The Republic of Korea (hereinafter Korea) bears one of the heaviest mental health burdens worldwide. The National Mental Health Survey of Korea 2021 found that 27.8 percent of adults have experienced a mental disorder at some point in their lives, showing that more than one in four people will face a psychiatric condition [1]. Although various policies have been introduced, the country’s suicide rate remains exceptionally high. OECD statistics indicate that the 2023 OECD average was 10.7 deaths per 100,000 people, while Korea recorded 23.2 deaths per 100,000 (based on 2022 data), which is more than double the OECD average and the highest among member countries [2]. Because this level of burden leads to considerable productivity losses, increased healthcare costs, and broad societal impacts, a more robust public health response is urgently required [3-5].

Meeting this urgent need requires a strategic shift from a treatment-oriented system to one that prioritizes promotion and prevention [6]. Aligning with recent OECD guidance, this review conceptualizes “promotion” and “prevention” as complementary strategies within a unified public mental health framework, where promotion enhances psychological wellbeing and prevention averts the onset of mental disorders [7]. This shift is driven by the recognition that even optimal access to high-quality clinical services is insufficient, on its own, to meaningfully reduce the population-level prevalence of mental disorders [6]. Several factors support this shift [8]. First, a significant gap exists globally between treatment need and provision, a trend evident in Korea as well [1,8]. Treatment utilization remains exceptionally low in the country, where only 4.4% of individuals with a lifetime mental disorder and 7.2% of those with a 12-month diagnosis have ever received care from a mental health specialist [1]. Furthermore, treatment does not ensure recovery, as many individuals experience suboptimal response or disengage early [8]. Since many psychiatric disorders follow relapsing or recurrent courses, preventing or delaying onset can significantly reduce lifetime treatment needs [8]. Additionally, economic evaluations demonstrate that well-implemented preventive programs can produce meaningful cost savings [8].

Based on this rationale, Korea has expanded its community-based prevention infrastructure and services; yet, it remains uncertain whether this quantitative increase has translated into measurable benefits. Since the Mental Health Act of 1995, the community mental health infrastructure has expanded markedly, currently comprising a network of 244 community mental health welfare centers, 17 metropolitan mental health welfare centers, and 58 integrated addiction management support centers [9,10]. Public education and community-based mental health activities have also grown; in 2023, community mental health education reached approximately 2.07 million participants, and participation in community-based mental health promotion programs increased by 7.4 percent, rising from 87,075 individuals in 2019 to 93,513 in 2023 [11]. However, quantitative expansion alone does not automatically indicate that promotive or preventive programs are achieving meaningful outcomes. The persistent stagnation of suicide rates despite these efforts suggests that this infrastructural expansion may not be effectively translating into tangible improvements in population mental health. Existing evaluations of community mental health welfare centers and integrated addiction management support centers, which serve as central organizations for promotion and prevention, primarily focus on administrative metrics, such as program volume and completion of required tasks [12]. They rarely incorporate outcome indicators that reflect clinical, functional, or social change. International guidance emphasizes that robust accountability requires evaluation systems that measure actual impact rather than relying on process-focused indicators [6]. Following rapid infrastructural growth, Korea now faces an urgent need to ensure that promotive and preventive services are truly improving mental health outcomes on a population scale.

In this regard, the state of academic research serves as a critical barometer for the maturity of current national mental health strategies. Prevention science frameworks emphasize that interventions move toward scale and long-term implementation only when supported by rigorous empirical studies that establish efficacy, effectiveness, and implementation feasibility [8]. Experts also argue that maximizing the value of mental health investments requires allocating resources to interventions with proven benefits, which is only possible when research is conducted systematically and consistently [6]. Examining the national research landscape, therefore, serves as an important diagnostic step, showing whether Korea’s expanding service infrastructure has been accompanied by a corresponding accumulation of robust evidence. Despite the country’s policy shift toward prevention, critical assessments of the scientific maturity and methodological rigor of relevant research remain scarce.

Accordingly, this narrative review was designed as a critical diagnostic assessment of whether Korea’s mental health promotion and prevention strategies are supported by evidence that meets internationally recognized standards of rigor and transparency. Beyond simply summarizing quantitative studies, it evaluates the methodological maturity of the existing evidence base to gauge the stability of the nation’s expanding service infrastructure. In doing so, the review identifies major gaps in the literature that may hinder the overall impact of national strategies. The ultimate goal is to provide a diagnostic overview that informs future research priorities and supports the development of evidence-based policies capable of reducing Korea’s substantial mental health burden.

This review provides the first critical assessment of internationally indexed quantitative research on mental health promotion and prevention interventions in Korea. The findings reveal a dynamic yet uneven landscape characterized by four primary deficits. First, although the volume of studies has increased sharply since 2020, the number of RCTs, which continue to represent the highest standard of evidence in prevention research [8], remains small. Second, the literature shows a marked lack of promotion-focused research targeting adolescents despite the developmental importance of this period. Third, a structural discontinuity exists in the research pipeline, where preliminary studies fail to progress to full-scale efficacy trials, consequently failing to provide a solid evidentiary basis for national policy implementation. Fourth, a disconnect persists between academic research and public service delivery, which leaves the core community mental health infrastructure largely unevaluated. Overall, these findings indicate that while prevention efforts are gaining momentum, the evidence base needed to support, sustain, and expand these initiatives remains incomplete.

A primary concern identified in this review is the substantial gap between the expanding volume of studies and the limited accumulation of high-certainty evidence. Only 23.7 percent of the 135 studies used randomized designs. Most relied on quasi-experimental methods, which are practical but insufficient for drawing firm causal conclusions. This issue is most evident in school settings. Schools provide one of the most suitable environments for promotive and preventive mental health programs, given the nearly universal enrollment of Korean children and adolescents [45]. Their structured nature also makes them well-suited for rigorous research, as reflected by the substantial body of school-based RCT evidence globally [46]. However, this review identified only one school-based RCT [24]. This scarcity mirrors findings from a comprehensive meta-analysis of Korean-language social-emotional learning intervention studies, which identified random allocation in only 1 of 23 studies [47]. The lack of rigorous research in this setting becomes a significant concern when national initiatives expand rapidly despite an insufficient domestic evidence base. A recent example is the push to scale up school mindfulness programs [48], even though local evidence remains scarce and a major overseas trial has reported null effects on depression risk and well-being [49]. This disconnect reflects a longstanding pattern in which Korean mental health initiatives have prioritized administrative expansion over research-informed program design [50], a systemic tendency illustrated by the earlier-discussed findings of Ryu et al. [27] regarding empirically unsupported suicide reduction targets. In contrast, countries such as the United States have prioritized prevention initiatives supported by credible scientific evidence [8]. As Korea reaches a stage of development where promotive and preventive mental health is gaining prominence, strengthening the evidence base should be regarded as an essential next step.

A second critical deficit identified in this review is the marked scarcity of promotion-focused research targeting adolescents. Although adolescence is the period in which the risk of developing mental disorders rises most sharply [6], research for this population remains limited and has focused primarily on reducing risks rather than strengthening psychological well-being. Only three studies directly aimed to enhance positive mental health among adolescents [38-40]. Because adolescence is the most influential period for shaping lifelong mental health trajectories, the lack of promotion-oriented research represents a missed opportunity for early intervention. Promoting mental well-being during this period is widely recognized as a highly effective strategy for preventing both immediate and future mental health problems [51]. For this reason, future research in Korea should prioritize the development and rigorous testing of promotion-focused interventions for adolescents to strengthen the psychological resilience of future generations.

A third structural challenge lies in the fragmentation of the research pipeline, particularly when viewed through the lens of the Medical Research Council (MRC) framework for complex interventions [52]. Mental health promotion and prevention programs are inherently complex and characterized by interacting components and context-dependent outcomes. According to the MRC guidance, robust evidence generation for complex interventions requires a phased approach in which key uncertainties regarding feasibility and context are resolved before determining efficacy. However, the current landscape in Korea reveals a fragmented pipeline where many studies begin as pilot or feasibility projects, but very few progress to full efficacy or effectiveness trials [31-34]. This discontinuity likely reflects a national R&D funding structure that favors short-term performance metrics over the phased, multi-year development required for complex interventions. Consistent with this misalignment, prior national analyses have shown that only 5.3% of mental health R&D funding is directed toward T2 translational research, the stage most closely aligned with the transition from pilot and efficacy studies to real-world service delivery, with just 2.9% allocated to prevention and disease management [53].

Regrettably, this fragmented pipeline is mirrored in national policy implementation, where large-scale initiatives are often launched without sufficient evidentiary or infrastructural verification. For instance, the limited impact of the NIMS, as reported by Lee et al. [44], exemplifies the consequences of bypassing feasibility testing; had a pilot phase been conducted, critical structural deficits, such as the absence of real-time monitoring and insufficient administrative capacity, could have been identified and addressed prior to national implementation. Similarly, the recently launched National Mental Health Psychological Support Program, a large-scale Korean government initiative that provides psychological counseling services [54], appears to bypass the foundational phases mandated by best practices. Indeed, this review identified no prior pilot or feasibility work for the initiative. This discontinuity stands in contrast to successful international models of mental health initiatives, such as England’s NHS Talking Therapies [55-57] and Zimbabwe’s Friendship Bench [58-60], both of which scaled up only after establishing a solid foundation comprising rigorous efficacy trials and subsequent service model pilots. To address these issues, national funding should support long-term, staged research that moves from early feasibility work to well-designed efficacy trials and implementation evaluations. This approach would improve research quality, support the responsible expansion of effective interventions, and increase the impact of national investments in mental health.

A fourth critical gap concerns a clear disconnect between academic research and the core public mental health institutions responsible for delivering services. Although the government has expanded community mental health welfare centers and integrated addiction management support centers, these facilities are seldom used as settings for empirical studies, while recent research has largely focused on digital and web-based interventions. This trend likely reflects the impact of the COVID- 19 pandemic and Korea’s well-established digital infrastructure, but it leaves core community institutions with little evidence about the actual outcomes of their programs. This lack of empirical attention is particularly concerning given that existing evaluations of these institutions rely mainly on administrative indicators such as the number of activities delivered, rather than on clinical, functional, or social outcomes [12]. To bridge this gap and enhance service accountability, researchers and public health authorities must collaborate to integrate routine outcome measurement into everyday practice. International models demonstrate the feasibility of this approach, including the systematic collection of symptom data in England’s NHS Talking Therapies [57], the monitoring of psychological distress and functioning via the national minimum data set in Australia’s headspace centers [61], and the mandatory reporting of clinical outcomes by Certified Community Behavioral Health Clinics in the United States [62]. If Korea adopts similarly rigorous monitoring systems, evaluation can shift from activity counts to meaningful evidence of improvement, helping ensure that major national investments result in real gains in population mental health.

Beyond the four key themes identified above, the composition of research leadership in this review points to a pressing need for greater engagement by psychiatrists in mental health promotion and prevention research. The analysis of corresponding authors shows that nursing professionals led nearly half of the included studies (n=64, 47.4%), while psychiatrists led fewer than one in five (n=26, 19.3%). Since corresponding authors typically drive the research agenda and funding, their distribution provides insight into which professional groups are shaping national promotion and prevention research. This disparity suggests that while nursing professionals have played a pivotal role in driving community-based inquiries, psychiatrists have yet to fully embrace their potential leadership role in mental health promotion and prevention. As Tandon [63] highlights, clinical medicine and public health are sister sciences that share core functions and a common mission to reduce morbidity and mortality. Psychiatrists are uniquely positioned to bridge these disciplines because their training encompasses the full spectrum of care, ranging from biological mechanisms and clinical pathology to the social determinants of health. Moreover, given that psychiatrists frequently serve as administrative directors of core community mental health institutions, they are ideally situated to ensure that clinical insights are effectively translated into population-level strategies. To address the heavy national burden of mental illness effectively, psychiatrists must expand their scope beyond individual treatment and actively lead research initiatives that inform promotive and preventive mental health policy.

This review is subject to two main limitations. First, study selection and data extraction were conducted by a single reviewer. Although efforts were made to ensure consistency through intra-rater reliability checks and validation by the corresponding author, the absence of a dual independent review process means that potential selection or extraction bias cannot be entirely ruled out. Second, despite the specific focus on the Korean context, the search strategy was restricted to international databases. This decision aligns with the study’s design as a critical narrative review focused on diagnosing the scientific maturity of the evidence base, rather than a broad scoping review attempting to map all available evidence exhaustively. Importantly, this restriction does not equate to excluding research published in Korean journals. Major Korean journals in psychiatry, nursing, and public health are indexed in the selected international databases and are therefore included in our search strategy. Furthermore, the decision was guided by methodological proportionality; an exploratory audit of a representative domestic database, DBpia, indicated that the vast majority of local records were small-scale pilot studies, isolated wellness activity reports, or specific psychotherapeutic approaches that did not align with the scope of this review. Consequently, we determined that systematically screening these heterogeneous reports would risk diluting the evidentiary standard of this review rather than enhancing the rigor of the diagnostic assessment regarding the scientific foundation of national policy. Thus, despite these limitations, this review stands as the first critical synthesis of internationally indexed quantitative evidence on mental health promotion and prevention in Korea, providing an essential evidentiary baseline for guiding future policy and research.

In conclusion, this review reveals that while the volume of research has expanded, the field has not yet achieved the methodological and structural maturity required to guide national policy effectively. Without a grounding in rigorous evidence, the actual impact of current promotive and preventive practice remains obscure. Given the severity of the mental health challenges facing the nation, there is no margin for allocating limited resources to unverified interventions. Establishing a scientific foundation is, therefore, the prerequisite for transforming current national endeavors into a system capable of delivering genuine population-level benefits. Ultimately, embracing this evidence-based approach is crucial for ensuring the scalability and sustainability of national initiatives, thereby aligning Korea with the global imperative to prioritize both the promotion of psychological well-being and the prevention of mental disorders.