1. 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

2. 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)

3. 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

4. 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

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

6. 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

7. 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

8. UK Disability Adjusted Life Years - WHO, 2002 www. who
UK Disability Adjusted Life Years - WHO,

9. 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%

10. 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

11. Mental health problems have a significant cost impact on society

12. 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 %
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)?

13. Mental Health Problems Have a Significant Impact Upon the Individual

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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. The Public Mental Health Framework

22. 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

23. 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 times for women and times for men

24. 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

25. Educational
Poster for
Expectant
Mothers
National
Child Welfare
Association
1919

26. Life Course Benefits Top 50% (no conduct
crime smoking drugs depression suicide no quals
Top 50%
(no conduct
problems)
Middle 45%
(some
problems)
Bottom 5%
(conduct
disorder)
(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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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%

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

44. 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

45. 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

46. 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.