The majority of those with enduring mental health disorders present for the first time to both primary care and secondary care services as adults. Therefore early intervention in mental health does not mean intervention at an early age, but intervention early in a patient’s care pathway, even before a diagnosis is clear. However, the current secondary mental health systems do not facilitate this with high thresholds jealously guarding a limited capacity. This may make every day practical sense, but the paradigm shift of this book argues that specialist mental health consideration is needed at an earlier developmental stage of a diagnosis. This would lead to both improvement in health outcomes and a benefit to the wider health economy. This chapter will focus on early intervention (EI) at the earliest stages and also on mental health promotion, which can be seen at a general population level to promote mental well-being and happiness.

This chapter will also explore the basis of this new paradigm and how EI services fit within the wider provision of adult mental health services. The current threshold for accessing secondary care adult mental services often requires a diagnosis and significant disability. We need to contrast this to mental health services for adolescents, where a presentation of symptom and distress is usually sufficient to receive specialist input. This thinking incorporates secondary prevention with the focus of treatment and intervention at the early developmental stage of a mental disorder. Secondary prevention detects those with a discernible disorder, decreases the duration of symptomatic distress and thereby reduces functional decline due to ongoing active pathology.

The development of preventative medicine for mental health has been recognised by governments across Scandinavia, Australasia and in the United Kingdom. In the United Kingdom, the Department of Health published a mental health strategy policy in 2011 ‘No Health Without Mental Health: a cross-government mental health outcomes strategy for people of all ages’ [1]. It notes:

• most mental disorders develop in childhood
  
• three-quarters of mental health problems first present by the mid-20s
  
• there is a need to improve the support for early detection and intervention for offenders
  
• there should be a parity with physical health care in the way mental health patients are treated (‘parity of esteem’)
  
• Improving Access to Psychological Therapies (IAPT) needs to be available nationally
  
• there is a need to promote mental health and well-being and prevent mental illness (this aim is further defined by an emphasis on public health developments, and the development of a mental well-being measure for the nation).

So as government policy drives change, those working in mental health services need to change practice at the front line.

‘The Anatomy of Melancholy’ published by Robert Burton 1621, which was based on earlier medical teaching from Persia and Greece, made reference to mental illness prevention [2]. Burton pointed out that melancholia (black bile) in excess leads to a specific course of illness through one’s life, while noting that it could also be a force of creativity. There was however a suggested way to prevent the associated disease in this case, with the advice of ‘be not solitary, be not idle’. This can be seen as a very important contemporary feature of primary prevention for mental illness and continues to be advice for mental well-being of behavioural activation and reducing social isolation. It is also interesting to note that, historically, disease of mind and body has had an interrelation within preventative medicine, and this is still fully incorporated in traditional Chinese medicine.

In recent decades, the drivers for preventative medicine in mental health for adults have come from a focus in the early identification of those with a schizophrenia illness. The last decade has seen a proliferation of EI services for psychosis right across the globe, and in the United Kingdom these services have been incorporated into the National Institute for Health and Care Excellence’s (NICE) recommendations for psychotic illnesses including bipolar affective disorder (psychosis). The supportive evidence ranges from an economic benefit, service user satisfaction and carer satisfaction, to hard evidence of a decrease in the morbidity on quality of life and the impact of each relapse. The plethora of research papers on EI services in psychosis has led to many centres incorporating strategies for the early detection of mental illness rather than being specific to the diagnosis of schizophrenia. Services have started focusing on young adults and those at a wider risk of psychosis diagnoses. There is the recognition that the life transition from adolescence to adulthood has inherent stress-vulnerability and services can help navigate the young person through this life stage. It is noted that the individualisation of breaking from one’s family, the financial and emotional independence, the first relationships’ break up, all need to be felt and internalised to lead to future mental health resilience.

In addition, wealth creation and gross domestic product (GDP) do not lead to improved mental and physical health across a population. This is reflected in the rising prevalence in obesity, diabetes and depression in the developed and the developing world. The argument is for the development of national prevention programmes, rather than just fund end-stage disease treatment when the patient is economically unproductive. In the United Kingdom there are several government initiatives to improve the mental health capital of the adult population. This economic imperative has directly led to improved primary care access for psychological therapies (IAPT), with an increase in thousands of cognitive behavioural therapists nationally. Having easy access to CBT in primary care is argued to have an economic benefit to society, as well as to the individual’s quality of life, with less people on financial benefits and more people in work. This programme is expected to pay for itself over a lifetime via a decrease in unemployment benefits and increased productivity of the working population.

Over the last two decades of individualism, with success measured in wealth, there has been a social movement towards well-being, which is different from the scientific epidemiological models of disease. Well-being is a rather catch-all phrase which includes someone’s satisfaction in their work–life balance, or self-definitions of success. This can be seen as a personal shift in modern priorities away from the previous generations’ definitions of success, e.g. marriage, children, a car, a secure job. How many of us satisfy that description? A life well lived, having a social network, having physical health, reaching one’s potential. These are some of the British philosopher’s Alain de Botton’s agents of happiness as opposed to competition with one’s neighbours. He was also the founder of ‘The School of Life’ in London and has shown that there is a demand from many young adults who are seeking an understanding of their happiness and have a desire to build a preventative strategy from future mental illness. It is noted that the stigma associated with seeking well-being at facilities such as The School of Life, which are not overtly a mental health clinic, is less than the stigma that is generally associated with adult mental health services and being seen by a psychiatrist.

A more scientific stance is taken by Seligman in the book, ‘Flourish – A Visionary New Understanding of Happiness and Wellbeing’ (2011) [3]. His seminal works have included the theories of learned helplessness in the 1960s and that of positive psychology in the 1990s. In ‘Flourish’, there are very practical ways to achieve happiness with the headlines being: engagement, positive emotions, positive relationships, meaning and accomplishment. There is a need for social connection to other people’s experiences as well as appraisal of what failure is and the internal settings of mental discontent. This book has been on international best sellers’ lists and show that there is a rare, unexpected demand from the public for mental health promotion and the understanding of mental well-being.

The first country to measure gross national happiness (GNH) as well as gross domestic product (GDP) is the Himalayan Kingdom of Bhutan. They will not be unique as the UK government has now developed a national happiness and well-being measure. We can see that any work on prevention of mental illness needs to start with an understanding of happiness and well-being, as this fits within the primary prevention strategy for mental health. By reporting and measuring happiness and well-being there is an opportunity to affect future mental health outcomes. This is also an area for adult mental health services to consider even in the absence of diagnosable mental disorder.

The implementation of prevention for mental illness has been impaired by the difficulty in the definitions of ‘Mental Health’ and ‘Prevention’. These terms are defined by the absence of illness, but for mental illness prevention this is too simplistic. The above discussion of happiness and well-being did not lend itself neatly to the practical day-to-day work for those working in adult mental health services. In these services, mental illness is seen as disorders with a specific diagnosis, but in reality are across a continuum of mental health symptoms. The concept of prevention of mental illnesses does not easily fit with much of the illnesses seen in the mental health clinics or in the hospital wards. For example the concept of prevention may fit for a patient presenting with Korsakoff’s dementia (related to Vitamin B deficiency and chronic alcohol dependency), but for most patients with diagnoses, such as schizophrenia, there is no clear link to aetiology. The worst outcome, suicide, is not specifically linked to a diagnosis or a single aetiology, but despite the sociological and environmental context, it still comes under the general heading of mental illness. Conceptually using the diagnosis to focus on the aetiology does not lead to an easy prevention strategy in most mental illnesses presenting in adulthood.