How can you promote and prevent mental illness?

5. Preventing mental illness and promoting mental well-being

Abstract

Policies to promote mental well-being and prevent mental ill-health have also been shown to make a meaningful impact on population health, and represent good value-for-money. Effective interventions to promote mental health, build mental resilience, and prevent mental ill-health can be found across the life course and in multiple settings. This chapter sets out some of the compelling reasons that promotion and prevention activities are a critical part of a high-performing mental health system, summarises the extent to which OECD countries have mental health promotion and prevention policies and interventions in place, and gives some recommendations of promising policies that could be used across OECD countries.

Introduction

Many of the protective factors for good mental health go beyond the scope of mental health systems or programmes designed specifically to strengthen or protect mental health. Social, economic and cultural factors, such as employment status, income, physical health, experiences during childhood and adolescence, all have a significant impact upon mental health across the life course. However, programmes or interventions designed to promote mental well-being and prevent mental ill-health have also been shown to make a meaningful impact and represent good value-for-money.

Interventions to promote mental health, build mental resilience, and prevent mental ill-health can be found across the life course and in multiple settings. Interventions to promote good mental-health and prevent mental ill-health are particularly in infancy, childhood, and adolescence, and most OECD countries are taking steps to promote mental well-being for children in schools. Workplaces, too, are common sites where OECD countries are taking steps to protect against risks to mental health, and some are introducing mental health promotion programmes as well. Increasingly, mental health promotion and prevention is seen as a cross-government, multi-sectoral effort, which includes efforts such as promoting good mental health literacy, a focus on positive mental health, training for front line actors, as well as comprehensive approaches to preventing suicide.

This chapter starts by setting out some of the compelling reasons that promotion and prevention activities are a critical part of a high-performing mental health system, summarises the extent to which OECD countries have mental health promotion and prevention policies and interventions in place, and gives some recommendations of promising policies that could be used across OECD countries. There are strong links between the discussion in this chapter and many of the other chapters in this report, and in particular with Chapter 4 on multi-sectoral and integrated policies, and Chapter 6 on good governance and leadership, which includes efforts to reduce stigma around mental health conditions.

Why do mental health systems need to prevent mental illness, and promote mental well-being?

In the OECD Mental Health Performance Framework, a high-performing mental health system should prevent mental illness and promote mental well-being. Good prevention and promotion policies should:

• Reduce the rate of suicide;

• Ensure mental health literacy;

• Make schools mental health-friendly environments that build resilience;

• Ensure that workplaces foster good mental health;

• Enable front line actors to recognise and respond to mental distress;

• Make it easy for individuals to seek help.

Mental health exists on a spectrum – and includes both positive mental health and poor mental health

One in every two people in OECD suffer from mental health problems in their lives and the direct and indirect cost of mental illness are estimated to exceed 4% of GDP [OECD/European Union, 2020[1]]. It is essential to support those with mental health issues by providing medical care, social support and financial aid. At the same time, preventing mental ill-health and promoting good mental well-being are critical parts of a high performing mental health system.

Mental health can be understood to exist on a spectrum, from positive mental health to poor mental health, and can also be conceptualised using the ‘dual continuum model’ for mental health, which sets out that mental illness and mental health are on related but different axes. Someone with a mental illness can have good mental health [i.e. be managing it well and experiencing good mental well-being], just as someone with no mental illness can experience poor mental health.

The purpose of health promotion and disease prevention programs is keeping people healthy, and improving people’s health. While disease prevention is a measure for reducing a risk of diseases and a severe condition of diseases. Both approaches are intended to result in increasing the quality of life and reducing the mortality of diseases.

Health promotion was discussed in the first International Conference on Health Promotion held in Ottawa in 1986 with a growing expectation for better public health. After 30 years of this conference, United Nations General Assembly adopted in 2015 “The 2030 Agenda for Sustainable Development”, aiming that all human being can fulfil their potential in dignity and equality in a healthy environment. One of the 17 goals of Sustainable Development Goals [SDGs] focus on ensuring healthy lives and promoting well-being for all people at all ages [WHO, 2017[2]].

Mental health promotion in this chapter includes ‘aiming to promote positive mental health by increasing psychological well-being, competence and resilience, and by creating supporting living conditions and environments’ [Saxena, Jané-Llopis and Hosman, 2006[3]]. Mental ill-health prevention is includes ‘having as its target the reduction of symptoms and ultimately of mental disorders. It uses mental health promotion strategies as one of the means to achieve these goals’ [McDaid, Hewlett and Park, 2017[4]; Saxena, Jané-Llopis and Hosman, 2006[3]].Mental health promotion encourages positive mental health by increasing psychological well-being and creating supporting living conditions and environments. Mental disorder prevention has as its target the reduction of symptoms and ultimately of mental disorders [Saxena, Jané-Llopis and Hosman, 2006[3]].

Preventing mental ill-health and promoting mental well-being has taken on a new importance – and new complexity – in light of the COVID-19 crisis

Up until 2020, adult mental health status was largely stable but children and young people were showing signs of increased mental distress

Even prior to the COVID-19 pandemic, reviews of available evidence have suggested some rising rates of self-reported mental distress, especially amongst adolescents [Choi, 2018[5]; Collishaw, 2015[6]; Blomqvist et al., 2019[7]]. Studies have pointed towards higher rates of internalised mental health symptoms especially amongst girls, higher rates of teenagers reporting ‘feeling low’ in the international HBSC survey or reporting feelings of anxiety about school work in the OECD’s PISA study, and some instances of rising rates of self-harm and suicidal ideation [Choi, 2018[5]; OECD, 2018[8]; OECD., 2017[9]; McManus et al., 2019[10]]. More time spent online, and stresses and pressures arising from significant social media use, have also been pointed to as areas of new concern for children and adolescents’ mental health, even if academic evidence for these trends remains partial [OECD, 2018[8]; Kowalski et al., 2014[11]]. Other literature suggests that an apparent increase in prevalence might be due to growing awareness and help-seeking behaviours children and young people and their parents, a broader classification of disorders, or more assiduous recording practices [Choi, 2018[5]; Comeau et al., 2019[12]].

During the COVID-19 pandemic, young people’s mental health appears to have worsened faster than the general population. For example, young people in Belgium and France were more likely to be experiencing depression or anxiety than the all-age population average in 2020, while in a survey of young people in the United Kingdom 80% of respondents stated that the pandemic had made their mental health worse, with 41% stating it had made their mental health ‘much worse’ [Santé Publique France, 2020[13]; Sciensano, 2020[14]; Young Minds UK, 2020[15]]. Young Minds UK undertook two mental health surveys, in September 2020 and June-July 2020: in September, just after schools had reopened, there was a slight rise in indicators such as the percentage of respondents feeling lonely or isolated, feeling anxiety [Young Minds UK, 2020[15]].

During 2020, population mental health status worsened across OECD countries

Overall levels of mental distress have not changed significantly across the past two decades. IHME data and other sources suggest that prevalence is fairly consistent, and the OECD average has been around 18% since 2002 [IHME, 2018[16]; OECD, 2015[17]]. The COVID-19 crisis across the course of 2020 has changed this trend. Overwhelmingly, surveys of OECD populations showed that mental health had worsened: in Australia 78% of respondents reported their mental health had worsened [Newby et al., 2020[18]]; in Austria 43.5% of respondents reported the psychological impacts of the COVID-19 outbreak as moderate or severe [Traunmüller et al., 2020[19]]; 50% of Canadians reported worsened mental health since the start of the pandemic, and 6 in 10 said their mental health had worsened ‘a lot’ [CAMH, 2020[20]]; in Luxembourg 37% reported their mental health had declined [Luxembourg Chronicle, 2020[21]]; in the United States 40.9% of 5 470 survey respondents in June 2020 reported an adverse mental or behavioural health condition [Czeisler et al., 2020[22]].

For example, regarding the prevalence of people who experienced anxiety, national surveys showed that anxiety increased in all countries in 2020 compared to previous years. New Zealand conducted the research between 15 and 18 April 2020 and showed 15.6% of anxiety prevalence, which is much higher than in 2017 [Cabarkapa et al., 2020[23]; Ministry of Health NZ, 2020[24]]. In Belgium, survey results point to significant increases in both self-reported anxiety [from 11% to 23%] and depression [from 10% to 20%] between 2018 and 2020 [Sciensano, 2020[14]]. In Czech Republic, the prevalence of anxiety disorders significantly increased between 2017 and 2020 [Winkler et al., 2020[25]]. Surveys in the United Kingdom and Denmark have also suggested that more people are feeling anxious and are having more difficulties staying upbeat [ONS, 2020[26]; Sønderskov et al., 2020[27]]. In the United Kingdom, where anxiety levels increased significantly from 21% in 2019 to 50% in 2020, this could show particularly high levels of anxiety amongst the population, but may also be influenced by reporting factors such as a population more open to discussing their mental state or a more sensitive survey instrument. In Canada, a national poll by Mental Health Research Canada, found that as of December 2020, levels of high anxiety and high depression among Canadians were elevated. The proportion of Canadians reporting high levels of anxiety was four times pre-COVID levels, with a quarter [23%] reporting that they had high anxiety, up from 6% before the outbreak. The proportion of Canadians reporting high depression [15%] was more than double pre-COVID estimates [6%] [Mental Health Research Canada, 2020[28]].

While it is difficult to compare prevalence of mental distress, and changes in mental distress, between countries given the differences in survey instruments, self-reported stress, worry and anxiety were higher in some countries than others in mid-2020. A survey by the Commonwealth Fund in August 2020 found that at least 10% of adults reported experiencing stress, anxiety, or great sadness that was difficult to cope with alone since the outbreak started, with a particularly high percentage of adults experiencing this mental distress in Canada [26%], the United Kingdom [26%] and the United States [33%] [Figure 5.1].

Figure 5.1. Levels of mental distress were higher in some countries than others in August 2020

Percent of adults who reported experiencing stress, anxiety, or great sadness that was difficult to cope with alone since the outbreak started

Note: Percentage of adults who reported experiencing stress, anxiety, or great sadness that was difficult to cope with alone since the outbreak started. Differences between the United States and all other surveyed countries were statistically significant at the P