Position Statement 17: Promotion of Mental Wellness

Policy

Mental health is an essential component of overall health and well-being.1

MHA (Mental Health America) considers the concept of wellness as encompassing its other systems transformation policies, which will not be stressed here:

• Position Statement 11: In Support of Recovery-Based Systems Transformation
• Position Statement 16: Health and Wellness for People with Serious Mental Illnesses
• Position Statement 25: Community Inclusion after Olmstead
• Position Statement 48: Prevention of Mental Health and Substance Use Disorders in Young People
• Position Statement 41: Early Identification of Mental Health Issues in Young People

The very significant body of evidence that has been developed about prevention of mental and substance use conditions and promotion of mental health should encourage policy makers to invest in proven prevention and wellness interventions.  Well-studied prevention and mental health promotion interventions can improve overall functioning as well as decrease the rates at which individuals develop mental health symptoms and diagnosable conditions2. Rigorous societal cost analyses further indicate that preventive interventions have a strong, positive return on public investments by increasing social benefits (such as academic achievement and stable marriages) while decreasing social costs (such as incarceration and violent behavior).3

Evidence-based prevention and early-intervention techniques can reduce both the incidence of mental health and substance use conditions and the duration and disability associated with them.  All problems are easier to resolve if they can be addressed before they develop or reach a painful point. This is the origin of the “B4stage4” (sm) campaign that MHA has made its core advocacy issue.

MHA will reach out to other health and wellness advocates to assure that mental health and substance use conditions are reframed as public health issues, on a par with the other major public health issues confronted by our society. Viewing mental wellness as the core of wellness and thus the core of public health, MHA is committed to develop a powerful wellness agenda that integrates mental health and substance use issues with general health issues.

All individuals and families are at risk of the harmful effects of toxic stress and trauma.  To build and maintain well-being, people need to develop protective factors which strengthen resilience to toxic stress as well as reduce risk factors by minimizing stressful circumstances and trauma.  Protective factors include "emotional intelligence,"4 coping skills, effective use of social supports, and openness and access to mental health counseling and advice including peer relationships. Risks can be reduced through parental support programs and social insurance programs that can reduce exposure to traumatic events such as child abuse and poverty.  Strengthening an individual's mental health and promoting resilience to handling life's stressors not only reduces the risk of mental and substance use conditions but contributes to improved general health, well-being and productivity, and a healthier society. MHA is committed to developing and implementing strategies and policies that promote mental wellness to ensure our relevance to the general population as well as strengthening overall population health.

Background

The realization that mental health is integral to overall health signals a fundamental change in our conceptualization of health - one that rejects the dualism of mind and body and realizes that the pursuit of health must be approached holistically by embracing a person's biology, psychology and social environment simultaneously.

The concept of wellness is holistic in its pursuit of optimal health for the individual, family, community and nation.  Wellness is a strategy for living that seeks to achieve the highest level of positive participation that an individual can achieve in his/her life, resonating with the World Health Organization’s definition of health.5 Consistent with its holistic orientation, wellness has been defined as involving social, intellectual, spiritual, physical, emotional and occupational dimensions. 

Wellness involves a set of life skills that promote well-being and help to prevent the onset of illness as well as social policies that reduce exposure to risks – such as toxic stress and trauma.  For individuals who have become ill, wellness seeks to shorten the duration of illness and the disability that may result from it.  As such, wellness strategies promote recovery for persons with severe illnesses by providing treatments, skills and supports to maximize achievement of a person's idiosyncratic goals and participation in the community. 

Mental and substance abuse conditions are among the most common health disorders in the United States, affecting nearly 50% of adults at some time during their lifetime.6 Each year, over 20 million adults (8.4%) have a substance use disorder. Of these, nearly 8 million people have both a mental disorder and substance use disorder, also known as a co-occurring mental and substance use disorder.7 Nearly 15% of adults will experience a substance use disorder, while approximately 25% of the adult population will experience both a mental and substance use condition.8 Additionally, there is growing evidence of the interaction between mental health conditions and other health conditions such as cardiovascular disease,9 cancer,10, HIV/AIDS, and diabetes.11 Exposure to socioeconomic adversity predicts the development of behavioral and emotional problems which in turn increase the likelihood of developing other chronic illnesses.12 When mental health, substance use and other chronic disorders co-occur and are not effectively treated in an integrated way, the course of illness is negatively affected, costs of treatment are increased and outcomes are typically worsened.13 Additionally, many of the chronic illnesses that account for approximately 75% of health care expenditures in the United States14 have important behavioral health components such as inactivity, smoking, poor management of chronic stress, etc.  It is imperative that we adopt an integrated approach to addressing the health and well-being of the population.  Wellness strategies respond to this need.

According to the World Health Organization (WHO), psychiatric disorders account for 5 of the 10 leading causes of disability.15 In the United States, mental illnesses and addictive disorders account for more burden of disease than any other health condition.  Significantly, the WHO defines mental health broadly, to include mental wellness: "A state of well-being in which the individual realizes his or her abilities, can cope with normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community."16 The definition again underscores the inherent linkages between all components of health and, by implication, the need for an integrated approach to achieving health which involves more than treatment.

Our medical care system is generally designed to diagnose and treat illness rather than to prevent its occurrence.  Similarly, our public mental health "systems" are generally designed to provide care and services only to those individuals with the most serious mental health conditions.  No public system is formally charged with the responsibility to carry out the critically important work of promoting health by fostering resilience and seeking to promote well-being. Similarly, lack of early detection and effective treatment of the range of mental health and substance use conditions remains a serious shortcoming of our current medical care system.  Promotion of mental health, prevention of mental illness and effective treatment of mental and substance use conditions are all important in preserving our health.

We need a coherent and effective health promotion and disease prevention strategy in this country to reduce the number of individuals in need of care and maximize their contributions to their communities, and as a matter of prudent health economics. To ignore this imperative is to leave people unprotected in the face of many sources of risk.

It is perhaps particularly important to emphasize early intervention strategies that can be either home- or school- based and that have been shown to produce long term benefits to individuals who receive these interventions.  For example, the Nurse Family Partnership supports new, low income mothers from conception through the first two years of the baby’s life and results in decreases in child abuse and decreases in welfare dependency among a number of other positive outcomes.17 Both the Good Behavior Game18 and the Seattle Social Development Project19 have long term follow-up data indicating that, 13-15 years following the interventions participants had improved social function, educational achievement and lower rates of problem behaviors.  These are illustrative of the long term beneficial effects of preventive programming.  A wide variety of evidence based programs and policy approaches are ready for implementation.  

At later stages in life – early adulthood and adulthood the stress in a society in which many people work extended hours or multiple jobs and take little time off continues to underlie the development of health problems. One in three U.S. employees is chronically over-worked,20 and the line between work and home life is often blurred, so that home may no longer be a place of rest.  Increasingly people have come to understand the significance of their mental health as sleep and exercise come to feel like luxuries, and they experience lack of connection with family, neighbors, and community, and decline in trust. Chronic inactivity, addictive behaviors such as tobacco and alcohol use, and poor diet all further contribute to the diminution of health.

Compounding the insidious stresses of modern life, most of us eventually encounter special challenges that test us and put our mental health and support systems at risk.  For some, it is the stress of care-giving, family dissolution, or the death of a loved one.  For others, it is living with a chronic illness -- diabetes, cancer, an addiction, or a major mental health condition such as depression or schizophrenia.  And even extraordinary stresses like domestic abuse, child abuse, sexual abuse, traffic accidents, street crime, natural disasters, war and even terrorist incidents are a persistent threat.  Mental wellness involves developing the resiliency and the coping skills to deal with such challenges as well as working actively to reduce these risk factors.

Modern U.S. society appears to cumulate and exacerbate many of these stressors. Thus, international studies indicate that Mexicans living in Mexico have far lower rates of mental health conditions than first and second generation Mexican immigrants living in the United States. Immigrants from Mexico to the US, however, experience increased rates of mental illness that equal those second generation immigrants and of the US population generally after having lived in the US for 13 years.21 

Scientists have recognized protective factors that may ameliorate risks to our mental and general health.  In recent years much has been learned about the importance of "promotive" factors as simple as exercise, good nutrition, adequate rest, healthy social interactions and support from peers. Employee assistance and substance use intervention programs at work, access to peer and professional counseling, and social inclusion for all are important interventions to enhance health.  These and other promotive measures need to be available to everyone so that people can cope with the risky situations and stressors that modern society imposes on all of us. A holistic approach takes into consideration appropriate developmental, cultural, and linguistic strategies to promoting wellness.

Wellness has great currency in contemporary life.  It can be associated with many intellectual and social movements such as holistic and integrative medicine, formerly known as CAM (complementary and alternative medicine), positive health, the independent living movement, public health/health promotion and the self -help/mutual support movement.22 Each of these seeks to maximize “health” as defined by the WHO and inherently appreciates the integration of body, mind and the social environment. 

The strategies that promote mental health and prevent mental and substance use conditions will have salutatory effects on health.  They will have positive effects not only for individuals, but also for multiple sectors of society:  in education (e.g., mentally healthy children can take fuller advantage of learning opportunities), in the economy (e.g., mentally healthy adults can be more effective in their job performance and thus benefit their families and employers), and in family life (e.g., strengthened families can stay together). There is a growing field of scholarly literature in this area.23

In June of 2007 the National Mental Health Association was renamed Mental Health America (MHA), reflecting an intention to develop and implement new strategies to engage the general public in a holistic approach to health, which fully embraces the centrality of mental health to overall health.  Promoting wellness strategies as relevant for the entire population is an integral part of this new direction for MHA as is detailed in this policy. 

MHA envisages a society that addresses health comprehensively and from a public health perspective. That society would apply the growing body of research on health promotion and disease prevention to help people achieve mental health and wellness. This can be accomplished by a sustained effort to increase individual and community resources for resilience, focusing on the wide public availability of systematic, evidence-based programs and public policies that have been shown to reduce risks, increase protection and promote resilience.   This approach also must embrace access to the more intensive treatment and supports to enable persons with serious mental health conditions to recover and lead productive and satisfying lives.  Prevention, treatment and rehabilitation are complementary interventions in an integrated public health approach.  

The concept of wellness recognized by the 2007 changes to the MHA mission statement represents a new policy direction for MHA, which broadens the organization's role to advocacy of the promotive measures that American society desperately needs to respond to the challenges of modern life and its multiple threats to our health and well-being. MHA believes that the concept of wellness is closely tied to the concept of recovery from mental health conditions, and that many of the tactics that are used to maintain good health also are useful in negotiating recovery from the disability associated with a chronic illness - including mental and substance use conditions.  Wellness needs to be everyone's concern.

Call to Action

A comprehensive public-health-oriented wellness strategy requires that mental health services foster and maintain mental health, including both programs and services to prevent the initial onset of illness and treatment and support services for people who have become ill.   No point on this continuum should be seen as less important than any other point.

The promotion of mental health and the prevention of mental health and substance use conditions should be central to the public health agenda, as important as treatment and supports.

• Accelerated research is needed concerning effective prevention, promotion, and treatment interventions for all age and ethnic groups and across a wide range of mental   health and substance use issues.  Systematic research on sustainable and effective implementation of existing evidence-based practices is critical.
• Based on the considerable existing research and the work yet to be done, implementation of science based promotion and prevention approaches for the entire population must be a high priority at the national, state and local levels.24 These approaches must be developed in culturally and linguistically competent ways for diverse populations with different needs and perspectives.   
• Mental and substance use conditions should be detected early and treated effectively.  Routine screening in schools, pediatric clinics, the workplace, primary care, among others should be the norm.  When individuals are identified as needing care, adequate treatment systems that focus on recovery and resilience should be available along with needed supports. These interventions should be pursued in culturally and linguistically competent ways for diverse populations with different needs.  Financing strategies that reimburse for collaborative care services is essential to realize these ends.
• Mental health promotion, prevention, treatment and recovery practices should reflect the diverse cultural norms that affect how people define mental health, promote health and seek help, diagnosis and treatment.  Comprehensive health care reform must incorporate these cultural norms in order to increase engagement in helpful activities and, subsequently, the effectiveness of prevention and promotion interventions as well as the rates of diagnosis and treatment of mental and substance use conditions.
• Groups that challenge the validity of evidence-based mental health policy and the need for access to treatment for mental health and substance use conditions should be vigorously challenged.
• Community-, school- and employment-based mental health services and mental wellness programs should be established and supported.

Effective Period

This policy was approved by the Mental Health America Board of Directors on December 5, 2015.  It is reviewed as required by the MHA Public Policy Committee.

Expiration:  December 31, 2020

2. Shern, D., Blanch, A. & Steverman, S. (In press) “Toxic Stress, Behavioral Health and the Next Major Era in Public Health.” American Journal of Orthopsychiatry.

3. Washington State Institute for Public Policy. (2014). Benefit-Cost Results - General Prevention. Retrieved from http://www.wsipp.wa.gov/BenefitCost?topicId=6

4. Goleman, D., Emotional intelligence. New York, NY: Bantam Books (1995).

5. “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

6. SAMHSA, Behavioral Health, 2012, http://www.samhsa.gov/data/2012BehavioralHealthUS/Index.aspx

7. Center for Behavioral Health Statistics and Quality, Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50) (2015), retrieved from http://www.samhsa.gov/data/

8. Id.

9. Kandauda, K., Wickrama, C., O’Neal, W, et al. ”Early Socioeconomic Adversity, Youth Positive Development and Young Adults’ Cardio-Metabolic Disease Risk.” Health Psychology, 34(9): 905-914 (2015).

10. Institute of Medicine, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press (2007). http://www.iom.edu/Reports/2007/Cancer-Care-for-the-Whole-Patient-Meeting-Psychosocial-Health-Needs.aspx

11. Ciechanowski, P. S., Katon, W. J., & Russo, J. E., “Depression and Diabetes:  Impact of Depressive Symptoms on Adherence, Function, and Costs,” Archives of Internal Medicine 160:3278-3285 (2000).

12. See, e.g., Marmot, M., “Social Determinants of Health Inequalities,” Lancet 365: 1099–104 (2005)

13. Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B., “Depression, Chronic Diseases, and Decrements in Health: Evidence from the World Health Surveys.” The Lancet, 369:1-8 (2007).

14. http://www.fightchronicdisease.org/facing-issues/about-crisis

15. http://www.who.int/mental_health/advocacy/en/Call_for_Action_MoH_Intro.pdf (2001); updated http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf?ua=1 (2013)

16. Id.

17. Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K.& Bondy, J. , “Effects of Nurse Home Visiting on Maternal and Child Functioning: Age 9 Follow-Up of a Randomized Trial.” Pediatrics, 120(4): e832-e845. doi:10.1542/peds.2006-2111 (2007).

18. Embry, D.,  “Prevention in Mental Health: A Lifetime Perspective,” Psychiatric Clinics of North America, 34(1): 1-34 (2011).

19. Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G., & Abbott, R. D.,“Effects of Social Development Intervention in Childhood 15 Years Later,” Archives of Pediatric and Adolescent Medicine,162(12):1133-1141 (2008).

20. http://www.familiesandwork.org/

21. Vega, W.A., Kolody, B., Aguilar-Gaxiola, S., Alderete, E., Catolano, R. & Caraveo-Andwaga, J., “Lifetime Prevalence of DSM-III-R Psychiatric Disorders Among Urban and Rural Mexican Americans in California,” Archives of General Psychiatry 55:771-778(1998).

22. Based on a 2007 review of the current literature conducted on behalf of MHA by the Center for Non-Profit Strategies.

23. The National Wellness Institute (Dr. Bill Hettler) was an early pioneer of the mental wellness concept, advocating a focus on six aspects of life: social, intellectual, spiritual, physical, emotional and occupational. The Institute and similar organizations have developed numerous tools and resources, including a Lifestyle Assessment Questionnaire, that explore multiple dimensions of mental wellness. David Goleman's 1995 book, Emotional Intelligence, made the case that emotional intelligence can be learned and supported. Peter Salovey (current President of Yale) and John D. Mayer have proposed a model of emotional intelligence including five domains: knowing one's emotions, managing emotions, motivating oneself, recognizing emotions in others, and handling relationships. These are the core of the emotional intelligence concept described by Goleman. "Emotional Intelligence," Imagination, Cognition and Personality 9:185-210 (1990).

24. The following research provides support for the use of evidence-based practices in the treatment of mental health conditions related to wellness management: (1) Mueser, K., Corrigan, P., Hilton, D.W., Tanzman, B., Schaub, A., Gingerich, S., Essock, S.M., Tarrier, N., Morey, B., Vogel-Scibilia, S., & Herz, M.I., “Illness Management and Recovery: A Review of the Research,” Psychiatric Services, 53 (10):1272-1284(2002),(2) Lincoln, T. M., Wilhelma, K., & Nestoriuca, Y. “Effectiveness of Psychoeducation for Relapse, Symptoms, Knowledge, Adherence and Functioning in Psychotic Disorders: A Meta-analysis, Schizophrenia Research 96: 232-245(2007), (3)Corrigan, P. W., Mueser, K. T., Bond, G. R., Drake, R. E., & Solomon, P., The Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach, New York: Guilford Press (2008).