socioeconomic crisis and mental health hosman prevention options
TRANSCRIPT
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
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
Access mental health care
Early detection and treatment
Rehabilitation Anti stigma
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
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
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
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
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
Prevention aims to influencemediating and moderating trajectories
between crisis and mental health
How related? How to influence?
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
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
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
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
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 impactschool work health
2016 Hosman
HealthyPregnancy - Early Start
Externalizingproblems
Conduct disorders
ParentingCompetence
Quality
Family Stress & Strenghts
Conflicts, ViolenceChild maltreatment
Divorce
SuicideSuicidal
behavior
Social-emotionalCompetence
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 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
Stress management programs
Depression prevention CBT programs
group- or internet based
Long term impactschool work health
2016 Hosman
Long term impactschool work health
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
What are the mediational and
moderating trajectories between
SE-crisis and mental health?
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 HealthWorkplaces
MediaInternet
Early Detection & treatment
Use of E-Mental Health technology
Advocacy
Policy change
Professional Guidelines
Training health professionals
2016 Hosman
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
What are the mediating and
moderating trajectories between
SE-crisis and mental health?
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
Reducingaccess to
lethal means
Long term impactschool work health
2016 Hosman
Media coverageof suicide
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
What are the mediating and
moderating trajectories between
SE-crisis and mental health?
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
Community developmentSocial empowermentSupport systemsConsumer organizationsMicro financing projectsSocial innovation initiatives
Long term impactschool work health
2016 Hosman
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
What are the mediating and
moderating trajectories between
SE-crisis and mental health?
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
Preschool Enrichment ProgramsSchool-based Soc Emot LearningAfter-school programs
Long term impactschool work health
2016 Hosman
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
What are the mediating and
moderating trajectories between
SE-crisis and mental health?
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
Parenting educationFamily supportChild abuse preventionDivorce programs
Long term impactschool work health
2016 Hosman
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
What are the mediating and
moderating trajectories between
SE-crisis and mental health?
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
Healthy start
Prenatal & postnatalhomevisting programs
MH Traininng nurses and midwives
Long term impactschool work health
2016 Hosman
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
What are the mediating and
moderating trajectories between
SE-crisis and mental health?
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
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