OUTCOMES MAP: MENTAL HEALTH

John Copps and Dawn Plimmer v

February 2013: Version 1.0
MAPPING OUTCOMES FOR SOCIAL INVESTMENT
This is one of 13 outcomes maps produced by NPC in partnership with the SROI Network, Investing for Good and Big Society Capital. Each map
examines a particular issue area or domain, and aims to document the relevant outcomes and indicators that are currently being measured by
charities, government, academics and practitioners working in this field.

This map is not intended to be prescriptive about what you should measure; instead it aims to be a starting point for social investors, funders, charities
and social enterprises thinking about measuring outcomes in this domain. Neither is it intended to be definitive or comprehensive: we plan to develop
the maps further in future as we learn more about measurement practice in this area.

If you have any feedback or suggestions for how we could do this, please get in touch with Tris Lumley at NPC by emailing tris.lumley@thinkNPC.org.

Outcomes maps in this series

Housing and essential needs Politics, influence and participation

Education and learning Finance and legal matters

Employment and training Arts and culture

Physical health Crime and public safety

Substance use and addiction Local area and getting around

Mental health Conservation of the natural environment and

climate change
Personal and social well-being
MEASUREMENT OVERVIEW: MENTAL HEALTH

Definition
Mental health describes a state of emotional and psychological well-being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and
meet the ordinary demands of everyday life. It includes positive aspects of well-being, such as joy and happiness, and negative aspects, such as anxiety and depression. Recent
definitions, including that of the World Health Organization, emphasise positive aspects of mental health. However, in practice, public policy and charities tend to address negative
aspects which require treatment. These mental health problems are the focus of this overview.

Mental health problems cover a wide variety of psychological experiences, from the anxieties we all experience as part of everyday life, to more serious long-term conditions. There
are several types of mental health problems including:

• Common mental health disorders: For example anxiety or depression. These cause distress and interfere with daily life but usually do not affect a person’s insight or cognition.

• Psychosis: For example schizophrenia, bipolar disorder. These cause disturbances in thinking and perception severe enough to disturb a person’s perception of reality.

• Eating disorders: For example anorexia nervosa and bulimia nervosa. Eating problems range in severity but often cause acute distress and serious physical complications.

• Personality disorders: These are severe and long-lasting distortions in thoughts, feelings and behaviour that that interfere with the ability to make and sustain relationships.

• Post-traumatic stress disorder: .This is caused by a traumatic event or events and is characterised by flashbacks, nightmares, avoidance, numbing, and hyper-vigilance.
Two important symptoms or indicators that can underlie some mental health problems include self-harming (including cutting, burning, scratching and hair pulling, which people do
deliberately but often in a secretive way) and suicidal thoughts.

Context
One in four adults experience some kind of mental health problem at some point in their life, and one in six people will experience a mental health problem at any one time. More
serious mental health problems, such as psychosis, are rarer than anxiety and depression: 0.4% of adults have a psychotic disorder. Mental health problems touch every aspect of a
sufferers life, from day-to-day functioning to relationships and work. As a result, people with mental health problems are more likely to be unemployed, suffer poor physical health, and
1
live alone. Mental health problems are known to rise during recessions and periods of economic difficulty.

1
Joy, I. and Miller, I. (2006) Don’t mind me: Adults with mental health problems. New Philanthropy Capital.
 Measurement overview: Mental health

The costs of poor mental health to the UK economy are enormous. According to the Centre for Mental Health, mental health problems cost the UK over £30bn in lost output and over
2
£21bn in health and social care costs every year. There are also huge impacts on the quality of people’s lives and impacts on families and friends.

The treatment of people with mental health problems depends on the type of problem and its severity. Services have changed significantly over the last twenty years as attitudes and
3
medical practice has progressed. Around 12 million people visit their GP each year, 1.3 million are referred to specialist services and 200,000 spend time on a hospital ward.
Responsibility for public services falls on the Department for Health, working through NHS mental health trusts and GPs. There are specialised services for young people, delivered by
Child and Adolescent Mental Health Services (CAHMS) teams.

In the charitable sector, the large providers of mental health services include Rethink and MIND, which work through local MIND associations. There are also a large number of other
providers and local community groups, on the fringes of the mental health system. In recent years, the charity sector has worked successfully together to tackle the discrimination and
stigma attached to mental health problems. This is visible in the Time to Change campaign, which campaigns for a better understanding around mental health and provides information
to the public.

Vulnerable groups
Mental health problems can affect anyone. Among the key groups to consider are:

• Teenagers and young adults: Mental health problems often become visible in adolescence as young people begin to take responsibility and live independently. Teenage girls
are most at risk of developing eating disorders, often associated with body image problems.
• People with a history of mental health in their family: Mental health is known to have a hereditary component, although the exact nature of the link has not been isolated. The
4
National Institute of Mental Health in the US says that at least 60% of the factors that give rise to schizophrenia may be related to genetic factors.
• Ex-service personnel: Members of the armed forces may have witnessed traumatic events or experienced severe stress. Over the last three decades, what used to be know as
‘shell shock’ has been recognised as post traumatic stress disorder and related issues. Services personnel returning from duty may have difficulty adjusting to civilian life.
• Older people: Older people are more likely to live alone, have low incomes and poor health, which are known to be risk factors in developing mental health problems. Stressful
events, for example, the loss of a partner can also trigger the onset of mental health problems.
• Unemployed people: Having a purpose in life is known to be important to good mental health. For most people work provides a focus and direction and takes up a large part of
their lives. Unemployment can also lead to financial problems and poverty and people can find themselves trapped in a downward spiral. an estimated 2.3 million people with
5
mental health problems do not work, and more than 70% of people on Incapacity Benefit have a mental health problem.

2
Centre for Mental Health (2010) The economic and social costs of mental health problems in 2009/10 and Centre for Mental Health (2007) Mental health at work: Developing the business case.
3
Joy, I. and Miller, I. (2006) Don’t mind me: Adults with mental health problems. New Philanthropy Capital.
4
Joy, I. and Miller, I. (2006) Don’t mind me: Adults with mental health problems. New Philanthropy Capital.
5
Rickey, B., Joy, I. and Paterson, E. (2012) Job well done: Employment and mental health problems. A guide for funders.
 Measurement overview: Mental health

Key outcomes
• People have improved mental health: An individual’s mental health is improved, they access the services that they need, and they avoid crisis.
• People are better able to manage their mental health and lead a full life: An individual’s ability to manage mental health problems and the effects on their lives is improved,
including impacts on work, financial situation, friendships, involvement in community and overall self-esteem.
• Families and friends of people with mental health problems have improved well-being: How the well-being of people close to people with mental health problems are
affected by their condition, including immediate family, friends and colleagues. This includes support and respite for carers.
• Reduced stigma and discrimination of mental health problems: The extent to which attitudes and behaviour within society and the workplace towards mental health problems
are improved. This includes measurements of the success of lobbying and campaigning.

Examples of typical interventions

The most common way of dealing with mental health problems is with medication. Millions of patients each year that visit their GP and are prescribed anti-depressants or other drugs.
In severe cases, people can admit themselves to hospital or are ‘sectioned’, and enter the care of a psychiatrist. Treatments also include talking therapies such as cognitive
behavioural therapy and counselling, which may be used alongside drugs. Complementary therapies, such as reflexology and aromatherapy, are also often used to relieve
anxiety.

Much of charities’ work focuses on helping individuals with mental health issues cope with day-to-day life and manage when crisis hits. Day to day support is given to individuals and
their families through clubhouses, arts-based activities, befriending services, and short breaks. Crisis services include telephone advice lines and crisis houses, short-term
support to manage and resolve crises in a residential, rather than hospital, setting.

Charities also promote good mental health, educating the public about their mental health and helping people to seek help when they need it. This is done through providing
information, advice and guidance and providing interventions to tackle factors that trigger mental health problems, such as financial difficulties, healthy living, and substance abuse.

Charities also run awareness campaigns and lobby government, representing the interests of those affected by mental health problems in areas such as changes to the benefits
system or employment legislation. Medical research looks for new treatment and approaches.

Current approaches to measurement

Patients within the NHS or any clinical environment have their mental health regularly assessed using validated psychological scales (of which there are many). Scales are chosen that
focus on particular aspects of mental health and behaviour, such as anxiety or narcissism. Clinical observation can also be used to test compulsive behaviours or to test if the mental
health problem is having an impact on physical health. This measurement is combined with professional judgment to make a decision on a patients clinical needs.
 Measurement overview: Mental health

In practice, many treatments, including talking therapies and use of anti-depressants, do not rely on any rigorous measurement. When they were developed they will have been part of
large clinical trials and have been approved for use in the health service. In this case, doctors tend to rely on whether the patient ‘feels better’.

Charities’ work is subject to a variety of different measurement. Most services will have some way of measuring the progress of individuals, sometimes through clinical scales or
sometimes through measurement tools, such as the widely-used Mental Health Recovery Star, or through anecdotal evidence from family or friends. Where services exist to address a
specific problem, for example related to housing, benefit claims or relationships, data is often captured on that measure. In addition, services often measure client satisfaction using
survey-based approaches.

Lobbying and awareness raising campaigns can be evaluated using measures of numbers of people engaged, whether policy change has been achieved, and changes in public
attitudes.

Key sources
• The King’s Fund research publication on mental health http://www.kingsfund.org.uk/topics/mental-health

• NHS’s Attitudes to Mental Health survey report 2011, http://www.ic.nhs.uk/webfiles/publications/mental%20health/mental%20health%20act/Mental_illness_report.pdf

• Centre for Mental Health (2010) The economic and social costs of mental health problems, http://www.centreformentalhealth.org.uk/pdfs/Economic_and_social_costs_2010.pdf

• Rickey, B., Joy, I. and Paterson, E. (2012) Job well done: Employment and mental health problems. A guide for funders.

• A guide for funders

• Joy, I. and Miller, I. (2006) Don’t mind me: Adults with mental health problems. New Philanthropy Capital.

• NHS mental health website, http://www.nhs.uk/LiveWell/Mentalhealth/Pages/Mentalhealthhome.aspx

• Time to Change, website www.time-to-change.org.uk

• MIND website www.mind.org.uk, Rethink website www.rethink.org, and YoungMinds website www.youngminds.org.uk

Related outcomes
Mental health is linked to outcomes in many other areas of life, including:

• Personal and social well-being

• Physical health
• Employment and training

• Substance use and addiction

 Measurement overview: Mental health

Stakeholders
Key outcomes Specific outcomes Indicators Existing measures Source and use Notes
(tagging)

Clinical tools
developed by
psychologists to
measure negative
symptoms of mental
distress. These
include:
The Patient Health
These tools are widely
Questionnaire (PHQ-9)
used in primary care
for symptoms of
settings to diagnose
depression.
and monitor mental
The Generalised health. Tools are
Anxiety Disorder available for adults and
Assessment (GAD-7) young people. Clinical tools usually
for symptoms of • Individuals contain a series of
People have an Number of people with generalized anxiety, questions regarding
Clinical tools can be • People with
People have improved improved mental state, fewer negative including panic and particular symptoms and
used to both assess a mental health
mental health. including reduced symptoms of mental stress. ask the client to rate on a
clients mental health problems
anxiety and distress. distress. CORE-IMS measures scale how frequently that
global clinical distress,
and also to measure • Young people symptoms has occurred in
change by comparing the last.
including subjective
symptoms between
well-being, commonly
two points in time. The
experienced problems
results can also be
or symptoms, and life
aggregated at a group
and social functioning,
level to demonstrate
as well as risk to self
the value of a service.
and others.
Measures of young
people’s mental health
include Goodman’s
Strengths and
Difficulties
Questionnaire (SDQ)
and CORE-YP.
 Measurement overview: Mental health

Data based on
Number of referrals to referrals from
mental health services. professionals and
sessions delivered.
These measures are
used widely but • Individuals
Data based on inconsistently by
referrals from organisations to • People with
Improved access to Number of people
professionals and monitor use of services mental health
and increased use of accessing mental
sessions delivered. problems
support services health services. It can be difficult to get
Questionnaires of benchmarks and know • Community and
users asking whether what rate to expect as society
they have used data is not published
Number of service
services, and how
users reporting
likely they are to use
improved access to
them in the future.
support.

Surveys of patients
and service users
asking whether they
feel they have access
Number of service to services.
users reporting that
they feel more Feedback can be
informed about their asked after using a These measures are
Service users feel service. Eg: Since you • Individuals
health and well-being. used widely but
more informed about contacted us, has the inconsistently by • People with
their health and well- information provided mental health
organisations to
being. helped you to live with problems
monitor use of services
your condition?

Number of information Data collected by

resources and organisations providing
publications information on number
downloaded or of downloads and
accessed. resources accessed.

Hospital statistics on • Individuals This approach may be

admissions related to supplemented with
Reduced admissions to Number of admissions • People with
mental health, questions of service users.
hospital or need to to hospital acute mental health
available from the For example, do you think
seek medical help. wards. problems
Department of Health that the services we have
and health trusts. • Community and provided have reduced your
 Measurement overview: Mental health

Data collected by society use of statutory services?

Number of admissions Options: Yes, definitely;
organisations providing
to crisis houses. Yes, maybe; No; Not sure
crisis house services.

Department of Health
data eg, data from the
Number of people Health and Social Care
‘sectioned’ under the Information Centre on
Mental Health Act. number of people
detained under the
Mental Health Act.

For example:
Number of people
accessing mental
health services,
according to ethnicity,
gender, and socio-
All of the outcomes in • Individuals
this paper can be
economic status. • People with
analysed (using the
Number of people mental health
relevant suggested
Reduced mental health satisfied with access to problems
measures) to
inequalities between mental health services, determine differences • People from black
different groups according to ethnicity, between groups and minority
gender, and socio- ethnic groups
See measures for
economic status. • Community and
specific outcome
Number of people areas. society
‘sectioned’ under the
Mental Health Act,
according to ethnicity,
gender, and socio-
economic status.

Validated
This has been used for
psychological scales to
Score on psychological over twenty years and
measure ability to
People are better able Increased numbers of scales to measure can form part of wider
cope, including Ways
to manage their people are able to ability to cope. mental health
of Coping scale • Individuals
mental health and manage their mental assessments.
(WOCS).
lead a full life health problems.
Score on Mental The Mental Health Developed by Triangle
Health Recovery Star. Recovery Star was Consulting
 Measurement overview: Mental health

Validated
psychological scales,
including:
• The Rosenberg
Self-esteem scale
(RSES);
• The General Self- These scales contain • Individuals
Efficacy Scale multiple-item measures
Number of service • People with eating
(GSES); containing statements
users with increased disorders
• Body image scale that individuals’
Service users have feelings of self-worth respond to. • People from black See well-being overview.
increased self-esteem. and improved self- (Franzoi &
and minority
assessment of their Shields); Change can be
ethnic groups
own capabilities. • NPC’s Well-being measured by observing
• Young people
Measure for young test scores at different
times. aged 11-16
people..
Self-reported scores
can also be compared
to other indicators of
well-being, reported by
family, friends or
professionals.

Number of service
users participating in
Data on number and
education and training
activities. level of qualifications
Service users increase and accreditations
their skills and gain Number of service attained. Published by National benchmarks • Individuals
See education overview.
appropriate users achieving the Department for are available. • Young people
qualifications. GCSEs, A Levels Education in England
NVQs, BTEC, degrees and by schools and
and other academic, colleges.
vocational or skills-
based qualifications.

Number of people with Office for National

mental health problems Statistics (ONS)
Increased numbers of Figures can be
that enter employment. Labour Force Survey See employment and
service users enter compared with general • Individuals
gathers data on training overview.
employment rates of employment.
Number of people with employment rates of
mental health problems DDA disabled people
 Measurement overview: Mental health

that sustain by main impairment,

employment. including mental
illness.

Validated
psychological scales
include:
• The Lubben Social
Responses validated
Service users have Network Scale
psychological scales See personal and social
improved social Revised (LSNS-R); • Individuals
looking at social well-being overview.
networks and
networks.
• Social integration
subscale of the
Social Provisions
Scale (SPS

Many other indicators

available. See politics and
influence survey.
Annual nationwide
Number of people who Use of suggested
survey looking at about
given any unpaid help measures of active
the lives, experiences,
or worked as a Questions in citizenship by people with
Service users become behaviours and beliefs
volunteer for any type Understanding Society • Individuals mental health problems can
more active citizens. of people in the UK run
of local, national or survey (wave 2) be used at a population
by the Institute for
international level to compare trends for
Social and Economic
organisation or charity those with and without
Research (ISER).
mental health problems,
and to track individual
progress

Number of service
users reporting that
they have adequate
OECD International
knowledge, confidence
Network on Financial
and access to personal Other outcomes and
Service users are Education (INFE)
finance, bank account, indicators also exist. See
better able to manage Financial literacy • Individuals
savings, and credit. financial security and legal
their finances. survey instrument –
matters overview.
for adults and 15 year
Number of service
olds.
users in control of
personal finances,
including budgeting,
 Measurement overview: Mental health

managing
indebtedness, and
claiming appropriate
level of benefits.

Measures using the

concept of ‘locus of
control’, or where the
individual sees control
over their life
Numbers of service Duttweiler (1984)
users reporting a Internal Control Index Measures can be used
Increased numbers of
sense of having control (28-item). Alternative to diagnose individual Also see politics and
service users feel in • Individuals
over their own destiny locus of control scale support needs and influence overview.
control of their lives (13-item) (Rotter 1966)
and ability to make track progress.
decisions.
Locus of Control scale
for children and
adolescents (21-item)
(Nowicki and Strickland
1971)

Number of carers of Carers’ Well-being and

people with mental Support Measure is
health problems feeling developed by Rethink
supported.
Rethink’s Carers’ Well- to evaluate adult • Individuals
being and Support carers’ satisfaction with
Number of hours • Young people
Improved support for Measure evaluates the support they get
carers.
respite and short
adult carers’ • Families and
breaks provided to Surveys of carers can
Families and friends of satisfaction with the children
carers. be used to assess
people with mental support they get • Carers
availability, relevance
health problems have
Number of periods of and access to support,
improved mental well-
respite provided to and track changes
being and life
carers. overtime.
satisfaction

Validated well-being Measures can be used • Individuals

Number of carers with measures to capture to assess changes in
Carers have improved • Young people
improved mental well- overall mental well- well-being overtime
well-being and life
being and life being and life and results can be • Families and
satisfaction. satisfaction, including: children
satisfaction. compared to norms for
• Warwick- other adult or child • Carers
 Measurement overview: Mental health

Edinburgh Mental populations

Well-being Scale
(WEMWBS)
• NPC’s Well-being
Measure (for 11-16
year olds)

For example:
Children have Huebner’s Multi- Measures can be used • Individuals
Score on validated dimensional Student to indicate the wider
improved attitudes • Young people For more indicators, see
psychological scale to Life Satisfaction Scale impacts of mental
towards family aged 5–18 social and personal well-
measure satisfaction 7-item family module. health issues on family
members with mental • Families and being overview.
with relationships. (Adapted to 5-item in relationships, and track
health problems. children
NPC’s Well-being changes over time.
Measure).

MAKS esd developed

by the Institute of
Psychiatry to measure
the knowledge,
attitudes and behaviour
Validated multiple-item
Number of people with of the general public to
The public have psychological scale eg,
improved knowledge people around mental • Community and
improved knowledge of the Mental Health
about mental health health. It is used in the society
mental health. Knowledge Schedule
problems. Department for
(MAKS).
Health’s National
Attitudes Survey. Use
Reduced stigma and with the general public,
discrimination of with responses
mental health aggregated.
problems.
CAMI used in the
Number of people with Department for
The public have Validated multiple-item
improved attitudes to Health’s National
improved attitudes psychological scale eg,
mental health problems Attitudes Survey. • Community and
towards people with the Community
(ie, how tolerant they society
experience of mental Attitudes to Mental Use with the general
are, and the language
distress. Illness Scale (CAMI) public, with responses
that they use)
aggregated

The public’s behaviour Number of people Validated multiple-item RIBS is used in the
• Community and
towards people with demonstrating psychological scale to Department for
society
experience of mental improved treatment of assess interactions in a Health’s National
 Measurement overview: Mental health

distress improves. people with mental range of contexts, Attitudes Survey.

health problems. including on the street, Use with the general
in public services and public, with responses
in the workplace. Eg, aggregated
the Reported and
Intended Behaviour
Scale (RIBS).

Training and surgery

data can be monitored
Number of practitioners
in GP surgeries or by
trained in mental health
training providers such
as Mind.

Number of practitioners
Health practitioners are that ‘feel confident’ at Data on practitioner
better able to identify dealing with mental qualifications and • Community and
mental illness and act health problems and surveys of society
appropriately. know where to direct knowledge/confidence
people.

GP diagnosis and
Number of mental
referral data collected
health cases
by the Department of
diagnosed and referred
Health and local health
from GP surgeries.
authorities.

Number of employers
willing to employ Example question: What if
people with a history of any accommodations have
mental health you made for employees
problems. who have mental health
Shaw Trust survey problems, that you did not
Workplaces
assessing have before?
demonstrate improved
Number of employers improvements in • Community and
understanding of a) Reduced working hours
willing to make workplace practices society
mental health b) Increased supervision
adaptations. towards people with
problems.
mental health issues c) Adjustment to role
d) Access to counselling
Number of employers
willing to be e) Option to work from
understanding in the home
event of a crisis.
 Measurement overview: Mental health

Number of court cases

and employment • Community and
Employment rates and
tribunals around society
court cases in statistics
discrimination of
employees with mental
published by the ONS. • Individuals
health problems.

Number of policy Observed change in

initiatives (at specified
policy (as determined
level eg, local/national
by what is written in
government, organisation rules,
employers) directed at white paper or statute),
improving support for and resulting outcomes
those with mental Self-evaluation of
Policy changes create health problems. policy change based
a society more on expectations of
• Community and See politics and influence
supportive of those change and estimation
society overview.
with mental health of ‘what would have
problems Number/extent of happened anyway’
outcomes attributed to Eg, ‘External agencies
policy change (ie, any dial’ developed by
of the outcomes NCVO’s Valuing
featured in this infrastructure
framework) programme, based on
a scoring system of
estimated influence.
TRANSFORMING THE CHARITY SECTOR

NPC occupies a unique position at the nexus between charities and funders, helping them achieve the greatest impact. We are driven by the values and mission of the charity
sector, to which we bring the rigour, clarity and analysis needed to better achieve the outcomes we all seek. We also share the motivations and passion of funders, to which we
bring our expertise, experience and track record of success.

Increasing the impact of charities: NPC exists to make charities and social enterprises more successful in achieving their missions. Through rigorous analysis, practical advice
and innovative thinking, we make charities’ money and energy go further, and help them to achieve the greatest impact.

Increasing the impact of funders: We share the passion funders have for helping charities and changing people’s lives. We understand their motivations and their objectives,
and we know that giving is more rewarding if it achieves the greatest impact it can.

Strengthening the partnership between charities and funders: Our mission is also to bring the two sides of the funding equation together, improving understanding and
enhancing their combined impact

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