health problems have serious consequences, not only for individuals and their families but also for the competitiveness of the economy and the well-being of society. Poor mental health is both a consequence and a cause of inequity, poverty and exclusion. mental health is also a strong risk factor for morbidity and mortality from other diseases. It has been demonstrated that the presence of depression, in particular, strongly affects the survival rates of people with cardiovascular diseases and cancer. Depressive disorder is twice as common among women as among men.
nearly all countries in the European Region have mental health policies and legislation, but the capacity and quality of services is uneven. Whereas some countries have closed or reduced the number of institutions and have replaced them with a variety of community-based services, many other countries still rely on basic and traditional psychiatric services and use up to 90% of the mental health budget on mental institutions. Investment in well-being programmes and preventing disorders in childhood, often the precursors of lifelong suffering, is negligible.
The most cost-effective intervention at the population level is creating employment, either in the public sector or by creating incentives for expanding the private sector. Of growing interest is the interface between employment and mental health, since good-quality employment is good for health and its determinants (such as a good standard of living, self-esteem, social participation). This can also contribute to a healthy and productive workforce, with secondary benefits for families and communities. Effective occupational health services can identify, monitor and support people at risk at from an early stage. For groups at higher risk, public health interventions such as screening and information can be effective. People with mental health problems need
Mental health
Situation analysis
Solutions that work
A WHO European regional strategy for mental health is being developed, and it is anticipated that this will be presented to the WHO Regional Committee for Europe in 2013. Challenges for mental health include sustaining the population’s well-being at times when economic growth is minimal and public expenditure is facing cuts. This may result in higher unemployment (particularly long-term unemployment) and an increase in poverty, with an associated risk of depression, while mental health services undergo budget cuts. The psychosocial stress associated with job insecurity is also considerable.
A particular challenge is to promote the early diagnosis of depressed people and to prevent suicide by initiating community-based intervention programmes and services such as telephone hot lines and counselling support.
young people at risk can be helped by developments in schools such as early warning systems and anti-mobbing campaigns. Research is beginning to yield a better understanding of the damaging association between mental health problems and social marginalization, unemployment, homelessness and alcohol and other substance use disorders. new forms of addiction related to virtual worlds also need to be addressed.
Some countries are responding to the threat to people’s mental health by expanding counselling services. Awareness is also growing of the association between debt and depression, and debt advice services are playing crucial roles in providing financial security.
A rights-based approach to health care requires mental health services to be safe and supportive and every patient to be treated with dignity and respect. People receiving mental health care should be involved in decision-making concerning their individual care. mental health professionals should encourage patients to make their own choices regarding their health care, facilitated by providing appropriate information, and people who use mental health services should be involved in designing, delivering, monitoring and evaluating them.
At the population level, the threat to mental health offers opportunities to establish links between sectors that rely on each other but do not traditionally work together, such as benefit offices, debt counsellors and community mental health services. Coordination is essential for effectiveness and efficiency, and community mental health personnel are well positioned to take this role.
WHO has produced the mental health gap Action Programme (mhgAP) (186), which specifies effective interventions for mental disorders. The WHO Regional Office for Europe’s forthcoming mental health strategy will address ways to improve the mental well-being of the population, prevent the development of mental disorders and offer equitable access to high-quality services. The Regional Office is also working with countries to develop a mental health workforce that is competent to face the challenges.
mental health care systems have expanded beyond their former focus on treating and preventing disorders. mental health policies, legislation and implementation strategies are being transformed towards creating structures and resources that aim to empower people with mental health problems to make use of their inherent potential and to participate fully in societal and family life. This task can be achieved only by providing services and activities that empower individuals as well as communities and that protect and promote human rights.
to be detected in primary care, and people with severe conditions should be referred to specialist services.
Injuries, whether unintentional (from road traffic accidents, poisoning, drowning, fires and falls) or intentional (from interpersonal and self-directed violence), cause 700 000 deaths each year in the WHO European Region (187). They are the leading causes of death among people aged 5–44 years. The leading causes of injury are road traffic accidents, poisoning, interpersonal violence and self-directed violence. Injuries are responsible for 9% of the deaths in the Region but for 14% of the burden of disease as measured by DALys (188). Although there has been a general downward trend, mortality rates from injuries have increased in times of socioeconomic and political transition (189). Injuries are a major cause of health inequities in the Region. The mortality rates in countries that are members of the CIS are still four times higher than those in the Eu, and 76% of the deaths in the Region are in low- and medium-income countries.
Within countries, injuries and violence are strongly linked to socioeconomic class and cause health inequities. There are cross-cutting risk factors for the different types of injury, such as alcohol and drug misuse, poverty, deprivation, poor educational attainment and unsafe environments (190,191). These also cut across other disease areas such as noncommunicable diseases, presenting opportunities for joint action. many of these risk factors are socially determined.
Developing preventive strategies requires addressing the underlying structural factors and modifying individual and population-level risk behaviour.
gender-based violence is one of the most sensitive indicators of gender inequity and can severely affect physical and mental health. There are no comparable data on this problem in the European Region, but surveys from several countries indicate between 10% and 60% of women have been attacked by an intimate partner.
Injuries and violence
Situation analysis
The Region has some of the safest countries in the world. If all countries were to match the lowest national mortality rates from injuries, an estimated half a million lives lost from injuries could be saved in the Region each year. Countries with low injury rates have invested in safety as a societal responsibility and have achieved this by combining legislation, enforcement, engineering and education to achieve safe environments and behaviour (such as on the roads, at home and in nightlife venues) (190). These responses involve sectors other than health, and the challenge in preventing and controlling violence and injuries lies in ensuring that these responses are placed high on the agenda of policy-makers and practitioners from the health sector and other sectors (192).
A life-course approach is advocated, and interventions targeted early in life will lead to benefits in later years and across generations.
There is growing evidence about effective strategies to prevent injuries and violence, and many strategies have also been shown to be cost-effective, proving that investing in safety produces benefits for society at large. For example, every €1 invested in child safety seats saves €32; for motorcycle helmets the saving is €16, for smoke alarms €69, for home visiting schemes educating parents against child abuse €19, for preventive counselling by paediatricians €10 and for poison control centres €7 (193). WHO has proposed 100 evidence-informed interventions, and implementing these would dramatically reduce the inequities in the burden of injuries across the Region (194). These include a range of population-level and individual approaches to prevention, such as mitigating alcohol misuse (a major risk factor for injuries and violence). Interventions that are cost-effective at the population level are regulation, considering pricing policies and regulating
Solutions that work
advertising, and, at the targeted level, brief counselling by physicians. The WHO strategy is to work with member States to advocate for implementing the 100 evidence-informed interventions, underpinned by WHO Regional Committee for Europe resolution EuR/RC55/R9 on the prevention of injuries (195). Periodic surveys show that good progress is being made, although much more needs to be done.
Examples of specific areas of action include the united nations Decade of Action for Road Safety 2011–2020, launched on 11 may 2011. many countries in the Region have mainstreamed road safety into their national agenda. WHO is working with health ministries and other partners to try to achieve national targets, which in many countries include halving the number of road traffic deaths by 2020. To advocate for halting the cycle of violence, surveys of adverse childhood experience are being undertaken in several countries. The survey results are presented at national policy dialogues, at which interventions for child maltreatment prevention are given priority for mainstreaming into child health and development programmes. greater action is also being sought in two other neglected areas of policy: preventing youth violence and preventing elder maltreatment.
Implementing evidence-informed interventions can reduce inequities in the burden of injuries. As noted above, WHO has proposed 100 such interventions for implementation and is monitoring this (194). The challenge in preventing injuries and violence is to promote the implementation of such measures.
Since some are outside the remit of the health sector, health systems need to strengthen their role as a steward for equitable prevention. This includes:
advocacy and policy development, prevention and control, surveillance, research and evaluation, and providing services for the care and rehabilitation of injury victims. To assist the health sector in fulfilling these roles, capacity can be built by mainstreaming WHO’s teach vip curriculum into curricula for health professionals (196).