The evidence base of mental health promotion and prevention

Kristian Wahlbeck

The Finnish Association forMental Health

EU Joint Action for MentalHealth and Wellbeing

Finnish National Institute for Health andWelfare (THL)

Faculty Disclosure

X No, nothing to disclose Yes, please specify:

13.03.2016 Evidence-based promotion and prevention2

13.03.2016 Evidence-based promotion and prevention3

World Psychiatry 2015;14:36-42

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

National public and non-profit funding for mental health research in euros for year 2011

GDP per capita in 2011Spain : $ 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

13.03.2016 Evidence-based promotion and prevention5

ROAMER: Geographic distribution of public mental health publications (weighted by GDP)

Forsman et al. 2015, Eur J Publ Health

Evidence based public mental health

Consentious use of critically appraisedmethods to promote mental health, preventmental health problems and provideservices.

Public mental health interventionsare typically complex, and a larger varietyof evaluation methods are needed thanIn a clinical context

Evidence-based promotion and prevention8

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?

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+

+

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Salience Does it matter?

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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?

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++

+

+

+

Adapted from Petticrew and Roberts

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?

++

++

+

+

+

Mental health determinants & riskfactors: Growing evidence base

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Early interaction deficitsNeglect, abuse and harsh

upbringingSchool bullying

Work place stressLack of social support &

networksCommunity environment

Socio-economic determinants(poverty, social exclusion)

Alcohol and illegal drug use

Common NCD Specific

Mental health systems

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Psychiatricservices

Primary care

Prevention of mental disorders

Mental healthpromotion

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

13.03.2016 Evidence-based promotion and prevention11

Primary prevention of mentaldisorders 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 periodSockol, J Aff Dis 2015

13.03.2016 Evidence-based promotion and prevention12

Effective public mental healthinterventions

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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Parenting support

13.03.2016 Evidence-based promotion and prevention14

Mental health is shaped early in life

Where and how we are born, grow, live, work and age determines our mental health

Cumulative incidence of first DSM-IV disorderby comorbidity and severity

“Generalized“ psychopathology already present at age 13

16Ormel et al., 201413.03.2016Evidence-based promotion and

prevention

Chart1

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12121212

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Sheet1

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16292.448584194.123926160.72455231.70704481.97450521.24578460.74154112.149421139.478766374.846941190.20395382.246165279.51937151.9249863.48297695.32757138.27896778.76319158418.46266312.25529810.14675214.627975.1751581.3412743.8346937.080148.80547823.6645812.0078255.19230817.6464253.2780930.2198856.0181558.7297334.97242417.6464259.2962488.7297335.1923091121.55820712.65459810.14675216.1395155.226151.3412745.4186927.4284488.80547826.81111512.3561335.19230819.2089623.2780930.2198857.6021539.078044.97242485.64099896.8446310090.63450899.02429510070.7678895.31116610088.26406497.18109510091.86558510010079.16381996.163185100

17315.322391196.815863160.72455247.04243981.97450521.24578468.279952114.841358139.478766397.720748192.89589182.246165294.85476751.9249863.482976102.865982140.97090478.76319158419.90671712.42524410.14675215.5961145.1751581.3412744.3106037.2500868.80547825.10863312.1777715.19230818.6145693.2780930.2198856.4940658.8996784.97242418.6145699.7721588.8996785.1923091121.55820712.65459810.14675216.1395155.226151.3412745.4186927.4284488.80547826.81111512.3561335.19230819.2089623.2780930.2198857.6021539.078044.97242492.33939198.18758510096.633199.02429510079.55062497.59893210093.6500998.5564910096.90564710010085.42401698.035236100

18341.481991200.448828160.72455255.64991682.78221521.24578485.832075117.666613139.478766424.688059195.72114682.246165304.26995351.9249863.482976120.418105143.79615978.76319158421.55820712.65459810.14675216.1395155.226151.3412745.4186927.4284488.80547826.81111512.3561335.19230819.2089623.2780930.2198857.6021539.078044.97242419.20896210.8802469.078045.1923091121.55820712.65459810.14675216.1395155.226151.3412745.4186927.4284488.80547826.81111512.3561335.19230819.2089623.2780930.2198857.6021539.078044.972424100100100100100100100100100100100100100100100100100100

19347.037677200.448828160.72455257.60960182.78221521.24578489.428076117.666613139.478766430.243744195.72114682.246165306.22963851.9249863.482976124.014106143.79615978.76319158421.90894412.65459810.14675216.2632325.226151.3412745.6457127.4284488.80547827.16185312.3561335.19230819.3326793.2780930.2198857.8291739.078044.97242419.33267911.1072669.078045.19230901#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!

20348.149363200.448828160.72455257.60960182.78221521.24578490.539762117.666613139.478766431.35543195.72114682.246165306.22963851.9249863.482976125.125792143.79615978.76319158421.97912612.65459810.14675216.2632325.226151.3412745.7158947.4284488.80547827.23203512.3561335.19230819.3326793.2780930.2198857.8993569.078044.97242419.33267911.1774499.078045.19230901#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!#NULL!

1 dx2 dx>=3 dx1 dx; mild2 dx; mild>=3 dx; mild1 dx; severe2 dx; >=1 severe>=3 dx; >=1 severe1 class2 classes3 or 4 classes1 class; mild dx2 classes; mild dx>=3 classes; mild dx1 class; >=1 severe dx2 classes; >=1 severe dx3 or 4 classes; >=1 severe dx1 dx2 dx>=3 dx1 dx; mild2 dx; mild>=3 dx; mild1 dx; severe2 dx; >=1 severe>=3 dx; >=1 severe1 class2 classes3 or 4 classes1 class; mild dx2 classes; mild dx3 or 4 classes; mild dx1 class; >=1 severe dx2 classes; >=1 severe dx3 or 4 classes; >=1 severe dx1 class (mild dx)1 class (>=1 severe dx) or 2 classes (mild dx)2 classes (>=1 severe dx)3 or 4 classes (all dx)1 dx2 dx>=3 dx1 dx; mild2 dx; mild>=3 dx; mild1 dx; severe2 dx; >=1 severe>=3 dx; >=1 severe1 class2 classes3 or 4 classes1 class; mild dx2 classes; mild dx>=3 classes; mild dx1 class; >=1 severe dx2 classes; >=1 severe dx3 or 4 classes; >=1 severe dx1 dx2 dx>=3 dx1 dx; mild2 dx; mild>=3 dx; mild1 dx; severe2 dx; >=1 severe>=3 dx; >=1 severe1 class2 classes3 or 4 classes1 class; mild dx2 classes; mild dx>=3 classes; mild dx1 class; >=1 severe dx2 classes; >=1 severe dx3 or 4 classes; >=1 severe dx

Sheet1

>=3 dx

2 dx

1 dx

Age-of-onset

Cumulative prevalence

Sheet2

>=3 dx; >=1 severe

>=3 dx; mild

2 dx; >=1 severe

2 dx; mild

1 dx; severe

1 dx; mild

Age-of-onset

Cumulative prevalence

Sheet3

3 or 4 classes

2 classes

1 class

Age-of-onset

Cumulative prevalence

3 or 4 classes (all dx)

2 classes (>=1 severe dx)

1 class (>=1 severe dx) or 2 classes (mild dx)

1 class (mild dx)

Age-of-onset

Cumulative prevalence

13.03.2016 Evidence-based promotion and prevention

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 mentalhealth problemsin adulthood

0,0

1,0

2,0

3,0

4,0

5,0

Normal population Maltreated Bullied

17

Odd

srat

io

Intergenerationaltransmission ofmental healthproblems canbe 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

40 % of mental disorders can beprevented in high-risk families

13.03.2016 Evidence-based promotion and prevention19

Effect of interventions on the risk in the child of the mental disorder diagnosed in the parent. Siegenthaler et al. JAACAP 2012

NIH/NIDA: A child’s first eight years are critical for substance abuse prevention

13.03.2016 Evidence-based promotion and prevention20

“There is strong evidence that a stable home environment, adequate nutrition, physical and cognitive stimulation, and supportive parenting can lead to good developmental outcomes.”

Income-to-needs ratio = poverty line = 1Internalizingproblems

Norwegian Mother and Child Cohort Study (MoBa), N=75296 (Zachrisson & Dearing, 2014)13.03.2016Evidence-based promotion and

prevention21

School programmes

School-based mental healthpromotion

• 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

13.03.2016 Evidence-based promotion and prevention23

Evidence-based school interventions

• Anti-bullying programmes• Whole-school approach• Teacher training programmes

13.03.2016 Evidence-based promotion and prevention24

Workplace interventions

13.03.2016 Evidence-based promotion and prevention26

Company performance and workplace wellbeing: indices by country

Source: Eurofound Third European Company Survey 201513.03.2016 Evidence-based promotion and prevention27

Evidence base for workplace interventions

• 14 systematic reviews show moderate effectivenessof 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

13.03.2016 Evidence-based promotion and prevention28

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

13.03.2016 Evidence-based promotion and prevention29

Universal or targeted interventions?

13.03.2016 Evidence-based promotion and prevention30

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 Rose1926-1993

13.03.2016 Evidence-based promotion and prevention31

Geoffrey Rose’s theory of prevention

Geoffrey Rose1926-1993

…. 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)

13.03.2016 Evidence-based promotion and prevention32

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

13.03.2016 Evidence-based promotion and prevention33

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

13.03.2016 Evidence-based promotion and prevention34

Gap between evidence and practice

13.03.2016 Evidence-based promotion and prevention36

13.03.2016 Evidence-based promotion and prevention

Social determinantsof mental health

Mental healthpromotion

37

13.03.2016 Evidence-based promotion and prevention

Social determinantsof mental health

Mental healthpromotion

Mental Health in AllPolicies

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

13.03.2016 Evidence-based promotion and prevention39

A tool for Mental Health in All Policies:Mental health impact assessment

How does the proposeddevelopment/policy impact on…

• social determinants of mental health

• equity• people’s control• people’s participation• resilience and communtiy assets• social inclusion?

Mental health inequityMental 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

13.03.2016 Evidence-based promotion and prevention41

13.03.2016 Evidence-based promotion and prevention

• Going upstream: Structural determinantsof mental health

42

PovertyGender inequalityWar and conflictsSocial exclusionIncome inequality

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

13.03.2016 Evidence-based promotion and prevention43

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 schoolsWorkplace mental health promotionPrevention of depression and suicidesCommunity care and deinstitutionalisationMental health in all policies

• Identifies best practices for cross-sectoral work and whole-of-government practices across Europe

www.mentalhealthandwellbeing.eu

13.03.2016 Evidence-based promotion and prevention44

The NCD challenge

We need to take the step from ”four diseases, four risk factors” to ”fivediseases, five risk factors”

DietExerciseAlcoholTobaccoAdverse childhood events

13.03.2016 Evidence-based promotion and prevention45

CardiovascularDiabetes

Chronic respiratoryCancer

Mental disorders

Effectiveness of exercise in preventing depression

Evidence-based promotion and prevention

Courtesy: Anders Hovland

13.03.2016 Evidence-based promotion and prevention47

Associations between physical activity and mental healthproblems at 8 years

Martikainen 2012

Successful mental health actions buildon intersectoral collaboration

13.03.2016 Evidence-based promotion and prevention49

Sources of evidence-based publicmental 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

http://www.nrepp.samhsa.gov/http://tecathsri.org/knowledge.asp

Thanks!

The evidence base of mental health promotion and prevention�Faculty DisclosureDia numero 3ROAMER- A Roadmap for Mental Health Research in Europe�National public and non-profit funding for mental health research in euros for year 2011ROAMER: Geographic distribution of public mental health publications (weighted by GDP)�Evidence based public mental healthDia numero 8Mental health determinants & risk factors: Growing evidence baseMental health systemsMental health promotionPrimary prevention of mental disorders and suicideEffective public mental health interventionsParenting supportMental health is shaped early in lifeCumulative incidence of first DSM-IV disorder� by comorbidity and severityRisk of mental health problems in adulthoodIntergenerational �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 201240 % of mental disorders can be prevented in high-risk familiesNIH/NIDA: A child’s first eight years are critical for substance abuse preventionDia numero 21School programmesSchool-based mental health promotionEvidence-based school interventionsWorkplace interventionsDia numero 26Dia numero 27Evidence base for workplace interventionsEU Joint Action: Promoting mental health at work offers benefits to individuals, enterprises and economiesUniversal or targeted interventions?Geoffrey Rose’s Theory of PreventionGeoffrey Rose’s theory of preventionThe Bell curve shift in populationsIs the health benefit of universal interventions higher than the benefit of targeted interventions?Gap between evidence and practiceDia numero 37Dia numero 38Novel delivery channelsA tool for Mental Health in All Policies:�Mental health impact assessmentMental health inequityDia numero 42ROAMER: High Level PrioritiesEU Joint Action for mental health and well-being 2013-2016The NCD challengeEffectiveness of exercise in preventing depressionDia numero 47Successful mental health actions build on intersectoral collaborationSources of evidence-based public mental health interventionsDia numero 50