Select Committee on European Union Minutes of Evidence

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, November 2006.


  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.


  2.1 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 and discrimination.

  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 example—there 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.


  3.1 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 book—Dated: 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 College, London.

  Professor Elias Mossialos, Co-Director, LSE Health and Social Care and & European Observatory on Health Systems & Policies, London School of Economics & Political Science.

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