135LEADING ARTICLES

Mental Health and Public Health

THE LANCETLONDON: : SATURDAY, JAN. 15, 1955

THERE was a time, not so long ago, when mentalhealth could be discussed only in terms of woollybenevolence. A fine thing, we all agreed ; but how

exactly did one come by it ? It would be nonsenseto pretend that we have since learnt how to produceit in abundance within a generation ; but at leastwe have some hypotheses, based on observation andexperiment, which deserve to be tested. Thus wehave reason to suppose that the newborn infant andhis mother (or her substitute) form a unit, and thatthe normal development of the child depends ontheir being kept together. We also think that aninfantile or over-anxious or unloving mother mayaffect her child’s development unfavourably, andfurthermore that she may herself be all or any ofthese things because her relations with her own parentswere unsatisfactory. We recognise that no man isan island (for the mental health of all of us is boundup with our experiences as members of a group) ;and that, while any of us may break down under toomuch stress, like an ill-used machine, yet, unlike amachine, most of us have the power to adapt ourselvesto severe stresses, and to a very wide range of them,provided we have some inner security and are giventime to make the adjustment. Since we are bornto trouble as the sparks fly upward, this last capacityis especially valuable for our health of mind. Besides,it is worth remembering that, if we are influencedby our surroundings, our surroundings are alsoinfluenced by us : both are plastic.Over the past century the public-health movement

- an outstanding example of man’s influence on hissurroundings—has measurably altered the physicalhealth of our people for the better ; and no doubtit has indirectly prevented some mental ill health aswell. But mental health has never been a definite

target in British public-health campaigns ; andbecause of this we, the pioneers, are now some waybehind other countries in this respect. For instance,on p. 142 Dr. JEAN MACLENNAN and Miss MURIELSMALL describe how mental hygiene is taught in

Vancouver; and it is noteworthy how large a parttheir well-trained public-health nurses play in the

programme. In the United States, mental-health

teaching is now a widely accepted duty of public-health departments. Dr. GERALD CAPLAN reportsthat for more than three years the department ofmaternal and child health of the Harvard School ofPublic Health has been successfully exploring thepossibilities of a team approach to the provision ofhealth services for the family, beginning early in thewife’sfirst pregnancy. The team (consisting ofspecialists in obstetrics, paediatrics, nutrition, psychi-atry social work, and public-health nursing) tries todiscocver in the initial stages any physical or emotionaltors which might disturb family health andstability, and to remedy them before they have doneserious harm. CAPLAN has had previous experience

1. Children, 1954, 1, 171.2. Mental Hygiene, 1951, 35, 41.

of this work, as psychiatric director of the Laskermental hygiene and child-guidance centre of Hadassah,Jerusalem. Here the problem of teaching was com-plicated by language difficulties and by the widelydifferent standards of culture of mothers attendingthe centre ; yet group discussions, kept on a simpleemotional plane, dealt with all sorts of topicsraised by the mothers themselves-fear of givingbirth to monsters, fear of the evil eye, fear of dying,fear of having too big a baby, sexual problems duringpregnancy, desire for abortion, fear of a second birthwhen the first was difficult, worries about householdmanagement and about the other children, suddenaversions towards husband and family, and suddenswings of mood. Apart from these discussions, shorttalks were given, in the course of which the motherswere warned how common it is to feel no love orwarmth to the baby for a few days or weeks afterthe birth, and were assured that this coldness passes.These simple measures, it was found, not only relievedthe emotional tensions of the normal pregnant womenbut revealed those who were more deeply disturbedand needed individual treatment. There are divisionsof mental hygiene and psychiatry in the school ofpublic health both at Yale University and at JohnsHopkins-where the programmes of teaching and fielddemonstration are extensive. (Nothing comparableis to be found in any public-health school inthis country). In the Netherlands, too, the teachingof mental health, and the training of public-healthstaff for this work, is well developed. Dr. A. QUERIDO,who is both the chief of the public-health section ofthe municipal health service of Amsterdam, and

professor of social medicine in Amsterdam University,speaks of mental hygiene as an integral part of

public-health care.3These instances suffice to show how far other

countries have advanced beyond us in the teachingof mental health. There are, however, some stirringsof life in this field, even here. Thus Prof. ALANMONCRIEFF urged as long ago as 1950, in his DawsonWilliams lecture,4 that maternity and child-welfarecentres should take up the duty of teaching mentalhygiene, and he pressed for it again in his Newsholmelectures.-’ 5 We have recently commented 6 on thereport of a London County Council study group, setup by Dr. J. A. SCOTT, medical officer of health forthe County of London. They made the same proposal,and suggested how it might be done ; and theirviews were supported by a cogent plea from Dr.HEDY SYMONDS,7 who gave examples of the types offamily situation which such teaching might ease. In

Edinburgh (p. 160) there is to be a campaign to

educate the public in the true nature of mentalillness, and to encourage the recruitment of nurses.But these seedling endeavours make but a small

showing on the bareness of the land.The original public-health movement had to fight

the inertia of the whole community ; and those whonow wish it to cover mental health meet, it seems,some degree of inertia within the service itself. For

3. European Seminar on Mental Health Aspects of Public HealthPractice. Amsterdam 1953. Geneva : World Health Org-anisation Regional Office for Europe, Palais des Nations. 1954.Pp. 136. Not for sale.

4. Brit. med. J. 1950, ii. 795.5. Child Health and the State. London, 1953.6. Lancet, 1954, ii, 1005. 7. Ibid, p. 1010.

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this the curriculum for the diploma of public healthis partly responsible. So little attempt does it maketo orient the future medical officer of health to this

.aspect of his duties that he is often less well informed

.about mental health than a recently trained healthvisitor. Indeed, a British nurse engaged in public-health work, who attended one of the W.H.O.seminars on the subject, remarked ruefully that shedid not know how she was going to get the mental-health point of view across to the doctor under whomshe was working. In saying this we do not, of course,imply that the training of health visitors in mentalhealth is by any means perfect : both their trainingand that of the future medical officers of health

requires revision and reorientation if this work is tobe done ; and courses are also badly needed for thosealready engaged in this field. Proposals for suchinstruction regularly encounter opposition from thosewho have matured in another tradition : " what,"these are inclined to ask, " can anyone tell us aboutthe management of mental-health problems which we.are not already doing on common-sense grounds ?

"

But it is also usual, as a course proceeds, for thisresistance to melt : the very common-sense of the

participants leads them to accept the new approachesopened up for them. Nevertheless, as Prof. G. KRAUS 3has suggested, where resistance is strong it may bewise to begin by training a few people only-choosingthose least at odds with the notions of psychiatry-and leaving them for a time to leaven the lump of theirco-workers.

" What is there to teach, anyway ? " is another

frequent question, and a far-reaching one ; and thetentative suggestions of the L.C.C. study group hardlybegin to touch on the answer. Of course the firstmonths and years of life are important ; of coursethe mother can do much in those years to make ormar the emotional development of her child and hissubsequent mental health; and of course the

maternity and child-welfare centres should accept theresponsibility for teaching her what to do and-equallyimportant—what not to do. But the causes ofmental ill health do not all begin to operate at thebirth of the child : some begin much earlier. Dr. G. R.HARGREAVES,8 whose paper we published recently,shares CAPLAN’S view that mental-health teachingshould begin in the antenatal clinic, in time to

allay the fears and anxieties of the mother duringher pregnancy. Such fears, when disregarded, some-times end in psychosis or severe neurosis which maydemand months or years of treatment. At an earlierstage, HARGREAVES says, the symptoms are still

plastic, and simple measures may tip the balancetowards adjustment and recovery. Many fears of thepregnant woman are absurd and archaic, but theyare none the less alarming on that account: it doesno good, and may do harm, to pooh-pooh them.llany of her anxieties, on the other hand, are wellgrounded, centring on the change in human relationswhich the birth of a baby brings to every family.Quite simple teaching at the antenatal clinic, as wellas group discussions of the kind suggested by CAPLAN,can help the mother at this time ; and even theobstetrician, as HARGREAVES suggests, should be ableto give such help, and be willing when necessary toseek the collaboration’ of a psychiatrist in bringingthe mother, whole and safe, through pregnancy,

8. Ibid, Jan. 1, 1955, p. 39.

labour, and the puerperium. Indeed, QUERIDO holdsthat the duty of the public-health service to preventmental ill health runs throughout the lives of even-one of us, and should properly embrace mothers.infants, preschool and school children, young people atwork, university students, those in their working years,women at the menopause, and the aged, as well asthose whose mental well-being is assailed by specialhazards-such as patients discharged from men.

tal hospitals, people living in overcrowded slums,unmarried mothers, those discharged from prisons,young delinquents, the disabled, and those sufferingfrom diseases (such as tuberculosis and venerealdisease) which affect their lives in the community.Much of the work done by our public servicesalready has some bearing on the mental health of

many of these people : the children’s officers, the

psychiatric social workers, and the probation officersare all aware of this side of their efforts. What isnow needed is to make what is implicit outspoken,and to extend the principles of mental hygiene intoevery part of public-health work. It is an urgenttask : not only our slums but our mental hospitalsare overcrowded, and more of us are nowadayshampered by neurosis and other forms of mentalill health than by the diseases which sprang fromlack of sanitation. Our sickness has changed, andpublic needs rather than tradition should now dictatethe pattern of our public-health service.

1. von Euler, U. S., Liljestrand, G. Acta. physiol. scand. 194612, 301.

2. Motley, H. L., Cournand, A., Werkö, L., Himmelstein, A.

Dresdale, D. Amer. J. Physiol. 1947, 150, 315.

Pulmonary HypertensionPULMONARY hypertension is now a well-recognised

disorder, but much remains to be discovered about itsaetiology. Usually it is a complication of cardiac orpulmonary disease, but occasionally it is found in theabsence of either. The normal pulmonary vascularresistance is low, and the pulmonary-artery pressureis less than the systemic, even in the presence of con-siderable variations in pulmonary blood-flow. Pulmo-nary hypertension can result either from a greatlyincreased pulmonary blood-flow (such as occurs witha large patent ductus arteriosus) or from an increasein the pulmonary vascular resistance. Sometimesmore than one mechanism operates in the same

patient, as in patent ductus arteriosus with narrowingof the pulmonary arterioles. In mitral stenosis hyper-tension in the lesser circulation may result either froman increase in pulmonary venous pressure caused bythe increased resistance at the mitral valve, or from anincrease in arteriolar resistance. Severe pulmonary-arterial hypertension is always due to reduction inthe pulmonary vascular bed at the pre-capillary or

arteriolar level. The causes of this reduction maybe obstructive (as in repeated pulmonary embolism.various forms of pulmonary arteritis, or carcinomatosis)or secondary to pulmonary fibrosis or emphysema.

Problems in the elucidation of pulmonary hyper-tension centre mainly around the mechanism respon-sible for reduction in the lumen of the arterioles, andfor the organic changes which may also be present.It has been known for some years that acute hypoxiacan cause pulmonary vasoconstriction and a rise in

pulmonary-artery pressure.1 2 This mechanism may