Dr Jonathan Campion, Director for Public Mental Health and Consultant Psychiatrist at South London and Maudsley NHS Foundation Trust, summarises his new report Public mental health: Evidence, practice and commissioning.
Mental disorder is responsible for 23.8% of UK disease burden although this underestimates the true impact by more than a third. The size of disease burden is due to a combination of high prevalence with almost a quarter of adults in England experiencing at least one mental disorder each year.
Most lifetime mental disorder arises before adulthood and a broad range of public health relevant impacts across health, education, employment, relationships, violence and crime. For instance, mental disorders produce a 7-25 year reduced life expectancy and 42% of adult tobacco consumption is by people with mental disorder. Similarly, mental wellbeing has a range of impacts across health, education, employment and relationships.
Particular factors increase risk of mental disorder. Given most lifetime mental disorder arises before adulthood, such factors are more important during pregnancy, childhood and adolescence. In particular, child adversity accounts for 30% of adult mental disorder. Similarly, particular factors improve mental wellbeing. Such factors are important to address to prevent mental disorder and promote mental wellbeing.
Evidence-based public mental health interventions exist to treat mental disorder, prevent associated impacts, prevent mental disorder from arising and promote mental wellbeing. Such interventions result in broad public health relevant impacts and associated economic savings even in the short term. Certain groups are at increased risk of mental disorder and poor mental wellbeing and require more targeted approaches.
However, population coverage of such interventions is poor: only a minority of people with mental disorders in England receive any treatment, far fewer with mental disorder receive interventions to prevent associated impacts, and even fewer receive interventions to prevent mental disorder from arising or promote mental wellbeing. This implementation gap results in population scale suffering, broad public health relevant impacts and associated economic costs. It also represents a breach of the 2010 Equality Act and the right to health.
Several reasons contribute to the public mental health intervention gap including:
- Lack of knowledge about size, impact and cost of the intervention gap at national or local level
- Lack of appropriate policy targets
- Lack of appropriate resource allocated to mental health: In England, this amounted to 12.0% of the NHS budget and 1.6% of the public health budget despite at least 23.8% of UK disease burden due to mental disorder. Furthermore, local authority expenditure reduced by 28.6% in real terms between 2010/11 and 2017/18
- Lack of public mental health knowledge and training in public health, primary care, secondary mental health care, social care and commissioning to reflect the large impact of mental disorder and wellbeing and evidence based public mental health interventions to address this
Coverage of public mental health interventions can be facilitated by:
- Public mental health practice consisting of mental health needs assessment to inform Joint Strategic Needs Assessments, mental health strategy and policy development followed by implementation and then evaluation of associated coverage and outcomes
- National assessment of the size, impact and cost of the public mental health intervention gap as well as impact and associated economic savings of improved coverage. This informs transparent agreement about nationally acceptable standards for minimum level of coverage of different public mental health interventions and required resource
- Improved population public mental health literacy
- Training for professionals and trainees in public health, primary care, secondary mental health care, social care, criminal justice, commissioning and policy to reflect the impact of mental disorder and wellbeing and evidence base for public mental health interventions
- Settings based approaches including antenatal settings, schools, workplaces and neighbourhoods
- Integrated approaches
- Use of digital technology
- Maximising existing resources through self-help, task-shifting, improved concordance and less intense interventions
- Addressing socioeconomic inequalities
- Specific interventions including parenting programmes, addressing parental disorder which could prevent 40% of offspring mental disorder, addressing child adversity and promoting physical activity
- Legislation, regulation and a human rights approach
- Public mental health lead roles in primary care, secondary mental health care and local authority settings