The Promotion of Mental Health and the Prevention of Mental and Behavioral Disorders; Surely the Time Is Right
by Nancy J. Davis, Ed.D.
International Journal of Emergency Mental Health, Volume 4, Number 1, Winter 2002
Comments | Post Your Own Comment
They Said It Couldn’t be Done
Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. Margaret Mead, 1958
Human history is replete with accomplishments that conventional wisdom, at one time or another, declared impossible. In 1156 BC, when Egyptian pharaoh Ramses V died of smallpox (plus a possible blow to the head by detractors), the idea that smallpox might someday be driven from the earth was the stuff of fantasy. Throughout the centuries, as smallpox killed millions of people, physicians used many techniques to try to control the disease. It was not until 1776, however, that an English surgeon, Dr. Edward Jenner, experimenting with the Eastern practice of inoculation, discovered that giving a person a small dose of the relatively benign cowpox virus could provide protection against the dreaded smallpox virus (“Jenner,” 2000).
The article is available full-text online.
World Health Organization – The World Health Report
Chapter 1: A public health approach to mental health
This report presents information concerning the current understanding of mental and behavioural disorders, their magnitude and burden, effective treatment strategies, and strategies for enhancing mental health through policy and service development. As the ultimate stewards of any health system, governments must take the responsibility for ensuring that mental health policies are developed and implemented. This report recommends strategies that countries should pursue, including the integration of mental health treatment and services into the general health system, particularly into primary health care. This approach is being successfully applied in a number of countries. In many parts of the world, though, much more remains to be accomplished.
Institute of Medicine. 1988. The Future of Public Health. Washington, DC: National Academy Press
This book contains proposals for ensuring that public health service programs are efficient and effective enough to deal not only with the topics of today, but also with those of tomorrow. In addition, the authors make recommendations for core functions in public health assessment, policy development, and service assurances, and identify the level of government--federal, state, and local--at which these functions would best be handled. An update to this report was released in 2002, The Future of the Public's Health in the 21st Century.
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
Just as the mainstream of public health takes a broad view of health and illness, this Surgeon General's Report on Mental Health takes a wide-angle lens to both mental health and mental illness. In years past, the mental health field often focused principally on mental illness in order to serve individuals who were most severely affected. Only as the field has matured has it begun to respond to intensifying interest and concerns about disease prevention and health promotion. Because of the more recent consideration of these topic areas, the body of accumulated knowledge regarding them is not as expansive as that for mental illness
The Future of the Public's Health in the 21st Century (2002)
This book reaffirms the vision of Healthy People 2010, and outlines a systems approach to assuring the nation’s health in practice, research, and policy. This approach focuses on joining the unique resources and perspectives of diverse sectors and entities and challenges these groups to work in a concerted, strategic way to promote and protect the public s health.
Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series (2006)
This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substance use conditions will benefit from this guide to achieving better care.
The Public Health Foundation: Developing a public mental health approach
The Mental Health Foundation was established in 1949 as a charity that funded clinical research - undertaken by academic researchers - into the causes, treatment and care of mental illness.1 The Foundations grants programme broadened in subsequent decades to include support for innovative services provided by voluntary organisations. From the early 1990s the Foundation also began to develop in-house capacity to undertake its own research work and to support and evaluate good practice initiatives. In 1997 the Foundation commenced a major programme of work on children and young people's mental health, Bright Futures.
Public Health Infrastructure – Healthy People 2010
In public health, a strong infrastructure provides the capacity to prepare for and respond to both acute and chronic threats to the Nation’s health. The public health infrastructure comprises the workforce, data and information systems, and public health organizations. Research also is a key activity of public health infrastructure in identifying opportunities to improve health, strengthen information systems and organizations, and make more effective and efficient use of resources. This document highlights the summary of objectives related to the public health infrastructure based on goal #23 of Healthy People 2010, which is to ensure that Federal, Tribal, State, and local health agencies have the infrastructure to provide essential public health services effectively.
Public Health in America - Healthy People 2010
This page outlines public health functions and essential public health services.
"Mind Matters: A Public Health Approach to Mental Illness and Well-Being"
By Adreanne Waller, MPH and Lily Guzman, MPH, MSW, February 2007
As a public health agency we are focused on prevention of health problems and we conduct surveillance to improve the information we have on health problems in our community. Our aim with this report is to improve the understanding of mental health as a catalyst for action. This report can help make the case for local mental health promotion and prevention strategies and support the treatment system through increasing awareness, identifying risk factors, removing stigma associated with seeking treatment, eliminating health disparities among groups and improving access to services.
University of California Postprints, “Mental health in schools and public health”
By Howard Adelman and Linda Taylor
Health policy and practice call for health and mental health parity and for a greater focus on universal interventions to promote, prevent, and intervene as early after problem onset as is feasible. Those in the public health field are uniquely positioned to help promote the mental health of young people and to reshape how the nation thinks about and addresses mental health. And schools are essential partners for doing the work.
Psychiatric Times article, “Integrating public mental health and children’s systems of care” by Jeanne M. Poduska, Sc.D., and Kimberly Kendziora, Ph.D.
September 2001, Vol. XVIII, Issue 9
In this article, the authors have brought together a public health perspective with the systems-of-care service-delivery perspective in order to focus thinking on how best to serve the needs of all children.
Federal, Provincial and Territorial Advisory Committee on Population Health. 1999. Toward a healthy future: second report on the health of Canadians. Ottawa: Minister of Public Works and Government Services Canada.
This document is a public policy report developed by the Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) in collaboration with Health Canada, Statistics Canada, the Canadian Institute for Health Information and a project team from the Centre for Health Promotion, University of Toronto. Both the full Report, as well as a series of brief "backgrounder" reports provide the most current information available about the health of Canadians.
Growing Absolutely Fantastic Youth: An e-Newletter for Maternal and Child Health Professionals Invested in Adolescent Health, May 2003
The information presented in this special double issue emphasizes the public health approach for mental health activities at a state and national level.
Public Health Institute of Scotland, Needs Assessment Report on Child and Adolescent Mental Health
The report discusses a wide range of activities, from specialist child and adolescent mental health services to the wide network of agencies working with children and young people, resilient or struggling, wherever they are.
In the course of this work, we gathered evidence both from published formal sources, for example, published research and policy documents, and from children, young people and those who care for them and work with them.
No one knew exactly how the cowpox virus worked to prevent smallpox. It was clearly so promising, however, that people tinkered with the vaccine until it was perfected. The use and success of smallpox vaccinations grew throughout the 19th and 20th centuries, but as late as 1967, an estimated 2,000,000 people died from the disease. At that point, the political will and funding came together to eliminate smallpox from the planet. The World Health Organization launched a massive vaccination project, and in 1977, smallpox was declared eradicated from the earth (“smallpox,” Encyclopaedia Britannica Online, 2000). The only remaining supplies of the virus were to be safeguarded at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and at a laboratory in Russia.
Mental illnesses have probably plagued humankind for at least as long as did smallpox. As was the case with smallpox, various attempts were made over the centuries to “control” mental illnesses, but all too often, the approach was to banish people with mental illnesses from society. It was not until the 19th century that the movement to promote mental health and prevent mental illnesses got under way in the United States with the advent of the mental hygiene movement. A number of organizations have been formed and reports commissioned over the years, but thus far, no national agenda to promote mental health and prevent mental and behavioral disorders has been developed in the United States. In some other countries, including Australia, New Zealand, and Canada, such an agenda has been developed.
At least three factors account for the relative lack of attention to promotion and prevention issues in the United States. First, the stigma attached to mental illnesses has led people to believe, among other myths, that nothing can be done to prevent mental and behavioral illnesses. Second, until recently, the hard evidence that something could indeed be done was scarce. However, current research in the relatively new field known as prevention science has brought the prevention of at least some mental and behavioral disorders into the realm of possibility, just as Jenner’s breakthrough with cowpox vaccinations made the eventual elimination of smallpox possible.
A third reason that promotion and prevention activities have not received more attention is the false dichotomy that currently exists between the concepts of prevention and treatment. This schism is largely due to the scarcity of funds available for mental health services of any sort. Advocates for more and better treatment services for people with mental illnesses have a good point; considerably more funding is needed for treatment and recovery services for people who already have mental illnesses. But promotion, prevention, treatment, and recovery are inextricably linked, and adequate funding for the whole continuum of services is as essential to the Nation’s psychological health as, say, funding for cancer research and services is to the Nation’s physical health.
The good news about treatment and the growing consumer recovery movement is that they work. People who once were thought to be on a “chronic, deteriorating course” are now holding jobs, living in the community, getting married, and being full participants in society. The good news about promotion and prevention is that, because this is an international movement with many scholars contributing to the effort, our knowledge of what works is increasing exponentially. Given the rapid exchange of information today, it seems likely that the 200 years from Jenner’s cowpox discovery to the eradication of smallpox will be shortened considerably for the eradication of many mental and behavioral illnesses. Even if it should take 200 years to eradicate all mental illnesses, humankind most likely will benefit along the way as researchers tinker with interventions and gradually learn what works well for whom.
While recognizing the enormous importance of treatment and recovery services, this article focuses mainly on issues related to promotion and prevention. The need for such services is growing, and many effective and/or promising programs are well under way. The time is clearly right for the mental health field to follow the lead of Jenner and others in the medical community and to invest heavily in the promotion of mental health and the prevention of mental and behavioral disorders.
WHY A PUBLIC HEALTH APPROACH IS NEEDED
It is a truism in the public health arena that no major epidemic has ever been eradicated by treating individual cases. The public health model virtually mandates that one take a broad perspective in developing promotion and prevention initiatives. The Surgeon General’s report on mental health describes this model as follows:
In the United States, mental health programs, like general health programs, are rooted in a population-based public health model. Broader in focus than medical models that concentrate on diagnosis and treatment, public health attends, in addition, to the health of a population in its entirety. A public health approach encompasses a focus on epidemiologic surveillance, health promotion, disease prevention, and access to service. Although much more is known through research about mental illness than about mental health, the report attaches high importance to public health practices that seek to identify risk factors for mental problems; to mount preventive interventions that may block the emergence of severe illnesses; and to actively promote good mental health (U.S. Department of Health and Human Services, 1999, p. viii).
The public health approach has had an extremely positive impact on the health status of Americans during the past century. For example, the campaign against cigarette smoking has led to the elimination of millions of cases oflung cancer, and the campaign encouraging the wearing of seat belts has greatly reduced the number of deaths from automobile accidents. It seems reasonable, therefore, to use the public health approach to promote mental health and prevent mental and behavioral disorders.
The core elements of the public health approach include:
- Community-based methods for identifying the sources of the problem -- taking a population-based perspective, in contrast to the individual intervention approach of the physician’s office;
- Epidemiological data and analyses for identifying and delineating patterns of risk and protective factors associated with the problem;
- Ongoing surveillance and tracking of the problem and the identified risk and/or protective factors to establish trends in their prevalence and incidence -- telling who suffers from specific problems and why;
- Designing community-based interventions based on a scientific analysis of the problem to reduce or eliminate risk factors and enhance or introduce protective factors;
- Evaluating and monitoring interventions to establish and improve their effectiveness; and
- Public education to share information about the problem and effective and ineffective interventions (Elliott et al., 1998, pp. 20-42).
The public health approach is an optimistic approach that provides tools for individuals and communities to proceed in a positive, problem-solving manner.
CLEARLY THE TIME IS RIGHT
As Dr. Jenner learned 200 years ago, discovering a method of preventing a dreaded illness – be it physical or mental – is only half the battle. Getting that method perfected, widely accepted, and implemented with fidelity brings human nature with all its foibles into the fray. The Royal Medical Society rejected Jenner’s article on the success of his vaccine, so in 1798, he published An Inquiry into the Causes and Effects of the Variolae Vaccinae, a Disease Known by the Name of Cow Pox, on his own. Even after publishing the book, he had trouble recruiting volunteers. The vaccine was popularized in London by two other doctors, one of whom tried to steal credit from Jenner, and the other of whom contaminated the vaccine with the smallpox virus (“Jenner,” 2000).
Fidelity proved to be a major problem for smallpox vaccinations, as doctors did not always follow the procedures exactly as Jenner instructed them to do. Other problems arose because pure cowpox vaccine was difficult to obtain, preserve, and transmit. Moreover, no one understood the biological factors that produced immunity, and many mistakes were made in the process of gathering information and standardizing effective procedures. Over the years, Jenner received many honors, but he also aroused much opposition.He apparently devoted so much time to promoting his vaccine that his private practice and personal affairs fell into disarray (“Jenner,” 2000).
In the promotion of mental health and the prevention of mental and behavioral disorders, scholars now readily acknowledge the need for more well-controlled research. However, they also generally conclude that adequate data are available for the field to proceed, provided that the research meets rigid standards of design, control, and evaluation. An NIMH committee concluded that, as a result of earlier research,
Scientifically rigorous studies are now yielding promising evidence of the efficacy of preventive interventions....The field is ready to build on prior prevention research accomplishments and integrate these with advances in the biomedical, behavioral, and cognitive sciences (NIMH, 1998, pp. 14-15).
One researcher sums up her position by saying
While the documented state of the art is in an early stage of development, intervention research has produced solid evidence that selected preventive programs and services are associated with positive outcomes and that the cost of providing them may be offset by savings elsewhere in the health care system (Dorfman, 1999, p. 3).
The story of the eradication of smallpox, though different in many obvious ways from the prevention of mental and behavioral disorders, reminds one of a proverb that all people interested in promotion and prevention must keep in mind: “A journey of a thousand miles begins with the first step.” The journey to prevent smallpox was a long one, but what if the Chinese had not spread the word about inoculation? What if Jenner had not noticed the connection between falling ill with cowpox and not falling ill with smallpox?
The first steps have been taken on the journey to promote mental health and prevent mental and behavioral disorders, but many more steps remain. We must remember that Jenner persisted despite personal attacks and human chicanery, and doctors eventually figured out why fidelity is so important. Surely the time is right to persist on this long journey, and for community advocates, consumers, researchers, program developers, clinicians, academicians, and policymakers to launch a major initiative to promote mental health and to make the eventual prevention of mental and behavioral disorders a reality.
In addition to the article above, here are some probing questions to keep in mind as you begin to think about the public health approach to mental health more in depth:
- What does the phrase, public health approach to mental health’ mean to you?
- What do you think are the most important components of a public health approach?
- Have you observed or worked in a public health approach to mental health? Please share your experiences.
- In your view, what kinds of efforts have been successful? Can you give some specific examples of public health/mental health interventions at the individual, community, or system level?
- When these efforts have been successful, who have been the champions?
- What IS mental health? What are the indicators of a child, youth, adolescent, family, community, state that is mentally healthy?
- What are the risk and protective factors that contribute to mental health? How do we assess, assure and determine policy that promotes mental health?
are your thoughts (submit comments below)?