Chapter 1. Promoting mental health in Europe: Why and how?

Mental health problems affect about 84 million people across EU countries

Although there are significant gaps in information about the prevalence of mental health problems across EU countries, all available evidence suggests that mental health problems affect tens of millions of Europeans every year. The data currently available from population-based surveys are often limited to a few specific mental health disorders, or specific age groups. However, the Institute for Health Metrics and Evaluation (IHME) provides estimates of the prevalence of a wide range of mental health disorders across all age groups based on a wide variety of data sources and a set of assumptions

According to the latest IHME estimates, more than one in six people across EU countries (17.3%) had a mental health problem in 2016 (Figure 1.1) – that is, nearly 84 million people.1 The most common mental disorder across EU countries is anxiety disorder, with an estimated 25 million people (or 5.4% of the population) living with anxiety disorders, followed by depressive disorders, which affect over 21 million people (or 4.5% of the population). An estimated 11 million people across EU countries (2.4%) have drug and alcohol use disorders. Severe mental illnesses such as bipolar disorders affect almost 5 million people (1.0% of the population), while schizophrenic disorders affect another estimated 1.5 million people (0.3%).

Figure 1.1. More than one in six people in EU countries have a mental health problem

Source: IHME, 2018 (these estimates refer to 2016).

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By country, the estimated prevalence of mental health disorders is highest in Finland, the Netherlands, France and Ireland (with rates of 18.5% or more of the population with at least one disorder), and lowest in Romania, Bulgaria and Poland (with rates of less than 15% of the population). Some of these cross-country differences may be due to the fact that people living in countries with greater awareness and less stigma associated with mental illness, as well as easier access to mental health services, may be diagnosed more easily or may be more likely to self-report mental ill-health. In many countries, there is still strong stigma associated with various mental health problems, and in some countries this stigma sits alongside a still-widespread belief that it is better to simply avoid talking about mental illness (Munizza et al., 2013).

Several mental illnesses are more common amongst women, including anxiety disorders, depressive disorders and bipolar disorders. Some of these gender gaps may be due to a greater propensity of women to report these problems. However, one exception is drug and alcohol use disorders, which are more than two times more likely to occur in men than women on average across EU countries (IHME, 2018).

Data from the 2014 European Health Interview Survey confirm a substantial gender gap in self-reported chronic depression, with more than one in twelve women (8.8%) indicating they experience chronic depression, compared with one in nineteen men (5.3%). The prevalence of chronic depression increases steadily with age among both women and men, and is particularly high in middle age (Figure 1.2). At age 55-64, more than 11.4% of women and 7.1% of men reported being chronically depressed across the EU as a whole in 2014. These rates decrease between the age 65 and 74, and then increase again in older ages. This increase in older ages may be partly explained by the fact that depression is often associated with poor physical health, frailty, perceived financial strain and lower social support (Grundy, van den Broek and Keenan, 2017).

Figure 1.2. Chronic depression is more often reported by women and increases with age in EU countries

Source: Eurostat Database (based on EHIS 2014).

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By level of education, people with at most lower secondary educational attainment are almost two-times more likely to report chronic depression compared to those with higher educational level. This is also the case for people in low-income groups. On average across EU countries, women and men living in the lowest income group are more than two times more likely to report chronic depression than those in the highest income group (Figure 1.3).

Figure 1.3. Women and men in the lowest income group are more than two times more likely to report chronic depression than those in the highest income group across the EU

Note: High income refers to people in the top income quintile (20% of the population with the highest income), whereas low income refers to people in the bottom income quintile (20% of the population with the lowest income). Countries are listed in order of rate of reported chronic depression by women (from lowest to highest). Data for Switzerland is not available.

Source: Eurostat Database (based on EHIS 2014).

 StatLink https://doi.org/10.1787/888933833958

People who are employed generally report lower levels of depression than those who are not, and people with a mental disorder are more likely to be unemployed (OECD, 2015). People with depression or other mental health problems often see improvement in their condition after finding work, as their labour-force status increases their self-esteem and sense of worth in society, and losing a job generally contributes to worsened mental health (OECD, 2018).

A considerable number of children experience mental health problems which, unless they receive appropriate care and support, may have a lasting effect throughout their lives. Evidence suggests that many mental disorders begin at adolescence or even younger; most studies find that roughly half of all lifetime mental disorders start by the mid-teens (Kessler et al., 2007).

A 2010 study found that in five of the six EU countries covered (Bulgaria, Germany, Lithuania, the Netherlands and Romania), 10% to 15% of children aged 6-11 years old experience at least one mental health or behavioural disorder (i.e. conduct disorder, emotional disorder, hyperactivity or inattention disorder). Italy is the only country where prevalence was less than 10%, but about 8% of children still had a mental or behaviour disorder (Kovess-Masfety et al., 2016).

Mortality related to mental health problems and suicides is substantial

Over 84 000 people died of mental health problems and suicides across EU countries in 2015, and this is an under-estimation as many people with mental health problems also die prematurely because of higher rates of physical health problems and chronic diseases that are not properly treated. “Excess mortality” for mental disorders – the gap between the mortality rate of the general population and the mortality rate for people with a mental disorder – is huge. For example, excess mortality amongst women who have been diagnosed with schizophrenia is above 6 in Finland, Norway and Sweden (OECD, 2018). Persons with severe mental illness die 10-20 years earlier than the general population (Liu et al., 2017; OECD, 2014; Coldefy and Gandré, 2018).

Of the 84 000 deaths directly related to mental health problems and suicides, most of these deaths were among men, mainly because of higher suicide rates among men (Figure 1.4). Some 43 000 men in EU countries died from suicide in 2015, compared with 13 000 women. However, the gender gap in suicide attempts is much smaller or even reversed in some countries, because women often use less fatal methods. For example, in France, while the completed suicide rate is more than three times greater among men than women, hospital discharge rate for suicide attempts was 52% greater among women in 2015 (Observatoire national du suicide, 2018). Many different factors may explain why some people are led to attempt or complete suicide, including major life events (such as the death of a loved one, a divorce or employment loss), social isolation, or socioeconomic or cultural context. However, a high proportion of people who have survived a suicide attempt or died from suicide have experienced a mental health disorder (Hoven, Mandell and Bertolote, 2010; Cavanagh et al., 2003; WHO, 2014). A cross-national analysis based on the WHO World Mental Health Surveys found that a wide range of mental disorders increased the odds of experiencing suicidal thoughts, and a smaller number of disorders increased the odds of acting on such thoughts (Nock et al., 2009).

Figure 1.4. The number of deaths from mental health problems and suicides generally increases with age

Note: Mental and behavioural disorders cover all the diseases in the related ICD-10 chapter with the exception of dementia.

Source: Eurostat Database (the data refer to 2015).

 StatLink https://doi.org/10.1787/888933833977

The number of suicides increases steadily with age among both men and women, reaching a peak among 45-64 years-olds (Figure 1.4). Between ages 65 and 74 the number of suicides decreases at least slightly.

By country, the suicide rate among the population of all ages is highest, by far, in Lithuania, with (age-standardised) rates of 30 deaths per 100 000 population in 2015. Slovenia, Latvia and Hungary also have high rates at around 20 deaths per 100 000 population, which is almost two times greater than the EU average (11 per 100 000 population). The lowest rates are reported in Southern European countries (Greece, Cyprus, Italy, Malta and Spain) (Figure 1.5). Some caution is required in interpreting suicide rates as these may reflect, at least in part, differences in recording practices. On average across all countries, the suicide rate among men was 3.7 times greater than among women. This gender gap was largest in the four countries with the highest rate, but also in Estonia, Poland and Romania.

Figure 1.5. Men are more likely to die from suicide in all EU countries

1. Three-year average (2013-15).

Source: Eurostat Database.

 StatLink https://doi.org/10.1787/888933833996

Despite the relatively low absolute number of suicides among younger age groups, suicide is nonetheless one of the leading causes of death among adolescents and young adults. Some 3 400 young people age 15-24 died from suicide in EU countries in 2015, making this the main cause of death in this age group after road traffic injuries. Young people are more likely to attempt suicide if they have a family history of alcohol and drug abuse disorders, have access to firearms, and experience difficult life events at school or at home (McLoughlin, Gould and Malone, 2015). However, it is heartening to note that suicide rates among teenagers have decreased by 20% on average across EU countries between 2000 and 2015. There has been a notable decrease in Finland, reflecting the success of suicide prevention campaigns targeting this age group (see Box 1.5).

Direct costs of mental health problems on health systems and social security benefits

Indirect costs of mental health problems on employment and productivity

Beyond the direct costs to health systems and social security benefits, mental ill-health also contributes to substantial indirect costs, primarily related to reduced labour market participation and productivity. These indirect costs include not only lower employment rates for people with mental health problems, but also reduced productivity due to higher absenteeism and lower productivity at work (often referred as “presenteeism”). These costs add up to over EUR 240 billion or 1.6% of GDP across EU countries in 2015.

Lost income due to lower employment rate of people with depression is estimated at EUR 176 billion per year across EU countries

Living with mental health problems has an impact on people’s daily lives, including their ability to work. Mental health problems often impede an individual’s ability to participate in the labour market which can lead to a “vicious” circle whereby the longer people are out of work, the more damaging the consequences are for their mental health (OECD, 2014).

The analysis here only focuses on the labour market impact of depression, as it is the only mental health problem considered in the last wave of the European Health Interview Survey in 2014. Figure 1.7 shows that people reporting chronic depression have much lower employment rates than the rest of the population. Only about half of the population aged 25-64 reporting chronic depression were in employment, compared with over three-quarter (77%) among those who do not report chronic depression on average across EU countries. This employment gap is particularly large in Cyprus, Croatia, Malta, Romania and Bulgaria, although this may partly be due to small sample sizes in EHIS. The cost of this lower employment rate related to chronic depression is estimated at about EUR 176 billion in 2015, representing an amount equivalent to 1.2% of GDP across EU countries as a whole.

Figure 1.7. People reporting chronic depression are much less likely to work in all EU countries

Note: Weighted EU28 average. People with depression are identified through the question “During the past 12 months, have you had any of the following diseases?” with depression being one of these diseases. Due to missing data, the assumption has been made that the situation in Ireland is the same as the EU average.

Source: Eurostat Database, based on the European Health Interview Survey (2014).

 StatLink https://doi.org/10.1787/888933834053

Preventing deaths by suicide

Though suicide remains a major cause of death, and still contributes significantly to mortality from mental illness (as discussed earlier in the chapter), longstanding national commitments to reducing suicide in European countries have helped to reduce the rate of suicide in most countries. On average, the number of deaths by suicide per 100 000 population fell from 12.5 in 2005 to 10.9 in 2015 (Eurostat, 2017). In some countries the falls were even more significant, albeit often from a higher starting rate. Between 2005 and 2015, deaths by suicide fell by more than 20% in almost half of all EU28 countries.

A range of measures are recognised as effective in reducing suicide, including restricting access to lethal means, raising awareness of suicide and suicide risk, improving access to mental health treatment, signposting to sources of help and protective measures in suicide “hotspots”, and tailored efforts to reduce suicide following hospitalisation, for example psychosocial assessment and good follow-up care (Hawton et al., 2016; Zalsman et al., 2016). Such approaches have helped some countries achieve significant falls in suicide rates (for instance Finland, see Box 1.5), even as all countries still continue to seek to prevent suicide more effectively.

Box 1.5. A renewed strategy to prevent suicide in Finland

In Finland, the rate of suicide has fallen by over 50% over the past 30 years. A significant driver of the reduction in suicide has been the fall amongst young men aged 20-29 (Figure 1.9). Nonetheless, death by suicide amongst young Finnish males remains high in comparison with other Nordic countries (Denmark, Norway, Sweden). Mental illness and alcohol dependence or abuse are significant causal factors (Titelman et al., 2013; Wahlbeck et al., 2011), but socioeconomic conditions have also had an impact.

Figure 1.9. Suicide amongst young Finns (15-29), 1980-2016

Source: Statistics Finland.

 StatLink https://doi.org/10.1787/888933834091

Suicide prevention campaigns in Finland began in the 1980s, and led to a series of national suicide prevention programmes that ran during the 1990s. Finland’s strategy identified depression, access to mental health care, substance and alcohol abuse, and access to lethal means as central features. The strategy also led to the establishment of crisis phone lines for persons experiencing suicidal thoughts, and guidance to the media, for instance not reporting suicide methods (Patana, 2014; Korkeila, 2013). Recognition that suicide was particularly high amongst young men led to the development of the “Time Out! Back on the track” (Aikalisä! Elämä raitelleen) initiative in 2004, which promoted social inclusion amongst vulnerable men. Two-thirds of participants reported that the participation in the programme was worthwhile, while about 60% considered it had improved their life situation (Appelqvist-Schmidlechner et al., 2012).

At the end of 2017, the Finnish Parliament allocated EUR 300 000 in 2018 to develop a new national strategy to prevent suicide, which will be included in Finland’s new broader National Mental Health Strategy. This work will establish a network for coordinating suicide prevention, and improve the planning, implementation, monitoring and evaluation of suicide prevention measures (Finnish Government, 2017).

Some countries have also developed dedicated national suicide strategies, or included suicide prevention in their broader mental health strategy. A comparative study also found that nationwide suicide prevention programmes had a positive effect in helping to reduce suicide, especially those focused on reducing suicide amongst elderly and young populations (Matsubayashi and Ueda, 2011). For example, Austria began “Suicide Prevention Austria” (Suizidprävention Austria [SUPRA]) in January 2017, focused on national and regional coordination of suicide prevention strategies, developing media support for suicide prevention, research, and integration of suicide prevention into other health promotion activities (EU Compass Consortium, 2017).

Early life interventions to promote mental well-being

Efforts to ensure good mental health in the first few years of life are cost effective in terms of mental, physical, and social outcomes. Effective actions can start even before a child is born: poor maternal mental health – conditions such as anxiety, depression, post-traumatic stress and psychosis affecting some 10-20% of women in the perinatal period (Gavin et al., 2005) – have been associated with poorer physical and cognitive development (Ibanez et al., 2015), higher risk of pre-term birth, and lower birth weight (Jarde et al., 2016).

Many countries have programmes that focus on maternal health, infant health, promoting mental well-being in pre-schools, or parenting support. In England, clinical guidelines by NICE suggest that primary care providers discuss mental health and well-being with women upon first contact during the early postnatal period (National Institute for Health and Care Excellence, 2018). In 2017 the Baby-Mother-Father Perinatal Mental Disorders Service in Hungary developed a new official guideline in intersectoral cooperation, providing support for treatment of perinatal and postnatal depression, which has started as a pilot programme in one hospital (EU Compass for Action on Mental Health and Wellbeing, 2018).

Programmes which promote parenting skills and seek to improve parent-child relationships, often targeting vulnerable or at-risk children, can have a positive impact on the mental health of parents and children. In Germany, the “Early Help” initiative gives support to parents of children aged 0 to 3, delivered by family midwives and other professionals, and is available to all families with more intensive services available for cases requiring more support (McDaid, Hewlett and Park, 2017).

Promotion of good mental health in schools

Schools are an ideal setting for interventions to promote mental well-being as almost all children and young people in Europe spend a good part of their day in school settings. School-based interventions can benefit mental health, develop mental health literacy, as well as improve social and educational outcomes; long-term benefits include improved academic performance, better resilience, and better cognitive skills (Weare and Nind, 2011; Durlak et al., 2011). Investing in good mental health for school-aged children can reduce the risk of children dropping out of school or having a difficult school-to-work transition (OECD, 2015).

School-based programmes often take a universal approach, covering either the full school population or a specific age group (e.g. primary school children or secondary school children). A few countries have introduced programmes that target vulnerable or at-risk children or young people – for instance Finland, Norway or the United Kingdom (McDaid, Hewlett and Park, 2017). Interventions delivered in schools can include actions targeting teaching skills, promotion of positive mental health or well-being, programmes to improve mental health “literacy” and understanding of mental disorders, reduce stigma, or actions to prevent bullying and cyberbullying (see Box 1.6). General mental health promotion programmes are common, for example in Slovenia, the Slovenian Network of Health Promoting Schools which covers 324 schools (around 55%), adopted the theme of mental health promotion in 2015-16, developing a manual for teachers to promote mental health. Zippy’s Friends is a universal school-based programme adopted in 27 countries, including Denmark, Ireland and Lithuania, which helps young children to develop coping and social skills. An evaluation in Norway found that the programme had helped improve the classroom atmosphere, reduce bullying, and improve academic scores (Holen et al., 2013; Clarke, Bunting and Barry, 2014).

Box 1.6. Understanding and preventing cyberbullying

With the increasing ubiquity of the internet, social media and online platforms, the way people, and particularly young people, interact has dramatically changed. While technological developments offer children and young people new opportunities for personal development and growth, they also present challenges to health and well-being. Concern has been rising in particular about cyberbullying. Cyberbullying can include sending offensive messages or comments online, spreading rumours, excluding victims from online groups and other forms of harassment (OECD, 2017). Like bullying, exposure to cyberbullying has been related to a wide range of negative outcomes, including stress and suicidal thoughts (Kowalski et al., 2014), depression and anxiety (Fahy et al., 2016).

The Health Behaviour in School-Aged Children (HBSC) survey of 42 countries asked children about their experiences of bullying on the internet, and found that on average 11% of children aged 11, 13 and 15 reported having been cyberbullied at least once by message. Just over 3% of children reported having been cyberbullied by message at least 2-3 times a month. In all countries the rate of bullying in school was found to be significantly higher than the rate of cyberbullying.

Figure 1.10. Bullying and cyberbullying experienced by children aged 11, 13 and 15, 2013/14

1. Proportions who reported being bullied at least twice at school in the past couple of months.

2. Proportions who had experienced cyberbullying by message (instant messages, wall-postings, emails and text messages) at least once.

Source: Health Behaviour in School-aged Children (HBSC) Survey, 2013/14.

 StatLink https://doi.org/10.1787/888933834110

Some interventions have been found as effective ways to counter cyberbullying, including school-based anti-bullying programmes, programmes including parent meetings, parent and child education, and teaching empathy and coping skills (Hutson, Kelly and Militello, 2018; Farrington and Ttofi, 2009) although the long-term effectiveness of these programmes is not clearly evidenced (Cantone et al., 2015).

Protecting and improving the mental health of the working-age population

Actions around mental health in the workplace – which 20 countries report having in place – include efforts to improve mental well-being, actions to support workers experiencing mental ill-health stay in work, and actions to facilitate return-to-work after a period of sickness absence. Such interventions can contribute to reducing some of the high economic costs related to mental illness noted earlier in the chapter and contribute to maximising productivity, opportunities and fulfilment for employees. The most economically effective interventions were found to be those targeting individuals rather than organisations (McDaid and Park, 2014; Hamberg-van Reenen, Proper and van den Berg, 2012).

Many European countries are using health and safety legislation and labour laws to safeguard and promote mental well-being at work. Austria, Belgium, Finland, France, Norway, and the Netherlands are using labour legislation to tackle psychosocial workplace risks. Finland and Lithuania require employers to assess and respond to mental stress and strain at work (McDaid, Hewlett and Park, 2017).

Workplace programmes can focus on the individual, or on an organisation-wide approach, for instance promoting mental health awareness amongst managers, changes to the physical working environment, and improving social relations at work. In Belgium prevention advisers give guidance to workplaces on psychological well-being, and support the preparation of risk assessment plans to minimise stress and violence at work (Samele, Frew Stuart and Urquia Norman, 2013). In the Netherlands the “SP@W: Stress Prevention at Work” aims to identify and deal with stress in the workplace through a learning network, a digital Occupational Stress platform, and roadmaps tailored to each individual company (EU Compass for Action on Mental Health and Wellbeing, 2017).

Few initiatives, though, were found to focus on improving the mental health of the unemployed, with actions reported or identified in the literature for only nine countries. This is despite strong evidence that unemployment is a strong risk factor for mental illness. As noted before, lost income due to lower employment rate of people with depression alone is estimated to amount to EUR 176 billion per year across EU countries, and these estimated costs would be even higher if other mental health disorders were included. Where they exist, many programmes focus on helping to reintegrate individuals who already had mental health problems, rather than supporting the mental well-being of unemployed persons (McDaid, Hewlett and Park, 2017). A few exceptions can be found. In a suburb of Athens, a centre for psychological support of the long-term unemployed was established in 2013, supported by the European Social Fund and Ministry of Health (Center of Psychosocial Support of Long-term Unemployed, 2016).

Given that unemployment is a strong risk factor for mental ill-health, it is important that policies to promote good mental health reach these more vulnerable populations.

Promoting good mental health among older people

As the European population ages – more than 18% of the European population is now over 65, and about 5% is over 80 – promoting healthy ageing is a growing policy priority (OECD, 2017). Mental well-being should be a key part of healthy ageing alongside physical health. There are key mental health risks linked to ageing, for instance around the sometimes-difficult transition from work to retirement, or related to physical illness and frailty. Social isolation, loneliness, and lower levels of contact with friends and family can also contribute to lower levels of mental well-being. Equally, older people commonly fall outside of social structures such as schools and workplaces where mental health promotion and illness prevention interventions are more common, as Figure 1.8 shows.

To promote mental well-being amongst older populations, interventions have focused on tackling some of the risk factors for mental illness, for example loneliness, and promoting activities that foster mental well-being, for instance through promoting social participation. Although evidence on the cost-effectiveness of interventions for the older population is limited, a systematic literature review including more than 10 countries found that participation in social activities, psychosocial educational interventions, intergenerational activities and volunteering, and some educational activities could help protect the mental well-being of older people (McDaid, 2015).

Though far fewer actions to promote the well-being of older people are found than for other parts of the life course, a number of countries are nonetheless intervening with actions primarily to reduce loneliness and isolation. In England, efforts to tackle loneliness amongst older people entailed identifying, signposting, and in some cases funding, of local activities such as lunch clubs, dance afternoons, befriending services, and sports groups (McDaid, Hewlett and Park, 2017). In Norway, government grants are awarded to local areas to create social activities with a social participation component, while in Iceland volunteers from the Icelandic Red Cross make weekly visits to older, ill, or isolated individuals.