The important factor often left out of mental health research

New research suggests mental well-being should be measured alongside standard tests for mental health conditions.

Measuring well-being alongside measures of psychological distress will paint a more accurate and thorough picture of mental health, say scientists at UNSW Sydney and Neuroscience Research Australia (NeuRA).

In a new study, published June 26 in Frontiers in Psychiatry, scientists have developed and validated an effective measure for mental well-being among adolescents, a factor that has traditionally been left out of mental health research.

The latest results found that adolescents who have clinical symptoms of mental ill-health or neurodevelopmental conditions, for example those who have been diagnosed with anxiety or depression, or ADHD, don't necessarily score low on mental well-being. Likewise, those who are not clinically diagnosed with these conditions don't necessarily score highly for mental well-being.

"If you consider the full definition of what mental health is, it's not just about the illness symptoms, it's also about mental well-being, and they're not simply opposite ends of a single spectrum," says Associate Professor Justine Gatt, who holds a joint position at UNSW Psychology and NeuRA, and led this project.

The research team hopes this study helps to challenge some of the misconceptions around well-being and mental ill-health, and encourages a more holistic approach to mental health research.

"The gold standard treatment for anxiety or depression could be supplemented with well-being programs that focus on positive emotions, self-worth, and autonomy," says A/Prof. Gatt. "If well managed, people with chronic mental health or neurodevelopmental conditions can report higher levels of well-being so that they are more functioning and content."

How can you accurately measure well-being?

Measuring well-being has historically been "messy," A/Prof. Gatt says. There is a common misconception that mental health is defined solely by diagnosable symptoms, and if you have an absence of symptoms, then you are doing well.

"In research, if mental well-being is measured as part of mental health, it typically includes measures of life satisfaction alone, and not mental well-being in its entirety," says A/Prof. Gatt. "This has left us with an incomplete understanding of what is going on."

In 2014, A/Prof. Gatt and her team developed the COMPAS-W scale, a measurement scale that has already been validated in adults. Unlike many previous measurements of well-being, this scale incorporates the two key elements of mental well-being—known as hedonia and eudaimonia.

"Hedonia, which is sometimes called subjective well-being, is your life satisfaction, but also happiness, pleasure and enjoyment," says A/Prof. Gatt. "And the other key component is eudaimonia, which is also sometimes called psychological well-being, which is made up of factors such as whether someone has a sense of life purpose, mastery, autonomy and self-worth."

The COMPAS-W scale takes a couple of minutes to complete and is made up of 26 questions, with ratings on a scale of 1 to 5 that cover elements of hedonia and eudaimonia. "By completing the scale, you will get a total score for your well-being, and from there we are able to categorize results into whether someone's mental well-being is languishing, moderate or flourishing," says A/Prof. Gatt.

"But there are also six sub-scales to COMPAS-W which include composure, own-worth, mastery, positivity, achievement and satisfaction."

The COMPAS-W scale

The data used in this study was collected in 2020 as part of a grant from Instagram to understand the impact of social media on well-being. The cohort had been asked to complete the COMPAS-W scale, as well as a series of other surveys. "So, for this particular paper, we pulled the data from respondents aged between 13 and 17 years old," says A/Prof. Gatt.

The team analyzed the responses of 1,078 adolescents across Australia and the US.

"The psychometric tests found that the COMPAS-W structure did hold for this age group," says A/Prof. Gatt. "We also found that the scale was more reliable in this age group when we removed a few items, so it ended up reducing the total scale from 26 to 23 questions."

Importantly, the cohort was taken from a general population sample. "This means that this group naturally included a sample of what you would see in the general population—about 20% had a mental health condition, or developmental disorder," says A/Prof. Gatt.

"So we wanted to actually look at how well-being differs in those who have a diagnosed mental health condition and/or neurodevelopmental disorder, compared to those who don't."

Digging into the results

The results found that on average, individuals who had a clinical mental illness diagnosis or neurodevelopmental disorder had lower well-being than non-clinical groups.

However, when looking at classification of well-being by the categories—languishing, moderate and flourishing—both clinical and non-clinical groups demonstrated incidence of well-being across all three categories.

For example, over half of the participants diagnosed with either a mental health condition or neurodevelopmental disorder scored moderate for well-being—65% and 71% respectively—and a small group fell into the flourishing category (1.5% and 5.6% respectively).

This means the clinical groups were mostly "moderately well" despite their diagnosis. The exception to this was for those with both psychiatric and neurodevelopmental conditions, for which incidence for moderate well-being was lower, at 46%. On the other side of the coin, there were many participants without a clinical diagnosis who nonetheless fell into the languishing category, or who had moderate mental well-being.

"This is a really significant finding because in many people, these conditions are chronic or recurring," says A/Prof. Gatt. "For some people, ADHD or chronic anxiety symptoms, for example, can persist into adulthood, and are conditions they have to learn to live with. So, to show that someone can still achieve adequate well-being is an important finding to share."

A call for change

As expected, the average scores for the clinical groups overall have a lower well-being than the "healthy" groups, but digging into the results emphasizes that the presence of illness does not mean an absence of well-being.

The team believe there are several reasons for these results. It is possible that individuals with clinical conditions who report moderate and, in a few cases, high well-being, have their condition well managed with pharmacological or behavioral treatment.

"If someone is managing their symptoms with treatment, you can imagine they may have the capacity to build their well-being. Someone may have the energy or the motivation to do things that they enjoy, which promotes positive emotions and life satisfaction and perceived control," says A/Prof. Gatt.

Similarly, it is plausible that non-clinical individuals report languishing well-being despite the absence of diagnosed clinical symptoms. In these cases, there is likely one of two scenarios happening. Either the participants did not seek medical support for feelings of low well-being (for whatever reason), or they did seek medical support but their symptoms were not deemed severe enough to be referred on to specialist mental health care.

Based on these findings, the research team are calling for the inclusion of measures of well-being alongside psychological distress to enable a better understanding of needs for early intervention in those who may not meet criteria for psychiatric illness, but are scoring low in well-being.

The inclusion of both measures also has the potential to help personalize treatment options in those who meet criteria for diagnosed illness and have low scores in well-being.

"We're currently working on validating a COMPAS-W scale for children, aged 5 to 12. In future work, we want to study how well-being changes over the lifespan," says A/Prof. Gatt. "But in the meantime, we'd like to increase awareness in the general public, but also researchers and clinicians on what this looks like, and eventually we'd like to see how mental health strategies can incorporate a measurement and promotion of well-being in those who need it."