Prevention of mental illness

Many factors affect mental health and, if addressed, may prevent mental ill-health at an individual and population level. Primary prevention is a core focus of public mental health interventions, with the aim of stopping people from developing mental health difficulties through a range of approaches that benefit the whole community. This may include parenting programmes and promoting parent–child attachment; ^{Reference Costantini, López-López, Caldwell, Campbell, Hadjipanayi and Cantrell9,Reference Al Sager, Goodman, Jeong, Bain and Ahun10} alcohol, drug and smoking reduction campaigns; ^{11,Reference Das, Salam, Arshad, Finkelstein and Bhutta12} encouraging physical activity; ^{Reference Hu, Turner, Generaal, Bos, Ikram and Ikram13,Reference Mueller, Rojas-Rueda, Cole-Hunter, de Nazelle, Dons and Gerike14} teaching emotional learning in schools; ^{Reference Murano, Sawyer and Lipnevich15} optimising workplace well-being; ¹⁶ and anti-stigma campaigns. ¹⁷

Secondary prevention is focused on the early identification of illness, particularly in individuals who are at higher risk, which may be related to life events, protected characteristics (attributes covered by equality law, such as race, religion and gender), migration or those with trauma histories among many other factors. Interventions may include early identification of psychosis through Early Intervention in Psychosis teams, ^{Reference Kendall18} screening for postnatal depression or the provision of targeted support for at-risk groups such as migrants. ^{Reference Stevenson, Fellmeth, Edwards, Calvert, Bennett and Campbell19}

Finally, tertiary prevention aims to manage symptoms for those with an established mental health condition to provide the best chance of recovery, prevent relapse and maximise quality of life. Interventions may include improving the physical health of those with severe mental illness ²⁰ and return-to-work support through Individual Placement and Support workers integrated in mental health teams. ²¹ There is, of course, overlap between these areas of prevention, and not all interventions fit neatly into the three categories.

Prevention is a cornerstone of both sustainable healthcare and public mental health. For psychiatrists, preventing the onset or reducing the impact of mental illness could result in less demand on mental health services, which would reduce waiting lists and caseload numbers. Earlier intervention could mean more care in the community, easing pressure on bed numbers, while offering a more affordable and less carbon-intensive model of care. ^{Reference Gilburt and Mallorie22} Many interventions offered with prevention in mind also align with the recovery model, a personalised holistic model of care encouraged within the NHS. ²³

Preventative interventions often lead to personal, societal and environmental gains. For instance, research shows that nearly half of all dementia cases could be prevented by tackling 14 risk factors, which include smoking, obesity, inactivity, air pollution and social isolation. ^{Reference Livingston, Huntley and Liu24} Population-level interventions such as clean air policies and measures to reduce salt intake and reduce smoking will not only improve quality of life, but also save up to £4 billion in England alone. ^{Reference Livingston, Huntley and Liu24}

Reducing health inequalities

The National Institute for Health and Care Excellence defines health inequalities as ‘differences in health across the population, and between different groups in society, that are systematic, unfair and avoidable’. ²⁵ These disparities are experienced by many, including those living in poverty, those belonging to societal groups more at risk of social exclusion (e.g. migrants and refugees) and individuals with certain protected characteristics. ²⁶ When a person belongs to multiple marginalised groups, such as being a refugee and identifying as LGBTQIA+, this intersectionality amplifies the impact. ^{Reference Tinner and Alonso Curbelo27}

As psychiatrists, we frequently encounter the disproportionate mental health burden borne by vulnerable groups. Poverty, for instance, both contributes to and may be exacerbated by mental illness. ^{Reference Elliott28} Migrants and refugees face significant challenges such as discrimination, poor working conditions and financial insecurity, which may elevate their risk of developing mental illness or exacerbate pre-existing conditions, while simultaneously creating barriers to accessing care. ²⁹ While there is a push to explore the role of artificial intelligence and digital solutions in healthcare, certain populations are more vulnerable to digital poverty, thus reducing their access to this form of support and widening these inequalities even further. ^{Reference Ibrahim, Liu, Zariffa, Morris and Denniston30}

Tackling these inequalities requires both targeted and systemic action. Improving access to services, embedding cultural competence and tailoring care to specific communities are essential for reducing disparities. Equally, mental health professionals must be supported to address the broader social determinants of health – such as housing, education and financial security – that underpin many of the inequities we observe in clinical practice.

Health inequalities also intersect with sustainability challenges. Climate change represents a health inequality because the impacts – such as extreme weather, food insecurity and displacement – disproportionately affect the most disadvantaged communities, who have the fewest resources to adapt and recover. These communities, as described above, often already experience poorer physical and mental health outcomes, and climate-related stressors further exacerbate existing health disparities by increasing exposure to trauma, instability and environmental hazards.

The Global South, for example, is disproportionately affected by climate change, with greater exposure to extreme weather events, subsequent displacement and risk of food insecurity – all of which increase the risk of forced migration and consequent mental health risks. ^{Reference Zhang, Braithwaite, Bhavsar and Das-Munshi31,Reference Lawrance, Thompson, Newberry Le Vay, Page and Jennings32} Not only are those most disadvantaged in society at most risk from the consequences of climate change, but as the impacts of climate change increase, so it will exacerbate and widen these disparities. ⁶ This represents a significant global and national challenge. Within the UK, for example, those living with higher levels of deprivation are also more likely to live in flood-prone areas, have poorly insulated housing and experience high levels of air pollution. ^{Reference Hall and Bailey33–35} These same individuals are at greater risk of mental illness, perpetuating a cycle of disadvantage. Environmental hazards, such as air and noise pollution, often prevalent in deprived neighbourhoods, also contribute to worse mental health outcomes. ^{Reference Bhui, Newbury, Latham, Ucci, Nasir and Turner36–Reference Newbury, Stewart, Fisher, Beevers, Dajnak and Broadbent38} Poor quality housing can directly impact mental health as well as increase the potential consequences from climate events such as heat waves and flooding, with issues like damp, mould and overcrowding. ^{Reference Hall and Bailey33–35,39}

Healthy environments

Our local environment plays a vital role in both public mental health and sustainability, making it a critical area of focus for psychiatrists. When we refer to environments, this may include the built environment (i.e. those areas that have been physically built) and the natural environment, which includes green spaces such as parks, nature reserves and woodland, as well as blue spaces such as rivers, seas and lakes. All of these elements can positively or negatively impact mental well-being, as well as either exacerbate climate challenges or support adaptive responses to climate change. Access to nature has profound effects on mental well-being. Research demonstrates that people living in neighbourhoods with more green space experience lower rates of anxiety and depression and report better overall well-being. ^{Reference Barton and Rogerson40,Reference Alcock, White, Wheeler, Fleming and Depledge41} Time spent in natural environments not only supports primary prevention of mental illness but also leads to meaningful improvements in conditions such as depression, anxiety and stress. ⁴² Nature also provides opportunities for physical activity, social connection and engaging in hobbies, further enhancing mental health.

A healthy environment promotes benefits that extend beyond individual health. Green spaces play a key role in climate change adaptation by providing shade, cooling urban heat islands and reducing flood risks. ^{Reference Yu, Xu, Zhang, Jørgensen and Vejre43,Reference Kirschner, Macků, Moravec and Maňas44} This will become increasingly important in a world afflicted by warming temperatures. These spaces also improve local biodiversity, helping ecosystems adapt to the challenges of a changing climate. Access to these resources, however, is not evenly distributed.

Disparities in access to nature highlights the intersection between environmental and mental health disparities. ⁴⁵ People living in the most deprived areas of the UK have the least access to green spaces and are more vulnerable to climate impacts like heatwaves and flooding. ^{45,Reference Turner, Israelsson, Reynolds, Umeh, O’Connor and Loveless46} While there is often poorer access to protective natural environments that enhance resilience, so there is also a higher exposure to environmental factors that impact mental health.

The environments we live in are also heavily influenced by commercial determinants of health, contributing to inequalities and impacting public mental health: ‘Commercial determinants of mental health describe how actions of private companies affect people’s mental health.’ ^{47,Reference Dun-Campbell, Hartwell, Maani, Tompson, van Schalkwyk and Petticrew48} Once again, vulnerable groups are disproportionately targeted and impacted, for example, fast-food outlets and alcohol retailers are more prevalent in deprived neighbourhoods, contributing to higher rates of obesity, addiction and related mental health conditions in these areas. ^{49,Reference Shortt, Tisch, Pearce, Mitchell, Richardson and Hill50} Factories emitting high levels of air pollution are also more likely to be found in deprived communities. ^{Reference Walker and Bickerstaff51} These same commercial interests drive a high-consumption society that is inherently unsustainable, while also contributing to poor mental health outcomes. This stands in contrast to the goals of a truly sustainable healthcare system, in which prevention is prioritised, equity is the norm and environmental impacts are minimised.

Implications for practice

Psychiatrists have a unique opportunity to support prevention, address health inequalities and contribute to a more sustainable mental healthcare system. By adopting a holistic and proactive approach, they can drive meaningful change at the individual, service and system levels.