Select Committee on European Union Fourteenth Report


CHAPTER 8: Mental health issues for population subgroups

237.  The Green Paper is concerned with mental health problems across the full age span, but focuses almost all of its attention on working age adults. Some subgroups within the working age population warrant particular attention, and there is also a need to ensure that the needs of children and adolescents and of older people are not overlooked. In our view, four groups need to be considered in a little more detail:

  • Children and adolescents
  • Older people
  • Black and minority ethnic groups
  • Women

238.  For each of these groups all of the issues discussed earlier in this report have relevance: stigma; discrimination; the need for preventive and promotion strategies; the advantages of community-based care systems; and the difficulties of working across agency boundaries to establish collaborative working. But there appear to be additional issues for these four groups.

Children and adolescents

239.  In its Green Paper, the Commission draws attention to issues of mental health concerning younger people. They suggest that, as mental health is strongly determined during the first years of life, promoting mental health in children and adolescents is an investment for the future. The view is taken that teaching parenting skills can improve child development; and that attention to these issues in schools can increase social competencies, improve resilience, and reduce bullying, anxiety and depressive symptoms.

240.  Among those expressing concern about the under-recognition of the mental health needs of children and adolescents, and the consequent under-provision of services, Ms Camilla Parker (Q 187) suggested to us that one in ten children developed mental health problems, and that the proportion was much higher among young people in care or in custody. Turning Point (pp 172-173) supported a strategy that encompassed people of all ages, giving particular mention to children; and the King's Fund (pp 124-127) noted how mental health resources in Europe were concentrated on working-age adults with enduring mental health needs, and wanted the EU strategy to emphasise the need to support children and older people among whom numbers of mental health problems were increasing.

241.  This under-recognition arises partly because it can be difficult to determine when emotional or behavioural characteristics warrant specialist attention. Partly it is because few professionals with "generic" training are sufficiently skilled to identify these needs, and in many countries there are shortages of trained specialists. Partly, too, there is limited availability of evidence on what works for children and adolescents, and treatments (such as medications) which have been tested and found to be effective for adults may not have been tested specifically for children. An added difficulty is the complexity of working across agencies in support of children and adolescents with mental health problems. Yet because of the strong threads of continuity in respect of emotional or behavioural problems running from childhood into adolescence and into at least early and mid adulthood, the need for concerted mental health promotion and prevention efforts should be obvious, as should the need for earlier recognition and treatment.

242.  West Sussex County Council (pp 174-176) expressed the Council's commitment to enabling children and young people to enjoy good physical and emotional health, to encourage them to choose healthy lifestyles, and to the eradication of health inequalities. These ends would be best served, they argued, by shifting the focus from treatment of established health problems towards prevention.

243.  The Open Society (pp 155-159) referred to the Bamford Report on Mental Health Promotion which identified as one of three key domains for action the need for better preventive efforts among children and adolescents. The NHS Confederation (pp 144-145) wanted to see identification and prevention of problems before adulthood as the cornerstone of service change across EU Member States.

244.  Among the promotion and prevention initiatives cited were "whole-school" approaches, reduction of bullying within schools, provision of universal support to parenting, and mechanisms to monitor progress on promoting children's mental health (pp 140-144). The Foundation also wanted to see less reliance on medication and further research into identifying effective ways of building resilience among children and young people. The Royal College of Psychiatrists recommended schools programmes, parental support and attention to city planning. Targeted interventions in school and community settings were supported by the European Public Health Alliance (pp 115-117).

245.  The Minister, Ms Rosie Winterton MP, commended some of the campaigns by the BBC targeted at young people as effective (Q 237). West Sussex County Council expressed the view to us that there was a need for advice to be provided to parents and children about physical activity, diet and nutrition in order to reduce obesity, which was linked to mental distress and exclusion (pp 174-176).

246.  A linked theme was the need for earlier identification of problems and needs. Mr Paul Corry of Rethink (Q 157) commented favourably on the UK's investment in early intervention services, supporting 15 to 18 year-olds before they develop serious mental health problems, when contrasted to the treatment of some children in countries such as Romania. But Ms Camilla Parker (Q 192) was critical of the arrangements in the UK, noting that too often, things were left until they reached crisis point, with the situation being worse for children and young people than for adults. She saw a major gap during the period of transition from child and adolescent services to adult services, with a lot of young people finding themselves ineligible for adult mental health services. According to the Mental Health Foundation, early intervention would significantly reduce the human and economic costs of mental health problems across the life course (pp 140-144).

247.  The European Public Health Alliance saw education as the key to alleviate the burden of mental health problems, particularly when children and young people were integrated in regular education and vocational training schemes (pp 115-117). When mental health problems did develop, however, it was pointed out by the Mental Health Foundation that specialist services would be needed (pp 140-144); and West Sussex County advocated good partnership working (pp 174-176).

248.  Ms Camilla Parker took the view that young people with mental health problems should not be placed in prison environments, on the grounds of human rights and welfare. She said, however, that this practice persisted in the UK and across much of Europe (Q 188). The Open Society Mental Health Initiative's evidence was that in parts of Central and Eastern Europe the need for improvement was more basic. Many children and young people with mental disabilities were accommodated in large orphanages, often because there was no community-based support for parents (pp 155-159). There were also many young people in prisons and young offender institutions whose emotional and behavioural needs were not being met.

249.  In Chapter 6 we noted the enduring stigma attached to mental health problems and the discrimination that can result for many people. These experiences are as relevant for children and adolescents as for anyone else. A mental health service user from the UK quoted by Rethink, (pp 60-63) argued—"Please, we have to work in schools with young children to make them understand that mental illness is nothing to be ashamed about, that it is a serious medical issue, and they should be taught about mental illnesses throughout their schooling". Similarly, the Open Society Mental Health Initiative wanted to see efforts to raise awareness in schools as part of a broader initiative on disability issues (pp 155-159).

250.  We recognise that to address the mental health needs of children and adolescents requires specialist attention, separate from the action needed in the case of adults. We note also that, for this action to be effective, especially good collaborative working by education, health, social services and other agencies is essential. We recommend, therefore, that the Commission encourage Member States to put in place, for children and adolescents with emotional and behavioural problems, proven preventive and treatment strategies with effective structures and incentives.

Older people

251.  In the Green Paper,[56] the Commission recognises that an ageing EU-population, with its associated mental health consequences, calls for effective action. It is argued that old age brings many sources of stress that may increase mental ill health, such as decreasing functional capacity and social isolation. Late-life depression and age-related neuro-psychiatric conditions, such as dementia, increased the burden of mental disorders. Support interventions have been shown to improve mental well being in older populations.

252.  As for children, however, the Commission goes on to say relatively little about the mental health issues affecting this population group. The Government's response to the Green Paper commented that most of the discussion and recommendations in the document were focused on younger adults (pp 30-34).

253.  A number of particular issues surface regularly in discussions of older people with mental health needs. One issue is the obvious one that the ageing of Europe's population means that there will be growing numbers of older people and hence growing numbers of people with dementia and other mental health needs associated with ageing. This was a point made by the King's Fund (pp 124-127), the International Longevity Centre (pp 120-123) and Age Concern (pp 108-110). Breakthroughs in medicine and investment in public health meant that more people were living to quite an advanced age, when the risk of dementia was especially high. Age Concern pointed out that those numbers were projected to increase rapidly over coming decades. Moreover, more people with illnesses such as schizophrenia were surviving into old age and, unlike such people in decades gone by, these people were unlikely to be spending their lives accommodated out of sight in the back wards of forgotten asylums (pp 108-110).

254.  A second concern is the under-recognition of needs; many old people do not have their mental health problems identified or treated. Depression seems to be particularly overlooked. The evidence from Age Concern noted that depression is the most common mental health problem among older people, affecting up to one in four people aged 65 and over at any point in time. Suicide rates were high among older people. Depression was especially prevalent (and largely untreated) in care homes and among older people receiving social care support in their own homes (pp 108-110).

255.  The Medical Ethics Alliance (an association of world faith organisations and individuals who share a common ethos as stated in the Hippocratic Oath) drew attention to the unmet faith needs of older people. Those who could not attend places of worship should receive visits in their own homes, and religious services should be arranged in care homes (pp 130-132).

256.  A further need identified by witnesses concerned protection. There was no reference in the Green Paper to the issue of the abuse of older people. The Government response to the Green Paper referred to the No Secrets guidance launched in the UK in 2000, aimed at improving support and protection for adults who were vulnerable to abuse (pp 30-34).

257.  Care professionals (social and health care) may be too ready simply to label these needs as part of the normal and inevitable process of ageing, and not to refer on for assessment or treatment. This suggests a need for better training so that care staff can recognise and respond to mental health needs. Age Concern emphasised that most older people enjoyed good mental health and made significant contributions to the economy and to society (pp 108-110).

258.  Age Concern went on to suggest that, as an issue, mental health in later life had fallen into a gap between mental health policy and ageing policy. They took the view that mental health policy tended to focus on younger people and adults "of working age" (meaning—on the basis of the present State Pension age in the UK—16 to 59 for women and 16 to 64 for men); and that ageing policy tended to focus on physical health. They thought that a life course perspective on ageing and mental health should be adopted, giving priority to mental health promotion and the prevention of mental illness (pp 108-110). In support of this approach, Mr McDaid and others suggested that the European Commission should facilitate better recognition of the psychological challenges faced by older people (pp 10-12).

259.  In many, perhaps most, EU countries today, therefore, older people with mental health problems face many disadvantages. Because their mental health needs are not recognised, older people do not get the same access as younger people to appropriate treatments and services. Rethink referred to this ageist discrimination against older people with mental health needs. Even though the UK was sometimes seen as fortunate in having a specialist psychogeriatric service—whereas many other EU Member States have less skilled, generic provision—the written evidence from Rethink included a quote from a service user: "Older people get a very poor deal in the statutory mental health sector" (pp 60-63).

260.  Mental health promotion among older people warrants much more attention. Age Concern pointed out how age discrimination could lead to mental health problems, as could barriers to participation in public and private life, isolation and loneliness, poor physical health and poverty (including anxieties about future financial insecurity) (pp 108-110). The Christian Council on Ageing also urged more attention to be paid to mental health promotion for older people which, they said, often took a back seat in provision, and to support interventions that were all too often rather neglected in this age group (pp 112-113). The Minister pointed out that the National Service Framework for older people[57] included emphasis on the promotion of good mental health (Q 229).

261.  The Government response to the Green Paper (pp 30-34) drew attention to Everybody's Business, published by the Department of Health in 2005, which outlined a comprehensive older people's mental health strategy and identified the promotion of good mental health for older people as a cross-cutting issue. Among the "essential prerequisites" for ensuing good mental health for older people, the Government response listed access to advocacy and specialist advice, lifelong learning, volunteering, transport, finance and benefits, housing and safety and environment, health, social care and social activities. The Government response also made reference to the Social Exclusion Unit report, Making Life Better for Older People, which set out an economic case for preventative services and activities in relation to older people.

262.  More generally, Age Concern wanted the Commission to ensure that its Strategy was "age-proofed" and did not discriminate against older people, either directly (by giving little attention to their needs) or indirectly (by negative images of ageing). They called for the Commission to develop parts of the Green Paper further by (pp 108-110) by:

  • acknowledging the costs to society of mental health problems in later life;
  • identifying a setting for action for older people (just as the school and workplace are the identified settings for younger groups);
  • recognising that suicide rates are high among older people; by ensuring that statistical descriptions include people aged 65 and over; and
  • eliminating age-discriminatory language (e.g. the distinction between "the working population" and "older people", since many older people still work).

263.  We recognise that there is a growing number of older people in the EU and that to address their mental health needs requires especially good collaborative working by health, social services and other agencies. We recommend, therefore, that the Commission encourage national governments to pay more attention to the identification, prevention and treatment of mental health problems experienced by older people, including those who may already be using social or other health care services. Among other things, this should include encouraging staff training so as to improve the recognition of mental health problems experienced by older people.

Ethnicity

264.  EU Member States have had very different migration patterns and hence have diverse populations and especially rather different ethnic mixes. Consequently, the policy and practice issues in relation to mental health and ethnicity also tend to vary between countries. The issue is a major one in the UK because of the accumulating evidence that people from black and minority ethnic communities are relatively disadvantaged in the care and treatment they receive from the mental health system. The independent report into the death of David Bennett after being restrained in an NHS clinic identified "institutional racism" in the Health Authority.[58] Since then, increasing attention has been paid to the implications of culture and faith when designing systems to identify and treat needs.

265.  Mind cited the 2003 report by the National Institute for Mental Health for England on race equality and mental health. That report had concluded that black and ethnic minority people were more likely to experience problems accessing mental health services. They were more likely also:

  • to express lower satisfaction with those services;
  • to have a greater likelihood of being transferred to medium and high secure facilities;
  • to have higher rates of voluntary admission hospital but to be less satisfied with hospital care;
  • to stay for longer in hospital;
  • to be readmitted to hospital more frequently and to be more likely to get coercive treatment; and
  • to be less likely to access talking treatments (i.e. treatments that provide an opportunity to explore issues with a trained professional such as a psychologist) (pp 54-60).

A number of other witnesses made similar points about unequal patterns of experience and discrimination, for example Ms Camilla Parker (Q 187) and Ms Rosie Winterton (Q 224).

266.  The NHS Confederation (pp 144-145) urged the European Commission to look at this issue of differential service use by ethnic group, arguing that there was much to learn about improving access for black and minority ethnic users across the European Union. But although there is not enough understanding of this area in the UK, it is possible that we have a more credible platform of acceptance of ethnic minorities in society generally and also a better record on disability (broadly defined) and ethnicity than in many other countries. Obviously, there are no grounds for complacency, but we think it possible that experiences and practices in the UK with these population sub-groups in the UK could serve as useful guides for other mental health systems.

267.  The Mental Disability Advocacy Center suggested that other groups such as Roma, migrants and asylum seekers, who already suffered from discrimination, could be at even greater risk if they suffered mental health problems. These groups should perhaps be separated for the purposes of formulating a mental health strategy at European level and in the policy responses of national governments. Migration itself could be a very stressful experience (pp 134-140).

268.  There are known to be differences in the incidence and prevalence of mental health problems across ethnic groups. There are a number of possible reasons for these differences, including social deprivation and associated stressors (including different feelings of isolation and exclusion from employment, quality housing, social networks and education), affordability of preventive action which could affect resilience, cultural acceptability of symptoms, levels of awareness and insight (perhaps linked partly to language), different thresholds of shame or stigma, and genetic risk factors. See the evidence from: Rethink (pp 60-63); Kent County Council (pp 123-124); the Open Society (pp 155-159); and Dr Matt Muijen (Q 213).

269.  Mr Paul Corry from Rethink noted that all the available information suggested that the occurrence of new cases of mental illness and the overall number of people with such problems were much higher in "second generation" groups in society. It did not matter where their first generation came from—Africa, Caribbean, Eastern Europe, Ireland or faith communities—there was no doubt, he argued, that the second generation experienced significantly higher rates of severe mental health problems. He did not think that the reasons for these higher rates of illness were fully understood, but suggested that it may be linked to the tensions and stresses of living in two cultures, although other factors were likely to be playing a part. He stated the view that, as population movements across Europe increased, particularly as people moved in search of employment, it would be very important for those groups who settled that services were in place for their children (Q 164).

270.  This last point about migration patterns was one to which a number of witnesses referred during the course of the Inquiry, linked in part, but not exclusively related, to refugees and asylum seekers. The King's Fund (pp 124-127) suggested that the stigma of having a mental health problem might be compounded by the stigma of being from an ethnic minority. Mr David McDaid and colleagues from the London School of Economics (pp 10-12) noted the challenges posed by the mental health needs of people displaced through conflict, persecution or economic migration. Mind argued that refugees and asylum seekers were exceptionally vulnerable to developing mental health problems, because of past experiences, but also because of current experiences of abuse, exclusion and marginalisation (pp 54-60).

271.  The Samaritans commented that many of the migrant workers now based in the UK came from new accession countries with high rates of suicide which, combined with a lack of normal support networks as a result of migration, could be a source of additional stress. The Samaritans themselves advertised and offered their services in a variety of languages (pp 164-167).

272.  The Royal College of Psychiatrists urged the Commission to ensure that its Strategy targeted migrants as a vulnerable group (pp 161-164). More broadly, a number of organisations gave emphasis to the added value of European-level action, given that, by definition, migration and its consequences had an international dimension. Turning Point saw the mental health of migrants and asylum seekers as an issue with a scope beyond individual countries (pp 172-173). The NHS London EU unit wanted the European Commission to encourage information sharing about cultural attitudes to mental health problems to support effective and culturally sensitive help for migrants and others from minority ethnic groups (pp 145-148).

273.  Dr Marcus Roberts of Mind wanted the Commission to go further. He advocated that the Commission should provide financial and other support to help countries developing culturally appropriate services in the necessary range of languages (Q 164). The Mental Health Research Network wanted to see support for research on cultural issues in any European mental health strategy (p 174).

274.  Whether or not the initiative should come from the Commission or from national governments, there is a strong need for culturally appropriate mental health services. The Minister gave examples of what had been done in England, such as the Delivering Race Equality programme, which issued guidance about promoting mental health for people from black and minority ethnic communities (Q 224).

275.  In the Green Paper,[59] the Commission recognises that migrants and other marginalised groups are at increased risk for mental ill health, but they do not discuss the issue further. Nor do they discuss either the specific need for a better understanding of the complex links between ethnicity and mental health, or the need for culturally appropriate service responses. Perhaps this lack of attention arose because these topics appear to have been debated much less in the EU generally than in the UK. Possibly also, as Mr Bowis MEP suggested to us (Q 123), there is a better understanding of these issues in this country than in most other EU Member States. However, with rapidly increasing rates of migration, this will surely become a growing challenge more widely across the EU.

276.  We anticipate that, as migration patterns change, so will the ethnic diversity of Europe's populations. Our view is that more attention needs to be paid to the mental health needs of people from minority ethnic groups, both established populations and migrants, and including refugees and asylum seekers.

277.  We draw attention also to the pressing need to develop culturally appropriate mental health services.

Women

278.  The European Parliament has expressed concern about the limited attention given to gender in the Green Paper, and particularly that the needs of women were overlooked.[60] Mr Bowis MEP summarised for us some of the concerns expressed in that paper. One concern was the high rate of pre- and post-natal depression, linked to evidence that if society could promote good mental health among mothers then their children were less likely to grow up with difficulties themselves. Asian women had very specific health problems, including mental health problems, which needed to be understood better (Q 123).

279.  The Mental Disability Advocacy Center referred to research that showed that men and women had significantly different experiences in mental health systems, with women being more vulnerable to discrimination and abuse (pp 134-140). Rethink drew attention to the psychological vulnerability of women who were single parents or who experienced domestic violence (pp 60-63). The European Public Health Alliance (pp 115-117) and Mind (pp 54-60) both advocated gender-sensitivity when designing and reforming mental health services.

280.  We recommend that differences in the prevalence and impact of mental health problems between men and women should be recognised in the European Commission's mental health strategy, and in the design of mental health systems in Member States.


56   op. cit. p. 9 Back

57   Department of Health National Service Framework for Older People: published 27 March 2001 Back

58   Report under HSG(94)27 by the Norfolk, Suffolk and Cambridgeshire Strategic Health Authority: published December 2003 Back

59   op. cit. p. 9 Back

60   European Parliament resolution on Green Paper 2006/2058(INI)-adopted 6/9/2006 Back


 
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