Positive mental health and mental illness

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by Heather Gilmour

The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”Note1 This definition emphasizes that mental health is more than the absence of mental illness. Knowledge about the prevalence and determinants of mental health is important for informing promotion and intervention programs.

This analysis examined the percentages of Canadians aged 15 or older in three mental health categories—flourishing, languishing  and moderate mental health—defined by the Mental Health Continuum–Short Form (MHC-SF).Note2 In accordance with the complete mental health model,Note2 mental health was assessed in combination with the presence or absence of six mental illnesses measured in the 2012 Canadian Community Health Survey–Mental Health (CCHS-MH): depression, bipolar disorder, generalized anxiety disorder, and alcohol, cannabis or other drug abuse or dependence, as measured by the World Mental Health—Composite International Diagnostic Interview 3.0 (see The data). To better understand the characteristics of people with the highest level of mental health, prevalence and adjusted odd ratios of complete mental health were examined in relation to socio-demographic and health correlates.

Complete mental health model

Keyes’ two continua modelNote2 identifies mental health and mental illness as separate but correlated axes—one representing the presence or absence of mental health; the other, the presence or absence of mental illness.  As measured by the MHC-SF, positive mental health (hereafter referred to as “mental health”) is a combination of feeling good about and functioning well in life. The scale consists of 14 questions (Appendix) that assess emotional well-being and aspects of psychological and social functioning in order to classify respondents’ mental health as flourishing (high positive emotions, high positive functioning), languishing (low positive emotions, low positive functioning), or moderate (neither flourishing nor languishing). Studies have found flourishing to be protective against all-cause mortalityNote3 and suicidal behaviour, and academic impairment among students,Note4 and predictive of future depression risk.Note5 Improvements in mental health have been  associated with lower odds of mental illness.Note6

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Questions in Mental Health Continuum Short Form (MHC-SF)

Emotional well-being

How oftenNote  in the past month did you feel ...
  1. happy?
  2. interested in life?
  3. satisfied with your life?

Positive functioning

How oftenNote  during the past month did you feel ...
  4. that you had something important to contribute to society? (social contribution)
  5. that you belonged to a community (like a social group, your neighbourhood, your city, your school)? (social integration)
  6. that our society is becoming a better place for people like you? (social growth)
  7. that people are basically good? (social acceptance)
  8. that the way our societiy works makes sense to you? (social cohenrence)
  9. that you liked most parts of your personaity? (self-acceptance)
  10. good at managing the responsibilities of your daily life? (environmental mastery)
  11. that you had warm and trusting relationships with others? (positive relationship with others)
  12. that you had experiences that challenged you to grow and become a better person? (personal growth)
  13. confident to think or express your own ideas and opinions? (autonomy)
  14. that your life has a sense of direction or meaning to it? (purpose in life)
Flourishing requires a response of "almost every day" or "every day" to 1 or more of the 3 emotional well-being questions, and to 6 or more of the 11 positive functioning questions.
Languishing requires a response of "once or twice" or "never" to 1 or more of the 3 emotional well-being questions, and to 6 or more of the 11 positive functioning questions.
Moderate mental health refers to those who are neither flourishing or languishing.

Source: Keyes.Note33

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The absence of mental illness does not imply the presence of mental health, or vice versa.Note2,Note7 The complete mental health model combines mental health (flourishing, languishing, moderate mental health) with the presence or absence of mental illness to classify individuals into one of six states. Complete mental health means both flourishing and being free of mental illness.  States other than complete mental health have been associated with limitations in activities of daily living, missed days of work, physical conditions, and greater use of acute health care services and prescription medication.Note2,Note8-11

Majority flourishing

In 2012, the percentages of Canadians classified as having flourishing, moderate or languishing mental health were 76.9%, 21.6% and 1.5%, respectively.  The percentage flourishing was higher than in the United States,Note4,Note23-25 the  Netherlands,Note16 South Africa,Note14 France,Note17 and Korea,Note18 which ranged from 11.7% to 69.1%. However, previous surveys that employed the MHC-SF used telephone, postal and internet instruments and population-based and convenience samples, and covered different age ranges, subpopulations, and levels of geography—each of these elements likely contributed to the range in the prevalence of flourishing. A bias could result if people in poor mental health were less likely to participate in the CCHS-MH.  Additionally, if mental health is substantially different in the three territories and among the groups excluded from the CCHS-MH, prevalence estimates could be affected.  However, the territories represent 0.3% of the target population,Note26 and exclusions, about 3%.Note27

Wide variation across countries in the prevalence of positive well-being was reported in a multi-country study in Europe that used consistent survey methodology.Note28  Based on a conceptually similar measure to the MHC-SF, a fourfold difference in the prevalence of “flourishing” was found between the lowest and highest countries (9.3% to 40.6%), which suggests that cultural factors may play a role.  In addition, a comparison of the MHC-SF in three countries (the Netherlands, South Africa and Iran)Note29 concluded that scale items functioned similarly across cultures; therefore, differences in MHC-SF and its associations with health outcomes were due to differences in the cultural groups, not to differential functioning of the scale.

Self-perceived mental health

To demonstrate construct validity, the prevalence of flourishing from the CCHS-MH and self-perceived mental health (SPMH) from the annual component of the 2012 CCHS were compared. SPMH is based on the question, “How would you rate your mental health?” Although is less comprehensive than the MHC-SF, it might be expected to measure similar constructs. The percentage of Canadians with “excellent” or “very good” SPMH (versus “good,” “fair” or “poor”) paralleled the percentage with flourishing mental health (Figure 1), although the measures diverged at older ages.  This lends credibility to the higher estimate of flourishing reported from the CCHS-MH, compared with other surveys.Note4,Note14,Note16-18,Note23,Note24

Mental disorder and mental health

In 2012, 10.1% of Canadians aged 15 or older (2.8 million) met the criteria for at least one of the six past 12-month mental or substance use disorders measured by the CCHS-MH.  These data are based on self-reported responses to the WMH-CIDI survey instrument (see The data) and do not include all possible mental disorders. As expected, an inverse relationship between mental health and mental disorder was apparent (Figure 2).

According to combined assessments of mental health and mental illness,Note2,Note7 in 2012, an estimated 72.5% of Canadians aged 15 or older (19.8 million) were categorized as having complete mental health—they were flourishing and did not meet the criteria for mental disorders (Table 1). This was higher than percentages reported in American studies:  32.7% of adults,Note16 37.9% of adolescents,Note23 and 49.3%4 and 60.7%Note24 of college students.  In addition to factors previously mentioned (different age groups, subpopulations, survey collection methodologies, cultural factors), differences in measurements of mental disorder may contribute to variation across studies.

Although much less common, flourishing or moderate mental health can occur in the presence of mental illness (4.5% and 4.7%, respectively), and languishing mental health can occur with or without the presence of a mental disorder (0.9% and 0.6%, respectively). In this study, the continuous mental health score was only moderately correlated with any mental disorder (-0.31), mood disorder (-0.31), generalized anxiety disorder (-0.23), or any substance use disorder (-0.13) (p < 0.01), which emphasizes that mental health is more than the absence of mental illness.

Who is in complete mental health?

An understanding of the characteristics of people in complete mental health can be useful in informing promotion and intervention programs.Note30,Note31  Analysis of the correlates of complete mental health has been limited, and none has been undertaken for the Canadian population.

In this study, men and women were equally likely to be classified as having complete mental health (Table 2).  Results from previous studies have been equivocal.  In a study of American adults,Note7 the prevalence of complete mental health was higher among men than women, but only for blacks. A study of Dutch adults found that women were more likely than men to have complete mental health.Note16  The Dutch study found that age-related differences in complete mental health age were no longer significant in multivariate analysis.Note16 By contrast, based on the results of the CCHS-MH, a positive association with age persisted even when socio-demographic and health factors were taken into account.  As well, people with a partner were more likely than those who were widowed, separated, divorced or single to be in complete mental health.

Canadians in the lowest household income quintile, without a postsecondary education, and without a job or permanently unable to work were less likely to report complete mental health.  In the United States, education was also positively associated with complete mental health.Note7 In the Netherlands, mental health was not significantly associated with income, but marital status was associated with complete illness (languishing and mentally ill).Note16

Although relatively high percentages of recent immigrants (0 to 4 years in Canada) and longer-term immigrants (15 or more years) reported complete mental health, the association was not significant in multivariate analysis. Given that immigrants are not a homogeneous group, analysis that incorporates immigrant type and country of origin would be required to disentangle associations between immigrant status and complete mental health.

A bivariate association between Aboriginal status (off reserve) and a lower prevalence of complete mental health did not persist in multivariate analysis.  Research based on samples large enough to study First Nations, Métis and Inuit groups separately, and including the population living on reserves, is required to better understand the relationship between Aboriginal status and complete mental health.

People living in urban environments were significantly less likely (72%) than rural residents (77%) to be in complete mental health.

Research has linked religion and spirituality with mental health.Note32 In this study, those who reported strong spirituality were significantly more likely (76% versus 66%) to be in complete mental health than were those not classified as having strong spirituality.

Physical health was also associated with mental health. Having one chronic condition or three or more conditions was associated with a lower likelihood of complete mental health in both bivariate and multivariate analysis; the presence of two chronic conditions was not. The association between chronic pain and complete mental health demonstrated a clear gradient—76% of those without pain were in complete mental health, compared with 66% with pain that prevented none or only a few activities, and 55% with pain that prevented some or most activities.  This gradient persisted in multivariate analysis.

Concluding remarks

Estimates of flourishing and complete mental health based on the CCHS-MH are higher than reported in previous studies. Results support Keyes’ two continua model, whereby mental health and mental illness are related, but distinct, phenomena. Further study is required to better understand to what extent differences in survey methodology account for variations in the prevalence of flourishing; whether Canadians are actually more likely than other populations to have flourishing mental health; and if so, what socio-demographic or cultural factors may explain this phenomenon.

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