Promoting Mental Health

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Promoting Mental Health

CONCEPTS

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EMERGING EVIDENCE

^■

PRACTICE

A Report of the

World Health Organization,

Department of Mental Health and Substance Abuse in collaboration with

the Victorian Health Promotion Foundation and

The University of Melbourne

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CONCEPTS

^■

EMERGING EVIDENCE

^■

PRACTICE

A Report of the

World Health Organization,

Department of Mental Health and Substance Abuse in collaboration with

the Victorian Health Promotion Foundation and

The University of Melbourne

Editors:

Helen Herrman

Shekhar Saxena

Rob Moodie

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WHO Library Cataloguing-in-Publication Data

Promoting mental health: concepts, emerging evidence, practice : report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne / [editors: Helen Herrman, Shekhar Saxena, Rob Moodie].

1.Mental health 2.Health promotion 3.Evidence-based medicine 4.Health policy

5.Practice guidelines 6.Developing countries I.Herrman, Helen. II.Saxena, Shekhar. III.Moodie, Rob.

ISBN 92 4 156294 3 (NLM classification: WM 31.5)

© World Health Organization 2005

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The World Health Organization (WHO) embraces a definition of health as “physical, mental, and social well-being”. Of these elements, mental well-being historically has been misunderstood and often forgotten. WHO has spent the last five years actively addressing the barriers that prevent access to mental health care and campaigning for the full incorporation of mental health in worldwide public health. Thanks greatly to their hard work, mental health now ranks as a priority within the international health and development agenda. Governments across the world and health professionals across the disciplines are now more aware of the importance of mental health issues to the overall health of individuals, communities, cities, and even entire nations.

Promoting Mental Health: Concepts, Emerging Evidence, Practice clarifies the concept of mental health promotion and is a potent tool for guiding public officials and medical professionals in addressing the behavioural health needs of their societies. It presents striking evidence that there is a strong link between the protection of basic civil, political, economic, social, and cultural rights of people and their mental health. In these times, when conflicts between individuals and communities are on the increase and economic disparities are widening, this message is especially relevant. Good mental health goes hand in hand with peace, stability and success, and Promoting Mental Health presents a powerful case for including mental health promotion in the public health policies of all countries.

WHO recognizes that besides the vital need for expanding services to those who currently receive none, prevention of mental disorders and vigorous promotion of healthy behaviours are critical for decreasing the international burden of mental illnesses and for helping people to realize their full potential. WHO’s efforts include international reviews of scientific evidence for interventions;

wide dissemination of evidence, particularly in lower and middle income countries; and assisting governments and non-governmental organizations in using the evidence to develop actual programmes.

Promoting Mental Health: Concepts, Emerging Evidence, Practice emphasizes that everyone has a role and responsibility in mental health promotion and encourages integrated participation from a variety of sectors such as education, work, environment, urban planning and community development as the best way to make the most positive improvement in people’s mental health.

It appropriately focuses on resource-poor settings; however, money is not the key determinant to ensure good mental health. Awareness and active involvement by each member of the community often have the greatest impact.

I congratulate WHO on this excellent work and urge policy-makers the world over to use this important information to effect real improvement in the mental health and well-being for all their people.

Rosalynn Carter

Chair, Mental Health Task Force The Carter Center

Atlanta, Georgia USA

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Foreword

“… not merely the absence of disease or infirmity.”

“… attainment by all people of the highest possible level of health.”

“… to foster activities in the field of mental health, especially those affecting the harmony of human relations.”

These objectives and functions of the World Health Organization (WHO) are at the core of our commitment to mental health promotion.

Unfortunately, health professionals and health planners are often too preoccupied with the imme- diate problems of those who have a disease to be able to pay attention to needs of those who are “well”. They also find it difficult to ensure that the rapidly changing social and environmental conditions in countries around the world support rather than threaten mental health. This situa- tion is only partly based on the lack of clear concepts or of adequate evidence for effectiveness for health promoting interventions. This has much to do with how the professionals and planners are trained, what they see as their role in society and, in turn, what society expects them to do. In the case of mental health, this also has to do with our reluctance to discuss mental health issues openly.

Promoting Mental Health: Concepts, Emerging Evidence, Practice is WHO’s latest initiative to over- come these barriers. It describes the concept of mental health and its promotion. It tries to arrive at a degree of consensus on common characteristics of mental health promotion as well as variations across cultures. It also positions mental health promotion within the broader context of health promotion and public health. The evidence provided for the health and non-health interventions for mental health benefits is likely to be useful to health policy planners and public health professionals. The emphasis, however, is on the urgent need for a more systematic genera- tion of evidence in the coming years, so that a stronger scientific base for further planning can be developed.

Prevention of mental disorders and promotion of mental health are distinct but overlapping aims.

Many of the interventions discussed in this report are also relevant for prevention. However, the scope as well as the target audience is considered much wider for mental health promotion. For this reason, WHO is releasing this report on promotion separately from a forthcoming report on the evidence for prevention of mental disorders.

I trust that the present full report, along with the summary report released earlier, will create a more definite place for mental health promotion within the broader field of health promotion and will be useful for the countries that WHO serves.

Dr Catherine Le Galès-Camus Assistant Director-General

Noncommunicable Diseases and Mental Health World Health Organization, Geneva

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Forewords

Rosalynn Carter . . . III Catherine Le Galès-Camus . . . IV Table of Contents . . . V Preface . . . XI Acknowledgements . . . XIV Key Messages . . . XVIII

Part I: Concepts

1. Introduction: Promoting Mental Health as a Public Health Priority . . . 2

Helen Herrman, Shekhar Saxena, Rob Moodie, Lyn Walker What is mental health? . . . 2

Towards a new public health . . . 2

A new enthusiasm for promoting mental health . . . 3

Promoting mental health is an integral part of public health . . . 4

Mental health is more than the absence of mental illness . . . 6

No health without mental health: mental health and behaviour . . . 6

Objectives and actions of mental health promotion . . . 8

International collaboration and the role of WHO . . . 11

Mental health is everybody’s business . . . 12

References . . . 15

Additional comments Thomas R Insel Promoting Mental Health: Lessons from Social Brain Research . . . 13

2. Health Promotion: A Sketch of the Landscape . . . 18

Maurice B Mittelmark, Pekka Puska, Desmond O’Byrne, Kwok-Cho Tang Concepts of health . . . 18

Determinants of health . . . 19

Health inequalities . . . 20

Health promotion responds to the challenge . . . 22

Health promotion practice . . . 22

Politics of health promotion . . . 24

Health promotion successes . . . 25

Health promotion in low income countries . . . 28

The nature of evidence of health promotion’s effectiveness . . . 29

Innovative funding strategies . . . 30

Conclusion . . . 32

References . . . 33

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PROMOTING MENTAL HEALTH VI • PROMOTING MENTAL HEALTHPROMOTING MENTAL HEALTH

3. Evolution of Our Understanding of Positive Mental Health . . . 35

Vivianne Kovess-Masfety, Michael Murray, Oye Gureje Introduction . . . 35

Concepts of mental health . . . 35

Quality of life . . . 41

Conclusion . . . 43

References . . . 44

4. The Intrinsic Value of Mental Health . . . 46

Ville Lehtinen, Agustin Ozamiz, Lynn Underwood, Mitchell Weiss Introduction . . . 46

Conceptualization and measurement of values . . . 47

Mental health as an individual capacity and experience . . . 47

Mental health and social interaction . . . 49

Mental health contributes to social capital . . . 52

Cultural values and mental health . . . 53

Spiritual dimensions of mental health . . . 55

Conclusion . . . 56

References . . . 57

Additional comments Bengt Lindstrom, Monica Eriksson The Salutogenic Perspective and Mental Health . . . 50

5. Concepts of Mental Health Across the World . . . 59

Shona Sturgeon, John Orley Introduction . . . 59

Who promotes mental health? . . . 59

Who defines mental health? . . . 59

Approach of this chapter . . . 60

Concepts of mental health in infancy and early childhood . . . 61

Concepts of mental health and the school context . . . 63

Concepts of mental health and under-age soldiers . . . 64

Concepts of mental health and HIV/AIDS . . . 65

Concepts of mental health and palliative care . . . 66

Concepts of mental health and older people . . . 67

Conclusion . . . 68

References . . . 69

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6. Social Capital and Mental Health . . . 70

Harvey Whiteford, Michelle Cullen, Florence Baingana Introduction . . . 70

Conceptualizing social capital . . . 70

Deconstructing social capital . . . 72

Social capital, health and mental health . . . 72

Mental health promotion and social capital . . . 76

Building social capital . . . 77

Conclusion . . . 78

References . . . 79

7. Mental Health and Human Rights . . . 81

Natalie Drew, Michelle Funk, Soumitra Pathare, Leslie Swartz Introduction . . . 81

The link between mental health and human rights . . . 81

The international human rights framework . . . 83

Vulnerable groups . . . 84

Conclusion . . . 87

References . . . 88

8. Responding to the Social and Economic Determinants of Mental Health: A Conceptual Framework for Action . . . 89

Lyn Walker, Irene Verins, Rob Moodie, Kim Webster Introduction . . . 89

The VicHealth framework to promote mental health and well-being . . . 89

Key aspects of the framework . . . 91

The framework in action: mental health promotion in refugee communities . . . .100

Future challenges . . . .103

References . . . .105

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PROMOTING MENTAL HEALTH VIII • PROMOTING MENTAL HEALTHPROMOTING MENTAL HEALTH

Part II: The Emerging Evidence

9. The Nature of Evidence and its Use in Mental Health Promotion . . . .108

Margaret M Barry, David V McQueen Introduction . . . .108

Evaluating the promotion of positive mental health . . . .108

Adopting an evidence-based approach: issues and challenges . . . .110

Evaluating the process of programme implementation . . . .113

Widening the evidence base: applying the evidence to low income countries . . . .115

Conclusion . . . .117

Additional comments Jodie Doyle The Cochrane Collaboration . . . .110

10. Social Determinants of Mental Health and Mental Disorders . . . .120

James C (Jim) Anthony Introduction . . . .120

Social mobilization of resources to prevent, reduce or ameliorate suffering . . . .123

Uncertainty of presently available evidence . . . .124

Future directions in research . . . .128

11. Links Between Mental and Physical Health and Illness . . . .132

Beverley Raphael, Margit Schmolke, Sally Wooding Introduction . . . .132

Concepts . . . .133

Interrelationships . . . .135

Developing mental health promoting health care systems and environments . . . .144

Additional comments Corey LM Keyes A Mental Health Continuum . . . .138

12. Indicators of Mental Health . . . .148

Stephen R Zubrick, Vivianne Kovess-Masfety Introduction . . . .148

Positive mental health and the absence of disorder . . . .148

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A social-ecological framework for positive mental health . . . .149

Criteria for selecting indicators . . . .152

Macro-level indicators . . . .153

Individual indicators of positive mental health . . . .155

Individual indicators of mental health distress . . . .157

Determinants of mental health . . . .161

Capacity building in mental health promotion . . . .163

Acknowledgements . . . .166

Additional comments Elise Maher, Elizabeth Waters Indicators of Positive Mental Health for Children . . . .159

13. The Evidence of Effective Interventions for Mental Health Promotion . . . .169

Clemens MH Hosman, Eva Jané-Llopis Introduction . . . .169

Macro interventions . . . .169

Meso and micro interventions . . . .172

Conclusions . . . .181

14. The Evidence for Mental Health Promotion in Developing Countries . . . .189

Vikram Patel, Leslie Swartz, Alex Cohen Introduction . . . .189

Human development and mental health . . . .189

The evidence . . . .191

Building the evidence base . . . .199

15. Evidence: The Way Forward . . . .203

Mark Petticrew, Dan Chisholm, Hilary Thomson, Eva Jané-Llopis Introduction . . . .203

The current evidence on policy interventions . . . .203

Mental health impact assessment . . . .206

Health economics and mental health promotion . . . .207

Improving the availability of evidence: an Internet-based system . . . .211

Conclusions . . . .212

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PROMOTING MENTAL HEALTH X • PROMOTING MENTAL HEALTHPROMOTING MENTAL HEALTH

Part III: Policy and Practice

16. Mental Health Promotion:

An Important Component of National Mental Health Policy . . . .216

Michelle Funk, Elizabeth Gale, Margaret Grigg, Alberto Minoletti, M Taghi Yasamy Investing in mental health promotion . . . .216

What is mental health policy and why is it important? . . . .216

Components of policy . . . .217

Intersectoral collaboration – making health promotion work . . . .220

Examples of strategies for mental health promotion . . . .220

Evaluation of mental health promotion policy . . . .224

17. Strategies for Promoting the Mental Health of Populations . . . .226

Eero Lahtinen, Natacha Joubert, John Raeburn, Rachael Jenkins Introduction . . . .226

Mental health and its promotion . . . .227

Three levels of action . . . .228

The Ottawa Charter for Health Promotion as a guide to population strategies . . . .230

Healthy public policies . . . .232

Supportive environments . . . .234

Community action . . . .235

Personal skills . . . .236

Reorientation of health services . . . .239

18. Community Development as a Strategy for Promoting Mental Health: Lessons from Rural India . . . .243

Rajanikant Arole, Beth Fuller, Peter Deutschmann Introduction . . . .243

Everyday life in a village – the impact on mental well-being . . . .243

The process of community development in Jamkhed . . . .246

The impact of community development at Jamkhed on mental health . . . .248

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19. Developing Sustainable Programmes: Theory and Practice . . . .252

Penelope Hawe, Laura Ghali, Therese Riley Introduction . . . .252

What is programme sustainability? . . . .252

What makes a programme likely to be sustained? . . . .253

Theories informing programme sustainability . . . .254

Beyond programmes: how the thinking about “what” gets sustained has evolved . . . .256

Issues and challenges . . . .257

Implications for building sustained interventions . . . .259

20. Intersectoral Approaches to Promoting Mental Health . . . .264

Louise Rowling, Alison Taylor Introduction . . . .264

Conceptualization of mental health and intersectoral collaboration . . . .264

Frameworks and action for mental health promotion . . . .267

Settings for intersectoral collaboration . . . .272

Additional comments Mason Durie Indigenous Health Promotion . . . .265

Chris Bale, Brian Mishara Zippy’s Friends . . . .269

Arabinda Chowdhury, Sohini Banerjee, Mitchell G Weiss An Intersectoral Approach to Mental Health and Pesticide Safety . . . .271

21. Conclusions and Recommendations . . . .284

Shekhar Saxena, Helen Herrman, Rob Moodie, Benedetto Saraceno What do we know? . . . .284

What can we do now? . . . .285

What do we need to know and do further? . . . .286

Key recommendations . . . .288

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Preface

Promoting Mental Health: Concepts, Emerging Evidence, Practice aims to bring to life the mental health dimension of health promotion. The promotion of mental health is situated within the larger field of health promotion, and sits alongside the prevention of mental disorders and the treatment and rehabilitation of people with mental illnesses and disabilities. Like health promotion, mental health promotion involves actions that allow people to adopt and maintain healthy lifestyles and create living conditions and environments that support health. This book describes the concepts relating to promotion of mental health, the emerging evidence for effectiveness of interventions and the public health policy and practice implications. It complements the work of another major WHO project focusing on the evidence for prevention of mental illnesses.

Many within and outside the fields of mental health and health promotion recognize a need to assemble, review and generate evidence about the tangible benefits of mental health promotion.

This includes evidence on the relationship between social and cultural factors and the mental health of individuals and communities. This book reviews the available evidence from a range of countries and cultures. It documents how actions such as advocacy, policy and project development, legisla- tive and regulatory reform, communications, research and evaluation may be achieved and monito- red in countries at all stages of economic development. It considers strategies for continued growth of the evidence base and approaches to determining cost-effectiveness of actions. International cooperation and alliances will play a critical role in generating and applying the evidence by encou- raging the social action required and monitoring the impact on mental health of a range of policies and practices.

Promoting Mental Health: Concepts, Emerging Evidence, Practice has been written for people working in health and non-health sectors whose decisions affect mental health in ways that they may not realize. It is also a sympathetic account for people in the mental health professions who need to endorse and assist the promotion of mental health while continuing to deliver services for people living with mental illnesses. It is relevant to people working to develop policies and programmes in countries with low, medium and high levels of income and resources, as well as those concerned with guidelines for international action. It uses a public health framework to address the dilemma of competing priorities that concerns planners and practitioners in low income as well as affluent settings.

Promoting Mental Health: Concepts, Emerging Evidence, Practice is the result of collaboration with scientific contributors from sectors outside as well as within health. The editors consulted a group of senior project advisers and contacted a wide group of interested people and organizations: professional, government, nongovernment and others. The aims of the project were to facilitate a better understanding of the evidence and approaches to gathering local evidence, activation of the scientific community and growth in international cooperation and alliances.

The book is divided into three parts. Part One introduces the topic and describes a number of concepts associated with health, health promotion and mental health, as well as their use across different cultures, countries and subpopulations. In Chapter 1, the introduction, we identify a new enthusiasm for mental health as a public health priority, and describe how international collaboration is crucial to stimulate much needed interest in mental health promotion. Chapter 2 sketches the landscape of health promotion. Since we consider mental health promotion as a subset of health promotion, this information is likely to be useful in our examination of the concept of mental health promotion. Chapter 3 discusses the concept of positive mental health and how our understanding of it has changed over time. The intrinsic value of mental health to individuals, families, communities and nations is discussed in Chapter 4, which also includes a discussion on the spiritual dimensions of mental health. How the concepts of mental health and mental health promotion may differ

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in different contexts across the world is taken up in Chapter 5, where the point is made that before engaging in mental health promotion in any community it is first necessary to understand that par- ticular community’s understanding of mental health. The concept of social capital has been of great interest to researchers across a number of disciplines in recent years, and the relationship between social capital and mental health is the focus of Chapter 6. Our view is that mental health is inextrica- bly linked with human rights and these links are discussed in Chapter 7, which gives an overview of the international human rights framework and discusses some of the groups particularly vulnerable to human rights violations. Chapter 8 describes how a framework for mental health promotion can bring the concepts already discussed together to guide actions to address the determinants of mental health.

Part Two focuses on evidence for mental health promotion. It begins with examining the nature of evidence in mental health promotion (Chapter 9) and then considers the available evidence in two specific areas – social determinants (Chapter 10) and the interface with physical health and illness (Chapter 11). Chapter 12 reviews the literature on indicators for mental health promotion and iden- tifies their strengths and weaknesses. The next chapter (13) reviews the evidence on effectiveness of interventions using available information from the published literature. Since this evidence most often comes from high income developed countries, a separate chapter (14) focuses on evidence accumulating in developing countries where interventions are most urgently needed. Since it is clearly recognized that the available evidence is limited in scope, even while sufficient to prompt national and international action, Chapter 15 describes the way forward for generating further evidence on determinants of mental health and the effectiveness and cost-effectiveness of interventions.

Part Three takes the concepts and evidence forward to examine and suggest actions for policy and practice that serve the needs of mental health promotion. Since national mental health policy often forms the blueprint for all actions in this area, Chapter 16 describes how mental health promotion can and should be an important component of policy. This is followed by a chapter (17) that traces the historical basis for mental health promotion within international charters and comments on the relevance and limitations of these approaches for policy and practice. Since community development can provide an important strategy for promoting mental health, Chapter 18 describes one such model being implemented in a low income country to illustrate a successful example.

Sustainability of interventions is a serious issue in all health promotion programmes; it is examined with relevance to mental health promotion in Chapter 19 and some lessons drawn. Chapter 20 emphasizes the importance of intersectoral approaches in developing and implementing mental health promotion programmes by giving examples from several relevant sectors.

Finally, Chapter 21 draws conclusions and key messages from the material presented in the earlier chapters and proposes a way forward to make evidence-based mental health promotion a reality.

As we worked on this project, we became aware of the richness of information available about programmes of proven effectiveness in the area of mental health promotion, as well as the limitations and shortcomings of the evidence in areas of greatest need. We believe there is much that can be done by countries and communities within the available financial and human resources to advance mental health promotion. We will feel rewarded in our efforts if the information provided in the chapters that follow encourages action and programmes to enhance mental health across the world, as well as stimulates further research.

Helen Herrman, Shekhar Saxena, Rob Moodie Editors

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Acknowledgements

The editors compiled Promoting Mental Health: Concepts, Emerging Evidence, Practice in collaboration with Ms Lyn Walker, Victorian Health Promotion Foundation. The editors gratefully ack- nowledge the work of the contributors and advisers listed below.

The editors also most sincerely thank Ms Christine Hayes for her assistance with editing, Ms Jean Cameron and Ms Rosemary Westermeyer for their administrative assistance, and

Ms Tushita Bosonet for the graphic design of the report. Ms Rosemary Westermeyer also supported production at WHO.

WHO gratefully acknowledges financial assistance from the Government of Finland in the production of this book.

Editors

Professor Helen Herrman St Vincent’s Health Melbourne and Department of Psychiatry The University of Melbourne Victoria, Australia

Dr Shekhar Saxena

Coordinator, Mental Health: Evidence and Research Department of Mental Health and Substance Abuse World Health Organization

Geneva, Switzerland Professor Rob Moodie Chief Executive Oﬃcer

Victorian Health Promotion Foundation Victoria, Australia

Advisers

Ms Beverley Long

World Federation for Mental Health Atlanta, GA, USA

Professor Norman Sartorius University of Geneva Geneva, Switzerland Dr Dusica Lecic Tosevski

Director, Institute of Mental Health and Chair, World Psychiatric Association Section on Preventive Psychiatry

Belgrade, Serbia and Montenegro Contributors

Dr James C (Jim) Anthony

Professor and Chairman, Department of Epidemiology College of Human Medicine

Michigan State University Michigan, USA

Dr Rajanikant Arole

Director, Comprehensive Rural Health Project Jamkhed, Maharashtra, India

Dr Florence Baingana

Senior Health Specialist (Mental Health) The World Bank

Washington, DC, USA Mr Chris Bale

Director, Partnership for Children London, United Kingdom Ms Sohini Banerjee

Swiss Tropical Institute, Department of Public Health and Epidemiology and University of Basel

Switzerland Dr Margaret Barry

Director, Centre for Health Promotion Studies National University of Ireland, Galway Ireland

Dr Dan Chisholm

Economist, Mental Health: Evidence and Research Department of Mental Health and Substance Abuse World Health Organization

Geneva, Switzerland

Professor Arabinda N Chowdhury

Professor of Psychiatry, University of Calcutta and Superintendent, Institute of Psychiatry

Kolkata, India Dr Alex Cohen

Assistant Professor of Social Medicine Harvard Medical School

Boston, MA, USA Ms Michelle Cullen Consultant, Post-Conﬂict Unit The World Bank

Washington, DC, USA

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Dr Peter Deutschmann

Executive Director, Australian International Health Institute

The University of Melbourne Victoria, Australia

Ms Jodie Doyle

Field Coordinator, Cochrane Health Promotion and Public Health Field

Ms Natalie Drew Technical Oﬃcer

Mental Health Policy and Service Development Department of Mental Health and Substance Abuse World Health Organization

Geneva, Switzerland Professor Mason Durie

Head of School, Te Pütahi-ä-Toi, School of Mäori Studies, Massey University

Palmerson North, New Zealand Ms Monica Eriksson

Project Leader, Nordic School of Public Health Sweden

Ms Beth Fuller

Senior Program Development Oﬃcer Australian International Health Institute The University of Melbourne

Victoria, Australia Dr Michelle Funk Coordinator

Geneva, Switzerland Ms Elizabeth Gale Chief Executive, Mentality London, United Kingdom Dr Laura Ghali

Centre for the Study of Social and Physical Environments and Health

University of Calgary Canada

Ms Margaret Grigg Technical Oﬃcer

Geneva, Switzerland Professor Oye Gureje

Department of Psychiatry, University of Ibadan Ibadan, Nigeria

Professor Penelope Hawe

Centre for the Study of Social and Physical Environments and Health

University of Calgary Canada

Professor Clemens Hosman

Prevention Research Centre on Mental Health Promotion and Mental Disorders Prevention Faculties of Social Sciences and Health Sciences Radboud University Nijmegen and Maastricht University

The Netherlands Dr Thomas R Insel

Director, National Institute of Mental Health Bethesda, MD, USA

Dr Eva Jané-Llopis

Head of Science-Based Knowledge and Policy Prevention Research Centre on Mental Health Promotion and Mental Disorder Prevention Academic Centre for Social Sciences Radboud University Nijmegen The Netherlands

Professor Rachael Jenkins Institute of Psychiatry London, United Kingdom Professor Natacha Joubert Head, Mental Health Promotion Unit Health Canada

Canada Dr Corey Keyes

Department of Sociology and Department of Behavioural Sciences and Health Education The Rollins School of Public Health Emory University

Georgia, USA

Professor Vivianne Kovess-Masfety

Directrice, Fondation MGEN pour la Sante Publique Paris, France

Dr Eero Lahtinen Senior Medical Oﬃcer

Ministry of Social Aﬀairs and Health in Finland Helsinki, Finland

Professor Ville Lehtinen

National Research and Development Centre for Welfare and Health (STAKES)

Mental Health Unit Helsinki, Finland

Professor Bengt Lindstrom Nordic School of Public Health Goteborg, Sweden

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PROMOTING MENTAL HEALTH XVI • PROMOTING MENTAL HEALTHPROMOTING MENTAL HEALTH

Dr David McQueen

Associate Director for Global Health Promotion Centers for Disease Control and Prevention Atlanta, GA, USA

Ms Elise Maher Research Fellow

School of Health and Social Development Deakin University

Victoria, Australia Dr Alberto Minoletti Director, Mental Health Unit Ministry of Health Santiago, Chile

Professor Brian Mishara

Director, Centre for Research and Intervention on Suicide and Euthanasia (CRISE)

University of Quebec Montreal, Canada

Professor Maurice Mittelmark

President, International Union for Health Promotion and Education

Research Centre for Health Promotion University of Bergen

Bergen, Norway Mr Michael Murray

Chief Executive, The Cliﬀord Beers Foundation University of Central England

Birmingham, United Kingdom Dr Desmond O’Bryne

Coordinator of Health Promotion

Health Education and Health Promotion Unit World Health Organization

Geneva, Switzerland Dr John Orley

Former Programme Manager in the Department of Mental Health

World Health Organization Geneva, Switzerland Professor Agustin Ozamiz Department of Sociology University of Deusto Bilbao, Spain Dr Vikram Patel

Reader in International Mental Health

London School of Hygiene and Tropical Medicine London, United Kingdom

Dr Soumitra Pathare Consultant Psychiatrist Ruby Hall Clinic Pune, India

Dr Mark Petticrew

MRC Social and Public Health Sciences Unit Glasgow, United Kingdom

Dr Pekka Puska

Director-General, National Public Health Institute (KTL)

Helsinki, Finland and

Former Director, Communicable Disease Prevention and Health Promotion

World Health Organization Geneva, Switzerland

Associate Professor John Raeburn University of Auckland

Auckland, New Zealand Professor Beverley Raphael Director, Centre for Mental Health, New South Wales Health Department New South Wales, Australia

Dr Therese Riley

VicHealth Centre for the Promotion of Mental Health and Social Wellbeing; and

School of Population Health The University of Melbourne Victoria, Australia

Associate Professor Louise Rowling School of Policy and Practice University of Sydney New South Wales, Australia Dr Benedetto Saraceno Director

Department of Mental Health and Substance Abuse World Health Organization

Geneva, Switzerland Dr Margit Schmolke

International Centre for Mental Health Mt Sinai School of Medicine

New York, USA Ms Shona Sturgeon

Department of Social Development University of Cape Town

Republic of South Africa Professor Leslie Swartz

Professor, Department of Psychology University of Stellenbosch and

Director, Child Youth and Family Development Human Sciences Research Council

Cape Town, Republic of South Africa Dr Kwok-Cho Tang

Senior Professional Oﬃcer World Health Organization Geneva, Switzerland

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Dr Alison Taylor

Chief Executive Oﬃcer, Mental Health Foundation Auckland, New Zealand

Ms Hilary Thomson

MRC Social and Public Health Sciences Unit University of Glasgow

Glasgow, United Kingdom Dr Lynn Underwood Fetzer Institute Kalamazoo, MI, USA Ms Irene Verins Senior Project Oﬃcer

Ms Lyn Walker

Director, Mental Health and Wellbeing Unit Victorian Health Promotion Foundation Victoria, Australia

Professor Elizabeth Waters Chair in Public Health

School of Health and Social Development Faculty of Health and Behavioural Sciences Deakin University

Victoria, Australia Ms Kim Webster Senior Project Oﬃcer

Professor Mitchell Weiss Professor and Head

Department of Public Health and Epidemiology Swiss Tropical Institute

Basel, Switzerland

Professor Harvey Whiteford Kratzmann Professor of Psychiatry University of Queensland The Park Centre for Mental Health Queensland, Australia

Dr Sally Wooding Senior Project Oﬃcer

Centre for Mental Health – Policy Division NSW Health Department

New South Wales, Australia Dr Mohammad Taghi Yasamy Department of Psychiatry

Shahid Beheshti University of Medical Sciences Tehran, Islamic Republic of Iran

Professor Stephen R Zubrick Head, Division of Population Sciences Curtin University of Technology Centre for Developmental Health

Telethon Institute for Child Health Research Perth, WA, Australia

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Key messages

There is no health without mental health

The World Health Organization (WHO) defines health as:

… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Mental health is clearly an integral part of this definition. The goals and traditions of public health and health promotion can be applied just as usefully in the field of mental health as they have been in heart health, infectious diseases and tobacco control.

Mental health is more than the absence of mental illness: it is vital to individuals, families and societies

Mental health is described by WHO as:

… a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

In this positive sense mental health is the foundation for well-being and effective functioning for an individual and for a community. This core concept of mental heath is consistent with its wide and varied interpretation across cultures.

Mental health is determined by socioeconomic and environmental factors

Mental health and mental illnesses are determined by multiple and interacting social, psychological and biological factors, just as health and illness in general. The clearest evidence for this relates to the risk of mental illnesses, which in the developed and developing world is associated with indicators of poverty, including low levels of education, and in some studies with poor housing and low income. The greater vulnerability of disadvantaged people in each community to mental illnesses may be explained by such factors as the experience of insecurity and hopelessness, rapid social change, and the risks of violence and physical ill-health.

Mental health is linked to behaviour

Mental, social and behavioural health problems may interact so as to intensify their effects on behaviour and well-being. Substance abuse, violence, and abuses of women and children on the one hand, and health problems such as heart disease, depression and anxiety on the other, are more prevalent and more difficult to cope with in conditions of high unemployment, low income, limited education, stressful work conditions, gender discrimination, unhealthy lifestyle and human rights violations.

Mental health can be enhanced by effective public health interventions

The improvement in heart health in several countries has had more to do with attention to environment, tobacco and nutrition policies than with specific medicines or treatment techniques.

The malign effects of changing environmental conditions on heart health have been reversed to varying extents by actions at multiple levels.

Similarly, research has shown that mental health can be affected by non-health policies and practices, for example in housing, education and child care. This accentuates the need to assess the effectiveness of policy and practice interventions in diverse health and non-health areas. Despite

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uncertainties and gaps in the evidence, we know enough about the links between social experience and mental health to make a compelling case to apply and evaluate locally appropriate policy and practice interventions to promote mental health.

Collective action depends on shared values as much as the quality of scientific evidence

In some communities, time-honoured practices and ways of life maintain mental health even though mental health may not be identified as the outcome, or identified by name. In other communities, people need to be convinced that making an effort to improve mental health is realistic and worthwhile.

A climate that respects and protects basic civil, political, economic, social and cultural rights is fundamental to the promotion of mental health

Without the security and freedom provided by these rights it is very difficult to maintain a high level of mental health.

Intersectoral linkage is the key for mental health promotion

Mental health can be improved through the collective action of society. Improving mental health requires policies and programmes in government and business sectors including education, labour, justice, transport, environment, housing and welfare, as well as specific activities in the health field relating to the prevention and treatment of ill-health.

Mental health is everybody’s business

Those who can do something to promote mental health, and who have something to gain, include individuals, families, communities, commercial organizations and health professionals.

Particularly important are the decision-makers in governments at local and national levels whose actions affect mental health in ways that they may not realize. International bodies can ensure that countries at all stages of economic development are aware of the importance of mental health to community development. They can also encourage them to assess the possibilities and evidence for intervening to improve the mental health of their population.

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PROMOTING MENTAL HEALTH XX •

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C O N C E P T S

Concepts

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Chapter 1 • Introduction:

Promoting Mental Health as a Public Health Priority

Helen Herrman, Shekhar Saxena, Rob Moodie, Lyn Walker

Public health is the science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society (WHO, 1998a, p. 3).

Health polices in the 21st century will need to be constructed from the key question…”What makes people healthy?” (Kickbusch, 2003, p. 386).

What is mental health?

Since its inception, WHO has included mental well-being in the definition of health. WHO famous- ly defines health as:

… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 2001b, p.1).

Three ideas central to the improvement of health follow from this definition: mental health is an integral part of health, mental health is more than the absence of mental illness, and mental health is intimately connected with physical health and behaviour.

Defining mental health is important, although not always necessary to achieving its improvement. Differences in values across countries, cultures, classes and genders can appear too great to allow a consensus on a definition (WHO, 2001c). However, just as age or wealth each have many different expressions across the world and yet have a core common-sense universal meaning, so too can mental health be understood without restricting its interpretation across cultures. WHO has recently proposed that mental health is:

… a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community (WHO, 2001d, p.1).

In this positive sense, mental health is the foundation for well-being and effective functioning for an individual and for a community. It is more than the absence of mental illness, for the states and capacities noted in the definition have value in themselves. Despite this, mental health is still por- trayed by some as a luxury. The misunderstandings on which this view is based are now clearer than they were in the past, and WHO and other international organizations identify the improvement of mental health as a priority concern for low and middle income countries as well as for wealthier nations and people (WHO, 2001b).

Neither mental nor physical health can exist alone. Mental, physical and social functioning are interdependent. Furthermore, health and illness may co-exist. They are mutually exclusive only if health is defined in a restrictive way as the absence of disease (Sartorius, 1990). Recognizing health as a state of balance including the self, others and the environment helps communities and individuals understand how to seek its improvement.

Towards a new public health

Public health in modern times has a broad scope as the organized global and local effort to promote and protect the health of populations and to reduce health inequalities. This ranges from the control of communicable diseases – the original impetus for public health work – to the leadership of intersectoral efforts to promote health (Beaglehole, 2003). The new public health is

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a social and political concept, aimed at improving health, prolonging life and improving the quality of life among whole populations. It works through health promotion, disease prevention and other forms of health intervention (WHO, 1998a).

Health promotion has had new prominence in recent decades. Its strategies are based on the question of how health is created, and it aims to offer people more control over the determinants of their health. The priority this gives to investing in the determinants of health is matched by the increasing focus on health outcomes around the world. The concept of ecological public health has also emerged. It emphasizes the common ground between achieving health and sustainable development, focusing on the economic and environmental determinants of health (WHO, 1998a).

Several key thinkers in the last two decades have influenced public health practice. Marmot, in his work with Wilkinson on the social determinants of health, noted that it is possible to alter

“the impact of the social environment on health, as represented by social inequalities in health”

(Marmot & Wilkinson, 1999, p. 3). Specific social determinants of health can be characterized and their effects studied. It is then potentially possible to affect these determinants with a consequent impact on health. Syme (1996) noted the importance of distinguishing between individual risk factors and environmental causes of disease. Rose (1992) suggested that the causes of individual differences in disease may not be the same as the causes of differences between populations.

These population determinants are the focus of much of the new public health and health promotion work.

The report of the Commission on Macroeconomics and Health, published by WHO in 2001, sup- ports the economic as well as humanitarian value of improving the health of poor and disadvantaged populations in all countries. Since the determinants of health and the most powerful means for health improvement are located at the global and regional levels, and since most public health work lies outside the conventional market framework and remains the responsibility of government, its “public good” nature can be stressed and is gaining acceptance. Reducing health inequalities requires action on the underlying structural determinants of social and economic deprivation and serious intersectoral action is required (Beaglehole & Bonita, 2003). Beaglehole and Bonita call for better education of public health practitioners to give them the skills for this type of work.

A new enthusiasm for promoting mental health

Along with enthusiasm for the new public health, over the past 20 years the interest in promoting mental health has grown (Friedli, 2002; Secker, 1998; Trent & Reed, 1992–6; Tudor, 1996; WHO, 1981, 2002). The fields of mental health and public health have a long history of weak interactions, despite the possibilities for a stronger working relationship (Cooper 1990; Goldberg &

Tantam, 1990; Goldstein, 1989). This relates mainly to the stigma of mental illness, and vagueness in the concepts of mental health and mental illness. The interest has grown recently for two main reasons. First, mental health is increasingly seen as fundamental to physical health and quality of life and thus needs to be addressed as an important component of improving overall health and well-being. The concept of health enunciated by WHO as encompassing physical, mental and social well-being is more and more seen as a practical issue for policy and practice. In par- ticular, there is growing evidence to suggest interplay between mental and physical health and well-being and outcomes such as educational achievement, productivity at work, development

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PROMOTING MENTAL HEALTH 4 • PROMOTING MENTAL HEALTHPROMOTING MENTAL HEALTH

of positive personal relationships, reduction in crime rates and decreasing harms associated with use of alcohol and drugs. It follows that promoting mental health through a focus on key determinants should not only result in lower rates of some mental disorders and improved physical health but also better educational performance, greater productivity of workers, improved relationships within families and safer communities.

Second, there is wide acknowledgement of an increase in mental ill-health at a global level.

The authoritative work undertaken by WHO and the World Bank indicates that by the year 2020 depression will constitute the second largest cause of disease burden worldwide (Murray & Lopez, 1996). The global burden of mental ill-health is well beyond the treatment capacities of developed and developing countries, and the social and economic costs associated with this growing burden will not be reduced by the treatment of mental disorders alone (WHO, 2001c). Evidence also indicates that mental ill-health is more common among people with relative social disadvantage (Desjarlais et al., 1995).

The global focus on mental ill-health has sparked interest in the possibilities for promoting mental health as well as preventing and treating illness. There is a need to ensure that appropriate care and treatment is in place for those experiencing mental ill-health while at the same time developing a greater focus on promotion of mental health and prevention of illness, and giving priority to each of these in global, national and local policy and practice. Many policy-makers, practitioners and academics working in public health are committed to addressing health inequalities resulting not only from biological and behavioural characteristics but also from a maldistribution of resources. Consequently, health promotion, including the promotion of mental health and well- being, is as much an emerging political and social project as a health project (Mittelmark, 2003).

Promoting mental health is an integral part of public health

Mental health and mental illness are determined by multiple and interacting social, psychological and biological factors, just as are health and illness in general. The clearest evidence relates to the risks of mental illness, which in the developed and developing world are associated with indicators of poverty, including low levels of education. The association between poverty and mental disorders appears to be universal, occurring in all societies irrespective of their levels of development. Factors such as insecurity and hopelessness, rapid social change and the risks of violence and physical ill-health may explain this greater vulnerability (Patel & Kleinman, 2003). Economic levels also have important implications for family functioning and child mental health (Costello et al., 2003; Rutter, 2003).

Mental, social and behavioural health problems may interact to intensify each other’s effects on behaviour and well-being. Substance abuse, violence and abuses of women and children on the one hand, and health problems such as heart disease, depression and anxiety on the other, are more prevalent and more difficult to cope with in conditions of high unemployment, low income, limited education, stressful work conditions, gender discrimination, unhealthy lifestyle and human rights violations (Desjarlais et al., 1995, p. 6).

Mental health for each person is affected by individual factors and experiences, social interaction, societal structures and resources and cultural values. It is influenced by experiences in everyday life, in families and schools, on streets and at work (Lahtinen et al., 1999; Lehtinen, Riikonen &

Lahtinen, 1997). The mental health of each person in turn affects life in each of these domains

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and hence the health of a community or population. Some of the newest research across the disciplines of genetics, neuroscience, the social sciences and mental health involves elaborations of ideas about the impact societies have on human life over and above the sum of the impact of the individual members of the society (as discussed in Chapter 10).

Ethnographic studies show how people living in adverse environments and social settings such as the slums of Mumbai are faced with problems such as migration and displacement, poor conditions, unequal distribution of amenities, demolition of housing, homelessness and communal and ethnic disharmony. These in turn shape local experience and affect the mental health of the inha- bitants and the community. Hopelessness, demoralization, addictions, distress, anger, depression, hostility and violence can all be linked back to these experiences and problems (Parkar, Fernandes

& Weiss, 2003).

Despite this, mental health and mental illness are largely viewed as residing outside the public health tradition with its fundamental concepts of health and illness as multifactorial in origin (Cooper, 1993) and of there being a continuum between health and illness (Rose, 1992). The consequences are twofold. First, the opportunities for improving mental health in a community are not fully exploited. Second, organized efforts by countries to reduce the social and economic burden of mental illnesses tend to focus mostly on the treatment of ill individuals.

Mental illnesses are common and universal. Worldwide, mental and behavioural disorders represented 11% of the total disease burden in 1990, expressed in terms of disability-adjusted life years (DALYs). This is predicted to increase to 15% by 2020. Depression was the fourth largest contribu- tor to the disease burden in 1990 and is expected to be the second largest after ischaemic heart disease by 2020 (WHO, 2001c). Mental health problems also result in a variety of other costs to the society (WHO, 2003). Yet mental illness and mental health have been neglected topics for most governments and societies. Recent data collected by WHO demonstrates the large gap that exists between the burden caused by mental health problems and the resources available in countries to prevent and treat them (WHO, 2001a). In contrast to the overall health gains of the world’s populations in recent decades, the burden of mental illness has grown (Desjarlais et al., 1995;

Eisenberg, 1998).

This neglect is based at least in part on confusion and false assumptions about the separate concepts of mental health and mental illness. Until now, the prevailing stigma surrounding mental illness has encouraged the euphemistic use of the term “mental health” to describe treatment and support services for people with mental illness. This usage adds to confusion about the concept of mental health as well as that of mental illness.

In most parts of the world the treatment of mental illness was alienated from the rest of medicine and health care at least until recently. In the isolated setting of asylums, practitioners saw many seemingly incurable patients. The supposed incurability of insanity and melancholy made practitioners believe the causes were entirely biological. The idea has since persisted that prevention of mental illness is “all or none” (Cooper, 1990). This concept of an irreversible process once a person becomes ill leads to a sense of therapeutic nihilism as well as a belief that prevention is either absolute and one-dimensional or unlikely to succeed at all. Furthermore, the promotion of mental health is sometimes seen as far removed from the problems of the “real world” and there are concerns it could shift resources away from the treatment and rehabilitation of people affected by mental illness.

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The twin aims of improving mental health and lowering the personal and social costs of mental ill-health require a public health approach.¹ Within a public health framework, the activities that can improve health include the promotion of health, the prevention of illness and disability, and the treatment and rehabilitation of those affected. These are different from one another, even though the actions and outcomes overlap. They are all required, are complementary, and no one is a substitute for the other.

Mental health is more than the absence of mental illness

As already noted, mental health implies fitness rather than freedom from illness. In 2003, George Vaillant in the USA commented that mental health is too important to be ignored and needs to be defined. As Vaillant pointed out, this is a complex task. “Average mental health” is not the same as “healthy”, for averaging always includes mixing in with the healthy the prevailing amount of psychopathology. What is healthy sometimes depends on geography, culture and the historical moment. Whether one is discussing state or trait also needs to be clear – is an athlete who is temporarily disabled with a fractured ankle healthy or unhealthy? Similarly, is an asymptomatic person with a history of bipolar affective disorder healthy or unhealthy? There is also “the two-fold danger of contamination by values” (Vaillant, 2003, p. 1374) – a given culture’s definition of mental health can be parochial, and, even if mental health is “good”, what is it good for? The self or the society? For fitting in or for creativity? For happiness or for survival? Even so, Vaillant advocates that common sense should prevail and that certain elements have a universal importance to mental health; just as despite every culture having its own diet, the importance of vitamins and the five basic food groups is universal.

No health without mental health: mental health and behaviour

Physical health and mental health are closely associated through various mechanisms, as studies of the links between depression and heart and vascular disease are demonstrating (see Chapter 11).

Many studies since the 1950s support the idea that medically ill patients with negative attitudes have worse outcomes than those with more positive attitudes. Now studies demonstrate that healthy people who are optimistic have lower death rates from heart disease than those who are pessimistic, even taking other risk factors into account (Giltay et al., 2004). The relevance of emo- tional status to the maintenance of good physical health and recovery from physical illness is now well substantiated, as is the converse.

Physical ill-health is detrimental to mental health as much as poor mental health contributes to poor physical health (Herrman & Jané-Llopis, in press). For example, malnourishment in infants can increase the risks of cognitive and motor deficits, and heart disease and cancer can increase the risk of depression (Blane et al., 1996; Marmot & Wilkinson, 1999). Strong evidence establishes depression as a risk factor for heart disease, and some national health policies now assert that the causal link is undeniable. The importance of short-term mental stress as a trigger for the

1 A number of books and articles have discussed this point. For example: CDHAC, 2000; Christodoulou, Lecic-Tosevski

& Kontaxakis, 1999; Goldberg & Tantam, 1990; HEA, 1997; Healthy Living, 2003; Herrman, 2001; Hosman, 2001;

Jenkins, 2001; Jenkins & Ustun, 1998; Lehtinen, Riikonen & Lahtinen, 1997; Mrazek & Haggerty, 1994; Newton, 1988;

Paykel & Jenkins, 1994; Rowling, Martin & Walker, 2002; Sartorius, 1998, 2002; Secker, 1998; VicHealth, 1999, 2005;

Walker, Moodie & Herrman, 2004; and WHO, 1998b.

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development of myocardial infarction and sudden death in people with heart disease is no longer questioned. The notion that hypertension may arise through psychological stress, in turn related to occupational and other adverse factors in the environment, remains contentious, but the idea is an old one (Esler & Parati, 2004). Low control at work and poor social support have important influences on both physical health (e.g. cardiovascular morbidity) and psychological health (e.g.

depression) (Kopp, Skrabski & Szedmák, 2000). Many of the people living with HIV/AIDS and their families experience stigma and discrimination as well as depression and anxiety and other mental illnesses (WHO, 2001c). Persistent pain is linked with suffering and lost productivity around the world. A WHO study across 15 centres in Asia, Africa, Europe and the Americas examined the relationship between pain and well-being in over 5000 individuals. Those with persistent pain were over four times more likely to have an anxiety or depressive disorder than those without pain (Gureje et al., 1998).

Research has pointed to two main pathways through which a person’s mental and physical health and functioning mutually influence each other over time (WHO, 2001c), interacting with social and environmental influences on health. The first pathway is directly through physiological systems, such as neuroendocrine and immune functioning. The second pathway is through health behaviour. The term health behaviour covers a range of activities, such as eating sensibly, getting regular exercise and adequate sleep, avoiding smoking, engaging in safe sexual practices, wear- ing safety belts in vehicles and adhering to medical therapies. The physiological and behavioural pathways are distinct yet interact with one another and the social environment: health behaviour can affect physiology (for example, smoking and sedentary lifestyle decrease immune functioning) and physiological functioning can influence health behaviour (for example, tiredness leads to accidents). In an integrated and evidence-based model of health, mental health (including emotions and thought patterns) emerges as a key determinant of overall health. Anxious and depressed moods, for example, initiate a cascade of adverse changes in endocrine and immune functioning and increase susceptibility to a range of physical illnesses. For instance, stress is related to the development of the common cold (Cohen, Tyrrell & Smith, 1991) and delays wound healing (Kielcot-Glaser et al., 1999).

While many questions remain concerning the specific mechanisms of these relationships, it is clear that poor mental health plays a significant role in diminished immune functioning, the development of certain illnesses and premature death. As WHO points out:

Understanding the determinants of health behaviour is particularly important because of the role that health behaviour plays in shaping overall health status. Noncommunicable diseases such as cardiovascular disease and cancer … are strongly linked to unhealthy behaviour such as alcohol and tobacco use, poor diet and sedentary lifestyle. Health behaviour is also a prime determinant of the spread of communicable diseases such as AIDS, through unsafe sexual practices and needle sharing …

The health behaviour of an individual is highly dependent on that person’s mental health. Thus, for example, mental illness or psychological stress affect health behaviour (WHO, 2001c, p. 9).

In young people, depression and low self-esteem are linked with smoking, binge drinking, eating disorders and unsafe sex, putting them at risk of a range of diseases including sexually transmit- ted diseases such as AIDS (Patton et al., 1998; Ranrakha et al., 2000). Depression in other age groups is linked with social isolation, alcohol and drug abuse and smoking (Hemenway, Solnick

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& Colditz, 1993). Mood disorders can lead to an increased risk of accidents and injuries and poor physical and role function (Wells et al., 1989). Other factors such as learning through experience or observation also have an effect on health behaviour. For example, it has been established that drug use before the age of 15 years is highly associated with the development of drug and alcohol abuse in adulthood (Jaffe, 1995). Environmental influences, such as poverty or societal and cultural norms, also affect health behaviour (WHO, 2001c).

There are complex interactions between the determinants of health, behaviours and mental health at all stages of life. A body of evidence indicates that the social factors associated with mental ill-health are also associated with alcohol and drug use, crime and dropout from school.

An absence of the determinants of health and the presence of noxious factors also appears to have a major role in other risk behaviours, such as unsafe sexual behaviour, road trauma and physical inactivity. For example, a lack of meaningful employment may be associated with depression and alcohol and drug use. This may in turn result in road trauma, the consequences of which are physical disability and loss of employment (Walker, Moodie & Herrman, 2004). Kleinman (1999) describes the clustering of mental and social health problems in “broken communities” in shantytowns and slums and among vulnerable and marginal migrant populations: civil violence, domestic violence, suicide, substance abuse, depression and post-traumatic disorder cluster and coalesce. He calls for a research agenda and innovative policies and programmes “that can prevent the simply enormous burden that mental illness has on the health of societies resulting from the variety of forms of social violence in our era” (Kleinman, 1999, p. 979). The corollary is the need for the development and evaluation of programmes that on the one hand control and reduce such clusters and on the other hand assist people and families to cope in these circumstances.

A life-course approach helps in understanding social variations in health and mental health.

Exposure to experiences and environments accumulate throughout life, increasing the risk of adult morbidity and premature death if they are disadvantageous. Exposure to health-damaging environments during adulthood may accumulate on top of health disadvantage during childhood (Holland et al., 2000). This approach takes into account the complex ways in which biological, economic, social and psychological factors interact in the development of health and disease. Such an approach reveals biological and social “critical periods” during which policies that will defend individuals against an accumulation of risk are particularly important. The policies of modern

“welfare states” can be seen to contribute in many ways to present-day high standards of health overall in developed countries (Bartley, Blane & Montgomery, 1997).

The evidence is clear: mental health is fundamentally linked to physical health outcomes. Mental health status is a key consideration in changing the health status of a community. Health and behaviour are influenced by factors at multiple levels, including biological, psychological and social. Interventions that involve only the individual, such as training in social skills or self-control, are unlikely to change long-term behaviour unless family, work and broader social factors are aligned to support a change (Institute of Medicine, 2001).

Objectives and actions of mental health promotion

This [20th] century has seen greater gains in health for the populations of the world than at any other time in history. These gains have been made partly as a result of improvements in income and education, with accompanying improvements in nutrition, hygiene, housing, water supply and sanitation. They are also the result of new knowledge about the causes, prevention and