How Can a Mental Health Service be Good for Your Health?

Professor James V. LuceyMedical Director

St. Patrick’s University Hospital, Dublin

National Mental Health Conference – September 14th, 2011

How Can a Mental Health Service be Good for Your Health?

• Can we solve the problems in our mental health care system.

• Is quality of service the answer? • Examples of a mental health service

dedicated to Quality?

20th Century Mental Health Care

21st Century Health Care

In Health Care Politics the debate is still dominated by questions of location

Primary Care Vs Community Care Vs Residential Care Vs Secondary Vs Regional Centre of Excellence

Hospital Care

Home Care

Community Care

Residential Care in “Castlebeck”

Primary Care

What is Mental Health Care?

• A pseudo-science?• A craft informed by science?• A pill for all ills?• A social or political construct?• A myth?

Mental Health Vs

Mental Health Disorder

Home Work Balance

The Existential Question?

32% of OCD patients have depression

31% of SPpatients have

depressionGAD

59% of GAD patients have depression

50% of panic disorder patients have depression

49% of PTSD patients have depression

Source: National Comorbidity Survey 69,400 patients

34% of specific phobia patients have depression

PanicDisorderSpecific

Phobia PTSD

SocialPhobia

OCD

Depression

Complexity of Mental Health DiagnosisCo-morbidity of Anxiety and Depression

Low High

Certainty

Consensus

High

Low

CHAOS

STANDARDISATION

ZONE OF COMPLEX JUDGEMENT

Consensus

Chaos

Standardize Zone of Complex Judgment

Low HighCertainty

High

Low

Obsessive Compulsive Disorder

“There's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy. Years ago people were unhappy, they weren't depressed, they weren't given the name depressed…I was aware that unlike other areas of health like cholesterol, diabetes, or coronary care, where you can measure the results of taking medication, in mental health, it is impossible to measure, scientifically, the results”

Minister Tim O`Malley, Pharmacist and Minister for Mental HealthIrish Medical News, November 2006

Dr. Steeven's Hospital 1901 Census

Mean Age 26.5 (23.5 women, 27.5 men)Female/Male 34/86 Religion C O I / COE: 17; Pres: 5, Refused: 1, RC: 97

Fully 50% of the 120 patients had infectiousdiseases readily curable now

“Arguably by the standards of 1901, no-one outside of the Cancer Care Unit and ICU is sick. Modern infections or fractures are treated within a week. Myocardial infarcts are surveilled and thombolysed or stented. The age curve in hospital has changed dramatically and one century later our illnesses are completely different.

Modern illnesses were unseen in 1901, because these disorders were either already fatal, or like Diabetes, untreatable. No one who attends an Orthopaedic Surgeon with knee pain would be accused of malingering, if there is a demonstrable irregularity on MRI, but that same patient would not have been admitted in 1901. They would have been dismissed as a waste of time unless their leg was infected or broken off. Mental health suffering is exactly the same. Active treatment in all its professional and societal forms (Psychotherapy, Pharmacology, Milieu, a more tolerant welfare state) has enabled community care for Mental Disorder. We now witness service users with more subtle illnesses or illnesses at earlier stages, but that doesn’t mean mental health suffering is not real. These are not sicknesses if you judge them by the standards of 1901 or those who operate today within those standards”.

Dr Ross Dunne TCD/HRB Research Fellow

Historical Fight for Mental Health

"He gave the little Wealth he had,To build a House for Fools and Mad:And shew'd by one satyric touch,No Nation wanted it so much:That Kingdom he hath left his Debtor,I wish it soon may have a Better.”

J Swift (1667-1745)

National Cancer Strategy

No New Drugs, No Silver Bullets and No More Money

Team Work in Health Care

The Ideal Mental Health Service

Model•Mission•Vision

•Strategy

Organisation•Structure

•Governanace •Rewards

•Responsibilities

Culture•Principles

•Ethos•Excellence

Perfect Storm

• Perception of service as too medically driven

• Government policy driving a move to community care

• Hospital struggling to meet regulatory standards

• Occupancy dropping• Financial difficulties • Entering a domestic and

global recession

MHM Phase 1

MHM Phase 2

Process of Strategy Development

• Consulted with service users and staff• Focused on the Mission and Culture not the

financials• Worked to obtain buy-in to the mission

Key elements of strategy

• Highest quality mental health care• Promoting Mental Health• Advocating for the rights of those suffering

from mental illness

Actions we took

• Quality Standards and strong Clinical Governance • Restructured and enhanced existing services• New services in community Dean Clinics and

Technology based supports• Invest in staff retention and training

St Patrick's TCD- Evolution

St. Patrick’s University Hospital Services

Phone calls to Referral Line Administrator 2011

Month Total Average per Day

January 144 7.5 February 202 10.6 March 247 11.76 April 217 10.3 May 239 11.3 June 205 9.76 July 129 6.10

No. Of Admissions

No of Admissions per Annum 2004-2011

2450

2500

2550

2600

2650

2700

2750

2800

2850

2900

2950

2004 2005 2006 2007 2008 2009 2010 2011

Year

No

Ad

mis

sio

ns

No. Admissionsper year

Adolescent Service 2010 YTD 2011 New referrals 174 166 Multidisciplinary assessments 102 76 Consultant review 121 111 Registrar review 1 0 CBT 268 166 Nurse therapist review 148 148 Psychology 91 122 OT 4 9 Dietician 28 49 SW/Family Therapy 12 8

Average Length of Stay

Average Length of InPatient Stay 2004-2011

313233

3435363738

394041

2004 2005 2006 2007 2008 2009 2010 2011

Year

Ave

rag

e L

eng

th o

f S

tay

(Day

s)

Average Length of Stay

Occupancy and ReadmissionOccupancy and Readmission Rates 2004-2007

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

2004 2005 2006 2007 2008 2009 2010 2011

Year

Occupancy

Re-admission rates

The CGI Explained• Clinical global impression scale*• Baseline score – before

treatment – patients have often been in hospital for some time, refractory to medication

• Outcome score – after treatment

• Usually 3-4 weeks (average 7 treatments with ECT)

CGI OutcomeScale

*Despite seeming crude, this scale has good inter-rater reliability and good face validity

Clinical Global impression scores for 83 patients

CGI OutcomeScale

Patients treated with ECT for 3-4 weeks (6-8 sessions)

Clinical global impression scores for 83 patients

Very much better

Much better

Minimally better No change Minimally

worseMuch worse

Borderline ill 1Mildly ill 2

Moderately ill 11* 5 1Markedly ill 2 16 6 3Severely ill 3 15 8 5

Extremely ill 2 2 1

Patients treated with ECT for 3-4 weeks (6-8 sessions)

Outcome

Baseline

*For example 11 patients who started out moderately ill were judged “much better” after ECT

Nothing acts faster than Anadin

Service User Satisfaction

Service User Overall Experience Average ( 2006-2010).

30%40%

60%

49%

48%

37%

12%

10%

2%9% 3% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2006 (n=46) 2007 (n=52) 2010(n=288)

YearVery Satisf ied Satisf ied Dissatisf ied Very Dissatisf ied

Compliance with Mental Health Commission Regulations and Standards

St Patrick's Dean Clinic Network

2 weeks ending:

YTD

20/0

3/20

11

03/0

4/20

11

17/0

4/20

11

01/0

5/20

11

15/0

5/20

11

29/0

5/20

11

12/0

6/20

11

26/0

6/20

11

10/0

7/20

11

24/0

7/20

11

07/0

8/20

11

21/0

8/20

11

Number of assessments 409 26 30 30 31 24 34 19 18 28 17 21 27 Immediate admission following assessment 83 10 4 4 4 4 8 4 4 9 6 3 2

Referral back to GP or referrer 64 2 3 8 0 2 14 3 4 4 3 1 1 Referral to CBT 66 3 3 8 6 5 8 0 2 3 2 3 4 Day Services / WRC 31 4 6 1 3 3 3 1 1 2 0 0 2 On going Consultant review 110 12 8 6 7 4 8 6 4 13 7 0 15 Psychotherapy in Deans 53 1 2 4 3 4 1 4 4 4 2 8 2 OT 5 0 0 0 1 1 0 0 0 0 0 3 0 EDP referral 3 0 0 0 1 2 0 0 0 0 0 0 0 Other 46 0 4 0 7 3 0 1 1 1 2 6 4 Total admissions from Deans 2011 151 16 9 6 7 9 10 5 7 17 13 8 2

18%

14%

14%

7%

24%

11%

1%

1% 10%

Immediate admission following assessment Referral back to GP or referrerReferral to CBT Day Services / WRCOn going Consultant review Psychotherapy in DeansOT EDP referralOther

Wellness and Recovery Centre

Day Patient Referrals

WRC Activity 2010 January Feb March April May June July Aug Total Alcohol step down 8 14 11 14 9(1) 7 3 7 73(1) Anxiety prog 14(3) 10 (3) 14(6) 13(3) 6(3) 13(4) 12(5) 7(3) 89(30) Bi Polar Prog 10 12 15(1) 12 11 3 9(1) 6(1) 78(3) Nurturing Hope 2 1 (1) 2 5 5 1(1) 2(1) 18(3) Depression 2(1) 4(2) 6(5) 4(1) 1 1 3(2) 2(1) 23(12) EDP 1 1 5 2 3 2 3 17 Living T D 14(1) 21 (3) 21(3) 7(2) 11(2) 11(3) 14(5) 5(2) 104(21) LTD ACG 13 8 19 3 43 Mens Mental 1 7 5(2) 3(1) 3(2) 6(1) 5 30(6) Mindfulness 9 7 20(2) 5 8(1) 2(2) 10(6) 61(11) Psychosis Prog 2 2 (1) 3 3(1) 2(1) 3(1) 3(1) 18(5) Recovery Prog 26 27(1) 24(2) 17(2) 15(2) 14(2) 15(7) 21 (5) 159(21) Recovery refresher 3 5 3 11 Recovery evening 3(1) 1 1 5(1) St. Eds DS 46 12 28(5) 27(4) 15(2) 13(1) 14(1) 10(1) 165(14) Young Adult Prog 2 3(1) 6(5) 2(2) 3(1) 1 1(1) 1(1) 19(11) Totals 136 (5) 143(13) 155 (31) 122(15) 112(14) 94(13) 87(27) 82 (23) 930(141)

**Numbers in brackets denote referrals from Dean Clinics**

Bed days used per year pre- and post- LTD particpation(Best 10 and Worst 10)

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 33 34 35 36 37 38 39 40 41 42

Particpants (Best 10 and Worst 10)

Bed

days

per

yea

r

Average No. of Bed days per year pre LTD No. of Bed days in the 12 months post LTD

Distress Tolerance Scale - Lower Scores indicate a lower tolerance to distress

0

2

4

6

8

10

12

Mean Score Pre- LTD Mean Score Post- LTD

Deliberate Self HarmDSH Inventory - 17 item self report questionnaire covering frequency, severity and types of self-harm

0

2

4

6

8

10

12

Mean Score Pre- LTD Mean Score Post- LTD

Support and Information service Jan Feb Mar April May June July Aug

YTD Total

Total Number of calls 136 99 134 243 185 170 126 37 1130

Support Calls 10 3 4 3 17 6 6 1 50

Information Calls 126 96 130 240 167 164 120 36 1079

No of callers to Dean Clinic Ref No 47 25 39 89 45 57 44 14 360

Health Care professional callers 4 5 8 3 6 5 5 0 36

General public callers 115 81 116 230 152 158 113 34 999

Service user callers 17 12 10 10 27 7 8 3 94

Calls re: treatment under 18 years 6 4 1 3 3 15 5 0 37

Calls forwarded to admissions 29 22 28 18 25 15 13 4 154

e-mails at info@stpatsmail.com 90 67 62 50 70 56 74 10 479

No of e-mail to admissions 4 2 1 1 4 3 3 1 19

No of e-mail to Dean Clinic Ref No 4 3 1 0 4 2 7 1 22

Callers given CBT referral procedure 10 7 12 21 8 25 13 6 102

Financial Information 2004-2011

Financial Information 2004-2011

-4%

-2%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2004 2005 2006 2007 2008 2009 2010 2011

Year

EBITDA %

Surplus %

AnnualGrow th inrevenue %

Compoundannualgrow thrate %

Cost per Treatment EpisodeAverage cost per treatment episode (€)

€0

€2,000

€4,000

€6,000

€8,000

€10,000

€12,000

€14,000

€16,000

€18,000

2004 2005 2006 2007 2008 2009 2010 2011

Average costper treatmentepisode

St. Patrick`s University HospitalMental Health Service

Model•Mission Independent•Human rights based•Vision National MDT

•Strategy Not-for-profit

Organisation•Structure - Dedicated•Governance - Charter

•Rewards - Responsibilities

Culture•Principles – Recovery

•User-centred involvement•Ethos – Non-Denominational

•Academia - Excellence