Dr. Corey Keyes
updated May 16, 2010
Mental Health is a complete state and not merely the absence of mental illness symptoms or diagnoses
There are three conceptions of health throughout human history, but only one—the pathogenic viewpoint—has informed our approach to population mental or physical health. The pathogenic approach views health as the absence of disability, disease, and premature death. The second approach is the salutogenic approach which views health as the presence of positive human capacities and functioning that protect against illness. The third approach is the complete state model, which is based on the conception of health as being hale, or whole, and is exemplified in the World Health Organisation’s 1948 definition of overall health consisting of the presence of positive human capacities and functioning as well as the absence of disease or infirmity.
Because it combines the pathogenic and salutogenic paradigms, the complete states approach is the only paradigm that can achieve true population health. Until recently, mental health as something more than the absence of psychopathology remained undefined, unmeasured, and therefore unrecognized. In the 1999 U.S. Surgeon General’s annual report, Dr. David Satcher conceived of mental health as “. . . a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with people, and the ability to adapt to change and to cope with adversity” (page 4). In 2004, the World Health Organisation described mental health as not merely the absence of mental illness, but the presence of “. . . 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”.
Both definitions affirm the vision of mental health as not merely the absence of mental illness, but the presence of something positive. Social and psychological scientists have been studying ‘something positive’ in the domain of subjective well–being—individuals’ evaluations and judgment of their own lives—for over fifty years. This research has yielded thirteen specific dimensions of subjective well–being in the U.S. adult and adolescent populations. Studies show that the scales measuring subjective well–being represent positive emotions toward one’s life (hedonic well-being) and positive functioning in life (eudaimonic well–being). The different dimensions of mental well being
Many studies of hedonic well-being have shown that it consists of two main dimensions, the first being how satisfied are you with your life overall and the other being the emotions that one experiences in a typical month (e.g. how frequently one experiences joy, contentment). The domain of functioning well in life consists of psychological and social well-being. Psychological well-being consists of dimensions such as self acceptance, purpose in life, personal growth, positive relations with others, autonomy, environmental mastery. Social well-being consists of acceptance of others, a sense of social contribution, feeling socially integrated, an interest in society and “what is going on,” and a sense of social growth. Thus, when the six dimensions of psychological well-being are combined with the five dimensions of social well-being, there are at least eleven different signs of positive functioning in life. With the two dimensions of hedonic well-being, which represent whether and how much one feels good about life, the set of thirteen dimensions of subjective well-being provide a comprehensive assessment of the overall quality of life.
Subjective well–being research yielded clusters of mental health symptoms that mirror the cluster of symptoms used to diagnose major depressive episode (MDE). In the same way that depression requires symptoms of an–hedonia, mental health consists of symptoms of hedonia such as emotional vitality and positive feelings toward one’s life. In the same way that major depression consists of symptoms of mal–functioning, mental health consists of symptoms of positive functioning. Each measure of subjective well–being is considered a symptom because it represents an outward sign of an unobservable state. Latent, or directly unobservable, conditions must be inferred from symptoms. Moreover, mental health, like mental illness, is identifiable only as collections of signs and symptoms that, as a syndrome, reflect an underlying state of health or its absence. The diagnosis of positive mental health flows from this compatibility of clusters of signs of mental health as in mental illness, particularly depression (i.e., anhedonia and hedonia; malfunctioning and positive functioning).
To be diagnosed as flourishing in life, individuals must exhibit high levels on at least one measure of hedonic well–being and high levels on at least six measures of positive functioning. Individuals who exhibit low levels on at least one measure of hedonic well–being and low levels on at least six measures of positive functioning are diagnosed as languishing in life. Languishing is the absence of mental health – a state of being mentally unhealthy. To be languishing is to be in a state of being stuck, stagnant, or empty, and devoid of positive functioning in life. Adults who are moderately mentally healthy do not fit the criteria for either flourishing or languishing in life.
Mental illness and mental health form two continua in the population
The theory that the MIDUS measures of mental health and mental illness (see details of study below) belong to latent continua was tested. Three scales served as indicators of mental health: the summed scale of emotional well–being (i.e., single item of satisfaction + scale of positive affect), the summed scale of psychological well–being (i.e., six scales summed together), and the summed scale of social well–being (i.e., the fives scales summed together). Four summary measures served as indicators of mental illness, based on the number of symptoms of four mental disorders: generalized anxiety, panic disorder, major depressive episode, and alcohol dependence. Two competing theories were tested. The single factor model hypothesizes that the measures of mental health and mental illness reflect a single latent factor, support for which would indicate that the absence of mental illness implies the presence of mental health. The two factor model hypothesizes that the measures of mental illness represent the latent factor of mental health that is distinct from, but correlated with, the latent factor of mental illness that is represented by the measures of mental illness. The data strongly supported the two factor model, which was a nearly perfect fitting model to the MIDUS data.
As predicted, there is a modest association between mental health and mental illness; level of mental health tends to increase as level of mental illness decreases. The modest correlation suggests, however, that the latent constructs of mental health and mental illness are distinctive. This distinctiveness raises the empirical question of the risk of an episode of mental illness as levels of mental health decrease. Languishing adults report the highest prevalence of any of the four mental disorders as well as the highest prevalence of reporting two or more mental disorders during the past year. In contrast, flourishing individuals report the lowest prevalence of any of the four 12–month mental disorders or their comorbidity. Compared with languishing or flourishing, moderately mentally healthy adults were at intermediate risk of any of the mental disorders or two or more mental disorders during the past year. Thus, the 12–month risk of major depressive illness, for example, is over five times greater for languishing than flourishing adults.
Support for the two factor model provides the strongest scientific evidence to date in support of the complete health approach to mental health. The evidence indicates that the absence of mental illness does not imply the presence of mental health, and the absence of mental health does not imply the presence of mental illness. Thus, neither the pathogenic nor salutogenic approaches alone accurately describe the mental health of a population. Rather, mental health is a complete state that is best studied through the combined assessments of mental health with mental illness. Complete mental health is a state in which individuals are free of mental illness and they are flourishing. Of course, flourishing may sometimes occur with an episode of mental illness, and moderate mental health and languishing can occur both with and without a mental illness.
Flourishing mental health is even better than moderate mental health
To have ‘complete mental health,’ one must be flourishing and free of most common mental disorders over the past year. Research has supported the hypothesis that anything less than complete mental health results in increased impairment and disability. For example, adults diagnosed as completely mentally healthy functioned superior to all others in terms of reporting the fewest workdays missed, fewest workdays cutback by one-half, the lowest rate of cardiovascular disease, the lowest level of health limitations of activities of daily living, the fewest chronic physical diseases and conditions, the lowest healthcare use, and the highest levels of psychosocial functioning. In terms of psychosocial functioning, this meant that completely mentally healthy adults report the lowest level of perceived helplessness, the highest level of knowing what they want from life, the highest level of self–reported resilience (e.g. that they try to learn from adversities), and the highest level of intimacy (e.g., that they have very close relationships with family and friends). In terms of all of these measures, completely mentally healthy adults functioned better than adults with moderate mental health, who in turn functioned better than adults who were languishing.
Just over 20% of adults in the MIDUS study had an episode of at least one of the four mental disorders. However, and very importantly, levels of mental health differentiate levels of impairment and disability even among adults who have had a mental illness in the past year. Adults with a mental illness who had either moderate level of mental health or were flourishing reported fewer workdays missed, fewer workdays cutback, and fewer health limitations of daily living than those who were languishing and had a mental illness. Thus, languishing individuals who also had one or more mental disorders functioned worse than all others on every criterion. Adults with a mental illness who also had either moderate mental health or flourishing function no worse than adults who were languishing and did not have a mental disorder. Thus, mental illness that is combined with languishing is more dysfunctional than the situation when a mental illness occurs in the context of moderate mental health or flourishing.
Another published paper investigated the association of the complete mental health diagnoses with chronic physical conditions associated with age. The complete mental health diagnosis was associated with 85% of the chronic physical conditions measured in the MIDUS study. The prevalence of chronic physical conditions was highest among adults who are languishing and had an episode of major depression, and lowest among completely mentally healthy adults. The prevalence of chronic physical conditions was slightly higher among moderately mentally healthy adults than completely mentally healthy adults, whereas languishing adults reported even more chronic conditions than adults with moderate mental health.
Overall, adults with major depression and languishing had an average of 4.5 chronic conditions. Adults with depression but who also had moderate mental health or flourishing had an average of 3.1 chronic conditions, which was the same as adults who were languishing but without any mental illness. Moderately mentally healthy adults without any mental illness had an average of 2.1 chronic conditions, compared with adults with complete mental health who had on average of 1.5 chronic conditions. When compared against completely mentally healthy adults, chronic physical conditions increased as the level of mental health decreased. It is noteworthy that mental health status was a significant predictor of chronic physical conditions even after adjustment for the usual sociodemographic variables as well as body mass index, diabetes status, smoking status, and level of physical exercise.
Further analyses revealed statistically significant interactions of age with two of the mental health diagnostic states. In short, languishing with, and languishing without, a mental illness is associated with increasing numbers of chronic physical diseases with advancing age.
Results from this study suggest two important findings. First, adults who were completely mentally healthy had the lowest number of chronic physical conditions at all ages. Second, the youngest adults who were languishing had the same number of chronic physical conditions as older flourishing adults. Younger languishing adults who also had MDE had 1.5 more chronic conditions than older flourishing adults. In other words, the absence of mental health—whether it is languishing or languishing combined with a mental illness—appears to compound the risk of chronic physical disease with age.
Last but not least, we have found healthcare utilization to be lowest among adults who are flourishing. Rates of overnight hospitalisations over the past year, outpatient medical visits over the past year, and number of prescription drugs were lowest among adults who were flourishing and physically healthy, followed by adults who were either flourishing but had physical illness conditions or adults who were not flourishing but were physically healthy. In short, complete mental health—i.e., flourishing and the absence of mental illness—should be central to any national debate about healthcare coverage and costs. Rather than focusing all discussions around healthcare delivery and insurance, our nation must increase and protect the number of individuals who are healthy, driving down the need for healthcare.
Why we need mental health promotion and protection as well as mental illness prevention and treatment
Scientific evidence points towards one unmistakable conclusion: Flourishing is a desirable condition that any community, organisation or government should want to protect or promote in its citizens. How much of the adult population is mentally healthy? Only 17% of U.S. adults who were free of a mental illness during the past year fit the criteria for flourishing in life. Most of the adult population (51%) did not have an episode of mental illness but were only moderately mentally healthy. Worse yet, 10% of adults are mentally unhealthy, as they are languishing and did not fit the criteria for any of the four mental disorders—and languishing adults averaged one symptom of mental illness. In addition, 23% of adults fit the criteria for one or more of the four mental disorders measured in the MIDUS. Of that 23%, 7% had a mental illness and fit the criteria for languishing (ie. individuals had an episode of mental illness along with the absence of mental health). Of the 23% with a mental illness, 14.5% had moderate mental health and 1.5% was flourishing.
The goal of any approach to population mental health should be:
• reduction of mental illness and
• promotion of rates of complete mental health.
Whereas it would be ideal if 60%, for example, of the population was flourishing and free of mental illness, barely 20% U.S. adults are truly mentally healthy. Too many adults experience an episode of mental illness in a year, and too few adults are flourishing. These findings suggest a need for national investments in the promotion of mental health as flourishing. The size of the adult population with moderate mental health, and its proximity to being completely mentally healthy, indicates a cost–effective leverage point for increasing national mental health. Evidence reviewed earlier suggests that reducing the size of the moderate mental health group by increasing its mental health could substantially reduce direct costs (eg. use of health care) and indirect costs (eg. workdays lost).
In conclusion, measures of mental illness and measures of mental health form two distinct continua in the U.S. population. Measures of disability, chronic physical illness, psychosocial functioning, and healthcare utilisation reveal that anything less than flourishing is associated with increased impairment and burden to self and society. Only a small proportion of individuals free of a common mental disorder are mentally healthy, i.e., flourishing. Thus, the absence of mental illness is not the presence of mental health, flourishing individuals function markedly better than all others, but only a fifth of the U.S. adult population is flourishing.
We can no longer blithely announce that we, as a nation, seek to promote the mental health of any population in this country, while investing only in treatment and risk reduction prevention. The two continua model debunks this as a “wanting-doing gap” in public health policy, where policies pronounce national efforts to seek health but engage in activities directed primarily or solely toward illness. Governments cannot promote mental health by solely reducing mental illness, and no amount of wishful thinking will make this fact disappear. Nations can, of course, ignore the science supporting the two continua model, but this will serve only to sacrifice more lives to the recurrent, chronic, and incurable condition of mental illness. The alternative and complementary approach to treatment is public mental health promotion and protection.
The paradigm of mental health research and services worldwide must change in this century from pathogenic to the complete states approach. This paradigm seeks to understand the causes of mental illness and the causes of mental health (i.e., flourishing) to create and implement effective treatments, prevention, and promotion in the population. To achieve a mentally healthier population, we must simultaneously reduce the number of cases of mental illness and increase the number of individuals who are flourishing. Toward that end, policy-makers must enact policies and programs to increase the rates of flourishing rather than only decreasing the rates of specific mental illnesses. In turn, branches within the National Institutes of Mental Health (in the U.S and in England) should be expanded to include ‘salutogenic’ laboratories for basic and applied science. Public Health can and should also focus its surveillance of health conditions to include not only mental illness and distress but also the presence and absence of positive mental health. In the end, only a complementary system of public health—one that promotes and protects true mental health at the same time it prevents and treats mental illness—can result in a population we all want for ourselves, or loved ones, and or citizens.
|dr. corey keyes|
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