The Momentum for Mental Health Promotion

Key words

* burden

* mental health

* mental disorders

The greater awareness and better understanding of mental health and its importance to overall health, social and economic development, has lead to a momentum for mental health promotion. In recent years, mental health finally seems to be coming out of the shadows.

There are several possible reasons for this increasing interest in the population’s mental health. First, the awareness of mental disorders being common and disabling is increasing. These problems are no more being regarded as affecting a small segment of the population and it is becoming common knowledge that as many as one in four of us may experience mental health problems during our life time. The Global Burden of Disease study by the WHO and the World Bank (Murray & Lopez, 1996) did an enormous service by demonstrating the massive death and disability burdens due to neuropsychiatric disorders.

Second, the economic consequences of mental health problems are becoming clearer (WHO, 2003). The aggregate cost of mental disorders is estimated to be between 2.5 to 4.0% of global GNP (WHO, 2003). In addition, increasing attention is paid to the costs that are not easily assessed, such as those associated with mental health problems not amounting to disorders, and their related impaired social functioning.

Third, the links between physical and mental health are better understood and appreciated. Physical and mental health are closely associated through a variety of mechanisms. These include comorbidity, behavioural and lifestyle factors playing a role in health and illness and also in treatment seeking and adherence. Mind- body relationship continues to be an area of intense research and might in time break the remaining artificial boundaries between physical and mental health.

Fourth, another important factor is the linkage of mental health with human rights issues. The stigma and discrimination as well as deprivation of basic human rights faced by those with mental disorders has attracted attention all over the world and is becoming a serious issue for debate and concern.

Finally, all of these reasons effectively conveyed in high level publications with a policy purpose, their wide dissemination, and the continuous advocacy efforts for mental health during last few years, have put this topic on the political and public agenda. Prominent among these reports are the World Health Report 2001 (WHO, 2001a), some high level reports from the U.S. (United States Department of Health and Human Services 1999; Center for Mental Health Services, 2001; New Freedom Commission on Mental Health, 2003), the publication Mental health promotion and mental disorder prevention: A Policy for Europe supported by the European Commission (Jan-Llopis & Anderson, 2005), and the recent WHO Declaration and Action Plan for Mental Health, endorsed at the European WHO Ministerial Conference, held in Helsinki in 2005 (WHO, 2005).

Burden of mental and behavioural disorders

According to the WHO’s World Health Report, more than 450 million people suffer from mental disorders worldwide, and one in four persons will develop a mental or behavioural disorder throughout their lifetime, including unipolar depression, bipolar affective disorder, schizophrenia, epilepsy, alcohol and other drug disorders, dementias such as Alzheimer’s, post-traumatic stress disorder and compulsive disorder, panic disorder and primary insomnia (WHO, 200Ia). The prevalence of mental and behavioural disorders is about 10% for the adult population worldwide (WHO, 2004). Twenty percent of the adolescents under the age of 18 suffer from developmental, emotional or behavioural problems, and one in eight has a mental disorder (WHO, 2004b). Among adolescents and children from poor communities, the rate is about one in five. Mental disorders are expected to be second only to heart disease as a leading source of the global burden of disease by the year 2020 (Murray & Lopez, 1996). Unipolar major depression is the number one cause of disabilityadjusted life years (DALYs) lost for developing countries, accounting for 9.9% of the DALYs lost at ages 1544 (WHO, 2004a).

The economic cost of mental disorders is substantial. Mental disorders are costly to the individual, families and communities. In 1996, the direct costs of mental health services in the United States of America were estimated to be more than $99 billion (Rice & Miller, 1996). Indirect costs of mental illness totalled approximately $79 billion in 1990 (the most recent estimate available). Many other costs associated with mental illness are indirect and not readily measurable. While the burden of mental and behaviour disorders has typically been discussed with respect to the economic costs associated with mental illness, the WHO strategy for improving mental health particularly for underserved communities is one that includes acknowledging the undefined and the hidden burden of mental disorders. Conceptualizing burden in this manner reveals that the defined burden has implications for the effect on individuals; however, the undefined and hidden costs often have implications on the emotional and socioeconomic impact on the family and community. Indirect costs measure loss of productivity attributable to the illness and include costs related to morbidity, premature mortality, incarceration and caregiver time. The hidden costs refer to those that are a consequence of social isolation, humiliation, stigma and other human violations (Weiss, Cohen & Eisenberg, 2001).

Adopting a mental health promotion approach

During the latter part of the twentieth century, public health went through many changes such that some referred to a new public health that incorporated health promotion, chronic diseases and an understanding of social epidemiology. The 1990′s witnessed the rise of chronic diseases into the mainstream of public health thinking and the recognition of the need for good epidemiological surveillance as an essential function of public health. The 1990′s also raised awareness on the tremendous burden of mental disorders worldwide and recognized the need for evidence-based practice.

As the scientific field continues to develop new ideas and research evidence, more researchers are acknowledging that mental health is not simply the absence of mental disorders. Mental health is largely seen as a state of well being that allows each individual to recognise his or her own abilities, to cope with the normal stresses of life, while working productively and fruitfully to contribute to his or her community (WHO, 2004c).

While mental ill-health must be treated when it occurs, increasingly international attention is being devoted to actively creating social and physical environments that contribute to and promote positive mental health (New Zealand Ministry of Health, 2002). Mental health and well-being are not only vital to the functioning of the individual, but is also vital to the functioning of societies and populations. To this end, it is important that mental health promotion be applied equally to people with undiagnosed mental or social distress as well as to those identified as having mental health problems.

Box 1

Social, environmental and economic determinants of mental health

Social and contextual determinants of mental health

Social determinants underlie and are related to mental well- being. Social and environmental factors such as poverty, industrialisation, discrimination, war and violence all play a key role in all aspects of public health, and are risk factors for mental health problems (WHO, 2004b). Because mental health and ill- health are intertwined with historical and contextual factors, it is important that they be considered in understanding the mental health of populations (Weiss, Cohen, Eisenberg, 2002). When communities lack social and physical infrastructures that support and affirm their members, people often do not develop to their fullest individual potential (Baum, 1999). The confluence of risk factors, including psychological problems, and social factors coupled with environmental influences has been shown to lead to mental health problems (WHO, 2004b).

Socio-environmental risk factors are also particularly common in low and middle income countries. For example, people in deprived areas or low socio-economic groups may typically not have adequate access to healthcare, education, or to as basic resources as food or shelter. In addition, low income countries often do not provide the conditions that are necessary to promote positive mental health such as suitable housing, adequate income, and opportunities for developing social coping skills. Such conditions prevent poor individuals from leading the kind of healthy life that populations in more affluent conditions enjoy (WHO, 2004c). Emphasis should be placed on encouraging positive mental health by eliminating individual, socioeconomic and environmental risk factors (e.g., stigma, discrimination, unemployment and social isolation) and by promoting protective factors (e.g., community and family cohesion). Box 1 presents some examples of socioeconomic and environmental risk and protective factors for mental health.

Population-based mental health inter\ventions

Consistent with this focus, current research and practice in the field is now moving towards the active promotion of mental health and identifying successful population-based public health interventions. The most successful mental health interventions are those programmes that focus on evidence based risk and protective factors. To date systematic reviews and meta-analyses on specific mental health topics have demonstrated that promotion of mental health and the prevention of mental disorders can bring about health, social and economic benefits to society. The evidence on their efficacy is reviewed and referenced by Jan-Llopis and colleagues in this volume (Jan-Llopis et al., 2005). For example, there is ample evidence of the positive effects on mental health of home visiting interventions for pregnant mothers, or school-based programmes to promote mental health (WHO, 2004b). Evaluations of home visiting programmes have found that such programmes can for example, reduce risk factors for child maltreatment such as physical and emotional abuse, improve parent-child interaction or can reduce violence and crime over time (WHO, 2004b). These interventions are particularly successful for those at highest risk such as unmarried, teen mothers or children of parents with mental disorders. On the other hand, ecologic multi-component interventions, such as school programmes that take a whole school approach and target generic risk and protective factors, have shown to be more successful in improving mental health and reducing externalising and internalising problems such as depressive symptoms, than programmes that have an individual base (WHO, 2004b; WHO 2004c).

Even with the promulgation of efforts promoting mental health and the development of ecologic and individuallevel interventions, there remain relatively few examples of evaluated population-based, public health approaches that address mental health comprehensively. There is an urgency to undertake effectiveness and costeffectiveness evaluations that can provide practitioners and policy makers with considerations about feasibility and cost of promotion programmes in the diversity of global settings, especially in low- and middle- income countries. When this evidence can be delivered, it has a good chance of being used.

Mental health surveillance

The underlying theoretical base for a socio-behavioural monitoring system has many underpinnings that are crucial to understanding mental health at a population level. Behavioural risk factors, lifestyle patterns, personal behaviours and social determinants all need to be monitored to understand their relationship to mental health and how changing patterns in these entities affect changes in reported mental health status. Surveillance encompassing mental health is no different from other forms of health surveillance in that the issues relate to technical and structural concerns. The technical concerns are the usual: questionnaire design, sampling, data collection methods, analysis and dissemination of information. The structural concerns relate to community/government buy-in, relationship to the public health infrastructure and the development of sustainable resources to maintain surveillance over time. While clinical, diagnostic measures used in the assessment of mental disorders have been developed for quite some time, there is still a paucity of international databases to asses the extent of mental health burden and disorder in the general population. Further, tracking systems oriented towards assessing positive mental health from a population health approach are particularly lacking.

A population health approach is one where the physical and mental health of large numbers of people is addressed; there is a careful delineation of the population; and societal and individuallevel determinants of health are considered (Moriarty et al., 2003). Tracking systems that are designed from a population health approach are particularly needed in low- and middleincome countries such as Asia, Africa, South America and the Western Pacific (Weiss et al., 2001). A few examples of population-based, survey and surveillance systems that contain some mental health component exist in the United States. For instance, the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (CDC) has developed the Health-related Quality of Life (HRQOL) set of questions and incorporated it into the nationwide Behavioural Risk Factor Surveillance System. The purpose of the HRQOL is to assess and track perceived physical and mental health over time with the inclusion of the concept of perceived mental health (Henessy, Moriarty, et al, 1994). Such measures track whole populations over time, and provide a summary score for positive mental health as well as poor mental health. Despite the considerable success of this single measure, there is a need for more measures similar to the HRQOL that are able to determine the number of individuals in the population who may have elevated levels of depressive symptoms but no depressive disorder; thereby determining the need for promotion and prevention interventions capable of reducing the number of people who go on to experience depressive episodes.

The way forward

In recent years the field of mental health promotion and prevention of mental disorders has acquired world-wide recognition. New initiatives are being undertaken and new research is emerging, however, there are many areas that need to be further developed. First, there is a need for greater investment in mental health policies and interventions that are evidence-based and incorporate social and contextual determinants of mental health. second, it is crucial to ensure that opportunities for addressing mental health issues and developing effective interventions are equally targeted and supported across low-, medium- and highincome countries. Currently available effective programmes need to be brought to scale, and whenever possible, disseminated, adopted and implemented across countries tailoring to the cultural variation in different social contexts and being adopted according to available resources. These efforts will move the field towards fully achieving the definition of health expressed by the World Health Organization: A state of complete physical, mental and social well-being and note merely the absence of disease or infirmity (WHO, 2001b p.1).

L’lan en faveur de la promotion de la sant mentale

II n’y a pas de sant sans sant mentale. Ce message simple oriente tous les efforts vers la promotion de la sant mentale. Les faits corroborent qu’il faut intensifier les efforts consentis au niveau mondial pour amliorer la sant mentale. On estime que prs de cinq cents millions de personnes dans le monde souffrent de troubles mentaux, neurologiques ou lis la consommation de substances psychoactives. Les calculs montrent que le poids de ces troubles reprsente prs de 13 pour cent du fardeau mondial de la maladie. Un tiers de toutes les incapacits rsultent de ces dsordres. Prs d’un million de personnes se suicident chaque anne. Une famille sur quatre est touche par des troubles mentaux. On estime que le cot total des troubles mentaux se situe entre 2,5 et 4 pour cent du PNB mondial. Cependant, ces statistiques n’ont pas mme commenc prendre en compte l’impact concevable d’une sant mentale moins qu’optimale sur d’autres maladies, tats pathologiques et conditions de vie.

La sant mentale a galement des dimensions positives. Il s’agit d’un tat de bien-tre dans lequel la personne peut se raliser, faire face aux tensions normales de la vie, accomplir un travail productif et fructueux et apporter sa contribution la vie de sa communaut. L’lan en faveur de la promotion de la sant mentale s’est amplifi au cours des quelques dernires annes par une plus grande prise de conscience et une meilleure comprhension de la sant mentale et de son importance pour la sant dans son ensemble. Cependant, alors mme que des efforts de promotion de la sant mentale se rpandent un peu partout, on a toujours relativement peu d’exemples d’approches de sant publique qui s’appuient sur la population pour aborder ce fardeau consquent. On constate un manque, l’chelle mondiale, d’tudes systmatiques et de travail sur les donnes de surveillance en matire de sant mentale.

Comme la littrature sur la faon de mettre en oeuvre des interventions stratgiques axes sur la population pour amliorer la sant mentale sont rares, les auteurs concluent leur introduction par un bref tour d’horizon des efforts et des suggestions manant d’organismes scientifiques et de plaidoyer en faveur de la sant mentale pour relever le dfi d’aborder enfin la question des interventions fondes sur la population. Il est urgent de fournir aux professionnels de la sant publique des preuves de l’efficacit des interventions de promotion de la sant mentale, notamment des lments de rflexion sur la faisabilit et le cot des programmes de promotion dans la diversit des contextes dans le monde. Si l’on peut apporter ces preuves, il y a de bonnes chances que la promotion de la sant mentale soit utilise.

El impulse de la promotion de la salud mental

No hay salud sin salud mental. Este sencillo mensaje orienta todas las iniciativas encaminadas a Ia promotion de la salud mental. Los hechos confirman la necesidad de aumentar el esfuerzo mundial por mejorar Ia salud mental. Se calcula que casi 500.000 millones de personas padecen trastornos mentales, neurologicos ? derivados del consume de estupefacientes. Las cifras muestran que estos trastornos representan casi un 13% de todas las enfermedades a escala mundial. Una tercera parte de las discapacidades driva de este tipo de trastornos. Cada ano se suicidan casi un millon de personas. Una de cada 4 familias se ve afecta\da por algun trastorno mental. Se calcula que el coste total de los trastornos mentales se halla entre el 2,5% y el 4,0% del PIB mundial. No obstante, las estadisticas ni siquiera rozan las potenciales consecuencias que tiene una salud mental dficiente en otras enfermedades y dolencias.

La salud mental tambin tiene dimensiones positivas. Es un estado de bienestar en el que la persona materializa sus capacidades, puede afrontar las tensiones de la vida cotidiana, trabajar de forma productive y util y contribuir a la buena marcha de la comunidad a la que pertenece. Durante los ultimes afios ha aumentado el impulse dado a la promocion de la salud mental, gracias a una mayor concienciacion y comprension de Io que es y de su importancia para la salud en general. Sin embargo, aunque se lleven a cabo iniciativas de promocion de la salud mental, siguen siendo relativamente escasos los ejemplos de intervenciones de salud publica basadas en la poblacion que intenten abordar esta pesada carga. Contamos con relativamente pocos trabajos de investigacion y de inspeccion que aborden la salud mental a nivel mundial.

Dada la escasez de literatura sobre como llevar a cabo iniciativas basadas en la poblacion para mejorar la salud mental, la introduccion concluye con un brve resumen de las mismas y sugerencias formuladas por los organismos mundiales de tipo cientifico y de concienciacion y movilizacion para asumir el reto de realizar intervenciones basadas en la poblacion. Es urgente ofrecer a los profesionales de la salud pblica pruebas de la eficacia de las iniciativas de promocion de la salud mental, en las que se incluyan consideraciones relativas a la viabilidad y al coste de los programas de promocion en la diversidad de entornos de este mundo. Si se les facilitan estos datos, no cabe duda que les resultarn de utilidad.

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Sheree Marshall Williams, PhD

Behavioural Scientist

Centers for Disease Control and Prevention (CDC)

National Center for Chronic Disease

Prevention and Health Promotion

Office of the Director

4770 Buford Hwy, NE

Atlanta, GA. 30341-3717, Mailstop K-40

Tel: + 1 770-488-8007

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Email: smw6@cdc.gov

Copyright International Union for Health Promotion and Education 2005