Mental Health in the EU

“Mental health and mental well-being are fundamental to the quality of life and productivity of individuals, families, communities and nations, enabling people to experience life as meaningful and to be creative and active citizens. We believe that the primary aim of mental health activity is to enhance people’s well-being and functioning by focusing on their strengths and resources, reinforcing resilience and enhancing protective external factors.”

(WHO Europe Mental Health Declaration 2005)

This document introduces issues such as:

• The acknowledgement of mental health as key factor for overall health and prosperity, the consequences and burden of ill health, and the increasing priority of mental health within EU and other international agenda’s (e.g. WHO)
• The importance of taking on a broad perspective, hence looking at mental well-being and mental ill health;
• The concerted efforts to find good indicators for mental health, and particularly to achieve a better balance between indicators for ill health and indicators for positive mental health
• The increasing evidence on effectiveness of preventive approaches, as well as
• The amount of work that has been done to map national policies across the European region.

Measuring mental health and mental health indicators

This section will incorporate information from a number of national and EC funded projects concerned with identifying indicators that could form a basis for measuring mental health and well-being. An important project in this respect is MINDFUL. This is currently the most comprehensive attempt at widening the scope of mental health monitoring by covering mental ill-health, positive mental health, mental health promotion, and the prevention of mental disorders.

Positive mental health

This will include outcomes from the European quality of life survey (EQLS) that was carried out in 2003, covering 28 countries and interviewing 26,000 people. The report revealed, among other things, that levels of individual wellbeing reflect levels of national prosperity. Dissatisfaction, unhappiness and feelings of alienation are concentrated in Europe’s poorer regions.

This section will also refer to the preliminary outcomes of the MINDFUL project, through which suggestions have come forward for positive mental health indicators, such as: ’Energy, vitality’ and ‘Happiness’

Negative mental health

Here, we plan to include information on overall ill health, and information based on indicators such as psychological distress, depression, and suicide, with links to EUphacts on depression and suicide. These EUphacts will be prepared by priority.

As in most EUphacts, the information on depression and suicide will address occurrence and trends; differences between population groups (m/f/age), and socio-economic differences.

Personal burden of mental ill health

Here, we will discuss issues such as reduced quality of life, disability and mental disorders, but also social exclusion, stigmatisation and discrimination; fundamental rights and dignity of people receiving treatment or care; reduced employment opportunities, and the risk of falling into a poverty trap.

Social and economic costs of mental ill health

Mental ill health is not only a challenge for the affected citizens and their families. It also imposes significant costs to society and its economic, educational, social, criminal and justice systems. It has been estimated that the economic costs of mental ill health result in a loss of up to 3-4% of the EU's GDP, mainly through lost of productivity.

Mental illness makes a major contribution to the overall burden of disease in high-income countries, and can be especially disruptive of careers and productivity.

This section will build also on the outcomes of the MHEEN project.

Mental health as resource for prosperity and growth

There is no health without mental health. At individual level, mental health and well-being enables people to realise their intellectual, social and emotional potential. It also supports them to make healthy choices and enhance their health literacy. Furthermore, good mental health is an important resource for society, more particularly for social cohesion, economic welfare and prosperity.

This line of thought is also an important argument for the development of an integrated EU mental health strategy.

Mental health problems result from interplay between risk and protective factors

Mental health problems are mostly a cumulative effect of:

• the presence of multiple risk factors;
• the lack of protective factors;
• the interplay between risk and protective situations.

Risk factors increase the probability of onset, the severity and duration of mental health problems. Protective factors improve people’s resistance to risk factors and disorders. These factors modify or improve a person’s response to particular environmental hazards that are associated with mental health problems (Rutter, 1986). Risk and protective factors include individual as well as environmental determinants. Individual determinants include biological and genetic factors, personality traits and family-related factors. For an overview of the individual determinants see Individual determinants for mental disorders.

Individual determinants have most impact in sensitive stages of life

Determinants related to individuals may have the strongest impact on a person’s mental health at sensitive periods in their lifespan (WHO, 2004d). For example, child abuse and parental mental illness during infancy and early childhood can lead to depression and anxiety later in life as well as in subsequent generations. Elderly people who are physically ill can also be exposed to a range of subsequent risk factors, such as chronic insomnia, alcohol problems, elder abuse, personal loss and bereavement. Mental disorders can also have genetic determinants. These presently fall outside of the scope of the European Union’s public health interventions (EC, 2007).

Self-esteem compared across Europe

The MINDFUL project (Mental health Information and Determinants for the European Level) has brought together data on two determinants for mental health: self-esteem and social support of family and friends (MINDFUL, 2007). MINDFUL aims at improving the status of mental health information within the European Union. Self-esteem is defined as one's sense of worthiness as a person. High self-esteem functions as a protective factor against anxiety. Low self-esteem is associated with an experience of uncontrollable stress, depression, and various measures of ill health. The Rosenberg self-esteem scale shows the mean scores of self-esteem in 19 EU-countries. The data reveal no particular geographical pattern. However, caution is required with any such general interpretations, due to the variations in the data collection procedures (see remarks to Rosenberg self-esteem scale). A comparative assessment of the social support offered in European countries and its impact will be provided in the EUphact social support.

Poor socio-economic circumstances are a major environmental risk factor

Environmental determinants are related to macro-issues such as poverty, war and inequity, see Environmental determinants of mental health. Populations living in poor socio-economic circumstances have an increased risk of developing poor mental health, depression and a lower subjective well-being . This is because poor people often live without the basic freedoms of security, action and choice that the better-off take for granted. They often do not have access to adequate food, shelter, education and health (WHO, 2004d). Consequently, socially isolated and disadvantaged people have a poorer health status. More socially cohesive societies are, therefore, healthier and have a lower mortality rate (WHO, 2004e). In recognition of this, the Lisbon Strategy emphasizes the need to reinforce social cohesion and reduce poverty (EC, 2003). For more information, see the EUphact Social support.

Refugees and asylum seekers have multiple environmental risk factors

Two major societal risk groups are refugees and asylum seekers, since they have to deal with multiple environmental risk factors. Post-Traumatic Stress Disorder (PTSD) is one of the major mental health problems experienced by refugees. The disorder is caused by the impact of war and war-related traumas on the refugee, for example the experience of torture, beatings, killings or rape in their country of origin (Watters, 2007). Such experiences can also lead to depression, anxiety and alcohol-related disorders, as described in the EUphact Alchol use and Alcohol policies. A difficult post-migration environment, such as bureaucratic procedures, poor living conditions, low social support and discrimination, can lead to additional mental health problems and increase the risk of PTSD symptoms among traumatised asylum seekers. War-related traumas can also create psychiatric vulnerabilities in the offspring of traumatised and depressed parents.

Determinants can be generic or disease-specific

Most risk factors and protective determinants of mental health are generic, which means they are common to several mental health problems and disorders. All Individual determinants and Environmental determinants, are generic, such as poverty, poor social circumstances, child abuse and loneliness. Some determinants are disease-specific, which means they are mainly related to the development of a particular disorder. For example, negative thinking is specifically related to depression, and major depression is specifically related to suicide (WHO, 2004d).

Mental and physical health influence each other

Mental and physical health are interrelated in various ways (WHO, 2004d; WHO, 2004e):

• They may have common determinants. Risk factors such as poor housing can lead to both poor mental and poor physical health. Additionally, protective factors can prevent the onset, and influence the course and outcomes of both physical and mental illnesses. Psychological beliefs, such as optimism, personal control and a sense of meaning, protect one’s mental health as well as physical health.

• Mental disorders can increase vulnerability to physical morbidity and vice versa. For example, depression increases the risk of subsequently developing cardiovascular diseases. Poor general physical health is also three times more common among people who report significant emotional distress. These people often engage in behaviours, such as sedentary habits, binge drinking, smoking, and eating a poor diet, thus increasing their risk of developing health problems. On the other hand, chronic physical illness can increase vulnerability for mental health disorders.

The interaction between mental and physical health is thought to occur through complex psychological and psycho-physiological mechanisms. This highlights the value of an holistic approach to health.

Protective factors target both prevention and promotion

Interventions to prevent mental ill-health aim to counteract risk factors and reinforce protective factors. Interventions aiming to strengthen protective factors overlap largely with mental health promotion, since most individual protective factors are actually also features of positive mental health (WHO, 2004d). Preventive interventions should focus on protective factors that are susceptible to change, such as the ability to cope with stress, feelings of mastery and control and self-esteem.

Effects of interventions aimed at generic determinants are potentially wide-ranging

Interventions that successfully address generic determinants can generate more wide-ranging preventive effects in comparison to interventions that address disease-specific determinants. For example, the risk factors poverty and child abuse make people vulnerable for depression, anxiety and substance abuse. Therefore, interventions that address both poverty and child abuse can help prevent three disorders simultaneously. Combined interventions that both address major risk and major protective factors and have a large impact will be the most cost-effective and attractive. The same applies to interventions that impact on a range of related problems, such as social and economic problems, simultaneously (WHO, 2004d).

Tackling determinants: effective interventions

Evidence generated from projects under the EU's Public Health programmes and other sources demonstrate that action on mental health is possible and can be cost-effective. This can be seen from many successful examples to promote good mental health, to reduce the burden of mental ill health and to protect the rights and the dignity of mentally ill and disabled people.

There is a large body of evidence on what works: the work from Hosman, Jané-Llopis, Saxena and Anderson (to name some key experts) can be very helpful here.

Currently, the main debates about mental health promotion concern the importance of achieving a balance between action to prevent mental health problems and action to promote mental health for all and the most effective ways of demonstrating the benefits of promoting mental health. Also here, outcomes of the MINDFUL project will be included.

(Effectiveness of) prevention of mental ill health

Suicide prevention

Prevention of depression

(Effectiveness of) mental health promotion (EUphact to be developed)

Concrete actions described may include:

• Support parenting and the early years of life
• Promote mental health in schools
• Promote workplace mental health
• Support mentally healthy ageing

In our definition of mental health polices, we will follow the lead from the WHO Global Atlas report:

'Mental health policy is a specifically written document of the Government or Ministry of Health containing the goals for improving the mental health situation of the country, the priorities among those goals and the main directions for attaining them…... A Mental health policy may include the following components: advocacy, promotion, prevention, treatment and rehabilitation’.

On this issue, we will develop a EUphact by priority.

European Union policies and strategies

Against the backdrop the EU’s mandate to improve mental health, this section will provide an overview of the various strategies and actions that have been taken over the years. Insofar as these projects and actions have contributed to the body of evidence on effective mental health policies, their outcomes will be incorporated in the ‘evidence’ section.

The progress since the Finnish presidency in 1999 (‘no health without mental health’), culminating in the Commission’s intention to prepare a strategic document on mental health for adoption in spring 2007 will be described, as will the outcomes of the consultation process on the Commission’s Green Paper on Mental Health.

Where intergovernmental agreements and efforts –such as the WHO Europe Ministerial Conference on Mental Health and Helsinki Declaration in 2005- have been instrumental in advancing the commitment of EU Member States and/or the Commission, these will also be highlighted.

Evidence: effective policy approaches

Here, we will present evidence on effective measures as put forward via peer-reviewed publications and/or cross-national research efforts. These findings will also resonate in the section on national policies.

National mental health policies in Member States

Here, we will try to identify whether and how countries are taking the existing evidence and EU/intergovernmental frameworks into account in designing and implementing their national policies. This text will also incorporate the results of the EU-funded IMPHA (country overviews) and EPREMED (European Policy Information Research for Mental Disorders) projects, as well as the country overviews available through the WHO Mental Health Atlas 2005.

Suicide (attempt)

Drug use

Life expectancy

Social support

Alcohol use

Alcohol policies

Healthy life expectancy

European Commission, Health Determinants

WHO mental health

WHO mental disorders

MINDFUL, Mental Health Information and Determinants for the European Level

IMHPA, Implementing Mental Health Promotion Action

Support Project

Mean score of EU-countries on the Rosenberg self-esteem (2004)

Authors: Tamsma N, Meijer S (RIVM, Bilthoven the Netherlands)

Editor: Kramers PGN (RIVM, Bilthoven, the Netherlands)