mental health, resilience and inequalities: a manifesto for action for pan? lynne friedli pan-wm 3...

Mental health, resilience and inequalities:

a manifesto for action for PAN?

Lynne Friedli

PAN-WM 3rd Annual ConferenceBirmingham

20th October 2008

Summary

• Why mental health matters

• Understanding the contribution of mental health to health and other outcomes

• Reflecting on the determinants of mental health

• Where physical activity fits in – over to you!

PAN-WM: the feel good factor [email protected]


This being human is a guest house.Every morning a new arrival.A joy, a depression, a meanness,Some momentary awareness comesAs an unexpected visitor.Welcome and entertain them all.Even if they’re a crowd of sorrows,Who violently sweep your houseEmpty of its furniture.Still treat each guest honourably.He may be clearing you out for some new delight.The dark thought, the shame, the malice,Meet them at the door laughing,And invite them in. (Jelaluddin Rumi, 1207-73)

Can mental health help to explain outcomes that cannot be wholly accounted for by other factors?

• Contribution mental health and mental illness make to wide range of outcomes

• The ‘unexplained excess’ – classical risk factors do not account for level of variation in outcomes

• Presence as well as absence...

(Friedli forthcoming)


How important is mental health?


Key elements of positive mental health

• Emotion (affect/feelings )• Cognition (perception, thinking, reasoning)• Social functioning (relationships, engagement)• Coherence (sense of meaning and purpose)

Emotional/cognitive and social well-being

Status, Control, Connection, Interaction


High mental health (flourishing)

Low mental health (languishing)

High level of mental illness

Low level ofmental illness

Curing illness does not necessarily result in health

(Pat Barker)

WEMWBS – Well and HEPS


(Taulbut & Parkinson forthcoming)

Adults with above average, average and below average WEMWBS score: 2006

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Well? (aged 16+) HEPS (aged 16-74)

%

Above average

Average

Below average

Benefits of positive mental health

A worthwhile goal in itself and leads to better outcomes

• overall prevalence/herd immunity

• physical health: mortality/morbidity

• health behaviour

• employability, productivity, earnings

• educational performance

• crime / violence reduction

• pro-social behaviour/social integration/relationships

• quality of life/recoveryPAN-WM: the feel good factor lynne.friedli@btopenworl

d.com

Life course benefits

crime smoking drugs depression suicide no quals

• top 50%(no conduct problems) 1.00 1.00 1.00 1.00

1.00 1.00

• middle 45% (some problems) 1.95 1.24 1.51 1.24

1.69 1.18

• bottom 5% (conduct disorder) 4.13 1.59 2.39 1.57

3.00 1.45

(adapted from Fergusson et al 2005)


Life course benefits (2)

per case total for 1-yearScotland

cohort in UK

£ £ million £ million

• Prevention (move bottom 5% to middle 45% 150,000 5,250

4.2

• Promotion (move middle 45% to top 50%) 75,000 23,625

18.9

(Friedli & Parsonage 2007)PAN-WM: the feel good factor lynne.friedli@btopenworl

d.com

Contribution of mental health to inequalities

Key domains:Education; Employment; Behaviour; Health; Consequences of illness; Services

(Whitehead & Dahlgren 2006)

Mental health is a significant determinant in each case, influencing:• readiness for school/learning• employability• capacity, motivation and rationale for healthy behaviours• risk for physical health (e.g. coronary heart disease)• chronic disease outcomes (e.g. diabetes) • relationship to health services, including

uptake/treatment



Not ‘every family in the land’Findings from 9 large scale population based studies:

•Material and relative deprivation•Low educational attainment•Unemployment•Environment: poor housing, poor resources, violence•Adverse life events•Poor support networks(Melzer et al 2004; Rogers & Pilgrim 2003)

Cycle of invisible barriers:•Poverty of hope, self-worth, aspirations

Mental health and deprivation

Psycho-biological pathways..........

Chronic low level stress ‘gets under the skin’ through the neuro-endocrine, cardiovascular and immune systems, influencing :

• hormone release e.g. cortisol, • cholesterol levels • blood pressure • inflammation e.g. C-reactive proteins.


Status Control Relatedness

Untangling the determinants

• Individual skills and attributes

• Material resources

• Inequalities in distribution of resources


I do worry about this emphasis on individual psychology; You can’t separate thoughts, feelings, self esteem, motivation from the material circumstances of people’s lives. Is it great to be positive? Maybe people are right to be pissed off.”Positive steps interviews


“...the Greeks and Romans lived, I suppose, very comfortably though they had no linen. But in the present times, through the greater part of Europe, a creditable day labourer would be ashamed to appear in public without a linen shirt, the want of which would be supposed to denote that disgraceful degree of poverty which, it is presumed, nobody can fall into without extreme bad conduct. Custom in the same manner has rendered leather shoes a necessary of life in England. The poorest creditable person of either sex would be ashamed to appear in pubic without them” (Adam Smith Wealth of Nations 1776)

Resilience, health assets and capabilities

• Resilient places

• Resilient communities

• Resilient individuals

• Resilient policies


‘Doing better than expected notwithstanding adversity’

Copyright ©2007 BMJ Publishing Group Ltd.

Tunstall, H. et al. J Epidemiol Community Health 2007;61:337-343

Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies and the British average (1996-

2001).


(the ecology of)Relationships Matter (1)

• Quality of social relationships is key factor in resilience in the face of adversity;

• Social integration buffers effects of low SES


Rates of poor social/emotional adjustment


(Graham & Power 2004)


Equalities Review 2007 Crown Copyright

Copyright ©2007 BMJ Publishing Group Ltd.

Tunstall, H. et al. J Epidemiol Community Health 2007;61:337-343

Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies and the British average (1996-

2001).


• Exposure• Susceptibility • Resistance


Resilient policies

•Policy responses to misfortune

•Social networks

•Service responses•Lay perceptions of poverty and health•Community assets•Collective action

(the ecology of)Relationships matter

‘tend to the social and the individual will flourish’

Rutherford 2008

• Mental health is produced socially

• Presence or absence of mental health is above all a social indicator

• Quality of social relationships is key factor in resilience

• Social as well as individual solutionsPAN-WM: the feel good factor lynne.friedli@btopenworl

d.com


A (wider) manifesto for action

Challenging material inequalities

Mental health

and well-being

Reducing poverty and

the impact of poverty

Respectful policy

responses to misfortune

Quality of social

relationships

Build capacity for collective

action(collective efficacy)

And what I shall endure, you shall endureFor every atom belonging to me as good belongs to you......

Walt Whitman


The contribution of physical activity?

Community safety/Environmental improvements

Mental health

and well-being

Affordable, accessible, inclusive routes to activity

Green, open spaces/ natural world/ nutrition

Social relationsh

ipsCollective action:

right to roam, wild swimming,

allotments, affordable food

Culture and

creativity

A just society is one that is aware that it is not yet sufficiently just,

that is haunted by this awareness and thereby spurred into action

Zygmunt Bauman



Select bibliography Carlisle Sandra Series of papers on cultural influences on mental health and well-being in Scotland (http://www.wellscotland.info/publications/consultations4.html).

Equalities Review (2007) Fairness and Freedom: the final report of the equalities review London: Cabinet Office www.theequalitiesreview.org.uksee also CEHR http://www.cehr.org.uk/

Lyybomirsky S, King L and Diener E (2005) The benefits of frequent positive affect: does happiness lead to success? Psychological Bulletin 131:6

Killeen Damian (2008) Is poverty in the UK a denial of people’s human rights? York: Joseph Rowntree Foundation http://www.jrf.org.uk/knowledge/findings/socialpolicy/2183.asp

Commission on Social Determinants of Healthhttp://www.who.int/social_determinants/resources/en/index.html

Select bibliography


Bartley M (editor) (2006) Capability and Resilience: beating the odds www.ucl.ac.uk/capabilityandresilience ESRC

Friedli L (in press) Mental health, resilience and inequalities – a report for WHO Europe and the Mental Health Foundation London/Copenhagen Friedli L and Parsonage M (2007) Mental health promotion: building an economic case Belfast: Northern Ireland Association for Mental Health

Jones C, Burström B et al (2006) Studying social policy and resilience in families facing adversity in different welfare state contexts – the case of Britain and Sweden. International Journal of Health Services 36 (3): 425–442.

Zaveleta RD (2007) The ability to go about without shame: a proposal for internationally comparable indicators of shame and humiliation Oxford: OPHI


Select Bibliography

Fergusson, D., Horwood, J. and Ridder, E. (2005) Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood Journal of Child Psychology and Psychiatry, 46:8

Keyes, C.L.M. (2002) The mental health continuum: from languishing to flourishing in life. J Health Soc Res 43:207-22

Graham H and Power C (2004) Childhood disadvantage and adult health: a life course framework London: Health Development Agency

Melzer D, Fryers T and Jenkins R (eds) (2004) Social inequalities and the distribution of the common mental disorders Hove: Psychology Press

Pickett KE and Wilkinson RG (2007) Child wellbeing and income inequality in rich societies: ecological cross sectional study BMJ 335:1080

mental health, resilience and inequalities: a manifesto for action for pan? lynne friedli pan-wm 3...

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