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Monday, 3 October 2011

Mental Health Promotion – Protecting our sanity.

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Found - Another important national monograph, supposedly released March 2011 – and seems to be getting some circulation finally now.   Mental Health Promotion and Mental Illness Prevention  in Canada looking specifically at value for money for certain types of mental health programming.  Why these gems remain hidden and waiting to be uncovered is a major mystery. 
The first tirade for today is the continuing expectation that prevention and promotion activities demonstrate money saved for the money expended.  This is not the expectation for other health services, in fact if health services were measured by this metre stick, most health services would be eliminated. 
The second tirade is the continuing expectation that the only benchmark for prevention and promotion interventions is randomized trials.  Yes they provide the best evidence when they are available.  The inherent literature biases inserted into decision making when research methodologies are complex, interventions can’t be clearly isolated, populations are the unit of outcome and not  individuals – all contribute to shortcomings in evidence, not necessarily shortcomings in effectiveness.  Work needs to be done on clarifying how this evidence is incorporated and respected.
Tirades aside, perhaps not surprising, the best mental health promotion and prevention evidence comes from childhood and adolescents situations.  The school setting affords the opportunity to limit extraneous variables and control the therapeutic setting leading to better quality research.   If you speak to clinicians, they would have told you that focusing attention on schools makes more sense anyway. 
The document does do justice in several areas.  First Mental Health is an underresourced, understudied and less evidence based sector than other parts of the system.   The report makes these conclusions admirably.  The conclusion is that we need to expect the same sense of rigour from Mental Health professionals, that may be challenging as there are decades of isolation and ostracization to overcome, and the health system is not a very patient patient. 
One key area identified in the conclusions is the need to meld language and not utilize similar terms to describe different issues.   John Last, the grandfather of Canadian public health, has led the effort to standardize epidemiological and public health terminology globally.  Prevention has three levels, primary, secondary and tertiary.   Health promotion takes its definition from the Ottawa Charter.  As the fields have expanded you will find reference to quaternary prevention, primordial prevention, and now mental health promotion that attempt to carve out niches for their language.   Credit to the monograph for placing so much emphasis on clarifying the differences between mental health promotion and illness prevention activities.  
The best part of the document is the clarity by which the outcomes that extend beyond the realm of mental health professionals are identified and measured.   Worth the look just to learn from the methodologies and appreciate the approach to trying to insert rigorous evaluation into a field that seems resistant.

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