Blue Monday: The truth about the false divide

In conversations about mental health it is often said that one in four people in the UK experience a mental health condition at some point each year. The truth is even more comprehensive… all of us do. We all have a mental health condition all of the time. That condition may be “good” or “fine”, but it may also be “anxious”, “stressed” or “depressed” and these are no less normal sometimes. Our mental wellbeing, just like our physical health, is a natural part of the human condition; something we should acknowledge and actively look after as a part of living a healthy life. When considered alongside physical health it is sometimes too easy to neglect our mental wellbeing; it may be less visible, but it is no less valuable.

January is a particularly busy time for mental health services. The perfect storm of the post-Christmas lull, bad weather and credit card bills hitting the mat has meant that today, the third Monday in January, has gained notoriety as “Blue Monday”; supposedly the most depressing day of the year.

Similarly January is also a notorious pressure point for hospitals and other physical health care providers. The cold weather and ongoing funding squeeze in our NHS is felt particularly acutely in the winter months. It stands intuitively to reason that there must be a link between the two – it can be harder to maintain a positive mood if you are struggling through a period of illness and similarly harder to pursue a healthy, active lifestyle if you are wrestling with depression and every activity requires a monumental effort of willpower.

The interconnections of health, lifestyle and other social factors run, of course, even more deeply. One phrase increasingly common among GPs and other health professionals is “Crap Lives Syndrome”. This term has gained traction for its pithy but evocative characterisation of the situations of increasing numbers of people who are presenting at their GPs with multiple, complex needs spanning the traditional thresholds of health and social care. For many of them it is not obvious exactly what the main causal factor is, or whether theirs is really a health condition by the conventional definition at all. Are they drinking too much because they are worried about paying the bills? And without the drinks can’t get off to sleep? But has this crossed the “dependence” line to the point that it’s contributing to depression? Causing them to worry more about keeping the roof over their head? The stress of that may be preventing them from being able to function at work at all, and making financial collapse and homelessness a real possibility. Drinking is making all this even worse, and all contributing to a harmful lifestyle, diet and poor nutrition, now manifesting in sleep and other physical health issues. They may have come to see their GP for help with these, but it is all enmeshed. The relationships can be symbiotic and circular; what is cause and what is effect?

More and more people are finding themselves in circumstances such as these; where multiple, interrelated problems are blighting their lives simultaneously, and more and more of them are turning to their GPs in the fallout. They may also have contact with addiction services, with the criminal justice system, with someone trying to help with their mental health, finances or housing. But no one professional has hold of the whole thread, and it is difficult to understand where the thread even begins.

People living through this simply know that they need help, and what we can say for sure is that, as a society, it is our duty to give it. Foremost and most profoundly for the sake of each individual themselves, but also because doing so helps everyone else too. Effective, coordinated interventions that make a real difference towards helping people with “crap lives” turn them around would mean less pressure and lower waiting times throughout the whole system.

For these reasons the goal of delivering truly coordinated and comprehensive support has been a long-standing holy grail in health and social care services, and this is why phrases such as “joined-up working” and “holistic care” feature prominently in the lexicon of those working in them. But making things work in the real world has proved difficult. Few policy aspirations have received so much verbal promotion yet translated into such little in the way of practical results. Meaningful connectivity has been hampered by a system that is not geared to accommodate the intrinsic interplay between health, social and “whole life” factors. NHS services deliver their part of the whole, Department of Work and Pensions employment services theirs, local authorities and charities serve an important, but often independent, function in parallel.

People working “on the ground” do their best to join the dots and avoid service users falling between cracks. There is genuine commitment and recognition that, because we all ultimately want to help people in whatever form, this challenge is ours to own collectively and to meet collectively. But this has only been possible to the extent that current structures permit and basic expedients are still missing. In an always connected world our health and social care services remain conspicuously disconnected digitally; lacking common IT systems and agreed protocols for sharing valuable information. Opportunities too often lost to excessively risk averse applications of patient confidentiality and data protection rules.

But an innovative attempt to better join some of these dots and transcend the narrowly specified structures many services currently operate in is now underway. Plans are being implemented to increase the number of people receiving NHS-commissioned primary care psychological therapy services by 66 per cent by 2020 as part of the national Improving Access to Psychological Therapies (IAPT) Programme. This upscaling of provision includes an expectation that some 60 per cent of extra referrals will be made up of people with at least one long term, co-morbid, physical health condition. And “early adopter” sites are now fostering direct collaboration between psychological therapy services and physical health workers in places like Nottinghamshire, Calderdale and East Kent under the “Integrated IAPT” banner.

The model involves psychological therapists leaving their usual places of work and co-locating with physical health colleagues in hospitals, care homes and other specialist settings such as those treating people with respiratory, cardiac or musculoskeletal conditions. It is inevitable that long-term health conditions such as these must have implications for people’s mental health, and similarly natural that support maintaining a positive mind-set must help these people better manage their physical health.

By co-locating in this way real meaning is given to aspirant buzz words like “joined-up working”; they become more than well-meant platitudes if people receiving physical health treatment can leave one room, walk straight into the next and receive immediate psychological assessment and support.

The early adopter sites are also seeing medical practitioners with different specialisms shadowing each other’s clinical sessions and team meetings, all to foster a deeper mutual understanding of how their efforts can be better coordinated for the benefit of service users. This should mean less time lost among medics in attempts to work out what a fellow health professional actually does, and fewer occasions where service users themselves suffer the frustration of having to repeat their story over and over to different health workers because they don’t speak directly.

These proactive, collaborative efforts are being complimented by improved use of the growing range of digitally enabled therapies that are now springing up. Digital interventions are by no means appropriate for everyone, but used judiciously can play a role in easing whole system pressures and improving convenience for service users.

Digital therapy may involve “live chat” or video messaging with a therapist so that service users receive their main therapy online, an option popular with people who may be working or otherwise unavailable through the day and prefer to access digitally enabled support out of hours.

Digital platforms often also include a suite of interactive modules tailored to particular conditions such as managing stress or coping with loss or bereavement. A therapist can select the content that compliments the needs of someone under their care, who will then log in to access the identified modules, typically a series of guided exercises designed to reinforce therapy and provide strategies for helping people manage their issues.

Outcomes from these “early adopter” sites will shape and refine the rollout of the next phase of the national IAPT mental health programme up to 2020. The learnings will be fascinating for their potential to create a better future for health and social care through genuine integration and innovation. And all of us involved in designing, delivering and making the funding decisions so vital to our health and care services must not stop there in the effort to “join dots” and better help those in need. “Crap Life Syndrome” cannot be allowed to proliferate unchecked yet further. The way society treats the poorest and most in need is a measure of our civilisation, and it is in difficult economic times that progressive forces have the hardest time overcoming those of reaction and division. We should not respond to adversity by abandoning people when the going gets tough; and it’s worth all of us remembering, on Blue Monday, the benefits that a spirit of generosity can deliver for ourselves as well others.

Richard Carlton-Crabtree (@rdcc1000) is director of services with Insight Healthcare. Insight is part of Concern, the Mental Health and Wellbeing Group and the UK’s largest non-NHS provider of primary care psychological therapies