Public Mental Health Seminar Dec 2012 Promoting Well-being at Population Level Sarah Stewart-Brown Professor of Public Health Percent of people (18-64yrs) reporting Problems with Work or Other Regular Daily Activity (SF-36) over 4 wks 16 14 12 10 8 % 6 4 2 0 Physical health Emotional health Both Postal questionnaire survey of 9332 adults in old Oxford Region Stewart-Brown S, Layte R. J Epid Comm Health 1997 •What is mental wellbeing •Measurement •Universal vs targeted approaches •Determining determinants •Determining the evidence base What is Wellbeing? Mental Social Physical Spiritual Internal vs External Subjective vs Objective Contributions • Philosophers – Western: Aristotle, Epicurus – Eastern: Buddhism, Hindu, Islam • Psychologists – Psychological functioning, – Positive psychology – Flourishing Wellbeing is something that is cultivated by the individual Psychological Wellbeing (Eudaemonic) Functioning well /flourishing • • • • • • Self acceptance Personal growth Purpose in life Environmental mastery Autonomy Positive relations with others Ryff 1995 Contributions • Social Scientists Wellbeing is something that is determined by social conditions – GDP – Income, wealth, poverty – Government – Services • Education • Health • Social Subjective Wellbeing (Hedonic) feeling good/happiness/ affective well-being • Feeling good • Life satisfaction • Happiness Diener 1993 Both matter Internal states External conditions Both matter Functioning Feeling Measurement The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) STATEMENTS None of Rarely Some of Often All of the time the time the time I’ve been feeling optimistic about the future I’ve been feeling useful I’ve been feeling relaxed I’ve been feeling interested in other people I’ve had energy to spare I’ve been dealing with problems well 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 I’ve been thinking clearly I’ve been feeling good about myself 1 2 3 4 5 1 2 3 4 5 I’ve been feeling close to other people 1 2 3 4 5 I’ve been feeling confident I’ve been able to make up my own mind about things I’ve been feeling loved I’ve been interested in new things 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 I’ve been feeling cheerful 1 2 3 4 5 WEMWBS vs CESD-D Pearson correlation .842 Distribution of WEMWBS scores: student and population samples Student sample: median score: 50 Population sample: median score: 51 Office of National Statistics Approach • Overall how satisfied are you with your life nowadays? • Overall how happy did you feel yesterday ? • Overall how anxious did you feel yesterday ? • Overall, to what extent do you feel things you do in your life are worthwhile ? Positive or Negative • Great majority of measures of mental health focus on the negative/ disease / distress • Focusing on the positive is an intervention in its own right. – ‘What you pay attention to is what you get more of’ • Public and patients prefer positive measures Crawford et al. Selecting outcome measures in mental health. J. Mental Health 2011(20)336-346 Distribution of WEMWBS scores: student and population samples Student sample: median score: 50 Population sample: median score: 51 Distribution is not bimodal Number of people Mental Illness Mental Wellbeing Disease prevention is problematical Number of people Mental Illness Mental Wellbeing Universal and targeted Number of people Mental Illness Mental wellbeing Determinants Regression analyses • Are best suited to investigations where there is a single determinant causing a single disease. Are not well suited to estimating effects in • – – – complex causal pathways or when several different agents or conditions interact together to create the conditions for disease examining holistic effects Mental Health and Social Inequalities Mental health problems Physical health problems Relationship problems Poverty, income inequality Friedli Lynne. Mental health, resilience and inequalities WHO Euro 2009 Life Satisfaction and GDP in the UK 1973-2011 By Kind Permission of Ewen Mckinnon Cabinet Office Nov 2012 A systems approach Parent Infant Adult Your mental wellbeing you My mental wellbeing community Remediable Determinants • Parenting – – – • Emotional trauma /threat – – – – • Parental mental illness Parental drug and alcohol misuse Child abuse, looked after children Bullying Conflict Social exclusion – deprivation, debt, income inequality, racism, homphobia Bereavement Drug and alcohol misuse Returns to a Unit Pound Invested . Heckman J, Schools, skills and synapses. Economic Inquiry 46(3), 2008, 289-324. 27 Targeting and The population paradox Proportion of children 5-10 years with antisocial behaviour 14 12 10 8 6 4 2 0 I II IINM IIIM IV V NW From: Mental health of children and adolescents in Great Britain Meltzer H. Gatward R. 1999 ONS, London The Stationary Office ONS Children 5-10 years Numbers with antisocial behaviour by social class 80 70 60 50 40 30 20 10 0 I II IINM IIIM IV V NW From mental health of children and adolescents in great Britain Meltzer H. Gatward R. 1999 ONS, London The Stationary Office ONS CAMs are not well suited to RCTs • RCTs unlikely to engage those most likely to benefit • Interventions cannot be standardised (pragmatic trials possible) • Placebo control is an issue • Disease based outcome measures will miss much important benefit What can be done ? Protective Factors • Good parenting – • • • • • • • Resilience Relationship skills Social capital Exercise Diet Mindfulness / spiritual development Green spaces Creative arts Programmes • Parenting programmes – Pregnancy and infancy – Behaviour – Teenage • School based programmes – – • • Workplace programmes Wellness programmes – • • Relationship skills Bullying Diet, exercise, Community development, volunteering, arts/gardening for health, CBT, EMDR, Mindfulness, EFT? Summing Up • • It is complex No simple answers – Evidence base cannot rely on RCTs – Targeting is inefficient – No simple prioritising – Everything is connected • Know your locality • Build on what is working • Magic can happen
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