Mental Health and Public Policy

As I've discussed in earlier postings, health promotion applies tools to help individuals change their behavior, as well as applying tools to change communities and social circumstances to support and promote better health.  In recent years I've been persuaded that health policy is much more powerful than I've thought in the past, and probably more powerful, in general, than individual behavior change strategies.  There are lots of examples of the two prongs of health promotion with infectious diseases, chronic diseases, and injuries.  When we turn to mental illnesses, the picture is not so clear.

Mental illness can cause death, and in the case of suicide, about 30,000 in the U.S. per year.  Intentional violence can also be related to mental illness, but the mortality toll is less clear than with suicide.  Aside from those most severe manifestations of mental illness, the greatest concern is disability.  By some estimates, mental illness is the greatest cause of disability in the U.S., and probably also in most developed nations.  Surveys of mental illness estimate that in an average year, 30% of the adult population will have a mental disorder, including phobias, post traumatic stress, general anxiety, depression, and drug dependence.  More than half of cases are serious or moderate severity, though those classifications may be more art than science.  Nevertheless, something like one of every 17 adults will have a"seriously debilitating mental illness in a year's time.

Because of the population impact of mental disorders, they must be considered through the public health lens.  There has been interest in perfecting our ability to measure the nature and extent of mental disorders in communities, and to tease out the personal and social risk factors to guide interventions.  Unfortunately this research has not advanced to the point where there are simple recommendations for progress.  What I mean is, if you want to avoid lung cancer, try not to breath in smoke, particularly from cigarettes.  For most people that's all they need to know. 

For mental health, there are no simple guidelines. Physical and emotional conditions of early life certainly are important - if you have a choice, try to be born into a family with two parents present and emotionally engaged, middle class income, with an extended social network, including relatives, neighbors,  coaches, music instructors, and other supportive adults.  This statement is obvious, but also supported by research.  Our dilemma is how to assure that every child is chosen and every family is successful in its social mission of nurturing children.  We dable with this through public and private programs, but there is such a strong tradition of family independence in our culture that we frown on outside intervention, except in the most egregious cases, so that the safety net has lots of holes through which disadvantaged children fall.

A significant portion of health is socially determined, with correlations between a person's vitality and life expectancy and where they are located in society - physically, socially, and geographically.  Those on the bottom rungs of income, education and status typically will have the worst health, including mental health.  This is a self-feeding cycle, so that disadvantaged persons have the smallest chance of achieving the best health, and because of sickness and disability, are more challenged to move into higher levels of education and income.  Theoretically, this circumstance should be responsive to public policy tools and strategies, but as a society we have not made much progress in this regard.  We don't even agree on whether government has a stake, or whether individuals should be empowered only by market incentives.

Perhaps none of the above thoughts are new to most people.  I think it important to point out that mental health is to some extent a function of broad social policies.  If we believe that society and governments should seek to promote the best mental health possible for citizens, this will not take place unless we put in place policies which assure social conditions in which people can thrive in every way.  This will be a long, uphill climb.