Mental health is everyone’s business

Attitudes have changed, but he believes the profession needs a better understanding of the close link between physical and mental health.

Wherever you work in physiotherapy, mental health is your business because it will impact on your engagement with patients, says clinical and academic physiotherapist Brendon Stubbs. As head of physiotherapy at one of the UK’s largest NHS mental health trusts, South London and the Maudsley, mental health is clearly his core business. But he points out that one in four of us will have a mental health condition at some point in our lives, so this is a big issue for all trusts. 

‘Typically, people come to physiotherapists because things aren’t going so well,’ he says. ‘Injury and pain are key risk factors for adverse wellbeing in mental health.

‘We have done research that demonstrates that one in five people with osteoarthritis at any one time has depression or anxiety. We have done other research demonstrating that a third of people with stroke meet the criteria for a depressive episode. If you work in respiratory and you are treating people with chronic lung conditions, there will be a really high prevalence of common mental health conditions, such as depression or anxiety.’ 

Isn’t this obvious to practising clinicians? Well, no. There is a tendency for clinicians to ‘compartmentalise’ their interventions, Brendon finds. ‘Within physiotherapy in non-mental health services, many of the clinicians I have spoken to still have the viewpoint that mental health is not really part of their agenda.’

Missed appointments

If physiotherapists fail to recognise mental illness, it may be catastrophic for patients. ‘Among the core symptoms of a mental health diagnosis are low mood, a chaotic lifestyle, or people may have poor memory. So they miss appointments because of their mental health symptoms. In the current climate, if people miss a couple of appointments, that’s it, they’re off the books.’ 

Brendon started a career in mental health by chance. After graduating as a physiotherapist in 2003, he was looking forward to a leisurely summer break. But his mother, the head of pharmacy at a major psychiatric hospital, had other ideas. She encouraged him to speak to the physiotherapy lead.

‘Before I knew it, I was having a job interview for a physiotherapy post at a mental health hospital, he says. ‘So it was a bit of an accident to start off with. Then I did some of the more traditional physiotherapy things, but I kept coming back to mental health and I’m very glad I did.

‘It’s just a wonderful environment to work in and looking at people in a really holistic manner is really satisfying. Most of my physiotherapy in non-mental health settings was very much about a particular injury or talking to someone about their pain on a scale or their balance scores.

‘But considering the whole person, and how their mental health may affect their physical health, was just much more interesting and challenging. I truly believe that as a result of my experience in mental health I’m a better physiotherapist.’

Award-winning research

At the inner-city Maudsley Hospital, there is no typical day for Brendon. Part of his role is clinical management, supporting and guiding physiotherapists who work across the trust’s four sites. As a jobbing clinician, he sees patients on acute wards, ‘our A&E for mental health’. Their stay may be brief, after a crisis, and Brendon will see them just once or twice.

A substantial part of his clinical role, however, is in suburban Beckenham at River House, the trust’s secure forensic unit on the site of Bethlem Hospital, one of England’s oldest psychiatric hospitals, founded in the 13th century.

The patients of River House are people who have a diagnosis of serious mental illness – often schizophrenia, bipolar disorder, personality disorder, or a combination of these and other conditions – and have entered the criminal justice system. They are detained at River House 
for treatment instead of going to prison.

Each week at his ‘typical MSK clinic’ in River House, he will see up to 16 patients. Many of them will be in the unit for years, so he will get to know them over a considerable period.

‘I should add the caveat that there is an abundance of research which demonstrates consistently that people with a mental health diagnosis are much, much more likely to victims of any crime, including violent crime, than to be perpetrators,’ Brendon says. 

Brendon’s clinical management and practice complements another important part of his work, as an award-winning clinical researcher. 

‘The two go together absolutely wonderfully,’ he says. ‘Because I am still working as a clinician, I am able to talk to patients or staff about issues that may be bothering them, or issues I can see with my own eyes. 

‘I can then take that forward within my research and see how we can improve the health and care for people with a mental health diagnosis.’

Activity boosts mental health

To date, Brendon Stubbs’ research has been published in more than 350 international articles. It has also featured in various media including Sky News, ITV News, the New York Times and Time magazine. His work is international too, and includes collaborations with colleagues in Australia, Italy, Belgium, Germany the United States and Brazil.

‘Research which made quite a bit of mainstream media, was looking at how physical activity for people with no mental health condition can protect them against depression,’ he says.

‘What we found, from over 49 studies, from across the world and in over 260,000 people, was that higher levels of physical activity, compared to low levels of physical activity, were consistently associated with a reduced risk of developing depression in the future. 

‘And it didn’t matter what geographical continent you were in, even when adjusted for BMI and smoking, physical activity appeared to protect against the emergence of depression.

‘The greatest impact was found when people were meeting the 150 minutes of moderate or 75 minutes of vigorous physical activity per week, with about a 30 per cent reduced risk of developing depression in the future. So that was particularly important.’

He welcomes a shift over the past five years towards valuing the physical health of people with serious mental illness. Certainly, attitudes were very different when he started as physiotherapist in mental health and people weren’t sure why he was in that environment. ‘It was just the culture at that time,’ he says.

Grossly underfunded

A key reason for the change, Brendon believes, is the increasing body of research and evidence demonstrating the ‘disgusting disparity’ in life expectancy between people with a serious mental illness and the general population. For instance, that people with schizophrenia die between 10 and 20 years earlier than members of the general population.

But mental health is still the poor relation in the NHS. Despite recent prime  ministerial promises, and a legal requirement for ‘parity of esteem’ between physical and mental health, lengthy waiting times for psychological therapy are common, and many people receive care a long way from home because services are not available locally. 

‘Mental health has been grossly underfunded for a considerable period of time, which is an absolute travesty,’ says Brendon.

While he’s glad that society is more open about mental health, in physiotherapy this has not translated into asking patients about their mental wellbeing and understanding mental illness, including common conditions such as anxiety, depression or post-traumatic stress disorder.

‘Across physiotherapy-related courses, people are not taught about mental illness,’ he says. ‘But it is very common in the people we work with. So I think it is important that we increase our education, awareness and openness about this important topic.’

Understanding mental health makes the physiotherapist’s job easier, Brendon believes. ‘Physiotherapists want to make people better. Having education and an understanding about mental health and how this may impact upon treatment will increase physiotherapists’ ability to engage and communicate. Ultimately, this means better outcomes for patients.’ 

More information

To find out more about Brendon Stubbs’ research into mental and physical health visit his website here. 

Author: Gill Hitchcock