mental health promotion essay

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Mental Health Promotion

Categories: Health Promotion Universal Health Care

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Words: 1628 |

Published: Jun 5, 2019

Words: 1628 | Pages: 4 | 9 min read

Mental health essay outline, mental health essay example, introduction.

Definition of mental health according to the World Health Organization (WHO)
Importance of a support system for mental well-being

Nurses' Role in Maintaining Mental Well-being

The need for nurses to maintain holistic fitness for quality patient care
Resilience as a key attribute for nurses
The impact of psychosocial and environmental factors on mental health

Challenges Faced by Nurses

The stress and challenges of working in healthcare settings
Shift work disorder and its consequences
The prevalence of bullying in the healthcare industry

Strategies and Policies for Promoting Mental Health

Policies and guidelines for minimizing shift work disorder
Measures to prevent workplace bullying
The role of support systems for nurses' mental health
The importance of mental well-being for nurses
The need for policies and support systems to promote mental health in the healthcare industry

Works Cited:

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Clark, T. (2007). The importance of understanding history. Learning Solutions Magazine. Retrieved from https://www.learningsolutionsmag.com/articles/331/the-importance-of-understanding-history
Johnson, P. (1999). A history of the American people. Harper Perennial.
Lerner, G. (1993). Learning disabilities: theories, diagnosis, and teaching strategies. Houghton Mifflin.
Loewen, J. (1995). Lies my teacher told me: Everything your American history textbook got wrong. The New Press.
MacMillan, M. (2013). The uses and abuses of history. Profile Books.
McNeill, W.H. (1985). Mythistory and other essays. University of Chicago Press.
Pomeroy, S.B., Burstein, S.M., Donlan, W., Roberts, J.T., & Tandy, D.W. (2004). Ancient Greece: A political, social, and cultural history. Oxford University Press.
Rosenzweig, R., & Thelen, D. (1998). The presence of the past: Popular uses of history in American life. Columbia University Press.
Wineburg, S. (2001). Historical thinking and other unnatural acts: Charting the future of teaching the past. Temple University Press.

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1 INTRODUCTION TO MENTAL HEALTH PROMOTION

Alanna Kaser and Megan Sponagle

1.1 HISTORY OF MENTAL HEALTH PROMOTION: MENTAL HEALTH VS. MENTAL ILL-HEALTH

1.1.1 Introduction

It is recognized that mental health is an inherent and central component of health and that promoting mental health optimizes our quality of life. In fact, mental health promotion has grown into a key field of health promotion research and programming, as well as a key priority in building thriving individuals, communities, and populations. However, recognition of mental health within the field of health promotion and the emergence of mental health promotion as its own distinct domain was delayed in part, by evolving perspectives and definitions of mental health and its scope of relevance. Understanding a brief history of the conceptualization of mental health is central to the evolution of mental health promotion and how it is widely understood and studied today.

1.1.2 Early Origins: Mental-Ill Health & Mental Illness

Early understandings and study of mental health existed within the domains of psychology and psychiatry, resulting in an approach focused on the treatment and prevention of mental illness at an individual level (Bertolote, 2008; Froh, 2004). By consequence, having “good” mental health was understood to be simply the absence of mental illness (Keyes, 2002). This was achieved and relevant only through a treatment lens, for individuals with existing mental health disorders. Eventually, this perspective expanded to include preventive approaches which identified and targeted risk factors to prevent poor mental health (i.e., the risk-reduction model). Fortunately, the utility of preventive approaches to extend beyond the individual-level (e.g., community programs, prevention policy) and the efficacy and reduced burdens available in seeking to prevent, instead of only treating mental health challenges enforced the recognition of protecting mental health as a key matter of public health. In 2001, the WHO published a report emphasizing the importance of addressing mental health on a global level and clarified the importance of the topic as a matter of public health. The report acknowledged mental health as having equal importance and interconnectedness with physical health, as well as, outlined its vital contributions to well-being, at and beyond the individual-level (WHO, 2001). However, the underlying view of mental health as solely the absence of illness and the dominant focus on treating and preventing mental disorders still informed the predominant prevention and treatment-based actions recommended within both programming and policy.

1.1.3 Influences from other disciplines: The paradigm shift in studying mental health

The paradigm shift towards a positive approach to mental health and its promotion was informed in part by health promotion and population/public health domains, but also by the fields of positive and community psychology. Although the views of more holistic and less-negative versions of mental health date back to the mid-1950s, the diseased-focused perspective of mental health remained dominant until positive psychology gained traction in the early-2000s. Positive psychology shifted focus towards identifying and promoting beneficial and strengthening factors that enhance people’s mental health and their overall quality of life, but the field remains largely focused on the individual (Froh, 2004; Seligman & Csikszentmihalyi, 2000). Community psychology functions to advance well‐being at multiple levels (i.e., individual, organizational, and community levels) to foster social change (Neigher et al., 2011). Therefore, contributions from community psychology have extended the promotion and positive-enhancement approach beyond the individual-level. Early research in these fields demonstrated that the enhancement of positive health-related factors can not only improve and prevent both mental and physical health challenges, but also enhance quality of life among individuals and communities in lasting ways (Fredrickson, 2001; Keyes, 2002; Seligman & Csikszentmihalyi, 2000). Additionally, positive psychology research clarified that mental illness and mental health are related, but distinct constructs, providing empirical evidence that mental health is more than the absence of mental illness (Keyes, 2002; Keyes, 2005), and introducing the concept of positive mental health. Early (mental) health promotion and population health research also supported the multi-level capacity and beneficial outcomes of promoting positive mental health. Findings demonstrated improved utility and health benefits of strengths-based programs focusing on positive psychosocial factors (i.e., empowerment, competence, resilience, active participation), in comparison to risk-reduction programs (Barry, 2001; Barry, 2007).

1.1.4 Solidifying mental health promotion as a distinct field of study

By 2005, the World Health Organization released their first report featuring mental health promotion, including a new definition of mental health as a state which encompasses positive functioning. The new definition cemented both the re-conceptualization of mental health and the essential place for mental health promotion in promoting population health. Around the same time, more and more research emerged, contributing to a growing body of literature studying theoretical and conceptual bases mental health promotion and demonstrating its utility and efficacy in improving health and preventing ill-health across a variety of settings (Barry, 2007; Barry, 2009; Jané-Llopis et al., 2005). The enhanced understanding of mental health and evidence of its utility across diverse populations and settings, emphasized the importance and efficacy of promoting positive mental health within the general population, as opposed to focusing only on individuals at-risk or diagnosed with mental illness. Although the disorder-focused model provides an important and necessary framework for treatment and prevention for individuals struggling with mental illness and for practitioners in relevant fields (e.g., clinical psychology, psychiatry), the shift towards a widely applicable and holistic view refined our understanding of mental health and unlocked its powerful ability to enhance overall health and prevent ill-health globally (Sharma et al., 2017). With this updated view taken in stride, contributions from positive psychology and mental health promotion pioneers have continued to inform an evolving framework for mental health promotion. Their research continues to explore MHP’s distinctiveness (as its own field), but inherent relevance to health promotion generally, its utility across multiple settings and scales, and its unique strengths-based capacity to simultaneously improve health and protect against poor health.

1.2 APPLYING PRINCIPLES OF HEALTH PROMOTION TO MENTAL HEALTH

1.2.1 Introduction

The meanings of health and well-being have evolved with time and vary across many contexts. There are various factors which can influence or contribute to both the absence/presence of disease, as well as good functioning. These are often referred to as types or sub-domains of health or well-being (i.e., physical, emotional, psychological, spiritual, social, and economic), all of which are important to overall quality of life (Government of Canada, 2019). The health promotion field operates within the public health domain and seeks to emphasize this holistic view of health by focusing on promoting well-being and supporting individuals facing illness at community, societal and governmental levels (World Health Organization, 2022). The scope of health promotion begins with improving healthy habits at the individual level, up to shaping health-related policy (World Health Organization, 2022). As effective health promotion results from the combined collaboration of individuals and institutions, everyone must take responsibility for their role in creating a healthy society (WHO, 1986). Rickwood (2011) found that mental health promotion has a goal to help individuals become their best selves, cope with stressors, and become active community participants at every life stage.

The World Health Organization (2005) provides the following definition of mental health: “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (p. 2). Mental Health is part of the “holistic definition of health and therefore builds on the basic tenets of health promotion” (Barry, 2017, p. 5).

Since all types of health are interconnected, mental health promotion theories should focus more on goals to improve overall health (Jané-Llopis et al., 2005). This makes health promotion theories an even better fit to be used in mental health promotion, as they already have a focus on overall well-being (World Health Organization, 2022). Specifically, mental health promotion refers to developing effective ways for individuals and communities to have positive mental health (Windsor-Essex County Health Unit, 2019). Barry (2017) describes mental health promotion (MHP) as multi-leveled (individual, communal, and socio environmental). MHP follows an upstream approach, meaning it focuses on making structural changes to improve mental well-being of the entire population (Barry, 2017; National Collaborating Centre for Determinants of Health, 2014). It is for everyone, as opposed to the downstream approach of clinical psychology, which as a primary focus on individuals with or at risk of mental illness (Barry, 2017; Gaspar de Matos et al., 2019; National Collaborating Centre for Determinants of Health, 2014; see figure 1 for comparison; source). The upstream and downstream approaches can be compared with an analogy by Irving Zola:

“A witness sees a man caught in a river current. The witness saves the man, only to be drawn to the rescue of more drowning people. After many have been rescued, the witness walks upstream to investigate why so many people have fallen into the river. The story illustrates the tension between public health’s protection mandates to respond to emergencies (help people caught in the current), and its prevention and promotion mandates (stop people from falling into the river)” (National Collaborating Centre for Determinants of Health, 2014, p. 2).

Here, clinical psychology (the downstream approach), can be compared to rescuing the individuals in the river- when an individual faces mental illness, clinical treatments aim to solve their mental health problems (National Collaborating Centre for Determinants of Health, 2014). In contrast, MHP (the upstream approach) consists of proactive measures that aim to prevent individuals from falling into the river in the first place (National Collaborating Centre for Determinants of Health, 2014). It responds to the determinants that contribute to an individual’s mental health, to inspire individuals to engage in a mentally healthy lifestyle (Barry, 2017).

Figure 1: A visual comparison of upstream and downstream approaches to mental health-promotion (National Collaborating Centre for Determinants of Health, 2014).

Adapted from: National Collaborating Centre for Determinants of Health. (2014). Let’s Talk: Moving upstream. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.

This section describes the how various approaches in health promotion (The Ottawa Charter, The Socio-ecological Model, and Strengths-Focused Approaches) can be applied in MHP practice.

1.2.2 MHP in Programming and Policy

MHP programs vary in scope and context; however, true to the holistic and positive view of mental health, all programs focus on enhancing mental health and well-being, rather than the prevention or treatment of mental health challenges (Barry, 2009; Hill et al., 2023). Given this holistic mental health approach, programs less often target a specific mental health risk or disorder treatment populations. Although some focus on broad demographics, programs typically strive for inclusivity and are often embedded in diverse community contexts (Hill et al., 2023). MHP programs have been deemed an effective public health approach because evidence has demonstrated their effectiveness in improving population well-being. For instance, Barry et al. (2013) reviewed 22 mental health programs in populations of children and teens living in low and middle-class countries. Results showed most of the interventions that were implemented in a school setting positively impacted children’s emotional health and ability to cope with stressors (Barry et al., 2013). Similarly, community interventions for teens positively influenced their psychological and social health (Barry et al., 2013). Adult programming findings have also been promising. Le et al., (2021) found that across 33 adult MHP programs, the majority were effective, producing benefits that justified the program costs. Primary benefits included reducing the risk of depression, suicide, substance use, psychosis, anxiety, and eating disorders (Le et al., 2021). Preventative workplace models were one type of program found to be effective (Le et al., 2021). It is important to consider the benefits compared to the program cost because public health and mental health organizations have budgets they must adhere to, therefore more funds should be allocated to programs that are more successful in improving population mental health (Le et al., 2021). Cost-benefit analyses maximize the efficiency of both programs and their budgets (Le et al., 2021).

Many social factors, or determinants, interconnectedly influence mental health and general well-being (Compton & Shim, 2015). Policy creates and influences the social, economic, and political infrastructure which shapes these determinants and, thus, has the potential to impact mental health (Compton & Shim, 2015). Compared to implementation and evaluation of MHP programming, policy efforts relating to mental health status are less frequently evaluated. Growing recognition around mental health promotion, has resulted in the publication of various reports and initiatives (i.e., WHO, 2005; WHO, 2022). Additionally, certain countries have implemented policies and mandates which focus on the promotion of mental health, especially through positive enhancement lens. For example, New Zealand’s first “Well-Being Budget” recently committed to changing the way they prioritize and measure well-being, including looking beyond GDP as a sole measure of well-being and prioritizing the improvement of mental health and other related social determinants (i.e., poverty, Indigenous inequalities; Mintrom, 2019). However, there a need for research empirically evaluating effectiveness and utility of specific policies and initiatives across health, education, political, and economic sectors in both reducing mental health burdens, but enhancing mental health and overall well-being (Enns et al., 2016).

1.2.3 Using the Ottawa Charter to Inform Mental Health Promotion

One key framework used in the field of health promotion is the Ottawa Charter, a well-known set of guidelines that shape many programs seen today (WHO, 1986). The Ottawa Charter was created 37 years ago, at the first health promotion conference, when the world knew they needed a new positively oriented public health strategy (Jackson, 2016). The Ottawa Charter can be used effectively for MHP because it focuses not only on the individual but also on the well-being of society (Rickwood, 2011). The five pillars of the Ottawa Charter contribute to understanding how a well-known approach to health promotion can be applied in mental health settings; they are summarized in Figure 2 below: (Jané-Llopis et. al, 2005).

Figure 2: The five pillars of The Ottawa Charter (WHO, 1986), and how they can be applied in mental health promotion settings.

*MHP = mental health promotion, template by (Amabile, n.d.-a)

Chapter 4 ( The Social and Structural Determinants of Mental Health ) reminds us that mental health is shaped by numerous factors (e.g., social support, spirituality, coping skills, workplace, and economic status) known as the determinants of mental health. The Ottawa Charter can be used as a program framework, to enhance the positive determinants of mental health, and eliminate the negative determinants of mental health (Jane-Llopis, 2007). For instance, the Youth Mental Organization in Australia is called Headspace and has found an effective basis on the five pillars of the Ottawa Charter, focusing on communicating, promoting, and preventing mental health disorders. It plays a large role in modifying the healthcare services available to youth and has helped them grow up in improved mental health settings (Rickwood, 2011). Some health promotion programs that have a basis in the Ottawa Charter have been shown to improve mental health even if that was not their primary goal, showing MHP programs can be effectively guided by the Ottawa Charter (Jane-Llopis et al., 2005).

We can see that MHP program results can motivate a larger change in the community (Herrman et al., 2007). Jané-Llopis et. al (2005) comment on the examples that build healthy health promotion programs and policies, to help community members learn and grow to their full potential. This includes improving the ability to provide nutritious foods and quality education to all people, regardless of socioeconomic status (Jané-Llopis et. al, 2005). Individuals need an environment that allows and encourages them to improve their determinants of mental health (Jané-Llopis et. al, 2005). This could include having a mental health professional periodically visit the homes of families at risk or with mental health disorders to assist (Jané-Llopis et. al, 2005). When locations at the organizational level (schools and workplaces) work together with families and friends at the interpersonal level, there is an opportunity for an additive effect to promote mental health (Jané-Llopis et. al, 2005).

The Ottawa Charter can be used as an assessment tool to determine the strengths and future directions of both MHP programs and the field as a whole (Rickwood, 2011). Rickwood (2011) notes the Ottawa Charter has helped develop stronger community involvement at the micro and macro levels. Micro level programs (such as Headspace mentioned above), empower community members and caregivers to participate in improving the mental health of the people around them (Rickwood, 2011). Macro level programs target larger scale policy measures (Rickwood, 2011). For instance, the GetUp ! program focused on holding political leaders responsible to act on important causes (Rickwood, 2011). This has stimulated community growth in other locations like Ireland and has created changes in funding to help youth gain increased access to therapy. Overall, the Ottawa Charter provides well-thought-out guidelines that have been effective across multiple mental health settings.

1.2.4 Applying the Socio-Ecological Model to Mental Health Promotion

Another framework used in health promotion is the Socio-Ecological model. The Socio-Ecological approach shows that MHP operates at all levels- individual, interpersonal, organizational, community, and public (shown in Figure 3 below; Barry, 2007). Barry (2007) emphasizes the connection between an individual and their environment, and how that needs to be part of how we develop MHP theories. We need interventions that target more than one level of the Socio-Ecological hierarchy. The Socio-Ecological model can be applied to MHP because it demonstrates interconnection from the individual to the public level (Barry, 2007). For example, Kousoulis and Goldie (2021) adapted this model and created a visual illustration of how it is applicable to community mental health ( Figure 4 ). Kousoulis and Goldie (2021) show that resilience and agency at the individual level are needed to sustain positive mental health at the community level. Individuals at the bottom of the diagram have barriers to positive mental health that get in the way of making a positive contribution to the interpersonal, organizational, community, and public levels (Kousoulis & Goldie, 2021). This reminds us that a community must be built on public pillars of equity, human rights, and respect, so all members can be active participants in positive public mental health (Kousoulis & Goldie, 2021).

Figure 3: The levels of the Socio-Ecological Model (Heise, 1999)

Template by (Aida, n.d.)

Figure 4: A Visual illustration of the Socio-Ecological Model adapted to fit the Scope of Mental Health (Kousoulis & Goldie, 2021)

1.2.5 Using Strength-Focused Models to Enhance MHP in Practice

Strengths-based models of MHP (i.e., competence enhancement model) emphasize the importance of the determinants of mental health, as they are the components these programs try to improve (e.g. resilience, physical activity, and parenting styles; see Chapter 4: The Social and Structural Determinants of Mental Health ) (Barry, 2007). An important aspect of this model is that it focuses on promoting positive mental health, while others simply aim to reduce mental illness or treating it when it occurs (i.e., risk-reduction, pathogenic approaches; Barry, 2007). These programs see mental health as a resource which helps individuals thrive and thus, focus on helping participants be confident and capable in coping with everyday life stressors by building positive mental health enhancing factors (Barry, 2007). For example, the competence-enhancement model focuses on integrating empowerment, participation, and collaboration to promote mental health ( Figure 5 ) (Barry, 2007; Jane-Llopis et al., 2005). The skills and factors featured in specific strengths-based models have considerable overlap with skills needed for positive mental health, demonstrating the central importance of positive mental health to effective mental health promotion (Barry, 2007; Barry, 2009).

Have you ever joined a program and left feeling bored, disconnected, or worse about yourself? After a negative experience, most people will not return to the program. Additionally, policies which focus solely on the prevention of treatment of mental disorders only address certain populations (i.e., at-risk, or already mentally) after issues have already manifested (i.e., risk or diagnosed mental illness). By contrast, following a strengths-based approach means that policies and programs take an upstream approach which simultaneously prevents mental illness and enhances both positive mental health and general well-being in a more inclusive, efficient, and beneficial way (Barry, 2007; Barry, 2009).

The strengths-based model can be applied to MHP practice among both youth and adults, by building policies and programs which foster factors empirically supported in enhancing mental health and related competencies. The Community Mothers program provides home visits to first-time low-income mothers, educating and empowering them with the skills needed to be an effective parent (Barry, 2007). The strengths-focus impacts the design of this program by empowering parents by “drawing out the potential of parents rather than giving advice and direction” (Johnson et al., 2000, p. 337). Using an approach that empowers and works directly with participants allows needs and areas of growth to be identified so resources can be used efficiently and the program can succeed (Barry, 2007, Jane-Llopis et al., 2005). Strengths-based models have also been proven to be effective in programs for teens and youth (Barry, 2007). The Promoting Alternative Thinking Strategies (PATHS) program set a goal to help children understand the emotional expression and regulation, self-control, and problem-solving (Greenberg et al., 1995). This uses positive elements characteristic of the strengths-based approach, including participation (questions throughout the lesson) and collaboration (role-play of skills) based activities (Paths Program LLC, 2021). When PATHS was used in 30 second and third-grade classrooms, results showed children could communicate and manage their emotional experiences better (Greenberg et al., 1995).

Figure 5 : The three components of the competence enhancement model (Barry, 2007)

Template by (Amabile, n.d.-b)

1.2.6 Conclusion

This portion of chapter 1 provides on overview of public health contributions to health promotion and supports the application of a health promotion approach in improving and promoting mental health. The Ottawa Charter informs MHP efforts by identifying five pillars on which to act (healthy public policy, supportive environments, community action, personal skills, and health services; WHO, 1986). This has been proven effective in many mental health programs, including Headspace (an Australian youth program). Like the pillars in the Ottawa Charter, the Socio-Ecological Model prioritizes health at every level, from the individual to public policy (Barry, 2007). The Socio-Ecological Model intends to create a society where individuals improve the health of communities, and communities improve the health of individuals in return (Barry, 2007). Across all these levels, employing a strengths-focused approach greatly enhances the efficacy and success of mental health promotion in practice. For example, looking at the community level of the Socio-Ecological approach, the competence enhancement approach guides programs to be empowering, interactive, and collaborative (Barry, 2007; Jane-Llopis et al., 2005). When these various models are tailored and used effectively within relevant populations, public mental health and general well0ebing can be improved.

1.3 SYSTEMATIC CONCEPT ANALYSIS OF MENTAL HEALTH PROMOTION

Clarifying the concept of mental health promotion and pinpointing contributing factors are imperative to overcoming existing barriers, guiding future research and study in this field, and maximizing the current utility of mental health promotion among individuals, communities, and across countries.

1.3.1 Introduction

The emerging field of mental health promotion has built on many theoretical and conceptual frameworks from the domains of health promotion, public health, and positive/community psychology. Definitions, research, and practice of mental health promotion also vary across contexts, cultures, political landscapes, and over time (Kovess-Mastefy et al., 2005; Tamminen et al., 2016). We’ve discussed many of the current models and perspectives informing current understanding of mental health promotion, including the competence-enhancement approach and socio-ecological model. These perspectives all make important contributions to the field, however, differences between them have challenged our ability to develop a one-size-fits-all conceptualization of mental health and mental health promotion. Thankfully, our understanding of mental health is largely widely accepted. However, there remains division and uncertainty regarding other aspects of mental health promotion. For example, some argue that mental health promotion encompasses both the prevention and promotion of mental health, while others see prevention of mental disorders as a distinct, separate goal outside the direct scope of mental health promotion.

As MHP and programming grows in popularity, it becomes harder to manage existing inconsistencies in the definitions, aims, and components which translate into practice (i.e., prevention and treatment). Fortunately, Tamminen et al., (2016) conducted a systematic concept analysis, which involved reviewing the existing literature on MHP and using a structured framework to identify the most consistently agreed upon attributes, antecedents and consequences, related concepts, and reference terms (Figure 6). These identifications greatly advance and organize knowledge on MHP and provide the clarification necessary to streamline its scope of relevance and practice. The map of their work depicted below provides a great educational tool outlining the concept of mental health promotion.

Figure 6 : Visualization of a concept mapping of mental health promotion based on a concept analysis and figure map completed by Tamminen and colleagues (2016).

1.3.2 Mental Health Promotion: What, Why and How?

The attributes of mental health promotion describe the concepts’ unique characteristics and qualities, in other words, the “what” of MHP. Based on attributes, mental health promotion can be understood to promote positive mental health to achieve well-being through empowerment, participation, and multi-sectoral partnerships. Positive mental health includes self-esteem, optimism, subjective well-being, and stress/adversity coping skills and in addition to mental well-being, was recognized in existing MHP research mostly at the individual-level (Tamminen et al., 2016). Both these attributes were recognized as important to MHP, but not central in current policy or strategy literature. Alternatively, the attributes of partnerships and cross-sectoral integration/efforts were dominant in the extant policy and strategy articles (Tamminen et al., 2016). Both empowerment and participation were identified as key features of mental health promotion, most specifically, in relation to how to foster mental health promotion in practice. For example, empowerment is an aim of the Ottawa Charter and both empowerment and participation are key aims considered in building and evaluating MHP programs (Barry, 2007; WHO, 1986).

The references clarify the domains and circumstances which mental health promotion is most relevant while antecedents identify what is required or what comes before MHP. Tamminen and colleagues (2016) review of MHP references illustrates that mental health promotion aims to improve mental health and well-being across multiple socio-ecological levels through policy, strategy/research, and practice (aka programming). Further, these goals and actions are situated within the scope of overall health promotion, specifically in relation to public and population health domains (Barry, 2007). While references provide context for the identified attributes, there are also certain factors (i.e., antecedents) which help ensure MHP has the attention and resources to thrive. These include political will, strong research theory and evidence-base, and people who value mental health and mental health promotion (Tamminen et al., 2016). The antecedents help identify important emphasis points for what can be done across multiple levels to advance the promotion of mental health either through direct actions from individuals, communities, or institutions/government or further research. Together, the references and antecedents help to identify the “how” of mental health promotion, which explains the relevant context and concrete factors leading/contributing to MHP.

The identified consequences tie everything together. As the “why” of MHP, the outcomes which occur from MHP rationalize why it is so important and widely beneficial. Findings demonstrate that MHP improves well-being, strengthens many protective factors and reduces risk factors for mental disorders, and also permits a wide range of broader societal benefits (e.g., social and economic capital, societal productivity; Moodie & Jenkins, 2005). Thus, the consequences of MHP can extend beyond the initial points of focus (i.e., mental health) and goals (i.e., enhancing well-being; Tamminen et al., 2016). For example, the ability for positive mental health promotion efforts to be effective in primary intervention/prevention of mental illness, in addition to enhancing well-being. These extended benefits emphasize the broad utility and efficacy of MHP and suggest that investing in MHP is a worthwhile endeavour, in the interest of individual and community mental health, public health, and general societal functioning.

1.3.3 Barriers to MHP in Understanding and Practice

Despite the value gained from synthesizing and reviewing current knowledge on MHP, many barriers continue to limit MHP research and practice and challenge consistent conceptualization of mental health promotion. Some of these barriers include a lack of research (especially recent research and programming/policy evaluation research specifically), cross-cultural inequalities (lack of programming/policy and evaluation in developing countries), and a persistent lack of a clear definition of MH(P) (e.g., understanding mental health separate from mental illness, confusing well-being, and mental health, Barry, 2007; Moodie & Jenkins, 2005; Tamminen et al., 2016). Therefore, future research and practice must also address gaps in our understanding of MHP itself and build a more solid evidence basis for its effectiveness, as filling these knowledge gaps will improve the efficacy of MHP in research practice and provide stronger rationale for public health action to promote mental health promotion. Addressing these barriers might include integrating a more concrete and widely accepted theoretical and conceptual definition of mental health promotion that can be adapted for use across various contexts, funding more policy and program implementation, evaluation, feasibility research to build a stronger evidence base for building the most effective MHP programs and policy, etc.

1.3.4 The Value of Concept Analysis: Moving forward with MHP

Clarifying MHP as a concept is essential in optimizing study and practice of MHP. Examining the findings from Tamminen’s concept analysis help to elucidate how and in what circumstances each component of MHP distinctly contributes to mental health promotion efforts. They also identify precursor factors which can be enhanced to ensure MHP can flourish and outline the outcomes that occur when it does. The vital information gained from synthesizing the literature to conceptualize MHP is useful in multi-faceted ways. It can act as an educational tool which enhances public/political understanding and appreciation for of the meaning and benefits of MHP or even a conceptual/theoretical guide for future MHP practitioners and researchers. Evaluating the current concept of MHP can also reveal strengths and weaknesses and help to guide concrete solutions based on these evaluations. For example, mapping the consequences not only rationalizes the importance of MHP to relevant populations (i.e., policy makers, government funding evaluators, the public, etc.), but it also may provide a list of outcomes useful for both targeting certain outcomes with tailored MHP initiatives and/or evaluating the success of MHP efforts following implementation. Additionally, the widespread socio-ecological levels and importance of cross-sectoral partnerships to MHP suggest that MHP must be addressed as an issue of public health and employ cross-sectoral approaches to ensure MHP efforts are effectively carried out across all relevant socio-ecological domains (Tamminen et al., 2016).

1.4 FLOURISHING AS A GOAL FOR MENTAL HEALTH PROMOTION

1.4.1 Mental Well-Being vs Mental Health

As you may have noticed throughout the chapter, well-being and mental health are often discussed together and sometimes used interchangeably. Indeed, well-being has been identified as both an attribute and outcome of mental health promotion. However, well-being and mental health are separate but related constructs (Cloninger, 2006). Well-being refers to an overall sense of how life is going which is subject to daily fluctuations (Waterman, 2007), and mental health reflects a spectrum of functioning that shapes one’s ability to handle stress, make decisions, and cope with the ups and downs of daily life (Orpana et al., 2016). Mental health and well-being may bidirectionally influence one another; maintaining positive mental health may lead to a sense of well-being (such as being satisfied with one’s life), and vice versa, enjoying a sense of well-being may be a protective factor against poor mental health. As mental health is a necessary component of overall well-being, there is a need for effective population interventions across the globe (Barry, 2007).

1.4.2 Positive Mental Health as Flourishing

Positive mental health is a true state of well-being rather than just the lack of mental illness (Barry, 2009, pg. 4). Possessing and maintaining positive mental health is known as flourishing (Keyes, 2002). In other words, flourishing can be thought of as a state of complete mental health, shown through consistently high levels of well-being across three key domains (i.e., psychosocial, social and emotional well-being; see Figure 7; Keyes, 2002; Keyes, 2014). Keyes (2014) argues “anything less than flourishing creates problems for society, it’s not just depression and mental illness” (14:42-14:50). Indeed, his research clarified that although positive mental health is related to mental illness, the two concepts are distinct from one another (Keyes, 2002; Keyes, 2005). These findings illustrate that mental illness is not a limiting factor that keeps one from flourishing, and that all individuals are capable of it (Keyes, 2014). This is an important perspective we carry throughout the rest of this textbook, and that generates strong support for positive mental health as an important goal for MHP.

1.4.3 Flourishing and MHP

Promoting flourishing is a route to well-being that is possible for all populations and has the potential to be extremely beneficial, not only to mental health, but to broader levels of both societal and individual functioning in everyday life (VanderWeele, 2017; Hone et al., 2014). When people are flourishing, they miss less work and face fewer physical limitations (REF). Additionally, having positive mental health is linked with many positive outcomes including problem-solving, productivity, and stress management (Jané-Llopis et al., 2005). These findings support that flourishing may act as a central indicator of human functioning, with determinants and outcomes which include and extend beyond physical and mental health (i.e., financial stability, sense of purpose; VanderWeele, 2017). Positive mental health or flourishing has, therefore, become an attractive concept within the domain of public health and (mental) health promotion. Even early advances in health promotion identified the importance of striving for positive health in an inclusive way. For example, the World Health Organization (WHO; 1986) emphasizes that good health promotion approaches focus on advocating for positive health, choosing programs that equally enable everyone to maximize their potential, and mediate the effects by getting the government and other stakeholders involved. Since then, positive mental health has been identified as both a key attribute and important outcome/aim of mental health promotion (Tamminen et al., 2016). Promoting positive mental health is widely recognized as central to successful mental health promotion efforts (Barry, 2001; Barry, 2009; Keyes, 2007; Kobau et al., 2011).

Figure 7 : The criteria for an individual to fit the definition of flourishing based on the characteristics that make up the 3 types of well-being- Psychological, Social and Emotional (Keyes, 2014).

1.4.4 Overcoming barriers using an integrated approach

Despite the recognized importance of flourishing to mental health promotion, there remains many barriers to its study, practice, and implementation. While support for flourishing as a pathway to overall mental well-being is more extensive, research investigating implementation and evaluation of flourishing-aimed practice is limited (Keyes, 2010). This precludes clarity in identifying the most effective ways to implement and evaluate interventions and policies in promoting flourishing. These barriers will be discussed more in later chapters which focus on MHP programming across various settings, as well as MHP policy needs (i.e., Chapter 3). However, some existing barriers might also be addressed by integrating the largest existing bases of knowledge and practice relating to positive mental health and flourishing.

Although the term flourishing as positive mental health originates from positive psychology, positive mental health is a shared goal/concept within both positive psychology and public (mental) health promotion (Kobau et al., 2011). Additionally, the term flourishing in public health domains is used more loosely to extend beyond mental health and include optimal functioning across many social and personal domains (VanderWeele, 2017). Across both fields, positive mental health is viewed as the resource which permits social, emotional, and psychological functioning across multiple levels, but both fields also view, define, study, and aim to foster positive mental health in unique ways (Kobau et al., 2011). Positive psychology focuses on examining and identifying psychological assets (i.e., positive individual traits, emotions, relationships, and enabling institutions etc.) which permit individuals and communities to thrive and flourish (Kobau et al., 2011; Seligman & Csikszentmihalyi, 2000). In contrast, health promotion and public health efforts focus on building strong public policy, socio-ecological environments, personal skills, and health services to promote health (Kobau et al., 2011).

Given the many similarities and shared goals and concepts between these fields, there has been some opportunity for cooperative development, research and practice relating to flourishing in positive psychology, and positive mental health in the field of mental health promotion (Kobau et al., 2011; Keyes, 2010). However, the disconnect between these fields exacerbates existing limitations and barriers within each. For example, there are multiple different definitions and models of flourishing within positive psychology and limited research providing practical guidance for the implementation of interventions which promote flourishing (Hone et al., 2014; Keyes, 2010). Thus, conceptual differences in terminology and research gaps between fields contribute to lesser integration of flourishing research and practice into public health MHP efforts, which tend to focus on more social factors, than psychological (Kobau et al., 2011). The disconnect between fields therefore limits understanding of how both psychological and social components and factors come together to contribute to the promotion of positive mental health. However, many of the field-specific strengths and limitations complement one another, with strengths in positive psychology accounting for weaknesses in public health promotion and vice versa. The integration of more concepts, theory, and practice from positive psychology on flourishing and public health on positive mental health may advance and improve MHP efforts in building flourishing individuals, communities, and societies (Kobau et al., 2011; Tamminen et al., 2016).

1.4.5 Conclusion

This chapter summarizes the central concepts of this textbook and their origins, existing empirical evidence and theory supporting mental health promotion, and practical realities and implications for mental health promotion today. We’ve reviewed that mental health promotion is researched and practiced largely within a mental health promotion framework in the domain of public health, but also incorporates important influences from positive and community psychology. Mental health promotion has evolved with these fields, and with public understanding of mental health, to grow into a vital area of research and practice, with its own distinct features and outcomes. MHP informs how we can foster positive mental health across multiple socio-ecological levels and has benefits which extend to overall well-being and functioning of individuals, communities, and society at large. Integrating existing research and knowledge within the health promotion field, as well as beyond (i.e., positive psychology and flourishing) may guide future practice (i.e., policy and programming) and research adjustments needed to overcome barriers and advance the field.

About the authors

name: Alanna Kaser

institution: Dalhousie University

Alanna Kaser is an honors thesis student in the Department of Psychology and Neuroscience at Dalhousie University. Her research interests are on mental health and personality. She has previously published papers on mental health promotion, positive mental health, and perfectionism.

name: Megan Sponagle

Megan Sponagle is an honors thesis student in the Department of Psychology and Neuroscience at Dalhousie University. Her research interests are on individual strengths that contribute to healthy and happy lives. Her undergraduate thesis examines students’ perceptions of mattering on campus. She plans to become an occupational therapist.

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REVIEW article

Mental health prevention and promotion—a narrative review.

$\nVijender Singh$

Department of Psychiatry, All India Institute of Medical Sciences Bhopal, Bhopal, India

Extant literature has established the effectiveness of various mental health promotion and prevention strategies, including novel interventions. However, comprehensive literature encompassing all these aspects and challenges and opportunities in implementing such interventions in different settings is still lacking. Therefore, in the current review, we aimed to synthesize existing literature on various mental health promotion and prevention interventions and their effectiveness. Additionally, we intend to highlight various novel approaches to mental health care and their implications across different resource settings and provide future directions. The review highlights the (1) concept of preventive psychiatry, including various mental health promotions and prevention approaches, (2) current level of evidence of various mental health preventive interventions, including the novel interventions, and (3) challenges and opportunities in implementing concepts of preventive psychiatry and related interventions across the settings. Although preventive psychiatry is a well-known concept, it is a poorly utilized public health strategy to address the population's mental health needs. It has wide-ranging implications for the wellbeing of society and individuals, including those suffering from chronic medical problems. The researchers and policymakers are increasingly realizing the potential of preventive psychiatry; however, its implementation is poor in low-resource settings. Utilizing novel interventions, such as mobile-and-internet-based interventions and blended and stepped-care models of care can address the vast mental health need of the population. Additionally, it provides mental health services in a less-stigmatizing and easily accessible, and flexible manner. Furthermore, employing decision support systems/algorithms for patient management and personalized care and utilizing the digital platform for the non-specialists' training in mental health care are valuable additions to the existing mental health support system. However, more research concerning this is required worldwide, especially in the low-and-middle-income countries.

Introduction

Mental disorder has been recognized as a significant public health concern and one of the leading causes of disability worldwide, particularly with the loss of productive years of the sufferer's life ( 1 ). The Global Burden of Disease report (2019) highlights an increase, from around 80 million to over 125 million, in the worldwide number of Disability-Adjusted Life Years (DALYs) attributable to mental disorders. With this surge, mental disorders have moved into the top 10 significant causes of DALYs worldwide over the last three decades ( 2 ). Furthermore, this data does not include substance use disorders (SUDs), which, if included, would increase the estimated burden manifolds. Moreover, if the caregiver-related burden is accounted for, this figure would be much higher. Individual, social, cultural, political, and economic issues are critical mental wellbeing determinants. An increasing burden of mental diseases can, in turn, contribute to deterioration in physical health and poorer social and economic growth of a country ( 3 ). Mental health expenditure is roughly 3–4% of their Gross Domestic Products (GDPs) in developed regions of the world; however, the figure is abysmally low in low-and-middle-income countries (LMICs) ( 4 ). Untreated mental health and behavioral problems in childhood and adolescents, in particular, have profound long-term social and economic adverse consequences, including increased contact with the criminal justice system, lower employment rate and lesser wages among those employed, and interpersonal difficulties ( 5 – 8 ).

Need for Mental Health (MH) Prevention

Longitudinal studies suggest that individuals with a lower level of positive wellbeing are more likely to acquire mental illness ( 9 ). Conversely, factors that promote positive wellbeing and resilience among individuals are critical in preventing mental illnesses and better outcomes among those with mental illness ( 10 , 11 ). For example, in patients with depressive disorders, higher premorbid resilience is associated with earlier responses ( 12 ). On the contrary, patients with bipolar affective- and recurrent depressive disorders who have a lower premorbid quality of life are at higher risk of relapses ( 13 ).

Recently there has been an increased emphasis on the need to promote wellbeing and positive mental health in preventing the development of mental disorders, for poor mental health has significant social and economic implications ( 14 – 16 ). Research also suggests that mental health promotion and preventative measures are cost-effective in preventing or reducing mental illness-related morbidity, both at the society and individual level ( 17 ).

Although the World Health Organization (WHO) defines health as “a state of complete physical, mental, and social wellbeing and not merely an absence of disease or infirmity,” there has been little effort at the global level or stagnation in implementing effective mental health services ( 18 ). Moreover, when it comes to the research on mental health (vis-a-viz physical health), promotive and preventive mental health aspects have received less attention vis-a-viz physical health. Instead, greater emphasis has been given to the illness aspect, such as research on psychopathology, mental disorders, and treatment ( 19 , 20 ). Often, physicians and psychiatrists are unfamiliar with various concepts, approaches, and interventions directed toward mental health promotion and prevention ( 11 , 21 ).

Prevention and promotion of mental health are essential, notably in reducing the growing magnitude of mental illnesses. However, while health promotion and disease prevention are universally regarded concepts in public health, their strategic application for mental health promotion and prevention are often elusive. Furthermore, given the evidence of substantial links between psychological and physical health, the non-incorporation of preventive mental health services is deplorable and has serious ramifications. Therefore, policymakers and health practitioners must be sensitized about linkages between mental- and physical health to effectively implement various mental health promotive and preventive interventions, including in individuals with chronic physical illnesses ( 18 ).

The magnitude of the mental health problems can be gauged by the fact that about 10–20% of young individuals worldwide experience depression ( 22 ). As described above, poor mental health during childhood is associated with adverse health (e.g., substance use and abuse), social (e.g., delinquency), academic (e.g., school failure), and economic (high risk of poverty) adverse outcomes in adulthood ( 23 ). Childhood and adolescence are critical periods for setting the ground for physical growth and mental wellbeing ( 22 ). Therefore, interventions promoting positive psychology empower youth with the life skills and opportunities to reach their full potential and cope with life's challenges. Comprehensive mental health interventions involving families, schools, and communities have resulted in positive physical and psychological health outcomes. However, the data is limited to high-income countries (HICs) ( 24 – 28 ).

In contrast, in low and middle-income countries (LMICs) that bear the greatest brunt of mental health problems, including massive, coupled with a high treatment gap, such interventions remained neglected in public health ( 29 , 30 ). This issue warrants prompt attention, particularly when global development strategies such as Millennium Development Goals (MDGs) realize the importance of mental health ( 31 ). Furthermore, studies have consistently reported that people with socioeconomic disadvantages are at a higher risk of mental illness and associated adverse outcomes; partly, it is attributed to the inequitable distribution of mental health services ( 32 – 35 ).

Scope of Mental Health Promotion and Prevention in the Current Situation

Literature provides considerable evidence on the effectiveness of various preventive mental health interventions targeting risk and protective factors for various mental illnesses ( 18 , 36 – 42 ). There is also modest evidence of the effectiveness of programs focusing on early identification and intervention for severe mental diseases (e.g., schizophrenia and psychotic illness, and bipolar affective disorders) as well as common mental disorders (e.g., anxiety, depression, stress-related disorders) ( 43 – 46 ). These preventive measures have also been evaluated for their cost-effectiveness with promising findings. In addition, novel interventions such as digital-based interventions and novel therapies (e.g., adventure therapy, community pharmacy program, and Home-based Nurse family partnership program) to address the mental health problems have yielded positive results. Likewise, data is emerging from LMICs, showing at least moderate evidence of mental health promotion intervention effectiveness. However, most of the available literature and intervention is restricted mainly to the HICs ( 47 ). Therefore, their replicability in LMICs needs to be established and, also, there is a need to develop locally suited interventions.

Fortunately, there has been considerable progress in preventive psychiatry over recent decades, including research on it. In the light of these advances, there is an accelerated interest among researchers, clinicians, governments, and policymakers to harness the potentialities of the preventive strategies to improve the availability, accessibility, and utility of such services for the community.

The Concept of Preventive Psychiatry

Origins of preventive psychiatry.

The history of preventive psychiatry can be traced back to the early 1900's with the foundation of the national mental health association (erstwhile mental health association), the committee on mental hygiene in New York, and the mental health hygiene movement ( 48 ). The latter emphasized the need for physicians to develop empathy and recognize and treat mental illness early, leading to greater awareness about mental health prevention ( 49 ). Despite that, preventive psychiatry remained an alien concept for many, including mental health professionals, particularly when the etiology of most psychiatric disorders was either unknown or poorly understood. However, recent advances in our understanding of the phenomena underlying psychiatric disorders and availability of the neuroimaging and electrophysiological techniques concerning mental illness and its prognosis has again brought the preventive psychiatry in the forefront ( 1 ).

Levels of Prevention

The literal meaning of “prevention” is “the act of preventing something from happening” ( 50 ); the entity being prevented can range from the risk factors of the development of the illness, the onset of illness, or the recurrence of the illness or associated disability. The concept of prevention emerged primarily from infectious diseases; measures like mass vaccination and sanitation promotion have helped prevent the development of the diseases and subsequent fatalities. The original preventive model proposed by the Commission on Chronic Illness in 1957 included primary, secondary, and tertiary preventions ( 48 ).

The Concept of Primary, Secondary, and Tertiary Prevention

The stages of prevention target distinct aspects of the illness's natural course; the primary prevention acts at the stage of pre-pathogenesis, that is, when the disease is yet to occur, whereas the secondary and tertiary prevention target the phase after the onset of the disease ( 51 ). Primary prevention includes health promotion and specific protection, while secondary and tertairy preventions include early diagnosis and treatment and measures to decrease disability and rehabilitation, respectively ( 51 ) ( Figure 1 ).

Figure 1 . The concept of primary and secondary prevention [adopted from prevention: Primary, Secondary, Tertiary by Bauman et al. ( 51 )].

The primary prevention targets those individuals vulnerable to developing mental disorders and their consequences because of their bio-psycho-social attributes. Therefore, it can be viewed as an intervention to prevent an illness, thereby preventing mental health morbidity and potential social and economic adversities. The preventive strategies under it usually target the general population or individuals at risk. Secondary and tertiary prevention targets those who have already developed the illness, aiming to reduce impairment and morbidity as soon as possible. However, these measures usually occur in a person who has already developed an illness, therefore facing related suffering, hence may not always be successful in curing or managing the illness. Thus, secondary and tertiary prevention measures target the already exposed or diagnosed individuals.

The Concept of Universal, Selective, and Indicated Prevention

The classification of health prevention based on primary/secondary/tertiary prevention is limited in being highly centered on the etiology of the illness; it does not consider the interaction between underlying etiology and risk factors of an illness. Gordon proposed another model of prevention that focuses on the degree of risk an individual is at, and accordingly, the intensity of intervention is determined. He has classified it into universal, selective, and indicated prevention. A universal preventive strategy targets the whole population irrespective of individual risk (e.g., maintaining healthy, psychoactive substance-free lifestyles); selective prevention is targeted to those at a higher risk than the general population (socio-economically disadvantaged population, e.g., migrants, a victim of a disaster, destitute, etc.). The indicated prevention aims at those who have established risk factors and are at a high risk of getting the disease (e.g., family history of psychiatric illness, history of substance use, certain personality types, etc.). Nevertheless, on the other hand, these two classifications (the primary, secondary, and tertiary prevention; and universal, selective, and indicated prevention) have been intended for and are more appropriate for physical illnesses with a clear etiology or risk factors ( 48 ).

In 1994, the Institute of Medicine (IOM) Committee on Prevention of Mental Disorders proposed a new paradigm that classified primary preventive measures for mental illnesses into three categories. These are indicated, selected, and universal preventive interventions (refer Figure 2 ). According to this paradigm, primary prevention was limited to interventions done before the onset of the mental illness ( 48 ). In contrast, secondary and tertiary prevention encompasses treatment and maintenance measures ( Figure 2 ).

Figure 2 . The interventions for mental illness as classified by the Institute of Medicine (IOM) Committee on Prevention of Mental Disorders [adopted from Mrazek and Haggerty ( 48 )].

Although the boundaries between prevention and treatment are often more overlapping than being exclusive, the new paradigm can be used to avoid confusion stemming from the common belief that prevention can take place at all parts of mental health management ( 48 ). The onset of mental illnesses can be prevented by risk reduction interventions, which can involve reducing risk factors in an individual and strengthening protective elements in them. It aims to target modifiable factors, both risk, and protective factors, associated with the development of the illness through various general and specific interventions. These interventions can work across the lifespan. The benefits are not restricted to reduction or delay in the onset of illness but also in terms of severity or duration of illness ( 48 ).On the spectrum of mental health interventions, universal preventive interventions are directed at the whole population without identifiable risk factors. The interventions are beneficial for the general population or sub-groups. Prenatal care and childhood vaccination are examples of preventative measures that have benefited both physical and mental health. Selective preventive mental health interventions are directed at people or a subgroup with a significantly higher risk of developing mental disorders than the general population. Risk groups are those who, because of their vulnerabilities, are at higher risk of developing mental illnesses, e.g., infants with low-birth-weight (LBW), vulnerable children with learning difficulties or victims of maltreatment, elderlies, etc. Specific interventions are home visits and new-born day care facilities for LBW infants, preschool programs for all children living in resource-deprived areas, support groups for vulnerable elderlies, etc. Indicated preventive interventions focus on high-risk individuals who have developed minor but observable signs or symptoms of mental disorder or genetic risk factors for mental illness. However, they have not fulfilled the criteria of a diagnosable mental disorder. For instance, the parent-child interaction training program is an indicated prevention strategy that offers support to children whose parents have recognized them as having behavioral difficulties.

The overall objective of mental health promotion and prevention is to reduce the incidence of new cases, additionally delaying the emergence of mental illness. However, promotion and prevention in mental health complement each other rather than being mutually exclusive. Moreover, combining these two within the overall public health framework reduces stigma, increases cost-effectiveness, and provides multiple positive outcomes ( 18 ).

How Prevention in Psychiatry Differs From Other Medical Disorders

Compared to physical illnesses, diagnosing a mental illness is more challenging, particularly when there is still a lack of objective assessment methods, including diagnostic tools and biomarkers. Therefore, the diagnosis of mental disorders is heavily influenced by the assessors' theoretical perspectives and subjectivity. Moreover, mental illnesses can still be considered despite an individual not fulfilling the proper diagnostic criteria led down in classificatory systems, but there is detectable dysfunction. Furthermore, the precise timing of disorder initiation or transition from subclinical to clinical condition is often uncertain and inconclusive ( 48 ). Therefore, prevention strategies are well-delineated and clear in the case of physical disorders while it's still less prevalent in mental health parlance.

Terms, Definitions, and Concepts

The terms mental health, health promotion, and prevention have been differently defined and interpreted. It is further complicated by overlapping boundaries of the concept of promotion and prevention. Some commonly used terms in mental health prevention have been tabulated ( Table 1 ) ( 18 ).

Table 1 . Commonly used terms in mental health prevention.

Mental Health Promotion and Protection

The term “mental health promotion” also has definitional challenges as it signifies different things to different individuals. For some, it means the treatment of mental illness; for others, it means preventing the occurrence of mental illness; while for others, it means increasing the ability to manage frustration, stress, and difficulties by strengthening one's resilience and coping abilities ( 54 ). It involves promoting the value of mental health and improving the coping capacities of individuals rather than amelioration of symptoms and deficits.

Mental health promotion is a broad concept that encompasses the entire population, and it advocates for a strengths-based approach and tries to address the broader determinants of mental health. The objective is to eliminate health inequalities via empowerment, collaboration, and participation. There is mounting evidence that mental health promotion interventions improve mental health, lower the risk of developing mental disorders ( 48 , 55 , 56 ) and have socioeconomic benefits ( 24 ). In addition, it strives to increase an individual's capacity for psychosocial wellbeing and adversity adaptation ( 11 ).

However, the concepts of mental health promotion, protection, and prevention are intrinsically linked and intertwined. Furthermore, most mental diseases result from complex interaction risk and protective factors instead of a definite etiology. Facilitating the development and timely attainment of developmental milestones across an individual's lifespan is critical for positive mental health ( 57 ). Although mental health promotion and prevention are essential aspects of public health with wide-ranging benefits, their feasibility and implementation are marred by financial and resource constraints. The lack of cost-effectiveness studies, particularly from the LMICs, further restricts its full realization ( 47 , 58 , 59 ).

Despite the significance of the topic and a considerable amount of literature on it, a comprehensive review is still lacking that would cover the concept of mental health promotion and prevention and simultaneously discusses various interventions, including the novel techniques delivered across the lifespan, in different settings, and level of prevention. Therefore, this review aims to analyze the existing literature on various mental health promotion and prevention-based interventions and their effectiveness. Furthermore, its attempts to highlight the implications of such intervention in low-resource settings and provides future directions. Such literature would add to the existing literature on mental health promotion and prevention research and provide key insights into the effectiveness of such interventions and their feasibility and replicability in various settings.

Methodology

For the current review, key terms like “mental health promotion,” OR “protection,” OR “prevention,” OR “mitigation” were used to search relevant literature on Google Scholar, PubMed, and Cochrane library databases, considering a time period between 2000 to 2019 ( Supplementary Material 1 ). However, we have restricted our search till 2019 for non-original articles (reviews, commentaries, viewpoints, etc.), assuming that it would also cover most of the original articles published until then. Additionally, we included original papers from the last 5 years (2016–2021) so that they do not get missed out if not covered under any published review. The time restriction of 2019 for non-original articles was applied to exclude papers published during the Coronavirus disease (COVID-19) pandemic as the latter was a significant event, bringing about substantial change and hence, it warranted a different approach to cater to the MH needs of the population, including MH prevention measures. Moreover, the COVID-19 pandemic resulted in the flooding of novel interventions for mental health prevention and promotion, specifically targeting the pandemic and its consequences, which, if included, could have biased the findings of the current review on various MH promotion and prevention interventions.

A time frame of about 20 years was taken to see the effectiveness of various MH promotion and protection interventions as it would take substantial time to be appreciated in real-world situations. Therefore, the current paper has put greater reliance on the review articles published during the last two decades, assuming that it would cover most of the original articles published until then.

The above search yielded 320 records: 225 articles from Google scholar, 59 articles from PubMed, and 36 articles from the Cochrane database flow-diagram of records screening. All the records were title/abstract screened by all the authors to establish the suitability of those records for the current review; a bibliographic- and gray literature search was also performed. In case of any doubts or differences in opinion, it was resolved by mutual discussion. Only those articles directly related to mental health promotion, primary prevention, and related interventions were included in the current review. In contrast, records that discussed any specific conditions/disorders (post-traumatic stress disorders, suicide, depression, etc.), specific intervention (e.g., specific suicide prevention intervention) that too for a particular population (e.g., disaster victims) lack generalizability in terms of mental health promotion or prevention, those not available in the English language, and whose full text was unavailable were excluded. The findings of the review were described narratively.

Interventions for Mental Health Promotion and Prevention and Their Evidence

Various interventions have been designed for mental health promotion and prevention. They are delivered and evaluated across the regions (high-income countries to low-resource settings, including disaster-affiliated regions of the world), settings (community-based, school-based, family-based, or individualized); utilized different psychological constructs and therapies (cognitive behavioral therapy, behavioral interventions, coping skills training, interpersonal therapies, general health education, etc.); and delivered by different professionals/facilitators (school-teachers, mental health professionals or paraprofessionals, peers, etc.). The details of the studies, interventions used, and outcomes have been provided in Supplementary Table 1 . Below we provide the synthesized findings of the available research.

The majority of the available studies were quantitative and experimental. Randomized controlled trials comprised a sizeable proportion of the studies; others were quasi-experimental studies and, a few, qualitative studies. The studies primarily focussed on school students or the younger population, while others were explicitly concerned with the mental health of young females ( 60 ). Newer data is emerging on mental health promotion and prevention interventions for elderlies (e.g., dementia) ( 61 ). The majority of the research had taken a broad approach to mental health promotion ( 62 ). However, some studies have focused on universal prevention ( 63 , 64 ) or selective prevention ( 65 – 68 ). For instance, the Resourceful Adolescent Program (RAPA) was implemented across the schools and has utilized cognitive-behavioral and interpersonal therapies and reported a significant improvement in depressive symptoms. Some of the interventions were directed at enhancing an individual's characteristics like resilience, behavior regulation, and coping skills (ZIPPY's Friends) ( 69 ), while others have focused on the promotion of social and emotional competencies among the school children and attempted to reduce the gap in such competencies across the socio-economic classes (“Up” program) ( 70 ) or utilized expressive abilities of the war-affected children (Writing for Recover (WfR) intervention) ( 71 ) to bring about an improvement in their psychological problems (a type of selective prevention) ( 62 ) or harnessing the potential of Art, in the community-based intervention, to improve self-efficacy, thus preventing mental disorders (MAD about Art program) ( 72 ). Yet, others have focused on strengthening family ( 60 , 73 ), community relationships ( 62 ), and targeting modifiable risk factors across the life course to prevent dementia among the elderlies and also to support the carers of such patients ( 61 ).

Furthermore, more of the studies were conducted and evaluated in the developed parts of the world, while emerging economies, as anticipated, far lagged in such interventions or related research. The interventions that are specifically adapted for local resources, such as school-based programs involving paraprofessionals and teachers in the delivery of mental health interventions, were shown to be more effective ( 62 , 74 ). Likewise, tailored approaches for low-resource settings such as LMICs may also be more effective ( 63 ). Some of these studies also highlight the beneficial role of a multi-dimensional approach ( 68 , 75 ) and interventions targeting early lifespan ( 76 , 77 ).

Newer Insights: How to Harness Digital Technology and Novel Methods of MH Promotion and Protection

With the advent of digital technology and simultaneous traction on mental health promotion and prevention interventions, preventive psychiatrists and public health experts have developed novel techniques to deliver mental health promotive and preventive interventions. These encompass different settings (e.g., school, home, workplace, the community at large, etc.) and levels of prevention (universal, selective, indicated) ( 78 – 80 ).

The advanced technologies and novel interventions have broadened the scope of MH promotion and prevention, such as addressing the mental health issues of individuals with chronic medical illness ( 81 , 82 ), severe mental disorders ( 83 ), children and adolescents with mental health problems, and geriatric population ( 78 ). Further, it has increased the accessibility and acceptability of such interventions in a non-stigmatizing and tailored manner. Moreover, they can be integrated into the routine life of the individuals.

For instance, Internet-and Mobile-based interventions (IMIs) have been utilized to monitor health behavior as a form of MH prevention and a stand-alone self-help intervention. Moreover, the blended approach has expanded the scope of MH promotive and preventive interventions such as face-to-face interventions coupled with remote therapies. Simultaneously, it has given way to the stepped-care (step down or step-up care) approach of treatment and its continuation ( 79 ). Also, being more interactive and engaging is particularly useful for the youth.

The blended model of care has utilized IMIs to a varying degree and at various stages of the psychological interventions. This includes IMIs as a supplementary approach to the face-to-face-interventions (FTFI), FTFI augmented by behavior intervention technologies (BITs), BITs augmented by remote human support, and fully automated BITs ( 84 ).

The stepped care model of mental health promotion and prevention strategies includes a stepped-up approach, wherein BITs are utilized to manage the prodromal symptoms, thereby preventing the onset of the full-blown episode. In the Stepped-down approach, the more intensive treatments (in-patient or out-patient based interventions) are followed and supplemented with the BITs to prevent relapse of the mental illness, such as for previously admitted patients with depression or substance use disorders ( 85 , 86 ).

Similarly, the latest research has developed newer interventions for strengthening the psychological resilience of the public or at-risk individuals, which can be delivered at the level of the home, such as, e.g., nurse family partnership program (to provide support to the young and vulnerable mothers and prevent childhood maltreatment) ( 87 ); family healing together program aimed at improving the mental health of the family members living with persons with mental illness (PwMI) ( 88 ). In addition, various novel interventions for MH promotion and prevention have been highlighted in the Table 2 .

Table 2 . Depiction of various novel mental health promotion and prevention strategies.

Furthermore, school/educational institutes-based interventions such as school-Mental Health Magazines to increase mental health literacy among the teachers and students have been developed ( 80 ). In addition, workplace mental health promotional activities have targeted the administrators, e.g., guided “e-learning” for the managers that have shown to decrease the mental health problems of the employees ( 102 ).

Likewise, digital technologies have also been harnessed in strengthening community mental health promotive/preventive services, such as the mental health first aid (MHFA) Books on Prescription initiative in New Zealand provided information and self-help tools through library networks and trained book “prescribers,” particularly in rural and remote areas ( 103 ).

Apart from the common mental disorders such as depression, anxiety, and behavioral disorders in the childhood/adolescents, novel interventions have been utilized to prevent the development of or management of medical, including preventing premature mortality and psychological issues among the individuals with severe mental illnesses (SMIs), e.g., Lets' talk about tobacco-web based intervention and motivational interviewing to prevent tobacco use, weight reduction measures, and promotion of healthy lifestyles (exercise, sleep, and balanced diets) through individualized devices, thereby reducing the risk of cardiovascular disorders ( 83 ). Similarly, efforts have been made to improve such individuals' coping skills and employment chances through the WorkingWell mobile application in the US ( 104 ).

Apart from the digital-based interventions, newer, non-digital-based interventions have also been utilized to promote mental health and prevent mental disorders among individuals with chronic medical conditions. One such approach in adventure therapy aims to support and strengthen the multi-dimensional aspects of self. It includes the physical, emotional or cognitive, social, spiritual, psychological, or developmental rehabilitation of the children and adolescents with cancer. Moreover, it is delivered in the natural environment outside the hospital premises, shifting the focus from the illness model to the wellness model ( 81 ). Another strength of this intervention is it can be delivered by the nurses and facilitate peer support and teamwork.

Another novel approach to MH prevention is gut-microbiota and dietary interventions. Such interventions have been explored with promising results for the early developmental disorders (Attention deficit hyperactive disorder, Autism spectrum disorders, etc.) ( 105 ). It works under the framework of the shared vulnerability model for common mental disorders and other non-communicable diseases and harnesses the neuroplasticity potential of the developing brain. Dietary and lifestyle modifications have been recommended for major depressive disorders by the Clinical Practice Guidelines in Australia ( 106 ). As most childhood mental and physical disorders are determined at the level of the in-utero and early after the birth period, targeting maternal nutrition is another vital strategy. The utility has been expanded from maternal nutrition to women of childbearing age. The various novel mental health promotion and prevention strategies are shown in Table 2 .

Newer research is emerging that has utilized the digital platform for training non-specialists in diagnosis and managing individuals with mental health problems, such as Atmiyata Intervention and The SMART MH Project in India, and The Allillanchu Project in Peru, to name a few ( 99 ). Such frameworks facilitate task-sharing by the non-specialist and help in reducing the treatment gap in these countries. Likewise, digital algorithms or decision support systems have been developed to make mental health services more transparent, personalized, outcome-driven, collaborative, and integrative; one such example is DocuMental, a clinical decision support system (DSS). Similarly, frameworks like i-PROACH, a cloud-based intelligent platform for research outcome assessment and care in mental health, have expanded the scope of the mental health support system, including promoting research in mental health ( 100 ). In addition, COVID-19 pandemic has resulted in wider dissemination of the applications based on the evidence-based psycho-social interventions such as National Health Service's (NHS's) Mind app and Headspace (teaching meditation via a website or a phone application) that have utilized mindfulness-based practices to address the psychological problems of the population ( 101 ).

Challenges in Implementing Novel MH Promotion and Prevention Strategies

Although novel interventions, particularly internet and mobile-based interventions (IMIs), are effective models for MH promotion and prevention, their cost-effectiveness requires further exploration. Moreover, their feasibility and acceptability in LMICs could be challenging. Some of these could be attributed to poor digital literacy, digital/network-related limitations, privacy issues, and society's preparedness to implement these interventions.

These interventions need to be customized and adapted according to local needs and context, for which implementation and evaluative research are warranted. In addition, the infusion of more human and financial resources for such activities is required. Some reports highlight that many of these interventions do not align with the preferences and use the pattern of the service utilizers. For instance, one explorative research on mental health app-based interventions targeting youth found that despite the burgeoning applications, they are not aligned with the youth's media preferences and learning patterns. They are less interactive, have fewer audio-visual displays, are not youth-specific, are less dynamic, and are a single touch app ( 107 ).

Furthermore, such novel interventions usually come with high costs. In low-resource settings where service utilizers have limited finances, their willingness to use such services may be doubtful. Moreover, insurance companies, including those in high-income countries (HICs), may not be willing to fund such novel interventions, which restricts the accessibility and availability of interventions.

Research points to the feasibility and effectiveness of incorporating such novel interventions in routine services such as school, community, primary care, or settings, e.g., in low-resource settings, the resource persons like teachers, community health workers, and primary care physicians are already overburdened. Therefore, their willingness to take up additional tasks may raise skepticism. Moreover, the attitudinal barrier to moving from the traditional service delivery model to the novel methods may also impede.

Considering the low MH budget and less priority on the MH prevention and promotion activities in most low-resource settings, the uptake of such interventions in the public health framework may be lesser despite the latter's proven high cost-effectiveness. In contrast, policymakers may be more inclined to invest in the therapeutic aspects of MH.

Such interventions open avenues for personalized and precision medicine/health care vs. the traditional model of MH promotion and preventive interventions ( 108 , 109 ). For instance, multivariate prediction algorithms with methods of machine learning and incorporating biological research, such as genetics, may help in devising tailored, particularly for selected and indicated prevention, interventions for depression, suicide, relapse prevention, etc. ( 79 ). Therefore, more research in this area is warranted.

To be more clinically relevant, greater biological research in MH prevention is required to identify those at higher risk of developing given mental disorders due to the existing risk factors/prominent stress ( 110 ). For instance, researchers have utilized the transcriptional approach to identify a biological fingerprint for susceptibility (denoting abnormal early stress response) to develop post-traumatic stress disorders among the psychological trauma survivors by analyzing the expression of the Peripheral blood mononuclear cell gene expression profiles ( 111 ). Identifying such biological markers would help target at-risk individuals through tailored and intensive interventions as a form of selected prevention.

Similarly, such novel interventions can help in targeting the underlying risk such as substance use, poor stress management, family history, personality traits, etc. and protective factors, e.g., positive coping techniques, social support, resilience, etc., that influences the given MH outcome ( 79 ). Therefore, again, it opens the scope of tailored interventions rather than a one-size-fits-all model of selective and indicated prevention for various MH conditions.

Furthermore, such interventions can be more accessible for the hard-to-reach populations and those with significant mental health stigma. Finally, they play a huge role in ensuring the continuity of care, particularly when community-based MH services are either limited or not available. For instance, IMIs can maintain the improvement of symptoms among individuals previously managed in-patient, such as for suicide, SUDs, etc., or receive intensive treatment like cognitive behavior therapy (CBT) for depression or anxiety, thereby helping relapse prevention ( 86 , 112 ). Hence, such modules need to be developed and tested in low-resource settings.

IMIs (and other novel interventions) being less stigmatizing and easily accessible, provide a platform to engage individuals with chronic medical problems, e.g., epilepsy, cancer, cardiovascular diseases, etc., and non-mental health professionals, thereby making it more relevant and appealing for them.

Lastly, research on prevention-interventions needs to be more robust to adjust for the pre-intervention matching, high attrition rate, studying the characteristics of treatment completers vs. dropouts, and utilizing the intention-to-treat analysis to gauge the effect of such novel interventions ( 78 ).

Recommendations for Low-and-Middle-Income Countries

Although there is growing research on the effectiveness and utility of mental health promotion/prevention interventions across the lifespan and settings, low-resource settings suffer from specific limitations that restrict the full realization of such public health strategies, including implementing the novel intervention. To overcome these challenges, some of the potential solutions/recommendations are as follows:

• The mental health literacy of the population should be enhanced through information, education, and communication (IEC) activities. In addition, these activities should reduce stigma related to mental problems, early identification, and help-seeking for mental health-related issues.

• Involving teachers, workplace managers, community leaders, non-mental health professionals, and allied health staff in mental health promotion and prevention is crucial.

• Mental health concepts and related promotion and prevention should be incorporated into the education curriculum, particularly at the medical undergraduate level.

• Training non-specialists such as community health workers on mental health-related issues across an individual's life course and intervening would be an effective strategy.

• Collaborating with specialists from other disciplines, including complementary and alternative medicines, would be crucial. A provision of an integrated health system would help in increasing awareness, early identification, and prompt intervention for at-risk individuals.

• Low-resource settings need to develop mental health promotion interventions such as community-and school-based interventions, as these would be more culturally relevant, acceptable, and scalable.

• Utilizing a digital platform for scaling mental health services (e.g., telepsychiatry services to at-risk populations) and training the key individuals in the community would be a cost-effective framework that must be explored.

• Infusion of higher financial and human resources in this area would be a critical step, as, without adequate resources, research, service development, and implementation would be challenging.

• It would also be helpful to identify vulnerable populations and intervene in them to prevent the development of clinical psychiatric disorders.

• Lastly, involving individuals with lived experiences at the level of mental health planning, intervention development, and delivery would be cost-effective.

Clinicians, researchers, public health experts, and policymakers have increasingly realized mental health promotion and prevention. Investment in Preventive psychiatry appears to be essential considering the substantial burden of mental and neurological disorders and the significant treatment gap. Literature suggests that MH promotive and preventive interventions are feasible and effective across the lifespan and settings. Moreover, various novel interventions (e.g., internet-and mobile-based interventions, new therapies) have been developed worldwide and proven effective for mental health promotion and prevention; such interventions are limited mainly to HICs.

Despite the significance of preventive psychiatry in the current world and having a wide-ranging implication for the wellbeing of society and individuals, including those suffering from chronic medical problems, it is a poorly utilized public health field to address the population's mental health needs. Lately, researchers and policymakers have realized the untapped potentialities of preventive psychiatry. However, its implementation in low-resource settings is still in infancy and marred by several challenges. The utilization of novel interventions, such as digital-based interventions, and blended and stepped-care models of care, can address the enormous mental health need of the population. Additionally, it provides mental health services in a less-stigmatizing and easily accessible, and flexible manner. More research concerning this is required from the LMICs.

Author Contributions

VS, AK, and SG: methodology, literature search, manuscript preparation, and manuscript review. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.898009/full#supplementary-material

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Keywords: mental health, promotion, prevention, protection, intervention, review, preventive psychiatry, novel interventions

Citation: Singh V, Kumar A and Gupta S (2022) Mental Health Prevention and Promotion—A Narrative Review. Front. Psychiatry 13:898009. doi: 10.3389/fpsyt.2022.898009

Received: 16 March 2022; Accepted: 08 June 2022; Published: 26 July 2022.

Reviewed by:

Copyright © 2022 Singh, Kumar and Gupta. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Snehil Gupta, snehil2161@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Int J Environ Res Public Health

Promotion of Mental Health Literacy in Adolescents: A Scoping Review

Joana nobre.

1 Health School, Polytechnic Institute of Portalegre, 7300-555 Portalegre, Portugal; tp.ergelatroppi@arieviloaluap (A.P.O.); tp.ergelatroppi@orietnomocsicnarf (F.M.)

2 Corporate Public Entity, Local Health Unit of North Alentejo, 7300-126 Portalegre, Portugal

3 Faculty of Nursing, University of Rovira i Virgili, 43003 Tarragona, Spain; [email protected]

Ana Paula Oliveira

Francisco monteiro, carlos sequeira.

4 Group Inovation & Development in Nursing (NursID), Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), 4200-450 Porto, Portugal; tp.fnese@arieuqessolrac

5 Nursing School of Porto, 4200-072 Porto, Portugal

Carme Ferré-Grau

Associated data.

Data sharing does not apply to this article as no new data were created or analysed in this study.

In recent years, there has been an important commitment to the development of programs to promote mental health literacy (MHL) among adolescents, due to the prevalence of mental health problems and the low level of MHL that affects this group. The aim of this study was to map the structure and context of programmes/interventions for promoting MHL among adolescents in school settings. A scoping review was conducted following the guidelines of The Joanna Briggs Institute. We searched for studies on programmes/interventions promoting at least one of the components of MHL of adolescents, written in Portuguese, English or Spanish, published from 2013 to 2020, in MEDLINE, CINAHL Plus with Full Text, SciELO, SCOPUS, OpenGrey, RCAAP and in the article reference lists. This review included 29 articles. The majority of programmes/interventions addressed one or more of the four components of MHL, with the knowledge of mental disorders and stigma reduction components being the most covered; were taught by adolescent’s regular teachers; used face to face interventions; had a height variable duration; used non-validated instruments; were implemented in a classroom environment; and showed statistically significant improvements in adolescent’s MHL levels. More research is needed to implement/construct programmes/interventions promoting adolescents’ MHL concerning knowledge on how to obtain and maintain good mental health.

1. Introduction

The world is currently facing a very challenging public health problem: the significant prevalence of mental health problems in the general population and adolescents and young people [ 1 , 2 ], as well as their low/moderate levels of mental health literacy [ 3 , 4 , 5 ].

Mental health problems account for 12% of illnesses worldwide, and in developed countries, the figure rises to 23% [ 6 ]. As far as children and adolescents are concerned, around 10–20% are affected by these types of problems worldwide [ 7 , 8 ], with most of these problems onsetting during early adulthood and adolescence [ 9 ]. The first episode may occur before the age of 14 [ 8 ], with about half of the cases that appear throughout life appearing to settle at this age, as reported by Kessler’s study in 2005 [ 10 ].

The literature so far shows us that the levels of mental health literacy (MHL) of the general population and adolescents have been progressively increasing but are still at low/moderate levels [ 3 , 4 , 5 ]. This contributes to the absence of help seeking by adolescents, affects their development and increases the risk of psychiatric disorders recurring [ 11 , 12 , 13 ].

The concept of MHL is not recent. It emerged in the late 1990s through the investigations of Jorm and colleagues [ 14 ]. They defined it as the knowledge and beliefs about mental disorders that aid their recognition, management and prevention. Since then, researchers worldwide have shown a growing interest in this phenomenon (MHL), leading to the evolution of the definition of the concept. Currently, MHL refers to the knowledge and skills needed to foster mental health [ 15 ]. MHL has four components: understanding how to achieve and maintain good mental health, understanding mental disorders and their treatments, decreasing the stigma related to mental disorders and increasing the effectiveness of help seeking [ 16 , 17 ].

In this review, we adopted the WHO definition of mental health [ 18 ], which conceptualizes it as something more than the absence of disease; rather, it considers that it “is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community” (p. 38). Another concept that is important to define is mental disorders, which encompasses several mental problems “generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others” [ 18 ] (p. 38). Regarding stigma, in this review, it is understood as “a mark of shame, disgrace or disapproval which results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society” [ 19 ] (p. 18). We consider that the concept of help seeking “is an adaptive coping process that is the attempt to obtain external assistance to deal with a mental health concern” [ 20 ] (p. 180), including formal (health professionals, etc.) or informal sources (friends, family, etc.), encompassing not only the self-help strategies but also the first aid skills to support others [ 15 ]. It is also important to clarify that in this review, the authors consider that knowledge on achieving/maintaining good mental health comprises how to prevent mental disorders and promote mental health, such as having stable friendships and family support, to sleep enough, practice exercise, think in a positive way, avoid substance abuse, to have meaningful and enjoyable activities and relax [ 15 ]. According to the World Health Organization [ 8 ], adolescence encompasses all individuals aged between 10 and 19 years. It is the period in the life cycle between childhood and adulthood, characterised by profound physical and mental changes, during which attitudes develop and can still be changed [ 21 , 22 ]. Therefore, adolescence is considered a crucial period of opportunity to promote mental health [ 18 ]. Better literacy at a young age has a direct and positive impact on adult life. It enables adolescents to acquire the knowledge and define the attitudes and behaviours that will accompany them in their future lives [ 7 , 23 ]. Specifically, it gives adolescents the ability to positively manage their thoughts and emotions to build healthy social and family relationships, all based on a strong, positive sense of identity. Therefore, without a good level of MHL, adolescents will not develop healthily as they grow to adulthood [ 7 , 17 ], because without the knowledge and skills necessary to prevent the onset of mental disorders and to promote good mental health, these disorders are more likely to set in during adolescence and perpetuate themselves chronically. For this reason, adolescents are a primary target population for the promotion of MHL.

The World Health Organization [ 18 ] defined in its Mental Health Action Plan 2013–2020 that one of the objectives to attain at a global level is to implement strategies for the promotion and prevention of mental health problems, highlighting the importance of intervening not only on the needs of people with defined mental disorders but also on the protection and promotion of the mental health of all citizens. One such strategy is mental health literacy.

Given the significant prevalence of mental health problems in adolescence and low/modest levels of MHL, there is a need to explore the currently available evidence regarding programmes/interventions to promote MHL among adolescents. To this end, we chose to perform a scoping review which we considered to be the most appropriate methodology, given the objective of this type of review: to map the existing evidence in relation to a particular area or topic; to assess the reliability, relevance and potential costs of conducting a systematic literature review; to provide a synthesis of research findings and disseminate them; and to identify potential gaps in the existing literature [ 24 , 25 , 26 , 27 ].

After a preliminary survey was conducted in September 2019 in the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, the CINAHL and in MEDLINE (via EBSCO); two systematic reviews of the literature were found in this area [ 23 , 28 ]. The systematic review by Wei et al. [ 28 ] included 27 articles published between 1988 and 2010. The authors concluded that there is little evidence of the effectiveness of programmes promoting MHL in schools. However, the interventions studied seemed promising as they showed positive results in the three outcomes studied (knowledge, attitudes/stigma and help-seeking behaviours). Concerning the systematic review by Morgado and Botelho [ 23 ], this included three studies, published between 2008 and 2012, with the authors concluding that cognitive–behavioural intervention, psycho–educational intervention and educational intervention are promoters of MHL and that school is the best means for promoting MHL, leaving as a future recommendation the importance of developing interventions in this area that are previously validated through pilot studies and then implemented more comprehensively.

Because in recent years, investment in developing programmes promoting MHL in adolescents has taken place, we felt the need to carry out this new scoping review to explore the existing evidence, from 2013, regarding adolescents’ MHL-promoting programmes/interventions, and to understand the characteristics of these programmes and the barriers/facilitators to their implementation, seeking to include published and unpublished studies.

This scoping review aims to map the structure and context of programmes/interventions for promoting MHL among adolescents in school settings, both at the level of published academic literature and grey literature.

The following primary research question was formulated to guide this study:

What are the programmes/interventions for promoting MHL among adolescents in school settings?

In addition to this, the following secondary research questions were posed:

What are the characteristics of the programmes/interventions for promoting MHL among adolescents highlighted in the literature?
In what settings/contexts are these programmes/interventions carried out?
What are the barriers and facilitators to the implementation of these programmes/interventions?

2. Materials and Methods

This scoping review follows the guidelines of The Joana Briggs Institute [ 26 , 27 ]. We used the checklist PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) for writing the review report [ 29 ].

The scoping review protocol was registered in the Open Science Framework on 10 November 2019 and is available for consultation [ 30 ].

2.1. Inclusion Criteria

Taking into account the questions formulated to guide this scoping review and using the PCC strategy—Participants, Concept, Context [ 26 , 27 ]—the following inclusion criteria were defined:

Participants—articles targeting adolescents aged between 10 and 19 years, without diagnosed mental illness;
Concept—studies on programmes/interventions for promoting MHL, covering at least one of the components of MHL;
Context—we accepted studies that included adolescents in a school setting (2nd and 3rd cycles of basic education and secondary education, which corresponds to 5–12th grade), including online intervention and/or face to face intervention.

Concerning the types of studies, published and unpublished primary and secondary studies were included in this review to access a wider range of available information. We included studies written in Portuguese, Spanish or English, since these are languages in which the reviewers are proficient. We considered studies published from 2013 to 2020 to have only articles with the most recent evidence.

2.2. Search Strategy

As defined in the guidelines of The Joanna Briggs Institute [ 26 , 27 ], this scoping review was conducted in three stages.

In the first stage, an initial search limited to two electronic scientific databases was conducted (MEDLINE and CINAHL Plus with Full Text), using MESH (Medical Subject Headings) descriptors in the following Boolean phrase: (adolescent * AND ‘mental health’ AND literacy AND ‘health literacy’ AND program * AND nursing). This search was followed by an analysis of the terms used in the titles and abstracts of the articles found to identify all relevant terms associated, and to define the final Boolean phrase: (adolescent * AND ‘mental health’ AND (literacy OR ‘health literacy’ OR ‘mental health literacy’) AND (program * OR course * OR intervention *) AND promotion AND school *), where all terms are MESH terms except for ‘mental health literacy’, course*, intervention * and promotion, which are words from the general language.

It should be noted that, at this stage, we needed to introduce two small changes to what we had planned in the protocol of this scoping review. Specifically, we had to remove the term ‘nursing’ from the search strings since we found in the various search attempts that it could be reductive to the search, since we were exploring the existing programmes/interventions. The other change was to add four natural language terms suggested by the databases consulted (mental health literacy, course, intervention and promotion).

In the second stage, we searched the electronic scientific databases MEDLINE, CINAHL Plus with Full Text, SciELO, and SCOPUS, using the final Boolean phrase defined in the previous step: (adolescent * AND ‘mental health’ AND (literacy OR ‘health literacy’ OR ‘mental health literacy’) AND (program * OR course * OR intervention *) AND promotion AND school *), retrospectively from 1 January 2013 to 31 July 2020. In the electronic repositories OpenGrey (a European repository) and RCAAP (the Open Access Scientific Repository of Portugal), the search was carried out using a shorter Boolean phrase: adolescent * AND ‘mental health’ AND school *, using the same period, and MESH and DECS (Descriptors in Health Science) terms as descriptors. The search in both databases and repositories was conducted in December 2019 and updated in August 2020 ( Table 1 and Table 2 ).

Studies obtained by search term and electronic database.

* Search term with truncation.

Studies obtained by search term and repository.

Abbreviations: RCAAP, the Open Access Scientific Repository of Portugal. * Search term with truncation.

In the third stage, the reference lists of all articles included in the second stage were analysed, and additional relevant articles were identified and included in this scoping review.

2.3. Selection of the Studies

The studies obtained were imported and processed using the bibliographic reference management software Mendeley Desktop ® version 1.19.4. (Elsevier, Amsterdam, Netherlands) and Microsoft ® Excel 365 (Microsoft Corporation, Redmond, WA, USA).

The selection process consisted of two levels of screening of the articles obtained: (1) a review of the title and abstract and (2) a review of the full text.

The article selection process was carried out independently by two researchers, considering the previously defined eligibility criteria. In situations of disagreement between the researchers, the intervention of a third researcher was requested to reach a consensus. The full text was reviewed in cases in which the title and abstract did not contain sufficient information for an adequate decision.

2.4. Data Extraction

Data were extracted from the articles with a full-text format that met the inclusion criteria, using an instrument created by the reviewers ( Appendix A , Table A1 ), according to the model proposed by The Joanna Briggs Institute [ 26 , 27 ] and aligned with the objectives and questions of the review. Data extracted from the articles were as follows: author(s), year of publication, country, objective(s) of the study, study design, participants, characteristics of the programmes/interventions implemented, data collection instruments used, main outcomes and barriers/facilitators. Any disagreements between the reviewers were resolved through discussion or with the use of a third-party investigator.

In the beginning, 104 articles were found in the search in the four databases and the two repositories consulted. After removing the duplicates and applying all the procedures, 29 articles were obtained. The results of the article selection process are summarised in Figure 1 in a PRISMA diagram [ 31 ].

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Article search and selection process—PRISMA diagram.

The list of included studies and the description of their characteristics are shown in Table S1 (Supplementary Material) . The studies included according to the components of MHL are in Table 3 .

List of studies included in the review according to the components of MHL.

Abbreviations: MH, mental health; MHL, mental health literacy; UK, United Kingdom; USA, United States of America.

The articles included in the review were published from 2013 to 2020. Seven articles were published in 2016, five articles in 2014, five articles in 2018, four articles in 2015, three articles in 2013, two articles in 2019, two articles in 2020 and one article in 2017.

Of the 29 articles included, twelve were experimental studies (of which two were study protocols and two were pilot studies), nine were quasi-experimental studies (two of which were pilot studies), three were descriptive articles, two were secondary analyses, two were systematic reviews of the literature and one was a mixed study (pilot study).

3.1. Component—Knowledge on Achieving/Maintaining Good Mental Health

Of the eight articles addressing knowledge on how to obtain/maintain good mental health, two were experimental studies [ 32 , 33 ], two were quasi-experimental [ 34 , 35 ], two were descriptive articles [ 36 , 37 ] and two were secondary analyses [ 38 , 39 ].

The participants in the programmes/interventions were adolescents aged 10 to 18 years. In five of those programmes, the adolescents were aged ≤14 years.

The duration of the programmes/interventions in these eight studies ranged from a single 3 h session to multiple sessions that could run up to a total of approximately 24 h.

The assessment instruments used were mostly developed by the authors of the programmes/interventions ( n = 4), followed by the combined use of validated instruments with instruments developed by the authors ( n = 2) and the use of validated instruments ( n = 1). One of the studies did not mention the instruments used.

After examining the assessment moments, we found that all the studies assessed the programmes/interventions at baseline ( n = 8), five performed the assessment immediately after, one ( n = 1) performed the assessment after 2 weeks and one ( n = 1) performed the assessment after 3 months. A follow-up stage was mentioned in five studies. Two studies implemented a follow-up at 2 months, two studies at 6 months and one study at 6 and 12 months.

Regarding the results, all studies referred to increased knowledge, but upon close examination, they only assessed knowledge about mental disorders.

It is worth noting that four of these articles referred to the same programme (“The Guide”) implemented in the same country (Canada). Still, the samples were different in terms of the ages of the participants or the country’s regions.

3.2. Component—Knowledge about Mental Disorders and Their Treatments

Twenty-four articles addressed programmes/interventions that aim to promote knowledge about mental disorders and their treatments, of which ten were experimental studies [ 32 , 33 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ], seven were quasi-experimental studies [ 34 , 35 , 48 , 49 , 50 , 51 , 52 ], three were descriptive articles [ 36 , 37 , 53 ], two were secondary analyses [ 38 , 39 ], one was a mixed study [ 22 ] and one was a systematic literature review [ 54 ].

The participants in these programmes/interventions were adolescents whose ages ranged from 10 to 18 years, with most studies targeting adolescents aged 14 years or younger.

Regarding the programme/intervention duration, there was wide variability, from a single 45 min session to multiple sessions. Only two studies did not mention the duration of their programmes/interventions.

The programmes/interventions in this component of MHL used mostly assessment tools developed by the authors ( n = 10). Other programmes/interventions used validated instruments ( n = 7), or combined validated and own instruments ( n = 4). Only three studies did not mention the instruments used.

Three studies did not mention any information concerning the assessment moments. Of the remaining twenty-one, all were assessed at baseline, thirteen were assessed immediately after the intervention, three were assessed after 3 months, two studies were assessed after 2 weeks, two studies were assessed after 1 week and one study was assessed after 6 weeks. The follow-up period was included in thirteen studies, of which four studies at 6 months, three studies at 3 months, two studies at 2 months, two studies at 6 and 12 months, one study at 4 months and one study at 12 and 24 months. It should also be noted that most studies present 3 moments of assessment ( n = 10), followed by those with 2 moments ( n = 8) and with 4 moments ( n = 3).

In terms of the results, most programmes/interventions report increased knowledge about mental disorders and their treatments ( n = 18), the results of which are statistically significant, and only one study reports that the increase in knowledge was slight, in which the results are not statistically significant [ 47 ]. Some studies that contemplate this category did not refer to the related results ( n = 5).

3.3. Component—Reducing Stigma Associated with Mental Disorders

Of the 24 articles that address programs/interventions whose objective is to reduce the stigma, ten were experimental studies [ 32 , 33 , 42 , 43 , 44 , 45 , 46 , 47 , 55 , 56 ], six were quasi-experimental [ 35 , 48 , 49 , 50 , 57 , 58 ], three were descriptive articles [ 36 , 37 , 53 ], two were secondary analyses [ 38 , 39 ], two were systematic reviews of the literature [ 54 , 59 ] and one is a mixed study [ 22 ].

The participants of the studies encompassed in this MHL category were aged 10 to 18 years, with most of the studies targeting adolescents aged ≤14 years.

The duration of these programmes/interventions ranged from a single 10 min session to multiple sessions, up to 4 months. Only two studies did not mention the duration of their programmes/interventions.

Most studies used validated assessment instruments ( n = 10) to assess the programmes/interventions. Other studies used their own instruments ( n = 8) or a combination of validated and their own instruments ( n = 3). Only three studies did not mention the instruments used.

In four studies, the time points of intervention assessment were not mentioned. All the remaining twenty studies assessed the programmes/interventions at baseline. Twelve studies assessed the programmes/interventions immediately after the intervention; three assessed after 3 months, two studies after 2 weeks, two studies after 1 week and one study after 6 weeks. A follow-up period was contemplated in eleven studies. Of these, three studies implemented a follow-up at 6 months, two studies at 3 months, two studies at 2 months, two studies at 1 month and one study at 6 and 12 months.

Most of the programmes/interventions ( n = 19) achieved a reduction in the stigma associated with mental disorders, and two studies did not register any change after implementing the programme/intervention. Those two studies were also the ones whose results were not statistically significant [ 45 , 57 ]. Three studies did not refer to the results of this component.

3.4. Component—Help-Seeking

Fifteen articles addressed programmes/interventions that aimed to promote help-seeking, of which seven were experimental studies [ 32 , 40 , 41 , 43 , 44 , 46 , 47 ], five were quasi-experimental studies [ 35 , 48 , 50 , 51 , 52 ], one was a descriptive article [ 53 ], one was a mixed study [ 22 ] and one was a systematic literature review [ 54 ].

The participants in the programmes/interventions were adolescents aged 10 to 18, thirteen of which were aged ≤14 years.

The duration of the programmes/interventions promoting help-seeking varied from a single session to multiple sessions. Two studies did not mention the duration of their programmes/interventions.

The programmes/interventions in this component of the MHL used mostly assessment tools developed by the authors ( n = 7). Others used validated instruments ( n = 4) or the combination of validated and own instruments ( n = 2). Two studies did not mention the instruments used to assess this component.

Two studies did not mention any information concerning the assessment moments of the programmes/interventions. All the remaining thirteen studies assessed the programmes/interventions at baseline. Six assessed immediately after the intervention, three assessed after 3 months, two studies after 2 weeks and two studies after 1 week. A follow-up period was included in eight studies. Four studies implemented a follow-up at 3 months, two studies at 6 and 12 months, one study at 12 and 24 months and one study at 6 months. It should also be noted that most studies presented two moments of assessment ( n = 6), followed by those with three moments ( n = 4) and with four moments ( n = 3).

Most programmes/interventions reported increased help seeking ( n = 11), the results of which were statistically significant, and only one study showed results that were not statistically significant [ 47 ]. Some studies that contemplated this component did not have results available ( n = 4).

In general, the following aspects were indicated as barriers to the implementation of the programmes/interventions common to all the MHL components in the articles included: the short duration of the intervention ( n = 1), the use of English instead of the native language ( n = 1), the difficulty in coordinating the implementation of the programme/intervention with the various stakeholders in the school ( n = 1), the programme/intervention interrupting the school curricula ( n = 1) and the lack of incentives for the participants ( n = 1). On the other hand, the following aspects were mentioned as facilitators: not having to resort to staff from outside the school ( n = 6), requiring only existing school resources ( n = 4), the programme/intervention being administered as part of the school curriculum ( n = 3), students being active agents of the intervention ( n = 1), the use of staff from outside the school ( n = 1), the use of role-playing rather than direct contact with people with mental illness ( n = 1), the inclusion of a quiz at the end of the programme/intervention ( n = 1), the incorporation of yoga exercises and postures ( n = 1), being a concise programme/intervention ( n = 1), being a short programme/intervention ( n = 1) and being a quick programme/intervention without any associated expenses ( n = 1).

4. Discussion

This review provides a comprehensive synthesis of the available evidence on the programmes/interventions promoting MHL in adolescents in school settings.

The first research question of this review intended to know what the programmes/interventions are for promoting MHL among adolescents in school settings. The results of this review show that most programmes/interventions address one or more of the four components of MHL defined by Kutcher, Wei and Coniglio [ 16 ]; that is, mental health disorders and problems, signs/symptoms and treatments, myths related to mental illness, non-stigmatising attitudes/behaviours and options/sources for help seeking. However, the programmes/interventions that seek to intervene in the component related to knowledge on how to obtain and maintain good mental health fall short of what is required. Therefore, future research should develop programmes/interventions with a more salutogenic and positive perspective regarding the MHL of adolescents. This scoping review highlights this gap, aligning with what is known from previous research [ 17 ].

Regarding the second research question, the objective was to discriminate the characteristics of programmes/interventions that promote MHL among adolescents. Most programmes/interventions targeted adolescents aged ≤14 years, thus making an important contribution to preventing the onset of mental health problems at an early age [ 8 ].

About half of the programmes/interventions were taught by the adolescents’ regular teachers. The rest used staff from outside the school, with only a few being taught by health professionals. These results highlight the need for greater intervention from health professionals, particularly those in primary health care and specifically nurses, who play a decisive role in the community’s health [ 5 ]. Nurses know the needs and specificities of their community like no one else, and this knowledge enables them to intervene holistically. Considering health professionals’ competences and level of expertise, we believe that one of the future options in this field may be a more active intervention by nurses and other health professionals, both in the implementation and administration teams of the programmes that promotes adolescents’ MHL, as well as in the teachers’ education/training on these programmes/interventions.

In terms of the strategies used, the results show the use of expositive, demonstrative, participative methodologies based on contact (direct or indirect) and/or the supply of information material. These strategies were used in isolation or as complements. In most studies, complementarity proved to be an added value in achieving an increase in the MHL of adolescents. However, one study showed that adding contact with patients with mental disorders did not add value to the educational intervention [ 47 ].

The variability of the duration of the programmes/interventions analysed indicates that they may be flexible in terms of time, even though a significant proportion of the analysed programmes/interventions state that the fact that they are of short duration is an advantage because they save resources. However, while it is true that when the aim is to intervene at the level of knowledge and help-seeking behaviour, a short-term intervention is effective, it is also true that when the objective is to act on attitudes, it is probably better to opt for a longer intervention, since attitudes cannot be changed easily, and they need time to be internalised and sedimented at a cognitive, emotional and behavioural level [ 34 ]. It is also suggested that in the future, programmes/interventions should have follow-up periods not only in terms of assessments of their short- and long-term effects, as occurred in a significant part of the studies included in this review, but also in terms of booster sessions, as in the study carried out by Lubman et al. [ 40 ], as the literature indicates their importance in increasing and maintaining the effects of interventions [ 60 ].

None of the reviewed studies used instruments to assess outcomes concerning knowledge about achieving and maintaining good mental health, which is in line with the findings of Wei et al. [ 9 ]. Future research should use instruments that assess this component of the MHL or, in its absence, should construct a new one. Furthermore, no study used an instrument that assessed the four components of MHL, probably because no instrument is considered a gold standard for assessing these components together, a situation already detected by Wei et al. [ 9 ]. The filling of this gap represents a future research area. Although about half of the programmes/interventions used validated instruments, a significant proportion used non-validated instruments, which compromises the appropriate assessment of results and the possibility of comparing them, a situation also mentioned by Wei et al. [ 28 ].

The third research question intended to know in which settings/contexts these programmes/interventions were carried out. Most of the programmes/interventions were implemented in a classroom environment. This fact demonstrates the importance of the school setting in promoting the MHL of adolescents and is in line with the research reported in this area [ 17 , 23 ]. It is also important to mention that the most programmes included in this scoping review consist of face to face interventions, only two programmes encompass online interventions (“EspaiJove.net” e “The Guide and MyHealth Magazine”) [ 32 , 36 ] and only one compares the same programme in its face to face version with the online version (“StresSOS”) [ 41 ]. Both “EspaiJove.net” [ 32 ] and the “StresSOS” [ 41 ] programmes do not have results yet because they are study protocols, but “The Guide and MyHealth Magazine” [ 36 ] already has results and they indicate improvements in the adolescents’ MHL when combining face to face and online interventions. However, we believe that in the future, more studies will be needed to compare both interventions and gather more evidence.

Finally, regarding the fourth research question, the objective was to know the barriers and facilitators to the implementation of these programmes/interventions. The results obtained indicate that the main barriers to implementing the programmes/interventions are the difficulty of coordination with the various school stakeholders, the interruption of school curricula and the lack of incentives for participants. The main facilitators were the programmes/interventions being part of the school curriculum, not depending on resources outside the school and using interactive methodologies. These aspects should be considered when implementing future interventions so as not to compromise their effectiveness.

Although this scoping review followed The Joanna Briggs Institute guidelines to maintain methodological and scientific rigour and was conducted by two independent researchers, it is possible to identify some limitations. First, the search was limited to articles published in Portuguese, English, or Spanish, which may have meant that important articles written in other languages were not included. Second, the quality of the included articles was not assessed, a situation inherent to the methodology of a scoping review, which prevents the presentation of recommendations for clinical practice. Thirdly, the fact that the original authors were not contacted to obtain information missing from the articles may have led to an inaccurate interpretation of the studies. Fourth, the fact that no studies were included in the scope of other areas (e.g., social sciences, etc.), nor articles with programmes implemented in contexts other than schools, is also a limitation.

5. Conclusions

The results of this review allow us to identify programmes/interventions that promote the MHL of adolescents, as well as to provide clues about some of the characteristics that such programmes/interventions should have, about some of the barriers and facilitators to their implementation and, finally, about the gaps found in this research area.

Although most of the analysed studies have apparently shown positive results in promoting the MHL of adolescents in school settings, these results are difficult to interpret and compare due to the lack of use of validated instruments and the great variability of the assessment instruments used.

Future research should be conducted to harmonise programmes/interventions that aim to promote each of the components of MHL, and MHL holistically in the adolescent population. To this end, further experimental or quasi-experimental studies should be carried out to obtain the best possible evidence, using validated assessment tools and including follow-up periods. Interventions should focus on adolescents aged ≤14 years; could be of short duration if the aim is to increase knowledge or help seeking, or of longer duration if the objective is to intervene at the level of adolescents’ attitudes/stigma; may include ‘booster’ sessions to reinforce and maintain the levels of MHL; should take place in the classroom; use complementary expository and interactive strategies; and have a more active intervention from health professionals.

We should focus on the implementation or construction of programmes/interventions that promote knowledge on how to obtain/maintain good mental health and the use or construction of instruments that assess this component of MHL, whose importance is currently being increasingly recognised by research.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/ijerph18189500/s1 , Table S1: Characteristics of the articles included ( n = 29).

Instrument for extracting data from the reviewed articles.

Author Contributions

Conceptualisation, J.N., C.S. and C.F.-G.; methodology, J.N., C.S. and C.F.-G.; validation, all authors; formal analysis, J.N. and A.P.O.; investigation, J.N. and A.P.O.; data curation, J.N.; writing—original draft preparation, J.N. and F.M.; writing—review and editing, J.N., F.M., C.S. and C.F.-G.; visualisation, all authors; supervision, C.S. and C.F.-G. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Research article
Open access
Published: 11 September 2013

A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries

Margaret M Barry 1 ,
Aleisha M Clarke 1 ,
Rachel Jenkins 2 &
Vikram Patel 3 , 4

BMC Public Health volume 13 , Article number: 835 ( 2013 ) Cite this article

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This systematic review provides a narrative synthesis of the evidence on the effectiveness of mental health promotion interventions for young people in low and middle-income countries (LMICs). Commissioned by the WHO, a review of the evidence for mental health promotion interventions across the lifespan from early years to adulthood was conducted. This paper reports on the findings for interventions promoting the positive mental health of young people (aged 6–18 years) in school and community-based settings.

Searching a range of electronic databases, 22 studies employing RCTs (N = 11) and quasi-experimental designs conducted in LMICs since 2000 were identified. Fourteen studies of school-based interventions implemented in eight LMICs were reviewed; seven of which included interventions for children living in areas of armed conflict and six interventions of multicomponent lifeskills and resilience training. Eight studies evaluating out-of-school community interventions for adolescents were identified in five countries. Using the Effective Public Health Practice Project (EPHPP) criteria, two reviewers independently assessed the quality of the evidence.

The findings from the majority of the school-based interventions are strong. Structured universal interventions for children living in conflict areas indicate generally significant positive effects on students’ emotional and behavioural wellbeing, including improved self-esteem and coping skills. However, mixed results were also reported, including differential effects for gender and age groups, and two studies reported nonsignficant findings. The majority of the school-based lifeskills and resilience programmes received a moderate quality rating, with findings indicating positive effects on students’ self-esteem, motivation and self-efficacy. The quality of evidence from the community-based interventions for adolescents was moderate to strong with promising findings concerning the potential of multicomponent interventions to impact on youth mental health and social wellbeing.

Conclusions

The review findings indicate that interventions promoting the mental health of young people can be implemented effectively in LMIC school and community settings with moderate to strong evidence of their impact on both positive and negative mental health outcomes. There is a paucity of evidence relating to interventions for younger children in LMIC primary schools. Evidence for the scaling up and sustainability of mental health promotion interventions in LMICs needs to be strengthened.

Peer Review reports

Mental health is fundamental to good health and wellbeing and influences social and economic outcomes across the lifespan [ 1 – 3 ]. Childhood and adolescence are crucial periods for laying the foundations for healthy development and good mental health. It is estimated that 10-20% of young people worldwide experience mental health problems [ 4 ]. Poor mental health in childhood is associated with health and social problems such as school failure, delinquency and substance misuse, and increases the risk of poverty and other adverse outcomes in adulthood [ 3 ]. Interventions that promote positive mental health equip young people with the necessary life skills, supports and resources to fulfill their potential and overcome adversity. Systematic reviews of the international evidence, which come predominantly from high income countries (HICs), show that comprehensive mental health promotion interventions carried out in collaboration with families, schools and communities, lead to improvements not only in mental health but also improved social functioning, academic and work performance, and general health behaviours [ 5 – 13 ].

Despite the recognition of the importance of mental health promotion for children and adolescents, mental health remains a neglected public health issue, especially in low and middle-income countries (LMICs). Mental health is inequitably distributed as people living in poverty and other forms of social disadvantage bear a disproportionate burden of mental disorders and their adverse consequences [ 14 – 17 ]. There is increasing recognition of the relevance of mental health to global development strategies, and in particular to the achievement of the Millennium Development Goals (MDGs), including improving child and maternal health, universal education, combating HIV/AIDS and other diseases, and eradicating poverty [ 18 , 19 ]. As 90% of the world’s children and adolescents live in LMICs, where they constitute up to 50% of the population [ 20 ], there is an urgent need to address the mental health of young people as part of the wider health promotion and development agenda.

Schools are one of the most important community settings for promoting the mental health of young people [ 21 ]. The school setting provides a forum for promoting emotional and social competence as well as academic learning and offers a means of reaching the significant number of young people who experience mental health problems [ 22 – 25 ]. Educational opportunities throughout life are associated with improved mental health outcomes. The promotion of emotional health and wellbeing is a core feature of the WHO’s Health Promoting Schools initiative [ 26 ]. There is good evidence that mental health promotion programmes in schools, especially those adopting a whole school approach, lead to positive mental health, social and educational outcomes [ 13 , 27 – 29 ]. Programmes incorporating life skills, social and emotional learning and early interventions to address emotional and behavioural problems, produce long-term benefits for young people, including improved emotional and social functioning, positive health behaviours, and improved academic performance [ 5 , 13 , 25 , 27 – 31 ]. To date there has been comparatively little research on school and community-based mental health promotion interventions for young people in LMIC settings and no systematic attempt to synthesize the evidence from such settings. This is the goal of this paper. The work described here was undertaken in 2011–2012 as part of the World Health Organization Task Force on Mainstreaming Health Promotion. Established on foot of the WHO 7 th Global Conference on Health Promotion [ 32 ], the Task Force sought to develop a package of evidence-based health promotion actions addressing priority public health conditions in LMICs.

The objectives of the review were:

To synthesize evidence on the effectiveness of mental health promotion interventions for young people that have been implemented in LMICs.

To identify gaps in the existing evidence and highlight areas where further research is needed.

Study selection

This systematic review conforms to the guidelines outlined by the PRISMA 2009 checklist. A research protocol for the original review was agreed with the Members of the WHO Task Force and the Cochrane Public Health Group (CPHG). Studies were eligible for inclusion if the intervention was designed to promote positive mental health for young people in LMIC settings. For the purpose of this review, mental health promotion interventions were defined as any planned action, programme or policy, which was undertaken with the aim of improving mental health or modifying its determinants. Evidence in relation to the studies for young people aged 6–18 years across all school and community settings was included, with no exclusions based on gender or ethnicity. Academic and grey literature published from 2000 onwards in printed or electronic format was deemed eligible for inclusion. In order to include studies of comparable quality, we considered study designs including randomized controlled trials, cluster randomized controlled trials, and quasi-experimental study designs. The primary outcomes of interest were mental health and wellbeing benefits including; indicators of positive mental health such as self-esteem, self-efficacy, coping skills, resilience, emotional wellbeing; negative mental health such as depression, anxiety, psychological distress, suicidal behaviour; and wellbeing indicators such as social participation, empowerment, communication and social support. Secondary health related outcomes were also noted. Studies with the following characteristics were excluded from the review; (i) selective and indicated prevention interventions, as defined by Mrazek and Haggerty [ 33 ], (ii) studies with no control/comparison group, and (iii) qualitative only studies.

Search strategy

Academic databases including PubMed, PsychInfo, Scopus, ISI Web of Knowledge, Cochrane database of systematic reviews were searched. Health Promotion and Public Health Review databases were also searched including Evidence for Policy and Practice information and Coordinating (EPPI) Centre; University of York National Health Service Centre for reviews and dissemination; National Institute of Clinical Excellence (NICE); Effective Public Health Practice, Health Evidence Canada; WHO programmes and projects. Additional sources included Google Scholar and reference list of relevant articles, book chapters and reviews. Key individuals and organizations identified through the search process were contacted to identify further details on publications. The electronic search strategy used across all databases is provided in Table 1 . The last search for the original systematic review of mental health promotion interventions was completed on 11 th March 2011 and included articles published between January 2000 - December 2010. A repeated search was conducted on 7th September 2012 to update results and included articles published between January 2011 – June 2012.

Study selection and data collection

Using the search strategy described above, all titles and abstracts retrieved were scanned for relevance. Duplicates, articles not relevant, and articles that did not meet the inclusion criteria were removed. Full text papers were obtained for studies that were selected for inclusion. Studies were subsequently selected relating to young people and were classified according to (i) school-based programmes (ii) community-based programmes for adolescents. Two reviewers assessed the studies in order to ensure that they met the inclusion criteria set out for this review.

Data analysis

As the interventions and outcomes evaluated in the included studies were too diverse to allow a quantitative synthesis of the study findings, a narrative synthesis was undertaken. Following the guidelines of the Cochrane Public Health Group, the methodological quality of the intervention evaluations was assessed using the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project [ 34 ]. Studies were assessed for selection bias, study design, confounders, blinding, data collection and withdrawals and drop-outs. Each study was rated independently by two reviewers (MB and AC). The quality assessments were compared and disagreements were resolved through discussion. Based on the ratings of each of the six components, each study received an overall global rating of strong, moderate or weak. Following the quality assessment stage, the inclusion of studies and extraction of key findings was finalized. Extracted data were entered into a table of study characteristics (Table 2 ) including the quality assessment ratings for each study.

The results of the search and study selection are shown in Figure 1 . The original search process carried out in 2011 produced 10,471 articles, 188 articles of which were selected for full review and exported to Endnote. Of these, 146 were either contextual articles related to mental health promotion in LMICs or studies that did not meet one of our inclusion criteria. Seven articles were systematic/summary reviews of the evidence base in LMICs, five of which were reviews of interventions for young people. A total of 35 primary studies were selected for review. Of these, 14 studies evaluated school or community-based interventions for young people in LMICs. During the repeated search performed in September 2012, a further eight studies evaluating school-based interventions were identified. The combined searches resulted in a total of 22 studies (14 school and eight community-based studies) undergoing quality assessment. No studies in non-English language specific to school and community based-interventions were identified in the review process.

Search results from original search of mental health promotion interventions in LMICs.

The five systematic review articles from LMICs that were identified examined the effectiveness of HIV related lifeskills interventions [ 69 , 70 ] and psychosocial interventions for children and adolescents affected by armed conflict in LMICs [ 71 – 73 ]. All relevant interventions across the reviews were identified and cross-referenced with the primary articles retrieved through the electronic search. Given the specific focus of this systematic review on mental health promotion and primary prevention, several studies from these systematic reviews did not meet the inclusion criteria for this review.

Regarding the number and percentage of evaluation studies carried out across LMICs, 18.2% (N = 4) of the interventions were carried out in low income countries, 36.4% (N = 8) were carried out in lower middle income countries and 45.4% (N = 10) were carried out in upper middle income countries. Just under one third of the interventions (N = 7) were carried out in South Africa alone.

School-based programmes

Fourteen studies describing thirteen interventions implemented in school settings in eight LMIC countries were identified. Four studies were carried out in Gaza/Palestine [ 48 , 50 , 55 , 56 ], three were carried out in South Africa [ 37 , 38 , 41 , 44 ], two in Uganda [ 45 , 49 ] and one intervention was carried out in India [ 35 ], Chile [ 36 ], Mauritius [ 42 ], Nepal [ 47 ], and the Lebanon [ 54 ]. The majority of studies (>60%) were published between 2010–2012. The quality of evidence from the majority of studies was strong. A total of eight studies received a strong quality rating [ 42 , 45 , 47 , 48 , 50 , 54 – 56 ], five studies received a moderate quality assessment rating as a result of selection bias [ 36 , 44 ] and not reporting the percentage of withdrawals/dropouts [ 35 , 38 , 49 ]. One study received a weak quality assessment rating due to selection bias, not reporting confounders and not reporting level of withdrawals [ 41 ].

The programmes were mental health promotion and universal prevention interventions designed for all children and adolescents of school going age. Interventions varied slightly in their focus from the development of social, emotional, problem solving and coping skills [ 35 , 41 ] to a combined mental health promotion with physical fitness programme [ 36 ], combined mental health promotion and sexuality education [ 37 , 38 ] and a universal depression prevention intervention [ 42 ]. Two interventions were designed specifically to support AIDS orphaned children, one was an art intervention [ 44 ], another was a peer support intervention led by teachers [ 45 ]. Seven interventions (eight studies) were school-based psychosocial interventions implemented in countries affected by armed conflict [ 47 – 50 , 54 – 56 ]. These interventions were designed to reduce distress, enhance resilience and coping skills. Four of these interventions incorporated cognitive behavioural techniques (CBT) and trauma related psychoeducation modules [ 47 – 50 , 54 ]. One intervention consisted of short writing sessions [ 55 ], another provided structured recreational activities [ 56 ].

Seven of the school-based interventions were designed for post-primary school students (>12 years of age). Four interventions were implemented with a broad age range from 6 – 18 years [ 44 , 48 , 54 , 56 ]. Three interventions were implemented with children in the senior end of primary school (>10 years of age) [ 45 , 49 , 50 ]. Eight interventions were implemented by the class teacher [ 35 – 38 , 42 , 44 , 49 , 54 , 55 ], with the remaining interventions implemented by mental health professionals [ 41 , 48 , 50 ], locally trained paraprofessionals [ 47 ] and local youth workers [ 44 , 56 ]. The majority of session ranged in length from 11 – 16 sessions implemented weekly. One intervention provided six booster sessions at 12 months following completion of the programme [ 37 , 38 ]. Eight school interventions were developed in the implementing country. Five interventions were adapted versions of evidence-based interventions from high income countries [ 37 , 38 , 42 , 47 – 49 ].

Regarding intervention outcomes, in terms of the seven universal programmes implemented with children affected by armed conflict, the findings are generally positive but with some studies reporting mixed effects. Loughry et al. [ 56 ] reported that the after-school recreational activities implemented over one year had a significant positive impact on children and adolescents’ externalising and internalising problem scores and also improved parental support as a result of parental involvement in the structured activities. Khamis et al. [ 48 ] reported that the Classroom-Based Intervention (CBI) had a significant positive effect on children (age 6–11) and adolescents (age 13–16) in terms of improved social and emotional wellbeing, communication skills and reduced conduct and peer problems and hyperactivity levels. Ager et al. [ 49 ] reported similar findings for the school-based Psychosocial Structures Activities intervention (PSSA) which is based on principles of the CBI, with the intervention having a significant positive effect on primary school children’s (mean age 10 years) wellbeing. Interestingly, the CBI study carried out in Nepal reported specific gender effects, with significant reductions in psychological difficulties and aggression among males only and improved prosocial behaviour among females only [ 47 ]. Two studies reported less positive findings. Karam et al. [ 54 ] found that the cognitive behavioural therapy intervention (CBT) implemented over 12 consecutive days had no significant effect on participant rates of depression, separation anxiety and post-traumatic stress disorder (PTSD). Lange-Nielsen et al. [ 55 ] reported that the three day short-term writing intervention had no effect on participants’ PTSD symptoms and anxiety scores. This study also reported that the writing intervention lead initially to significantly increased depression symptoms for participants between pre and post-intervention but that symptoms significantly declined at five months follow up. Contrasting findings in terms of gender effects were reported across three studies; two studies reported that the interventions have a more positive effect on girls [ 48 , 49 ] while another intervention reported no programme effect for girls with PTSD scores improving only in male participants [ 50 ].

Regarding the universal lifeskills and resilience school-based interventions, all six studies reported significant positive effects on students’ mental health and wellbeing in terms of improved self-esteem [ 35 , 36 , 42 ], motivation [ 38 ] and self-efficacy [ 44 ]. The peer-group support intervention implemented with AIDS orphan children resulted in significant improvements in participants’ depression, anger and anxiety scores but not for self-concept [ 45 ]. The combined fitness lifeskills education intervention reported improvements in anxiety symptoms, however, there was no change in participants’ depression scores [ 36 ]. The depression prevention intervention on the other hand reported a significant reduction in depressive symptoms (medium effect size) and hopelessness (medium effect size) and a significant increase in coping skills (medium effect size) amongst participants in the intervention group [ 42 ]. Long-term findings from this depression prevention intervention included improved self-esteem and coping skills (medium effect size) at six months follow up. In addition, the resilience intervention in South Africa also reported long-term findings with improved self-appraisal scores maintained at three months follow up [ 41 ]. Additional outcomes from these studies include improved behaviour [ 35 ], school adjustment [ 35 ], fitness [ 36 ], attitudes about reproductive and sexual health [ 37 ] and a reduction in the level of substance misuse [ 37 ]. The art intervention for AIDS orphan children reported the least positive findings with a significant improvement reported in the intervention groups’ self-efficacy score but no change in participants’ depression, self-esteem and emotional and behavioural scores [ 44 ]. While the results from the resiliency intervention indicated significant improvements in participants’ emotional reactivity, self appraisal and interpersonal strength, the weak quality of this study must be considered when interpreting these findings.

Community-based interventions

This review identified eight studies evaluating seven out-of-school community interventions for adolescents in five countries. Four studies were carried out in South Africa [ 60 , 61 , 63 , 64 ], one study was carried out in India [ 57 ], Honduras [ 58 ], Egypt [ 59 ] and Uganda [ 65 – 68 ]. All eight studies were published between 2006 and 2010. The quality of evidence from these studies was moderate to strong. Four studies received a strong quality assessment rating [ 57 , 60 , 61 , 65 ] and four studies received a moderate quality assessment rating due to small sample size [ 58 ] and failure to report validity and reliability of measures used in three studies [ 59 , 63 , 64 ].

Interventions included a multi-component school and community-based intervention for youth aged 16–24 years [ 57 ]; a family-based strengthening programme ( Familias Fuertas ) for parents and their adolescent children [ 58 ]; a multidimensional programme ( Ishraq ) aimed at improving the life skills, literacy, recreational activities and health knowledge of 13–15 year old girls in Egypt [ 59 ] and combined HIV prevention and lifeskills interventions ( Stepping Stones and CHAMPSA ) for adolescents in South Africa [ 60 , 61 ]. Two studies evaluated the Intervention with Microfinance for AIDS and Gender Equity ( IMAGE ), a poverty-focused microfinance initiative for women that is combined with a 12–15 month gender and HIV education curriculum [ 63 , 64 ]. One study examined the effects of small individual loans and mentorship on health and mental health functioning of primary school children [ 65 – 68 ]. Five of the seven interventions were designed for young people aged 13+. The Familias Fuertas intervention was designed for children age 10–14 and one of the evaluations of the IMAGE microfinance intervention was implemented with females aged 18 and over. Two interventions provided parent training [ 58 , 61 ] and two interventions were designed specifically for females [ 59 , 63 , 64 ]. Five of the interventions were implemented by local trained community caregivers [ 59 – 61 , 63 – 68 ]. The Familias Fuertas intervention was implemented by a local nurse [ 58 ] and the multi-component school and community intervention in India was implemented by a team of social workers, psychologists and peer educators [ 57 ]. Five of the interventions were developed in the implementing country. Two interventions were adapted versions of evidence-based interventions that were developed in the United States [ 58 , 61 ].

Collectively, the results from these studies indicate the significant positive effect of community-based mental health promotion interventions on young people’s mental health and social wellbeing. Five interventions provided strong evidence of their positive impact on mental health. Balaji et al. [ 57 ] reported that the community-based youth health intervention in India resulted in significant improvements in participants’ depression scores, reported levels of suicidal behaviour, and knowledge and attitudes about mental health. South Africa’s IMAGE intervention resulted in significant improvements in empowerment, social participation and levels of openness among women in the combined IMAGE-microfinance intervention, with no change evident the microfinance only intervention [ 64 ]. In addition, Pronijk et al. [ 64 ] reported that participants in the IMAGE intervention were significantly more likely to participate in training, and had greater participation in social and community groups. Ssewamala et al. [ 65 , 66 ] reported that the SUUBI economic empowerment intervention for AIDS orphaned children had a significant positive impact on participants’ self-esteem and levels of depression. Results from the parent-youth interventions indicate the significant effect of the programmes on positive parenting communication and behaviours, parental self-esteem and family relations [ 58 , 61 ].

Other reported outcomes also included significantly improved: peer relations [ 59 ]; academic performance [ 59 , 68 ]; student-teacher relations [ 57 ]; communication [ 64 ]; improved gender roles [ 64 ] and significantly reduced sexual risk behaviour [ 60 , 63 ] one year follow up; physical and sexual partner violence [ 57 , 60 , 63 , 64 ]; and substance abuse [ 57 , 60 ]. Bell et al., [ 61 ] reported medium effect sizes for improved caregiver communication comfort. Long-term findings from the Stepping Stones intervention include reduced physical and sexual partner violence at two years follow- up, and reduced substance abuse at one year follow up [ 60 ].

This review sought to determine the effectiveness of mental health promotion interventions designed for young people (aged 6–18 years) in LMICs. A total of 22 studies evaluating 20 interventions were identified. The majority of interventions were implemented in upper and lower middle income countries, thus highlighting the paucity of evidence from low income countries. Four interventions were carried out in low income countries, three of which were conducted in Uganda. It is encouraging to note, however, the significant increase in publications from LMICs in the last four years, with the majority of interventions identified in this review published since 2008.

With regard to the school-based interventions, the quality of evidence from the 14 studies is moderate to strong. Findings from these studies indicate that there is reasonably robust evidence that school-based programmes implemented across diverse LMICs can have significant positive effects on students’ emotional and behavioural wellbeing, including reduced depression and anxiety and improved coping skills. Promising interventions include the Resourceful Adolescent Program (RAP-A), which was implemented by teachers in Mauritius [ 42 ]. This study is an example of an evidence-based intervention adapted from a HIC for implementation in a LMIC and points to the potential of such interventions when adapted to meet the cultural needs of young people in LMICs. Another promising intervention is the teacher led peer-group support intervention for AIDs orphaned children which was implemented in a low-income country [ 45 ]. The findings from this study suggest the potential of peer support mental health promotion interventions in optimizing adjustment and decreasing the psychological distress associated with AIDS orphanhood in the adolescent age group. Such interventions may have great potential in addressing the increased risk of depression, peer relationship problems, post-traumatic stress and conduct problems among AIDS orphans [ 74 – 76 ]. There is also some encouraging evidence that interventions which combine lifeskills with reproductive and sexual health education [ 37 , 38 ] and physical health and fitness [ 36 ] can have a significant positive effect on pupils’ risk-taking and prosocial behaviour. These findings are consistent with the substantive evidence from multiple reviews of school-based interventions in HICs which report the greater effectiveness of multi-component interventions (i.e. interventions that adopt a social competence approach and develop supportive environments), when compared with interventions that focus on specific problem behaviours [ 8 , 28 , 77 – 79 ]. The integration of multicomponent programmes within a whole school approach [ 13 ] based on generic social and emotional skills training addressing comon risk and protective factors, delivered within a supportive school environment in partnership with parents and the local community, has the potential to reach larger population groups with fewer resources.

The evidence for universal interventions implemented with young people affected by war attests to the important role of the school as an accessible setting for such interventions. Similar to previous reviews [ 72 , 73 ], the heterogeneity across the studies in terms of programme content, delivery, duration, and study sample makes it difficult to draw general conclusions about the effectiveness of these interventions as a whole. However, there is evidence that the more structured interventions of longer duration can have a significant positive effect on mental health and wellbeing. The results from the Classroom-Based Intervention (CBI) and the school-based Psychosocial Structured Activities intervention (PSSA), which is based on CBI principles, highlight the positive effect of these interventions on young people’s social, emotional and behavioural wellbeing. The differential effects according to gender reported across these interventions, however, calls for further investigation into possible gender specific components. The optimum age for programme implementation also needs further examination. There is evidence from Khamis et al. [ 48 ] that CBI did not yield the same significant positive changes with older males (12–16 years) as with the younger group (aged 6–11). This finding is in line with substantive evidence from HICs regarding the need to reach children when they are young in order to sustain their existing resilience and strengthen their coping capabilities [ 4 , 12 , 80 – 82 ].

Non-significant findings were also found for a writing intervention implemented with young people aged 12–17 [ 55 ] and a CBT intervention implemented with children and adolescents aged 5–16 [ 54 ]. It is important to note the initial negative impact of the writing intervention on participants’ depression symptoms, which then subsequently declined at follow-up. Common characteristics of these interventions were their short duration and the broad age range of the intervention participants. This is in contrast to the year long after-school intervention implemented with children and adolescents and their parents living in Gaza and the West Bank, which resulted in significant improvement in participants’ social and emotional wellbeing and parenting behaviours [ 56 ]. The results from these studies underscore the importance of understanding optimum programme components in terms of content, duration, and target age range in order to ensure the development of effective school-based interventions in conflict areas. This is in line with recommendations from previous reviews of school-based interventions implemented in war exposed countries [ 71 , 72 ] including those from secondary prevention interventions, not covered in this review, which also point to the need for more rigorous research on the differential intervention effects related to age, gender and war-related experiences [ 73 , 83 ]. The studies in this review support previous findings concerning the role of universal school programmes for children living in conflict areas as an effective, accessible and efficient means of enhancing and protecting good mental health alongside more targeted approaches for students at higher risk [ 84 ]. The exploration of a whole school approach to interventions in this area carries potential for reaching the wider community through the school setting.

The majority of the school-based interventions included in this review were implemented with young people age 12–16 years. In view of the paucity of evidence of mental health promotion interventions for young children in primary schools in LMICs (age 5–10 years), there is an urgent need for high quality studies with longitudinal designs to assess the impact of school-based intervention for younger primary school children in order to strengthen the evidence base in this area. Schools are arguably one of the most important settings for reaching out to young children and their families and early intervention is recognised as one of the key principles of effective mental health promotion and prevention interventions [ 4 , 8 , 12 , 80 ]. In addition, eight of the interventions were implemented by trained class teachers, with the remaining interventions implemented by psychologists, paraprofessionals and youth workers. As Srikala & Kumar [ 35 ] argue, any programme incorporated into the education system in LMICs has to be feasible and cost-effective. The findings from this review suggest that trained teachers can effectively deliver mental health promotion interventions. Similar to findings from HICs, several of the studies reviewed highlighted the importance of teacher training and the provision of ongoing support during programme implementation. Harnessing the skills of teachers and providing support in the school setting offers a sustainable and low cost method of improving children’s emotional and behavioural wellbeing, developing positive coping strategies and promoting school performance. As the Millennium Development Goals have set out as a target that all boys and girls will be able to complete a full course of primary schools by 2015, the integration of social and emotional learning and lifeskills development in the primary school curriculum and the development of a whole school approach to health promotion is an important component of this development agenda.

In terms of the evidence for community-based interventions in LMICs, there are a limited number of very promising youth interventions addressing sexual and emotional health, HIV prevention, substance misuse, violence prevention, functional literacy, economic empowerment and social participation among excluded groups. The results from these multicomponent interventions are impressive given the improvements that were shown across a broad range of adolescent health outcomes. Although limited in number, the three microfinance interventions for young adults and primary school children included in this review, provide encouraging evidence that combined microfinance and training interventions promoting essential lifeskills, asset building and reourcefulness, can result in significant mental health and wellbeing benefits. Further evaluations of such multicomponent community-based interventions are needed to determine the long-term impact on more specific mental health outcomes.

Study limitations

This systematic review has a number of important limitations, which impact on its validity. Firstly, there are limitations relating to the scope of the systematic search, which impact on the validity of the findings. Due to the timescale and resources available, a systematic search for studies published in the grey literature was not included, and neither was effort made to find well-designed studies that had not been reported at all due to non-significant findings. Furthermore, a search in languages other than English was not undertaken and, therefore, key studies in the other former colonial languages of French, Spanish, Portuguese and Dutch were not included.

Secondly, there are limitations relating to the selection criteria, which also impact on the validity of the findings. Studies not employing traditional experimental or quasi-experimental designs were excluded from the search and therefore, qualitative and other such study designs were discarded in the search process. Of the studies that were included, justification of sample size and validation of the outcome measures employed were not reported in a small number of the papers. It could be argued that such studies should also have been excluded from the review, but in our methodology they were included but received lower quality assessment ratings due to the absence of information on these issues. Finally, as a narrative synthesis the review is not designed to generate summary statistics derived from meta-analyses. Despite these limitations, the studies included in this review clearly demonstrate that high quality and effective mental health promotion interventions, and their evaluation through well-designed research studies, are feasible in LMIC settings.

The review findings indicate that mental health promotion interventions for young people can be implemented effectively in LMIC settings. There is good quality evidence regarding the impact of school-based programmes and promising evidence from multicomponent community-based studies that such interventions offer a viable means of promoting the mental health and wellbeing of young people. Notably, the studies reviewed demonstrate the feasibility and effectiveness of integrating mental health promotion interventions into education and community programmes such as community empowerment, poverty reduction, HIV/AIDS prevention, reproductive and sexual health. While the mental health promotion interventions identified in this review have achieved success across a diverse range of countries, relatively few have been systematically scaled up to serve the needs of young people at a regional or national level. Thus, evidence for their sustainability and effectiveness when scaled up through the educational system and community settings in LMICs needs to be strengthened, especially in low-income countries. In addition, the short-term follow-up periods of many of the studies point to the need for future research to evaluate long-term outcomes. Research is also needed to strengthen the evidence-base on the interrelationship between mental health and other health, educational and social wellbeing outcomes. Such research would strengthen the case for mainstreaming the integration of mental health into key health, education and development priorities for young people in LMICs.

The studies reviewed demonstrate the feasibility and potential sustainability of implementing mental health promotion interventions in LMICs through employing existing infrastructures and resources, working with local teachers, community workers, young people and their families. Further research is needed on the contextual factors influencing the adoption and adaptation in LMICs of well-validated interventions that have been developed in low resource settings in HIC countries. In particular, implementation research is needed to ensure the successful adaptation and transfer of school-based interventions for younger primary school children across educational, cultural and socio-economic settings. The development of culturally valid measures of mental health, that will support the evaluation of culturally appropriate interventions in LMICs, is also identified as an area for methodological development. Existing standardized mental health measures from HICs need to be locally validated and the development of culturally sensitive indicators of positive mental health and wellbeing will be particularly important in determining the benefits of mental health promotion interventions delivered in diverse cultural contexts. Developing capacity in LMICs for the implementation and evaluation of mental health promotion policies and practices is fundamental to promoting and sustaining action for positive youth mental health development.

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The authors wish to acknowledge the support of the WHO Task Force on Mainstreaming Health Promotion Evidence Project led by Dr Gauden Galea at WHO Geneva, who commisioned the original evidence review on which this paper is based. We are grateful to Dr Taghi Mohammad Yasamy, WHO Department of Mental Health and Substance Abuse, who acted as WHO focal point, and Professor Elizabeth Waters, Coordinating Editor of the Cochrane Public Health Group and Consulting Editor for the Mainstreaming Health Promotion Evidence Project, for their technical guidance and comments on the original review. We also acknowledge the assistance of a number of study authors globally who supplied us with additional information on the interventions and their evaluation. The views expressed in this paper are solely those of the authors and do not necessarily reflect the views of WHO. The authors have declared that no competing interests exist. VP is supported by a Wellcome Trust Senior Research Fellowship in Tropical Medicine. His work with young people is additionally supported by the MacArthur Foundation.

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Margaret M Barry & Aleisha M Clarke

WHO Collaborating Centre for Research and Training for Mental Health, Institute of Psychiatry, King’s College London, 16 De Crespigny Park, London, SE5 8AF, UK

Rachel Jenkins

Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK

Vikram Patel

Sangath, Goa, India

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MB designed the study and AC performed the data search; MB and AC reviewed the studies and carried out the quality assessment ratings; RJ and VP contributed to the interpretation of the data and the drafting of the manuscript. All authors read and approved the final manuscript.

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Barry, M.M., Clarke, A.M., Jenkins, R. et al. A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health 13 , 835 (2013). https://doi.org/10.1186/1471-2458-13-835

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Article Contents

Introduction, identity development and the sources of negative self-esteem, outcomes of poor self-esteem, mechanisms linking self-esteem and health behavior, examples of school health promotion programs that foster self-esteem, self-esteem in a broad-spectrum approach for mental health promotion.

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Michal (Michelle) Mann, Clemens M. H. Hosman, Herman P. Schaalma, Nanne K. de Vries, Self-esteem in a broad-spectrum approach for mental health promotion, Health Education Research , Volume 19, Issue 4, August 2004, Pages 357–372, https://doi.org/10.1093/her/cyg041

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Self-evaluation is crucial to mental and social well-being. It influences aspirations, personal goals and interaction with others. This paper stresses the importance of self-esteem as a protective factor and a non-specific risk factor in physical and mental health. Evidence is presented illustrating that self-esteem can lead to better health and social behavior, and that poor self-esteem is associated with a broad range of mental disorders and social problems, both internalizing problems (e.g. depression, suicidal tendencies, eating disorders and anxiety) and externalizing problems (e.g. violence and substance abuse). We discuss the dynamics of self-esteem in these relations. It is argued that an understanding of the development of self-esteem, its outcomes, and its active protection and promotion are critical to the improvement of both mental and physical health. The consequences for theory development, program development and health education research are addressed. Focusing on self-esteem is considered a core element of mental health promotion and a fruitful basis for a broad-spectrum approach.

The most basic task for one's mental, emotional and social health, which begins in infancy and continues until one dies, is the construction of his/her positive self-esteem. [( Macdonald, 1994 ), p. 19]

Self-concept is defined as the sum of an individual's beliefs and knowledge about his/her personal attributes and qualities. It is classed as a cognitive schema that organizes abstract and concrete views about the self, and controls the processing of self-relevant information ( Markus, 1977 ; Kihlstrom and Cantor, 1983 ). Other concepts, such as self-image and self-perception, are equivalents to self-concept. Self-esteem is the evaluative and affective dimension of the self-concept, and is considered as equivalent to self-regard, self-estimation and self-worth ( Harter, 1999 ). It refers to a person's global appraisal of his/her positive or negative value, based on the scores a person gives him/herself in different roles and domains of life ( Rogers, 1981 ; Markus and Nurius, 1986 ). Positive self-esteem is not only seen as a basic feature of mental health, but also as a protective factor that contributes to better health and positive social behavior through its role as a buffer against the impact of negative influences. It is seen to actively promote healthy functioning as reflected in life aspects such as achievements, success, satisfaction, and the ability to cope with diseases like cancer and heart disease. Conversely, an unstable self-concept and poor self-esteem can play a critical role in the development of an array of mental disorders and social problems, such as depression, anorexia nervosa, bulimia, anxiety, violence, substance abuse and high-risk behaviors. These conditions not only result in a high degree of personal suffering, but also impose a considerable burden on society. As will be shown, prospective studies have highlighted low self-esteem as a risk factor and positive self-esteem as a protective factor. To summarize, self-esteem is considered as an influential factor both in physical and mental health, and therefore should be an important focus in health promotion; in particular, mental health promotion.

Health promotion refers to the process of enabling people to increase control over and improve their own health ( WHO, 1986 ). Subjective control as well as subjective health, each aspects of the self, are considered as significant elements of the health concept. Recognizing the existence of different views on the concept of mental health promotion, Sartorius (Sartorius, 1998), the former WHO Director of Mental Health, preferred to define it as a means by which individuals, groups or large populations can enhance their competence, self-esteem and sense of well-being. This view is supported by Tudor (Tudor, 1996) in his monograph on mental health promotion, where he presents self-concept and self-esteem as two of the core elements of mental health, and therefore as an important focus of mental health promotion.

This article aims to clarify how self-esteem is related to physical and mental health, both empirically and theoretically, and to offer arguments for enhancing self-esteem and self-concept as a major aspect of health promotion, mental health promotion and a ‘Broad-Spectrum Approach’ (BSA) in prevention.

The first section presents a review of the empirical evidence on the consequences of high and low self-esteem in the domains of mental health, health and social outcomes. The section also addresses the bi-directional nature of the relationship between self-esteem and mental health. The second section discusses the role of self-esteem in health promotion from a theoretical perspective. How are differentiations within the self-concept related to self-esteem and mental health? How does self-esteem relate to the currently prevailing theories in the field of health promotion and prevention? What are the mechanisms that link self-esteem to health and social outcomes? Several theories used in health promotion or prevention offer insight into such mechanisms. We discuss the role of positive self-esteem as a protective factor in the context of stressors, the developmental role of negative self-esteem in mental and social problems, and the role of self-esteem in models of health behavior. Finally, implications for designing a health-promotion strategy that could generate broad-spectrum outcomes through addressing common risk factors such as self-esteem are discussed. In this context, schools are considered an ideal setting for such broad-spectrum interventions. Some examples are offered of school programs that have successfully contributed to the enhancement of self-esteem, and the prevention of mental and social problems.

Self-esteem and mental well-being

Empirical studies over the last 15 years indicate that self-esteem is an important psychological factor contributing to health and quality of life ( Evans, 1997 ). Recently, several studies have shown that subjective well-being significantly correlates with high self-esteem, and that self-esteem shares significant variance in both mental well-being and happiness ( Zimmerman, 2000 ). Self-esteem has been found to be the most dominant and powerful predictor of happiness ( Furnham and Cheng, 2000 ). Indeed, while low self-esteem leads to maladjustment, positive self-esteem, internal standards and aspirations actively seem to contribute to ‘well-being’ ( Garmezy, 1984 ; Glick and Zigler, 1992 ). According to Tudor (Tudor, 1996), self-concept, identity and self-esteem are among the key elements of mental health.

Self-esteem, academic achievements and job satisfaction

The relationship between self-esteem and academic achievement is reported in a large number of studies ( Marsh and Yeung, 1997 ; Filozof et al. , 1998 ; Hay et al. , 1998 ). In the critical childhood years, positive feelings of self-esteem have been shown to increase children's confidence and success at school ( Coopersmith, 1967 ), with positive self-esteem being a predicting factor for academic success, e.g. reading ability ( Markus and Nurius, 1986 ). Results of a longitudinal study among elementary school children indicate that children with high self-esteem have higher cognitive aptitudes ( Adams, 1996 ). Furthermore, research has revealed that core self-evaluations measured in childhood and in early adulthood are linked to job satisfaction in middle age ( Judge et al. , 2000 ).

Self-esteem and coping with stress in combination with coping with physical disease

The protective nature of self-esteem is particularly evident in studies examining stress and/or physical disease in which self-esteem is shown to safeguard the individual from fear and uncertainty. This is reflected in observations of chronically ill individuals. It has been found that a greater feeling of mastery, efficacy and high self-esteem, in combination with having a partner and many close relationships, all have direct protective effects on the development of depressive symptoms in the chronically ill ( Penninx et al. , 1998 ). Self-esteem has also been shown to enhance an individual's ability to cope with disease and post-operative survival. Research on pre-transplant psychological variables and survival after bone marrow transplantation ( Broers et al. , 1998 ) indicates that high self-esteem prior to surgery is related to longer survival. Chang and Mackenzie ( Chang and Mackenzie, 1998 ) found that the level of self-esteem was a consistent factor in the prediction of the functional outcome of a patient after a stroke.

To conclude, positive self-esteem is associated with mental well-being, adjustment, happiness, success and satisfaction. It is also associated with recovery after severe diseases.

The evolving nature of self-esteem was conceptualized by Erikson ( Erikson, 1968 ) in his theory on the stages of psychosocial development in children, adolescents and adults. According to Erikson, individuals are occupied with their self-esteem and self-concept as long as the process of crystallization of identity continues. If this process is not negotiated successfully, the individual remains confused, not knowing who (s)he really is. Identity problems, such as unclear identity, diffused identity and foreclosure (an identity status based on whether or not adolescents made firm commitments in life. Persons classified as ‘foreclosed’ have made future commitments without ever experiencing the ‘crises’ of deciding what really suits them best), together with low self-esteem, can be the cause and the core of many mental and social problems ( Marcia et al. , 1993 ).

The development of self-esteem during childhood and adolescence depends on a wide variety of intra-individual and social factors. Approval and support, especially from parents and peers, and self-perceived competence in domains of importance are the main determinants of self-esteem [for a review, see ( Harter, 1999 )]. Attachment and unconditional parental support are critical during the phases of self-development. This is a reciprocal process, as individuals with positive self-esteem can better internalize the positive view of significant others. For instance, in their prospective study among young adolescents, Garber and Flynn ( Garber and Flynn, 2001 ) found that negative self-worth develops as an outcome of low maternal acceptance, a maternal history of depression and exposure to negative interpersonal contexts, such as negative parenting practices, early history of child maltreatment, negative feedback from significant others on one's competence, and family discord and disruption.

Other sources of negative self-esteem are discrepancies between competing aspects of the self, such as between the ideal and the real self, especially in domains of importance. The larger the discrepancy between the value a child assigns to a certain competence area and the perceived self-competence in that area, the lower the feeling of self-esteem ( Harter, 1999 ). Furthermore, discrepancies can exist between the self as seen by oneself and the self as seen by significant others. As implied by Harter ( Harter, 1999 ), this could refer to contrasts that might exist between self-perceived competencies and the lack of approval or support by parents or peers.

Finally, negative and positive feelings of self-worth could be the result of a cognitive, inferential process, in which children observe and evaluate their own behaviors and competencies in specific domains (self-efficacy). The poorer they evaluate their competencies, especially in comparison to those of their peers or to the standards of significant others, the more negative their self-esteem. Such self-monitoring processes can be negatively or positively biased by a learned tendency to negative or positive thinking ( Seligman et al. , 1995 ).

The outcomes of negative self-esteem can be manifold. Poor self-esteem can result in a cascade of diminishing self-appreciation, creating self-defeating attitudes, psychiatric vulnerability, social problems or risk behaviors. The empirical literature highlights the negative outcomes of low self-esteem. However, in several studies there is a lack of clarity regarding causal relations between self-esteem and problems or disorders ( Flay and Ordway, 2001 ). This is an important observation, as there is reason to believe that self-esteem should be examined not only as a cause, but also as a consequence of problem behavior. For example, on the one hand, children could have a negative view about themselves and that might lead to depressive feelings. On the other hand, depression or lack of efficient functioning could lead to feeling bad, which might decrease self-esteem. Although the directionality can work both ways, this article concentrates on the evidence for self-esteem as a potential risk factor for mental and social outcomes. Three clusters of outcomes can be differentiated. The first are mental disorders with internalizing characteristics, such as depression, eating disorders and anxiety. The second are poor social outcomes with externalizing characteristics including aggressive behavior, violence and educational exclusion. The third is risky health behavior such as drug abuse and not using condoms.

Self-esteem and internalizing mental disorders

Self-esteem plays a significant role in the development of a variety of mental disorders. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), negative or unstable self-perceptions are a key component in the diagnostic criteria of major depressive disorders, manic and hypomanic episodes, dysthymic disorders, dissociative disorders, anorexia nervosa, bulimia nervosa, and in personality disorders, such as borderline, narcissistic and avoidant behavior. Negative self-esteem is also found to be a risk factor, leading to maladjustment and even escapism. Lacking trust in themselves, individuals become unable to handle daily problems which, in turn, reduces the ability to achieve maximum potential. This could lead to an alarming deterioration in physical and mental well-being. A decline in mental health could result in internalizing problem behavior such as depression, anxiety and eating disorders. The outcomes of low self-esteem for these disorders are elaborated below.

Depressed moods, depression and suicidal tendencies

The clinical literature suggests that low self-esteem is related to depressed moods ( Patterson and Capaldi, 1992 ), depressive disorders ( Rice et al. , 1998 ; Dori and Overholser, 1999 ), hopelessness, suicidal tendencies and attempted suicide ( Overholser et al. , 1995 ). Correlational studies have consistently shown a significant negative relationship between self-esteem and depression ( Beck et al. , 1990 ; Patton, 1991 ). Campbell et al. ( Campbell et al. , 1991 ) found individual appraisal of events to be clearly related to their self-esteem. Low self-esteem subjects rated their daily events as less positive and negative life events as being more personally important than high self-esteem subjects. Individuals with high self-esteem made more stable and global internal attributions for positive events than for negative events, leading to the reinforcement of their positive self-image. Subjects low in self-esteem, however, were more likely to associate negative events to stable and global internal attributions, and positive events to external factors and luck ( Campbell et al. , 1991 ). There is a growing body of evidence that individuals with low self-esteem more often report a depressed state, and that there is a link between dimensions of attributional style, self-esteem and depression ( Abramson et al. , 1989 ; Hammen and Goodman-Brown, 1990 ).

Some indications of the causal role of self-esteem result from prospective studies. In longitudinal studies, low self-esteem during childhood ( Reinherz et al. , 1993 ), adolescence ( Teri, 1982 ) and early adulthood ( Wilhelm et al. , 1999 ) was identified as a crucial predictor of depression later in life. Shin ( Shin, 1993 ) found that when cumulative stress, social support and self-esteem were introduced subsequently in regression analysis, of the latter two, only self-esteem accounted for significant additional variance in depression. In addition, Brown et al. ( Brown et al. , 1990 ) showed that positive self-esteem, although closely associated with inadequate social support, plays a role as a buffer factor. There appears to be a pathway from not living up to personal standards, to low self-esteem and to being depressed ( Harter, 1986 , 1990 ; Higgins, 1987 , 1989 ; Baumeister, 1990 ). Alternatively, another study indicated that when examining the role of life events and difficulties, it was found that total level of stress interacted with low self-esteem in predicting depression, whereas self-esteem alone made no direct contribution ( Miller et al. , 1989 ). To conclude, results of cross-sectional and longitudinal studies have shown that low self-esteem is predictive of depression.

The potentially detrimental impact of low self-esteem in depressive disorders stresses the significance of Seligman's recent work on ‘positive psychology’. His research indicates that teaching children to challenge their pessimistic thoughts whilst increasing positive subjective thinking (and bolstering self-esteem) can reduce the risk of pathologies such as depression ( Seligman, 1995 ; Seligman et al. , 1995 ; Seligman and Csikszentmihalyi, 2000 ).

Other internalizing disorders

Although low self-esteem is most frequently associated with depression, a relationship has also been found with other internalizing disorders, such as anxiety and eating disorders. Research results indicate that self-esteem is inversely correlated with anxiety and other signs of psychological and physical distress ( Beck et al. , 2001 ). For example, Ginsburg et al. ( Ginsburg et al. , 1998 ) observed a low level of self-esteem in highly socially anxious children. Self-esteem was shown to serve the fundamental psychological function of buffering anxiety, with the pursuit of self-esteem as a defensive avoidance tool against basic human fears. This mechanism of defense has become evident in research with primary ( Ginsburg et al. , 1998 ) and secondary school children ( Fickova, 1999 ). In addition, empirical studies have shown that bolstering self-esteem in adults reduces anxiety ( Solomon et al. , 2000 ).

The critical role of self-esteem during school years is clearly reflected in studies on eating disorders. At this stage in life, weight, body shape and dieting behavior become intertwined with identity. Researchers have reported low self-esteem as a risk factor in the development of eating disorders in female school children and adolescents ( Fisher et al. , 1994 ; Smolak et al. , 1996 ; Shisslak et al. , 1998 ), as did prospective studies ( Vohs et al. , 2001 ). Low self-esteem also seems predictive of the poor outcome of treatment in such disorders, as has been found in a recent 4-year prospective follow-up study among adolescent in-patients with bulimic characteristics ( van der Ham et al. , 1998 ). The significant influence of self-esteem on body image has led to programs in which the promotion of self-esteem is used as a main preventive tool in eating disorders ( St Jeor, 1993 ; Vickers, 1993 ; Scarano et al. , 1994 ).

To sum up, there is a systematic relation between self-esteem and internalizing problem behavior. Moreover, there is enough prospective evidence to suggest that poor self-esteem might contribute to deterioration of internalizing problem behavior while improvement of self-esteem could prevent such deterioration.

Self-esteem, externalizing problems and other poor social outcomes

For more than two decades, scientists have studied the relationship between self-esteem and externalizing problem behaviors, such as aggression, violence, youth delinquency and dropping out of school. The outcomes of self-esteem for these disorders are described below.

Violence and aggressive behavior

While the causes of such behaviors are multiple and complex, many researchers have identified self-esteem as a critical factor in crime prevention, rehabilitation and behavioral change ( Kressly, 1994 ; Gilbert, 1995 ). In a recent longitudinal questionnaire study among high-school adolescents, low self-esteem was one of the key risk factors for problem behavior ( Jessor et al. , 1998 ).

Recent studies confirm that high self-esteem is significantly associated with less violence ( Fleming et al. , 1999 ; Horowitz, 1999 ), while a lack of self-esteem significantly increases the risk of violence and gang membership ( Schoen, 1999 ). Results of a nationwide study of bullying behavior in Ireland show that children who were involved in bullying as either bullies, victims or both had significantly lower self-esteem than other children ( Schoen, 1999 ). Adolescents with low self-esteem were found to be more vulnerable to delinquent behavior. Interestingly, delinquency was positively associated with inflated self-esteem among these adolescents after performing delinquent behavior ( Schoen, 1999 ). According to Kaplan's self-derogation theory of delinquency (Kaplan, 1975), involvement in delinquent behavior with delinquent peers can increase children's self-esteem and sense of belonging. It was also found that individuals with extremely high levels of self-esteem and narcissism show high tendencies to express anger and aggression ( Baumeister et al. , 2000 ). To conclude, positive self-esteem is associated with less aggressive behavior. Although most studies in the field of aggressive behavior, violence and delinquency are correlational, there is some prospective evidence that low self-esteem is a risk factor in the development of problem behavior. Interestingly, low self-esteem as well as high and inflated self-esteem are both associated with the development of aggressive symptoms.

School dropout

Dropping out from the educational system could also reflect rebellion or antisocial behavior resulting from identity diffusion (an identity status based on whether or not adolescents made firm commitments in life. Adolescents classified as ‘diffuse’ have not yet thought about identity issues or, having thought about them, have failed to make any firm future oriented commitments). For instance, Muha ( Muha, 1991 ) has shown that while self-image and self-esteem contribute to competent functioning in childhood and adolescence, low self-esteem can lead to problems in social functioning and school dropout. The social consequences of such problem behaviors may be considerable for both the individual and the wider community. Several prevention programs have reduced the dropout rate of students at risk ( Alice, 1993 ; Andrews, 1999 ). All these programs emphasize self-esteem as a crucial element in dropout prevention.

Self-esteem and risk behavior

The impact of self-esteem is also evident in risk behavior and physical health. In a longitudinal study, Rouse ( Rouse, 1998 ) observed that resilient adolescents had higher self-esteem than their non-resilient peers and that they were less likely to initiate a variety of risk behaviors. Positive self-esteem is considered as a protective factor against substance abuse. Adolescents with more positive self-concepts are less likely to use alcohol or drugs ( Carvajal et al. , 1998 ), while those suffering with low self-esteem are at a higher risk for drug and alcohol abuse, and tobacco use ( Crump et al. , 1997 ; Jones and Heaven, 1998 ). Carvajal et al. ( Carvajal et al. , 1998 ) showed that optimism, hope and positive self-esteem are determinants of avoiding substance abuse by adolescents, mediated by attitudes, perceived norms and perceived behavioral control. Although many studies support the finding that improving self-esteem is an important component of substance abuse prevention ( Devlin, 1995 ; Rodney et al. , 1996 ), some studies found no support for the association between self-esteem and heavy alcohol use ( Poikolainen et al. , 2001 ).

Empirical evidence suggests that positive self-esteem can also lead to behavior which is protective against contracting AIDS, while low self-esteem contributes to vulnerability to HIV/AIDS ( Rolf and Johnson, 1992 ; Somali et al. , 2001 ). The risk level increases in cases where subjects have low self-esteem and where their behavior reflects efforts to be accepted by others or to gain attention, either positively or negatively ( Reston, 1991 ). Lower self-esteem was also related to sexual risk-taking and needle sharing among homeless ethnic-minority women recovering from drug addiction ( Nyamathi, 1991 ). Abel ( Abel, 1998 ) observed that single females whose partners did not use condoms had lower self-esteem than single females whose partners did use condoms. In a study of gay and/or bisexual men, low self-esteem proved to be one of the factors that made it difficult to reduce sexual risk behavior ( Paul et al. , 1993 ).

To summarize, the literature reveals a number of studies showing beneficial outcomes of positive self-esteem, and conversely, negative outcomes of poor self-esteem, especially in adolescents. Prospective studies and intervention studies have shown that self-esteem can be a causal factor in depression, anxiety, eating disorders, delinquency, school dropout, risk behavior, social functioning, academic success and satisfaction. However, the cross-sectional character of many other studies does not exclude that low self-esteem can also be considered as an important consequence of such disorders and behavioral problems.

To assess the implications of these findings for mental health promotion and preventive interventions, more insight is needed into the antecedents of poor self-esteem, and the mechanisms that link self-esteem to mental, physical and social outcomes.

What are the mechanisms that link self-esteem to health and social outcomes? Several theories used in health promotion or prevention offer insight into such mechanisms. In this section we discuss the role of positive self-esteem as a protective factor in the context of stressors, the developmental role of negative self-esteem in mental and social problems, and the role of self-esteem in models of health behavior.

Positive thinking about oneself as a protective factor in the context of stressors

People have a need to think positively about themselves, to defend and to improve their positive self-esteem, and even to overestimate themselves. Self-esteem represents a motivational force that influences perceptions and coping behavior. In the context of negative messages and stressors, positive self-esteem can have various protective functions.

Research on optimism confirms that a somewhat exaggerated sense of self-worth facilitates mastery, leading to better mental health ( Seligman, 1995 ). Evidence suggests that positive self-evaluations, exaggerated perception of control or mastery and unrealistic optimism are all characteristic of normal human thought, and that certain delusions may contribute to mental health and well-being ( Taylor and Brown, 1988 ). The mentally healthy person appears to have the capacity to distort reality in a direction that protects and enhances self-esteem. Conversely, individuals who are moderately depressed or low in self-esteem consistently display an absence of such enhancing delusions. Self-esteem could thus be said to serve as a defense mechanism that promotes well-being by protecting internal balance. Jahoda ( Jahoda, 1958 ) also included the ‘adequate perception of reality’ as a basic element of mental health. The degree of such a defense, however, has its limitations. The beneficial effect witnessed in reasonably well-balanced individuals becomes invalid in cases of extreme self-esteem and significant distortions of the self-concept. Seligman ( Seligman, 1995 ) claimed that optimism should not be based on unrealistic or heavily biased perceptions.

Viewing yourself positively can also be regarded as a very important psychological resource for coping. We include in this category those general and specific beliefs that serve as a basis for hope and that sustain coping efforts in the face of the most adverse condition… Hope can exist only when such beliefs make a positive outcome seem possible, if not probable. [( Lazarus and Folkman, 1984 ), p. 159]

Incidence = organic causes and stressors/competence, coping skills, self-esteem and social support

Identity, self-esteem, and the development of externalizing and internalizing problems

Erikson's ( Erikson, 1965 , 1968 ) theory on the stages of psychosocial development in children, adolescents, and adults and Herbert's flow chart ( Herbert, 1987 ) focus on the vicissitudes of identity and the development of unhealthy mental and social problems. According to these theories, when a person is enduringly confused about his/her own identity, he/she may possess an inherent lack of self-reassurance which results in either a low level of self-esteem or in unstable self-esteem and feelings of insecurity. However, low self-esteem—likewise inflated self-esteem—can also lead to identity problems. Under circumstances of insecurity and low self-esteem, the individual evolves in one of two ways: he/she takes the active escape route or the passive avoidance route ( Herbert, 1987 ). The escape route is associated with externalizing behaviors: aggressive behavior, violence and school dropout, the seeking of reassurance in others through high-risk behavior, premature relationships, cults or gangs. Reassurance and security may also be sought through drugs, alcohol or food. The passive avoidance route is associated with internalizing factors: feelings of despair and depression. Extreme avoidance may even result in suicidal behavior.

Whether identity and self-esteem problems express themselves following the externalizing active escape route or the internalizing passive avoidance route is dependent on personality characteristics and circumstances, life events and social antecedents (e.g. gender and parental support) ( Hebert, 1987 ). Recent studies consistently show gender differences regarding externalizing and internalizing behaviors among others in a context of low self-esteem ( Block and Gjerde, 1986 ; Rolf et al. , 1990 ; Harter, 1999 ; Benjet and Hernandez-Guzman, 2001 ). Girls are more likely to have internalizing symptoms than boys; boys are more likely to have externalizing symptoms. Moreover, according to Harter ( Harter, 1999 ), in recent studies girls appear to be better than boys in positive self-evaluation in the domain of behavioral conduct. Self-perceived behavioral conduct is assessed as the individual view on how well behaved he/she is and how he/she views his/her behavior in accordance with social expectations ( Harter, 1999 ). Negative self-perceived behavioral conduct is also found to be an important factor in mediating externalizing problems ( Reda-Norton, 1995 ; Hoffman, 1999 ).

The internalization of parental approval or disapproval is critical during childhood and adolescence. Studies have identified parents' and peers' supportive reactions (e.g. involvement, positive reinforcement, and acceptance) as crucial determinants of children's self-esteem and adjustment ( Shadmon, 1998 ). In contrast to secure, harmonious parent–child relationships, poor family relationships are associated with internalizing problems and depression ( Kashubeck and Christensen, 1993 ; Oliver and Paull, 1995 ).

Self-esteem in health behavior models

Self-esteem also plays a role in current cognitive models of health behavior. Health education research based on the Theory of Planned Behavior ( Ajzen, 1991 ) has confirmed the role of self-efficacy as a behavioral determinant ( Godin and Kok, 1996 ). Self-efficacy refers to the subjective evaluation of control over a specific behavior. While self-concepts and their evaluations could be related to specific behavioral domains, self-esteem is usually defined as a more generic attitude towards the self. One can have high self-efficacy for a specific task or behavior, while one has a negative evaluation of self-worth and vice versa. Nevertheless, both concepts are frequently intertwined since people often try to develop self-efficacy in activities that give them self-worth ( Strecher et al. , 1986 ). Self-efficacy and self-esteem are therefore not identical, but nevertheless related. The development of self-efficacy in behavioral domains of importance can contribute to positive self-esteem. On the other hand, the levels of self-esteem and self-confidence can influence self-efficacy, as is assumed in stress and coping theories.

The Attitude–Social influence–self-Efficacy (ASE) model ( De Vries and Mudde, 1998 ; De Vries et al. , 1988a ) and the Theory of Triadic Influence (TTI) ( Flay and Petraitis, 1994 ) are recent theories that provide a broad perspective on health behavior. These theories include distal factors that influence proximal behavioral determinants ( De Vries et al. , 1998b ) and specify more distal streams of influence for each of the three core determinants in the Planned Behavior Model ( Azjen, 1991 ) (attitudes, self-efficacy and social normative beliefs). Each of these behavioral determinants is assumed to be moderated by several distal factors, including self-esteem and mental disorders.

The TTI regards self-esteem in the same sense as the ASE, as a distal factor. According to this theory, self-efficacy is influenced by personality characteristics, especially the ‘sense of self’, which includes self-integration, self-image and self-esteem ( Flay and Petraitis, 1994 ).

The Precede–Proceed model of Green and Kreuter (Green and Kreuter, 1991) for the planning of health education and health promotion also recognizes the role of self-esteem. The model directs health educators to specify characteristics of health problems, and to take multiple determinants of health and health-related behavior into account. It integrates an epidemiological, behavioral and environmental approach. The staged Precede–Proceed framework supports health educators in identifying and influencing the multiple factors that shape health status, and evaluating the changes produced by interventions. Self-esteem plays a role in the first and fourth phase of the Precede–Proceed model, as an outcome variable and as a determinant. The initial phase of social diagnosis, analyses the quality of life of the target population. Green and Kreuter [(Green and Kreuter, 1991), p. 27] present self-esteem as one of the outcomes of health behavior and health status, and as a quality of life indicator. The fourth phase of the model, which concerns the educational and organizational diagnosis, describes three clusters of behavioral determinants: predisposing, enabling and reinforcing factors. Predisposing factors provide the rationale or motivation for behavior, such as knowledge, attitudes, beliefs, values, and perceived needs and abilities [(Green and Kreuter, 1991), p. 154]. Self-knowledge, general self-appraisal and self-efficacy are considered as predisposing factors.

To summarize, self-esteem can function both as a determinant and as an outcome of healthy behavior within health behavior models. Poor self-esteem can trigger poor coping behavior or risk behavior that subsequently increases the likelihood of certain diseases among which are mental disorders. On the other hand, the presence of poor coping behavior and ill-health can generate or reinforce a negative self-image.

Self-esteem in a BSA to mental health promotion and prevention in schools

Given the evidence supporting the role of self-esteem as a core element in physical and mental health, it is recommended that its potential in future health promotion and prevention programs be reconsidered.

The design of future policies for mental health promotion and the prevention of mental disorders is currently an area of active debate ( Hosman, 2000 ). A key question in the discussion is which is more effective: a preventive approach focusing on specific disorders or a more generic preventive approach?

Based on the evidence supporting the role of self-esteem as a non-specific risk factor and protective factor in the development of mental disorders and social problems, we advocate a generic preventive approach built around the ‘self’. In general, changing common risk and protective factors (e.g. self-esteem, coping skills, social support) and adopting a generic preventive approach can reduce the risk of the development of a range of mental disorders and promote individual well-being even before the onset of a specific problem has presented itself. Given its multi-outcome perspective, we have termed this strategy the ‘BSA’ in prevention and promotion.

Self-esteem is considered one of the important elements of the BSA. By fostering self-esteem, and hence treating a common risk factor, it is possible to contribute to the prevention of an array of physical diseases, mental disorders and social problems challenging society today. This may also, at a later date, imply the prevention of a shift to other problem behaviors or symptoms which might occur when only problem-specific risk factors are addressed. For example, an eating disorder could be replaced by another type of symptom, such as alcohol abuse, smoking, social anxiety or depression, when only the eating behavior itself is addressed and not more basic causes, such as poor self-esteem, high stress levels and lack of social support. Although there is, as yet, no published research on such a shift phenomenon, the high level of co-morbidity between such problems might reflect the likelihood of its existence. Numerous studies support the idea of co-morbidity and showed that many mental disorders have overlapping associated risk factors such as self-esteem. There is a significant degree of co-morbidity between and within internalizing and externalizing problem behaviors such as depression, anxiety, substance disorders and delinquency ( Harrington et al. , 1996 ; Angold et al. , 1999 ; Swendsen and Merikangas, 2000 ). By considering the individual as a whole, within the BSA, the risk of such an eventuality could be reduced.

The BSA could have practical implications. Schools are an ideal setting for implementing BSA programs, thereby aiming at preventing an array of problems, since they cover the entire population. They have the means and responsibility for the promotion of healthy behavior for such a common risk and protective factor, since school children are in their formative stage. A mental health promotion curriculum oriented towards emotional and social learning could include a focus on enhancing self-esteem. Weare ( Weare, 2000 ) stressed that schools need to aim at helping children develop a healthy sense of self-esteem as part of the development of their ‘intra-personal intelligence’. According to Gardner (Gardner, 1993) ‘intra-personal intelligence’ is the ability to form an accurate model of oneself and the ability to use it to operate effectively in life. Self-esteem, then, is an important component of this ability. Serious thought should be given to the practical implementation of these ideas.

It is important to clearly define the nature of a BSA program designed to foster self-esteem within the school setting. In our opinion, such a program should include important determinants of self-esteem, i.e. competence and social support.

Harter ( Harter, 1999 ) stated that competence and social support, together provide a powerful explanation of the level of self-esteem. According to Harter's research on self-perceived competence, every child experiences some discrepancy between what he/she would like to be, the ‘ideal self’, and his/her actual perception of him/herself, ‘the real self’. When this discrepancy is large and it deals with a personally relevant domain, this will result in lower self-esteem. Moreover, the overall sense of support of significant others (especially parents, peers and teachers) is also influential for the development of self-esteem. Children who feel that others accept them, and are unconditionally loved and respected, will report a higher sense of self-esteem ( Bee, 2000 ). Thus, children with a high discrepancy and a low sense of social support reported the lowest sense of self-esteem. These results suggest that efforts to improve self-esteem in children require both supportive social surroundings and the formation and acceptance of realistic personal goals in the personally relevant domains ( Harter, 1999 ).

In addition to determinants such as competence and social support, we need to translate the theoretical knowledge on coping with inner self-processes (e.g. inconsistencies between the real and ideal self) into practice, in order to perform a systematic intervention regarding the self. Harter's work offers an important foundation for this. Based on her own and others' research on the development of the self, she suggests the following principles to prevent the development of negative self-esteem and to enhance self-worth ( Harter, 1999 ):

Reduction of the discrepancy between the real self and the ideal self.

Encouragement of relatively realistic self-perceptions.

Encouraging the belief that positive self-evaluations can be achieved.

Appreciation for the individual's views about their self-esteem and individual perceptions on causes and consequences of self-worth.

Increasing awareness of the origins of negative self-perceptions.

Providing a more integrated personal construct while improving understanding of self-contradictions.

Encouraging the individual and his/her significant others to promote the social support they give and receive.

Fostering internalization of positive opinions of others.

Haney and Durlak ( Haney and Durlak, 1998 ) wrote a meta-analytical review of 116 intervention studies for children and adolescents. Most studies indicated significant improvement in children's and adolescents' self-esteem and self-concept, and as a result of this change, significant changes in behavioral, personality, and academic functioning. Haney and Durlak reported on the possible impact improved self-esteem had on the onset of social problems. However, their study did not offer an insight into the potential effect of enhanced self-esteem on mental disorders.

Several mental health-promoting school programs that have addressed self-esteem and the determinants of self-esteem in practice, were effective in the prevention of eating disorders ( O'Dea and Abraham, 2000 ), problem behavior ( Flay and Ordway, 2001 ), and the reduction of substance abuse, antisocial behavior and anxiety ( Short, 1998 ). We shall focus on the first two programs because these are universal programs, which focused on ‘mainstream’ school children. The prevention of eating disorders program ‘Everybody's Different’ ( O'Dea and Abraham, 2000 ) is aimed at female adolescents aged 11–14 years old. It was developed in response to the poor efficacy of conventional body-image education in improving body image and eating behavior. ‘Everybody's Different’ has adopted an alternative methodology built on an interactive, school-based, self-esteem approach and is designed to prevent the development of eating disorders by improving self-esteem. The program has significantly changed aspects of self-esteem, body satisfaction, social acceptance and physical appearance. Female students targeted by the intervention rated their physical appearance, as perceived by others, significantly higher than control-group students, and allowed their body weight to increase appropriately by refraining from weight-loss behavior seen in the control group. These findings were still evident after 12 months. This is one of the first controlled educational interventions that had successfully improved body image and produced long-term changes in the attitudes and self-image of young adolescents.

The ‘Positive Action Program’ ( Flay and Ordway, 2001 ) serves as a unique example of some BSA principles in practice. The program addresses the challenge of increasing self-esteem, reducing problem behavior and improving school performance. The types of problem behavior in question were delinquent behavior, ‘misdemeanors’ and objection to school rules ( Flay and Ordway, 2001 ). This program concentrates on self-concept and self-esteem, but also includes other risk and protective factors, such as positive actions, self-control, social skills and social support that could be considered as determinants of self-esteem. Other important determinants of self-esteem, such as coping with internal self-processes, are not addressed. At present, the literature does not provide many examples of BSA studies that produce general preventive effects among adolescents who do not (yet) display behavioral problems ( Greenberg et al. , 2000 ).

To conclude, research results show beneficial outcomes of positive self-esteem, which is seen to be associated with mental well-being, happiness, adjustment, success, academic achievements and satisfaction. It is also associated with better recovery after severe diseases. However, the evolving nature of self-esteem could also result in negative outcomes. For example, low self-esteem can be a causal factor in depression, anxiety, eating disorders, poor social functioning, school dropout and risk behavior. Interestingly, the cross-sectional characteristic of many studies does not exclude the possibility that low self-esteem can also be considered as an important consequence of such disorders and behavioral problems.

Self-esteem is an important risk and protective factor linked to a diversity of health and social outcomes. Therefore, self-esteem enhancement can serve as a key component in a BSA approach in prevention and health promotion. The design and implementation of mental health programs with self-esteem as one of the core variables is an important and promising development in health promotion.

The authors are grateful to Dr Alastair McElroy for his constructive comments on this paper. The authors wish to thank Rianne Kasander (MA) and Chantal Van Ree (MA) for their assistance in the literature search. Financing for this study was generously provided by the Dutch Health Research and Development Council (Zorg Onderzoek Nederland, ZON/MW).

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1Department of Health Education and Promotion, Maastricht University, Maastricht and 2Prevention Research Center on Program Development and Effect Management, The Netherlands

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Mental Health Promotion and Effective Interventions Essay (Article)

In their article “The Evidence of Effective Interventions for Mental Health Promotion,” Clemens Hosman and Eva Jane-Llopis state that to prove the effectiveness of the programs contributing to mental health, it is necessary to refer to the evidence of the program’s effects received with the help of quasi-experimental studies. The authors focus on the intervention programs which have the most obvious positive effect on people’s mental health. These interventions can be divided into macro interventions and meso and micro-interventions.

The programs focused on improving nutrition belong to macro interventions, and they are effective when being combined with counseling services. The programs developed to improve housing work to overcome poverty and create appropriate conditions for living. The interventions to improve education work to increase the population literacy and education level to reduce the stress of being cheated, to overcome the gender gap, and to develop cognitive and emotional competencies. I can state that these programs can contribute to people’s mental health because they are oriented to satisfying the persons’ basic needs to provide them with the opportunities to overcome everyday stress.

According to Hosman and Jane-Llopis, to reduce economic insecurity, the poverty-alleviation programs are used to support the low-income population. Intervention to strengthen community networks are used to develop the persons’ vision of social responsibility and to overcome social violence. I am sure that the focus on the people’s interactions within the community is the first step to predicting the problems with mental health. The interventions used to reduce the misuse of addictive substances are based on the banning policies, laws to change the legal drinking age, and policies to predict the use of substances during pregnancy. In my opinion, the success of these interventions can contribute to people’s mental health more obviously because substance abuse often leads to mental health problems.

Hosman and Jane-Llopis’s meso and micro-interventions are more diverse, and they are focused on supporting children, adults, and elderly persons. Interventions for children include the support during the early stages of life in the form of home visiting to develop the parents’ competencies; parenting interventions to develop the positive relations between parents and children; and preschool education interventions to develop the children’s emotional and cognitive skills. I should state that these interventions are effective because children need a healthy start in their life to develop their mental health in the future. Parents should know the ways of promoting the children’s mental health to avoid any disorders.

Much attention is paid to the programs associated with school settings to help children adapt to the new settings and build strong relations with peers. The school ecology programs work to change the whole school environment in relation to the positive pattern, and targeted programs work to cope with concrete problems such as anxiety disorders. In this case, the targeted programs are very effective to overcome the results of the social pressure, ineffective parenting, and other problems.

Definite programs are proposed for adults to help them cope with the unemployment situation and stress at the workplace in order to become an active member of society and avoid depressions. I am sure that adults need support while coping with the challenging situations of losing the job or while surviving in dangerous working environments. That is why these programs should be promoted in society. Furthermore, a range of programs is proposed for elderly persons, and these interventions include the focus on physical activity and exercises, befriending, and providing hearing aids. The elderly persons are the vulnerable social category, and to reduce their depressions, stresses, and physical sufferings, effective intervention programs should be developed.

Thus, I am inclined to agree with Hosman and Jane-Llopis’s discussion of the intervention programs as effective to improve people’s mental health.

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The Importance of Mental Health

It's not just a buzzword

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

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Risk Factors for Poor Mental Health

Signs of mental health problems, benefits of good mental health, how to maintain mental health and well-being.

Your mental health is an important part of your well-being. This aspect of your welfare determines how you’re able to operate psychologically, emotionally, and socially among others.

Considering how much of a role your mental health plays in each aspect of your life, it's important to guard and improve psychological wellness using appropriate measures.

Because different circumstances can affect your mental health, we’ll be highlighting risk factors and signs that may indicate mental distress. But most importantly, we’ll dive into why mental health is so important.

Mental health is described as a state of well-being where a person is able to cope with the normal stresses of life. This state permits productive work output and allows for meaningful contributions to society.

However, different circumstances exist that may affect the ability to handle life’s curveballs. These factors may also disrupt daily activities, and the capacity to manage these changes. That's only one reason why mental health is so important.

The following factors, listed below, may affect mental well-being and could increase the risk of developing psychological disorders .

Childhood Abuse

Childhood physical assault, sexual violence, emotional abuse, or neglect can lead to severe mental and emotional distress. Abuse increases the risk of developing mental disorders like depression, anxiety, post-traumatic stress disorder, or personality disorders.

Children who have been abused may eventually deal with alcohol and substance use issues. But beyond mental health challenges, child abuse may also lead to medical complications such as diabetes, stroke, and other forms of heart disease.

The Environment

A strong contributor to mental well-being is the state of a person’s usual environment . Adverse environmental circumstances can cause negative effects on psychological wellness.

For instance, weather conditions may influence an increase in suicide cases. Likewise, experiencing natural disasters firsthand can increase the chances of developing PTSD. In certain cases, air pollution may produce negative effects on depression symptoms.

In contrast, living in a positive social environment can provide protection against mental challenges.

Your biological makeup could determine the state of your well-being. A number of mental health disorders have been found to run in families and may be passed down to members.

These include conditions such as autism , attention deficit hyperactivity disorder , bipolar disorder , depression , and schizophrenia .

Your lifestyle can also impact your mental health. Smoking, a poor diet , alcohol consumption , substance use , and risky sexual behavior may cause psychological harm. These behaviors have been linked to depression.

When mental health is compromised, it isn’t always apparent to the individual or those around them. However, there are certain warning signs to look out for, that may signify negative changes for the well-being. These include:

A switch in eating habits, whether over or undereating
A noticeable reduction in energy levels
Being more reclusive and shying away from others
Feeling persistent despair
Indulging in alcohol, tobacco, or other substances more than usual
Experiencing unexplained confusion, anger, guilt, or worry
Severe mood swings
Picking fights with family and friends
Hearing voices with no identifiable source
Thinking of self-harm or causing harm to others
Being unable to perform daily tasks with ease

Whether young or old, the importance of mental health for total well-being cannot be overstated. When psychological wellness is affected, it can cause negative behaviors that may not only affect personal health but can also compromise relationships with others.

Below are some of the benefits of good mental health.

A Stronger Ability to Cope With Life’s Stressors

When mental and emotional states are at peak levels, the challenges of life can be easier to overcome.

Where alcohol/drugs, isolation, tantrums, or fighting may have been adopted to manage relationship disputes, financial woes, work challenges, and other life issues—a stable mental state can encourage healthier coping mechanisms.

A Positive Self-Image

Mental health greatly correlates with personal feelings about oneself. Overall mental wellness plays a part in your self-esteem . Confidence can often be a good indicator of a healthy mental state.

A person whose mental health is flourishing is more likely to focus on the good in themselves. They will hone in on these qualities, and will generally have ambitions that strive for a healthy, happy life.

Healthier Relationships

If your mental health is in good standing, you might be more capable of providing your friends and family with quality time , affection , and support. When you're not in emotional distress, it can be easier to show up and support the people you care about.

Better Productivity

Dealing with depression or other mental health disorders can impact your productivity levels. If you feel mentally strong , it's more likely that you will be able to work more efficiently and provide higher quality work.

Higher Quality of Life

When mental well-being thrives, your quality of life may improve. This can give room for greater participation in community building. For example, you may begin volunteering in soup kitchens, at food drives, shelters, etc.

You might also pick up new hobbies , and make new acquaintances , and travel to new cities.

Because mental health is so important to general wellness, it’s important that you take care of your mental health.

To keep mental health in shape, a few introductions to and changes to lifestyle practices may be required. These include:

Taking up regular exercise
Prioritizing rest and sleep on a daily basis
Trying meditation
Learning coping skills for life challenges
Keeping in touch with loved ones
Maintaining a positive outlook on life

Another proven way to improve and maintain mental well-being is through the guidance of a professional. Talk therapy can teach you healthier ways to interact with others and coping mechanisms to try during difficult times.

Therapy can also help you address some of your own negative behaviors and provide you with the tools to make some changes in your own life.

The Bottom Line

So why is mental health so important? That's an easy answer: It profoundly affects every area of your life. If you're finding it difficult to address mental health concerns on your own, don't hesitate to seek help from a licensed therapist .

World Health Organization. Mental Health: Strengthening our Response .

Lippard ETC, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders . Am J Psychiatry . 2020;177(1):20-36. doi:10.1176/appi.ajp.2019.19010020

Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

National Institutes of Health. Common Genetic Factors Found in 5 Mental Disorders .

Zaman R, Hankir A, Jemni M. Lifestyle Factors and Mental Health . Psychiatr Danub . 2019;31(Suppl 3):217-220.

Medline Plus. What Is mental health? .

National Alliance on Mental Health. Why Self-Esteem Is Important for Mental Health .

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

California Health Care Foundation

2022 edition — mental health in california.

Mental illnesses are among the most common health conditions faced by Californians: Nearly 1 in 7 California adults experiences a mental illness, and one in 26 has a serious mental illness that makes it difficult to carry out daily activities. 1 in 14 children has an emotional disturbance that limits functioning in family, school, or community activities.

A number of positive changes have helped strengthen California’s mental health system. These changes include federal and state laws mandating parity in coverage of mental and physical illness, and the expansion of Medi-Cal eligibility and scope of mental health services under the Affordable Care Act. In addition, there have been numerous public and private efforts to expand access to care, encourage better integration of physical and mental health care, and reduce stigma. Nonetheless, a majority of Californians who need it fail to receive needed care.

Using the most recent data available, Mental Health in California: Waiting for Care provides an overview of mental health statewide: disease prevalence, suicide rates, supply and use of treatment providers, and mental health in the criminal justice system. The report also highlights available data on quality of care and mental health care spending.

Selected Findings

This slideshow displays highlights from the full report, which is available for download below.

Key findings include:

The prevalence of serious mental illness varied by income, with much higher rates of mental illness for both children and adults in families with incomes below 100% of the federal poverty level.
Rates of serious psychological distress reported by California adolescents and adults increased between 2016 and 2019.
California’s rate of suicide was below both the national rate and the Healthy People 2030 target, although rates varied within the state by gender, race/ethnicity, and county.
Close to two-thirds of adults with a mental illness and two-thirds of adolescents with major depressive episodes did not get treatment.
People incarcerated in California’s jails and prisons have high rates of mental illness. In 2019, 30% of female prison inmates and 20% of the male prison population received mental health treatment while incarcerated.

The full report, a quick reference guide, and all the charts found in the report are available for download below. In addition, serious mental illness prevalence by county files are available for download as a data file.

These materials are part of CHCF’s California Health Care Almanac , an online clearinghouse for key data and analyses describing the state’s health care landscape. See our entire collection of current and past reports on mental and behavioral health in California.

Document Downloads

Mental Health in California Almanac, 2022: Waiting for Care ( PDF )

Mental Health in California Almanac, 2022 — Quick Reference Guide ( PDF )

Mental Health in California Almanac, 2022 — Charts ( ZIP )

Mental Health in California Almanac, 2022 — Data ( ZIP )

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COMMENTS

Mental Health Promotion: [Essay Example], 1628 words
While mental health promotion upholds the significance for psychological well-being that will enable an individual to develop its coping mechanism rather than enhancement of mental ill-health symptoms (WHO, 2002). It is the duty of healthcare providers in delivering and sustaining an optimum level of patient's holistic well-being.
Mental Health Prevention and Promotion—A Narrative Review
Mental health promotion is a broad concept that encompasses the entire population, and it advocates for a strengths-based approach and tries to address the broader determinants of mental health. ... Additionally, we included original papers from the last 5 years (2016-2021) so that they do not get missed out if not covered under any published ...
Mental Health Promotion in Public Health: Perspectives and Strategies
Mental health promotion seeks to foster individual competencies, resources, and psychological strengths, and to strengthen community assets to prevent mental disorder and enhance well-being and quality of life for people and communities. 1-4 Positive psychology is the study of such competencies and resources, or what is "right" about people—their positive attributes, psychological ...
Why Good Mental Health Is Important and How to Promote It
Good mental health is not possible without policies and an environment that respects and protects basic civil, cultural, political, and socio-economic rights. People must have the security and ...
INTRODUCTION TO MENTAL HEALTH PROMOTION
MENTAL ILL-HEALTH. 1.1.1 Introduction. It is recognized that mental health is an inherent and central component of health and that promoting mental health optimizes our quality of life. In fact, mental health promotion has grown into a key field of health promotion research and programming, as well as a key priority in building thriving ...
Mental health
Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape ...
Mental Illness Prevention and Mental Health Promotion: When, Who, and
According to our conceptualization (1-6), the social determinants of mental health are societal problems affecting large segments of the population (individuals, families, communities, and, indirectly, the entire population) that interfere with optimal mental health.These factors increase risk for mental illnesses and substance use disorders, worsen outcomes among those with existing mental ...
Mental Health Prevention and Promotion—A Narrative Review
Introduction. Mental disorder has been recognized as a significant public health concern and one of the leading causes of disability worldwide, particularly with the loss of productive years of the sufferer's life ().The Global Burden of Disease report (2019) highlights an increase, from around 80 million to over 125 million, in the worldwide number of Disability-Adjusted Life Years (DALYs ...
Promoting mental health as an essential aspect of health promotion
INTRODUCTION. It is of great concern that mental health promotion is frequently overlooked as an integral part of health promotion (Desjarlais et al., 1995; WHO, 2001; Lavikainen et al., 2000).This is surprising because, in theory, mental health is accepted as an essential component of health (), the close relationship between physical and mental health is recognized and it is generally known ...
Mental Health Promotion in Society
Health promotion work should be done in collaboration with a community using program planning and implementation strategies. Firstly, a thorough study regarding the needs and resources of a community should be conducted. Secondly, a plan of action should be made and implemented. Evaluation of the final results is an important step in the ...
Mindfulness' Role in Mental Health Promotion Essay
Mindfulness' Role in Mental Health Promotion Essay. Exclusively available on IvyPanda Available only on IvyPanda. Updated: Jan 10th, 2024 ... Mindfulness-based programmes for mental health promotion in adults in nonclinical settings: a systematic review and meta-analysis of randomised controlled trials. PLoS medicine, 18(1), 1-40. Web.
Promotion of Mental Health Literacy in Adolescents: A Scoping Review
1. Introduction. The world is currently facing a very challenging public health problem: the significant prevalence of mental health problems in the general population and adolescents and young people [1,2], as well as their low/moderate levels of mental health literacy [3,4,5].Mental health problems account for 12% of illnesses worldwide, and in developed countries, the figure rises to 23% [].
A systematic review of the effectiveness of mental health promotion
Background This systematic review provides a narrative synthesis of the evidence on the effectiveness of mental health promotion interventions for young people in low and middle-income countries (LMICs). Commissioned by the WHO, a review of the evidence for mental health promotion interventions across the lifespan from early years to adulthood was conducted. This paper reports on the findings ...
Mental Health Promotion and Prevention
The terms mental health promotion and prevention have often been confused. Promotion is defined as intervening to optimize positive mental health by addressing determinants of positive mental health before a specific mental health problem has been identified, with the ultimate goal of improving the positive mental health of the population. Mental health prevention is defined as intervening to ...
Self-esteem in a broad-spectrum approach for mental health promotion
A mental health promotion curriculum oriented towards emotional and social learning could include a focus on enhancing self-esteem. Weare (Weare, 2000) stressed that schools need to aim at helping children develop a healthy sense of self-esteem as part of the development of their 'intra-personal intelligence'. According to Gardner (Gardner ...
Promoting mental health
Mental health promotion interventions improve overall wellbeing and are delivered in the settings where people live, work, learn, and thrive. These include school and workplace mental health programs, early childhood interventions, social support and community engagement, women empowerment, anti-discrimination programs, and other interventions that address the social determinants of mental health.
Mental Health Promotion and Effective Intervention
Mental Health Promotion and Effective Interventions Essay (Article) In their article "The Evidence of Effective Interventions for Mental Health Promotion," Clemens Hosman and Eva Jane-Llopis state that to prove the effectiveness of the programs contributing to mental health, it is necessary to refer to the evidence of the program's ...
Mental health promotion: Guidance and strategies
Abstract. Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease.
The Importance of Mental Health
Because mental health is so important to general wellness, it's important that you take care of your mental health. To keep mental health in shape, a few introductions to and changes to lifestyle practices may be required. These include: Taking up regular exercise. Prioritizing rest and sleep on a daily basis.
2022 Edition
Download Now. Mental illnesses are among the most common health conditions faced by Californians: Nearly 1 in 7 California adults experiences a mental illness, and one in 26 has a serious mental illness that makes it difficult to carry out daily activities. 1 in 14 children has an emotional disturbance that limits functioning in family, school ...
PDF Adverse Community Experiences and Resilience: Learning from Practice
mental health and wellbeing, climate change, and substance misuse). It is also being used by multiple sectors (e.g., public health, behavioral health, health care/practitioners, advocates, and philanthropy). 3. Healing is an important starting point supportive of further action. Healing is a starting point
Mental illness and well‐being: an affect regulation perspective
Often, they support adaptive functioning. At other times, however, they can become detrimental to mental health via maladaptive affect generation processes and/or maladaptive affect regulation processes. Here, we present an integrative framework for considering the role of affect generation and regulation in mental illness and well‐being.
Health Promotion Planning: An Educational and Ecological ...
Author(s): Green, L.W. and Kreuter, M.W. Publisher: Mayfield Publishing Publishing Year: 1999 Publisher Location: Mountain View, California, USA Pages: 621 ISBN: 0 ...