In my parent's generation there was a sea change in health behaviour. Not so long ago smoking was considered normal, diets were conducive to heart disease and exercise was a marginal pursuit. In just fifty years most people acknowledge the importance of exercise and diet. Smoking has become a marginal pursuit. There has been a huge tipping point.
Has a similar tipping point been passed for mental health? Andrew Flintoff, Ruby Wax, Clarke Carlisle, Marcus Trescothick, Kelly Smith, Frank Bruno and Kjell-Magne Bondevik have openly shared their experience, strength and hope around mental health. Many people know that Winston Churchill made his huge contribution to the UK while living with his "black dog" of depression. Charities like MIND, SANE and the Charlie Waller Memorial Trust have done much to de-stigmatise mental ill health. Campaigns like "Time to Change," policy groups like the Kings Fund and political manifestos consistently point to the importance of mental health.
There has been a tipping point in the narrative around mental health. There is much greater awareness, normalisation and compassion around mental health than there was just a few years ago.
A recent government initiative called for parity of esteem between mental and physical health. The recent Mindfulness All Party Parliamentary Group publication of the UK Mindful Nation Report called for mindfulness to play a role in health, education, workplaces and the criminal justice system and called on policy makers to action a series of tractable recommendations. While beliefs may have started to change, there is a long way to go to improve access to high quality mental health services that provide evidence-based treatments on a par with those for physical health problems. Indeed, given how frequently mental and physical health problems co-occur there is a long way to go before we have integrated services. Many environments in which we learn, work and house our most vulnerable citizens could do much more to promote good mental health.
There is now a pressing need for the changed narrative around mental health to translate into investment of resources in mental health. Although mental ill health represents about 38% of ill health, most countries spend no more than 13% of their healthcare budget on it (Layard & Clark, 2014). Richard Layard and David Clark estimate that mental health problems cost the UK 7% of its national income through its effects on employment, co-morbidity, mental health care and social impact. We urgently need to progress our psychological understanding of mental health, enhance the effectiveness of our treatments and make high quality treatments accessible to all those who need them (Holmes, Craske, & Graybiel, 2014).
In the UK the Wellcome Trust, NIHR and the MRC have been instrumental in supporting mental health research. They have supported the translation from innovation through to implementation of many psychological treatments such as cognitive-behavioural therapy and mindfulness-based cognitive therapy. I have had the privilege of contributing to NIHR funded projects asking if psychological treatments might be effective where first line treatments have failed (Wiles et al., 2013) and if mindfulness-based cognitive therapy is an alternative to maintenance anti-depressants (Kuyken et al., 2015). Building on this previous work, our current work, funded by the Wellcome Trust, asks if mindfulness training in schools can prevent mental health problems and promote resilience. This project is part of a groundswell of work promoting the mental health of children and young people (Bonell et al., 2014).
The UK has led the way in innovation and research (Clark, 2004; Holmes et al., 2014) and there have been Herculean attempts to make evidence-based treatment accessible (Clark et al., 2009; Layard, 2006). However, the stark reality remains that many parts of the mental health service are under-resourced, some have experienced cuts in their budgets and in many places hugely committed staff are over-stretched.
One of the best ways to promote mental health and prevent mental health problems is to work with young people, during a time in their life when they are developing life skills and resilience through facing the challenges of childhood and adolescence. This is why my work has increasingly moved to working with young people and schools. Adam Long learned mindfulness in his school and described at the All Party Parliamentary Group launch of the UK Mindful Nation Report how he wanted to live more fully, be a "human being" not a "human doing;" in short to "bite life to the core." Some visionary schools realise that when they promote mental health, this goes hand-in-hand with all other aspects of education. It is not a zero-sum game, quite the reverse, mental health, physical health and flourishing tend to go hand in hand.
My hope is that my children's generation will see stepwise innovations around mental health. Can we consider the whole lifespan, including inter-generational risk and resilience? Can we make a spectrum of low-key evidence-based treatments available to those who need them? Can we ensure that the more intensive treatments that work are also available in the care pathway, offered by people with appropriate training and supervision? Can we broaden our focus to key contexts beyond the individual, to families, schools, workplaces and prisons? I attended a parents' briefing at one of my daughter's secondary schools recently and they talked about supporting the young people in developing resilience and life skills. Looking around the room everyone looked attentive, some were nodding. A tipping point in how we see mental health has been and gone. Now let's have a change in how we promote mental health and manage mental health problems.
Willem Kuyken will be speaking at the University of Oxford Mindfulness Centre's Summer School, which this year features a focus on mindfulness-based cognitive therapy and is an unprecedented opportunity to hear Zindel Segal, Mark Williams and John Teasdale, the three developers of MBCT together again for the first time in more than ten years reflecting on the state of the field.
A version of this blog post was published as part of the National Institute for Health Research mental health awareness raising.
Bonell, C., Humphrey, N., Fletcher, A., Moore, L., Anderson, R., & Campbell, R. (2014). Why schools should promote students' health and wellbeing. Bmj-British Medical Journal, 348. doi:ARTN g3078
Clark, D. M. (2004). Developing new treatments: on the interplay between theories, experimental science and clinical innovation. Behaviour Research and Therapy, 42(9), 1089-1104. doi:Doi 10.1016/J.Brat.2004.05.002
Clark, D. M., Layard, R., Smithies, R., Richards, D. A., Suckling, R., & Wright, B. (2009). Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 47(11), 910-920. Retrieved from WOS:000272364700003
Holmes, E. A., Craske, M. G., & Graybiel, A. M. (2014). Psychological treatments: A call for mental-health science. Nature, 511(7509), 287-289. doi:10.1038/511287a
Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., . . . Byford, S. (2015). Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): A randomised controlled trial. The Lancet. doi:10.1016/S0140-6736(14)62222-4
Layard, R. (2006). Health policy - the case for psychological treatment centres. Br Med J, 332, 1030-1032.
Layard, R., & Clark, D. M. (2014). Thrive: The power of evidence-based psychological therapies. London: Allen Lane.
Wiles, N., Thomas, L., Abel, A., Ridgway, N., Turner, N., Campbell, J., . . . Lewis, G. (2013). Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial. Lancet, 381(9864), 375-384. doi:Doi 10.1016/S0140-6736(12)61552-9