder (Green et al, 2005)
Particularly important opportunity to prevent physical
illness and premature mortality

19. Impact of mental disorder on physical
illness

20. Mental disorder increases risk of physical
illness and associated premature mortality
Depression associated with 50% increased mortality
from all disease (Mykletun et al, 2009)
Schizophrenia associated with 20.5 year reduced life
expectancy for men and 16.4 year reduced life
expectancy for women (Brown et al, 2010) (PH)

21. c) Mental disorder is common
Proportionately increase with level of deprivation
• 10% of children and young people (Green et al, 2005)
• 17.6% adults at least one CMD (McManus et al, 2009)
• 0.4% adults have psychosis
• 6% alcohol dependent, 3% dependent on illegal
drugs, 21% dependent on tobacco
• 5.4% of men and 3.4% of women have diagnosable
personality disorder (Singleton et al, 2001)
• Dementia:
5% of people aged over 65
20% of those aged over 80

22. Local estimation of levels of mental disorder
• Levels of mental disorder vary by locality depending
on levels of risk/protective factors and numbers
from higher risk groups
• JCPMH guidance enables estimation of local
numbers with different mental disorder

23. Estimated numbers of children and adolescents with
mental disorder in Northamptonshire (JCPMH)
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3351 have emotional disorder
5299 have conduct disorder
2049 have hyperkinetic disorder
2940 11-16 year olds report self harm
5040 of 11-15 year olds reported drinking alcohol in
the previous week
• 5040 of 11-15 year olds used illegal drugs in the past
year and 2540 in the previous month
• 2100 of 11-15 year olds were regular smokers
• 3360 of 11-15 year olds smoked in previous week

24. Estimated numbers of adults with mental disorder
in Northamptonshire (JCPMH guidance)
• Common mental disorder 86,888
• Psychosis: each year 2145 in Northamptonshire
experience a psychotic disorder with 171 new cases
• Alcohol dependence: 31,645
• Drug misuse in 2011/12:
39,876 used an illegal drug
13,441 used class A drugs
15,073 taken an illicit drug
Tobacco smokers 107,270
Personality disorder: 23,475 (1609 people ASPD)
Dementia: 5302 people

25. Examples of local variation of substance misuse
across Northamptonshire
• Rate of opiate or crack use per 1000
Corby
12.8
South Northamptonshire 2.0
England
8.9
• Tobacco dependence
South Northamptonshire 11.2%
Corby
25.5%
England
20.0%

26. Level of sub-threshold mental disorder
• 18% of 5-16 year olds have sub-threshold conduct
disorder (Colman et al, 2009)
• 17% of adults experience sub-threshold common
mental disorder (McManus et al, 2009)
• 5% of adults have sub-threshold psychosis (van Os
et al, 2009)
• 24% hazardous drinkers (McManus et al, 2009)
• Impacts on quality of life and also increases the risk
of threshold disorder

27. Impact of mental health/ wellbeing

28. Impact of mental health/ wellbeing
• More than just absence of mental disorder
• Improved resilience to broad range of adversity
• Important in prevention of mental disorder

29. Health benefits of mental wellbeing
Associated with reductions in and prevention of:
• Mental disorder in children and adolescents
including persistence
• Mental disorder and suicide in adults (PH)
• Physical illness
• Associated health care utilisation (PH)
• Mortality (PH)

30. Benefits outside health
• Improved educational outcomes (PH)
• Healthier lifestyle/ reduced risk taking (PH)
• Increased productivity at work, fewer missed days
off work (PH)
• Higher income
• Social relationships/ contentedness (PH)
• Reduced anti-social behaviour, crime and violence
(PH)
• Reduced smoking/ alcohol/ drug misuse (PH)

31. Impact depends on wellbeing levels
ONS (2012) UK survey of 165,000 adults
• Life satisfaction:
76% scored 7/10 or more
7% scored less than 5/10
• Life worthwhile
80% scored 7/10 or more
5% scored less than 5/10
• Happiness yesterday: 78% scored 7/10 or more
11% scored less than 5/10
• Local level of wellbeing (PH outcome)/ social carerelated quality of life (SC)

32. Relationship between mental disorder and
wellbeing
• Wellbeing reduces risk of mental disorder
• Mental disorder reduces wellbeing.
• Single largest group with poor wellbeing are those
with mental disorder.
• Number of other groups are at increased risk of both
mental disorder and reduced wellbeing
• Higher risk groups disproportionately benefit from
public mental health interventions

33. Risk factors for mental disorder, protective
factors for wellbeing

34. Risk and protective factors
• Public health approach recognises wider
determinants and lifelong impact of mental health
• Addressing determinants important to prevent
mental illness and promote wellbeing
• Public health outcomes framework identifies local
level of risk and protective factors as outcomes

35. Inequality underpins many of the risk factors
for mental disorder and poor wellbeing

36. Inequality - a key underlying factor
• Inequality underlies most risk factors – key outcome
to address to prevent mental disorder
• Mental disorder then further increases inequality
which can also be prevented
• Higher risk groups benefit more from intervention to
both prevent and treat mental disorder

37. Inequality as a key risk factor for mental
disorder and poor wellbeing
Index Multiple Deprivation gives measure of
deprivation: Most deprived area scores 1, least
deprived area scores 326
• Northamptonshire overall 102
• Corby
57
• Northampton
119
• Wellingborough
133
• Kettering
164
• East Northamptonshire 225
• Daventry
248
• South Northamptonshire 323

38. Inequality as a key risk factor for mental
disorder and poor wellbeing (JCPMH guidance)
• % of under 16s living in low income households:
7.1% in South Northamptonshire
22.5% in Northampton
21.9% in England
• % population living in most deprived quintile:
19.8% in England
13.0% Northamptonshire
0 in South and East Northamptonshire
31.1% in Corby

39. Risk factors for mental disorder during childhood
• Pregnancy and birth: Smoking (PH), alcohol,
prematurity (Nosarti et al, 2012), birth weight (PH )
• Socioeconomic: Children from lowest quintile of
household income - 3 fold increased risk of mental
health problems (Green et al, 2005) (PH)
• Parental factors
Poor parental mental health - 4–5 fold increased
rate in onset of mental disorder
Parenting
• Child factors: Sex, age, ethnicity, screen time

40. Childhood adversity
• Childhood adversities strongest predictors of mental
disorder (Kessler et al, 2010)
• Child abuse: several fold increased of all mental
disorder (Jonas et al, 2011)
• Sexual abuse: increased rates of adult:
depressive disorder (OR 6.2)
PTSD (OR 6.8)
probable psychosis (OR 15.3)
alcohol dependence (OR 5.2)
eating disorder (OR 11.7) (Jonas et al, 2011)
attempted suicide (OR 9.4) (Bebbington et al. 2009)

41. Risk factors in adulthood
Include
• Socioeconomic inequality
• Unemployment (2.7 fold increase in CMD)
• Debt (3 fold increase in CMD)
• Violence and abuse (PHs: violent crime/ domestic
violence)
• Stressful life events
• Inadequate housing/ homelessness (PH)
• Fuel poverty (1.7 fold increased risk of CMD) (PH)

42. Population level of risk factors
• Child abuse in UK: 25.3% of 18-24 year olds and
18.6% of 11-17 year olds experienced severe
maltreatment during childhood (NSPCC, 2011)
• Sexual abuse in England: 2.9% of women and 0.8% of
men experienced sexual abuse in childhood (sexual
intercourse) (Bebbington et al, 2011)

43. Estimation of local numbers experiencing different
types of violence and abuse (JCPMH guidance)
In Northamptonshire
• 15,020 of 11-17 year olds experience severe
maltreatment during childhood
• 4206 of 11-17 year olds and 6725 of 18-24 year olds
experience physical violence by an adult
• Sexual abuse in under 18s, 12,300 experience sexual
touching and 3100 experience sexual intercourse

44. Protective factors for wellbeing
• Genetic background, maternal (ante-natal and postnatal) care, early upbringing and early experiences
• Socio-economic factors including access to
resources and inequality (PH)
• Emotional and social literacy
• Education (JCP)
• Employment (JCP)
• Physical activity (JCP)
• Physical health/ healthy life expectancy (JCP)
• Community trust and participation (PH)
• Spirituality/ meaning

45. Higher risk groups

46. Certain groups at much higher risk of mental
disorder and low wellbeing
• Benefit proportionately more from intervention to
promote wellbeing, prevent mental disorder and treat
mental disorder if it arises
• Proportionate universalism
• Need for information about numbers from higher risk
groups (Campion & Fitch, 2012)

47. Children and adolescent higher risk groups
• Looked after children - 5 fold increased risk of
mental disorder (Meltzer et al, 2003) (PH)
• Children with learning disability - 6.5 fold increased
risk of mental illness (Emerson and Hatton, 2007)
• Young offenders: 18 fold increased risk of suicide
for men in custody age 15–17 (Fazel et al, 2005) (PH)

48. Estimated local numbers from higher risk groups
(JCPMH guidance)
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735 looked after children
1070 primary school children with statements
1275 secondary school children with statements
3590 children with Special Educational Needs
916 children with Autistic Spectrum Disorder known
to schools
• 2442 children with learning difficulties known to
schools

49. Numbers of child and adolescent from higher risk
groups estimated to have mental disorder in
Northamptonshire (JCPMH guidance)
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331 looked after children
1580 children with Special Education Needs
879 children with learning difficulties
3324 children from one parent families
4058 children living in poverty

50. Adult higher risk groups
• BME groups (7.9% of UK population)
Rates of schizophrenia (Kirkbride et al, 2012)
5.6 times higher in the black Caribbean group
4.7 times higher in black African group
2.4 times higher in Asian groups (CCG)
Prisoners - higher risk of all mental disorder psychosis (20 fold) (Stewart, 2008) and ASPD (130 fold)
(NICE, 2009) (PH)
Learning disability – 3 fold increased risk of
schizophrenia (PH)

51. • Homeless people (Bebbington et al, 2004) (PH)
11.3 fold increased risk of probable psychosis
5.5 fold increased alcohol dependence
• Long term physical conditions
2–3 times increased risk of depression (NICE, 2009),
7 times increased risk of depression in people with
two or more chronic physical conditions
(NHS – improved QoL)
• Possible to estimate local numbers from higher risk
groups

52. Interventions to promote wellbeing, prevent
mental disorder and treat mental disorder

53. Different levels of prevention and promotion
Primary: Wider determinants across whole
populations. Selective prevention - targeting groups
at higher risk e.g. LTC’s , certain child/ adolescent/
adult group
Secondary (indicated): Early detection of risk factors/
illness and intervention . Half of lifetime mental
disorder arises by age 14 , three quarters by mid 20’s
Tertiary: People with established disease to promote
recovery and reduce risk of relapse.

54. Interventions to promote wellbeing, prevent
mental disorder and treat mental disorder
Good evidence exists for a range of public mental
health interventions across the life course which
reduce associated inequalities (RCPsych, 2010;
Campion & Fitch, 2012)
• Intervention for mental disorder and associated
inequalities
• Prevention of mental disorder
• Promotion of mental health

55. Interventions from a range of service providers
Include:
• Primary and secondary care
• Public Health service providers
• Local authorities
• Social care service providers
• Third sector social inclusion providers
• Education providers
• Employers
• Criminal justice services

56. Early intervention for mental disorder
• Associated with better outcomes
• Time between onset and access
• Improved through better recognition of mental disorder
through:
improved detection and treatment by health
professionals
improved mental health literacy among the population
to facilitate prompt help seeking
including higher risk groups such as BME (CCG)

57. Example of conduct disorder
• Affects 6% of 5-16 year olds
• Precedes different adult mental disorder (NICE, 2013)
• £795 million - lifetime cost of each one year cohort of 516 year olds with conduct disorder in Northamptonshire
• Parenting interventions are NICE first line treatments for
conduct disorder and ADHD
• Prevents antisocial personality disorder in adulthood
(NICE, 2009)
• Lack of provision of parenting interventions

58. Early recovery and intervention for physical health
• Early promotion of recovery through early provision of
activities such as supported employment (PH/ NHS/SC)
and settled accommodation (PH/SC)
• Early intervention to promote physical health to prevent
physical illness and premature mortality (PH/NHS):
early promotion of physical health
physical health checks (CCG)
Intervention for health risk behaviour such as
smoking

59. Early intervention results in net savings per £
invested (DH/Knapp et al, 2011)
• Treatment of conduct disorder with parenting
interventions £8
• Early detection and treatment of depression at work
£5
• Early intervention for the stage which precedes
psychosis £10
• First episode psychosis £18
• Screening and brief interventions in primary care for
alcohol misuse £12

60. Prevention interventions
Prevention of
• mental illness and dementia
• health risk behaviours including smoking, alcohol
and drug misuse
• inequalities
• discrimination and stigma
• suicide (PH)
• violence and abuse (PH)

61. Preventing inequalities
• Inequalities increase risk of mental disorder/ poor
wellbeing and underlie many other risk factors
• Addressing inequalities - important intervention to
prevent mental disorder and promote mental health
• Mental disorder results in a further range of
inequalities which can also be prevented by early:
treatment of mental disorder
interventions for health risk behaviours
treatment of physical illness
targeted wellbeing promotion to facilitate recovery

62. Prevention interventions
Cost effective interventions:
• school based bullying prevention (£14)
• prevention and addressing child abuse
• prevention of conduct disorder through school based
social emotional programmes (£84)
• school based violence prevention programmes
• suicide prevention (£44)
• smoking cessation prevents premature mortality
particularly in people with mental disorder

63. Mental health promotion interventions
• Starting well (PH – breast feeding; child development age
2-2.5 years)
• Developing well (PH - school readiness)
• Living well (PH/NHS/SC - LD/ stable accommodation; PH use of green space for health/ exercise; PH – social
contentedness)
• Working well (PH/SC: LD/ paid employment)
• Ageing well (PH: older people’s perception of community
safety)
• Caring well (NHS/ SC: Carer QoL)

64. Economics of interventions to promote wellbeing
• School based social emotional learning programmes
result in net savings of £84 for each £ spent (DH, 2011)
• Work based mental health promotion programmes
result in net savings of £10 for each £ spent (DH, 2011)
• Other cost effective interventions include debt advice
(£4) services, physical activity, befriending services,
timebanks and community navigators
• Cost effective targeted promotion interventions for
those recovering from mental disorder include
supported employment and supported housing

65. Result in range of improved health/ other outcomes
• Reflects broad impacts of mental disorder and wellbeing
• Improved mental health and resilience, physical health,
life expectancy, healthy lifestyles, economic productivity,
social functioning and quality of life
• Reduced
Burden of mental ill-health
Economic costs of mental ill-health (Knapp et al, 2011)
Inequalities
Health risk behaviour (PH)
Crime, violence (PH)
• Economic savings

66. Intervention gap

67. Intervention gap
• Despite evidence based interventions, only a
minority with mental disorder except psychosis
receive treatment
• Parity gap
• Compare to cancer where almost all receive
intervention

68. Proportion with mental disorder in UK receiving any
intervention (Green et al, 2005; McManus et al, 2009)
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28% of parents of children with conduct disorder
24% of adults with common mental disorder
28% of adults screening positive for PTSD
81% of adults with probable psychosis received
some form of treatment compared to 85% in 2000.
65% of adults with ‘psychotic disorder’ in past year
14% of adults dependent on alcohol
14% of adults dependent on cannabis only
36% of adults dependent on other drugs
Less than 10% of older people with depression
receive adequate treatment

69. Intervention gap
• In UK, 11% of NHS budget spent on treatment vs
23% burden of disease
• People with mental disorder lack
access to physical health care despite...
access to interventions for health risk behaviour
• Even greater lack of access to interventions to
prevent mental disorder and promote mental health
despite.... virtually no spend in UK

70. Size and impact of intervention gap
• Results in broad range of associated outcomes and
costs
• Since majority of life time mental disorder arises by
mid 20's, these impacts continue over a large part of
life course
• JSNA requires information on size, impact and cost
of public mental health intervention gap

71. Public Mental Health commissioning guidance
Enables local estimation of numbers/ proportion
including from higher risk groups with:
• risk factors for mental disorder
• risk/protective factors for wellbeing
• mental disorder and poor wellbeing
• receiving interventions for treatment, prevention and
promotion
Enables estimation of local
• Impact and savings of current service provision
• Impact and cost of current lack of provision

72. Broader public mental health outcomes
Facilitates
• Early treatment of mental disorder to:
Improve recovery outcomes for mental disorder
Reduce associated health risk behaviour
Reduce associated physical illness and premature
mortality
Reduce suicide
• Prevent mental disorder by addressing risk factors
• Promote population mental health by enhancing
protective factors

73. Summary
Public mental health intelligence facilitates :
• Coverage of a key area in the local JSNA
• Assessment of size, impact and cost of local public
mental health intervention gap
• Proportionate local targeting and monitoring of access/
outcomes for higher risk groups
• Informs local Health and Wellbeing Board Strategy and
commissioning

74. Public mental health
• Central part and solution to local issues due to
broad range of impacts
• Can prevent large proportion of mental disorder and
promote population wellbeing
• Can facilitate early intervention for mental disorder
and reduced treatment gap
• Results in significant improvements in NHS, public
health, social care and other outcomes

75. References and contact
• Campion J, Fitch C (2012) Guidance for the
commissioning of public mental health services.
Joint Commissioning Panel for Mental Health.
www.jcpmh.info
• Campion J, Bhui K, Bhugra D (2012). European
Psychiatric Association guidance on prevention of
mental disorder. European Psychiatry 27: 68-80.
• Campion (2013) Public mental health: The local
tangibles. The Psychiatrist 37: 238-243
• Email: jonathan_campion@yahoo.co.uk