ANDY MAYERS - (@DrAndyMayers)
On September 21st, the BMJ interviewed Sir Simon Wessely, President of the Royal Society of Medicine (formerly President of the Royal College of Psychiatrists). The central message of that interview suggested that we should stop raising awareness about mental health.
The argument was that we do not have the resources to cater for those seeking help. Raising more awareness would, the article argues, only serve to put more pressure to an already over-stretched system.
In this blog, I will argue that we need more investment in those services; not fewer awareness campaigns. At the same time, we need to ensure that those campaigns are realistic, safe and appropriate.
I would like to start by stating my utter respect for Sir Simon. He has often spoken out for the need for better support for people with mental health problems. That is perhaps why I was so surprised when I read the BMJ article. A few of us took to Twitter to (I hope politely) challenge the arguments put forward. In his defence, Sir Simon stated that a short interview can only capture a small part of what he was trying to say. Nonetheless, what was said could potentially do a great deal of damage to people with a range of mental health difficulties. Perhaps there’s an argument there for writing one’s own press releases; I often do.
In one quote, Sir Simon said “We don’t need people to be more aware. We can’t deal with the ones who already are aware.” For me, mental health awareness campaigns are not about making people aware that they may have certain conditions. Most people, unless they lack insight or have a complex personality disorder, are aware that there are unwell; they just lack the confidence to seek help, or they fear stigma and judgement. Instead, campaigns should be about a whole raft of other factors – including persuading governments and commissioners that we need to invest in services, reducing social stigma, helping people not to feel guilty, and making it OK not to be OK.
I have been part of several campaigns that have influenced the Government.
Through the Maternal Mental Health Alliance (Everyone’s Business) campaign and
the 1001 Critical Days
initiative, we have seen commitment to investment that would not have occurred
without the awareness campaigns. The Time to Change campaigns have
raised awareness across all areas of society reducing stigma and getting people
talk positively about mental health. All of these campaigns have probably saved
I agree that, by successfully raising awareness about mental health, we have been the victims of our own success. More people are coming forward to potentially seek help. That is indeed putting greater strain on services. However, that should not be a reason to stop. It’s the investment that’s wrong. Reducing awareness and failing to tackle stigma will not make that problem go away. All it will do is make people less likely to seek support, which would put their lives at even greater risk. Not raising awareness will not reduce depression, bipolar disorders, or psychoses. Any more than diabetes will go away if we stop raising awareness about that. The conditions will still be there; they just will not be diagnosed and properly treated. Reducing awareness might place less burden on services, but it would be wrong and indefensible.
Furthermore, those coming forward to seek support need not
be a burden on NHS services. We need to radically rethink how we deal with
mental health. With the right investment, the charity and voluntary centre can
play a big part too. During the interview Sir Simon said “We should stop the
awareness now. In fact, if anything we might be getting too aware. One wonders
what’s happening when you have 78% of students telling their union they have
mental health problems—you have to think, ‘Well, this seems unlikely.’”. Of
course, it’s unlikely that three-quarters of students have a diagnosable
condition. But, there’s a lot more to mental health support than primary and
secondary care. At my own university, we have a whole range of support
services, where students are, essentially, triaged. It’s a question of
signposting to the right support. Many may need no more than simply directing
towards activities that might tackle low mood and anxiety. Others may need counselling
support. A few may need something more intensive. We frequently run awareness
events, and wouldn’t stop those for fear of overwhelming demand. Without
awareness, they might not seek help at all (and the problem could escalate). We
have responsibility to support our students and adapt to what we can offer or
In any case, mental health awareness is not just about
making people aware about mental illness. Far from it. Campaigns can also teach
people about how to lead better mentally health lives. We can show the
importance of exercise, diet, sleep, and work-life balance, for example. We can
also use campaigns to educate those with life-long conditions about tool kits
that can help them stay well and reduce relapse. There are many excellent
programmes across the UK doing just that. These very same people can be trained
to be peer supporters, using lived experience to help others. We need to use
public awareness campaigns to illustrate the benefit of peer support – to those
who give the support as well as those being supported. Investment in those
services, typically provided by charities, can help with prevention of relapse,
or escalation of mild mental ill health into something more serious. It could
save a great deal of money in future spending and, more importantly it can save
Sir Simon was cautious about promises made by the Government about mental health investment, especially on the recruitment of mental health staff. I share his concerns. But that should not stop the awareness campaigns. Instead, we must use these campaigns to show that the Government still does not ‘get it’. I said as much in a blog I wrote in August. We need a revolution in the way we see mental health. Our awareness campaigns should focus on how we can foster a mentally healthy population (through positive lifestyles). Mental health education in schools can teach young people about emotional wellbeing, and how to seek help if they become unwell (as well as look out for friends and family). Early intervention could prevent a lifetime of mental illness – and that intervention, if early enough, need not be expensive either.
I also agree with Sir Simon about the need for integrated physical and mental health services. Much of what he says in the latter part of the article (which many readers could not see without a subscription to BMJ) was applaudable. Sadly, the message about mental awareness campaigns, which pervaded the opening paragraphs, might have done more damage than Sir Simon might have imagined. Sure, many of these campaigns are not perfect. In fact, we have a duty to make sure that campaigns are realistic, safe, and appropriate. A campaign that is not underpinned by networks that can, at the very least, signpost to support is dangerous. But having fewer mental health campaigns is also dangerous. We run the risk of undoing all the work that has been done over the last few years.
I will continue to campaign and raise awareness, but I will also continue to lobby Parliament for more investment (partly through my political work) and to be a critical voice in mental health services (I am a Public Governor for Dorset Healthcare University NHS Foundation Trust). I will also continue to advocate the role that charities can play in providing services (I hold trustee and ambassadorial roles to several local and national mental health charities, including Dorset Mind). We can all play a role in putting mental health at the heart of everyday living. It is a public health priority.
JIM MCMANUS - (@)
The use of some kind of substance to enhance sex is known and common through history (drinks while dating?) But recently the phenomenon of chemsex has become somewhat better known than it was. Chemsex is a term for a complex of behaviours – use of dating apps to have parties where sustained group use of drugs happens, particularly drugs like cocaine, crack, GHB (gamma hydroxybutyrate) and crystal methamphetamine.
Sex is often but not always a given at some of these parties. Slamming – injection of drugs for quicker highs, sometimes happens, and with it sometimes sharing needles. But increasingly use of chems is reported by men using dating apps for 1-1 encounters too. Recent work has shed more light on the multiple motivations and issues at play. Weatherburn et al identify a range of motivations linked to “enhancing the qualities valued in sex” including enhancing attraction, heightening sensation, intensifying intimacy and connection and, for some men, overcoming lack of libido.
The increasing reporting by clinicians and community groups of problems presenting from this is concerning. From understandable motives - socialising, feeling good, enjoying sex and coping with life pressures are reported as factors, certainly in GHB use for some time , the drug use is primarily intended as a facilitator of these. But clinicians are reporting a range of harms including addiction and other sequelae.
Dedicated professionals like David Stuart and others working on this issue, have brought greater light on chemsex. The publication by James Wharton of his chemsex experiences in Something for the Weekend and the associated meda reporting,have gone some way to cast some light on this as an issue which needs addressing.
not the only places, however, where chemsex is becoming an issue. Increasing
use of “chems” with sexual hook ups means some men may rarely have sex sober.
It’s not just physical risk, but psychological. Intimacy may become associated
with being high, and for some, dependent on it.
A 2014 BMJ editorial suggested a minority of men engage in chemsex but community reports suggest this is growing and becoming more prevalent. There are as yet no robust epidemiological estimates. Weatherburn et al report up to 18% of men from three London Boroughs uses cocaine and 10.5% GHB compared to 4.8% and 1.6% respectively of men elsewhere in England.
Wharton quotes estimates that a gay man dies in London from GHB overdose every 12 days but very few have been high profile. Estimates of prevalence vary in recent reports but what is clear is that this is becoming an increasingly prevalent presenting problem in sexual health clinics, and few services as yet seem prepared to address it effectively.
Whether or not this is a minority phenomenon, the harms are significant and the barriers to accessing services also important disablers of helping men deal with harms arising from chemsex.
What we don’t know reliably is how many men engage in chemsex without coming to some form of harm. Most data from clinics and the small amount of research to date identifies some kind of harm. A spectrum of harms across physical, psychological and social health is possible.
|Physical Health||STIs, HIV and
other Blood borne viruses ; Physical
effects of comedowns; Risks to
circulatory system from injection; Respiratory
risk from frequent use; Risk of death
from overdose; Disrupted sleep
patterns, anorexia, weight loss; Impaired immune
|Psychological/Mental Health||Use of chemsex to facilitate social contact and overcome loneliness, isolation; Coping mechanism for stigma and homophobia; Impact on coping skills, sleep, employment, cognitive functioning; Impact on relationships of becoming habituated on having sex while using drugs; Psychological impact of financial problems from financing habit; Impact on identity integration and acceptance; Bereavement from people in social networks dying as a result of G|
|Social health||Group identification; Coping with stigma; Holding down a job and responsibilities; Risk of debt and homelessness; Criminalisation for possession of drugs and sometimes dealing|
Public Health Issues
Chemsex is not just a drugs or an HIV or a sexual health issue. For most men it seems to be linked to a complex manifold of issues. From the physical risks to health, to the psychological risks and impact on lifecourse development, there are significant issues which impact on the populations and individuals who use it.
The mental health impact of being unable to have sex or be
intimate unless high presents a number of challenges. But there is another set
of issues. If some gay men use chemsex to cope with stigma or feelings about
being gay, that must be seen as potentially problematic. It is a commonplace in
psychology of LGBT populations that a key task is identity integration and
Theory and evidence assumes that identity integration and assimilation is
crucial to health and wellbeing outcomes for gay men across the lifecourse,,.
It is assumed to be especially important to ensure inclusion for LGBT people in
education and employment. If chemsex disrupts such processes, or means a
population or sub-population of gay men can only feel good enough about
themselves where mediated through drug use (either individual or in groups),
there may be significant avoidable psychological morbidity as a result. If what
Wharton says about younger gay men finding it easy to get into this scene is
true, then that has worrying implications about the ability of those men to
form attachments and integrate their identity as they grow, with potential
maladaptation and poor coping and mental health across the lifecourse.
Policy frameworks and action
While Chemsex is mentioned in the new UK Drugs Strategy, there has been much criticism of the lack of commitment on what to do about it. There remains no coherent public health response. Community harm reduction approaches including safer injecting kits are most visible interventions with the best available frameworks for clinical response being those developed by David Stuart There is as yet no clear national policy framework or consensus guideline on what can or should be done. Community intelligence
What can be done?
A range of action is needed, and this needs to be revised as we know more:
1. We need as clear a picture of prevalence, service use, harm, morbidity and mortality as can be compiled, nationally and locally
2. We need to work with providers of dating and sex hook-up apps to target information on harm reduction to users engaging in chemsex
3. Agencies working on this should convene with experts on drug use, sexual health and LGBT development to develop some consensus guidelines on harms and issues, and intervention strategies
4. The current good practice (chemsex care plan and harm reduction information and kits) should be rolled out to those areas who identify they have a developing issue
5. Support harm reduction including continued information and kits to reduce harm
6. Agencies could consider safer chemsex courses as a way of helping reduce harm including teaching people skills of what to do about GHB overdoses
7. Agencies should combine efforts to make available a single reliable source of information on reducing harm from chemsex and where to get help
8. Services should consider whether they can recruit people recovering from chemsex harm to work with others
9. Sexual health and drugs services should identify what they can to do ask gay men about, identify and respond to chemsex issues, and develop collaborative approaches to sharing skills
10. Those services should become skilled in particular identity and lifecourse issues facing gay men
11. LGBT community groups who provide social groups or counselling facilities should consider what they can do to continue to support gay men with lifecourse identity development
12. Employers with large numbers of gay men in population centres likely to be affected should consider what resilience and support packages they can put in place for employees with performance issues arising from chemsex
13. Sex venues should consider placing information on chemsex and where users can get help
 Wharton, James (2017) Something for the Weekend: London : Biteback Publishing
 Hammack, P.L (2009) The Story of Sexual Identity: Narrative Perspectives on the Gay and Lesbian Life Course New York: Oxford University Press
KATHRYN MULLEN - (@KathrynMu11en)
Discrimination. The term used to depict unfair treatment of a person simply for having different coloured skin to us, or for being a different age, sex, sexual preference or even ability. It leads to action that is quick to occur, often impulsive, and usually carried out with little thought of the impact on those at the receiving end.
The link between discrimination and public mental health can be explained within the ‘Minority Stress Model’. This has been described as ‘being related to the juxtaposition of minority and dominant values and the resultant conflict with the social environment experienced by minority group members’ (Meyer, 1995). Put more simply, challenging social experiences cause more stress in minority groups due to increased levels of stigma.
To make things even more difficult, it is apparent that those who identify themselves as belonging to multiple minority groups are at an even higher risk of poor mental health as a result of discrimination. Khan et al (2017) looked at the impact of ‘multifactorial discrimination’ on the mental health of 396 male and female participants who were lesbian, gay or bisexual (LGB) and either White, Black/African-American or Latino/Hispanic. NB: The study did not include any trans people as participants or represent other groups who may also experience significant discrimination.
Kahn et al found that both racism and homophobia were greater predictors of psychological distress, depression, anxiety, suicidal thoughts and substance misuse in LGB ethnic minority participants than among their white LGB counterparts.
One explanation for this may be related to how important a person’s sexuality identity is to their self identity and daily lives. For example some members of the lesbian, gay and bisexual (LGB) community may feel that being LGB is more salient to them than other members. Could it be that those who don’t perceive it as such a prominent aspect of their lives are simply less affected by any discrimination they receive?
Secondly, social support networks are also relevant, which are of course a powerful determinant of mental wellbeing. These networks may differ depending on the multifactorial discrimination experienced. For example, while it is not uncommon for ethnic minority communities to provide social support networks to each other from the get-go (i.e. birth), LGB communities may not experience this support until later in life and may need to seek it out off their own back. If we broaden this to include support for those with multiple minority identities, it may be that the support once again changes and may be only partial. So for example, if we consider a person of ethnic minority who is LGB, it may be that while they receive social support for the experiences that occur as a result of their ethnic identity, that same community may not be able to offer such support for their experiences from identifying as LGB (Bostwick, 2014). A disconnect that may well be a result of cultural traditions or religious views.
Here in the UK, in a society where groups with multiple characteristics are growing and minorities are becoming less of a minority, it’s startling that such discrimination still exists. If we can take a step back and recognise the link between multifactorial discrimination and mental health we will be better placed to build a society that doesn’t accept stigma as the norm. Only then can community support, resilience and public mental health really flourish.
LISA MCNALLY - (@lisa_mcnally1)
Social isolation is a killer. It increases mortality risk by around a third and is linked with everything from heart disease to depression and cognitive decline (Holt-Lunstadet 2015). Given this, it’s no surprise that programmes able to connect people to their community also serve to improve health outcomes and reduce healthcare costs (Pitkala et al 2009).
While there is still a lack of good quality studies, evidence is emerging that social prescribing programmes can achieve significant improvements in health, mental well-being and reduced costs to the health & social care system (Kings Fund, 2017).
Of course, just as a doctor’s prescription can only improve health if the patient has access to a well stocked pharmacy, so social prescribing schemes depend on a well stocked community. There needs to be a wide range of identified, local community groups and services that will offer a warm welcome to anyone referred. The process of identifying, mapping and supporting these ‘community assets’ is therefore a crucial element in social prescribing programmes.
Local authorities are well placed to make this happen.
For example, in Bracknell Forest, our Public Health team have developed a “Community
Map” of local groups that serves as a key resource for social prescribing.
Crucially, this map wasn’t developed by simply downloading details from local
voluntary service directories. Rather the team got out and explored local
areas, discovering those smaller groups that were not on any official ‘list’
but still had great potential to offer support and companionship.
Our elected members have been a central part of this process. Their knowledge of what is ‘out there’, as well as their well established relationships with local communities, has been invaluable to finding local groups and getting them on board.
Of course, the work doesn’t stop with simply mapping community groups. We have also sought to build an ongoing relationship with those groups through our “Community Development Offer”. This comprises support on a range of issues, with the most popular being help with promotion, in the form of local press releases, videos, social media and ‘showcasing’ events. By doing this, we have not only supported existing community groups, but also managed to inspire the emergence of new groups that are now flourishing and offering a warm welcome to our residents.
Social prescribing has transformed the way we work. What started as a simple mapping project has now snowballed into an ongoing collaboration with our residents on a wide range of initiatives. It has enabled our health and social care colleagues to take a more holistic approach, while for our team, it has really put the ‘public’ back into ‘public health’ work.
This was first published by the Centre for Mental Health (2016)
LISA MCNALLY - (@lisa_mcnally1)
The current controversy around young people’s mental health services isn’t really that controversial. In fact, you’ll do well to find an issue on which there is greater consensus. Everyone from the media to government ministers are queuing up to tell us that the system is “failing”, “inadequate”, “broken” or “in crisis”.
A key cause for concern is that many young people are waiting a
long time for an assessment by NHS mental health services, only then to be told
that they are not ‘ill enough’ for treatment. Many others, despite
experiencing severe emotional distress, don’t even get on to the NHS waiting
list in the first place. In short, the system is overloaded and many
young people are dealing with significant mental health distress without
Of course, one way to address this issue is to fund more capacity within NHS services. However, that can’t be the only answer. Especially when we consider that many young people’s poor mental well-being is not simply a diagnosable clinical disorder, but actually a natural reaction to the bullying, exam stress, family problems or other issues they may be facing. Maybe we need to invest in mental health support, not just mental health treatment?
Local authorities are crucial to ensuring this support is in
place. Their involvement in education, youth services, social care,
public health and many other systems means they are perfectly positioned to
coordinate a whole systems approach to supporting emotional well-being in young
In Bracknell Forest we set ourselves two key challenges. First, we committed to create a local environment in which young people’s mental well-being was routinely supported, not just when a problem emerged. Second, we set out to ensure that, when a problem did arise, professional mental health support was accessible without a need for diagnosis or long waiting times.
achieve the first aim, we regularly work with young people to co-create school
based sessions aimed at promoting emotional resilience and breaking down
stigma. The primary school programme encourages children to write stories
about mental well-being based on a ‘superheroes’ theme. These stories are
shared online either as written, illustrated stories or turned into animations
(voiced and directed by the children themselves). View the films here.
The secondary school programme co-produces short videos or drama productions with young people based on what they think is important in relation to mental health. Both involve discussion and the sharing of ideas about how we can look after our mental health just like we look after our physical health.
To achieve our second aim of ensuring early mental health
support is accessible when needed, we turned to the internet. The kooth.com
service provides our young residents with a range of online services including
the support of professional counsellors, linking up with NHS services when
necessary. Aside from being cost effective to deliver, internet
based services have the advantage of offering support in an environment that
young people are familiar and confident with. The result is less fear of
seeking help. As one young person said:
“…thank you so much! I’ll definitely be using this site more often, it’s just nice to have someone to talk to who knows about this stuff! I was really scared for my first chat but you made it easy :):)”
there is so much more to do, we have already seen an impact of this work.
A significant increase in uptake of the online service coincided with the NHS
CAMHS providers reporting a significant decrease in referrals. While
causation can’t be confirmed outside of a controlled research trial, this
finding does at least suggest some positive effects (brief evaluation here).
Of course we do still need more treatment capacity with young people’s NHS mental health services. But we also need to invest more in the contribution that other agencies can make, especially schools and local authorities, to reducing demand on those services. Only then will we have a complete response to an issue that otherwise threatens everything we are trying to achieve in our local communities.
First published by Centre for Mental Health (2017)
LISA MCNALLY - (@lisa_mcnally1)
Once a year, English children can be seen queuing up at school to be weighed and measured. Letters are then sent to parents informing them if their child is overweight, with the dangers of obesity highlighted and changes in behaviour advised. This is all part of the National Child Measurement Programme (NCMP), which is directed by Public Health England and implemented by local authorities as part of their mandated responsibilities.