Select Committee on European Union Fourteenth Report


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


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


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


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


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


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


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


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


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


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


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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