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Dementia: a false promise
Editorial
Tamara Lucas
The integration of mental and physical health care
For the CMO annual report see https://www.gov.uk/ government/publications/chiefmedical-officer-cmo-annualreport-public-mental-health For more on the CMO report see Viewpoint see http://www. thelancet.com/journals/lancet/ article/ PIIS0140-6736(14)61400-8/ fulltext
Last week, UK Chief Medical Officer (CMO) Dame Sally Davies launched her annual report on public mental health, which informs national and local government policy in England. The report calls for the integration of health-care services through a biopsychosocial framework and makes 14 policy recommendations. It has been welcomed by the Royal College of Psychiatrists (which defined six goals in response), the Faculty of Public Health, and others. The report emphasises employment: the economic cost of mental illness is £13 billion per year. This cost is growing, with work days lost to “stress, depression and anxiety” having increased by 24% since 2009, and days lost to serious mental illness having doubled. The CMO calls for better support from employers for staff with mental illness and recommends that training for doctors must include psychiatry. Stigma and discrimination continue to be a major issue. This is related to other difficulties that people with mental illness face: problems with sustaining social relationships, diminished opportunities for employment, and unmet needs for adequate physical and mental care.
Problems experienced by children and young people have lifelong repercussions, however critics at the report’s press conference suggested that the total disconnect between the Department of Education and the Department of Health render this impossible to overcome. Critics have suggested that for the report to make any difference a much more radical vision is needed. The separation of mental and clinical health care has made integration impossible to achieve in any practical setting. Mental health has become an unattractive area of medicine to trainees, and the often mentioned parity of esteem remains elusive. Funding must be redefined such that it is a figure for health per se—not one apportioned between physical and mental health. The comorbidities of mental illness, such as obesity, heart disease, and lung disease, could then be treated in a holistic way. Perhaps the best that this report can hope to achieve is for the influence and voice of the CMO to stimulate discussion of this crisis, given that wholesale reconstruction of the system remains a distant prospect. The Lancet
Custom Medical Stock Photo/Science Photo Library
Dementia: a false promise
For the Dementia UK report see http://www.alzheimers.org.uk/ dementiauk For the Alzheimer’s UK report see http://www.alzheimers.org. uk/dementia2014 For more on modifiable risk factors see Articles Lancet Neurol 2014; 8: 788–94 For more on NIH spending on dementia see http://report.nih. gov/categorical_spending.aspx
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On Sept 11–12, 2014, the pharmaceutical and biotechnology industries met with academics and politicians at Global Action Against Dementia, an event hosted by Canada and France. Following on from the 2013 G8 Summit on Dementia—which set an ambitious goal to find a dementia cure by 2025—their focus was to maximise “academia–industry synergies”. Yet, in the same week, researchers from King’s College London and the London School of Economics emphasised the reality on the ground for people living with dementia. They estimated not only that the prevalence of dementia in the UK was 7·1% in people older than 65 years (816 000 individuals), but also that 42 000 younger people have the disorder. Overall, dementia costs the UK £26·3 billion each year, mostly borne by private spending on social care (22%) and by 670 000 unpaid carers of people with dementia (44%). Moreover, Alzheimer’s UK reports that 42% of people living with dementia have a poor quality of life and that up to two-thirds are undiagnosed in some areas; a planned government cap on the cost of residential
care, due in 2016, will limit costs only beyond £72 000 per year and will not include living expenses. If the UK (a high-income country with free-to-access universal health care) cannot provide affordable and comprehensive dementia care, then what hope have the low-income and middle-income countries in which 62% of people with dementia live? Despite the ambitions of the summit on dementia to find a cure, at best there is hope for a therapy that slows onset or limits cognitive decline to a small extent, probably only in the early stages of disease, and probably available more than a decade from now. Meanwhile, modifiable risk factors (such a physical activity) and disease mechanisms are under-researched. In terms of research funding, dementia lags far behind other chronic diseases; in the USA, the National Institutes of Health is due to spend just US$666 million of its $30 billion budget for 2014 specifically on dementia. A dementia cure without affordable care or action on prevention is not the legacy that patients deserve. The Lancet www.thelancet.com Vol 384 September 20, 2014
Tamara Lucas
The integration of mental and physical health care
For the CMO annual report see https://www.gov.uk/ government/publications/chiefmedical-officer-cmo-annualreport-public-mental-health For more on the CMO report see Viewpoint see http://www. thelancet.com/journals/lancet/ article/ PIIS0140-6736(14)61400-8/ fulltext
Last week, UK Chief Medical Officer (CMO) Dame Sally Davies launched her annual report on public mental health, which informs national and local government policy in England. The report calls for the integration of health-care services through a biopsychosocial framework and makes 14 policy recommendations. It has been welcomed by the Royal College of Psychiatrists (which defined six goals in response), the Faculty of Public Health, and others. The report emphasises employment: the economic cost of mental illness is £13 billion per year. This cost is growing, with work days lost to “stress, depression and anxiety” having increased by 24% since 2009, and days lost to serious mental illness having doubled. The CMO calls for better support from employers for staff with mental illness and recommends that training for doctors must include psychiatry. Stigma and discrimination continue to be a major issue. This is related to other difficulties that people with mental illness face: problems with sustaining social relationships, diminished opportunities for employment, and unmet needs for adequate physical and mental care.
Problems experienced by children and young people have lifelong repercussions, however critics at the report’s press conference suggested that the total disconnect between the Department of Education and the Department of Health render this impossible to overcome. Critics have suggested that for the report to make any difference a much more radical vision is needed. The separation of mental and clinical health care has made integration impossible to achieve in any practical setting. Mental health has become an unattractive area of medicine to trainees, and the often mentioned parity of esteem remains elusive. Funding must be redefined such that it is a figure for health per se—not one apportioned between physical and mental health. The comorbidities of mental illness, such as obesity, heart disease, and lung disease, could then be treated in a holistic way. Perhaps the best that this report can hope to achieve is for the influence and voice of the CMO to stimulate discussion of this crisis, given that wholesale reconstruction of the system remains a distant prospect. The Lancet
Custom Medical Stock Photo/Science Photo Library
Dementia: a false promise
For the Dementia UK report see http://www.alzheimers.org.uk/ dementiauk For the Alzheimer’s UK report see http://www.alzheimers.org. uk/dementia2014 For more on modifiable risk factors see Articles Lancet Neurol 2014; 8: 788–94 For more on NIH spending on dementia see http://report.nih. gov/categorical_spending.aspx
1072
On Sept 11–12, 2014, the pharmaceutical and biotechnology industries met with academics and politicians at Global Action Against Dementia, an event hosted by Canada and France. Following on from the 2013 G8 Summit on Dementia—which set an ambitious goal to find a dementia cure by 2025—their focus was to maximise “academia–industry synergies”. Yet, in the same week, researchers from King’s College London and the London School of Economics emphasised the reality on the ground for people living with dementia. They estimated not only that the prevalence of dementia in the UK was 7·1% in people older than 65 years (816 000 individuals), but also that 42 000 younger people have the disorder. Overall, dementia costs the UK £26·3 billion each year, mostly borne by private spending on social care (22%) and by 670 000 unpaid carers of people with dementia (44%). Moreover, Alzheimer’s UK reports that 42% of people living with dementia have a poor quality of life and that up to two-thirds are undiagnosed in some areas; a planned government cap on the cost of residential
care, due in 2016, will limit costs only beyond £72 000 per year and will not include living expenses. If the UK (a high-income country with free-to-access universal health care) cannot provide affordable and comprehensive dementia care, then what hope have the low-income and middle-income countries in which 62% of people with dementia live? Despite the ambitions of the summit on dementia to find a cure, at best there is hope for a therapy that slows onset or limits cognitive decline to a small extent, probably only in the early stages of disease, and probably available more than a decade from now. Meanwhile, modifiable risk factors (such a physical activity) and disease mechanisms are under-researched. In terms of research funding, dementia lags far behind other chronic diseases; in the USA, the National Institutes of Health is due to spend just US$666 million of its $30 billion budget for 2014 specifically on dementia. A dementia cure without affordable care or action on prevention is not the legacy that patients deserve. The Lancet www.thelancet.com Vol 384 September 20, 2014