26th May 2016
Hot topic: Migraine and mental health, an integrated approach
What does NHS England’s vision of integration mean for people with migraine and a mental health condition?
Following the recent Mental Health Awareness Week our Advocacy, Policy and Campaigns Manager Hannah Verghese explores NHS England’s vision of integration and what it means for people with migraine and a mental health condition.
Physical and mental health services
The NHS Five Year Forward View set out a vision for the future in which services are better integrated to support the complex and ongoing needs of patients. It highlights the need for better integrated physical and mental health services to support people with long-term health conditions. The King’s Fund reports that people with long-term physical health conditions are two to three times more likely to experience mental health problems.1 Despite this, the detection of co-morbid mental health problems and the provision of support for the psychological aspects of physical illness are not of a consistently high standard; patients and practitioners alike tend to focus on physical symptoms during consultations; failure to address these issues is costing the NHS more than £11billion and care is less effective than it could be according to The King’s Fund.
Migraine and mental health
Co-morbid migraine and mental health issues, typically depression and anxiety, are common among migraineurs. In October 2015 the All-Party Parliamentary Group on Primary Headache Disorders met in the House of Commons to discuss the benefits and challenges of an integrated approach to primary headache disorders and mental health. Expert witnesses provided compelling evidence of the need to improve clinical care and support for patients experiencing co-morbid conditions and symptoms. People with migraine are three times more likely to have depression and patients with depression are three times more likely to have migraine.2 Despite this there is no routine screening for anxiety and depression among migraine sufferers in general practice, although this does exist for other conditions. There is considerable variation in support and services available across the UK for those patients with complex support needs. This is often dependent on the understanding of individual health practitioners, local funding priorities and referral pathways. Chronic migraineurs, those who experience headache on 15 days of the month or more, at least 8 of which are migraine, are more likely to experience co-morbid depression. However, the lack of coding of chronic migraine by GPs in primary care means that many patients do not receive the timely interventions needed. This exacerbates poor health and well-being in patients with this chronic and highly disabling form of the condition.3
Slipping through the gaps
The current approach sees these patients ‘slip through the gaps’. Medication-overuse headache and increased anxiety are common outcomes for patients who do not have adequate information and support to understand and self-manage their migraine. This has huge knock-on implications for overstretched neurology services and patients seeking support for their condition outside of primary care. Referral to secondary care and brain scanning are commonly associated with high levels of anxiety by the patient rather than relational to the severity of the pain.4 Headache accounts for 33% of all new referrals to neurology and is the most common neurological reason for A&E attendance, despite the fact that approximately 97% of cases can be managed in primary care.5 Equipping primary care practitioners with better training and education on migraine and headache and improving local patient pathways provide an opportunity to plug these gaps. Prevention and early intervention are key to identifying and supporting patients experiencing co-morbid conditions and symptoms. The challenge comes in not only integrating clinical care but also service design, clinical guidance, pathways, funding, audits and training as well as tackling the overarching issues of stigma surrounding both migraine and mental health.
Neurology and mental health
These issues are by no means isolated to migraine. The latest NHS England GP patient survey shows that patients with long-term neurological problems report both some of the worst states of pain and some of the highest levels of anxiety or depression, with the lowest health outcome scores of any long-term condition.6 This presents a huge problem for already under prioritised and overstretched neurology services.7 Co-morbid mental health problems raise total health care costs by at least 45% for each person with a long-term condition and co-morbid mental health problem. Between 12% and 18% of all expenditure on long-term conditions is linked to poor mental health and well-being – at least £1 in every £8 spent on long-term conditions.8
With the right systems and fundamental resources in place a truly integrated approach could prove highly beneficial for migraine patients. However, unravelling the current system will likely be slow and complicated. Until neurology is given the recognition and priority that it deserves by the Department of Health and NHS England patients will continue to slip through the gaps of services and support. There is a long way to go before full integration can be successfully achieved.
APPG on Primary Headache Disorders Meeting: Primary Headache Disorders and Mental Health. An integrated Approach?
- Naylor C. et. al. Bringing together physical and mental health. A new frontier for integrated care. The King’s Fund.
- Breslau N., Davis G. C., Schultz L. R., Peterson E. L. Migraine and major depression: A longitudinal study. Headache 1994.
- Presentation by Professor Leone Ridsdale to the APPG on Primary Headache Disorders meeting on Primary Headache Disorders and Mental Health. An integrated Approach? October 2015.
- Ridsdale L et. al. Patient pressure for referral for headache: a qualitative study of GPs’ referral behaviour. BJGP 2007.
- All-Party Parliamentary Group on Primary Headache Disorders, Headache Services in England, 2014.
- Internal exploratory analysis carried out by NHS England’s Analytical Services Team, using the 2013-14 GP Patient Survey. Source data not available. Via The Neurological Alliance.
- The Public Accounts Committee Services to people with neurological conditions: progress review inquiry. February 2016.
- Naylor C. et. al. Long-term conditions and mental health. The cost of co-morbidities. The King’s Fund and Centre for Mental Health 2012.
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