The 3 keys to “solving” mental health
“Mental health is a societal issue long before it becomes a clinical one.”
Can we reduce population mental illness and addiction to zero? This is not an easy task, but it is an essential one.
We have previously argued that mental health needs to be “solved” urgently and globally. Only an intersectoral, systemic, intentional and co-ordinated effort will shift the needle on the barometer of mental health.
To “solve” mental health at a technical level, a complete reimagining of the complex societal mental health ecosystem is needed across the life course.
The Thrive Foundation proposes to use scientific evidence and innovation to actually solve mental health in our community. Our approach is to tackle mental health across the life-course of the population, from conception to old age, using a multi-level systems framework of determinants of mental health, as described in Figure 1, below.
The above framework illustrates the complexity of mental health within a society. Tackling any one of these components alone is unlikely to achieve the dramatic improvements necessary to turn the tide.
One approach to complex problems like cancer and brain research is “convergence science” which, it has been recently argued, should also apply to population health. The complex determinants of mental health, above, can thus be condensed into three core principles.
These principles are:
- Prevention and Health Promotion: protection and resilience enhancement
- Perfect Care: innovative treatments and suicide prevention
- People Power: social justice, democracy, and community empowerment
When applied together, we believe that Mental Health can be “solved” in a society.
No one has yet brought the elements together with the intention of solving mental health at a national level. This is possible in Guernsey because of its manageable size and structure as a test bed nation, a simplified single-layer bureaucracy, innovative and visionary leadership, the ability to access rapid policy development, and the power to dive deeply into systems for meaningful change.
Below we present the Thrive Foundation principles framework in more detail.
Prevention and Health Promotion
Mental illness is largely preventable. Genomics research has demonstrated complex multi-gene influences on health where hereditary (genetic) factors alone only account for a small proportion of illness liability. Genomic science has clarified that environmental influences, probably from before conception, and continuing throughout life, have the strongest effects on health. The vast majority of mental illness is thus caused or triggered by social determinants and environmental factors like trauma, abuse, poverty, inequality, substance use and toxic stress. Lifestyle factors like diet, exercise, mindfulness practice, connection and meaning contribute to poor mental and physical health. Each of these can, we believe, be systematically addressed using engaged communities, existing science and cutting-edge innovation.
Population mental health is normally distributed from thriving to surviving to suffering. Scientists have demonstrated that whole population mental wellbeing can be shifted towards thriving and away from suffering. The normal distribution curve of population health shifts left away from illness towards thriving (Figure 2, below).
Based on epidemiologist Prof Geoffrey Rose’s work, the principle of whole population shift has also been demonstrated in such diverse areas as obesity, gambling, smoking, alcohol use, suicide, educational attainment, blood pressure and cholesterol.
From a mental healthcare perspective, fewer people cross the illness line to become “clinical cases” who require costly treatment, and incur other costs (unemployment, etc), all of which negatively impact the economy. Workplace wellbeing is rightly an economic priority area.
If health care (treatment) only contributes some 10–20% to health outcomes, the biggest impact will be focusing on the 80%: prevention.
There is a compelling business case for investing in population health – it makes human, health, and economic sense. A Public Mental Health prevention approach brings impressive returns on investment. For example, for each Pound invested in prevention, the return on investment is £2.37 (workplace wellbeing), £5.08 (school-based resilience programme), and £1.26 (tackling loneliness in the elderly). £10 is saved in treatment for alcohol or other substance abuse for every £1 spent on prevention (NIDA, 2003).
The more people thriving, the greater the opportunity for self-actualization at national level.
As a caring society, should we not tackle poverty, inequality, childhood adversity and substance misuse, to actually prevent sustained stress and mental illness?
“If environmental risk factors for [mental illness] can be validated and confirmed … they will point to preventive measures that lower their risks and morbidity.”
–Alan Brown, Columbia University Medical Center, quoted here.
Existing care systems can implement proven systems to radically improve outcomes and reduce risk. Innovative new treatments, like psychedelic-assisted therapies and gene therapies, are held back by outdated and inefficient bureaucracy. To disseminate innovation is much quicker in a smaller health system within a nimble regulatory framework.
Similarly there is strong evidence for developing detection, early intervention and optimal evidence-based care for mental disorders that occur despite prevention efforts. Using whole-system approaches, suicides have been reduced to zero in health systems using “perfect depression care” models.
Health outcomes for people with psychosis are better in developing countries, despite – or because of — the lack of access to modern medicine, and the maintenance of integrated communities. We want to develop community-based peer support and expert patient networks to offer both out-of hospital, crisis support, advocacy, and leadership in transforming their services.
“If zero is not the right goal, then what is?”
Mental health is dependent on structural determinants: mental wellbeing is best achieved in equitable, just, and non-violent societies (Patel 2014).
Few Western countries truly harness the power of the people within their communities. We are reportedly lonelier than ever, despite being more connected. One key approach that we like is Asset-Based Community Development (ABCD) which:
- demonstrates that local assets and individual strengths are key to ensure sustainable community development
- seeks to make hidden community assets (people, physical assets etc.) visible – to uncover what’s strong, not fix what’s wrong
- supports indigenous community invention
- seeks to “support communities to reduce institutionalisation and increase interdependency in community life”
ABCD is an approach and way of working with communities that focuses on discovering and connecting the rich pool of talents and assets in a community to make positive and sustainable community change. This requires some risk taking on the part of the agencies we work with, since they are asked in the first instance to leave their agendas off the table, and instead relocate the authority for the setting of outcomes to local residents. For more detail, see the incredible work by our friends at nurturedevelopment.org).
WIth ABCD at the core, we think that these additional evidence-based approaches will make for an optimal ecosystem (this is not a complete list as we are open to better ideas):
- An equitable, just and non-violent society;
- Participative democracy;
- Universal basic income;
- Restorative justice;
- Science-based drug public mental health approaches, including drug regulation and disability legislation.
These approaches across a nation will not only empower citizens and communities but they also provide impressive returns on investment.
A thriving mental health ecosystem
We consider that solving mental health requires an ecosystem approach. It’s like trying to rebuild an area of scorched earth in the Amazon jungle. It requires attention to soil, water, nutrients, sunlight, seeds, plants, microbes, fungi and animals of increasing complexity. Each is interlinked in complex webs. Each component plays a small but important role in the bigger picture.
No single ecosystem has attempted to join the dots in the way, scale or time-scale that the Thrive Foundation is doing.
Better treatment for mental health would improve happiness directly; and improving happiness in other ways would reduce the frequency of mental illness… If we want a happier world, we need a completely new deal on mental health.”