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
