On the pursuit of happiness – reflections on a mental health commission report, eudaimonia and evidence based medicine

The Centre Forum Mental Health Commission recently published their final report entitled – The pursuit of happiness: a new ambition for our mental health. This report outlines several concepts relating to the core idea of Mental Wellbeing:

a dynamic state in which an individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community.

Closely related to this idea of wellbeing is that of Mental Capital:

a person’s cognitive and emotional resources

Having defined wellbeing the report moves on to consider its relationship with mental health presenting an orthogonal dimensional system that relates concepts of mental health problems (minimal to maximal) and wellbeing (minimal to maximal). There is then a description of mental health problems represent a leading cause of poor wellbeing – I think there is a greater complexity here perhaps than is indicated as reverse causation is possible too? For example if my wellbeing drops then presumably my mental health may suffer, this direction of relationship is not discussed in the report.

Interaction between mental wellbeing and mental health

Interaction between mental wellbeing and mental health

Having set out the concept of mental wellbeing and its relationship to mental health the report then proposes that the development of wellbeing should be a governmental priority highlighting a number of domains in which this could be considered:

  1. Communities
  2. Families
  3. Schools
  4. Workplaces
  5. Health and social care institutions

For me though the most interesting recommendation from the report was as follows:

That the goal of promoting wellbeing and mental capital should be measured through a basket of new and existing metrics

The commission propose the extension of this concept to evaluations such as those published by NICE in order that the impact of interventions on an individual’s subjective well being be adequately gauged.

I think this is an important point – we need to incorporate measures of subjective wellbeing into our evidence base in order that we can adequately inform decision making with regard to support choices, for example the role of medication. For example – taking one recent pharmacology study that I read (chosen as simply the most recent study I’ve read) comparing oral and monthly injected aripiprazole sought to compare the efficacy of three preparations (oral and two doses of injectable medication) and demonstrate non-inferiority of the injectable formulation (Fleischhacker, W. W., Sanchez, R., Perry, P. P., Jin, N., Peters-Strickland, T., Johnson, B. R., et al. (2014). Aripiprazole once-monthly for treatment of schizophrenia: double-blind, randomised, non-inferiority study. The British Journal of Psychiatry, 205(2), 135–144. doi:10.1192/bjp.bp.113.134213). The primary outcome was defined as time to impending relapse (worsening clinical symptoms, increase in suicidal ideation or behaviour, hospital admission owing to psychotic symptoms or violent behaviour), other outcomes included time to discontinuation of treatment. No quality of life or subjective well being measures were included in the study – arguably these are to some extent reflected in the time to discontinuation, but it would have been nice for them to be measured directly.

Broken Evidence based medicine

There was a recently commentary published in the BMJ (Greenhalgh, T., Howick, J., Maskrey, N., for the Evidence Based Medicine Renaissance Group. (2014). Evidence based medicine: a movement in crisis? BMJ, 348(jun13 4), g3725–g3725. doi:10.1136/bmj.g3725) looking at the current practice of evidence based medicine. The authors commented on 5 crisis points for the idea of evidence based practice:

  1. Misappropriation of evidence based practice by vested interest
  2. Volume of evidence has rendered the paradigm unmanageable
  3. Statistical benefits do not always translate to clinical benefits
  4. Inflexibility can bias the system to be target not individual patient driven
  5. Multimorbidity is poorly considered within the current evidence base

In the commentary several potential solutions to address these problems. In my opinion metrics that adequately assess the psychological and social impact of these issues, as are called for in the above report, would go a long way to overcoming these issues by delivering evidence that is readily translated down to individual experience.

Eudaimonia – a theoretical framework for psychological well-being

The concept of well-being is complex however and is impacted on by various factors that are difficult to consider within research paradigms. For example the concept of Eudaimonia was first described by Ryff in 1989 and seeks to outline key factors that are important to the concept of individual wellbeing, while outlining the theoretical underpinnings of each factor:

  1. Self-acceptance
  2. Purpose in life
  3. Environmental mastery
  4. Positive relationships
  5. Personal growth
  6. Autonomy

Support of these factors shows clear overlap with the core features of personal recovery experiences.

Seeking happiness

The commission’s report has received an interesting degree of commentary, for example a Presidential statement from the Royal College of Psychiatry raising concerns regarding the evidence for such suggestions and an accompanying commentary on Mad in America.

As these differing interpretations illustrate and the complexity of highlighted domains within the concept of eudaimonia suggest the interaction between mental health and mental wellbeing is no doubt complex. For me personally however this report was a positive call for measures that can provide overarching descriptions of personal experience. Beyond arguments relating to the nature of mental health and the possibility of such a thing as mental illness a focus on measures that support individual subjective wellbeing seems a good aim for society in general as well as future mental health services.

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