Abstract
A balanced approach to promoting mental health, preventing mental illness and treating those affected is recommended by experts and governments in a number of countries [1–3]. However, in most communities the value of mental health and how to promote it are poorly understood. On the other hand, mental illness is stigmatized, and often believed to be untreatable. Prevention of mental illness is regarded as unlikely, and mental health promotion has been hampered by the diffuse nature of the proposed action [4], [5].
The present paper begins by noting the effects of mental illnesses on communities and individuals, and then discusses the concepts of mental illness and mental health. These ideas in themselves have a strong influence on understanding the needs for mental health promotion and the prevention and treatment of mental illnesses. The final sections consider the complementary activities of promotion, prevention and treatment, some of the controversies and dilemmas that prevail, and the required next steps.
The message from epidemiology I: high prevalence, disability and costs
Until now, the priority assigned to mental illness and mental health on the international public health agenda is, by any criterion, vanishingly small. In relation to the staggering toll of disability resulting from mental and behavioural pathology, so low a priority is simply perverse. Why does mental illness fare so badly? [6] p.142].
There are several reasons. The first relates to the stigma and poor understanding of mental health and illness. Another relates to health statistics. Death rates greatly underestimate the disease burden resulting from mental illnesses. In recent years the World Bank, in cooperation with the World Health Organization, developed a new index to measure total health burden: disability adjusted life years (DALYs). This statistic summarizes the ill health, disability and loss of life from identifiable diseases into a single numerical measure. Although still imperfect, it gives a much more realistic measure of the relative level of health burden attributed to mental illness [6]. According to these measures, the burden of mental illnesses constitutes 10%% of the global burden of disease. Depression will be one of the largest health problems worldwide by the year 2020. Problems of mental health are a major and increasing threat to the quality of life, to the economy, and to public health throughout the world [2].
The National Survey of Mental Health and Wellbeing in Australia has results comparable with other major surveys in recent years, indicating that during 1 year, almost one in five (18%%) people in the community has a diagnosable form of mental illness at some time [7]. Young adults aged 18–24 years have the highest prevalence (27%%). For young men the major problem is substance abuse, and for young women it is anxiety and depression. Three per cent have a critically disabling mental illness, such as schizophrenia, manic-depression, severe depression, severe anxiety and drug dependence; 5%% have chronic and disabling mental illnesses such as depression, anxiety, and substance use. Significant disorders occur in childhood and adolescence and may continue to adulthood, whereas many adult disorders begin in adolescent years.
People living with severe mental illnesses are among the most disadvantaged people in any community. The physical and emotional consequences of illness affect their ability to function in family, social and vocational realms, and they experience discrimination in many aspects of life [8]. The complications include family disruption, substance abuse, suicide, illness and premature death from other causes, unemployment, poverty, social isolation and homelessness. Many of these critical outcomes can be avoided with early recognition and treatment, or with appropriate and sustained support for people and families living with long-term illness [9].
However, most people with potentially remediable disorders are not treated [10]. There is a continuing failure to recognize and treat mental illness, particularly anxiety and depression, in people attending general practitioners or general hospitals. Approximately 20%% of these patients suffer from a well-defined mental illness, often associated with a physical illness; in a high proportion this is chronic with substantial disability and increased use of health care. The cost to the community may be calculated in several ways, but it is very high.
The message from epidemiology II: variations with time, place and person
Social and environmental conditions, and particularly relative social disadvantage [11], have significant effects on mental health and illness. People from poor socioeconomic backgrounds, those who are unemployed and those who live alone experience poorer health and wellbeing than those in other groups. There are major decrements in social and emotional well-being in many immigrant and indigenous communities. This is linked to loss of land, family and identity, and to poor general health.
Stressful life events influence the onset and outcome of illnesses of various types. Major life events can, for instance, provoke a depressive illness and the risk of their doing so is increased by the presence of underlying vulnerability factors, including deficiencies in family and social support. On the other hand, social ties and support can have protective effects. Preventive strategies can usefully aim at reducing vulnerability in persons at increased risk for depression by strengthening their social networks [12].
Although schizophrenia and related disorders are not ‘social diseases’, social and cultural factors including the opportunity to work and others’ expectations strongly influence the course of the disorder and the likelihood of recovery [11], [13]. Early intervention is likely to have an important influence on recovery and course of the disorder [14].
Improving mental health
Health can be defined as a state of balance that individuals establish within themselves and with their environment [15]. It is the product of a number of interrelated dimensions, including mental, physical, emotional, social, cultural and spiritual dimensions. Mental health is included within this definition: the ability of people to think and learn, and the ability to understand and live with their own emotions and the reactions of others.
The activities that can improve health include the prevention of disease, impairment and disability, the treatment of diseases and the promotion of health. These are quite different from one another. The promotion of health requires changing the place that health has on the scale of values of individuals, families and societies. The methods of health promotion are different from those used to prevent or treat mental illness, and from those used to rehabilitate people disabled by mental illness [15].
These are all required, are complementary, and cannot be substituted for one another. It is not enough to rely on treatment. This is just as true for mental as for physical disorders. However, confusion about the concepts of mental illness and mental health have influenced the development of programs and the availability of resources in each of these domains.
Concepts of mental illness and mental health
People with mental illness are often considered to be identifiable and different from the rest of the population. Yet the term mental illness means different things to different people. Confusion about the term has been a powerful reason for the low priority given to mental illness [16], and scepticism about the capacity to treat or prevent it.
Two potent sources of confusion about the idea of mental illness exist in the public mind. First, mental illness has to be distinguished from other causes of social deviance also involving distress and abnormal behaviour [17]. Mental illness, eccentricity and badness are different in meaning. Some individuals may be labelled with more than one of these terms, but it is vital to keep these terms separate. If mentally ill people are seen as ill rather than as eccentric or bad, it is easier to seek ways of providing them with appropriate services, and to seek approaches to prevention and mental health promotion [16]. A second source of confusion is the tendency to ‘overlook the highly specific dysfunctions because of their kinship with common misery and crises’ [18]. The illnesses of depression and anxiety for instance often have a quality difficult or impossible for those suffering the ‘common misery’ to understand.
The treatment of mental illness has historically been alienated from the rest of medicine and health care. In the isolated setting of the asylums, practitioners saw many seemingly incurable patients. The supposed incurability of insanity and melancholy made practitioners believe the causes were entirely biological. The idea has since persisted that prevention of mental illness is ‘all or none’. The psychoanalytic and psychotherapeutic practice that flourished outside the asylums from the middle of the last century concentrated on processes within the individual. There was a similar lack of focus on illness as ‘a product of an ecosystem’ [19].
The fundamental concept of disease as multifactorial in origin is the basis for preventive medicine. Mental illness has generally been excluded from this framework. However, psychiatric treatment services have changed greatly over the last 50 years. Most treatment and care now occur outside large institutions. The expectation is that treatment and care in the community will foster approaches to the problems of mental illness similar to those of other illnesses [20].
Turning to mental health, there are a number of barriers to understanding and definition [16]. Just as with mental illness, confusion and vagueness about the concept are powerful reasons for the low priority given to mental health programmes, and the difficulty in mobilizing all those concerned with supporting an overall strategy. The barriers include the belief that either mental or physical health can exist alone. Health includes mental, physical and social functioning, which are interdependent. Likewise, mental and physical illnesses do not exist on their own. Mental illness can accompany, follow, or precede physical disorder. The second major barrier is the belief that health and illness are mutually exclusive. They are mutually exclusive only if health is defined in a restrictive way as the absence of disease. Defining health as a state of balance between the self, others and the environment changes the thinking.
Mental health promotion and prevention of mental illness
The World Health Organization defines health promotion as action and advocacy to address the full range of potentially modifiable determinants of health [21]. These determinants include not only those related to the action of individuals, such as behaviours and lifestyles, but also factors such as income and social status, education, employment and working conditions, access to appropriate health services, and the physical environment. Health promotion and prevention are necessarily related and overlapping activities. Because the former is concerned with the determinants of health and the latter focuses on the causes of disease, promotion is sometimes used as an umbrella concept covering also the more specific activities of prevention [2].
A strong body of evidence identifies the personal, social and environmental factors promoting mental health and protecting against ill health [1], [2], [22], [23]. These factors may be clustered conceptually around three themes [1], [2]:
1. The development and maintenance of healthy communities, which then provide a safe and secure environment, good housing, positive educational experiences, employment and good working conditions, a supportive political infrastructure, minimize conflict and violence, allow self-determination and control of one's life, and provide community validation, social support, positive role models, and the basic needs of food, warmth and shelter.
2. Each person's ability to deal with the social world through skills such as participating, tolerating diversity and mutual responsibility; associated with positive experiences of early bonding, attachment, relationships, communication and feelings of acceptance.
3. Each person's ability to deal with thoughts and feelings, the management of life and emotional resilience; associated with physical health, self esteem, ability to manage conflict and the ability to learn.
The fostering of these individual, social and environmental qualities, and the avoidance of the converse, are the objectives of mental health promotion and prevention. As an example, the Victorian Health Promotion Foundation [24] has defined three broad themes for action after a review of expert opinion and the evidence linking mental and physical health to each other and to aspects of social connectedness, discrimination and violence, and economic participation.
These activities of mental health promotion are mainly sociopolitical: reducing unemployment, improving schooling and housing, working to reduce stigma and discrimination of various types, and wearing seat belts to avoid head injury. The key agents are politicians and educators, and members of non-government organizations. The job of mental health professionals is to remind them of the evidence for the importance of these key variables [25].
Prevention of illness is sometimes categorized by stages of intervention in an assumed causal chain: primary (to prevent onset of illness), secondary (to reduce the duration and associated disability by early treatment) or tertiary (to reduce sequelae). When causal pathways can be identified, as in some cases of depression, this concept is useful in prevention of mental illness.
Another approach to health promotion categorizes interventions according to the levels of risk of illness or scope for health promotion, in various population groups, and makes it clearer what type of collective action is required: universal (directed to the whole population, e.g., good prenatal care), selected (targeted to subgroups of the population with risks significantly above average, e.g., family support for young, poor, first pregnancy mothers) or indicated (targeted at highrisk individuals with minimal but detectable symptoms, e.g., screening and early treatment for symptoms of depression and dementia) [26]. This second approach emphasizes the capacity to act despite the conundrum that: (i) the evidence for direct causal pathways is generally strongest for the most immediate influences; (ii) most illnesses have multiple causes interacting in a ‘vicious spiral’ over time [11]; and (iii) important factors such as child abuse and neglect may influence the later occurrence of several types of illness, and the level of well-being in later life. Other life events and circumstances will interact favourably or unfavourably to contribute to resilience or the development of illness.
‘Mainstreaming’ mental health promotion
The activities of mental health promotion may usefully be ‘mainstreamed’ with health promotion, although the advocacy needs to remain distinct. Many of these activities as mentioned previously will also promote physical health, and physical and mental health are closely associated. Physical health is an important influence on mental health. Conversely, the importance of mental health in the maintenance of good physical health and in the recovery from physical illness is now well substantiated. Mental health status is associated with risk behaviours at all stages of the life cycle. For instance, in young people, depression and low self-esteem are linked with smoking, binge drinking, eating disorders and unsafe sex [27]. Depression in older people is linked with social isolation, alcohol and drug abuse and smoking [28], and poor physical and role functioning [29]. Mental health status is a key issue for changing the health status of the community.
Dilemmas and controversies
Universal or indicated (‘high risk’) strategies or both
Screening, or the pursuit of earlier diagnosis, and treating defined high risk groups, are two strategies used in several areas of health care. These strategies are important in preventing and treating a number of defined disorders such as breast cancer and depression. In primary health care, for example, preventive interventions are likely to be effective with groups at high risk of depression, such as the bereaved [30], mothers with a previous episode of postnatal depression, and those who drink harmful levels of alcohol [25]. Counselling, education and support by members of the health and social service teams can be crucial in preventing episodes of ill-health.
However, these strategies will have little effect on promoting population health or in lowering rates of illness in the population, because of our limited ability to predict which individuals will become sick. Risk factors may identify a group with a much increased relative risk, but most high-risk individuals are likely to remain well and most clinical cases occur in those who were not at conspicuous risk: ‘a large number of people exposed to a small risk commonly generate many more cases than a small number exposed to a high risk’ [31] p.554]. Rose bases this important point on the understanding that, in all fields, disease and normality are part of a continuum, and not separate entitites.
This reasoning is particularly relevant when considering strategies to lower the rates of suicide in a population [32], [33]. For instance, detection and treatment of depression in primary care will be important in saving a number of people from death by suicide, as mental illness is a major risk for suicide. However, most people who become depressed will not die in this way. Reducing rates of suicide is more likely to be achieved using universal population-based strategies [34]. Reducing the availability of methods commonly used for suicide is the most practical current policy. Wider approaches depend on the epidemiological evidence of a strong association over time in different parts of the world between suicide and social conditions, including the rate of unemployment. A reduction in suicide rates is likely to result from universal or population-level actions. Examples are social interventions that are effective in improving mental health among unemployed people; altering school environments in ways shown to avert the antecedents of suicide (depression, harmful drinking and deliberate selfharm); and parenting support effective in reducing the chances of domestic violence and abuse, and improving the nurturing of children.
These interventions have a further relevance. Not only do most clinical cases occur in low-risk individuals, but also subclinical degrees of abnormality generate much morbidity. As much as three-quarters of depressionrelated social disability may arise in those whose scores on a depression inventory fall below the accepted threshold for a case [31].
Bolting the stable door…
The harm done to children by physical and sexual abuse presents a sad dilemma [25]. The evidence is now strong that child abuse and neglect are powerful risk factors for a number of psychiatric disorders, including substance abuse, and for adult homelessness. A definitive understanding of the mechanisms through which these risk factors operate awaits further research. Interventions (such as teaching parenting in secondary schools, and supporting families) that can reduce the occurrence of child abuse and neglect may ultimately yield a large dividend by preventing social and mental health problems. However, most efforts are now in the form of tertiary prevention by social workers in child protection services.
Increasing the evidence base: program evaluation and aetiological research
Mental health promotion has been seen to ask for peace, social justice, decent housing, education, and employment. The call for intersectoral action has sometimes been diffuse [32]. Specific evidence-based proposals that can be expected to produce measurable outcomes are required. However, asking individual health promotion projects to demonstrate long-term changes in ill-health, death from suicide, or quality of life is often unrealistic and unnecessary. What is required instead is: (i) a marshalling of the evidence linking mental health with its critical determinants (aetiological research); and (ii) program design and evaluation to demonstrate changes in the same determining or mediating variables. Programs and policies can aspire, in other words, to produce changes in indicators of economic participation, levels of discrimination, or social connectedness. Identifying and documenting the mental health benefits of these changes, and developing indicators of these determinants, are complementary areas of work needing further support [24].
Support for research and evaluation of programs in these areas is disproportionately low. An evidence base for mental health promotion does exist but it needs boosting with aetiological research and program evaluation. Promising areas include the sources of well-being and resilience in the face of adversity, the modifying factors in the course of various types of illnesses and disabilities, and the relationship between mental health status and other illnesses and risky behaviours [16], [23]. The development of quality-of-life measures encourages health-care providers to consider the views of consumers, and to consider domains wider than symptoms and disability as the concerns of health care [35], [36].
Projects assessing the utility and cost-effectiveness of specific programs for families or schools or workplaces require support over a long lead time. A project determining the staff and training requirements of successful community care [37] will require information-gathering and cooperation across several areas and service sectors. An example of an integrated program of research and health promotion concerning family caregivers was sponsored by the Victorian Health Promotion Foundation. The results suggest a number of ways to support caregivers with the aim of improving well-being and preventing ill health [38].
Most players are necessary and not sufficient
Mental health practitioners will often underestimate the scope of mental health promotion or prevention of mental illness because of the clinical focus that is their business. Those who see the importance of these activities feel daunted by the task. Politicians and educators may not understand the effects of their work on mental health, nor have access to relevant information, or equally likely, have to set priorities which exclude health promoting measures. Once the community grasps the relationship between social conditions and mental health, politicians and educators will be able and encouraged to act.
Mental health programs often involve spheres of action beyond health care. As mentioned above, a number of important interventions are a matter of education and policy change: for example, efforts to create a more tolerant society, and reduce stigma and discrimination generally, as with chronic illnesses, race or gender. The attention to violence and its causes and consequences, including the critical links with mental health and alcohol use in young men, is an example of crossdiscipline work central to developing effective community policies and programs. In individualistic societies, strategies which require collective endeavour need to be well articulated and justified. In societies with a stronger collective orientation, some programs such as improving antenatal care seem obvious and are readily organized [26].
The treatment of mental illness
An understanding that mental health is affected by individual and community action underpins the development of health promotion programs. On the other hand, an understanding that mental illnesses are treatable can encourage early entry to care, improve outcomes, and lessen the stigma and discrimination related to mental illness.
In clinical practice, the momentum is growing to introduce and promote standards, clinical guidelines, staff training, quality improvement, outcomes assessment, and research. Mental health services need to stand comparison with services for the physically ill. The rigid practices of the recent past and in many cases of the present day, associated with impersonal and authoritarian staff behaviours which may be exaggerated by staff demoralization and ‘burn-out’, add to the burdens of isolation and discrimination which many people and their families experience upon receiving a diagnosis of mental illness.
Early detection and treatment of illness and effective management of disabilities can make a profound difference to outcomes for people with depression, anxiety and psychotic disorders. This requires primary health and community-based mental health services which are linked with each other and with social, housing and employment services. The victims of abuse and young homeless people with mental illness, among others, often fail to get access to the required types of help. Collaboration and shared training between youth workers, welfare and accommodation workers, and mental health and drug service workers are vital [39], as is the voice of consumers.
Conclusions
What is needed next?
Developments in promotion, prevention and intervention are complementary. Improving mental health requires developments in each.
1. Promoting community understanding about the nature of mental health and mental illness, is the key to changing the policies and practices in education, employment, law and health which are critical to mental health. Respect for the human rights of those with mental illness is the first step to improving treatment and care services.
2. The development of a set of priorities for mental health promotion and programs for prevention of mental illness which are institutionalized yet flexible, based on evidence and ‘mainstreamed’ with health promotion where relevant.
3. Coordinated efforts of politicians, governments, educators and health professionals to develop plans and evaluate programs and policies.
4. Develop integrated programs of research and health promotion which add to the evidence base and change in response to its implications.
5. Develop and maintain best practice in services to people with mental illnesses. This requires services research to establish:
– the capacity for service access and early intervention where applicable, as in the detection and treatment of depression and psychosis;
– the needs of those with longstanding and severe disabilities, and ensure that they are not overlooked;
– how best to include consumers and families in service planning and monitoring;
– interagency working: how best to facilitate work between the many agencies, including health, housing, employment, social services and the voluntary sector, which are needed to provide comprehensive services and support;
– the primary/secondary care interface: how to facilitate cooperation and communication between general practitioners community health and specialist mental health services;
– personnel needs: determining the staffing and training requirements of successful community care. The training, support and attitudes of service providers, whether health, mental health, housing or police, need as much continuing attention as community attitudes;
– carers: how to support the informal carers of people with severe illnesses and disabilities.
– assessing disability and quality of life as well as symptoms is important to understanding the illness burden and the cost effectiveness of services and supports for people with mental illness.