Memorandum by The Royal College of Psychiatrists
The Royal College of Psychiatrists is the leading
medical authority on mental health in the United Kingdom and the
Republic of Ireland and is the professional and educational organisation
for doctors specialising in psychiatry.
The Royal College of Psychiatrists warmly welcomes
this Green Paper as a prospective contribution to the WHO Declaration
and Action Plan, and commends the work that has been done to develop
and promote the strategy.
The case for an integrated mental health strategy
is well made in the paper, and the dual emphasis upon promotion
of positive mental wellbeing and the prevention and treatment
of mental illness is strongly supported. Pressures to which every
fourth citizen succumbs at some stage must be so prevalent that
they are felt by almost everyone. The strategy should therefore
include the right mix of measures for improving the mental health
of the whole population, and for providing a social, psychological
or medical remedy for groups of people who are particularly at
risk of incapacitating mental illnesses.
Responsibility for detecting and responding
to mental ill health is shared not only between patients and health
workers, but also by staff in social, educational, occupational,
housing, criminal justice and other settings—and of course
by their carers and by members of the public. All of these people
need to understand their roles and feel able to act.
In most countries individuals and agencies who
are striving to improve the lot of those with mental health problems
experience a lack of political and financial resource. The mental
health lobby is small in comparison with its competitors. Where
mental health is a part of general health provision it is our
experience that it will rarely come first on the list for action.
Unfortunately, negative attitudes or indifference towards the
care of people with mental health problems is often as commonplace
amongst health workers and administrators as in the general population.
This EU strategy should help to overcome those barriers to progress.
The College therefore particularly welcomes the suggestion that
a stakeholder's platform be set up to provide an opportunity for
views and expertise to be received, in the expectation that support
and empowerment will be returned.
The Green Paper includes two proposals for Council
Recommendations, which address the numerically largest groups
affected:
A Council Recommendation on the promotion of
mental health should encourage positive attitudes towards social
and family cohesion, and creativity and empowerment within society
as a whole. There is a common view that modern lifestyles are
becoming less conducive to a sense of well-being and therefore
to good mental health. The strategy cannot ignore that view, but
should actively investigate these conflicted issues, and within
its competency create a practical framework of mechanisms for
change.
A Council Recommendation on the reduction of
depression and suicidal behaviour would have the potential to
influence the largest diagnostic group, as well as those who are
most at risk—and suicide and deliberate self harm rates
are elevated in all mental illnesses. There is now enough reliable
evidence upon which to base strategic decisions. As indicated
in the Green Paper, new strategies for prevention can be built
upon practices that have proven effectiveness, in different States,
various age groups and in diverse settings.
So far as treatment is concerned, at the base
of the pyramid of severity of depression, psychosocial interventions
and lifestyle changes may be recommended by a range of people
with limited specialist training. However there is a shortage
of professionals able to treat moderately severe cases, for whom
the initial treatment of choice is formalised psychological therapy
such as a cognitive behavioural approach.
Treatment of severe depression and other mental
illnesses may require medical and nursing care in hospital, not
least to preserve the physical health and safety of patients and
those around them until their mental state improves. Reliance
upon hospitalisation varies between Member States. Although the
College supports the least restrictive approaches to care, and
is fully aware of the potential for institutionalisation and ill-treatment
in badly run hospitals, nevertheless a balance must be struck,
for closing hospital facilities without adequate alternatives
can result in increased risk and stigmatisation in the community,
and effective re-incarceration in "mini-institutions".
THE COLLEGE'S
RESPONSES TO
THE THREE
CONSULTATION QUESTIONS
ARE AS
FOLLOWS:
How relevant is the mental health of the population
for the EU's strategic policy objectives, as detailed in section
1?
Mental health is highly relevant to the EU's
strategic policy objectives, and the EC is well placed to make
a number of valuable interventions.
The need for change is well summarised in Section
1, and the secondary benefits of improved mental health to other
policy areas, including economics, are enumerated and clear. We
wish to emphasise also the increasing capacity for change, due
not least to the recent expansion in knowledge about mental health
and mental illness: about risk and protective factors, primary,
secondary and tertiary prevention, and improvements in a wide
range of medical treatments and psychological therapies. This
more optimistic view of what can be done to relieve mental health
problems and improve recovery is slowly replacing traditional
associations with sequestered custodial care. A wide-reaching
and authoritative strategy, with an effective means of dissemination,
should accelerate the acceptance of this positive view.
Would the development of a comprehensive EU-strategy
on mental health add value to the existing and envisaged actions
and does section 5 propose adequate priorities?
The College agrees that added value would flow
most readily from initiatives that facilitate inter-agency and
inter-state collaboration; co-ordinate parallel developments between
policy areas; and facilitate the provision of appropriate information
for users at all organisational levels.
Satisfactory mental health in a community will
depend in part upon economic and political stability and on settings
that promote family life, good schooling, cohesion, rewarding
work and care of the elderly. The strategy should encourage the
richness of local diversity as well as offering standard approaches.
The College also agrees that provision of effective
mental health care is a first priority, and suggests that the
strategy should address the problems faced by all Member States
in setting realistic threshold criteria for entry to services.
Although states are exclusively competent for organisation of
their own mental health care and psychiatric services, nonetheless
supportive actions might be taken by the EC to promote discussion
and understanding of the principles involved. Those most mildly
affected by mental health problems often have the greater personal
resources, are the most articulate, and the most numerous; while
the long term severely mentally ill have the greatest need. Variations
in local prevalence and social deprivation should also affect
the distribution of services. This introduces particular pressures
upon state intervention. Added value would accrue from shared
research and development on epidemiology and resourcing mechanisms.
As indicated in Section 4.1 of the Green Paper,
recent Community initiatives on mental health have so far arisen
independently from a variety of policy areas. The strategy should
not hinder such initiatives from arising wherever they are required.
However, there is a risk that a series of independently-generated
projects will not fully cover the ground, that efforts may be
duplicated, and that initiatives may turn out to be incompatible.
The College therefore strongly supports the plan for a single
integrating strategy, with a strong co-ordinating influence.
Such a complex strategy must nonetheless be
structured into a number of elements, and the question arises
as to whether those should be denoted by existing policy areas.
An alternative might be to recognise the differing needs within
specific target populations, with sub-strategies (implemented
by linked programmes or teams) as follows:
A. Promoting mental health in the whole population
(but separating Children, Adolescents, Adults of Working Age,
and Older Adults).
For children, schools programmes, parental support,
city planning and dealing with conduct disorders deserve special
attention.
The strategy should respond to the increasing
age distribution of the population.
B. Preventing mental illness and its effects
in target vulnerable groups, such as:
— Those with a past or family history
of mental illness (including alcohol and drug abuse).
— Those with a history of psychological
trauma (including abuse at any age, combat and terrorism).
— Those with learning/intellectual
disabilities (including specific and pervasive developmental disorders).
— Those with long-term physical
illnesses and disabilities.
— Prisoners (pre- and post-conviction).
— Those at risk from discrimination
or exploitation.
Each programme would need to work across policy
areas and consider a number of facets (which may or may not coincide
with existing policy) including:
— Promotion and Prevention.
— Knowledge and Information.
— Ethics and Human Rights.
The fourth stated priority, the development
of a mental health information, research and knowledge system
for the EU is a complex and specialised task. Technological advances
have implications for many aspects of the organisation and delivery
of mental healthcare. They also demand significant financial investment.
A European perspective would therefore be extremely valuable.
Each of the specialist programmes would also
benefit the Community through joint work with the WHO and Council
of Europe.
Are the initiatives proposed in sections 6 and
7 appropriate to support the coordination between Member States,
to promote the integration of mental health into the health and
non-health policies and stakeholder action, and to better liaise
research and policy on mental health?
The proposed initiatives set an ambitious and
far-reaching agenda. The WHO Network of Promoting Hospitals and
the European Alliance against Depression seem to provide good
examples.
Co-ordination between Member States should take
place at all levels and the proposals in Section 7 seem likely
to ensure that.
Integration of mental health into general health
and non-health policies would be assisted by a strengthened central
Mental Health presence, rather than the domain being represented
by a scattering of unconnected projects and stakeholder champions.
Hopefully this will provide the energy, breadth of understanding
and influence required. Those involved in the strategy may need
to avoid becoming fragmented into interest groups corresponding
to each policy area.
Successful implementation of the strategy will
not occur without extensive training and re-training. This will
need to extend through mental health professions to primary and
secondary health staff, the wide range of workers already mentioned,
to carers and the general public.
Greater clarity is perhaps required in the areas
of knowledge and information, and with respect to the goal of
improving the liaison between research and policy. The knowledge
and information required for setting and monitoring strategies,
for managing services, and for patient care are of different types
but are frequently inter-dependent—or else they may be presented
by using different analysis of the same raw data. Information
may be gathered through original research initiated for a set
purpose, or as a by-product of routinely collected information.
Information is required about mental health problems in general,
about services, and about individuals. And it is required by the
public, policy makers, commissioners, service managers, care professionals,
carers and service users. In view of these inter-dependencies
and the difficulty in obtaining good quality data, it may be inappropriate
to focus too much upon research and policy.
In conclusion, the College will be keen to be
active in publicizing and promoting the policies and initiatives
of the proposed EU Strategy.
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