Memorandum by Martin Knapp, David McDaid,
Elias Mossialos and Graham Thornicroft
Note: Much of the material for this submission
is drawn from the forthcoming book Mental Health Policy and
Practice Across Europe edited by Martin Knapp, David McDaid,
Elias Mossialos and Graham Thornicroft. Open University Press/McGraw-Hill,
1. WOULD AN
EU STRATEGY ON
1.1 One in four of the European population can
expect to experience a mental health problem during their lifetime.
Nearly all of us will know someone either in our families, at
our workplaces or in our local communities with a mental health
problem. Good mental health is a critical aspect of public health.
The risk of poor physical health is significantly higher in those
individuals experiencing mental health problems. The consequences
of poor mental health go beyond health, impacting on all aspects
of life. Other consequences can include loss of employment and
housing, deterioration of family relationships, and increased
contact with the criminal justice system. The level of stigma
experienced by those with mental health problems can be profound.
20 JULY 2006
1.2 The Green Paper was the European Commission's
response to the 2005 Helsinki WHO European Region Ministerial
Declaration and Action Plan for Mental Health. Greater visibility
for mental health at an EU level can help challenge the low priority
it receives in some European countries. Both the development of
national policies and the level of funding for mental health services
or initiatives have been disappointing across almost the length
and breadth of Europe. Most countries now do have national or
regional mental health policies in place. Some have a long pedigree,
and are revised quite regularly, but others are rather dated and
clearly in need of reform.
1.3 Funding in some EU Member States remains
below 5 per cent of the total public health expenditure, despite
poor mental health accounting for as much as 20 per cent of the
total burden of ill health. This is however much variation in
funding and service provision across Europe. Data from the Mental
Health Economics European Network indicates, for instance, that
the UK allocates one of the highest known shares of health budget
to mental health (around 13 per cent in England alone).
1.4 Despite growing policy attention, as well
as advances in recognition and treatment, there are concerns that
the situation in some parts of Europe could get worse before it
gets better, widening inequalities in health. Rapid economic and
social change in central and eastern Europe has been accompanied
by a decline in population mental health, with increasing rates
of alcohol problems, violence and suicide. The mental health needs
of people displaced through conflict, persecution or economic
migration pose further challenges. The changing demography of
Europe will clearly generate growth in age-related needs over
the next few decades.
1.5 The EU also has an important role to play
in promoting good mental health. There is a small but growing
body of robust evidence indicating that there are effective promotion
and prevention interventions available to reduce the risks of
poor mental health. Examples include parent training programmes
and interventions for the early identification of mental health
problems in schools, flexible practices and access to counselling
and support in the workplace, and bereavement counselling and
social activities to reduce isolation and the risk of depression
in older age. Despite the growth in this evidence base, mental
health promotion continues to receive little attention in most
countries; recent EC sponsored action however through the Implementing
Mental Health Promotion Action network has had some success in
raising the profile of mental health promotion.
1.6 The EU can also play an important role,
perhaps through the proposed Fundamental Rights Agency, in helping
to address and draw attention to human rights violations, stigma,
discrimination and social exclusion. Few other health problems
are characterised by such disadvantages. Violations of rights
have been reported across Europe, but are most visible in the
psychiatric institutions and social care homes that remain the
mainstay of mental health systems in parts of central and Eastern
Europe. In some countries, individuals admitted to institutional
settings still have a very low probability of ever returning to
live in the community.
2. WHAT ELEMENTS
EU STRATEGY CONTAIN?
2.1 Intelligence gathering might be one
crucial element of the strategy. This would not simply be a question
of regularly collecting comparable data on the level of mental
well-being and poor mental health across Europe (in the same way
that data on physical health is collected), but also collecting
some basic information about services and structures in countries.
Ideally this would not be confined to the health system but would
look at the provision of services and development of national
and regional strategies in other sectors. Currently there is a
lack of information on the pervasiveness of stigma towards mental
disorders. The EU could also play a greater role in collecting
information Europe-wide on public attitudes, as well as looking
at the success of legislation and other strategies to tackle stigma
2.2.1 Enhancing the evidence base. There
are already many national and international organisations looking
at the effectiveness of health care interventions such as anti-psychotics
and anti-depressants. The EU Strategy could concentrate on areas
where the evidence base is more limited and where research funding
is more difficult to obtain. Primarily through the EU's Research
Framework Programme, but also through individual directorates,
more work could be done to enhance our understanding of effective
interventions and strategies for the promotion of mental well-being
and prevention of mental disorders. Another area for research
would be to look at interventions intended improve public attitudes
and reduce stigma towards people with mental health problems.
A first step would be to synthesise the existing evidence base
rather than reinventing the wheel. A second step would be the
commissioning of additional research in areas where it is clear
that knowledge is very limited.
2.2.2 While there is a small but growing evidence
base for non health care interventions, much of this information
has been published in the United States and its applicability
to different European contexts may be questioned. The EU should
not only look at issues of effectiveness but also consider what
resources and infrastructures would need to be in place to deliver
interventions. For instance more work could be done to look at
the cost effectiveness of workplace mental health promotion strategies
in Europe or on the effectiveness of strategies to help people
with more severe mental health problems return to work. The perspectives
of service users are important. Outcomes of importance to service
users, such as self esteem, reduction in social isolation, and
greater sense of empowerment may not necessarily be identified
by professional groups.
2.3 Making the evidence base accessible.
Evidence on what interventions and strategies work, in what context,
and at what cost, needs to be easily accessible. This might perhaps
be through a database placed on the EU's Health Portal, but information
also needs to be available in other formats to promote accessibility
to policy makers, service users and other stakeholders.
2.4 Both the research capacity to produce evidence
on what works, as well the capacity of the policy making community
to interpret different source of evidence, are limited in some
Member States. Training and capacity building initiatives to address
these limitations might also form one element of the strategy.
2.5 An EU strategy might also encourage Member
States to think about the consequences of shifting the responsibility
for supporting people with mental health problems out of the health
sector. The availability of and entitlement to services outside
the health sector can be very variable and subject to means testing.
For instance in some provinces of Austria, individuals and/or
their families have to pay up to one third of the costs of social
care services out of pocket.
2.6. Actions in the workplace are important.
Occupational health and safety actions could more explicitly address
mental health in the workplace. The strategy could also help promote
workplace/employment integration for people with mental health
problems. Helping individuals return to/enter the workforce can
help reduce stigma and discrimination and promote social inclusion.
Employment also helps reduce poverty and thus empower individuals.
2.7 Promoting better coordination between
parts of government and communities. To take child and adolescent
mental health as just one examplethere is a need to coordinate
schools, general medical services, social care, social welfare,
criminal justice, and housing services with those specialist mental
health services. This can promote better identification of and
responses to emotional and behavioural problems in childhood/adolescence.
Similar actions might take place in other sectors, for instance
building on the recent agreement between the European Social Partners
on Stress in the Workplace.
2.8 The EU might also facilitate better recognition
that the psychological challenges faced by older people are not
just to be accepted as inevitable consequences of the ageing process.
They can devastate quality of life and often treatable. Depression
is not well recognised; older age groups can also have relatively
high rates of suicide.
2.9 Promote awareness of and information
campaigns related to mental health. Stigma distinguishes mental
health disorders from most other health problems and is the major
reason for discrimination and social exclusion. Fear of stigmatisation
reduces an individual's willingness to seek help. There are no
easy solutions, but long-term actions such as intervention in
schools to raise awareness of mental health, and constructive
engagement with the media (who can reinforce negative social attitudes
by sensationalist and inaccurate portrayals of mental illness)
appear to be effective if concerted and prolonged.
3. HOW MIGHT
AN EU STRATEGY
3.1 Unlike most other pertinent international
agencies, such as the World Health Organisation or the International
Labour Organisation, the EU has the advantage of having jurisdiction
across many different sectors; this multi-sectoral involvement
is essential to any mental health strategy. It has already taken
actions that promoting good mental health as well as addressing
social exclusion and discrimination through a number of different
Directorates. An EU Strategy could also help to improve co-ordination
of actions and communication within the European Commission.
3.2 There have been some very positive development
in national policies for mental health and well-being in Europe,
as for instance in Scotland, where mental health policy enjoys
a high profile. But there has been little development and/or implementation
of modern mental health policies in some EU Member States, as
well as in Candidate and neighbouring countries. A higher profile
for mental health at an EU level, coupled with monitoring arrangements
on the state of mental health, issues of social exclusion and
discrimination, as well as on service provision, might act as
a catalyst to promote an appropriate level of attention to mental
health in these countries.
3.3 The development of community based services
to help shift the balance of care away from a predominance of
institutional care is expensive. Community services must be in
place before institutions can be phased out. Raised visibility
and a strategy for mental health might encourage Member States
whose resources are more limited to apply for European Structural
Funds for mental health reforms. A good example of this might
be seen in Greece, where international concerns about institutional
care in the 1980s, and subsequent access to EU funds, have acted
as a catalyst for ongoing system reform.
3.4 It is clear that many actions remain the
responsibility of individual Member States. The EU strategy might
however through the open method of co-ordination, facilitate a
process, by which Member States can if they so choose, come together
to work on common goals related to mental health that go beyond
the competence of the EU.
On behalf of all four editors of the bookDated:
5 June 2006.
David McDaid, Research Fellow, PSSRU, LSE Health
& Social Care & European Observatory on Health Systems
& Policies, London School of Economics & Political Science.
Professor Martin Knapp, PSSRU, & Co-Director,
LSE Health & Social Care, London School of Economics &
Political Science & Centre for the Economics of Mental Health,
Institute of Psychiatry, King's College, London.
Professor Graham Thornicroft, Head of Health
Services Research Department, Institute of Psychiatry, King's
Professor Elias Mossialos, Co-Director, LSE
Health and Social Care and & European Observatory on Health
Systems & Policies, London School of Economics & Political