Lack of evidence for mental health promotion in primary care


Mental health promotion (MHP) is defined by the World Health Organisation as “an umbrella term that covers a variety of strategies all aimed at having a positive effect on mental health. The encouragement of individual resources and skills and improvement in the socioeconomic environment are among them”.

MHP focuses on the general population (as opposed to treatment approaches which focus on those who already have or are considered at risk of developing a mental health problem.) It does overlap with mental health prevention efforts, as although prevention focuses on tackling risk factors that contribute to developing a mental health problem, the positive focus of MHP can be seen as potentially enhancing the role of protective factors.

Primary care centres can be seen as ideal places for MHP efforts then, as they are the ‘front line’ of care and see the most individuals, including those with no mental health problems and those at risk.


Promoting mental and physical wellbeing is a core part of primary care work.


  • The authors wanted to look at interventions to improve general mental health rather than improving specific conditions. They included RCTs that evaluated the impact of primary care professionals on promoting the mental health of adult patients. They excluded studies that looked at interventions for people already diagnosed with a mental health problem.
  • They restricted the included interventions to those that aimed to increase the participant’s ability to cope with daily stressors and those which were delivered by a primary care professional (as opposed to where primary care was involved in referring on to an external service).
  • They followed the PRISMA reporting guidelines for systematic reviews, and two researchers independently conducted each stage of the review.


  • 32 studies were assessed for eligibility and only 3 of these made it into the final review. Two were from the US and one from the UK.
  • The samples included were actually quite specific in their own way – the first in “elderly Medicare beneficiaries with disabilities” and the other two with parents of children who have mental health problems.
  • The interventions were delivered by nurses and family physicians.
  • Study quality was assessed as low to moderate.
  • The studies with the elderly participants found no impact of the intervention on mental well-being. One study with the parent sample found a statistically significant difference at follow up but with a small effect size; those in the intervention group showed a reduction of around 1.7 points on the General Health Questionnaire.
The review focused on "enhancing skills to cope with daily stressors" rather than a broader definition of mental health promotion.

The review focused on “enhancing skills to cope with daily stressors” rather than a broader definition of mental health promotion.


The authors say:

The most important result of this systematic review is that we do not have enough evidence to recommend, or not, the implementation of MHP activities in the primary health care setting.

They raise in the discussion several potential barriers to implementation of such interventions, such as competition from multiple other tasks during time-limited sessions and a perceived lack of skill to engage with mental health interventions by untrained professionals. They conclude:

The challenge is how to integrate MHP into primary health care, keeping in mind the complexity and barriers of this setting.

Quite a lot of reviews end on a bit of a damp note when there isn’t enough evidence, or enough high quality evidence, to draw conclusions, but this one is damper than usual. Given that the introduction argued that primary care was an ideal site for MHP, the discussion seems to back track and say that MHP of this kind may be very difficult to achieve in complex primary care settings.

It does remind us though that the question for health research is increasingly not just “Does this intervention work?” but “Can it work in the real world?” This includes “Can it be delivered in this setting?” (Implementation), “Can it be delivered within existing services?” (Integration) and “Can it be continued and kept available outside of a trial?” (Sustainability).


  • The authors focus on “mental health promotion” as being a holistic term but then the intervention they focus on is very specific (enhancing skills to cope with daily stressors). This may have contributed to only a small number of studies being eligible. It’s also not made clear why they chose this as their definition of the intervention.
  • What reviews like this can’t do is tell us what is happening ‘au naturel’ on the ground. One GP commenter on the useful but hideously acronymed ACCESSSS site mentions that the review “demonstrates we have little evidence to support what a lot of us in primary care are likely already doing” and another says the small sample could indicate “too few primary care practitioners are publishing what they do”. This suggests that those working in primary care do think that quite a bit of MHP goes on there. It would be interesting to know what staff on the ground think about MHP and their role in delivering it.
[This review] “demonstrates we have little evidence to support what a lot of us in primary care are likely already doing”.

[This review] “demonstrates we have little evidence to support what a lot of us in primary care are likely already doing”.


Fernandez A et al. Is there a case for mental health promotion in the primary care setting? A systematic review. Pre Med 2014 Dec 2. pii: S0091-7435(14)00462-9. doi: 10.1016/j.ypmed.2014.11.019. [Epub ahead of print] [PubMed abstract]

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Sarah Knowles

Sarah is a Research Fellow with the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester at the University of Manchester. She is a health researcher with a particular focus on evaluating mental health treatments and services. She works on a variety of randomised controlled trials, systematic reviews and qualitative studies. Her main research interests are implementation research, e-health and mental health technologies, co-morbidity of mental and physical health problems, moderators of treatment effects and patient and public involvement in research.

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