A public mental health approach to promoting emotional well being in children Jo-anne Alner Acting Consultant West Sussex PCT and Mental Health Directorate, Department of Health

Public Mental Health …a definition “…is the art, science and politics of preventing mental ill health and inequalities through the organised efforts of society: By reducing risk and promoting protective evidence-based interventions In order to improve physical and mental well-being And create flourishing, connected individuals, families and communities (National Expert Group for Public Mental Health and Well Being, 2008)

A public mental health approach Describe the problem – prevalence, risk and protective factors Come up with solutions – evidence-based and cost-effective approaches Address root causes – upstream thinking, wider determinants, inequalities Develop strategies and policy Promote leadership and collaborative working – to achieve change and implement policy Encourage reflective learning and evaluation – and sharing of good practice

Develop sustainable, connected communities Create flourishing, connected communities A Public Mental Health Framework for Developing Well–Being Promote meaning and purpose Reduce risk factors Promote protective factors Develop sustainable, connected communities Integrate physical and mental health and well-being Build resilience and safe, secure base Ensure a positive start in life

Presentation outline The ‘problem’ The vision Overview of the Public Mental Health framework Taking this work forward and next steps

The ‘problem’ Poor mental health contributes significantly to overall health inequalities and the burden of disease Mental health problems have a significant cost impact on society

Mental health problems are common 1 in 6 the adult population experiences mental ill health at any one time 10% of children have a mental health problem, many continue to have mental health problems into adulthood 10% of new mothers suffer from postnatal depression 19% of women and 13.5% of men are affected by depression or anxiety at any one time Half of all women and a quarter of men will be affected by depression at some time in their life and 15% experience a disabling depression 4% of population has a personality disorder 1% of population have a serious mental health problem

UK Disability Adjusted Life Years - WHO, 2002 www. who UK Disability Adjusted Life Years - WHO, 2002 www.who.int/healthinfo/bodestimates/en/index.html

UK Disability Adjusted Life Years by mental illness WHO 2002 Total UK DALY due to mental illness is 26.1%, of which the following are the largest contributors: Uni-polar depression – 7.8% Serious Mental Illness – 2.3% Alcohol Misuse – 3.7% Drug Misuse – 2.1% Dementia – 3.7%

Vision A reflection on life, death and well-being Integrate Well-Being Improve Health Reduce Inequalities Promote well-being Positive Outcomes Health & well-being Educational achievement Productivity & efficiency Safer communities Social Inclusion Integrate Well-Being Promote Physical Health Promote Mental Well-Being Promote Social Well-Being Public Health & Early Prevention Health Services Social Health Risk Factors Mental Health Risk Factors Physical Health risk factors Negative Outcomes Inequalities in health Poor education Reduced productivity Increased crime Social exclusion Reduce risk factors Ill-Health Death Nurse J, 2006

Mental health problems have a significant cost impact on society

Cost of mental health problems in England Source: Kings Fund 2008 Impact on society Cost of mental health problems in England Source: Kings Fund 2008 Cost of mental health care in England/ year Health and social care service costs Loss of employment costs Total GDP cost 2007 £22.5 billion p.a. £48.6 billion p.a. 2026 £47.5 billion p.a. £88.45 billion p.a. 10.1% 5.3% Jo – is it worth adding anything here about how much we spend on mental health care in the NHS and the proportion of health spend as a whole – we have some lines on this which show it to be the biggest area of spend (or do we not want to draw attention to that)?

Mental Health Problems Have a Significant Impact Upon the Individual

Deliberate Self Harm and Suicide Accounts for 20% of all deaths among young people aged 15-24 ChildLine received 1,265 calls in 2005-2006 in connection with Suicide

Deliberate Self Harm and Suicide < 24,000 teenagers admitted to A&E after self harming each year Estimated 1 in 10 Teenagers Self harm ChildLine received 2,012 calls in 2005/06 in connection with self harm

To create flourishing, connected communities The vision To create flourishing, connected communities

Shifting focus from illness to well-being Mental health more than absence of mental illness Shift from treatment to providing greater focus on promoting well-being in the whole population and early intervention for high risk groups Positive mental health is a key asset which benefits physical health, educational outcomes, families, community safety and the economy

Benefits of flourishing (Keyes 2007) Fewest missed days of work Healthiest psychosocial functioning, i.e. low helplessness, clear goals, high resilience Lowest cardiovascular disease Lowest number of physical diseases with age Fewest health limitations of activities of daily living Lower health care utilisation

Moderate mental health The mental health spectrum From: Huppert Ch.12 in Huppert et al. (Eds) The Science of Well-being Moderate mental health Mental disorder Flourishing Languishing Number of symptoms or risk factors

Moderate mental health The effect of shifting the mean of the mental health spectrum From: Huppert Ch.12 in Huppert et al. (Eds) The Science of Well-being Flourishing Moderate mental health Mental disorder Languishing Number of symptoms or risk factors

The Public Mental Health Framework

connected communities Create flourishing, connected Communities A Public Mental Health Framework for Developing Well–Being Meaning from Adversity: Post traumatic growth Psychological therapies Positive reflection Promote meaning & purpose Reduce Social Exclusion: Address discrimination and stigma Target high risk groups Develop sustainable, connected communities Integrate physical & mental health & well-being Reduce: Smoking Alcohol Drugs Obesity Reduce risk factors Reduce Inequalities: Unemployment Fuel Poverty Homelessness Violence and Abuse Impact of Climate Change Build resilience & a safe, secure base Prevent and reduce impact of Adverse Childhood Experiences: Child abuse Parental mental illness Parental substance misuse Parental Domestic Abuse Household offender Childhood bereavement Ensure a positive start in life Nurse J 2008

Ensure a positive start Risk factors Adverse childhood experiences mean people are 12 times more at risk of attempting suicide 10 times of injecting drug use 7 times of being an alcoholic 4 times of being depressed or using illicit drugs Violence and abuse A history of child abuse increases the risk of lifetime prevalence of depression by 1.8 - 2.7 times for women and 1.6 - 2.6 times for men

Ensure a positive start Risk factors Looked after children are 8 times more likely to develop conduct disorder 3 times an emotional disorder 7 times a hyperkinetic disorder and up-to 5 times more likely to attempt suicide Poor education Those leaving school who are under 15 years of age are 2.5 times more at risk of developing a mental health problem

Educational Poster for Expectant Mothers National Child Welfare Association 1919

Life Course Benefits Top 50% (no conduct crime smoking drugs depression suicide no quals Top 50% (no conduct problems) 1.00 1.00 1.00 1.00 1.00 1.00 Middle 45% (some problems) 1.95 1.24 1.51 1.24 1.69 1.18 Bottom 5% (conduct disorder) 4.13 1.59 2.39 1.57 3.00 1.45 (prevalence in UK 5-6%) Longitudinal studies suggest that conduct disorder persists into adulthood in about 40% of cases and is strongly predictive of a range of poor outcomes, including criminal behaviour, substance misuse, poor educational and labour market performance and disrupted personal relationships (Stewart-Brown 2004). 25-year longitudinal analysis of a birth cohort of young people in New Zealand. Information was collected on child conduct problems at age 7-9 and subsequently on a wide range of outcomes in early adulthood, including crime, substance use, mental health, sexual/partner relationships and education/employment those in the bottom 5% in terms of disturbed childhood behaviour are four times as likely as those in the top 50% to have committed a violent offence by age 25, three times as likely to have attempted suicide and nearly three times as likely to have become a teenage parent, after controlling for other potential influences in each case. 26

Build resilience and a safe secure base Risk factors Flooding Increases risk of depression four fold Unemployment ‘Economically inactive’ are up to 5.5 times more at risk Fuel poverty 2.3 million vulnerable people live in fuel poverty in the UK, cold homes increase the risk of depression by 50% Violence and abuse Levels of community violence have increased over last 50 years – associated with mental health problems

Inequalities & Poor Environment The cycle of violence and abuse across the life-course Inequalities & Poor Environment I N C R E A S G Negative Parenting Adverse Childhood Experiences Conduct & Emotional Disorders Risk Behaviours Violence & Abuse Poor Mental Health Poor Physical Health & Socio-Economic Outcomes Nurse J, 2008

Integrate physical and mental health and well-being Risk factors A meta-analysis found that depression at age 65 was linked with a 70% increased risk of dying early Having a physical Illness increases your risk of developing a mental health problem by 6.4 times Following a myocardial infarction: A depressed/anxious person with myocardial infarction is up to three times more likely to die within two years An anxious person is up to six times more likely to die of coronary heart disease

Integrate physical and mental health and well-being Risk factors Obesity and depression The 20-25% of the population who are obese and smoke are concentrated in among the 26% of the population living in poverty, who also have the highest prevalence of depression and anxiety Smoking Having a mental health problem is associated with a two-fold increased risk of smoking, compared to the non smoking population

Integrate physical and mental health and well-being Risk factors Hazardous drinking A longitudinal study found that in adulthood, especially for women, the risk of developing hazardous drinking increased following two or more stressful life events Alcohol dependency People with a common mental disorder were twice as likely to have dependency on alcohol than those without a mental health problem and for those with a serious mental health problem, it was three times the rate

Develop sustainable connected communities Risk factors Recently released prisoners 35 times more likely to commit suicide if they are female and 8 times if they are male, young offenders 18 times more likely Urban environment Lack of social support increases the risk by two-fold, and a lack of green spaces by 80% Disconnected societies enhance social exclusion Groups who experience discrimination generally experience higher levels of mental health problems

connected communities Create flourishing, connected communities A Public Mental Health Framework for Developing Well–Being Promote meaning & purpose Cultivate purposefulness & fulfilment: In life, work, education and volunteering By creativity, coherence and flow With inclusive beliefs and values Develop sustainable, connected communities Enhance: Community engagement Ecological intelligence and connectedness Improve: Physical activity Healthy food Sexual health Health checks Integrate physical & mental health & well-being Promote protective factors Promote: Employment Benefits checks Safe green spaces Insulated and warm homes Partnership working Build resilience & a safe, secure base Improve: Parenting and parental health Social and emotional literacy in healthy schools Violence & abuse prevention skills Early interventions for conduct & emotional disorders Ensure a positive start in life Nurse J 2008

Ensure a positive start in life Key messages Majority of mental health problems start in childhood: Up to three quarters of adult mental health problems start in childhood Pre-natal and early life factors are important in influencing well-being Adverse childhood experiences can have long-term negative effects on both physical and mental health Interventions Positive parenting skills for the whole population and targeted at high risk groups; treat parental mental illness Develop social and emotional literacy skills Develop violence and abuse prevention skills Intervene early with conduct and emotional disorders

Build resilience and a safe secure base Key messages - interventions Reduce socio-economic inequalities, unemployment and homelessness Reduce community based violence – share information and reduce alcohol Promote resilience against climate change: Create safe, green spaces: to increase resilience to climate change (aides flood management, reduces heat, improves air quality); and reduces mental health problems Address fuel poverty: insulate homes to increase resilience from heat and cold and reduce CO2 emissions. Warmer homes decrease the risk of depression by 50%

Integrate physical and mental health and well-being Key messages - interventions Target interventions to risk factors for those with mental health problems Ensure health promotion activities target those with mental health problems Promote mental health in those with physical health problems Develop integrated clinical pathways to the prevention and treatment of physical and mental ill health

Mental Health Physical Health Historically, mental and physical health have been seen as separate and non- interacting domains, resulting in separate treatment approaches and policies Mental Health Physical Health

In reality, there is considerable overlap and interaction between physical and mental health Poor mental health is probably a larger contributor to health risk behaviours and poor physical health than the other way round Mental Health Physical Health

Develop sustainable connected communities Key messages Target groups that experience discrimination for interventions to reduce risk factors and promote mental health Apply ecological principles as they potentially help to increase wider sustainability and a sense of being connected to a community Multiple health benefits of green spaces exist, including mental well-being, reduced violence, increased physical activity, reduced obesity and greater social capital

Target groups Target socially excluded and discriminated groups: Those with mental health problems Lesbian, gay, bisexual and transgender Black and minority ethnic groups Looked after children Offenders and ex-offenders Travellers Immigrants and asylum seekers Older people

Promoting meaning & purpose Key messages Work in partnership to create a vision of well-being Improve access to psychological therapies to help develop meaning from adverse circumstances Promote meaning and purpose within education, work and voluntary community activity Organisations to develop and adopt inclusive beliefs and values Promote activities that develop creativity, coherence and flow

connected communities Create flourishing, connected communities A Public Mental Health Framework for Developing Well-Being Meaning from adversity: Post traumatic growth Psychological therapies Positive reflection Promote meaning & purpose Cultivate purposefulness & fulfilment: In life, work, education and volunteering By creativity, coherence and flow With inclusive beliefs and values Enhance: Community engagement Ecological intelligence and connectedness Reduce social exclusion: Address discrimination and stigma Target high risk groups Develop sustainable, connected communities Integrate physical & mental health & well-being Improve: Physical activity Healthy Food Sexual Health Health Checks Reduce: Smoking Alcohol Drugs Obesity Reduce risk factors Promote protective factors Reduce Inequalities: Unemployment Fuel Poverty Homelessness Violence and Abuse Impact of Climate Change Promote: Employment Benefits Checks Safe Green Spaces Insulated & Warm Homes Partnership Working Build resilience & a safe, secure base Prevent and reduce impact of Adverse Childhood Experiences: Child abuse Parental mental illness Parental substance misuse Parental Domestic Abuse Household offender Childhood bereavement Improve: Parenting & Parental Health Social and Emotional Literacy in Healthy Schools Early interventions for conduct & emotional disorders Ensure a positive start in life Nurse J 2008

Taking this work forward …and next steps Summary to be developed and circulated in the New Year for wider consultation – DH, OGDs and National Experts Draft report to be circulated for comments National launch event of final report Spring 2009 Key messages to inform New Horizon’s work Comments to Jo.Nurse@dh.gsi.gov.uk

Key messages – a reminder The problem: Poor mental health contributes significantly to overall health inequalities and burden of disease The vision: To create flourishing, connected communities Aim of the report: To provide an evidence-based public mental health framework for generating well-being and flourishing within individuals, families, communities and society

Key messages – a reminder Ensure a positive start in life: The majority of mental health problems start in childhood and early interventions to promote well-being have a potentially bigger impact upon overall population well-being. Build resilience and a safe secure base: Everyone needs a home, sufficient income, freedom from violence and a need to develop resilience. Integrate physical and mental health and well-being: Lessons from neuro-science will help transform the way we approach and treat physical and mental health. Develop sustainable connected communities: Socially excluded groups experience more mental health problems and need targeting. Ecological principles can help to increase the feeling of being connected. Promoting meaning and purpose: If we do this in all that we do, we can help people overcome adversity and promote a greater sense of well-being.