EN Official Journal of the European Union C 44/36

Opinion of the European Economic and Social Committee on ‘The European Year of Mental Health — Better work, better quality of life’ (own-initiative opinion)

2013/C 44/06

Rapporteur: Mr SCHLÜTER

On 12 July 2012, the European Economic and Social Committee, acting under Rule 29(2) of its Rules of Procedure, decided to draw up an own-initiative opinion on the

European Year of Mental Health — Better Work, Better Quality of Life.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 23 November 2012.

At its 485th plenary session on 12 and 13 December 2012 (meeting of 13 December 2012) the European Economic and Social Committee adopted the following opinion by 74 votes to 1 with 2 abstentions:

1. Summary and recommendations

1.1 Mental health forms an integral part of quality of life and well-being for all people in the EU. The WHO defines mental health as ‘a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community’ (1). Economic data such as GDP are an inadequate reflection of this. The current crisis has plunged many millions of people into fear for their very existence, identity crises, and unemployment, and has had an impact on the risk of suicide. Mental well-being, rather than abstract financial issues, is therefore the key to the happiness of a very large number of people. Mental well-being is the prerequisite for individuals being able to realise their intellectual and emotional potential. For society, it is a source of social cohesion and of better social well-being and economic prosperity.

1.2 This initiative is geared towards improving mental health and the public's awareness of it in the broad sense. In addition to chronic and acute mental illnesses and disabilities, it also covers debilitating stresses which are not classified as illnesses and which may also have physical causes or effects. There are many facets to the subject of mental health and these are impacted by medical and socio-political issues as well as aspects of life such as the world of work, young people, old age and poverty.

1.3 Mental disorders can have various causes and consequences – such as trauma, stressful childhood experiences, drug use, stress, unemployment, homelessness, exclusion – and may be combined with genetic predisposition. The solutions and the relevant policies are just as diverse. It is often possible to influence these causes, which should therefore be given appropriate consideration in any inclusive policy and economic system. The social economy, civil society and new approaches predicated on social entrepreneurship can play a key role. Prevention, early recognition and treatment of mental illness must be based on a multidimensional approach (psychotherapy, as well as medical and socio-economic measures). Greater account must be taken of mental disorders and illnesses in the general education of health professionals, educators, teachers and people in executive positions. A publicly supported health promotion plan and a modern corporate culture can support people with disabilities and minimise the occurrence of work-related problems.

1.4 It is vital to strengthen civil, voluntary, family and professional networks and boost the participation of those affected and associations representing them. Prevention and raising awareness are tasks for society as a whole. Community-based outpatient support and assisted living can often help prevent restrictions on freedom and inpatient treatments. European recommendations and good practices are particularly important here and should include an appropriate reduction of inpatient psychiatric treatment and medication in order to help build up socio-environmental support measures and other alternative forms of assistance. The resources this would generate for science and research could also be directed more towards maintaining mental health. Even for financially weaker Member States, restructuring and new priorities are possible.

1.5 Raising broad public awareness of this issue, including in nurseries and schools, in businesses, among doctors and in care establishments, should be promoted across the EU. Campaigns to destigmatise mental illness and the use of non-discriminatory language in the media could reduce the discrimination experienced by people with mental health problems. People's state of health also has major economic consequences. These are secondary when compared with the more serious personal consequences of mental health problems (2). More questions should be asked about the social, political and economic interests and structures which make this problem worse and how inclusion can be promoted actively through the effective development of care systems geared towards the individual and through supporting families as the setting in which people first start to learn about life. Major advances in medicine, professional and voluntary support as well as the business model on preventative health care must be given greater consideration and promoted more strongly.

2. Background

2.1 The most common mental illnesses in Europe are anxiety disorders, depression and dependency-based illnesses. According to studies from 2010, 38 % of Europeans suffer from mental health problems (3). The figure was already 27 % in 2005 (4). Each year, 58 000 people commit suicide. By 2020 depression will become the second most common illness in industrialised countries (5). According to figures for people insured by a major German health insurance fund, between 2006 and 2009, mental illness accounted for a 38 % increase in lost working hours among workers and a 44 % increase among unemployed people (6). Prescriptions of ‘medication to treat the nervous system’, which includes antidepressants, increased by 33 % (7) in this period. In Great Britain too, 44 % of employers reported an increase in problems related to mental health and 40 % an increase in stress-related absences (8).

2.2 Mental health and well-being has so far not been the focus of a European Year. However, prejudice around mental health problems and psychosocial disabilities, and stigmatisation in society or at work, for example, is still a daily occurrence. The Europe 2020 strategy calls for greater social inclusion of this group and for relevant EU health programmes to be set up with an eye to inclusive and sustainable growth. Furthermore, the UN Convention on the Rights of Persons with Disabilities, which was concluded by the EU as the first ever international human rights instrument, provides a clear set of rights for persons with psychosocial disabilities. The rights enshrined in this convention need to be respected and implemented by means of all relevant EU policies and activities. Dedicating a European Year to mental health and well-being would therefore be a means of giving these requirements appropriate attention.

2.3 Since the mid-1990s, mental health has been the subject of several specific projects on European health policy and has been given a place of central importance (9). In 2005, the Commission launched a consultation based on the Green Paper on mental health (10).

2.4 The EESC stands by its opinion on the Green Paper (11) and underlines the social and personal importance of mental health as a key component in the concept of health. For the European Union, which is viewed as a community of values, mental health is an important source of social cohesion and universal participation. This is also advocated by the UN Convention on the Rights of Persons with Disabilities, which seeks to ensure through its human rights provisions that people with disabilities participate and are viewed from a holistic perspective.

2.5 In looking at this subject, the Commission also addresses issues relating to the economy, employment policy and public health. Ensuring a high level of health protection is one of the EU's cross-cutting tasks, as stated in Article 168 of the Treaty on the Functioning of the European Union (TFEU). What is more, a European Year of Mental Health would enable the EU to carry out the task specified in Article 6 TFEU, namely ‘to carry out actions to support, coordinate or supplement the actions of the Member States [… on…] protection and improvement of human health’, at European level.

2.6 The EU strategy for mental health has, among other things, promoted the 2008 European Pact for Mental Health and Well-Being (12), which also informed the Council's conclusions of June 2011 (13).

2.7 The conferences in this field held as part of the EU strategy were not adequately geared to raising broader public awareness and putting mental health issues on everyone's lips in Europe. This is something a European Year on Mental Health could achieve. Public authorities at all levels would focus on the issue, as well as civil society stakeholders in their multiple roles as experts, disseminators and social enterprises. A European Year of Mental Heath would, first and foremost, have to be consistent with the UN Convention on the Rights of Persons with Disabilities (CRPD). People with mental health problems or disabilities must be recognised as equal before the law and be able to enjoy in full their legal freedoms and their freedom to act (see Article 12 CRPD).

2.8 From a technical and ethical point of view, many people with mental health problems do not receive the necessary forms of treatment, rehabilitation and support to enable them to participate in society, although medicine and social services have made great progress in this area. Mental health is often not a health policy priority. Instead of support structures being built up, essential services and treatments are often scaled back or made more expensive, especially when budgets are under pressure and in periods of crisis. Instead, and especially in the economic crisis, investments in fostering participation, education and the social economy would be required. In times of crisis especially, government cannot be allowed to simply withdraw from the welfare sector. Particularly in the case of acute problems, waiting lists and long distances are counterproductive. Residential care and restrictions on freedom should be kept to an absolute minimum, in favour of community-based outpatient services, meeting points, advice centres and possibilities for medical treatment. It is essential to put in place legal entitlements and appropriate schemes to boost the autonomy of the people affected, so that, rather than having decisions taken for them, they are given the requisite support to determine for themselves, for instance, what assistance or therapy they need, without thereby ultimately having to have their legal capacity curtailed. Classification into disease categories, unilateral referral into the psychiatric system, the administration of psychotropic drugs and the use of force must, systematically, be subject both to critical review and to the application of standards underpinned by the rule of law and human rights. In all types of facilities and living arrangements, the overall concept must include provision for the people concerned to take part in society, engage in meaningful employment and have a properly structured day. The effects of psychotropic drugs on the ability to participate and morbidity should be considered in a more sensitive manner. The accessibility of support must not be curtailed through a fragmentation of support structures and bureaucratic and time-consuming application procedures. Crisis intervention and suicide prevention require easily accessible, specialist services. National emergency numbers and other specific support measures should be introduced across Europe.

2.9 At the same time, account must also be taken of the mutually reinforcing nature of socio-economic circumstances, unemployment and the burdens of illness. Furthermore, there are people with psychiatric illness who need resources and support in order to have a good quality of life. This means that promoting opportunities for participation and strengthening the legal status of those with chronic psychiatric illnesses and mental disabilities should be taken into account when setting the priorities for a European Year of Mental Health.

2.10 Assistance for people with mental disabilities should take into consideration philosophical, religious, pastoral and spiritual needs and beliefs.

2.11 Social factors are important in maintaining good mental health. Decent work plays a key role here in providing a meaningful sense of identity. To some extent, however, everyday living and working conditions are no longer governed by reliable cultural traditions and democratic decisions taken at local level, but by centralised economic choices and structures. Economic and structural policy should therefore take account of peoples' mental health and the goals of decent and inclusive residential areas and working conditions.

2.12 People in the modern world see new opportunities in today's multi-option, media and consumer-based society, but also new stress factors. In this connection, education systems are in many cases unable to meet the urgent need for high-quality ethical, cognitive and social education. Such education could, however, promote the independence and mental well-being that is required. Social ties continue to weaken, leading to a loss of external resources, such as friends, families and colleagues. Frequent changes of job and domicile, unemployment and loosening ties in personal relations do not contribute to the development of social networks in one's immediate neighbourhood. It is thus all the more important to ensure the mandatory involvement of the people affected and the associations representing them in the design of assistance and network structures.

2.13 Where the balance of personal responsibility and social security is disturbed, the risk of mental illness increases. This is relevant, for example, to incentives to enter the labour market, which can have no demonstrable effect because of a lack of jobs and a structurally-based lack of opportunities for business start-ups. Homelessness and mental impairments are also often closely intertwined, so that assistance must address both these issues. Parents in insecure employment and their children are prey to a whole range of stresses and strains caused by uncertainty, poverty, the sheer demands of child-rearing, time pressure and family stress. Assistance must be correspondingly diverse and must include, for example, publicly-funded pedagogical support and family recreational facilities. High levels of public debt and economic difficulties as well as cuts to social security and high unemployment are significantly increasing the risk of depression, anxiety and addictions. The suicide rate in eleven EU Member States increased by more than 10 % in the first half of 2011. Proper investment in social security and social services would alleviate this situation considerably (14).

3. Mental health in particular areas of life

3.1 The world of work

3.1.1 Discontinuity in employment, frequent restructuring, the need to be available at all times, time pressure, excessive workloads and increasing demands on flexibility and mobility: all of these often have repercussions for mental health (15). Disability statistics from the Netherlands show that, in 2010, mental health problems were the main reason for long-term sick leave (55 days). In Great Britain the HSE (16) estimates that about 9,8 million working days were lost through work-related stress (2009-2010), and on average, each person suffering from work-related stress was written off sick for 22,6 days. In 2010-2011, 10,8 million working days were lost (17). The inability to reconcile a professional life with family, care for relatives and time for cultural, physical and mental recreation poses further risks. Some countries have introduced measures enabling employees to take time off work to care for a relative and a right to ask for leave of absence. Often, businesses also have to deal with problems that have arisen outside the work context. There should be stronger public promotion of model approaches to preventive health care, inclusion, suitable part-time solutions, assistance at the workplace and ongoing training for management and staff. Innovative corporate cultures can also enhance the quality of work and products. Proactive stress risk management, based on research into stress factors and their reduction and elimination, should be part of a consistent prevention strategy, in accordance with the Treaty provisions, Framework Directive 89/391/EEC on the introduction of measures to encourage improvements in the safety and health of workers at work and the Framework agreement on work-related stress reached by the European social partners in 2004. Uncertainty over jobs and livelihoods and powerful structural forces in the labour market pose additional risks. There must be clear limits on any competition among employees to outdo one another in terms of productivity and any competition to undercut on working conditions. The losers in the labour market are often given the blame, even if they are not responsible. Employers' demands for employees to show the requisite reasonable flexibility are just as valid as employees' own demands for flexibility so that they can look after their families, care for individuals and deal with personal problems (care on the part of the employer and a ‘person-centred’ approach). People with mental health problems have a higher risk of losing their jobs or being unable to work because of their illness. Here too, social prejudices play a crucial role. This leads to losses for workers, resources in general and wealth creation.

3.1.1.1 The current quota rules for people with disabilities in some countries are, for example, far from sufficient as instruments. What is needed is a bold employment integration policy to help the many people who are currently excluded and to help society.

3.1.2 A more open approach to this subject could be brought about by the establishment of joint publicly backed advice and redress bodies. Bodies should be set up either inside the company or externally to represent the interests of working people with disabilities and mental health issues at the workplace. What is more, the risks should be limited by appropriate protection against dismissal, statutory employment protection, unemployment support schemes, a publicly promoted occupational health management system, return-to-work plans and an active labour market and family policy. In the interests of employers, and SMEs in particular, it is essential to safeguard competitiveness, avoid red tape and ensure the reliability of public support structures. Community service bodies and welfare associations and other civil society stakeholders can play an important role in providing political and practical support for those concerned, for businesses and for employment services (18).

3.2 Children and young people

3.2.1 There are hardly any precise statistics on mental health problems in children and young people. This is partly because it is often difficult to differentiate between someone who is ill and someone with behavioural problems for psychological reasons, between people in need of advice, education or treatment. This means that, generally speaking, it is almost impossible to distinguish between these needs: transitions are fluid. For example, according to the German Psychotherapeutenkammer (association of psychotherapists) the annual prevalence is between 9,7 % (mentally ill) and 21,9 % (behavioural problems) (19). Regarding depression, the risk of becoming ill for the first time is increasing, while the age at which the illness initially occurs is going down. Experts are seeing a growing number of anxiety and behavioural disorders and a definite increase in the use of psychotropic drugs among children and young people.

3.2.2 At the same time, child day care centres and schools have reported an increasing number of children and young people who are dropping out (14,4 % across the EU), who have behavioural problems or concentration difficulties or who have been violent. Often there is a combination of problems, accompanied by mental health disorders, an inability to resist consumer products (20) and media entertainment, computer or other addictions as well as general development deficits. What is alarming is the increasing consumption of antidepressants, methylphenidate and other medications among children and young people. There is an urgent need to compile statistics across Europe and to develop alternatives.

3.2.3 The increasing uncertainty experienced by children and young people as well as their parents is a problem that child and adolescent psychiatry is unable to solve, at least by itself. Early childhood assistance and support for the key role played by families are just as important as fostering the requisite skills among nursery staff and paediatricians and in schools. It is therefore not helpful if every behavioural problem is defined as a mental health problem or illness and complex individual and social problems are made into problems of the medical profession alone (21). Individualisation, varying levels of access to school education, unemployment, poverty, social exclusion, personal shame and parents who are unable to cope as well as systems of education based on an increasing sense of competition from the earliest age, limiting opportunities for those unable to keep up with the leaders in the race may be factors that a preventive approach has to take into account. Shared responsibility among all social stakeholders is what is needed here: a dynamic living environment, appropriate approaches to young people's education, well equipped schools and day care centres, a standard provision of non-commercial leisure activities, youth groups, clubs and cultural events and a comprehensive network of professional interdisciplinary care, such as advisory services to help with child-rearing issues and non-formal education. Drug abuse should be tackled consistently through early detection, prevention, counselling and therapies, as well as by controlling supply channels. Investing in this area will avoid immense personal and social damage. Inclusion in education, work and other forms of useful employment must be legally guaranteed for adolescents and young adults. In all these fields, non-profit services and social welfare and civil society organisations have a key political and practical role to play.

3.3 Older people (22)

3.3.1 Increased and further increasing life expectancy is one of several crucial explanations for the overall rise in the number of mental health problems. Physical multi-morbidity increases in old age, accompanied by a heightened risk of depression. Furthermore, depression is often a side-effect of certain age-related illnesses, such as Alzheimer's and Parkinson's. A dynamic living environment favourable to participation, accessible and outpatient social services, opportunities to volunteer, appropriate forms of workforce participation and participation in business and ensuring that care institutions have the right focus: these are all key factors in heading off loneliness and in preventative healthcare. Social facilities, care services and doctors should be sufficiently competent in handling psychiatric issues in older people. Best practice models, especially as regards people suffering from dementia, should be examined more thoroughly at European level.

3.3.2 Older people are usually cared for by general practitioners, who do not refer enough cases to neuro-psychiatric specialists. In cases of dementia and depression, however, early diagnosis is important, so there is a uniform need for a cross-cutting approach to care: in most general old people's homes, there is a lack of regular specialist psychiatric care. This is also true of other services for older people, such as advice centres. Advances in medicine and especially gerontology and technical assistance should be used in a suitable way for the benefit of all those concerned.

3.3.3 Overall, the particular features of child, adolescent and geriatric psychiatry should be given greater consideration both in the training programmes for general medicine and general psychiatry and in general psychotherapy.

4. Destigmatisation policy

4.1 An approach based on human rights would be of central importance in a European Year of Mental Health. Medical as well as mental welfare services should support the individuals concerned and make them stronger, boosting their potential for self-help through empowerment. The dignity and legal rights of the individual should play a central role here, providing a focus for those supporting that person through their crisis. Furthermore, professionals from different types of services require capacity building in order to increase their understanding of mental health problems and psychosocial disabilities.

4.2 People going through a mental crisis often do not deal with their illnesses because of the social stigma involved. The media contribute significantly to this. The image conveyed of mental illness often generates fear amongst the general public makes people defensive and causes mistrust in useful forms of treatment. Europe-wide campaigns to destigmatise mental illness are urgently required. They must be organised on a long-term basis and focus on prevention. These campaigns should also involve people employed in all legally relevant sectors (justice, police, public authorities, etc.), in order to improve the technical and professional conditions at their disposal for dealing with people with mental health problems. Stigmatisation should also be avoided whenever possible in the organisation and financing of assistance. In particular, facilities to strengthen life management skills should be generally available to all. The promotion of encounters and exchanges between patients and people without psychiatric experience should be a key element of such a policy.

4.3 In employment too, every effort should be made to avoid the creation of separate worlds, which pigeonhole people with mental health problems without taking account of their wishes and their right to choose. First of all, the individuals concerned should be able to decide for themselves whether they carry out supported work in a specialised institution or in a general working environment. In many cases, job-based support enabling those concerned to return to work increases the chances of restoring their working capacity (‘supported employment’) (23). Generally speaking, a standard wage must be paid, which should be negotiated by the social partners. Providing ‘pocket money’ to cover basic needs is not appropriate for people with mental health problems or disabilities. A relatively successful model for gradual reintegration is the so-called Hamburg model (24).

4.4 The following human rights violations against people with mental health problems have been reported in the EU: excessive restrictions on freedom and forced treatment without the informed consent of the person concerned, and often there are few opportunities to appeal. There is an important role for de-institutionalisation programmes, community-based outpatient care services, unbureaucratic access to support, agreements on treatment which respect human rights and a destigmatisation policy, which should also involve people with mental health problems, who are experts on their own lives.

4.5 The EU mental health strategy should be reviewed. Above all, the EESC sees a need to examine the extent to which the exclusion from society of people with mental illness has become widespread, especially in the labour market. The issue of how full and partial work incapacity can be avoided through prevention or good care should also be examined. There is also the question of how the use of language in medicine, the media and society hampers or prevents inclusion.

4.6 This initiative will increase the chances of raising the public profile of mental health issues. It will influence the thematic priorities of the political agenda and create a good climate for promoting innovative ideas which can benefit everyone.

4.7 In order to promote the European Year of Mental Health, not only the EESC itself, but also relevant civil society stakeholders must be involved first and foremost, including groups and associations and other players with experience of psychiatry and health services, as well as the relevant directorates-general of the Commission, MEPs and the Committee of the Regions. At national level, the relevant ministries should participate as well as the members of national parliaments. Those actually affected must be more involved overall in framing the relevant policies.

4.8 In order to ensure that the initiative has a tangible impact in Member States, the Mental Health Action Framework should be used in parallel, involving the development of commonly endorsed reference frameworks for action on mental health through health systems and social policy as well as in relevant fields such as schools and workplaces. As an instrument for mutual learning, peer reviews should be used in a similar way to the OMC. These measures must take the form of legislation, financial rules and activities under the ESF, as well as rights for people with mental health problems and for businesses. Consideration should be given to whether a permanent observatory can provide continuous monitoring of the issue. EU health reporting should include more detailed European data on mental impairment and especially on the type of aid, the number of inpatient psychiatric units and the consumption of psychotropic drugs. Potential partners from right across society should be enlisted over time as long-term supporters. The impact of the initiative and the European year itself should not have a limited timeframe. Instead, they should give rise to a lasting and sustainable awareness of mental health issues and have a tangible impact on those concerned.

Brussels, 13 December 2012. The President of the European Economic and Social Committee Staffan NILSSON

(1) http://www.who.int/mediacentre/factsheets/fs220/en/ (visited 4.10.2012).

(2) COM(2005) 484 final.

(3) The size and burden of mental disorders and other disorders of the brain in Europe 2010, H.U. Wittchen et al., European Neuropsychopharmacology (2011) 21, pp. 655 – 679.

(4) http://www.psychiatrie-psychotherapie.de/archives/14 (visited 15.8.2012).

(5) See footnote 1.

(6) Health report 2010, Techniker Krankenkasse, Germany.

(7) See footnote 6.

(8) Catherine Kilfedder, British Telecom, Hearing EESC, 30.10.2012.

(9) Action for Mental Health. Activities co-funded from European Community Public Health Programmes 1997–2004.

(10) See footnote 1.

(11) COM(2005) 484 final.

(12) European Pact for Mental Health and Well-being, Brussels, 12-13 June 2008.

(13) 309th Council meeting, EPSCO, 6.6.2011.

(14) Press release, Depressions and suicides: how to reduce the human cost of the crisis, EP press service, 25.6.2012.

(15) Health report 2011, Betriebskrankenkassen (BKK), Germany.

(16) Health and Safety Executive, http://www.hse.gov.uk/

(17) European Agency for Health and Safety at the Workplace, Bilbao/Spain.

(18) OJ C 351, 15.11.2012, pp. 45–51.

(19) See details provided by the Bundespsychotherapeutenkammer, Germany, http://www.bptk.de/presse/zahlen-fakten.html (visited 15.8.2012).

(20) OJ C 351, 15.11.2012, p. 6–11.

(21) Study group on psychiatry of AOLG – Report for the regional health minister conference in Germany 2012, 15.3.2012, p. 20.

(22) OJ C 51, 17.2.2011, p. 55-58.

(23) Opinion of the associations belonging to Kontaktgespräch Psychiatrie (psychiatry discussion forum) on the United Nations Convention on the Rights of Persons with Disabilities, Freiburg/Berlin/Stuttgart, 15.5.2012.

(24) Section 74, volume V of the social code and section 28, volume IX of the social code (for people with disabilities or more specifically at risk of disability). The employee agrees on an integration plan with their doctor, which corresponds to the progress of the employee's recovery. The doctor's certificate includes a reintegration plan and, where possible, a prediction of when the employee is expected to be able to work again. The employer and the health insurance fund are required to give their consent before this process begins. Employees continue to receive sick pay from their health insurance fund or an interim allowance from the pension insurance system.