1. Promoting mental health and preventing mental illness: the economic case for investment in Wales Lynne Friedli and Michael Parsonage All Wales Mental Health Promotion Annual Conference Glyndwr University, 17 th March 2010

2. Summary Mental health/mental illness: terms and definitions Methodology: constraints and limitations Economic case: prevention, promotion and lifetime benefits ‘Best buys’ Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

3. Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Dimensions of mental health Mental health (capital) Emotional resources e.g. coping style, mood, emotional intelligence Cognitive resources e.g. learning style, knowledge, language, flexibility, innovation, creativity Social skills e.g. listening, relating, communicating, co operating, accepting Meaning and purpose e.g. vision, spiritual growth, connectedness If I am not for myself, who will be for me? And if I am only for myself, what am I?If not now, when?

4. Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Population distribution of mental health emotional cognitive social Good (14%)Average (73%)Poor (14%) (WEMWBS) After Keyes 2002; Rose 2001; Huppert 2005 Possible disorder (high GHQ12) – 17%

5. Dual continuum model of mental health Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk High mental health (flourishing ) Low mental health (languishing) Low level of mental illness High level of Mental illness

6. Constraints and limitations Problems of evaluation: mental health can be defined and measured in many different ways better mental health has many potential benefits the benefits of better mental health may accrue over many years many things affect mental health interventions to promote mental health may take many different forms Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

7. The general economic case: overview Benefits of preventing mental illness Benefits of promoting positive mental health Lifetime benefits Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

8. Benefits of prevention (1) Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk (2007/8 figures) Cost of mental illness in Wales

9. Benefits of prevention (2) WHO ‘Global burden of disease’, UK 2004 % of total burden mental illness 20.0 cardiovascular diseases 16.2 cancer 15.6 respiratory diseases 8.3 musculoskeletal diseases 4.1 Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

10. Benefits of prevention (3) Limited effectiveness of treatment: % of burden averted Current coverage, current treatment 13 Current coverage, optimal treatment 20 100% coverage, optimal treatment 40 Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

11. Benefits of promotion (1) A worthwhile goal in itself and leads to better outcomes: reduces prevalence of mental illness physical health: mortality/morbidity health behaviour employability, productivity, earnings educational performance crime / violence reduction pro-social behaviour/social integration/relationships quality of life Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

12. Benefits of promotion (2) Positive mental health benefits physical health by improving: protection from heart disease stroke incidence and survival harmful health behaviours (smoking, drinking, drugs) overall lifetime mortality rates and life expectancy Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

13. Lifetime benefits (1) Strong evidence of continuity between adverse mental states in childhood and in adult life: among adults with mental illness, 50% first meet diagnostic criteria for a psychiatric disorder by age 15 and 75% by the late teens 40% of cases of childhood conduct disorder persist into adulthood Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

14. Life time benefits (2) crime smoking drugs depression suicide no quals top 50% (no conduct problems) 1.00 1.00 1.00 1.00 1.00 1.00 middle 45% (some problems) 1.95 1.24 1.51 1.24 1.69 1.18 bottom 5% (conduct disorder ) 4.13 1.59 2.39 1.57 3.00 1.45 Promoting mental health in Wales Lynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

15. Lifetime savings per case total for 1-yearWales cohort in UK £ £ million£ million Prevention (move bottom 5% to middle 45% ) 150,000 5,250247.5 Promotion (move middle 45% to top 50%) 75,000 23,6251,113.75 Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Annual UK birth cohort =700,000 Annual Welsh birth cohort = 33,000

16. ‘best buys’ Supporting parents and early years: parenting skills/ pre- school education/home learning environment/reading Supporting lifelong learning: health promoting schools and continuing education Improving working lives: employment/ workplace Positive steps for mental health: lifestyle (diet, exercise, sensible drinking) and social support Supporting communities: environmental improvements Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

17. Parenting programmes Typical cost of parenting programmes (2003 ) Group programme: community £1,350 Individual programme: home £6,000 Welsh births per year 33,000 Success rate needed: 1 in 25 and 1 in 55 (effect size of 2-4%) Promoting mental health in Wales Lynne.friedli@btopenworld.co m Michael.parsonage@scmh.org.u k Cost of programme (one year birth cohort) Benefits Disorder£9.9 million£247.5 million Problem£20 million£1,113.74 million

18. Health Promoting Schools Preventing depression Improving academic outcomes Emotional and social functioning Reducing health damaging behaviour Reducing bullying Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Life/social skills (LST) returns: $25-45 per $1 per pupil Around 50% fewer using tobacco, alcohol, cannabis at 40 months Place2be: £6 return per £1 invested (payback period 5 years) (US Department for Health and Human Services 2007; Place2be 2009)

19. Lifelong learning Basic educational qualifications reduce risk of depression and improve mental health; impact strongest for women No qualification to basic saves £230 m per year, based simply on reducing depression in women (by 3.5%) Adult learning: Small positive changes in health and social outcomes (Hammond & Feinstein 2005; Chevalier & Feinstein 2006) Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

20. Employment/workplace (1) Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Projected increase in cases of mental illness in UK workplace 20082030 Men2.4 m2.8 m Women4 m4.2 m (Foresight 2009) Costs of mental illness in the workplace in Wales: £1.2 billion per annum = £860 per employee

21. Promoting mental health in Wales Lynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Key workplace factors: demand/control; support; job security; effort/reward balance; change management Effective programmes include:  Recognition  Prevention  Awareness  Access to help  Rehabilitation Potential savings: £400million per annum Employment/Workplace (2)

22. Lifestyle and social support Diet : mood, symptoms, outcomes Alcohol : violence, crime, mood, relationships Exercise :mood, symptoms, self-efficacy, outcomes, cognitive function Social support 5 ways to wellbeing Interventions:  GP consultation (costs £30)  Timebanks;  Social prescribing Scale of potential benefits........ Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

23. Five ways to well-being Commissioned by the Foresight Project to summarise the evidence from the Mental Capital and Wellbeing Project into 5 key messages Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

24. Environmental improvements Key factors: neighbour noise; overcrowding; escape facilities; safety/fear of crime; damp; street level incivilities Promising interventions:  Contact with nature (green exercise; forest schools)  Access to green open spaces  Reducing motor vehicle traffic density Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk

25. Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Exposure to green space: reducing the health gap (Marmot 2010)

26. Promoting mental health in WalesLynne.friedli@btopenworld.com Michael.parsonage@scmh.org.uk Spend to save..... Good (14%) (flourishing) Average (73%) Poor (14%) (WEMWBS) (languishing) Scottish scores on Warwick Edinburgh Mental Wellbeing Scale