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Promoting wellbeing: A practical way to improve public mental health

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Contents

03 Introduction

03 1. Scale of the problem

• Millionsaffected

• Earlyonset

• Significantimpact

• Highcosts

06 2. Who is most at risk?

08 3. Why focus on wellbeing?

• Whatiswellbeing?

• Feelinggood

• Functioningeffectively

• Whyfocusonwellbeing?

• Preventspoormentalhealth

• Reducesburdenofdisease

• Improvesphysicalhealth

12 Conclusion

ThisdocumentwascreatedbyShift(formerlyknownasWeAreWhatWeDo)aspartoftheresearchphaseofaproduct/servicedevelopmentprocessaimedatimprovingwellbeingamongstyoungpeopleintheUK,commissionedbyTheNominetTrust.

ItwaswrittenbyKathleenCollett.

Formoreinformationseeshiftdesign.org.uk

Contact

KathleenCollettkathleen.collett@shiftdesign.org.uk@shift_org

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IntroductionMentalhealthisapublichealthissuewithcomplexcausesandseriousconsequences.Thispapergivesabriefoverviewofthescaleoftheimpactofpoormentalhealthonindividualsandsociety.Itgoesontoexploresomeofthefactorsthatputsomeindividualsatmoreriskofdevelopingmentalhealthproblemsthanothers,andexplainwhychildhoodandadolescenceareparticularlyimportanttimes

formentalhealthpromotion.Itlooksatwhatconstituteswellbeing,andtheevidenceforbelievingthatpromotingpositivewellbeingatthepopulationlevelcanreducetheincidenceofpoormentalhealth,andwellasincreasingthenumberofindividualswhoexperiencehighlevelsofwellbeing.Finally,itlooksatexistingproductsandservicesthataimtopromotewellbeing.

1. Scale of the problemMentalhealthproblemsrepresentthelargestsinglesourceofburdenofdiseaseintheUK.1Thismeansthatmentalhealthproblemsaccountformoreyearsofhealthylifelostthananyothersinglesourceofillness.2Forexample,in2004mentalhealthdisorders(includingself-inflictedinjury)accountedfor22.8%ofthetotalburdenofdisease,significantlymorethaneithercardiovasculardisease(16.2%)orcancer(15.9%).3

Millions affectedPartofthereasonthatmentalhealthdisordersaresuchamajorsourceofburdenofdiseaseintheUKisthatahighproportionofthepopulationisaffectedbypoormentalhealth.TheMentalHealthFoundationestimatesthateveryyeararound1in4peopleinBritainwillexperiencesomeformofmentalhealthproblem.4

Ofthosewhoexperiencementalhealthproblems,onlyaminorityhavepsychoticsymptomswhichinterferewithaperson’sperceptionofreality.TheRoyalCollegeofPsychiatristsreportsthatin2009,only0.4%ofthepopulationhadpsychosisandafurther5%hadsymptomsthatwereclinicallysignificantbutbelowthethresholdforthediagnosisofpsychosis(sub-thresholdpsychosis).5

Themajorityofthosewhoexperiencementalhealthproblemshave“neurotic” symptoms,whichareregarded

asextremeformsofnaturalemotionalexperiencessuchasdepression,anxietyorpanic.These“neurotic” symptomsarenowfrequentlycalled“common mental disorders”(CMDs).6

ThemostrecentAdultPsychiatricMorbiditySurvey,alargehouseholdsurveywhichprovidesdataonbothtreatedanduntreatedmentalhealthdisorders,suggestedthataround17.5%oftheUKpopulationsuffersfromcommonmentaldisordersatanyonetime,andthatasimilarproportionhave“symptoms which do not fulfil the full diagnostic criteria for common mental health disorder”.7GeneralisedAnxietyDisorder(GAD),depressivedisordersandmixedanxietyanddepressionarethemostprevalentcommonmentaldisorders,affecting5.8mpeopleinEnglandoutofatotalof6.1mpeoplesufferingfromcommonmentaldisorders.8

Thesefiguresarelikelytounderstatethenumberofpeopleexperiencingcommonmentaldisorders.TheNationalInstituteforHealthandClinicalExcellence(NICE)pointsoutthatdepressionandparticularlyanxietyoftengoundiagnosed.Under-recognitionisaparticularproblemforanxietydisorders,andNICEestimatesthatonlyasmallminorityofthosewhohaveanxietydisorderseverreceivetreatment.Thisispartlyduetounder-diagnosisbyGPs,butmayalsobedrivenbypatients’reluctancetoseekhelp,duetoconcernaboutstigma.9

1RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.2BurdenofdiseaseismeasuredinDisabilityAdjustedLifeYears(DALYs).AccordingtotheWorldHealthOrganisation:”OneDALYcanbethoughtofasonelostyearof”healthy”life.ThesumoftheseDALYsacrossthepopulation,ortheburdenofdisease,canbethoughtofasameasurementofthegapbetweencurrenthealthstatusandanidealhealthsituationwheretheentirepopulationlivestoanadvancedage,freeofdiseaseanddisability”3RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.4MentalHealthFoundation(2007)TheFundamentalFacts:Thelatestfactsandfiguresonmentalhealth.London:MentalHealthFoundation.5RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.6MentalHealthFoundation(2007)TheFundamentalFacts:Thelatestfactsandfiguresonmentalhealth.London:MentalHealthFoundation.7McManus,S.,Meltzer,H,Brugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.8Owncalculationsbasedonhttp://bit.ly/19oY8Ib9NICE(2011)Commonmentalhealthdisorders:Identificationandpathwaystocare,NICEclinicalguideline123.Manchester:NICE

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MentalIllnessinEngland(fromRoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth)

• 10%ofchildrenandyoungpeoplehaveaclinicallyrecognisedmentaldisorder:of5-to16-year-olds,6%haveconductdisorder,18%subthresholdconductdisorderand4%anemotionaldisorder

• 17.6%ofadultsinEnglandhaveatleastonecommonmentaldisorderandasimilarproportionhassymptomswhichdonotfulfilfulldiagnosticcriteriaforcommonmentaldisorder

• postnataldepressionaffects13%ofwomenfollowingchildbirth

• inthepastyear0.4%ofthepopulationhadpsychosisandafurther5%subthresholdpsychosis

• 5.4%ofmenand3.4%ofwomenhaveapersonalitydisorder;0.3%ofadultshaveantisocialpersonalitydisorder

• 24%ofadultshavehazardouspatternsofdrinking,6%havealcoholdependence,3%ilegaldrugsdependenceand21%tobaccodependence

• 25%ofolderpeoplehavedepressivesymptomswhichrequireintervention:11%haveminordepressionand2%majordepression;theriskofdepressionincreaseswithage-40%ofthoseover85areaffected

• 20-25%ofpeoplewithdementiahavemajordepressionwhereas20-30%haveminororsubthresholddepression

• dementiaaffects5%ofpeopleagedover65and20%ofthoseagedover80

• incarehomes,40%ofresidentshavedepressio,50–80%demetiaand30%anxiety

• athirdofpeoplewhocareforanolderpersonwithdementiahavedepression

Source:RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.

Early OnsetAnotherfactorthatexplainswhymentalhealthissuchasignificantcontributortotheoverallburdenofdiseaseintheUKisthat,incomparisonwithdiseasessuchacardiovasculardiseaseandcancer,mentalhealthproblemsaffectpeoplewhentheyarerelativelyyoung.1in10youngpeopleaged5–16inGreatBritainhadaclinicallydiagnosedmentaldisorderaccordingtoamajornationalstudyofthementalhealthofchildrenandyoungpeoplein2004.10Further,studiesbyKim-CohenetalandKessleretalfindthathalfofallcasesofmentalhealthdisorderstartbyage14yearsandthreequartersbyage24years.11,12

Thementalhealthproblemsyoungpeopleexperienceoftenpersistintoadulthoodinarelatedform.Forexample,youngpeoplewhoexperiencedepressioninmid-adolescence(14-16yearsold)aremorelikelytoexperiencemajordepressionandanxietydisordersasadults,evenonceconfoundingsocial,familialandindividualfactorsaretakenintoaccount.13Similarly,youngpeoplewithjuvenileanxietydisordersareat

ahigherriskofanxietydisordersandmajordepressioninlaterlife.Again,thislinkpersistsevenonceothercontributingsocial,familialandindividualcharacteristicsaretakenintoaccount.14

Mentalhealthproblemsinearlylifealsoprecedethedevelopmentofdifferenttypesofmentalhealthproblemsinlaterlife.Forexample,conductdisorderandoppositionaldefiantdisorders,characterisedby“a pattern of repeated and persistent misbehaviour”,precedeawidevarietyofadultmentalhealthdisorders.AccordingtoRichardsonandJoughin“approximately 40-50% of children with conduct disorder go on to develop antisocial personality disorder as adults”butconductdisorderisalsolinkedtoothernegativeoutcomessuchassubstancemisuse,mania,schizophrenia,obsessive-compulsivedisorder,majordepressivedisorderandpanicdisorderinlaterlife.15

Theearlyonsetofmentalhealthproblemsmeansthatthoseaffectedoftenexperiencementalhealthissuesthroughoutlargeportionsoftheirlives,includingcrucialyearsforsocialandcareerdevelopment.

10Green,H.,McGinnity,Á.,Meltzer,H.,Ford,T&Goodman,R.(2004)MentalhealthofchildrenandyoungpeopleinGreatBritain,2004:AsurveycarriedoutbytheOfficeforNationalStatisticsonbehalfoftheDepartmentofHealthandtheScottishExecutive.London:ONS.11Kim-CohenJ,CaspiA,MoffittTE,HarringtonH,MilneBJ,PoultonR.(2003)Priorjuvenilediagnosesinadultswithmentaldisorder:developmentalfollow-backofaprospective-longitudinalcohort.ArchivesofGeneralPsychiatry60(7):709-17.12Kessler,R.,Berglund,P.,Demler,O.,Jin,R.,Merikangas,K.&Walters,E.(2005)Lifetimeprevalenceandage-of-onsetdistributionsofDSM-IVdisordersintheNationalComorbiditySurveyReplicationArchivesofGeneralPsychiatry62(6):593-602.13FergussonDM,WoodwardLJ.(2002)Mentalhealth,educational,andsocialroleoutcomesofadolescentswithdepression.ArchivesofGeneralPsychiatry59(3):225-31.14FergussonDM,WoodwardLJ.(2002)Mentalhealth,educational,andsocialroleoutcomesofadolescentswithdepression.ArchivesofGeneralPsychiatry59(3):225-31.15Richardson,J&Joughin,C.(2002)ParentTrainingProgrammesfortheManagementofYoungChildrenwithConductDisorders:FindingsfromResearch.London:RoyalCollegeofPsychiatrists.

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Significant impactThefinalreasonwhymentalhealthcontributessomuchtotheoverallburdenofdiseaseisthatithassuchasignificantimpactonthelivesofthosewhoitaffects.Theextentoftheimpactofmentalhealthproblemsisoftennotfullyrecognisedasconnectionsbetweenmentalhealthandotheraspectsofhealthandwellbeingarenotalwaysapparentandaremosteasilyseenatthepopulationlevelratherthanattheindividuallevel.

Theimpactofpoormentalhealthbeginsearly.Childrenandyoungpeoplewhoexperiencementalhealthproblemsaremorelikelytohavepooreducationalachievement,withnegativeconsequencesforcareerdevelopmentandearnings.Theyarealsoatagreaterriskofsuicideandsubstancemisuse,anti-socialbehaviour,offendingandearlypregnancy.Poormentalhealthinchildhoodandadolescenceisalsoassociatedwithpoorhealthandsocialoutcomesinadulthood.16

Overthelifecourse,peoplewhoexperiencementalillnessexperiencemorephysicalillness,andhavealowerlifeexpectancy.17Depressioninparticularisstronglycorrelatedwithcardiovasculardiseaseandcancer:mortalityfromcardiovasculardiseaseis67%higherinthosewhoaredepressed,andmortalityfromcanceris50%higher.18AlargecohortstudyinNorwayshowedthatdepressionsignificantlyincreasedmortalityfrombothcardiovasculardiseaseandalsoallothercauses,evenaftertakingintoaccounthealth-relatedbehaviours(smoking,alcoholuse,andphysicalactivity),physicalsymptomsandimpairments,educationandsocioeconomicstatus,andphysicalmeasurementssuchasbodymassindex,bloodpressureandcholesterol.19

Individualswhoexperiencementalhealthproblemsaremorelikelytoself-harm,andareatahigherriskofsuicide.Suicideisthethirdlargestcontributortoprematuremortality(afterheartdiseaseandcancer)inBritain.20TheRoyalCollegeofPsychiatristsreportsthat“in some studies, the rate of a diagnosed mental illness of those who have killed themselves has been found to be more than 80%”,andtherateofsuicideamongstthosewithseverementalillnessis12timeshigherthaninthegeneralpopulation.21Self-harmbehaviourisalsomorecommonamongstthosewithamentaldisorder.22Self-harmandsuicidearestatisticallylinked:recentstudiessuggestthatthosewhoself-harmareatan

approximately30-foldgreaterriskofsuicide,comparedwiththegeneralpopulation.23

Mentalhealthproblemsareassociatedwithlowerlevelsofself-carebehaviour,andhigherlevelsofriskyhealthbehaviours.AlmosthalfofalltobaccointheUKisconsumedbythosewhohaveamentalhealthdiagnosis.24Smokingsignificantlyincreasestheriskofmanyseriousdiseases,andreduceslifeexpectancy.Mentalillness,particularlymajordepression,increasestheriskofobesity.25Depressionmayalsoaffectthewaythatindividualsseekhelpforhealthproblems,withtheconsequencethatphysicalillnessesarediagnosedatamoreadvancedstagethantheymightotherwisehavebeen,anditmayreduceadherencetotreatmentplans,negativelyaffectingtheirhealthoutcomes.26

Poormentalhealthisalsoassociatedwithalcoholmisuse.Ratesofalcoholmisusearemuchhigheramongstthosewithpoormentalhealth.Youngpeoplewithanemotionalorconductdisorderare2-4timesmorelikelytodrinkregularly(morethantwiceaweek).27Alcoholconsumptionmayalsocontributeorworsenmentalhealthproblems:highlevelsofalcoholconsumptionare“associated with higher levels of depressive and affective problems, schizophrenia and personality disorders.”28

Theeffectsofmentalillnessspilloutfarbeyondtheindividualaffected.Peoplewithmentaldisordersaremorelikelytobevictimsofcrimeandviolencethanperpetrators.29Atthesametime,mentalillnessisanimportantfactorintheproblemofcrimeatthepopulationlevel.TheSainsburysCentreforMentalHealthestimatesthat“around 80% of all criminal activity is attributable to people who had conduct problems in childhood and adolescence, including about 30% specifically associated with conduct disorder.”30Theriskofviolentbehaviourissignificantlyincreasedonlyforthosewhomisusealcoholanddrugs.31

Mentalhealthalsohasalargeimpactonworkandproductivity.Whileemploymentcanprovideagrouptobelongto,anincomeandasenseofpurpose,workcanalsobestressfulandinsecure.Around11.4millionworkingdaysarelostannuallyinBritainduetowork-relatedstress,anxietyordepression.32

Forthosewithmentalhealthproblems,itismoredifficulttofindandremaininproductiveemployment,andmentalillnessisconsequentlyassociatedwith

16RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.17RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.18RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.19Mykletun,A.,Bjerkeset,O.,Dewey,M.,Prince,M.,Overland,S.&Stewart,R.(2007)Anxiety,Depression,andCause-SpecificMortality:TheHUNTStudyPsychosomaticMedicine69:323–331.20RoyalCollegeofPsychiatrists(201)Self-harm,suicideandrisk:helpingpeoplewhoself-harm.CollegeReportCR158.London:RoyalCollegeofPsychiatrists.21RoyalCollegeofPsychiatrists(201)Self-harm,suicideandrisk:helpingpeoplewhoself-harm.CollegeReportCR158.London:RoyalCollegeofPsychiatrists.22RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.23RoyalCollegeofPsychiatrists(201)Self-harm,suicideandrisk:helpingpeoplewhoself-harm.CollegeReportCR158.London:RoyalCollegeofPsychiatrists.24RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.25RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.26Mykletun,A.,Bjerkeset,O.,Dewey,M.,Prince,M.,Overland,S.&Stewart,R.(2007)Anxiety,Depression,andCause-SpecificMortality:TheHUNTStudyPsychosomaticMedicine69:323–331.27RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.28RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.29RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists30SainsburyCentreforMentalHealth(2009)Thechanceofalifetime:Preventingearlyconductproblemsandreducingcrime.London:SainsburyCentreforMentalHealth.31RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.32RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.

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anincreasedlikelihoodofunemployment.Only20%ofthoseusingspecialistmentalhealthservicesareinpaidworkorfull-timeeducation.33Thesocialexclusionandfinancialchallengesexperiencedbymanyofthosewhoareunemployedcaninturncontributetopoormentalhealth,leadingtoaviciouscycle.

Despitenationalcampaignstoraiseawarenessoftheimportanceofmentalhealthandreducethestigmaattachedtomentalhealthdiagnoses,discriminationstillcompoundstheimpactofmentalhealthproblemsformanyindividuals.TheRoyalSocietyofPsychiatristsalsopointsoutthatpeoplewithmentalhealthproblemsexperienceexclusionalongavarietyofdimensions(economic,social,politicalexclusionandalsoserviceexclusion),compoundinginequality,whichisitselfariskfactorforpoormentalhealth.

High costsBecausementalhealthproblemsstartsoearly,andbecausetheyhavesuchsignificantandwide-rangingconsequencesfortheindividualsdirectlyaffectedandthoseconnectedwiththem,theeconomicburdenofpoormentalhealthisverylargeindeed.TheRoyalCollegeofPsychiatristsestimatesthatthewidercostsofmentalillnessinEnglandare£105.2

bnayear.In2007,thedirectcostsofmentalhealthtoNHSwere£10.4bn,andtheCentreforMentalHealthestimatedthatthecombinedcostsofhealthandsocialcare,includingNHSandlocalauthorityservicesforpeoplewithmentalhealthproblems,wereapproximately£21.3bnin2009/2010.34

Thereisaparticularlystrongeconomiccaseofearlyintervention.Theeconomicevaluationofcoststosocietyofmentalillnessinchildrenandadolescentshasproducedestimatesrangingfrom£11,030to£59,130perchildperyear.35TheNationalCAMHSSupportServicepointstostudiesthatshowthatpublicservicescouldsave£100meveryyearbydeliveringearlyinterventionservicestojust1in10oftheyoungpeoplereceivingprisonsentences,andthat£50mperyearcouldbesavedbyprovidingearlyinterventionservicesforpatientswithpsychosis.36

Itisclearthatmentalhealthisamajorpublichealthissue,anditsdevelopmentisheavilyinfluencedbyearlyexperiencesandshapedbyriskfactorsinearlylife.Whatcanbedonetopreventthedevelopmentofpoormentalhealth?Understandingwhatthetypicalriskfactorsareforthedevelopmentofpoormentalhealthisvital,asisidentifyingprotectivefactorsthatcouldhelppreventthedevelopmentofpoormentalhealth.

2. Who is most at risk?Mentalhealthisamajorpublichealthproblem,whichiswidelyprevalent,startsearlyandhasamajorimpactonqualityoflife.Manyoftheconsequencesofpoormentalhealthinfactreinforcepoormentalhealthinaviciouscycle.Butwhatarethefactorsthatpredisposepeopletomentalhealthdisorders?

Certaingroupsofindividualsareathigherriskofdevelopingmentalhealthproblems.Overall,intheUKwomenaremorelikelytohaveacommonmentalhealthdisorderthanmen.A2007UKhouseholdsurveyfoundthatnearly1in5womenhadacommonmentaldisordercomparedwithonly1in8men.37

Thesamestudyfoundthatratesofcommonmentaldisordervariedbyage.Theoldestgroupinthesurvey(thoseaged75andover)hadthelowestincidenceofcommonmentaldisorderwithonly6.3%ofmenand12.2%ofwomenexperiencingdisorders.Womenbetween45and54yearsoldhadthehighestrate:overaquarter(25.2%)ofthisgroupmetthecriteriaforatleastoneCMD.Formen,therateofCMDspeakedbetween25and54yearsold(14.6%of25–34yearolds,15.0%of35–44yearolds,14.5%of45–54yearolds).38

Thoselivinginhouseholdswithlowerlevelsofincomearemorelikelytoexperiencecommonmentaldisordersthanthoseinhouseholdswithhigherlevelsofincome.MacManusetal(2009)foundthat23.5%ofmeninthelowesthouseholdincomegrouphadaCMD,comparedtoonly8.8%ofthoseinthehighestincomehouseholds,afteradjustingforage.39

ThesestatisticssummarisetheincidenceofCMDsfordifferentgroupsoftheadultpopulation.Alongsideage,genderandincome,therearealsoalargenumberofotherriskfactorswhichcontributetothedevelopmentofpoormentalhealth.Because75%ofmentalhealthdisordersstartinchildhoodorearlyadulthood,riskfactorsforthedevelopmentofpoormentalhealthearlyinlifeareparticularlyrelevanttounderstandingthefactorsthatputindividualsatgreaterrisk.

Riskfactorsinthedevelopmentofmentaldisordersamongyoungpeoplecanbeidentifiedattheindividuallevel,familylevel,schoollevelandatthelevelofcommunityandculture.Someriskfactorsalsorelatetospecificlifeevents,suchastraumaorloss.40,41Thefactorsexploredbelowareoverallriskfactorsforthedevelopmentofmentalillnessingeneral–riskfactorsforparticularillnesseswillbedifferent.

33RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.34CentreforMentalHealth(2010)Theeconomicandsocialcostsofmentalhealthproblemsin2009/10London:CentreforMentalHealth.35RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.36NationalCAMHSSupportService(2011)Bettermentalhealthoutcomesforchildrenandyoungpeople:aresourcedirectoryforcommissioners.London:NationalCAMHSSupportService(NCSS)37McManus,S.,Meltzer,HmBrugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.38McManus,S.,Meltzer,HmBrugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.39McManus,S.,Meltzer,HmBrugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.40Kutz,Z.(2009)TheEvidenceBasetoGuideDevelopmentofTier4CAMHS.London:DepartmentofHealth41RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.

Community and culture

socio-economicdisadvantage

socialorculturaldiscrimination

isolation neighbourhoodviolenceorcrime

deviantpeergroup highpopulationdensityandpoor

housingconditions

lackofsupportservices,includingtransport,shoppingandrecreational

facilities

Life events and situations

physical,sexualoremotionalabuse

changingschoolsfrequently

unemployment

divorceandfamilybreak-up

deathoffamilymember

homelessness

physicalillnessordisability

incarceration

povertyoreconomicinsecurity

jobinsecurity

unsatisfactoryworkplace

relationships

workplaceaccidentorinjury

caringforsomeonewithanillnessor

disability

livinginanursinghome

warornaturaldisasters

School

bullying peerrejection poorattachmenttoschool

inadequatebehaviour

management deviantpeergroup

failureatschool

Family

havingateenagemotherorasingleparent

absenceoffatherinchildhood

largefamily

antisocialrolemodelsinchildhood

familyviolenceordisharmony

maritaldiscordinparents

poorsupervisionormonitoring

neglectinchildhood

lowparentalinvolvementinchild’sactivities

long-termparental

unemployment

criminalityinparent

parentalsubstancemisuse

parentalmentaldisorder

harshorinconsistent

disciplinestyle

socialisolation

experiencesofrejection

lackofwarmthandaffection

Individual

prenatalbraindamage

prematurebirth

birthinjury

lowbirthweight,birth

complications

physicalorintellectualdisability

poorhealthininfancy

insecureattachmentininfantorchild

lowintelligence

difficulttemperament

chronicillness

poorsocialskills

lowself-esteem

alienation

impulsivity

Figure 1: Risk factors for developing mental illness

Basedon:ChildrenandMentalHealthKnowledgeExchange(2007)Bestpracticesguidelinesformentalhealthpromotionprograms

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Thefollowinggroupsareathigherriskthantheirpeersformentalhealthproblems:

Becauseexperiencesinchildhoodand

adolescenceplaysuchakeyroleinthedevelopmentofanindividual’smentalhealth,thisisakeypointforintervention.

Table 1: Impact of risk factors on prevalence of any mental disorder

Risk Factor Expected prevalence of mental disorder

Lookedafterchildren 45%

ChildrenwithSpecialEducationalNeedsrequiringstatutoryassessment

44%

Childwithlearningdisability 22%

Householdswithnoworkingparent 20%

Childabsentfromschoolmorethan11daysinayear 19%

Parentalmentalillness 18%

5ormorechildreninhousehold 18%

Loneparentfamilies 16%

Childrenlivinginlessprosperous/mixedareas 16%

Parentswithnoeducationalqualifications 15%

3. Why focus on wellbeing?Untilrelativelyrecently,thedefactoapproachtoaddressingmentalhealthhasbeenacombinationoftreatmentforthosewhoareexperiencingmentalhealthproblemsandinitiativesaddressingriskfactorsformentalhealthtargetedatgroupsathighriskofdevelopingmentalhealthproblems.Recently,however,therehasbeenrecognitionthatthisapproachhasnotbeensufficienttoreduce“the prevalence, burden, or early onset of mental disorder”.42

Toaddressthepublichealthissuethatmentalhealthposes,majorpublichealthbodiesandpsychologicalandpsychiatricassociationsincreasinglybelievethatthefocusshouldbeondevelopingandprotectingpositivementalhealthormentalwellbeing,asawayofpreventingmentalhealthproblems.Mentalhealthpromotionisnowseenasanessentialpartofpublicmentalhealth,inadditiontoinitiativesthatreduceriskfactorsformentalhealthproblems,andtheprovisionoftreatment.

What is wellbeing?Goodmentalhealthormentalwellbeingismorethantheabsenceofmentalillness.TheWorldHealthOrganisationdefinespositivementalhealthas:“a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community… Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”43Wellbeingisnowwidelyunderstoodashavingtwokeydimensions.

Feeling goodOnedimensionofwellbeingrelatestoindividual’ssubjectiveexperience.FeliciaHuppertattheWell-beingInstituteatCambridgesimplydescribesthisas“feeling good”.Othershavecalleditsubjective

wellbeingorhedonicwellbeing.AccordingtoDiener,Suh,LucasandSmith,subjectivewell-beinghasthreeinterrelatedcomponents:“life satisfaction (an overall cognitive sense of satisfaction with one’s life), pleasant affect (enjoyable moods and emotions), and unpleasant affect.”45

Functioning effectivelyAnotheraspectofwellbeingreferstohoweffectivelyanindividualisabletofunction.Thisisoftencalledpsychologicalwellbeingoreudaimonicwellbeing.AninfluentialmodeldevelopedbyRyff(2006)suggeststhatpsychologicalwellbeingisconstitutedbyself-acceptance,positiverelationswithothers,autonomy,environmentalmastery,purposeinlifeandpersonalgrowth.Huppertdescribestheseaspectsas”developing one’s potential, having some control

42Keyes,C.,Dhingra,S.,Simoes,E.(2010)ChangeinLevelofPositiveMentalHealthasaPredictorofFutureRiskofMentalIllness.AmericanJournalofPublicHealth,100(12)43WorldHealthOrganisation(2013)Mentalhealth:astateofwell-being.Downloadedfrom<http://www.who.int/features/factfiles/mental_health/en/>44Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.45Diener,E.,Suh,E.,Lucas,R.&Smith,H.(1999)SubjectiveWell-being:Threedecadesofprogress.PsychologicalBulletin,Vol125(2),Mar1999,276-302.46Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.

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over one’s life, having a sense of purpose, including working towards valued goals, and experiencing positive relationships.”46

Huppertpointsoutthat“sustainable well-being does not require individuals to feel good all the time: the experience of painful emotions is a normal part of life, and being able to manage these negative or painful emotions is essential for long-term well-being. Psychological well-being is, however, compromised when negative emotions are extreme or very long-lasting and interfere with a person’s ability to function in his or her daily life.”47

Wellbeingisdistinctfromtheabsenceofmentalhealthproblems.Thereisnowasignificantamountofevidencethatwhilesomeofthefactorsthatcontributetomentalillnessandmentalwellbeingarethesame,othersarenot.48Keyes,forexample,suggeststhatthefindingsfrommanystudieswhichexaminetherelationshipbetweenwellbeingandmentalillnesssupporttheideathattherearetwocontinuumsrelevanttomentalhealth:“one indicating the presence or absence of mental health, the other indicating the presence or absence of mental illness symptoms.”49Keyesarguesthatthetwoshouldbeunderstoodasseparateaspectsofmentalhealth.

Mentalwellbeingisoftenrepresentedonacontinuumfromflourishingtolanguishing.Theconceptofflourishingisoftenusedtodescribethewhatmentalhealthdevelopmentshouldaimat.FredricksonandLosadadescribeflourishingasliving“within an optimal range of human functioning, one that connotes goodness, generativity, growth, and resilience.”50Theterm“languishing”isusedtodescribetheotherendofthecontinuum,whereindividualsexperienceunhappinessandstagnationbutnotnecessarilymentalillness.

Althoughmentalwellbeingtendstoimproveasmentalillnesssymptomsdecrease,thisisnotalwaysthecase.51Bolier,HavermanandBohlmeijerexplainthat“people can be free of mental illness and at the same time be unhappy and exhibit a high level of dysfunction in daily life … . Likewise, people with mental disorders, can be happy by coping well with their illness and enjoy a satisfactory quality of life”.52Thisperspectivehasbeenadoptedatthepolicylevelinseveralcountries.Forexample,theScottishGovernmentsuggestthat“someone can experience signs and symptoms of mental illness and still have good or flourishing mental well being … just as people with a physical illness or condition can live positively, flourish and have a good sense of wellbeing”.53

Why focus on wellbeing?

Prevents poor mental health Variousstudiessuggestthatgoodmentalwellbeingcanactasabufferforpoormentalhealth.Psychologistswhofocusontheprotectiveeffectofwellbeingonmentalhealtharguethatknocks,stressors,traumasandlossesareinevitableinlifeandcanhaveahugeimpactonaperson’sstateofmentalwellbeing,particularlyinrelationtoCMDssuchasanxietyanddepression.Acoreaimofmentalhealthpromotionistohelppeopletobuildthecognitiveandemotionalresourcesthattheyneedinorderto“cope”notonlyintimesofcalmbutalsointimesoftrouble,inorderthattheriskoftriggeringaCMDisreduced.

MartinSeligman,anearlyproponentoftheideathatpsychologyshouldfocusonunderstandingandpromotingfullhumanflourishingaswellasaddressingdysfunction,arguedthat“nurturing human strengths such as optimism, courage, future mindedness, honesty and perseverance serve as more efficacious buffers against mental illness as compared to medication or therapy”.54

Theviewthatgoodmentalhealthprotectsagainstmentalillnesshasfoundempiricalsupportinseveralstudies.

Forexample,thereisevidencethatwellbeingprotects

againstthenegativeeffectsofstressonmentalhealth.Grant,GuilleandSen(2013)assessedthewellbeinglevelsof1621medicalinternsdirectlybeforetheystartedtheirinternships,anexperiencerecognisedtobestressfulandatimeduringwhichdepressivesymptomsareknowntoincreasesignificantly.Thoseinternswhohadhigherlevelsofwellbeingatthestartoftheirinternshipsshowedasmallerincreaseindepressivesymptomsoverthe3monthsofthestudy.55

Thereisalsoevidencethatmaintaininggoodlevelsofwellbeingisassociatedwithalowerlikelihoodofdevelopingamentalillness.Keyesetal,inalarge10yearfollow-upstudy,foundthatindividualsthatwerelanguishingatboththebeginningandtheendofthe10yearperiodweremorethan6timesaslikelytohaveamentalillnessattheendoftheperiodcomparedtothosewhohadstayedflourishingatbothpoints.Theyalsofoundthatgainsinmentalhealthdecreasedthelikelihoodofexperiencingamentalillnesswhilelossesinmentalhealthincreasedit.Inall,theirstudyprovidessupportforthehypothesisthatpromotingandprotectinggoodmentalhealthcanprotectagainstthedevelopmentofmentalillness.56

Reduces the burden of diseaseSmallimprovementsinwellbeingcouldsignificantlyreducetheincidenceofmentalhealthdisordersinthepopulation.

47Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.48Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.49Keyes,C.,Dhingra,S.,Simoes,E.(2010)ChangeinLevelofPositiveMentalHealthasaPredictorofFutureRiskofMentalIllness.AmericanJournalofPublicHealth,100(12)50Fredrickson,B.&Losada,M.(2005)PositiveAffectandtheComplexDynamicsofHumanFlourishing.TheAmericanPsychologist60(7):678-686.51Keyes,C.(2002)TheMentalHealthContinuum:FromLanguishingtoFlourishinginLife.JournalofHealthandSocialBehavior,43(2):207-222.52Bolier,L.,Haverman,M.,Westerhof,G.,Riper,H.,Smit,F.,Bohlmeijer,E.(2013).Positivepsychologyinterventions:ameta-analysisofrandomizedcontrolledstudies.BMCPublicHealth,13:119.53TheScottishGovernment(2007)TowardsaMentallyFlourishingScotland:TheFutureofMentalHealthImprovementinScotland2008-11.Downloadedfrom:<http://www.scotland.gov.uk/Publications/2007/10/26112853/1>54Terjesen,M.,Jacofsky,M.,Froh,J.&DiGiuseppe,R.(2004)Integratingpositivepsychologyintoschools:Implicationsforpractice.PsychologyintheSchools,Vol.41(1),200455Grant,F.,Guille,C.&Sen,S.(2013)Well-BeingandtheRiskofDepressionunderStress.PLoSOne.8(7):e67395.56Keyes,C.,Dhingra,S.,Simoes,E.(2010)ChangeinLevelofPositiveMentalHealthasaPredictorofFutureRiskofMentalIllness.AmericanJournalofPublicHealth,100(12)

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Keyes(2002)suggeststhatalthoughmentalillnessandmentalwellbeingaredistinct,thereareenoughcommonunderlyingfactorstojustifyrepresentingmentalhealthasbeingonacontinuumwhichmovesfromafullmentalhealthdisordertoflourishingatthepopulationlevel.57ThestagesofKeyes’continuumareflourishing,moderatelymentallyhealthy,languishing,andDSM-III-Rmajordepressiveepisode.Inagivenpopulation,themajorityofpeoplearelanguishingormoderatelymentallyhealthy,andonlyaminorityhaveaclinicallydiagnosablementalillnessorcanbesaidtobeflourishing.58

Figure2:FiguretakenfromHuppert,F.(2009)PsychologicalWellbeing:Evidenceregardingitscausesandconsequences

Evidencefromepidemiologysuggeststhatifthekeyconcernistoreducethenumberofindividualswithclinicallysignificantdisorders,ratherthanfocusingontreatmentandcureforthisgroup,itmaybemoreeffectivetotargetthelargeproportionofthepopulationwithsymptomswhicharenotyetclinicallysignificant(sub-thresholdsymptoms)orwhoarefreefrommentalhealthproblemsbutnotflourishing.59

Thetheoryisthatshiftingtheoveralllevelsofwellbeingofthepopulationreducesthenumberofpeoplewhoarelanguishing,andmorelikelytodevelopmentalhealthdisorders,andincreasestheproportionwhoaremoderatelymentallyhealthyandflourishing,andthuslesslikelytodevelopmentalhealthdisorders,therebyreducingtheoveralllevelsofmentalhealthdisorderinthepopulation.

Figure3:FiguretakenfromHuppert,F.(2009)PsychologicalWellbeing:Evidenceregardingitscausesandconsequences

Empirically,thereisevidenceofarelationshipbetweenaveragelevelsofwellbeinginapopulationandtheproportionofindividualsexperiencingmentalhealthdisorders.FelicityHuppertpointstoastudywhichcomparedtheaveragelevelsofpsychologicaldistressandtheincidenceofclinicallysignificantdisordersinanumberofpopulationgroupsthatdifferedintermsofsocio-demographiccharacteristics.Thestudyfoundacrossthegroups,therewasaclearrelationshipbetweenthepercentageofpeopleexperiencingaclinicallysignificantcommonmentaldisorderandthemeanlevelofsymptomsofmentaldistress.Theirmodelsuggestedthatasmallchangeinthemeanscoresformentaldistresswouldleadtoarelativelylargechangeintheprevalenceofcommonmentaldisordersinthatpopulation.Afollow-upstudybroadlyconfirmedthisfinding.WhittingtonandHuppertfound“a linear relationship between the decrease in the mean symptom score and the decrease in the percentage of people who had clinically significant disorder. For every one point decrease on the symptom scale, the prevalence of disorder dropped by 6%. Moreover, as the mean number of symptoms decreased, a higher percentage of the sample moved into a no-symptom category, which could be described as flourishing.”60

Thisrelationshipbetweentheprevalenceofadisorderandtheaveragelevelsofunderlyingsymptomsorriskfactorsinthepopulationisalsopresentformanyothercommonphysicalandmentaldisorders,includingalcoholism,gamblingaddictionandhypertensionandheartdisease.61Foralloftheseconditions,”[i]f the mean number of symptoms in a particular population is low, it turns out that the percentage of people who meet criteria for a common disorder is low; if the mean number of symptoms in a population is high, the percentage of people who meet criteria is high.”62

Thissuggeststhatinsofarasthecontributingfactorstomentalwellbeingandpoormentalhealthareshared,interventionsthatcanachieveasmallshiftintheoveralllevelofwellbeingofthepopulationcouldhaveadisproportionatelylargeeffectonthenumbersexperiencingmentalhealthproblems.

Insofarascontributingfactorsarenotthesameformentalillhealthandgoodmentalhealth,mentalhealthpromotionwillresultinhealthbenefitsforthepopulationoverandabovereductioninillhealth,whichisagoodthinginitself.

Takentogether,thesefactssuggestthateffortstoincreasethelevelsofwellbeinginapopulationmaybeamoreeffectivewayofreducingtheincidenceofcommonmentalandbehaviouralproblemsthanfocusingontreatmentorriskreduction.63

57Keyes,C.(2002)TheMentalHealthContinuum:FromLanguishingtoFlourishinginLife.JournalofHealthandSocialBehavior,43(2):207-222.58Keyes,C.(2002)TheMentalHealthContinuum:FromLanguishingtoFlourishinginLife.JournalofHealthandSocialBehavior,43(2):207-222.59Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.60Huppert,F.A.(2009),Anewapproachtoreducingdisorderandimprovingwell-being,PerspectivesonPsychologicalScience4(1),108-111.61Huppert,F.A.(2009),Anewapproachtoreducingdisorderandimprovingwell-being,PerspectivesonPsychologicalScience4(1),108-111.62Huppert,F.A.(2009),Anewapproachtoreducingdisorderandimprovingwell-being,PerspectivesonPsychologicalScience4(1),108-111.

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Improves physical healthWellbeingalsohasapositiveeffectonphysicalhealth.Alargenumberofcross-sectionalandlongitudinalstudieshaveshownthatpositivementalstatesareassociatedwithbetterphysicalhealthandgreaterlongevity.64,65Theeffectofpositivementalstatesonimmunityhasalsobeenconvincinglydemonstrated.Severalstudieshaveshownthatindividualswhohaveapositiveemotionalstylearelesslikelytobecomeillaftercontrolledexposuretoavirus,66andproducemoreantibodiesinresponsetovaccination.67Studies

havealsoindicatedthatinducingapositivementalstate(throughmeditation)increasesantibodyproductionrelativetoacontrolgroup.68

Inadditiontohavingadirectimpactonhealththroughimmuneandhormonalresponses,individualswithahighlevelofwellbeingalsotendtohavehealthierlifestyles.Theyalsotendtohavestrongerandmorepositiveinterpersonalrelationships,whichareknowntohaveaprotectiveeffectonhealthandlifeexpectancy.69

How can wellbeing be promoted?Althoughgenetic,demographicandsocioeconomicfactorsaffectwellbeing,studiessuggestthatthesefixedfactorsandlifecircumstancestogetheraccountforonlyaround60%ofthethevariationinwellbeingbetweenindividuals.70Theother40%ofthevariationinwellbeingisdrivenbyfactorsthatareunderindividuals’control.Inotherwordsintentionalactivities,includingbehaviours,cognitionsandmotivationsarealsoimportantdriversofpsychologicalwellbeing.71Manypsychologistsnowbelievethatinterventionsthattargetbehaviours,cognitionsandmotivationshavethepotentialtoimprovewellbeing.

Overthelastfewyears,proponentsofpositivepsychologyhavebeenlookingatwhathappypeoplecharacteristicallythinkanddo,examiningtheirhabits,behaviours,cognitivepatterns(includinggratefulandoptimisticthinking,andprosocialbehavior).72Theyhavebeendevisingpositiveactivitieswhichreplicatethesecharacteristics,andtestingoutwhetherpractisingtheseactivitiescanincreasewellbeinginothers.Lyubomirskydefinespositiveactivitiesas“simple, intentional, and regular practices meant to mimic the myriad healthy thoughts and behaviors associated with naturally happy people”.73Manypositiveactivitieshavebeenshowntoeffectivelyincreasebothsubjectivewellbeing(positiveaffectandlifesatisfaction)andpsychologicalwellbeing(effectivefunctioning).Theseactivitiesincludewritinggratitudeletters,countingblessings,performingactsofkindness,cultivatingstrengths,visualisingpositivefutureselvesandmeditating.74AsLyubomirskypointsout,aswellasbeingeffective,allthesepracticesarecheap,brief,andcanbedonewithoutoutsidehelp.75

SinandLyubormirsky(2009)conductedameta-reviewofrandomisedcontrolledstudiesofpositivepsychologyinterventions,includingmindfulnessinterventions(whichtheydefineas“treatment methods or intentional activities aimed at cultivating positive feelings, positive behaviors, or positive cognitions”).76Lookingat51interventions,across4,266individuals,theyfoundthattheseinterventions,whichpromptedpeopletothinkgratefully,optimisticallyormindfully,didsignificantlyimprovewellbeing,andalsosignificantlyreducedsymptomsofdepression.77Subsequentmeta-reviewshavebackedupthefindingthatpositivepsychologyiseffectiveinimprovingwellbeingandreducingdepression.Bolieretal(2013)conductedasimilarmeta-reviewofrandomisedcontrolledstudiesinvestigatingtheeffectofpositivepsychologyinterventions,andalsofoundtheinterventionshadasignificant,althoughsmall,effectonwellbeinganddepression,andthattheeffectonwellbeingpersistedevenafter3–6months.78Mindfulnessinterventionswereexcludedfromthisstudybecausetheireffectivenesshadalreadybeenconvincinglydemonstrated.

Inadditiontothesereviews,meditationandmindfulness-basedtherapieshavebeenseparatelytestedandfoundtobeeffectiveinimprovingmentalhealthandwellbeingbothinindividualswithdiagnosedmentalproblems,andalsointhosewithout.79,80,81ProfessorMarkWilliamsfromtheUniversityofOxfordDepartmentofPsychiatryhascalledtheevidencefortheireffectiveness“incontrovertible”.82

63Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.64Bolier,L.,Haverman,M.,Westerhof,G.,Riper,H.,Smit,F.,Bohlmeijer,E.(2013).Positivepsychologyinterventions:ameta-analysisofrandomizedcontrolledstudies.BMCPublicHealth,13:11965Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.66Cohen,S.,Alper,C.Doyle,W.,Treanor,J.&Turner,R.(2006)PositiveEmotionalStylePredictsResistancetoIllnessAfterExperimentalExposuretoRhinovirusorInfluenzaAVirus.PsychosomaticMedicine68(6):809-15.67http://www.ncbi.nlm.nih.gov/pmc/articles/PMC196942/68SeeHuppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.69Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.70Boehm,J.K.,&Lyubomirsky,S.(2011).Thepromiseofsustainablehappiness.InS.Lopez&C.Snyder(Ed.),Handbookofpositivepsychology(2nded.).Oxford:OxfordUniversityPress.71Lyubomirsky,S.,Schkade,D.&Sheldon,K.(2005)PursuingHappiness:TheArchitectureofSustainableChangeReviewofGeneralPsychology9(2)111–131. 72 Lyubomirsky,S.(2001).Whyaresomepeoplehappierthanothers?Theroleofcognitiveandmotivationalprocessesinwell-being.AmericanPsychologist,56:239-249.73Lyubomirsky,S.,&Layous,K.(2013)Howdosimplepositiveactivitiesincreasewell-being?CurrentDirectionsinPsychologicalScience,22(1):57-62. 74Lyubomirsky,S.,&Layous,K.(2013)Howdosimplepositiveactivitiesincreasewell-being?CurrentDirectionsinPsychologicalScience,22(1):57-62.75Lyubomirsky,S.,&Layous,K.(2013)Howdosimplepositiveactivitiesincreasewell-being?CurrentDirectionsinPsychologicalScience,22(1):57-62.76Sin,N.L.,&Lyubomirsky,S.(2009)Enhancingwell-beingandalleviatingdepressivesymptomswithpositivepsychologyinterventions:Apractice-friendlymeta-analysis.JournalofClinicalPsychology:InSession,65:467-487.77Sin,N.L.,&Lyubomirsky,S.(2009)Enhancingwell-beingandalleviatingdepressivesymptomswithpositivepsychologyinterventions:Apractice-friendlymeta-analysis.JournalofClinicalPsychology:InSession,65:467-487.78 Bolier,L.,Haverman,M.,Westerhof,G.,Riper,H.,Smit,F.,Bohlmeijer,E.(2013)Positivepsychologyinterventions:ameta-analysisofrandomizedcontrolledstudies.BMCPublicHealth13:119.79Hofmann,S.,Sawyer,A.etal(2010)TheEffectofMindfulness-BasedTherapyonAnxietyandDepression:AMeta-AnalyticReview,Journalofconsultingandclinicalpsychology87(2):169-183.80Halliwell,E(nd)MindfulnessReport.London:MentalHealthFoundation.81Khoury,B.,Lecomte,Y.etal(2013)Mindfulness-basedtherapy:Acomprehensivemeta-analysis.ClinicalPsychologyReview33:763–771.82Halliwell,E(nd)MindfulnessReport.London:MentalHealthFoundation.

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ConclusionThereisaclearcasetobemadeforpublichealthinterventionstofocusonpromotingwellbeingasapreventativemeasure,andnotaddressingwellbeinginterventionsonlytothosewithdiagnosablesymptomsofmentaldistress.Thereisalsogoodevidencethatwellbeingcanbeimprovedthroughpositivepsychologyinterventions,mindfulnessandmeditation.Youngpeopleareaparticularlyimportanttargetforthesetypesofwellbeinginterventions,asimprovementstomentalhealthinchildhoodandadolescencecanhavealargepositiveeffectoverthelifecourse.

Thisraisesthechallengeofreachinglargenumbersofyoungpeoplewithoutspecificmentalhealthconditions,andencouragingthemtoengageinactivitiesthatpromotementalwellbeing.