Mental health promotion in the hospital setting: do we have enough evidence?

1. Mental health promotion in the hospital setting:do we have enough evidence? Dr. Eva Jané-Llopis Radboud University of Nijmegen The Netherlands

2. WHY MENTAL HEALTH?

3. The burden of mental disorders Suicide and self-inflicted injury, all ages per 100000 • 450 million suffer a mental health problem every year • One in four of us • 20% of all ill health and premature death Sources: Ustun et al., 2004; Chisholm et al, 2004; WHO HFA database

4. DEPRESSION Depression in patients with physical illness Source: WHO (2003) Investing in Mental Health

5. Mental health problems in hospital staff

6. Mental health problems in hospital staff High psychological distress Anxiety Anxiety Depression Stress Stress Psychiatric morbidity Psychiatric morbidity Burnout Maunz & Steyer, 2001; Bourbonnais et al, 1999; McGrath & Boore, 2003; Borill et al; Benett et al. 2001

7. Mental Health on the Political Agenda!WHO European Ministerial Conference on Mental Health (Helsinki, January 2005) 31 Ministers of Health - 51 European Countries signed the Declaration and Action Plan

8. The WHO Declaration for Mental Health • that European countries have agreed to support, calls to: • Promote mental health across the lifespan • Prevent mental disorders • Implement interventions for vulnerable groups • Network with medical care to approach mental health • Develop a competent workforce through education and training programmes • Develop and support research and evaluation of the above actions

9. So, what can we do about it? Picture: from Atonement, Ian McEwan

10. MENTAL HEALTH PROMOTION CAN BE EFFECTIVE REVIEWS from: WHO and the IUHPE http:/www.iuhpe.org present the evidence for mental health promotion and mental disorder prevention http:/www.who.int Source: Jané-Llopis et al., 2005; WHO, 2004

11. What can be done in the hospital setting?Is there enough evidence to support mental health promotion and mental disorder prevention? Overview of some efficacious approaches: • Nurses and - Patients at risk for mental health problems

12. Stress management for hospital staff • Stress management is used as a general concept for interventions to improve coping abilities and reduce stress. • The underlying principles, mechanisms and outcomes are very similar in both types of interventions Stress Management (SM) - Prevention - Promotion

13. Stress management for hospital staff 1. Environmental management: arranges work environments to reduce stress sources

14. 1. ENVIRIONMENTAL MANAGEMENT Shastin Hospital (HPH since 2003) Ulaan Baatar, Mongolia

15. 1. ENVIRIONMENTAL MANAGEMENT Environmental management • Computerized – appointment based outpatient system

16. 1. ENVIRIONMENTAL MANAGEMENT Environmental management • Computerized – appointment based outpatient system • Change from 10 patients per room (!) to 4 patients per room • Intranet system for efficient communication • Salary increase

17. Stress management for hospital staff 1. Environmental management: arranges work environments to reduce stress sources  not many studies available

18. Stress management for hospital staff 1. Environmental management: arranges work environments to reduce stress sources  not many studies available 2. Individual support: supports personnel to deal with a variety of stressful situations  a) generic stress management  b) communication skills

19. 2. INDIVIDUAL SUPPORT a) Generic stress management • To counteract the distress response in the individual • Methods: education, role playing, empowerment, relaxation, music, exercise, humor, cognitive techniques Source: Mimura & Griffiths, 2003;

20. 2. INDIVIDUAL SUPPORT a) Generic stress management • Cognitive techniques Effective • Exercise, music and relaxation training Potentially effective • Social support education Questioned but possibly effective Evidence is weak; further research is needed before making recommendations Source: Mimura & Griffiths, 2003;

21. 2. INDIVIDUAL SUPPORT b) Communication skills • Communication difficulties are a stress factor among health professionals. In palliative care nurses try to avoid psychological discussions, focusing on the physical complaints • This adds to the patients’ stress: “they dislike being regarded as a hospital number, wish to be treated with respect for their dignity and needs” Source: Dep of health, 2002; Wilkinson 1999;

22. 2. INDIVIDUAL SUPPORT b) Communication skills • Several RCTs have demonstrated efficacy • 3 systematic reviews: promising results Outcomes: • 30% increase in relevant questions • 70% increase in empathy • Nurses used more emotional speech for anxiety and distress. • Patients used more emotional terms Sources: Wilkinson et al., 1999, 2003; Fellowes et al., 2003

23. Interventions for hospital users

24. Support during pregnancy and the first years of life

25. Support during pregnancy Programme: Nurse home-visitation Adolescent low income pregnant women During pregnancy up to 24 months Goals: Maternal and child functioning Health behaviour Parenting care giving practices Maternal life course development Olds et al., 1998; 2000

26. Mothers’ Outcomes: 38%  emergency visits 75%  in preterm deliveries 25%  smoking 83% employment Prenatal Early Infancy Project: OUTCOMES Olds et al., 1998; 2000

27. Children’s Outcomes: Mothers’ Outcomes: 38%  emergency visits 75%  in preterm deliveries 25%  smoking 83% employment Prenatal Early Infancy Project: OUTCOMES  birth weight (>400 grams)  IQ scores (age 4) At age 15: 56%  alcohol - drug use 56%  arrests 81%  convictions Olds et al., 1998; 2000

28. Interventions for hospital users • Support to pregnant mothers:

29. Interventions for hospital users • Support to pregnant mothers: 70%  caesarean birth  antenatal anxiety 50%  be worried about their babies 40%  dissatisfied with care No impact in the likelihood of giving birth too early or birth weight Sources: Hodnett and Fredericks, 2003

30. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients: Sources: Hodnett and Fredericks, 2003

31. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients:  psychological well being  anxiety and depressive symptoms Sources: Hodnett and Fredericks, 2003Nixon et al., 2002;

32. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients • Massage (aromatherapy) for cancer patients: Sources: Hodnett and Fredericks, 2003Nixon et al., 2002;

33. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients • Massage (aromatherapy) for cancer patients: 19-32% anxiety symptoms Sources: Hodnett and Fredericks, 2003Nixon et al., 2002; Fellowes et al., 2004;

34. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients • Massage (aromatherapy) for cancer patients • Patient education for rheumatoid arthritis: Sources: Hodnett and Fredericks, 2003Nixon et al., 2002; Fellowes et al., 2004;

35. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients • Massage (aromatherapy) for cancer patients • Patient education for rheumatoid arthritis: 5% psychological status 12% improvement in depression No change for anxiety Sources: Hodnett and Fredericks, 2003Nixon et al., 2002; Fellowes et al., 2004; Riemsma et al., 2003;

36. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients • Massage (aromatherapy) for cancer patients: • Patient education for rheumatoid arthritis • Psychological and SM for patients with CHD: Sources: Hodnett and Fredericks, 2003Nixon et al., 2002; Fellowes et al., 2004; Riemsma et al., 2003;

37. Interventions for hospital users • Support to pregnant mothers • Aerobic exercise for HIV-Aids patients • Massage (aromatherapy) for cancer patients: • Patient education for rheumatoid arthritis • Psychological and SM for patients with CHD: in anxiety and depression (small) Sources: Hodnett and Fredericks, 2003Nixon et al., 2002; Fellowes et al., 2004; Riemsma et al., 2003; Rees et al., 2004

38. Environmental management Individual support Behavioural Exercise, relaxation… Communication skills Support to pregnant mothers Aerobic exercise for HIV-Aids patients Massage for cancer patients Patient education for rheumatoid arthritis Psychological and SM for patients with CHD We have seen… For nurses: For users:

39. One consistency: More RESEARCH More RESEARCH More RESEARCH With high quality

40. All reviews stress the need for… • well-designed, • adequately powered, • multicentre, • randomised controlled trials • with high quality • assessing the effectiveness on multiple outcomes • including mental health • using appropriate methodology… Source: across studies and systematic reviews

41. So bad or good news? The problem is: • NOT that it does not work • That there are not enough studies yet to make absolute recommendations To engage high level decision makers we need strong arguments and, good evidence will help

42. What challenges can be taken on board by HPH? • Improve quality of research undertaken and stimulate new research: cost-effectiveness  Creation of partnerships between practice and research centres to evaluate existing initiatives 2. Understand the impact of existing health promotion interventions on mental health Develop strategies that include mental health in existing health promotion practices

43. Conclusions • Mental health problems are very common in secondary health care • Interventions are available to promote mental health • Good quality research is essential to continue improving the evidence base • Partnerships can help this happen • Mental health is high in the political agenda

44. In the last 10 minutes, only in Europe: • Over 600 people have got a new depressive disorder • About 200 have suffered from new mental harm done by alcohol • 3 people have died from suicide Sources: Ustun et al., 2004; Chisholm et al, 2004; WHO HFAdatabase

45. and the hospital setting provides an exceptional opportunity to reach a large proportion of those at risk

46. Thank you

47. We would like to hear your views Workshop: discussion in groupsHow can we integrate mental health promotion in health promoting hospitals? Facilitated by: Eva Jané Llopis, Christina Dietscher and Juergen Pelikan Session III.2: Adelaide Room