CMO report on Public Mental Health

The Summary

The concept of ‘well-being’ has been increasingly used in public mental health and public policy over the last six years. It has been generally accepted that increasing ‘well-being’ improves mental health and reduces the prevalence of mental illness in the population i.e. that the ‘Rose’ hypothesis can be applied to public mental health. However, such conclusions are problematic, not least since concepts as fundamental as the meaning of the term ‘well-being’ lack consensus definitions. Mental illness and ‘well-being’ are not ends of the same continuum: it is possible to have high levels of subjective well-being despite having a mental illness, and vice versa. This invalidates many previous attempts to measure ‘well-being’, which have wrongly assumed that measures of mental illness can be used to measure well-being. Other research has used the results of studies from other fields and erroneously rebadged them as evidence for ‘well-being’, critically compromising the strength of the evidence base on which policy is subsequently built. The result of this confusion has been an unhelpful blurring of the boundaries between well-being promotion, prevention of mental illness, and treatment of mental illness. There is no robust evidence that a population approach to improving well- being will have any impact on the prevalence of mental illness. It is crucial that priority is given to interventions in public mental health for which there is strong evidence of effectiveness. ‘Well-being’ approaches based on evidence, such as the NICE Public Health Guidelines about social and emotional well-being in children, should form one fine strand of a much wider approach to public mental health. Further work must be done at a national level to build a body of ‘well-being’ evidence based on workable definitions and appropriate metrics. In the meantime, policy should not run ahead of evidence. It is important that strategies to prevent and treat mental illness in the population are not supplanted by a myopic focus on ‘well-being’. The World Health Organization has suggested a useful model for public mental health. This illustrates that there are ample opportunities for mental health promotion, mental illness prevention and treatment of and recovery from mental illness, for which there is a sufficient evidence base to make a real and sustained public health impact (see Figure). These are ‘low hanging fruit’. We have a great deal of evidence about what is effective and indeed cost effective. Much of the evidence is contained in the Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence. We should invest in these opportunities rather than being side-tracked by ill-defined approaches to ‘well-being’ which currently out-run the evidence.

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