East Asian Arch Psychiatry 2013;23:4-5


Public Mental Health — What is to be Done?

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Mental health has been an integral part of an individual’s well-being, although there have been difficulties in defining it and in whether mental illness should be seen as the opposite end of this spectrum. Sartorius1 defined mental health as a state of the organism which allows the full performance of all its functions or as a state of balance within oneself and between an individual and his or her physical, social (and cultural) environment. Another definition used is absence of disease. However, the key is that an individual must be able to function well and in so doing meet the needs of food, shelter, survival, and so forth.2 Mental health is related to feelings of self-worth and contributes to self-esteem. As such mental health is a mixture of physical, social, and psychological well-being. Interactions between the individual and that person’s immediate family and peers and society at large will allow him or her to function effectively and successfully. Bhugra et al3 noted that mental health is about a state of equipoise, where the individual is at peace with themself, functions effectively socially, and is able to look after his or her needs. Psychiatry has often focused too much on mental illness and not enough on mental health. Training both at undergraduate and postgraduate levels may cover some aspects of preventive and social medicine, but often does not deal with mental health and well-being. We ignore the interaction between physical and mental health at our peril. There is ample evidence that co-morbidity of physical and mental illness can diminish overall prognosis.

Positive mental health can result in better educational attainment, greater productivity, reduced mortality, and reduced risk behaviours.4 The relationship between mental health promotion and prevention of mental ill health is important. Clinicians are trained in managing mental illness and mental ill health. The challenge is to encourage them to lead on prevention.

Mental ill health poses a considerable imposition on society directly and indirectly. In the United Kingdom, for example, mental ill health accounts for 22.8% of total disease burden, compared to 15.9% on cancer and 16.2% on cardiovascular disease, and the economic cost of mental illness is £105 billion in England alone.4 The case for prevention is significant not only for economic reasons but for the functioning of society as a whole. There is evidence to indicate that the burden of mental illness cannot be reduced simply by treating mentally ill individuals.5 It has been argued that the only sustainable method of reducing the burden of disease is prevention.6

We know that half of lifetime mental illnesses (except dementia) starts by the age of 14 years and 75% by the mid-20s.7,8 Risk factors for mental ill health in adulthood date back to childhood where these factors can be divided into those relating to the child, those relating to the family, and those related to the household itself. Maternal stress, substance abuse during pregnancy, child (physical, sexual and emotional) abuse, lone parents, low income, poor housing, overcrowding, debt, violence, unemployment, and other factors all play a role. Looked-after children (those in care), the elderly, women, lesbians / gay / bisexual and transgender (LGBT) people, and prisoners are all at a higher risk of developing mental ill health. Mental health and physical health should be promoted together and not in isolation from each other.

Mental health promotion can be focused on societies and families as well as on individuals. Individuals must develop the personal ability to deal with the social environment and that subject’s internal world. The entire population as a whole should be seen as the base of a pyramid. Most individuals will seek help from their personal, social and folk sector in the first instance. A small proportion will seek help in primary care and of these only a few may be referred on to secondary care. Those being referred to tertiary care will further be filtered out at the secondary care level. Thus, different interventions and health promotion strategies have to focus on different levels in order to be successful. Kalra et al9 suggested that mental health promotion should be targeted at different groups such as children and adolescents, adults, women, the elderly, LGBT and migrants, among others.

Thus, health promotion can be targeted at a universal level (for the entire population), selected groups (targeted high-risk groups) and individuals (targeted high-risk individuals). This means that different emphases and strategies are required for each level. Cultural variations are absolutely vital in our understanding of mental ill health and the potential for successful interventions. What should clinicians and policy-makers do? First and foremost, public mental health is about social inequalities and their impact on the individual’s physical and mental health, all of which are inextricably inter-linked. Education about types of stress and managing stress must start at an early age in schools. It must be directed to children and teachers, as well as to parents. In addition, social inequalities need to be tackled.

Promoting physical and mental health through parenting skill interventions, home visitations, and peer support can reduce the likelihood of developing mental ill health. Pre-school and school-based health education can help prevent conduct and emotional disorders, as can prevention of violence and abuse.

Early interventions for mental ill health such as conduct disorders, psychosis, and addictions can be helpful in reducing long-term illness and problems. For specific at-risk groups, it is important to build information portals which can be used appropriately. Teaching reduction in risk-taking behaviours (such as smoking cessation and alcohol abuse) can reduce the likelihood of developing co-morbidity.

Promoting strength and resilience through school- based programmes, work-based promotion, promoting well-being individually, as well as environmentally improving housing, transport, green spaces can all contribute to improved mental health. Suicide prevention programmes have been shown to be extremely successful. Early management of physical illness can also be helpful in reducing the onset of mental ill health.

There is ample evidence from research that confirms the value of mental health promotion, but there is urgent need to translate this into interventions and deliver them in a way to reduce the burden of disease due to mental disorder. Education and empowerment are critical in engaging populations and in helping to improve public mental health.

Dinesh Bhugra, CBE, PhD, FRCPsych
(email: dinesh.bhugra@kcl.ac.uk)
Professor of Mental Health and Cultural Diversity
Health Service and Population Research Department
Institute of Psychiatry, King’s College
London London SE5 8AF 
United Kingdom


  1. Sartorius N. Fighting for mental health. Cambridge: Cambridge University Press; 2002.
  2. Maslow A. Towards a psychology of being. New York: Van Nostrand; 1968.
  3. Bhugra D, Till A, Sartorius N. What is mental health. Int J Soc Psychiatry 2013;59:3-4.
  4. Campion J, Bhui K, Bhugra D; European Psychiatric Association. European Psychiatric Association (EPA) guidance on prevention of mental disorders. Eur Psychiatry 2012;27:68-80.
  5. Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H. Utilising survey data to inform public policy: comparison of the cost- effectiveness of treatment of ten mental disorders. Br J Psychiatry 2004;184:526-33.
  6. Saxena S, Jané-Llopis E, Hosman C. Prevention of mental and behavioural disorders: implications for policy and practice. World Psychiatry 2006;5:5-14.
  7. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.
  8. Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustün TB. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry 2007;20:359-64.
  9. Kalra G, Christodoulou G, Jenkins R, Tsipas V, Christodoulou N, Lecic-Tosevski D, et al. Mental health promotion: guidance and strategies. Eur Psychiatry 2012;27:81-6.
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