The Public Health Approach to Mental Health Monograph
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Promoting and Protecting Mental Health as Flourishing: A Complementary Strategy for Improving National Mental Health
By Corey L. M. Keyes, Emory University, American Psychologist, February-March 2007

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The National Institute of Mental Health (NIMH) recently declared cure therapeutics as a goal of its portfolio of research (Insel & Scolnick, 2006). The assumption is that by reducing the number of cases of mental illness, either by preventing those at risk or by successfully treating more cases of mental illness, the American population will be mentally healthier. This is truly an assumption, because it rests on one of the most simple and inexplicably untested empirical hypotheses: The absence of mental illness is the presence of mental health. Put in psychometric terminology, the success of the current approach to mental health hinges on the hypothesis that measures of mental illness and measures of mental health belong to a single, bipolar latent continuum. There is mounting empirical evidence that the paradigm of mental health research and services in the United States must change in the 21st century. First, measures of mental illness and measures of mental health form two distinct continua in the U.S. population (Keyes, 2005b). Second, measures of disability, chronic physical illness, psychosocial functioning, and health care utilization reveal that anything less than flourishing is associated with increased impairment and burden to self and society. Third, only a small proportion of those otherwise free of a common mental disorder are mentally healthy (i.e., flourishing). Put simply, the absence of mental illness is not the presence of mental health; flourishing individuals function markedly better than all others, but barely one fifth of the U.S. adult population is flourishing (Keyes, 2002, 2003, 2004, 2005a, 2005b).

The two continua model (see also Tudor, 1996) calls for the adoption of a second, complementary national strategy: the promotion and maintenance of genuine mental health as flourishing. Curing or eradicating mental illness will not guarantee a mentally healthy population. Because mental health belongs to a separate continuum, and the absence of mental health—a condition described later as “languishing in life”—is as bad as major depressive episode (MDE), the current national strategy of focusing solely on mental illness can, at best, reduce mental illness but not promote mental health. The U.S. strategy for mental health must simultaneously (a) continue to seek to prevent and treat cases of mental illness and (b) seek to understand how to promote flourishing in individuals otherwise free of mental illness but not mentally healthy. To paraphrase the famous Johnny Mercer song (Mercer & Arlen, 1944), if mental health is truly society’s national objective—and I would like to make a case in this article that it must be—then it has to “accentuate the positive (i.e., flourishing), eliminate the negative (i.e., mental illness) . . . , and don’t mess with mister in-between (i.e., languishing).”

Mental Health: Identifying What People Say They Have Wanted All Along
Until recently, mental health remained undefined, unmeasured, and therefore unrecognized at the level of governments and nongovernmental organizations. In 1999, the Surgeon General, then David Satcher, conceived of mental health as “a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with people, and the ability to adapt to change and to cope with adversity” (U.S. Public Health Service, 1999, p. 4). In 2004, the World Health Organization published a historic first report on mental health promotion, conceptualizing mental health as not merely the absence of mental illness but the presence of “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” (World Health Organization, 2004, p. 12).

Flourishing Is Good for People and Society
Research has supported the hypothesis that anything less than complete mental health results in increased impairment and disability (Keyes, 2002, 2004, 2005a, 2005b). Adults who were diagnosed as completely mentally healthy functioned superior to all others in terms of the fewest workdays missed, fewest half-day or less cutbacks of work, lowest level of health limitations of activities of daily living, the fewest chronic physical diseases and conditions, the lowest health care utilization, and the highest levels of psychosocial functioning. In terms of psychosocial functioning, this meant that completely mentally healthy adults reported the lowest level of perceived helplessness (e.g., low perceived control in life), the highest level of functional goals (e.g., knowing what they want from life), the highest level of self-reported resilience (e.g., learning from adversities), and the highest level of intimacy (e.g., feeling very close with family and friends). In terms of all of these measures, completely mentally healthy adults functioned better than adults with moderate mental health, who in turn functioned better than adults who were languishing.

Adults with a mental illness who also had either moderate mental health or flourishing reported more workdays missed or more work cutbacks than languishing adults (Keyes, 2004). However, languishing adults reported the same level of health limitations of daily living and worse levels of psychosocial functioning than adults with a mental illness who also had moderate mental health or flourishing. Individuals who were completely mentally ill—that is, languishing and one or more of the mental disorders— functioned worse than all others on every criterion. In general, adults with a mental illness who also had either moderate mental health or flourishing functioned no worse than adults who were languishing and did not have a mental disorder. Thus, mental illness that is combined with languishing is more dysfunctional than the situation in which a mental illness occurs in the context of moderate mental health or flourishing.

Complete Mental Health: How Much Is Out There?
If “almost there” is good enough, the current approach to national mental health is succeeding, because approximately one half of the adult population is moderately mentally healthy. However, because genuine mental health should be the goal, the current approach to national mental health is a failure, because only 17% of adults are completely mentally healthy. Worse yet, 10% of adults are mentally unhealthy, as they are languishing and do not fit the criteria for any of the four mental disorders (and they averaged about one symptom of mental illness, suggesting that languishers may not be subsyndromal). In addition, 23% of adults fit the criteria for one or more of the four mental disorders measured in the MIDUS. Of that 23%, 7% had a mental illness and fit the criteria for languishing, meaning individuals not only had an episode of mental illness along with the absence of mental health (i.e., languishing). Of the 23% with a mental illness, 14.5% had moderate mental health and 1.5% were flourishing (Keyes,
2005b).

Epidemiology of Complete Mental Health: Who Has It?
The literature on race and mental illness presents a paradox insofar as rates of common mental disorders are not higher in the group with greater inequality and discrimination. That is, rates of substance, mood, and anxiety disorders are either lower in Blacks or the same between Blacks and Whites (see Williams & Harris-Reid, 1999). In turn, racial– ethnic differences in levels of the six scales of psychological well-being—which form part of the diagnostic battery of flourishing—revealed that Blacks reported higher levels than Whites on all six scales before any covariates were introduced into the model (Ryff, Keyes, & Hughes, 2003). After controlling for education, income, a host of other demographics variables, and perceived discrimination, the Black advantage over Whites in psychological well-being increased. Because psychological well-being improved after controlling for discrimination, Ryff et al.’s (2003) findings suggest that Blacks would have an even better profile of psychological well-being than Whites were it not for the fact that Blacks experienced more discrimination than Whites.3 This, therefore, leads to the hypothesis investigated here that Blacks should be more likely than Whites to have complete mental health.

Findings also support the hypothesized advantage of Blacks over Whites in complete mental health. On average, Blacks reported a higher level of overall mental health than Whites. Last, findings provide partial support for the hypothesized advantage of men over women in complete mental health. Although men generally reported a higher level of overall mental health than women, separate analyses of variance for Whites and Blacks reveal a gender gap only among Blacks, with Black men reporting higher overall mental health than Black women. White men and women reported the same level of overall mental health at all levels of education.

Discussion
Health care in the 21st century United States must include an intensive effort to add healthy years to the years of life added in the 20th century. However, and despite established conceptions of health as more than the absence of disease, public health policy and evaluation of health programs are based on reduction of mortality and morbidity (Robine & Ritchie, 1991). The exclusion from policy and research of health and well-being—which some consider the counterdimension of disease and illness (Sullivan, 2003)—may explain why the health profile of the U.S. population is poor relative to other developed nations. Indeed, physical and psychiatric conditions frequently co-occur, and individuals without manifest signs of disease are not “healthy” (Keyes, 2002). Policies that direct programmatic interventions that bring about reductions in illness and enhancements in mental as well as physical health are needed to reach a new vision in U.S. health care policy: the protection and promotion of health to increase disability free and healthy life expectancy.

Toward that end, evidence is unequivocal that mental illness must receive equal attention as physical illness. The prevalence and toll of mental illness certainly argue for expanding the scope of mental illness research. Such evidence, however, can be construed to restrict rather than expand the scope of “the other side of the coin” of mental illness (i.e., mental health research). However, there are salient reasons for expanding the scope of clinical and epidemiological research to include mental health as something more than the absence of psychopathology. Evidence reviewed in this article suggests there are important reasons to expand society’s understanding of the problems and challenges concerning the presence and the absence of mental health. Very few adults who are free of any 12-month mental disorder could be classified as genuinely mentally healthy. Less than 2 in 10 adults were completely mentally healthy as defined by freedom from an episode of mental illness over the past year and flourishing in life. Over 2 in 10 adults had some form of mental disorder, many cases of which were comorbid with languishing in life. About one half of the adult population between the ages of 25 and 74 was moderately mentally healthy, and about 1 in 10 adults were languishing (Keyes, 2005b).

When compared with complete mental health, moderately mentally healthy and languishing adults exhibited substantial impairment. Languishing and moderate mental health are associated with high limitations of daily living, more reductions in work productivity due to cutbacks and lost days of work, more chronic physical disease, and poorer psychosocial functioning. Strikingly, functioning was considerably worse when languishing was “comorbid” with an episode of mental illness, and this group functioned markedly worse than adults with a mental illness who had moderate mental health or were flourishing. Thus, the mental health continuum also distinguishes level of impairment within the category of the mentally ill.

To paraphrase Albert Einstein, science and society cannot solve the mental health problems of today by using the same kind of thinking that was used when, I believe, science and society helped to create them. The transition from acute to chronic diseases requires a shift from, not toward, the language of “cures” and “eradication.” If it is broken, science and society may not be able to fix it, and refusal to turn some of this nation’s assets toward the promotion and maintenance of mental health may serve only to make matters worse. Medical leaders are calling for a shift toward prospective medicine, believing that the current system is too reactive and responds only when individuals are sick (Snyderman & Williams, 2003). Among the many appealing aspects of a prospective approach to health care-mental or physical-is the objective of determining the earliest deviations from health (i.e., providing very early detection of disease onset) so as to intervene at the earliest stage and restore health rather than wait to manage chronic illness.

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Recent Comments

With a track of the upcoming Training Institutes dedicated to the public health approach to mental health I think a lot of folks are eagerly awaiting the unveiling of the new monograph. Looking forward to kicking things off with the June conference call. (6/17/08)

In the TA call a July 30th Webinar was mentioned. Can you provide more information about this? (7/15/08)

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