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Mental health, resilience and inequalities: a manifesto for action for PAN? Lynne Friedli PAN-WM 3 rd Annual Conference Birmingham 20 th October 2008.

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Presentation on theme: "Mental health, resilience and inequalities: a manifesto for action for PAN? Lynne Friedli PAN-WM 3 rd Annual Conference Birmingham 20 th October 2008."— Presentation transcript:

1 Mental health, resilience and inequalities: a manifesto for action for PAN? Lynne Friedli PAN-WM 3 rd Annual Conference Birmingham 20 th October 2008

2 Summary Why mental health matters Understanding the contribution of mental health to health and other outcomes Reflecting on the determinants of mental health Where physical activity fits in – over to you! PAN-WM: the feel good factor

3 PAN-WM: the feel good factor This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, Some momentary awareness comes As an unexpected visitor. Welcome and entertain them all. Even if they’re a crowd of sorrows, Who violently sweep your house Empty of its furniture. Still treat each guest honourably. He may be clearing you out for some new delight. The dark thought, the shame, the malice, Meet them at the door laughing, And invite them in. ( Jelaluddin Rumi, )

4 Can mental health help to explain outcomes that cannot be wholly accounted for by other factors? Contribution mental health and mental illness make to wide range of outcomes The ‘unexplained excess’ – classical risk factors do not account for level of variation in outcomes Presence as well as absence... (Friedli forthcoming) PAN-WM: the feel good factor How important is mental health?

5 PAN-WM: the feel good factor Key elements of positive mental health Emotion (affect/feelings ) Cognition (perception, thinking, reasoning) Social functioning (relationships, engagement) Coherence (sense of meaning and purpose) Emotional/cognitive and social well-being Status, Control, Connection, Interaction

6 PAN-WM: the feel good factor High mental health (flourishing) Low mental health (languishing) High level of mental illness Low level of mental illness Curing illness does not necessarily result in health ( Pat Barker)

7 WEMWBS – Well and HEPS PAN-WM: the feel good factor (Taulbut & Parkinson forthcoming) Adults with above average, average and below average WEMWBS score: % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Well? (aged 16+)HEPS (aged 16-74) % Above average Average Below average

8 Benefits of positive mental health A worthwhile goal in itself and leads to better outcomes overall prevalence/herd immunity physical health: mortality/morbidity health behaviour employability, productivity, earnings educational performance crime / violence reduction pro-social behaviour/social integration/relationships quality of life/recovery PAN-WM: the feel good factor

9 Life course benefits crime smoking drugs depression suicide no quals top 50% (no conduct problems) middle 45% (some problems) bottom 5% (conduct disorder ) (adapted from Fergusson et al 2005) PAN-WM: the feel good factor

10 Life course benefits (2) per case total for 1-yearScotland cohort in UK £ £ million£ million Prevention (move bottom 5% to middle 45% 150,000 5, Promotion (move middle 45% to top 50%) 75,000 23, (Friedli & Parsonage 2007) PAN-WM: the feel good factor

11 Contribution of mental health to inequalities Key domains: Education; Employment; Behaviour; Health; Consequences of illness; Services (Whitehead & Dahlgren 2006) Mental health is a significant determinant in each case, influencing: readiness for school/learning employability capacity, motivation and rationale for healthy behaviours risk for physical health (e.g. coronary heart disease) chronic disease outcomes (e.g. diabetes) relationship to health services, including uptake/treatment PAN-WM: the feel good factor

12 PAN-WM: the feel good factor Not ‘every family in the land’ Findings from 9 large scale population based studies: Material and relative deprivation Low educational attainment Unemployment Environment: poor housing, poor resources, violence Adverse life events Poor support networks (Melzer et al 2004; Rogers & Pilgrim 2003) Cycle of invisible barriers: Poverty of hope, self-worth, aspirations Mental health and deprivation

13 Psycho-biological pathways Chronic low level stress ‘gets under the skin’ through the neuro-endocrine, cardiovascular and immune systems, influencing : hormone release e.g. cortisol, cholesterol levels blood pressure inflammation e.g. C-reactive proteins. PAN-WM: the feel good factor Status Control Relatedness

14 Untangling the determinants Individual skills and attributes Material resources Inequalities in distribution of resources PAN-WM: the feel good factor I do worry about this emphasis on individual psychology; You can’t separate thoughts, feelings, self esteem, motivation from the material circumstances of people’s lives. Is it great to be positive? Maybe people are right to be pissed off.” Positive steps interviews

15 PAN-WM: the feel good factor “...the Greeks and Romans lived, I suppose, very comfortably though they had no linen. But in the present times, through the greater part of Europe, a creditable day labourer would be ashamed to appear in public without a linen shirt, the want of which would be supposed to denote that disgraceful degree of poverty which, it is presumed, nobody can fall into without extreme bad conduct. Custom in the same manner has rendered leather shoes a necessary of life in England. The poorest creditable person of either sex would be ashamed to appear in pubic without them” (Adam Smith Wealth of Nations 1776)

16 Resilience, health assets and capabilities Resilient places Resilient communities Resilient individuals Resilient policies PAN-WM: the feel good factor ‘Doing better than expected notwithstanding adversity’

17 Copyright ©2007 BMJ Publishing Group Ltd. Tunstall, H. et al. J Epidemiol Community Health 2007;61: Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies and the British average ( ). PAN-WM: the feel good factor

18 (the ecology of)Relationships Matter (1) Quality of social relationships is key factor in resilience in the face of adversity; Social integration buffers effects of low SES PAN-WM: the feel good factor

19 Rates of poor social/emotional adjustment PAN-WM: the feel good factor (Graham & Power 2004)

20 PAN-WM: the feel good factor Equalities Review 2007 Crown Copyright

21 Copyright ©2007 BMJ Publishing Group Ltd. Tunstall, H. et al. J Epidemiol Community Health 2007;61: Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies and the British average ( ). PAN-WM: the feel good factor

22 Exposure Susceptibility Resistance PAN-WM: the feel good factor Resilient policies Policy responses to misfortune Social networks Service responses Lay perceptions of poverty and health Community assets Collective action

23 (the ecology of)Relationships matter ‘tend to the social and the individual will flourish’ Rutherford 2008 Mental health is produced socially Presence or absence of mental health is above all a social indicator Quality of social relationships is key factor in resilience Social as well as individual solutions PAN-WM: the feel good factor

24 PAN-WM: the feel good factor A (wider) manifesto for action Challenging material inequalities Mental health and well-being Reducing poverty and the impact of poverty Respectful policy responses to misfortune Quality of social relationships Build capacity for collective action (collective efficacy) And what I shall endure, you shall endure For every atom belonging to me as good belongs to you Walt Whitman

25 PAN-WM: the feel good factor The contribution of physical activity? Community safety/ Environmental improvements Mental health and well-being Affordable, accessible, inclusive routes to activity Green, open spaces/ natural world/ nutrition Social relationships Collective action: right to roam, wild swimming, allotments, affordable food Culture and creativity

26 A just society is one that is aware that it is not yet sufficiently just, that is haunted by this awareness and thereby spurred into action Zygmunt Bauman PAN-WM: the feel good factor

27 PAN-WM: the feel good factor Select bibliography Carlisle Sandra Series of papers on cultural influences on mental health and well-being in Scotland (http://www.wellscotland.info/publications/consultations4.html).http://www.wellscotland.info/publications/consultations4.html Equalities Review (2007) Fairness and Freedom: the final report of the equalities review London: Cabinet Office see also CEHR Lyybomirsky S, King L and Diener E (2005) The benefits of frequent positive affect: does happiness lead to success? Psychological Bulletin 131:6 Killeen Damian (2008) Is poverty in the UK a denial of people’s human rights? York: Joseph Rowntree Foundation Commission on Social Determinants of Health

28 Select bibliography PAN-WM: the feel good factor Bartley M (editor) (2006) Capability and Resilience: beating the odds ESRC Friedli L (in press) Mental health, resilience and inequalities – a report for WHO Europe and the Mental Health Foundation London/Copenhagen Friedli L and Parsonage M (2007) Mental health promotion: building an economic case Belfast: Northern Ireland Association for Mental Health Jones C, Burström B et al (2006) Studying social policy and resilience in families facing adversity in different welfare state contexts – the case of Britain and Sweden. International Journal of Health Services 36 (3): 425–442. Zaveleta RD (2007) The ability to go about without shame: a proposal for internationally comparable indicators of shame and humiliation Oxford: OPHI

29 PAN-WM: the feel good factor Select Bibliography Fergusson, D., Horwood, J. and Ridder, E. (2005) Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood Journal of Child Psychology and Psychiatry, 46:8 Keyes, C.L.M. (2002) The mental health continuum: from languishing to flourishing in life. J Health Soc Res 43 : Graham H and Power C (2004) Childhood disadvantage and adult health: a life course framework London: Health Development Agency Melzer D, Fryers T and Jenkins R (eds) (2004) Social inequalities and the distribution of the common mental disorders Hove: Psychology Press Pickett KE and Wilkinson RG (2007) Child wellbeing and income inequality in rich societies: ecological cross sectional study BMJ 335:1080


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