The term mental health sits alongside the larger topic of mental disorder with which it overlaps while retaining a wider concept of general, including physical health, well-being, positive functioning, and the development and maintenance of interpersonal relationship functioning. The promotion of mental health depends in part on the prevention of mental disorder, a vital but largely neglected topic for which there are now promising signs of progress.
Introduction and Concepts
Mental health has been defined in several related ways. It describes a level of psychological well-being, or an absence of a mental disorder; the World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” Most recently, the field of ‘global mental health’ has emerged, which prioritizes equity in mental health for all people in the world. From the perspective of ‘positive psychology’ or ‘holism,’ mental health may include an individual’s ability to enjoy life, and create a balance between life activities and efforts to achieve psychological resilience. Mental health can also be defined as an expression of emotions, and as signifying a successful adaptation to a range of demands. Mental wellbeing relates to a person’s psychological functioning, life satisfaction and ability to develop and maintain mutually benefiting relationships. Psychological well-being includes the ability to maintain a sense of autonomy, self-acceptance, personal growth, purpose in life and self esteem. Staying mentally healthy is more than treating or preventing mental illness (Tennant et al., 2007).
When originally introduced, the term ‘mental health’ was intended to be interpreted literally. Its originators were primarily motivated by the wish to promote mental health and tackle any obstacle to this aim (Bertolote, 2008). This article is devoted to an overview of understanding and evidence about mental health and how it can be achieved or sustained within human populations. We focus on the historical, conceptual, policy, population, and intervention evidence underpinning mental health. Historically, the term mental health owes its origins to the mental hygiene movement developed by Clifford Biers in nineteenth-century America (Bertolote, 2008) based on his personal experiences of mental hospital admissions. Its initial purpose was to promote early diagnosis and treatment and humane care for psychiatric patients but notably it expanded to the wider community, policy and government embracing “not a single patient, but a whole community; and it considered each member of that community as an individual whose mental and emotional status was determined by definite causative factors and whose compelling need was for prevention rather than cure.” However, the eventual, gradual and welcome embrace of psychiatry and of mental disorder officially at national and international levels (for example, the World Health Organization) soon adopted the term ‘mental health’ with little more than a side reference to well-being, prevention and promotion Conceptually, it may also be unhelpful to keep apart the terms mental health and mental disorder. The trouble is that people perceive, think and fear, in categories and prefer the language of ‘mental breakdown’ to that of ‘increasing anxiety or depression.’ Evidence suggests that the two represent different ends of a smooth distribution (Melzer et al., 2002). At its very simplest, a depression score that is low or zero can be described as health, but at or above an agreed threshold as disorder. Guidelines on treating depression now advocate a stepped care approach in which investigation and intervention are tailored to severity, chronicity (and risk). This approach can be seen as replacing earlier binary guidance hinging on whether or not a patient meets an all or nothing set of diagnostic criteria, with all resources being devoted to the latter only.
Achieving (or sustaining) mental health thus means avoiding or preventing mental disorder and to do the first arguably could result in the second although this has not yet been shown. This requires an understanding of normal development and of how psychopathology in its different forms unfolds, which we can describe and measure reliably in psychiatry although it is less understood. Any definition must also consider the terms mental health, mental well-being, and mental illness or disorder. But research suggests that mental well-being is not simply part of the mental health disorder continuum. Thus, although similar factors are associated with mental disorder and mental well-being, models that incorporate both together do not suggest that they are equivalent (Weich et al., 2011).
The term mental health is gradually being over shadowed by the term mental well-being (perhaps because well-being appeals to policymakers and politicians and because they have allowed the term mental health to mean absence of mental disorder). Mental well-being is not just the opposite of mental disorder; evidence suggests that both states can coexist in one person or population subgroup. The same factors have also been shown to be associated with both states (Weich et al., 2011). Mental well-being may also be said to be a predictor of and predicted by mental health. Mental well-being can be defined as the positive end of a spectrum that includes the concepts ‘mental health’ and ‘positive mental health’ (Weich et al., 2011). There are two broad (and complementary) traditions in conceptualizing wellbeing: the ‘hedonic ’ and ‘eudaimonic’ approaches. The hedonic approach emphasizes happiness (pleasant affect, life satisfaction) whereas the eudaimonic approach (with origins in Platonic philosophy) emphasizes optimal psychological and social functioning (or ‘flourishing’) (Weich et al., 2011).
Measurement of well-being has often relied on single questions assessing aspects of mental well-being, for example, questions on calmness and energy or on distinct factors derived from measures of mental symptoms, as in the General Health Questionnaire and the mental health component of the Short Form (SF-36 and SF-12) (Ware, 1993), which is also used to measure the related concept of quality of life. Thus components and elements of well-being measures can include mental health symptoms, principally of anxiety and depression, but possibly including somatic symptoms such as sleep problems, pain, fatigue, low drive, sexual functioning disturbances. There may also be positive well-being items like feeling healthy, energetic etc. Well-being measures tend to extend further to social functioning items, possibly activity items (work, leisure, community activities). But purpose designed measures are now being developed, which should foster better research. A significant development in the measurement of mental health and wellbeing outcomes is the Warwick-Edinburgh Mental Well-being Scale (Tennant et al., 2007).
Mental well-being is beginning to be regarded by national governments for its economic importance because higher national income has not brought the better quality of life that many expected (Layard, 2010). Gross Domestic Product and National Accounts measure economic well-being according to an internationally agreed system, but they are increasingly seen as measuring only part of societal well-being. Governments in Europe are, therefore, beginning to monitor trends in well-being. Specific measures have been developed that are used in repeat general population surveys that also keep track of possible determinants of well-being, economic prosperity, education and health outcomes, progress in housing and welfare policies.
Physical and Mental Health
In this section on health, we need to ask is the distinction between mental and physical health valid? There are many indications that such a distinction often should be questioned: the growth of research into the biological including genetic underpinnings of mental disorder as if such disorders were physical; the idea that, for example, taking time off from work for a spell of depression should be viewed as no different than taking time off for back pain, a viral respiratory infection etc.; and the often quoted contemporary health policy statement ‘no health without mental health’ (Prince et al., 2007). It has long been recognized in primary care that mental health problems often present initially as physical complaints. Epidemiologists are increasingly demonstrating that throughout the world physical and mental health are interrelated in research also showing that mental disorders are more likely to be associated with severe disability than are chronic physical conditions (Scott et al., 2009). Interestingly in the last decade depression has overtaken back pain as the number one medical reason for claiming work absence benefits in England.
Mental Disorder and Disorders from a Neurodevelopmental Perspective
If mental health is defined in part as the absence of mental and behavioral disorders it is important to move toward a seamless approach that takes into account phases of development (of psychopathology) across the full life course (Kingdon et al., 2010). Readers new to the subject will notice the puzzling but distinctive difference between current childhood and adulthood classifications of mental and behavioral disorders. Although the same conditions that appear in child classifications, for example, conduct disorder and autism, are recognized in adulthood, in practice they either acquire a different term, for example, antisocial personality disorder, or are rebranded, for example, Asperger syndrome, learning disability. Definitions and defining boundaries also shift making empirical comparison, learning, and understanding more difficult. The problem probably reflects a lack of consensus on what underlies mental and behavioral disorders. A simple biological analogy may assist us, based on the growth of a tree (or any plant).
If genetically abnormal, growth will be stunted although that may not become evident until maturity has been reached. The human analogy, such as intellectual disability or a specific neurodevelopmental disorders such as autism can continue into old age. Disease may impinge at any time in the absence of previous abnormality (for example, conditions that usually present first from puberty onward such as functional psychosis, depression etc.). Damage may also be caused by environmental challenge such as extreme weather (in the human example, adverse life events or long-term difficulties such as debt, prolonged physical and mental abuse). Growth, development, and aging may also be affected by climate, nourishment (analogous to unemployment, isolation caused by racism, stigma, prolonged conflict). In common across these examples is the notion of healthy and interrupted development. Any example, therefore, demands a consideration of prior level of development unless the condition is a clearly recognized example of a late onset disorder such as dementia where prior development has little effect on later outcome. And yet it is unusual for professionals looking at an adult needing an assessment or treatment to devote time and effort to obtaining information about prior growth and development and prior environmental exposure (parenting and other childhood social and learning experiences). The same argument goes for research to be meaningful and to cast a light on complex causal mechanisms that could help maintain mental health and lead to prevention of disorder.
Mental Health and Resilience, Personality, Resources, Social Support Networks, and Relationships, Social Structures and Social Capital
As well as well-being measures extending to social functioning, relationship quality, work, leisure, community activities, there is also ample evidence interconnecting these separate factors with mental health and with individual characteristics, which must form part of any account of mental health (Brugha, 2003). The complexity of such connections can be illustrated by a number of research findings. Anger or irritability, a sign of depression, is often directed at others and must partly explain the isolation that results from depression. An extensive literature connects adverse life events with many different types of mental disorder and probably interacts with temperament and personality (Goodyer, 2002). Associations involving the structure and composition of social relationships, including social network research, has been consistently shown to be important in mental health over many decades of research.
Not all findings are in the expected direction, however. Structural characteristics of communities including the relatively newer concept of social capital, represented by local characteristics such as the way that people contribute to a community, local crime rates etc., have been found to add little if anything to associations with mental health and disorder that include individual, household and family factors (Weich et al., 2003). There is also a disappointing lack of experimental research testing hypotheses linking such social factors to mental health or disorder. There is also the curious observation that interpersonal communication and relationship quality seems to underlie some of the effectiveness of psychological therapies. A recent systematic review of psychological therapy treatment trials concluded that most of the effect of therapy for adult depression is realized by nonspecific factors, with the results suggesting that the contribution of specific effects (cognitive behavioral, psychodynamic etc.) is limited at best (Cuijpers et al., 2012). It is hardly surprising, therefore, if interpersonal relationships (in this example between client and therapist) play a fundamental part in sustaining mental health as well as in defining it.
The Epidemiology of Mental Health and Mental Disorder
While ‘rates’ of mental health have not been specifically addressed in community surveys and studies, there exists an extensive literature on the frequency of mental disorders from which much can be approximately inferred. Earlier, we conceptualized mental health (and disorder) as being a dimensional construct within which it is useful to identify typologies or syndromes and to set thresholds, which expert consensus agrees to recommend as the dividing line between normality and clinically significant psychopathology. An unusual but compelling suggestion has been to describe common mental disorder in the population in terms of mean scores with normal or skewed distributions (Melzer et al., 2002), but most studies focus mainly on the frequency of types of disorders, which seems to appeal to policymakers, with dimensionality or severity receiving relatively less attention (Demyttenaere et al., 2004). The international setting for synthesizing such categorical disease or morbidity frequency information is the Global Burden of Disease study (GBD) (Murray et al., 2012), which ranks neuropsychiatric disorders such as schizophrenia and depression consistently above most physical causes of disability.
So how common is mental health (and or mental disorder) and are rates declining or increasing? The proportion of the child and adult population free of mental disorder has perhaps been most closely represented in estimates of common mental disorder as a dimension or score (Goldberg and Huxley, 1992; Meltzer et al., 1995). These two closely related approaches suggest that between 75 and 84% of the adult population enjoy mental health (or have few if any symptoms of common mental disorder). However, if one goes on to factor in problems associated with drug and alcohol dependency or misuse and lifelong factors such as intellectual disabilities these estimates fall further.
Good news is not exciting and does not grab media attention. No matter how many times good survey designs are repeated, using consistent methodology, seemingly well informed media discussions persist in presuming that rates of disorder in childhood and adulthood are rising. But as the GBD syntheses and high quality UK, Netherlands and US studies have shown rates are largely stable over recent decades (Murray et al., 2012). We do not know why. It is possible that a mix of positive and negative factors have been operating over time to increase and decrease rates. But as mentioned earlier, increased use of treatments for the commoner depressive disorders has not lead to any reduction in rates of these conditions (Brugha et al., 2004; Kessler et al., 2005). This has lead to calls to focus more on prevention because preventive approaches have had a positive impact on other forms of morbidity, globally (Murray et al., 2012).
Interventions to Promote Mental Health and Well-Being – A Research Method Note
Assessment of well-being and mental health outcomes has been considered above. Nonexperimental, observational research, whether to discover (or confirm) social, psychological, and environmental or genetic profiles associated with health states cannot finally determine causality and the means to improve health outcomes. Only experimental research designs involving controlled exposure to interventions can achieve this step forward convincingly, the gold standard experimental design being the randomized controlled trial (RCT). Contrary to expectation, scientific activity devoted to conducting RCTs and the synthesis of the findings of multiple RCTs (systematic reviews) have not ignored well-being and mental health as outcomes of importance and interest. A search for the term ‘wellbeing’ on the world leading Cochrane Collaboration Web site yielded 96 ‘hits’ on well-being (http://www.cochrane.org/search/site/wellbeing) and 243 on ‘well-being.’ Frequently targeted population subgroups were cancer patients, women in labor, the fetus, older children, adults in stressful environments. Just to pick out a couple of specific examples: a completed systematic review of flexible working conditions and their effects on employee health and well-being (the findings of which ‘seem to indicate that flexibility in working patterns, which gives the worker more choice or control is likely to have positive effects on health and well-being’); a protocol under development for a systematic review of organizational interventions for improving well-being and reducing work-related stress in teachers; a completed systematic review of parental training for improving parental psychosocial health.
Mental Health Promotion and Prevention
At the heart of initial thinking on mental health was the idea that mental health is a value and a state to be taken note of, considered and given attention to. This set of values was intended to be applied not just to those who are well (not mentally ill) but also to those with mental disorder including those suffering from its most severe forms. What began as a much needed set of values and principles has not, however, been taken up in the form of scientifically supported evidence development and testing leading to the effective prevention of mental disorders.
Well-being and emotional health is central to the mental health promotion movement. Various activities have been suggested as increasing well-being and mental health including, activity and expressive therapies, meditation, biofeedback, counseling, and psychotherapy.
Selected, Indicated and Universal Prevention
If achieving mental health is substantially about prevention of mental disorder, progress with the latter deserves effort and attention. Gains have been made in two areas: providing resources to families and small children, and identifying adults at high risk of developing mental disorder and providing early intervention similar to psychological treatment. There is some evidence that parenting programs improve parental psychosocial health and child outcomes (Sandler et al., 2011). One of the most promising long term, experimentally designed programs was designed to promote resilience of parentally bereaved children and their bereaved surviving parent (Sandler et al., 2010).
Evidence for the possibility of preventing mental disorders in older children and adults has come mainly from clinical researchers expanding the range of techniques that are effective treatments, such as cognitive behavior therapy (CBT), to a wider range of individuals than those who would normally be treated, such as those at high risk of developing, for example, depression, in the near future (Munoz et al., 2012). Thus there are now several studies showing that children in the final years before leaving school who already exhibit symptoms of depression (but are not clinically depressed) do benefit from CBT approaches applied within schools at a group level. Targeting older school children at high risk of becoming cases of depression with school-based psychological prevention programs seems to be effective (Garber et al., 2009).
Prevention and Policy
Quite appropriately, the global mental health movement has prioritized the narrowing of the gap between the burden of mental disorder and the delivery of care and services particularly in less-developed countries of the world (Prince et al., 2007). When mentioned, it is acknowledged that there is little evidence on which to base prevention but that governments should follow the evidence that exists. But how well would this work? One country has made the prevention of depression in adulthood a matter of national policy, the Netherlands. However, although indicated prevention of depression is available for about 80% of the Dutch population at little or no cost, only a small proportion of those with subthreshold depression make use of these services (Cuijpers et al., 2010). Most ambulatory mental health services have a prevention department serving the local or regional community but only 1% of adults with subthreshold depression access these services, which make use of a group-based depression prevention intervention, ‘Coping with Depression’ (Lewinsohn, 1987) that has been shown to be effective. While, it is important to find ways of persuading more people to consider using these approaches different ways of delivering prevention interventions are needed that overcome possible barriers including stigma, denial, and hopelessness (Cuijpers et al., 2010).
Selected and indicated approaches, for example, targeting high-risk groups face a further limitation: the relatively few who benefit are unlikely to alter significantly population prevalence and thus societal burden. This has lead to the recommendation to position prevention services in primary care or to integrate prevention interventions in communitywide interventions (Cuijpers et al., 2010). RCT-based evidence for prevention, particularly covering the whole population, offers the hope of measurable declines in the prevalence of depression attributable to prevention programs. But universal prevention trials are extremely rare in the mental health field partly because they require the involvement of substantial numbers of participants and are therefore very costly (Munoz et al., 2012). Particular windows of opportunity do exist when people face challenging life transitions and have normal high contact with experienced health professionals, for example, during pregnancy and after childbirth. At such times there is both increased actual or perceived risk and normal access to nonstigmatizing care. Encouraging evidence that such a phased psychological service reorganization, possibly lowering the risk of depression, could be acceptable and feasible comes from a cluster RCT (Morrell et al., 2009). Women who scored positively on a postnatal test for depression were given guided psychological support based on counseling or cognitive behavioral principles provided by their community health visitor (who had undergone additional psychological training). In a secondary analysis of the same RCT (Brugha et al., 2011), postnatal women at 4–6 weeks following childbirth testing negative on the Edinburgh Depression Scale (Cox and Holden, 1994) were less likely to develop later postnatal depression if attended by a health visitor trained to offer the additional psychological support. Development of symptoms of depression was also experimentally shown to be less likely where the health visitor had also evaluated and discussed with the mother her risk of depression 6–8 weeks after childbirth. The same research group has since pilot demonstrated that services for women during pregnancy provided by community midwives can undertake the necessary additional training and follow the same model of treatment and prevention, but large-scale trials are needed to test this promising approach fully.
Primary Care Mental Health
As the previous section shows, primary care is a key setting for understanding and promoting mental health. The same epidemiological surveys mentioned earlier also show that most forms of mental disorder are mild in severity and adults suffering from them are often in contact with primary health care services, rarely engaging with specialized services. While the accent is on the medical model of disorder detection and treatment, primary care physicians increasingly view mental health as they do physical health as a responsibility attached to their role. A sign that not all is as it should be is consistent evidence that a significant proportion of prescribing of psychotropic medication is being taken up by the mentally well part of the population (Brugha et al., 2004; Kessler et al., 2005), which seemed to occur following a period of rapid expansion in prescribing particularly of SSRI antidepressive medication. It is not known if this is a sign that individuals are being prescribed in order to prevent recurrence of previous depressive disorder, or if it is a sign of unnecessary prescribing of preparations that are increasingly known to be effective only for moderate to severe forms of depression, or represents dependency. It may also reflect demand from service users who should be encouraged and supported instead to address possible causes in their lives and to pursue lifestyle activities that are thought to promote well-being, physical and mental health.
The achievement of mental health can be an outcome in its own right but cannot be completely separated from considering mental disorder and its prevention and early treatment. Mental well-being is a term that is increasingly occupying the space originally intended by the term ‘mental health,’ which often is used as a nonstigmatizing term for mental disorder and for psychiatry. Far too little research is devoted to prevention of mental disorders thereby, promoting mental health but there are seeds of promise that need to be nourished.
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