Public Mental Health Evidence Review 2024

Mental health’s profile has risen in recent years accompanied with a change in public attitudes and foothold on the political agenda. 2012’s Health and Social Care Act enshrined safe, timely and effective care for those with mental health problems in the same way as those with physical issues. Measures taken throughout the COVID-19 pandemic served to bring the mental health and wellbeing of the population into sharp focus.

Four years later, in 2016, an Independent Mental Health Taskforce found that this parity of services had not been achieved in their Five Year Forward View for Mental Health. They identified continuing failings in care quality and access to services but detailed priority areas for action:

• a 24/7 NHS providing the right care in the right place at the right time
• expand proven community-based services for people of all ages with severe mental health problems who need support to live safely as close to home as possible
• an integrated, evidence-informed, mental, and physical health approach
• increase access to evidence-based psychological therapies
• prevention at key moments in life e.g., Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) programme
• tackling inequalities: those living in poverty, are unemployed, who already face discrimination and those in the criminal justice system
• development and application of new mental health research, plus benchmarking data

A further commitment was made by the government via 2019’s NHS Long Term Plan. By 2023/24, an extra £2.3bn funding was pledged for mental health care to increase service expansion and faster access to services. 380,000 more people would receive therapy for depression and anxiety and a similar number would benefit from community-based physical and mental care for people with severe mental illness.

These targets will be reviewed considering the COVID pandemic which occurred after the report’s publication. March 2021 saw the release of the Mental Health Recovery Action Plan which provided £0.5bn to address public mental health impacted by the pandemic. It specifically lays out a strategy to address the wider determinants of health and ensuring the provision and transformation of NHS services to meet the previously listed priorities. The Royal College of Psychiatrists (RCPSYCH) summarised the evidence for public mental health interventions in June 2022 and relevant examples with strong evidence ratings will be noted in this report. The research and references can be found in the report.

Pregnancy, infants and young children 

The RCPSYCH's October 2023 report: Infant and early childhood mental health: the case for action, summarised the evidence to date. It focused on the first five years of life, as these together with the pre-birth period and even the time before conception, are crucial to a child’s development, which in turn protects them from future mental health conditions. With half of mental health conditions established by age 14 and three-quarters by age 24, there is overwhelming evidence for providing support to children and young people, as well as parents and carers at the earliest opportunity [10].

The NHS Long Term mental health implementation plan for 2019/20 to 2023/24 targets an extra 345,000 children and young people aged 0 to 25 accessing NH-funded mental health services. It also aims to extend the coverage of specialist community perinatal mental health services to cover the age of conception to 24 months after birth. In March 2021, the government's "The best start for life: a vision for the 1,001 critical days" further highlighted the importance of focusing on the early years. The DHSC progress report detailed the government's commitment to a £300m budget towards a Family Hubs and Start for Life programme and £150m dedicated to delivering new and improved infant feeding services and perinatal mental health and parent-infant relationship support. This report focuses on 0 to 2-year-olds and does not directly address resource or workforce challenges. The 2012 Health and Social Care Act in England detailed how Clinical Commissioning Groups (CCGs) and local authorities should detail health and social needs via needs assessments and Joint Health and Wellbeing Strategy.

The Health and Care Act 2022 described the statutory duties of Integrated Care Partnerships to set out the how assessed needs are to be met by the Integrated Care Board, and how it will partner with local authorities and the NHS through the Integrated Care Strategy.     

In 2017, the national prevalence of mental health conditions in 2 to 4-year-olds was 5.5% which comprised: behavioural disorder, emotional disorder, hyperactivity disorder and, less commonly, autism spectrum disorder, sleep disorder or feeding disorder. Risk factors for child mental health conditions include maternal smoking, alcohol, and substance abuse during pregnancy [11] together with prenatal infection [12], prenatal anxiety or depression [13], low birthweight [14], poor maternal nutrition [15] or obesity [16], and minority ethnic groups receiving poor maternity care [17]. Many of these factors are more common among lower socio-economic status families. Adverse Childhood Experiences (ACEs) are important risk factors and may include domestic abuse, neglect, having a parent with a mental health condition or attachment difficulties, deprivation, and racial discrimination. Breast feeding, secure attachment and play are protective factors associated with good mental well-being [18, 19].

The prevention and promotion gap:

• health visitor workforce shortage – only 13% of health visitors in England were able to deliver antenatal contact to all families and only 6% of health visitors worked with the recommended ratio of 250 children per health visitor
• uptake of first-year postnatal checks and primary care consultations – teenagers and most deprived least likely to receive these
• alcohol and smoking use during pregnancy – often not assessed and no interventions provided
• childcare – a quarter drop off in registered child minders allied to rising costs
• child adversity – most children affected by adversity are not known to services
• social work services – reduction in workforce and no evidence of public health interventions
• socio-economic inequalities – real-term benefit cuts for families with young children, reduction in benefit cap and introduction of the two-child limit leading to increases in child poverty
• service engagement – more children are missing developmental milestones but aren’t engaging with services
• attachment – few parents receive support to foster their attachment to their baby

Public mental health interventions can be applied to mitigate the risk factors or to address protective factors including:

Primary prevention:

• substance misuse and the risk factors listed previously should be addressed during pregnancy, which is assisted by early screening and identification [20, 21]
• support for breastfeeding should be provided together with skin-to-skin contact; the latter is important where breastfeeding is not possible [22, 23]
• parent-child relationships can be supported – enhancing attachment – by parenting and home visit programmes, providing information or adult mental health teams working with parents [24, 25]
• parenting programmes also improve child development, sleeping problems and may be delivered online [26, 27, 28]
• early childhood education helps the child receive their full potential including good health and nutrition and laying a foundation for economic progress [e.g. 29]
• preventing childhood adversity can be aided by addressing socio-economic deprivation and targeting high-risk groups such as looked after children or those on the edge of care [30]

Secondary prevention:

• early identification of mental health conditions in under 5s can mitigate the risk of mental health conditions developing throughout the life-course [31]

Evidence is compelling for parenting programmes, psychodynamic interventions, parent-child interaction therapy and other early pathway programmes and those that are group-based which have demonstrated an improvement in emotional and behavioural outcomes [26, 32, 33, 34].

Adolescents

Rates of mental health illness in young people in the UK have risen a great deal in recent years [35]. An NHS Digital report showed a 50% increase in children diagnosed with significant mental health conditions in October 2020 compared to the previous survey of 2017. One in six children aged 5 to 16 were identified as having a probable mental health problem in July 2021. The Royal College of Paediatrics and Child Health (RCPCH)'s 2020 State of Child Health in the UK report that the sharpest prevalence rise for children aged 5 to 15 has been within emotional disorders e.g. anxiety, depression, OCD, phobias, increasing from 4.3% to 5.8% from 1999 to 2017. 14.9% of young people aged 17 to 19 have emotional disorders in 2017, rising to 22.4% of women for this age group.

In 2021, the Children's Society published their Good Childhood Report surveying adolescents aged 10 to 17 years in the UK, ascertaining their life satisfaction and happiness. Their resilience is amply demonstrated with just 12% classed as having low wellbeing. This correlated with being female, being attracted to “someone of the same or both genders”, being bullied at school, less physically active, worried about or experienced crime, or living in an economically disadvantaged family. There may be an association between unhealthy diet and poorer mental health [36].

The COVID-19 pandemic exacerbated existing inequalities compounding the risks in vulnerable children. Hence, it is a priority for the UK government to help families living in poverty or experiencing unemployment, improve educational outcomes and improve access to health and social care services. Adolescence is arguably a period of emotional and developmental vulnerability associated with many physical and environmental changes. Relatively recent innovations, such as social media, are often experienced for the first time at this age and may be associated with symptoms of mental illness and self-harm [37]. Social media use may be integral to adolescents’ lives and the potential benefits of its use in practice should not be ignored [38].

Evidence and case studies

The RCPSYCH evidence summary highlighted interventions during pregnancy, childhood and adolescence as a means of preventing the majority of lifetime mental disorders which arise in this period. There is strong evidence for perinatal interventions targeting parent tobacco and alcohol use. Tobacco control policies were associated with reductions in preterm birth and lower rates of childhood infections. Smoking cessation in pregnancy was effectively aided by pharmacotherapy, psychosocial, behavioural, financial, and digital interventions.

Parenting programmes can aid with some parental factors: poor quality relationship with parent, poor parenting or quality of attachment, and parental mental disorder. They can tackle substance use, antisocial behaviour, and bullying, prevent unintentional injury, improve child behaviour including in children with ADHD and those with a developmental disability; and can be aimed at ethnic minority parents, foster parents and young offender parents. Adding home visiting programmes improved attachment-related outcomes in preschool children.

Child adversity prevention would reduce adult mental health disorders by a third and a large amount of health-harming behaviour. This can be ameliorated by parent-training and home-visiting programmes, school-based interventions, and adult trusted support. For early years and primary school, educational programmes focused on social-emotional development help externalising problems and reduce aggressive behaviour. For adolescents, development and social-emotional functioning can be enhanced by learning programmes reducing conduct issues, drug use and improving social behaviour and academic performance. School-based interventions have proven effective in reducing violence, bullying, cyberbullying, sexual abuse, and dating violence.

Tackling perinatal mental health problems

Collaboration between the London borough of Barne, the NHS and local council. All staff who work with mothers have been trained to ask about mental health and assign to a green, amber, or red pathway. Universal services support green pathway parents whilst red pathway women display immediate or severe mental health concerns and involves referral to the specialist perinatal mental health service. Further helps is available from Home Start and an online wellbeing app.

Learn more about Barnet’s perinatal mental health support pathway.

National Citizen Service (NCS)

Designed especially for 16 to 17-year-olds, the National Citizen Service is a part-residential youth programme to build the skills and confidence of young people built on social cohesion, civic engagement, and social mobility. Local authorities are key partners and can shape how NCS works locally. All projects are youth-led, and graduates give back an average seven hours more than non-participants to their community. All young people may attend and can develop skills that can prepare them for employment and transitioning into adulthood. These may include leadership, problem-solving, managing money and time-management. Funding is provided by the government and participants never pay more than £50 to attend.

Parent and Infant Relationship Service (PAIRS)

PAIRS is a specialised parent-infant relationship team in Lambeth that successfully implemented Circle of Security Parenting groups and enabled its scale-up to reach many more families across Lambeth. LEAP is part of the National Lottery Community Fund ‘A Better Start’ initiative and has been funded for ten years to deliver, continuously improve, and evaluate a range of services for pregnant women, children aged 0 to 3 years and their families. As well as providing direct clinical interventions, PAIRS offers training, supervision and consultation including: reflective supervision for parenting workers and children's centre practitioners; midwives and health visitors delivering the Baby Steps antenatal parenting group programme.

Peer Education Project (PEP)

The Peer Education Project is a secondary school-based educational programme that aims to give young people the skills and knowledge they need to safeguard their mental health and that of their peers. PEP can be delivered in schools in 4 steps, using resources and support provided by the Mental Health Foundation:

1. school staff complete a series of online training videos, which cover the key concepts, project structure and materials. By training school staff to deliver the project in their own schools, the project aims to build capacity within schools to run the project year on year
2. the trained school staff select and train older pupils, known as Peer Educators, using our detailed training plan. Peer Educators are typically aged 14 and upwards
3. older pupils deliver the five lessons to younger pupils, known as Peer Learners, using our detailed lesson plans. Peer Learners are typically aged 11 and 12
4. embedding this crucial mental health knowledge within the curriculum can support a whole-school approach to positive mental health and wellbeing and directly create a learning opportunity for senior pupils. We support and direct schools to additional resources to help build upon the project and develop mentally healthy school culture

University-led evaluations showed that older pupils opening up helped them realise that help-seeking was acceptable. Pitching the material at the right level was important in engagement and retention. With the support of teachers, Peer Educators grew in confidence in providing the lessons. Having an invested "Staff Lead" in the schools helped foster a school culture more open to discussing mental health and ensuring a high-quality level of lessons.

The Nest

Free mental wellbeing advice and support service launched by Southwark Council during the first lockdown for children and young people, up to the age of 25, offering drop-in support and one-to-one services including counselling and talking therapies. Response to perceived lack of services with some young people admitting to self-harming to get seen quicker. The children and young people helped design the service which would be more relaxed and informal. It initially opened with remote consultations but moved to include in-person support when possible. Hundreds of people have been referred by schools, GPs and self-referral allowing expansion of services e.g. for families of Black African and Caribbean heritage. Recruited staff reflect the make-up of the community. 

The World Health Organization (WHO) notes in their “Mental health at work” report that decent work can protect mental health by providing a livelihood, a sense of purpose, community inclusion, and structured routines. There are numerous psychosocial risks associated with work including: being under or over skilled, excessive workloads or pace, long hours, poor working conditions, harassment or bullying, lack of control over one’s work, job insecurity or inadequate pay and many others. Most of the global workforce are part of the informal economy where there is no regulatory protection. Actions to address mental health at work should involve workers and their representatives, and people with lived experience of mental health conditions. The WHO outlines four areas for action with some recommendations:

Prevent work-related mental health conditions including:

• employers should implement organisational interventions that directly target working conditions and environments
• these interventions assess, and then mitigate, modify or remove workplace risks to mental health
• examples include: flexible working arrangements, or implementing frameworks to deal with violence and harassment at work

Protect and promote mental health at work - strengthening capacities to recognise and act on mental health conditions at work, particularly for persons responsible for the supervision of others, such as managers. To protect mental health, WHO recommends:

• manager training for mental health: recognise and respond to emotional distress; build interpersonal skills; foster better understanding of the effects of job stressors
• training for workers in mental health literacy and awareness
• interventions for individuals to build skills to manage stress and reduce mental health symptoms

Support people with mental health conditions to participate in and thrive at work: 

• reasonable accommodations at work adapt working environments to the capacities, needs and preferences of a worker with a mental health condition e.g. flexible working hours, extra time to complete tasks, modified assignments to reduce stress, time off for health appointments or regular supportive meetings with supervisors
• return-to-work programmes combine work-directed care with ongoing clinical care to support workers in meaningfully returning to work after an absence associated with mental health conditions, while also reducing mental health symptoms
• supported employment initiatives help people with severe mental health conditions to get into paid work

Create an enabling environment for change - both governments and employers, in consultation with key stakeholders, can help improve mental health at work by creating an enabling environment for change. In practice this means strengthening, leadership and commitment to mental health at work, investing sufficient funds and resources, rights to participate in work, participation of workers in decision-making, using evidence-informed guidance, and complying with laws and regulations.

Evidence and case studies

The RCPSYCH evidence summary addresses the loss of healthy years and interventions against risky behaviours. This highlights the effectiveness of tobacco control programmes including smoking bans, plain packaging, and mass media campaigns. Similarly, alcohol prices and taxes relate inverse to consumption together with policies restricting access. People with mental illnesses were at a higher risk of COVID-19 infection and hence should have been prioritised for vaccination – of possible future importance.

Specific workplace interventions aim to reduce employee stress, mental disorders or increase wellbeing. NICE’s 2022 report “Mental Wellbeing at Work” offered a number of recommendations to improve mental wellbeing in the workplace [39]. These are designed to tackle the estimated £33 to 42bn lost by employers each year to poor mental wellbeing. Around 15% of people at work are thought to have symptoms of an existing mental health problem. Section 1.10 lists recommendations for local and regional authorities and include:

• champion mental wellbeing and prevent poor mental wellbeing at work as part of public health and wellbeing
• promote strategies whilst engaging with local and regional employers, employee representatives, chambers of commerce, local enterprise partnerships and voluntary, charity and social enterprises
• raise awareness among the public and employers of the importance of mental wellbeing at work e.g., through social media
• identify and address local barriers and facilitators to employer engagement with local mental wellbeing at work initiatives
• offer support to help local employers improve the mental wellbeing and prevent poor mental wellbeing of their employees e.g. advice, developing action plans or Local Workplace Health Accreditation Scheme
• curate or work with local business support organisations to list local and national sources of support for employers and employees
• explore and evaluate the value of incentives or pilot incentive programmes to promote uptake of support and encourage employers to participate in accreditation schemes

Use contracting and ethical procurement arrangements to strongly encourage supply chain organisations to promote mental wellbeing among their employees.

LiveWell Dorset smoking cessation pathways

Increasing local support increases chances of quitting by four. 90% supported people make it to a month smoke-free. LiveWell Dorset's smoking cessation pathway includes free advice and coaching provided for adults. They offer face-to-face support, regular phone calls, nicotine replacement, vape starter kit and a one-day seminar to Allen Carr’s Easyway.

Treating Tobacco Dependency programme

East Dorset and University Hospital Dorset offer patients and soon-to-be parents stop smoking support via 1-to-1 behavioural support and free Nicotine Replacement Therapy (NRT). Dorset County Hospital's “CARED” smoking cessation project systematically identifies all active smokers admitted to the hospital and provide NRT for the duration of their stay. They have a consultation with a Specialist Adviser to construct a long-term, post-discharge plan.

Connected Communities - Mental wellbeing and social inclusion (no ages specified)

Connected Communities is a research partnership between the Royal Society of Arts (RSA), the University of Central Lancashire (UCLan) and the London School of Economics (LSE) took place across seven English neighbourhoods. It sought to understand how wellbeing is affected by community and social connections; develop best practice using local data to enhance positive connections and wellbeing; and feed this back into wider public policy.

Interventions with local people included: service delivery changes e.g. self-directed support, co-production of community projects fostering self-help, and making existing social networks more visible. Examples from their report (with evaluation) include:

• Murton Mams (County Durham) - a social group that was set up to provide enjoyable and supportive activities for single mothers, who were found in our research in the area to be vulnerable to isolation and low wellbeing. Focus group selected social group providing activities such as cookery, Reiki or making Christmas cards. Reported increase in confidence, networking and wellbeing leading to paid employment, a return to education, plus attributed weight loss and withdrawing from antidepressant use
• Social Mirror (Bristol) - digital social prescribing tool linking people to their local activities and groups. Trialled on 150 people: 77% users reported improved wellbeing; 13% went to prescribed social groups; 43% said they felt more positive about their area
• Wick - organised network of local community changemakers to tackle this "urban island". Here, the community organisers networked with the Tenants and Residents Association (TRA) on the main social housing estate. This group has led:
  -volunteer-led affordable childcare and afterschool clubs
  -running a youth club and arranging day trips for older children to promote healthy lifestyles
  -a ‘SmartArt’ arts and crafts group attended by a mixed group
  -converting a disused patch of land behind a community centre into an ‘edible garden’, with vegetables grown by children
  -a peer-support group for people caring for family members
  -winning permission to turn a disused council building on the estate into an affordable café and mixed-use ‘social space’
  -plans to take over a shop in Littlehampton town to sell items made or donated from the Wick community to raise funds for the group
• L8 (Liverpool) - brokering new relationships between health services and a previously isolated group of people from ethnic minorities. Developed "Treasure Your Wellbeing" website from survey discussing wellbeing, cultural values and experiences. Became an important way for locals to contribute their views, and a source of new friendships, connections, and cultural exchange. Worked with MerseyCare and NHS Trust
• New Cross Gate - Training individuals in mental health counselling to build their personal resilience and enable them to support others in their community: the Talk for Health model. Free 4-day training programmes. Fostered community belonging and had formed a supportive emotional community

Training hairdressers, personal trainers and hospitality staff to become champions

Collaboration between Shropshire and the Samaritans on training hairdressers, personal trainers and hospitality staff to become mental health champions. Organised free, two-hour informal workshops to train staff to respond to "difficult conversations" and signpost to local health wellbeing services. Used Instagram and Facebook to advertise course after emails failed. Forty-three hairdressers have covered listening skills, self-care, and signposting: “our invisible frontline”.

Recovery college

Wokingham Borough Council setup a recovery college which offers a range of 30 free courses and workshops to encourage them to become experts in their own care. Each course is co-produced by people with personal experience of mental illness and covers wellbeing, life skills, creativity, and next steps e.g. employment support, CV writing and interview skills. 130 students have registered with the most people aged between 46 and 59. Students are asked to complete the Warwick-Edinburgh Mental Wellbeing Scale which shows many moving up from low to moderate.

Embedding a culture of staff wellbeing

Followed on from a new focus on staff wellbeing at North Yorkshire Improving Access to Psychological Therapies (IAPT) service. Aware of research into staff working in mental health settings. Designed and delivered a series of wellbeing continuing professional development (CPD) days for our administrators, trainees, psychological wellbeing practitioners (PWP) and high intensity workers (HIW). Key actions included:

• establishing wellbeing champions in each team (supported by clinical lead)
• creation of wellbeing boards to encourage, support and promote ongoing wellbeing activities including mindfulness classes, Yoga sessions, lunchtime walks, inspirational quotes
• adding wellbeing e.g. a short activity, to the agendas of leadership, team, clinical supervision, and individual performance management meetings
• opportunities to acknowledge individual contributions made by staff
• greater emphasis has been placed on workload management tools and techniques to address work-related stress
• staff are encouraged to book most of their annual leave at the start of the leave period to ensure regular breaks throughout the year

Health, work and wellbeing in local authorities

This 2010 report provides some case studies and lessons for implementation in the work place. These include:

• establishing a driver for the introduction of wellbeing initiatives e.g. sickness absence statistics
• targeting staff with initiatives - especially where access is difficult
• communicating wellbeing work - using more than one method with effective two-way communication
• linking to national initiatives and national issues - raises the profile of the scheme
• obtaining financial resources - creative use of existing budgets with research of external funding
• obtaining human resources - mostly possible with existing staff but identify any required specialist needs
• extending well-being work into the community - e.g. extending to family and friends
• assessing the effectiveness of initiatives - set out measures to evaluate at start, ideally with baseline data
• national awards and assessments - can shape thoughts of authorities, indicator of success and an aspirational target

Age UK reported that older people have similar rates of anxiety and depression as younger people but are much less likely to be receiving appropriate support. Just 5% of referrals made for NHS talking therapies were for people aged 65 or over. Over half a million people over 65 experience anxiety disorder with women disproportionately affected, and just under half a million have a major depressive disorder. This condition is chronic in almost 200,000 people. Globally, the WHO reports that loneliness and social isolation are key risk factors for mental health conditions in later life. One in six older adults experience abuse and approximately 14% of adults aged over 60 live with a mental disorder. Social stigma may impact their accessing care and seeking a diagnosis.

The NHS Long Term Plan and NHS Mental Health Implementation Plan 2019/20 to 2023/24 ensures that the NHS will provide consistent access to mental health care for older adults with functional needs i.e. depression, anxiety and severe mental illnesses. All adult mental health services are expected to remove upper age barriers and provide services appropriate for their demographics: access will be based on needs, not age. Local areas should provide NHS Talking Therapies for Anxiety and Depression services. Community-based mental health crisis response teams should liaise with Ageing Well Urgent Community Response services to provide a coordinated rapid response. New and integrated models of primary and community mental health care will enable patients to have greater choice and control over their care.

Specific groups may require extra awareness of symptoms. For example, LGBTQ older adults may require culturally competent care to contend with unique mental health needs reflecting the impacts of politics, culture, and social norms throughout their life [40]. An awareness of depressive symptoms should be screened in end-of-life care to reduce the risk of complicated grief and suicide [41].

Case studies

LinkAge Plus

Hull’s LinkAge programme aimed to enhance the lives of older people – aged 55 and over – by arranging a variety of activities such as walking groups to coffee mornings through older people-led hubs. This directly impacted on social isolation. This programme runs nationwide as LinkAge Plus. East London provides physical activity classes, information and advice sessions, creative activities, learning opportunities, lunch clubs and can signpost to other local support services. Other sites provide services that reflect client needs and available services. An evaluation reflected on a central role of the programme to not only combat social exclusion but also impact on mental health through outreach and mentoring services together with befriending and volunteering services.

Action for Elders Programmes in York

Begun in 2013, the Balanced Lives social exercise groups have been running in the area ever since and developed close ties with the community and local GPs. They've proven beneficial in falls prevention but also worked as a social group. The York group collaborated on a special project entitled Grannies’ Moustache – an entertaining book of the funny things children say to grandparents, which provided a creative project to complement the physical exercise.

Living close to or spending time in green or blue spaces (e.g., parks, lakes, or beaches) is associated with better mental health. This may be due to increased social contact, reduced cognitive impairment, reduced stress, and mental and physical health-promoting physical activity with wider ecological benefits such as clean air [1, 2]. Living in or moving to areas with more green space or better access to GBS - ambient exposure - is associated with lower odds of subsequent common mental health disorders (CMD) such as anxiety or depression [3]. Every additional 360m to the nearest GBS was associated with higher odds of CMD (1·05, 1·04–1·05), and positive effects of GBS on mental health appeared to be greater in more deprived quintiles.

The People and Nature Survey for England, led by Natural England, provides data on people's views of the environment. For adults, access to natural spaces is associated with socio-economic status. Fewer visits are reported by those living in areas of high deprivation, have low levels of income or education, or are unemployed. Similarly, older people, people from minority ethnic groups, those with a long-term health condition and people without children are also less likely to have visited a natural space. This inequality of access was likely exacerbated by the pandemic. COVID-19 also highlighted the importance of private gardens as a main access point but those living in poverty have significantly less access to private garden space. Respondents identified the main reasons for visiting a natural space was for fresh air, their physical and mental health, and to connect with nature.

A recent government systematic review sought to separate the social benefits of blue space from green space. Rivers, lakes and coastal waters were found to provide a range of social and health benefits. Living near the coast is associated with lower levels of being overweight and some evidence of higher levels of self-reported mental health. Walking is the most popular activity but and are less "physically active" than those in green spaces. People who use Blue Space say they derive psychological benefits from the experience. However, those from ethnic minority groups are less likely to access blue space. Older people are more likely to access these areas than younger persons. Blue space visits reflect the seasons although people report willing to travel further with their children to visit the coast. 80% of environmental visits are to green spaces, however, and this is more likely to be the site of intense physical activity.  Women are more likely to visit beaches than men, whilst men are more likely to visit woodlands, moors, hills and mountains than women.

Case studies

Chill Dorset CIC 

Chill Dorset CIC is a not-for-profit organisation dedicated to providing sea swimming courses as a form of therapy for people with long term health conditions.

They are based in Dorset with access to some of the most beautiful beaches in the UK. Their structured, supportive, and gentle courses allow an introduction to the wonderful therapeutic benefits of spending time in the sea. Chill have recently received funding from Sport England’s Together Fund, and this film shows the impact the funding has had on the project.

In 2021, the University of Portsmouth conducted an evaluation of the structured Chill programme delivered to NHS staff in Cornwall and London. Their results suggested that outdoor swimming, as a workplace intervention, can be effective in promoting staff wellbeing and reducing personal and work-related burnout. It could offer personal fulfilment, through learning something new, and opportunities for social connection. These conclusions echo the benefits found in other studies of open water swimming.

Rupert Lloyd (working with Rachel Partridge) kindly provided information for projects taking place in Dorset:

Health and Nature Dorset (HAND)

HAND is a collaboration that grew from existing partnership working between Dorset AONB (via the Stepping into Nature project), Dorset Local Nature Partnership, Active Dorset and Dorset Council Public Health. Their aim is to embed nature-based wellbeing into the health system. Focus groups were used to understand barriers to nature connection for those with long-term health needs. Themes included: quality of greenspace, people to go with, provision of information, transport, and cost.

BCP Green Infrastructure Strategy

BCP Council's Green Infrastructure Strategy sets out our ambitions for investing in green infrastructure across Bournemouth, Christchurch and Poole over the next 10 years. Aims are to increase health and wellbeing outcomes to reduce pressure on health and social services; reverse biodiversity loss, and strengthen resilience of people, places and nature to climate change. Planning future green infrastructure gives an opportunity to tackle health inequalities through greater equity of access.

Green Heart Parks project - The Parks Foundation and BCP Council

Thirteen urban parks were chosen for the Green Hear Parks project based on their size, proximity to a densely populated area or an area of deprivation, as well as their potential for biodiversity improvements and community growing which is a particular focus of the project. Employed a Community Partnerships Officer who will focus on diversifying the audiences using the parks, and a Parks Activator who will deliver fun and informative activities as well as physical enhancements such as planting trees and wildflowers. Both positions are funded for two years. Some spaces will also operate community cafes.

Dorset ICS NHS Green Plan

The Dorset ICS NHS Green Plan document consolidates the Green Plans or Sustainable Development Strategy of each Dorset NHS Trust. They are committed to protecting the natural environment and reducing pollution which "will help support and improve the physical and mental wellbeing of staff, patients and the wider community through access to green space, biodiversity and interactions with nature". Their case studies include:

• wellbeing garden for Blandford Ambulance Station - a space to be enjoyed by staff on their downtime or by colleagues without a garden at home
• EcoEarn Platform - staff engagement digital platform to help promote net zero carbon reduction activities and other sustainability and wellbeing behaviours. Each organisation is set up as a team engaging in "friendly competition". Receive regular newsletters and integrated with other initiatives to provide e.g. lift-sharing or physical exercise with Strava
• University Hospitals Dorset IT - IT replacement project was opportunity to find a more sustainable method of getting rid of outdated equipment in a secure manner. Two-thirds of the required equipment was suitable for refurbishment and resale
• Dorset lift share - NHS employees within the catchment area register their desired journeys. Staff will be rewarded with green credits and other rewards
• Light Emitting Diode (LED) Project - Dorset Healthcare were able to this change the lighting at 10 of our large Trust sites and South Western Ambulance trust were able to fit out 11 Dorset ambulance stations This plan will save money and reduce our carbon emissions
• Solar Photovoltaics (PV) Project - In 2019, Dorset Healthcare sought to install Solar photovoltaics (PV) panels at 3 of their hospital sites Alderney, Blandford and Bridport. Shareholders purchase shares to collectively fund the specific project. The shareholders will receive a dividend and their initial deposit will be renumerated over several years. A Power Purchase Agreement (PPA) with the non-profit making organisation, Dorset Community Energy (DCE) the Trust would purchase the solar energy it generated from its sites via Dorset Community Energy (DCE) and use it on the sites where it the energy was produced
• Dorset NHS Pharmacy Environmental Awareness - e.g. selection of the most environmentally sustainable inhaled anaesthetics, utilisation of dry-powder respiratory inhalers over those using hydrofluorocarbon gases

UHD - Recycled Paper - purchased 100% recycled paper for printing and copying. Trials in a couple of areas had shown no quality or equipment compatibility issues. Also saw a financial benefit.

DCH - Reusable Gowns - gowns can be used and washed 100 times before being disposed. This has created huge carbon savings.

Food for Life - run by the Soil Association who serve fresh food, source environmentally sustainable and ethical food, champion local producers and promote a healthy diet.

Thriving Communities in Dorset

A 15-month project to strengthen arts and nature-based social prescribing opportunities in Dorset, taking place between April 2021 and June 2022, that aimed to:

• increase the skills of voluntary and community organisations to better support community members who are referred through social prescribing
• increase the knowledge of social prescribing link workers around available arts and nature-based activities suitable for social prescribing
• develop partnership working between community, voluntary and healthcare organisations
• develop Nature Buddies, a scheme to pair volunteers with community members who need support to experience nature for their wellbeing

An evaluation found Nature Buddies participants reported improvements in wellbeing, such as reduced anxiety or increased confidence, including the confidence to go into nature independently. The VCSE sector reported increased skills and knowledge to deliver new or enhanced activities to attract more people to engage with activities.

The wider (or social) determinants of health is a broad term referring to the social, cultural, political, economic, commercial and environmental factors i.e. non-medical factors, that shape the conditions in which people are born, grow, live, work and age. Understanding these determinants developed the "social gradient" concept: that individuals with lower social status have greater health risks and lower life expectancy than those with higher status, and that this social impact accumulates over time [42]. It describes how poor and disadvantaged populations are more affected by mental disorders throughout their life-course; the gradient impacting on their risk of disorder and access to services affecting outcomes [43]. One model described how downstream determinants, such as behaviours, are influenced by upstream determinants such as economic resources, education, and discrimination [44].

There are many ways for these determinants to have an impact on mental health. Generally, chronic stress may manifest through simply navigating everyday situations, anxiety over living conditions or a perceived lack of control [45]. In midlife, unemployment was linked to a higher risk of declining mental health, and this risk was even higher for those excluded from the labour market e.g. people with permanent or temporary sickness or disability [46]. This may have a greater impact on men's than women's mental health [47]. There is a greater prevalence of poor mental health among individual with lower incomes [48, 49]. Within local authorities, Deaths of Despair (DoD), significant increases were reported for people living in the North, living alone, White British ethnicity, lower inward migration, economic inactivity, income deprivation in older people, employment in elementary occupations, unemployment, and education deprivation in adults [50].

Psychological wellbeing is significantly harmed in adults or children experiencing persistent exposure to poor quality housing [51, 52]. An increase is recorded for those living in overcrowded conditions. There are a few mechanisms of poor mental health that may manifest with poor housing. These include stress and anxiety at the challenging situation, social phobia, sleep problems, depression or low self-esteem, loneliness, and substance abuse. Homelessness exacerbates many of these issues. Up to 70% of homeless people have mental health problems and a third self-harm. Common mental health problems are more than twice as high, in this population, and psychosis is up to 15 times higher. Dual needs - including for substance abuse - are common, particularly for those on the streets or rough sleeping. Services may be aimed at "high-risk" points including hospital discharge or prison release. Crime can have direct physical effects, but the fear of crime can have psychological effects as well as reduce health promoting behaviours. Both offenders and victims of crime are more likely to live in the most deprived areas.

Food insecurity (FI) may also impact on mental health [53]. This is often a long-term situation and is associated with the cost-of-living and fuel poverty. Difficulties were described accessing emergency food aids, worsened by the stigma attached to them and poor choice of food. There are documented links between FI, depression, stress and poverty, and mood disorders with psychosis [54, 55].

Discrimination affects mental illness and manifests in various forms: race/ethnicity, immigration status, sexual orientation, or may occur at work [56]. Having an illness, disability, including mental health, is also subject to discrimination and stigma. This can lead to self-harm or suicidal thoughts and attempts, discriminatory violence and general discriminatory inequalities, substance abuse and addiction, trauma, depression, and anxiety. Healthy relationships may also impact on mental health both positively and negatively. Supportive family members can enhance self-esteem and self-worth encouraging optimism and a positive affect [57]. Stress in relationships can lead to mental distress and health-compromising behaviours as coping mechanisms [58]. Being part of a happy marriage or couple is associated with lower stress and depression, although single people have better mental health outcomes than unhappily married people [59]. It should be remembered that the reciprocal situation is also true: mental illness can have an impact on social determinants e.g. finances, homelessness, relationship stability [56].

Downstream determinants may have positive as well as negative effects. For example, physical activity is associated with mental health benefits to accompany the benefits to physical health. Finding a suitable, fun activity can help build a sense of purpose increasing motivation, whilst reducing tension and stress. Its contribution to self-esteem and weight loss can benefit people who are overweight or obese. Obesity is associated with issues related to low mood and self-esteem, quality of life and body image [60]. Specific associated conditions include depression [61], eating disorders [62], anxiety [63], and more likely to engage in substance abuse [64].

Public mental health interventions are non-clinical services that aim to promote wellbeing and prevent mental ill health at the population level, for example, through knowledge and skills training, welfare and financial advice services, legal advice, and social and peer support groups. In England, the health, social and community system is characterised by complex and fragmented inter-sectoral relationships. To overcome this, there has been an expansion in co-locating public mental health services within clinical settings.  This is where the evidence-base to date has focused, with less attention on co-locating services and interventions within community settings. 

Baskin et al. (2023) sought to explore how co-location in community-based settings can support adult mental health and reduce health inequalities [65]. The study found that co-locating public mental health services within communities can impact on multiple social determinants of poor mental health and has a role in reducing mental health inequalities. They found that co-located services:

• improved provision of holistic and person-centred support
• reduced stigma by creating non-judgemental environments that were not associated with clinical or mental health services
• delivered services in psychologically safe environments by creating a culture of empathy, friendliness, and trust where people felt they were being treated with dignity and respect
• helped to overcome barriers to accessibility by making service access less costly and more time efficient
• enhance the sustainability of services through better pooling of resources

Please refer to the above sections for further details, especially of specific case studies. A summary is provided here.

Childhood and adolescence

This section underscores the importance of early intervention, especially in the first five years of life. There are challenges in addressing mental health issues in early childhood due to workforce shortages, inequalities, and limited engagement with services. The COVID-19 pandemic has exacerbated existing inequalities and increased the risk for vulnerable children. Emotional disorders like anxiety and depression have become increasingly prevalent.

Additionally, adolescence is characterised by emotional and developmental vulnerability, with factors including social media contributing to mental health symptoms and self-harm.

Primary prevention strategies focus on:

• addressing substance misuse during pregnancy
• supporting breastfeeding
• enhancing parent-child relationships
• providing early childhood education

Secondary prevention involves early identification of mental health conditions in under 5s. Effective interventions include:

• perinatal interventions
• parenting programs
• school-based interventions
• community support services

Other initiatives include collaborative efforts between local governments, NHS, and community organisations, such as the National Citizen Service and Parent and Infant Relationship Service to address mental health issues and promote wellbeing.

Peer Education and Support: peer education projects in schools and community-based support services like "The Nest" provide valuable resources and assistance for young people facing mental health challenges.

Working age adults

These recommendations and case studies underscore the importance of addressing mental health in the workplace through comprehensive strategies that involve prevention, protection, support, and creating enabling environments for change:

Prevent work-related mental health conditions:

• implement organisational interventions targeting working conditions and environments
• assess, mitigate, modify, or remove workplace risks to mental health
• examples include flexible working arrangements and frameworks to address violence and harassment at work

Protect and promote mental health at work:

• provide manager training for mental health recognition and response, interpersonal skills development, and stress management
• offer mental health literacy and awareness training for workers
• implement interventions to build stress management skills and reduce mental health symptoms

Support people with mental health conditions at work:

• offer reasonable accommodations such as flexible working hours and modified assignments
• provide return-to-work programs that combine work-directed care with ongoing clinical support
• establish supported employment initiatives to help individuals with severe mental health conditions enter paid work

Create an enabling environment for change:

• strengthen leadership and commitment to mental health at work
• invest in sufficient funds and resources for mental health initiatives
• promote workers' rights to participate in decision-making
• use evidence-informed guidance and comply with laws and regulations

Additional evidence and case studies:

• RCPSYCH evidence summary: highlights the effectiveness of tobacco control programs and workplace interventions to reduce employee stress and enhance mental wellbeing
• NICE's 2022 report: provides recommendations for local and regional authorities to improve mental wellbeing in the workplace, emphasising the importance of engagement, support, and incentive programs
• LiveWell Dorset and Treating Tobacco Dependency Programs: offer smoking cessation support and interventions for patients and soon-to-be parents
• connected communities project: Demonstrates community-based interventions to enhance social connections and wellbeing, such as social groups and digital social prescribing tools
• training programs for hairdressers and personal trainers: Aim to equip staff with skills to respond to difficult conversations and promote mental wellbeing
• recovery college: offers free courses and workshops to empower individuals with mental illness to become experts in their own care and enhance their wellbeing
• staff wellbeing initiatives: embed a culture of staff wellbeing through training, support networks, workload management, and acknowledgment of contributions

Older adults

These recommendations and case studies highlight the importance of providing tailored mental health care and support for older adults, addressing issues such as social isolation, access barriers, and specific mental health needs within this demographic:

• access to mental health care: ensure consistent access to mental health care for older adults with functional needs, including depression, anxiety, and severe mental illnesses. Remove upper age barriers in adult mental health services
• NHS Long Term Plan: implement integrated models of primary and community mental health care to offer greater choice and control over care for older adults
• awareness and screening: increase awareness of mental health symptoms among specific groups, such as LGBTQ older adults, and screen for depressive symptoms in end-of-life care to reduce the risk of complicated grief and suicide

From the case studies:

• LinkAge Plus (Hull): a nationwide program offering various activities for older people, such as walking groups, coffee mornings, physical activity classes, and learning opportunities. It aims to combat social isolation and impact mental health positively through outreach, mentoring, befriending, and volunteering services
• Action for Elders Programmes (York): balanced lives social exercise groups have been beneficial in falls prevention and serve as social groups. Special projects like "Grannies’ Moustache" provide creative outlets and complement physical exercise, fostering community ties and mental wellbeing

Natural space

These recommendations emphasise the importance of equitable access to green and blue spaces, the integration of nature-based interventions into healthcare systems, and community-driven initiatives to enhance wellbeing and environmental sustainability:

• impact of green and blue spaces (GBS): access to green or blue spaces is linked to better mental health due to factors like social contact, reduced stress, and physical activity. Living near such spaces correlates with lower odds of common mental health disorders like anxiety and depression, with stronger effects observed in deprived areas
• inequality of access: socio-economic status influences access to natural spaces, with fewer visits reported by those in areas of high deprivation, low income, or unemployment. Older people, minority ethnic groups, and those with long-term health conditions also visit less frequently. The COVID-19 pandemic exacerbated access disparities
• government initiatives: recent government reviews highlight the social and health benefits of blue spaces like rivers and coastal areas. Living near the coast is associated with better mental health outcomes. However, access to blue spaces is lower for ethnic minority group

From the case studies:

• Chill Dorset CIC: provides sea swimming courses as therapy for long-term health conditions, promoting staff wellbeing and reducing burnout among NHS staff
• Health and Nature Dorset (HAND): aims to embed nature-based wellbeing into the health system, addressing barriers to nature connection for those with long-term health needs
• BCP Green Infrastructure Strategy: aims to invest in green infrastructure to increase health and wellbeing outcomes, reverse biodiversity loss, and address climate change resilience
• Green Heart Parks Project: enhances urban parks in Bournemouth, Christchurch, and Poole, focusing on community engagement and biodiversity improvements
• Dorset ICS NHS Green Plan: implements sustainable development strategies across NHS trusts, promoting staff wellbeing through initiatives like eco-friendly practices and social prescribing

Wider determinants of mental health

These recommendations underscore the need for comprehensive approaches that address the broader social determinants of mental health and promote equitable access to support services within communities:

Social determinants impact: Social, cultural, economic, and environmental factors significantly influence mental health outcomes. The "social gradient" concept highlights that individuals with lower social status face greater health risks and lower life expectancy.

Impact factors include:

• chronic Stress: navigating everyday situations, living conditions, and perceived lack of control contribute to chronic stress
• unemployment and income: unemployment and lower income levels are associated with higher risks of declining mental health
• housing quality: persistent exposure to poor-quality housing, including overcrowded conditions and homelessness, correlates with poor mental health outcomes
• food insecurity: long-term food insecurity is linked to depression, stress, and mood disorders
• discrimination: discrimination based on race, ethnicity, immigration status, sexual orientation, or illness contributes to mental illness and stigma

Positive determinants include:

• healthy relationships: supportive relationships positively impact self-esteem and mental wellbeing, while stress in relationships can lead to mental distress
• physical activity: regular physical activity contributes to mental health benefits, including stress reduction, self-esteem improvement, and motivation enhancement
• public mental health interventions: non-clinical services like knowledge and skills training, welfare and financial advice, legal advice, and social support groups promote wellbeing and prevent mental ill health at the population level
• co-locating services: co-locating public mental health services within communities improves access, reduces stigma, and provides holistic support, creating psychologically safe environments and overcoming barriers to accessibility
• reducing inequalities: co-located services help address multiple social determinants of poor mental health and contribute to reducing mental health inequalities by enhancing service sustainability and resource pooling

1. Royal College of Psychiatrists (RCSYCH). 2010. Royal College of Psychiatrists Position Statement October 2010. No health without public mental health: The case for action [online].
2. World Health Organization (WHO). 2008. Closing the gap in a generation: health equity through action on the social determinants of health - Final report of the commission on social determinants of health [online]. Available from: https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1 
3. World Health Organization (WHO). 2021. Comprehensive mental health action plan 2013–2030 [online]. Available from: https://www.who.int/publications/i/item/9789240031029 
4. Walker ER, McGee RE, Druss BG. 2015. Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis . JAMA Psychiatry. 72(4):334–341. doi:10.1001/jamapsychiatry.2014.2502
5. Too LS, Spittal MJ, Bugeja L, Reifels L, Butterworth P, Pirkis J. 2019. The association between mental disorders and suicide: A systematic review and meta-analysis of record linkage studies. J Affect Disord. 259:302-313. doi:10.1016/j.jad.2019.08.054
6. Mental Health Foundation / The London School of Economics and Political Science (LSE). 2022. The economic case for investing in the prevention of mental health conditions in the UK [online]. Available from: https://www.mentalhealth.org.uk/sites/default/files/2022-06/MHF-Investing-in-Prevention-Report-Summary.pdf 
7. Campion, J. 2019. Public mental health: Evidence, practice and commissioning. Royal Society for Public Health [online]. Available from: https://www.rsph.org.uk/our-work/policy/wellbeing/public-mental-health-evidence-practice-and-commissioning.html 
8. Compton MT, Shim RS. 2020. Mental Illness Prevention and Mental Health Promotion: When, Who, and How. Psychiatr Serv. Sep 1;71(9):981-983. doi: 10.1176/appi.ps.201900374. PMID: 32867610
9. Campion J, Javed A, Lund C, Sartorius N, Saxena S, Marmot M, Allan J, Udomratn P. 2022. Public mental health: required actions to address implementation failure in the context of COVID-19. Lancet Psychiatry. Feb;9(2):169-182. doi: 10.1016/S2215-0366(21)00199-1. PMID: 35065723; PMCID: PMC87762
10. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. 2005. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62 (6) pp. 593-602. doi:10.1001/archpsyc.62.6.593
11. Ruisch IH, Dietrich A, Glennon JC, Buitelaar JK and Hoekstra PJ. 2018. Maternal substance use during pregnancy and offspring conduct problems: a meta-analysis. Neuroscience & Bio behavioural Reviews, 84: 325–36
12. Flinkkilä E, Keski-Rahkonen A, Marttunen, M and Raevuori A. 2016. Prenatal inflammation, infections and mental disorders. Psychopathology, 49(5): 317–33: https://doi.org/10.1159/000448054
13. Madigan S, Oatley H, Racine N, Fearon RP, Schumacher L, Akbari E et al GM. 2018. A meta-analysis of maternal prenatal depression and anxiety on child socioemotional development. Journal of the American Academy of Child & Adolescent Psychiatry, 57(9): 645–57
14. Dooley N, Healy C, Cotter D, Clarke M and Cannon M. 2022. The persistent effects of foetal growth on child and adolescent mental health: longitudinal evidence from a large population-based cohort. European Child & Adolescent Psychiatry. https://doi.org/10.1007/s00787-022-02045-z
15. O’Neil A, Itsiopoulos C, Skouteris H, Opie RS, McPhie, S, Hill B and Jacka FN. 2014. Preventing mental health problems in offspring by targeting dietary intake of pregnant women. BMC Medicine, 12(1): https://doi.org/10.1186/s12916-014-0208-0
16. Arango C, Dragioti E, Solmi M, Cortese S, Domschke K, Murray RM et al. 2021. Risk and protective factors for mental disorders beyond genetics: an evidence‐based atlas. World Psychiatry, 20(3): 417–36
17. MacLellan J, Collins S, Myatt M, Pope C, Knighton W, Rai T. 2022. Black, Asian and minority ethnic women's experiences of maternity services in the UK: A qualitative evidence synthesis. J Adv Nurs. Jul;78(7):2175-2190. doi: 10.1111/jan.15233. Epub 2022 Mar 24. PMID: 35332568; PMCID: PMC9314829
18. Gibbs BG, Forste R and Lybbert E. 2018. Breastfeeding, Parenting and Infant Attachment Behaviours. Maternal and Child Health Journal, 22(4): 579–88. https://doi.org/10.1007/s10995-018-2427-z
19. Amodia-Bidakowska A, Laverty C and Ramchandani, PG. 2020. Father-child play: A systematic review of its frequency, characteristics and potential impact on children’s development. Developmental Review, 57: 100924
20. Claire R, Chamberlain C, Davey MA, Cooper SE, Berlin I, Leonardi‐Bee J et al. 2020. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane database of systematic reviews, (3)
21. Ujhelyi Gomez K, Goodwin L, Jackson L, Jones A, Chisholm A and Rose AK. 2021. Are psychosocial interventions effective in reducing alcohol consumption during pregnancy and motherhood? A systematic review and meta‐analysis. Addiction, 116(7): 1638–63
22. Gavine A, Shinwell SC, Buchanan P, Farre A, Wade A, Lynn F, Marshall J, Cumming SE, Dare S, McFadden A. 2022. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. Oct 25;10(10):CD001141. doi: 10.1002/14651858.CD001141.pub6. PMID: 36282618; PMCID: PMC9595242
23. Moore ER, Bergman N, Anderson GC and Medley N. 2016. Early skin-to-skin contact for mothers and their healthy newborn infants. The Cochrane Library, (11): https://doi.org/10.1002/14651858. cd003519.pub4
24. Barlow J, Schrader‐McMillan A, Axford N, Wrigley Z, Sonthalia S, Wilkinson T et al. 2016. Attachment and attachment‐related outcomes in preschool children–a review of recent evidence. Child and Adolescent Mental Health, 21(1): 11–201
25. Harder S, Davidsen K, MacBeth A, Lange T, Minnis H and Andersen MS. 2015. Wellbeing and resilience: mechanisms of transmission of health and risk in parents with complex mental health problems and their offspring—The WARM Study. BMC Psychiatry, 15(1): https://doi.org/10.1186/s12888-015-0692-6
26. Jeong J, Franchett EE, Ramos de Oliveira CV, Rehmani K and Yousafzai AK. 2021. Parenting interventions to promote early child development in the first three years of life: A global systematic review and meta-analysis. PLoS medicine, 18(5): e1003602
27. Mihelic M, Morawska A and Filus A. 2017. Effects of early parenting interventions on parents and infants: a meta-analytic review. Journal of Child and Family Studies, 26: 1507–26
28. Thongseiratch T, Leijten P and Melendez-Torres GJ. 2020. Online parent programs for children’s behavioural problems: a meta-analytic review. European Child & Adolescent Psychiatry, 29: 1555–68
29. Robling M, Lugg-Widger F, Cannings-John R, Sanders J, Angel L, Channon S et al. 2021. The Family Nurse Partnership to reduce maltreatment and improve child health and development in young children: the BB: 2 6 routine data-linkage follow-up to earlier RCT. Public Health Research, 9
30. Ford T, Vostanis P, Meltzer H and Goodman R. 2007. Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households. The British Journal of Psychiatry, 190(4): 319–25
31. Kohlhoff J, Lieneman C, Cibralic S, Traynor N and McNeil CB. 2022. Attachment-Based Parenting Interventions and Evidence of Changes in Toddler Attachment Patterns: An Overview. Clinical Child and Family Psychology Review, 25(4): 737–53: https://doi.org/10.1007/s10567-022-00405-4
32. Sleed M, Li E, Vainieri I and Midgley N. 2023. The Evidence-Base for Psychodynamic Interventions with Children Under 5 Years of Age and Their Caregivers: A Systematic Review and Meta-Analysis. Journal of Infant, Child, and Adolescent Psychotherapy, 1–36: https://doi.org/10.1080/15289168.2023.2223739
33. Thomas R, Abell B, Webb HJ, Avdagic E and Zimmer-Gembeck MJ. 2017. Parent-child interaction therapy: A meta-analysis. Pediatrics, 140(3)
34. Hare MM, Landis TD, Hernandez ML, & Graziano PA. 2023. A Systematic Review of Infant Mental Health Prevention and Treatment Programs. Evidence-based Practice in Child and Adolescent Mental Health, 1–24: https://doi.org/10.1080/23794925.2022.2140458
35. The Lancet Child Adolescent Health. 2021. Adolescent wellbeing in the UK. Lancet Child Adolesc Health. Oct;5(10):681. doi: 10.1016/S2352-4642(21)00284-4. Epub 2021 Sep 4. PMID: 34487690
36. O'Neil A, Quirk SE, Housden S, Brennan SL, Williams LJ, Pasco JA, Berk M, Jacka FN. 2014. Relationship between diet and mental health in children and adolescents: a systematic review. Am J Public Health. Oct;104(10):e31-42. doi: 10.2105/AJPH.2014.302110. PMID: 25208008; PMCID: PMC4167107
37. Flynn HC, Mote SL, Morse BL.2022.  Social Media and Adolescent Mental Health: Sounding the Alarm. NASN School Nurse. Sep;37(5):271-276. doi: 10.1177/1942602X221079758. Epub 2022 Feb 15. PMID: 35168436
38. O'Reilly M. 2020. Social media and adolescent mental health: the good, the bad and the ugly. J Ment Health. Apr;29(2):200-206. doi: 10.1080/09638237.2020.1714007. Epub 2020 Jan 28. PMID: 31989847
39. National Institute for Health and Care Excellence (NICE). 2022. NICE guideline [NG212]: Preventing suicide in community and custodial settings [online]. Available from: https://www.nice.org.uk/guidance/ng212/chapter/Recommendations [Accessed 22nd December 2023]
40. Inventor BR, Paun O, McIntosh E. 2022. Mental Health of LGBTQ Older Adults. J Psychosoc Nurs Ment Health Serv. Apr;60(4):7-10. doi: 10.3928/02793695-20220303-01. Epub 2022 Apr 1. PMID: 35353662
41. Mayahara M, Paun O. 2023. Mental Health of Older Adults at the End of Life. J Psychosoc Nurs Ment Health Serv. Jan;61(1):12-15. doi: 10.3928/02793695-20221207-03. Epub 2023 Jan 1. PMID: 36595303
42. Marmot M, Bell R. 2016. Social inequalities in health: a proper concern of epidemiology. Ann Epidemiol. Apr;26(4):238-40. doi: 10.1016/j.annepidem.2016.02.003. Epub 2016 Mar 3. PMID: 27084546
43. Allen J, Balfour R, Bell R, Marmot M. Social determinants of mental health. Int Rev Psychiatry. 2014 Aug;26(4):392-407. doi: 10.3109/09540261.2014.928270. PMID: 25137105
44. Braveman P, Egerter S, Williams DR. 2011. The social determinants of health: coming of age. Annu Rev Public Health. 32:381-98. doi: 10.1146/annurev-publhealth-031210-101218. PMID: 21091195
45. Fisher M, Baum F. 2010. The social determinants of mental health: implications for research and health promotion. Aust N Z J Psychiatry. Dec;44(12):1057-63. doi: 10.3109/00048674.2010.509311. Epub 2010 Oct 25. PMID: 20973623
46. Henking C, Gondek D. 2023. Social determinants of mental health trajectories during midlife: a prospective British birth cohort study. Lancet. Nov;402 Supply 1:S48. doi: 10.1016/S0140-6736(23)02129-3. PMID: 37997090
47. Affleck W, Carmichael V, Whitley R. 2018. Men's Mental Health: Social Determinants and Implications for Services. Can J Psychiatry. Sep;63(9):581-589. doi:10.1177/0706743718762388. Epub 2018 Apr 19. PMID: 29673270; PMCID: PMC6109884
48. Brydsten A, Hammarström A, San Sebastian M. 2018. Health inequalities between employed and unemployed in northern Sweden: a decomposition analysis of social determinants for mental health. Int J Equity Health. 17(1):59 10.1186/s12939-018-0773-5
49. Reibling N, Beckfield J, Huijts T, Schmidt-Catran A, Thomson KH, Wendt C. 2014. Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? Findings from the European Social Survey (2014) special module on the determinants of health. Eur J Public Health. 27(supply_1):47–54. 10.1093/eurpub/ckw225
50. Camacho C, Webb RT, Bower P, Munford L. 2023. Deaths of despair in England: an observational study of local authority mortality data. Lancet. Nov;402 Supply 1:S31. doi:10.1016/S0140-6736(23)02124-4. PMID: 37997072
51. Pevalin DJ, Reeves A, Baker E, Bentley R. 2017. The impact of persistent poor housing conditions on mental health: A longitudinal population-based study. Prev Med. 105:304–10
52. Rollings KA, Wells NM, Evans GW, Bednarz A, Yang Y. Housing and neighbourhood physical quality: Children’s mental health and motivation. J Environ Psychol. 2017;50:17–23
53. Giles EL, Eskandari F, McGeechan G, Scott S, Lake AA, Teasdale S, Ekers D, Augustine A, Le Savauge N, Lynch C, Moore H, Smith J. 2023. Food insecurity in adults with severe mental illness living in Northern England: Peer research interview findings. Int J Ment Health Nurs. Dec 7. doi: 10.1111/inm.13270. Epub ahead of print. PMID: 38059552
54. Spinosa J, Christiansen P, Dickson JM, Lorenzetti V, Hardman CA. 2019. From Socioeconomic Disadvantage to Obesity: The Mediating Role of Psychological Distress and Emotional Eating. Obesity (Silver Spring). Apr;27(4):559-564. doi: 10.1002/oby.22402. Epub 2019 Feb 28. PMID: 30821100; PMCID: PMC6593860
55. Jih, J., Nguyen, T.T., Jin, C., Seligman, H., Boscardin, W.J. & Ritchie, C.S. 2020. Food insecurity is associated with behavioural health diagnosis among older primary care patients with multiple chronic conditions. Journal of General Internal Medicine, 35, 3726–3729
56. Alegría M, NeMoyer A, Falgàs Bagué I, Wang Y, Alvarez K. 2018. Social Determinants of Mental Health: Where We Are and Where We Need to Go. Curr Psychiatry Rep. Sep 17;20(11):95. doi: 10.1007/s11920-018-0969-9. PMID: 30221308; PMCID: PMC6181118
57. Symister P, Friend R. 2003. The influence of social support and problematic support on optimism and depression in chronic illness: a prospective study evaluating self-esteem as a mediator. Health Psychol. Mar;22(2):123-9. doi: 10.1037//0278-6133.22.2.123. PMID: 12683732
58. Ng DM, Jeffery RW. 2003. Relationships between perceived stress and health behaviours in a sample of working adults. Health Psychol. Nov;22(6):638-42. doi: 10.1037/0278-6133.22.6.638. PMID: 14640862
59. Holt-Lunstad, J., Birmingham, W., & Jones, B.Q. 2008. Is There Something Unique about Marriage? The Relative Impact of Marital Status, Relationship Quality, and Network Social Support on Ambulatory Blood Pressure and Mental Health. Annals of Behavioural Medicine, 35, 239–244
60. Sarwer DB, Polonsky HM. 2016. The Psychosocial Burden of Obesity. Endocrinol Metab Clin North Am. Sep;45(3):677-88. doi: 10.1016/j.ecl.2016.04.016. PMID: 27519139; PMCID: PMC6052856
61. Faith MS, Matz PE, Jorge MA. 2002. Obesity-depression associations in the population. J Psychosom Res. Oct;53(4):935-42. doi: 10.1016/s0022-3999(02)00308-2. PMID: 12377306
62. da Luz FQ, Hay P, Touyz S, Sainsbury A. 2018. Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches. Nutrients. Jun 27;10(7):829. doi: 10.3390/nu10070829. PMID: 29954056; PMCID: PMC6073367
63. Fulton S, Décarie-Spain L, Fioramonti X, Guiard B, Nakajima S. 2022. The menace of obesity to depression and anxiety prevalence. Trends Endocrinol Metab. Jan;33(1):18-35. doi: 10.1016/j.tem.2021.10.005. Epub 2021 Nov 5. PMID: 34750064
64. Almandoz JP, Xie L, Schellinger JN, Mathew MS, Bismar N, Ofori A, Kukreja S, Schneider B, Vidot D, Messiah SE. 2021. Substance use, mental health and weight-related behaviours during the COVID-19 pandemic in people with obesity. Clin Obes. Apr;11(2):e12440. doi: 10.1111/cob.12440. Epub 2021 Feb 4. PMID: 33539652; PMCID: PMC7988649
65. Baskin C, Duncan F, Adams EA, Oliver EJ, Samuel G, Gnani S. 2023. How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation. BMC Public Health. Dec 7;23(1):2445. doi: 10.1186/s12889-023-17404-x. PMID: 38062427; PMCID: PMC10702025