Memorandum by Professor Stefan Priebe
Thanks for asking me to comment on the EU Green
Paper on Mental Health Strategy for the House of Lords EU Select
Committee enquiry.
The EU Green Paper touches on so many fundamental
issues of a mental health strategy that the evidence related to
it would fill whole libraries. In my view, the EU Green Paper
is most welcome to shift public attention to the most important
subject of mental health. At the same time, it suggests ways forward
on which one might have different views. This applies in particular
to the tendencies to a) define distress in a society in terms
of individual mental disorders requiring medical or psychological
treatment of the individual concerned, and b) consider general
issues of societal importance such as unemployment and social
isolation as specific mental health issues. For your information,
I attach a commentary on the EU Green Paper that I was asked to
write for Psychiatric Bulletin. It will probably be published
in August and explains the two points above.
If you have any specific queries or would like
me to elaborate on any of the above or other points, I will be
more than happy to be contacted at any time.
SIGN OF
PROGRESS OR
CONFUSION? A COMMENTARY
ON THE
EUROPEAN COMMISSION
GREEN PAPER
ON MENTAL
HEALTH
In the history of psychiatry in Europe, there
have been several texts and documents inspiring new ideas, influencing
the way professionals and the Public think about mental health
care and, subsequently, impacting on every day practice. Examples
for such texts maybe the Psychiatrie-Enquete in Germany, and the
law 180 initiated by Franco Basaglia in Italy. It is unlikely
that future generations will count the recent green paper on mental
health, published by the European Commission (Commission of the
European Communities 2005), among such seminal texts. Nevertheless,
it is worth noticing. It illustrates important challenges to mental
health care at the beginning of the 21st century and highlights
issues that might change the direction for the future.
The paper came out in October 2005 following
the WHO European Ministerial Conference on Mental Health in the
same year. It has the noble intention "to launch a debate
with the European institutions, governments, health professionals,
stakeholders and other sectors about the relevance of mental health
for the EU, the need for a strategy at EU—level and its
possible priorities." It portrays "mental ill health"
as a growing problem in the EU with wide economic consequences,
and suggests preventive action, social inclusion of mentally ill
people, and more data on mental health across the EU. In the paper,
the Commission invited everyone in the EU to contribute to a consultation
process, which ended in May 2006. The results of the consultation
process are not yet known in detail, but one can expect that most
of the contributors will have agreed that mental health is relevant
indeed, that a comprehensive EU strategy on mental health is welcome,
and that an interface between policy and research should be developed
to improve prevention and care. Yet, whether the consultation
process will also yield a clear concept of how mental health should
be best promoted, an agreement on achievable priorities, and specific
ideas for actions is less certain.
The paper reflects a general dilemma in psychiatry
about the concept of "mental ill health" and the scope
of mental health care. It begins with quoting an epidemiological
study estimating that more than 27 per cent of adult Europeans
experience at, least one form of mental ill health within a year.
This is in line with various findings of epidemiological research
in industrialised countries showing a prevalence of mental disorders
of 25 per cent or more. These figures have rarely been challenged
in the psychiatric literature. However, does a concept of mental
disorder or "mental ill health" really make sense if
it applies to 27 per cent of the population? Why have psychiatrists
not taken these figures as a reason to re-consider the definition
of mental disorders or—at least—the methods employed
to identify them? The definitions of health and illness will always
be fuzzy at the edges, but are essential to define the scope of
medicine and professional mental health care. The green paper,
which is surely not to be blamed for the dilemma that it highlights,
states that "there is agreement that a first priority is
to provide effective and high-quality mental health care and treatment
services to those with mental ill health". Putting this and
the previous wisdom about the prevalence of mental ill health
in the population together would lead to the conclusion that mental
health services should be established for 27 per cent of the population,
a suggestion which will be regarded as ludicrous by many in both
professional groups and the public. What "high-quality mental
health care and treatment services" can be developed—and
funded—for more than a quarter of the population? Neither
does the paper explicitly ask for new armies of psychotherapists
and other mental health professionals to provide such care, nor
does it specify what approaches other than conventional services
might deliver effective treatment for 27 per cent of the population
every year. Either the concept of mental ill health or that of
effective treatment may require revising. Any useful debate on
the future of mental health care cannot avoid this dilemma. Using
an inconsistent terminology that mixes the terms mental illness,
mental disorder, mental ill health, poor mental health and mental
health problems on the one hand, and medical treatment, health
and social care, professional help, psychosocial support and therapy
on the other without meaningful and consistent definitions for
any of them will not be a solution in the long term.
The green paper mentions a number of possible
preventive actions and—in doing so—touches on another
dilemma. The suggestions for actions include reducing the social
isolation of older people, interventions for the unemployed to
re-enter the labour market, prevention of bullying throughout
society, and strengthening of social cohesion. All these are certainly
important tasks for European societies, and achievements on any
of them may have a positive impact on the mental health of the
groups concerned. A society with an increasing disparity between
the rich and the poor, less social cohesion and a lower degree
of general trust is likely to be bad for the mental health of
the population. Yet, should all of these wider social problems
be tackled under the banner of "prevention of mental ill
health"? Changing the fabric of society is not mainly a matter
of improving health indicators, but foremost of social and political
values. Reducing economic inequalities with all its consequences
may therefore be regarded as a primarily political task, and not
one for specific mental health policies or care. Clarifying this
might help to decide on the most appropriate action, and avoid
overloading mental health care with issues that it alone cannot
shoulder.
The paper asks for comparable information across
Europe. The differences among European countries in traditions
of psychiatry, attitudes to and philosophy of health care, organisation
of the health care systems, and funding arrangements can be used
as a naturalistic experiment, and comparative data might help
all countries to learn from each other and understand how different
factors impact on the mental health of the population as a whole
and specific sub-groups (Priebe 2005). Whoever has tried to put
data from different countries together, will have found the experience
more difficult than anticipated. Reliable information on simple
parameters such as the provision of different types of services,
let alone more sophisticated indicators, can be extremely difficult
to obtain, and comparisons are further complicated by different
definitions and connotations. Additionally, there are various
language problems which are hard to overcome, even if and when
all documents and data are translated into English. Cynics might
say that it will probably take another 20 years of European collaboration
before the participants understand to what extent they misunderstand
each other. Despite these problems, communication and exchange
of ideas and information are important and worthwhile. Better
collection, accessibility and comparisons of data across Europe
are both feasible and promising. Such data should feed into a
wider debate on the future of mental health care addressing the
above-mentioned issues.
So, if we are going to have a debate, where
is that debate supposed to happen? There is no obvious European
forum for it. On national levels, some countries such as Germany
and Italy have begun to organise large national psychiatric congresses,
which are held at the same place and time every year and attract
more than 4-5,000 participants. In the UK, such a congress does
not exist, but there are excellent journals which might take the
debate forward. For instance, the Psychiatric Bulletin
recently published a full series of debate papers on future directions
of mental health care (Priebe 2004). Perhaps, discussions on future
challenges and directions can also be held in local services,
although—for whatever reasons—this currently does
not often happen.
The green paper does not contain new ideas and
gives rather confusing signals about the direction of travel for
mental health care. Yet, it might reflect a new interest in mental
health in the wider society and on a political level. If this
is the case, it could herald exciting times for developing and
improving mental health care. One may conclude from history that
major reforms of psychiatry were possible only when psychiatric
issues received wider public attention and political interest.
Is the green paper a sign that we are at the beginning of a new
era of such public interest in mental health and innovative reforms
of care? As always, the future will tell.
REFERENCES
Commission of the European Commission: Green
Paper—Improving the mental health of the population. Towards
a strategy on mental health for the European Union. Brussels,
14.10.2005 COM(2005) 484 final.
Priebe, S (2004) Psychiatry in the future. Where
is mental health going? A European perspective. Psychiatric Bulletin,
28, 315-316.
Priebe, S (ed) (2005) Mental Health Care in
European Capitals. European Psychiatry, 20, Supplement 2, S265-S300.
Stefan Priebe
Professor of Social & Community Psychiatry, Queen
Mary, University of London, Newham Centre for Mental Health, London
E13 8SP, e-mail: s.priebe@qmul.ac.uk
|
