In a shared sponsorship between the University of Otago Wellington and Te Pou o te Whakaaro Nui, 42 people from all over the country gathered together in Wellington late in February. The group were diverse, but shared a common aim to improve the physical health of tāngata whai ora/mental health service users. This was a special opportunity to hear and discuss some of the latest evidence on the physical health disparities for people with mental health and/or addiction problems and most importantly how to address this disparity. We also heard about some amazing initiatives and actions that are really making a difference to people.
The day was made up of three sessions, each full of evidence that still confronts me, alongside moving stories of courageous people willing to step outside the accepted norms and commit to being the change this issue so badly needs.
Session one: Understanding the problem
In this session Dr Ruth Cunningham, who is well known to the Equally Well work, talked about understanding the problem from a public health perspective –how physical health affects mental health and vice versa, and that social determinants affect both. She concluded by saying “the way we think about framing up the causes informs the thinking about the solutions”.
Dr Allister Bush, a child and adolescent psychiatrist working in Kaupapa Māori mental health, gave a very thought provoking presentation about his work with Māori healer and cultural therapist Wiremu Niania, based on the recent publication ‘Tātaihono’. Allister talked about the links with the adverse childhood events (ACE) study and gave a moving account from his work about the impact on a young person’s recovery through a cultural approach.
Caro Swanson, from Te Pou o te Whakaaro Nui, spoke of the wholeness of people and how all facets – spiritual, emotional, physical, relational – affect the other. So the importance of seeing the person within their own context and understanding what’s important to them is pivotal. That solutions were not a one-stop ‘fix’ but multi-faceted, cumulative and individual. She also spoke of the importance of true informed consent – people making treatment choices understanding ALL the potential gains and losses of the proposed treatments. This includes using plain language not jargon and committing to increase a person’s health literacy through using their language. This does involve more time with the person, but it would be more than worth the investment.
Professor Tony Dowell concluded the first session from a primary care perspective. He reminded us of a few things:
- 90 per cent of all organised health care happens in primary care, so there is a big opportunity for providers
- people aren’t “single disease entities” and multiple-morbidities is one of the most important tasks facing primary care.
Tony proposed the solutions need to occur within stepped care systems, which will include “circular care” alongside structural and process changes that include new ways of working. Examples he gave included nurse clinics, shared care, navigators, team working, links with NGOs and building on existing initiatives. His take home thought was “we need to listen more, talk less”.
Session two: Understanding the causes
Dr Susanna Every-Palmer, psychiatrist and clinical director of forensic services at Capital and Coast DHB, spoke to us about her insights into the role of psychiatric medications and that we can’t look to industry funded research (for the truth). She felt we need to look at history to understand and think about the future, for example how ‘evidence-based medicine’ is failing due to selective trials and selective publication. Susanna went on to present her own study to inform ‘the Porirua Protocol’. She found that 300-600 out of 1,000 people treated with clozapine will experience significant gastro-intestinal adverse effects (“slow gut” – slow, silent and significant) which created huge problems including some deaths for people taking Clozapine. As this was found to be so common people need to be treated prophylactically with laxatives when taking Clozapine to prevent harm.
Dr Ruth Cunningham presented on the wider social determinants of housing, poverty and the food environment. She included work happening in the Population Health department at the University of Otago on housing and homelessness, especially the prevalence of people who experience mental health and addiction problems in the ‘Housing First’ study. This work looks at the impact of housing costs as a proportion of income and the impact of crowding; cold damp housing and unsafe accommodation such as those situations found often in boarding houses.
Ruth then spoke about our food environment, especially the impact on physical health of high cost healthy foods vs cheap, readily available sugar loaded options. She went on to expand on this into the issue of child poverty in New Zealand – what money can buy (or can’t) when combined with the effects of stress in the household.
Acknowledging New Zealand’s siloed health structures that are difficult for people to get to, Ruth went on to discuss relevant studies looking at health systems, especially in the USA. From these, it appears that physical health care is getting worse for people who experience serious mental health and addiction problems, particularly in care and treatment for cancer, cardiovascular disease and diabetes for people.
Ruth concluded her presentation with a snapshot of her cancer survival work, where she compares breast and colorectal cancer survival over five years for people who experience serious mental health problems and people who don’t. She left us with the question “where should we intervene?”
Stella Vickers talked to us about the results of her fascinating study on Tobacco Use in New Zealand. What makes it fascinating is Stella extensively interviewed people who smoke, from all walks of life. Although rates of smoking have reduced in New Zealand due to increasing tax hikes and social restrictions on smoking, 15-16 per cent of all New Zealanders still use tobacco. Stella confirmed what many of us have noticed: the relationship between smoking and mental health problems is complex. She considers the high tax on this addictive (and legal) substance for this population group to be unfair. “You’re suddenly a dirty person” was the experience of many of the people she interviewed in her study. Stella’s observation was that past approaches to mental health care have reinforced tobacco use and left a legacy.
Session three: Reducing inequalities in mental health
It’s always good to hear Tony O’Brien present and the summer school was no exception! Tony spent 10 weeks late last year looking at what Metabolic Screening policies district health boards (DHBs) have, and the quality of them. Mental health nurses are well placed within their scope of practice to monitor and screen for metabolic syndrome. Unfortunately the evidence, if the lack of policies is an indicator, is that hardly anyone is doing this work!
The best practice standard and definition of metabolic syndrome from Alberti et al 2009 was used to develop a best practice guideline against which services policies were audited. The response rate was 100 per cent. Tony found 75 per cent of DHBs plus the Ashburn Clinic have some form of policy, however there is a wide variation in terms of differing formats and quality. The conclusion is many services do not have adequate policies in place and this is contributing to low levels of metabolic monitoring of people being prescribed antipsychotic medications as part of their treatment. An incidental finding is many DHBs had developed metabolic monitoring initiatives driven by one or more interested clinicians. Saying this though, Tony went on to tell us that there is a high level of interest in the results and seeing standardised guidelines.
His work didn’t review non-government organisations, primary health organisations or general practice policies, and didn’t seek evidence from people who experience mental health and addiction problems. The next steps are to publish this paper and further review.
Dr Sarah Gordon, a senior research fellow at the University of Otago, Wellington and service user academic spoke about the reformation of undergraduate medical students’ education, the goal being to reduce stigma around people who experience mental health and addiction issues. The changes made to the teaching content through introducing learning about recovery including clinical placements in peer run services and making the reflective writing summative assessment mandatory have had mixed results and been adjusted accordingly. They now appear to be creating sustainable attitude changes for the better. Sarah’s research is inspirational.
Brigitte Sistig talked about her work using mindfulness based movement therapy, going on to do an interactive exercise with us. Incorporating yoga and mindfulness, Brigitte’s aim is to offer an equalising health intervention that both staff and people can easily use that strengthens wellbeing for all. Brigitte has taken this work through some rigorous trials, including with participants from the Mason Clinic, and has shown success in terms of reducing stress and increasing peace and happiness.
Helen Lockett finished an invigorating day with some of her reflections, that so often we’ve been referring to this issue as a wicked problem, particularly one that ‘fights back when you try to solve it’! But we have more than 100 organisations across the country formally committed to taking action through their endorsement of the Equally Well consensus position, so we need to consider our language. We should stop describing it as a 'wicked issue' as this language just reinforces how hard it is to address. Instead we talk about how the Equally Well movement is using the power of networks and people committed to addressing health disparities, to bring about change. This doesn't take away the fact this is still a huge issue affecting millions of people, but by having the collaborative, people aren’t trying to solve it in isolation.
Helen shared several examples of innovative work under the Equally Well banner, including funded GP consultations at Tairāwhiti and Pegasus; the changes to the primary care guidelines on assessment of cardiovascular disease risk to prioritise people who experience mental health and addiction problems; and the importance of ensuring people who experience mental health and addiction problems are prioritised in the new national bowel screening programme.
Participant's blog: Sarah O'Connor
Sarah O'Connor attended the summer school and has written a great blog about the event.