Search

Table of contents

Level of need in the population

Adults :: Adult mental health [Update in progress] :: Level of need in the population

This section will detail level of need in 3 areas: 1. Promoting mental health and wellbeing 2. Levels of mental ill health 3. Suicide rates

1. Promoting mental health and wellbeing

1.1 Positive mental health

Positive mental health is more than an absence of mental illness. Mental wellbeing can be defined as “a dynamic state, in which an individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their communities"[1].

Promoting mental health and wellbeing is important in 3 key areas
• Promoting population mental health and wellbeing
• Promoting mental health and wellbeing in those most at risk of mental ill health.
• Promoting mental health and wellbeing in those with existing mental health problems

In 2012 the government published new national and local data on wellbeing. In July 2012 subjective data on wellbeing was published at local authority level and this is shown below.

The government is still working on broader national wellbeing indicators but only the national figures for this have been published to date.

  Medway South East England
Satisfaction with life overall (rated medium or high) 73.1 78.5 75.7
Feeling worthwhile (rated medium or high) 79.4 82.2 79.9
Happiness yesterday (rated medium or high) 73.2 72.8 71.0
Anxiety yesterday (rated medium or low) 59.2 61.2 60.1
Table 1: Measures of subjective wellbeing in Medway compared with the southeast and England 2012.
Source: Office for National Statistics

This data shows that Medway is significantly worse than the South East average with respect to life satisfaction but not significantly different with respect to people feeling that what they do is worthwhile, feeling happy yesterday or feeling anxious yesterday to either the England or the South East average.

1.2 At risk groups

Key data on risk groups for poor mental health who should be targeted for mental health promotion work (as outlined in the introduction) are as follows:

1.2.1 Unemployment

As stated previously, unemployment is associated with an increased likelihood of having a mental health issue hence this is a key group for targeted mental health promotion work in order to increase resilience and reduce the risk of mental health problems developing. The overall Job Seekers Allowance rate for Medway is 3.4% of adults aged 16-64 in August 2013. This is higher than both the South East rate at 2.1% and the England rate at 3.3%.

The graph below shows the proportion of people on Job Seekers Allowance by ward in Medway which shows Chatham Central having the highest proportion of JSA claimants (7.1%) with Hempstead and Wigmore the lowest (1.0%).

The total number of JSA claimants in August 2013 in Medway was 5,938.

Figure 1: Proportion of the working age population claiming Jobseekers Allowance - August 2013.
Figure 1: Proportion of the working age population claiming Jobseekers Allowance - August 2013
Source: Office for National Statistics via NOMIS

JSA claimant count records the number of people claiming Jobseekers Allowance (JSA) and National Insurance credits at Jobcentre Plus local offices. This is not an official measure of unemployment, but is the only indicative statistic available for areas smaller than Local Authorities.

Rates for wards are calculated using the mid-2010 resident population aged 16-64. Rates for Medway Unitary Authority and England are calculated using the mid-2012 resident population aged 16-64.

1.2.2 People claiming incapacity benefit due to mental health problems.

A significant proportion of people claiming incapacity benefit do so because of mental health problems. In Medway 1.6% of the population claim incapacity benefit or severe disablement allowance which is higher than the SE region average but lower than the England average. The number of people claiming Incapacity Benefit/Severe Disablement Allowance in Medway as at February 2013 was 3,390. The proportion of these claiming incapacity benefit due to mental health issues is 41% (1,400).

The graph below shows the proportion of the population by ward in Medway who claim incapacity benefit. Additional support needs to be given to this group in order to facilitate a return to good employment.

Figure 2: Proportion of the population aged 16 years and over claiming Incapacity Benefit or Severe Disablement Allowance.
Figure 2: Proportion of the population aged 16 years and over claiming Incapacity Benefit or Severe Disablement Allowance - February 2013
Source: Office for National Statistics via NOMIS

Incapacity benefit (IB) was introduced in April 1995 and is paid to people who are incapable of work and who meet certain contribution conditions. Severe Disablement Allowance (SDA) was paid to those unable to work for 28 weeks in a row or more because of illness or disability. Since April 2001 it has not been possible to make a new claim for SDA.

Rates for wards are calculated using the 2011 Census resident population aged 16+. Rates for Medway Unitary Authority, South East and England are calculated using the mid-2012 resident population estimates aged 16+.

Mental health promotion work to support employers to develop good practice around wellbeing in the workplace and also support for employees who are suffering from mental health problems will help to address this issue.

1.2.3 Deprivation

Mental health problems are also linked to living in an area of high deprivation. Figure 3 shows deprivation levels across Medway. Areas of high deprivation are likely to see a higher demand for mental health services.

Figure 3: Locally ranked deprivation scores by Lower Super Output Area.
Figure 3: Locally ranked deprivation scores by Lower Super Output Area
Source: Indices of Multiple Deprivation 2010, Department of Communities and Local Government
1.2.4 Homelessness and fuel poverty

Homelessness and poor quality damp housing are risk factors for poor mental health. The table below sets out the rate of households accepted as being homeless and in priority need in Medway, the South East region and England since 2004/05. In 2012/13 there were 257 households accepted as being homeless in Medway. The chapter on seasonal excess winter deaths gives further information on fuel poverty and seasonal excess winter deaths.

  2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
Medway UA 6.2 6.6 3.4 1.8 1.2 1.4 1.6 2.4
South East 3.7 2.7 2.0 1.6 1.4 1.1 1.3 1.5 1.6
England 5.7 4.5 3.5 3.0 2.5 1.9 2.0 2.3 2.4
Table 2: Households accepted as being homelessness and in priority need per 1,000 households
Source: Department of Communities and Local Government
1.2.5 Carers

Issues for carers are covered in more detail in the Carers chapter. However they are at greater risk of mental health problems than the general population so therefore should also be targeted for specific mental health promotion work.

1.2.6 Social isolation

It is difficult to capture social isolation accurately with routinely available data. Some possible proxy indicators include self assessed health status, older people living alone and single parents. It is also interesting to note the difference in prevalence of all common mental health disorders by marital status and gender. This indicates that a stable relationship is associated with better mental health.

Figure 4: Prevalence of all common mental disorders in England PMS 2007, by marital status and gender.
Figure 4: Prevalence of all common mental disorders in England PMS 2007, by marital status and gender
Source: Adult psychiatric morbidity survey 2007, The NHS Information Centre for Health and Social Care.

Geographically many of these indicators show high rates in our most deprived wards so reaching these groups would indicate a need to focus on these areas and also the employers of groups in these areas in order to tackle mental health inequalities more effectively.

2 Mental ill health in the population

There are different diagnoses of mental health disorders but they can be grouped together under the following main headings
• Common mental health problems
• Psychosis
• Other mental health disorders including maternal mental health disorders, ADHD, personality disorder, PTSD

2.1 Common mental health problems

Common mental disorders (CMDs) are mental conditions that cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. They comprise different types of depression and anxiety, and include obsessive compulsive disorder.

The main nationally collected survey which measures mental ill health in the population is the Psychiatric Morbidity Survey. This survey was carried out in 1993, 2000 and 2007. The overall picture nationally indicates that after the rise in common mental health problems between 1993 and 2000, the rates between 2000 and 2007 remained similar. The 2007 psychiatric morbidity survey (PMS) found that 17.6% of the population surveyed met the diagnostic criteria for at least one CMD, with women (19.7%) more affected than men (12.5%)[2]. We use this data to estimate our local rates however it does not take into account deprivation or any other local variation so can only be taken as an estimate.

Immediately below Figure 5 shows this estimate of common mental health disorders for all ages by age and gender across Medway using the PMS 2007 national prevalence rates applied to 2013 population projections for Medway. The total number of people in Medway living with a common mental health disorder at any one time in 2013 is estimated to be approximately 34,900. As can be seen prevalence is higher in women than in men in all age groups. Rates are also higher in younger and middle-aged groups rather than in older people.

Figure 5: Estimated prevalence in Medway of all common mental disorders in past week, by age and gender
Figure 5: Estimated prevalence in Medway of all common mental disorders in past week, by age and gender.

Estimates of rates of common mental health problems in Medway compared with other areas have been produced using a model developed by the North East Public Health Observatory. This model is based on findings from the Psychiatric Morbidity Survey for Adults 2000, combined with indicators from the Heady and Ruddock model[3] and mid-2005 population estimates from Office for National Statistics. It estimates that the rate of any neurotic disorder in the past week in Medway is 161.2 per 1,000 population aged 16-74). The conditions included in the definition are mixed anxiety and depression, general anxiety disorder, depressive episodes, all phobias, obsessive compulsive disorder and panic disorder.

Using this method which includes weighting for deprivation, Figure 6 below shows that Medway's rate for common mental health disorders is slightly below the England average and is near the middle of its ONS comparator group.

Figure 6: Modelled rate of common mental health problems amongst 16-74 year olds by Primary Care Trust in England.
Figure 6: Modelled rate of common mental health problems amongst 16-74 year olds by Primary Care Trust in England
Source: North East Public Health Observatory, 2008

Figure 7 shows that within Kent and Medway according to the modelling method above, Medway has the highest rate of common mental health problems second only to Thanet.

Figure 7: Modelled rate of common mental health problems amongst 16-74 year olds by Local/Unitary Authorities in Kent & Medway.
Figure 7: Modelled rate of common mental health problems amongst 16-74 year olds by Local/Unitary Authorities in Kent & Medway
Source: North East Public Health Observatory, 2008

However again these estimates can only be taken as a guide, as while they are the best available at the present time they are based on information which is now considerably out of date.

Prevalence of common mental health problems nationally also varies by:


• ethnicity, with South Asian women recording the highest prevalence (34.3%)
• marital status, with a higher prevalence among divorced and separated adults, see previous section.
• household income, with adults in the lowest quintile of household income more likely to have a common mental health problem than adults in the highest quintile. This is a particularly strong association among men, with men in the lowest household income quintile three times more likely to have a common mental health problem than men in the highest household income quintile.

Primary care information

There is no routinely collected local information on population prevalence of all common mental health problems. The Quality and Outcomes Framework primary care data collection does collect information on depression incidence and prevalence from depression registers held in GP practices and this information is shown below (Figures 8 and 9), but this does not cover all common mental illnesses and may also be subject to under recording by practices. It shows that there are 22,829 people aged 18 and over in Medway who have been diagnosed with Depression at some point in their lives. Between April 2011 and March 2012 2,583 people aged 18+ were newly diagnosed with depression. This equates to an incidence rate for Medway of 1.3% which is greater than the England rate of 1.1%.

Figure 8: Depression prevalence (recorded ever) by GP practice in Medway 2011/12.
Figure 8: Depression prevalence (recorded ever) by GP practice in Medway 2011/12
Source: Quality and Outcomes Framework, NHS Information Centre for Health and Social Care
Figure 9: Depression incidence (recorded in last year) by GP practice in Medway 2011/12.
Figure 9: Depression incidence (recorded in last year) by GP practice in Medway 2011/12
Source: Quality and Outcomes Framework, NHS Information Centre for Health and Social Care

It appears that there is large variation in the prevalence and incidence of depression across GP practices which needs to be explored further.

2.2 Psychosis and severe mental illness

Psychoses are disorders that produce disturbances in thinking and perception severe enough to distort perception of reality. The main types are schizophrenia and affective psychosis, such as bi-polar disorder. In the Psychiatric Morbidity Survey 2007 the overall prevalence of psychotic disorder nationally was found to be 0.4% (0.3% of men, 0.5% of women).

In both men and women the highest prevalence was observed in those aged 35 to 44 years (0.7% and 1.1% respectively). The age standardised prevalence of psychotic disorder was significantly higher among black men (3.1%) than men from other ethnic groups. The prevalence of psychosis (0.2%of white men, no cases observed among men in the South Asian or 'other' ethnic group). There was no significant variation by ethnicity among women[2]. Prevalence is also higher in people with lower household incomes (0.1% of adults in highest income quintile and 0.9% in adults in the lowest income quintile)[2].

To estimate the prevalence of psychosis locally we have extrapolated the national prevalence reported in the Adult Psychiatric Morbidity Survey, to Medway using 2011 based population projections for 2013. This provides an estimate of approximately 862 people suffering from probable psychosis in Medway. The graph below shows the variation in prevalence across age and gender extrapolated to Medway also showing estimated local numbers in each category.

Figure 10: National prevalence of psychotic disorder in past year by age and gender.
Figure 10: National prevalence of psychotic disorder in past year by age and gender (estimated numbers living in Medway in 2013 shown in bars)

Similarly to the information collected for depression GP practices maintain a register of patients that have schizophrenia, bipolar disorder and other psychoses as part of the QOF.

In 2011/12 there were 1,740 patients recorded on the QOF mental health register across Medway's practices, giving a recorded prevalence rate of 0.6%, which is lower than the national rate of 0.8%. Recorded prevalence rates at practices in Medway practices ranged from 0.2 to 2.5%.

Figure 11: Severe Mental Illness prevalence by GP practice in Medway.
Figure 11: Severe Mental Illness prevalence by GP practice in Medway 2011/12
Source: Quality and Outcomes Framework, NHS Information Centre for Health and Social Care

Understanding the level of need for mental health services: MINI 2000

The Mental Health Needs Index 2000 (MINI 2000)[4] has not been updated since 2000 and is therefore the information it contains is out of date. Using it as a predictor of need for hospital admission is also likely to be misleading as it does not take into account the development of new models of care such as crisis resolution home treatment services which means that the threshold for admission is likely to have increased. However it does provide some comparison of need for mental health services for those with severe mental health services in different areas in Medway.

The level of mental illness severe enough to require hospital admission in Medway is identified by the MINI 2000. This is estimated to be slightly lower than the England average. (0.91 in Medway compared to 1 in England). Within Medway, wards that are identified as at least 20% more likely to require hospital admission than the England are shown in the darkest colour. These are Chatham Central, Luton and Wayfield, Rochester East and Gillingham South.
This is broadly consistent with what we would expect given levels of deprivation in those wards.

Note: As stated above the MINI Index has not been updated since 2000 however we do not have any alternative indices for comparison so it is still being used nationally as an aid to comparison between areas.

Figure 12: MINI 2000 scores by electoral ward.
Figure 12: MINI 2000 scores by electoral ward
Source: North East Public Health Observatory (map produced by Kent & Medway Public Health Observatory)

Compared with it's ONS cluster towns, Medway has the second highest MINI index score indicating a higher level of need than it's comparator areas.

Figure 13: MINI 2000 scores Primary Care Trusts.
Figure 13: MINI 2000 scores Primary Care Trusts in ONS Cluster group ‘New and Growing Towns’. Source: North East Public Health Observatory
2.3 Veterans mental health

A veterans mental health needs assessment was carried out for Kent and Medway by the Public Health Directorate in 2011[5]. There is no accurate local source of information as to current numbers of local veterans living in Kent and Medway and the level of mental health need in this group. The information below has been estimated using information taken from mapping work carried out by Royal British Legion in conjunction with Experian and, specifically with respect to mental health problems from the Kings Centre for Mental Health (KCMHR) cohort study commissioned by the MoD. This looked at the mental health of 9,990 serving personnel and veterans who had been deployed to Iraq and Afghanistan.

Overall, using the best data which was available in 2010, 10.9% of Medway's over 16 population are estimated to be veterans. This equals 22,479. This figure is high because it still includes many WW2 veterans.

However in more recent years, the recently deployed veteran population has been of increasing importance with respect to need for services. The information below sets out estimates of the mental health issues experienced by recently deployed veterans compared with the general population.

  Military General population
Probable PTSD 4% 3%
Common mental disorder ~20% ~20%
Alcohol misuse 13% 6%
Table 3: Comparison of mental health problem prevalence in military and general populations
Source: KCMHR cohort study, 2010

This indicates somewhat surprisingly that level of PTSD in the armed forces and amongst veterans in recent years is very similar to those in the general population and the level of common mental health problems is also broadly similar. However the level of alcohol misuse is significantly higher in the military population than in the civilian population.

The study had a 56% response rate and although the results were adjusted to take into account the characteristics of non responders, there are still legitimate concerns that the results may not be representative of all veterans.

From this work the number of veterans under 65 with mental health problems has been estimated in Table 4 below

  Kent & Medway Medway
Probable PTSD 2,169 360
Common mental disorder 10,843 1,798
Alcohol misuse 7,043 1,170
Table 4: Estimated Number of Veterans aged under 65 with mental health problems in Kent and Medway

There are significant problems with this extrapolation, since the age structure, military experience and general lifestyle of the general veteran population is very different to that of the recently deployed population surveyed by KCMHR however it is the best data we have available at present.

2.4 Maternal mental health

Mental disorders during pregnancy and the postnatal period can have serious consequences for the mother, her infant and other family members. During this period, women are more likely to come into contact with mental health services, than any other time in their life, particularly those at an increased risk of relapse of an existing disorder.

Low mood is thought to affect up to 15% of pregnant women. NICE guidance recommends psychological treatment or social support for pregnant women whose lives are significantly affected by sub-syndromal depression and anxiety, and the guideline estimates this prevalence at 2.6%.

An estimated 10% to 15% of women suffer from depression after the birth of an infant[6][7], although studies vary considerably. However, it is argued that about half of these cases will never come to medical attention. 3% to 5% of women giving birth have moderate or severe depression, with about 1.7% being referred to specialist mental health services[8][9]. Thus, around 17 women per 1,000 live births may be referred to specialist mental health services with depression postnatally.

Puerperal psychosis (i.e. in the early postnatal period, up to three months after delivery) is a severe and relatively rare form of postnatal mental illness affecting between 0.1% and 0.2% of all new mothers.

If half of mothers experiencing postnatal depression request treatment, (5-7.5%) and if 0.1-0.2% per cent experience psychosis then this would equate to 270 and 10 Medway women in 2011 respectively (based on approximately 3550 births).

Many women admitted with psychosis in the postnatal period have a pre-existing mental disorder, including bipolar disorder and schizophrenia.) The rate of recurrence of postnatal depression after a subsequent birth is about 30%. Relapse rates for bipolar disorder approach 50% in the antenatal period and 70% in the postnatal period[10].

2.5 Personality Disorders

Personality disorders are longstanding, ingrained distortions of personality that interfere with the ability to make and sustain relationships. Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are two types with particular public and mental health policy relevance.

ASPD is characterised by disregard for and violation of the rights of others. People with ASPD have a pattern of aggressive and irresponsible behaviour which emerges in childhood or early adolescence. They account for a disproportionately large proportion of crime and violence committed. ASPD was present in 0.3% of adults aged 18 or over (0.6% of men and 0.1% of women). In Medway this equates to approximately 750 people.

BPD is characterised by high levels of personal and emotional instability associated with significant impairment. People with BPD have severe difficulties with sustaining relationships, and self-harm and suicidal behaviour is common. The overall prevalence of BPD was similar to that of ASPD, at 0.4% of adults aged 16 or over (0.3% of men, 0.6% of women). In Medway this equates to approximately 950 people.

3 Self harm and suicide and undetermined injury

Suicide is a serious public health problem. In Medway in 2011 there were 13 suicides. As suicides are more likely to occur in younger age groups than most other causes of death they contribute a significant amount to total years of life lost for a population even though the number of deaths are small. The information below shows that over the last nearly two decades suicide rates nationally have been declining. This has to some extent been reflected locally although given the small numbers locally there has been considerable year on year variation and differences by local area.

Figure 14: Trends in suicide and undetermined injury mortality rates.
Figure 14: Trends in suicide and undetermined injury mortality rates
Source: Health & Social Care Information Centre and Kent & Medway Public Health Observatory

In Medway in 2010 suicide rates were below the England average. At this point the national data for 2011 has not been released so we cannot compare with the national position for 2011 and 2012.

Common mental disorder Borderline personality disorder Antisocial personality disorder Psychotic disorder Two or more psychiatric disorders
M F P M F P M F P M F P M F P
2012 10,400 16,292 26,692 250 496 746 499 83 582 250 414 663 5,741 6,203 11,943
2015 10,563 16,489 27,051 254 502 756 507 84 591 254 419 672 5,831 6,278 12,108
2020 10,800 16,784 27,584 259 511 770 518 85 604 259 426 685 5,962 6,390 12,352
2025 11,013 17,100 28,112 264 521 785 529 87 615 264 434 698 6,079 6,510 12,589
2030 11,238 17,297 28,534 270 527 797 539 88 627 270 439 709 6,203 6,585 12,788
Table 5: Numbers of suicide and undetermined injury in Kent and Medway by local authority area
Source: Kent & Medway Public Health Observatory

Some of the apparent variation in numbers and rates has also been due to the way suicide data is collected. Suicide data is recorded at the point of the coroners verdict so at the point of registration rather than at date of death so delays in inquests can skew figures. When actual date of death is looked at rather than point of death registration the variation for the last 4-5 years largely disappears. This can be seen in the table above where date of death figures (in red) are compared with the registration of death figures. So overall in Kent and Medway there has been no significant change in suicide rates or numbers over the last 5 years rather what we may be seeing is a flattening out of the suicide rates rather than an ongoing decrease.

We have analysed figures by age and sex across Kent and Medway as analysis in Medway only at sub group level would not be possible given the small numbers. Nationally we know that approximately 75% of suicides are males. This is reflected in the Medway figures . The highest numbers and rates of suicide can be found in the 30-60 age group for men whereas in women suicide rates exhibit less variation between 10 year age groups after the age of 30.

Figure 15: Rates of suicide and undetermined injury by age and sex, 2010-12.
Figure 15: Rates of suicide and undetermined injury by age and sex, 2010-12
Source: Kent & Medway Public Health Observatory

With respect to method of suicide, between 2008-12, 49% of all suicides were due to hanging with 24% due to drugs and poisoning. Jumping from a high place accounted for 10% of suicides in Kent and Medway.

Figure 16: Number of deaths due to suicide and undetermined injury by method, 2008-12.
Figure 16: Number of deaths due to suicide and undetermined injury by method, 2008-12
Source: Kent & Medway Public Health Observatory

The most common method of committing suicide in men is hanging. There is no significant difference in method among women.

Figure 17: Trends in number of deaths caused by hanging and poisoning by sex.
Figure 17: Trends in number of deaths caused by hanging and poisoning by sex
Source: Kent & Medway Public Health Observatory

References

[1]   The Government Office for Science, London. Foresight Mental Capital and Wellbeing Project (2008). 2008; The Government Office for Science, London. http://www.bis.gov.uk/foresight/our-work/projects/published-projects/mental-capital-and-wellbeing/reports-and-publications .
[2]   McManus S, Meltzer H, Brugha T, et al. Adult psychiatric morbidity in England, 2007: Results of a household survey 2009; The NHS Information Centre for health and social care. http://bit.ly/GAxluS .
[3]   Heady P, Ruddock V. Report on a project to estimate the incidence of psychiatric morbidity in small areas 1996; Office for National Statistics.
[4]   Gyles Glover DW. A needs index for mental health care in England based on updatable data 2004; North East Public Health Observatory. http://www.nepho.org.uk/pages.php5?pg=140#d335 .
[5]   Howarth G. Veterans (ex-military) Health Needs Assessment for Kent and Medway 2011; Kent Public Health Directorate. http://www.kmpho.nhs.uk/population-groups/veterans/ .
[6]   Brockington I. Motherhood and Mental Health 1996;
[7]   Nonacs R, Cohen L. Postpartum mood disorders: diagnosis and treatment guidelines Journal Clinical Psychiatry 1998; 59: Suppl 2:34-40.
[8]   Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression British Journal of Psychiatry 1993; 163: 27-31.
[9]   O'Hara MW, Swain AM. Rates and risk of postpartum depression -- a meta-analysis International Review of Psychiatry 1996; 8: 87-98.
[10]   Viguera A, Nonacs R, Cohen L, et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance American Journal of Psychiatry 2000; 157: 179-184.