I’M From the Government and You Want Me to Invest in Mental Health Promotion. Well Why Should I?

Key words

* mental health

* health promotion

* social cohesion

* discrimination

* participation

This paper presents the rationale for governments to promote mental health: Mental health is not only fundamental to the health of a population, but is also fundamental to its human, social and economic development.

The paper discusses the responsibility for promoting mental health, by expanding the traditional view about who ‘owns’ mental health promotion, and who actually does, or can, promote mental health in most populations. It presents strategies for action largely drawn from the authors’ experience in the UK and Australia. The paper finishes with some ideas about how to get mental health promotion on the national agenda, and what might be included.

Using a broad understanding of mental health1 we argue that every government, at local, provincial/state or national level, whether in developing, transitional or developed countries would benefit from the inclusion of mental health promotion as a integral part of overall health, social and economic policies.

Mental health promotion not only enhances positive mental health, but also contributes to the reduction of risk behaviours such as tobacco, alcohol, and drug misuse, unsafe sex; the reduction of social and economic problems such as drop out from school, crime, absenteeism from work and intimate partner violence; and the reduction of rates, severity of, and mortality from, physical and mental illness.

Time to make a stand: why governments should promote mental health

At a societal level, good mental health is an important resource for individuals, families and communities. Mental health is an indivisible part of public health, contributes to the functions of society and has an effect on overall productivity. Mental health contributes to human, social and economic capital.

As introduced by Williams and colleagues in this volume (Marshall Williams, Saxena and McQueen, 2005), neuropsychiatric disorders account for 13% of the Global Burden of Disease, with depression alone currently accounting for 6.1% (Ustun, AyusoMateos, Chatterji, Mathers and Murray, 2004). Predictions estimate that, by 2020, depression will be the second leading cause of disability in the world (Murray and Lopez, 1996).

Poor mental health unequally affects those who are socially and economically disadvantaged while also contributing directly to poverty (Fryers, Meltzer and Jenkins, 2004).

Poor mental health also contributes to poor physical health (Herrman and Jan-Llopis, 2005). For example, depression, social isolation and lack of social support are significant risk factors for Coronary Heart Disease that are independent of conventional risk factors such as smoking, high cholesterol and hypertension and are of similar magnitude to these conventional risk factors (Bunker et al., 2003).

Promoting mental health has the potential to reduce a whole range of risk behaviours and their consequences such as loss of productivity, crime, drop-out from school, and disrupted family relationships.

Increasingly we are seeing similarities appear in the antecedents of a number of different health and social outcomes. For example, the presence of the same risk factors (eg., low attachment to one’s community, school, family and workplace; parental alcohol and drug use, family conflict, inconsistent parenting, marital instability and friends engaging in problem behaviours), and the absence of protective factors (a culture of cooperation and tolerance between individuals and between institutions and diverse groups in society, a sense of belonging to family, to school, to one’s workplace and to one’s community, good relationships within and outside the family, positive achievements, stability and security) can result in increased crime, drop out from school, increased risk of alcohol abuse, sexual activity, depression and suicide, drug addiction (Homel et al, 1999; Bond, Thomas, Toumbourou, Paton and Catalane, 2000).

Workplace studies are revealing the costs of poor mental health such as lost productivity and lost creativity. It has been estimated that 30-40% of sickness absence is attributable to mental disorders (e.g. Jenkins, 1985). Workplace claims resulting from stress related causes are reported to be on the rise in Australia (Pelly, 2004).

School studies show us the importance of mental health for learning. We know that anxious children, and children that are depressed, perform less well academically at school. And a major study in schools has shown that up to 30% of depressive symptoms in high school students can be attributed to harassment or bullying at school (Bond et al., 2000).

A largely untapped area is the associations between poor mental health and disrupted family and personal relationships, and the social, health, economic and intergenerational costs that arise from breakdown of these relationships (Quintan and Rutter, 1998).

Research in the field of mental health promotion has generally been stronger about the association (and to a lesser extent the causality) of certain risk and protective factors listed above and poor mental health, than it is in showing how interventions can work. Nonetheless, there is now a rapidly growing body of evidence on the effectiveness of intervention (Mrazek and Haggerty, 1994; Jan- Llopis, Hosman, Jenkins and Anderson, 2003).

The combination of knowledge about risk factors, and social economic consequences of poor mental health, together with knowledge of effective interventions, makes a persuasive case that the less governments pay attention to the promotion of mental health, the more they will have to pay in a whole range of ways such as crime, drug abuse, poor educational performance, poor productivity, and poor physical health. Some may even pay the costs at the ballot box!

Whose responsibility is it to promote mental health?

In the light of the determinants of mental health such as the risk and protective factors listed above, then it makes great sense for governments at all levels:

* To focus on mental health promotion as a means of developing a physically and emotionally healthier, safer, better educated and more productive community.

* To bring the relevant parts of the community, public and private sectors together to work on the upstream determinants of mental health such as social cohesion, community building, urban renewal, participation in the economy, parenting and reduction of discrimination.

Traditionally mental health promotion has been seen as the responsibility of the health sector, and the mental illness services in particular. But when we look at the determinants of mental health, two issues become obvious.

Firstly, that while the health sector has to pick up the pieces resulting from poor mental health, it has little effect on these determinants. Secondly, individuals and organisations in business and industry, housing, local government, sports, recreation, arts and popular culture, primary, secondary and tertiary education, and justice already are promoting or in some cases, demoting, mental health. Often however, they are not aware of the effect they have on mental health and can be further encouraged to either expand their health promoting work, or reduce the health damaging effects of their work. An example of the former is supporting and encouraging the role of good sports coaches or drama teachers in promoting the mental health of adolescents, and an example of the latter is changing work practices that actively encourage bullying in the workplace.

The challenge is to work out how to create effective partnerships with these individuals and organisations. The first step is to understand what is in their interest that aligns with ours in promoting mental health. For example, participation in sports and the arts has positive associations with social inclusion and reducing risk factors for poor mental health (Harrison and Narayan, 2003). Sports, recreation and arts organisations are generally very interested in reaching higher levels of participation (including active participants as well as coaches, leaders, teachers, managers and other volunteers) and so are those interested in mental health promotion. But in this case it is not enough to promote any form of sport, recreation or arts. It has to be inclusive sport, arts and recreation where a welcoming environment, that promotes health and respectful relationships, is as important as performance and the results on the field or on the stage.

Strategies for action

In addition to the evidence presented in this volume (Jan-Llopis et al., 2005), in this section we present a number of ideas, projects and programmes that governments can use at all levels. They are presented to stimulate thinking rather than suggest they either have ironclad evidence for their success, or that they should be copied, without local adaptation. These projects and ideas are not representative but have been selected on the basis of the authors’ experience and contacts, so are based in the UK and Australia.

A larger review of the evidence can also be found in the reviews on mental health promotion and mental disorder prevention or the world health organization (WHO, 2004a; WHO, 2004b). Further examples of men\tal health promotion initiatives from a number of different countries can be found in a series of case studies published by the World Federation for Mental Health and World Health Organization (Saxena and Garrison, 2004).

It is our view that the way the programmes are developed and implemented, and the relationships developed among organisations, and between participants and these organisations are crucial to the long term results. As a study of housing in the UK shows, the context in which the programme is implemented is crucial to the promotion of mental health – see below (Thompson, Petticrew and Douglas, 2003).

Early childhood development and parenting

Group-based parenting training programmes improve the mental health of both parents and children (Barlow, 1999; Barlow, Coren and Stewart-Brown, 2001) and may be more acceptable to parents than clinic-based programmes for individual parents. A Primary Care Health Improvement Programme for mental health in Suffolk has established a partnership involving health, education and social services. They have set up a Healthy Schools Programme involving two primary schools and one upper school.

The Primary Care Trust is covering the cost of six 90-minute parenting classes for parents of children between five and 15 years of age. A nursery is also provided. The classes are facilitated by school nurses and health visitors and promote positive parenting messages in a relaxed atmosphere. The aim of the classes is to increase parents’ self-esteem and confidence about parenting.

Two major national initiatives aim to improve emotional development of young children within comprehensive child development programmes. Sure Start is a large national initiative in the UK, begun in 2001, currently running in 524 local programmes involving up to 400,000 children in less advantaged areas. It aims to increase the life chances of children living in disadvantaged neighbourhoods by increasing the availability, affordability and quality of child care, improving their health, education and emotional development, as well as supporting their parents as parents and in their aspirations for employment (NESS, 2004; Sure Start, 2004). Predating Sure Start is the US government’s Head Start programme, begun in 1965. The programs, for children, pregnant women and families aim to improve school readiness of young children in low income families. The programmes are run by local organisations and in 2003 they reached over 900,000 children, employing 206,000 staff, supported by 1,372,000 volunteers (Head Start, 2004).

Teenage development

As reviewed in this volume, there are different approaches that can be used to promote the mental health of young people (Jan- Llopis, et al., 2005). They might include school based programs (e.g., Gatehouse project, Patton et al., 2003,), including those that limit victimisation, discrimination and bullying (Kallestad and Olweus, 2003), and programmes to enhance young people’s participation in the economy (VicHealth, 2004a).

Other approaches include direct youth services such as the “331 Young People’s Centre” in London, funded by Barnet Local Authority, Barnet Primary Care Trust and the local Connexions service. It is a multi-disciplinary service providing advice, information, support and counselling to young people from 12 – 21 years. It is a general service, also providing information on sexual health needs. Young people were involved in the Centre’s development and young volunteers working in the Centre continue to input ideas. The main aim is to provide a high quality service that will inform, empower and respect young people so they are able to access the appropriate specialist local statutory and voluntary services. The project runs part time and has had over 12,000 contacts in its first three years. A second 331 centre has opened in West Hendon in January 2004 (331 Young People’s Centre, 2004).

Promoting mental health and active ageing

Similarly with older people there is a great range of possible approaches to improve mental health. Most of them represent the fundamental importance of valued participation, including paid and unpaid employment, connectedness, support, and encouragement.

The ”Ageing Well UK Network”, facilitated by Age Concern England, is a national health promotion programme with and for older people. The projects recruit and train volunteers aged 55 or older, known as Peer Mentors to provide support, encouragement, advice and information to their peers in order to promote positive physical and mental health. One of the projects in the Network, the Positive Mental Health Project in Warrington, is developing some groundbreaking work using trained volunteer peer mentors to help older people improve their mental health and outlook on life. They also offer support for people to access social and heath activities in their local community. (Further information about this and other schemes can be found on http://www.ageconcern.org.uk/AgeConcern/ staying.htm).

Sports and recreation

VicHealth was established in 1987 by using a dedicated tax on tobacco to buy out and replace tobacco company sponsorship in sports and the arts with health promotion. The buy out was completed and now VicHealth’s Sport and Active recreation programme, representing an annual AU$8million investment in sports, and active recreation is focussed on increasing participation levels – for two reasons – for the physical health benefits of good sport, but also to promote mental health through improving capacity to welcome, encourage and maintain active participants, coaches, managers and volunteers (VicHealth, 2004b).

Arts and culture

The Women’s circus, started in 1991, is a project of the Footscray Community Arts Centre in Melbourne, and is an initiative to empower women through the development of circus skills. It welcomes all women but gives priority to women who have been victims of physical and sexual abuse, women over 40 and women from diverse cultural and linguistic backgrounds (Women’s Circus, 2004).

Somebody’s Daughter Theatre Company was started in a women’s prison in 1980. The company works in art, drama and music with women and now young people who have been excluded from the cultural and social life of the community (Somebody’s Daughter, 2004).

Vocal Nosh is a programme to teach singing and develop local community choirs based on the notion of eating and singing together. It is based along principles of creative participation, cooperation and celebration, respect and inclusiveness. It now is expanding through teaching leaders skills to scale up the programme across the state of Victoria (Community Music Victoria, 2004).

Urban planning

In the UK a large prospective controlled trial has shown that housing improvements can reduce anxiety, depression, and self reported mental health problems (Thompson, Petticrew and Douglas, 2003). And, like the example of sport above it is not simply the provision of housing that influences mental health, it is also the context in which it is provided. For example the tenure and ownership, housing design and moving needed, as well as the relationships and negotiations between provider and tenant, have to be taken into consideration, so that it becomes “mental health promoting” housing, not just the provision of bricks and mortar.

The Planning Institute of Australia has been providing professional development and training for its members, underpinned by the understanding that good [mental] health can be planned into a community, as can poor mental health. This project includes focus on the physical design and layout of new and old communities, traffic management, provision of public transport, walking and bicycle paths, the resiling of shopping precincts and community amenities (Planning Institute of Australia, 2004).

Local government

In many countries, local governments have been the core promoters of mental health in their communities, through the provision of services such as maternal and child care, early learning programs, sports and cultural amenities for all ages, local employment, democratic local decision making, local traffic management, urban design and walking and bicycle paths.

The Walking school bus has begun in many countries including the UK, New Zealand, USA and Australia. In Victoria, Australia the programme has been introduced under the auspices of local councils. The evaluation of the first four projects in Victoria has shown that although this has been fundamentally introduced as an initiative to promote physical activity it has considerable reported positive effects on mental health for students (inclusiveness, prevention of bullying while walking to school) and for parents and volunteers involved (VicHealth, 2003).

Business, industry and employment

Business and industry can promote mental health in two major ways. Firstly, employment compared to unemployment is inherently better for mental health, and secondly workplaces can become ideal places for promoting mental health, rather than actively harming mental health, as many currently do.

England’s Department of Health has worked with key agencies including the Confederation of British Industry, the Trade Union Congress, the Health and Safety Executive and others to promote mental health in the workplace (Department of Health, 1995; Jenkins and Warman, 1993; Jenkins and Coney, 1992).

The (negative) evidence suggests that one of the best things you can do for someone’s physical or mental health is to assure them a satisfying and secure job. So good employers have been health promoters for years, yet how many are really aware of this role? Whitelion and Connectas are relatively new initiatives that bring together unions, employers, health and welfare agencies, sports and popular culture identities and local governments to provide training, mentoring and employment opportunities young people in the juvenile justice system (Whitel\ion, 2004) and others in communities with high levels of risk factors and low levels of protective factors (Connectus, 2004). They not only provide support for the young people at risk but also provide support for the employers who need to be “young people ready” just as much as the young people need to be “job ready”.

And there is another reason why business and industry might be interested in investing in mental health promotion. A recent study claims that the quality of workplace relationships is the most important driver of excellence in Australian workplaces (Hull and Read, 2003). Similarly emotional intelligence (in other words ‘good mental health’) is increasingly being understood as the hallmark of effective leaders (Goleman, 2000). Governments might even want to use the public service departments both to promote the mental health of its own public servants, and to increase their collective productivity.

Getting mental health promotion in the agenda

Each country is different, with different contexts, cultures, and existing service structures, and even different interpretations of mental health. But, nonetheless it would seem, as suggested in the discussion above, we face some very similar issues for which we need locally tailored solutions.

Research is obviously a key part of any national strategy, all the more so, because we are collectively building the (evidence) boat as we are sailing it. A good national example is in the impact of urban design on health. Because of their conviction that the design of a community’s built environment influences the physical and mental health of its citizens, the U.S. Centres for Disease Control has developed a research agenda for further understanding the relationship between community design and health – not only physical health but mental health, social capital and crime (Dannenberg et al., 2003).

In order to get mental health promotion into national policy it is important to: 1) have a good understanding of the current situation (context, needs, demands, existing policies); 2) then develop an overall mission statement, national goals and targets, strategic plans and comprehensible and comprehensive explanatory frameworks. Such frameworks should be addressed to decision makers and to those not in the health sector, but who are major or potentially major promoters of mental health.

It is crucial, in particular, to look for partners outside the mental health sector that may become allies, such as those working in HIV/AIDS, tobacco, alcohol and other drugs. The available evidence and strong rationale that improved mental health will decrease these other health risks, provides an argument that partnership will increase health and efficiency for all. Similarly, it is important to look for allies outside the health sector such as in urban renewal, arts, sports, employment as they will add to the chances of mental health getting on the political agenda, just as the [mental] health rationale can help them in their case for added financial and political support

I’m from the government, am I convinced?

Well I have just read this paper by Moodie and Jenkins, and to be honest I admire their enthusiasm and their approaches, and I think it would be a good idea for us to start mental health promotion programmes. I am concerned, however, that the Departmental Secretary, my boss, won’t support this, as it is so hard to prove or show some quick outcomes that he can show to the Minister. I think we’ll need to get some key community and business leaders to convince the secretary and the Minister.

Box 1

J’appartiens au gouvernement et vous voudriez que j’investisse dans la promotion de la sant mentale. Pourquoi ?

La sant mentale est non seulement essentielle la sant d’une population ; elle est galement essentielle son dveloppement conomique, social et humain.

Nous adoptons une acception large de la sant mentale pour faire valoir que les pouvoirs publics tous les niveaux – local, province/ tat ou national – des pays en dveloppement, en transition ou industrialiss, doivent faire de la promotion de la sant mentale un lment central des politiques globales sociales, conomiques et de sant. Dans cet article, les auteurs expliquent pour quelles raisons les gouvernements doivent favoriser la sant mentale, qui peut avoir comme rsultat de rduire la morbidit et la mortalit imputables la fois aux maladies physiques et mentales, de rduire galement la prvalence et la gravit d’un ensemble de comportements risque (par exemple le tabac, l’alcool, les drogues, les troubles de l’alimentation) et de problmes sociaux et conomiques tels que l’abandon scolaire, la criminalit, l’absentisme au travail et la violence dans les couples.

Ils examinent qui incombe la responsabilit de promouvoir la sant mentale en poussant plus loin l’ide traditionnelle de qui a la charge de la promotion de la sant mentale et qui l’assume effectivement ou peut l’assumer dans la majorit des populations. Ils prsentent des stratgies d’action et des exemples pratiques tirs largement de leur exprience au Royaume-Uni et en Australie. Ils concluent en exposant quelques ides sur la faon d’inscrire la promotion de la sant mentale l’ordre du jour des pays et sur ce qui devrait y tre inclus.

Yo estoy en el gobierno y tu quieres que invierta en promotion de la salud mental. Convnceme

La salud mental es de vital importancia no solo para la salud de la poblacion, sino tambin para su desarrollo humano, social y econmico.

Tomando la acepcion mas amplia de salud mental, defendemos que todo gobierno, local provincial, national o estatal, deberia incluir la promotion de la salud mental como parte fundamental de su politica general en materia sanitaria, social y economica, independientemente del grado de desarrollo de cada pas.

El artcule presenta las razones por las cuales los gobiernos deberan promover la salud mental, y sus consecuencias en la reductin de la morbilidad y de la mortalidad tanto en relacin con las enfermedades fsicas como mentales, en la reduccion de la prevalencia y de la gravedad de toda una gama de comportamientos de riesgo (consume de tabaco, alcohol, estupefacientes, trastornos de la alimentatin) y de una sere de problemas sociales y economicos como el absentismo escolar o laboral, la delincuencia y la violencia en el seno de la pareja.

Aborda la cuestion de la responsabilidad de la promocion de la salud mental ampliando la perspectiva tradicional de a quin le corresponde y quin lo hace en la prctica o puede hacerlo en la mayor parte de las poblaciones. Presenta estrategias de accion y ejemplos practices tornados en gran medida de la experiencia de los propios autores en el Reino Unido y Australia. El articule concluye con algunas ideas sobre como incluir la promocion de la salud mental en la agenda nacional y los temas que deberia abordar.

1. Mental health includes a sense of well-being, self-esteem, optimism, sense of mastery, ability to initiate, develop and sustain mutually satisfying relationships and the ability to cope with adversity (resilience). Together, these will enhance the individual’s capacity to contribute to family and other social networks, the local community and society at large. Good mental health is fundamental in avoiding risk taking behaviours.

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Dr. Rob Moodie

Chief Executive Officer

Victorian Health Promotion Foundation (VicHealth)

15-31 Pelham St., Carlton

Victoria Australia

Email: rmoodie@vichealth.vic.gov.au

Copyright International Union for Health Promotion and Education 2005