Mental health is a subject that’s long overdue for public health attention. The UK’s chief medical officer, Professor Sally Davies, has given the topic urgency by calling for mental health to be given the same level of esteem as other urgent public health priorities such as obesity.
Writing in The Lancet medical journal recently, Professor Davies drew on her most recent annual report to call for better mental health training for all doctors and greater integration of mental and physical health services. One reason for this is that it recognises the vital links between mental and physical health, and the limitations of trying to address one without the other.
However on other aspects of this topic, Davies has also come to some surprising conclusions, using arguments that do not stand up to scrutiny and are likely to be detrimental to public mental health. This is particularly true on the issue of mental wellbeing as part of public health policy.
Mental wellbeing concerns the positive end of mental health rather than just the absence of mental illness. It is most commonly defined as “feeling good and functioning well”, whereas the diagnosis of mental illness is based on feeling bad and functioning poorly.
In her most recent report, Davies stated: “There is insufficient evidence to justify the framing of public mental health policy and commissioning in terms of wellbeing.”
She argued that that the concept of mental wellbeing is not well-defined, that its measurement is imprecise and that this “crucially compromises the credibility of the evidence base”.
This stands in curious contrast to one of the conclusions of her 2011 report, in which she recommended that: “Public Health needs to encompass not only physical health but also mental health and wellbeing. All current interventions should be reviewed to consider how improving wellbeing can be incorporated.”
Many authorities have defined mental wellbeing and, while their definitions are not all identical, there is a broad measure of agreement. As the topic of wellbeing has only recently emerged into the public domain, there is unsurprisingly still room for reflection and discussion about its definition. This is healthy and appropriate and doesn‘t mean we cannot develop and implement useful programmes in the meantime.
A better understanding of the nature of mental wellbeing will follow rather than precede interest in this area. We are still not clear on the precise definition of the physical activity that is optimum for health, for example, but we are clear that it would be a good idea to encourage more participation in exercise.
There are also many examples of well-validated instruments that do the job of measuring mental wellbeing. There is no need to be able to measure public health issues with great precision before starting preventive programmes. Well enough is often good enough in public health.
If we did need to precisely measure a problem before trying to tackle it, we wouldn’t have begun public health activity on diet, physical activity or alcohol consumption. Research and development on how to measure such issues and define their ideal outcome should be undertaken hand in hand with public health programmes themselves.
New ideas spread gradually, but the concept of mental wellbeing is one that is spreading rather faster than most because it enables people to talk about an aspect of health that people recognise intuitively to be important but is not addressed by health services. Professor Davies’ recommendation is therefore at best surprising and at worst likely to be detrimental to the very subject she is aiming to promote.
Policy makers and practitioners rightly regard the chief medical officer as a figure of authority. If, as a result of her report, they decide to disinvest from services that support mental wellbeing or end discussion about future service development, this would be damaging to public mental health.