Select Committee on European Union Fourteenth Report

CHAPTER 2: Defining mental well-being and mental health problems

The concept of mental well-being

19.  As the World Health Organization emphasises, mental health is not merely the absence of disease or infirmity, but rather a condition of complete mental well-being. In turn, the concept of mental well-being is seen by the WHO to be a state in which individuals recognise their abilities, are able to cope with normal stresses of life, work productively and fruitfully, and make a contribution to their communities. Mental health is about enhancing competencies of individuals and communities and enabling them to achieve their self-determined goals.

20.  This approach to the definition of mental health has widespread support, although preferences as regards terminology vary. For example, the Samaritans organisation suggested that mental health is increasingly becoming synonymous with well-being. The Samaritans now refer to "emotional health" since this is seen as a less threatening and less medical term (pp 164-167). In similar vein, Mind argued that "mental well-being" was preferable to "mental (ill) health" on the grounds that the concept of well-being was something that all European citizens could readily relate to their own lives and experiences. It was naturally associated with a whole range of life factors and events, not with a narrow set of clinical and forensic interventions (pp 54-60). The Scottish Association for Mental Health (SAMH) recommended use of the term "mental health problems" rather than "mental illness" or "disorder", because this was a less stigmatising form of words (pp 167-170).

21.  Of course, the spectrum of mental health problems is wide. Dr Matt Muijen (Regional Adviser for Mental Health at the European Region of the World Health Organisation) warned against clustering all mental health problems together when they need very different interventions and have different outcomes (Q 205). Some severe mental health problems—such as schizophrenia, bipolar disorder, severe depression, obsessive compulsive disorder, severe dementia or some forms of personality disorder—were likely to manifest themselves in ways that would suggest to a member of the general public that something is wrong. These more severe mental health problems were also likely to be recognised by health care professionals, although not always very early in the course of the illness. Towards the other end of the spectrum were milder conditions, which may not so easily be recognised as problematic or indeed as treatable disorders. For example, mild or moderate depression or anxiety might simply be dismissed by the sufferer or by a relative as part of the normal stresses of everyday life, despite the debilitation that usually results and the often marked effects on quality of life. Similarly, the early stages of cognitive decline that might be diagnosed as a form of dementia, or the sadness exhibited by many older people might be viewed as just part of the normal processes of ageing. As Age Concern England pointed out, treatable mental health problems experienced by many older people tended to be missed by care systems in the UK (pp 108-110).

22.  The Commission Green Paper follows a broad definition of mental health problems, including: mental health problems and strain, impaired functioning associated with distress, symptoms, and diagnosable mental disorders, such as schizophrenia and depression.

23.  The Committee accepted the evidence of a number of expert witnesses, including that of Professor Thornicroft (Consultant psychiatrist at the South London and Maudsley NHS Trust) that an international consensus existed on the forms of suffering that should be included within the broad remit of mental health problems, in line with the Green Paper approach. When these criteria were applied to national populations across the world, there was a consistent finding that around 25 to 30 per cent of people, in any one year, suffered mental health problems which were serious enough to affect work, social relations or everyday functioning (Q 48).

24.  Mr McDaid (Mental health policy analyst at the London School of Economics) commented that the Green Paper deliberately takes a broad definition of mental health problems in order to emphasise the importance of mental wellbeing (Q 48). Of relevance to Mr McDaid's point is the evidence from the National Health Service (NHS) and Regional Public Health Group London, which suggested that the Commission should be asked to consider whether the aims of mental health strategy might be better served by using the term "emotional well-being" in place of "mental health". The argument put forward was that the use of this terminology could help to overcome the entrenched and institutional stigma attached to the subject of mental health and mental illness (pp 145-147).

The extent of mental health problems

25.  Following the broader definition of mental health problems, Annex 2 of the Green Paper includes a table in which recently generated estimates[11] are given of the numbers of people in the EU who are affected by different types of mental health problem over a one-year period. In total, summing over all disorders, the estimates shown in the table indicate that 27.4% of the EU population aged 18 to 65 suffer from one type or another of mental health problem during each one-year period.

26.  Professor Stefan Priebe (Head of the Unit for Social and Community Psychiatry at Newham Centre for Mental Health) took a rather different line. His view was that the wide definition of mental health problems used in the Commission Green Paper reflects a dilemma in psychiatry. He recognised the academic basis of the figures of 25 to 27 per cent quoted by the Commission to represent the proportion of national populations which, in any one year, suffer mental problems. However, he questioned whether a concept of "mental ill health" which applied to such a high percentage of people could really make sense.

27.  Professor Priebe's argument was that if, as stated in the Green Paper, "there is agreement that a first priority is to provide effective and high-quality mental health care and treatment services accessible to those with mental ill health", it would be entirely impractical to supply mental health services for a segment of the population as large as 25 to 27 per cent. Professor Priebe concluded that either the concept of mental ill health or that of its effective treatment may need revising; and that any useful debate on the future of mental ill health could not avoid this dilemma. (pp 159-161).

28.  Notwithstanding the passage quoted from the Green Paper by Professor Priebe, Mr Scheftlein from the European Commission told us that he did not think that every mental health problem needed medical intervention (Q 13). He explained that the Green Paper set out a public health approach to mental health and did not present it as a medical issue alone (Q 11). A similar point was made to us by Ms Camilla Parker (a legal and policy consultant working on the field of mental health disability and human rights). She expressed the view that, for the purposes of promoting mental health issues, some very broad, and inclusive, concepts of mental health were valuable. She added that, in contrast, for the discussion of people with severe conditions perceived to be dangerous, some very clear criteria were needed of mental illness, alongside other criteria, in order to ensure that only in limited circumstances did people become subject to compulsory detention or treatment (Q 179).

29.  There will obviously continue to be debate about where to draw boundaries between "illness" and "distress" (or "stress"). There are standard diagnostic classificatory systems in use across the world that aim to structure, regularise and institutionalise definitions. But, as noted by the Commission and others, there are advantages in not getting too mired in medical models of mental health[12] (QQ 48, 124).

30.  Wherever the boundaries are eventually drawn, a number of observations come through clearly from the arguments in the Green Paper and also from much of our evidence. These would appear to apply to all EU Member States:

(a)  The prevalence of mental illness is higher than most members of the general public appreciate.

(b)  Many people with a diagnosable mental health problem do not refer themselves or get referred to the health system for treatment.

(c)  Some people who are receiving mental health treatment no longer need it, probably because they have recovered.

(d)  Health professionals still have a low rate of recognition of many mental health problems.

(e)  Health systems do not provide sufficient or good enough treatment for most mental health problems.

31.  In each of these five respects, the situation has undoubtedly improved in most EU Member States over the past decade or longer. There is, for example, better appreciation of the large number of people who suffer mental health problems. There is, in some countries at least, a greater willingness on the part of people with more common mental health problems (such as mild depression or anxiety) to approach a health professional for treatment. But, as our evidence makes plain (see later chapters), despite improvements in recent years, across the EU there is a pervasive tendency to under-recognise, under-resource and under-treat.

32.  In later chapters the distinction will be made between different mental health problems. For instance, there are particular human rights issues concerning people with severe mental health problems who face compulsory treatment or who spend long periods of their lives in asylums; these same issues generally do not arise for people with mild depression or anxiety. The stigmatising of mental health problems and the people who suffer from them is also differently experienced by people at the different ends of the "severity spectrum" (see chapter 6).

33.  We welcome the recognition by the Commission of the considerable extent of mental health problems; and we recommend that action is taken to ensure that people with diagnosable and treatable problems get access to appropriate, evidence-based care.

Learning or intellectual disability

34.  Another definitional issue raised by our witnesses concerned learning disability. This condition or need is sometimes called learning difficulty or intellectual disability, and—in the US—mental retardation. Getting the term right is important, partly to avoid confusion with more general "learning difficulties" within mainstream education systems, and partly because people with this characteristic express preferences about the terminology.

35.  MENCAP (a leading UK charity that works with adults and children who have a learning disability), pointed out that a learning disability was not the same as "mental ill health". MENCAP explained that a learning disability was lifelong and untreatable, and affected the way people learned, understood, communicated and interacted with others. They said that people with learning disabilities faced different challenges, and had different needs, from people with mental health problems. Against this background, MENCAP criticised the use the terminology "mentally ill or disabled people" in the Green Paper, without any reference to the factors which distinguished the two conditions. MENCAP's recommendation was that any future Commission document in this field should either confine itself to discussion of mental health problems and drop reference to disability; or make it explicit that the scope of concern did include disability, in which case it should make clear the different issues that arose for these groups of people (pp 132-133).

36.  There are, of course, people with learning disabilities who also have mental health problems. Indeed, the mental health needs of many people with learning disabilities—which are difficult to assess—are often missed by services, and appropriate treatment is not provided.[13] The Mental Disability Advocacy Center, in their evidence to the Inquiry (pp 134-140), noted that people with intellectual disabilities and mental health problems had been particularly neglected and excluded.

37.  The Open Society Mental Health Initiative (MHI) also commented on the lack of clarity in the Green Paper about the distinction between the categories of people with mental health problems and those with intellectual disabilities (a term they prefer to use rather than learning disabilities). MHI's view was that the people with intellectual/learning disabilities should be covered by an EU strategy and that this group and the issues they face should be identified much more clearly in future documents. There were undoubted similarities between the experiences of people with learning disabilities and people with mental health problems, not least their marginalisation within society and the fact that in many Member States of the EU large numbers of people continued to languish for most of their lives in forgotten institutions. However, there were also many other ways in which the two groups had very different experiences and needs, and it did not help to confuse the policy and practice issues (pp 155-159).

38.  Dr Matt Muijen explained to us that, in the Green Paper, the word "disability" was mentioned but that this was intended to refer to disability in the workplace. He added that learning disability was not included in the 2005 WHO Helsinki Declaration, and that his understanding was that the strategy for mental health set out in the Commission Green Paper was not intended to include learning disability (QQ 215-218). He nevertheless recognised what he called WHO's "embarrassing" lack of activity in the learning disability field. Ms Rosie Winterton MP, Minister of State for Health Services, explained that the Government's view was that the needs of people with learning disabilities were ultimately different from the needs of people with mental health problems, and the Government did not think that service users would necessarily appreciate being bracketed together in a single strategy (p 107).

39.  We consider that it is wrong to group together learning disability and mental health problems for the purposes of the programme of action for mental health envisaged in the Green Paper. The two conditions are clearly separate and, indeed, a person with a learning disability, just as any other person, may or may not suffer from a mental health problem. We recommend, however, that the Commission give serious consideration to launching an action programme to address concerns about people with learning disabilities in Europe, how they are supported and the lives they are able to lead.

11   Hans-Ulrich Wittchen and Frank Jacobi (2005): "Size and burden of mental disorders in Europe: a critical review and appraisal of 27 studies". European Neuropsychopharmacology, vol. 5, no. 4, pp 357-376. Back

12   op. cit. p. 5 Back

13   Eric Emerson et al. (2001) Learning Disabilities: The Fundamental Facts, Foundation for People with Learning Disabilities, London Back

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