Better Mental Health for All: Strengthening Public Health Practice

1. Better Mental Health for All:Strengthening Public Health Practice No Health Without Mental Health - Mike McHugh and Chris Nield

2. ‘There is no health without mental health’ WHO 2008English Government 2011 ‘

3. Plan • Studies suggesting that mental health is a determinant of future physical health • The mind and body are one system • Social change & improvements to health • Social and Economic Inequalities – Psycho social implications

4. Mental Wellbeing prevents Death Chida Y, Steptoe A. 2008 Meta-analysis to 2008 • Positive affect: (emotional wellbeing, positive mood, joy, happiness, vigour, energy) and • Positive dispositions: (life satisfaction, optimism, sense of humour) Are equally predictive • 35 Studies in healthy populations • Hazard Ratio 0.82 (0.76-0.89) • 35 Studies in diseased populations • Hazard Ratio 0.98 (0.95-1.00)

5. Positive Affect protects Health Pressman SD Cohen S Psych Bulletin 2005 Narrative review of prospective studies: • 14 Studies of mortality • 6 Studies of morbidity • 12 Studies of survival in life threatening disease • Trait positive affect predicts lower morbidity, less pain, fewer symptoms and increased longevity • Relationship to survival in life threatening disease inconsistent

6. Positive Relationships Prevent DeathHolt-Lunstad J. Smith TB, Layton JB 2010 Meta-analysis • 148 Studies • OR 1.50 (1.42-1.59) favouring stronger social relationships • Measures of social integration OR 1.91(1.63-2.23) were more strongly predictive than measures of social networks OR 1.19 (0.99-1.44)

7. Descartes was misrepresented The mind and body work as one system Every emotion has a physiological correlate No health without mental health ‘For even the mind depends so much on temperament and the disposition of one’s bodily organs that, if it is possible to find a way to make people generally more wise and more skilful than they have been in the past, I believe that we should look for it in medicine’. Descartes Book 6 of Discourse on Method

8. Paradigm 2 Holism • Descartes has been misrepresented • The mind and body are one system; • We are all connected • Humans are part of the ecological system

11. Social Change and improvements to health

12. Huge social changes and improvements to health Engagement Eve Brown and William Smith Mid 1920’s

13. Brothers Arnold, Ronnie , Paul Smith 1936

14. Eve & Joan Smith 1942

15. Arnold, Ronnie, Paul, Joan and Dad William 1943

16. Eve Smith early 1960’s

17. Joan 2018 age 77

18. Changes in Eve’s & Joan’s Lifetime • Women rights - getting the vote, contraception • Clean air act • Better Housing – Slum Clearance • Introduction of NHS • Advances in medicine • Health and Safe legislation – workplace • Vaccination • Equal pay> • Travel • Internet

19. Social and Economic Inequalities – Psycho social implications

21. www.equalitytrust.org.uk Inequality... How much richer are the richest 20% in each country than the poorest 20%? Income gaps How many times richer are the richest fifth than the poorest fifth? Wilkinson & Pickett, The Spirit Level

22. Health and social problems are worse in more unequal countries www.equalitytrust.org.uk Index of: • Life expectancy • Math & Literacy • Infant mortality • Homicides • Imprisonment • Teenage births • Trust • Obesity • Mental illness – incl. drug & alcohol addiction • Social mobility Index of health and social problems Wilkinson & Pickett, The Spirit Level

23. Valued or Devalued? More inequality • More superiority and inferiority • More status competition and consumerism • More status insecurity • More worry about how we are seen and judged • More “social evaluation anxiety”(threats to self-esteem & social status, fear of negative judgements

24. Psychosocial risk factors for ill health • Low social status • Weak social connections • Stress in early life (pre- and postnatally) 24

25. Young People feeling Low Young People feeling low Overall, 26% of young people feel low at least once a week Increases with age 54% of girls over 15 feel low once a week compared with 18% of 11 year olds Gender differences from the age of 11 twice as many girls as boys report feeling low once a week

26. Inequalities & social relationships • Inequality has a huge impact on health and social issues • A good quality of life requires enough to be able to participate in social relationships and community life • Individual and communities view of their ability to take part , feeling respected and valued and listened to and given opportunities to participate influences their health • More unequal societies can increase stress and poor mental health

27. Stress response • In healthy state, the stress response is followed by re-establishment of balance, but this takes time to happen • Repeated or chronic stress results in permanent imbalance, and ultimately dysregulation of the stress response • The stress response affects all physiological systems including respiration, cardiovascular, digestion, immunity and memory

28. Autonomic Nervous SystemPNS: Parasympathetic SNS: Sympathetic Primates PNS (Ventral Vagal Complex) Mammals SNS Reptiles PNS (Dorsal Vagal Complex) The Polyvagal Theory. Porges, S.,W. 2011

29. Autonomic Nervous SystemPNS: Parasympathetic SNS: Sympathetic PNS Ventral Vagal Complex ON Heart – Lungs Middle ear / larynx Facial muscles Eye / neck - orienting Mastication and swallowing Relaxation Relationship Homeostasis Immunity, repair, growth Hart Lungs Gut

30. Autonomic Nervous SystemPNS: Parasympathetic SNS: Sympathetic PNS Ventral Vagal Complex ON Heart Lungs Middle ear / larynx Facial muscles Eye / neck - orienting Mastication and swallowing PNS VVC OFF Heart Lungs Senses Relaxation Senses attuned to Relationship Homeostasis Digestion, Immunity, repair, growth Senses attuned to Danger Hart Lungs Gut

31. Autonomic Nervous SystemPNS: Parasympathetic SNS: Sympathetic PNS Ventral Vagal Complex ON Heart – Lungs Middle ear / larynx Facial muscles Eye / neck - orienting Mastication and swallowing PNS VVC OFF Heart Lungs Senses SNS Relaxation Relationship Homeostasis Immunity, repair, growth Alert to Danger Heart Lungs Musculature Gut Fight and Flight

32. Autonomic Nervous SystemPNS: Parasympathetic SNS: Sympathetic PNS Ventral Vagal Complex ON Heart – Lungs Middle ear / larynx Facial muscles Eye / neck - orienting Mastication and swallowing PNS VVC OFF Heart Lungs Senses SNS ON Relaxation Relationship Homeostasis Immunity, repair, growth Heart Lungs Musculature Gut Alert to Danger PNS Dorsal Vagal Complex ON Heart Lungs Gut Fight and Flight The Polyvagal Theory Porges, S.,W. 2011 Immobilisation Depression

35. What Reduces Stress?

36. What reduces stress/stimulates parasympathetic nervous system ? • Meditation and mindfulness - Shapiro Carlson 2010 • Relaxation exercises - Horowitz 2010 ; • Bodywork: Yoga, Tai Chi, Qi Gong • SandlundNorlander 2000 • Natural environment - FPH 2010 • Breathing - Keltner 2009 • Heart rate coherence - McCraty et al 2008 • Positive social contact and touch • Uvnas-Moberg 1998 • Smiling and laughter - Keltner 2009 • Sleep -Diekelmann and Bom 2010

37. Emotional Intelligence • Emotional awareness • Respect for own and others emotional states • Emotional regulation • Capacity to integrate thinking and feeling • Capacity to communicate emotional information Chemiss and Goleman 2001

38. Exercise and Neurotransmitters ↑Serotonin • improves mood • helps stave off stress, counteracting effects of cortisol ↑GABA • anxiolytic ↑Dopamine • Improves mood and heightens attention

39. Exercise and the Brain • Research consistently shows...the fitter you are, the more resilient your brain becomes and the better it functions both cognitively and psychologically. Eg. Penedo F 2005 • Current NICE Guidance on Depression recommends structured physical activity

40. Five ways to well-being

42. Jacobs et al Psychoneuroimmunology 2010 Intensive meditation training, immune cell telomerase activity and psychological mediators Ornish et al PNAS 2008 Changes in prostate gene expression in men undergoing an intensive relaxation, nutrition and lifestyle intervention Carlson et al Psychoneuroimmunology 2004 Mindfulness- based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosteone sulphate (DHEAS), and melatonin in breast and prostate cancer outpatients Other ‘Science’ The human genome is just the keyboard; genetic expression is determined by the environment

43. Summing Up • Mental and physical health are all part of one system and have a great influence on each other • Social and Economic Inequalities have Psycho social implications • Mental health seems to have a greater influence on physical health than vice versa • The stress response is a key mechanism