The Need For Mental Health Promotion: Helen Herrman
The Need For Mental Health Promotion: Helen Herrman
The Need For Mental Health Promotion: Helen Herrman
Helen Herrman
Objective: To examine the concept and evidence for mental health promotion, within an
understanding of mental health and mental illness and their determinants.
Method: A selective review of literature and opinion in the fields of public health and mental
health.
Results: Mental health and mental illness are often given a low priority, despite growing
evidence of the burden of disease and costs to the economy. Improving mental health and
reducing mental illness will improve quality of life, public health and productivity. The needs
for mental health promotion are complementary to the needs for prevention and treatment
of mental illness. The required activities are different. Mental health professionals have a
necessary but not sufficient role in mental health promotion.
Conclusions: An understanding that mental illnesses are treatable can encourage early
entry to care, improve outcomes and lessen the stigma and discrimination related to mental
illness. In primary health care there is some evidence that preventive interventions with
groups at high risk of depression can prevent episodes of ill health. However, mental health
promotion involves another dimension. Better understanding of the nature of mental health
and mental illness is the key to changing the priorities, policies and practices in education,
law, social services, housing and health critical in turn to the conditions conducive to mental
health.
Key words: epidemiology, mental health promotion, prevention of mental illness, suicide.
A balanced approach to promoting mental health, on understanding the needs for mental health promotion
preventing mental illness and treating those affected is and the prevention and treatment of mental illnesses. The
recommended by experts and governments in a number final sections consider the complementary activities of
of countries [1–3]. However, in most communities the promotion, prevention and treatment, some of the con-
value of mental health and how to promote it are poorly troversies and dilemmas that prevail, and the required
understood. On the other hand, mental illness is stigma- next steps.
tized, and often believed to be untreatable. Prevention of
mental illness is regarded as unlikely, and mental health The message from epidemiology
promotion has been hampered by the diffuse nature of I: high prevalence, disability and costs
the proposed action [4,5].
The present paper begins by noting the effects of
Until now, the priority assigned to mental illness and
mental illnesses on communities and individuals, and
mental health on the international public health agenda
then discusses the concepts of mental illness and mental
is, by any criterion, vanishingly small. In relation to the
health. These ideas in themselves have a strong influence
staggering toll of disability resulting from mental and
behavioural pathology, so low a priority is simply per-
Helen Herrman, Professor and Director of Psychiatry verse. Why does mental illness fare so badly? [6 p.142].
The University of Melbourne, Department of Psychiatry, St Vincent’s
Mental Health Service, 41 Victoria Parade, Fitzroy, Victoria 3065,
There are several reasons. The first relates to the
Australia. Email: [email protected] stigma and poor understanding of mental health and
Received 7 March 2001; revised 30 May 2001; accepted 6 June 2001. illness. Another relates to health statistics. Death rates
710 THE NEED FOR MENTAL HEALTH PROMOTION
greatly underestimate the disease burden resulting from The message from epidemiology
mental illnesses. In recent years the World Bank, in II: variations with time, place and person
cooperation with the World Health Organization, dev-
eloped a new index to measure total health burden: Social and environmental conditions, and particularly
disability adjusted life years (DALYs). This statistic relative social disadvantage [11], have significant effects
summarizes the ill health, disability and loss of life from on mental health and illness. People from poor socio-
identifiable diseases into a single numerical measure. economic backgrounds, those who are unemployed and
Although still imperfect, it gives a much more realistic those who live alone experience poorer health and well-
measure of the relative level of health burden attributed being than those in other groups. There are major decre-
to mental illness [6]. According to these measures, the ments in social and emotional well-being in many
burden of mental illnesses constitutes 10% of the global immigrant and indigenous communities. This is linked
burden of disease. Depression will be one of the largest to loss of land, family and identity, and to poor general
health problems worldwide by the year 2020. Problems health.
of mental health are a major and increasing threat to the Stressful life events influence the onset and outcome
quality of life, to the economy, and to public health of illnesses of various types. Major life events can, for
throughout the world [2]. instance, provoke a depressive illness and the risk of
The National Survey of Mental Health and Wellbeing in their doing so is increased by the presence of underlying
Australia has results comparable with other major surveys vulnerability factors, including deficiencies in family
in recent years, indicating that during 1 year, almost one and social support. On the other hand, social ties and
in five (18%) people in the community has a diagnosable support can have protective effects. Preventive strategies
form of mental illness at some time [7]. Young adults can usefully aim at reducing vulnerability in persons at
aged 18–24 years have the highest prevalence (27%). For increased risk for depression by strengthening their
young men the major problem is substance abuse, and for social networks [12].
young women it is anxiety and depression. Three per cent Although schizophrenia and related disorders are not
have a critically disabling mental illness, such as schizo- ‘social diseases’, social and cultural factors including the
phrenia, manic-depression, severe depression, severe opportunity to work and others’ expectations strongly
anxiety and drug dependence; 5% have chronic and dis- influence the course of the disorder and the likelihood of
abling mental illnesses such as depression, anxiety, and recovery [11,13]. Early intervention is likely to have an
substance use. Significant disorders occur in childhood important influence on recovery and course of the dis-
and adolescence and may continue to adulthood, whereas order [14].
many adult disorders begin in adolescent years.
People living with severe mental illnesses are among Improving mental health
the most disadvantaged people in any community. The
physical and emotional consequences of illness affect Health can be defined as a state of balance that individ-
their ability to function in family, social and vocational uals establish within themselves and with their environ-
realms, and they experience discrimination in many ment [15]. It is the product of a number of interrelated
aspects of life [8]. The complications include family dis- dimensions, including mental, physical, emotional,
ruption, substance abuse, suicide, illness and premature social, cultural and spiritual dimensions. Mental health is
death from other causes, unemployment, poverty, social included within this definition: the ability of people to
isolation and homelessness. Many of these critical out- think and learn, and the ability to understand and live
comes can be avoided with early recognition and treat- with their own emotions and the reactions of others.
ment, or with appropriate and sustained support for The activities that can improve health include the pre-
people and families living with long-term illness [9]. vention of disease, impairment and disability, the treat-
However, most people with potentially remediable dis- ment of diseases and the promotion of health. These are
orders are not treated [10]. There is a continuing failure quite different from one another. The promotion of health
to recognize and treat mental illness, particularly anxiety requires changing the place that health has on the scale of
and depression, in people attending general practitioners values of individuals, families and societies. The methods
or general hospitals. Approximately 20% of these of health promotion are different from those used to
patients suffer from a well-defined mental illness, often prevent or treat mental illness, and from those used to
associated with a physical illness; in a high proportion rehabilitate people disabled by mental illness [15].
this is chronic with substantial disability and increased These are all required, are complementary, and cannot
use of health care. The cost to the community may be be substituted for one another. It is not enough to rely on
calculated in several ways, but it is very high. treatment. This is just as true for mental as for physical
H. HERRMAN 711
disorders. However, confusion about the concepts of mental illness, confusion and vagueness about the con-
mental illness and mental health have influenced the cept are powerful reasons for the low priority given to
development of programs and the availability of mental health programmes, and the difficulty in mobi-
resources in each of these domains. lizing all those concerned with supporting an overall
strategy. The barriers include the belief that either
Concepts of mental illness and mental health mental or physical health can exist alone. Health
includes mental, physical and social functioning, which
People with mental illness are often considered to be are interdependent. Likewise, mental and physical ill-
identifiable and different from the rest of the population. nesses do not exist on their own. Mental illness can
Yet the term mental illness means different things to dif- accompany, follow, or precede physical disorder. The
ferent people. Confusion about the term has been a power- second major barrier is the belief that health and illness
ful reason for the low priority given to mental illness [16], are mutually exclusive. They are mutually exclusive
and scepticism about the capacity to treat or prevent it. only if health is defined in a restrictive way as the
Two potent sources of confusion about the idea of absence of disease. Defining health as a state of balance
mental illness exist in the public mind. First, mental between the self, others and the environment changes
illness has to be distinguished from other causes of the thinking.
social deviance also involving distress and abnormal
behaviour [17]. Mental illness, eccentricity and badness Mental health promotion and prevention of
are different in meaning. Some individuals may be mental illness
labelled with more than one of these terms, but it is vital
to keep these terms separate. If mentally ill people are The World Health Organization defines health promo-
seen as ill rather than as eccentric or bad, it is easier to tion as action and advocacy to address the full range of
seek ways of providing them with appropriate services, potentially modifiable determinants of health [21]. These
and to seek approaches to prevention and mental health determinants include not only those related to the action of
promotion [16]. A second source of confusion is the individuals, such as behaviours and lifestyles, but also
tendency to ‘overlook the highly specific dysfunctions factors such as income and social status, education,
because of their kinship with common misery and crises’ employment and working conditions, access to appropri-
[18]. The illnesses of depression and anxiety for instance ate health services, and the physical environment. Health
often have a quality difficult or impossible for those suf- promotion and prevention are necessarily related and
fering the ‘common misery’ to understand. overlapping activities. Because the former is concerned
The treatment of mental illness has historically been with the determinants of health and the latter focuses on
alienated from the rest of medicine and health care. In the causes of disease, promotion is sometimes used as an
the isolated setting of the asylums, practitioners saw umbrella concept covering also the more specific activities
many seemingly incurable patients. The supposed incur- of prevention [2].
ability of insanity and melancholy made practitioners A strong body of evidence identifies the personal,
believe the causes were entirely biological. The idea has social and environmental factors promoting mental
since persisted that prevention of mental illness is ‘all or health and protecting against ill health [1,2,22,23]. These
none’. The psychoanalytic and psychotherapeutic prac- factors may be clustered conceptually around three
tice that flourished outside the asylums from the middle themes [1,2]:
of the last century concentrated on processes within the 1. The development and maintenance of healthy com-
individual. There was a similar lack of focus on illness as munities, which then provide a safe and secure environ-
‘a product of an ecosystem’ [19]. ment, good housing, positive educational experiences,
The fundamental concept of disease as multifactorial employment and good working conditions, a supportive
in origin is the basis for preventive medicine. Mental political infrastructure, minimize conflict and violence,
illness has generally been excluded from this framework. allow self-determination and control of one’s life, and
However, psychiatric treatment services have changed provide community validation, social support, positive
greatly over the last 50 years. Most treatment and care role models, and the basic needs of food, warmth and
now occur outside large institutions. The expectation is shelter.
that treatment and care in the community will foster 2. Each person’s ability to deal with the social world
approaches to the problems of mental illness similar to through skills such as participating, tolerating diversity
those of other illnesses [20]. and mutual responsibility; associated with positive expe-
Turning to mental health, there are a number of bar- riences of early bonding, attachment, relationships, com-
riers to understanding and definition [16]. Just as with munication and feelings of acceptance.
712 THE NEED FOR MENTAL HEALTH PROMOTION
3. Each person’s ability to deal with thoughts and feel- ‘Mainstreaming’ mental health promotion
ings, the management of life and emotional resilience;
associated with physical health, self esteem, ability to The activities of mental health promotion may usefully
manage conflict and the ability to learn. be ‘mainstreamed’ with health promotion, although the
The fostering of these individual, social and environ- advocacy needs to remain distinct. Many of these activi-
mental qualities, and the avoidance of the converse, are ties as mentioned previously will also promote physical
the objectives of mental health promotion and preven- health, and physical and mental health are closely asso-
tion. As an example, the Victorian Health Promotion ciated. Physical health is an important influence on
Foundation [24] has defined three broad themes for mental health. Conversely, the importance of mental
action after a review of expert opinion and the evidence health in the maintenance of good physical health and in
linking mental and physical health to each other and to the recovery from physical illness is now well substanti-
aspects of social connectedness, discrimination and ated. Mental health status is associated with risk behav-
violence, and economic participation. iours at all stages of the life cycle. For instance, in young
These activities of mental health promotion are mainly people, depression and low self-esteem are linked with
sociopolitical: reducing unemployment, improving smoking, binge drinking, eating disorders and unsafe sex
schooling and housing, working to reduce stigma and [27]. Depression in older people is linked with social iso-
discrimination of various types, and wearing seat belts to lation, alcohol and drug abuse and smoking [28], and
avoid head injury. The key agents are politicians and poor physical and role functioning [29]. Mental health
educators, and members of non-government organiza- status is a key issue for changing the health status of the
tions. The job of mental health professionals is to remind community.
them of the evidence for the importance of these key
variables [25]. Dilemmas and controversies
Prevention of illness is sometimes categorized by
stages of intervention in an assumed causal chain: Universal or indicated (‘high risk’) strategies or both
primary (to prevent onset of illness), secondary (to
reduce the duration and associated disability by early Screening, or the pursuit of earlier diagnosis, and treat-
treatment) or tertiary (to reduce sequelae). When causal ing defined high risk groups, are two strategies used in
pathways can be identified, as in some cases of depres- several areas of health care. These strategies are impor-
sion, this concept is useful in prevention of mental tant in preventing and treating a number of defined dis-
illness. orders such as breast cancer and depression. In primary
Another approach to health promotion categorizes health care, for example, preventive interventions are
interventions according to the levels of risk of illness likely to be effective with groups at high risk of depres-
or scope for health promotion, in various population sion, such as the bereaved [30], mothers with a previous
groups, and makes it clearer what type of collective episode of postnatal depression, and those who drink
action is required: universal (directed to the whole pop- harmful levels of alcohol [25]. Counselling, education
ulation, e.g., good prenatal care), selected (targeted to and support by members of the health and social service
subgroups of the population with risks significantly teams can be crucial in preventing episodes of ill-health.
above average, e.g., family support for young, poor, However, these strategies will have little effect on pro-
first pregnancy mothers) or indicated (targeted at high- moting population health or in lowering rates of illness
risk individuals with minimal but detectable symp- in the population, because of our limited ability to
toms, e.g., screening and early treatment for symptoms predict which individuals will become sick. Risk factors
of depression and dementia) [26]. This second may identify a group with a much increased relative risk,
approach emphasizes the capacity to act despite the but most high-risk individuals are likely to remain well
conundrum that: (i) the evidence for direct causal path- and most clinical cases occur in those who were not at
ways is generally strongest for the most immediate conspicuous risk: ‘a large number of people exposed to a
influences; (ii) most illnesses have multiple causes small risk commonly generate many more cases than a
interacting in a ‘vicious spiral’ over time [11]; and (iii) small number exposed to a high risk’ [31 p.554]. Rose
important factors such as child abuse and neglect may bases this important point on the understanding that, in
influence the later occurrence of several types of all fields, disease and normality are part of a continuum,
illness, and the level of well-being in later life. Other and not separate entitites.
life events and circumstances will interact favourably This reasoning is particularly relevant when consider-
or unfavourably to contribute to resilience or the devel- ing strategies to lower the rates of suicide in a popula-
opment of illness. tion [32,33]. For instance, detection and treatment of
H. HERRMAN 713
depression in primary care will be important in saving projects to demonstrate long-term changes in ill-health,
a number of people from death by suicide, as mental death from suicide, or quality of life is often unrealistic
illness is a major risk for suicide. However, most people and unnecessary. What is required instead is: (i) a mar-
who become depressed will not die in this way. Reducing shalling of the evidence linking mental health with its
rates of suicide is more likely to be achieved using uni- critical determinants (aetiological research); and (ii) pro-
versal population-based strategies [34]. Reducing the gram design and evaluation to demonstrate changes in
availability of methods commonly used for suicide is the the same determining or mediating variables. Programs
most practical current policy. Wider approaches depend and policies can aspire, in other words, to produce
on the epidemiological evidence of a strong association changes in indicators of economic participation, levels
over time in different parts of the world between suicide of discrimination, or social connectedness. Identifying
and social conditions, including the rate of unemploy- and documenting the mental health benefits of these
ment. A reduction in suicide rates is likely to result from changes, and developing indicators of these determi-
universal or population-level actions. Examples are social nants, are complementary areas of work needing further
interventions that are effective in improving mental support [24].
health among unemployed people; altering school envi- Support for research and evaluation of programs in
ronments in ways shown to avert the antecedents of these areas is disproportionately low. An evidence base
suicide (depression, harmful drinking and deliberate self- for mental health promotion does exist but it needs
harm); and parenting support effective in reducing the boosting with aetiological research and program evalua-
chances of domestic violence and abuse, and improving tion. Promising areas include the sources of well-being
the nurturing of children. and resilience in the face of adversity, the modifying
These interventions have a further relevance. Not only factors in the course of various types of illnesses and dis-
do most clinical cases occur in low-risk individuals, but abilities, and the relationship between mental health
also subclinical degrees of abnormality generate much status and other illnesses and risky behaviours [16,23].
morbidity. As much as three-quarters of depression- The development of quality-of-life measures encourages
related social disability may arise in those whose scores health-care providers to consider the views of con-
on a depression inventory fall below the accepted thresh- sumers, and to consider domains wider than symptoms
old for a case [31]. and disability as the concerns of health care [35,36].
Projects assessing the utility and cost-effectiveness of
Bolting the stable door . . . specific programs for families or schools or workplaces
require support over a long lead time. A project deter-
The harm done to children by physical and sexual mining the staff and training requirements of successful
abuse presents a sad dilemma [25]. The evidence is now community care [37] will require information-gathering
strong that child abuse and neglect are powerful risk and cooperation across several areas and service sectors.
factors for a number of psychiatric disorders, including An example of an integrated program of research and
substance abuse, and for adult homelessness. A defini- health promotion concerning family caregivers was
tive understanding of the mechanisms through which sponsored by the Victorian Health Promotion Founda-
these risk factors operate awaits further research. Inter- tion. The results suggest a number of ways to support
ventions (such as teaching parenting in secondary schools, caregivers with the aim of improving well-being and pre-
and supporting families) that can reduce the occurrence venting ill health [38].
of child abuse and neglect may ultimately yield a large
dividend by preventing social and mental health problems. Most players are necessary and not sufficient
However, most efforts are now in the form of tertiary pre-
vention by social workers in child protection services. Mental health practitioners will often underestimate the
scope of mental health promotion or prevention of mental
Increasing the evidence base: program evaluation illness because of the clinical focus that is their business.
and aetiological research Those who see the importance of these activities feel
daunted by the task. Politicians and educators may not
Mental health promotion has been seen to ask for understand the effects of their work on mental health, nor
peace, social justice, decent housing, education, and have access to relevant information, or equally likely,
employment. The call for intersectoral action has some- have to set priorities which exclude health promoting
times been diffuse [32]. Specific evidence-based propos- measures. Once the community grasps the relationship
als that can be expected to produce measurable outcomes between social conditions and mental health, politicians
are required. However, asking individual health promotion and educators will be able and encouraged to act.
714 THE NEED FOR MENTAL HEALTH PROMOTION