First response

Simon, a man in his late 20s, is struggling when he consults with me. A relationship breakdown means he’s become homeless and is ‘sofa surfing’, between different friends, acquaintances and relatives. He’s devastated to be parted from his children. He’s just about managing to keep up his shift work in a warehouse but is feeling anxious and depressed and often wonders if he might be better off dead.

Mental health is said to be an issue in one in three consultations with GPs. For doctors working with the most deprived patients, that may well be a significant underestimate. In clinic I see some patients who feel low or anxious, and often even suicidal, simply because their lives are extremely tough.  Patients who struggle with the most harrowing symptoms and problems with addictions have often suffered unspeakable traumas in early childhood. Along with the hardships exacerbated by austerity, the rise in the number of children living with digital peer pressure and photoshopped expectations seems to be driving alarming levels of self-harm and dissatisfaction.

With rising awareness and demand mental health services are so stretched that intensive input is usually rationed for only the most severe cases. One initiative that has generated significant interest has been mental health first aid. Several workplaces, such as Thames Water and Royal Mail, have introduced this training for staff, claiming impressive reductions in sick leave and improved levels of wellbeing. The charity which delivers the training, Mental Health First Aid England, is campaigning to change the law to make mental health first aid Training mandatory for employers. The campaign has attracted prominent supporters notably Luciana Berger MP who has argued passionately for legislation, including in a Fabian Society report.

So, could mental health first aid be part of the solution to our crisis in mental health? The concept is appealing. Its symmetry with existing health first aid law is an attractive gesture towards achieving the notional ‘parity of esteem’ that is supposed to exist between physical and mental health. It also places some of the responsibility for mental health with the employers who manage workplaces which in many cases contribute to illness. And mental health first aid seems to offer confidence to employees to help spot signs that colleagues are struggling and offer practical support.

Yet, health professionals are conspicuously few amongst the supporters of mental health first aid. I share this ambivalence. We simply don’t know how well mental health first aid works – or indeed if its works at all. Although, the programme seems self evidently laudable, the history of health policy is inundated with ‘good ideas’ introduced with exemplary intentions and scarce evidence. Such evidence as there is for mental health first aid points to improvements in awareness of mental health amongst staff and ability to signpost those in crisis to appropriate services. A research summary by the Health and Safety Executive noted limited evidence for mental health first aid in general and no evidence that it has improved the organisational management of mental health in workplaces. Another evaluation, published by RAND for Public Health England, reached similar conclusions, although comparing it favourably to most other workplace interventions which have even less supporting evidence.

Impressive results cited by employers like Thames Water and others certainly warrant examination but they are difficult to separate from other positive changes to workplace culture that likely accompanied the training. While the serious investments such organisations have made in employees’ mental health is to be celebrated, we need to know more before we can say whether all employees would benefit from this training or whether there might be other more effective interventions.

Admittedly there probably wasn’t an ample evidence base to support the health and safety legislation that mandated first aid provision in the workplace in the early 80s. But, almost 40 years on, it is sensible to demand adequate evidence before launching major health initiatives. Calling for mandatory mental health first aid might be a reasonable judgement to make as a politician, but it will strike many in health as premature to plump for an intervention which surely wouldn’t meet the criteria of proven effectiveness set by the National Institute of Health and Social Care Excellence (NICE) for use in the NHS.

Would mental health first aid benefit Simon? Maybe, but perhaps employers, employees and people with mental health problems deserve to know for sure before making it mandatory.

‘Simon’ is a fictionalised patient based on several different patients.