Guest Editorial

Keeping promotion and prevention on the agenda in mental health: Issues and challenges

Jennie Parham
Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet), Flinders University, SA

PP: 010 - 014

Keywords

mental health promotion, prevention, policy, implementation, whole of government response, workforce development

Article Text

In the late 1990s, there was recognition and acknowledgement from the Australian Government that there needed to be a much greater focus on prevention of mental disorder and promotion of mental health and wellbeing in mental health policy and service orientation. As a result, a number of actions were taken, including the development of a National Promotion and Prevention Working Party to advise the Australian Health Ministers' Advisory Council (AHMAC), the development of national policy on mental health promotion and illness prevention, and the funding of a range of national initiatives (including Auseinet) to address key promotion and prevention issues.

These developments put Australia on the map internationally. Other countries (eg, England, Scotland, Ireland) have used Australian policy as the benchmark and have adapted Australian programs and models (eg, MindMatters, Mental Health First Aid, Triple P) for their particular use.

However, over the past few years much of that momentum has been lost as the pendulum in mental health has swung back to early intervention and treatment. While acknowledging that the Council of Australian Governments (COAG) mental health reform initiative has injected huge investment into mental health, on close analysis, most of this investment is targeted at 'downstream' activities such as early intervention and treatment.

No one would deny that the mental health service system is in need of greater investment, but there is also an ongoing and important need to invest in more 'upstream' prevention. With a new government at the federal level, there are fresh opportunities to re-position Australia as a world leader in this area. However, to do this some fundamental issues and challenges need to be addressed. Some of these are:

• Recognition that investment in mental health promotion and prevention of mental ill-health is important and necessary for the future of Australia;
• The need for a whole of government approach which engages broader cross-sectoral investment;
• Greater investment in national coordination and leadership to drive change;
• Attention to workforce issues to enable effective implementation on the ground; and
• Increased focus on research to support investment and implementation.

Investing in mental health promotion and prevention of ill-health

There are two main reasons for investing in prevention: reducing the impact of illness, and enhancing quality of life and wellbeing. Generally, the rationale provided for investing in prevention of mental ill-health is about reducing the prevalence and burden of illness and the potential negative outcomes such as suicide. Many of us are fairly familiar with the rhetoric espoused in most international mental health policy documents, which refer to the evidence that the burden of mental health problems and mental disorders is high and rising. 'Five of the ten leading causes of premature death worldwide are psychiatric conditions. Mental disorders represent not only an immense psychological, social and economic burden to society, but also increase the risk of physical illnesses' (WHO, 2004a). Included in this is the recognition that treatment interventions alone cannot significantly reduce the burden of mental disorder and that there is compelling evidence that implementation of promotion, prevention and early intervention approaches will significantly reduce the burden of mental illness and mental disorder.

However, there also needs to be greater attention given to the positive aspects of health and wellbeing as a case for investing in prevention. According to WHO (2004a), 'there is no health without mental health'. Mental health is a positive construct, not merely the absence of illness, and is a positive resource for everyday life. Positive outcomes of health and wellbeing such as productivity and social participation are essential to economic sustainability and active communities. Mental health contributes to the social, human and economic capital of society. There is a growing body of evidence and emerging conceptual frameworks focussing on the positive aspects of health and wellbeing (eg, positive psychology, quality of life research, economics of wellbeing and happiness) which refocus the attention to wellness rather than illness (eg, Hamilton, Eckersley & Denniss, 2005; New Economics Foundation, 2004; Seligman, 2002). A focus on health and wellbeing embraces a social view of health and therefore requires a reorientation from a narrow medical model to a broader perspective focussing on strengths rather than deficits and on the interrelationship between the environment and the individual. It is the positive aspects of health and wellbeing that often engage sectors outside of health more effectively in the promotion and prevention agenda.

I think the case for investing in promotion and prevention is clear. However, the process of translation into action is problematic if investment is dependent on the mental health sector alone. There will always be competition for health funding between prevention and treatment so the answer lies, I believe, in engaging sectors outside of health to contribute in partnership with the health sector.

Whole of government approach

Mental health is regarded as 'everybody's business' as it is determined by multiple biological, psychological, social and environmental factors. Mental health is affected by individual factors and experiences, social interaction, societal structures and resources, and cultural values. It is influenced by experiences in everyday life, in families and schools, in workplaces and communities. Therefore, implementing strategies for enhancing mental health and wellbeing and preventing mental ill-health is not just a health issue; it requires collaboration across multiple sectors and portfolio areas.

The establishment of the National Promotion and Prevention Working Party to develop the National Action Plan for Promotion, Prevention and Early Intervention for Mental Health (Commonwealth Department of Aged Care, 2000) represented a collaboration between public health and mental health. This collaboration resulted in the development of mental health policy that embraced a social view of health, was underpinned by a population health approach and articulated a health promotion framework (Parham, 2007). This was a significant shift in mental health policy which is traditionally underpinned by a medical model. However, with changes to the AHMAC committee structure over the last year, the Working Party no longer exists and an effective mechanism for debate and discussion of the issues has been lost. The future of the promotion and prevention agenda in mental health is reliant on the continuation of that collaboration otherwise there is the risk of reverting to a predominantly medical model.

The responsibility for investment in mental health promotion and prevention needs to expand beyond the mental health sector to include other sectors within health (eg, public health, drug and alcohol, child and youth health) and other sectors outside of health (eg, housing, employment, families, Indigenous affairs). Even though the mental health sector has a major stake in this area, it is not the only sector which has a responsibility. Increasingly, the investment needs to be shared across a range of portfolio areas and therefore, a whole of government approach is required.

Taking a whole of government approach at the state/territory and federal level encourages cross sectoral investment and ownership in enhancing mental health and wellbeing and facilitates more effective policy development that supports mental health and intersectoral collaboration. A good example of this has been in the area of suicide prevention.

Advocating for a whole of government approach is timely with a new government and may provide the impetus to raise the profile of promotion and prevention as a high priority for the future health of all Australians. Auseinet, and hopefully other organisations seeking to advocate for promotion and prevention, will provide a submission to the Prime Minister's 2020 Summit in April this year. Maybe it's an opportune time to advocate for a National Advisory Council on Mental Health and Wellbeing with representation from a range of different sectors to progress the work in this area.

National coordination and leadership

The effective implementation of promotion and prevention approaches is complex as it requires a diverse range of sectors and workforces to work in collaboration. It also involves cooperation between different levels of government and across different government departments. To effectively drive change, a higher level of coordination, leadership and advocacy will be required than has been invested in to date. Auseinet has played a major role in providing leadership and coordination over the past nine years, but the current investment is not sufficient for the scope of the task at hand. The model that Auseinet has developed to drive implementation of promotion and prevention programs has received international attention, with other countries recognising the importance of an organisation dedicated to assisting the implementation process across diverse workforces and sectors. In line with the establishment of a National Advisory Council, it may well be timely to consider a national peak body to provide leadership and advocacy across portfolio areas. Without a higher level of engagement and profile, promotion and prevention has the potential to lose currency.

Workforce issues

Barry and Jenkins (2007) assert that 'the development and sustainability of mental health promotion and prevention is dependent on having a skilled and informed workforce with the necessary competencies. Partnership approaches and the implementation of cross-sectoral strategies call for high levels of expertise in order to engage and facilitate the participation of diverse sectors.' They further categorise the workforce into two levels:

• Dedicated mental health promotion and prevention specialists who facilitate and support the development of policy and good practice across a range of settings; and
• The wider workforce drawn from different sectors such as health, education, employment, community and non-government organisations.

In Australia, there is an expectation that the wider workforce carry out the task of implementing promotion and prevention approaches, as only few jurisdictions have established dedicated mental health promotion officer positions. The wider workforce is expected to undertake this work with minimal supervision and minimal investment in workforce development programs. However, it is becoming increasingly clear that there needs to be investment in the strategic leadership and specialist skills required for translation of policy and evidence into effective and sustainable local implementation. State and territory jurisdictions need to consider the workforce skill mix required for mental health services. Given that promotion and prevention is a priority area, mental health services need to ensure that they have a component of their workforce with appropriate knowledge and skills.

It was of great concern recently when the Draft Standards for Mental Health Services were disseminated for feedback, that there was a notable absence of a standard relating to promotion and prevention. This further highlights the lack of synergy between policy and practice. Current national mental health policy (National Mental Health Plan 2003-2008: Australian Health Ministers, 2003) requires that mental health services embrace promotion and prevention activities as well as treat illness. This calls for a mental health service system which contributes to the enhancement of mental health and wellbeing as well as the treatment of illness.

Workforce development programs also need to be available for the wider workforce to assist them in understanding their role and to develop the appropriate level of skills to undertake it. A range of workforce development programs need to be developed and implemented to address these diverse needs. These programs can build on the work currently being undertaken by VicHealth, Auseinet and other organisations.

Increased focus on research

Ongoing investment in research and evaluation is essential to support the implementation of evidence-based interventions and policy development. Increasingly, there is a growing body of evidence that effective prevention can reduce the risk of mental disorders (WHO, 2004a, 2004b). There is a wide range of evidence-based programs that have been found to reduce risk factors, strengthen protective factors and minimise the onset of some mental disorders. They also improve positive mental health, contribute to better physical health and generate social and economic benefits. These multi-outcome interventions illustrate that prevention can be cost effective. Examples include comprehensive parenting programs, school based interventions, community interventions, and mental health literacy.

Despite the growing evidence base, there are still significant gaps and areas to be strengthened. There is a need for more evidence on the 'upstream policy interventions' and on the economic benefits of promotion and prevention strategies. Economic data on the cost effectiveness of interventions, particularly in relation to reduced hospital and treatment costs as well as indirect costs such as disability and family burden, are beginning to emerge. The economic evaluation is particularly helpful in informing resource allocation and convincing funders of the long term benefits. Another important area of research that needs strengthening is health impact assessment. There are well developed indicators for mental illness, but indicators for positive mental health that can be measured need further development. Similarly, there has been significant investment in the development of health impact assessment tools, but this does not necessarily include the impact on mental health. NIMHE (NorthWest) in the UK has developed a Mental Health and Wellbeing Impact Assessment Tool (Coggins, Cooke, Friedli et al., 2007), which they are currently trialling in the UK (and which can be downloaded from their website at www.northwest.csip.org.uk/mwia).

One of the challenges in this area is the research paradigm and how it determines what constitutes 'evidence' and the associated methodologies. Aligned with this is the longitudinal nature of most prevention research, where the outcomes are not realised immediately. Given that the field is made up of diverse stakeholders with varying needs, each of the stakeholders will view the evidence from a different perspective. This multiplicity and diversity of need with respect to evidence and its use provides the impetus for bringing together researchers, policymakers and practitioners to create some innovation and to set an agenda for investing in research that will underpin both policy and practice in the future.

Summary

In summary, the political and economic climate in Australia is conducive to repositioning mental health promotion and illness prevention on the federal government's agenda. The halcyon days of the early 2000s witnessed the development of cutting edge policy, world leading initiatives bringing together different sectors (eg, health and education, health and media) and a vision for the future which embraced a social view of health. It's time to reflect on the activities and investments of the past eight years, together with new and emerging conceptual frameworks and evidence, and move forward with renewed vision. If Australia is to enhance the mental health and wellbeing of Australians, promotion and prevention must become a higher priority on both the federal and state/territory government agendas. In addition, strong intersectoral partnerships, which lead to greater investment in funding, workforce development and research, need to be established.

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