“We wait for people to break down and park ambulances at the bottom of the cliff.”

Dr. Corey Keyes,
on mental health support

Introduction

What if the way we think about mental health and mental illness is all wrong?

Many experts argue that contemporary understandings of mental health are hindering efforts to prevent mental illnesses at a population level. In episodes 85 and 86 of the Public Health Insight podcast, the team sits down with psychologist and sociologist Dr. Corey Keyes to discuss this critical shortcoming and explore an alternative conceptualization of mental health and illness. Today’s blog will discuss:

• The global burden of mental illness
• The two-continua model: re-imaging the concept of mental health
• The road to a flourishing society

The Global Burden of Mental Illness

Mental health is a major global public health issue. In the last decade, mental health conditions and substance use disorders have increased by an estimated 13% (World Health Organization, n.d.). It’s predicted that by 2030, depression will be among the leading causes of disability and mortality worldwide, second only to heart disease. 

Many countries have placed greater attention on population-level mental illness in recent years – so why do mental health outcomes appear to be getting worse?

The answer may lie, in part, in the way we think about mental illness and mental health. Experts tend to evaluate the mental health outcomes of a population based on the presence or absence of a diagnosed mental illness like depression or anxiety. Mental health and mental illness are often conceptualized as opposites – if a person is free of mental illness, they must be mentally healthy.

This, however, is not necessarily true. Through his research, Dr. Keyes has demonstrated that the presence or absence of mental illness does not accurately predict an individual’s mental well-being. In fact, individuals who did not have a diagnosed mental illness but experienced low levels of well-being functioned just as poorly as individuals with a diagnosed mental illness when it came to work productivity, psychosocial relations, and accessing healthcare (Westerhof & Keyes, 2010). 

This metric for measuring mental illness also has implications for the way in which it is treated within a population. A person with a diagnosed mental illness may be treated using prescription drugs or through therapy, insinuating that the most effective way to decrease the burden of mental illness is to treat those who are already affected. However, support is not offered to those without a diagnosis who still experience low levels of mental well being. This leaves them to essentially fend for themselves, which may cause their situations to worsen and lead to the eventual development of a clinically diagnosed mental illness. 

To this point, traditional concepts of mental health and illness are not sufficient to adequately address the global mental health crisis – it is clear that more must be done to recognize the mental health needs of those without a clinical diagnosis. This will truly work to reduce the global burden of mental illness by preventing it from propagating in the first place.

The Two-Continua Model: Re-Imagining the Concept of Mental Health

An alternative to the typical conceptualization of mental health is Dr. Keyes’s two-continua model of mental health. Like the name suggests, the two-continua model measures two interconnected factors of mental wellbeing – mental illness and positive mental health. The former describes the absence/presence of a clinically diagnosed mental illness (measured along the x-axis), while the latter describes an individual’s level of mental well-being (measured along the y-axis)  (Westerhof & Keyes, 2010).

The well-being continuum defines the concept on two extremes: flourishing and languishing. “Flourishing” describes “a state where individuals combine a high level of subjective well-being with an optimal level of psychological and social functioning” (Westerhof & Keyes, 2010), while “languishing” describes “apathy, a sense of restlessness or feeling unsettled or an overall lack of interest in life or the things that typically bring you joy” (Fielding, 2021). In contrast to a mental illness – which is clinically diagnosed based on a series of specific symptoms –  flourishing and languishing are a fluid series of emotions that can affect a person’s state of mind. 

The cross-section of both continua creates four distinct quadrants. A person who falls in the upper left quadrant, for instance, has a diagnosed mental illness but still displays behaviours and emotions consistent with flourishing. Likewise, a person in the lower right quadrant does not have a diagnosed mental illness but still displays characteristics associated with languishing.

It is this latter category of people that are of concern to Dr. Keyes. According to him, these individuals are at high risk of developing a mental illness and shifting to the graph’s lower left quadrant. This makes intervention crucial for this group – in order to decrease the population burden of mental illness, preventative measures must be implemented to take individuals from faltering to flourishing.

The Road to a Flourishing Society

What can we do to help people flourish?

On a day-to-day basis, individuals can take several steps to improve their mental health over time. Dr. Keyes describes six activities associated with better mental health:

• Exercising
• Social interactions
• Pro-social behaviour (e.g., helping someone in need)
• Learning something new
• Playing/having fun
• Engaging in spiritual activity

Individuals who regularly engage in these activities, he states, tend to become more observant, less emotionally reactive, and generally experience improved mental health over time.

While helpful, these measures will not work for everyone. For many, the road to positive mental health is impeded by poor socio-economic circumstances that cannot be improved with simple lifestyle changes. According to the WHO, poverty, financial problems, and social deprivation are all major risk factors for mental health problems and disorders (World Health Organization, 2011). A recent Canadian study found that adults from low-income households were less likely to have their mental health needs met than those from high-income households and were almost twice as likely to experience an anxiety disorder (Public Health Agency of Canada, 2022). 

A society is unable to truly flourish while these inequalities persist. Economic reform and financial security are therefore crucial components of mental health policy and must be treated as such. By engaging in such a strategy over a treatment-only approach, experts will be able to prevent languishing and eventual mental illness before it ever occurs – a strategy that embodies the fundamental spirit of public health.

Conclusion/Key Takeaways

The presence or absence of mental illness is not necessarily an indicator of a person’s overall mental health. In order to truly improve mental well-being at a population level, preventative measures that allow individuals and populations to flourish must be emphasized. Today’s blog has covered:

• The global burden of mental illness and traditional conceptualizations of mental illness and health
• Re-conceptualizing mental health using Dr. Keyes’s two-continua model
• Actions that can be taken at individual and societal levels to help populations flourish

If you or a loved one are struggling with their mental health, know that you are not alone. Consider reaching out to a certified professional and/or consult the resources below for more information:

• Talk Suicide Canada – Nationwide, 24-hour bilingual support to anyone facing suicide
• The LifeLine App – Free suicide prevention and awareness app
• Kids Help Phone – Support services for children and youth
• Good2Talk – Free, confidential support services for post-secondary students in Ontario and Nova Scotia
• Hope for Wellness Hotline – Support for Indigenous people across Canada (available in multiple languages)
• LifeVoice
• Government of Canada – Support by province

Written by: Claire Borgaonkar