1. What does a mental health-in-all-policies approach look like?

Mental health conditions are widespread and costly for individuals, employers and society. At any point in time, about 20% of the population experiences a mental health condition. People with mental health conditions have much lower rates of employment, higher rates of unemployment, lower wages and incomes, and higher rates of dependence on all types of working-age benefits. The total cost of mental health is estimated to be at least 4% of GDP, including through labour market costs such as reduced productivity and increased absence, social spending costs and direct costs for health care systems (OECD, 2021[1]). The characteristics and impacts of mental health conditions imply that the health system alone cannot solve the problems, which instead require a whole-of-government response.

Mental health is critical throughout one’s lifetime from childhood to old age. For young people, whose mental health status also depends on their parents’ mental health and any genetic predisposition, mental health issues can affect education and labour market outcomes. For adults of working age, mental health issues can affect performance at work and result in prolonged sick leave, unemployment and labour market exit. For the elderly, poor mental health affects participation in society and is associated with loneliness. Across the OECD, students indicating mental distress are 35% more likely to have repeated a grade at school, and adults with mental health issues are 20% less likely to have a job.

Despite the strong links between mental health and labour market outcomes, widespread stigma surrounding mental health persists. Individuals experiencing mental health issues are often considered unable to work, to learn or to live together with other members of society, even when they can in most instances. Promoting mental health in all areas of societies thus remains crucial to cultivating a culture of acceptance of mental health issues. This could help to address myths that still surround mental health, and create an accepting environment for individuals to seek support.

A comprehensive policy response to the challenges posed by mental health conditions not only requires cross-sectoral action, but also changes in delivery of policies and services. A three-way change is required, characterised by (1) intervention and support by the right persons and especially front-line actors (the “who”), (2) early intervention, including the timely identification of mental health issues (the “when”), and (3) the provision of integrated services and interventions (the “what”).

The key foundations of an integrated approach to mental health policy form the body of the OECD Recommendation on Integrated Mental Health, Skills and Work Policy, which was adopted by the OECD Council in 2015. This Recommendation sets out how governments can promote the provision of early and fully integrated services to improve social and labour market outcomes for people with mental health problems.

The OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy (hereafter “the Recommendation”) is a legal instrument that sets out policy guidelines and principles for an integrated whole-of-government approach to promote the social, educational and labour market inclusion of individuals experiencing mental health conditions. It was adopted by the OECD Council in 2015 on the proposal of the OECD’s Employment, Labour and Social Affairs Committee and the Health Committee, in consultation with the Education Policy Committee.

At the time of release of this publication, all 38 OECD countries had adhered to the Recommendation, thus expressing their political will and commitment to fulfilling the principles set out in the Recommendation, and no non-OECD countries had adhered. This publication therefore looks at policy developments and indicators in all and only OECD countries. The term “OECD countries” is therefore used in the place of the term “Adherents” throughout this publication.

The Recommendation draws heavily on Fit Mind, Fit Job: From Evidence to Practice in Mental Health and Work (OECD, 2015[2]), a landmark publication published in 2015 that synthesised and summarised findings from nine country-specific reports on the link between mental health and work (Australia, Austria, Belgium, Denmark, the Netherlands, Norway, Sweden, Switzerland and the United Kingdom). Fit Mind, Fit Job found that the impact of mental health for education, labour market and social policies had long been neglected, resulting in insufficient attention and policies to improve the education, employment and social outcomes of individuals experiencing mental health conditions, with mental health policies delivered in silos.

At the High Level Policy Forum on Mental Health and Work hosted by the Netherlands in 2015, ministers and high-level government officials welcomed Fit Mind, Fit Job, and called on the OECD to develop policy principles on integrated mental health, skills and work policies. In December 2015, the Recommendation was finalised and adopted, and in early 2016, Ministers of Health and Employment from all OECD countries welcomed the Recommendation at the OECD Employment and Labour Ministerial and High-Level Policy Forum held in Paris. Since then, the Recommendation has been used by OECD countries to shape reform and inform progress towards integrated mental health, skills and work policy.

The Recommendation sets out principles on how countries that have adhered to the Recommendation can strengthen mental health policies through coherent action across three dimensions. These are the involvement of front-line stakeholders not normally seen as mental-health actors (the “who” of a good policy approach), a focus on early identification and early intervention in all policy areas (the “when”), and the provision of integrated health, education and employment services (the “what”). The Recommendation covers policy principles in the following four thematic areas:

  • Mental health care systems should provide more timely and appropriate access to services that take into account the role that meaningful education and work can play in promoting good mental health. The Recommendation thus outlines the need to ensure primary care workers are trained in mental health, and the value of strengthening the education and employment focus of the mental health care system.

  • Youth and education systems should support young people throughout all stages of education and in the transition from school to work. The Recommendation thus calls for co-ordinated and timely access to support for children and young people delivered through schools, investments in preventing early school leaving, and continuous support for young people experiencing mental health issues in the transition from school to higher education and/or work.

  • Workplaces should promote good mental health at work and support employees experiencing mental health issues in their return to work. The Recommendation thus calls for policies to promote psychosocial risk assessment, to increase awareness and competence of line managers in mental health, and to support return-to-work for workers experiencing mental health issues on sick leave.

  • Social protection systems and employment services should be equipped with the knowledge and resources to respond to the needs of people experiencing mental health issues. The Recommendation thus calls for ensuring caseworkers receive training to understand mental health issues, and for integration of mental health treatments into the delivery of employment services to support jobseekers experiencing mental health issues into work.

To develop an integrated mental health, skills and work policy, countries need to take into account who is carrying out an intervention or providing support, when intervention or support is taking place, and what intervention or support is provided. It is only when each of these three dimensions are addressed, that intervention can be effective. Interventions to support and promote mental health often leave out key stakeholders, come too late, and are provided in an isolated manner that fails to reflect the integrated nature of the challenges of mental health issues.

As shown in Figure 1.1, these three dimensions are interlinked and reinforcing each other. For instance, the impact of policies to reduce waiting times e.g. for psychotherapy (seeking to address the “when”) can be amplified by ensuring that mental health supports are integrated into and available in all areas of society including in schools and workplaces where symptoms of mental health issues can first become apparent (the “what”). In turn, to ensure that mental health, skills and work supports are effective in schools and workplaces, front-line actors such as teachers and line managers need to be trained and have competence in mental health such that they can identify potential mental health issues and initiate support (the “who”).

To realise integrated mental health, skills and work policies in full, countries need to combine integrated services and supports at the working level with a cross-sectoral and strategic prioritisation of mental health, as reflected in integrated mental health plans and strategies. In the absence of such plans, while there may be some good practices of integrated services that support mental health, these are likely to be isolated cases that do not reflect a general approach.

It is not possible to achieve progress towards integrated mental health, skills and work policy if the task of supporting individuals with mental health problems is left to specialist mental health care workers and institutions alone. Effective policy harnesses the key role that front-line actors across all of society – especially but not only teachers, line managers, general practitioners and employment counsellors – have in identifying mental health conditions and addressing its impact on students, workers, patients and jobseekers. This relates to both training offered to them and ensuring there are individuals with experience and understanding of mental health issues in schools, universities, workplaces and employment services. The importance of competence-building (see Box 1.3 for a definition of mental health competence) also closely relates to timelier intervention (the “when”), as in the absence of adequately trained front-line actors, possible signs of mental health issues are likely to go unnoticed resulting in late intervention and support.

In the health system, a key priority for the “who” dimension is the expansion of mental health competence among workers in the primary care sector such as general practitioners, nurses and occupational health specialists. These health care workers often act as gatekeepers within the health system to specialist health services such as treatment from a psychiatrist or psychotherapist, and thus are well-placed to refer individuals experiencing mental health conditions, where deemed appropriate. In education and youth support systems, policies should increase awareness and understanding of mental health issues among education professionals and families of students, and provide actors in the education system with an understanding of psychological and behavioural adaptations that are crucial to the learning process. In workplaces, raising competence is an important part of broader anti-stigma policies at work, including the development of guidelines for line managers, human resource professionals and worker representatives such that employees experiencing mental health issues can get appropriate support. It is also vital to invest in mental health competence and training for caseworkers, social workers and vocational counsellors who are responsible for administering employment services and social benefits, not least as poor mental health can be a key barrier to finding employment.

Early identification and intervention is the most effective way to support people experiencing mental health issues. Youth and workplace policies are crucial as workplaces, schools and universities are often the first places where symptoms of potential mental health issues arise before individuals turn to or are recommended to seek support through the health system. Evidence suggests that measures to address mental health issues are far more effective if put in place when students are in schools rather than after they have stopped attending. Similarly, supporting people to stay in work is far more effective than helping them return to a job after unemployment or sickness absence, including for individuals with mental health conditions (OECD, 2015[2]).

For young people, a key pillar of the “when” dimension is the provision of timely access to co-ordinated and non-stigmatising support and treatment for this group. More broadly, investment in prevention of early school leaving including through ensuring access to mental health care can be beneficial, as keeping young people in school can protect against poor mental health, and strengthens future labour market outcomes.

In workplaces, the promotion and rigorous enforcement of workplace psychosocial risk assessments and workplace strategies to enhance mental health and well-being can play an important role in minimising the risk factors of poor mental health. For workers absent from work or on sick leave due to mental health issues, early support and intervention is necessary to prevent long-term sick leave and facilitate a lasting return-to-work. As outlined in Chapter 2, among workers who take sick leave, individuals with mental health conditions take more than 50% more days off sick than their counterparts who are not experiencing mental health conditions across OECD countries. Early action is particularly important for this group, as returning to work becomes more difficult as absences are prolonged, and as many individuals may have undiagnosed mental health conditions that prevent timely return-to-work. In Sweden, for example, prior OECD analysis has shown that return to work becomes difficult after three months of sick leave for people experiencing mental health issues (OECD, 2015[2]).

After an individual with mental health conditions drops out of the labour market and services and social benefits kick in, intervention once again comes too late, resulting in further detachment from the labour market and the risk of deterioration of mental health. Yet few initiatives have sought to address the mental health issues experienced by unemployed jobseekers (McDaid, Hewlett and Park, 2017[3]), and mental health treatments thus need to be integrated in public and private employment services. Effective early treatment can also help to reduce preventable disability benefits.

Another challenge is the lack of early action in the health system itself to help people reconnect with school or work. Even after an individual has first seen a mental health specialist, or has discussed mental health problems with a general practitioner, they then often face long waiting times to receive the care, treatment and support they require, and when they receive support, it may not have an education or employment focus. As outlined in Chapter 2, on average across European OECD countries, in the mid-2010s, more than two-thirds (67%) of individuals with mental health conditions reported difficulty accessing medical care due to financial, waiting time or transportation constraints. The promotion of timely access to effective treatment of mental health conditions in both community and primary care settings is therefore critical.

The core premise of an integrated mental health, skills and work policy is that action is required in a range of policy fields – including health, youth, labour, and welfare policy – to address various needs concurrently. For such an approach to be planned and delivered, decision-makers in different thematic areas need to prioritise the integration of services and interventions.

This requires a greater focus in the mental health care system on the employment dimension, including the introduction of education and employment outcomes as a measure to evaluate performance. Medical professionals should address issues at work and school – such as sickness absence and truancy – that are often closely associated with mental health. Similarly, appropriate support structures need to be put in place that link youth and community centres and educational institutions at all ages – from pre-school, school and higher education institutions – to assistance through treatment and counselling that may primarily be offered in the health system.

Integrated interventions are equally important in the workplace and in social protection systems. Work has a profound impact on mental health and meaningful work is often an important contributing factor to recover from mental health conditions. Enforcement and promotion of psychosocial risk assessment in the workplace is only possible with the support and involvement of occupational health services. Promoting timely return-to-work, which is also a key element of the “when” and “who” dimensions, requires the involvement of physicians and mental health practitioners in addition to dialogue between employers, employees and their representatives. In welfare systems, employment services should integrate mental health treatment into their services, including through the delivery of evidence-based psychological counselling combined with employment support for individuals with mild-to-moderate mental health conditions. Such policies are key to facilitating a return to work and preventing labour market exit for individuals with mental health conditions, as evidence suggests that standalone treatments (without employment support) has only a limited impact in supporting individuals experiencing mental health conditions in finding work (OECD, 2015[2]).

Raising awareness of mental health and normalising discussions around mental health is a key component of mental health plans and strategies. Discrimination against individuals living with mental health conditions remains widespread, and discussions around mental health remain a taboo subject in many contexts across OECD countries.

In 2019, Ipsos conducted a global survey on attitudes on mental health in 29 countries, including 19 OECD countries, which found that stigma surrounding mental health remains prevalent, although with significant variation across countries (Figure 1.2). On average, across the OECD countries, 60% of respondents agreed that mental illness was an illness like any other [illness], while 25% agreed that anyone with a history of mental illness should be excluded from public office (The Policy Institute | King’s College London and Ipsos, 2019[4]). A lack of public awareness weakens all initiatives and interventions to support individuals with mental health conditions.

Moreover, in the absence of self-awareness and presence of stigma at the individual level, individuals are less likely to seek mental health support when they need it. In 2019, on average across the OECD countries, less than two-thirds of respondents stated that they considered seeing a mental health professional as a sign of a strength (Figure 1.2). In the presence of such stigma, even if an individual is aware of the need to seek help, they are unlikely to do so if they sense that their co-workers will ostracise them, or that any colleague or manager they seek help from would be dismissive of their need for treatment or support. In an environment with widespread stigma, workplace programmes that offer support for individuals with symptoms of mental distress alone may be insufficient, as workers experiencing mental health conditions may be reluctant or afraid to seek support. The same analogy applies to schools and higher education institutions, as well as welfare systems.

Raising awareness and addressing stigma is also a foundation to increase the mental health competence of front-line actors as outlined in Box 1.3. For example, public awareness-raising campaigns can help front-line actors to understand what mental health is and how to communicate and talk about mental health in a non-stigmatising manner. Awareness is particularly important for those who come into regular contact with individuals with mental health conditions, whether teachers, caseworkers or line managers, as without awareness, there is no foundation on which to build competence.

This publication covers four thematic policy areas that play a key role in integrated mental health, skills and work policies – namely health systems, youth support systems, workplaces, and welfare systems. As outlined below, action across each of these policy areas is vital to improving the health, educational and labour market opportunities and outcomes of people experiencing mental health issues.

Health care systems often face a dual challenge of under-investment in mental health care and structural barriers to integrating such care with social and employment support. Ensuring timely access to effective treatment for individuals experiencing mental health issues must remain a priority, including for mild to moderate mental health conditions, and not only in specialist care, but also through primary health care and community mental health services. Expanding the mental health competence of front-line actors in primary health care is vital as most individuals experiencing mental health issues receive treatment from non-specialists, and individuals are likely to first approach general practitioners, family doctors and occupational health specialists when experiencing mental health issues.

Health systems and care providers must also recognise the beneficial role that meaningful work and education can play in promoting mental health, and thus ensure integration of considerations into the delivery of interventions and services. This includes strengthening the employment focus of the mental health care system, including by introducing employment outcomes in quality and outcomes frameworks within health systems and strengthening co-ordination with employment services. Policies should also ensure health professionals have the resources needed to support people who are absent from school or work due to issues related to mental health through evidence-based treatment and integrated support. The key role that health systems play in promoting good mental health and ensuring timely, accessible and high-quality mental health services is expanded upon in more detail in A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health (OECD, 2021[1]). This publication offers insights into how well countries are delivering the mental health policies and services that matter for good mental health outcomes.

A recent meta-analysis on age of onset found that around half of all mental health conditions are established by age 18, and two in three by age 25 (Solmi et al., 2021[5]), consistent with prior findings which have shown that mental health conditions predominantly emerge from childhood to young adulthood (Kessler et al., 2005[6]). This means that in many cases, symptoms and signs of mental health issues are apparent from a young age, making mental health interventions and support in childhood, adolescence and youth particularly important. If mental health issues remain unaddressed during this period, symptoms and conditions may deteriorate and prevent individuals from living fulfilling and productive working lives.

Schools and educational institutions play a particularly important role in promoting the mental health of children, adolescents and young people. Monitoring and improving the overall school and preschool climate to promote socio-emotional learning and mental health through whole-of-school interventions is therefore critical. Irregular attendance at school can often be one of the first signs of mental health issues and eventually result in early school leaving.

Childhood, adolescence and youth are stages of life that are also characterised by important life transitions that can place significant pressures on mental health. Over the period of around 20 to 30 years, individuals have to adapt from being fully dependent on a caregiver to being self-sufficient contributors to society. This publication looks specifically at policies to support young people navigate the transition from secondary education into post-secondary education and into the labour market, and the need to ensure access to treatment for individuals with mental health conditions through each of these transitions.

Employers play an important role in helping their employees to manage and deal with mental health issues. Workplaces are environments where most individuals spend a significant proportion of their lives, yet there remains both a lack of awareness and understanding of the impact mental health can have on the work of individuals and the labour productivity losses that can result from poor mental health among employees. The implementation of strategies to raise awareness of mental health in the workplace can help to address stigma and discrimination, and guidelines on mental health – often developed by governments – can help line managers, co-workers and human resource professionals, as well as work representatives, support individuals experiencing mental health issues.

Policies must also recognise the many layers of workplace policies required to both prevent the exacerbation of mental health issues and promote good mental health among all workers. As a foundation, psychosocial risks should be a core component of occupational health and safety policies, but this should be supplemented by policies to promote good mental health in the workplace so that all employees and workers can experience better mental health. These policies are of particular importance as poor-quality jobs, bad leadership and high job-strain can contribute to stress in the workplace and the worsening of mental health among employees. Such policies include measures to require and encourage employers to support individuals with mental health conditions on sick leave in returning to work.

Mental health conditions also place significant pressure on social benefits and employment services of OECD countries. Mental health conditions are prevalent not only among disability benefit recipients, but also among recipients of unemployment benefits and social assistance. As shown in Chapter 2 of this publication, across the OECD, between one-third and one-half of all benefit recipients experience mental health conditions, and the longer people receive social benefits, the higher the prevalence of mental ill-health, reflecting, at least in part, the negative effects that joblessness can have on mental health.

These pressures on social benefits and employment services are rising further as awareness of mental health conditions continues to grow. A dual challenge therefore exists to better support individuals with mental health conditions in the social protection system, and also to alleviate the increasing pressure placed on the system, and in particular on disability benefits. Improving the responsiveness of social benefits and employment services to the needs of individuals experiencing mental health conditions addresses both of these challenges. This not only reduces pressure on the disability system but can also bring benefits for individuals experiencing mental health conditions, as meaningful employment can be beneficial for their mental health.

This requires a mix of legislation and policies to strengthen services in welfare systems and employment services. The recognition of possible work capacity – even if this is partial – of individuals claiming benefits for reasons related to mental health, for example, is one form of legislation that can facilitate individuals to return to work after periods of prolonged absence. Policies can also strengthen the mental health component of social benefits and employment services, including through providing access to employment and mental health support together to help jobseekers into work.


[6] Kessler, R. et al. (2005), Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication, https://doi.org/10.1001/archpsyc.62.6.593.

[3] McDaid, D., E. Hewlett and A. Park (2017), “Understanding effective approaches to promoting mental health and preventing mental illness”, OECD Health Working Papers, No. 97, OECD Publishing, Paris, https://dx.doi.org/10.1787/bc364fb2-en.

[1] OECD (2021), A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health, OECD Health Policy Studies, OECD Publishing, Paris, https://dx.doi.org/10.1787/4ed890f6-en.

[2] OECD (2015), Fit Mind, Fit Job: From Evidence to Practice in Mental Health and Work, Mental Health and Work, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264228283-en.

[5] Solmi, M. et al. (2021), “Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies”, Molecular Psychiatry, https://doi.org/10.1038/s41380-021-01161-7.

[4] The Policy Institute | King’s College London and Ipsos (2019), World Mental Health Day 2019, https://www.ipsos.com/sites/default/files/ct/news/documents/2019-10/world-mental-health-day-2019_0.pdf (accessed on 11 March 2021).

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