Opinion of the European Economic and Social Committee on the Green Paper Improving the mental health of the population — Towards a strategy on mental health for the European Union (COM(2005) 484 final)
Date: 2006-05-17
Institutions: European Economic and Social Committee
Subjects: health policy, mental health

C 195/42

EN

Official Journal of the European Union

18.8.2006

Opinion of the European Economic and Social Committee on the Green Paper Improving the
mental health of the population — Towards a strategy on mental health for the European Union

(COM(2005) 484 final)

(2006/C 195/11)

On 14 October 2005 the Commission decided to consult the European Economic and Social Committee,
under Article 262 of the Treaty establishing the European Community, on the abovementioned proposal.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the
Committee's work on the subject, adopted its opinion on 3 May 2006. The rapporteur was Mr Bedossa.

At its 427th plenary session, held on 17 and 18 May 2006 (meeting of 17 May), the European Economic
and Social Committee adopted the following opinion by 142 votes to 1 with 1 abstention.

1. Summary

— the explosion in mass demand throughout society, driven

by a shift from psychiatry to mental health,

There can be no ambiguity about the importance of mental
health in Europe or the need for a strategy in this area, which:

— the irreversible entry onto the scene of patients and/or their
representatives, who now have an impact on all policies,

— Covers several different aspects, namely:

— improving health education,

— reacting more rapidly to health threats,

— reducing health inequalities,

— the imbalance between hospital and outpatient care and
problems of flexibility across the whole spectrum of health-
care from emergency to medico-social services.

— guaranteeing a high level of social protection and good

health by means of an intersectoral strategy.

2. The issue

— Defines objectives:

— promoting the mental health of all,

— putting prevention to the fore,

— improving the quality of life of people with a mental

illness or psychiatric disability, and

— developing a mental health information system and

research programme for the EU.

— Draws up recommendations, specifically:

— a pilot project on the creation of regional information

networks linking all the various players,

Five of the ten leading causes of disability worldwide are
2.1
psychiatric conditions, meaning that mental
ill health has
devastating social and economic consequences for individuals,
families and governments.

People with mental health problems often experience
their

2.2
discrimination or exclusion and serious violations of
fundamental rights.

There is an association between mental ill health and
2.3
illnesses and
poverty, which increases the risk of mental
reduces access to the medical treatment essential to mental
health. Accordingly, states should put mental health problems
high up on their public health agenda.

— promoting the process of deinstitutionalisation, to make

better use of available resources.

2.4
However, mental health is often not a priority, partly
because not all countries have the requisite capacity to establish
comprehensive and efficient mental health services.

— Determines best practice for promoting the social inclusion
and protecting the rights of people with a mental illness or
psychiatric disability, which should be one of the responsi-
bilities of
the European Union's Fundamental Rights
Agency.

The emerging recognition of the importance of mental health
is connected with several different factors:

2.5
The Community's mental health instrument comes
under the European Union's public health programme for
2003-2008, which is based on Article 152 of the EU Treaty.
However, the ensuing actions must take account of Member
States' competences in relation to organising health services
and providing health care.

18.8.2006

EN

Official Journal of the European Union

C 195/43

2.6
The Commission's Green Paper aims to launch a broad-
ranging debate on managing mental ill health and promoting
mental health, at EU level, within the framework of the Euro-
pean Action Plan. Its reasons for doing so are:

— There is no health without mental health, which is impor-
tant both for
individuals and societies. Mental health
enables individuals to realize their potential and find their
roles in social, school and working life and is a vital source
of social cohesion for the EU,
if it wishes to become a
knowledge society.

— Mental health problems are a heavy burden. Everyone
knows someone close to them who suffers from mental ill
health. Mental health problems impair the quality of life of
those who suffer from them and their families. Mental ill
health is a major cause of disability.

— Mental ill-health has a high social and economic cost and
imposes significant losses and burdens on the economic,
social and educational as well as criminal and justice
systems. Evidence from certain countries shows that mental
disorders are one of the leading causes of absence from
work, early retirement and disability pensions.

— Stigmatisation, discrimination and non-respect

the
human rights and the dignity of people with a mental
illness or psychiatric disability still exist. Treatments may
fail
fundamental rights and dignity,
giving rise to feelings of defiance against society and
thereby lessening the EU's ‘social capital’.

to respect patients'

for

2.7
Following the January 2005 World Health Organisation
(WHO) European Ministerial Conference on Mental Health, in
the European Commission, a collaborating
October 2005,
the conference, published a Green Paper on
partner of
Improving the mental health of the population: Towards a strategy on
mental health for the European Union, based on the provisions for
public health set out in Article 152 of the EC Treaty, and
launched an EU-wide consultation process on mental health.

2.8
The clearly stated purpose is to improve the mental
health of the European population, as an element in a strategy
whose policy objectives go beyond the health field itself to
include putting Europe ‘back’ on the path to long-term pros-
perity and improving solidarity, social
justice and quality of
life.

The Green Paper is intended to stimulate debate and
2.9
launch a consultation process with the public authorities,
health professionals
in 2006,
resulting in proposals for action at Community level at the end
of 2006, that will constitute the EU's strategy on mental health.

and patient organisations

mental ill health during any one year, of which 6.3 % are soma-
toform disorders, 6.1 % major depressions and 6.1 % phobias.

3.1.2
than from road traffic accidents or HIV/AIDS.

Currently, in the EU, more citizens die from suicide

The implications for society are manifold and the
3.1.3
report gives a cost analysis covering loss of productivity, and
the expenditure incurred by the social welfare, education, penal
and judicial systems.

3.1.4
within, Member States.

There are significant inequalities between, and also

3.2 … which justifies an EU level mental health strategy

3.2.1
currently has several objectives:

The European Union's public health programme

— improving health information,

— reacting more rapidly to health threats,

— guaranteeing a high level of social protection and good

health by means of an intersectoral strategy,

— reducing health inequalities.

3.2.2
following objectives:

A Community mental health strategy could have the

— promoting the mental health of all,

— addressing mental ill health through preventive action,

— improving the quality of life of people with a mental illness
inclusion and the

or psychiatric disability through social
protection of their rights and dignity, and,

— developing a mental health information,

research and

knowledge system for the EU.

Possible initiatives at Community level could include
3.2.3
Council recommendations on the reduction of depression and
suicidal behaviour, modelled on a pilot project on the creation
of regional
information networks linking the health sector,
patients and their relatives and community facilitators, which
led to decreases in suicide rates of 25 % amongst young people.

3. The analysis and proposals contained in the Green

Paper

3.1 An unambiguous statement on the importance of mental health

for Europe

3.1.1
According to informed estimates, 27 % of adult
Europeans are estimated to experience at least one form of

In connection with its work to promote the social
3.2.4
illness or psychiatric
inclusion of people with a mental
disability, the European Commission invites the Member States
to speed up the process of deinstitutionalisation.
In recent
years, it has funded a study that has confirmed that replace-
ment of psychiatric institutions by community-based alterna-
tives improves quality of life for patients. In June 2005, a call
for tenders was launched for a new study to analyse and
present how current financial resources could be best used and
provide evidence about the cost of de-institutionalisation.

C 195/44

EN

Official Journal of the European Union

18.8.2006

3.2.5
work at Community level:

Other initiatives could be envisaged within this frame-

— The European Union could identify models of best practice
for promoting the social inclusion and protecting the rights
of people with a mental illness or psychiatric disability.

— The situation of people with a mental illness or psychiatric
disability and psychiatric institutions should be guaranteed
by the fundamental rights and human rights set out in the
Charter contained in the draft European Constitution.

3.2.6
The European Union wishes to improve knowledge on
mental health by supporting research programmes and estab-
lishing interfaces between policy and research.

4. Point of view on the proposals

4.1 The emerging recognition of the importance of mental health is

connected with several different factors

The past few years have been marked by a number of
4.1.1
phenomena,
including an explosion in demand throughout
society, a paradigm shift from psychiatry to mental health and
the now irreversible entry onto the scene of patients and their
relatives. Each of these aspects has led to changes in laws and
regulations,
countries,
rhythms
depending on the degree to which they have been taken into
account at political and administrative levels.

in different

at different

is

to saturation point,

The extensive demand, which has brought all

4.1.2
the
linked with the
available services
complex interaction between society's changing image of
mental illness and psychiatry, which has become more gener-
ally accepted or less stigmatised, and the services on offer. This
change, which has been experienced in all developed countries
over the same period, is reflected in the epidemiology, which
shows: 15 to 20 % of the diagnosable mental disorders preva-
lent in any one year in the general population, 12 to 15 % —
as many as cardio-vascular disease and twice as many as cancer
— resulting in disabilities, and 30 % of all the years lost to
premature death or invalidity (WHO, 2004). This pressure is
also reflected in the expansion of health planning, which has
attributed psychiatry a growing range of tasks over the years.

burden or be supported in resuming their position as the main
actors in assistance or therapy. This dialectic and the some-
times-conflicting tensions between clinical, ethnical and organi-
from
sational
psychiatry to mental health. They also sometimes give rise to
contradictory terminology, particularly in official documents.
However, at international level, the literature generally makes a
clear distinction between psychiatry and mental health.

to the paradigm shift

issues bear witness

Lastly, the final and far from least important aspect
4.1.4
has been the growing power of users and representatives of
families. This is evidence of a wide-reaching change, both in
France and worldwide, which is not confined to psychiatry and
has been intensified by various diseases (such as HIV/AIDS),
which have transformed the relationship between doctors and
patients. One of the most noteworthy signs of this change is
the emergence of legislation on patients' rights and the refer-
ence to users and their families in administrative documents
relating to the organisation of psychiatric services and response
to needs and their actual implementation.

4.1.5
Community representatives and representatives of all
potential users have also taken a more active role. There are
increasing interfaces between municipal policy and health
policy. Elected representatives are increasingly drawn in by the
repercussions of the changes in psychiatry, which increasingly
require their involvement.

4.1.6
These changes have made the imbalance between
hospital and outpatient care and the problems of flexibility
along the whole care spectrum, from emergency to medico-
social services, all the more acute. They have also drawn atten-
tion to the frequent failures of deinstitutionalisation, the incom-
plete integration of psychiatry into general hospitals. Given the
porous nature of
the boundaries between the medical and
social fields and between professions and training, initial and
continuous training for new functions are a key to future solu-
tions. In addition to these profound changes, new issues have
emerged,
including those of prisoners with mental disorders
and elderly people with neurodegenerative pathologies that
translate into mental disabilities and particularly deprived
groups of the population.

4.1.3
The combination of increasing demand and changing
perceptions has led to increasing demands for outpatient care,
thus blurring the traditional polar distinction between illness
and health by drawing attention to the continuum of clinical
states, up to and including mental suffering. It is now impos-
sible to separate mental disorders from the social environment
in which they emerge and necessary to include the social
impact of mental disorders in needs assessments. One of
psychiatry's main tasks is now to distinguish between psychia-
tric and non-psychiatric cases and to define what warrants
psychiatric intervention, but without narrowing the approach
to this aspect alone, so that other partners can share the

In most developed countries,

4.1.7
the accumulation of
factors including the end of the Second World War, the aware-
the experience of concentration camp victims and
ness of
human rights, a critical view of psychiatric hospitalisation as
practised at the time, the development of psychoactive drugs,
the emergence of patients' movements and budget constraints,
have plunged psychiatry into a process of transformation that
the international literature refers to as ‘de-institutionalisation’.
This means moving the focus of care and services away from
hospitalisation towards approaches based on keeping patients
within their own environment.

18.8.2006

EN

Official Journal of the European Union

C 195/45

4.1.8
However, a number of stumbling blocks have emerged
whenever deinstitutionalisation has been based on dehospitali-
sation: a tendency for society and psychiatry to hold large
numbers of people with mental disorders in prison or transfer
them to it, vulnerable or marginal patients left to their own
devices, whose care has been broken off or finished, without
housing or welfare benefits and becoming homeless; the so-
called ‘revolving door syndrome’ whereby some patients enter
into a vicious circle of being admitted to hospital, discharged,
and admitted again. Over time,
these
phenomena, successive budget cuts and the increasing demand
have brought emergency psychiatric departments and hospitals
to saturation point, ultimately resulting in the creation of addi-
tional full-time hospital beds, that could probably have been
avoided. Serious incidents, such as attacks by or on people
with a mental illness or psychiatric disability have sometimes
contributed to this trend. Policy makers have then been suscep-
tible to public opinion, which has pushed them either to intro-
duce measures prioritising public safety or to draw up mental
health strategies.

the combination of

4.2 Information and the media

Mental health is most often mentioned by the media in connec-
tion with violent
incidents involving people suffering from
mental disorders (although the figures are actually no higher
than for the general population). The effect of this is to create
negative stereotypes and heighten fears about safety, which in
intolerance and rejection of people
turn leads to greater
suffering from mental ill health. We cannot allow information
on mental health to remain, as it is now, an uncontrolled
increasingly sensitive issue; we need to clarify the whole infor-
mation process, focusing on averting serious effects and using
the media and media professionals to reach the general public.

to the mental health situation. Furthermore, the states which
are due to join the EU in the long-term have considerable
ground to make up in this area and the gap may well widen
before their actual accession.

It is already possible to list a number of prerequisites:

Before a common strategy can be defined, there has to
4.3.3
be a common definition and explanation of
terms and
concepts, such as ‘mental ill health’ and ‘person suffering from
mental disability’.

4.3.4
action is that mental health be recognised as a priority,
accordance with actual needs.

Another considerable advance and prerequisite for
in

4.3.5
From a different angle, this will require cataloguing of
evidence of existing needs and current responses to those
needs.

4.3.6
In terms of action, the proposals in the Green Paper
are to be welcomed. The proposals concerning mental health
focus on children and adolescents, the working population and
the elderly.

4.4 Towards a mental health approach integrating the person and

their environment

4.4.1 Mental health is concerned with the suffering of indi-
viduals within their family and community environments in a
given society. The issue requires a combined approach,
including:

— measures for combating mental illness, which must necessa-

rily combine prevention, care and re-integration,

4.3 The prerequisites

for and content of an EU mental health

strategy

— preventive measures for specific target groups,

4.3.1
The EESC supports the Commission initiative on
developing an integrated European strategy on mental health. It
believes that
identifying and
developing such a strategy must take place in the context of
the knowledge society. This means, among other things, that
European society must acquire:

the discussion on researching,

— a clear idea of the concepts relevant to mental health and

their implications;

— a precise understanding of the extent of the problem as it

currently stands, but also of its likely development;

— strong support for substantive participation of European
society in shaping conditions for developing alternative
integrated solutions.

4.3.2
Consequently, in order to meet needs on this scale, it
is necessary to draw up an ambitious programme and define a
common strategy based on a small number of shared princi-
ples. It is worth pointing out that other, smaller scale, health
problems are already given priority attention. There are also
considerable differences between European countries in regard

— care provision to address the mental suffering of particular

population groups,

— positive mental health initiatives aimed at changing harmful
behaviour on the part of individuals, groups or society
itself.

From this perspective, emphasis must be placed on the
4.4.2
three aspects of prevention (primary, secondary and tertiary),
with the balance between them depending on the particular
area concerned. Initiatives need to be developed in a number of
areas,
including the promotion of mental health and public
information, the acquiring and maintaining of healthy ways of
living and the creation of an environment favourable to indivi-
dual self-development. The same goes for other prevention
measures aimed at reducing the incidence of mental disorders
by addressing risk factors and pathogenic situations, including:

— early intervention for mothers and infants presenting with

symptoms of depression or feelings of non-fulfilment,

— targeted measures for children who are failing at school,

— information and support for families faced with mental

illness,

C 195/46

EN

Official Journal of the European Union

18.8.2006

— studies of risk factors or expressions of mental distress in

different ethnic and cultural backgrounds,

4.5.2
connection with social exclusion are equally important
mental health.

The responses that need to be found to these issues in
for

— the introduction of consultation-liaison psychiatry, permit-
ting a more holistic approach to somatopsychic pathologies
as well as both active and passive family involvement, (such
as teaching coping strategies and how to support those
suffering from an illness and, if necessary, providing finan-
cial assistance). Psychological support is preferable to the
use of psychotropics alone.

4.4.3
There is no question that meeting children's and
adolescents' needs is a priority. The demands are not only
expressed or borne by families, but also by educational, judicial
and social institutions, the police and local authorities, experi-
encing increasingly serious situations affecting ever-younger
children and families with multiple problems. It is primarily
families and children who are affected by societal change.

4.4.4
Coherent and coordinated organisation should lead to
provision of a basket of services, coordinated and structured
around three basic modules or programmes:

— a programme focusing on early childhood, families and the
partners working with this age group in the social, health,
education and judicial fields;

— a programme focusing on school age children, families and

the partners;

4.5.3
Lastly, the ageing of the population will require appro-
priate responses. Only 20 % of elderly people have what the
WHO terms an ‘successful ageing’, meaning that 80 % suffer
from various illnesses and loss of autonomy. Mental
illness
does not disappear with advancing age, quite the reverse. Senile
dementia, which affects only 1 % of 60 year olds becomes
more common with age, affecting 30 % of the over 85s. Over
70 % of these individuals have behavioural problems.

4.6 Asylum seekers

4.6.1
The issue of mental health arises in connection with
support for asylum seekers during the reception procedure,
their living space and conditions and their personal
lives,
which embody their personal history and psychic temporality.
The seriousness of the traumas they have suffered, often invol-
ving extreme, intentional and collective cruelty, bears witness
to situations of organised violence. Within this population,
post-traumatic stress is often worsened by multiple bereave-
ments and very painful experiences of exile.

— a programme focusing on adolescents, their families and

the partners.

4.7 The mental health issue

In addition to offering programmed outpatient care
4.4.5
and services, each module should also offer options for more
intensive care within institutions, correlated to age, care during
acute incidents and long-term care. To ensure that programmes
are flexible and responsive, psychiatric services should be
involved in early diagnosis, crisis prevention and outpatient
support for families and their partners.

These basic programmes should be complemented by
4.4.6
specialised programmes for at-risk groups or situations that
would make primary as well as secondary prevention a realistic
option in areas such as early diagnosis of developmental
problems, disorders affecting young children, dysfunctional
early-years parental care, young single mothers, families with
multiple problems and addiction problems suffered by youths.
Further attention must be given to the social, educational and
judicial structures (including prevention services and prisons)
that admit individuals with serious social problems who already
have, or are likely to develop, mental health problems as a
result of the gravity of their situation or its cumulative effects.

4.5 The relationship between work, unemployment and health

4.5.1
In view of their impact on mental health, attention
should be paid to improving conditions for those both in and
out of employment. The issue of work and mental health
touches on questions such as the value attributed to work and
its personal cost, the impact of unemployment and invalidity.

4.7.1
The same issue arises in connection with the sizeable
prison population with mental health problems, who receive
very little in terms of care provision.

4.7.2
depression, suicide and addiction prevention programmes.

Support must be given for

the establishment of

4.7.3 With regard to deinstitutionalisation and the new
model
it proposes, a new period began in the late 1990s,
marked by the end of both the downward trend in hospitalisa-
tion model and the illusions about de-institutionalisation, with
a resulting need for a combined approach offering both effec-
tive community-based care and full-time hospitalisation. Too
much focus on hospitalisation means that resources are not
available to develop the range of services in the community
needed by patients and their families. Conversely, too much
focus on outpatient services is ineffective without back-up from
hospital services that are permanently available, and accessible
at short notice, for patients with acute symptoms requiring
brief periods of in-patient hospital treatment. Lastly, it is only
possible to avoid over-use of hospitalisation if outpatient
services have the resources to prevent
for example, by
supporting patients undergoing long-term in-patient care, to
ensure that they are adequately prepared for their discharge
from hospital, supporting patients receiving care in the com-
munity to ensure that such care is adequate and meets their
needs and supporting patients who need to alternate between
outpatient care and hospitalisation.

it,

18.8.2006

EN

Official Journal of the European Union

C 195/47

4.7.4
The decision to treat a person suffering from mental
illness by means of hospitalisation or outpatient care is strongly
influenced by specific factors such as the patient's degree of
isolation and the training model and culture of the profes-
sionals concerned as well as by more general, socio-cultural
factors such as the degree of tolerance within the particular
society and the profile of vulnerability in the area concerned,
which may lead to preferences for particular approaches and
impact on the availability of alternatives. It is therefore impos-
sible to make categorical
regarding the
number of hospital beds required for patients in an acute
phase, without taking account of local conditions.

recommendations

4.7.5 Moreover, the most important factor is the nature of
the treatment, in other words, what benefits it is intended to
provide, for which needs, and to what level, above and beyond
the setting in which it is dispensed.

It is generally acknowledged that hospital treatment
4.7.6
has a number of advantages, with regard to availability of
trained staff, a secure and appropriate environment for patients
and therapeutic support under safe conditions. However, these
advantages disappear if a lack of beds means that too many
are
non-cooperative patients with very severe disorders
grouped together within a hospital, leading to unacceptable or
dangerous disruptions to the surrounding work.

4.7.7
A number of international and French studies have
shown that up to 40 % of the patients with acute disorders
voluntarily seeking or prescribed hospital admission, can be
treated with other forms of therapy, provided that they are
willing to cooperate or can be persuaded to do so, for example,
with the support of close family or social support networks
(emergency or crisis
support). As alternative approaches
become more effective, there is a tendency for hospitalisation
to be reserved for the ‘unavoidable’ cases,
including patients
requiring a two-pronged psychiatric and physical assessment,
patients presenting with particularly severe mixed, acute disor-

Brussels, 17 May 2006.

ders, relapses from known psychiatric disorders, or uncontrol-
lably violent or suicidal behaviour. In such cases, compulsory
hospitalisation is often necessary. As we shall see, this has an
impact on organisation and treatment.

4.7.8
In view of the above, the same studies recommend a
minimum threshold of 0.5 beds per 1 000 adult inhabitants for
patients in acute phases, a figure which will have to be
reviewed if the target objective of an 80 to 85 % service occu-
pation rate is envisaged, as we recommend. Naturally, this
minimum threshold is premised on the assumption that
upstream and downstream alternative treatment sites are suffi-
ciently equipped and effective and does not include secure beds
for acute patients receiving psychiatric care within the criminal
justice system, beds for adolescents or elderly people. If the
requirements for proper ambulatory services are not met,
coming too close to this threshold would lead to the creation
of extremely costly additional psychiatric or medical beds.

4.8 Environment of care

4.8.1 Whilst the threshold for bed numbers may vary from
country to country, the minimum standards for accommoda-
tion can be more assertively presented. All accommodation
should be fit for its purpose and, whilst possibly provided in
older settings, must aspire to contemporary values of dignity
and respect for residents. It is essential for the purposes of
recovery that the environment is appropriate. Environmental
risks must be assessed and addressed in regard to the particular
needs of the residents.

4.8.2
The residents should have access to a wide range of
therapies that compliment and contribute to their care and
treatment. All mental health staff should contribute to this
environment by being appropriately trained,
skilled and
humane in their approach.

The President

of the European Economic and Social Committee

Anne-Marie SIGMUND