Towards collaboration on mental health in the Small Countries Initiative: background paper

Towards collaboration on mental health in the Small Countries Initiative Background paper Abstract This background document was developed specifically for reporting on the status of the eleven countries participating in the Small Countries Initiative (SCI) (Andorra, Cyprus, Estonia, Iceland, Latvia, Luxembourg, Malta, Monaco, Montenegro, San Marino and Slovenia) regarding collaboration on mental health at the Ninth High-level Meeting of the Small Countries Initiative (SCI), Luxembourg, 10–12 May 2023. It summarizes discussions at an online meeting involving mental health experts from the SCI countries, focusing on key priorities such as enhancing mental health support for children and adolescents, strengthening the mental health workforce, and addressing the pervasive issue of stigma and discrimination in mental health care. The meeting underscored the importance of collaborative efforts among small countries to advance mental health care and identified specific actions for the future, emphasizing continuous professional development, empowering individuals with lived experience, and investing in evidence-based campaigns to combat stigma. Keywords ADOLESCENTS, CHILDREN, COLLABORATION, MENTAL HEALTH, MENTAL HEALTH WORKFORCE, SMALL COUNTRIES, STIGMA, WELL-BEING. Document number: WHO/EURO:2024-8941-48713-72418 © World Health Organization 2024 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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All photos: ©WHO Towards collaboration on mental health in the Small Countries Initiative Background paper iii Contents Acknowledgements ...................................................................................................................................................... iv Background ...................................................................................................................................................................1 Opening of the meeting ................................................................................................................................................1 Objectives of the meeting .............................................................................................................................................1 Improving the mental health and well-being of children and adolescents ...............................................................2 Strengthening capacities of the mental health workforce ..........................................................................................3 Addressing mental health stigma and discrimination ................................................................................................4 Summary and next steps ..............................................................................................................................................4 iv Acknowledgements This background paper was prepared by Milena C Oikonomou (Consultant, WHO Regional Office for Europe) under the strategic and technical guidance of Ledia Lazeri (Regional Adviser for Mental Health, WHO Regional Office for Europe) and Bettina Menne (Senior Policy Advisor, Healthy Settings, WHO Regional Office for Europe). This work benefitted from the overall guidance of Natasha Azzopardi Muscat (Director, Division of Country Health Policies and Systems, WHO Regional Office for Europe). Special thanks go to Ana Maria Tijerino Inestroza (Technical Officer, Mental Health Flagship, WHO Regional Office for Europe), Cassie Redlich (Technical Officer, Mental Health Flagship, WHO Regional Office for Europe) and Elena Shevkun (Technical Officer, Mental Health Flagship, WHO Regional Office for Europe) for their detailed review of and input to the document. We are grateful to the Ministry of Health in Iceland, especially Ingibjörg Sveinsdóttir (Senior Advisor, Ministry of Health, Iceland) and Ásthildur Knútsdóttir (Director General, Ministry of Health, Iceland), the WHO/Europe mental health team, especially Ledia Lazeri, Ana Maria Tijerino Inestroza, Elena Shevkun, Luca Naccari (Assistant, Mental Health Flagship, WHO Regional Office for Europe), as well as Martin Krayer von Krauss (Senior adviser, WHO Regional Office for Europe) for organizing the online meeting. Finally, thanks go to the SCI MH focal points for offering their precious time to talk about the mental health situation in their countries. 1Background The WHO Regional Office for Europe Small Countries Initiative (SCI) is a platform through which 11 of the least populated Member States in the WHO European Region work together to address common public health challenges. The participating countries are Andorra, Cyprus, Estonia, Iceland, Latvia, Luxembourg, Malta, Monaco, Montenegro, San Marino and Slovenia. The Roadmap towards better health in small countries in the WHO European Region, 2022–20251 and the WHO European framework for action on mental health 2021–20252 call for action on improving mental health of citizens. In the context of the Pan-European Mental Health Coalition3 and the fifth Nordic Summit on Mental Health,4 the Icelandic Ministry of Health and the WHO Regional Office for Europe invited mental health experts from the countries of the SCI to an online meeting on 24 March 2023. The countries represented were Andorra, Cyprus, Estonia, Iceland, Latvia, Malta, Montenegro, Slovenia. This background paper summarizes the discussions on the three priority topics at the meeting. It aims to serve as input to the deliberations at the Ninth High-level Meeting of the SCI, to be held on 11–12 May 2023, in Luxembourg. It also will be used as a reference for future SCI activities in the field of mental health. Opening of the meeting Ásta Valdimarsdóttir, Permanent Secretary at the Ministry of Health of Iceland, welcomed the representatives of the SCI countries and highlighted the importance of mental health for Iceland, honouring the spirit of co- creation and collaboration across SCI countries. Natasha Azzopardi-Muscat, Director of Health Policies and Systems at the WHO Regional Office for Europe, addressed mental health from a health systems perspective and emphasized the need to strengthen relationships among mental health colleagues in the SCI countries. Objectives of the meeting The aim of the meeting was to exchange knowledge and good practices, and to explore the potential for further collaboration on mental health in small countries on the following priority topics: z improving the mental health and well-being of children and adolescents; z strengthening capacities of the mental health workforce; and z addressing mental health stigma and discrimination. 1 Roadmap towards better health in small countries in the WHO European Region, 2022–2025. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps.who.int/iris/handle/10665/354487, accessed 2 May 2023). 2 WHO European framework for action on mental health 2021–2025. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps.who.int/iris/handle/10665/352549, accessed 1 May 2023). 3 The Pan-European Mental Health Coalition. In: WHO/Europe [website]. Copenhagen: WHO Regional Office for Europe; 2023 (https://www.who.int/europe/initiatives/the-pan-european-mental-health-coalition, accessed 1 May 2023). 4 As part of the Icelandic presidency of the Nordic Council of Ministers, the fifth Nordic Summit on Mental Health was held in Reykjavík, Iceland, on 23 March 2023. The theme of the Summit was collaboration and co-production in mental health. 2The meeting was also intended to strengthen relationships among leading mental health experts in SCI countries. Improving the mental health and well-being of children and adolescents The lack of mental health support in community settings and the lack of meaningful and ethical participation of young people in designing mental health programmes remain major challenges to improving the mental health of children and adolescents. Participants expressed concerns about increased anxiety and susceptibility to mental health conditions among young people due to issues such as climate change, the pandemic, the war in Ukraine and challenges in the school system. Moreover, the online meeting revealed gaps in provision of and access to consistent, high-quality mental health care, and issues with strengthening relationships between the health and education sectors to accelerate implementation of mental health promotion and prevention activities in schools. To address these challenges, several opportunities and priority actions were discussed, including developing structures and opportunities to support increased participation and engagement with young people and youth organizations. Strengthening supportive environments for young people through free, open and anonymous community-based and online services, where they can receive support and referrals for further psychosocial support or more intensive services as appropriate, is of the utmost importance. It is crucial to improve the quality of mental health care by accelerating implementation of evidence-based interventions and delivering social and emotional education, as well as mental health literacy, through school-based programmes and other community platforms. A critical priority action is to address stigma as a barrier to young people’s use of mental health-care services. The meeting also highlighted the importance of training and supervising mental health professionals to encourage good practice, including provision of financial support for high-quality education. Other solutions include: z the planned development by the WHO Regional Office for Europe of a quality-of-care tool for child and adolescent mental health; z strengthening data and research on mental health; and z increasing innovation – including the use of digital platforms and the peer workforce5 to reach young people. 5 “Peer workforce” refers to the professionalized lived experience workforce – for example, young people with lived experience of mental health conditions working in designated “peer worker” roles within mental health services, who use their experience to support clients to engage with services and/or are trained to provide low-intensity psychosocial support. 3Strengthening capacities of the mental health workforce The online meeting introduced various challenges related to the mental health and care workforce, including chronic underfunding and under-resourcing of mental health services, as well as missing data on the mental health workforce. Another challenge is the lack of political will to invest in acute, specialized and individualized mental health workforce. Salary levels and limited opportunities for specialized education and professional growth have led to migration of the health and care workforce from smaller to larger cities, and from eastern and central parts to western parts of the WHO European Region. This is especially relevant for service provision in the context of ageing societies and workforce. A few countries in the Region have initiated processes to professionalize peer support and involve people with lived experience in the offer of care. Issues with recruitment and retention of medical and allied health students in mental health specialty training and the availability of specialty training programmes in some countries remain barriers to increasing numbers of qualified mental health-care professionals. Mental health stigma among health-care professionals and service users and specific pressures during the pandemic were discussed as issues related to access and use of mental health services and to the mental health and well-being of mental health workers. The meeting highlighted opportunities for strengthening and developing the mental health workforce in line with the WHO European Framework for Action on Mental Health 2021–2025. Participants also discussed further opportunities for small countries to strengthen their mental health workforce, including training in multidisciplinary approaches, person-centred and community care, and embedding of mental health education across the whole health sector. To address educational challenges, it is crucial to: z strengthen mental health services with interdisciplinary expertise in prevention, treatment and psychosocial rehabilitation; z attract, train and retain health-care and social-care professionals; and z provide training in service organization and management, and in identification and management of mental health conditions for other nonspecialized health professionals. This requires capacity-building in rights-based care and investment in the mental health workforce. It also necessitates collection of data and gaining a better understanding of regulations and population needs, expanding the use of digital tools, and strengthening health information systems. Professionalization of peer support provides opportunities for improving mental health services,and exchanges of best practices need to be encouraged. Exploring the provision of external supervision, when there is a lack of specialists, creates an opportunity to ameliorate the lack of mental health workforce. The online meeting reinforced the importance of appropriate preparation of health systems and the health-care workforce for integrating mental health into primary health care. 4Addressing mental health stigma and discrimination Mental health stigma and discrimination are widespread issues that can have serious consequences at both individual and societal levels. Persistent even within the health system and among health-care workers, stigma and discrimination remain serious barriers to access to high-quality mental health care. One of the major challenges in reducing stigma is the lack of knowledge about effective anti-stigma work due to the low priority given to research on this topic. Another challenge is the lack of evidence-based interventions and peer-learning networks. Moreover, all voices – including providers, users, families and communities – need to be better integrated in the development and communication of mental health conditions and services. Developing advocacy and communication tools to raise public awareness, producing guidance to improve policies and developing a co-produced toolkit with service users, families and carers are priority actions under the WHO European framework for action on mental health 2021–2025. Understanding and monitoring public attitudes and trends in stigma towards specific mental health conditions are inevitable parts of long-term and multilevel approaches for targeted and inclusive interventions. Research and evidence-based interventions are indispensable to tackling mental health stigma. Supporting peer-learning exchanges and networks can provide valuable insights to improve understanding of the causes and consequences of stigma and discrimination. It is crucial to strike an equitable balance of power between people with lived experience of mental health conditions and professionals, and to ensure that people with lived experience are involved in campaigns and in shaping services across the whole health sector. This can be achieved by: z increasing the professionalization of people with lived experience; z improving direct and indirect social contact between people with and without lived experience; and z taking a whole-of-society approach across sectors. Interventions within school systems were also discussed as effective measures. Job integration of people with mental health conditions can be promoted by bringing together employees, employers, trade unions, government and the health sector on a long-term basis, creating more inclusive workplaces and societies. Summary and next steps Intersectoral multilevel cooperation and cross-border cooperation in mental health are crucial to address common challenges and shared visions in small countries. Future cooperation to change mental health working conditions and culture should involve mental health professionals, politicians, people with lived experience of mental health conditions and young advocates. Mental health-related work needs to be aligned with other areas of work, including the well-being economy, and should take advantage of the networks offered by the Pan-European Mental Health Coalition. Specific areas that might benefit from collaboration among small countries include mental health of children, adolescents and young people; addressing stigma; promoting the professionalization of peer-support work; addressing isolation and loneliness; and innovative approaches to strengthening the mental health workforce. 5Proposed items for discussion at the Ninth High-level Meeting of the SCI in Luxembourg on 10–12 May 2023 are: z continuous professional development of the mental health workforce, incorporating opportunities for peer mentoring/support, networks and cooperation in training across SCI countries; z empowering people with lived experience – including young people – to contribute to service delivery through professionalization and competency-based training for the workforce with lived experience; and z investment in evidence-based campaigns that address stigma and discrimination. 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