# C_2023349EN.01010001.xml

| 29.9.2023 | EN | Official Journal of the European Union | C 349/100 |
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29.9.2023

EN

Official Journal of the European Union

C 349/100

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Opinion of the European Economic and Social Committee on ‘Measures to improve mental health’

(Exploratory opinion requested by the Spanish Presidency)

(2023/C 349/16)

| Rapporteur: | Milena ANGELOVA |
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| Co-rapporteur: | Ivan KOKALOV |

Rapporteur:

Milena ANGELOVA

Milena ANGELOVA

Co-rapporteur:

Ivan KOKALOV

Ivan KOKALOV

| Request from the Spanish Presidency of the Council | Letter, 8.12.2022 |
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| Legal basis | Article 304 of the Treaty on the Functioning of the European Union |
| | Exploratory opinion |
| Section responsible | Employment, Social Affairs and Citizenship |
| Adopted in section | 21.6.2023 |
| Adopted at plenary | 13.7.2023 |
| Plenary session No | 580 |
| Outcome of vote
  (for/against/abstentions) | 205/0/2 |

Request from the Spanish Presidency of the Council

Letter, 8.12.2022

Legal basis

Article 304 of the Treaty on the Functioning of the European Union

Exploratory opinion

Section responsible

Employment, Social Affairs and Citizenship

Adopted in section

21.6.2023

Adopted at plenary

13.7.2023

Plenary session No

580

Outcome of vote

(for/against/abstentions)

205/0/2

1.   Conclusions and recommendations

Conclusions and recommendations

| 1.1. | Mental health has a complex nature. It is affected by a plethora of factors: biological, psychological, educational, social, economic, occupational, cultural and environmental. Successful improvement and promotion of mental health (1) and prevention of mental health issues require a complex, multidisciplinary, life-long approach to be applied and firmly embedded as a cross-cutting top priority in policy-making at EU and national (regional and sectoral) level in order to: |
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1.1.

Mental health has a complex nature. It is affected by a plethora of factors: biological, psychological, educational, social, economic, occupational, cultural and environmental. Successful improvement and promotion of mental health (1

| 1.1.1. | Encourage reform of health systems across the EU to ensure that they deliver integrated and planned long-term interventions and care not only to cure, but to prevent medical conditions using multidisciplinary teams, instead of being organised around episodic models of care. The ultimate goal should be to realign the dominant direction of the health system in the field of mental health towards complex biopsychosocial and human-rights-based practices, ensuring prevention, early detection and screening of ill mental health and effective case management and provision of a person-centred approach in the community. |
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1.1.1.

Encourage reform of health systems across the EU to ensure that they deliver integrated and planned long-term interventions and care not only to cure, but to prevent medical conditions using multidisciplinary teams, instead of being organised around episodic models of care. The ultimate goal should be to realign the dominant direction of the health system in the field of mental health towards complex biopsychosocial and human-rights-based practices, ensuring prevention, early detection and screening of ill mental health and effective case management and provision of a person-centred approach in the community.

| 1.1.2. | Focus on constant promotion of mental health, prevention of mental illness and building resilience that is mainstreamed into all EU, national, regional and sectoral policies. While looking towards its forthcoming communication on a holistic approach to mental health, the EESC welcomes the European Commission’s communication on a comprehensive approach to mental health (2), backs strongly its ‘major public policy goal to ensure that no one is left behind, that citizens have equal access to prevention and mental health services across the EU, and that reintegration and social inclusion guides collective action addressing mental health illnesses’ and calls for its swift transposition into an EU Mental Health Strategy that has a timeframe, is sufficiently funded, defines responsibilities and includes indicators to monitor progress across the EU and Member States — including in the framework of the European Semester process. The Semester should give more consideration to the impact of socioeconomic and environmental factors on mental health, including the important benefits of improving access to affordable and quality services of general interest (housing, energy, waste/water, etc.). Ideally, this would steer national-level work by, for example, requiring Member States to develop and implement action plans which the Commission could periodically review and bring countries together to exchange and inspire each other to strive for ambitious actions. The main environmental and social risk factors should be constantly monitored and relevant strategies and measures should be swiftly adopted to minimise and eliminate those risks. |
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1.1.2.

Focus on constant promotion of mental health, prevention of mental illness and building resilience that is mainstreamed into all EU, national, regional and sectoral policies. While looking towards its forthcoming communication on a holistic approach to mental health, the EESC welcomes the European Commission’s communication on a comprehensive approach to mental health (2

| 1.1.3. | Provide possibilities for early diagnosis, adequate treatment, psychotherapy and rehabilitation for people with mental health conditions and psychological disabilities and social inclusion based on respect of personal dignity, human rights, freedom and equality. |
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1.1.3.

Provide possibilities for early diagnosis, adequate treatment, psychotherapy and rehabilitation for people with mental health conditions and psychological disabilities and social inclusion based on respect of personal dignity, human rights, freedom and equality.

| 1.1.4. | Mental health should be recognised in all Member States as a serious topic that requires an adequate degree of attention and a holistic, coordinated, structured and human-centred response. Coercion, stigma, segregation and discrimination around mental health conditions need to be lifted. Appropriate funding for health services to address mental health problems is essential for those services to be made universally accessible and affordable. This includes investments in properly trained health care personnel in sufficient numbers. Adequate levels of pay, constant up-skilling and sufficient staffing levels would ensure enough attention and time devoted not only to patients, but also to people seeking medical advice, opinion or treatment. The funding aspect, both in physical and social infrastructures in the health sector, should be better developed in the NRRPs in which representation and coverage of health-related projects are significantly lacking in their current form. Many NRRPs do not adequately address recent multiple crises that aggravate the risk of cascading mental health issues and therefore they should be updated promptly. |
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1.1.4.

Mental health should be recognised in all Member States as a serious topic that requires an adequate degree of attention and a holistic, coordinated, structured and human-centred response. Coercion, stigma, segregation and discrimination around mental health conditions need to be lifted. Appropriate funding for health services to address mental health problems is essential for those services to be made universally accessible and affordable. This includes investments in properly trained health care personnel in sufficient numbers. Adequate levels of pay, constant up-skilling and sufficient staffing levels would ensure enough attention and time devoted not only to patients, but also to people seeking medical advice, opinion or treatment. The funding aspect, both in physical and social infrastructures in the health sector, should be better developed in the NRRPs in which representation and coverage of health-related projects are significantly lacking in their current form. Many NRRPs do not adequately address recent multiple crises that aggravate the risk of cascading mental health issues and therefore they should be updated promptly.

| 1.1.5. | Improved access should be provided to support services, treatment, psychotherapy, medical and social rehabilitation, special and general care and activities related to psychosocial support. This should be done by developing and implementing innovative, personalised and evidence-based interventions, improving and ensuring equal and socially acceptable access to medication, support for the families of persons with mental health conditions, improving the capacity and qualification of those providing general and specialised care and building a system for integrated care, including community-based, delivered by multidisciplinary teams. |
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1.1.5.

Improved access should be provided to support services, treatment, psychotherapy, medical and social rehabilitation, special and general care and activities related to psychosocial support. This should be done by developing and implementing innovative, personalised and evidence-based interventions, improving and ensuring equal and socially acceptable access to medication, support for the families of persons with mental health conditions, improving the capacity and qualification of those providing general and specialised care and building a system for integrated care, including community-based, delivered by multidisciplinary teams.

| 1.1.6. | Develop and implement complementary approaches to provide appropriate support in crisis and emergency situations. It is necessary to establish a ‘pyramid of interventions’ based on embedding social and cultural considerations into core measures to tackle medical conditions, strengthening community ties and family support through focused non-specific support and providing specialist services and assistance from various health professionals for citizens with more severe conditions. At all levels of education, health promotion curricula should focus on developing adequate behaviour and ensuring basic health care, as well as on mental health hazards and how to avoid or reduce their impact, with emphasis on special cases such as pandemics or natural disasters. |
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1.1.6.

Develop and implement complementary approaches to provide appropriate support in crisis and emergency situations. It is necessary to establish a ‘pyramid of interventions’ based on embedding social and cultural considerations into core measures to tackle medical conditions, strengthening community ties and family support through focused non-specific support and providing specialist services and assistance from various health professionals for citizens with more severe conditions. At all levels of education, health promotion curricula should focus on developing adequate behaviour and ensuring basic health care, as well as on mental health hazards and how to avoid or reduce their impact, with emphasis on special cases such as pandemics or natural disasters.

| 1.1.7. | Enable rights-based, person-centred, recovery-oriented, community-based mental health systems that prioritise the person’s empowerment and active participation in their own recovery with the ultimate goal of improving the quality of life of people with mental health conditions. Promote the efforts to implement inclusive care and support within the mental health system to focus on the needs of specific and vulnerable groups, such as children, older people, refugees and migrants, LGBTIQ+ as well as people in disadvantaged socioeconomic situations. |
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1.1.7.

Enable rights-based, person-centred, recovery-oriented, community-based mental health systems that prioritise the person’s empowerment and active participation in their own recovery with the ultimate goal of improving the quality of life of people with mental health conditions. Promote the efforts to implement inclusive care and support within the mental health system to focus on the needs of specific and vulnerable groups, such as children, older people, refugees and migrants, LGBTIQ+ as well as people in disadvantaged socioeconomic situations.

| 1.1.8. | Provide global, inter-state and inter-sectoral cooperation in the field of mental health, build multi-stakeholder capacity and a guarantee of inclusive participation into the implementation of the initiatives. This should: entail coordination, exchange of information, experience and good practices; boost scientific research and innovation; aim towards positive health and social outcomes and digitisation of processes; promote work in networks/platforms of social partners, researchers and scientists, health professionals, social workers, patient NGOs and social services. |
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1.1.8.

Provide global, inter-state and inter-sectoral cooperation in the field of mental health, build multi-stakeholder capacity and a guarantee of inclusive participation into the implementation of the initiatives. This should: entail coordination, exchange of information, experience and good practices; boost scientific research and innovation; aim towards positive health and social outcomes and digitisation of processes; promote work in networks/platforms of social partners, researchers and scientists, health professionals, social workers, patient NGOs and social services.

| 1.1.9. | Workplaces are seen as cradles for nurturing mental health and support. Therefore, common initiatives and joint actions of social partners aimed at continuously improving working conditions should be promoted, including via sufficient funding. Psychosocial risks in the workplace must be assessed and eliminated, and every effort must be made to prevent violence and mental harassment (3). |
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1.1.9.

Workplaces are seen as cradles for nurturing mental health and support. Therefore, common initiatives and joint actions of social partners aimed at continuously improving working conditions should be promoted, including via sufficient funding. Psychosocial risks in the workplace must be assessed and eliminated, and every effort must be made to prevent violence and mental harassment (3

| 1.2. | Because of the growing importance of mental health, and in order to send a strong signal for the need to form a strong alliance to improve and promote mental health, the EESC calls upon the EC to declare 2024 as the European Year of Mental Health. |
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1.2.

Because of the growing importance of mental health, and in order to send a strong signal for the need to form a strong alliance to improve and promote mental health, the EESC calls upon the EC to declare 2024 as the European Year of Mental Health.

| 1.3. | There is a direct link between human rights violations and mental ill health as people with mental disabilities, intellectual disabilities and substance abuse problems often experience bad treatment, human rights violations and discrimination in health care settings. In many countries, the quality of care in both inpatient and outpatient facilities is poor or even harmful and can actively hinder recovery (4). It is necessary to monitor existing social and mental health care services against the UN Convention on the Rights of Persons with Disabilities standards, develop rights-based practices and invest in services and support that are respectful of the free and informed consent of the person, and safe from coercion and forced treatment. It is necessary to adopt guidelines and protocols, as well as provide training on rights-based approaches for health and social care workers. |
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1.3.

There is a direct link between human rights violations and mental ill health as people with mental disabilities, intellectual disabilities and substance abuse problems often experience bad treatment, human rights violations and discrimination in health care settings. In many countries, the quality of care in both inpatient and outpatient facilities is poor or even harmful and can actively hinder recovery (4

2.   Background

Background

| 2.1. | Mental health is a growing concern across the EU as it is not only a cornerstone of wellbeing and the European way of life, but also costs 4 % of EU GDP annually. Therefore, the EESC decided to devote an own-initiative opinion to it. In her State of the EU speech in September 2022, European Commission President Ursula von der Leyen announced the EC’s intention to present a new comprehensive approach to mental health in 2023 (included in the EC Work Programme 2023). The growing importance of mental health was also stressed in the conclusions of the Conference on the Future of Europe, calling — following a special request from young people — for initiatives to improve understanding of mental health issues and how to deal with them. The revised CultureForHealth report in December 2022 (5) also calls upon the European Commission to focus on mental health as a strategic priority. |
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2.1.

Mental health is a growing concern across the EU as it is not only a cornerstone of wellbeing and the European way of life, but also costs 4 % of EU GDP annually. Therefore, the EESC decided to devote an own-initiative opinion to it. In her State of the EU speech in September 2022, European Commission President Ursula von der Leyen announced the EC’s intention to present a new comprehensive approach to mental health in 2023 (included in the EC Work Programme 2023). The growing importance of mental health was also stressed in the conclusions of the Conference on the Future of Europe, calling — following a special request from young people — for initiatives to improve understanding of mental health issues and how to deal with them. The revised CultureForHealth report in December 2022 (5

| 2.2. | Following the request of European citizens, the EP (6) and the Council also called for action in this area. Recently, the forthcoming Spanish Presidency requested an exploratory opinion from the EESC, which was coupled with the initial own-initiative proposal. |
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2.2.

Following the request of European citizens, the EP (6

3.   Determinants of mental health

Determinants of mental health

| 3.1. | The most important determinants of mental health are micro- and macro-environment, individual socio-psychological factors and cultural-environmental factors, e.g., family status, gender, lack of supportive relationships, low level of education, low income and/or socioeconomic status, occupational problems, poor or precarious working conditions, unemployment, financial difficulties, perceived stigma and discrimination, poor somatic health, loneliness, low self-esteem, poor living conditions, ageing, negative life events, etc. Vulnerabilities and uncertainty for the future, combined with changes in value systems and adherence to them by the new generations also aggravate the risk of mental problems. The assessment of individualised psychosocial risks is of paramount importance in the world of work — especially when high responsibility, uncertainty, precariousness, hazardous environment or atypical work is involved. Individual characteristics, e.g. stress tolerance, chronic diseases, etc. must be taken into account as well. |
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3.1.

The most important determinants of mental health are micro- and macro-environment, individual socio-psychological factors and cultural-environmental factors, e.g., family status, gender, lack of supportive relationships, low level of education, low income and/or socioeconomic status, occupational problems, poor or precarious working conditions, unemployment, financial difficulties, perceived stigma and discrimination, poor somatic health, loneliness, low self-esteem, poor living conditions, ageing, negative life events, etc. Vulnerabilities and uncertainty for the future, combined with changes in value systems and adherence to them by the new generations also aggravate the risk of mental problems. The assessment of individualised psychosocial risks is of paramount importance in the world of work — especially when high responsibility, uncertainty, precariousness, hazardous environment or atypical work is involved. Individual characteristics, e.g. stress tolerance, chronic diseases, etc. must be taken into account as well.

| 3.2. | At the population level, risk factors are associated with adverse childhood experience, poverty, poor governance, discrimination, human rights abuses, poor education, unemployment, poor health care, lack of housing and adequate social and health services, quality of social protection policies, lack of opportunities, etc. There is an interdependence between poverty and mental health conditions and a vicious circle occurs — mental conditions lead to poverty, and poverty is a risk factor for poor mental health. |
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3.2.

At the population level, risk factors are associated with adverse childhood experience, poverty, poor governance, discrimination, human rights abuses, poor education, unemployment, poor health care, lack of housing and adequate social and health services, quality of social protection policies, lack of opportunities, etc. There is an interdependence between poverty and mental health conditions and a vicious circle occurs — mental conditions lead to poverty, and poverty is a risk factor for poor mental health.

| 3.3. | Environmental factors also affect mental health. Their influence is always complex and depends on the prevailing context or background against which mental health conditions occur. Many of them relate to climate, natural phenomena and disasters such as hurricanes or earthquakes. Others are linked to the availability and quality of drinking water, availability of sewage disposal, the degree of urbanisation, etc. |
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3.3.

Environmental factors also affect mental health. Their influence is always complex and depends on the prevailing context or background against which mental health conditions occur. Many of them relate to climate, natural phenomena and disasters such as hurricanes or earthquakes. Others are linked to the availability and quality of drinking water, availability of sewage disposal, the degree of urbanisation, etc.

| 3.4. | Determinants of mental health affect different groups of people to different degrees. Usually, the more vulnerable the group, the stronger the effects are on it. More vulnerable groups include young people and single older people, people feeling lonely and those living with pre-existing conditions or intellectual or mobility disabilities, and migrants. |
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3.4.

Determinants of mental health affect different groups of people to different degrees. Usually, the more vulnerable the group, the stronger the effects are on it. More vulnerable groups include young people and single older people, people feeling lonely and those living with pre-existing conditions or intellectual or mobility disabilities, and migrants.

| 3.5. | Any form of addiction — be it substance-related or behavioural, jeopardise good mental health. Alongside alcohol, tobacco and drugs, some medication can also cause addiction — including those prescribed to alleviate mental health conditions. Therefore, it is important for everyone in need to have fast-track access to professional psychiatrists and psychotherapists who can help tackle these problems in depth. Medicines can be a temporary solution while getting professional help. Behavioural addictions need special attention, especially those stemming from excessive use of digital devices (‘no-mob-phobia’ (7)), as they especially affect children and adolescents. Algorithms that are used to personalise content in social media may also create risks of aggravating mental conditions by continuing to suggest the content that causes mental health issues — most often anxiety and depression. Regarding psychedelic therapies, which are emerging as a new class of groundbreaking treatments for conditions like severe depression, PTSD and alcohol use disorder, more research is needed in a controlled therapeutical setting. The EESC recognises the potential of these treatments and asks for devoted funding for promoting research, development and eventual commercialisation of them. |
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3.5.

Any form of addiction — be it substance-related or behavioural, jeopardise good mental health. Alongside alcohol, tobacco and drugs, some medication can also cause addiction — including those prescribed to alleviate mental health conditions. Therefore, it is important for everyone in need to have fast-track access to professional psychiatrists and psychotherapists who can help tackle these problems in depth. Medicines can be a temporary solution while getting professional help. Behavioural addictions need special attention, especially those stemming from excessive use of digital devices (‘no-mob-phobia’ (7

| 3.6. | The Headway Mental Health Index (8) describes impacts including increased mortality, impulsive and aggressive behaviour and higher suicide rates. It also revealed that previously little-discussed factors such as an average monthly temperature increase of one degree were associated with a 0,48 % increase in mental health emergency room visits and a 0,35 % increase in suicides. |
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3.6.

The Headway Mental Health Index (8

| 3.6.1. | The index reveals that approximately 22,1 % of people in a conflict environment experience a mental health condition (13 % have mild forms of depression, anxiety and post-traumatic stress disorder, 4 % have more moderate forms, 5,1 % have major depression and anxiety, schizophrenia or bipolar disorder). Approximately one in five people continue to live with a post-conflict mental health condition. |
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3.6.1.

The index reveals that approximately 22,1 % of people in a conflict environment experience a mental health condition (13 % have mild forms of depression, anxiety and post-traumatic stress disorder, 4 % have more moderate forms, 5,1 % have major depression and anxiety, schizophrenia or bipolar disorder). Approximately one in five people continue to live with a post-conflict mental health condition.

| 3.6.2. | With 27 ongoing conflicts (9) around the world and 68,6 million people displaced worldwide (10), addressing the mental health needs of people affected by conflict and migration is a key priority and requires increased health monitoring — for at least three years after the event. |
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3.6.2.

With 27 ongoing conflicts (9

10

| 3.6.3. | The index further outlines key opportunities for health systems to improve or maintain mental health outcomes in the future. Data reveal a significant gap in mental health strategies, policies and legislation, and there are large differences in health care spending across Member States (e.g. France 14,5 % v. Luxembourg 1 %) (11). On a positive note, strides are being made with outpatient mental health facilities increasing from 3,9 to 9,1 per one million people. |
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3.6.3.

The index further outlines key opportunities for health systems to improve or maintain mental health outcomes in the future. Data reveal a significant gap in mental health strategies, policies and legislation, and there are large differences in health care spending across Member States (e.g. France 14,5 % v. Luxembourg 1 %) (11

4.   The effect of recent multiple crises on mental health

The effect of recent multiple crises on mental health

| 4.1. | Before COVID-19, data suggested that over 84 million people (or one in six) in the EU were affected by mental illness — a figure that has certainly increased since then (12). About 5 % of the working-age population had high needs due to a mental health condition and another 15 % had moderate mental health needs that reduced their employment prospects, productivity and wages. Mental health and behavioural conditions account for approximately 4 % of deaths per year in Europe and are the second most common cause of death among young people. |
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4.1.

Before COVID-19, data suggested that over 84 million people (or one in six) in the EU were affected by mental illness — a figure that has certainly increased since then (12

| 4.2. | Mental health has deteriorated further since the start of the COVID-19 pandemic in general, but the impact is particularly felt among young people, the elderly, people who have lost a loved one due to COVID-19 and other vulnerable groups. Social isolation and societal stress affect mental health and well-being of people negatively. People with underlying health issues are exposed to a risk of deterioration of physical and mental health. Contrary to increased demand for mental health care services, access to health care was greatly disrupted in the context of the pandemic, at least in its first phase. The increased demand for mental health care highlights the growing importance of telemedicine and digital solutions in the prevention, diagnosis, treatment and monitoring of mental health problems. |
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4.2.

Mental health has deteriorated further since the start of the COVID-19 pandemic in general, but the impact is particularly felt among young people, the elderly, people who have lost a loved one due to COVID-19 and other vulnerable groups. Social isolation and societal stress affect mental health and well-being of people negatively. People with underlying health issues are exposed to a risk of deterioration of physical and mental health. Contrary to increased demand for mental health care services, access to health care was greatly disrupted in the context of the pandemic, at least in its first phase. The increased demand for mental health care highlights the growing importance of telemedicine and digital solutions in the prevention, diagnosis, treatment and monitoring of mental health problems.

| 4.3. | Stressful events accompanying the COVID-19 pandemic include: the risk of infection and transmission of the virus to other people, fear of the long-term consequences of the pandemic (including economic ones), symptoms of other diseases (especially respiratory) being incorrectly interpreted as symptoms of COVID-19, the closure of schools and kindergartens increasing the stress of parents and caregivers, feelings of anger and dissatisfaction with the government and medical personnel, or mistrust of information provided by the government and other official bodies. |
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4.3.

Stressful events accompanying the COVID-19 pandemic include: the risk of infection and transmission of the virus to other people, fear of the long-term consequences of the pandemic (including economic ones), symptoms of other diseases (especially respiratory) being incorrectly interpreted as symptoms of COVID-19, the closure of schools and kindergartens increasing the stress of parents and caregivers, feelings of anger and dissatisfaction with the government and medical personnel, or mistrust of information provided by the government and other official bodies.

| 4.4. | In addition, frontline health care workers (including nurses, doctors, ambulance drivers, laboratory technicians and paramedics) experience additional stressors during the pandemic, such as stigmatisation of working with at-risk patients, insufficient personal protective equipment and lack of equipment for the care of severe patients, need for constant vigilance, increased working hours, increased number of patients, need for constant up-skilling and training, changing protocols for diagnosis and treatment of patients with COVID-19, reduced social support, insufficient personal capacity for self-care, insufficient medical information about the long-term effects of the infection and fear of infecting family and loved ones. |
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4.4.

In addition, frontline health care workers (including nurses, doctors, ambulance drivers, laboratory technicians and paramedics) experience additional stressors during the pandemic, such as stigmatisation of working with at-risk patients, insufficient personal protective equipment and lack of equipment for the care of severe patients, need for constant vigilance, increased working hours, increased number of patients, need for constant up-skilling and training, changing protocols for diagnosis and treatment of patients with COVID-19, reduced social support, insufficient personal capacity for self-care, insufficient medical information about the long-term effects of the infection and fear of infecting family and loved ones.

| 4.5. | Recently, Russian aggression against Ukraine and its consequences for livelihoods and uncertainty about the future have created new shocks with long-term effects on mental health. Non-EU nationals such as those fleeing Ukraine may face particular mental health challenges due to traumatic experiences in their home country or fleeing to the EU. At the same time, the war creates spill-over effects and burdens the EU population socioeconomically, thus generating additional long-term risks for mental health across the EU. |
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4.5.

Recently, Russian aggression against Ukraine and its consequences for livelihoods and uncertainty about the future have created new shocks with long-term effects on mental health. Non-EU nationals such as those fleeing Ukraine may face particular mental health challenges due to traumatic experiences in their home country or fleeing to the EU. At the same time, the war creates spill-over effects and burdens the EU population socioeconomically, thus generating additional long-term risks for mental health across the EU.

5.   Vulnerable groups

Vulnerable groups

| 5.1. | Children and adolescents. Early childhood mental health promotion interventions should be an integral part of general health care for children and their parents and care-givers. These start during pregnancy and continue with support for responsible parenting and early childhood development advice. Educational systems should focus on information and awareness raising, prevention and screening for violence — both physical and online, alcohol, tobacco or drug abuse, etc. The use of social media threatens mental health when it is excessive, but these media also offer opportunities for treatment of mental conditions. The influence of school stress and school performance may also cause pressure on mental health. |
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5.1.

Children and adolescents

| 5.1.1. | Programmes to promote mental well-being should be introduced in schools and mental health literacy advanced. Effective pathways to the health care sector should be developed to support children from a young age to recognise their feelings and those of others, and to deal with difficult emotions and situations by choosing effective coping strategies. Online platforms for the promotion of mental health in educational institutions and interactive age-appropriate websites for young people are imperative. |
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5.1.1.

Programmes to promote mental well-being should be introduced in schools and mental health literacy advanced. Effective pathways to the health care sector should be developed to support children from a young age to recognise their feelings and those of others, and to deal with difficult emotions and situations by choosing effective coping strategies. Online platforms for the promotion of mental health in educational institutions and interactive age-appropriate websites for young people are imperative.

| 5.1.2. | Children’s mental health protection requires not only medical measures to ensure the absence of clinical symptoms, but also targeted efforts for a good quality of life and full social adaptation. A collaborative approach (joining forces of educational, health care and social sectors) is needed in schools to promote mental health, address trauma, and prevent and treat mental health problems, substance use and abuse, suicide, youth violence and various forms of bullying. |
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5.1.2.

Children’s mental health protection requires not only medical measures to ensure the absence of clinical symptoms, but also targeted efforts for a good quality of life and full social adaptation. A collaborative approach (joining forces of educational, health care and social sectors) is needed in schools to promote mental health, address trauma, and prevent and treat mental health problems, substance use and abuse, suicide, youth violence and various forms of bullying.

| 5.2. | People in advanced age. The average life expectancy in Member States is constantly increasing, which brings the issue of old age to the fore. Aging processes often may cause life changes (incl. psychosensory) and development of needs related to mental conditions. Violations in the psychomotor and sensory spheres and the gradual loss of acuity of perception and difficulties in adapting to the changing environment lead to anxiety and depression. Neurological disorders involving the cortex, a combination of age-related changes in the brain, along with genetic, environmental and life-style factors, are also causing effects. While there are growing needs for up-skilling to deal with increasingly complex household appliances, with advanced age the abilities to learn and acquire new skills decrease and this may cause stress in daily life. Furthermore, experience of certain life changes, difficulties, losses and isolation also add pressure to mental health in older age. To cope with all these challenges, it is necessary to develop standards for structured care that goes beyond the institutional level and addresses older people’s personal needs. The development of person-centred care-giving programmes in the community is vital so as not to limit the services only to institutions such as homes for older people or hospices. Further effort must be made to actively search for people who need support, especially in crisis situations or after a traumatic event. |
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5.2.

People in advanced age.

| 5.3. | Gendered perspectives. Gender imbalances linked to mental health also pose a problem. The European Institute for Gender Equality (EIGE) via its Gender Equality Index 2022 (13) found that women reported lower levels of mental well-being than men in each of the three waves of the pandemic. There has also been a significant increase in domestic violence during the pandemic, called the ‘shadow pandemic’. Furthermore, women are twice as likely as men to experience long COVID-19 with neurological symptoms and higher levels of depression and anxiety (14). The European Care Strategy (15) also addresses work-life balance-related needs especially in relation to women (16). |
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5.3.

Gendered perspectives.

13

14

15

16

| 5.3.1. | There should be a gender impact assessment in all mental health policies at EU and national level to ensure gender mainstreaming. There are biological differences, but psychological and social factors also play an important role. Although quite a bit is already known about prevalence differences, little is often clear about the influence this can have on prevention, risks, diagnosis and treatments. Therefore, more research is needed. An important example is the trend of much sharper deterioration of mental health for teenage girls compared to boys, and the pressures on girls are three times stronger currently than 20 years ago. |
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5.3.1.

There should be a gender impact assessment in all mental health policies at EU and national level to ensure gender mainstreaming. There are biological differences, but psychological and social factors also play an important role. Although quite a bit is already known about prevalence differences, little is often clear about the influence this can have on prevention, risks, diagnosis and treatments. Therefore, more research is needed. An important example is the trend of much sharper deterioration of mental health for teenage girls compared to boys, and the pressures on girls are three times stronger currently than 20 years ago.

| 5.3.2. | There is an urgent need for gender-tailored mental health support and treatment. During a woman’s lifecycle, there are many episodes that could induce mental health issues. For instance, premenstrual dysphoric disorder (PMDD); the mental, physical, psychiatric and pharmacokinetic effect of menopause or oral contraception; the lack of drug therapy for pregnant and breastfeeding women; the lack of tailored mental and health care and treatment after domestic and/or sexual violence, early marriage and (early) exposure to (violent) pornography, or trafficking. All these can lead to worsening mental health and wellbeing. |
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5.3.2.

There is an urgent need for gender-tailored mental health support and treatment. During a woman’s lifecycle, there are many episodes that could induce mental health issues. For instance, premenstrual dysphoric disorder (PMDD); the mental, physical, psychiatric and pharmacokinetic effect of menopause or oral contraception; the lack of drug therapy for pregnant and breastfeeding women; the lack of tailored mental and health care and treatment after domestic and/or sexual violence, early marriage and (early) exposure to (violent) pornography, or trafficking. All these can lead to worsening mental health and wellbeing.

| 5.4. | People with addictions. A special emphasis should be placed on mental health conditions related to alcohol and/or illicit drug addiction. Alcohol-use-related risks are of particular importance due to their widespread use. The prelude to alcoholism is excessive and harmful drinking, which starts with the excuse of using it as a stress reliever and often leads to addiction. Unfortunately, the EU study ESPAD shows that this risky use of alcohol is also visible among the younger generation. The use of other illicit drugs has also become a serious public health problem in recent decades, with a particularly pronounced generational aspect. |
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5.4.

People with addictions.

| 5.5. | People with intellectual and psychosocial disabilities. People with high mental health care needs require a good quality and accessible person-centred and rights-based chain of services in mental health services in the community. During the COVID-19 pandemic, persons with disabilities living in institutions were ‘cut off from the rest of society’ with reports of residents being overmedicated, sedated or locked up and examples of self-harm also were reported (17). During the COVID-19 pandemic, there were higher mortality rates among persons with intellectual disabilities, who are also less likely to receive intensive care services (18). Providing individualised person-centred care and support under crisis conditions is significantly more challenging to deliver in large scale institutions, which puts people with intellectual and psychosocial disabilities at considerable risk of inequalities in care and treatment (19). Thus segregation practices have to be abolished, deinstitutionalisation has to be at the core of social policies to enable people with disabilities to enjoy their right to live in the community. |
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5.5.

People with intellectual and psychosocial disabilities.

17

18

19

5.6.   Excessive stress exposure — e.g. pandemic, natural disasters, conflicts

Excessive stress exposure — e.g. pandemic, natural disasters, conflicts

| 5.6.1. | The COVID-19 pandemic and following long COVID-19 syndrome has exacerbated many risk factors affecting individuals, leading to poor mental health, and weakened many protective mechanisms, leading to an unprecedented prevalence of anxiety and depression. In certain Member States, this prevalence has doubled (20). Mental health tended to be at its worst around the peaks of the pandemic, with depression symptoms usually highest around the time of strict containment measures. |
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5.6.1.

The COVID-19 pandemic and following long COVID-19 syndrome has exacerbated many risk factors affecting individuals, leading to poor mental health, and weakened many protective mechanisms, leading to an unprecedented prevalence of anxiety and depression. In certain Member States, this prevalence has doubled (20

| 5.6.2. | The COVID-19 pandemic highlighted the possible avenues for positive interaction between safe and healthy working conditions and public health (21). It also proved some occupations to be exposed to psychosocial factors that can increase exposure to stress (22) and produce negative impacts. For example, staff burnout and demographic changes threaten a permanent contraction in the European health workforce (23). Some professions are more exposed than others to precariousness (24) and to risk of physical harassment — e.g., workers in: health care and education (14,6 %), transport and communication (9,8 %), hospitality (9,3 %), retail (9,2 %). Those sectors also report unwanted sexual attention: hospitality (3,9 %), health care and education (2,7 %) and transport and communication (2,6 %) (25). Such stressful events may cause mental issues and conditions and must be prevented. |
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5.6.2.

The COVID-19 pandemic highlighted the possible avenues for positive interaction between safe and healthy working conditions and public health (21

22

23

24

25

| 5.6.3. | People who have experienced the dangerous environment of uncontrollable natural disasters, e.g., earthquakes, hurricanes, fires and floods, victims of human trafficking as well as international protection seekers. There are also different types of reactions (26) after a potential trauma event:






  — | Stress: overcome almost immediately, |
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5.6.3.

People who have experienced the dangerous environment of uncontrollable natural disasters

26

—

Stress: overcome almost immediately,

| — | Acute stress: attention decreases, consciousness is blurred, momentary amnesia, disorientation, tremors, aggressiveness and anxiety appear, which can last from several hours to four weeks, |
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—

Acute stress: attention decreases, consciousness is blurred, momentary amnesia, disorientation, tremors, aggressiveness and anxiety appear, which can last from several hours to four weeks,

| — | Post-traumatic stress disorder: the same symptoms appear up to a month after the event (e.g. the earthquake). |
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—

Post-traumatic stress disorder: the same symptoms appear up to a month after the event (e.g. the earthquake).

6.   Examples of good practices

Examples of good practices

| 6.1. | During the pandemic, many Member States took steps to increase support for mental health. Most developed new mental health information and/or helplines advising on coping measures during the COVID-19 crisis, while many countries also increased prevention and promotion efforts and increased access to mental health services and funding for these services (27). Some examples include:






  — | Cyprus — extending the remit of epidemiological committees from addressing the physical health risks to also incorporate mental health issues in specialised subcommittees (28), |
| --- | --- | --- |

6.1.

During the pandemic, many Member States took steps to increase support for mental health. Most developed new mental health information and/or helplines advising on coping measures during the COVID-19 crisis, while many countries also increased prevention and promotion efforts and increased access to mental health services and funding for these services (27

—

Cyprus — extending the remit of epidemiological committees from addressing the physical health risks to also incorporate mental health issues in specialised subcommittees (28),

28

| — | Finland — as a country of long distances and high take-up of digital technologies, use of digital tools can provide easier, cost-efficient and lower-threshold access to mental health services (prevention, diagnostic, treatment, monitoring). For example, Mielenterveystalo.fi is an online service that provides information and services on mental health for citizens and social and health care professionals in Finland. Especially in areas lacking physical mental health care services and among vulnerable groups such as young people who are using digital tools and devices actively or people with physical disabilities, digital solutions can increase the take-up of mental health services and prevent mental health problems. |
| --- | --- |

—

Finland — as a country of long distances and high take-up of digital technologies, use of digital tools can provide easier, cost-efficient and lower-threshold access to mental health services (prevention, diagnostic, treatment, monitoring). For example, Mielenterveystalo.fi is an online service that provides information and services on mental health for citizens and social and health care professionals in Finland. Especially in areas lacking physical mental health care services and among vulnerable groups such as young people who are using digital tools and devices actively or people with physical disabilities, digital solutions can increase the take-up of mental health services and prevent mental health problems.

| — | Portugal — free 24-hour telephone line for psychological support, |
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—

Portugal — free 24-hour telephone line for psychological support,

| — | France — introduced free consultations with a psychologist or psychiatrist for students, |
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—

France — introduced free consultations with a psychologist or psychiatrist for students,

| — | Ireland — provided additional funding of EUR 50 million in 2021 to create new mental health services in response to a crisis, as well as additional support for existing mental health needs, |
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—

Ireland — provided additional funding of EUR 50 million in 2021 to create new mental health services in response to a crisis, as well as additional support for existing mental health needs,

| — | Latvia — increased funding for mental health professionals and family doctors providing mental health support, |
| --- | --- |

—

Latvia — increased funding for mental health professionals and family doctors providing mental health support,

| — | Lithuania — national mental health platform with information on how to maintain mental health and resources for support, |
| --- | --- |

—

Lithuania — national mental health platform with information on how to maintain mental health and resources for support,

| — | Czechia — most compulsory health insurance funds have introduced partial reimbursement of psychotherapy open to all their beneficiaries. |
| --- | --- |

—

Czechia — most compulsory health insurance funds have introduced partial reimbursement of psychotherapy open to all their beneficiaries.

| 6.2. | Other Member States have also introduced national strategies to address the challenges of mental health. For instance, Spain has dedicated an entire chapter of its 2022–2026 national strategy to mental health challenges as a result of the COVID-19 pandemic, introducing a set of guidelines on addressing such challenges during and post-crisis. In Lithuania, in 2020, an action plan in response to COVID-19 was developed to strengthen the provision of mental health care and mitigate the potential negative consequences of the pandemic (29). The action plan in Lithuania also sets out a series of measures to expand and adapt existing services, introducing new services such as psychological community crisis teams, availability of low-threshold psychological counselling at municipal level and making services to promote mental health more accessible. |
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6.2.

Other Member States have also introduced national strategies to address the challenges of mental health. For instance, Spain has dedicated an entire chapter of its 2022–2026 national strategy to mental health challenges as a result of the COVID-19 pandemic, introducing a set of guidelines on addressing such challenges during and post-crisis. In Lithuania, in 2020, an action plan in response to COVID-19 was developed to strengthen the provision of mental health care and mitigate the potential negative consequences of the pandemic (29

| 6.3. | Psychotherapy, psychological counselling, various talking and group therapies are evidence-based treatments, which have to be scaled up to be affordable, accessible and available for people who need it in order to balance the prevailing traditional methods of treatment. |
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6.3.

Psychotherapy, psychological counselling, various talking and group therapies are evidence-based treatments, which have to be scaled up to be affordable, accessible and available for people who need it in order to balance the prevailing traditional methods of treatment.

| 6.4. | The mid- to long-term impacts of the pandemic on the need for mental health services remain to be seen. There are some indications that mental health and well-being have improved in the first few months of 2022, yet signs of poor mental health remain high. The limited national data available shows higher symptoms of depression and anxiety among adults than before the pandemic (30). |
| --- | --- |

6.4.

The mid- to long-term impacts of the pandemic on the need for mental health services remain to be seen. There are some indications that mental health and well-being have improved in the first few months of 2022, yet signs of poor mental health remain high. The limited national data available shows higher symptoms of depression and anxiety among adults than before the pandemic (30

Brussels, 13 July 2023.

The President of the European Economic and Social Committee

Oliver RÖPKE

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(1)  C. Winslow (1923) defined health promotion as an organised effort by society to educate the individual on personal health issues and develop a social system that provides each individual with a standard of living adequate to maintaining and improving their health.

1

(2)  COM(2023) 298 final.

2

(3)  Specific elements regarding precarious work and mental health are tackled in detail in Opinion of the European Economic and Social Committee on Precarious work and mental health (exploratory opinion requested by the Spanish Presidency) (OJ C 228, 29.6.2023, p. 28).

3

(4)  WHO QualityRights tool kit to assess and improve quality and human rights in mental health and social care facilities. Geneva, World Health Organization, 2012.

4

(5)  https://www.cultureforhealth.eu/knowledge/.

5

(6)  European Parliament resolution of 10 July 2020 on the EU’s public health strategy post-COVID-19 (2020/2691(RSP)) (OJ C 371, 15.9.2021, p. 102), https://www.europarl.europa.eu/doceo/document/TA-9-2020-0205_EN.html.

6

(7)  Fear of not having access to a mobile phone or other device, also related to social media and internet addiction.

7

(8)  https://eventi.ambrosetti.eu/headway/wp-content/uploads/sites/225/2022/09/220927_Headway_Mental-Health-Index-2.0_Report-1.pdf.

8

(9)  https://eventi.ambrosetti.eu/headway/wp-content/uploads/sites/225/2022/09/220927_Headway_Mental-Health-Index-2.0_Report-1.pdf, p. 60.

9

(10)  UN data.

10

(11)  https://www.angelinipharma.com/media/press-releases/new-headway-report-highlights-environmental-determinants-of-mental-health/.

11

(12)  https://health.ec.europa.eu/system/files/2022-12/2022_healthatglance_rep_en_0.pdf.

12

(13)  Read the report via https://eige.europa.eu/sites/default/files/documents/gender_equality_index_2022_corr.pdf. See also https://eige.europa.eu/publications/gender-equality-index-2021-report/women-report-poorer-mental-well-being-men.

13

(14)  https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/females-twice-more-likely-to-suffer-from-long-covid-who-releases-alarming-data-on-sufferers-and-symptoms/photostory/94194227.cms?picid=94194317.

14

(15)  https://ec.europa.eu/commission/presscorner/detail/en/ip_22_5169.

15

(16)  https://ec.europa.eu/social/main.jsp?langId=en&catId=89&furtherNews=yes&newsId=10382#navItem-relatedDocuments.

16

(17)  Brennan, C.S., Disability Rights During the Pandemic: A Global Report on Findings of the COVID-19 Disability Rights Monitor. 2020, COVID-19 Disability Rights Monitor.

17

(18)  https://www.who.int/news-room/fact-sheets/detail/disability-and-health.

18

(19)  https://apps.who.int/iris/bitstream/handle/10665/333964/WHO-EURO-2020-40745-54930-eng.pdf.

19

(20)  Health at a Glance: Europe 2022 © OECD/European Union, 2022.

20

(21)  https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A52021DC0323.

21

(22)  https://osha.europa.eu/en/themes/health-and-social-care-sector-osh.

22

(23)  Opinion of the European Economic and Social Committee on Health Workforce and Care Strategy for the future of Europe (own-initiative opinion) (OJ C 486, 21.12.2022, p. 37).

23

(24)  Opinion of the European Economic and Social Committee on Precarious work and mental health (exploratory opinion requested by the Spanish Presidency) (OJ C 228, 29.6.2023, p. 28).

24

(25)  https://osha.europa.eu/en/themes/health-and-social-care-sector-osh.

25

(26)  Flore Gil Bernal, Iberoamerican university in Mexico, www.fearof.net.

26

(27)  Office for National Statistics (2021), Coronavirus and depression in adults, Great Britain: July to August 2021.

27

Coronavirus and depression in adults

(28)  Long Covid Syndrome — https://www.oeb.org.cy/egcheiridia-long-covid-cyprus.

28

(29)  Wijker, Sillitti and Hewlett (2022), The provision of community-based mental health care in Lithuania, https://doi.org/10.1787/18de24d5-en.

29

The provision of community-based mental health care in Lithuania

(30)  Sciensano, 2022; Santé publique France, 2022.

30

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