- Email: [email protected]
Responses to the Chief Medical Officer's report 2013
systems, as well as ongoing support, all at zero or very low cost, to assist with the development of local educational capacity, integrated within the global medical education community. “The future is about interdependence and co-development: Richer and poorer countries both need each other and can learn from each other”2 The centrepiece of the iNSoMed approach is adaptive learning, in which learning tasks are continuously responsive to the backgrounds, goals, readiness, and performance of individual learners. In other words, our learning approaches are similar to clinical care—diagnostic information is continuously gathered to guide decisions about what is most appropriate to suggest and do at any given time. With our collaborators, we will devise content and processes that are matched to their local circumstances: their culture, backgrounds, economies, and expectations. Our overriding mission is to help low-resource settings enlarge and enhance their capacities for educating doctors and other health professionals who are well suited for their local needs. We believe that new and emerging technologies, which provide memory support, learning process support, and continuous tracking of learners’ capabilities and achievements, make possible a level of individualisation of learning experiences that is overdue, but has not previously been affordable. Continuous formative assessment, constructive feedback, and adaptive learning experiences are the foundations of each iNSoMed student’s learning pathway. We will establish educational systems that achieve locally desired outcomes consistently, reliably, and affordably. We agree that meaningful change from traditional approaches is difficult. To help ensure that we can foster fresh approaches to medical education, iNSoMed and our collaborators are choosing to rely on evidence,3–5 not tradition, as our primary guide to www.thelancet.com Vol 385 June 27, 2015
the programmes we are pursuing. To help to achieve our mission, we are partnering with local health-care communities and students to ensure that learning experiences are the best for their setting and are locally owned. We welcome additional questions and seek potential collaborators from all parts of the world. We declare no competing interests.
*Hilliard Jason, Andrew Douglas [email protected] International New School of Medicine, Miami, FL 33143, USA 1
2 3
4
5
Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Omaswa F, Crisp, N. African health leaders. Oxford: Oxford University Press, 2014: p 5. Medina J. Brain rules: 12 principles for surviving and thriving at work, home, and school, 2nd edn. Seattle: Pear Press, 2014. Herrington J, Reeves TC, Oliver, R. A guide to authentic e-learning. New York: Routledge, 2010. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: the realities of community-engaged medical education. Acad Med 2015; published online May 20. DOI:10.1097/ACM.0000000000000765.
Responses to the Chief Medical Officer’s report 2013 The focus on public mental health in the 2013 Chief Medical Officer’s annual report1 was eagerly anticipated by not-for-profit sector organisations working in the field. The report has been welcomed for upholding and strengthening the principle of parity of esteem and for further opening up the debate about strategy and funding in this area. However, consensus is growing that one of the central themes of the recommendations needs to be challenged. We believe that the term wellbeing, and its validity as a model for prevention and intervention in mental health, needs to be developed further rather than dismissed. The report states that wellbeing initiatives should not form part of
public health strategy or receive the requisite funding. However, the term wellbeing, and the desire to create a society where wellbeing is valued, has been given credence at a national and global level. WHO define mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”2 Nationally, the UK Government has honoured its pledge to include wellbeing as one of the wider determinants of health. Public Health England states that it will “work with the NHS, local authorities and other partners to help more people have good mental health, improve the physical health and wellbeing of those with mental illness”.3 In view of the few years that wellbeing has been recognised as a model for mental health prevention and intervention and the fact that many wellbeing therapies cannot be tested using a randomised controlled trial (RCT)-based approach, the existence of what the report refers to as insufficient evidence to prove its effectiveness is unsurprising. Many mental health professionals deem wellbeing interventions to be a powerful approach to support and improve quality of life. Indeed, research published in The Lancet Psychiatry4 reported that talking therapies reduced risk of suicide by 26%. However, many wellbeing therapies or initiatives do not lend themselves to this methodology, but rather than dismissing the validity of the wellbeing model on the basis of its inability to be tested by RCTs, we suggest that a new research framework is needed. We would welcome further research about how a person-centred approach to mental health can be researched by use of a person-centred framework. The Chief Medical Officer states that she won’t “take a leap of faith with people’s health” 1 and
Department of Health
Correspondence
For more about the iNSoMed approach see https://vimeo. com/100601365
2575
Correspondence
yet by recommending that “wellbeing interventions should not be commissioned in mental health as there is insufficient evidence to support this”,1 we think there is a risk she could be doing just that. I declare no competing interests.
Poppy Jaman [email protected] Mental Health First Aid England, London, UK; and Public Health England, London N1 6AH, UK 1
2
Published Online April 27, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60306-3
3
4
For a full response to the Chief Medical Officer’s 2013 report from the Faulty of Public Health see http://www.fph.org. uk/reflections_on_the_annual_ report_of_the_chief_medical_ officer_2013
2576
Davies SC. Annual report of the Chief Medical Officer 2013, public mental health priorities: investing in the evidence. London: Department of Health, 2014. WHO. Mental health: a state of wellbeing. August 2014. http://www.who.int/features/ factfiles/mental_health/en/ (accessed Feb 24, 2015). Public Health England. Health and wellbeing: introduction to the directorate. May 16, 2013. https://www.gov.uk/government/ publications/health-and-wellbeingintroduction-to-the-directorate/health-andwellbeing-introduction-to-thedirectorate#our-programmes (accessed Feb 24, 2015). Erlangsen A, Lind BD, Stuart EA. Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. Lancet Psychiatry 2015; 2: 49–58.
At the Faculty of Public Health, we welcomed the 2013 report of the UK Chief Medical Officer, which was the first ever to cover mental illness. However, we were surprised to see the recommendation about wellbeing, repeated in The Lancet (April 11, p 1472),1 that “There is insufficient evidence to justify the framing of public mental health policy and commissioning in terms of wellbeing”. This statement contrasts with one of the conclusions of the Chief Medical Officer’s 2011 report2 in which she recommended that “Public Health needs to encompass not only physical health but also mental health and wellbeing. All current interventions should be reviewed to consider how improving wellbeing can be incorporated”. In 2013, the Chief Medical Officer argued that that the concept of mental wellbeing was not sufficiently well defined and that measurement
was therefore often based on proxy measures “crucially compromising the credibility of the evidence base”.1 Many public health problems, such as physical activity, are difficult to define and measure precisely, but this is not deemed a good reason for inaction. The second argument made by the Chief Medical Officer is that there is no evidence to support the Rose Hypothesis—ie, that continuously distributed public health issues are best addressed with universal approaches that shift the population mean and, in doing so, reduce the prevalence of the public health problem.3 The evidence needed to support this argument exists: the prevalence of mental disorders can be predicted by the mean level of mental health in the population4,5 and it is possible to change the mean level of mental health or established risk factors in universal populations.6,7 SS-B developed the Warwick-Edinburgh Mental Well-being Scale (a way to measure mental wellbeing).
*Sarah Stewart-Brown, John Middleton, John Ashton [email protected] UK Faculty of Public Health, London NW1 4LB, UK 1
2
3
4
5
6
7
Mehta N, Croudace T, Davies SC. Public mental health: evidenced-based priorities. Lancet 2015; 385: 1472–75. Davies SC. Annual Report of the Chief Medical Officer, volume one, 2011, on the state of the public’s health. London: Department of Health, 2012: 12. Rose G, Khaw K, Marmot M. Rose’s strategy of preventive medicine. Oxford: Oxford University Press, 2008. Goodman A, Goodman R. Population mean scores predict child mental disorder rates: validation SDQ prevalence estimators in Britain. J Child Psychol Psychiatry 2011; 52: 100–08. Veerman JL, Dowrick C, Ayuso-Mateos JL, Dunn G, Barendregt JJ. Population prevalence of depression and mean Beck Depression Inventory score. Br J Psychiatry 2009; 195: 516–19. Weare K, Nind M. Mental health promotion and problem prevention in schools: what does the evidence say? Health Promot Int 2011; 26 (suppl 1): i29–69. de Vibe M, Bjørndal A, Tipton E, Hammerstrøm K, Kowalski K. Mindfulness based stress reduction (mbsr) for improving health, quality of life, and social functioning in adults. Campbell Systematic Reviews 2012; published online Feb 1. DOI:10.4073/ csr.2012.3.
Department of Error Yacoub M. Cardiac donation after circulatory death: a time to reflect. Lancet 2015; 385: 2554-56—In this Comment, the twelfth bar in the figure should have read Austria. This correction has been made to the online version as of April 27, 2015, and the printed Comment is correct. Clotet B, Feinberg J, van Lunzen J, et al. Once-daily dolutegravir versus darunavir plus ritonavir in antiretroviral-naive adults with HIV-1 infection (FLAMINGO): 48 week results from the randomised open-label phase 3b study. Lancet 2014; 383: 2222–31—In this Article (April 1), in the Results section, the third sentence of the sixth paragraph should have read, “The dolutegravir group had significantly fewer LDL values of grade 2 or higher than did the darunavir plus ritonavir group (5% vs 16%; p=0·0001), against a pre-specified p value threshold of 0·045 (two-sided; appendix).” This correction has been made to the online version of the Article as of June 26, 2015. Ong ACM, Devuyst O, Knebelmann B, Walz G, on behalf of the ERA-EDTA Working Group for Inherited Kidney Diseases. Autosomal dominant polycystic kidney disease: the changing face of clinical management. Lancet 2015; 385: 1993–2002—In figure 3, panel C, of this Review (May 16), the baseline mean estimated glomerular filtration rate of the placebo group in the sirolimus study should be 92 mL/min/1·73 m² and the mean age 32 years. This correction has been made to the online version as of June 26, 2015. Dzau VJ, Ginsburg GS, Van Nuys K, Agus D, Goldman D. Aligning incentives to fulfil the promise of personalised medicine. Lancet 2015; 385: 2118–19—In this Viewpoint (May 23), the Declarations of interest section should have stated that David Agus co-founded Navigenics in 2006, but has had no financial interest in the company since February, 2010. This correction has been made to the online Viewpoint as of June 26, 2015.
www.thelancet.com Vol 385 June 27, 2015
the programmes we are pursuing. To help to achieve our mission, we are partnering with local health-care communities and students to ensure that learning experiences are the best for their setting and are locally owned. We welcome additional questions and seek potential collaborators from all parts of the world. We declare no competing interests.
*Hilliard Jason, Andrew Douglas [email protected] International New School of Medicine, Miami, FL 33143, USA 1
2 3
4
5
Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Omaswa F, Crisp, N. African health leaders. Oxford: Oxford University Press, 2014: p 5. Medina J. Brain rules: 12 principles for surviving and thriving at work, home, and school, 2nd edn. Seattle: Pear Press, 2014. Herrington J, Reeves TC, Oliver, R. A guide to authentic e-learning. New York: Routledge, 2010. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: the realities of community-engaged medical education. Acad Med 2015; published online May 20. DOI:10.1097/ACM.0000000000000765.
Responses to the Chief Medical Officer’s report 2013 The focus on public mental health in the 2013 Chief Medical Officer’s annual report1 was eagerly anticipated by not-for-profit sector organisations working in the field. The report has been welcomed for upholding and strengthening the principle of parity of esteem and for further opening up the debate about strategy and funding in this area. However, consensus is growing that one of the central themes of the recommendations needs to be challenged. We believe that the term wellbeing, and its validity as a model for prevention and intervention in mental health, needs to be developed further rather than dismissed. The report states that wellbeing initiatives should not form part of
public health strategy or receive the requisite funding. However, the term wellbeing, and the desire to create a society where wellbeing is valued, has been given credence at a national and global level. WHO define mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”2 Nationally, the UK Government has honoured its pledge to include wellbeing as one of the wider determinants of health. Public Health England states that it will “work with the NHS, local authorities and other partners to help more people have good mental health, improve the physical health and wellbeing of those with mental illness”.3 In view of the few years that wellbeing has been recognised as a model for mental health prevention and intervention and the fact that many wellbeing therapies cannot be tested using a randomised controlled trial (RCT)-based approach, the existence of what the report refers to as insufficient evidence to prove its effectiveness is unsurprising. Many mental health professionals deem wellbeing interventions to be a powerful approach to support and improve quality of life. Indeed, research published in The Lancet Psychiatry4 reported that talking therapies reduced risk of suicide by 26%. However, many wellbeing therapies or initiatives do not lend themselves to this methodology, but rather than dismissing the validity of the wellbeing model on the basis of its inability to be tested by RCTs, we suggest that a new research framework is needed. We would welcome further research about how a person-centred approach to mental health can be researched by use of a person-centred framework. The Chief Medical Officer states that she won’t “take a leap of faith with people’s health” 1 and
Department of Health
Correspondence
For more about the iNSoMed approach see https://vimeo. com/100601365
2575
Correspondence
yet by recommending that “wellbeing interventions should not be commissioned in mental health as there is insufficient evidence to support this”,1 we think there is a risk she could be doing just that. I declare no competing interests.
Poppy Jaman [email protected] Mental Health First Aid England, London, UK; and Public Health England, London N1 6AH, UK 1
2
Published Online April 27, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60306-3
3
4
For a full response to the Chief Medical Officer’s 2013 report from the Faulty of Public Health see http://www.fph.org. uk/reflections_on_the_annual_ report_of_the_chief_medical_ officer_2013
2576
Davies SC. Annual report of the Chief Medical Officer 2013, public mental health priorities: investing in the evidence. London: Department of Health, 2014. WHO. Mental health: a state of wellbeing. August 2014. http://www.who.int/features/ factfiles/mental_health/en/ (accessed Feb 24, 2015). Public Health England. Health and wellbeing: introduction to the directorate. May 16, 2013. https://www.gov.uk/government/ publications/health-and-wellbeingintroduction-to-the-directorate/health-andwellbeing-introduction-to-thedirectorate#our-programmes (accessed Feb 24, 2015). Erlangsen A, Lind BD, Stuart EA. Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. Lancet Psychiatry 2015; 2: 49–58.
At the Faculty of Public Health, we welcomed the 2013 report of the UK Chief Medical Officer, which was the first ever to cover mental illness. However, we were surprised to see the recommendation about wellbeing, repeated in The Lancet (April 11, p 1472),1 that “There is insufficient evidence to justify the framing of public mental health policy and commissioning in terms of wellbeing”. This statement contrasts with one of the conclusions of the Chief Medical Officer’s 2011 report2 in which she recommended that “Public Health needs to encompass not only physical health but also mental health and wellbeing. All current interventions should be reviewed to consider how improving wellbeing can be incorporated”. In 2013, the Chief Medical Officer argued that that the concept of mental wellbeing was not sufficiently well defined and that measurement
was therefore often based on proxy measures “crucially compromising the credibility of the evidence base”.1 Many public health problems, such as physical activity, are difficult to define and measure precisely, but this is not deemed a good reason for inaction. The second argument made by the Chief Medical Officer is that there is no evidence to support the Rose Hypothesis—ie, that continuously distributed public health issues are best addressed with universal approaches that shift the population mean and, in doing so, reduce the prevalence of the public health problem.3 The evidence needed to support this argument exists: the prevalence of mental disorders can be predicted by the mean level of mental health in the population4,5 and it is possible to change the mean level of mental health or established risk factors in universal populations.6,7 SS-B developed the Warwick-Edinburgh Mental Well-being Scale (a way to measure mental wellbeing).
*Sarah Stewart-Brown, John Middleton, John Ashton [email protected] UK Faculty of Public Health, London NW1 4LB, UK 1
2
3
4
5
6
7
Mehta N, Croudace T, Davies SC. Public mental health: evidenced-based priorities. Lancet 2015; 385: 1472–75. Davies SC. Annual Report of the Chief Medical Officer, volume one, 2011, on the state of the public’s health. London: Department of Health, 2012: 12. Rose G, Khaw K, Marmot M. Rose’s strategy of preventive medicine. Oxford: Oxford University Press, 2008. Goodman A, Goodman R. Population mean scores predict child mental disorder rates: validation SDQ prevalence estimators in Britain. J Child Psychol Psychiatry 2011; 52: 100–08. Veerman JL, Dowrick C, Ayuso-Mateos JL, Dunn G, Barendregt JJ. Population prevalence of depression and mean Beck Depression Inventory score. Br J Psychiatry 2009; 195: 516–19. Weare K, Nind M. Mental health promotion and problem prevention in schools: what does the evidence say? Health Promot Int 2011; 26 (suppl 1): i29–69. de Vibe M, Bjørndal A, Tipton E, Hammerstrøm K, Kowalski K. Mindfulness based stress reduction (mbsr) for improving health, quality of life, and social functioning in adults. Campbell Systematic Reviews 2012; published online Feb 1. DOI:10.4073/ csr.2012.3.
Department of Error Yacoub M. Cardiac donation after circulatory death: a time to reflect. Lancet 2015; 385: 2554-56—In this Comment, the twelfth bar in the figure should have read Austria. This correction has been made to the online version as of April 27, 2015, and the printed Comment is correct. Clotet B, Feinberg J, van Lunzen J, et al. Once-daily dolutegravir versus darunavir plus ritonavir in antiretroviral-naive adults with HIV-1 infection (FLAMINGO): 48 week results from the randomised open-label phase 3b study. Lancet 2014; 383: 2222–31—In this Article (April 1), in the Results section, the third sentence of the sixth paragraph should have read, “The dolutegravir group had significantly fewer LDL values of grade 2 or higher than did the darunavir plus ritonavir group (5% vs 16%; p=0·0001), against a pre-specified p value threshold of 0·045 (two-sided; appendix).” This correction has been made to the online version of the Article as of June 26, 2015. Ong ACM, Devuyst O, Knebelmann B, Walz G, on behalf of the ERA-EDTA Working Group for Inherited Kidney Diseases. Autosomal dominant polycystic kidney disease: the changing face of clinical management. Lancet 2015; 385: 1993–2002—In figure 3, panel C, of this Review (May 16), the baseline mean estimated glomerular filtration rate of the placebo group in the sirolimus study should be 92 mL/min/1·73 m² and the mean age 32 years. This correction has been made to the online version as of June 26, 2015. Dzau VJ, Ginsburg GS, Van Nuys K, Agus D, Goldman D. Aligning incentives to fulfil the promise of personalised medicine. Lancet 2015; 385: 2118–19—In this Viewpoint (May 23), the Declarations of interest section should have stated that David Agus co-founded Navigenics in 2006, but has had no financial interest in the company since February, 2010. This correction has been made to the online Viewpoint as of June 26, 2015.
www.thelancet.com Vol 385 June 27, 2015