Sarah Stewart-Brown Professor of Public Health Director Health Sciences Research Institute Warwick Medical School School mental health promotion: evidence for effectiveness from systematic reviews

Plan What is mental health ? Findings from systematic reviews –Mental health promotion –Health promoting schools Recommendations –Policy –Practice –Research

What is mental health? Absence of mental illness Positive mental health Mental well-being

Some Terminology Subjective well-being Psychological well-being Emotional and social well-being Emotional intelligence/literacy

Subjective Well-being Happiness Feeling good Life satisfaction

Psychological Well-being Autonomy Self acceptance Personal growth Purpose in life Environmental mastery Positive relations with others

Emotional and social well-being Absence of behaviour problems Absence of emotional problems Doing what they are told Self esteem Good relationships with peers

Emotional Intelligence Emotional awareness Respect for own and others emotional states Emotional regulation Capacity to integrate thinking and feeling Capacity to communicate emotional information

WEMWBS Warwick Edinburgh Mental Well-being Scale I’ve been feeling:- optimistic about the future relaxed close to other people useful interested in other people good about myself confident cheerful loved I’ve been:- thinking clearly able to make up my own mind about things interested in new things dealing with problems well I’ve had:- energy to spare None of the time, rarely, some of the time, often, all of the time

Systematic Reviews of Reviews covering School Mental Health Promotion Interventions Lister Sharpe D, Chapman S, Sasia A, Stewart-Brown S. Health Promoting Schools and Health Promoting Schools; two systematic reviews. Health Technology Assessment 1999:3(22) Stewart-Brown S. What is the evidence on school health promotion in improving health or preventing disease and, specifically what is the effectiveness of the health promoting schools approach. WHO Euro _schools/ _schools/

Systematic Reviews of Reviews covering School Mental Health Promotion Interventions Green J, Howes F, Waters E, Maher E, Oberklaid F. Promoting the social and emotional health of primary school aged children: reviewing the evidence base for school based interventions International Journal of Mental Health Promotion 2005;7: Tennant R, Goens C, Barlow J, Stewart-Brown S. A systematic review of interventions to promote mental health and prevent mental illness in children and young people J Public Mental Health – forthcoming,

Systematic Reviews: Strengths: –Comprehensive –Controlled studies –Clear inclusion criteria –Critical appraisal Weaknesses: –Study quality cf programme quality –Limited to quantitative outcomes –Information about programme implementation and content often scant –Limited by inclusion / exclusion criteria

Aspects of mental health on which SR/Trials have focused Positive mental health/well-being –Self concept, self esteem, ego identity –Assertiveness, mastery, self efficacy –Relationship skills Emotional literacy Social problem solving Interpersonal negotiating strategies Conflict resolution strategies

Aspects of mental health on which SR/Trials have focused Mental illness, lack of mental health/well-being –Suicidal tendencies, depression, hopelessness –Behavior problems, violence, aggression hostility, conduct problems –Anxiety

Types of intervention covered Whole school approaches developed over several years involving development of all staff, changes to school ethos, programmes for parents and class based curriculum Class based programmes –delivered by class teachers/outside experts/peers –Sessions: single/multiple/over several terms Information based/experiential skill based School transition programmes Exercise programmes Programmes targeting children with problems Parenting programmes offered through schools

HTA SR of SRs 1999 Most likely to be effective: Interventions involving environmental change Health areas: –Healthy eating/physical activity –Mental health –Injury prevention Family involvement useful in improving health knowledge Health promoting school approach supported

WHO HEN SR 2006: Focus of Reviews

Results WHO HEN 2005: Mental Health Universal approaches (17 RCTs +CCTs): –Whole school and HPS approaches better –Longer programmes better –Promotion of MH > prevention of MI –Medium to large effects Depression and self esteem (7 SRs + 5 studies) –Primary prevention better (medium to large effects) –Self esteem programmes modest effects –Knowledge based not effective –Suicide prevention – potential for harm

Results WHO HEN 2005: Mental Health Aggressive behaviour (221 RCTs CCTs) –Range of different programmes effective –Better studies and well implemented programmes > effect –Effects > high risk groups Violence prevention (16) –Cognitive and behavioural strategies both effective –Primary prevention, multiple settings, qualified leaders, and longer time scales > effect Violence Prevention (44) –Non response and relationship programmes effective –Small to moderate effects overall

Results WHO HEN 2005: Substance Use Smoking (76) –Most programmes (including information, social competence and multimodal) not effective –Some social influences programmes positive Drug prevention (207) –Universal programme focus –Impact small to very small Drugs psycho-education (62) –18/62 some evidence of effect –Best programmes can achieve is short term delay

WHO HEN 2005: Contradictory Results Universal cf targeted Age groups Gender Suicide prevention

Behaviour Assessment Inventory (BAI) - Population Control Study MRC Institute of Hearing Research (Nottingham) N = 545 Age range = 2-9 years Data from Primary Schools in Nottinghamshire, Derbyshire, Leicestershire, Renfrewshire and Avon Distribution of algorithm score (Higher scores represent more behaviour problems)

Bimodal Distribution

Results WHO HEN report: Approaches Health Promoting School (12) –No programmes implemented HPS in entirety –Studies poor and underpowered –Impact on social and physical environment, staff development, provision of exercise, school lunches and social atmosphere Peer led (64) –Highly positive appraisal by young people –But contradictory results Peer led (13) –Methodological issues –Peers as effective as teachers

Green, Howes, Waters, Maher, Oberklaid 2005 Emotional and social health in primary school (8 reviews) Most studies of short class based programmes But more effect from: Sustained approaches (> I year) Whole school approaches with changes to school ethos Focus on promotion Involving parents Targeted programmes have a place

Tennant R, Goens C, Barlow J, Stewart-Brown forthcoming 26 reviews –Anxiety and depression prevention –Self esteem –School programmes –Parenting programmes

Problems with Evidence Process and implementation measures rarely/not reported Descriptions of interventions limited Quality of studies –Study size; implementation fidelity cf statistical power –Cluster design –Loss to follow up –Sensitivity of outcome measures

Issues in RCTs of health promotion Participation Autonomy Programme fidelity Randomisation Time scales

Recommendations: practice and policy School mental health promotion programmes can be effective but by no means always are Controlled trials/ systematic reviews rarely help us understand what does and does not make programmes effective Health promoting schools approach supported but no trial evidence –School ethos –Teacher development and well-being Universal backdrop likely to be important, but targeted programmes may also be necessary Longer programmes likely to be more effective Programmes more effective when focusing on positive health and wellbeing

Recommendations: research R&D of school mental health programmes is time consuming and costly; there are no quick fixes Need for greater understanding of strengths and weaknesses of controlled trials and systematic reviews Need for a range of research methods and multi- method approaches More consideration needs to be given to appropriate outcomes