Green Paper - Improving the mental health of the population - Towards a strategy on mental health for the European Union
Date: 2005-10-14
Institutions: European Commission
Subjects: health policy, mental health

COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 14.10.2005 
COM(2005) 484 final 

GREEN PAPER 

Improving the mental health of the population. 
Towards a strategy on mental health for the European Union 

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TABLE OF CONTENTS 

1. 

2. 

3. 

4. 

4.1. 

4.2. 

5. 

6. 

Introduction .................................................................................................................. 3 

Mental health – central for citizens, society and policies ............................................ 4 

The situation – mental ill health, a growing challenge for the EU .............................. 4 

Developing responses: Policy initiatives on mental health.......................................... 5 

The European Community, its mandate and activities in the field of mental health ... 5 

Mental health in Member States .................................................................................. 6 

The need for an EU-strategy on mental health............................................................. 7 

Seeking solutions – options for action ......................................................................... 8 

6.1. 

Promoting mental health and addressing mental ill health through preventive action 8 

6.1.1.  Promoting the mental health of the population ............................................................ 8 

6.1.2.  Addressing mental ill health through preventive action .............................................. 9 

6.2. 

 Promoting the social inclusion of mentally ill or disabled people and protecting their 
fundamental rights and dignity................................................................................... 11 

6.3. 

Improving information and knowledge on mental health in the EU.......................... 12 

7. 

7.1. 

7.2. 

7.3. 

8. 

A consultation process for the development of an EU-strategy on mental health ..... 12 

Creating a Dialogue with Member States on Mental Health ..................................... 13 

Launching an EU-Platform on Mental Health ........................................................... 13 

Developing an interface between policy and research on mental health ................... 13 

Next steps ................................................................................................................... 13 

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GREEN PAPER 

Improving the mental health of the population. 
Towards a strategy on mental health for the European Union 

1. 

INTRODUCTION 

The mental health of the European population is a resource for the attainment of some of the 
EU’s  strategic  policy  objectives,  such  as  to  put  Europe  back  on  the  path  to  long-term 
prosperity,  to  sustain  Europe’s  commitment  to  solidarity  and  social  justice,  and  to  bring 
tangible practical benefits to the quality of life for European citizens1.  

However, the mental health of the EU population can be considerably improved: 

•  Mental ill health affects every fourth citizen and can lead to suicide, a cause of too many 

deaths; 

•  Mental ill health causes significant losses and burdens to the economic, social, educational 

as well as criminal and justice systems; 

•  Stigmatisation,  discrimination  and  non-respect  for  the  human  rights  and  the  dignity  of 

mentally ill and disabled people still exist, challenging core European values. 

Improvement is possible. Many initiatives have already been taken. Further development and 
consolidation  of  the  existing  actions  is  required.  The  January  2005  WHO  European 
Ministerial Conference on Mental Health established a framework for comprehensive action, 
and  created  strong  political  commitment  for  mental  health.  It  invited  the  European 
Commission,  a  collaborating  partner  of  the  conference,  to  contribute  to  implementing  this 
framework  for  action,  in  line  with  its  competencies  and  the  Council’s  expectations  and  in 
partnership with the WHO. 

This Green paper is a first answer to this invitation. It proposes to establish an EU-strategy on 
mental  health.  This  would  add  value:  by  constituting  a  framework  for  exchange  and 
cooperation  between  Member  States;  by  helping  to  increase  the  coherence  of  actions  in  the 
health  and  non-health  policy  sectors  in  Member  States  and  at  Community  level;  and  by 
allowing involvement of a broad range of relevant stakeholders into building solutions.  

The  purpose  of  this  Green  Paper  is  to  launch  a  debate  with  the  European  institutions, 
Governments,  health  professionals,  stakeholders  in  other  sectors,  civil  society  including 
patient organisations, and the research community about the relevance of mental health for the 
EU, the need for a strategy at EU-level and its possible priorities.  

In  accordance  with  the  provisions  made  in  Article  152  of  the  EC  Treaty,  some  of  the 
proposals  for  action  in  the  field  of  public  health  made  in  this  Green  Paper  fall  under 
Community  competence.  Further  proposals  will  be  the  exclusive  competence  of  Member 
States. For proposals for action in other policy fields, the appropriate legal bases will apply. 

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The Commission’s intention is to publish the results of the consultation process together with, 
if appropriate, its proposal for a strategy on mental health for the EU by the end of 2006.  

2. 

MENTAL HEALTH – CENTRAL FOR CITIZENS, SOCIETY AND POLICIES  

There  is  no  health  without  mental  health.  For  citizens,  mental  health  is  a  resource  which 
enables  them  to  realise  their  intellectual  and  emotional  potential  and  to  find  and  fulfil  their 
roles  in  social,  school  and  working  life.  For  societies,  good  mental  health  of  citizens 
contributes  to  prosperity,  solidarity  and  social  justice.  In  contrast,  mental  ill  health  imposes 
manifold costs, losses and burdens on citizens and societal systems.  

Mental health, mental ill health and its determinants: 

The WHO describes mental health as: “a state of well-being in which the individual realizes 
his  or  her  abilities,  can  cope  with  the  normal  stresses  of  life,  can  work  productively  and 
fruitfully, and is able to make a contribution to his or her community”2.  

Mental ill health includes mental health problems and strain, impaired functioning associated 
with  distress,  symptoms,  and  diagnosable  mental  disorders,  such  as  schizophrenia  and 
depression. 

The  mental  condition  of  people  is  determined  by  a  multiplicity  of  factors  (annex  1), 
including  biological  (e.g.,  genetics,  gender),  individual  (e.g.,  personal  experiences),  family 
and social (e.g., social support) and economic and environmental (e.g., social status and living 
conditions). 

3. 

THE SITUATION – MENTAL ILL HEALTH, A GROWING CHALLENGE FOR THE EU 

The health dimension 

More than 27% of adult Europeans are estimated to experience at least one form of mental ill 
health during any one year (see annex 2)3. 

The most common forms of mental ill health in the EU are anxiety disorders and depression. 
By  the  year  2020,  depression  is  expected  to  be  the  highest  ranking  cause  of  disease  in  the 
developed world4. 

Currently, in the EU, some 58,000 citizens die from suicide every year (annex 3), more than 
the annual deaths from road traffic accidents, homicide, or HIV/AIDS5. 

Mental and physical health is closely inter-related. One implication: Integrating mental health 
into  the  provision  of  general  hospital  care  can  significantly  shorten  hospitalization  periods, 
thereby releasing economic resources. 

The impact on prosperity, solidarity and social justice 

The implications of mental ill health are manifold:  

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Mental  ill  health  costs  the  EU  an  estimated  3%-4%  of  GDP,  mainly  through  lost 
productivity6.  Mental  disorders  are  a  leading  cause  of  early  retirement  and  disability 
pensions7. 

Conduct and behavioural disorders in childhood incur costs for the social, educational as well 
as criminal and justice systems (see annex 4)8. 

Further intangible costs concern how society treats mentally ill and disabled persons. Despite 
improved treatment options and positive developments in psychiatric care, people with mental 
ill  health  or  disability  still  experience  social  exclusion,  stigmatisation,  discrimination  or  the 
non-respect of their fundamental rights and dignity. 

4. 

DEVELOPING RESPONSES: POLICY INITIATIVES ON MENTAL HEALTH  

The growing perception of mental ill health as a problem has triggered policy makers, health 
professionals and other stakeholders to look for solutions, most recently at the January 2005 
WHO European Ministerial Conference on Mental Health9. 

There is agreement that a first priority is to provide effective and high-quality mental health 
care and treatment services, accessible to those with mental ill health10. 

However, although medical interventions play a central role in tackling challenges, they alone 
cannot address and change social determinants. Therefore, in line with the WHO strategy, a 
comprehensive  approach  is  needed,  covering  the  provision  of  treatment  and  care  for 
individuals,  but  also  action  for  the  whole  population  in  order  to  promote  mental  health,  to 
prevent  mental  ill  health  and  to  address  the  challenges  associated  with  stigma  and  human 
rights. Such an approach should involve many actors, including health and non-health policy 
sectors  and  stakeholders  whose  decisions  impact  on  the  mental  health  of  the  population. 
Patient organisations and civil society should play a prominent role in building solutions. 

4.1. 

The  European  Community,  its  mandate  and  activities  in  the  field  of  mental 
health 

The mandate for action at Community level in the field of public health is defined in Article 
152  of  the  EC-Treaty.  It  stipulates  that  “a  high  level  of  human  health  protection  shall  be 
ensured  in  the  definition  and  implementation  of  all  Community  policies  and  activities”11. 
Community action shall complement national policies for improving health, preventing illness 
and disease, health information and education, as well as reducing drug-related damage, and 
shall  encourage  cooperation  between  Member  States  in  these  fields.  Member  states  are 
exclusively competent for the organisation of health services and care. For other Community 
policies the appropriate legal bases apply. 

Based on these competencies, mental health is an issue for the European Community through: 

•  The contribution that good mental health of the population can make to some of the EU’s 

strategic policy objectives; 

•  The role of the Community to encourage and support cooperation between Member States 

and to address inequalities between them; and 

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•  The obligation for the Community to contribute to a high level of human health protection 

through all its policies and activities. 

Over the past years, several specific initiatives have been developed in different Community 
policies: 

–  The  Community’s  health  policy  has  covered  mental  health  since  1997  through  specific 
projects and policy initiatives12 (annex 5). The EU Public Health Programme 2003-200813 
provides the legal basis for action. Further related priorities addressed the abuse of drugs 
and the harm done by alcohol. 

–  Initiatives  under  the  Community’s  social  and  employment  policy  targeted  the  non-
discrimination of people with mental ill health, the social inclusion of people with mental 
disabilities, and the prevention of stress at the workplace, including: 

–  The adoption of directive 2000/78/EC which prohibits inter alia discrimination on 

grounds of disability in the field of employment14; 

–  Actions under the European Year for People with Disabilities in 2003; and 

–  The  adoption  of  a  European  Framework  Agreement  on  work-related  Stress 

between social partners in 2004. 

–  The Community’s Framework Programmes for Research have been and continue to be 
an importance source of funding for European research on mental health15. An example is 
the “MHEDEA-2000”-project, which carried out a European assessment of mental health 
disability16 

–  Information  society  and  media  policy  supported  the  development  of  Information  and 
Communication Technology (ICT) -based tools for use in prevention, diagnosis and care17. 

–  Regional policy supports infrastructure investments in the health sector that is beneficial to 

the regions' structural adjustment. 

–  Educational  policy  addresses  mental  health  as  part  of  its  policy  work  (e.g.  on  key 

competences for the knowledge society) and through projects. 

–  As  part  of  the  Community’s  freedom,  justice  and  security  policy,  the  DAPHNE  II-
programme combats violence against children, young people and women18. Such violence 
can cause mental health problems. 

However,  a  comprehensive  strategy  on  mental  health,  which  would  link  all  these  activities, 
does not yet exist at Community level. Such a strategy would strengthen the coherence and 
effectiveness of current and future initiatives. 

4.2.  Mental health in Member States 

There are significant inequalities between (and also within) Member States. One example is 
suicide  rates,  which  range  from  3.6  per  100,000  population  in  Greece  to  44  per  100,000 
population  in  Lithuania,  the  highest  in  the  world19.  The  proportions  of  the  health  budgets 
dedicated to mental health are also highly variable across Member States (see annex 6). 

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The 2004 report “The state of mental health in the European Union”20 found that the status of 
mental  health  is  not  uniform  across  Member  States,  instead,  reflecting  a  diversity  between 
countries, their situations, traditions and cultures.  

Country  stories  compiled  in  the  2005  publication  “Mental  health  promotion  and  mental 
disorder  prevention  across  European  Union  Member  States:  an  overview”21  present 
challenges, policies and structures across Member States. 

Given the diversity between Member States, it is not possible to draw simple conclusions or 
to propose uniform solutions. However, there is scope for exchange and cooperation between 
Member States and the opportunity to learn from each other. 

A number of policy documents adopted by the Council of Ministers since 199922 , signalled a 
wish of Member States to use the EU-level for cooperation in the field of mental health. The 
Council Conclusions adopted in June 2005 reinforced this message by inviting Member States 
to give due attention to the implementation of the results of the WHO European Ministerial 
Conference on Mental Health. The Commission was invited to support this implementation on 
the basis of its competencies. 

5. 

THE NEED FOR AN EU-STRATEGY ON MENTAL HEALTH 

The establishment of a strategy on mental health at EU-level would add value by: 

(1) 

(2) 

(3) 

Creating a framework for exchange and cooperation between Member States; 

Helping to increase the coherence of actions in different policy sectors; 

To  open  up  a  platform  for  involving  stakeholders  including  patient  and  civil  society 
organisations into building solutions. 

The  consultation  should  identify  in  which  way  the  Community’s  policies  and  financial 
instruments, for instance the Framework Programmes  for Research,  contribute to improving 
the mental health of the population. Member States are encouraged to assess with the regions 
and the Commission how the Structural Funds can be better used to improve long-term care 
facilities and  health  infrastructure  in  the field of mental health. A horizontal contribution of 
the  Commission  could  be  to  generate  information  and  knowledge  on  the  status  of  mental 
health in the EU, about the determinants of mental health and the possibilities to tackle mental 
ill health. 

The  WHO’s  strategy  for  the  European  Region,  the  outcomes  of  activities  under  the  EU’s 
Programmes, as well as evidence available in Member States should be used to develop the 
strategy. 

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The Commission proposes that an EU-strategy could focus on the following aspects: 

(1) 

Promote the mental health of all; 

(2) 

Address mental ill health through preventive action; 

(3) 

Improve the quality of life of people with mental ill health or disability through social 
inclusion and the protection of their rights and dignity; and 

(4) 

Develop a mental health information, research and knowledge system for the EU. 

6. 

SEEKING SOLUTIONS – OPTIONS FOR ACTION 

There is a need to translate the existing political commitments into action. Projects under the 
EU’s Public Health Programmes have shown that action is possible and can be successful and 
cost-effective.  Other  projects  have  contributed  to  an  improved  knowledge  and  information 
base on mental health in the EU. 

The network “Implementing Mental Health Promotion Action (IMPHA)”23 has developed an 
Internet database describing existing programmes, a review of the evidence in prevention and 
promotion, and an action plan “Mental health promotion and Mental Disorder Prevention. A 
Policy for Europe”24. 

6.1. 

Promoting  mental  health  and  addressing  mental  ill  health  through  preventive 
action 

Promotion  of  mental  health  and  prevention  of  mental  ill  health  address  individual,  family, 
community and social determinants of mental health, by strengthening protective factors (e.g., 
resilience) and reducing risk factors25 (annex 7). Schools and workplaces, where people spend 
large parts of their time, are crucial settings for action. 

6.1.1.  Promoting the mental health of the population 

Building mental health in infants, children and adolescents 

As mental health is strongly determined during the first years of life, promoting mental health 
in  children  and  adolescents  is  an  investment  for  the  future.  Teaching  parenting  skills  can 
improve  child  development.  A  holistic  school  approach  can  increase  social  competencies, 
improve resilience, and reduce bullying, anxiety and depressive symptoms. 

Some successful actions identified through EU-projects26: 

Babies and children: address postnatal depression in mothers; improve parenting skills; home 
visits of nurses to assist future and new parents; interventions of nurses at school. 

Adolescents and young people: conducive school environment and ethos; resource packs on 
mental health for students, parents and teachers. 

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Promoting mental health in the working population 

While good mental health increases work capacity and productivity, poor working conditions 
including the intimidation by colleagues lead to poor mental health, sick leave and increased 
costs.  Up  to  28%  of  employees  in  Europe  report  stress  at  work27.  Interventions  to  improve 
individual  capacity  and  to  reduce  stressors  in  the  work  environment  increase  health  and 
economic development. 

Some successful actions identified through EU-projects28:  

A participative workplace and management culture; identification of mental ill health in staff; 
working arrangements in line with staff needs (e.g. flexible working time).  

Promoting mental health in older people 

An ageing EU-population, with its associated mental health consequences, calls for effective 
action. Old age brings many stressors that may increase mental ill health, such as decreasing 
functional capacity and social isolation. Late life-depression and age-related neuro-psychiatric 
conditions,  such  as  dementia,  will  increase  the  burden  of  mental  disorders.  Support 
interventions have shown to improve mental well being in older populations. 

Some successful actions identified through EU-projects29:  

Social support networks; encouragement of physical activity and participation in community 
and volunteering programmes.  

Targeting vulnerable groups in society 

Low social and economic status increases vulnerability for mental ill health. Job loss and not 
being  in  employment  can  lower  self-esteem  and  lead  to  depression.  Migrants  and  other 
marginalised  groups  are  at  increased  risk  for  mental  ill  health.  Interventions  for  the 
unemployed to re-enter the labour market can be cost effective. Support to vulnerable groups 
can  improve  mental  health,  strengthen  social  cohesion,  and  avoid  associated  social  and 
economic burdens. 

Some successful actions identified through EU-projects30: 

Counselling for groups at risk; support to enter the labour market; supported employment for 
those with mental ill health or disability. 

Possible initiative at Community level: 

Suggestions developed through the consultation process in response to this Green paper could 
feed into a proposal by the Commission for a Council Recommendation on the promotion 
of mental health31 

6.1.2.  Addressing mental ill health through preventive action 

Preventing Depression 

Depression is one of the most serious health problems in the EU. 

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The  2004  Commission  expert-report  “Actions  Against  Depression”  analyses  depression  and 
its implications for public health as well as social and economic systems, and presents options 
for action32. 

School  approaches  including  life  skills,  and  bullying  prevention,  workplace  approaches  to 
reduce  stress,  and  physical  activity  in  older  groups  can  all  reduce  depressive  symptoms. 
Raising public awareness of depression can encourage seeking help and decrease stigma and 
discrimination. 

Some successful actions:  

Cognitive  behavioural  interventions;  psychological  support  for  those  at  risk;  training  health 
care professionals in prevention, recognition and treatment of depression. 

Reducing substance use disorders 

Alcohol, drugs and other psychoactive substances are often a risk factor for, or a consequence 
of,  mental  health  problems.  Drugs  and  alcohol  are  established  priorities  of  health  policy  at 
Community level: 

- Drugs 

In 2004, the Council adopted a EU Drug Strategy 2005-201233. In 2005, the Council adopted 
a Drugs Action Plan for the years 2005-200834. By the end of 2006 the Commission plans a 
report on the Member States’ implementation of the Council Recommendation35.  

- Alcohol 

In 2001 the Council adopted a Recommendation on the drinking of alcohol by young people. 
The  Commission  is  assessing  the  implementation  of  the  Recommendation,  and  preparing  a 
comprehensive Community strategy to reduce alcohol-related harm.  

Preventing suicide 

Suicide prevention strategies are being developed across Member States. Evidence to prevent 
suicide supports: restricting the access to methods for committing suicide, training of health 
care  providers  and  collaboration  between  secondary  care  and  follow-up  care  after  suicide 
attempts.  

Successful action: 

The  European  Alliance  against  Depression  (EAAD)  aims  to  reduce  depression  and  suicidal 
behaviour  by  creating  regional  networks  of  information  between  the  health  sector,  patients 
and  their  relatives,  community  facilitators  and  the  general  public.  A  pilot  project  showed 
decreases of 25 % in suicides and suicide attempts, particularly among young people36. 

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Possible initiative at Community level: 

Suggestions developed through the consultation process in response to this Green paper could 
feed into a proposal by the Commission for a Council Recommendation on the reduction of 
depression and suicidal behaviour. 

6.2. 

 Promoting the social inclusion of mentally ill or disabled people and protecting 
their fundamental rights and dignity 

People with mental ill health or disability meet fear and prejudice from others, often based on 
misconceptions about mental ill health. Stigma increases personal suffering, social exclusion 
and can impede access to housing and employment. It may even prevent people from seeking 
help for fear of being labelled. Article 13 of the EC Treaty sets out a legal basis for action at 
Community level for combating discrimination inter alia based on disability. There is also a 
need  for  a  shift  in  the  attitudes  of  the  public,  social  partners,  public  authorities  and 
Governments: improving public awareness about mental ill health and treatment options, and 
encouraging  the  integration  of  mentally  ill  and  disabled  people  into  work  life,  can  create 
greater acceptance and understanding across society. 

A change in paradigm 

The  deinstitutionalisation  of  mental  health  services  and  the  establishment  of  services  in 
primary care, community centres and general hospitals, in line with patient and family needs, 
can  support  social  inclusion.  Large  mental  hospitals  or  asylums  can  easily  contribute  to 
stigma.  Within  reforms  of  psychiatric  services,  many  countries  are  moving  away  from  the 
provision  of  mental  health  services  through  large  psychiatric  institutions  (in  some  new 
Member States, such institutions still account for a large share of the mental health services 
infrastructure)  towards  community-based  services.  This  goes  hand  in  hand  with  instructing 
patients  and  their  families  as  well  as  the  staff  in  active  participation  and  empowerment 
strategies37. 

A  study  for  the  Commission,  “Included  in  Society”38,  confirmed  that  replacement  of 
institutions  by  community-based  alternatives  in  general  provides  opportunities  for  better 
quality of life for disabled people. A new study will analyse and present how current financial 
resources  could  be  best  used  to  meet  the  needs of people with disabilities,  and  will provide 
evidence about the cost of de-institutionalisation39. 

Relevant activities of other international organisations: 

Within  the  WHO  network  of  Health  Promoting  Hospitals,  a  Task  Force  on  Health 
Promoting  Psychiatric  Services40  has  identified  models  of  good  practice  of  mental  health 
promotion in psychiatry.  

The Council of Europe in 2006 will initiate work to develop a “European reference tool for 
ethics and human rights in mental health” 

Some patients seek psychiatric inpatient care on a voluntary basis. Compulsory placement of 
patients  in  psychiatric  institutions  and  involuntary  treatment  affects  severely  their  rights.  It 
should only be applied as a last resort, where less restrictive alternatives have failed. 

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The  project  “Compulsory  Admission  and  Involuntary  Treatment  of  Mentally  Ill  Patients  – 
Legislation  and  Practice  in  EU-Member  States”41  showed  that  legal  regulations  across  EU 
countries  were  very  heterogeneous.  Cultural  traditions  and  attitudes  and  the  structure  and 
quality  of  the  mental  health  care  systems  also  determine  actual  practice.  The  prevalence  of 
compulsory admissions varies greatly between Member States. 

Challenges  to  the  mental  health  and  dignity  of  persons  may  also  exist  in  other  residential 
environments, such as nursing homes for older people, children’s homes or prisons. 

Possible initiatives at Community level: 

-  Suggestions  developed  through  the  consultation  process  could  identify  best  practice  for 
promoting the social inclusion and protecting the rights of people with mental ill health 
and disability.  

- People with mental ill health or disability and the situation in psychiatric institutions could 
be  included  in  the  activities  of  the  Fundamental  Rights  Agency  of  the  EU,  which  will 
become operational by 1 January 200742. 

6.3. 

Improving information and knowledge on mental health in the EU 

Mental  health  is  poorly  covered  by  existing  health  monitoring  systems.  Major  efforts  are 
needed  to  harmonise  existing  national  and  international  indicators  on  mental  health  and 
disability in populations to create a comparable dataset across the EU. More data is required 
on the social, demographic and economic determinants of mental health, as well as promotion 
and preventive infrastructures, activities and resources. 

It should be identified how available Community instruments such as the Seventh Framework 
Programme for Research43 could be used to build research capacities and to support research 
for  mental  health  in  the  EU.  Better  knowledge  on  the  relevance  of  mental  health  and  the 
consequences of mental ill health to health, quality of life, economic and social welfare, social 
inclusion  and  fundamental  rights,  and  to  mental  health  services  (e.g.,  equity,  access)  would 
allow improvement of current practice. 

Possible initiative at Community level: 

An interface between policy and research could be established convening Community and 
national authorities, academic institutions and stakeholders. Its role could be to give advice on 
relevant mental health indicators for the EU, the monitoring of mental health, and on priorities 
for research activities at EU-level. 

7. 

A  CONSULTATION  PROCESS  FOR  THE  DEVELOPMENT  OF  AN  EU-STRATEGY  ON 
MENTAL HEALTH 

The crosscutting  relevance of mental health makes it  appropriate to develop an EU-strategy 
on mental health based on a broad and inclusive consultation process.  

The following activities are envisaged: 

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7.1. 

Creating a Dialogue with Member States on Mental Health  

This forum will enable exchange and cooperation between Member States. One objective is to 
identify  priorities and  elements  for an  action plan on mental health, leading to a set of core 
actions  in  health  and  non-health  policies  together  with  targets,  benchmarks,  timelines  for 
action and a mechanism to monitor implementation. The WHO Mental Health Action Plan for 
Europe  could  serve  as  model,  together  with  the  Action  Plan  “Mental  Health  Promotion  and 
Mental  Disorder  Prevention:  A  Policy  for  Europe”  developed  under  the  EU-Public  Health 
Programme44.  The  Dialogue  should  also  consider  the  need  for  the  two  proposed  Council 
Recommendations  on  a)  the  promotion  of  mental  health  and  b)  the  reduction  of  depression 
and suicidal behaviour. 

7.2. 

Launching an EU-Platform on Mental Health 

The EU-Platform on Mental Health should promote cross-sectoral cooperation and consensus 
on  mental  health  through  involving  a  variety  of  actors  such  as  policy  makers,  experts  and 
stakeholders from the health and non-health sectors, and representatives of civil society. The 
Platform should analyse key mental health aspects, identify evidence-based practice, develop 
recommendations  for  action,  also  at  Community  level,  and  identify  best  practice  for 
promoting  the  social  inclusion  of  people  with  mental  ill  health  and  disability  and  for 
protecting their fundamental rights and dignity, all of which can be fed into the Dialogue with 
Member States. 

7.3. 

Developing an interface between policy and research on mental health 

This  third  group  shall  engage  relevant  stakeholders  to  stimulate  a  dialogue  around  the 
development of an indicator system that would include information on mental health and its 
determinants,  impact  assessment  and  evidence  based  practice.  It  would  explore  the  most 
effective  ways  to  identify  research  priorities,  and  to  ensure  a  better  interface  between  data 
systems,  research  knowledge  and  policy-making.  Its  recommendations  could  be  included  in 
the Action Plan. 

8. 

NEXT STEPS  

There  is  widespread  agreement  that  the  human,  social  and  economic  dimension  of  mental 
health  need  wider  recognition  by  policy  makers  and  greater  public  awareness.  Important 
initiatives are being taken at the level of Member States, the EU and the WHO. 

The Commission invites all interested citizens, parties, organisations and the European Union 
institutions to contribute to the preparation of a possible EU-Strategy and an Action Plan on 
Mental Health by commenting on this Green Paper. 

The Commission is particularly interested in views on the following questions: 

(1) 

How  relevant  is  the  mental  health  of  the  population  for  the  EU’s  strategic  policy 
objectives, as detailed in section 1? 

(2)  Would the development of a comprehensive EU-strategy on mental health add value to 
the existing and envisaged actions and does section 5 propose adequate priorities? 

EN 

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(3) 

Are the initiatives proposed in sections 6 and 7 appropriate to support the coordination 
between  Member  States,  to  promote  the  integration  of  mental  health  into  the  health 
and non-health policies and stakeholder action, and to better liaise research and policy 
on mental health aspects? 

Contributions in the context of this consultation process should be sent to the Commission by 
31  May  2006,  by  email  to  the  address  “mental-health@cec.eu.int”,  or  by  post  mail  to  the 
following address: 

European Commission 

Directorate-general for Health and Consumer Protection 

Unit C/2 “Health Information” 

L-2920 Luxembourg 

This  Green  paper  and  the  contributions  received  will  be  published  on  the  Commission’s 
website45,  unless  requests  not  to  do  so  have  explicitly  been  made.  In  late  2006,  the 
Commission  intends  to  present  its  analysis  of  the  responses  received  together  with,  if 
appropriate, its proposal and/or initiatives for a strategy on mental health for the EU. 

EN 

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ANNEX 1 
The functional model of mental health 

antecedent
antecedent
PRED ISPOSIN G 
PRED ISPOSIN G 
FACTORS
FACTORS
•
•
s
s

- genetic factors
- genetic factors
- factors related to 
- factors related to 

pregnancy and birth
pregnancy and birth

- early childhood
- early childhood
experiences
experiences

- family environment
- family environment
- social circumstances
- social circumstances
- physical environment
- physical environment
- education
- education
- employment
- employment
- work conditions
- work conditions
- housing
- housing

society & culture
society & culture

precipitating
precipitating
•
•
factors
factors

PRECIPITATIN G
PRECIPITATIN G

e.g. life events
e.g. life events

M EN TAL H EALTH
M EN TAL H EALTH

Individual resources
Individual resources

present social context
present social context

PRESEN T SOCIAL 
PRESEN T SOCIAL 
CO N TEX T
CO N TEX T

e.g. social support
e.g. social support

society & culture
society & culture

outcomes
outcomes

O U TCO M ES
O U TCO M ES

- level of wellbeing
- level of wellbeing
- physical health
- physical health
- symptoms
- symptoms
- knowledge & 
- knowledge & 

skills
skills

- quality of 
- quality of 

relationships
relationships

- sexual satisfaction
- sexual satisfaction
- use of services
- use of services
- productivity
- productivity
- public safety
- public safety

Source:  

Lahtinen, E., Lehtinen, V., Riikonen, E., Ahonen, J. (eds.): Framework for promoting mental 
health in Europe, Hamina 1999 

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15 

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ANNEX 2 
Estimated number of subjects in the general EU population (age 18–65) affected by 
mental disorders within past 12 months46 

Diagnosis (DSM-IV) 

12-month estimate (%) 

12-month estimate (million) 

Alcohol dependence 

Illicit substance dependence 

Psychotic disorders 

Major depression 

Bipolar disorder 

Panic disorder 

Agoraphobia 

Social phobia 

Generalised  Anxiety  Disorder 
(GAD) 

Specific phobias 

Obsessive-compulsive 
(OCD) 

Disorder 

Somatoform disorders 

Eating disorders 

2.4 

0.7 

1.2 

6.1 

0.8 

1.8 

1.3 

2.2 

2.0 

6.1 

0.9 

6.3 

0.4 

Any mental disorder 

27.4 

Source: 

7.2 

2.0 

3.7 

18.4 

2.4 

5.3 

4.0 

6.7 

5.9 

18.5 

2.7 

18.9 

1.2 

82.7 

Hans-Ulrich Wittchen, Frank Jacobi (2005). Size and burden of mental disorders in Europe: a 
critical  review  and  appraisal  of  27  studies.  European  Neurospsychopharmacology,  Volume 
15,  Number  4,  pp.  357-376.  12-months  values  rounded  by  Commission.  Percentage  values 
based on Commission’s own calculations. 

EN 

16 

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ANNEX 3 
Standardised death rate for suicide per 100.000 people across EU Member States in 
200247 

44

50

45

40

35

30

25

20

15

10

5

0

27.3

26 25.4

24.5

19.9 19.5 18.4

17 16.8

14.7 13.7 13 12.7 12.2 11.7 11.5 10.5 10.1

9.1

7.1 6.8 6.8

6

3.6

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ANNEX 4 
Long term economic costs of mental health problems. Costs converted to Euros and 
2002 prices used 

Financial costs of social exclusion: long term 
follow up of children without and with conduct 
problems or disorders

Crime

Lost employment

Relationships

Foster and residential
care
Health

No
problems

Conduct
Problems

Conduct
Disorder

Education

s
o
r
u
E

140000

120000

100000

80000

60000

40000

20000

0

Source: 

Scott, S.; Knapp, M.; Henderson, J.; Maughan, B.: Financial cost of social exclusion. Follow-
up study of anti-social children into adulthood, British Medical Journal (BMJ), 323, 191-196. 
Costs  converted  into  Euro-values  by  David  McDaid,  Mental  Health  Economics  European 
Network.  

EN 

18 

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ANNEX 5 
Summary of selected EC events relating to mental health between 1999 and 2005 

Year 

Title of the event 

Level 

Council 
resolutions/conclusions 

04/1999  Balancing  Mental 

Health 
Promotion  and  Mental  Health 
Care 

Joint  EU/WHO 
Meeting 

10/1999 

Conference 

European 
on 
Promotion  of  Mental  Health  and 
Social Inclusion 

EU Presidency 

03/2000  Health Determinants in the EU 

EU Presidency 

06/2000  Violence  and  Promotion  of 
Mental  Health  of  Children  and 
Young People 

EU Presidency 

09/2000 

Prevention of Youth Suicide 

EU Presidency 

Council resolution on the 
of  mental 
promotion 
health 

Council 
action 
determinants 

resolution  on 
health 
on 

01/2001  Young People and Alcohol 

WHO  Ministerial 
conference/EU 
Presidency 

Council conclusions on a 
Community  strategy 
to 
alcohol-related 
reduce 
harm 

09/2001 

Future Mental Health Challenges 
in  Europe:  Impact  of  Other 
Policies on Mental Health 

Joint  EU/WHO 
Meeting 

10/2001  Coping  with 

and 
Depression-Related  Problems  in 
Europe 

Stress 

Joint 
Presidency 
WHO 

EU 
and 

Council  conclusions  on 
and 
stress 
combating 
depression-related 
problems 

12/2002 

Future Mental Health Challenges 
in  Europe:  Strengthening  Co-
operation between EU and WHO 

Joint  EU/WHO 
seminar 

03/2003  Mental  Illness  and  Stigma  in 
Europe:  Facing  up 
the 
Challenges  of  Social  Inclusion 
and Equity 

to 

Joint 
EU 
Presidency, WHO 
and  Council  of 
Europe 

Council  conclusions  on 
combating  stigma  and 
discrimination  in  relation 
to mental health 

EN 

19 

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10/2003  Mental  Health  in  Europe:  New 

Challenges, New Opportunities 

09/2004 

The  Mental  Health  of  Children 
and Adolescents 

EC-funded 
conference/co-
sponsored by WHO 

Jointly  organised  by 
Commission/WHO/
Luxembourg 

01/2005  WHO 

Europe  Ministerial 

Conference on Mental Health 

Commission  as  a 
coorganiser 

EN 

20 

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ANNEX 6 
Mental Health Expenditure in European Economic Area countries (% of total health 
expenditure) 

16

14

12

10

8

6

4

2

0

Luxembourg

Source: 

Germany
Sweden
UK

Hungary
Netherlands
Malta

Denmark

Lithuania

Cyprus

Ireland

Iceland

Belgium

Spain

Latvia

Portugal
France

Slovakia
Czech

Mental Health Economics European Network (2004) 

EN 

21 

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ANNEX 7 
Social, environmental and economic determinants of mental health 

Risk factors 

Protective factors 

Access to drugs and alcohol 

Empowerment 

Displacement 

Ethnic minorities integration 

Isolation and alienation 

Positive interpersonal interactions 

Lack of education, transport, housing 

Social participation 

Neighbourhood disorganisation 

Social responsibility and tolerance 

Peer rejection 

Social services 

Poor social circumstances 

Social support and community networks 

Poor nutrition 

Poverty 

Racial injustice and discrimination 

Social disadvantage 

Urbanisation 

Violence and delinquency 

War 

Work stress 

Unemployment 

Source: 

WHO: Prevention of Mental Disorders. Effective Interventions and Policy Options, Summary 
Report, Geneva 2004, p.21 

EN 

22 

   EN 

 
 
 
 
 
 
 
 
 
 
REFERENCES 

1 

2 
3 

4 
5 

6 
7 

8 

9 

10 

11 
12 

13 

14 

15 

16 

17 

18 
19 
20 

Communication  “Strategic  Objectives  2005-2009.  Europe  2010:  A  Partnership  for  European  Renewal. 
Prosperity, Solidarity and Security”, COM(2005)12 of 26.01.2005 
WHO, Strengthening mental health promotion, Geneva 2001 (Fact sheet no. 220) 
Wittchen HU, Jacobi F: Size and burden of mental disorders in Europe: a critical review and appraisal of 
27  studies.  European  Neurospsychopharmacology,  Volume  15  (2005),  Number  4,  pp.  357-376. 
Percentage values based on Commission’s own calculations. 
WHO, World Health Report 2001, p. 11. http://www.who.int/whr/2001 
Deaths  caused  by  traffic  accidents:  50700,  homicide:  5350,  HIV/AIDS:  5000,  WHO  figures  for  2002. 
Own calculations based on Eurostat statistics and WHO Health For All Mortality Database  
Estimation by ILO. http://agency.osha.eu.int/publications/newsletter/8/en/index_23.htm 
As  confirmed  by  Mental  Health  Economics  European  Network,  project  co-funded  from  Community 
Health  Promotion  Programme  (1997-2002),  implemented  by  Mental  Health  Europe-Santé  Mentale 
Europe, (2001-2003), http://www.mentalhealth-econ.org. 
Scott  S,  Knapp  M,  Henderson  J,  Maughan  B:  Financial  costs  of  social  exclusion:  follow-up  study  of 
antisocial children into adulthood, British Medical Journal, 323 (2001), 191-196. 
The conference established a Mental Health Declaration for Europe and a Mental Health Action Plan for 
Europe, both for the WHO European Region. http://www.euro.who.int/mentalhealth2005 
Only 26% of adult Europeans with a mental disorder have a contact with formal health services (Alonso, 
J., Angermeyer, M., Bernert, S.et al. (2004). Use of Mental Health Services in Europe: Results from the 
European  Study  on  Epidemiology  of  Mental  Disorders  (ESEMeD)  Project.  Acta  Psychiatr  Scand;  109 
(suppl 420): 47-54. 
Article 152 of the EC Treaty, http://europa.eu.int/eur-lex/en/treaties/selected/livre235.html 
An overview is given in the publication: “Action for Mental Health. Activities co-funded from European 
Community Public health Programmes 1997-2004”,  
http://europa.eu.int/comm/health/ph_determinants/life_style/mental_health_en.htm.  A 
completed and ongoing such projects can be found under:  
http://europa.eu.int/comm/health/ph_projects/project_en.htm 
Decision  No  1786/2002/EC  of  the  European  Parliament  and  of  the  Council  of  23  September  2002 
adopting a programme of Community action in the field of public health (2003-2008). Official Journal L 
271, 09.10.2002 
Council  Directive  2000/78/EC  of  27  November  2000  establishing  a  general  framework  for  equal 
treatment in employment and occupation, Official Journal L303 of 2.12.2000, 16-22 
Fifth Framework Programme for research, technological development and demonstration activities (1998 
to  2002),  Decision  No  182/1999/EC  of  the  European  Parliament  and  of  the  Council  of  22.12.1998, 
Official  Journal  L26/1  of  01.02.1999,.Sixth  Framework  Programme  for  research,  technological 
development and demonstration activities covering the period 2002-2006, Decision N° 1513/2002/EC of 
the  European  Parliament  and  of  the  Council  of  27.06.2002,  Official  Journal  L232/1  of  29.08.2002; 
Official Journal L294/1 of 29.10.02. 
Mental health disability : a european assessment in the year 2000, MHEDEA-2000, RTD Project QLG5-
1999-01042, 
http://dbs.cordis.lu/fep-cgi/srchidadb?ACTION=D&SESSION=41092005-9-
8&DOC=18&TBL=EN_PROJ&RCN=EP_DUR:36&CALLER=PROJ_LIFE 
A  list  of  health-related  projects  under  the  Information  Society  Technologies  Programme  (IST)  under 
Reseach Framework Programmes can be found under    
http://www.cordis.lu/ist/ka1/health/projectbooklet/others.htm.  Mental  health-related  projects 
MULTIPLE, ALDICT, ACTION, TASK, ASTRID, MEDIATE and VEPSY UPDATED.  
http://europa.eu.int/comm/justice_home/funding/daphne/funding_daphne_en.htm 
Eurostat. Figures for 2002 (Greece: latest available figure), as in annex 2. 
Project co-funded from the Community Health Monitoring Programme (1998-2002), implemented by the 
Mutelle  Générale  de  l’Education  Nationale,  Paris  (2001-2004).  The  project  covered  the  former  15 
Member States of the EU, Norway and Iceland, 
.http://europa.eu.int/comm/health/ph_projects/2001/monitoring/fp_monitoring_2001_frep_06_en.pdf.  A 
corresponding  project  to  collect  data  and  information  for  the  new  Member  States  is  currently  being 
implemented  as  part  of  the  “project  “Mental  health  Information  and  Determinants  for  the  European 
Level”,  cofunded  from  the  Community  Public  Health  Programme  (2003-2008),  implemented  by 
STAKES, Finland, http://www.stakes.fi/mentalhealth/mindful.html. 

include 

list 

all 

of 

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21 

22 

23 

24 

25 

26 

27 

28 

29 
30 

31 

32 

33 
34 
35 
36 

37 

38 

3 

of 

on 

and 

June 

2005. 

conclusions 

a  Community  Mental  Health  Action 

Established through the project co-funded from the Community Public Health Programme (2003-2008): 
Generalitat  de  Catalunya,  European  Platform  for  Mental  Health  Promotion  and  Mental  Disorder 
Prevention: indicators, interventions and strategies. Http://www.impha.net 
Council  resolution  of  18  November  1999  on  the  promotion  of  mental  health.  Official  Journal  C  086, 
24/03/2000 P. 0001 - 0002, Council Recommendation of 5 June 2001 on the drinking of alcohol by young 
people. Official Journal L161, 16/06/2001, P. 0038- 0041 
Council  conclusions  of  5  June  2001  on  a  Community  strategy  to  reduce  alcohol-related  harm.  Official 
Journal C 175, 20/06/2001 P. 0001- 0002 
Council conclusions of 15 November 2001 on combating stress and depression-related problems. Official 
Journal C 006 , 09/01/2002 P. 0001 - 0002 
Council Conclusions on combating stigma and discrimination in relation to mental illness of 2 June 2003. 
Official Journal C 141, 17/06/2003 P.0001-0002 
Council 
http://europa.eu.int/comm/health/ph_determinants/life_style/mental/docs/ev_20050602_en.pdf  
Project  co-funded  under  Community  Health  Promotion  Programme  (1997-2002):  Academic  Centre  of 
Social  Sciences,  University  of  Nijmegen:  Integrating  mental  health  promotion 
interventions  
into countries's policies, practice and the health care system (2002-2005), www.imhpa.net 
The documents can be downloaded under 
http://europa.eu.int/comm/health/ph_projects/2002/promotion/fp_promotion_2002_frep_16_en.pdf 
http://www.imhpa.net 
For further reading: WHO: Promoting Mental Health. Concepts, Emerging Evidence, Practice. Summary 
Report, Geneva 2004; WHO: Prevention of Mental Disorders. Effective Interventions and Policy Options, 
Summary Report, Geneva 2004. http://www.who.int/mental/evidence/en 
Projects  co-funded  from  the  Community  Health  Promotion  Programme:  Mental  Health  Europe-Santé 
Mentale  Europe,  Mental  Health  Promotion  of  Adolescents  and  Young  People  (2000-2001), 
http://europa.eu.int/comm/health/ph_projects/2000/promotion/promotion_project_2000_full_en.htm#14; 
Mental Health Europe-Santé Mentale Europe, Mental Health Promotion of Children up to 6 years of Age 
(1997-1999), 
http://europa.eu.int/comm/health/ph_projects/1998/promotion/promotion_project_1998_full_en.htm#17. 
Merllie, D. & Paoli, P. (2001) Ten years of working conditions in the European Union. Dublin: European 
Foundation for the Improvement of Living and Working Conditions  
Projects  co-funded  from  the  Community  Health  Promotion  Programme:  Belgische  Interuniversitair 
Centrum,  Coping  with  Stress  and  Depression-related  Problems 
(2001-2003), 
http://europa.eu.int/comm/health/ph_projects/2001/promotion/promotion_project_2001_full_en.htm#7; 
Mental  Health  Promotion  and  Prevention  Strategies  for  Coping  with  Anxiety,  Depression  and  Stress 
related disorders in Europe (2001-2003), 
http://europa.eu.int/comm/health/ph_projects/2001/promotion/promotion_project_2001_full_en.htm#2 
as in footnote 21 
Project co-funded from the Community Health Promotion Programme: Universidad de Deusto, Faculty of 
Sociology, Unemployment and Mental Health,  
http://europa.eu.int/comm/health/ph_projects/1999/promotion/promotion_project_1999_full_en.htm#6 
Council  Resolution  of  18.11.1999  (cf.  footnote  22)  on  the  promotion  of  mental  health  invited  the 
Commission  to  consider,  after  consultation  of  the  member  states,  the  need  to  draw  up  a  proposal  for  a 
Council recommendation on the promotion for mental health.  
Expert Report “Actions against depression. Improving mental and well-being by combating the adverse 
health, social and economic consequences of depression”, Commission 2004. 
http://europa.eu.int/comm/health/ph_determinants/life_style/mental/depression_en.htm 
http://europa.eu.int/comm/health/ph_determinants/life_style/drug/documents/drug_strategy0512_en.pdf 
Official Journal C 168 of 08/07/2005, p. 1-18  
http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/l_165/l_16520030703en00310033.pdf 
Project co-funded under the Community Public Health Programme 2003-2008, implemented by Ludwig 
Maximilians-University Munich (2004-2005), http://www.eaad.net 
Berger, H (1999). Health Promotion - A Change in the Paradigms of Psychiatry. In: Berger, H., K. Krajic, 
R.  Paul  (Hrsg.):  Health  Promoting  Hospitals  in  Practice:  Developing  Projects  and  Networks.  Conrad, 
Gamburg 
Project  under  the  European  Social  Fund:  Inclusion  Europe,  Included  in  Society  (2003-2004), 
http://europa.eu.int/comm/employment_social/index/socinc_en.pdf 

in  Europe 

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39 

40 
41 

42 
43 

44 

45 
46 
47 

Comparative  cost  analysis:  Community  based  services  as  an  alternative  to  institutions",  tender  no. 
VT/2005/021, Official Journal on 22 June 2005 N° 2005/S 119-117014 
http://www.hpps.net 
Project  co-funded  from  the  Community  Health  Monitoring  Programme  (1997-2002),  implemented  by 
Central Institute of Mental Health, Mannheim (2000-2002). 
http://europa.eu.int/comm/health/ph_projects/2000/promotion/promotion_project_2000_full_en.htm#8 
COM(2005)280 of 30 June 2005  
Proposal  for  a  Decision  of  the  European  Parliament  and  of  the  Council  concerning  the  Seventh 
Framework  Programme  of  the  European  Community  for  research,  technological  development  and 
demonstration activities (2007 to 2013) COM(2005) 119 final of 6th April 2005 
Developed  under  The  project  “Implementing  Mental  Health 
www.imhpa.net 
http://europa.eu.int/comm/health/ph_determinants/life_style/mental/green_paper/consultation_en.htm 
Total population EU countries (plus Iceland, Norway, Switzerland; age 18-65): 301,7 million 
Source:  Eurostat,  For  Greece  latest  year  available.  Please  note  that  the  official  statistics  very  likely 
underestimate  death  from  suicide.  Recording  a  death  as  suicide  depends  on  many  factors,  including 
cultural and religious ones. 

into  Policy  Actions  (IMHPA)” 

EN 

25 

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