APPENDIX 4: WHO MENTAL HEALTH ACTION
PLAN FOR EUROPE FACING THE CHALLENGES, BUILDING SOLUTIONS
Facing the Challenges, Building Solutions
This Action Plan is endorsed in the Mental Health
Declaration for Europe by ministers of health of the Member States
in the WHO European Region. They support its implementation in
accordance with each country's needs and resources.
The challenges over the next five to ten years are
to develop, implement and evaluate policies and legislation that
will deliver mental health activities capable of improving the
well-being of the whole population, preventing mental health problems
and enhancing the inclusion and functioning of people experiencing
mental health problems. The priorities for the next decade are
to:
i. foster awareness of the importance of mental well-being;
ii. collectively tackle stigma, discrimination and
inequality, and empower and support people with mental health
problems and their families to be actively engaged in this process;
iii. design and implement comprehensive, integrated
and efficient mental health systems that cover promotion, prevention,
treatment and rehabilitation, care and recovery;
iv. address the need for a competent workforce, effective
in all these areas;
v. recognize the experience and knowledge of service
users and carers[66]
as an important basis for planning and developing services.
This Action Plan proposes ways and means of developing,
implementing and reinforcing comprehensive mental health policies
in the countries of the WHO European Region, requiring action
in the 12 areas as set out below. Countries will reflect these
policies in their own mental health strategies and plans, to determine
what will be delivered over the next five and ten years.
1. Promote mental well-being for all
Challenge
Mental health and well-being are fundamental to quality
of life, enabling people to experience life as meaningful and
to be creative and active citizens. Mental health is an essential
component of social cohesion, productivity and peace and stability
in the living environment, contributing to social capital and
economic development in societies. Public mental health and lifestyles
conducive to mental well-being are crucial to achieving this aim.
Mental health promotion increases the quality of life and mental
well-being of the whole population, including people with mental
health problems and their carers. The development and implementation
of effective plans to promote mental health will enhance mental
well-being for all.
Actions to consider
i. Develop comprehensive strategies for mental health
promotion within the context of mental health, public health and
other public policies that address the promotion of mental health
across the lifespan.
ii. Adopt promotion of mental health as a long-term
investment and develop education and information programmes with
a long time frame.
iii. Develop and offer effective programmes for parenting
support and education, starting during pregnancy.
iv. Develop and offer evidence-based programmes that
foster skills, provide information and focus on resilience, emotional
intelligence and psychosocial functioning in children and young
people.
v. Improve access to healthy diets and physical activity
for older people.
vi. Promote community-based multilevel interventions
involving public awareness campaigns, primary care staff and community
facilitators such as teachers, clergy and the media.
vii. Integrate mental health promotion components
into existing generic health promotion and public health policies
and programmes, such as those supported by WHO health promoting
networks.
viii. Encourage the consumption of healthy products
and reduce the intake of harmful products.
ix. Create healthy workplaces by introducing measures
such as exercise, changes to work patterns, sensible hours and
healthy management styles.
x. Offer effective mental health promotion activities
to groups at risk such as people with enduring mental or physical
health problems and carers.
xi. Identify clear mechanisms for empowering the
population to take responsibility for health promotion and disease
prevention targets, for example by heightening public awareness
of the importance of life choices.
2. Demonstrate the centrality of mental health
Challenge
Mental health is central to building a healthy, inclusive
and productive society. Sound and integrated public policies,
such as those on labour, urban planning and socioeconomic issues,
also have a positive impact on mental health and reduce the risk
of mental health problems. The mental health implications of all
public policy, and particularly its potential impact on groups
at risk, therefore need to be considered. Mental health policy
requires intersectoral linkages and should incorporate multisectoral
and multidisciplinary approaches.
Actions to consider
i. Make mental health an inseparable part of public
health.
ii. Incorporate a mental health perspective and relevant
actions into new and existing national policies and legislation.
iii. Include mental health in programmes dealing
with occupational health and safety.
iv. Assess the potential impact of any new policy
on the mental well-being of the population before its introduction
and evaluate its results afterwards.
v. Give special consideration to the relative impact
of policies on people already suffering from mental health problems
and those at risk.
3. Tackle stigma and discrimination Challenge
Mental health policy development and implementation
must not be jeopardized by the widespread stigma attached to mental
health problems that leads to discrimination. In many instances,
people with mental health problems suffer from a lack of equal
opportunities because of such discrimination. Human rights and
respect for people with mental health problems must be protected.
Empowerment is a crucial step towards meeting these objectives,
as it enhances integration and social inclusion. The lack of empowerment
of service users' and carers' organizations and poor advocacy
hinder the design and implementation of policies and activities
that are sensitive to their needs and wishes. The exclusion experienced
by mental health service users, whether in asylums and institutions
or in the community, needs to be tackled in a variety of ways.
Actions to consider
i. Instigate activities to counter stigma and discrimination,
emphasizing the ubiquity of mental health problems, their general
good prognosis and treatability, and the fact that they are rarely
associated with violence.
ii. Introduce or scrutinize disability rights legislation
to ensure that it covers mental health equally and equitably.
iii. Develop and implement national, sectoral and
enterprise policies to eliminate stigma and discrimination in
employment practices associated with mental health problems.
iv. Stimulate community involvement in local mental
health programmes by supporting initiatives of nongovernmental
organizations.
v. Develop a coherent programme of policy and legislation
to address stigma and discrimination, incorporating international
and regional human rights standards.
vi. Establish constructive dialogue with the media
and systematically provide them with information.
vii. Set standards for representation of users and
their carers on committees and groups responsible for planning,
delivery, review and inspection of mental health activities.
viii. Stimulate the creation and development of local
and national nongovernmental and service user-run organizations
representing people with mental health problems, their carers
and the communities they live in.
ix. Encourage the integration of children and young
people with mental health problems and disabilities in the regular
educational and vocational training system.
x. Establish vocational training for people suffering
from mental health problems and support the adaptation of workplaces
and working practices to their special needs, with the aim of
securing their entry into competitive employment.
4. Promote activities sensitive to vulnerable
life stages Challenge
Infants, children and young people, and older people
are particularly at risk from social, psychological, biological
and environmental factors. Given their vulnerability and needs,
young and older people should be a high priority for activities
related to the promotion of mental health and the prevention and
care of mental health problems. However, many countries have inadequate
capacity in this area, and services and staff are often poorly
prepared to deal with developmental and age-related problems.
In particular, disorders in childhood can be important precursors
of adult mental disorders. Supporting the mental health of children
and adolescents should be seen as a strategic investment which
creates many long-term benefits for individuals, societies and
health systems.
Actions to consider
i. Ensure that policies on mental health include
as priorities the mental health and well-being of children and
adolescents and of older people.
ii. Incorporate the international rights of children
and adolescents and of older people into mental health legislation.
iii. Involve young people and older people as much
as possible in the decision-making process.
iv. Pay special attention to marginalized groups,
including children and older people from migrant families.
v. Develop mental health services sensitive to the
needs of young and older people, operated in close collaboration
with families, schools, day-care centres, neighbours, extended
families and friends.
vi. Promote the development of community centres
for older people to increase social support and access to interventions.
vii. Ensure that age- and gender-sensitive mental
health services are provided by both primary care and specialized
health and social care services and operate as integrated networks.
viii. Restrict institutional approaches for the care
of children and adolescents and older people that engender social
exclusion and neglect.
i Improve the quality of dedicated mental health
services by establishing or improving the capacity for specialized
interventions and care in childhood and adolescence and old age,
and by training and employing adequate numbers of specialists.
x. Improve coordination between organizations involved
in alcohol and drugs programmes and children's and adolescents'
health and mental health at national and international levels,
as well as collaboration between their respective networks.
xi. Ensure parity of funding in relation to comparable
health services.
5. Prevent mental health problems and suicide
Challenge
People in many countries are exposed to harmful stress-inducing
societal changes that affect social cohesion, safety and employment
and lead to an increase in anxiety and depression, alcohol and
other substance use disorders, violence and suicidal behaviour.
The social precipitants of mental health problems are manifold
and can range from individual causes of distress to issues that
affect a whole community or society. They can be induced or reinforced
in many different settings, including the home, educational facilities,
the workplace and institutions. Marginalized and vulnerable groups,
such as refugees and migrant populations, the unemployed, people
in or leaving prisons, people with different sexual orientations,
people with physical and sensorial disabilities and people already
experiencing mental health problems, can be particularly at risk
Actions to consider
i. Increase awareness of the prevalence, symptoms
and treatability of harmful stress, anxiety, depression and schizophrenia.
ii. Target groups at risk, offering prevention programmes
for depression, anxiety, harmful stress, suicide and other risk
areas, developed on the basis of their specific needs and sensitive
to their background and culture.
iii. Establish self-help groups, telephone help-lines
and websites to reduce suicide, particularly targeting high-risk
groups.
iv. Establish policies that reduce the availability
of the means to commit suicide.
v. Introduce routine assessment of the mental health
of new mothers by obstetricians and health visitors and provide
interventions where necessary.
vi. For families at risk, provide home-based educational
interventions to help proactively to improve parenting skills,
health behaviour and interaction between parents and children.
vii. Set up in partnership with other ministers evidence-based
education programmes addressing suicide, depression, alcohol and
other substance use disorders for young people at schools and
universities and involve role models and young people in the making
of campaigns.
viii. Support the implementation of community development
programmes in high-risk areas and empower nongovernmental agencies,
especially those representing marginalized groups.
ix. Ensure adequate professional support and services
for people encountering major crises and violence, including war,
natural disasters and terrorist attacks in order to prevent post-traumatic
stress disorder.
x. Increase awareness among staff employed in health
care and related sectors of their own attitudes and prejudices
towards suicide and mental health problems.
xi. Monitor work-related mental health through the
development of appropriate indicators and instruments.
xii. Develop the capacities for protection and promotion
of mental health at work through risk assessment and management
of stress and psychosocial factors, training of personnel, and
awareness raising.
xiii. Involve mainstream agencies responsible for
employment, housing and education in the development and delivery
of prevention programmes.
6. Ensure access to good primary care for mental
health problems
Challenge
For many countries in the European Region, general
practitioners (GPs) and other primary care staff are the initial
and main source of help for common mental health problems. However,
mental health problems often remain undetected in people attending
GPs or primary care services and treatment is not always adequate
when they are identified. Many people with mental health problems,
particularly those who are vulnerable or marginalized, experience
difficulties in accessing and remaining in contact with services.
GPs and primary care services need to develop capacity and competence
to detect and treat people with mental health problems in the
community, supported as required as part of a network with specialist
mental health services.
Actions to consider
i. Ensure that all people have good access to mental
health services in primary health care settings.
ii. Develop primary care services with the capacity
to detect and treat mental health problems, including depression,
anxiety, stress-related disorders, substance misuse and psychotic
disorders as appropriate by expanding the numbers and skills of
primary care staff.
iii. Provide access to psychotropic medication and
psychotherapeutic interventions in primary care settings for common
as well as severe mental disorders, especially for individuals
with long-term and stable mental disorders who are resident in
the community.
iv. Encourage primary health care staff to take up
mental health promotion and prevention activities, particularly
targeting factors that determine or maintain ill- health.
v. Design and implement treatment and referral protocols
in primary care, establishing good practice and clearly defining
the respective responsibilities in networks of primary care and
specialist mental health services.
vi. Create centres of competence and promote networks
in each region which health professionals, service users, carers
and the media can contact for advice.
vii. Provide and mainstream mental health care in
other primary care services and in easily accessible settings
such as community centres and general hospitals.
7. Offer effective care in community-based services
for people with severe mental health problems
Challenge
Progress is being made across the Region in reforming
mental health care. It is essential to acknowledge and support
people's right to receive the most effective treatments and interventions
while being exposed to the lowest possible risk, based on their
individual wishes and needs and taking into account their culture,
religion, gender and aspirations. Evidence and experience in many
countries support the development of a network of community-based
services including hospital beds. There is no place in the twenty-first
century for inhumane and degrading treatment and care in large
institutions: an increasing number of countries have closed many
of their asylums and are now implementing effective community-based
services. Special consideration should be given to the emotional,
economic and educational needs of families and friends, who are
often responsible for intensive support and care and often require
support themselves.
Actions to consider
i. Empower service users and carers to access mental
health and mainstream services and to take responsibility for
their care in partnership with providers.
ii. Plan and implement specialist community-based
services, accessible 24 hours a day, seven days a week, with multidisciplinary
staff, to care for people with severe problems such as schizophrenia,
bipolar disorder, severe depression or dementia.
iii. Provide crisis care, offering services where
people live and work, preventing deterioration or hospital admission
whenever possible, and only admitting people with very severe
needs or those who are a risk to themselves or others.
iv. Offer comprehensive and effective treatments,
psychotherapies and medications with as few side effects as possible
in community settings, particularly for young people experiencing
a first episode of mental health problems.
v. Guarantee access to necessary medicines for people
with mental health problems at a cost that the health care system
and the individual can afford, in order to achieve appropriate
prescription and use of these medicines.
vi. Develop rehabilitation services that aim to optimize
people's inclusion in society, while being sensitive to the impact
of disabilities related to mental health problems.
vii. Offer services for people with mental health
needs who are in non-specialist settings such as general hospitals
or prisons.
viii. Offer carers and families assessment of their
emotional and economic needs, and involvement in care programmes.
ix. Design programmes to develop the caring and coping
skills and competencies of families and carers.
x. Scrutinize whether benefit programmes take account
of the economic cost of caring.
xi. Plan and fund model programmes that can be used
for dissemination.
xii. Identify and support leaders respected by their
peers to spearhead innovation.
xiii. Develop guidelines for good practice and monitor
their implementation.
xiv. Introduce legal rights for people subject to
involuntary care to choose their independent advocate.
xv. Introduce or reinforce legislation or regulations
protecting the standards of care, including the discontinuation
of inhuman and degrading care and interventions.
xvi. Establish inspection to reinforce good practice
and to stop neglect and abuse in mental health care.
8. Establish partnerships across sectors
Challenge
Essential services which in the past were routinely
provided in large institutions or were not considered as relevant
to the lives of people with mental health problems are nowadays
often fragmented across many agencies. Poor partnership and lack
of coordination between services run or funded by different agencies
lead to poor care, suffering and inefficiencies. The responsibilities
of different bodies for such a wide range of services need coordination
and leadership up to and including government level. Service users
and their carers need support in accessing and receiving services
for issues such as benefits, housing, meals, employment and treatment
for physical conditions, including substance misuse.
Actions to consider
i. Organize comprehensive preventive and care services
around the needs of and in close cooperation with users.
ii. Create collaborative networks across services
that are essential to the quality of life of users and carers,
such as social welfare, labour, education, justice, transport
and health.
iii. Give staff in mental health services responsibility
for identifying and providing support for needs in daily living
activities, either by direct action or through coordination with
other services.
iv. Educate staff in other related services about
the specific needs and rights of people with mental health problems
and those at risk of developing mental health problems.
v. Identify and adjust financial and bureaucratic
disincentives that obstruct collaboration, including at government
level.
9. Create a sufficient and competent workforce
Challenge
Mental health reform demands new staff roles and
responsibilities, requiring changes in values and attitudes, knowledge
and skills. The working practices of many mental health care workers
and staff in other sectors such as teachers, benefit officers,
the clergy and volunteers need to be modernized in order to offer
effective and efficient care. New training opportunities must
respond to the need for expertise in all roles and tasks to be
undertaken.
Actions to consider
i. Recognize the need for new staff roles and responsibilities
across the specialist and generic workforce employed in the health
service and other relevant areas such as social welfare and education.
ii. Include experience in community settings and
multidisciplinary teamwork in the training of all mental health
staff.
iii. Develop training in the recognition, prevention
and treatment of mental health problems for all staff working
in primary care.
iv. Plan and fund, in partnership with educational
institutions, programmes that address the education and training
needs of both existing and newly recruited staff.
v. Encourage the recruitment of new mental health
workers and enhance the retention of existing workers.
vi. Ensure an equitable distribution of mental health
workers across the population, particularly among people at risk,
by developing incentives.
vii. Address the issue of lack of expertise in new
technologies of present trainers, and support the planning of
"train the trainers" programmes.
viii. Educate and train mental health staff about
the interface between promotion, prevention and treatment.
ix. Educate the workforce across the public sector
to recognize the impact of their policies and actions on the mental
health of the population.
x. Create an expert workforce by designing and implementing
adequate specialist mental health training for all staff working
in mental health care.
xi. Develop specialist training streams for areas
requiring high levels of expertise such as the care and treatment
of children, older people and people suffering from a combination
of mental health problems and substance use disorder (comorbidity).
10. Establish good mental health information
Challenge
In order to develop good policy and practice in countries
and across the Region, information has to be available about the
current state of mental health and mental health activities. The
impact of any implementation of new initiatives should be monitored.
The mental health status and the help-seeking behaviour of populations,
specific groups and individuals should be measured in a manner
that allows comparison across the WHO European Region. Indicators
should be standardized and comparable locally, nationally and
internationally in order to assist in the effective planning,
implementation, monitoring and evaluation of an evidence-based
strategy and action plan for mental health.
Actions to consider
i. Develop or strengthen a national surveillance
system based on internationally standardized, harmonized and comparable
indicators and data collection systems, to monitor progress towards
local, national and international objectives of improved mental
health and well-being.
ii. Develop new indicators and data collection methods
for information not yet available, including indicators of mental
health promotion, prevention, treatment and recovery.
iii. Support the carrying out of periodic population-based
mental health surveys, using agreed methodology across the WHO
European Region.
iv. Measure base rates of incidence and prevalence
of key conditions, including risk factors, in the population and
groups at risk.
v. Monitor existing mental health programmes, services
and systems.
vi. Support the development of an integrated system
of databases across the WHO European Region to include information
on the status of mental health policies, strategies, implementation
and delivery of evidence-based promotion, prevention, treatment,
care and recovery.
vii. Support the dissemination of information on
the impact of good policy and practice nationally and internationally.
11. Provide fair and adequate funding
Challenge
Resources dedicated to mental health are often inadequate
and inequitable compared to those available to other parts of
the public sector, and this is reflected in poor access, neglect
and discrimination. In some health care systems, insurance coverage
of access and rights to treatment discriminate severely against
mental health problems. Within the mental health budget, resource
allocation should be equitable and proportionate, i.e. offering
greatest relative share and benefits to those in greatest need.
Actions to consider
i. Assess whether the proportion of the health budget
allocated to mental health fairly reflects the needs and priority
status of the people with needs.
ii. Ensure that people with the most severe problems
and the poorest in society receive the largest relative benefits.
iii. Assess whether funding is allocated efficiently,
taking into account societal benefits, including those generated
by promotion, prevention and care.
iv. Evaluate whether coverage is comprehensive and
fair in social and private insurance-based systems, on an equal
level to that for other conditions, not excluding or discriminating
against groups and particularly protecting the most vulnerable.
12. Evaluate effectiveness and generate new evidence
Challenge
Considerable progress is being made in research,
but some strategies and interventions still lack the necessary
evidence base, meaning that further investment is required. Furthermore,
investment in dissemination is also required, since the existing
evidence concerning effective new interventions and national and
international examples of good practice are not known to many
policy-makers, managers, practitioners and researchers. The European
research community needs to collaborate to lay the foundations
for evidence-based mental health activities. Major research priorities
include mental health policy analyses, assessments of the impact
of generic policies on mental health, evaluations of mental health
promotion programmes, a stronger evidence base for prevention
activities and new service models and mental health economics.
Actions to consider
i. Support national research strategies that identify,
develop and implement best practice to address the needs of the
population, including groups at risk.
ii. Evaluate the impact of mental health systems
over time and apply experiences to the formulation of new priorities
and the commissioning of the necessary research.
iii. Support research that facilitates the development
of preventive programmes aimed at the whole population, including
groups at risk. Research is needed on the implications of the
interrelated nature of many mental, physical and social health
problems for effective preventive programmes and policies.
iv. Promote research focused on estimating the health
impacts of non-health sector policies, as there is a clear potential
for positive mental health to be improved through such policies.
v. Bridge the knowledge gap between research and
practice by facilitating collaboration and partnerships between
researchers, policy-makers and practitioners in seminars and accessible
publications.
vi. Ensure that research programmes include long-term
evaluations of impact not only on mental health but also on physical
health, as well as social and economic effects.
vii. Establish sustainable partnerships between practitioners
and researchers for the implementation and evaluation of new or
existing interventions.
viii. Invest in training in mental health research
across academic disciplines, including anthropology, sociology,
psychology, management studies and economics, and create incentives
for long-term academic partnerships.
ix. Expand European collaboration in mental health
research by enhancing networking between WHO's European collaborating
centres and other centres with research activities in the field
of prevention.
x. Invest in regional collaboration on information
and dissemination in order to avoid the duplication of generally
applicable research and ignorance of successful and relevant activities
elsewhere.
Mental Health for Europe: Facing the Challenges
Milestones
Member States are committed, through the Mental Health
Declaration for Europe and this Action Plan, to face the challenges
by moving towards the following milestones. Between 2005 and 2010
they should:
- prepare policies and implement
activities to counter stigma and discrimination and promote mental
well-being, including in healthy schools and workplaces;
- scrutinize the mental health impact
of public policy;
- include the prevention of mental
health problems and suicide in national policies;
- develop specialist services capable
of addressing the specific challenges of the young and older people,
and gender-specific issues;
- prioritize services that target
the mental health problems of marginalized and vulnerable groups,
including problems of comorbidity, i.e. where mental health problems
occur jointly with other problems such as substance misuse or
physical illness;
- develop partnership for intersectoral
working and address disincentives that hinder joint working;
- introduce human resource strategies
to build up a sufficient and competent mental health workforce;
- define a set of indicators on
the determinants and epidemiology of mental health and for the
design and delivery of services in partnership with other Member
States;
- confirm health funding, regulation
and legislation that is equitable and inclusive of mental health;
- end inhumane and degrading treatment
and care and enact human rights and mental health legislation
to comply with the standards of United Nations conventions and
international legislation;
- increase the level of social inclusion
of people with mental health problems;
- ensure representation of users
and carers on committees and groups responsible for the planning,
delivery, review and inspection of mental health activities.
66 The term 'carer' is used here to describe a family
member, friend or other informal care-giver. Back
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