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Reflections on the Annual Report of the Chief Medical Officer 2013

Reflections on the Annual Report of the Chief Medical Officer 2013

Public Mental Health Priorities: Investing in the Evidence

The Annual Report of the Chief Medical Officer is a report from the UK Government’s principal medical adviser about the state of the public’s health.  Volume 2 of the 2013 report, published in 2014, takes mental health as its theme [1].  This is a very welcome development.  The historic division in medicine, policy and society between physical and mental health, along with the highly unequal investment in physical health compared to mental health, has had damaging consequences for health services and for the health of the public.

The report provides a very valuable compendium of evidence and information relating to mental illness which will be useful to many across health, local government, the police, education, the criminal justice system and employers, and for partners on Health and Wellbeing Boards who are concerned about the wider determinants of both physical and mental health.

The report sends a strong message to professionals, citizens, decision makers and leaders at all levels that there is no mind-body separation:  to have good health means to have good physical and mental health.  Nationally and locally, successful programmes to improve the health of the population will need to take an integrative and whole person perspective – ‘there is no health without mental health.’

The report also comes to some controversial conclusions on the subject of mental wellbeing.
 
This briefing highlights some of the welcome messages in the report and provides the Faculty of Public Health’s perspective on the controversial sections, mindful both of FPH’s role to promote high professional standards across its membership and in the local government setting in which many members now practice.

Welcome messages from the report

•    The call to integrate mental and physical health across primary and secondary services, supported by improved intelligence on mental health nationally and in Joint Strategic Needs Assessments. 

•    Recognition that the stigma surrounding mental illness and the discrimination experienced by people with mental illness are both profoundly damaging and amenable to intervention.

•    Recognition of the impact of wider determinants on mental health.  The association of poverty, unemployment, debt and poor housing with stress and reduced self-efficacy among people who were previously coping, and people already experiencing mental illness, is strong. 

The importance of a positive, safe, stable and loving environment in infancy and childhood to lifelong resilience and prevention of mental illness is becoming increasingly clear.  This is important for public health professionals as responsibility for commissioning health visiting and school nursing shifts to local government.  The acknowledgement of the impact of loneliness and social isolation on the mental health of older people is essential for prevention and for planning integrated health and social care.

•    Recognition of the centrality of employment to mental health and of the workplace as a potent setting in which to promote mental health and wellbeing, prevent mental illness and support recovery.  Health and social care providers should be exemplars here.

•    Recognition of the importance of the mental health of doctors and the need for special services to address mental illness in this group. 

We would add that all public facing staff in health, social care and other settings face particular challenges in dealing with the human condition and need appropriate training and support to maintain their mental health.

•    The call for greater investment into public mental health research is very welcome.

A Faculty of Public Health perspective on some key issues raised


Disease prevention and health promotion models:

The WHO model for prevention and promotion in the field of mental health is a helpful one on which to base public mental health practice.  A model of health that incorporates the individual and biological, social and cultural, material, structural and political influences helps to organise thinking and action [2]. 

Polices, local strategies and investment plans should encompass treatment and care of the full spectrum of mental illness as well as prevention (reduction of disorder, disease, illness and disability, including actively promoting recovery of people with lived experience of mental illness) and promotion of positive mental wellbeing in the population.

Links between mental and physical health:

The increased risks of poor physical health and premature death experienced by people with mental illness and the increased risk of poor mental health among people with physical health problems have been ignored for far too long.  Progress in improving this situation depends on understanding the fundamental links between physical and mental health. 

Programmes to encourage lifestyle change and treat long term conditions, for example, should also pay greater attention to psychological and emotional factors.  Health services for people with mental illness need to pay particular attention to physical health and provide accessible, acceptable preventive interventions and treatment. 

In local authorities, leads  for active transport, leisure and physical activity, guardians of parks and green spaces, planners and anyone commissioning these public services and amenities also need to understand these links, as do people responsible for housing, education and economic growth.  This requires training and development of staff, medical and otherwise, to understand and embrace mind-body links. The Faculty of Public Health is developing core competencies in mental health for public health training.

Clarity of definitions, outcomes and measurement

Clarity of terminology in mental health is important but the plethora of terms, particularly the euphemistic ones for mental illness, comes in part from people with lived experience and their carers.  Language is crucial in communicating with the very wide range of professionals, patients, carers and members of the public outside medicine and the health service with whom public health staff work every day. 

Public health professionals straddle the divide between academic rigour and the daily practicalities of communicating messages effectively and influencing change.  Mental wellbeing is a term which has enabled previously difficult conversations about positive mental health to take place in many different sectors. ‘Feeling good and doing well’ may be as useful as the WHO definition of positive mental health for people who do not t naturally see it as their business.   Thus, while consistency is valuable, the use of terminology should not become restrictive or exclusive.

Clarity about optimum states is not always necessary before embarking on public health programmes.  Knowledge about optimum blood pressure and cholesterol levels and their impact on the cardiovascular system was not available when programmes to address these risk factors were introduced.  Knowledge about optimum physical activity levels in different population groups is still uncertain and measurement of physical activity remains an inexact science. This has not and need not delay implementation. It should spur further research and evaluation and a willingness to revise programmes in line with new evidence as it emerges.

Promoting mental wellbeing prevents mental illness:

Professor Geoffrey Rose proposed that where a health issue is continuously distributed in the population, the mean predicts the proportion of the population with a diagnosable illness.  This has been demonstrated to be true for both child [1] and adult [2] populations with regard to common mental disorders (depression and anxiety in adults and emotional and behavioural problems in children).  It follows, at least for common mental disorders, that if it can be demonstrated than an intervention offered at universal level improves the mean mental health in a universal population, that the intervention will reduce the level of diagnosable illness in the population.  This has been done with regard to a number of mental health promotion approaches:

•    Universal parenting support interventions can improve parenting and reduce child abuse, improving mental health outcomes in the children[3-5]
•    Universal interventions to improve mental health in schools have a strong evidence base and can be effectively combined with targeted support [6-8]
•    School interventions  to increase physical activity in all children [9] improve mental health at universal level
•    Adult interventions  to teach mindfulness[10,11] improve mental health at universal level
•    Preventing social isolation and loneliness in communities is a valuable approach to preventing common mental disorders in older people [12].

The Rose hypothesis has not to our knowledge been demonstrated as either true or false for severe and enduring mental illness (SEMI).  However the ubiquity of common mental disorders and their substantial cost to the economy are sufficient justification for universal approaches regardless of the effect on SEMI.  It would therefore be detrimental to the health of the public for local authorities to decommission wellbeing initiatives, especially the evidence based interventions described above.  Where evidence is suggestive rather than robust, such as for ‘Five Ways to Wellbeing’, public health and commissioners should rigorously monitor and evaluate  programmes and make results available for others to learn from.  The National  Institute for  Health  Research  should issue a call for proposals to strengthen the evidence  base for these interventions - whether the outcomes prove to be positive or negative.

The impact of mental health promotion on physical health.

Unhealthy lifestyles can be a response to stress, which plays a part in the course of many chronic diseases. Mental health promotion is a component of several interventions to prevent physical disease. The potential contribution of mental health promotion to physical health is not addressed in the report. For example, there is much qualitative evidence that suggests personal issues such as self image, self esteem and coping  skills determine the outcomes of weight management, drug and alcohol recovery  programmes.

Rebadging the work of other disciplines

Public health is inter- and multi-disciplinary, and other disciplines, particularly engineers, statisticians, psychologists, educationalists and those working in the third sector have made well recognised contributions to public health. Psychologists, educationalists and the third sector in particular have played an important role in the development of programmes to promote mental health and prevent mental illness.  Adopting good ideas from other disciplines is to be encouraged rather than dismissed.

Evidence-based public health

There is a great need for more research in public mental health to support evidence based practice.  That evidence base must draw on a wide range of research methods and paradigms.  Randomised controlled trials (RCTs) are a valuable tool in establishing what works.  Cluster randomised  trials have a potential place in evaluating complex mental health intervention However, because complexity is the norm in day-to-day public health practice – with multiple inputs, processes, outputs and outcomes – RCTS are often impractical and prohibitively expensive. They can also give misleading results because controlling any part of a complex system will influence the way that system works.  Many valuable public health initiatives, for example communicable disease outbreak investigation and control, do not have RCT evidence but are used routinely and successfully in public health practice.

In Summary

The Faculty of Public Health welcomes the CMO’s report and its much needed focus on public mental health.  The evidence presented on the prevention and treatment of mental illness, particularly severe and enduring mental illness, is welcome. 

The review of evidence on mental health promotion is however incomplete and does not do justice to what is known in this field.  FPH strongly recommends that public health professionals and local authorities continue to promote mental wellbeing to enhance both physical and mental health and ensure that programmes and projects are thoroughly evaluated. The Faculty of  Public Health would welcome a dialogue with the Chief Medical Officer,  the National Institute of  Health  Research and others about how the public mental health research strategy can be developed to respond to the gaps in our current  knowledge.

References

1. Goodman A, Goodman R (2011). Population mean scores predict child mental disorder rates: validation SDQ prevalence estimators in Britain. J Child Psychology and Psychiatry 2011; 52:100-108
2. Veerman JL, Dowrick C, Ayuso-Mateos JL, Dunn G, Barendregt JJ (2009). Population prevalence of depression and mean Beck Depression Inventory score. British Journal of Psychiatry 2009; 195: 516–519. Read more on ecological models of health here
3. National Academy for Parenting Practitioners 
4. Stewart-Brown S, Scharder-McMillan A (2011). Parenting for mental health: what does the evidence say we need to do? Report of Workpackage 2 of the DataPrev project. Health Promotion International 2011;26:i10-i28.
5. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR (2009). Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prevention Science, 10(1), 1-12.
6. Weare K, Nind M (2011).  Mental health promotion and problem prevention in schools: what does the evidence say? Health Promot  Int 2011; 26( 1): i29-i69. doi: 10.1093/heapro/dar075
7. Adi Y, Killoran A, Janmohamed K, Stewart-Brown S (2007). Systematic review of the effectiveness of interventions to promote mental wellbeing in children in primary education. Report 1: Universal approaches: non-violence related outcomes. University of Warwick, Coventry, UK 2007. A report to the National Institute of Health and Clinical Excellence (NICE, 2009). 
8.  Adi Y, Killoran A, Schrader Macmillan A., Stewart-Brown S (2007). Systematic review of the effectiveness of interventions to promote mental wellbeing in primary schools Report 3: Universal Approaches with focus on prevention of violence and bullying. University of Warwick, Coventry,UK. 2007. A report to the National Institute of Health and Clinical Excellence, NICE 2009.   
9 Lees C, Hopkins J.  Effect of aerobic exercise on cognition, academic achievement, and psychosocial function in children: a systematic review of randomized control trials. Preventing Chronic Disease 2013; 10: E174
10. de Vibe M, Bjørndal A, Tipton E, Hammerstrøm K, Kowalski K (2012). Mindfulness Based Stress Reduction (MBSR) for Improving Health, Quality of Life, and Social Functioning in Adults. Campbell Systematic Reviews 2012:3: 01 February, 2012. The Campbell Collaboration, Oslo, Norway.
11. Asuero AM, Queraltó JM, Pujol-Ribera E, Berenguera A, Rodriguez-Blanco T, Epstein RM (2014). Effectiveness of a Mindfulness Education Program in Primary Health Care Professionals: A Pragmatic Controlled Trial. J Contin Educ Health Prof 2014; 3(1);4–12 
12. Cattan M, White M, Bond J, Learmouth A (2005). Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Ageing and Society 2005;25:41-67.


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