Presentation of current evidence for promotion of mental wellbeing and prevention of mental disorders. The presentation argues for moving from research to action, using the mental health in all policies approach.

1. The evidence base of mental health
promotion and prevention
Kristian Wahlbeck
The Finnish Association for
Mental Health
EU Joint Action for Mental
Health and Wellbeing
Finnish National Institute for
Health andWelfare (THL)

2. Faculty Disclosure
X No, nothing to disclose
Yes, please specify:
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World Psychiatry 2015;14:36-42

4. ROAMER- A Roadmap for Mental Health
Research in Europe
1. Consorcio CIBER para el Área Temática de Salud Mental
2. King's College London, Institute of Psychiatry
3. Fondation FondaMental
4. European Clinical Research Infrastructures Network
5. Maastricht University Medical Centre
6. Technical University of Dresden
7. London School of Economics
8. University of Heidelberg, Central Institute of Mental Health
Mannheim
9. Nordic School of Public Health
10. University of Naples
11. Semmelweis University Budapest
12. University of Manchester
13. Cambridge University,
14. CF consulting
Partners

5. National public and non-profit funding for mental health
research in euros for year 2011
GDP per capita in 2011
Spain : $ 31 118 Finland : $ 48 695 France : $ 42 578 United-Kingdom : $ 38 927
Total amount
allocated for
mental health
research (M€)
% of health
research budget
allocated to
mental health
Funding per capita
for mental health
research (€ /
inhabitant)
Spain 16.8 5.6 0.4
Finland 10.2 9.7 1.9
France 84.8 4.1 1.3
UK 95.3 7.0 1.5
ROAMER: National funding for MH
research
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6. ROAMER: Geographic distribution of
public mental health publications
(weighted by GDP)
Forsman et al. 2015, Eur J Publ Health

7. Evidence based public mental health
Consentious use of critically appraised
methods to promote mental health, prevent
mental health problems and provide
services.
Public mental health interventions
are typically complex, and a larger variety
of evaluation methods are needed than
In a clinical context

8. Evidence-based promotion and
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An example of a typology of evidence.
Research question
Qualitative
research Survey
Case-
control
studies
Cohort
studies RCTs
Quasi-
experimental
evaluations
Non-
experimental
evaluations
Systematic
reviews
Effectiveness
Does it work? Does doing this
work better than doing that?
+ ++ + +++
Process of service delivery
How does it work?
++ + + +++
Salience
Does it matter?
++ ++ +++
Safety
Will it do more good than
harm?
+ + + ++ + + +++
Acceptability
Will children/parents be willing
to or want to take up the
service offered?
++ + + + + +++
Cost effectiveness
Is it worth buying this service?
++ +++
Appropriateness
Is this the right service for
these children?
++ ++ ++
Satisfaction with the service
Are users, providers and other
stakeholders satisfied with the
service? ++ ++ + +
+
Adapted from Petticrew and Roberts

9. Mental health determinants & risk
factors: Growing evidence base
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Early interaction deficits
Neglect, abuse and harsh
upbringing
School bullying
Work place stress
Lack of social support &
networks
Community environment
Socio-economic determinants
(poverty, social exclusion)
Alcohol and illegal drug use
Common NCD Specific

10. Mental health systems
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Psychiatric
services
Primary care
Prevention of
mental disorders
Mental health
promotion

11. Mental health promotion
• MHP aims to strengthen mental health and wellbeing in the population
• Mental health is dependent on structural determinants: mental wellbeing
is best achieved in equitable, just and non-violent societies (Patel 2014)
• New evidence shows that mental health promotion is effective
• Parenting support
• Socio-emotional learning programmes in schools
• Work-life interventions to improve stress coping skills
• Social activities for elderly people
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12. Primary prevention of mental
disorders and suicide
• More than 30 randomized trials have demonstrated that preventive
interventions can reduce the incidence of new episodes of major
depressive disorder by about 25% and by as much as 50% when
preventive interventions are offered in stepped-care format
Cuijpers, JAMA 2012
• There is strong evidence that CBT interventions are effective for
preventing depression during the perinatal period
Sockol, J Aff Dis 2015
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13. Effective public mental health
interventions
Parenting support interventions have been shown to promote life-long
mental health and well-being of the offspring.
School programmes have consistently been shown to have positive moderate
to strong effects on social and emotional skills and competences
Workplace reorganisation and increased control over work life improve
mental wellbeing, increase productivity and reduce costs
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14. Parenting support
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15. Mental health is shaped early in life
Where and how we are born, grow, live, work and age
determines our mental health

16. Cumulative incidence of first DSM-IV disorder
by comorbidity and severity
“Generalized“ psychopathology already present at age 13
16
Ormel et al., 201413.03.2016
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prevention

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Children who have been
maltreated or bullied are much
more likely to have mental health
problems in adulthood
Great Smoky Mountains Study, Lereya et al
Lancet 2015
Risk of mental
health problems
in adulthood
0.0
1.0
2.0
3.0
4.0
5.0
Normal population Maltreated Bullied
17
Oddsratio

18. Intergenerational
transmission of
mental health
problems can
be stopped
Risk of mental disorders in the offspring
of parents with mental disorders is reduced
by 40% by preventive interventions
Siegenthaler et al. JAACAP 2012

19. 40 % of mental disorders can be
prevented in high-risk families
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Effect of interventions on the risk in the child of the mental disorder
diagnosed in the parent. Siegenthaler et al. JAACAP 2012

20. NIH/NIDA: A child’s first eight years
are critical for substance abuse
prevention
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“There is strong
evidence that a stable
home environment,
adequate nutrition,
physical and cognitive
stimulation, and
supportive parenting
can lead to good
developmental
outcomes.”

21. Income-to-needs ratio = poverty line = 1
Internalizing
problems
Norwegian Mother and Child Cohort Study (MoBa), N=75296 (Zachrisson & Dearing, 2014)13.03.2016
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22. School programmes

23. School-based mental health
promotion
• a.k.a. ”socio-emotional learning, “emotional literacy”, “emotional
intelligence”, “resilience”, “life skills” and “character education”, targeting
• skills
• curriculum
• teacher education,
• peer support
• whole school approach
• Strong evidence of effectiveness
• Strong effects on socio-emotional skills
• Small to medium effects on emotional well-being
• Evidence of reduction of depression, aggression, impulsiveness and
antisocial behavior
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24. Evidence-based school interventions
• Anti-bullying programmes
• Whole-school approach
• Teacher training programmes
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25. Workplace interventions

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27. Company performance and workplace wellbeing: indices by country
Source: Eurofound Third European Company Survey 2015
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28. Evidence base for workplace
interventions
• 14 systematic reviews show moderate effectiveness
of workplace interventions
Wagner et al 2016, Int J Occup Envir Med
• A systematic review and meta-analysis of universal
workplace interventions for prevention of
depression (9 RCTs, mostly CBT-based interventions)
show a small positive effect
Tan et al 2014, BMC Med
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29. EU Joint Action: Promoting mental
health at work offers benefits to
individuals, enterprises and economies
• Improvements in quality of life of employees
and their families
• Increased productivity and competitiveness
among companies and countries
• Reduction of burden on health services
• Promotes social inclusion
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30. Universal or targeted interventions?
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31. Geoffrey Rose’s Theory of
Prevention
If disease risk is widespread (viz. depression),
measures that decrease risk for everyone are
more effective in reducing the burden of
disease than a ‘high-risk’ approach, in which
measures are targeted only to those
individuals with a substantially increased risk
for disease (Rose, 1993).
Geoffrey Rose
1926-1993
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32. Geoffrey Rose’s theory of
prevention
Geoffrey Rose
1926-1993
…. Because: If disease rates rise continuously
with higher levels of exposure to the risk factor,
the larger number of people with a small
elevation in risk will usually contribute more
disease cases to the total burden of disease than
the smaller number of people exposed to a high
risk (Rose, 2008)
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33. Shifting the whole population into a lower risk category benefits more
individuals than shifting high risk inviduals into a lower risk category
The Bell curve shift in
populations
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34. Is the health benefit of universal
interventions higher than the benefit of
targeted interventions?
• Review of all successfull prevention programs in
Netherland 1970-2010
• Results
• Primary prevention: ¾ of the effects
• Secondary prevention: ¼ of the effects
Machenback et al, 2012
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35. Gap between evidence and practice
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Social determinants
of mental health
Mental health
promotion
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Social determinants
of mental health
Mental health
promotion
Mental Health in All
Policies
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38. Novel delivery channels
• Evidence indicates that e-mental health interventions are effective
• Several promotive and preventive interventions have been
developed for the internet and mobile apps, usually based on CBT
or ACT. Results from RCTs are promising, but attrition rates are
high
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39. A tool for Mental Health in All Policies:
Mental health impact assessment
How does the proposed
development/policy impact on…
• social determinants of
mental health
• equity
• people’s control
• people’s participation
• resilience and communtiy assets
• social inclusion?

40. Mental health inequity
Mental disorders are, generally speaking, twice as common among socio-
economically disadvantaged individuals than among those close to the top of
the social ladder
Mental health follows a social gradient
• poverty and low income
• insecure housing
• limited education
• recent unemployment/loss of social status
• high-demand or low-control work
• child abuse or neglect
• poor neighbourhood conditions
• low social support/networks
• discrimination
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• Going upstream: Structural determinants
of mental health
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Poverty
Gender inequality
War and conflicts
Social exclusion
Income inequality

42. ROAMER: High Level Priorities
1. Research into mental disorder prevention, mental health promotion
and other interventions in children, adolescents and young people
2. Focus on the development and causal mechanisms of mental health
symptoms, syndromes and well-being across the lifespan (including
older populations)
3. Developing and maintaining international and interdisciplinary
research networks and shared databases
4. Developing and implementing better interventions using new
scientific and technological advances
5. Reducing stigma and empowering service users and carers in
decisions about mental health research
6. Health and social systems research that addresses quality of care and
takes account of socio-cultural and socio-economic contexts and
approaches
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43. EU Joint Action for mental health and
well-being 2013-2016
Based on the European Pact for Mental Health and Well-being
Mental health promotion in schools
Workplace mental health promotion
Prevention of depression and suicides
Community care and deinstitutionalisation
Mental health in all policies
• Identifies best practices for cross-sectoral work and whole-of-
government practices across Europe
www.mentalhealthandwellbeing.eu
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44. The NCD challenge
We need to take the step from ”four diseases, four risk factors” to ”five
diseases, five risk factors”
Diet
Exercise
Alcohol
Tobacco
Adverse childhood events
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Cardiovascular
Diabetes
Chronic respiratory
Cancer
Mental disorders

45. Effectiveness of exercise in preventing
depression
Evidence-based promotion and
prevention
Courtesy: Anders Hovland

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Associations between physical activity and mental health
problems at 8 years
Martikainen 2012

47. Successful mental health actions build
on intersectoral collaboration

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Sources of evidence-based public
mental health interventions
National Registry of Evidence-Based Programs and Practices (NREPP
Database) (USA)
http://www.nrepp.samhsa.gov/
Evidence Based Practice in Behavioral Health (Canada)
http://tecathsri.org/knowledge.asp
No Pan-European resource exists

49. Thanks!