Public mental health and associated opportunities

Public mental health (PMH) takes a whole population approach to sustainably reduce mental disorder and improve mental well-being through the provision of PMH interventions to treat mental disorder, prevent associated impacts, prevent mental disorder from arising, and promote mental well-being. This article outlines important opportunities which PMH offers.

Impacts of mental disorder and well-being

Mental disorder is responsible for at least 16% of disease burden in India and 20% globally[1] although even this underestimates the true impact by at least a third.[2] This is due to a combination of a high prevalence of mental disorder;[3] most lifetime mental disorders arising before adulthood;[4] and a broad range of impacts including higher rates of health risk behaviors such as smoking, physical illness, reduced life expectancy of 7–25 years, suicide, reduced educational and employment outcomes, increased crime and violence, as well as stigma and discrimination.[5] Conversely, mental well-being is associated with reduced rates of mental disorder; suicide; health risk behaviors; heart disease; and mortality as well as improved educational, employment, and social outcomes.[5] Mental disorder and well-being are interrelated so that people with mental disorder are several times more likely to experience poor mental well-being, whereas mental well-being is associated with lower rates of mental disorder.

Risk factors, protective factors, and higher risk groups

Various factors influence mental health. The population impact of any factor depends on both effect size of the factor and proportion affected by it.

Risk factors for mental disorder are particularly important during pregnancy, childhood, and adolescence,[5] given most lifetime mental disorders arise before adulthood.[4] During childhood and adolescence, child adversity accounts for a third of adult mental disorder.[6] During adulthood, other factors increase the risk of mental disorder.[5] Socioeconomic inequalities underpin many risk factors and are, therefore, particularly important.[5,7] Similarly, a range of factors are associated with improved mental well-being.[5]

Risk factors for mental disorder and poor mental well-being cluster in specific groups which are at much higher risk. Examples of such groups include the homeless, offenders, the unemployed, and people with learning disability.[5]

Public mental health interventions

PMH interventions can be divided into mental disorder prevention and mental well-being promotion at primary, secondary, and tertiary levels.[5] At each level, higher risk groups require targeting to prevent widening of inequalities.

Primary mental disorder prevention addresses risk factors to prevent mental disorder from arising including:[5]

• Socioeconomic inequalities

• Perinatal parental issues such as substance use, prematurity, prenatal infection, low birth weight, nutrition, breastfeeding support, and treatment of parental mental disorder which can prevent 40% of offspring mental disorder[8]

• Child adversity, violence, and abuse

• Social isolation, physical inactivity, screen time, insomnia, diet and environmental factors such as pollution, flooding and climatic change

• Child mental disorder at an early stage which prevents subsequent adult mental disorder

• Specific interventions to prevent anxiety, depression, psychosis, substance use disorder, dementia, and suicide.

Secondary mental disorder prevention involves early intervention for mental disorder and associated impacts as soon as they arise. Most mental disorders are preceded by a subthreshold stage, so intervention at this stage can also prevent transition to mental disorder.

Tertiary mental disorder prevention involves implementation of evidence-based treatments for mental disorder, prevention of relapse, and action to both address and prevent associated impacts including health risk behaviors, physical health conditions, socioeconomic problems, housing problems, stigma and discrimination, suicide, violence, and abuse.

Primary mental well-being promotion involves promotion of protective factors for mental well-being. Secondary promotion involves early promotion in those with recent deterioration in mental well-being. Tertiary promotion focuses on those with long-standing poor mental well-being. Interventions to promote mental well-being can also be considered by different stages of the life course, as follows:[5]

• Starting well: Promotion of parental mental and physical health, breastfeeding support, parenting support and education, parenting programs, and family intervention

• Developing well: Preschool and early education programs, school-based mental health promotion programs, after-school programs, and family-based intervention

• Living well: Promotion of social interaction, physical activity promotion, neighborhood and housing interventions, access to green space, arts and creativity, positive psychology interventions, mindfulness and meditation, spiritual and religious interventions, financial interventions

• Working well: Work-based mental health promotion, work-based stress management, and support for people recovering from mental disorder

• Aging well: In addition to living well interventions (above), psychosocial interventions, socialization, reablement, reminiscence, volunteering, and addressing hearing loss.

Resilience mitigates impacts of stress and trauma as well as protecting against mental disorder and poor mental well-being. Resilience can be promoted through school- and work-based interventions.[5]

Many effective PMH interventions also have cost–benefit evaluation and result in net economic savings even in the short term.[5]

Public mental health implementation gap

The population impact of any intervention depends on both its effect size and coverage. However, despite the existence of effective PMH interventions, none are implemented to scale: in England, only a minority of those with mental disorder receive any treatment,[5] with treatment coverage far less in low- and middle-income countries (LMICs).[9] Coverage of interventions to prevent associated impacts is far less than treatment, whereas coverage to prevent mental disorder from arising or promote mental well-being is negligible. This implementation failure results in population-scale preventable suffering to individuals and families as well as broad impacts and associated costs across different sectors.

Reasons for the implementation gap include lack of:[5]

• PMH knowledge and training including for professionals and trainees in health, public health, and policy

• Information about size, impact, and cost of PMH unmet needs at local and national levels

• Information about estimated impacts and associated economic benefits of improved coverage at national level to inform transparent decisions about acceptable coverage and required resource

• Appropriate policy targets to reflect required coverage

• Appropriate resource to address the implementation gap[5,9] associated with lack of political will and/or understanding by those who allocate resources.

Improving coverage of public mental health interventions

Coverage of PMH interventions can be improved in several ways.

Assessment of population need

Assessment of population need at national and local levels informs providers, planners, and policymakers about the levels of mental disorder and well-being, risk and protective factors, higher risk groups, coverage and outcomes of different PMH interventions, size and cost of the PMH intervention gap, and estimated impact and economic benefits from improved coverage.[5,10]

Public mental health practice

This involves:[5]

1. Assessment of size, impact, and cost of unmet PMH needs as well as impact and associated economic benefits from improved coverage

2. Use of this information to inform mental health strategy and policy development to address unmet needs, planning, interagency coordination, and wider advocacy

3. Implementation of PMH interventions

4. Evaluation of coverage and outcomes including for higher-risk groups.

Provision of appropriate resource

National assessment informs transparent agreement about acceptable national coverage levels of different PMH interventions and required resource to support local implementation.[5,10,11]

Appropriate workforce capacity

Delivery of interventions requires appropriate numbers of trained workforce across different sectors, which is informed by the needs assessment. Training includes impacts of mental disorder and well-being, risk and protective factors, PMH interventions, size and impact of the PMH intervention gap, impact and associated economic benefits of improved intervention coverage, mental health needs assessment and its use to inform policy and commissioning at national and local levels, implementation, and evaluation. Training should be directed to both professionals and trainees in primary care, secondary mental healthcare, public health, social care, criminal justice, and planning, as well as local and national policy.

Setting-based and integrated approaches

Setting-based approaches can support improved coverage of different PMH interventions. Examples of settings accessed by large proportions of the population or particular groups include antenatal and postnatal settings, preschools, schools, workplaces and neighborhoods. Integrated approaches across sectors at both national and local levels facilitate coordinated delivery of PMH interventions.

Use of digital technology

Good evidence exists for the effectiveness of the internet and mobile phones to improve the coverage of PMH interventions including in LMICs.[5]

Maximizing existing resources

Examples include self-help, task shifting, improving concordance with treatment, less intense intervention, and use of traditional healers.

Particular interventions

Socioeconomic inequality underpins many other risk factors for mental disorder.[5,7] Therefore, national strategies to reduce inequalities are important[12] and include appropriate fiscal policy such as taxation which can impact across a large proportion of the population including those at higher risk of mental disorder and poor mental wellbeing. Other interventions with particularly large impacts if implemented to scale include parenting programs, addressing parental mental disorder which could prevent 40% of offspring mental disorder,[8] addressing child adversity responsible for almost a third of adult mental disorder[5,6] and physical activity promotion.

Legislation, regulation, and a human rights approach

Various legislation exists to support the implementation of PMH interventions.[5] Regulation can reduce the availability of alcohol and smoking. A rights approach to health also applies to PMH interventions and is supported by the United Nations.[13]

The World Psychiatric Association has highlighted the importance of PMH[14] and recommended such a population approach to reduce mental disorder and promote mental health including in its 2021–2023 Action Plan.

CONCLUSION

Mental disorder accounts for a large proportion of disease burden due to high prevalence, most mental disorders arising before adulthood, and broad impacts across the life course, with mental well-being having similarly broad impacts. Effective PMH interventions exist to prevent mental disorder and promote mental well-being at primary, secondary, and tertiary levels. However, population coverage of these interventions is poor, resulting in large-scale suffering, impacts, and associated economic costs. A range of opportunities exist to improve PMH intervention coverage: An important first step includes assessment of level of unmet need and impact of improved coverage which informs mental health strategy and policy, transparent agreement about acceptable national coverage of PMH interventions, associated required resource including workforce and training, implementation, and interagency coordination. Other opportunities include setting-based and integrated approaches; use of digital technology; maximizing existing resources; use of legislation; adopting a human rights approach to mental health; and implementing particular interventions such as addressing socioeconomic inequalities, child adversity, and parental mental disorder, as well as parenting programs and physical activity promotion. The subsequent increased coverage of PMH interventions results in a broad set of improved outcomes and associated economic benefits.