Background to the evaluation
Men’s mental health and well-being is increasingly of concern. In England and Wales, the suicide rate is now almost four times higher for men (78%) than women (22%). Rates of diagnosis of men’s mental health problems do not capture distress among men well, as men may express distress in atypical ways (eg acting out, blunting emotions), suggesting that we need a deeper understanding of male experiences of distress and ‘men-friendly’ services to better help men. One such service, Atlas, was designed as a potential way of improving access to mental health services for men. Atlas was originated by Professor Damien Ridge, co-designed by Prof Ridge and Professor David Peters, and managed and governed by adapting University of Westminster Polyclinic guidelines, developed over 15 years. The Atlas Men’s Well-being Programme was designed to be ‘male sensitive’, to provide counselling and/or acupuncture for men suffering from stress or distress. Based at the Victoria Medical Centre (VMC), a busy NHS GP practice in central London, the pilot Programme ran from March 2013 until July 2014 for practice patients only. Our evaluation collected quantitative patient outcomes and qualitative data, to examine clinical changes in patients and their experiences of the Programme. In addition, interviews were conducted with a wide range of key stakeholders involved in the Programme. The aims of the interviews were to (a) understand the Programme from the perspectives of key stakeholders, and (b) improve the Programme early on by identifying any problems and feeding them back to the people who needed to know.
Questionnaires: All patients using the Atlas service were invited to take part in the evaluation. Questionnaires were used to collect predominantly quantitative data and were completed by patients prior to using the Programme as well as on finishing the Programme. Measures collected included anxiety, depression, perceived stress, positive well-being, physical health and outcomes for problems identified as most important by each individual patient. Open-ended questions collected written data regarding patient experience of the Atlas Programme.
Interview data: Semi-structured interviews with 14 key stakeholders (including Atlas practitioners, VMC GPs, VMC administration staff and other VMC practice staff) were conducted five to six months into the Programme. In addition, narrative interviews were conducted with six men who used Atlas to provide deeper insights behind the numerical results. The narrative interviews provided an understanding of men’s distress and Atlas. All qualitative data were analysed using thematic analysis.
Cost implications: Additional questions regarding patients’ employment and service use were collected on patient questionnaires (before and after engaging in Atlas services) and formed the basis for the cost implications analysis.
• GPs played a key role in referring and encouraging men to attend Atlas.
• Patients took a variety of routes through the service, using counselling and acupuncture in different combinations, according to their needs, in consultation with their GPs and practitioners.
• Of the 107 patients using the Programme, 102 (95%) completed a pre-treatment questionnaire, and 82 (80%) of those went on to complete their post-treatment questionnaire.
• Men said that they were attending the Programme to help reduce psychological and physical symptoms, promote positive mental states and relaxation, improve daily functioning, understand and manage their problems, talk things through, and deal with a range of specific issues affecting their lives such as work and relationships.
• Comparisons between pre- and post-treatment revealed statistically significant improvements in anxiety, perceived stressed, positive well-being, physical health and patient-centred outcomes (ie problems rated as most important to each patient at the time of first attendance).
• Overall there was no change in depression, but this is likely to be because a significant proportion of the men using the Programme were not initially identified as depressed. However, the sub-sample (n=50) of men who were at risk of depression (as identified using recommended cut-off scores on our depression scale) before using the Programme did experience a statistically significant improvement in depression post-treatment.
• 78% of patients said that they felt better after their Atlas sessions, 13% reported no change and 4% felt a little worse.
• Patients reported an improvement in their understanding and awareness of themselves and/or the situation that they found stressful, and found ways of coping with and managing their issues as a result of using the Programme.
• Some patients described being able to talk to an objective professional as helpful, although challenging at times. Some patients wanted a more structured or directive approach to working with their problems than counselling could provide.
• The unanimous opinion among stakeholders was that the Atlas Men’s Well-being Programme functioned well. Some minor challenges for professionals included pressures on scarce room space, a lack of clarity regarding which health professionals were able to refer to Atlas, and occasional difficulties for receptionists with appointment bookings. Some patients wanted to have more than their allocated six or 12 sessions. When the demand for the Programme allowed, practitioners were able to provide up to six additional sessions.
• Professional stakeholders felt that having a male-only service sent an implicit message to men that validated their emotional needs and normalised the idea of getting help for stress/distress, and attuned practitioners and GPs to the emotional needs of men. Other stakeholders felt the Programme should also be available to women. In interviews, men said that it being a male-only service had not occurred to them (GP referral was the most likely route rather than the flyer) and was not of particular significance. However, many agreed there was an unmet need for male mental health services, and that having a male-only service may improve access for other men.
• Often counselling was more acceptable to patients than acupuncture as a way of helping them with their mental health problems. However, the acupuncture service was well used and was reported to reduce stress, and patients evaluated it well.
• Qualitative data suggested a synergy between counselling and acupuncture: Atlas practitioners considered that acupuncture might help patients to be more emotionally ‘open’ in counselling sessions, or that acupuncture could help relax patients after a challenging counselling session. Further research will be needed to explore this interaction.
• Atlas reduces costs, when taking costs related to health and social care usage and lost employment into account; reductions in these costs exceeded the cost of the Atlas counselling and acupuncture sessions, with an average saving of nearly £700 per patient.
Quotes from Atlas participants
“It was great to have someone independent from the situation to talk to and get objective feedback from. The action of talking about issues is itself a therapeutic process and helps one understand.” P2
“A good blend of professional and approachable. I guess these things can be a little strange at the beginning (especially if you are not pre-disposed to talking about your issues such as I), but she made me feel comfortable early and established credibility and trust early too. This helped develop the relationship quickly, which in turn helped get maximum benefits from the conversations.” P2
“The realisation that I was suffering from serious stress, which I wasn’t addressing and how to stop that happening in the future. I got a much-needed sense of perspective and was able to see that things had become almost unbearable in terms of not communicating how I was feeling.” P109
“It helped understand the reasons behind thoughts and emotions I had been experiencing. This led to a better acceptance of my moods/worries.” P13
“Helped me to understand myself better – ideally what’s important to me, what makes me special, who I am. Helped to identify my strengths and what makes a brilliant person. It was the first step on the road to recovery.” P22
“[Acupuncture practitioner] found ways of exploring my depression which were helpful, even though I sought only treatment via acupuncture.” P79
The evaluation demonstrates a hitherto under-investigated pathway by which men experiencing mental health problems can be identified in primary care and helped to talk about the problems that are concerning them, and/or receive physical therapy aimed at reducing stressed-related symptoms.
Findings from this evaluation suggest that the Atlas Men’s Well-being Programme was helpful for stressed and distressed men, particularly in terms of reducing anxiety and stress and improving physical health, positive well-being and individual problems important to each patient.
The Programme also promoted relaxation as well as better understanding and coping with problems. Consistent with previous research in this area, the study found that a ‘one size fits all’ approach is unlikely to be useful for men, and indeed men using Atlas had varying preferences and expressed diverse needs in relation to the Programme.
We found that it is possible to effectively develop and deliver a primary care-based programme offering help to men for their mental and physical symptoms of stress and distress. Flexibility (timing and treatment options), the close involvement and encouragement of GPs, and high-quality branding appear to be important considerations when providing men’s mental health services. This evaluation highlighted the value of engaging GPs in encouraging stressed/distressed men to identify – and seek help for – mental health problems.