Mental health promotion must be a priority

The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being: all three aspects interact. The two-way relation between physical and mental well-being is well understood. Social well-being — how we feel about and respond to our relationships with others in our families and communities, and to links with our environment — is also vital to mental health.

But along with much of the rest of the medical profession, and society as a whole, we in public health have neglected mental health in favour of addressing physical health problems. This is largely because we tend to look at mortality rather than morbidity, and at quantity of life rather than quality.

Yet the 2013 Global Burden of Disease study found that major depression was the second most important cause of years lived with disability (YLD) globally; anxiety was seventh and, overall, five mental disorders were among the top 20 causes. Mental disorders accounted for more than 21% of YLD and 7% of disability-adjusted life years. In Canada, depression was the fourth leading cause of YLD — after three different forms of musculoskeletal disorder — and anxiety eighth. Some experts subsequently suggested that, for various reasons, these figures underestimate the disease burden for mental illness by more than a third, which would make mental illness by far the largest contributor to YLD.

The challenge, from a public health perspective, is how do we keep people mentally healthy so that they, and society, can avoid bearing this huge disease burden, the management and treatment of which requires substantial effort and resources? How do we prevent the occurrence of those factors that harm mental health?

Doing so would require three things. First, we need to invest in a much better understanding of the determinants of good mental health, all the way from the molecular to the upstream social, economic, environmental and cultural determinants. Second, we need to understand what interventions — at all levels — create good mental health. And, third, we must invest in those interventions.

A 2014 WHO report on the social determinants of mental health called for all countries to prioritize mental health, and recommended universal interventions, proportionate to need, at all stages of the lifecycle and in all settings. The report noted that “social inequalities are associated with increased risk of many common mental disorders” and that “promoting access to employment, health care, housing, and education, can have positive benefits for mental health.”

In particular, the WHO report emphasized that giving children a good start in life would lead to both societal and mental health benefits of the greatest magnitude. This is why public health supports the push to eliminate child poverty, the existence of which is unacceptable and scandalous in a country as rich as Canada. It is also why we need to support parental education, parental-leave provisions for new parents, universal high-quality affordable daycare and quality early childhood education. Other high-income countries manage this and have better child outcomes than we do, according to Organisation for Economic Cooperation and Development data. There is no reason why we cannot match their investment and outcomes.

Other key WHO recommendations are to develop policies for the treatment of maternal depression, social welfare of the unemployed and control of alcohol use, all of which are noted to “have a clear social class gradient.” At the local level, we need to create schools, colleges and universities that foster mental wellbeing, as well as mentally healthy workplaces and neighbourhoods.

In the 21st century, mental health needs to become a much higher priority for public health. The suggestion of a recent review of federal health organizations to abolish the Mental Health Commission of Canada is a bad idea. Although the commission may need repurposing to consider how we create a mentally healthy Canada, abolishing it is out of line with our current understanding of the important contribution of mental health to population health.