Preventing Mental Ill-Health

Informing public health planning and mental health practice

Jennifer Newton

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781136199462
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Is there any evidence that we can reduce the incidence of mental ill health? Is it possible to prevent recurrence of mental ill health?

Aspirations to achieve both these goals have featured in mental health policy and practice for over 100 years. This comprehensive and accessible book draws on research on the development and persistence of behavioural problems in childhood, adult depression and schizophrenia. The association between social disadvantage and mental ill health, as well as the need for preventive care to start from conception and the crucial importance of maternal mental health, are discussed.

A variety of prominent programmes which have good evidence of efficacy are described. These include:

• Targeted approaches with individuals and families
• Macro policies affecting housing and employment
• Lifestyle contributions such as diet and exercise

However, some attempts to achieve preventive benefits have not succeeded, and reflecting on these problems is an important feature of this review.

Jennifer Newton has written extensively on these issues for over twenty years, and her careful examination of the research literature provides a succinct overview of the state of current knowledge which will benefit mental health professionals, and students of health psychology and public health. It also takes a life course perspective, and considers how, when and why vulnerability persists through childhood into adult life, so will interest those whose work focuses on child well-being.

1
Introduction

To focus a book on prevention suggests there might indeed be some magic pill, a fish oil capsule perhaps, or other chemical or a psycho-social equivalent, that we could take or administer to others to immunize us against the often miserable, sometimes frightening, sometimes confused, occasionally exciting feelings we call mental illness. In a sense there is – we need to inherit the right genes, be kept safe from accidental damage and traumatic experience, feel the love and protection of a parent or parent figure throughout childhood, learn the life skills to keep us safe, and find our own place in society alongside people or at least one person who cares about us. Easy. But how important is each one of these, and how far can strength in one compensate for vulnerability in another?

The following 11 chapters tell this story, including the magic pill and the fish oil detour, but starting by questioning the words and assumptions behind the concept of prevention, and the reasons for our interest in this. Discussion of the possibilities requires engaging with hugely contested and controversial issues and ideas, not least of which is the choice of words to describe mental ill-health and whether it matters. Chapters 2 and 4 take these two areas of controversy in turn, setting out the basis of enquiry for subsequent chapters. In this first chapter, these difficulties will be side-stepped, to explore the increasing interest in prevention in policy, to provide a brief account of early progress, and to explain how this informs the structure of this book.

Why so much interest in prevention now?

To a large extent, the answer is – money. First and foremost, the realization that the increasing wealth of the Western world is not reflected in increasing happiness (Layard, 2006a). Second, that unhappy people, as well as those with diagnosed mental illness, are more likely to be found in poorer districts within a society, or to live in relatively poor material circumstances, these differences becoming ever more visible in wealthier countries (Wilkinson, 1996). Third, that those with poor mental health cost the economy a great deal.

The numbers of books appearing in the past few years on happiness, and on inequalities in health, attest to our renewed fascination with what is now popularly referred to as ‘wellbeing’. Many question why, with all the wealth of the developed world, their peoples are not happier. Various estimates of population happiness do not show a greater proportion of happy people as GDP rises; in fact, in some cases changes can go in the opposite direction (Wilkinson, 1996; Layard, 2006a). Richard Easterlin was one of the first to describe the paradox that at any one point in time, happiness and income levels are correlated, and over the short term income and happiness continue to go together – happiness falls in an economic downturn, and rises during an expansion – but over a period of 10 years or more, happiness does not rise with rising GDP, a finding confirmed by drawing on data from developing countries and Eastern European countries as well as those in the West (Easterlin et al., 2010). Those exploring the differences between countries are emphasizing social factors such as trust, equality, full employment, crime, and willingness to help one another as likely to account for much of the difference (e.g. Putnam, 2000), and see a link between these societal characteristics not only with subjective happiness, but with mental and physical ill-health and with life expectancy (Marmot Review, 2010).

But the concern with cost is also linked to population change, and the increasing challenge for governments of funding welfare services to support people who are out of the labour market. This concern pre-dates the banking crisis that has shaken governments in the Western world over recent years, and policy has been shifting the priority from treatment and care towards prevention and public health for many years, as exemplified by an opening statement of the Report of the Surgeon General in the US (1999: 3):

The report was prepared against a backdrop of growing awareness in the United States and throughout the world of the immense burden of disability associated with mental illnesses. In the United States, mental disorders collectively account for more than 15 percent of the overall burden of disease from all causes and slightly more than the burden associated with all forms of cancer (Murray & Lopez, 1996). These data underscore the importance and urgency of treating and preventing mental disorders and of promoting mental health in our society.

(emphasis in original)

The Murray and Lopez reference is to the major study sponsored by WHO and the World Bank and based at Harvard University known as the Global Burden of Disease study, which calculated the health effects of more than 100 diseases and injuries in eight regions of the world, starting in 1990, and updated in 2004. It provided a comprehensive and internally consistent estimate of mortality and morbidity by age, gender and region, using a new measure of ‘disease burden’ – a calculation of years of life lived with disability of a defined level of severity, or years of life lost through premature death (together described as the disability adjusted life years or DALYs). As a proportion of total DALYs, cardiovascular diseases as a group were top of the list of days lost (18.6%) in established market economies in 1990, but ‘all mental illness’ came in second place with 15.4%, slightly ahead of cancers at 15%. Days lost to alcohol use and respiratory conditions, the next largest problems, fall a long way short of these figures, both just under 5%. Separating the cardiovascular and mental illness categories into specific disorders shows that unipolar major depression is the mental illness diagnosis contributing to the most DALYs, and in ‘global burden’ this is second only to ischaemic heart disease (Murray and Lopez, 1996).

The various costs associated with mental ill-health are not simply the costs to governments of treatment (including expenditure on services and drugs), or of state benefits to sustain those not working, but also the cost to industry of lost productivity through absence from work or from people working below full capacity, and the human costs to individuals and their families of reduced quality of life and often reduced income. About 7% of the UK population are without work and receiving incapacity benefit due to long-term health conditions or disabilities (Black, 2008); the average UK employee takes 6.4 days of sick leave, and over a third of short periods of sick leave (under a week) and about half of longer periods are due to mental health related problems (CBI, 2010). Numbers who are less productive than usual, perhaps reflected in impaired concentration or energy, are unknown, but thought to be substantial – a problem described as ‘presenteeism’ (SCMH, 2007), and bringing more attention now to preventive strategies in the workplace.

Government spending around the world on mental health varies greatly, with 28% of countries not having any allocated budget, and a further 36% allocating only 1% or less of public health funds to mental health (WHO, 2001). A study commissioned by the Alberta Mental Health Board (Canada) compared spending by a selected eight other developed countries with its own, finding the UK government to spend the largest proportion of the health budget on mental health (12%), more than twice the proportion allocated by Canada (5.4%) (Lim et al., 2008), though it is noted that these comparisons are not wholly reliable given the difficulty in ensuring comparable budget scope. The UK’s New Horizons policy for mental health from 2010 quoted a more recent figure of 14% of NHS funds spent on mental health, and taking government, industry and individual and family cost together, estimates the total as £77 billion for 2003 (calculations by SCMH, 2007), a cost it suggests may double within 20 years. This presumably reflects the fact that by 2009, mental ill-health had overtaken cardiovascular diseases as having the highest total burden in the UK, with 26% of DALYs lost due to mental ill-health, and expected to rise to 31% by 2030 (DH, 2009b).

Funding associated costs is the worry – the challenge faced by public services that rely to a large extent on funds from a shrinking working population. Across the world, life expectancy is increasing, and the dependency ratio with it. For instance, the proportion of the population over the age of 65 in the UK is projected to rise from 16% in 2008 to 23% in 2033, meaning that there were 3.2 people of working age for each person of state pensionable age in 2008, but this will only be 2.8 by 2033 after taking account of increases in retirement ages planned during this period (ONS, 2009a). Given the correlations between dementia and age, many dramatic statistics have been published in recent years about the ‘global epidemic’ of Alzheimer’s disease (e.g. Brookmeyer et al., 2007). Recent UK calculations are that spending on dementia will rise from 66% of all mental health service costs to 73% by 2026, and total spending on mental health will rise by over 40% (McCrone et al., 2008). Public policy in the UK and elsewhere has been responding to this challenge by looking for all kinds of cost savings, as public service arrangements come under strain. Keeping people of all ages out of the most expensive care options – hospitals and nursing homes – has been top of the list for many years already.

Not surprisingly, options that may prevent ill-health and disability are currently gaining much greater prominence, as are policies that bring people who may hitherto have considered themselves, or been considered by others, as disabled back into the work force (DH, 2009a). This change is one that many will welcome, along with a major shift in emphasis from a treatment focus to prevention towards inclusion and recovery (as defined by the service user), and towards social care and support deriving from communities, other people with similar problems, the individual themselves, and families, rather than the state, and for which the case is clearly laid out by the government (DH, 2008).

What have we tried in the past, and what did we learn?

The possibility of preventing mental illness has been a focus of policy and practice for at least 100 years, most notably among philanthropists and reformers; sociologists, psychotherapists and social psychiatrists; and psychiatrists attached to the military services.

Reformists and philanthropists

Some of the early reformists of treatment services, such as Philippe Pinel (1745– 1820, whose grandson Samuel was the first to describe it as le traitement moral (Tuke, 1813)), believed mental ill-health had psycho-social causes. Pinel emphasized the importance of individual sentiments and their social context, such as being held in esteem, being treated with respect, retaining dignity (Gerard, 1997: 388), and the role of extreme experiences of frustration, disappointment and humiliation that he believed typically preceded an episode of ‘mania or mental alienation’ (Gerard, 1997: 389). The treatment he provided at the Bicêtre hospital in Paris also emphasized a healthy diet, firm management to ensure order, but through kindness, not force, and used recovering patients as attendants with important roles in creating a respectful therapeutic climate. In England William Tuke followed his example at the York Retreat (Tuke, 1813). Such therapy was far from typical of the time, when in fact ‘manic’ patients in many hospitals were still frequently restrained with chains, and patients in many hospitals for many decades after this experienced inhumane treatment, as Clifford Beers describes, documenting his own experiences in A Mind that Found Itself (published in 1908), hoping to stimulate public opinion against them.

An influential American psychiatrist, Adolph Meyer, became interested in Beers’ writing, and persuaded Beers to work with him toward reform of the system, including public education and eventually the prevention of mental illness (Levine, 1981; Leighton, 1982). Meyer wished to integrate the best of the then declining tradition of moral treatment and the associated ideas for the role of the social environment with the more recent ideas on the biology of the brain. Together Meyer and Beers founded first the Connecticut Society for Mental Hygiene, and the following year (1909) in New York, the National Committee for Mental Hygiene.

A similar non-governmental organization, the National Council for Mental Hygiene, was formed in London in 1923, and Clifford Beers spoke at two of its meetings in the first year. As described by Newton (1988), it had six aims, of which the first two related to prevention:

1. The improvement of the Mental Health of the Community. This involves a closer and more critical study of the social habits, industrial life, and environments of the people, with a view to eradicating those factors that lead to mental ill-health and unhappiness and to educating the public in all matters that militate for and against good mental health.
2. To study the causes underlying congenital and acquired mental disease,¹ with a view to its prevention. To further this the Council will promote scientific investigation by competent workers.

Three subcommittees were formed, one to prepare reports on the prevention and early treatment of mental disorders, chaired by Sir Maurice Craig; the other two to work towards the other objectives, relating to the aftercare and treatment of the insane, and on mental deficiency and crime. Preventive proposals centred on child development: good antenatal care (diet, exercise, avoidance of infection), then regular checks on the child and early referral for signs of mental disorder (National Council for Mental Hygiene, 1927).

Both the British and the American mental hygiene organizations developed branches across the country to promote their ideals nationally, and, in line with the changing emphasis in psychiatry, renamed themselves associations for mental health. The hygiene and health movements had much in common, both being concerned with reforming mental hospitals, with community participation and with prevention. But the latter had anti-medical components that increased with time, and the rationale for moving away from institutional care became primarily social. From the 1960s, ideas relating to culture, social class, stress, social disorganization and unhealthy roles became prominent, and a new academic discipline came to the fore known as social psychiatry (Leighton, 1982; see Newton, 1988).

In the early days of the mental hygiene movement, however, child guidance centres were arguably the first preventive mental health service, numbers increasing rapidly to 617 separate agencies by 1935 in the US. The first child guidance clinic opened in London in 1927. Children with delinquent, difficult or neurotic behaviour could be seen by a psychiatrist, social worker or psychologist. The hope was that these services would lead to a better understanding of child development and psychological causes of difficulty, and by providing timely guidance would reduce current problems and help to prevent more serious problems later in life (Sampson, 1980). Their focus was soon extended to include educational problems, and their remit then greatly increased.

In the US, the origins of child guidance clinics were born from aspirations to prevent juvenile delinquency by the Commonwealth Fund, which funded a number of demonstration clinics in the US, and at first included a community outreach approach with a focus on the neighbourhood, school, family and home life. But this shifted quite rapidly towards a professional, institution-based service and a more medical ethos that located the problems in the child. According to Horn (1989), the psychotherapeutic focus and shift towards problems in middle class children were a consequence of this change in emphasis. She illustrates these points in her description of 179 cases seen in a Philadelphia clinic between 1925 and 1944, showing a shift from social to individual problems, from lower class to middle class families, and from referrals from schools to referrals from parents. Jones (1999) finds the same changes in her analysis of case records of the Boston Clinic. Horn notes that the increasing dominance of psychiatrists provided no improvement in positive outcomes compared to that achieved by the educators and social reformers who were early pioneers. Despite some critiques of the ‘medicalization’ of child difficulty (Horn, 1989) the description of the service in the south of England between 1984 and 1996 still showed the staffing to be psychologists, psychiatrists, nurses, social workers and psychotherapists, and to discuss their work in terms of treatment (Thompson et al., 2003). There was, however, during this period a shift in workload from doctors to nurses, and back towards a community outreach approach, which was beginning to be reflected in a higher proportion of working class service users, and engagement with the problems of very young children. The focus remained on the management of the young child’s difficult behaviour and/or sleep problems, and often on the mother’s parenting skills.

The American philanthropists behind the Commonwealth Fund also funded the first English child guidance centres, setting aside $68,000 in 1929 for the English programme (Stewart, 2006). In addition, the fund sponsored the first diploma for psychiatric social work at the London School of Economics in the same year, as it saw this role as central to its approach to supporting the family. In 1931, the fund contributed to one of the first successful child guidance centres in Scotland – conditional on the scheme adhering to its medical approach (led by a child psychiatrist, psychologist, and psychiatric social worker), despite being run by a Catholic nun, Sister Marie Hilda (Stewart, 2006). She combined her religious and therapeutic aspirations as:

to socialise the neurotic and aggressive, encourage the dull and retarded, and redeem the delinquent, and thus to decrease the number of mental breakdowns and to lessen the number of prison inmates in later life. By its constructive methods, the (Notre Dame) Clinic hopes to build up integrated personalities capable of taking their place as members of the family, of the Church and of the State.

(Sister Marie Hilda, in a 1950 pamphlet for the Catholic Truth Society entitled Child Guidance, cited by Stewart, 2006: 68)

The Glasgow Catholic newspaper heralded the opening of the centre with a slightly different summary of the target group: ‘the study and treatment of children who, though given average home and school conditions, remain an enigma to their parents, and by their undisciplined behaviour form one of the chief difficulties of the classroom’ (cited by Stewart, 2006: 61). The role of the psychiatric social worker was initially to help the mother to acquire better habits through simple advice and guidance, such as how to respond to temper tantrums (Horn, 1984). From 1931 onwards, their role appeared to be more supportive and encouraging and less directive, which Horn (1984) describes as due to the professional development of social work. As they became...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface and acknowledgements
• 1 Introduction
• 2 Labels, and why they matter
• 3 Prevalence and distribution of mental ill-health
• 4 Preventing ill-health or promoting wellbeing?
• 5 Depression
• 6 Psychosis
• 7 Events, coping and support
• 8 Mind and body
• 9 Childhood: Secure foundations
• 10 Strengthening support for children: Effective interventions
• 11 Society, status and participation
• 12 Ready to change
• Bibliography
• Index