The effectiveness of public mental health policies: stressing the return on investment

In recent years, public mental health has become an essential part of mental health, as convincingly pointed out in the paper by K. Wahlbeck (1). Public mental health is conceived as a theoretical framework, as an academic field or medical discipline, or as an integral part of health service provision. This conceptual flexibility contributes both to the strengths and to the weaknesses of the public mental health approach.

Although developments have been made in recent years, a feasible definition of “public mental health” and its major aspects such as mental health promotion is still lacking. This might be due to the comparatively short history of the concept, but it seriously limits its strategic power. In part as a consequence of this, evidence for the potential social capital impact of public mental health policies is not strong.

So, despite the progress outlined in Wahlbeck's paper, many countries currently seem much more willing to acknowledge public mental health as a theoretical concept or framework than to apply specific features of it into routine mental health care or other societal sectors. Among others, the social welfare and educational systems, the labor market and administration, and the criminal justice sector may benefit in the long run, if public health mental health policies are seriously and thoroughly implemented.

Enlarging the evidence base about the benefits of public mental health policies meets serious methodological challenges. For solid findings, research activities should assess determinants and effects across sector boundaries. When doing so, many and often widely fragmented services, agencies or institutions have to be included and analyzed simultaneously with similar and standardized methods.

This is a well-known challenge to community mental health care and services research. The fragmentation of psychiatric services and their separation from sectors such as the social welfare or the labor administration afflict many mental health care systems. The cost of under-, double- or over-provision caused by this phenomenon is estimated as high. Many strategies are being developed and efforts are being made to address the negative consequences of fragmentation, such as treatment discontinuation or marginalization and neglect of specific risk groups. These efforts, however, are often themselves costly or have only limited effects.

Public mental health activities might be seen as accelerating or multiplying the efforts against the detrimental effects of service or sector fragmentation. However, this has to be clearly demonstrated. Analyzing effects across societal sectors usually requires complex research designs, time and patience – in other words, a lot of funding for long-term and inter-sector studies. Additionally, such studies must communicate their findings in a language likely to be understood by decision makers. In order to raise awareness and convince politicians or agencies, any beneficial outcome of public mental health policies should be translated into economic terms or expressed in financial values. In principle, adapted economic methods for measuring extra-financial value across societal sectors are available, such as the social return on investment approach (2). However, these methods are not applied broadly enough in public mental health (3).

Innovative steps may help to address this problem. New directions in neurosciences are highlighting the detrimental effects of urbanicity or urban upbringing on neural stress processing (4,5). If confirmed in larger samples, such findings may have far reaching public mental health consequences. If so, it might be rather shortsighted not to model population health effects and economic impacts as a component of studies that are focusing on such associations.

If this becomes an agreed research agenda, public mental health could get access to and participate in the budgets spent for research in neurosciences. Both allies might benefit from the collaboration. Usually it takes decades until neuroscience findings are translated into interventions or policies ready for being marketed or implemented into routine care. This process might be significantly accelerated by the above collaboration, as the development of interventions and policies is public mental health's core business.

Societies all over the world should be receptive to this multifaceted integrative potential of public mental health.