Andrew McCullough argues public health messages need a makeover so people base their lifestyles on an understanding of wellbeing that ties mental and physical health together
We have seen huge success in public health over the past 20 or 30 years, including the response to HIV/AIDS and measures to tackle smoking. These have led to improvements in some aspects of physical health, but not - so far - in mental health.
We now face a new series of interrelated health challenges. Possible increases in obesity, diabetes, dementia and common mental health problems are all subjects of discussion. But we fall into the trap of looking at mental and physical health separately.
An eminent psychiatrist recently asked me: "What are the possible risk factors for Alzheimer's disease?" My crude summary of the evidence base - familial and genetic factors, high-fat diet, lack of exercise, lack of mental stimulation, possibly lifetime anxiety levels - was greeted with surprise. But these are the same risks as for heart disease and cancer, he said. Exactly.
Despite overwhelming evidence that illnesses come in clusters with mental and physical components, we continue to present public health as a series of separate issues - "stop smoking", "lose weight", "drink less". This is confusing, disempowering and psychologically naive. The public has no idea what to prioritise and is prone to either write off illness as inevitable, or to feel inadequate and anxious, leading to further unhealthy behaviour. People see mental illness as mysterious and frightening and physical illness as explicable and fixable. Neither view encourages healthy lifestyles.
There is huge underinvestment in mental health promotion and a failure to join up what mental health promotion there is with physical health promotion. A classic example is the piecemeal response to co-morbidity such as diabetes and depression or heart disease and depression. Public health messages need a total makeover so patients and clinicians base their activities on a modern understanding of health and wellbeing, which ties mental and physical health together.
Planned investment in mental health promotion in adult mental health services in England in 2007-08 was£4m out of a total adult mental health spend of£4.5bn - less than 0.1 per cent. This is clearly inadequate. Recent reports aim to establish mental health promotion at the heart of NHS activity. With concern about people being able to maintain good mental health in the current economic instability and a public mental health strategy on the way, it couldn't be more pressing for the government to listen.
Next stage review
A significant push has come from Lord Darzi's next stage review. This made it clear that the NHS "needs to focus on improving health as well as treating sickness… and has the responsibility to promote good health" and made improved mental health one of six key goals.
The health minister's message was comprehensively backed by the think tank Foresight's mental capital and wellbeing project report, which received little publicity. It draws on all the available evidence to show the social, health and economic benefits of investing in mental wellbeing and highlights the importance of programmes to support whole population mental health, suggesting that even small improvements in population-wide levels of wellbeing will reduce the prevalence of mental illness.
There is clear evidence of the need to turn the potential of mental health promotion into a reality. It won't be easy, not least because everyone's mental - and physical - health depends on things such as family relationships, housing, work status and the environment.
Promoting good mental health involves many organisations with different remits and responsibilities, such as schools, housing associations and large employers. NHS bodies will have to use existing local partnership arrangements and possibly develop new ones as well.
Mental health promotion needs to be clearly specified in strategic health authority and primary care trust strategic plans as part of health promotion generally to achieve comprehensive wellbeing programmes. PCTs must recognise that world class commissioning encompasses public mental health work as much as any other. The commissioning of effective local mental health promotion programmes is likely to require proportionately more spending than is seen currently.
If such programmes are properly integrated with other public health and primary care work, there could be savings at a strategic level.
Fundamentally, mental health and wellbeing need to underpin all public health campaigns, on any theme. Only then will we end the piecemeal approach being taken by the Department of Health and deliver coherent public health messages to the their intended audience, the general public.