Local levels of mental disorder and well-being including in higher-risk groups

One in two people experience a mental disorder during their lifetime. ^{Reference Kessler, Berglund, Dernier, Jin, Merikangas and Walters8} In England, national psychiatric morbidity surveys show that mental disorder is common:

1. • 10% of children and young people experience a mental disorder ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9}

2. • 17.6% of adults experience at least one common mental disorder ^{Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10}

3. • 0.4% of adults have psychosis ^{Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10}

4. • 6% have alcohol dependence ^{Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10}

5. • 3% are dependent on illegal drugs ^{Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10}

6. • 21% have tobacco dependence ^{Reference McManus, Meltzer and Campion11}

7. • 5.4% of men and 3.4% of women have diagnosable personality disorder ^{Reference Singleton, Bumpstead, O'Brien, Lee and Meltzer12}

8. • 5% of people aged over 65 and 20% of those aged over 80 have dementia. ^{Reference Knapp and Prince13}

Subthreshold mental disorders are also common, result in significant burden and increase the risk of transition to threshold disorder. Levels of subthreshold disorder include:

1. • 18% of 5- to 16-year-olds experience subthreshold conduct disorder ^{Reference Colman, Murray, Abbott, Maughan, Kuh and Croudace14}

2. • 17% of adults experience subthreshold common mental disorder ^{Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10}

3. • 5% of adults experience subthreshold psychosis ^{Reference van Os, Linscott, Myin-Germeys, Delespaul and Krabbendam15}

4. • 24% of adults drink more than the safe upper limit of alcohol. ^{Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10}

Well-being levels in the UK have been highlighted by an Office for National Statistics survey ¹⁶ of 165 000 adults, which found that for life satisfaction 76% scored 7 or more out of 10 and 7% scored less than 5, for life being worthwhile 80% scored 7 or more and 5% scored less than 5, whereas for happiness yesterday 78% scored 7 or more and 11% scored less than 5. An important risk factor for poor well-being affecting a large proportion of the population is mental disorder and subthreshold mental disorder.

Local levels of risk and protective factors

Mental disorder and well-being are associated with a range of risk and protective factors. ^{Reference Campion and Fitch1,Reference Campion, Bhui and Bhugra18} A public health approach emphasises the importance of addressing such factors to prevent mental disorder and promote well-being. Commissioning decisions can be informed by local level of risk and protective factors including in higher-risk groups as well as impact of such factors. ^{Reference Campion and Fitch1}

Factors associated with increased risk of mental disorder during childhood and adolescence include: ^{Reference Campion and Fitch1}

1. • during pregnancy and at birth:

   1. • smoking during pregnancy is associated with increased risk of conduct disorder ^{Reference Murray, Irving, Farrington, Colman and Bloxsom19}

   2. • alcohol consumption during pregnancy: fetal alcohol spectrum disorder is the most common non-genetic cause of intellectual disability ^{Reference Carpenter20}

   3. • stress: maternal stress during pregnancy is associated with child behavioural problems ^{Reference O'Connor, Heron, Golding and Glover21} and impaired cognitive and language development ^{Reference Bergman, Sarkar, O'Connor, Modi and Glover22}

   4. • premature birth is associated with increased risk of mental illness in offspring ^{Reference Nosarti, Reichenberg, Murray, Cnattingius, Lambe and Yin23}

   5. • women with mental disorder have an increased risk of low birth weight and prematurity in their offspring ^{24,Reference Grote, Bridge, Gavin, Melville, Ivengar and Katon25}

2. socioeconomic factors including household income, state benefits, tenure and type of area: ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9} children from lowest household income have threefold increased risk of mental disorder ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9}

3. family factors including family structure ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9}

4. parental factors: education qualifications, employment and presence of mental disorder ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9}

5. child factors: age, gender, ethnicity, special education needs and physical illness.

Some of the strongest predictors of mental disorder are childhood adversity, particularly when associated with maladaptive family functioning (such as parental mental disorder, child abuse, neglect). ^{Reference Kessler, McLaughlin, Green, Gruber, Sampson and Zaslavsky26} For instance, child abuse is associated with increased risk of depression (odds ratio (OR) = 2.9), post-traumatic stress disorder (PTSD) (OR = 4.0), psychosis (OR = 2.7), alcohol dependence (OR = 1.8) and drug problems (OR = 2.1). ^{Reference Jonas, Bebbington, McManus, Meltzer, Jenkins and Kuipers27} Repeated sexual abuse during childhood and adolescence is associated with even higher rates of adult mental disorder including depressive disorder (OR = 6.2), PTSD (OR = 6.8), probable psychosis (OR = 15.3), alcohol dependence (OR = 5.2), eating disorder (OR = 11.7) ^{Reference Jonas, Bebbington, McManus, Meltzer, Jenkins and Kuipers27} and attempted suicide (OR = 9.4). ^{Reference Bebbington, Cooper, Minot, Brugha, Jenkins and Meltzer28}

Factors associated with mental disorder in adulthood include deprivation, unemployment, debt, violence, stressful life events, inadequate housing and fuel poverty. ^{Reference Campion and Fitch1} Factors associated with dementia include smoking, hypertension and high body mass index.

Inequality and deprivation are key underlying elements for a range of risk factors for mental disorder and poor mental well-being, which then further increase inequality. Whereas higher-risk groups benefit more from public mental health interventions, larger groups at less elevated risk also benefit. Therefore, a proportionate universalistic approach can both target higher-risk groups and accommodate larger population groups.

Impact of mental disorder and poor well-being

In the UK, mental disorder is responsible for 22.8% of burden of disease; for comparison, the figure for cardiovascular disease is 16.2% and for cancer 15.9%. ²⁹ No other health condition matches mental ill health in the combined extent of prevalence, persistence and breadth of impact. It is therefore important that local strategy development, commissioning and public health take account of the local impact of mental disorder.

A key reason for the size of impact is that mental disorder starts early, with 50% of lifetime mental illness (excluding dementia) starting by age 14, ^{Reference Kessler, Berglund, Dernier, Jin, Merikangas and Walters8,Reference Kim-Cohen, Caspi, Moffitt, Harrington, Milne and Poulton30} and 75% starting by the mid-20s. ^{Reference Kessler, Amminger, Aguilar-Gaxiola, Alonso, Lee and Ustün31} Mental disorder during childhood and adolescence results in a broad range of disadvantages including worse health, social skills and school outcomes, higher levels of health-risk behaviours such as smoking, alcohol and drug misuse, higher levels of self-harm and suicide, as well as antisocial behaviour and offending (Table 1). ^{Reference Campion and Fitch1,Reference Campion, Bhui and Bhugra18}

Table 1 Impact of mental disorder on health and social skills, school outcomes and risk-taking behaviours in children and adolescents ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9}

	Emotional disorder, %	Conduct disorder, %	Hyperkinetic disorder, %	Whole survey prevalence, %
Age 5-16 years
Health and social skill outcomes
Health is fair or bad (parent report)	23	17	18	7
Found it harder than average to make friends	35	24	32	10
No friends	6	8	10	2
School outcomes
2 or more years behind in intellectual development	23	36	40	9
More than 15 days’ absence in the previous term	17	14	11	4
Ever been excluded from school	12	34	29	2
Age 11-16 years
Self-reported risk-taking behaviours	19	30	15	6
Regularly smokes
Regularly drinks	13	19	13	9
Drinks twice a week or more	5	12	7	3
Taken drugs at some time	20	28	23	8
Taken drugs, mainly cannabis	16	23	18	7
Taken drugs other than cannabis	7	16	7	2
Self-reported self-harm	28	21	18	7

Mental disorder during childhood and adolescence also results in worse subsequent adult health outcomes including higher rates of adult mental disorder and suicide, unemployment and lower earnings, marital problems, crime and violence. ^{Reference Campion and Fitch1} In adults, mental disorder increases risk of:

1. • physical illness

2. • reduced life expectancy - for instance, schizophrenia is associated with 20.5 years’ reduced life expectancy for men and 16.4 years’ reduced life expectancy for women ^{Reference Brown, Kim, Mitchell and Inskip32}

3. • suicide and self-harm

4. • health-risk behaviour including poor diet, less exercise, more smoking, drug and alcohol misuse; smoking is the largest single preventable cause of death, yet 42% of adult tobacco consumption in England is by those with mental disorder ^{Reference McManus, Meltzer and Campion11} and 43% of under-17-year-old smokers have either emotional or conduct disorder ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9}

5. • unemployment

6. • poor housing

7. • stigma and discrimination.

Numbers receiving intervention to treat mental disorder, prevent mental disorder and promote mental health: estimating level of unmet need

Regarding treatment, the most recent national psychiatric morbidity surveys show that only a minority of those in the UK with mental disorder except psychosis receive any intervention; ^{Reference Green, McGinnity, Meltzer, Ford and Goodman9,Reference McManus, Meltzer, Brugha, Bebbington and Jenkins10} the following proportion receiving any intervention for different mental disorder:

1. • 23-28% of children with emotional and conduct disorders are seen by child and adolescent mental health services and receive less support from other services

2. • 24% of adults with common mental disorder; however, less than 10% of older people with depression receive adequate treatment

3. • 28% of adults screening positive for PTSD

4. • 81% of adults with probable psychosis received some form of treatment compared with 85% in 2000

5. • 65% of adults with ‘psychotic disorder’ in past year

6. • 14% of adults with alcohol dependence

7. • 14% of adults with cannabis dependence

8. • 36% of adults with dependence on other drugs.

Public mental health commissioning guidance ^{Reference Campion and Fitch1} enables estimation of the local proportion of those with different mental disorder who receive intervention, thereby highlighting the size of unmet need. The guidance also draws attention to the fact that an even smaller proportion receive prevention or promotion interventions and highlights ways to estimate local promotion and prevention of unmet need. Establishing the size of unmet need informs the JSNA, which in turn informs health and well-being board decisions regarding priorities and commissioning.

The proportion of individuals receiving public mental health interventions is related to available local resources. The commissioning guidance ^{Reference Campion and Fitch1} includes spend per head of population since level of local resource often does not reflect the level of mental disorder and poor well-being.

The previous section on public mental health intelligence can support coordinated delivery of effective public mental health intervention.