Pauline Perspective

MENTAL HEALTH THEN AND NOW A BOARD ROOM PERSPECTIVE

Tom Hayhoe has been chairman of West London NHS Trust since 2015 and for many years was closely involved as a friend in the care of Robert Silver, whose obituary appears in this edition of Atrium.

Arriving at St Paul’s from a comprehensive school in the late 1960s, about the only Latin I recognised was “Mens sana in corpore sano”. Looking back from my current role chairing an organisation providing mental health services for a large part of the school’s catchment, I recall plenty of provision for “corpore sano” but precious little for “mens sana”.

Physical wellbeing was ostensibly part of the purpose of compulsory rugby in the autumn term and in the wide choice of sport during the rest of the year. A local GP served as school doctor, undertaking periodic physical checks as we passed through adolescence. For those who didn’t head home at the end of the school day, the School House and High House matrons administered aspirin gargles for any ailment irrespective of diagnosis. On the other hand, any provision or concern for our mental wellbeing beyond the tutorial system was well concealed.

The picture today is very different. St Paul’s is deservedly recognised as a pioneer and leader for its investment in mental wellbeing. It has a dedicated senior member of staff, Sam Madden, designated as Deputy Head (Wellbeing and Mental Health). All tutors complete an externally accredited two-day Mental Health First Aid course. Paulines attend lectures from external mental health campaigners. The School is piloting an on-line tool for tracking the emotional wellbeing of younger boys. 8th Formers run a society called ‘MindMatters’ with the goal of tackling mental health related stigma and promoting positive wellbeing. The importance of this work is demonstrated by the evidence for increasing pressures on the mental wellbeing of teenagers: the rate of referral nationally into NHS child and adolescent mental health services doubled between 2012/13 and 2018/9.

The disparity nationally between the status of mental and physical health in the 1960s was enormous. However, change was already on the way. New psychiatric medicines were coming on stream and the emphasis was shifting from treating people in hospital to supporting them in the community. The decade opened with a speech delivered by Enoch Powell as Minister of Health to the National Association for Mental Health that has passed into NHS legend: “This is a colossal undertaking…. in the sheer inertia of mind and matter which is required to be overcome. There they stand, isolated, majestic, imperious, brooked over by the gigantic water tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day…. We have to strive to alter our whole mentality about hospitals and about mental hospitals especially... We have to get the idea into our heads that a hospital is a shell, a framework, however complex, to contain certain processes, and when the processes change or are superseded, then the shell must most probably be scrapped.”

Fifty to sixty years on, the approach we take to mental health is transformed but there is still much to be done. The water towers have gone and most of the old asylum buildings have been demolished or repurposed as desirable residential developments. A few vestiges of the old mental health estate remain including, scandalously, some dormitory style wards. The NHS Trust that I chair is desperate for capital to move from the remaining pre-Victorian wards it occupies at the St Bernard’s Hospital (originally built as the Hanwell County Asylum). It was only last December that we finally moved the patients at Broadmoor High Secure Hospital from buildings erected in 1863 to an environment fit to support the recovery of men who are extremely unwell and a high risk to themselves as well as the public, preparing them for an eventual return, via less secure hospitals or prison, to life in the community.

Fifty to sixty years on, the approach we take to mental health is transformed but there is still much to be done.

The transformation in the approach to mental health involves more than the relocation of people with acute mental illness from long-term hospitals. As a lay person working in this area, my impression is that the change results from continual improvement in the clinical understanding of mental illness and the tools for helping people experiencing difficulties in their mental health.

Our mental health reflects a huge range of potential influences: genetic inheritance, organic illness throughout our life, psychological influences in our families, upbringing, working and domestic lives, traumatic events, what we put into our bodies – not just drugs (prescribed or otherwise) and alcohol – but the food we eat and the accompanying organisms (both good and bad for us) that affect our individual gut flora. This is no different to other aspects of our health. While there may be specific immediate causes for our “-itis”, “-algia”, “-opathy”, or “-noma”, the upstream causes, our susceptibility, and our ability to cope with physical health conditions are just as diverse as those determining our mental health. We are hugely complex organisms exposed to an almost infinite variety of external factors and experiences.

Correspondingly, professions in mental health that have traditionally been at loggerheads about treatment methods are increasingly accepting of the wide range of interventions to help recovery or at least manage symptoms. Antipsychotic drugs over the years have become more effective for schizophrenia, schizoaffective disorder, some bipolar disorder and severe depression by reducing or controlling symptoms, and have fewer side effects. Cognitive behaviour therapy (CBT), extensively used for people with much less acute conditions, can also assist by providing these patients with strategies to help cope with unpleasant or difficult experiences arising from the underlying psychotic condition. Similarly, while some people with anxiety or depression come through their condition with psychological therapies alone, others benefit from medication, most commonly from one of the classes of serotonin reuptake inhibitors that increase the level of an important naturally occurring neurotransmitter in the brain.

The change in the pattern of mental health care delivery for those in most acute need has been dramatic. The number of mental health inpatient beds in England fell from 130,000 in the 1940s to 80,000 by the mid-1980s and currently stands at 19,000, made possible by more effective therapeutic interventions and a shift in resources. Looking at international comparisons, the reduction could go further: the average length of stay in an inpatient mental health unit in England is 32 days, compared to 11 days in Australia and 9 days in Sweden. However, to make progress we need to invest more in support for patients following discharge from hospital, not least around social care needs and housing.

The biggest change in the delivery of mental health care in the UK has been in the improved support for people with less acute problems, such as mild depression and anxiety, through the delivery of psychological therapies under the IAPT (Improved Access to Psychological Therapies) programme launched by the Labour government in 2008 and taken up with enthusiasm first by the Coalition and since by the Conservatives. 1.1 million courses of treatment were delivered during last year and the ambition in the NHS Long Term Plan is for this to increase to 1.9 million. The benefits of this investment are twofold: psychological therapies help most of the people referred to the service address their symptoms and get back on track; and, for those with deeper underlying problems, symptoms are spotted earlier and the risk of potentially longer term problems mitigated.

The good news for anyone with an interest in mental health is the increased interest in the area. Prince William and Prince Harry have emerged as great champions. There is progress in the commercial world, with exemplary leaders being open about their own mental health challenges, employers recognising the need to take more care of their staff and engage in programmes such as Mental Health First Aid, and the success of initiatives like the City Mental Health Alliance. Our politicians are increasingly interested in mental health, evidenced by the increase of mentions of mental health in the party manifestos: the Conservative Party’s general election manifesto carried five mentions in 2015, rising to 35 in 2017, and Labour’s four mentions in 2015 and 13 in 2017.

As chair of an NHS Trust providing mental health services, I take heart from the commitment of the Department of Health and Social Care to increasing the funding for mental health. And as OPs we can be proud of our association with a school that now treats the mental wellbeing of its pupils as an equal priority with its tradition of academic excellence.

And as OPs we can be proud of our association with a school that now treats the mental wellbeing of its pupils as an equal priority with its tradition of academic excellence.

 Tom Hayhoe (1969-73)

MENTAL HEALTH TODAY A PATIENT PERSPECTIVE

Men’s mental health is gaining more and more exposure, which can only be a good thing. If your eyes do not work so well, you wear spectacles.

If you have a broken arm, you have a plaster cast until it is better. The same applies to mental health. There is no shame in admitting part of your body does not work properly even if it is your brain.

However, professional and researched help is available (NHS and/or privately) for those who suffer from this debilitating and scary illness. Mental illness/ psychological trauma / being a bit nuts, however you are comfortable in labelling any issues you might have, the message is clear: there is nothing to be ashamed of. If you need it, get help from your GP or, in emergency the crisis line for your local NHS Trust.

Previous generations used euphemistic phrases like “midlife crisis”, “nervous breakdown”, “the only difference between madness and eccentricity is wealth”, “the men in white coats“ etc. etc. These are not helpful in addressing what is a very serious issue, and one that affects a quarter of the population in any given year. Depression is not the same as sadness. Anxiety is not the same as trepidation. Bipolar is not the same as having an off day. Psychosis is not the same as disappointment.

Part of the problem is our understanding of these and related words. Personally, I use the term “a little bit nuts”; it deflects sympathy but maintains gravitas. It is no longer okay to sweep mental health issues under the carpet, as our forefathers had to. Another part of the problem is that men are under-diagnosed, we are all stubborn and many of us are introspective; that does not mean we are not susceptible, no matter how much it piques our masculinity.

The audience for this magazine is largely professional, intelligent, and high achieving men. We all have St Paul’s School in common although time and distance may separate us. As members of this (or any) community it behoves us to help one another in the spirit of common decency and good manners.

Mental illness is like a cold sore; while it may not be always flared up, it is always there in the background with the potential to appear at any trigger. Although I am probably not qualified to have an opinion on this, I think that the sociocultural awakening for this generation will be that it is okay to have mental health issues. Our greatgrandparents’ views on race and grandparents’ attitudes towards homosexuality are unsavoury to the modern palate. Where Martin Luther King and the Stonewall movement spearheaded breakthroughs for those generations, I am hopeful that one legacy we can hand down is tolerance of psychological divergence. While one could never condone intervention for issues of race and sexuality, with mental health, treatment is proven to improve quality of life.

If you have advised a loved one to see a doctor when they felt unwell, take your own advice. Yes, we are all busy, yes none of us want to admit there might be something wrong, and yes we’d see a doctor if one of our fingers fell off.

I am not a mental health professional and can only speak from personal experience. After many years of low mood and disturbing episodes, after the death of my brother from cancer aged just 41, my undiagnosed mental illness spiralled terrifyingly out of control. I was clinging to the wreckage of my own sanity and it was scary. I had become a danger to myself and others, but one visit to my GP set me on the right track. I was not sectioned. She realised that the black dog had me firmly in its jaws and that hallucinations and paranoia were clouding my better judgement. The GP expedited me to the local mental health team who took me on with kid gloves. This was two years ago. Now, with the help of a kind and patient shrink (she prefers to be called a counsellor), and prescribed medication, I am on the road to recovery. would not play a part in my recovery but, by and by, my psychologist and I concluded that it would be the best course of action, alongside therapy. Science has improved since the days of the so-called happy pills.

I was initially prescribed 50mg of sertraline, which was incrementally raised until my present dose (still under supervision by the mental health nurse). Side effects have included double incontinence and fluctuating libido, but the positives far outweigh the negatives.

Everybody is different but in my case the drugs also triggered my sense of taste. Before, I ate out of necessity deriving no pleasure from food. I thought I could taste food in the same way as everyone else, but now I realise that I was wrong. The first food I ever tasted, at the age of 38 was a microwaved cheese pizza; absolutely nothing special, but the flavour explosion I experienced was an epiphany. Mood has been noticeably less low too, yes, there are bad days and good days, but the lows no longer approach the terrifying depths pre-medication. At present I am still not able to work and some days are difficult but, had it not been for the NHS and my GP, my mother would be mourning both her sons.

I do not mean to sound sanctimonious or preachy but if this has resonated in any way with the reader, I strongly encourage you to book an appointment with your GP, be open about any concerns you have. In any other area of life, it is sensible to take professional advice when your own capability falls short, mental health should not be the exception.

Mental illness is like a cold sore; while it may not be always flared up, it is always there in the background with the potential to appear at any trigger.