Sign of progress or confusion? A commentary on the European Commission Green Paper on mental health

In the history of psychiatry in Europe, there have been several major initiatives that have inspired new ideas, influenced the way professionals and the public think about mental healthcare and, subsequently, had an impact on everyday practice. Examples of such initiatives might include the Psychiatrie-Enquete in Germany in 1975 and the Italian Law 180 in 1978 which was inspired by Franco Basaglia. It is unlikely that future generations will count the recent Green Paper on mental health (European Commission, 2005) as a seminal text. Nevertheless, it illustrates important challenges to mental healthcare at the beginning of the twenty-first century and highlights issues that might change the direction in the future.

Green Paper

The paper came out in October 2005 following the World Health Organization European Ministerial Conference on Mental Health in the same year. It has the noble intention ‘to launch a debate with the European institutions, governments, health professionals, stakeholders and other sectors… about the relevance of mental health for the EU [European Union], the need for a strategy at EU-level and its possible priorities’. It portrays ‘ mental ill health’ as a growing problem in the EU with wide economic consequences, and suggests preventive action, social inclusion of people with mental illness and more data on mental health across the EU. In the paper, the Commission invited all potential stakeholders in mental healthcare in the EU to contribute to a consultation process, which ended in May 2006. The results of the consultation process are not yet known in detail but one can expect that most of the contributors will have agreed that mental health is relevant, that a comprehensive EU strategy on mental health is welcome and that an interface between policy and research should be developed to improve prevention and care. However, whether the consultation process will also yield a clear concept of how mental health should be best promoted, an agreement on achievable priorities and specific ideas for actions is less certain.

Concept of ‘mental ill health’

The Paper reflects a general dilemma in psychiatry about the concept of ‘ mental ill health’ and the scope of mental healthcare. It begins with quoting an epidemiological study which estimates that more than 27% of adult Europeans experience at least one form of mental ill health within a year. This is in line with various findings from epidemiological research in industrialised countries which show a prevalence of mental disorders of 25% or more. These figures have rarely been challenged in the psychiatric literature. However, does a concept of mental disorder or ‘mental ill health’ really make sense if it applies to 27% of the population? Why have psychiatrists not been prompted by these figures to reconsider the definition of mental disorders or - at least - the methods employed to identify them? The definitions of health and illness will always be fuzzy at the edges, but are essential to define the scope of medicine and professional mental healthcare. The Green Paper, which is surely not to be blamed for the dilemma that it highlights, states that ‘there is agreement that a first priority is to provide effective and high-quality mental health care and treatment services… to those with mental ill health’. Putting this and the previous wisdom about the prevalence of mental ill health in the population together would lead to the conclusion that mental health services should be established for 27% of the population, a suggestion which will be regarded as ludicrous by many professionals and members of the public. What ‘ high-quality mental healthcare and treatment services’ can be developed - and funded - for more than a quarter of the population? The Paper does not explicitly ask for new armies of psychotherapists and other mental health professionals to provide such care but neither does it specify what approaches other than conventional services might deliver effective treatment for 27% of the population every year.

Either the concept of mental ill health or that of effective treatment may require revision. Any useful debate on the future of mental healthcare cannot avoid this. Using an inconsistent terminology that mixes the terms mental illness, mental disorder, mental ill health, poor mental health and mental health problems on the one hand, and medical treatment, health and social care, professional help, psychosocial support and therapy on the other, without meaningful and consistent definitions for any, will not be a solution in the long term.

Prevention

The Green Paper mentions a number of possible preventive actions and - in doing so - touches on another dilemma. The suggestions for actions include reducing the social isolation of older people, helping the unemployed to re-enter the labour market, the prevention of bullying throughout society and the strengthening of social cohesion. All these are certainly important tasks for European societies and achievement of any may have a positive impact on the mental health of the groups concerned. Increasing disparity between the rich and the poor, less social cohesion and a lower degree of general trust is likely to be bad for the mental health of the population. However, should all of these wider social problems be tackled under the banner of ‘ prevention of mental ill health’ Changing the fabric of society is not simply a matter of improving health indicators but requires change in social and political values. Reducing economic inequalities, with all its consequences, may therefore be regarded as primarily a political task and not one for specific mental health policies or care. Clarifying this might help to decide on the most appropriate action and avoid overloading mental healthcare with issues that it alone cannot shoulder.

Call for comparable information

The Paper asks for comparable information from across Europe. The differences among European countries in traditions of psychiatry, attitudes to and philosophy of healthcare, organisation of the healthcare systems, and funding arrangements can be used as a naturalistic experiment, and comparative data might help all countries to learn from each other and understand how different factors have an impact on the mental health of the population as a whole and specific subgroups in particular (Priebe, 2005). Those who have tried to pull data from different countries together will have found it to be more difficult than anticipated. Reliable information on simple parameters such as the provision of different types of services, let alone more sophisticated indicators, can be extremely difficult to obtain, and comparisons are further complicated by different definitions and connotations. In addition, there can be various language problems which are hard to overcome, even if all documents and data are translated into English. Cynics might say that it will probably take another 20 years of European collaboration before the participants understand to what extent they misunderstand each other. Despite these problems, communication and exchange of ideas and information are important and worthwhile. Better collection, accessibility and comparisons of data across Europe are both feasible and promising. Such data should feed into a wider debate on the future of mental healthcare which addresses the above-mentioned issues.

Forum for debate

Hence, if we are going to have a debate, where is that debate supposed to happen? There is no obvious European forum. Some countries such as Germany and Italy have begun to organise large national psychiatric congresses, which are held at the same place and time every year and attract more than 4-5000 participants. In the UK, such a congress does not exist. The annual meeting of the Royal College of Psychiatrists has failed to take that role, not only because many psychiatrists prefer to attend meetings of the American Psychiatric Association. Yet, there are excellent journals which might take the debate forward. For instance, Psychiatric Bulletin recently published a full series of debate papers on future directions of mental healthcare (Priebe, 2004). Discussions on future challenges and directions might also be held in local services, although - for whatever reasons - this currently does not often happen.

Conclusions

The Green Paper does not contain new ideas and gives rather confusing signals about the future direction of mental healthcare. However, it might reflect a new interest in mental health in the wider society and on a political level. If this is the case, it could herald exciting times for the development and improvement of mental healthcare. One may conclude from history that major reforms of psychiatry were possible only when psychiatric issues received wider public attention and political interest. Is the Green Paper a sign that we are at the beginning of a new era of such public interest in mental health and innovative reforms of care? As always, the future will tell.