Memorandum by Mind
Mind's vision is of a society that promotes
and protects good mental health for all, and that treats people
with experience of mental distress fairly, positively, and with
respect.
The needs and experiences of people with mental
distress drive our work and we make sure their voice is heard
by those who influence change.
Our independence gives us the freedom to stand
up and speak out on the real issues that affect daily lives.
We provide information and support, campaign
to improve policy and attitudes and, in partnership with independent
local Mind associations, develop local services.
We do all this to make it possible for people
who experience mental distress to live full lives, and play their
full part in society.
Being informed, diversity, partnership, integrity
and determination are the values underpinning Mind's work.
23 NOVEMBER 2006
1. INTRODUCTION
1.1 Mind welcomes the European Commission's
Green Paper on mental health and the intention to develop a strategy
on mental health for the European Union.
1.2 We also welcome the opportunity to submit
evidence to the House of Lords Committee on the European Union
for its inquiry into the Green Paper.
1.3 This submission is based on our response
to the Green Paper and follows the questions posed in it.
1.4 We would be happy to supply further evidence
if required.
2. HOW RELEVANT
IS THE
MENTAL HEALTH
OF THE
POPULATION FOR
THE EU'S
STRATEGIC POLICY
OBJECTIVES?
2.1 Mind believes that safeguarding and promoting
good mental health is essential to achieving the EU's strategic
policy objectives. Protecting and promoting the mental health
of the European population must be a central component of the
EU's strategy to put Europe back on the path to long-term prosperity.
Economic costs
2.2 As the Green Paper states, mental ill health
costs the EU an estimated 3 per cent to 4 per cent of GDP. In
the UK, the Sainsbury Centre for Mental Health calculates that
the total economic and social costs of mental illness in England
alone in 2002-03 were £77 billion. This is broken down into
£12.5 billion in health and social care costs, £23 billion
in output losses and £41.8 billion in human costs, which
were calculated by putting a monetary value on the suffering,
pain, disability and distress associated with mental ill health
(Sainsbury Centre 2003).
2.3 This means that only 15 per cent of this
total expenditure of £77 billion was actually invested in
mental health and related services, while 85 per cent was accounted
for by lost productivity and human suffering. This is despite
the fact that the UK invests a higher proportion of its total
health budget in mental health services than any other EU country
with the exception of Luxembourg (Annex 6 of the Green Paper).
2.4 To our knowledge the human costs of mental
ill health have never been calculated in the way used by the Sainsbury
Centre at European level—if they were the figure would run
to many hundreds of billion Euro. Such a calculation could be
useful in informing the EU's mental health strategy.
2.5 We know that properly resourced mental health
and social support services can significantly reduce the overall
costs of mental ill health—to individuals, families and
society as a whole. Greater investment in service provision and
the promotion of mental well-being across the EU could significantly
reduce the economic cost, with a substantial positive impact on
the economic performance of European countries. But, to achieve
this, the development of mental health policy must be sensitive
to the needs of people with mental health problems, informed by
their voices, evidence based and well-resourced.
Mainstreaming mental well-being
2.6 The EU could play a major role in promoting
mental well-being as a mainstream public health concern across
Europe—helping to transform the way that EU countries think
about the issue of mental health. The press release that accompanies
the European Commission's Green Paper rightly highlights the fact
that one in four adults in Europe suffer from mental health problems
each year. Annex 2 reprints the findings of a 2005 study by Wittchen
and Jacobi that concluded that 27.4 per cent of the general EU
population aged 18 to 65 had been affected directly by mental
disorders in the previous 12 months—nearly 83 million people.
2.7 Depression and anxiety are not marginal
to the lives of European citizens. They are part of the day-to-day
reality of their lives. The economic costs are substantial. Nearly
10 per cent of GNP in the UK is lost each year due to job-related
stress. The Confederation of British Industry (CBI) estimates
that 30 times as many working days are lost due to mental ill-health
as from industrial disputes. Half of all days lost through mental
ill health are due to anxiety and stress conditions (cited in
Gray P 2000, see Mind 2005).
Stigma and exclusion
2.8 One of the main barriers to the participation
of people with experience of mental health problems in the work
place is the stigma that is still associated with mental illness—especially
the most serious disorders—and the lack of flexibility among
employers.
2.9 In the UK, the Social Exclusion Unit (SEU)'s
report Mental Health and Social Exclusion concluded that "fewer
than four in 10 employers would consider employing someone with
a history of mental health problems, compared to more than six
in 10 for physical disability". It added that "three
quarters of employers believe that it would be difficult or impossible
to employ someone with schizophrenia, even though schizophrenia
can be controlled with medication and would not require physical
adaptations to the work environment (SEU 2004).
2.10 More recently, the Chartered Institute
of Personnel and Development (CIPD) found that more than 60 per
cent of 755 employers surveyed disregarded applications from people
with drug or alcohol problems, criminal records, a history of
mental health problems or incapacity. Fifty five per cent of respondents
said nothing would persuade them to recruit from these "core
jobless" groups (CIPD 2005).
2.11 It is likely that attitudes to mental health
are more progressive in the UK than in some other EU countries,
where experience of stigma and exclusion may be greater still.
Benefits
2.12 Some people are not able to contribute
to economic prosperity because of ill health. They are entitled
to a fair share of prosperity through welfare benefits. Condemning
people to poverty simply because they are too ill to work is contrary
to the basic principles of justice and community of the EU. Interventions
for the unemployed to enter the labour market are cost effective,
as the Green Paper states. But care must be taken to ensure that
people with mental health problems are not coerced into work and
that adequate and appropriate support is available to those for
whom work is not a realistic option. It is also important to make
work more flexible, and increase opportunities for people on welfare
benefits to supplement their income by working part time.
2.13 The World Health Organisation identifies
the main protective factors for mental health as empowerment,
ethnic minority integration, positive personal interactions, social
participation, social responsibility and tolerance, social services
and social support and community networks (Annex 7 of the Green
Paper). Where people are not able to participate in paid work
they can potentially get many of these benefits from involvement
in voluntary work—as well as from drop-in and social centres,
art and music therapy groups, opportunities to participate in
outdoor activities and so on. These kinds of projects make a vital
contribution to the well-being and social inclusion of people
with mental health problems, and it is important that they are
properly funded as part of a comprehensive European mental health
strategy.
Marginalisation
2.14 The Social Exclusion Unit report on mental
health begins by stating that "adults with mental health
problems are one of the most excluded groups in society"
(SEU 2004). A strategy that seeks to address deprivation and marginalisation
among people with experience of mental illness is essential to
underpin the EU's wider commitment to solidarity, community and
social justice. In order to do so effectively it must also address
issues of race, gender, disability, age and sexual orientation.
2.15 People in prison should be added to the
Green Paper's list of marginalised groups to be targeted. In the
UK, the SEU has estimated that 72 per cent of male prisoners and
70 per cent of female prisoners suffer from two or more mental
disorders, respectively 14 and 35 times the level in the general
population (SEU 2002). A more recent report from the Prison Reform
Trust found that up to three quarters of men in prison suffered
from two or more mental disorders; about one in 10 had a functional
psychosis; and an estimated 3,000 to 3,700 prisoners at any time
have problems sufficiently serious as to require urgent transfer
to secure NHS facilities (Rickford and Edgar 2005).
Quality of life
2.16 Good mental health is an essential component
of a good quality of life. Conversely, a good quality of life
protects and enhances mental well-being. Impact on mental health
must be a central consideration for all initiatives intended to
bring tangible practical benefits to the quality of life of European
citizens—as, indeed, it should be in initiatives right across
the EU's policy portfolio.
2.17 The development of an EU strategy on mental
health would help to ensure that impact on mental well-being is
a central consideration in the development and implementation
of all EU policies. A good example is the potential link with
the European Commission's environmental action plan and agricultural
policies. There is growing empirical evidence that exposure to
nature has substantial mental health benefits. Promoting activities
such as walking, fishing and conservation work as part of a mental
well-being strategy could also contribute to the regeneration
of rural economies across the EU.
2.18 In 2004, green "care farms" were
developing across Europe, with 500 farms in Norway, 430 in the
Netherlands, 300 in Italy, 300 in Germany, 250 in Austria, 140
in Belgium and 15 in Slovenia (Pretty J). This is a good example
of an area where it would be useful to monitor the development
of different approaches to mental health policy across Europe
and for the EU to play a role in supporting promising initiatives,
evaluating them and disseminating good practice.
2.19 Other areas of policy with clear links
to a mental well-being agenda would include sport and exercise,
nutrition and health and safety at work.
3. WOULD THE
DEVELOPMENT OF
A COMPREHENSIVE
EU STRATEGY ON
MENTAL HEALTH
ADD VALUE
TO EXISTING
AND ENVISAGED
ACTIONS AND
DOES SECTION
PROPOSE ADEQUATE
PRIORITIES?
Whole more than parts
3.1 Historically, EU initiatives on mental health
have been restricted to specific initiatives in separate policy
areas. Although these initiatives are all welcome, they may not
complement and underpin each other as effectively as they might
if they were part of a coherent, strategic whole. For example,
investment in initiatives to reduce the stigma of mental illness
are unlikely to succeed if governments pursue policies, or indulge
in rhetoric, that portrays people in mental distress as a threat
to public safety, as is happening at present in England and Wales,
as exemplified by the debate over how the 1983 Mental Health Act
should be reformed.
3.2 If an EU mental health strategy results
in a more coherent approach, and increases the prominence given
to considerations of mental well-being across the policy spectrum—this
will add value to existing and envisaged initiatives.
A social model
3.3 Mind endorses the priorities set out in
section 5. The EU strategy must ensure that due regard is given
to the enormous diversity of the EU population. A recent report
by the National Institute for Mental Health for England (NIMHE)
on race equality and mental health in England concludes that black
and minority ethnic people are more likely to experience a whole
range of problems with mental health services, including problems
with accessing services; lower satisfaction with services; higher
rates of transfer to medium and high secure facilities; higher
voluntary admission rates to hospital; lower satisfaction with
hospital care; longer stays in hospital; higher rates of readmission;
more coercive treatments and lower access to talking treatments
(NIMHE 2003). Refugees and asylum seekers are exceptionally vulnerable
to developing mental health problems, both as a result of their
past experience and, too often, of their present experiences of
abuse, exclusion and marginalisation.
3.4 The consideration of action to prevent mental
ill health must be based on a thorough understanding and comprehensive
knowledge of the many different factors that can contribute to
mental ill health, as identified by the World Health Organisation
in Annex 7 of the Green Paper: exposure to drugs and alcohol,
displacement, isolation and alienation, lack of education, transport
and housing, neighbourhood disorganisation, peer rejection, poor
social circumstances, poor nutrition, poverty, racial injustice
and discrimination, social disadvantage, urbanisation, violence
and delinquency, war, work stress and unemployment.
3.5 Medical models of mental health are still
dominant in many of the EU countries. They obscure the social
causes and contexts of mental distress. For example, medication—while
it can be effective in controlling symptoms—is clearly not
an answer to lack of housing, racial injustice or excessive work
stress. But it is obvious that these factors have a profound psychological
effect.
3.6 Given this "mental well-being"
is perhaps a more useful term to use than "mental (ill) health".
The concept of well-being is something that all European citizens
can readily relate to their own lives and experiences. It is naturally
associated with a whole range of life factors and events, not
with a narrow set of clinical and forensic interventions.
Rights and welfare
3.7 The third proposed priority could usefully
be broken into two priorities: (i) bringing about social inclusion
and (ii) protecting people's rights and dignity. Although very
closely linked—and both essential to improving quality of
life—they are not necessarily synonymous.
3.8 People with mental health problems should
have rights to ensure they are not unnecessarily or inappropriately
submitted to compulsory treatment. More generally, the World Health
Organisation has stated that "all people with mental disorders
have a right to receive high quality treatment and care delivered
through responsive health care services. They should be protected
against any form of inhuman treatment or discrimination"
(WHO 2003).
3.9 It is essential that these rights are protected
and promoted by the EU, but they will not necessarily have a direct
impact on social exclusion. Conversely, effective policies to
combat exclusion will require more than simply the protection
of basic rights. For example, the stigma associated with mental
health problems can act as a barrier to employment, even if a
formal "right to work" is recognised.
4. ARE THE
INITIATIVES PROPOSED
IN SECTIONS
6 AND 7 APPROPRIATE
TO SUPPORT
THE COORDINATION
BETWEEN THE
MEMBER STATES,
TO PROMOTE
THE INTEGRATION
OF MENTAL
HEALTH INTO
HEALTH AND
NON-HEALTH
POLICIES AND
STAKEHOLDER ACTION,
AND TO
BETTER LIAISE
RESEARCH AND
POLICY ON
MENTAL HEALTH
ASPECTS?
4.1 Mind believes the initiatives are appropriate.
Participation and empowerment
4.2 A proposal by the Commission for a Council
Recommendation on the promotion of mental health would be welcome,
but would need to include, as well as all the areas covered in
the Green Paper, a substantial input from those who have experienced
mental distress. In identifying best practice for promoting the
social inclusion of people with mental health problems, the EU
strategy should put in place specific, easily accessible channels
whereby people with experience of mental distress can contribute
to the development and implementation of a mental health strategy.
The voluntary and community sector should be included as much
as possible, and organisations in different member states should
be encouraged to share their experience and expertise.
4.3 This would build on and develop the work
currently being undertaken by Mental Health Europe (MHE), with
support from the EU. The membership of MHE is drawn from right
across Europe, and brings together individuals and organisations
with different kinds of mental health interests, experiences,
expertise and responsibilities, who form an equal partnership.
The membership includes user organisations, volunteers and professional
organisations working at the regional, national and European level.
MHE's core belief is that "the burden caused by mental illness
for individuals, families and society is too heavy, and that the
stigma and taboos are too great, to leave mental health development
only to politicians and professionals".
Depression and suicidal behaviour
4.4 A proposal by the European Commission for
a Council Recommendation on the reduction of depression and suicidal
behaviour should include as wide a range of factors as possible,
including access to (and funding for) support networks, early
intervention (including work place interventions supported by
employers), employment policies, alternatives to drug treatments—such
as talking treatments (not only cognitive behavioural therapy)—exercise,
diet and environment.
4.5 There is a need to investigate further the
links between some drug treatments and suicidal behaviour.
4.6 The EU is also uniquely placed to conduct
research to explain why suicide rates vary so much across the
EU countries. Why, for example, is the death rate from suicide
per 100,000 people more that seven times higher in Lithuania than
the UK? (Annex 3 of the Green Paper.) Is it related to the fact
that the proportion of the Lithuanian health budget spent on mental
health is only about half that of the UK? (Annex 6 of the Green
Paper.) Or are there wider environmental or societal causes? Addressing
these sorts of questions can improve our understanding of mental
distress, its causes and remedies, and contribute to the development
of an evidence-based approach in Europe.
Rights and institutionalisation
4.7 Regarding the protection of the rights of
people with mental health and disability, Mind welcomes the move
away from institutionalisation. Mind agrees that compulsory treatment
must only ever be a last resort.
4.8 The World Health Organisation has stated
that "where there is a potential for voluntary admission,
this [ie compulsory treatment] should only be used in very specific
circumstances and in accordance with the law. Public misconceptions
about the dangerousness of people with mental disorders lead to
an undue emphasis on protecting society" (WHO 2003).
4.9 The WHO concludes that involuntary admission
should be permissible only if two criteria are both met:
1. there is evidence of a mental disorder
of sufficient severity as defined by internationally accepted
standards; and
2. there is a likelihood of self-harm or
harm to others and/or a deterioration in the patient's condition
if treatment is not given.
The promotion of these safeguards across all
EU member states would be a positive step forward. Mind would
like to see more stringent criteria. There should, for example,
be a requirement that proposed treatment has a therapeutic benefit
and there needs to be an appropriate threshold for risk of harm
or self-harm. (For further discussion of these issues, see Mind's
comments on the draft Mental Health Bill on our website at http://www.mind.org.uk/.
Fundamental rights
4.10 We welcome the proposal in the Green Paper
to include people with mental ill health or disability and the
situation in psychiatric institutions in the activities of the
Fundamental Rights Agency of the EU, which becomes operational
on 1 January 2007. The role of this new agency is to be an independent
centre of expertise on fundamental rights issues, and to undertake
analysis and data collection. It will also provide input on how
to prepare and implement legislation in the area of fundamental
rights. The inclusion of mental ill health and psychiatric institutions
within its remit is, therefore, not optional, but essential.
Research and dissemination
4.11 The development of a mental health information,
research and knowledge system for the EU is essential to the success
of the EU mental health strategy. The strategy should also ensure
that mental health practice is monitored and evaluated, and best
practice is shared between member states, as the Green Paper indicates
will be the case.
4.12 By supporting research and introducing
safeguards, the EU can also help to prevent policy being dominated
by special interests—such as pharmaceutical companies—whose
economic power can mean that they have undue influence over research
agendas and information flow.
4.13 A number of EU institutions could potentially
play a role in data analysis and policy development. These include
the Fundamental Rights Agency (see above), the European Foundation
for Improvement of Living and Working Conditions, European Agency
for the Evaluation of Medicinal Products, European Monitoring
Centre for Drugs and Drug Addiction and the European Parliament's
Disability Intergroup and Intergroup on Ageing.
4.14 In October 2005, the final report to the
European Commission from the Implementing Mental Health Promotion
Action (IMHPA) project concluded that "most programs implemented
across Member States are not considered to have sufficient evidence
base to be good practice. Countries are in need of information
on effective practices and guidelines for effective policy and
program development and implementation" (IMPHA 2005).
4.15 In developing an interface between policy
and research, the Commission might consider creating an agency
similar to the European Monitoring Centre for Drugs and Drug Addiction
(EMCDDA) with a mental health remit. The EMCDDA has made a significant
contribution to evidence based drug policy and contributed to
the development of more effective drug services across the EU.
It is recognised as a central source of comprehensive and reliable
information on drugs and drug addiction.
4.16 A dialogue with member states on mental
health, and the launch of an EU platform, would help to ensure
that best practice is not only identified, but also shared. Policy,
practice, investment in and attitudes to mental health vary widely
within the EU. It is questionable whether the approach to mental
health in all member states is compliant with the European Convention
of Human Rights, particularly since the expansion of the EU.
5. CONCLUSION
5.1 The WHO Mental Health Action Plan for Europe
(Facing the Challenges, Building Solutions) was agreed in Helsinki
in January 2005, and endorsed by the UK government.
5.2 It identifies five key priorities for the
coming decade:
1. To foster awareness of the importance
of mental health.
2. To collectively tackle stigma, discrimination
and inequality, and empower and support people with mental health
problems and their families to be actively engaged in the process.
3. To design and implement, comprehensive,
integrated and efficient mental health systems that cover promotion,
prevention, treatment and rehabilitation, care and recovery.
4. To address the need for a competent work
force, effective in all these areas.
5. To recognise the experience and knowledge
of service users and carers as an important basis for planning
and developing services.
An EU strategy that took forward these priorities
and promoted them across Europe would be a major step forward.
But it is important that good intentions translate into progressive
policy, evidence based practice and effective implementation.
For example, it is important that service users are engaged in
a systematic, and not a tokenistic, way—and that the EU
strategy fully engages with the social, cultural and experiential
diversity among people who experience mental distress.
5.3 The pursuit of mental well-being cannot
be isolated from wider EU policy to tackle risk factors such as
drug and alcohol misuse, poverty, exclusion, work stress, displacement
and experience of racial injustice and discrimination. Nor will
the strategy deliver on its promises unless mental health and
social support services are properly resourced. As argued above,
this makes economic sense too.
5.4 Finally, and to repeat, Mind would urge
as full a role as possible for mental health service users and
non-governmental organisations in the process of developing an
EU strategy.
Mind's report on stress in the workplace is
available on our website at http://www.mind.org.uk/Mindweek/report.htm
Mind's current campaign highlighting the neglected
problem of mental distress in later life is at http://www.mind.org.uk/News+policy+and+campaigns/Campaigns/ages/
REFERENCES
CIPD (2005) at www.cipd.co.uk/news/—articles/employersexcludecorejobless.htm.
Gray P (2000), Mental Health in the Work Place,
Mental Health Foundation, London.
IMHPA (2005), Final report to the European Commission,
DG SANCO/G (at http://ec.europa.eu/comm/health/ph—projects/2002/promotion/fp—promotion—2002—annexe1—16—en.pdf).
Mind (2005), Stress and mental health problems
in the workplace, Mind, London.
NIMHE (2003), Delivering race equality: A framework
for Action, Department of Health, London.
Pretty J (2006), From Green Exercise to Green
Care:A New Opportunity for Agriculture in the UK?, University
of Essex, Unpublished.
Dora Rickford & Kimmett Edgar (2005), Troubled
Inside: Responding to the Mental Health Needs of Men in Prison,
PRT, London.
SEU (2002), Reducing Re-offending by ex-prisoners,
ODPM publications, London.
SEU (2004), Mental health and social exclusion,
ODPM Publications, London.
World Health Organisation (2003), Mental health
legislation and human rights, Mental Health Policy and Service
Guidance Package, WHO.
World Health Organisation (2005), Mental Health
Action Plan for Europe—Facing the challenges, building solutions,
EUR/04/5047810/7, 14 January 2005.
WEBSITES
Mind's website is at http://www.mind.org.uk/.
The Sainsbury Centre for Mental Health website
is at http://www.scmh.org.uk/.
The Mental Health Europe website is at http://www.mhe-sme.org/.
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