Press backgrounder EURO 10/2001
Copenhagen,  4 October 2001

The world health report 2001
Mental health: new understanding - new hope

Implications for Europe: four questions – four answers:
Question 1. What is new in the world health report 2001?
Question 2. How relevant is WHR 2001 for the European Region?
Question 3. What is the extent of the mental health burden in Europe?
Question 4. Are there solutions?

Question 1. What is new in the world health report 2001? 

The world health report 2001 (WHR 2001) provides coherent and integrated answers to problems that have challenged mental health care in the world for a long  time. Both problems and proposed solutions are spelled out below.  

Ideology or science 

Mental health care in many countries still relies on approaches that are ideological, or based on experience uncritically reproduced or on untested beliefs. All care that is humane or respectful of a person’s dignity is welcome, but this not enough.

WHR 2001 reviews the research-based knowledge that has emerged and offers it to countries simply and directly. It identifies effective biological, psychological and social interventions – many developed here in Europe – that have solid anchor in research.   

Denial versus acknowledgement 

Countries have a long denied the extent of mental health problems. Health ministers from across Europe and beyond highlighted this problem during the World Health Assembly in 2001  The extent of the burden of the disorders is largely ignored, and awareness of the existence of modern means of intervention is mostly lacking.

WHR 2001 data show that 20–25% of all people have a mental disorder at some time in their lives. The young are not immune: more than 10% of all children have one or more mental and behavioural disorders.  

Institutional versus community care 

Many countries continue to rely on large mental hospitals to provide care for people with the most severe disorders. This care can have adverse effects, and the needs of many ill people outside the institutions remain unmet.

WHR 2001 strongly favours community-based care, presenting the benefits of care delivered close to home and recommending the proper use of a range of services. By cautioning countries about the process and pace of reform, in which services are transferred from the mental hospital into the community, WHR 2001 warns  that problems have resulted from moving away from hospitalization without creating alternative means of care in the community; e.g., the homeless person with mental illness.

Several European countries have been leaders in the movement towards effective community-based care.

Question 2. How relevant is WHR 2001 for the European Region?  

Policy 

WHR 2001 indicates that health benefit results from having policies that orient mental health action in a systematic and comprehensive way. New WHO data show that one third of the countries of the WHO European Region still have no explicit policies.

Legislation 

WHR 2001 recommends that developments in programmes and services, and human rights issues be placed within the framework of the law. In spite of remarkable progress in legislation on mental health, 10% of the countries of the WHO European Region still have none and legislation is outdated in a further 25%.   

Community-based care 

WHR 2001 reviews the advantages of community care and the availability of psychiatric beds in general hospitals.

Of the countries of the WHO European Region, 13 have neither started to switch to community-based care nor stated a willingness to do so. Of the remainder, 25 countries have initiated the reform or have developed community-based services in some localities, and 13 have fully established them. Nevertheless, Europe has a lower proportion of psychiatric beds in general hospitals (10%) than the world average (16%).  

Consumer involvement 

WHR 2001 strongly endorses the involvement of consumers and families in the planning and delivery of care. It uses the word partnership, suggesting  a symmetrical alliance that injects democracy in the system.

While consumer–community partnerships are evolving in most European countries, a few show little or no involvement of families, community or consumer organizations in planning or delivery of care. European consumer organizations were the principal actors in many events connected with this year’s World Health Day, which had mental health as its theme.  

Integration of mental health in primary care 

WHR 2001 discusses the rationale for the integration of mental health in primary care.

In Europe, as in the rest of the world, many people with mental disorders contact primary care services to ask for a referral for a specialist or, more typically, receive treatment in primary care when the disorder is recognized. In some European countries, the primary care system is in fact a mental health system, since mental health professionals are too few to handle the population’s needs. Studies show that mental health problems account for up to 30% of consultations with general practitioners.

Nevertheless, 12 of the countries of the WHO European Region have not integrated the services, keeping mental health and primary care working on parallel tracks. In contrast, 22 countries have achieved partial integration of the systems and 16, fuller integration.

In one out of five European countries, primary care does not include freely available access to at least three of the essential psychotropic drugs.  

Human resources 

WHR 2001 points out that specialized mental health personnel are not the sole resource of a good mental health system, but their presence in adequate numbers is essential in the network of services.

On average, the situation in the WHO European Region is much better than in other regions of the world. Europe has 9.0 psychiatrists, 27.5 psychiatric nurses, 3.0 psychologists and 2.4 social workers per 100 000 population.

Nevertheless, the number of mental health professionals in some European countries is still extremely limited.

Question 3. What is the extent of the mental health burden in Europe? 

Mental disorders place a heavy burden on individuals, families and communities all across Europe. No country is immune to them, although some disorders may differ in frequency. While many people suffer from a variety of disorders, care is not available to all who need it.   

Depression 

In the WHO European Region, 33.4 million people per year have been estimated to suffer from severe depression (58 out of 1000 adults). Of all the disability-adjusted life-years (DALYs) lost, depressive disorders account for the largest share.

Care providers recognize the problem in less than 50% of all depressed patients seeking medical care. Only about 18% of such patients get correct and specific treatment.

Depression is also a condition increasingly affecting adolescents. In a recent European investigation, 5% of all girls and 1.3% of all boys aged 16, in the country studied, fulfilled the criteria for severe depression. Fourteen percent of girls and about 5% of boys studied were found to be moderately depressed. 

Alcohol abuse and dependence 

About 41 million adults are estimated to abuse or be dependent on alcohol, with the proportion of men affected overwhelmingly higher that of women. About 66% of such people receive no treatment. About one to two thirds of alcohol-dependent men are considered to be “self-medicating”: using alcohol owing to unrecognized and untreated depressive conditions. The costs of alcohol abuse and dependence for some European societies have been calculated to amount to about 3% of their gross domestic product (GDP).  

Schizophrenia 

Schizophrenia affects 6.6 million people in the WHO European Region (7 per 1000). From 36% to 45% are estimated to be untreated.   

Epilepsy 

While 6 million people in Europe were estimated to be affected by epilepsy in 1998, 15 million will have epilepsy at some point in their lives. In some European countries, the proportion untreated reaches 56%.

Problems with children and adolescents A European study has shown that 57% of young people affected by a psychiatric disorder were untreated .  

Dementia 

Current estimates calculated the number of people with Alzheimer’s disease in European Member States at 1.4 million. This figure is projected to double in most European countries by 2025.

A recent European study calculates that the number of employable persons per demented patient, which was 120 in 1950, will fall to 17 in 2050.  

Suicide 

Suicide rates in Europe range from 11 to 36 per 100 000 population; the highest rates in the European Region are also the highest in the world. Certain populations are at particular risk, such as males in eastern Europe. In western Europe, however, adolescents and women are at increasing risk. Higher rates for suicide accompany  higher rates of of  homicide and purposeful injury (16.6 per 100 000 in the NIS and 7.2 per 100 000 in the European Region as a whole) and motor vehicle traffic accidents (15.6 per 100 000 in the NIS and 12.7 per 100 000 in the European Region as a whole).

In a northern European country, the cost of a suicide has been calculated at approximately US $2.5 million, and attempted suicide, US $7100 per case. In a country such as Sweden, which has a rather average number of suicides, these costs would amount to 1.5% of annual GDP.  

Question 4. Are there solutions? 

Fortunately, there are solutions.

Work for the better recognition and monitoring of depressive disorders has led to positive effects (including those on suicide rates) in some Member States.

Comprehensive treatment programmes directed at the addictive and depressive features in alcoholism have been shown to be effective.

WHR 2001 recommends ten kinds of action. These apply to Europe as much as to other WHO regions:

1.       providing treatment in primary care;

2.       making psychotropic drugs available;

3.       giving care in the community;

4.       educating the public;

5.       involving communities, families and consumers in care;

6.       establishing national policies, programmes and legislation;

7.       developing human resources for promoting mental health and preventing and tackling problems;

8.       engaging all sectors of society in action on mental health;

9.       monitoring community mental health services; and

10.   supporting more research.

WHR 2001 suggests action based on the realities of available resource. In other words, mental health action can be taken in all countries. Of course, strategies and programmes will vary, but countries can respond to their populations’ needs.