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Alleviating Mental Health Impact of Economic Crises
- 1. Socio-economic Crises and Mental Health: From Research to Action Round Table Policies 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 Hosman Emeritus Professor of Mental Health Promotion and Prevention Maastricht University & Radboud University Nijmegen
- 2. 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 preventive interventions implemented, scaled, reaching target populations and to create significant public impact? ?
- 3. Alleviating the impact of economic crisis on mental health: Preventive Actions Socio- Economic Crisis Mental health Mental disorders children adolescents adults Elderly Vulnerable groups Health, social and economic outcomes What could we do? Policies Interventions Practices
- 4. Alleviating the impact of economic crisis on mental health: Preventive Actions Socio- Economic Crisis Mental health Mental disorders children adolescents adults Elderly Vulnerable groups Health, social and economic outcomes Access mental health care Early detection and treatment Rehabilitation Anti stigma
- 5. Alleviating the impact of economic crisis on mental health: Preventive Actions Socio- Economic Crisis Mental health Mental disorders children adolescents adults Elderly Vulnerable groups Health, social and economic outcomes Mediating factors Moderating factors Macro level Community Family Person Access mental health care Early detection and treatment Rehabilitation Anti stigma Interventions programs Practices Policy 2016 Hosman
- 6. Alleviating the impact of economic crisis on mental health: Preventive Actions Socio- Economic Crisis Mental health Mental disorders children adolescents adults Elderly Vulnerable groups Health, social and economic outcomes Mediating factors Moderating factors Macro level Community Family Person Conditions for Implementation and Public Impact 2016 Hosman
- 7. Mediators of impact socio-economic crisis on mental health Poor Mental Health Mental disorders Depression - Anxiety Externalising problems Alcohol-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 and economic outcomes Mediating determinants Socio- Economic Crisis Community Family Individual Negative impact 2016 Hosman
- 8. Impact model socioeconomic crisis on mental health Socio- Economic Crisis Pre-existing strengths Mediating determinants negative changes in: Work, Income, Housing, Debts Neighborhood quality Health care & Social services Social protection Social capital, support and connectedness Family functioning & Parenting Stress & Vulnerabilty in children, adults, elderly Moderators Coping capacities: vulnerabilities & strengths Family functioning, SES, parental mental illness Social support, comm.involvement, social protection Quality of primary and MH health care Prevention support weaknessesCommunity Family Individual Poor Mental Health Mental disorders Depression - Anxiety Externalising problems Alcohol-related disorders Suicide Health, social and economic outcomes 2016 Hosman
- 9. To design effective prevention policies and interventions We need insight and evidence: Causality of factors and role mediators ‒ moderators Interaction & cumulative effects Effect sizes - Public impact Causal sequences of factors across 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)
- 10. How do mediating and moderating variables work between 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 stategies Combining theories could support integrative prevention policy
- 11. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking Associations found between SE-crisis and many outcome variables Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Long term impact school work health 2016 Hosman
- 12. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking Prevention aims to influence mediating and moderating trajectories between crisis and mental health How related? How to influence? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Long term impact school work health
- 13. 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
- 14. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media 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) Long term impact school work health 2016 Hosman
- 15. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Mental health Depression Alcohol use Problem drinking What are the mediational and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Stress management programs Depression prevention CBT programs group- or internet based Long term impact school work health 2016 Hosman
- 16. Long term impact school work health Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediational and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Early Detection & treatment Use of E-Mental Health technology Advocacy Policy change Professional Guidelines Training health professionals 2016 Hosman
- 17. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediating and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Reducing access to lethal means Long term impact school work health 2016 Hosman Media coverage of suicide
- 18. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediating and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Community development Social empowerment Support systems Consumer organizations Micro financing projects Social innovation initiatives Long term impact school work health 2016 Hosman
- 19. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediating and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Preschool Enrichment Programs School-based Soc Emot Learning After-school programs Long term impact school work health 2016 Hosman
- 20. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediating and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Parenting education Family support Child abuse prevention Divorce programs Long term impact school work health 2016 Hosman
- 21. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediating and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Healthy start Prenatal & postnatal homevisting programs MH Traininng nurses and midwives Long term impact school work health 2016 Hosman
- 22. Healthy Pregnancy - Early Start Externalizing problems Conduct disorders Parenting Competence Quality Family Stress & Strenghts Conflicts, Violence Child maltreatment Divorce Suicide Suicidal behavior Social-emotional Competence resilience, vulnerability enrichment Anxiety Depression Alcohol use Problem drinking What are the mediating and moderating trajectories between SE-crisis and mental health? Distress & Coping Parental mental disorders / addiction Children COPMI Socioeconomic Crisis Income loss, Debts, Poverty Insecure jobs and housing Social material deprivation Community Social Support /Capital Pre-school School system Health care Public Health Workplaces Media Internet Long term impact school work health COPMI support Preventive interventions for Children and Families dealing with parental mental illness or addiction 2016 Hosman
- 23. Healthy Start of life Pre-, postnatal Home-visiting Prevention Training Professionals nurses and midwives Alcohol prevention programs and measures School-based SEL Social-emotional learning Violence prevention Suicide prevention programs Social Protection Policies & Measures JOBS program Innovative options Integrating MH and preventive elements in other Sectors & Programs Prevention Early detection & treatment Relapse prevention Depression Anxiety Parent support Parenting education COPMI Preventive support children & Families Preschool enrichment programs Child protection Prevention Early intervention Relapse prevention Stress management programs Community Programs Communities-that-Care Social connectedness Community development E-mental Health – SocMedia Disorder specific Positive psychology Integral policy Universal + Targeted 2016 Hosman
- 24. 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
- 25. Effective? Cost-Benefit ratio? Return of Investment (ROI)
- 26. 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 & attachment abuse, neglect, domestic violence bullying and safety social isolation and social capital Populations at risk e.g. Increased symptoms, prodrome COPMI: transmission parents to child parental separation or death low SES families and communities workers under stress; unemployed for all these targets evidence exists of significant effects prevention and promotion programs Preventing, Mental, Emotional and Behavioral Disorders Among Young People Progress and Possibilities Health Promotion International Many systematic reviews & meta-analyses +
- 27. How effective? Examples of Evidence from meta-analyses / reviews post FU %RR ES ES Relative Reduction School-based SEL SEL skills .57 .26 (213 programs) Conduct problems .22 .14 Emotional distress .24 .15 Academic performance .27 .32 Stress management youth (19) stress symptoms .86 Parenting programs (37) child maltreatment .30 Universal prevention in children Anxiety .13 .11 Depression .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
- 28. 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
- 29. 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
- 30. 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 rate low / selective access and reach low public impact from HICs Preventive programs can only make a difference when implemented at large scale
- 31. 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
- 32. 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 Create the conditions Hosman 2016
- 33. 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 Hosman@psych.ru.nl