Mental Health : A Major Challenge for Health Authorities
WHO in its World Health Report 2001 Mental Health: New Understanding, New Hope states that “mental health – neglected for far too long – is crucial to the overall well-being of individuals, societies and countries and must be universally regarded in a new light” .
In our review we pursued 3 objectives in order to better understand the importance of mental health disorders in a public health perspective: First, identify the prevalence of mental health disorders and its related costs; second identify WHO recommendations for action and third identify efficient interventions for mental disorders prevention and mental health promotion.
A non-exhaustive non-systematic review of the literature via two databases (Medline, and Scholar Google) and several keywords (mental health, prevalence, burden of disease, health costs, prevention, health promotion, health policy recommendations) was undertaken. We essentially focused on WHO reports, meta-analysis of systematic reviews and reviews of original studies.
Concerning the situation in Europe, Gustavsson and colleagues  reported specific disease-related economical data. They estimated costs of mental health disorders as follows: Mood disorders (depression): € 113 billion; Dementia: €105 billion; Anxiety disorders: € 66illion; Addictions: €66 billion; Psychoses: €29 billion with a significant increase in the future. Furthermore, the cost projections by Knapp et al. established for England for the years 2007 to 2026 the following evolution: Dementia: £ 14.9 / £ 34.8 billion; Anxiety disorders: £ 8.9 / £ 14.2 billion; Personality disorders: £ 7.9 / £ 12.3 billion; Depression: 7.5 /12.2 billion; Bipolar disorders: 5.2 /8.2 billion; Schizophrenia: 4.0 / 6.5 billion £ .
Mental Health, a call for action: In 2013, the 66th WHO World Health Assembly adopted the 2013-2020 Mental Health Action Plan , following the recommendations of the 65th Assembly , including the following general objectives, i.e.; “Strengthening effective leadership and governance in mental health; providing comprehensive, integrated and responsive health and social services within a community framework; implementing strategies for promotion and prevention in the field of mental health; strengthening information systems, evidence and research in the field of mental health “. These general objectives are broken down into specific measurable objectives, such as, for example: 80% of countries will have updated their mental health policies and laws by 2016; 80% of countries allocate at least 5% of state health expenditure to mental health in 2020; 80% of countries have at least two national multi-sectorial programs for mental health promotion and protection in operation by 2016 (a universal program and a program targeting vulnerable groups); by 2020, 80% of countries collect and report a minimum core of mental health indicators each year. The Action Plan is based on six cross-cutting principles: universal health coverage, respect for basic human rights, evidence-based practices, a multi-sectorial approach, attention to all life stages, empowerment of people suffering from mental disorders and psychosocial disabilities.
The WHO European Regional Office has recently developed a new European strategy on mental health . It is in line with the WHO Global Action Plan 2013-2020 and the new European Health and Welfare Policy “Health 2020” . The strategy has seven general objectives, i.e.: “Everyone has an equal opportunity to realize mental well-being throughout their lifespan, particularly those who are most vulnerable or at risk ; People with mental health problems are citizens whose human rights are fully valued, respected and promoted ; Mental health services are accessible, competent and affordable, available in the community according to need ; People are entitled to respectful, safe and effective treatment ; Health systems provide good physical and mental health care for all ; Mental health systems work in well coordinated partnership with other sectors ; Mental health governance and delivery are driven by good information and knowledge”. These general objectives are also broken down into specific objectives while distributing tasks between Member States and WHO bodies.
Given the public health importance of mental health disorders and their economic impact, and in light of the health authorities’ awareness of the health issues associated with mental health disorders, one might wonder why mental health is not higher on the political agenda in many/most countries. Could it be, like some authors suggest , a lack of capacity building in the field of mental health and/or some misconception by decision makers of what mental disorders are and/or stigmatization by the population of persons with mental disorders? It seems imperative to inform thoroughly politicians, communities and society at large about the actual disease burden of mental disorders, of their important social and economic costs, but also of the possibilities to reduce this burden through effective and efficient interventions, which do exist. This means that professionals must speak up with arguments based on relevant data. Let’s mention some studies/data that can strengthen the arguments.
• In a priority-setting research  among 422 researchers/professionals/clinicians/ advocates working in more than 60 countries 25 top mental health intervention challenges were identified. The 5 top challenges, ranked by “disease burden reduction, impact on equity, immediacy of impact and feasibility”, are “a) integrate screening and core packages of services into routine primary care; b) reduce the cost and improve the supply of effective medication; c) provide effective and affordable community based care and rehabilitation; d) improve children’s access to evidence-based care by trained providers in lowand middle-income countries; e) strengthen the mental health component in the training of all health care personnel.”
• The DataPrev Project (Developing the Evidence Base for Mental Health Promotion and Prevention in Europe: a Database of programs and the production of guidelines for policy and practice) funded by the European Commission  “summarizes the evidence for actions to prevent disorders and to promote positive mental well-being  through parenting , at school , at the workplace  and in older age  supported by economic analysis ”.
• Parenting: Stewart-Brown and Schrader-McMillan  analysed 52 systematic reviews evaluating approaches to partenting support. Perinatal programs including antenatal programs, Parenting support programs in infancy and early years and Formal parenting programs with focus on prevention of behavioral problems “were shown to be effective in improving parenting and children’s mental health”. The evidence was not quite conclusive in Parenting support in highest risk groups programs (parents suffering from mental disorders, on drugs, with alcohol abuse and families in which abuse had already occurred).
• Interventions in Schools: Weare and Nind  reviewed 52 systematic-reviews and meta-analyses of mental health in schools. Numerous interventions had a beneficial impact on children, families and communities. The most effective interventions included (among others): teaching skills, focusing on positive mental health; balancing targeted and global approaches; starting with young children; operating over a long period of time. To be effective interventions had to be implemented lege artis.
Table 1. Examples of mental health interventions with return on investment (adapted and simplified according to Knapp ).
• Interventions at workplace: Czabala at al.  reviewed 79 intervention studies essentially aiming at reduction of stress, better coping, mental health improvement, reduction of absenteeism and increased job satisfaction and effectiveness. Conclusive evidence of effectiveness was not straight forward, partially due to lacking outcome evaluation. Yet, Stress Inoculating Training programs showed the most promising approach as long as contextual /organizational factors could be integrated.
• Interventions in older age: Forsman et al.  reviewed 69 prospective controlled trials. Globally psychosocial interventions influenced positively the quality of life of the elderly and their mental health; the interventions also had a significant effect on reducing depressive symptoms.
• Economic aspects of mental health interventions (in high-income countries): McDaid and Park  reviewed 47 studies of “considerable variability in quality”, thus “caution must be exercised in interpreting the results”: parenting and health-visitor- related programs appear most efficient; stress management programs in the workplace are also reported as efficient as well as psychosocial interventions targeting the elderly.
• In Table I we reproduce as examples some interventions that according to Knapp et al.  “pay for” themselves over the long term, but “quick wins” are rare. Some of these effective interventions have a multi-sectorial approach, others are more rooted in clinical practice, highlighting both the key role of public health actors and the no less important role of caregivers.
• Last but not least to be considered are the close links between poverty (to be understood as a multi-dimensional social phenomenon)[ 36] and common mental disorders : programs investing in education, in strengthening treatment of common mental disorders in primary care, in fighting discrimination and stigmatization, in supporting decent living/working conditions may reduce the risk of mental disorders and improve the well-being of individuals and communities [11, 15, 36].
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