Policies and practices for mental health in Europe

1 Policies and practices for mental health in Europe - meeting the challenges Abstract This WHO report, co-funded by the European Commission, gives an overview of Policies and practices for mental health in 42 Member States in the WHO European Region. Nearly all countries have made significant progress over the past few years, and several are among the leaders in the world in such areas as mental health promotion, mental disorder prevention, service reform and human rights. Nevertheless, this report also identifies weaknesses in Europe : some systematic, such as the lack of consensus on definitions and the absence of compatible data collection, and others that show great variation across countries, such as the stage of community services development and the level of investment in various areas. It also identifies gaps in information in areas of strategic importance for the development of mental health Policies . This report is a baseline against which progress can be measured towards the vision and the milestones of the mental health Declaration for Europe .

2 Keywords: mental health . health POLICY. health PROMOTION. mental health SERVICES - organization and administration PRIMARY health CARE. Europe . ISBN 978 92 890 4279 6. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8. DK-2100 Copenhagen , Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site ( ). World health Organization 2008. All rights reserved. The Regional Office for Europe of the World health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

3 Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World health Organization.

4 Photo credits/cover: Melitta Jakab, WHO/ Europe , Dan Eckert/I-stock, Liliana Urbina, Aldo Murillo/I-stock, Grigory Bibikov/I-stock, Anne de Haas/I-stock The European Commission (Directorate-General for health and Consumer Protection) co-funded this project. Policies and practices for mental health in Europe - meeting the challenges ii Contents Policies and practices for mental health in Europe Tables and figures vi Foreword xii Acknowledgements xiii 1. Introduction 1. 2. Methods 5. Content of the baseline assessment questionnaire 5. Development of the questionnaire 5. Languages 6. Data collection 6. Timeline 6. The data collection process 6. Data submission 6. Data sources and data cross-checking 6. Participating countries 7. Data analysis 8. Recording of the data 8. Methods of analysis 8. 3. Policy and legislation on mental health 11. mental health policy 11. Main developments since 2005 14. mental health legislation 14. Discussion 16. 4. Promoting mental health and preventing mental disorders 21.

5 Promoting mental health and tackling stigma and discrimination 21. Raising public awareness 21. Tackling stigma and discrimination 22. mental health promotion programmes and activities 24. Preventing mental disorders 26. Policies and programmes implemented during the past five years 26. Main activities initiated and developed since 2005 30. Centrality of mental health 31. Discussion 32. 5. mental health in primary care 35. Roles of general practitioners and family doctors in mental health care 35. Identification and referral to specialist services 35. Diagnosis 37. Treatment 39. Limitations on the role of general practitioners and family doctors in treating people with mental disorders 40. Right to prescribe medication 40. Right to perform certain tasks 41. Pressure on mental health care in primary care 41. Availability of national guidelines on assessment and treatment for GPs dealing with people with mental health problems 42. iii Refresher training courses in the rational use of psychotropic drugs and in psychosocial intervention 43.

6 Main activities initiated and developed since 2005 related to mental health services in primary health care 44. Training 44. Structural changes 44. Discussion 44. 6. mental health services 47. Inpatient services 47. Availability of specialized mental health facilities 47. Beds in inpatient facilities 48. Median number of days in the facility 51. Admissions to inpatient units 51. Outpatient services 54. Availability of specialized mental health facilities 54. Visits to mental health outpatient facilities 56. Community-based specialist mental health treatment and care 58. Community-based crisis care daytime only 59. Community-based crisis care 24 hours 61. Home treatment 63. Assertive outreach 65. Community-based early intervention 67. Community-based rehabilitation services 69. Residential health facilities 71. Availability of specialized mental health facilities 71. Beds in residential facilities 71. Forensic units 74. mental health services for children and adolescents 75.

7 Inpatient facilities 75. Outpatient facilities 77. Social institutions 77. Main activities initiated and developed since 2005 related to the mental health of children and adolescents 78. mental health services for older people 79. Inpatient facilities 79. Outpatient facilities 80. Social institutions 81. Access to interventions 81. Access to psychosocial interventions 81. Use of prescribed antidepressants 82. Sex distribution 83. Sex distribution of visits and admissions 83. Sex distribution of beds and places 83. Access to and appropriateness of mental health services for linguistic and ethnic minorities and other vulnerable groups 83. Access to mental health services for linguistic minorities 83. Use of mental health services by ethnic and minority groups 87. Discussion 88. iv Policies and practices for mental health in Europe 7. Workforce for mental health care 93. National Policies and programmes on the workforce for mental health care 93.

8 Availability of specialist mental health workers 95. Number of psychiatrists per 100 000 population 95. Number of nurses working in mental health care per 100 000 population 96. Other personnel groups 97. Psychiatrists emigrating and immigrating across the European Region 98. Main activities initiated and developed since 2005 related to the availability of specialist mental health workers 99. Competencies of specialist mental health workers 99. Undergraduate training hours on mental health 99. Specialist training for psychiatrists and psychologists 103. Continuing education 104. Main activities initiated and developed since 2005 related to education and training and the development of competencies 109. Discussion 110. 8. Funding of mental health services 115. mental health budget or expenditure as a proportion of the total health budget or expenditure 115. Allocation of the national mental health budget or expenditure (or aggregated regional or local budgets) 118.

9 Free access (at least 80% covered) to psychotropic medication and psychotherapy 120. Medication 120. Psychotherapy 121. Allocation of the local or regional budget for mental health based on a formula taking into account the relative needs of the population 123. Main activities initiated or developed since 2005 related to funding of mental health services 123. Discussion 124. 9. Social inclusion and welfare 127. Social welfare benefits or pensions because of disability due to mental health problems 128. mental illness as a cause of sick leave 128. Policies and programmes to improve social inclusion 129. Legal protection from discrimination: housing, dismissal and lower wages 131. Subsidized housing for people with severe mental disorders 132. Supported employment for people who are disabled due to mental disorders 133. Formal collaborative programmes between mental health departments and agencies and other parts of the health sector and other sectors 135.

10 Partnerships within the health sector 135. Partnerships between the health sector and other sectors 137. Main activities initiated and developed since 2005 related to social inclusion and partnership 137. Social inclusion of people with mental health problems 137. Partnership for intersectoral working 139. Discussion 139. v 10. O. pportunities for the empowerment and representation of service users and carers 143. Representation of service users on committees and groups responsible for mental health services 143. Representation of service users on committees and groups responsible for anti-stigma, mental disorder prevention and mental health promotion activities 146. Representation of families or carers on committees and groups responsible for mental health services 148. Representation of families or carers on committees and groups responsible for anti-stigma, mental disorder prevention and mental health promotion activities 150. Government support for organizations of service users and carers 150.