Look upstream to improve mental health
Our headlines are flooded with mental health crises. It's time to address the real root causes.
A colleague once remarked that people are so busy dealing with the important that they don’t have time to deal with the critical. That applies to the healthcare system as a whole. It is so busy dealing with people who are ill or injured that it doesn’t give much priority to looking upstream and trying to stop people becoming sick in the first place.
That especially applies to the field of mental health and addictions, which has been described as the orphan of the health care system, neglected and underfunded. But in fact mental health problems are among the most common and most expensive health problems today. The Centre for Addictions and Mental Health (CAMH) in Toronto reports that “the disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together.”
CAMH reports that “in any given year, 1 in 5 Canadians experiences a mental health or addiction problem” (including dementia) and that “mental illness is a leading cause of disability” and can markedly shorten life. Not surprisingly, people with mental illness have high rates of unemployment and work absence; at least half-a-million employed Canadians are off work due to a mental health problem every week. The overall societal cost of mental illness cost in Canada in 2011 was estimated in one study to be about $42 billion, with half that being health care costs.
"Simply managing the problems of people with mental disorders or addictions is not enough; we need to reduce the toll of mental health in our communities."
This is why the creation of a new Ministry of Mental Health and Addictions in BC is an interesting development. Time will tell whether it proves to be an important strategy to focus attention on a long-neglected issue or whether, as some have suggested, it divides resources and attention and becomes a problem. One thing is for sure; it highlights the growing importance of mental health problems in society.
But simply managing the problems of people with mental disorders or addictions is not enough; we need to reduce the toll of mental health in our communities. This means the new Ministry needs to focus on why people develop mental health problems in the first place, how we can prevent that happening, and how we can improve the overall mental health of the population.
Happily, BC has developed quite a strong focus on the prevention of mental health problems and on mental health promotion in the past decade. Its 10-year mental health strategy, adopted in 2010 and updated in 2017, states “Research tells us that doing a better job of promoting mental wellness, preventing mental illness and harmful substance use, and intervening at the beginning of illness, especially for our children and youth is a wise investment.”
As with much else in public health, what this means in practice is that we need to look well beyond the health care system, to society as a whole. A recent report from the UK’s Faculty of Public Health suggests what needs to be done.
"We need to look well beyond the health care system, to society as a whole."
First, we need to focus on childhood factors, and in particular, family relationships. Infants and young children need to feel secure in their attachment to their family, which enables them to develop trust in others. Failure to do so “leads to lifelong problems in learning, behaviour, resilience, coping, and both physical and mental health.” Adverse childhood experiences such as abuse, neglect, parental substance use or mental illness compound the problems, and call for early intervention.
In addition to good parenting, the school environment is also important: “The school ethos, mental wellbeing of teachers, relationships with peers and prevalence of bullying all matter.” And as young people transition from school to college or work—“a time of upheaval and uncertainty”—strong relationships with caring friends and adults are important, while loneliness is a problem. This continues into adulthood, where stable relationships and mentally healthy workplaces are important, while unemployment increases the risk of anxiety or depression by 4 to 10 times.
Good mental health benefits us all, but clearly is a much bigger issue than the new Ministry can address on its own. It will need to engage the whole of government and the wider society—schools, workplaces and communities—in creating a mentally healthy society.
Good mental health needs a good start in life
Not only is poor mental health costly to manage, but it also represents a large burden of human suffering and loss of human potential and—to the extent it is preventable—a tragic societal failure. So it is good to see that, finally, we are beginning to pay attention to improving the mental well-being of the population.
The evidence is clear that good mental health begins in infancy and childhood; a good start in life can create more positive and resilient young people, better able to handle adversity when it occurs. This evidence must be used to inform and guide the work of B.C.’s new Ministry of Mental Health and Addictions, the health-care system, the government as a whole and indeed the whole of society.
There are in essence two key approaches: First, creating supportive environments that protect people from known risk factors and provide a positive, mentally healthy situation. Second, providing resources and programs that enable people—especially children—to become resilient, with the skills they need to manage life’s ups and downs. In practice, these two approaches interact and need to complement each other.
One of the key strategies, as with health in general, is to reduce the level of poverty in our society. A 2010 Statistics Canada report noted that Canadians in the lowest income group are three to four times more likely than those in the highest income group to report low levels (poor to fair) of mental health.
"A good start in life can create more positive and resilient young people, better able to handle adversity when it occurs."
Living in poverty is stressful, and, not surprisingly, is associated with higher levels of anxiety and depression, among other things. The effects of poverty are compounded in Indigenous and some other communities by the legacies of colonialism, racism and discrimination, making these important mental-health risk factors to combat.
In a 2007 background document, the Ontario Division of the Canadian Mental Health Association noted “losing stabilizing resources, such as income, employment and housing, for an extended period of time, can increase the risk factors for mental illness,” especially for those who might already be predisposed to mental health problems. Because of the importance of poverty reduction, CMHA Ontario “has been calling for poverty-reduction strategies that increase access to economic and community supports for vulnerable populations.” CMHA B.C. has also recently welcomed the poverty-reduction measures brought in by the B.C. government.
Infants and children are particularly vulnerable to the adverse effects of poverty and colonialism on the family and community environments in which they develop. A 2016 report from the U.K.’s Faculty of Public Health noted that poverty in the early years leads to poor cognitive performance, while in adolescence “it increases risks of depression, substance abuse, and early sexual and criminal activity.” It is not hard to see how these impacts can lead to the perpetuation of the cycle of poverty.
Efforts to buffer the effects of poverty and colonialism, even while working to reduce them, begin in infancy, indeed, even before birth. High-risk or vulnerable parents (such as young, poor and single mothers, or parents with mental health or addiction problems) should be identified and provided with supportive services, both to improve their health in pregnancy and to help them develop better parenting and coping skills.
"The effects of poverty are compounded in Indigenous and some other communities by the legacies of colonialism, racism and discrimination, making these important mental-health risk factors to combat."
A study from the University of Ireland found that “high-quality early childhood enrichment provided through preschool results in enduring gains in children’s social and emotional well-being, cognitive skills, problem behaviours and school readiness.”
But while it might seem intuitive that high-risk families are the ones who need to be reached, it is well established in public health that the majority of cases for most conditions do not occur in the high-risk population but in the far more numerous moderate- and low-risk populations. So all families need to be reached, assessed and offered services, with those found to be at risk provided with more focused, intensive and tailored support, proportionate to their need, an approach known in the U.K. as proportionate universalism.
So any government that is genuinely interested in ensuring the long-term mental well-being of our society has to invest in poverty reduction, support for parents, especially the most vulnerable, and early child development.
Creating mentally healthy communities
The communities in which we live are both physical places and social spaces, and both affect mental wellbeing. A report released by the California–based Prevention Institute in September delves into this issue.
Beginning with a framework that identifies factors in the community most related to medical conditions that show the greatest disparity (and thus are related to environmental, social and economic conditions and the behaviours they shape), the Institute looked at how those factors relate to mental health. They found seven factors in the broad categories of ‘People’ (our social spaces), ‘Place’ and ‘Equitable opportunity’ that “have a particularly strong impact on mental wellbeing.”
There are three social factors - Social networks and trust, Participation and willingness to act for the common good, and Norms and culture; three aspects of the physical environment— look, feel and safety, housing, and arts and cultural expression; and one in the area of equitable opportunity—living wages and local wealth.
"The physical environment also has an impact on mental wellbeing."
The report notes the considerable body of evidence that “strong social networks and connections correspond with significant increases in mental and physical health”, as well as less violence and addiction and even improvements in academic and economic performance. These strong and positive social connections must be built in families, networks of friends and in schools, workplaces and places of worship – even through connection with pets and therapy animals.
A related strategy is to build community capacity to participate and act together to improve things; there is a positive and reciprocal relationship between the community and individual empowerment and there is good evidence that empowerment has significant health impacts. This can include efforts to build a more participatory democratic system. Evidence from Brazilian cities such as Porto Alegre and Belo Horizonte has linked participatory budgeting with improvements in housing, utilities such as water and sanitation, health centres and cultural and recreational facilities, all of which are themselves determinants of health.
"Unattractive, poorly-maintained neighbourhoods are more common in disadvantaged groups."
The third social factor—which is related to the first two—is to change the community’s culture and social norms. We have seen this with respect to smoking and to drinking and driving, both of which are now much less socially acceptable than they were a few decades ago.
Now we see efforts to change the social norms around bullying in school and on the internet, gender and racial discrimination and harassment in the workplace, domestic violence and other issues that have led to significant mental health impacts. The report notes “Positive social norms that foster inclusion and respect for all persons can enhance individual self-esteem and wellbeing.”
The physical environment also has an impact on mental wellbeing. Unattractive, poorly-maintained neighbourhoods are more common in disadvantaged groups. People living there are less likely to have good-looking schools, good parks nearby, shade trees, attractive streetscapes or public art. Moreover, access to attractive, safe, walkable neighbourhoods and parks facilitates physical activity, which in turn improves mental health.
Unpleasant environments convey the message that ‘you don’t matter’, which makes peole feel neglected and worthless, less empowered and less able to take action on these issues. Arguably, people living in such neighbourhoods actually need extra investment in higher quality, better maintained built environments to make up for the deficits in the determinants of mental health that they experience in many facets of their lives.
Then there are the homes we live in. Being homeless is, of course, a major threat to mental wellbeing, but poor housing quality is also a threat to both mental and physical health, as is insecure tenure. We also need to look at how housing design supports—or fails to support—social connection; high-rise buildings are generally worse performers here.
Finally, there is good evidence that “music, dance, and all forms of artwork foster mental wellbeing”, as well as community solidarity; the report suggests ensuring that people have access to the spaces and resources needed for artistic expression.
Like Rome, mentally healthy communities cannot be built in a day—but they can be built. Hear more from Dr. Hancock in the 7th episode of Upstream Radio. See Dr. Hancock speak Closing the Gap: Better health for all. Read more from Dr. Hancock on his website. Article (part one) published 20 September 2017 with the Times Colonist. Article (part two) published 27 September 2017 with the Times Colonist. Article (part three) published 5 October 2017 with the Times Colonist.