World Health Organisation Collaborating Centre for Health Promotion Research National University of Ireland, Galway Ol

1. Promoting Mental Health and Wellbeing: Concepts, Practice and Policy Professor Margaret Barry World Health Organisation Collaborating Centre for Health Promotion Research National University of Ireland, Galway Ollscoil na hÉireann, Gaillimh

2. Overview • Concepts of positive mental health and wellbeing • Adopting a mental health promotion approach generic principles of practice • Addressing the determinants of mental health implications for research, practice and policy M. Barry, January 2011

3. Concepts of mental health • Concepts of mental health vary as a function of time, place, culture and context • changing and competing perspectives concerning the nature of mental health and ill-health • Mental health has been conceived as a medical, psychological and sociological phenomenon - disease entity approach - normality and abnormality; ‘ideal self’ - social construct - ‘deviance’ and social causation - impact of poverty, social position, poor housing, unemployment, social stressors • The merging of perspectives - biopsychosocial model M. Barry, January 2011

4. Concepts of mental health • Relationship between mental health and mental disorder continuum or separate entities? • Population approach - continuous distribution of mental health and mental disorder across the population • Mental health is fundamental to good health and quality of life ‘complete physical, mental and social well-being’ ‘a resource for everyday life which enables us to manage our lives successfully’ • Mental health as an integral part of health and wellbeing (Lancet series on Global Mental Health 2007) M. Barry, January 2011

5. Current definitions of mental healthmore than the absence of mental illness • Mental health may be defined as; • “a state of emotional and social well-being in which the individual realises his or her own abilities, can manage the normal stresses of life, can work effectively, and is able to play a role in his or her community” (WHO, 1999) “The capacity of the individual, the group, and the environment to interact in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective, and relational), the achievement of individual and collective goals consistent with justice; and, the attainment and preservation of conditions of fundamental equality” (Striking a Balance, Epp, 1988) M. Barry, January 2011

6. Aspects of wellbeing • Emotional wellbeing - affect/feeling • Psychological wellbeing - positive functioning • Spiritual wellbeing - meaning and purpose in life • Physical wellbeing - physical health and fitness • Social wellbeing - relations with others and society M. Barry, January 2011

7. Concepts of mental health • Emergence of positive psychology - ‘the scientific study of the strengths and virtues that enable individuals and communities to thrive’ (Positive Psychology Centre, University of Pennsylvania, 2007) • optimism, love, emotional intelligence, hope, wisdom, creativity and humour • focus on happiness- positive emotion, engagement and meaning • Cowen’s concept of ‘wellness’ – resilience, competence, social change and empowerment • Overlaps with the wider population health and ‘wellbeing’ agenda • social and economic prosperity will depend on improving mental health and wellbeing • rethinking of public policy M. Barry, January 2011

8. Mental health and wellbeing • Mental Health Action Plan for Europe (WHO, 2005) • ‘mental health is an essential component of social cohesion, productivity and peace and stability in the living environment, contributing to social capital and economic development in societies” • UK Foresight Project on Mental Capital and Wellbeing (2008) “ A key message is that if we are to prosper and thrive in our changing society and in an increasingly connected and competitive world, both our mental and material resources will be vital. Encouraging and enabling everyone to realise their potential throughout their lives will be crucial for our future prosperity and wellbeing” (www.foresight.gov.uk) M. Barry, January 2011

9. Economics of happiness and wellbeing • Richard Layard (2005)- ‘Happiness: Lessons from a New Science?’ income and happiness - no direct correlation - ‘hedonic treadmill’ • Economic growth produces many unwanted side-effects - diminishing returns (Sustainable Development Commission, 2003) • Rethinking economic policy - how the economy affects our well-being is the object of public policy maximising economic growth or the sum of human wellbeing? M. Barry, January 2011

10. A policy focus on wellbeing • New Economics Foundation - A Well-being Manifesto for a Flourishing Society “What would politics look like if promoting people’s well-being was one of the government’s main aims?” • Integration of social, economic and ecological policies M. Barry, January 2011

11. Measure what matters - set of national well-being audits Well-being economy - employment, meaningful work and environmental taxation Reclaim our time Education system that promotes flourishing Health service that promotes complete health Invest in the early years and parenting Discourage materialism and promote authentic advertising Strengthen active citizenship social well-being and civil society A policy focus on wellbeing M. Barry, January 2011

12. Adopting a mental health promotion approach • A socio-ecological model of mental health • Mental health promotion concepts are positive, dynamic and empowering - focus on enhancing the strengths and competencies of individuals, communities and society • Multidisciplinary - theories and methods • Builds on the basic concepts and principles of health promotion • Where mental health is created - contexts and settings M. Barry, January 2011

13. Assessment Evaluation Planning Implementation Health Promotion action areas Build healthy public policy Create supportive environments Reorient health services Strengthen community action Develop personal skill combined into Health Promotion strategies Systems Policies environmentorganisationcommunityperson Systems scale Health PromotionModel (WHO Ottawa Charter) The process of enabling people to increase control over their health and the determinants of health micro - macro Health Promotion Principles(participation, empowerment, equity) M. Barry, January 2011

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15. Generic principles of effective mental health promotion • Adopt a socio-ecological approach - bring about change at the level of the individual, family, group/community and broader society • Adopt a competence enhancement approach - resourcefulness and competence • Implementation approach that is empowering, collaborative and participatory • Adopt a comprehensive approach - integrated strategies • Address social inequity - multi-sectoral initiatives tackling sources of disadvantage and inequalities • Theory base, research principles of efficacy, needs assessment and high quality implementation M. Barry, January 2011

16. Standard treatment for known disorders Case identification Indicated Compliance with long-term treatment Selective After-care (including rehabilitation) Strategies for promoting well-being & quality of life Universal Competence Empowerment Resilience Supportive Environments M. Barry, January 2011 Barry, M.M. (2001) International Journal of Mental Health Promotion, 3(1) 25-34.

17. Concepts of positive mental health • Conceptualisations of positive mental health (Keyes, 2002; Huppert, 2005; Ryff et al., 2006) • Hedonic - subjective well-being and life satisfaction • Eudaimonic - positive functioning, engagement, fulfilment and social well-being • Keyes’ concept of optimal mental health or ‘flourishing’ M. Barry, January 2011

18. Concepts of positive mental health • Measuring positive mental health - more than the absence of mental ill-health (Kovess-Masfety et al., 2005) • Sense of Coherence scale (Antonovsky, 1993) • Affectometer 2 scale (Kammann & Flett, 1983) • Energy and Vitality Index (SF-36) • Keyes (2002, 2005) -suite of measures • WHO Wellbeing Index (2004) • Warwick Edinburgh Mental Wellbeing scale (Tennant et al., 2006) • Wellbeing Indicators at country level - National Accounts of Well-being (New Economics Foundation, 2008) - ‘measure and act on well-being within the broader context of societal and environmental stability’ M. Barry, January 2011

19. Determinants of mental health • Healthy structures - economic, political, social and cultural framework for developing and maintaining positive mental health • Citizenship - social support, sense of social integration and inclusion • Emotional resilience - self-esteem, coping , life skills, sense of control M. Barry, January 2011

20. Determinants of positive mental health • Barry and Friedli (2008) - review of the determinants of positive mental health for the UK Government’s Foresight Project on Mental Capital and Wellbeing • Existing evidence is drawn from epidemiological studies of mental disorders and intervention studies • Few studies have focused on analysing the determinants of positive mental health among whole populations M. Barry, January 2011

21. Findings from European studies • Eurobarometer study (Lehtinen et al., 2005) • 2002 survey of 10, 878 people over 15 years across 11 European countries using the recommended set of mental health indicators for the European Union (1999-2001) • Energy & Vitality Index (SF-36) - measure of positive mental health • Positive mental health was higher for those with higher levels of social support • Gender and social and economic factors • Lowest income quartile had the poorest mental health status in all countries M. Barry, January 2011

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23. Findings from SLÁN 2007 study (Barry et al., 2009) • Mental health and social wellbeing of 10, 364 Irish adults • Positive and negative mental heath as part of the national health survey • Lower levels of loneliness and higher levels of social support are associated with positive mental health • Gender and social and economic factors • Markers of social advantage - higher income, employed, higher education - associated with better mental health M. Barry, January 2011

24. Positive Mental Health M. Barry, January 2011

25. Psychological Distress M. Barry, January 2011

26. Psychological Distress and Energy and Vitality by Income M. Barry, January 2011

27. Psychological Distress and Energy and Vitality by Social Support M. Barry, January 2011

28. Flourishing by Health Behaviour M. Barry, January 2011

29. Psychological Distress by Health Behaviour M. Barry, January 2011

30. Determinants of mental health and wellbeing • Dolan et al., 2006 - review of causative factors associated with subjective wellbeing (analysis of British Household Panel Survey) • Identified relationships and neighbourhood social contact, income, health, and employment as being positively associated with mental health and well-being • direction of causality • within group variance • distribution across different population sub-groups M. Barry, January 2011

31. Addressing the determinants of mental health • Markers of social disadvantage are all associated with poorer mental health • Association between mental health, social wellbeing and physical health • Promoting mental health is central to population health and wellbeing M. Barry, January 2011

32. Addressing the determinants of mental health • Strengthening individuals - cognitive and emotional resources, identity, social relationships, life skills • Social networks - social support, exchange, sense of social belonging and inclusion • Community level - civic engagement, leisure, membership of clubs etc., volunteering, neighbourhoods, physical environment • Societal level - role in wider society, work, citizenship, democratic participation • Access to resources and opportunities • supportive relationships, education, employment, opportunities for social inclusion • Multilevel action M. Barry, January 2011

33. Effectiveness of mental health promotion • Growing international evidence base on the effectiveness of mental health promotion practice (Hosman & Jané-Llopis, 1999; WHO, 2004; Jané-Llopis et al., 2005; Herrman et al., 2005; Keleher & Armstrong, 2005; Barry & Jenkins, 2007; Barry et al., 2009) • Evidence sources • Health Evidence Canada • Cochrane database of systematic reviews • US Mental Health and Substance Abuse (SAMSHA) • UK NICE - evidence briefings • There is sufficient knowledge to move evidence into practice (Jané-Llopis, Barry, Hosman and Patel (IUHPE Special Issue, 2005) M. Barry, January 2011

34. The evidence on social determinants of mental health • Social exclusion and isolation have a negative impact on mental health • racism, discrimination, stigmatisation and hostility • unemployment • lower levels of education • lower levels of income and poverty • Research - interaction of indicators of deprivation and social inclusion • Practice - opportunities for social engagement, remove structural barriers to social inclusion • Policy - higher levels of education, freedom from discrimination, access to quality employment, improved standards of living - enhance mental health and wellbeing M. Barry, January 2011

35. The evidence on social determinants of mental health • Social cohesion - quality of social relationships and existence of trust, mutual obligation and respect - protective of health • Inequality is corrosive of good social relations • Societies with higher levels of income inequality tend to have lower social capital (Putnam, 2001) and higher levels of mental ill-health (Pickett et al., 2006; Wilkinson & Pickett, 2010) • Research - interaction between social cohesion, equality and positive mental health; impact of inequality on mental health • Practice - strengthen community ties, social organisations and civil society • Policy - reducing social and economic inequalities; population mental health and social and economic policies M. Barry, January 2011

36. The evidence on social determinants of mental health • Social support and strong networks play a significant role in protecting mental health • Positive impact of supportive social relationships in maintaining resilience • Research - interaction with material living conditions and socioeconomic status - offset the effects of deprivation? • Practice - strengthen levels of social support and remove structural barriers to social contact • Policy implications - transport, housing, regeneration, community development, social care M. Barry, January 2011

37. Promoting mental health: intervention studies • Individual level determinants - life skills and social competencies - protective of mental health • Sense of self -control, efficacy and esteem • Relationship skills • Coping skills • Communication • Cognitive style • Emotional literacy • Problem solving skills • Sense of connectedness - home, school, community M. Barry, January 2011

38. Promoting mental health across the lifespan • Children - close relationships contribute to resilience in adulthood • Early attachment, warm and affectionate parenting; secure and safe home, informal sources of community support • Positive effect of parenting on child development • Relationships with peers and wider community - social support from at least one caring adult is protective from a wide range of adversities M. Barry, January 2011

39. Promoting mental health across the lifespan • High-quality early-childhood interventions • home visiting programmes; parenting programmes • Pre-school education, school-based approaches • Robust evidence base - cost of not putting these programmes in place • Marked socioeconomic gradients in social and emotional adjustment across childhood (Graham and Power, 2004) • Part of a wider range of public policy measures - reduce health inequalities and eliminate poverty M. Barry, January 2011

40. Promoting mental health across the lifespan • Adults and the role of work and paid employment • Mental health impact of unemployment is well documented • Evidence-based interventions to facilitate re-employment, job retention, supported employment • Workplace - interventions and legislation on bullying and harassment • Organizational approaches - management and decision-making, social support, demand-control, effort-reward balance M. Barry, January 2011

41. Promoting mental health across the lifespan • Older people • Loss of social support, loneliness, lack of social participation - exclusion • Limited evidence base on effective interventions - befriending, peer support (Widow-to-Widow programme), targeted outreach, intergenerational programmes • Interaction with material and social inequalities M. Barry, January 2011

42. Implications of addressing social determinants of mental health • Evidence-based interventions addressing proximate or individual level determinants • Targeted interventions - vulnerable, disadvantaged and marginalised groups • Broader social determinants - more evidence of impact of structural level interventions and of population-level patterns and interactions • Relative importance of material factors - housing, income, employment - and psychosocial factors - social position, relationships, social competency skills • Community level - need for more evidence of effectiveness of interventions at this level M. Barry, January 2011

43. Conclusions • Development and refinement of measures of positive mental health - mental health status and well-being; determinants • Implementing and evaluating ‘upstream’ interventions addressing the broader determinants of mental health • Documenting wider health and social gain - integration of mental health in health promotion and public health initiatives; cost-effectiveness studies • Mental health as a consequence of and contributor to inequality (WHO Commission on the Social Determinants of Health, 2008) M. Barry, January 2011

44. Conclusions • Addressing the social determinants of mental health co-ordinated multi-sectoral policy - deliver on improved mental health at a population level • Engaging the political will to promote mental healthat a policy level • Mobilising a public demand for a mentally healthy society - concern with emotional and social wellbeing, social values, culture, economic and social policies M. Barry, January 2011