Preventive psychiatry: a paradigm to improve population mental health and well-being

Summary

The government's Public Health White Paper for England sets out a utopian vision of how to prevent and remedy mental health problems. The public health approach relies on primary prevention, promoting individual responsibilities and resilience, while also sustaining existing services and tackling inequalities. These ambitions are consistent with the preventive psychiatric paradigm, and with the best of evidence-based psychiatric practice. Although the evidence on cost-effectiveness of public mental health interventions is growing, the challenge is to ensure that specialist knowledge informs policy, practice and research so that inequalities are not compounded. Specialist mental health professionals are needed to inform and lead public health reforms.

Kamaldeep Bhui (piectured) is Public Health Lead at the Royal College of Psychiatrists, Professor of Cultural Psychiatry and Epidemiology at the Wolfson Institute of Preventive Medicine, Queen Mary University of London, and an honorary consultant psychiatrist with East London Foundation Trust. Sokratis Dinos is a Senior Research Fellow at the Wolfson Institute of Preventive Medicine, Queen Mary University of London.

The Public Health White Paper

The Public Health White Paper ¹ for England signals a new way of conceptualising health, taking account of well-being and positive health states, and not just the absence of symptoms or illness. There are three components of the White Paper's approach to public health: (a) health improvement (lifestyles, health inequalities and improving the wider social influences of health); (b) health protection (infectious diseases, environmental hazards and emergency preparedness); and (c) health services (service planning, efficiency, audit and evaluation). There is a paradox as the emphasis on service provision includes secondary and tertiary prevention; and this sits uncomfortably with the neglected area of primary prevention which promises to deliver greater health gains by shifting risk factor profiles for entire populations. ²

The UK Faculty of Public Health defines public health as ‘The science and art of preventing disease, prolonging life and promoting health through organised efforts of society’. ³ Consistent with this definition, the Public Health White Paper shifts responsibility for health and well-being from the government to the individual and to society. The focus is on prevention by promoting well-being in the community using a whole systems approach, alongside actions to target groups that are vulnerable to health problems. The Royal College of Psychiatrists’ position statement on public mental health ⁴ provides the evidence base on cost-effective preventive interventions (Appendix 1). One priority is to ensure a positive start in life through parenting and youth programmes. Public mental health is also about promoting well-being and preventing health problems by ‘educating’ people to make healthier, responsive and informed choices about their health. Is this the business of psychiatrists and mental health specialists?

Freud was a public health physician

Since the days of asylums and physical restraints, psychiatric practice and the evidence base for treatment have advanced incredibly. Preventive psychiatry can help shift the stigma associated with historical accounts of psychiatric treatment. Preventive psychiatry can mitigate negative stereotypes about professionals that undermine public confidence in modern specialist psychiatric expertise and evidence-based interventions. Not all in historical practice was bad. Freud advocated understanding the influence of childhood adversity on adult psychopathology; he also attended to problems of society and group relations. Researchers and policy makers are still interested in a similar interplay of factors; public mental health models of ‘risk’ and ‘protective’ factors exist at the individual, family and community levels to describe the processes associated with mental health problems. These categories of risk and protection exist on and interact at multiple levels.

This complexity, in part, explains the challenge facing mental health specialists; as well as treating the immediate symptoms of an illness, they must also:

1. (a) help to remedy the consequences of adversity and vulnerabilities in childhood that lead to the illness;

2. (b) prevent further disabilities or illnesses, either through preventing progression of distress or through dealing with behaviours that compound disability, for example substance misuse or minor offending behaviour;

3. (c) break the risk of intergenerational transmission of violence, abuse, trauma, poverty and inequalities to the children of adults experiencing mental health problems due to childhood adversity;

4. (d) attend to the physical health consequences of mental illness and vice versa.

Preventive psychiatry also has a role in managing work stress, returning people to work as soon as possible following illness, and preventing work-related health problems especially among the most vulnerable. Thus preventive psychiatry, located within a public mental health framework, provides an opportunity to recognise more explicitly important preventive elements of existing psychiatric practice.

Dilemmas and decisions facing the practice of preventive psychiatry

Psychiatrists and all mental health practitioners will need further skills and ways of managing the dilemmas that now face them.

‘Public mental health takes resources away from secondary and tertiary care and prevention’

This is the most common response we have encountered among clinicians in specialist care, that public mental health will remove resources from their local services, implicitly, prioritising other populations over those who are already socially excluded and poorly served. Such populations are perceived to need effective interventions within a more coherent service framework that is already fragmented and constantly being reorganised. An alternative analysis is to consider the benefits for society as a whole, and whether some public monies might more usefully be shifted to a primary prevention role that reaches all those in the local population. Importantly, such interventions will need to be adapted where necessary to reach those in receipt of specialist mental healthcare. Although preliminary research evidence is promising, cost-effectiveness studies are necessary alongside any changes in policy and service delivery. However, there is merit in universal public health approaches: people with mental health problems are seen as legitimate and entitled consumers of public health interventions. Thus the management, for example, of obesity and nutrition and alcohol use in society as a whole is also a way to ensure that health improvements are possible among those in receipt of specialist mental healthcare.

Public mental healthcare needs specialist skills to avoid widening inequalities

Preceding and complementing the White Paper, The Marmot Review drew attention to actions to prevent ‘the societal organisation of misery’ by attacking the wider determinants of inequalities in health (www.marmotreview.org/). Health inequalities are evident in both high- and low- and middle-income countries and public health actions must be taken locally, nationally and globally. A criticism of public mental health is that targeted interventions are not considered at all, and so fail those most in need. The inverse care law, inverse prevention law and inverse equity law need combating, through the advocacy role and the expertise found among specialist mental health professionals. Targeted interventions will be necessary to prevent a widening of inequalities. ⁵ Evidence suggests that there are disparities in the prevalence of mental health problems and access to mental healthcare for high-risk groups (Appendix 2). Black and minority ethnic, ^6,7 lesbian, gay, bisexual and transgender ⁸ groups as well as people with intellectual disabilities ⁹ and offenders are some of these groups. Such groups are likely to be stigmatised and discriminated against and have a significantly higher prevalence of mental health problems than the general population; inequalities of access to healthcare, inappropriate medical and psychological treatments, discrimination and general lack of understanding are also found. These disparities call for a change of practice that will enhance inclusivity and accessibility to safe and effective services as part of a total systems approach to public health.

A capable workforce skilled for public mental health roles

A new cadre of specialists is needed if the challenges posed by the White Paper are to be met, while also delivering on the Marmot Review. The White Paper was published with specific suggestions for general practitioners to become part of the public health workforce, with no consideration of other specialists. Some psychiatrists and mental health professionals are trained in population sciences, epidemiology and public health. Psychiatric research and clinical services are now more inclusive of common mental disorders and subthreshold disorders, ¹⁰ and population phenotypes of psychosis. ¹¹ Child and adolescent psychiatrists already undertake significant preventive work. Perinatal psychiatry offers good opportunities to break the intergenerational transmission of risk of mental disorder in later life. Forensic psychiatry and child protection work can also be seen in this light. So rather than necessarily competing with secondary and tertiary prevention, public health encompasses these areas of practice but locates these foci within a broader network of systems and interventions. It is likely that public health physicians will need knowledge about and skills to work with the broad range of states of mind that make up the spectrum from well-being, emotional and mental distress to mental disorders. Specialists have a role to play in informing the development of generic policies and actions, highlighting where targeted interventions are essential, and then informing their development.

The research evidence

It is vital for future psychiatric research to consolidate the evidence already available (Appendix 1) and to develop new research if evidence is limited; for example, what is the best balance of universal and targeted interventions for those who are most vulnerable. Public mental health has adopted a model of ‘risk’ and ‘protection’ and a great deal of the focus in the White Paper is on promotion or strengthening of those protective factors (e.g. social capital, family relations, educational and academic achievement) by helping people become more resistant or resilient to the risks imposed by adverse circumstances. ¹² We must ensure research into resilience, and monitor inequalities for early signs that they are worsening or remaining static. We must interrogate the way non-specialists interpret information and evidence about mental health problems, as well as embark on ambitious and essential research that will benefit public health and reduce inequalities locally, nationally and globally.

Appendix 1

Evidence-based wide interventions for promotion of well-being and prevention of mental illness ⁴

1. • Interventions to improve parental health

2. • Pre-school and early education interventions

3. • School-based mental health promotion and mental illness prevention

4. • Prevention of violence, abuse and suicide

5. • Early intervention for mental illness

6. • Alcohol, smoking and substance misuse reduction and prevention

7. • Promoting healthy lifestyle behaviours

8. • Promoting healthy workplaces

9. • Prevention of mental illness and promotion of well-being in older years

10. • Addressing social inequalities, enhancing social cohesion and promotion of housing interventions

11. • Reducing stigma and discrimination

12. • Positive mental health and recovery from mental illness

Appendix 2

Groups at risk of developing mental heath problems

Children and young people

1. • Children with parents who have mental health or substance use problems

2. • Children experiencing personal abuse or witnessing parental domestic violence

3. • ‘Looked after’

4. • Children excluded from school

5. • Teen parents

6. • Young offenders

7. • Young lesbian, gay, bisexual and transgender people

8. • Young Black and minority ethnic groups

9. • Children in families living in socioeconomic disadvantage

Adults

1. • People with mental illnesses

2. • Black and minority ethnic groups

3. • Homeless people

4. • Adults with a history of violence or abuse

5. • Adults with alcohol or substance misuse

6. • Offenders and ex-offenders

7. • Lesbian, gay, bisexual and transgender adults

8. • Travellers, asylum seekers and refugees

9. • People with a history of being looked after/adopted

10. • People with intellectual disabilities

11. • Isolated older people