Indian Journal of Social Psychiatry

: 2019  |  Volume : 35  |  Issue : 3  |  Page : 164--168

Strategies toward building preventive mental health

Shanmugiah Arumugam 
 Department of Psychiatry, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Correspondence Address:
Dr. Shanmugiah Arumugam
Department of Psychiatry, Coimbatore Medical College Hospital, Coimbatore - 641 018, Tamil Nadu


Preventive aspect of mental health deals with identification, monitoring, and controlling risk factors. Mental health promotion leads to positive mental health and thus reduces the prevention of psychiatric morbidity. The concept of mental health promotion relies on the identification of mental health determinants at various contexts. The determinants include the risk factors for the development of mental health issues and protective factors for positive mental health. The risk factors are of macrofactors such as poverty, illiteracy, war, displacement, and discrimination. Microfactors play at individual, family, social, and community level. The risk factors also vary across the life span of the individual. The protective factors are at play in various contexts such as public health policy, empowerment, strengthening the community, and improving the protective factors of the individuals such as self-esteem, family atmosphere, and social as well as community support. Identification also should look at the special populations such as women, children, elderly, and migrant population. Strategies involving psychological approaches and social interventions focusing at these factors and early intervention strategies for the first episode psychosis will reduce the psychiatric morbidity results in the prevention of mental health issues and related disability paving the way for prevention and positive mental health.

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Arumugam S. Strategies toward building preventive mental health.Indian J Soc Psychiatry 2019;35:164-168

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Arumugam S. Strategies toward building preventive mental health. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Nov 18 ];35:164-168
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Mental health promotion often refers to positive mental health. Hodgson in 1996 defined mental health promotion as the enhancement of the capacity of individuals, families, groups, or communities to strengthen or support positive emotional, cognitive, and related experiences.

Mental health promotion or positive mental health is defined as the creation of individual, social, and environmental conditions that help optimal psychological and psycho development. Prevention of mental disorders is the aims and outcomes of a broader mental health promotion strategy. Mental ill-health refers to signs and symptoms leading to distress and disability. The strategies to improve or promote mental health toward positive side should focus on reducing risk factors that lead to mental ill health and enhancing protective factors. In the context of public health, positive mental health aims at reducing the magnitude of mental disorders and identifying and reducing the risk factors. Mental health promotion, in turn, reduces the incidence and prevalence mental disorders. Positive mental health serves as a powerful protective factor against mental illness. Positive mental health as concept has dimensions of a continuum. A review of many scientific contributions reveals six major approaches defining the concept of positive mental health such as attitudes of the individual toward himself, degrees to which person realizes his potentialities through action, unification of the function in the individual personality, individuals degree of independence of social influences, how the individuals see the world around him, and the ability to take life as it comes and master it. Mental disorders and positive mental health cannot be described as the different ends of a linear scale but rather as two overlapping and interrelated components of a single concept of mental health. Preventive and promotive components are often presents within the same strategies to produce different but complementary outcomes.

Risk factors are associated with an increased probability of onset, severity, and duration of mental ill-health. The links between the risk factors and its influence on the development of mental disorders have been evident.[1]

Risk factors are classified into genetic risk factors and disease-specific risk factors.

Genetic risk factors are common risk factor for some mental ill-health and disorders. Strategies that address these risk factors may address a broad-spectrum preventive effect. Populations living in poor socioeconomic circumstances are at high risk to develop mental health problems.[2] Macrorisk factors such as urbanization, war, displacement, racial discrimination, and economic instability lead to increased psychiatric morbidity. Psychiatric morbidity includes depression, anxiety, and alcohol-related disorders.

Microrisk factors are classified into social, individual, familial, and economic. Individual and family-related risk factors can be biological, emotional, cognitive, behavioral, interpersonal, and family context related.

Child abuse and mental illness in parents during infancy and childhood can lead to depression and anxiety later in life as well as in the next generations. Maternal risk behavior during pregnancy and adverse events early in life lead on to disorders. Marital discord can lead to conduct disorder in children, depression in women, and alcohol-related problems in both parents. Marital dissatisfaction is associated with higher levels of depressive symptoms among both parents. Longitudinal studies also have demonstrated that individuals in unhappy marriages experience increase in depressive symptoms. Depression leads to decrease in marital quality in men, whereas in women, lower marital quality leads to depression. Marital discord was associated with bipolar disorder and depression. The association between marital distress and major depressive disorder increased in magnitude with increasing age.[3] Geriatric population suffers from a range of risk factors such as elder abuse, personal loss, and bereavement. Bereavement is the most commonly experienced adverse event in older age. Loss of a child leads to higher rate of bereavement, and older adults are more vulnerable for complicated grief in 4.8% of a general population of older adults. There is no gender difference of complicated grief in the old age group.[4]

Individual factors

Psychosocial risk factors predict the morbidity rate of psychiatric disorders. A low level of education was associated with increased morbidity, which could be indirect indicator of type of work and lower income. Perceived stress is an important risk factor for high morbidity. Perceived stress level may be related to work stress, feelings of insecurity, abnormal mood states, and interpersonal relationship. The presence of life events was found to be a significant determinant of psychiatric morbidity. In addition, the nature of the event supporting resources, defenses, and coping mechanism of the individual also influence the relationship between the life event and psychiatric morbidity. Education level, job satisfaction, perceived stress, and stressful life events were the independent determinants of psychiatric morbidity.[5]

Familial factors

Social environment of the families reveals more problems in rural population than urban population. Active recreational orientation in urban population is one variable contributing for good mental health outcome. Deficiencies in three areas in the families of rural population, namely, cohesion, moral religious emphasis, and organization have been associated with vulnerable mental health outcome.[6]

The cumulative effects of the various risk factors and the lack of protective factors and the interplay between these two predispose individuals to increased vulnerability then to mental ill-health and finally to a diagnosable mental disorder.

 Concept of Protective Factors

Protective factors refer to conditions that improve people's resilience to risk factors and disorders. Protective factor is defined as the factor that modifies, eliminates, or alters a person's response to environmental hazard that predisposes to maladaptive outcome. Individual protective factors are identical of positive mental health.

Individual protective factors

Across the life's span factors including good intelligence, easy temperament, and the presence of supportive adult have all been at play as protective factors against the expression of psychopathology. Resilience in late adolescence is associated with good interpersonal relationship and a strong sense of self.[7]

Social protective factors

Majority of the studies assessing the structural aspect of the social capitol found a statistically significant association between the measures of low social capital and poor mental health. Social capitol is defined as the resources available to the individuals and to the society through social relationship, the features of social organization such as civic participation, norms of reciprocity, and trust in others that facilitate cooperation for mutual benefit.[8]

Preventive science has developed over the last two decades. Contribution from social, biological, and neurological sciences has made insight into the role of risk and protective factors in the developmental pathway to mental health.

Strategies to promote positive mental health aim to reinforce protective factors along the life span. A collective approach focusing the entire population and wide range of activities targeting positive mental health is mental health intervention spectrum.

Spectrums of interventions are as follows:

PreventionEarly interventionTreatmentContinuing care.

 Principles of Strategic Approaches in Positive Mental Health

Mental health promotion interventions have been targeted either within defined settings such as (school, workplaces, and cities) or with identified population groups such as (older group and younger group).

The five main strategies for mental health promotion for action are as follows:

Building public health policyCreating supportive environmentsStrengthening community actionDeveloping personal skillsExpanding the orientation of health service.[9]

Building public health policy

Policy and funding decisions in the welfare, education, and judiciary are important to promote positive mental health, for example, universal antenatal screening and follow-up of mothers at risk of postnatal depression.

Creating supportive environments

Supportive social, economic, cultural, and physical environments provide a basic framework for and developing and maintaining mental health. Absence of war and conflict is fundamental to emotional and social well-being.

The strategies at microlevels to implement in the society (schools and workplaces) are as follows:

Antibullying schemesTo reduce the rate of physical abuseTo reduce the rate of verbal abuse.

Improving the physical environments through infrastructure promote mental health, for example, good public transport.

Strengthening community action

Affordable and accessible leisure activities, social support, strong social networks, and a sense of integration and inclusion are key predictors of positive mental health. It is important to be supportive of parents and families, as early childhood experiences within the family form a platform for later mental health.

Supportive environment at workplaces can promote positive mental health. Communities with high levels of social capital are characterized by trust, tolerance, and reciprocity. They offer a wide range of networks that provide many opportunities for mutual support and participation at all levels along with exchange of skills and information. This type of community may be called as empowered community.

Media strategy

Media promotes mental health literacy in the community and reduces stigma and discrimination to promote recovery and understanding of mental illnesses and increase appropriate early help-seeking behavior. The media also influence attitudes on a range of everyday life issues that affect mental health.

Developing personal skills

Mental health promotion acknowledges the importance of psychological process, how people think, feel, and interpret the world at all levels. Mental health, therefore, incorporates the development of personal skills to enhance emotional and social life.

Personal skills include the ability to manage change, and to recognize, acknowledge, and communicate thoughts and feelings, the ability to make and maintain relationship.

Skills are necessary to cope with stress and adversity. Every individual needs to have feelings of self-worth and empowerment, the belief that they can control and influence the environment.

Personal skills can be addressed at various levels; major achievements in mental health can be attained by improving the environments that affect the development of resilience in children.

For example,

Parenting skills programQuality child careTraining at school level.

Expanding the orientation of health services

The component of incorporating promotion, prevention, and early intervention within health services will address the positive mental health.

The objectives of these strategies are as follows:

Reducing the risk factorsStrengthen the protective factorsDecrease psychiatric morbidityTo reduce the rate of disabilityTo reduce the onset of psychiatric disorders.

 Principles of Prevention Strategies

The prevention of mental health problem depends on identifying and modifying the determinants of mental health. Effective prevention requires an understanding of the risk and protective factors for mental health. Identification of the potential groups and individuals who can benefit from the development, dissemination, and implementation of effective interventions.

 Principles of Early Intervention Strategy

Early intervention focuses on people with early signs and symptoms of a mental health problem or disorder or developing or experiencing a first episode of mental illness.


Early signs and symptom of developing mental disorders are as follows [Table 1]:{Table 1}

Symptoms those require for syndromal diagnosisPresent for shorter period of timeLess intense and disruptive than those of a diagnosable disorder.

There are many diagnostic instruments for the first episode of mental disorder based on the Diagnostic and Statistical Manual of Mental disorder, fourth edition [10] and the International Classification of Diseases, tenth edition (ICD-10).[11] These instruments detect only fully developed disorders.

Fully developed disorders (diagnosable) should have specific symptoms for a designated length of time and a particular intensity.

Potential early signs and symptoms

The focus on early intervention will be on reducing risk factors and enhancing protective factors rather than providing treatment. Mental health promotion across the life span.

Many developmental tasks and life changes are important factors for mental health promotion. A successful negotiation of these life changes and developmental tasks enhances mental health.

Developmental tasks and sectors across the life span

Sectors across the life span

CommunityHealth careWorkforceSocial relationshipEducationFamily.

Developmental tasks and life changes

Birth and development marriageDeveloping Social skills ParentingAcademic performance VocationalPsychosocial CaregiverCoping with loss Being Grandparent.

Life stages

Infancy and ToddlerhoodChildhoodAdolescenceAdultMental health promotion is essential across the entire life span, regardless of current health status.

 Strategies for Special Population


Prevention and early intervention for postnatal depression have valuable multigenerational effects. Postnatal depression influences the women's health, development of the child, relationship with other children, and the marital relationship.[12]

Prevention and early intervention of psychosis

At present, no known prevention for psychotic disorders such as schizophrenia and bipolar disorder, but research shows the positive effects of early intervention. The duration of untreated psychosis (DUP) was associated with more complications including severe behavioral disturbances and family difficulty.[13] The time to remission and level of remission were related to DUP.

Substance use disorder

The extent to which genetic, environmental, and learned behaviors interacts to determine substance misuse. Parental drug or alcohol abuse is established as a major risk factor. Emotional and behavioral problems along with peer and family influences are associated with substance misuse.

Preventive programs have focused on controlling access to substances and educating people as to these harmful effects. Studies have shown that just a few minutes of structured advice is an effective and efficient intervention for harmful and hazardous drinking.[14]

Suicide prevention strategy

Individuals with mental health problem and mental disorders are at markedly increased risk of suicide. The mental disorder most commonly associated with suicide is depression. Harmful drug use and psychotic disorders are prominently associated with suicide among younger adults.[15] Therefore, early intervention of mental health problem and mental disorders has the potential to reduce the incidence of associated suicides. Suicide is the final outcome of what is usually a complex, cumulative, and interacting set of risk factors. Personal and environmental factors that place people at increased risk for suicide including hopelessness, recent loss, a previous attempt, and active suicidal ideation.[16] Suicide prevention is approached indirectly through risk and protective factors.


Prevention of mental health morbidity is the need of the hour. The risk factors as well the protective factors interplay across the life's span of an individual in various context, namely, individual, family, society, and the community. The individual and social determinants of an individual predict the expression of psychopathology of various psychiatric disorders. However, protective factors of an individual and society determine the onset and development of psychiatric morbidity. The intervention strategies focusing on reducing the mental health morbidity, identifying, and strengthening the protective factors across life's span may give an optimistic hope for prevention of mental health morbidity and promotion of positive mental health. In the future, studies are required to address the determinants of risk and protective components across the life span of human community to strengthen the hope for preventive mental health.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Ingram RE, Price JM, editors. Hand Book of Vulnerability to Psychopathology: Risk Across the Life Span. 2nd ed. New York: Guilford Publishers; 2000.
2Patel V, Jane-Llopis E. Prevention of Mental Disorders: Effective Intervention and Policy Option. Summary Report. Geneva: World Health Organization; 2004.
3Whisman MA. Marital distress and DSM-IV psychiatric disorders in a population-based national survey. J Abnorm Psychol 2007;116:638-43.
4Newson RS, Boelen PA, Hek K, Hofman A, Tiemeier H. The prevalence and characteristics of complicated grief in older adults. J Affect Disord 2011;132:231-8.
5Dutta S, Kar N, Thirthalli J, Nair S. Prevalence and risk factors of psychiatric disorders in an industrial population in India. Indian J Psychiatry 2007;49:103-8.
6Mubarak AR. A comparative study on family, social supports and mental health of rural and urban Malay women. Med J Malaysia 1997;52:274-84.
7Mrazek PJ, Haggerty RJ; Institute of Medicine (US) Committee on Prevention of Mental Disorders. Reducing Risk Factors for Mental Disorders. Frontiers for Preventive Intervention Research. Washington, D.C: National Academies Press (US); 1994.
8Silva M, Loureiro A, Cordosa G. Social determinants of mental health; A review of mental health; A review of the evidence. Eur J Psychiatry 2016;130:259-92.
9World Health Organization. Ottawa Charter for Health Promotion: WHO and Canadian Public Health Association. Ottawa: World Health Organization; 1986.
10American Psychiatric Association. Diagnostic and Statistical manual of Mental Disorders DSM-IV. 4th ed. Washington: American Psychiatric Association; 2000.
11World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders, Clinical Description and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
12Boyce P, Stubbs J. The importance of postnatal depression. Med J Aust 1994;161:471-2.
13Johnstone EC, Crow TJ, Johnson AL, MacMillan JF. The Northwick Park study of first episodes of schizophrenia. I. Presentation of the illness and problems relating to admission. Br J Psychiatry 1986;148:115-20.
14Saunders JB, Lee NK. Hazardous alcohol use: Its delineation as a subthreshold disorder, and approaches to its diagnosis and management. Compr Psychiatry 2000;41:95-103.
15Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED, et al. Relationships of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. Am J Psychiatry 1996;153:1001-8.
16Australian Psychological Society. Suicide: An Australian Psychological Society Discussion Paper. Melbourne, MO: Australian Psychological Society; 1999.