For the Mental Illness Fellowship Victoria Melbourne, Victoria

17th May 2011Assoc Prof Sharon Lawn sharon.lawn@flinders.edu.au

08 84042321 / 0459 098 772

‘In It Together’The 13th Annual Woodcock Memorial Lecture

An Urgent Priority

• Almost half of all cigarettes smoked in Australia, USA and UK are smoked by people with mental illness.

• People with serious mental illness die, on average, 25 years sooner than they should.

• Mortality and morbidity from all the priority physical health conditions is 2-3 times higher for people with mental illness.

What we know- The Numbers

• The leading contributor to premature death is cardiovascular disease • Not in decline, as per general population trends

• Diabetes present in 10 – 15% of all individuals with mental illness• In schizophrenia, diabetes related complications ranks as the third leading

cause of death, after suicide and epilepsy • An independent risk factor for diabetes!

• No difference in cancer rates in people with mental illness, however mortality 40% higher in men & 20% higher in women • People with schizophrenia almost twice as likely to have bowel cancer in

UK

• Metabolic syndrome (abdominal obesity, hypertension, hyperglycaemia & dyslipidaemia) verging on epidemic proportions

• Smokers with Schizophrenia have 10-fold increased death rates from respiratory disease

Why don’t people just do what workers tell them to do?

Why don’t people do what they know is good for their health?

Barriers to Physical Health & Wellbeing

• More sedentary

• Less likely to eat fruit & vegetables

• Particularly likely to smoke…

• Less likely to engage with services early if at all

• Often experience compounded stresses

• Effects of long term use of medications!

More Real Barriers

• Cognitive & psychosocial problems - reduced accurate self-assessment of physical symptoms & relay to others

• Low uptake of advice due to co-morbid depression, social isolation, low

self-efficacy, social determinants which render it irrelevant to needs • Homelessness & itinerancy

• Avoidance or neglect of contact with GPs or health care services

• Stigma & discrimination, resulting in fear or reluctance to discuss physical symptoms, mistrust of health workers & advice they provide

• Unreported / masked physical symptoms, reduced pain sensitivity

• Negative symptoms or sedating effects of antipsychotic meds resulting in low levels of motivation & engagement

System Barriers

• Poor uptake of Best Practice Guidelines

• Lack of agreement over who is responsible for monitoring or screening

• Lack of continuity of care & follow up

• Capacity to provide physical health services or support (eg. general

health check-ups) often inadequate in mental health service systems

• Physical complaints may be regarded as symptoms of SMI

• Opportunistic physical health advice is not offered in MH settings

• Attention is often focussed exclusively on mental health issues and

ignores physical health

Little Wonder Then… System & Cultural Reinforcement:

When people are highly distressed & perceived motivation & hope are low, this is really hard work!

In the absence of adequately trained staff, adequately supported staff, or systems of support that acknowledge these complexities, workers do what they can at the time!

Typical reactions - Opt out, blame others, abrogate responsibility & accountability to others, defeatist view that have consequences for all concerned but especially the person

• Many ‘pre-contemplators’ are not choosing this stance

• Many people want to have better health & wellbeing

• Many just feel that they can’t succeed

• Many are scared of becoming unwell

The Importance of Self-Efficacy

Each day is a different country!

...with constantly shifting landscapes

This Thing Called Health Literacy• Assumption 1: That it will improve engagement by the person in their

own healthcare.• Assumption 2: That the person has the problem engaging with

services & that greater health literacy on their part will improve this.

• ...So long as systems of care and the broader social circumstances in which people live their lives are also addressed so that we don’t create barriers for them.

• People have complex life histories that impact on health behaviour in spite of knowing what is ‘good for them’.

• Knowledge alone makes no difference to health outcomes. Supporting behaviour change by walking alongside people does.

The Importance of Thoughts, Feelings, Actions

• Self-esteem• Self-efficacy / confidence• Social Connection / Inclusion• Health Beliefs• Stigma & Hope

These things determine how people:• Feel• Behave• Motivate themselves• Think about their situation

Insidious & Vicious Cycles of Need

(Mark - Schizophrenia)• The first time when I had no money and I couldn’t get credit at the

deli, I used to go around the streets looking for butts...looking for butts...I don’t know where or who they came from but I’d unroll them and join them all up again into one. (pause) It was just a smoke wasn’t it? I’ve been that bad. When you can’t have a smoke you just go around knocking on people’s door asking for smokes and some I didn’t even know the people, and they’d say, ‘Who are you and what do you want?’ Some just used to swear at me and push the door in my face, bang the door. It was just a smoke (pause). I would have done anything for one at the time.

(Joan – Bipolar)• When I’m more agitated it’s like I can’t do things but I also can’t not do

anything. Having a cigarette fits right in that gap.

Is this a good enough response?

(John – consultant psychiatrist/ex -smoker)

> In my heart of hearts, with patients with schizophrenia, I feel that they haven't got much left for them, so good luck to them. If they want to smoke, let them.

Why Action is Needed … apart from the obvious reasons!

• People die sooner than they should & their contributions are lost

• No mental health without physical health

• Others feel the impacts

• Passive acceptance leads to reduced worker skills

Experts Together through Lived Experience

In our first 12 months of operation, we:

• Provided 230 support packages

• Provided 1494 hours of support

• Saved 1178 Bed days for our hospital wards

• Saved approx. $400, 000 in bed costs for our health system, after service running costs.

Chronic Condition Self-Management – a mental health example

Aim: To develop & trial a generic model of self-management based on assessment of self-management, peer support & collaboration between mental health workers & GPs, for people with both mental & physical illness living in the community.

• GP Management Plan (GPMP) & Team Care Arrangements (TCA)

• 12 months Duration (2001-2002)• Individualised self-management assessment & care planning

using the Flinders Program• Stanford peer-led, self-management groups – 6 week course• One-to-one peer support to promote goal achievement

Qualitative Results• It challenged mental health workers’ perceptions of clients’

potential to improve

• Structured assessment that gave new information from the person’s perspective by asking what they: • knew already • did, did well, found difficult • saw as the problem

• Peer workers’ emotional & physical health improved

• GPs learned more & became more comfortable when working with people with mental illness

How we take the steps with people to support them is the most important thing

• Strong Leadership

• Organisational Culture that embraces innovation

• Effective Training (Demystify change, practical tools)

• Committed Staff (Shared responsibility, expertise, support)

• Adequately Resourced

Creating an accepting empowering environment where people:

• Feel safe

• Feel valued

• Receive non-judgemental assistance across the spectrum of services with supported referral & linkage

• Are respected & listened to

• Have adequate support throughout the journey

We are after all…

In it Together!

Thank you