socioeconomic crisis and mental health hosman prevention options

Socio-economic Crises and Mental Health:From Research to Action

Round TablePolicies and strategies to alleviate

the mental health impact of socioeconomic crisis

What could Research, Policies and Practices of

Mental Health Promotion and

Mental Disorder Prevention contribute?

Clemens HosmanEmeritus Professor of Mental Health Promotion and Prevention

Maastricht University & Radboud University Nijmegen

Questions

1. Analysis and theory: What are the mediating and moderating factors and processes between Socioeconomic crises and Mental Health, that could be targets and entrees for preventive actions?

2. From Theory to Action: What evidence-based interventions are available in the domain of prevention in Mental Health? How effective? Are they relevant for alleviating the MH burden of Socioeconomic crises?

3. From Interventions to Public Impact: What is needed to get preventiveinterventions implemented, scaled, reaching target populations and tocreate significant public impact?

?

Alleviating the impact of economic crisis on mental health:

Preventive Actions

Socio-

Economic

Crisis

Mental health

Mental disorders

children

adolescents

adults

Elderly

Vulnerablegroups

Health, socialand economic

outcomes

What could we do?

Policies Interventions Practices


Preventive Actions

Socio-

Economic

Crisis

Mental health

Mental disorders

children

adolescents

adults

Elderly

Vulnerablegroups


outcomes

Access mental health care

Early detection and treatment

Rehabilitation Anti stigma


Preventive Actions

Socio-

Economic

Crisis

Mental health

Mental disorders

children

adolescents

adults

Elderly

Vulnerablegroups


outcomes

Mediating factors

Moderating factors

Macro level

Community

Family

Person

Access mental health care

Early detection and treatment

Rehabilitation Anti stigma

Interventions programsPractices

Policy 2016 Hosman


Preventive Actions

Socio-

Economic

Crisis

Mental health

Mental disorders

children

adolescents

adults

Elderly

Vulnerablegroups


outcomes

Mediating factors

Moderating factors

Macro level

Community

Family

Person

Conditions for Implementation and Public Impact2016

Hosman

Mediators of impact socio-economic crisis on mental health

Poor Mental Health

Mental disordersDepression - Anxiety

Externalising problemsAlcohol-related disorders

Suicide

Work Income Debts Housing

Neighbourhood quality

Family functioning and Parenting

Stress, Vulnerability and Coping

Health care quality and access

Social capital: support and connectedness

Social protection

Entree points and targets of preventive Action

Health, social andeconomic outcomes

Mediating determinants

Socio-

Economic

Crisis

Community

Family

Individual

Negative impact ��

2016 Hosman

Impact model socioeconomic crisis on mental health

Socio-

Economic

Crisis

Pre-existing strengths

Mediating determinants

negative changes in:

Work, Income, Housing, Debts

Neighborhood qualityHealth care & Social services

Social protection

Social capital, support and connectednessFamily functioning & Parenting

Stress & Vulnerabilty in children, adults, elderly

ModeratorsCoping capacities: vulnerabilities & strengths

Family functioning, SES, parental mental illnessSocial support, comm.involvement, social protection

Quality of primary and MH health care

Prevention support

weaknessesCommunity

Family

Individual

Poor Mental Health

Mental disordersDepression - Anxiety

Externalising problemsAlcohol-related disorders

Suicide

Health, social andeconomic outcomes

2016 Hosman

To design effective prevention policies and interventions

We need insight and evidence:

� Causality of factors and rolemediators ‒ moderators

� Interaction & cumulative effects

� Effect sizes - Public impact

� Causal sequences of factorsacross levels ‒ life course

� Integration of scattered knowledge

Need for comprehensive

and useful theoretical

frameworks

on mediating and

moderating processes

‒ to guide RESEARCH

and build a stronger

evidence base

‒ to guide ACTION

‒ Achieve PUBLIC IMPACT

?

“There is nothing so practical as a good theory” Kurt Lewin (1951)

How do mediating and moderating variables workbetween Socio-Economic Crises and Mental Health?

Multiple causal frameworks could be used to understand “how”

SE crisis impacts on development of mental health / disorders

generic biological, psychological and social theories

Crisis-, Cognitive-behavioral, Stress-competence-support; Positive psychology

Neurobiological, epigenetic, Developmental, Family-system, Socio-ecological

Community development, Organizational, Macro-social and economic,

Problem-specific theories (e.g. depression, anxiety; poverty; violence; social isolation)

?

� Different theories guide to different preventive stategiesCombining theories could support integrative prevention policy

HealthyPregnancy - Early Start

Externalizingproblems

Conduct disorders

ParentingCompetence

Quality

Family Stress & Strenghts

Conflicts, ViolenceChild maltreatment

Divorce

SuicideSuicidal

behavior

Social-emotionalCompetence

resilience, vulnerability

enrichment

Anxiety

Depression

Alcohol use

Problem drinking

Associations found between SE-crisis

and many outcome variables

Distress&

Coping

Parental mentaldisorders / addiction

Children COPMI

Socioeconomic Crisis

Income loss, Debts, PovertyInsecure jobs and housing

Social material deprivation

Community Social Support /Capital

Pre-school School system

Health care Public Health

WorkplacesMedia

Internet

Long term impactschool work health

2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking

Prevention aims to influencemediating and moderating trajectories

between crisis and mental health

How related? How to influence?

Distress&

Coping


Children COPMI







WorkplacesMedia

Internet


From Theory to Action

� Target at which factors? Which mediating causal trajectories?

� What strategies and interventions are available in the field of prevention and from prevention science?

� Effective? Cost-benefit ratio? Return-of-Investment ?

� Are they relevant for alleviating the mental health burden of socioeconomic crises?

Next to research outcomes other sources are also relevant and welcome:

‒ experience-based knowledge

‒ best practices fom citizens initiatives

‒ low budget solutions from LMICs

‒ inspiring examples from social innovation



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking

Distress&

Coping


Children COPMI







WorkplacesMedia

Internet

Social Protection Policies and Measures

Income e.g. tax measures, minimum income,

social benefits, debt management

Labor e.g. labor market programs, generating jobs,

better access, incentives to work, job seeking training,

micro-financing projects

Housing (e.g. housing projects, affordable rent,

shelters for homeless)

Material support (e.g. food stamps, transportation)


2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Mental health

Depression

Alcohol use

Problem drinking

What are the mediational and

moderating trajectories between

SE-crisis and mental health?

Distress&

Coping


Children COPMI







WorkplacesMedia

Internet

Stress management programs

Depression prevention CBT programs

group- or internet based


2016 Hosman




Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking

What are the mediational and



Distress&

Coping


Children COPMI






Health care

Public HealthWorkplaces

MediaInternet

Early Detection & treatment

Use of E-Mental Health technology

Advocacy

Policy change

Professional Guidelines

Training health professionals

2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking

What are the mediating and



Distress&

Coping


Children COPMI







WorkplacesMedia

Internet

Reducingaccess to

lethal means


2016 Hosman

Media coverageof suicide



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking




Distress&

Coping


Children COPMI







WorkplacesMedia

Internet

Community developmentSocial empowermentSupport systemsConsumer organizationsMicro financing projectsSocial innovation initiatives


2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking




Distress&

Coping


Children COPMI





Pre-school

School system


WorkplacesMedia

Internet

Preschool Enrichment ProgramsSchool-based Soc Emot LearningAfter-school programs


2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking




Distress&

Coping


Children COPMI







WorkplacesMedia

Internet

Parenting educationFamily supportChild abuse preventionDivorce programs


2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking




Distress&

Coping


Children COPMI







WorkplacesMedia

Internet

Healthy start

Prenatal & postnatalhomevisting programs

MH Traininng nurses and midwives


2016 Hosman



Conduct disorders

ParentingCompetence

Quality



Divorce

SuicideSuicidal

behavior



enrichment

Anxiety

Depression

Alcohol use

Problem drinking




Distress&

Coping


Children COPMI







WorkplacesMedia

Internet


COPMI support

Preventive interventions for

Children and Families dealing withparental mental illness or addiction

2016 Hosman

Healthy Start of lifePre-, postnatal Home-visiting

Prevention Training Professionals

nurses and midwives

Alcohol prevention programs and measures

School-based SELSocial-emotional learning

Violence prevention

Suicide prevention

programs

Social ProtectionPolicies & Measures

JOBS program

Innovative optionsIntegrating MH and preventive

elements in other Sectors & Programs

Prevention

Early detection & treatment

Relapse prevention

Depression Anxiety

Parent supportParenting education

COPMIPreventive support

children & Families

Preschool enrichmentprograms

Child protectionPrevention

Early interventionRelapse prevention

Stress management programs

Community ProgramsCommunities-that-Care

Social connectedness

Community development

E-mental Health – SocMediaDisorder specific

Positive psychology

Integral policy

Universal + Targeted

2016 Hosman

Focus at vulnerable groups during economic recession

Groups most hit by economic consequences

� Adults with job loss /unemployed

� People mired in debt and housing/mortgage problems; poverty

� Families in recession-related stress and divorce

� Elderly with low pension

Groups with pre-existing vulnerability

� Chronically mentally ill

� COPMI Children and families dealing with Parental Mental Illness

� Low SES groups

� Refugees and immigrants

Groups at high risk of severe, long term, multiple consequences

� Children under stress, especially during pregnancy and early years

� Unemployed adolescents (NEETs): not in education, employment or training

Hosman 2016

Effective?

Cost-Benefit ratio?

Return of Investment (ROI)

Mental disorders / problems

• depression and anxiety• behavioral problems, conduct disorder• substance use; eating disorders• psychotic episode• suicide

Mental health - Mental capital

• emotional resilience – stress management• problem solving and social competence

Risk and Protective factors

parenting competence & attachmentabuse, neglect, domestic violencebullying and safetysocial isolation and social capital

Populations at risk e.g.

Increased symptoms, prodrome

COPMI: transmission parents to childparental separation or deathlow SES families and communitiesworkers under stress; unemployed

for all these targets evidence existsof significant effects prevention and promotion programs

Preventing, Mental,

Emotional and Behavioral

Disorders Among Young

PeopleProgress and Possibilities

Health Promotion International

Manysystematicreviews &meta-analyses

+

How effective? Examples of Evidence from meta-analyses / reviews

post FU %RRES ES Relative Reduction

School-based SEL SEL skills .57 .26(213 programs) Conduct problems .22 .14

Emotional distress .24 .15Academic performance .27 .32

Stress management youth (19) stress symptoms .86

Parenting programs (37) child maltreatment .30

Universal prevention in children Anxiety .13 .11Depression .11 .07

Selective + Indicated Depression prevention (19) -22% (onset)

Mindfulness CT Depression relapse prevention (9) -34% (43%)

Early childhood education – arrest violent crime -33% ‒ 41%

COPMI children parental MI depr.symptoms (7) .22 -40% (onset)

Fagan & Catalano 2012

Durlak et al. 2011

Cuijpers et al. 2008

Piet & Hougaard 2011

Siegentaler et al. 2012

Kraag et al. 2006

Ahlen et al. 2015

Chen et al. 2016

2016 Hosman

� domestic violence ��

� youth violence & delinquency �� ROI $2 to $5

� lossed productivity ��

� cost welfare ��

� income ��

� school achievement ��

� social participation ��

Mental Health

Promotion

Prevention

programmes

show also

Social

and

economic

Benefits

Crucial for involving

stakeholders and getting public support

Economic benefits exceed costs of youth programmes up to 10x

IOM Report 2009; MHEEN Report of Zechmeister et al. 2008;

Aos et al. 2004 on >50 early childhood studies

Conclusions from outcome research

g Preventive interventions can be effective and cost-effective

g Evidence for broad spectrum of preventive outcomes and social & economic benefits from variety of intervention

g Long term effects found (up to 40 years)

g Large variation in efficacy and effectiveness: From large to small / no / iatrogenic effects. Meta-analyses Mean ES: small-moderate. Need for improvement

g Low implementation rate and low reach in population, almost no evidence on public impact

g Most interventions person-family oriented and from HICs More focus needed on social interventions and their outcomes

�

From Interventions to Public Impact

What is needed to get preventive interventions

implemented, scaled, reach target populations

and to create public impact?

Major bottleneck worldwide:

low implementation ratelow / selective access and reach

low public impactfrom HICs

Preventive programs can only make a difference when implemented at large scale

Improve Implementation, Scaling, Reach and Public Impact

� Improve effects of intervention (effect management)

� Use intervention & dissemination methods with large reach & low costs

� More interventions more adaptable and cosumable: working elements, kernals

� Make the multiple health, social and economic benefits visible

� Advocate for more prominent position of prevention and mental health in ….

� Increase power: Involve citizens, social movements, stakeholders

� Embed prevention in sectors, policies and legislation

� Enlarge resources for prevention by budget shifts and return for investment

� Train professionals and officials in preventon and mental health expertise

� Interorganisational collaboration and monitoring

� Use principles of ‘Colective Action’ and ‘Collective Impact”

� Improve management and shared leadership

Programs

Advocacy

Capacity

Shared leadership

Hosman 2016

Make it

smaller

Kernals

Principles

Working elements

Make it

Bigger & Coherent

integral

multicomponent program

+ wide implementation

Relevant Effective

preventive interventions

databases

for dissemination

Widely integrated in

daily life & practice

Prevention Density

Multually supporting &

complementory activities

to achieve Collective Impact

Make

implementation

large public reach

public impact

possible

Expertise

Manpower

Public support

Policy & legislation

Organization

Collaboration

Knowledge & Research

Crisis &

derpression

Single programs

you could adopt

and be inspired by

Createthe conditions

Hosman 2016

Thank you

Contact:

Prof. dr. Clemens M.H. Hosman

Emeritus Professor of Mental Health Promotion and Mental Disorder Prevention Radboud University Nijmegen & Maastricht University

Hosman Prevention Consultancy & Innovation, Berg en Dal, the Netherlands

[email protected]

socioeconomic crisis and mental health hosman prevention options

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