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Preventive psychiatry: a paradigm to improve population mental health and well-being

  • Kamaldeep Bhui (a1) and Sokratis Dinos (a2)

Summary

The government's Public Health White Paper for England sets out a utopian vision of how to prevent and remedy mental health problems. The public health approach relies on primary prevention, promoting individual responsibilities and resilience, while also sustaining existing services and tackling inequalities. These ambitions are consistent with the preventive psychiatric paradigm, and with the best of evidence-based psychiatric practice. Although the evidence on cost-effectiveness of public mental health interventions is growing, the challenge is to ensure that specialist knowledge informs policy, practice and research so that inequalities are not compounded. Specialist mental health professionals are needed to inform and lead public health reforms.

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Copyright

Corresponding author

Professor K. Bhui, Wolfson Institute of Preventive Medicine, Centre for Psychiatry, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK. k.s.bhui@qmul.ac.uk

Footnotes

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Declaration of interest

None.

Footnotes

References

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1 HM Government. Healthy Lives, Healthy People: Our Strategy for Public Health in England. TSO (The Stationery Office) 2010.
2 Rose, G. The Strategy of Preventive Medicine. Oxford University Press, 1992.
3 Davies, L. The new public health strategy for England. BMJ 2010; 341: c7049.
4 Royal College of Psychiatrists. No Health without Public Mental Health: The Case for Action (Position Statement PS4). Royal College of Psychiatrists, 2010 (http://www.rcpsych.ac.uk/PDF/Position%20Statement%204%20website.pdf).
5 Mackenbach, JP, Bos, V, Andersen, O, Cardano, M, Costa, G, Harding, S, et al. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol 2003; 32: 830–7.
6 Kirkbride, JB, Barker, D, Cowden, F, Stamps, R, Yang, M, Jones, PB, et al. Psychoses, ethnicity and socio-economic status. Br J Psychiatry 2008; 193: 1824.
7 Bhui, K, Stansfeld, S, Hull, S, Priebe, S, Mole, F, Feder, G. Ethnic variations in pathways to and use of specialist mental health services in the UK. Systematic review. Br J Psychiatry 2003; 182: 105–16.
8 King, M, Semlyen, J, Tai, SS, Killaspy, H, Osborn, D, Popelyuk, D et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008; 8: 70.
9 Emerson, E, Hatton, C. Mental health of children and adolescents with intellectual disabilities in Britain. Br J Psychiatry 2007; 191: 493–9.
10 Rai, D, Skapinakis, P, Wiles, N, Lewis, G, Araya, R. Common mental disorders, subthreshold symptoms and disability: longitudinal study. Br J Psychiatry 2010; 197: 411–2.
11 van Os, J, Linscott, RJ, Myin-Germeys, I, Delespaul, P, Krabbendam, L. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychol Med 2009; 39: 179–95.
12 Luthar, SS, Cicchetti, D, Becker, B. The construct of resilience: a critical evaluation and guidelines for future work. Child Dev 2000; 71: 543–62.

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Preventive psychiatry: a paradigm to improve population mental health and well-being

  • Kamaldeep Bhui (a1) and Sokratis Dinos (a2)
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eLetters

Progressive, informed, evidence-based policies and practices: a role for specialists.

Kamaldeep S Bhui, Professor & Hon.Consultant Psychiatrist
21 July 2011

We are indebted to Caan for an opportunity to further debate the potential of preventive psychiatry within a public health context. A failure to address

inequalities reflects not only a failure of leadership but also lack of commitment by all sectors to recognise potential benefits in human capital

and economic savings over the next decades. The Royal College of Psychiatrists position statement, which informed the DH strategy for England No Health without Mental Health sets out the evidence base and the need for further research. Recognising the role of psychiatrists and specialists in

primary, secondary and tertiary prevention as well as the need for further

development to include a role for specialists with appropriate training and accreditation processes is vital.

Preventive psychiatry is not new and remedying the consequences of adversity and vulnerabilities are but one of a number of preventive activities that already take place within existing psychiatric practice. The editorial sets this out alongside the new challenges facing specialists but also the wider public health community (Bhui & Dinos, 2011). The prevention of violence and hostility between adults and young people has been long recognised as a core task of preventive psychiatry (Saul, 1949). As set out in the Royal College’s Position Statement, No Health without Public Mental Health, protecting and

promoting health and optimal maturation of young people whilst taking account of complex interactions between biology and the environment are key objectives and are also at the heart of more complex approaches to medicine in general (Bousquet et al, 2011); preventing gender violence, sexual exploitation and abuse, promoting best parenting, nutrition, exercise, and

education, protecting mental capital and physical health, and delivering interventions that develop mature adults who enjoy the responsibilities of

adulthood whilst still enjoying the pleasures of life over the life-courseare clearly important objectives. These policy priorities, although challengedby the need for more evidence and related research questions, are as important in low and middle income countries as in the higher income neighbours (Collins et al, 2011).

These ambitious frameworks require local adaptations and actions, which incorporate an understanding of people’s lifestyle, attitudes, beliefs, cultures, and status reflected in the delivery of interventions (Collins et al, 2011). Existing universal and global policies are being challenged by socially excluded groups and by people suffering from multiple health problems, as well as those presenting with novel phenotypes (Bousquet, et al, 2011). There is a role for specialists to be central to both policy and delivery, and to inform other stakeholders of the many varieties of personal distress and illness that is often lumped together under the title of mental health; an approach that would not be acceptable say for infectious diseases (see Lemkau, 1954). Inclusive and progressive policies and practices must protect the health and well being of the population as a whole but also of the most vulnerable, including those victim to inequalities and social exclusion or those with complex needs that do not conform to unitary concepts of what constitutes mental health, illness and mental disorder (Madhusoodanam, 2010); these opportunities must be seized whilst also dealing with economic and financial crises that are adversely impacting on population mental health.

ReferencesBhui K, Dinos S. (2011) Preventive Psychiatry: a paradigm for population mental health. British Journal of Psychiatry 198, 417-419.

Bousquet J. Anot JM, Sterk P, et al (20111) Systems medicine and integrated care to combat chronic non-communicable diseases. Genome Medicine, 3: 43.

Collins Y, Patel V, Joestl S. et al. (2011) Grand challenges in global mental health. Nature, 475: 27-30.

Lemkau, P. (1954) Preventive Psychiatry: its application to general practice and by health agencies. Southern Medical Journal, 47(5): 498-505.

Madhussodanam S. (2010) Preventive Psychiatry: we are getting closer to fulfilling the promise of reducing mental illness. Annals of Clinical Psychiatry, 22(4): 217-218.

Saul LJ (1949) Preventive Psychiatry. Proceedings of the American Philosophical Society, 93(4) : 330-334.

Declaration of interests: none
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Conflict of interest: None Declared

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It is not enough 'to remedy the consequences of adversity and vulnerabilities'.

Woody Caan, Professor of Public Health
08 June 2011

Thank you, BJP, for your timely editorial on population mental health(Preventive psychiatry, June 2011). It is a pity that the authors did not mention the strategy for England "No Health Without Mental Health" published in February (before their final submission) as this strategy didinvolve precisely the teamwork of psychiatrists, public health specialistsand economists that they see as 'the challenge'. Their 'must' list for psychiatry begins with help 'to remedy the consequences of adversity and vulnerabilities'.

A key weakness of UK attempts to address health inequalities has beena failure of leadership [1] - and the common mental disorders show a steeper Social Gradient than common physical illnesses like heart disease.Can the Royal College of Psychiatrists take a lead in addressing the antecedents of adversity and vulnerability, not just the 'consequences'? Desolate, impoverished neighbourhoods spawn childhood mental illness [2] and rising unemployment breeds desperate drinking and suicidal despair.[3]In the original 1946 NHS Act, maternity services were the exemplar of planning equitable care on the basis of population health needs.... but inEngland today many maternity services are at breaking point, with antenatal care services widely sacrificed, to maintain staffing for deliveries. The Royal College could speak with unique authority on the need for better antenatal care, to prevent a generation blighted by neurodevelopmental problems.[4]

I suspect that consultant psychiatrists are, on average, better educated, more articulate and able to reflect than, say, Members of Parliament. Urban degeneration, worklessness and the breakdown of comprehensive health services need to be linked explicitly to escalating economic and social costs of mental illness. Only the Royal College could "join up the dots" convincingly, for MPs to respond to urgent population mental health needs.

There is a timely opportunity to test such specialist influence on National policy. Thanks to heroic lobbying by thousands of women before the last election, the training and deployment of 4,200 extra health visitors became one of the Goverment's Top 10 Priorities.[5] The editorialon preventive psychiatry describes 'opportunities to break the intergenerational transmission of risk'. Can psychiatric expertise now permeate into the skill set and effective practice of these 4,200 public health practitioners?

[1] Caan W. UK public accounts committee report on health inequalities. Lancet 2011; 377: 207.

[2] Booth KJ, Caan W. Poverty and mental health. BMJ 2005; 330: 307.

[3]Caan W. Unemployment and suicide: is alcohol the missing link? Lancet 2009; 374: 1241-1242.

[4]Caan W. Being of sound mind, in the beginning… NIMHE: Mental Health Promotion Update 2005; 2: 13-15.

[5]Policy Watch. Re-energising health visiting. NMC Review 2011; 1(1): 30-31.

Declaration of interest: Editor of the Journal of Public Mental Health and currently involved with the National demonstration site for a Victims and Vulnerable Persons Index (in North Lincolnshire).
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Conflict of interest: None Declared

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