AXA : L'indice AXA de santé mentale 2024

The development of the AXA Mind Health Index from over 200 scientific papers gave us a robust platform from which to widen the discussion from mental ill health to a broader view of causal factors and their impact on wellbeing. This is important because stress, anxiety and low mood are reaching epidemic proportions, but as issues often rooted in our lifestyle, work and environment.

This year's study continues the successful format started in 2022, which draws a distinction between struggling, languishing, getting by and flourishing. This formula gives us a more stable view of where an individual is on the spectrum of mind health, the factors that put them there and, most importantly, what can we do as individuals and as a society to help everyone flourish.

Having expanded to include five new countries in 2023, this year's MHI is based on interviews with 16,000 people across 16 countries.

The results show that more people are struggling compared with last year. In fact, the numbers have returned to the same levels that were recorded during the pandemic. Worryingly, the index shows that too some people who are affected

by mind health issues are unaware and those living with severe mental health conditions do not consider accessing professional support to manage their struggles.

We are seeing the same at work, though work can contribute to ones mental health, people are slow to recognise the link between mind health and issues such as tiredness, difficulties to focus and lack of sleep. The report underlines the important role that companies can play in identifying disengagement as the first sign of mind health issues in the workplace. Bringing awareness on early signals and taking preventive actions can lower the occurrence of sick leave.

My sincere thanks to the scientific design and research teams in AXA, our team of international experts, Ipsos our fieldwork partner and the AXA Research Fund.

Introduction

Mind health includes our emotional, psychological, and social wellbeing. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices.1

As a major global investor and philanthropist in multiple health topics, AXA has identified an opportunity to contribute meaningfully to the knowledge base of mental health through a global survey, known as the Mind Health Index (MHI).

The goal of the MHI is to provide scientifically backed insights into mind health related topics for multiple audiences: the general public, employers, insurance industry, consulting partners, and government.

Published in 2022, the first MHI was used to survey over 11,000 participants from eight European and three Asian countries (Belgium, France, Germany, Ireland, Italy, Spain, Switzerland, UK, Mainland China, Hong Kong and Japan). Shaped by the global backdrop of COVID-19, MHI22 identified concrete levers and coping strategies which allowed people, employers and society to flourish.

The success of the survey resulted in an ongoing commitment by AXA to track the MHI over the subsequent five-year period, with an extended offering to an additional five countries (Mexico, Philippines, Thailand, Turkyie and USA).

Carried out in 2023, this year's MHI survey (MHI24) conducted 16,000 interviews with the general population aged 18 to 75 years old in the same 16 countries. MHI24 continues

to track the progress of mind health across the four core categories of flourishing, getting by, languishing and struggling. This latest report shone a light on lack of awareness, mental health stigma and the need for people who are struggling to access professional care.

Core questions

The survey consists of two main categories of questions:

1. A 'static' component (the index) which remains unchanged year on year, thereby allowing changes over time to be accurately and comparatively tracked, and
2. A 'dynamic' component of supplementary questions that are updated annually to provide insights into current themes and topics of interest.

As in previous years, we used a systems approach to help understand the aetiology and maintenance of mind health2. Using this framework, we sought to understand the factors that impact mind health at the individual, social and societal levels. A benefit of taking a multidimensional approach is that it provides a more holistic understanding of mental health and wellbeing, and as a result provides greater insight into how mind health can be supported and improved.

The core questions fell into 3 groups. These are also outlined in detail in the previous MHI White Paper,3 however a brief synopsis is provided here:

1. Predictors - individual skills and behaviours that have some predictive capability in terms of mental health outcomes (e.g. exercise is a predictor of mental health,
   it reduces stress, anxiety and depression, whilst improving life satisfaction via multiple pathways)
2. Outcomes - positive and negative mental health outcomes. On the negative side - stress, anxiety and depression, on the positive side - happiness and life satisfaction.

The behaviours and skills in the predictor group impact mental health outcomes, but they are impacted by an intermediary pathway: modifiers.

1. Modifiers - factors that mediate the degree to which the predictors impact outcomes. These include factors such as the health care system, intractable personality traits such as attachment style, as well as past and
   current mental health conditions.

The MHI score is an aggregation of these three sub-indices.

Predictors

Preventive actions/skills

Authentic pride

Authentic pride is related to feelings of confidence and achievement and is associated with a psychologically healthy and socially desirable personality profile marked by high levels of agreeableness and conscientiousness, intrinsic motivation, perseverance, and a tendency to engage in a range of prosocial behaviours, including empathy and respect.4 Whereas 'hubristic' pride is viewed as arrogant and self-serving, 'authentic' pride exudes accomplishment, conviction, and success.

Challenge response - rumination

Dwelling on mistakes (rumination) and being overly self- critical has been found to negatively impact mental health and wellbeing.5 Rumination is essentially the opposite of resilience. Resilient people move on more quickly, whereas ruminators tend to find it hard to move on.

Delayed gratification

Delayed gratification is the ability to resist temptation of an immediate pleasure in the expectation of obtaining a valuable and long-lasting reward in the longer-term. It is a pivotal component of emotional intelligence, and studies have shown that the ability to delay reward is present in highly successful people and is associated with better mental health outcomes.

Delayed gratification is evident in children as young as four years of age and appears to be a potent predictor of success in later life, as demonstrated by Walter Mischel of Stanford University in the legendary 'Marshmallow Test' in 1972.6 The phenomenon appears to be pervasive in the animal kingdom, having been demonstrated in creatures as diverse as chimpanzees to cuttlefish (Sepia officinalis).7

6 I AXA Mind Health Index 2024

Emotional Competency

Emotional competency is the degree to which people successfully utilise EQ related skills.8 Self-awareness, emotional self-regulation, social awareness and social skills represent the foundations of good EQ. A higher EQ can improve lifelong physical and mental health even more than academic ability. According to a 2018 report, people with a high EQ are eight times more likely to have a high quality of life compared to those with lower scores.9

Exercise

The benefits of physical activity have been demonstrated definitively across a broad range of both physical and psychological health. Physical activity has been found to reduce symptoms of anxiety and depression.10 Exercise participation has been linked to the prevention of mental health problems11 and as little as 16 weeks of regular exercise has been found to be equally as effective as antidepressant medication in treatment of mild to moderate depression.12

Kindness/giving

'Giving' and acts of kindness are pro-social behaviours that have been shown to improve immune function and stimulate the production of serotonin in both the recipient and the person extending the kindness. Even those observing the act of kindness have similar beneficial results.13

Research has also found that participation in voluntary services is significantly predictive of better mental and physical health, life satisfaction, self-esteem, happiness, lower depressive symptoms, psychological distress, and mortality and functional inability.14

Locus of control

Locus of control represents the degree to which we perceive to have control over our lives. Perceived control over outcomes in life (i.e. internal locus of control) is associated with good health and wellbeing, while relying on chance and/or powerful others (i.e. external locus of control) is related to stress and poor health.15 Individuals with an internal locus of control attribute the events in their life primarily to their own doing. An internal locus of control has been found to positively correlate with the ability to cope with stress and negatively with depression, anxiety and interpersonal problems.16

Me time

'Time out for self' is fundamental to life balance which is linked to positive mental health outcomes. Pushing through life without taking time out can lead to burnout, exhaustion, immunosuppression and consequently, more frequent and severe illness. Once considered an indulgence, 'Me time' is now considered a vital inclusion in any mental health self- care strategy.17

Meaning/purpose

Meaning and purpose in life are predictive of emotional wellbeing and result in better recovery from negative life events.18 A literature review of thirty-two papers on 'meaning in life' and mental health found overwhelmingly that relationships, particularly relationships with family, are cited as the most important source of meaning in people's lives in all cultures and age groups.19 This review also found that failure to address 'meaninglessness' can lead to psychopathologies such as depression, anxiety, addiction, aggression, hopelessness, apathy, lower levels of wellbeing, physical illness, and suicide.

Mindfulness

Mindfulness is a way of paying attention to the present moment, using techniques like meditation, breathing and yoga. It helps people become more aware of their thoughts and feelings, in a non-judgemental fashion, so that instead of being overwhelmed, they are better able to manage them.

Studies show that mindfulness-based approaches can significantly reduce the symptoms of anxiety and depression. They can also help people who have had multiple depressive episodes to avoid relapsing.20

Nutrition

Multiple studies have demonstrated the relationship between nutrition and mood disorders such as depression. Studies comparing 'traditional' diets, like the Mediterranean diet and the traditional Japanese diet, to a typical 'Western' diet have shown that the risk of depression is 25% to 35% lower in those who eat a traditional diet.21 Changes in eating habits are also a common symptom of mood disorders.

Openness to experience

Openness to experience is one of the 'Big 5' domains which are used to describe human personality in the Five Factor Model.22 Openness to experience refers to one's willingness to try new things as well as engage in imaginative and intellectual activities. People who score low on openness to experience prefer routine. They are uncomfortable with change and trying new things, so they prefer the familiar over the unknown. On the whole, openness appears to be largely unrelated to symptoms of mental disorders23 but does have significant (positive) associations with happiness, positive affect, and quality of life.24

Optimism

Optimism is a tendency to see the positives; a glass half full vs half empty mentality. This is important because how we see the world and events around us has a big impact on our mental wellbeing and quality of life.25 Through the deployment of specific coping strategies, optimism also exerts an indirect influence on quality of life. Optimistic people consistently outperform neutral or pessimistic people in quality-of-life measures. Optimism influences mental and physical wellbeing by promoting a healthy lifestyle, as well as by adaptive behaviours and cognitive responses associated with greater flexibility, problem-solving capacity and a more effective processing of negative information.26

Positive actions

The 'positive actions' constitute those factors which are both predictive of mental health, and 'internal' to the individual. These factors can be self-managed for improved mental health.

Resilience

Psychologists define resilience as the process of 'adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress - such as family and relationship problems, serious health problems, or workplace and financial stressors'. As much as resilience involves bouncing back from these difficult experiences, it can also involve profound personal growth.27 Lack of resilience means the adverse psycho-emotional consequences of the threat linger well after the threat has passed, exacerbating its impact.

A meta-analysis of 60 studies showed that lack of resilience was correlated to negative indicators of mental health.28

Self-acceptance

Self-acceptance is defined as 'an individual's acceptance of all of their attributes, positive or negative'.29 Historically, self-acceptance has long been a stimulus for personal improvement in Eastern and Western religion and culture, as well as in psychological literature. Different theologies (e.g., Christianity, Buddhism), psychological theories (e.g., Humanism), and therapies (e.g., RET, CBT) view self-acceptance as a mechanism for reducing emotional misery. Self-acceptance supports the progression towards happiness and fulfillment. Research continues to show that self-acceptance is strongly related to mental health and wellbeing in people of all ages. For example, it has been found to influence the differential risk of being a member of a minority group on mental health.30

Self-efficacy

Belief in one's abilities underpins successful self- management of behaviour; without self-belief, the incentive to engage in protective/preventive actions in relation to mental health is undermined. Poor self-belief therefore not only lowers the likelihood of success, it lowers the likelihood of an attempt to succeed. Research has found that self- efficacy ameliorates the effects of daily stressors on mental health, with the strongest relationship being found between self-efficacy and positive mental health31.

Sleep

Sleep disturbances have been shown to be an important factor in many different mental health difficulties, both contributing to their development and then being a key source of distress for the individual involved.32

Social Connectedness

From the very young, to the very old, social relationships promote health and wellbeing. There is evidence to support the role of our social networks in both protecting from negative mental health and facilitating positive psychological health.33 Conversely, loneliness has been described as a hidden epidemic found to be as damaging to our health

as smoking 15 cigarettes a day.34

Wellbeing locus of control

Whereas locus of control is generalised to a whole of life situation, wellbeing locus of control is a relatively new concept that limits the context to control of factors affecting wellbeing.

A fundamental underlying assumption of positive psychology is that an individual can influence their wellbeing through their own behaviour. Research published in 2021 was the first to validate the concept of 'Wellbeing Locus of Control' (WB-LOC) and develop a multidimensional scale with which to measure it (WB-LOC12).35 This new scale showed robust psychometric properties and a WB-LOC question was therefore included in the MHI23 survey - and retained in MHI2024.

'Modifiers' are also predictive, but they can be external or personal factors.

We chose to use the mental health continuum as a universal outcome measure in the MHI (from poor to optimum mental health). Mental health conditions can therefore be viewed as modifiers that can impact on the outcome measures. The positive actions individuals use (knowingly or not) deliver the mental health outcomes via modifiers, which gives us the MHI model.

Positive actions Modifiers Outcomes

Many modifiers are simple demographics such as age/ gender, education and socio-economic status, but factors such as past/current mental health conditions, attachment style and access to health care also play an important role in moderating the impact of actions on outcomes. A simple manifestation of the model is that, given a certain skill set shared by two people, say resilience and optimism, it's easy to accept that the mental health outcomes for these two people may differ depending on their age, socio-economic status and knowledge of the health care system.

Attachment style

Attachment theory describes the dynamics of human relationships, in particular when people are feeling distressed, in need, scared or under threat. The human need for attachment is said to have arisen out of evolutionary pressures for infants to elicit the care and protection of their caregivers in order to ensure survival. Research in the 1960's and 70's showed that infants develop different patterns

of attachment behaviour depending primarily on their experiences in these early relationships.36 Four categories have been identified: secure, insecure avoidant, insecure anxious and fearful avoidant. An adult's attachment style has been shown to be an important predictor in their ability to cope with stressful life events and predicts their utilisation of mental health services.37

The health care system

Mental health difficulties are responsible for 32% of years of disability and 13% of disability adjusted life years (DALYs) globally.38 In addition, those with mental health difficulties face increased rates of morbidity from general medical conditions and a higher risk of premature mortality.39 Among those with mental health difficulties, disparities in quality and outcomes of care are more pronounced

for racial/ethnic minorities, and those of lower socio-economic status.

Those with severe mental health conditions (e.g., schizophrenia and bipolar disorder) constitute an increasingly marginalised population whose needs outstrip the available health care resources in almost every country in the world.40 It is estimated that life expectancy is reduced by up to 25 years in these groups. Despite the contribution of mental health difficulties to the global burden of disease, the quality of care for these disorders remains suboptimal, and there are persistent gaps in access to and receipt of mental health services worldwide.41

The six characteristics that determine quality of care in mental health are safety, effectiveness, patient-centred, timely, efficient, and equitable care42.

Current and past mental health conditions

Diagnosed mental health conditions are a powerful modifier of mental health outcomes.

We asked participants about their personal history regarding the major mental health conditions using DSMV/ICD11 groupings as outlined below.

• Depression
• Anxiety disorder, phobia or PTSD
• Substance abuse disorder
• Eating disorder (i.e. Anorexia/bulimia/ binge eating disorder etc.)
• Schizophrenia, bipolar or related disorders
• Obsessive-compulsivedisorder
• Other/prefer not to say

The number and type of current or past mental health conditions was combined with the participants self-rating of how well the condition is/was managed to derive an overall score for these factors. A single well-managed condition was scored more favourably than multiple poorly- managed conditions.

We also queried how a condition was diagnosed, and how it was managed. This enabled us to look at differential outcomes for self-diagnosis vs professional diagnosis, as well as for different management strategies (i.e. self-managed, GP/psychologist/psychiatrist managed, with or without medication etc.).