Aug 27, 2012 — Risks to mental health over the life course: Risks to mental health manifest themselves at all stages in life.

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RISKS TO MENTAL HEALTH: AN OVERVIEW OF VULNE RABILITIES AND RISK FACTORS BACKGROUND PAPER BY WHO SECRETARIAT FOR THE DEVELOPMENT OF A COMPREHENSIVE MENT AL HEALTH ACTION PLA N 27 AUGUST 2012 This WHO Discussion Paper does not represent an official position of WHO (please refer to the disclaimer included on the last page of this paper).

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Risks to mental health Page 2 Risks to mental health: an overview of vulnerabilities and risk factors Background paper by WHO secretariat for the development of a comprehensive mental health action plan 27 August 2012 _____________________________________________________ Key points The value of mental health and well – being : Mental well – being makes up a n integral part of an individual’s capacity to lead a fulfilling life, including the ability to form relationships, study, work or pursue leisure interests, as well as to make day – to – day decisions and choices. Determinants of mental health and well – being : Mental health and well – being is influenced not only by individual attributes, but also by the social circumstances in which persons find themselves and the environment in which they live; these determinants interact with each other dynamically, and may th Risks to mental health over the life course : Risks to mental health manifest themselves at all stages in life. Taking a life – course perspective shows how risk exposures in the formative stages of lif e including substance use in pregnancy, insecure attachment in infancy or family violence in childhood – can affect mental well – being or predispose towards mental disorder many years or even decades later. Vulnerability to mental disorders : Depending on the local context, c ertain groups in society may be particularly susceptible to experiencing mental health problems , including households living in poverty, people with chronic health conditions , minority groups, and persons exposed to and/or displaced by war or conflict. Vulnerability among persons with mental disorders : Person with a mental disorder have their own set of vulnerabilities and risks, including an increased likelihood of experiencing disability and premature mortality, stigma and discrimination, social exclusion and impoverishment . Mental health promotion and protection : Since the range of risks to mental health is wide , responses to them need to be multi – layered and multi – sectoral. Broad strategies include: nurturin g of core individual attributes in the formative stages of life (such as self – esteem and resilience) ; early recognition and prevention of emotional or behavioural problems , especially in childhood and adolescence; provision of living and working conditions that enable psychosocial development and self – determination (particularly among vulnerable persons); promotion of positive interactions within and between social groups; social protection for the poor; anti – discrimination laws and campaigns; and promotion of the rights , opportunities and care of individuals with mental disorders .

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Risks to mental health Page 3 1. C ontext, objectives and scope Mental health or psychological well – being makes up a n integral part of an individual’s capacity to lead a fulfilling life, including the ability to form and maintain relationships, to study, work or pursue leisure interests, and to make day – to – day decisions about educational, employment, housing or other choices. Di sturbances to an individual’s mental well – being can adversely compromise these capacities and choices, leading not only to diminished functioning at the individual level but also broader welfare losses at the household and societal level. In the context o f national efforts to develop and implement mental health policy , it is vital to not only address the needs of persons with defined mental disorders , but also protect and promote the mental well – being of its citizens. T he intrinsic value of positive mental health is enshrined in – being and not merely the a . 1 At its Sixty – fifth session, held in May 2012, the World Health Assembly adopted a resolution calling on WHO to develop, in consultation with Member States , a comprehensive action plan that actively addresses not only the need for early identification and appropriate care for persons with mental disorders , but also assesses vulnerabil it ies and risks as a basis for developing the mental health plan . As a background input to the preparation of a comprehensive mental health action plan by WHO M ember S tates and secretariat , this paper sets out to pro vide a conceptual outline of the main v ulnerabilities and risk factors relating to mental health and ill – health , as well as a n overview of the available evidence for mitigating risks through appropriate promotion and protection efforts . The focus is on the set of vulnerabilities and risk facto rs that should be taken into account when developing and implementing appropriate health and social policies or strategies. In reviewing the contribution and interaction of different determinants to mental health and well – being , not only their adverse but also the ir protective influences are considered . 2. Determinants of mental health and well – being A commonly used definition of mental health is – being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively 2 Reference to this definition makes it clear that m ental or psychological well – being is influenced not only by individual characteristics or attributes, but also by the socioeconomic circumstances in which persons find themselves and the broader environment in which they live ( Figure 1 ) : Individual attributes and behaviours : These relate to a person’s innate as well as learned ability to deal with thoughts and feelings and to manage him/her sel f in daily life ( ‘ emotional intelligence ‘ ) , as well as the capacity to deal with the social world around by partaking in social activities, taking responsibilities or respectin g the views of others ( ‘ social intelligence ‘ ) . A n can also be influenced by g enetic and biological factors ; that is, determinants that persons are born or endowed with , including chromosomal abnor malities (e.g. Down’s syndrome) and intellectual disability caused by prenatal exposure to alcohol or oxygen deprivation at birth .

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Risks to mental health Page 4 Soci al and economic circumstances : The capacity for a n indi vidual to develop and flourish is deeply influenced by their immediate social surroundings including their opportunity to engage positively with family members, friends or colleagues , and earn a living for themselves and their families and also by the socio – economic circumstances in which they find themse lves . Restricted or lost opportunities to gain an education and income are especially pertinent socio – economic factors . E nvironmental factors : The wider socio cultural and geopolitical environment in which people live can also affect , levels of access to basic commodities and services (water, essential health services, the rule of law), exposure to predominating cultural beliefs, attitudes or practices, as well as by social and economic policies formed at the national level ; for example, the on – going global financial crisis is expected to have significant mental health consequences , including increased rates of suicide and harmful alcohol use . 3 Discrimination, social or gender i nequality and conflict are examples of adverse structural determinants of mental well – being . Figure 1 Contributing factors to mental health and well – being It is important to emphasize that these different determinants interact with each other in a Table 1 provides an illustrative set of factors that may threate n or protect mental health. For – worth could be enhanced or diminished depending on social support or economic security at the household level, which in turn might be influenced by the extent of political stability, social justice or economic growth in a country. Mental health and well – being Individual attributes and behaviours Social and economic circumstances Environmental factors

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Risks to mental health Page 5 Table 1 M ental health determinants Level Adverse factors Protective factors Low self – esteem Self – esteem , confidence Individual attributes Cognitive/e motional immaturity Ability to solve problems and manage stress or adversity Difficulties in communicating Communication skills Medical illness, substance use Physical health, fitness Loneliness, bereavement Social support of family & friends Neglect , family conflict Good parenting / family interaction Social Exposure to violence/abuse Physical security and safety circumstances Low income and poverty Economic security Difficulties or failure at school Scholastic achievement Work stress, unemployment Satisfaction and success at work Poor access to basic services Equality of access to basic services Environmental Injustice and discrimination Social justice, tolerance, integration factors Social and gender inequalities Exposure to war or disaster Social and gender equality Physical security and safety 3 . Risks to mental health A further critical way in which risks to mental health interact is over age and time. Risks to mental health manifest themselves at all stages in life. A life – course approach is used here , since it shows how risk exposures in the formative stages of life can affect mental well – being many years or even decades later. 4 5 6 Figure 2 presents a schematic overview of some of the main individual, social and env ironmental risks presenting themselves over the life course. Alternative approaches or perspectives could be taken ( such as using gender, socioeconomic status or income rather than age group as the primary unit of interest ). It is also the case that not all risk s pertain to a particular age gr oup ; for example, gender, ethnicity and place of residence are independent of age ; these are also discussed below. Pre – conception and pre – natal period : r circumstances occurring before their birth or even their conception. Pregnancies that are unwanted or take place during adolescence, for instance, can raise the chance of risky health behaviours in pregnancy or mental health problems in childhood. 6 Like wise, poor adaptation to pregnancy can be considered a potential risk 6 It is already wel l established that malnutrition, low birth weight and certain micronutrient deficiencies ( such as iodine defic iency ) significantly heighten the risk to brain development, as do risky health behaviours in pregnancy, especially the use of tobacco, alcohol and drugs. 2 7 8

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Risks to mental health Page 6 Infancy and early childhood The re is a strong body of evidence to show the importance of attachment by neonates to their mothers or another primary caregiver for subsequent social and emotional development. 9 10 Separation from the primary caregiver – due for example to parental absence or rejection – leads to anxiety, stress and insecurity. P ost – natal depression among new mothers can likewise contribute to sub – optimal attachment and development. Parents who have difficulties in bonding, have limited skills or exhibit negative attitudes place their children at increased risk of exposure to stre ss and behavioural problems. Other important risks to physical and cognitive development in infancy and early childhood include maltreatment and neglect ( by parents and other caregivers ), malnutrition and infectious or parasitic diseases. 9 10 Figure 2 S chematic overview of risks to mental health over the life course (Adapted from: Foresight project, 2008; Kieling et al, 2011; Fisher et al, 2011) 4 5 6 Childhood C hildhood years are vital for developing life skills. Negative experiences within the home or at school – due to family conflict or play – ground bullying, for instance – have a damaging effect on the development of these core cognitive and emotional skills. 6 9 Supportive parenting, a secure home life and a positive learning environment in schools are key protective factors in building and protecting mental well – being or capital at this stage of life. R isks to mental health include family violence or conflict, negative life events, and a low sense of connecti on to schools or other learnin g environments. At their worst, exposure to such risks – as a

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Risks to mental health Page 8 absence of respite care ex erts a negative force on an individual’s well – being as well as on the social capital of the community. A further core dimension of individual welfare is health itself , not only for its enabling value (for carrying out work and leisure activities) but also its intrinsic value ; that is, people prefer to be healthy than sick . Ill – health or disability therefore constitutes another important risk factor for psychological well – being in general and depression in particular. 8 Individuals with chronic disease or disability whether comorbid with depression or not – are at an elevated risk of bei ng marginalized from social or community activities, particularly those associated with stigma or discrimination (such as HIV/AIDS). While some disease processes directly affect the brain such as cerebral malaria, HIV/AIDS, stroke and substance use disor ders – others primarily create a psychological burden due to the challenges of living with the condition (such as an altered lifestyle or coming to terms with the prospect of prolonged illness or premature death). Older age Older age is the single most important predictor for cognitive decline and dementia. Older adults are also particularly at risk of social isolation , as they withdraw from the labour market (which may deprive them of a steady income) and become more susceptible to chronic disease ( whi ch may deprive them of their mobility, independence and cognitive skills ) . Feelings of i solation can also come about due to the loss of their partner or friends to illness, or due to inattentive or uncaring family members. The elderly are also vulnerable to physical neglect or abuse, either by formal or informal carers, and this has obvious negative implications for their state of well – being. Social and family isolation – and also bereavement – are significant predictors o f depression in older age. S ince chronic physical illness is a lso a risk factor for depression, the higher prevalence of physical health conditions in this age group further contributes to elevated rates of depression . Other risks (affecting any age gr oup) In addition to the risks that typically present or manifest themselves at different points over the life course, there are other potential threats to mental health that can impact on persons at any age or stage in their lives, depending on the broader sociocultural and geopolitical context into which they are born and/or within which they exist (see Figure 3 for an overview of the interplay between increased vulnerability, mental disorders and development outcomes). Since even the most b asic socio – demographic characteristics of individuals are framed by social chances of developing a mental health condition. Racism or discrimination towards a p articular adversity, thereby placing them at a higher risk of stress, anxiety and other common mental disorders. Similarly, the socially – defined role of women i n many societies exposes them to greater stresses, which, together with other factors including family violence and abuse, leads to higher rates of depression and anxiety. By contrast, substance use disorders are more common among men, influenced in part again by social attitudes or norms.

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Risks to mental health Page 9 Persons exposed to violence, armed conflict and natural disasters represent a further vulnerable group at a significantly elevated risk of psychological distress and morbidity, as are those forcibly displaced by such events (of whom almost half are children and adolescents). 17 Poverty and associated conditions of unemployment, low educational level, deprivation and homelessness are all strong markers for mental illness. These adverse conditions prevail in the populations of many rich as well as poor countries. Mental illness and poverty are considered to interact in a negative cycle; that is, not only is the risk of mental illness among people who live in poverty higher, but so too is the likelihood that those living with mental illness will drift into or remain in poverty. 1 5 18 Accordingly, both the poor as well as people with mental disorders constitute vulnerable groups requiring targeted social and financial protection or assistance. 19 20 Figure 3 Vulnerab ilities, mental disorders and adverse development outcomes (Source: WHO, 2010) 20

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Risks to mental health Page 10 4 . Risks and vulnerabilities among persons with mental disorders While the focus thus far has been on risks to mental health among different age or social groups, it is important to emphasise that those who go on to experience a mental disorder have their own set of risks / vulnerabilities. As just mentioned, one such heightened risk is impoverishment, due to the difficulties that people with mental disorders can have in securing or maintaining work and income. So from this way round, mental ill – health acts as the risk factor in this case, for unemployment, debt and poverty. T he same argument applies to discrimination, human rights abuse , violent victimiza tion and social exclusion, which are far more likely to be experienced by people with mental health problems than those in the population as a whole. In health terms, t he onset or presence of a mental disorder raises the chance of disability and premature mortality from other diseases , including cardiovascular disease, diabetes, HIV/AIDS and other chronic conditions . 8 The higher than expected occurrence of these diseases in persons with mental disorders can be attributed to a range of factors, inc luding general neglect of their physical health (by themselv es, families or care providers), elevated rates of psychoactive substance use in this population, diminished physical activity, an unhealthy diet and, in many cases, side – effects of medication . H ealth outcome s for persons with comorbid mental and physical conditions are markedly worse, due to diminished health – seeking behaviour, adherence and follow – up for these cases. Along with suicide, these chronic diseases produce a level of pre – mature mort ality far in excess of the general population ; even in the relatively affluent context of Nordic countries, this mortality gap has been put at 20 years for men and 15 for women . 21 Put another way, people with mental disorders have a considerably reduced lif e expectancy, and this is only partly explained by fatal events directly linked to a mental health diagnosis ( including suicide) . 5 . Addressing risks: mental health promotion and protection It is evident from the foregoing overview that mental well – being can be put at risk by a wide range of factors that span not only the life course but also different spheres of life , including: cognition and behaviour at the individual level; living and wor king conditions at the social level; and opportunities and rights at the broader environmental level. Equally, therefore, public mental health responses to these risks need to take place across these different levels and social groups. The precise nature of the response will depend on its specific purpose and target group , but can be broadly split into actions that promote or protect mental health versus those that seek to restore or improve it through appropriate treatment and care of people with mental disorders . The conceptual and evidential basis for mental health promotion has been the subject of a number of publications and reviews by WHO and its partners. 2 1 1 22 23 Accordingly, only a broad overview of key strategies to address mental health risks and vulnerabilities is provided here, with reference made to these recent reviews for a more detailed account of available evidence. Table 2 provides an il lustrative set of mental health promotion and protection strategies , which aim to enhance mental well – being and , among certain target groups, may also prevent the onset of mental ill – health . These actions need to take place within a broad public health framework which is informed by an understanding of the social, economic, cultural and political forces at work in a particular setting, and which is carried out in conjunction with other sectors (including education, housing, employment and social welfare / protection ).

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Risks to mental health Page 11 T able 2 Key directions for mental health promotion a nd protection Strategic direction Key interventions Developing and protecting individual attributes Mothers and infants : Enable early attachment; provide appropriate parent training and natal care (including post – natal depression care); develop safe, stable and nurturing relationships between children and their parents and caregivers ; Children and adolescents : Ensure s ufficient nutrition and stimulation Older adults : Healthy ageing policies and co mmunity activities; All age groups : Regular physical activity / healthy diet; discourage / restrict tobacco, alcohol and other psychoactive substance use Supporting households and communities Families : Ensure s ecure living conditions for children and adolescents ; target prevention on those with behavioural disorders and those with a mentally ill parent; prevent intimate partner violence ; Workers / employees : Support increased employment opportunities, and p romote safe and supportive working conditions (including stress management); Low – income households : Ensure basic living conditions (shelter, water and sanitation); provide social and financial protection; Communities : Make neighbourhoods safe; enhance civic assets / social network; r estrict availability of alcohol , drugs and tobacco Supporting vulnerable groups in society Develop and implement social inclusion policies ; I mplement anti – discrimination laws and policies; Make education available and accessible to all P romote rights and freedoms; gender – equity policies P rovide early intervention to refugees after exposure to trauma (including those caught up in conflicts); C onduct awareness raising campaigns; F oster re sponsible reporting in the media Developing and protecting individual attributes At its core , mental health and well – being rests on the capacity of individuals to manage their thoughts, feelings and behaviour , as well as their interaction s with others. It is essential that these core attributes of self – control, resilience and confidence be allowed to develop and solidify in the formative stages of life , so that individual s are equipped to deal with the complex choices and potential adversities they will face as they grow older. Promoting a healthy start in life is therefore vital, and there is ample evidence to indicate that early intervention programmes do have an important protective or preventive effect. The most successful programmes addressing risk and protective factors early in life are targ eted at child populations at risk, especially from families with low income and education levels , including: home – based interventions in pregnancy and inf ancy; efforts to reduce tobacco and alcohol use during pregnancy; and parent management training and p re – school programmes. 2 11 20 Recent review s of evidence from low – and middle – income countries likewise found significant positive effects for interventions delivered by community members on g of both m others and children . 6 2 2 24

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