Mental health problems result from interplay between risk and protective factors

Mental health problems are mostly a cumulative effect of:

• the presence of multiple risk factors;
• the lack of protective factors;
• the interplay between risk and protective situations.

Risk factors increase the probability of onset, the severity and duration of mental health problems. Protective factors improve people’s resistance to risk factors and disorders. These factors modify or improve a person’s response to particular environmental hazards that are associated with mental health problems (Rutter, 1986). Risk and protective factors include individual as well as environmental determinants. Individual determinants include biological and genetic factors, personality traits and family-related factors. For an overview of the individual determinants see Individual determinants for mental disorders.

Individual determinants have most impact in sensitive stages of life

Determinants related to individuals may have the strongest impact on a person’s mental health at sensitive periods in their lifespan (WHO, 2004d). For example, child abuse and parental mental illness during infancy and early childhood can lead to depression and anxiety later in life as well as in subsequent generations. Elderly people who are physically ill can also be exposed to a range of subsequent risk factors, such as chronic insomnia, alcohol problems, elder abuse, personal loss and bereavement. Mental disorders can also have genetic determinants. These presently fall outside of the scope of the European Union’s public health interventions (EC, 2007).

Self-esteem compared across Europe

The MINDFUL project (Mental health Information and Determinants for the European Level) has brought together data on two determinants for mental health: self-esteem and social support of family and friends (MINDFUL, 2007). MINDFUL aims at improving the status of mental health information within the European Union. Self-esteem is defined as one's sense of worthiness as a person. High self-esteem functions as a protective factor against anxiety. Low self-esteem is associated with an experience of uncontrollable stress, depression, and various measures of ill health. The Rosenberg self-esteem scale shows the mean scores of self-esteem in 19 EU-countries. The data reveal no particular geographical pattern. However, caution is required with any such general interpretations, due to the variations in the data collection procedures (see remarks to Rosenberg self-esteem scale). A comparative assessment of the social support offered in European countries and its impact will be provided in the EUphact social support.

Poor socio-economic circumstances are a major environmental risk factor

Environmental determinants are related to macro-issues such as poverty, war and inequity, see Environmental determinants of mental health. Populations living in poor socio-economic circumstances have an increased risk of developing poor mental health, depression and a lower subjective well-being . This is because poor people often live without the basic freedoms of security, action and choice that the better-off take for granted. They often do not have access to adequate food, shelter, education and health (WHO, 2004d). Consequently, socially isolated and disadvantaged people have a poorer health status. More socially cohesive societies are, therefore, healthier and have a lower mortality rate (WHO, 2004e). In recognition of this, the Lisbon Strategy emphasizes the need to reinforce social cohesion and reduce poverty (EC, 2003). For more information, see the EUphact Social support.

Refugees and asylum seekers have multiple environmental risk factors

Two major societal risk groups are refugees and asylum seekers, since they have to deal with multiple environmental risk factors. Post-Traumatic Stress Disorder (PTSD) is one of the major mental health problems experienced by refugees. The disorder is caused by the impact of war and war-related traumas on the refugee, for example the experience of torture, beatings, killings or rape in their country of origin (Watters, 2007). Such experiences can also lead to depression, anxiety and alcohol-related disorders, as described in the EUphact Alchol use and Alcohol policies. A difficult post-migration environment, such as bureaucratic procedures, poor living conditions, low social support and discrimination, can lead to additional mental health problems and increase the risk of PTSD symptoms among traumatised asylum seekers. War-related traumas can also create psychiatric vulnerabilities in the offspring of traumatised and depressed parents.

Determinants can be generic or disease-specific

Most risk factors and protective determinants of mental health are generic, which means they are common to several mental health problems and disorders. All Individual determinants and Environmental determinants, are generic, such as poverty, poor social circumstances, child abuse and loneliness. Some determinants are disease-specific, which means they are mainly related to the development of a particular disorder. For example, negative thinking is specifically related to depression, and major depression is specifically related to suicide (WHO, 2004d).

Mental and physical health influence each other

Mental and physical health are interrelated in various ways (WHO, 2004d; WHO, 2004e):

• They may have common determinants. Risk factors such as poor housing can lead to both poor mental and poor physical health. Additionally, protective factors can prevent the onset, and influence the course and outcomes of both physical and mental illnesses. Psychological beliefs, such as optimism, personal control and a sense of meaning, protect one’s mental health as well as physical health.

• Mental disorders can increase vulnerability to physical morbidity and vice versa. For example, depression increases the risk of subsequently developing cardiovascular diseases. Poor general physical health is also three times more common among people who report significant emotional distress. These people often engage in behaviours, such as sedentary habits, binge drinking, smoking, and eating a poor diet, thus increasing their risk of developing health problems. On the other hand, chronic physical illness can increase vulnerability for mental health disorders.

The interaction between mental and physical health is thought to occur through complex psychological and psycho-physiological mechanisms. This highlights the value of an holistic approach to health.

Protective factors target both prevention and promotion

Interventions to prevent mental ill-health aim to counteract risk factors and reinforce protective factors. Interventions aiming to strengthen protective factors overlap largely with mental health promotion, since most individual protective factors are actually also features of positive mental health (WHO, 2004d). Preventive interventions should focus on protective factors that are susceptible to change, such as the ability to cope with stress, feelings of mastery and control and self-esteem.

Effects of interventions aimed at generic determinants are potentially wide-ranging

Interventions that successfully address generic determinants can generate more wide-ranging preventive effects in comparison to interventions that address disease-specific determinants. For example, the risk factors poverty and child abuse make people vulnerable for depression, anxiety and substance abuse. Therefore, interventions that address both poverty and child abuse can help prevent three disorders simultaneously. Combined interventions that both address major risk and major protective factors and have a large impact will be the most cost-effective and attractive. The same applies to interventions that impact on a range of related problems, such as social and economic problems, simultaneously (WHO, 2004d).