Multisectoral action for mental health: thematic brief on mental health

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life and can contribute to his or her community. Mental disorders, by contrast, represent disturbances to a person’s mental health that are often characterized by some combination of troubled thoughts, emotions, behaviour and relationships with others. Mental disorders are one of the most important public health challenges in the WHO European Region since they are the main cause of disability in many coun- tries and a major burden to economies. The Sustainable Development Goals emphasize the promotion of mental health and well-being as an integral part of combatting noncommunicable diseases and ensuring healthy lives. Achieving the Sustainable Development Goals requires recognizing mental health as a fundamental human right and applying September 2019 Synergy between sectors: fostering and protecting mental health through multisectoral action Thematic brief on Mental Health Multisectoral action for mental health multisectoral approaches to promote and protect mental well-being and prevent and treat mental disorders.Key reasons for including mental health in Health 2020 and the 2030 Agenda for Sustainable Development include the intrinsic value of good mental health, the wide-ranging effects of mental disorders and the multisectoral nature of its formation, preservation and restoration. Action is necessary across sectors to promote mental well-being, since there is indeed no health without mental health. Mental disorders are treatable, with evidence of effectiveness of both psychosocial and pharmaceutical interventions. However, much of the challenge lies in a lack of access to high-quality, evidence-informed mental health services; accordingly, WHO and other international partners emphasize the need to enhance access to these services. Achieving increased treatment coverage requires mental health services to work in partnerships with other sectors. The association between inequality and childhood mental health prob- lems, such as hyperactivity, conduct disorders and anxiety, is strong. These mental health problems are also strongly associated with deprivation, poverty, inequality, and social and eco- nomic determinants of health. Mental health problems are exacerbated by higher levels of smoking, alcohol and drug abuse, unemployment, obesity and poor nutrition, which affect some populations more than others. Comor- bidities of mental health problems are also risk factors for noncommunicable diseases, just as noncommunicable diseases are risk factors for mental health. Mental health problems and co- morbidities are clustered in the bottom socioeconomic quartile of the popula- tion in the European Region. Key messages The goal of Health 2020 is to significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality. 1 2 34 5 Physical and mental health and well-being are best achieved if the whole of government works together, and Health 2020 pro- motes whole-of-government and whole-of-society approaches. Physical and mental health and well-being can be improved and health inequalities reduced through appropriate policies and working with other sectors. Different countries, cities and communities have different starting-points: each is unique and can pursue common goals through different pathways. Social progress is best meas- ured by objective indicators of physical and mental health, health equity and well-being, and this includes the conditions in which people are born, live and work. . HEALTH 2020 Physical and mental health and well-being are public goods and assets for human development that contribute to strong, dynamic and creative societies. In 2017, 4.2% of the population had depression (37 million people) and 4.5% anxiety (40 million people), with women being disproportionately affected by both, making them the most common mental disorders in the WHO European Region. Other mental disorders, classified as more severe, include bipolar disorder and psychotic disorders and afflict about 1% of the population each. One fourth of the population in a given year has mental ill health, and mental disorders are a major burden to economies. The annual direct cost from depression alone in the European Union was estimated to be €617 billion in 2013, mainly caused by costs to employers from absenteeism and costs to the economy from lost output. Mental ill health is also strongly related to suicide, and men have a five-fold greater risk of completing suicide than women. In 2016, the suicide rate in the Region was 12.9 per 100 000 population, corresponding to about 300 suicides per day every day of the year in the Region, affecting individuals, families, communities and society as a whole. Because of lack of access, many peo- ple with mental ill health or mental dis- orders either receive no treatment or experience long delays. For example, 3 of 4 people with major depression in the Region do not receive adequate treatment. The life expectancy of people with mental disorders is 10–20 years lower than that of the general population because of unrecognized and untreated physical health condi- tions. When access to mental health ser- vices is increased, leaving no one behind is also essential. This includes targeting populations at risk such as refugee and immigrant populations and LGBTQ individuals, whose rates of mental health conditions are at least three times as high as the general population. Setting the scene: mental health and mental disorders in the WHO European Region 4.2% estimated depressions of the population in the WHO European Region 37m people (2017) 4.5% estimated anxiety of the population in the WHO European Region 40m people (2017) 3 All Member States of the WHO European Region have agreed to monitor progress against six common targets: What makes societies prosper and flourish can also make people healthy: policies that recognize this have more impact. Building awareness and capacity to make health objectives part of society’s overall socioeconomic and human development is essential. All policy fields, including health, need to reform their ways of working and use new forms and approaches to policy at the global, national and local levels. Reduce premature mortality in the European Region by 2020 Increase life expectancy in the European Region Reduce health inequalities in the European Region Enhance the well-being of the European Region population Ensure universal health coverage and the right to the highest attainable level of health Set national goals and targets related to health in Member States Health 2020: a framework for action The goal of Health 2020 is to significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality. 1. 2. 3. 4. 5. 6. The Sustainable Development Goals All 193 Member States of the United Nations adopted the United Nations 2030 Agenda for Sustainable Development at the United Nations Sustainable Development Summit in 2015. The 17 Sustainable Development Goals are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. They build on the successes of the Millennium Development Goals while including new areas such as climate change, economic inequality, innovation, sustainable consumption and peace and justice. The Goals are interconnected and require multisectoral and intersectoral action – the key to success for any one Goal involves tackling issues more commonly associated with another. Multisectoral action for mental health across the lifecourse A comprehensive and coordinated response to mental health promotion, protection and care requires strong and enduring partnerships across multiple public and private sectors, including health care, education, employment, judiciary, housing, social welfare and other relevant sectors. These sectors must work across the life-course, as demonstrated in Fig.1. The mental health problems of parents and caregivers can also affect chil- dren, worsening the quality of care they receive and increasing the risks of anxiety, depression and poor school performance. This, in turn, affects children’s life chances and outcomes across the life-course. For example, an economic crisis can produce mental health effects that may increase suicide and alcohol death rates. These effects also differ by sex, with women especially having higher risk of being diagnosed with anxiety after a recession. However, the effects of an economic crisis can be prevented by social welfare and other policy measures, such as active labour market programmes and family support. These interventions are proven helpful in addressing mental health problems, preventing job loss and promoting faster re- employment when necessary – with subsequent benefits for children. Likewise, unaffordable housing can quickly exacerbate the effects of social disadvantage and is a major risk factor for mental health problems among children and their families. Parents, families and households Child protection Education Health Housing Labour • Deprived parental material conditions (income, resource access, housing and employment) • Low level of pregnancy and maternal care and social support • Experiences of child abuse Schools Education Health Justice Social affairs • Bullying or discrimination • Substance misuse • Poor nutrition Workplaces Education Health Justice Labour Social Affairs • Job stress • Job insecurity and unemployment • Bullying and discrimination Care of older people Housing Education Health Transport Welfare • Social isolation • Experience of elder abuse or neglect • Poor physical health Cross-cutting aspects • Age and sex • Gender • Socioeconomic status • Minority status • Genetic factors Fig. 1: D ifferent sectors and m ental health challenges at different stages of the lifecourse Intersectoral policies and interventions to address the determinants of mental health and well-being As reflected in Fig. 1, given the diversity of government actors involved in mental health, interventions within and outside the health sector are needed to address the underlying determinants of health. The following charts include examples of adequate joint actions to promote and protect mental health and prevent and treat mental disorders. Ensuring that mental health is considered in all policies Housing, judiciary, employment Contact with green areas, good-quality living conditions and wellness at work are examples of factors known to positively affect mental health. Access to these factors must be ensured through multisectoral cooperation, incorporating the goal of promoting mental well-being into the agendas of all actors involved CHALLENGES MAIN SECTORS INVOLVED JOINT ACTION TO IMPROVE MENTAL HEALTH AND WELL-BEING Promoting mental health Addressing common misunderstandings of the causes of mental health problems and promoting the importance of mental health as an integral part of well-being Education, health, government Awareness programmes and anti-stigmatization campaigns have been shown to improve mental health literacy, and these efforts therefore need to be implemented further Building resilience to adverse life events and promoting socio-emotional intelligence in the population Education, health, government Evidence-informed school interventions addressing the socio-emotional intelligence of young people need to be implemented further CHALLENGES MAIN SECTORS INVOLVED JOINT ACTION TO IMPROVE MENTAL HEALTH AND WELL-BEING Maintaining and protecting the mental health of individuals or households at risk Judiciary, social welfare Individuals and households at risk need legal protection (such as child welfare), social protection (such as support for low-income households) and financial protection (such as protection for people who are unemployed or in debt) to lower the risk of mental health problems Protecting mental health Ensuring legal protection against violence and abuse, including the highly marginalized and vulnerable group of adults with psychosocial and intellectual disabilities living in institutions Judiciary, health, social welfare Policies and legislation urgently need to be revised to assure alignment with the United Nations Convention on the Rights of Persons with Disabilities and other human rights conventions, including the right to exercise legal capacity; community-based care needs to be developed as an alternative to institutions Reducing rates of self-harm, suicide and mental disorders Education, judiciary Evidence-informed school programmes to reduce bullying, problem behaviour and substance misuse need to be implemented; introducing population-based restrictions on the availability and marketing of alcohol and tobacco have shown positive results on adolescent mental health and indicate that these need to be further expanded CHALLENGES MAIN SECTORS INVOLVED JOINT ACTION TO IMPROVE MENTAL HEALTH AND WELL-BEING Preventing mental disorders and self-harm Improving the proportion of children who are developmentally on track in health, learning and psychosocial well-being Social welfare, health Providing family support programmes for those at risk, such as families in which one or more parent has a severe mental disorder; these programmes show robust evidence for improving the social and emotional skills of both children and parents CHALLENGES MAIN SECTORS INVOLVED JOINT ACTION TO IMPROVE MENTAL HEALTH AND WELL-BEING Ensuring early identification of mental health or behavioural problems and providing access to effective interventions, since they are key to recovery Education, employment, health Awareness campaigns and educational programmes are needed in schools and workplaces to encourage individuals to seek help early; investing in easily accessible support services at schools and workplaces as a first line of help or a referral point is needed Treating people with mental disorders Mental health services are often fragmented and lack coordination Health, social welfare Joint planning of health services and social care must be improved for people with severe mental health disorders 7 Reducing health inequalities requires addressing the following LIFE-COURSE STAGE • Adequate social and health protection for those at risk of mental health problems • Universal, high-quality and affordable early-years education and care system • Secure healthy workplaces and access to employment and high-quality work • Intersectoral action to tackle inequalities at old age, both to prevent and manage comorbidities of mental health problems WIDER SOCIETY • Improve social protection, according to need • Co-creating partnerships with those affected by mental health problems, civil society and civic partners to reduce inequalities • Action to reduce social exclusion and empower people affected by mental disorders and psychosocial disabilities • Gender equity approach BROADER CONTEXT • Increase budget spending on mental health • Long-term planning by working with environmental, social and economic factors affecting mental health SYSTEMS • Comprehensive response from governments in promoting and protecting mental health • Regular reporting of inequalities in health Intersectoral response to other key challenges beyond mental disorders In addition to key mental health efforts targeting individuals with severe men- tal disorders, efforts to promote and protect mental health in the general population should also be strength- ened. Mental health is a fundamental human right for all people. We must move away from a binary approach of individuals being mentally well or unwell and move towards interven- tions and approaches that recognize and support individuals as they move on a spectrum throughout their lives from freedom of mental distress, through non-specific symptoms causing intermittent mental distress to clear syndromes causing increasingly severe functional impairment. Cross-cutting aspects Reducing health inequalities and achieving health for all requires imple- menting joint policies and interventions between actors and sectors with full respect for the principle of non-dis- crimination and, overall, following a human rights approach. Special attention must be given to individuals at risk of mental health problems such as those with a family history of mental illness, members of minority groups, those at risk of vulnerability, people who live in deprived communities, ex- cluded groups including the homeless and those who live in unstable house- hold conditions with violence or abuse. Further, interventions must consider social determinants when trying to achieve the greatest impact, such as women’s increased risk of depression and anxiety and men’s increased risk of completing suicide. Applying an equity lens to health and non-health interventions will positive- ly affect outcomes across the whole population, since those at the greatest risk will benefit the most while also benefiting society as a whole by effec- tively preventing more severe mental health problems. HEALTH 2020 8 For further information, see the Concept note: assessment tool for governance for health and well- being. SDGs for action in promoting mental health The right to health and sector mandates for multisectoral and intersectoral action for health and well-being Resourcing organization for multisectoral and intersectoral action for health and well-being The capacity of institutions and individuals for designing, implementing and delivering multisectoral and intersectoral action for health and well-being 2030 Agenda for Sustainable Development: a political mandate and transformative call for action 1. 2. 3. Achieving the Sustainable Develop- ment Goals (SDGs) requires working in a transformative way in order to implement a set of coherent, evi- dence-informed policies that address health, well-being and all their deter- minants throughout the life course and across all sectors of government and society. Revitalized global and re- gional partnerships are essential, and will provide the support and momen- tum to this societal and global effort. Transformative governance for action in mental health The adoption of the Health 2020 health policy framework for the WHO European Region in 2012 by all European Member States, with governance for health as a twin strategic objective alongside improved health equity, marked an invigorated strategic approach in the Region to strengthen governance for health and intersectoral action. This provides an excellent foundation for putting into operation and implementing the 2030 Agenda and the Sustainable Development Goals, which call for good governance, new models of partnership and scaling up intersectoral work as the means to achieve global, regional and national goals and targets and to meet today’s complex global challenges. Moving towards models of governance that deliver through their design health, equity and well-being is an example of the transformative response called for by the 2030 Agenda. Involving, managing, coordinating, developing accountability and coherence and supporting the implementation of action between diverse actors across all levels of government and beyond are necessary to achieve global, regional and national goals and targets and to effectively address today’s complex global challenges. The transformative approach to improved governance is facilitated through whole-system approaches at each individual level or node within a system (such as whole of government, whole of society, whole of city and whole of school) that engage all levels of governance within a system, from the international through the national and the regional to the local. Capacity for intersectoral governance for health and well-being depends on three key factors: Sustainable Development Goal 1: End poverty in all its forms everywhere Income inequality, financial strain, relative deprivation 1.3 Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable Sustainable Development Goal 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture Food security 2.1 By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages Access to health care, exposure to risk factors 3.4 By 2030, reduce by one third premature mortality from noncommunicable diseases through preven- tion and treatment and promote mental health and well-being 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.8 Achieve universal health coverage, including finan- cial risk protection, access to quality essential health- care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Sustainable Development Goal 4: Ensure inclusive and eq- uitable quality education and promote lifelong learning opportunities for all Community and individual social capital, social stability, social support 4.1 By 2030, ensure that all girls and boys complete free, equitable and quality primary and secondary education leading to relevant and effective learning outcomes 4.4 By 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs and entrepreneurship 4.5 By 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities, indigenous peoples and children in vulnerable situations Sustainable Development Goal 5: Achieve gender equality and empower all women and girls Community diversity, gender equality5.1 End all forms of discrimination against all women and girls everywhere Sustainable Development Goal 6: Ensure availability and sustainable management of water and sanitation for all Infrastructure, neighbourhood deprivation 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations Sustainable Development Goal 7: Ensure access to afforda- ble, reliable, sustainable and modern energy for all Infrastructure, safety and security7.1 By 2030, ensure universal access to affordable, reliable and modern energy services GOAL SUSTAINABLE DEVELOPMENT GOAL TARGET JOINT ACTION TO IMPROVE MENTAL HEALTH AND WELL-BEING Sustainable Development Goal targets for action in promoting mental health Sustainable Development Goal 10: Reduce inequality within and among countries Relative deprivation10.2 By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status 10.3 Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices and promoting appropriate legislation, policies and action in this regard Sustainable Development Goal 11: Make cities and human settlements inclusive, safe, resilient and sus- tainable Built environment, housing structure, overcrowding, recreation 11.1 By 2030, ensure access for all to adequate, safe and affordable housing and basic services and upgrade slums 11.3 By 2030, enhance inclusive and sustainable urbani- zation and capacity for participatory, integrated and sustainable human settlement planning and manage- ment in all countries Sustainable Development Goal 12: Ensure sustainable con- sumption and production patterns Built environment12.2 By 2030, achieve the sustainable management and efficient use of natural resources Sustainable Development Goal 13: Take urgent action to combat climate change and its impacts Natural disasters, climate change, forced migration 13.1 Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries Sustainable Development Goal 16: Promote peaceful and inclusive societies for sustainable develop- ment, provide access to justice for all and build effective, accountable and inclusive institutions at all levels War and conflict, industrial disasters, trauma 16.1 Significantly reduce all forms of violence and related death rates everywhere 16.3 Promote the rule of law at the national and inter- national levels and ensure equal access to justice for all Sustainable Development Goal 9: Build resilient infrastruc- ture, promote inclusive and sustainable indus- trialization and foster innovation Infrastructure, safety and security9.1 Develop quality, reliable, sustainable and resilient infrastructure, including regional and transborder infrastructure, to support economic development and human well-being, with a focus on affordable and equitable access for all Sustainable Development Goal 8: Promote sustained, inclusive and sustainable economic growth, full and productive employ- ment and decent work for all Economic recessions, income, debt, assets 8.3 Promote development- oriented policies that support productive activities, decent job creation, entrepreneurship, creativity and innovation and encour- age the formalization and growth of micro-, small- and medium-sized enterprises, including through access to financial services 8.5 By 2030, achieve full and productive employment and decent work for all women and men, including for young people and persons with disabilities, and equal pay for work of equal value 8.8 Protect labour rights and promote safe and secure working environments for all workers, including migrant workers, in particular women migrants, and those in precarious employment 11 GOAL SUSTAINABLE DEVELOPMENT GOAL TARGET JOINT ACTION TO IMPROVE MENTAL HEALTH AND WELL-BEING The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Original: English This brief has been produced as part of the Multi- and Intersectoral brief series by the Governance for Health Programme, Division of Policy and Governance for Health and Well-being, in collaboration with the Mental Health and Mental Disorders Programme, Division of NCDs and Promoting Health through the Life-Course, both WHO Regional Office for Europe. For more, please go to this link URL: www.euro.who.int © World Health Organization 2019. All rights reserved. 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