House of Lords - European Union

Select Committee on European Union Fourteenth Report

CHAPTER 3: The social and economic impact of mental health problems

40. Mental health problems have wide social and economic consequences. A World Health Organization Fact Sheet[14] identifies some of the social and economic costs of mental ill health. These impacts can be grouped under five heads, moving out from the individual with the mental health problem, to their family, the health and social care system, and then the wider society and economy:

(a) lost production from premature deaths caused by suicide (generally equivalent to, and in some countries greater, than deaths from road traffic accidents);

(b) lost production from people with mental illness who are unable to work, in the short, medium or long term;

(d) reduced productivity from people being ill while at work;

(e) cost of accidents by people who are psychologically disturbed, especially dangerous in people like train drivers, airline pilots, factory workers;

(f) supporting dependents of the mentally ill person;

(g) direct and indirect financial costs for families caring for the mentally-ill person;

(h) unemployment, alienation, and crime in young people whose childhood problems, e.g., depression, behaviour disorder, were not sufficiently well addressed for them to benefit fully from the education available;

(i) poor cognitive development in the children of mentally ill parents; and the

(j) emotional burden and diminished quality of life for family members.

Impacts on individuals

41. Mental health problems have distressing symptoms, as the clinical labels used to describe some of them so graphically convey—deep troughs of depression, periods of unremitting anxiety, mania, panic, traumatic stress, obsessional behaviour, cognitive decline. There are treatments for many of these symptoms, but some of the widely used medications can have unpleasant side effects. The voluntary organisation Rethink (one of the leading mental health charities in the UK) described how people with severe mental health problems want more investment in drug research aimed at finding ways to reduce the side effects of medication (pp 60-63).

42. As many witnesses pointed out, mental health problems can clearly have enormous undesirable consequences for quality of life. The NHS Confederation (pp 144-145) noted how the quality of life effects were felt in individuals' personal relationships and social networks, as well as damaging their employment prospects and career progression. Some of those consequences stemmed directly from the symptoms of illness and their effects on individuals' abilities to enjoy life, to express themselves, to function normally and to interact with others. But other quality of life consequences stemmed from the ways that other people reacted to a mental health problem, with stigma and discrimination being especially widespread and damaging (see chapter 5). Social exclusion was a common experience. Rethink argued that better access to education, housing, transport, employment, leisure facilities and social networks could also improve the quality of life of someone with mental health problems (pp 60-63).

43. It was also the case, as the Minister pointed out, that poor quality of life could itself be a cause of mental health problems (Q 228). Policies intended to improve poor housing, employment rates and urban renewal could therefore all contribute to the promotion of better mental health (see chapter 7 of this report).

44. Mental health problems such as depression, eating disorders and schizophrenia are associated with much higher then normal mortality rates. Suicide is one of the leading causes of premature death in Europe, often among young people. There are marked variations in suicide rates across the EU, with especially high rates in Lithuania, Slovenia, Hungary, Estonia, Latvia and Finland.[15] Many factors have been argued to play a part in explaining differences between countries, including genes, lifestyle, alcohol consumption, weather and health care. Cultural factors and a reluctance to record deaths as suicides undoubtedly also explain some of the inter-country variation, and suggest that the figures quoted in the Green Paper and in other official documents are probably underestimates because of under-reporting. In the UK as a whole, suicide rates have been falling in recent years, but this general trend masks some significant increases in Scotland and Northern Ireland.

45. In addition, as the Samaritans organisation commented, many people with mental health problems committed acts of deliberate self-harm (pp 164-167). They expressed disappointment that the Green Paper did not mention self-harm, and emphasised that policies needed to recognise the prevalence of such behaviour, while mental health interventions needed to be based on an understanding of self-harm.

46. Suicide is not the only cause of premature mortality. As Rethink pointed out (pp 60-63), mental health was fundamentally linked to physical health, so that regular health checks would help to tackle many of the physical ailments that affected people with mental health problems, often the result of their medication. Ensuring that primary care workers were better trained and were given the adequate resources would help them to address the physical needs of those with mental health problems.

47. Another area of concern is employment. Work provides an opportunity not only for someone to earn wages, and thereby achieve greater financial security, but also confers social status and identity, a sense of achievement and a means of structuring one's time. Mental health problems may develop if work is stressful, perhaps because of the nature or organisation of the job, unsupportive line-management, long or unsocial hours, lack of control or flexibility, or when pay and other rewards are not commensurate with effort expended. One study has suggested that, across the EU, work-related stress is now thought to affect one third of the workforce.[16]

48. There is also evidence from across Europe of increasing absenteeism and early retirement due to mental health problems, and also evidence of reduced performance when people are actually at work, because of their mental state (pp 60-63). Data collected by the Mental Health Economics European Network, funded by the European Commission, for example, showed that 31.9 million lost working days in France in 2000 were attributed to depression, and that mental health problems accounted for a quarter of all cases of long-term sick leave in Sweden. Between 1995 and 2002 there was a 74% increase in the number of people registered as long-term sick due to mental health problems in Germany.[17]

49. Several witnesses also pointed out that the link between mental health problems and employment problems can additionally flow in the other direction. People with mental health problems find it difficult to secure paid employment and to retain it. They are often overlooked for promotion and general career advancement. Rethink quoted statistics from the Department of Work and Pensions that people with long-term mental health problems were less likely to be in employment than people with other disabilities (21% compared to 49%) (pp 60-63). An obvious and immediate consequence was dependence on benefits and/or poverty. As Mind pointed out, it was contrary to the basic principles of justice and community of the EU to condemn people to poverty simply because they were too ill to work. But in helping people after a period of poor mental health, it was important to ensure that individuals did not feel coerced into work before they were ready, and also that good support was available for those people who could not take up employment (pp 54-60). Opportunities for part-time working and greater flexibility in the benefits system would also make it easier for people to return to employment. Rethink supported these arguments, additionally suggesting greater use of job-sharing arrangements and voluntary work (pp 60-63).

Impacts on families

50. Rethink noted that mental ill health not only affected those who experience it but those who provide informal care for them; their friends and families (pp 60-63). A few years ago, a study funded by the Commission looked at the families of people with schizophrenia in five European cities. It found that the principal family carer spent on average between 6 and 9 hours per day supporting their relative with schizophrenia. The "impacts" most commonly reported by family members were restrictions on social activities, disruption to family life and feelings of loss.[18]

51. Stresses and strains are particularly associated with care. Rethink estimated that there were 1.5 million carers of people with mental health problems in the UK. They emphasised the importance of supporting these informal social networks to enable better social inclusion for individuals experiencing mental health problems and their families. They urged that the European Union's mental health strategy should recognise the impacts on carers' own health and wellbeing, and should therefore include recommendations for supporting carers (pp 60-63). West Sussex County Council (pp 174-176) argued that the EU Strategy needed to consider the mental health needs of carers. Similarly, Kent County Council emphasised the need to acknowledge the huge contributions made by people who care for people with mental health problems and the debt that society owed them (pp 123-124).

52. Research described by the UK Social Exclusion Unit[19] suggests that, in supporting people with mental health problems, carers themselves are twice as likely to have mental health problems if they provided substantial care. The emotional and health impacts for carers could certainly be substantial. This is why one of the standards of England's National Service Framework for Mental Health targets the support of carers.

53. The economic impacts on families can be large. There are considerable costs borne by families, mainly because one or more parents often has to give up work or take a part-time or lower paid job. Given that mental health problems are more prevalent in lower income groups, if the (largely hidden) individual and family costs are ignored when policy or practice decisions are taken, this might exacerbate the social exclusion of what is already a quite marginalised group. Siblings of children who exhibit antisocial behaviour will often suffer difficulties themselves.

54. At the other end of the age spectrum, the spouses and children of most people with dementia will carry a large part of the responsibility of care. While most carers will gain satisfaction from their contributions to maintaining the quality of life of a loved relative, they will also carry a lot of burden and strain. It is well known that carer well-being (including health status and coping skills) is a key influence on the decision to admit an older person to a care home.

55. One of the most tangible effects of caring is reduced opportunity to work and reduced income. In the report Dementia UK,[20] it is estimated that this lost income could annually amount to £690 million each year. This same report included an estimate of the economic value of informal care provided (mainly) by family members, which is equivalent to more than a third of the annual cost of dementia in the UK.

56. Families of people with mental health problems might also experience stigma, which can add to their feelings of marginalisation, neglect and disadvantage (see chapter 6).

Impacts on the health and social care system

57. Health and social care systems across Europe obviously carry primary responsibility for delivering the "formal" services needed by people with mental health problems. Calculations by the European Brain Council[21] relating to 28 European countries (all of Western Europe and eight Eastern European countries) estimated the total cost of mental health problems as €295 billion in 2004. Of this amount, they calculated that 20% was accounted for by inpatient hospital care, 3% drugs, 12% outpatient care, 13% social services, 3% informal care, 2% other directs costs, 33% sick leave, 7% early retirement, and 7% premature death. In other words, half the total was as a result of health and social care treatment and support.

58. The 2007 Alzheimer's Society report, "Dementia UK", estimated service costs of almost £11 billion. If service arrangements today were replicated in the future, the costs of long-term care for people with dementia would be likely to treble over the next thirty years.[22] By that time, based on these projections, long-term care for people with dementia would account for 1% of GDP.

59. The Commission point out in the Green Paper that the service consequences of mental health problems are enduring, drawing for evidence on a study conducted in London that followed a group of ten year olds into early adulthood. The service costs were calculated for each of these young people between the ages of ten and twenty-seven, and summarised as Annex 4 to the Green Paper. They demonstrate that ten-year olds with antisocial behaviour that is sufficient to justify a diagnosis of conduct disorder (which is the most common mental health problem among children) have costs over the next 17 years that are ten times as large as the costs of services used by ten-year olds with no behavioural or emotional problems. Most of these costs are incurred in the criminal justice system. Crime costs are also an important consideration when looking at the social impact of addictions.

60. The EPSILON multi-country study of people with schizophrenia, funded by the Commission, demonstrated how service systems and availability varied greatly between five study sites. A high proportion of in-patient care was used in the Danish site compared to the English, Italian, Spanish and Dutch sites, but there were many more beds available for use. In contrast, the Spanish site had relatively few inpatient beds and the overall budgetary contribution of inpatient care was therefore lower.[23] The ERGOS multi-country study of services used by people with schizophrenia also found marked differences in treatment patterns of treatments across Europe; for example, family therapy was rarely used in France, Portugal or the Netherlands, but frequently provided in Italy and Spain.[24]

Impacts on the wider society and economy

61. The extent to which the consequences of mental health problems fall outside the health and social care sectors will obviously depend on how those and neighbouring sectors are organised and configured: different boundaries are drawn in different European countries between health, social services, education, housing and other service sectors. But however these services are organised, people with mental health problems often have needs for help from a number of different areas. Education, housing, criminal justice, youth justice, social security and other sectors could all be called upon to make inputs. These various services could be provided by the state, by private sector bodies, or by voluntary organisations. Patterns of provision vary from country to country. In central and eastern Europe, for instance, the public sector has historically dominated service provision; the almost complete absence of civil society structures for many years has left many voluntary sector activities rather weak.

62. These multiple impacts are hard to factor into decision-making. According to Mr David McDaid and colleagues at the London School of Economics, there was a need to promote better coordination between the different parts of government and communities. They offered the example of child and adolescent mental health, where there was a need to coordinate schools, general medical services, social care, social welfare, criminal justice, and housing services with specialist mental health services. Better coordination would promote better identification of and responses to emotional and behavioural problems in childhood and adolescence (pp 10-12). A major challenge was "silo budgeting" under which resources located in specific agencies or budgets could not easily be shifted, indeed might be rigorously protected. One of the problems in increasingly performance-reviewed health and social care systems was that service professionals might find it hard to take decisions that were in the interests of somebody else's budget (including the service user's) if it could only be achieved at a cost to their own agency's resources.

63. The British media, probably more so than their counterparts elsewhere in the EU, give much coverage to the public risks associated with certain mental health problems[25]. Whether it thereby stokes exaggerated public fears and stigma is a moot point (see chapter 6), but there is clearly a need to be aware of the real and perceived impact of mental health problems on the wider society. Helping service users to maintain contact with services and to take their medications, and thereby to lessen the rates of deliberate self-harm, suicide and violent criminal acts is a key policy aim in all countries.

64. Another societal and economic impact is linked to the inability of people with mental health problems to work, either because of their capabilities at a time when they are ill, or because of the reactions from employers and others who discriminate against people with a history of mental health problems (see chapter 6). The economic consequences can be substantial. To give an example, the Health and Safety Executive in the UK has estimated that between 5 and 6 million days are lost per annum because of depression. Another calculation is that the cost of depression in terms of lost working days (and hence the loss to national productivity) was 23 times larger than the treatment costs falling to the NHS.[26] The Green Paper notes that mental health problems are the leading cause of early retirement in many European countries.

65. These negative employment effects associated with depression are obviously most immediately felt by people with the condition, but clearly also have an impact on employers and the economy more generally through reduced productivity, lower tax revenues and higher social security payments. In the UK, recent figures from the Department of Work and Pensions show that 40 per cent of the 2.7 million people claiming incapacity benefit in the UK in 2006 are described in official statistics as unable to work because of mental illness.

66. Just as the service implications of mental health problems can persist over many years, so too can the wider economic consequences. Evidence from a number of studies in the UK has shown that children with emotional or behavioural problems are much less likely than their peers to be in employment as adults, and that if they are, then their salaries are generally lower than those earned by their peers.[27] In other words, the societal consequences persist, as do the social exclusion disadvantages of young people who have already endured the distressing symptoms of mental health problems at an early age.

Summary of impacts

67. A document submitted to us by the International Longevity Centre UK (ILC),[28] cited a number of reports in which the economic cost of mental ill health had been assessed. Among these was the Policy Brief of the European Observatory on Health Systems and Policies[29] which conservatively estimated that the economic costs—for the 15 countries that were members of the European Union (EU) before 1 May 2004—were at least 3-4% of gross national product. Of this total, the report stated that most of the quantifiable costs occurred outside the health sector, being due to lost employment, absenteeism, poor performance within the workplace and premature retirement. Typically, they accounted for between 60% and 80% of the total economic impact/consequences of major mental health problems. Other important consequences, such as stigmatisation, social exclusion and fundamental abuses of human rights were rarely included in economic analyses—because they were not measurable in cost terms—but should not be ignored.

68. Mind quoted a report[30] that in England in 2002/03 the total economic and social costs of mental ill health were £77 billion. This was broken down in the report into the following categories:

£12.5 billion health and social care costs;
£23 billion in output losses;
£41.8 billion in "human costs" (calculated by assigning a monetary value to the human suffering, pain, disability and disease associated with mental health).

69. The evidence we received has supported the statement in the Green Paper that:

"There is no health without mental health. For citizens, mental health is a resource which enables them to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life. For societies, good mental health of citizens contributes to prosperity, solidarity and social justice. In contrast, mental ill health imposes manifold costs, losses and burdens on citizens and societal systems."

70. We urge a wider public recognition of the considerable body of evidence which indicates the substantial social and economic impact of mental health problems. Our view is that the heavy responsibilities carried by the families and other carers of people with mental health problems are too often overlooked, and that better recognition and support of carers is essential. We recommend that the Commission encourages EU Member States to take steps to address these issues, coordinating action as necessary across many different parts of government and society.

14 WHO Fact Sheet No. 218 Mental health problems: the undefined and hidden burden. Revised November 2001. Back

15 Brock A, Baker A, Griffiths C et al. Suicide trends and geographical variations in the United Kingdom, 1991-2004. Health Stat Q. 2006;31:6-22 Back

16 I Ivanov (2005) Mental health and working life. WHO Ministerial Conference on Mental Health Briefing Paper, Copenhagen: World Health Organization Regional Office for Europe. Back

17 See Chapter 4 of Martin Knapp et al. (2007) Mental Health Policy and Practice across Europe, Open University Press. Back

18 Lorenza Magliano et al. (1998) Burden on the families of patients with schizophrenia: results of the BIOMED I study, Journal of Social Psychiatry and Psychiatric Epidemiology. Back

19 Mental Health and Social Exclusion, Office of the Deputy Prime Minister, June 2004, p.4 Back

20 The rising cost of dementia in the UK. Are we prepared?, Alzheimer's Society 2007 Back

21 Patrik Andlin-Sobocki et al. (2005) Cost of disorders of the brain in Europe, European Journal of Neurology, 12, 1-27 Back

22 Adelina Comas-Herrera et al. (2007) Cognitive impairment in older people: the implications for future demand for long-term care services and their costs, International Journal of Geriatric Psychiatry, forthcoming. Back

23 Martin Knapp et al. (2002) Comparing patterns and costs of schizophrenia care in five European countries: the EPSILON study, Acta Psychiatrica Scandinavica. Back

24 Viviane Kovess et al. (2005) Professional team's choices of intervention towards problems and needs of patients suffering from schizophrenia across six European countries, European Psychiatry. Back

25 Mind. Counting the cost Back