Select Committee on European Union Fourteenth Report

CHAPTER 7: Promotion and prevention

206.  Clearly, central concerns of any mental health care system should be how to prevent the emergence of mental health problems in the first place, and how to promote better mental well-being (better quality of life) of individuals and families affected by illness. Among other things, this could be taken to argue that health systems look beyond "merely" alleviating symptoms or reducing the probability of relapse, and instead encourage services and therapies that are more holistic and more ambitious in their aims.

Mental health promotion and prevention

207.  Mental health promotion and prevention are not the same thing. The aim of mental health promotion is to protect, support and sustain emotional and social well-being. This can be achieved by creating the right conditions (individual, social and environmental) for good psychological and psycho-physiological functioning, and so enhance mental health. Consequently, mental health promotion initiatives are generally directed at whole populations rather than at people who already have or are recovering from mental health problems.

208.  Prevention initiatives, in contrast, endeavour to tackle the risk factors associated with mental health problems, and also to enhance the protective factors. The primary aim is to prevent mental health problems from emerging. Associated aims are to shorten the duration of an episode of illness, to reduce the risk of a relapse, and to reduce the impacts that mental health problems have on the individual, their family and the wider society. As Chapter 3 described, these impacts are many and wide-ranging.

209.  Although the concepts are different, prevention and promotion initiatives can overlap. Eva Jané-Llopis and Peter Anderson,[53] of the WHO European Region office, referred to the recommendations of the 2005 WHO Declaration and Action Plan (see Appendix 4). They suggested an integrated approach that not only used the health system to promote better mental health, but also involved linked action across other social policy areas. This could mean working to: reduce economic insecurity for individuals and their families; improve social cohesion; and provide better access to education, introduce labour market policies that promote better health and improve housing and urban planning. This had been called a "public health" approach to mental health. Such a broad approach to promotion and prevention had been seen by many as necessary to address the complex causes of mental health problems.

210.  Social scientists, policy makers and international institutions agree that for people to build networks of personal, community and work-related contacts (social capital) may help to reduce the number of people newly developing mental health problems and the overall number of people in the population with these problems. The Department of Health has explicitly cited the development of social capital as an important feature of mental health promotion, something that was also given emphasis in the Social Exclusion Unit's 2004 report on the links between mental health and social inclusion. Their report recommended actions such as developing social networks, but there is still little hard evidence as to whether such actions lead to any improvements.[54]

211.  Most EU governments have given relatively limited attention to policies that can promote population well-being and individual mental health. The Commission, working with the WHO and national governments, could encourage more and better public mental health initiatives. An obvious starting point would be to set up structures to share examples of good practice (i.e. initiatives of proven effectiveness). This means that mental health decision makers need to engage with groups such as teachers, social workers, employers, trades unions, local community groups and faith-based organizations.

212.  We believe that a "public health" approach for addressing the promotion and prevention of mental health issues is to be encouraged, recognising the multiple influences on the mental health of populations, from outside as well as from within the mental health system as conventionally defined.

213.  Dr Matt Muijen referred to the distinction made in the WHO Helsinki Declaration between "mental wellbeing" to cover positive mental health, and "mental health problems" to cover negative mental health (Q 205). The importance of this distinction was that prevention can refer to different groups of people and problems. It was important, he argued, not to cluster together a whole group of disorders and a whole group of people who had nothing in common. People with relatively minor anxiety states and people with very major forms of schizophrenia need very different interventions and have different outcomes. Prevention was particularly relevant for stress-related disorders, anxiety and depression. Dr Muijen also noted how there was widespread support for prevention but it was very often secondary to other forms of government action.

214.  The Green Paper's emphasis on promotion and prevention stems partly from work by the WHO which we have summarised above.[55] "Promotion of mental health and prevention of mental ill health address individual, family, community and social determinants of mental health, by strengthening protective factors (e.g., resilience) and reducing risk factors. Schools and workplaces, where people spend large parts of their time, are crucial settings for action".

215.  Witnesses described several examples of successful mental health promotion and prevention initiatives, both local and national, short-term and long-term, drawn from the UK and elsewhere, and targeting the general public, policy makers, informal carers, employers or others. Some of these examples are noted below. They included initiatives in childhood and old age. The case studies submitted are exactly the sort of thing that would be disseminated in an evidence-sharing exercise of the kind envisaged for the Commission's platform approach.

216.  However, it is hard to judge the robustness of the supporting material. For example, economic savings are often cited, as are better social outcomes, but as Dr Muijen noted, the evidence for high level prevention strategies was not very strong because they were non-specific and of high cost (Q 205).

217.  He also commented that, with respect to the newer countries in the EU, although they lacked basic structures and services in mental health, there was evidence of micro-initiatives in prevention and promotion and of mental health. But again, carefully evaluated national activities were scarce (Q 210).

218.  We recommend that the Commission encourage national governments to investigate ways to provide early identification and early intervention services. At the European level, we support the Commission's proposal for a platform approach that would help to bring together different Commission Directorates and encourage parallel efforts in Member States.

Examples of good practice

219.  Examples and case studies provided to us cover a variety of activities and initiatives. Dr Muijen referred to posters on buses in France that said "Your neighbour may suffer from mental illness", but he was not sure whether this was helpful or not. He was positive about activities in Greece where famous singers and other "champions" of mental well-being were involved. He referred also to initiatives in Finland, the Netherlands and Scotland, but effective evaluation had not taken place (Q 210).

220.  Mr Scheftlein, Mr Bowis and Ms Parker, among others, emphasised that efforts to counter stigma would help to encourage people to refer themselves or their relative for treatment at the early signs of a mental health problem, rather than allowing the problem to develop into something more serious that was not only much more distressing but might also require more drastic (and more costly) service responses. Similarly, improving "mental health literacy" among the general public ought to improve early recognition of symptoms, and so should have preventive benefits (QQ 13, 112, 182).

221.  The Mental Health Foundation argued that investment in early detection and early intervention services appeared (from UK evidence in one or two areas) to pay dividends in terms of health, quality of life and cost-effectiveness. They also referred to whole-school approaches to mental health promotion, aiming to reduce bullying in schools, providing universal support to parents and mechanisms to monitor progress on promoting children's mental health. The Foundation advocated less reliance on medication and more attention to be paid to identifying effective ways of building resilience (pp 140-144).

222.  Mind told us that in Estonia, an attempt was made to encourage local communities to be more welcoming of people with mental health problems by screening the film A Beautiful Mind (Q 161). The International Longevity Centre UK sent us information that in Denmark, the Danish Mental Health Fund had experimented with a "Happy Bus", providing full educational facilities, including internet access. A mobile unit went around the community and targeted children and young adults. They described "Mindfull", a project promoted by STAKES, the Finnish National research and development centre for welfare and health, which demonstrated the power of good information in raising awareness and understanding of severe mental health problems and their treatment (pp 120-123).

223.  A number of witnesses described how programmes such as Mind out for Mental Health, Shift (in England) and See Me (in Scotland) provide examples that are making a positive impact. The Minister, Ms Rosie Winterton MP, pointed to some of the real successes in the five-year Shift programme. She thought a lot of the work with the media had been quite successful and some of the BBC campaigns targeted at young people had been effective (Q 237).

224.  Action is also needed outside the mental health system. Among the areas mentioned were: urban improvements; housing; employment opportunities; skill development; physical activity; investment in social capital; and healthy workplaces. The European Public Health Alliance pointed out the link between good nutrition, physical activity and mental health (pp 115-117). Mind informed us that there was growing empirical evidence that participation in physical activities, such as walking and conservation work, could have substantial mental health benefits (pp 54-60).

225.  The encouraging work undertaken by big employers like Royal Mail and BT to give advice to managers to be more open about mental health issues was also mentioned by the Minister. Such initiatives could help to reduce the embarrassment and counter the stigma associated with mental health problems. These companies had sought to create environments that positively influenced the mental health of their employees. The Minister questioned whether major national campaigns were as effective as smaller efforts to tackle what was happening to people in their everyday lives, particularly in the workplace. She drew attention also to workplace mental health promotion efforts in Spain and France (Q 237).

226.  Mr Jurgen Scheftlein (Q 19) referred to "corporate social responsibility", which he saw as an avenue for spreading information about good practice and involving companies in mental health promotion. Mr Muijen explained that there was technical evidence that certain ways of working and the workplace atmosphere can be directly inimical to mental well-being (Q 207). Mr McDaid told us that the Boeing Company's long-standing programme on promoting mental as well as physical health has apparently shown some good outcomes (Q 66).

227.  Mr Jurgen Scheftlein described how the European Alliance against Depression (EAAD) had sponsored the establishment of regional networks of information-sharing among different sections of the community—media, teachers, priests, police and doctors. This had apparently resulted in some pilot projects reporting a 25% reduction in suicides and suicide attempts. Effective promotion and prevention campaigns did make people understand and helped them to seek medical care (Q 13).

228.  The Citizens Advice Bureaux report published in April 2004, Out of the Picture, highlighted problems resulting from an interaction between debt and mental illness. This motivated the International Longevity Centre to produce a film and training materials entitled Money Worries to improve the advice and support offered by finance providers to those with mental health difficulties and debt problems (pp 120-123).

229.  Evidence from Mr McDaid and colleagues from the London School of Economics noted the use of parent training programmes and interventions for the early identification of mental health problems in schools, as well as bereavement counselling and social activities to reduce isolation and the risk of depression in older age (pp 10-12).

230.  Rethink told us that informal carers often needed better information, communication and support and that it had been reported that informed, involved and supported carers had a better experience and were more effective carers than those who were uninvolved and without access to support and information. Targeting informed carers in such a manner significantly reduced the risk of developing depression and suicidal tendencies (pp 60-63). The International Longevity Centre described an example of this approach in Poland, where priests working with carers in innovative partnerships had been able to reduce the number of suicides. The ILC gave details of a number of training programmes for carers across Europe (pp 120-123).

231.  Promoting public understanding of mental health problems would help to change the way the public perceive those affected by such problems, particularly if the policy aim is to integrate people in the community. For example, Mr John Bowis MEP described the case of a woman who was concerned about her mentally ill neighbour living alone, but then felt reassured because of information campaigns and knowledge that she could approach relevant agencies to seek out help for her neighbour in times of need (Q 127).

232.  We have been impressed by the many examples of good practice in mental health promotion and prevention, both in the community and in the workplace, that have been drawn to our attention in this inquiry. We support the Commission's proposals to encourage Member States and employers to learn from such examples and to recognise the benefits of adopting such an approach.

Sharing good practice

233.  It was not possible for us to judge whether initiatives based on the examples of good practice described to us would indeed prevent mental health problems from emerging, delay onset of symptoms or improve quality of life for individuals, families and communities. It would be important, however, for the Commission and national governments to encourage the sharing of experience that was, as far as this can be ascertained, of proven benefit. As Mr Scheftlein remarked, the European Commission was funding the Mental Health Economics European Network which was currently gathering evidence on mental health promotion and prevention from 32 countries, looking especially at early childhood interventions and the workplace (Q 19).

234.  Department of Health officials noted that there was a very helpful publication that accompanied the Green Paper, Country Stories, that collected stories about successful activities around promoting mental health from different Member States. Mrs Tyson, one of the DH officials, argued that the UK should be carrying out its own mental health promotion and prevention activities to tackle the particular problems that arose in the particular context of this country. She expected other Member States to have the same view. In the same way as other witnesses, she referred to the difficulty of identifying whether a mental health promotion initiative had indeed been effective (Q 88).

235.  Consequently, Mrs Tyson noted that the Department of Health was alive to the possibility that input from an EU strategy might help with the UK's own national promotion and prevention agenda. This might be by raising the profile of mental health issues and the actions that people could take in their everyday lives to preserve and promote their own mental health. It might be through the sharing of good practice (Q 88).

236.  We support the Commission's proposal for sharing good practice across the EU, and indeed more broadly, and we believe it would be helpful for the Commission and/or the WHO to take responsibility for the collation of these examples, with the help of national governments. Those examples should be of proven effectiveness.

53   A policy framework for the promotion of mental health and the prevention of mental disorders, in Knapp M, McDaid D, Mossialos E, Thornicroft G (eds) Mental Health Policy and Practice across Europe, (2007) Open University Press, pp. 188-214). Back

54   Mental Health and social exclusion. Social Exclusion Unit Report, June 2004  Back

55   op. cit. p.8 Back

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