Publication Series from the Federal Institute for Occupational Safety and Health
- Research Report - Fb 1011
H. Berkels J. Henderson N. Henke K. Kuhn J. Lavikainen V. Lehtinen A. Ozamiz P. Van den Heede K. Zenzinger
Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress related Disorders in Europe Final Report 2001 - 2003
Dortmund/Berlin/Dresden 2004
behalf of the Federal Institute for Occupational Safety and Health. The responsibility for the contents of this publication lies with the authors.
Consortium: John Henderson Karl Kuhn Ville Lehtinen Agustin Ozamiz
Authors: Policy Report John Henderson
“Children, Adolescents and Young Kirsten Zenzinger People“ (up to 24 years)
“Working Adults” (24 – 60 years) Hilke Berkels Nathalie Henke
“Older People” (from 60 years) Juha Lavikainen Publication/
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Funded by the European Commission
List of Contents
Page
Abstract 5
Kurzreferat 6
Résumé 7
1 Preamble
82 Policy Report
102.1 Executive Summary 10
2.2 Ten Key Recommendations 12
2.3 Introduction 14
2.4 Policy and Planning 19
2.5 Conclusions for Strategy Development 23
3 Sector Report “Children, Adolescents and Young... ”
263.1 Introduction 26
3.2 Description of Process and Methods 32
3.3 Models of Best Practice 34
3.4 Outcomes 42
3.5 Annex 1: Listing of all Selected Projects 59
3.6 Annex 2: Listing of all Projects 68
4 Sector Report “Working Adults... ”
814.1 Introduction 81
4.2 Description of Process & Methods 88
4.3 Models of Best Practice 89
4.4 Outcomes 96
4.5 Annex 1: Listing of all Selected Projects 105
4.6 Annex 2: Listing of all Projects 125
5 Sector Report “Older People... ”
1315.1 Introduction 131
5.2 Description of the Process and Methods 134
5.3 Outcomes and Selected Best Practices 136
5.4 Conclusions 141
5.5 Annex 1: Listing of all Selected Projects 152
5.6 Annex 2: List of all Projects 172
6 List of the Project Group
1746.1 Executive Committee 174
6.2 Sector: Children, Adolescents and Young People to 24 Years
in Educational and other Relevant Settings 174 6.3 Sector: Working Adults between 25 – 60 Years 177 6.4 Sector: Older People from 60 Years in Various Settings 179 6.5 Project Financial Management and Progress Assessment 182
Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress Re- lated Disorders in Europe (2001-2003)
Abstract
The aim of the project was to create a state of the art of existing programmes con- cerning mental health promotion and prevention strategies (including early detection and intervention of anxiety disorders, various forms of depression as well as stress related disorders) on local, regional and national level.
Therefore two major strands were defined: a review of scientific literature and a status quo analysis collecting community, enterprise and institutional programmes.
To realise this, two different questionnaires were distributed among national partners in 15 European Member States. These questionnaires were developed to collect in- formation on the national situation concerning mental health and on mental health promotion and prevention programmes within three sectors, referring to certain peri- ods of life (children, adolescents and young people; working adults; older people) and different settings (e.g. educational settings, workplace, elderly care services). According to a list of criteria all programmes suggested by the national partners, were evaluated. The evaluation led to a selected list of “models of best practice”, on which recommendations for mental health promotion and mental ill health prevention are based. The recommendations are also based on additional findings within the project.
Even though this project resulted in a large collection of good programmes, many of them had not been evaluated yet in a more structured way. Therefore it is even more important to tackle promotion and prevention activities including their evaluation in order to combat mental health problems.
Key words:
mental health promotion, prevention, psychiatric disorders, depression, anxiety
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Förderung von Mental Health und Präventions- maßnahmen zu Bewältigung von Ängsten, Depres- sionen und stressbezogenen Störungen in Europa (2001-2003)
Kurzreferat
Ziel des Projektes war eine Bestandsanalyse von Programmen (lokal, regional, na- tional) bezüglich der Förderung von Mental Health (psychischer Gesundheit) und der Realisierung von Präventionsmaßnahmen. Dafür wurden zwei wesentliche Schwer- punkte gesetzt:
Ø die Rezension wissenschaftlicher Publikationen
Ø die Analyse existierender kommunaler, betrieblicher und Institutioneller Pro- gramme
Es wurden zwei Fragebögen entwickelt und an Partner in 15 EU-Mitgliedsstaaten ausgegeben. Die Fragebögen erfassen Informationen über die nationale Situation bezüglich Mental Health allgemein und über die Förderung psychischer Gesundheit sowie über den Präventionsmaßnahmen in drei Bereichen: Kinder, Jugendliche und junge Erwachsene, die Erwerbsbevölkerung und Ältere Menschen in verschiedenen Settings (z.B. Ausbildungsstätten, Arbeitsplätze, Altenpflegeeinrichtungen).
Anhand einer Liste von Qualitätskriterien wurden alle Programme bewertet, die von den nationalen Partnern vorgeschlagen worden sind. Die Bewertung führte zu einer Liste sogenannter „Models of Best Practice“ (gute Praxisbeispiele), welche wiederum zur Formulierung von Empfehlungen zur Förderung von Mental Health und zur Prävention psychischer Störungen beitrug. Zusätzlich sind auch Befunde - z.B. aus der Literatur - in die Empfehlungen eingearbeitet worden. Obwohl viele gute Pro- gramme für das Projekt zusammengetragen wurden, sind viele nicht im wissen- schaftlichen Sinne evaluiert. Deshalb ist es umso wichtiger, Mental Health und the- menspezifische Maßnahmen zu fördern, um psychischen Gesundheitsproblemen zu begegnen.
Schlagwörter:
Förderung von Mental Health, Prävention, psychische Erkrankungen, Depression
La promotion de la santé mentale et les stratégies pour faire face à anxiété, la dépression et autres maladies liées au stress
Résumé
Le but de ce projet était d’analyser la situation et les programmes existants concer- nant la promotion de la santé mentale ainsi que les stratégies de prévention au niveau local, régional et national, y compris les interventions, les détections précoces et les différentes formes de dépressions et de maladies liés au stress.
Deux questionnaires ont été distribués parmi les partenaires nationaux dans les 15 pays européens. Ces questionnaires ont été développés afin de rassembler des in- formations concernant la santé mentale et les programmes de promotion de la santé mentale pour trois tranches d’âge différentes (les enfants et les adolescents, les adultes dans la vie active et les personnes âgés) et dans différents lieux (l’éducation, les lieux du travail, les services de soins aux personnes âgées).
Tous les programmes ont été évalués conformément à une liste de critères dévelop- pés en coopération avec les experts nationaux. Cette évaluation a résultée dans une sélection de modèles de bonne pratique qui a servie de base à des recommanda- tions. Celles-ci contiennent également les résultats de l’analyse bibliographique ainsi que des informations concernants les différents pays participants à ce projet.
Bien que ce projet ait mené à une grande variété de bons programmes et de bons projets, beaucoup entre eux n’ont pas été évalués au sens propre du terme. C’est aussi pour cela qu’il est important de traiter ce sujet de promotion et de prévention en insistant sur une évaluation afin de mieux combattre les problèmes de santé men- tale.
Mots clés:
Promotion de la Santé Mentale, Prévention, maladies mentales, Dépression, anxiété
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1 Preamble
This report is the result of a European-wide project on ‘Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress Related Disor- ders in Europe. It was supported by the European Commission (General Directorate for Health & Consumer Protection) and organised by a consortium of four organisa- tions:
· Agustin Ozamiz, University of Deusto (Bilbao, Spain)
· John Henderson, Mental Health Europe – Santé Mentale Europe MHE (Brus- sels, Belgium)
· Ville Lehtinen, National Research and Development Centre for Welfare &
Health STAKES (Helsinki, Finland)
· Karl Kuhn, Federal Institute for Occupational Safety & Health FIOSH (Dort- mund, Germany)
Each organisation had to accomplish detailed tasks within the project, according to the background and fields of action of the organisations. This was accomplished by the establishment of a network of national partners from EU and EEA Member States for each sector.
The University of Deusto was responsible for the financial management and the proj- ect assessment, MHE organised the work for the sector ‘Children, adolescents and young people’, FIOSH took care of the activities in the sector ‘working adults’ and STAKES had charge of the sector ‘older people’. Within each sector the partners looked for so-called ‘Models of best practice’. Common criteria were established to identify projects and programmes on mental health promotion and prevention strate- gies, in order to gain an overview of the work, which has been done already and from which to develop relevant recommendations for the political, enterprise and individual level. Throughout the 18 months period the project was actively supported by part- ners active in the field of mental health – in the 15 Member States of the EU and countries of the EEA, who had subcontracts with the organisations responsible for the three sectors.
The work of the organisations and their partners was closely interlinked all the time and joint meetings were held to maintain the transfer of information and to ensure the quality.
We would like to thank kindly all our colleagues and their contact persons in the in- stitutions and enterprises of all member states for their effort and interest in the proj- ect. The success of this project was greatly dependent on their willing collaboration.
The final report consists of four sections: policy report and the three sector reports
‘Children, adolescents and young people’, ‘Working adults’ and ‘Older people’. Each sector is responsible for the content and quality of its report.
The organisation, national partners and experts are listed in the annex:
University of Deusto, Spain FIOSH, Germany ENWHP
Mental Health Europe – Stakes, Finland
Santé Mentale Europe, Belgium
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2 Policy Report
Foreword
This report on Policy is derived from the European Commission supported Project on Mental Health Promotion and Prevention Strategies for Coping with Depression, Anxiety and Stress Related Disorders in Europe. The policy issues and strategies have been prepared from the reports and evidence obtained from the three Sector Reports on Children, Adolescents and Young People up to age 24 years, Working Adults and Older People. These sector reports are annexed.
2.1 Executive Summary
Health, and mental health specifically, are affected profoundly by the impact of many significant environmental patterns and circumstances, such as biological, psychologi- cal, sociological, economic, political and cultural forces in our societies which have an influence on life styles and life events.
The mental health status of populations in different age epochs is influenced by many significant and different factors or variables such as individual factors, family structure and relationships, relationships at work, employment regimes, welfare and social systems and the like. However, social inclusion, neighbourhood solidarity and com- munity development are all processes that aim to strengthen networks and structures that provide individual confidence, organisational resource support and community support all contributing towards improvement of health and mental health. his results in reducing health inequalities, raising educational and knowledge standards, com- bating social exclusion and developing sustainable employment and self- independence. All of these have their manifestations in creating positive mental health and protecting against common mental disorders.
It is a complex task to develop a policy and, subsequently, a strategy for mental health promotion and prevention of mental health problems, including anxiety, de- pression and stress related disorders. In this task, it is necessary to engage many dimensions across many different settings and societal sectors, at different levels (European, national, regional and local), each with competing and opposing perspec- tives rather than a single shared vision.
Mental health promotion and prevention can provide coping strategies for dealing with mental health problems such as anxiety, depression and stress related disor- ders. They can make a real difference to these areas of concern and can, in turn, help to promote positive mental health and thus health and well being in general.
Strategies for mental health promotion and prevention will include addressing barri- ers to the recognition of mental health as a component of public health and in sectors other than health alone. Employment, education, housing and legal sectors are other examples. A strategy for promotion and prevention involves the development of cop- ing skills leading to the strengthening of resilience factors particularly in high-risk groups and settings, as well as actions in the community to reduce risk factors and to strengthen protective factors.
The experiences from this project have led to the recognition of the importance of a move towards a more holistic approach to the challenges of promotion and preven- tion in the mental health field. The need is for strategic approaches that are cognisant of the dangers of medicalising and stigmatising the nature of the problems being ad- dressed and of the virtue and value of stakeholder empowerment and involvement in planning, developing and implementing the appropriate interventions in practice. A robust and practical evaluation is essential for the effectiveness and practicality for transferability of interventions within the strategy for implementation.
The reflections of the analyses of practices identified in member states and pre- sented by the three sectors of the project, bring into relief the elements of best prac- tices in different settings and at different levels of implementation, from which the various policy and strategy elements are elaborated in this policy report.
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2.2 Ten Key Recommendations
1. Promotion and prevention activities in mental health are essential steps in re- ducing the increasing social and economic burdens in society due to common mental health problems such as anxiety, depression and stress related disor- ders and they contribute also to combating the stigmatisation caused by men- tal illness.
2. Mental health promotion and prevention activities are most effective when in- tegrated throughout Europe in national, regional and local health policies, their strategies for implementation, and the subsequent intervention actions.
3. The promotion of life skills training for coping with anxiety, depression and stress related disorders requires specific interventions to be developed which will be focussed on different settings, for example in family life, in education, in the workplace and in health and welfare systems, for example in hospitals and in care homes for the elderly. Identified vulnerable groups and those at high risk of anxiety, depression and stress related disorders need also to be taken account of in the planning of focussed interventions.
4. Transitional life periods have a high potential risk for, anxiety, depression and stress related disorders. Intervention measures need to be focussed on these episodes of possibly stressful life events and need to be developed at national, regional and local levels. Vulnerability is increased for example during transi- tion from childhood to working life and from working life to retirement.
5. Mental health promotion and prevention strategies for all interventions shall be based on the best available evidence of robustness and effectiveness.
6. Mental health of children, adolescents and young people is a crucial issue since it has an impact not only on the health of the current generation in this age group but also for their well being in their future adult years. Mental health promotion and prevention strategies require support to be given to good par- enting and to the development of a strong parent/child relationship. These form a basis for empowerment, self-confidence and resilience for a lifetime. A holistic approach to strategies for promotion and prevention in schools, col- leges, universities and establishments that provide young people with training
for work shall involve a co-ordinated approach that shall involve children, stu- dents, their teachers and parents.
7. Mental health actions on promotion and prevention of anxiety, depression and stress related disorders have a significant place in the world of work, and in particular, have a positive impact to well being at work as well as outside of work. Strategies for mental health promotion and prevention support personal development, empower individual competencies and offer a positive impact on mental health and well being throughout lifetime employment. Thus, mental health promotion and prevention shall be included in occupational safety and health schemes as well as promotion and prevention activities in enterprises.
8. In older people, mental health promotion and prevention of anxiety, depression and stress related disorders requires that supportive actions be created to en- sure their social cohesion, social inclusion and their empowerment. Coping skills training and prevention of loneliness and isolation require to be taken ac- count of in both community approaches and in care settings.
9. Multi-disciplinary and multi-sectoral working are essential to the effective strategies which need to be developed and implemented in mental health promotion and prevention in order to improve the coping abilities of individuals and communities at risk from anxiety, depression and stress related disorders.
10. The civil and human rights of persons suffering from common mental disorders such as anxiety, depression and stress related disorders require to be fully re- spected, as well as those of their families and carers with a view to combating stigmatisation and any consequential discrimination. Self help and non- governmental organisation support groups shall contribute valuable and inno- vative initiatives to mental health promotion and prevention activities.
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2.3 Introduction
This large-scale project aimed at building a European Strategy to initiate and imple- ment actions on Mental Health Promotion and Prevention for coping with anxiety, depression and stress related disorders in European countries. A consortium of four organisations representing public bodies and non-governmental organisations com- petent in the fields concerned, each one encouraging multidisciplinary collaboration, has carried out the project.
The joint project follows several earlier projects carried out by different members of the consortium within the EC Health Promotion and Health Monitoring Programme of the Community Action Programme on Public Health 1996-2002. These projects in- cluded the following: - “Key Concepts on Mental Health Promotion”, “Mental Health Promotion of Children to age 6 Years of age”, “Putting Mental Health on the Euro- pean Agenda”, “Establishment of Mental Health Indicators”, “Unemployment and Mental Health”, “Success factors and Quality of Workplace Health Promotion”,
“Workplace Health Promotion in Small and Medium sized Enterprises “, “Workplace Health Promotion in the public administration sector”, “Workplace Health Promotion in Latin and Southern European countries” and “Mental Health Promotion of Children, Adolescents and Young People”.
From experience gained from previous projects it was decided to collect information on best practices in mental health promotion and prevention activities with a specific focus in each member state on seeking information on preventive and promotional activities in coping effectively with anxiety, depression and stress related disorders in the three age epochs of childhood, working life and older people. Past experience of conducting projects on mental health promotion had revealed the value of employing strategies for targeting promotion and prevention actions towards high-risk age groups, and in high-risk settings. The project chose to focus therefore on the impact of prevention and promotion interventions aimed at reducing and combating the magnitude of the mental disorders of anxiety, depression and stress related disor- ders, in all age ranges, in transition periods of the lifespan and in different settings.
The Project Partners
The project was carried out during the period November 2001-July 2003 and was managed by a Project Executive Committee, representing the four member organi- sations of the Consortium. For the sectors, the Europe wide Non Governmental Or- ganisation Mental Health Europe (MHE) undertook the sector for children and ado- lescents up to 25 years. The Federal Institute for Occupational Safety and Health, Germany (FIOSH) undertook the sector for adult working age people from 25-60 years. The National Research and Development Centre for Welfare and Health, Fin- land (STAKES) undertook the sector for older people over 60 years. Project financial management and assessment was in the charge of the University of Deusto, Bilbao, Spain (UD). The national partners carrying out the project were from EU Member States and EEA countries and functioned within each sector as an active, collabora- tive network. These networks, responsible for the project, had previously gained in- valuable experience and adopted effective working methods in collecting information and evidence of best practices in mental health promotion and prevention practices as well as the means of achieving wide dissemination of relevant outcomes.
The Sector Reports annexed to this Policy Report contain the description of the pro- cess and methods of enquiry; investigation and analysis carried out in each sector.
Each sector adopted and applied general guidelines and questionnaires in a stan- dard format for the conduct of the work of the national partners. The sectors also used agreed criteria for methodological evaluation of the collected projects of mental health promotion and prevention strategies for coping with anxiety, depression and stress related mental health problems.
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Mental Health Promotion
Mental health promotion is viewed as an interdisciplinary and socio-cultural endeav- our geared to the achievement of conditions that enhance the well being of individu- als, groups and communities. The process is life long from pregnancy through child- birth, infancy, childhood and adolescence to adulthood and old age. Mental health promotion implies the creation of individual, social, societal and environmental condi- tions that enable optimal psychological and psycho-physiological development as well as a reduction in mental health problems. Mental health promotion can enhance emotional resilience, give rise to greater social inclusion and societal participation, can improve the person-environment fit, as well as increasing the productivity of indi- viduals. However mental health promotion is not the prerogative of health staff alone.
A multi-sectoral and multi-agency approach in practice leads to a significant reduc- tion of mental health problems in general and in the prevalence of anxiety, depres- sion and stress related disorders as well as an increase in understanding by the gen- eral public of positive mental health and well being.
Many factors outside health and social care influence the mental health and well be- ing of our communities and thus significantly influence the need for a wide range of policy initiatives from all sectors and disciplines in society. It is these factors and the subsequent policies, gleaned from the best practices elicited by the three sectors of the project, that lend importance to the recognition of policy issues which are effec- tive, affordable and transferable. From these are developed the consequential strate- gies that will take forward, and increase our knowledge and deliver the means of coping with and preventing common mental health problems such as anxiety, de- pression and stress related disorders.
Prevention in Mental Health
Prevention of mental health problems is approached from the viewpoint of primary and secondary prevention. Primary prevention is directed at reducing the incidence (the rate of occurrence of new cases) in the community by reducing risk factors and strengthening protective factors. Primary prevention is achieved also by enhancing the coping abilities of people who are currently without a mental disorder but are be- lieved to be at risk of developing a particular disorder. Secondary prevention in- volves efforts to reduce the prevalence of a disorder by reducing its duration of effect.
Secondary prevention programmes are usually directed at people who show early signs and symptoms of a disorder and the goal is to shorten the duration of the dis- order by early detection and prompt treatment intervention.
An important development in the concept of prevention has been the notion of tar- geting. In order to clarify this issue it is necessary to introduce three further defini- tions:
· Universal prevention refers to measures that are desirable for everyone, and the decision to implement them is taken if their benefits clearly outweigh theircosts and risks.
· Selective prevention refers to measures that are deemed to be appropriate for specific population groups, age, sex or occupation, whose risk of becoming ill is above normal.
· Indicated prevention refers to measures for groups at sufficiently high risk for an illness that some intervention would appear to be clinically important such as per- sons experiencing a severe traumatic event.
It is also important to note that in practice mental health promotion and prevention of mental ill health are interlinked. The same measure contributes usually both to pro- motion of good mental health and to prevention of illness. Some regard mental health as an umbrella concept and prevention of mental ill-health as one of its many out- comes.
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Anxiety and Depression
Anxiety, depression and stress-related disorders rank high among the common mental disorders in the general population in the community. They are likely to be the major cause of the increase in the burden of disability in years to come, as evidenced by the WHO World Health Report 2001. Estimates of the prevalence and incidence of these conditions vary depending on the definitions and case finding methods used, but for anxiety, depression and stress related disorders, more than half of subjects experience episodes over a life time, with the risk of recurrence increasing with every successive episode.
The Global Burden of depressive disorders, in a study conducted by WHO and the World Bank, predicted that unipolar major depression will rank second after ischae- mic heart disease in leading causes of Disability Adjusted Life Years (DALYS) by the year 2020. There is convincing evidence that depression exists with considerable frequency also in childhood and adolescence as well as in older people. In addition there are the problems arising from the complexity of diagnosis, management and treatment due to co-morbidity with anxiety, depression and stress related disorders, in which major issues arise from alcohol and substance abuse as well as psychoso- matic presentation.
Addressing the rising problems of anxiety, depression and stress related disorders presents a substantial challenge to our communities, at home, in educational set- tings, in the workplace and in retirement. However there are many gaps in our knowledge of effective and affordable management of these disorders, including promoting and preventive interventions. This is so particularly in our knowledge of preventive interventions that are expected to lead to greater improvements in health, mental health and well being, which, in turn, lead to greater productivity of individu- als, households and communities alike. It is important to determine the positive ef- fects emanating from these preventive and promotional interventions. Both promotion and prevention activities in EU member states and EEA countries have been in- cluded for examination, analysis and evaluation in the project.
Work Related Stress
Work related stress may be defined as a pattern of emotional, cognitive, behavioural and physiological reactions to adverse and noxious aspects of work content, work organisation and the working environment. It is a state characterised by high levels of arousal and distress accompanied often by feelings of not coping.
2.4 Policy and planning
The promotion of mental health and the prevention of common mental health prob- lems, including anxiety, depression and stress related disorders requires policy initia- tives, not only from the health sector, but also from the many other sectors of local, regional and national government. Undoubtedly the main policy areas are those which are influential at the individual level of family life, in education and training, in employment and in retirement. Policy initiatives are required not only at national level but also at the community level of local or regional responsibility for welfare, educa- tion and training facilities, in enterprises and the workplace, and within the communi- ties themselves. Among other major areas for policy development by member states are the statutory and voluntary services for health, welfare and social affairs. Policy development is required also at Inter-governmental agency levels, regional and global. In Europe, the intergovernmental agencies include the World Health Organi- sation Regional Office for Europe, the European Union, the Council of Europe and the International Labour Organisation.
The World Health Report 2001, “Mental Health: New Understanding, New Hope”
launched globally by the WHO provides information on a wide range of strategies to improve mental health and prevent mental disorders. These strategies can contribute also to the reduction of other social problems such as youth delinquency, child abuse and absenteeism from work and days lost to illnesses, both physical and mental.
Within the ten overall recommendations in the conclusions of the World Health Re- port 2001, public education, involvement of communities, families and consumers and linkage with other sectors feature among the minimum requirements for the im- provement of mental health globally.
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In 1995 the European Union adopted a Community Action Programme on health promotion, including mental health promotion, and implementation of a number of projects took place during the period 1996-2002. In the Project report “Framework for Promoting Mental Health in Europe”, published in 1999, the key concepts of mental health promotion were defined, and the following priorities for action were proposed:
1) Enhancing the value and visibility of mental health; 2) Enhancing empowerment, participation and development of information society; 3) Promoting mental health in working life; 4) Considering mental health in unemployment; 5) Supporting and pro- tecting children, young people and families with children; 6) Enhancing quality of life of elderly people; 7) Promoting mental health of alcohol and drug abusers; 8) Sup- porting research and development in the field; and 9) Developing information and dissemination systems concerning mental health. Several specific key areas of action were proposed under each of the main headings.
A project report “Public Health Approach on Mental Health in Europe”1, published in 2000, advocated strongly the need to shift the focus of mental health to a compre- hensive population approach including promotion and prevention of mental health. A public health approach to mental health within the European context is important be- cause of the vital contribution made by mental health to the well being of populations, and to the protection of their social, human and economic capital. The report de- clared that mental health is an indivisible part of public health. It is therefore of utmost importance that mental health and its promotion should be integrated closely with all public health strategies. The value of mental health needs to be recognised through- out Europe and across all levels and all sectors of society.
The Council of the European Union, in a Resolution of November 1999 invites mem- ber states to develop mental health promotion policies, to develop and implement action to promote mental health and prevent mental illness and to stimulate research on mental health and its promotion. The Resolution calls on the European Commis- sion to incorporate mental health into the public health programme and to consider
1Lavikainen J; Lahtinen,E; Lehtinen;V; Editors: Public Health Approach on Mental Health in Europe. National Research and Development Centre for Welfare and Health, STAKES, Finland, 2000.
drawing up a recommendation on the promotion of mental health and to assess the mental health impact of EU policies.
In November 2001, Council Conclusions on combating stress and depression related problems invited member states to take actions to improve knowledge on the promo- tion of mental health in primary care and other health services as well as in social services.
The EU Community Action Programme in the field of Public Health 2003-2008 (OJ L 271, 9.10.2002, p.1.) continues the commitment to promote health and prevent dis- ease including specific actions also in mental health. It seeks to build on a review of existing best practices and to develop strategies for implementation of interventions to promote mental health and prevent anxiety, depression, suicide and stress related disorders
The Council of Europe Parliamentary Assembly in 2003 will establish an inquiry into mental health including promotion and prevention practices in Europe. This follows the earlier Council of Europe Recommendations on psychiatric services and the protection of the rights of people with mental health problems.
In 1989 the EU Framework Directive (89/391/EEC0) recommended a holistic ap- proach to the employees’ well being at work including psychological well being as well as good physical health, as components of a preventive occupational safety and health policy. Although most countries of the European Union and those from the EEA, do have policies concerning health and safety at work, including policies on mental health in the workplace, there are significant numbers of countries that do not have such policies.
The new Community strategy on safety and health at work 2002-2006 (COM (2002) 118 final) has novel features. It adopts a global approach to well being at work, taking account of changes in the world of work and the emergence of new risks, especially of a psycho-social nature. As such, it is geared to enhancing the quality of work and it regards a safe and healthy working environment as one of the essential components.
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It is based on consolidating a culture of risk prevention, on combining a variety of po- litical instruments- legislation, social dialogue, progressive measures and best prac- tices, corporate responsibility and economic incentives-and on building partnerships between all the players in the safety and health scene.
Prevention actions, which encompass these general policies, are directed towards identified vulnerable high-risk groups within the community for whom measures can be taken to avoid the onset of emotional disturbance and to enhance their level of mental health and well being. Prevention programmes are primarily educational rather than clinical in concept and operation, with their ultimate goal being to increase people’s capacities for dealing with crises and for taking steps to improve their own lives.
Mental health promotion looks beyond prevention alone, towards social, economic and health benefits accruing from promotional actions and interventions. The overall objective of mental health promotion is to improve health and well being, to reduce the risk of mental health problems and to assists recovery from mental illnesses.
Much more needs to be done to ensure that mental health promotion activities are firmly incorporated in the health policies of member states in the EU and the EEA.
While national policies for health, in some, already do incorporate mental health, they seldom include mental health promotion specifically. Promotion of mental health en- tails a psycho-social-cultural-educational approach. The objective is to promote so- cial and functional competence, coping capacities and positive mental health.
In a general context mental health promotion activities should offer the means to strengthen coping skills of individuals in the family, at home, in educational settings, in the workplace and during the years of retirement. Such skills are needed through- out the life cycle and are used to counteract bullying and harassment, for example at home, at school or in the workplace. In addition, by ensuring good parenting skills in early years, by promoting self-esteem and self confidence in the years leading to adulthood, encouraging interpersonal communication and respect, and supporting
the transition to retirement, improved mental health and well being can be main- tained.
In the guidelines for the project, attention was drawn to mental health promotion as an important and protective intervention in the life cycle periods of transition, for ex- ample, from childhood to adolescence, from school and further education to adult- hood and into working life. However, only one model of best practice of this kind could be found among those submitted. This was a project aiming to prepare people for retirement from employment. However it remains important to give emphasis to the importance of these transition periods for adequate policy planning and develop- ment.
Policy development can be influenced greatly by evidence of need. In each of the sector reports there is evidence that those countries that have data available, such as on prevalence and incidence of mental health problems, including research on mental health problems, appear to be more willing to invoke national policies that in- clude promotional and preventive actions in mental health. The evidence of these actions arising from policy decisions was witnessed in this project by the greater number of projects submitted from those countries known to have policies on mental health promotion and prevention integrated within national plans and policies for mental health.
2.5 Conclusions for strategy development
Developing a strategy for mental health promotion and prevention of common mental health problems, including anxiety, depression and stress related disorders, is a rela- tively new endeavour in the mental health field. Perhaps all the more so since neither the conceptual framework or the need has been well understood nor declared. It is a task that engages stakeholders from many sectors of society, from the statutory services and from civil society. The need for a policy and a strategy for mental health promotion and prevention follow significantly that which established health promotion in its own right as an essential component of a general health care policy. So, in the same mode, is mental health promotion and prevention seen to be an essential com- ponent of the mental health care policy of all member states on the one hand, and on
24
the other hand also in general health promotion, thus encouraging inter-sectoral and multi-disciplinary approaches and taking account of factors necessary for the mental health and well being of individuals.
Health care alone cannot claim sole propriety of the task however. It is essential that many other sectors of government and civil society take a share of responsibility al- though the lead responsibility is better placed within health structures. Key players need to be identified at an early stage in building a strategy whether at national, re- gional or local levels. Consultation is not enough however and commitment to the strategy has to be assured.
The aims and objectives of a strategy for mental health promotion and prevention of common mental health problems will be evidence based, building on identified needs and the overall objective of attaining the highest level of well being and high quality of mental health care. Simultaneously the strategy will link with other policy initiatives of government supporting the interventions for promotion and prevention in the many settings, and in those populations at risk of developing mental health problems.
The strategy will identify target populations in selected settings, in consultation with stakeholders, among them representatives from users, families and carers, profes- sionals, decision-makers and the lay public. The interventions included within the strategy will take account of different levels of operation and will aim to strengthen organisations, communities and individuals in a variety of settings.
Public education will become an essential and contiguous component and objective of the strategy and alliances will be required with many elements of the media en- suring thereby the means of fostering positive public relations and the necessary in- volvement of civil society.
A training element of the strategy will require a working partnership development with existing training establishments and programmes in professional settings appropriate to mental health care but also in public and professional settings in the community, in the workplace and in the voluntary sector.
Having established the aims and objectives of the strategy, a structure for delivery and implementation needs to be created together with the identification of the neces- sary human and material resources. The strategy needs also to have a firm opera- tional plan strongly evidence based for which adequate indicators for demonstrating progress and achievements are available ensuring effective evaluation and mental health monitoring as part of health monitoring in general.
26
Mental Health Europe- Santé Mentale Europe
(MHE)
Final Report
3 Sector Report “Children, Adolescents and Young People up to 24 years in educational and other relevant settings
3.1 Introduction
The importance of working with children, adolescents and young people
In recent years, mental health issues of children, adolescents and young people – particularly the prevention of mental health problems and the promotion of positive mental health – have been receiving considerable attention throughout European Union Member States. The European Commission published a report On the State of Young People’s Health in the European Union in March 2000. Aimed at policy mak- ers, analysts and researchers in the EU Member States, it outlines the particular health risks among young people in the EU and their health and well being and in- cludes a section on mental health.
Between 1997 and 2001, Mental Health Europe, a non governmental organisation based in Brussels and committed to the promotion of positive mental health and the prevention of mental distress, carried out two Action Projects financed by the Euro- pean Commission in the framework of the EU Community Action Plan for Health Promotion, Information, Education and Training. Between 1997-1999 and between 2000-2001, two reports on “Mental Health Promotion for Children up to 6 Years” and
“Mental Health Promotion of Adolescents and Young People” were completed. Re-
ports of the content and outcome of these projects are published in Directory format and are available upon request2.
The present project “Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress-related Disorders in Europe” (November 2001- July 2003) focuses on promoting positive mental health and more particularly on the prevention of anxiety and depression.
When discussing the mental health status about children, adolescents and young people, it is important to take into consideration the fact that they do not by any means form a homogeneous group. They can be divided into the following sub- groups: young children (1-6 years), children (7-12 years), pre-adolescents and ado- lescents (13-18 years), and young adults (18-24 years). All these different age groups deserve particular and distinctive attention, one of the main reasons being that childhood and adolescence are crucial stages in life. The incidence of many dis- orders, such as for instance depression, is known to increase from childhood to ado- lescence, and to continue to rise into adulthood3. Mental health promotion of these age groups is therefore essential since the influences in the early stages of the life cycle will have an impact on the rates of disorder in later stages of the child and young person’s life. Depression is one of the most prevalent psychiatric disorders, which affects 340 million people world-wide and occurs across the life span.
Depressive symptoms, particularly in adolescents and young people are seen by adults as being part of the mood swings that can occur with changes in the develop- mental stages of the life cycle. However, if these signs do not go away, and the problems are left untreated, they can have long-lasting effects in all aspects of the young people in their adult years. Since the pace of a young person’s life is fast, it is important to prevent problems and intervene before it is too late and before problems become overwhelming and unmanageable.
Depression commencing in adolescence, is a highly recurrent condition causing se- vere psychosocial impairment, and is a major public health problem. Depression in
2 Directories are available at Mental Health Europe, 7, boulevard Clovis, B-1000 Brussels.
3 Hackauf, Horst and Winzen, Gerda: On the State of Young People’s Health in the European Union.
(1999) Munich: German Youth Institute, p.27.
28
childhood and adolescence is associated with subsequent adjustment problems, underachievement in education and suicidal behaviour4. In addition, depression in children and adolescents has also been associated with conduct or oppositional dis- order, aggression, antisocial behaviour, anxiety, and substance abuse {Rohde, Lewinsohn, et al. 1991 269 /id}.
According to the epidemiological data available, the lifetime prevalence of major de- pression is about 4% in the age group 12-17 and 9% at age 185. Although some studies have found depression to be twice as high in females as in males, it has been shown from a developmental perspective that among children, male depressives are twice as prevalent as females, the reverse of the sex ratio in adolescence. The latest findings suggest an increase in the prevalence of adolescent depression6. Moreover, population surveys show that one third of people that have met criteria for major de- pression in their lifetimes report that the first attack occurred before the age of 21 (Andrews, G. 2001) Child adversities have also been linked with the presence of de- pression later in life. For example, a recent case-control study in Boston indicated that women who had suffered from any abuse in their childhood or adolescence were 3.4 times more likely to suffer from major depression in adulthood7. Other childhood hardships have also been linked to a later risk for depression during adulthood, such as separation from a parent or family turmoil {Kessler, Davis, et al. 1997 393 /id}8. Children of depressed mothers are at considerably increased risk for depression (Downey et al., 1990)9 and children and adolescents who suffer from depression are at greater risk for recurrence of depression than are adults.
4 Hackauf, Horst and Winzen, Gerda: On the State of Young People’s Health in the European Union.
(1999) Munich: German Youth Institute, p.27.
5 Hackauf, Horst and Winzen, Gerda: On the State of Young People’s Health in the European Union (1999) Munich: German Youth Institute, p. 27.
6 Hackauf, Horst and Winzen, Gerda: On the State of Young People’s Health in the European Union.
(1999) Munich: German Youth Institute, p. 27.
7 Wise, Zierler, et al. 2001 246/id
8 Kessler, 1997
9 Downey & Coyne, 1990
Prevention of anxiety and depression
Because of the burden attributed to depression, since the nineteen eighties there has been increased attention to the development and implementation of universal, selec- tive and indicated programmes (Mrazek et al., 1994a) for the prevention of depres- sive or anxiety symptoms and disorders. Such programmes aim to target the reduc- tion or prevention of depressive and anxiety symptoms, the reduction of depressive or anxiety disorders, or target symptoms or disorders indirectly by focusing on a vari- ety of risk factors associated with depression and anxiety. Systematic reviews have shown that by no means all interventions are effective, and that promoting young people’s mental health is a challenging business (Harden et al, 2001).
There are only a few programmes that have shown that the onset of depression (Clarke et al., 1995); (Clarke et al., 2001b) and anxiety ({Dadds, Spence, et al. 1997 49 /id}{Dadds, Holland, et al. 1999 50 /id}) can be prevented in children and adoles- cents. For example, recently, Clarke and Beardslee {Clarke, Hornbrook, et al. 2001 279 /id}, identified parents with a history of depression and targeted their adolescent children (13-18 years of age) who had symptoms of depression. The implementation of a 15-session group cognitive therapy programme used a randomised controlled design for its evaluation in which the control groups received usual care. After 15 months, the programme showed a one-third reduction of the incidence of depression for the children in the intervention group as opposed to the children in the control condition (9.3% v. 28.8%).
In addition there is extensive evidence available of programmes that have led to re- ductions in depressive and anxiety symptomatology for both universal populations and populations at increased risk (Gillham et al., 2000); (Munoz et al., 1993b). For example, in quasi-experimental study the Penn Optimism Programme, which aims to change cognitive distortions and to improve coping skills ({Gillham, Reivich, et al.
1995 13 /id}{Jaycox, Reivich, et al. 1994 59 /id}) in children with depressive symp- toms, indicated reductions in depressive symptoms by half (22% in experimental group versus 44% in controls) at post-treatment, 6-month and 2-year follow-up ({Gillham, Reivich, et al. 1995 13 /id}. This program has recently been adapted and implemented with success in China (Lei Yu, Seligman, 2002). It reduced and pre-
30
vented levels of depressive symptomatology up to six months for children and ado- lescents at risk. The efficacy of this programme’s adaptation to cultural variability is of great importance to prove the feasibility and potential effectiveness of program ad- aptation to different cultural situations.
Table 1 describes a range of interventions that have shown an improvement of over 25% in depression or anxiety symptoms for those in the intervention groups as op- posed to controls.
Table 1: Description of 10 effective programmes (aimed at children and adoles- cents) and their outcomes
Programme, Author, Year
Interven- tion
Target Group
Goals Setting N
Type of research
% Im- provement in symp- toms compared to control group*
Other out- comes
% im- provement compared to control group*
Cognitive behavioural stress man- agement intervention (Hains 1992)
Anxiety manage- ment training
Adoles- cents (prepa- ration for college)
Coping, anxiety, depres- sion, self- esteem, anger
School (N=16)
Ran- domised con- trolled trial:
RCT
Depression 35%
Anxiety:
46%
Self es- teem: 23%
Anger:
30%
Cognitive behavioural stress man- agement intervention (Hains1992)
Cognitive training
Adoles- cents (prepa- ration for college)
Coping, anxiety, depres- sion, self- esteem, anger
School (N=17)
RCT Depres-
sion: 26%
Anxiety 50%
Self es- teem: 33%
Anger:
12%
Coping with Stress Course (Clarke et al. 1995)
Coping with stress course
Adoles- cents
Depressive symptoms and de- pressive episode
School (N=120)
RCT Depression
27%
Prevention of new ca- ses of de- pression:
14% ver- sus 26% in control group
Psycho- logical problems:
17,5%
Coping skills training adjunct to intensive therapy for diabetes (Grey et al.
1998)
Coping skills and diabetes manage- ment
Adoles- cents to initiate insulin treat- ment
Quality of life, de- pression, upsetting feelings, coping, self- effi- cacy
Groups treat- ment setting (N=
65)
RCT Depres-
sion: 35%
Mental health:
38%
Self effi- cacy: 45%
Cognitive stress re- duction intervention programme (Hains &
Szyjakowski 1990)
Cognitive interven- tion
Adoles- cents
Stress, negative arousal, self es- teem, anxiety, depres- sion, anger
School (N=21)
RCT Depres-
sion: 29%
Self es- teem: 43%
Irritability:
39%
Anxiety:
16%
School in- tervention for children at risk (King &
Kirschen- baum 1990)
Full service social skills and con- sultation
Children rural area, Parents and teachers
Depres- sion, problem behaviour, social ad- justment problems
School (N=46)
RCT Depres-
sion: 38%
Stress in- oculation training on anxiety, stress and academic performance (kiselica et al.
1994)
Stress in- oculation (cognitive restructur- ing, relaxa- tion)
Ninth grade students
Anxiety, academic perform- ance, stress, as- sertiveness
School (N=48)
RCT Anxiety:
39%
Stress: 26%
The Children of Divorce Intervention Programme:
CODIP (Pedro- Carroll &
Cowen 1985)
CODIP:
support skill and cogni- tive building
Children of divorce
Compe- tence, stig- ma, support problem solving, anger, ad- justment, communica- tion, anxiety, problem behaviour
School (N=72)
RCT Anxiety:
27%
Problem behaviour:
42%
Compe- tence: 32%
Divorce related: 30%
Videotape modelling to prepare children psychologi- cally for surgery (Pinto &
Holland- sworth 1989)
Videotape surgery story nar- rated by adult with the parent present
Children under- going first time surgery
Anxiety, fear, arousal
Hos- pital (N=20)
RCT Anxiety:
37%
Fear: 25%
Evaluation of a sub- stance abuse pre- vention and mental health pro- motion pro- gramme for children of divorce (Short 1998)
Stress manage- ment and alcohol awareness pro- gramme:
Smaap
Children of di- vorced parents
Coping, self- esteem, assertive- ness, anxi- ety, de- pression, problem behaviour and sub- stance use
School (N=124)
Matched compari- son group
Anxiety:
25%
Substance depend- ence: 20%
Mental health:
18%
Self es- teem: 22%
* The outcomes’ percentages of improvement are approximate and calculated from standardised mean difference effect sizes (Hedges & Olkin 1985) according to the Binomial Effect Size Display (Rosenthal & Rubin 1983).
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3.2 Description of Process and Methods
In order to identify and recruit national partners for this project, Mental Health Europe contacted its national member organisations, the European Network for Health Pro- moting Agencies (ENHPA), some of the National Members of the EC Health Promo- tion Committee and others to ask them to propose prospective partners.
As a result, a network of national partners was created in 12 EU Member States (all except Denmark, Ireland and Luxembourg) and the EEA-countries Iceland and Nor- way. Represented in the network were partners from institutes, organisations and centres in the field of mental health with a particular interest in mental health promo- tion and prevention for children, adolescents and young people.
The task of the National Partners in each of their countries was to identify and to evaluate, projects and models of best practice in mental health promotion and the prevention of anxiety, depression and related disorders in the target group of chil- dren, adolescents and young people up to 24 years in various settings. National partners were encouraged to contact research institutes and universities in their country where project development, implementation and evaluation are undertaken.
This exercise also has the beneficial aspect of putting the practice field in contact with different research groups in their countries and facilitating future collaboration in project design, evaluation and implementation issues.
Three experts were appointed with expertise in mental health promotion and preven- tion of mental illness, child and adolescent mental health promotion, and child and adolescent psychiatry. All three had also been involved in the previous project un- dertaken by Mental Health Europe in 2000-2001 "Mental Health Promotion of Ado- lescents and Young People".
Their particular task in the current project was to participate in meetings of the net- work, to help with the development of the inclusion criteria and subsequently in the selection of best practices for the sector. They assisted also with the preparation of
the final report, including the conclusions and recommendations derived from the re- search in the countries involved.
During the first meeting of the national partners, a set of key criteria that the projects to be collected would have to fulfil was agreed.
The probability of including a single practice on the final selection of projects to be recommended for wider use within the EU and the participating countries was related to its capability to fulfil as many as possible of the following criteria:
· The project was evaluated by using some kind of a control or comparison group.
If this is not the case, then before and after evaluations may be applicable.
· It was designed by multi-professional teams, including both practitioners and re- searchers, and ideally including end users/sufferers in the design.
· It was delivered by multi-professional teams, and ideally have some involvement by end users, use peer involvement etc.
· It was applied on a larger scale and with larger numbers of people (i.e. at least local level, rather than just one site).
· It used several inter-related methods and approaches e.g. education for profes- sionals as well as treatments/therapies.
· It was in place for some time (i.e. at least two years, ideally longer).
· It was fully reported in writing with full methodological details so that they could be judged properly.
· It was sustainable, i.e. did not require specialist resources, specially trained per- sonnel, or a great deal of finance – the project built on existing capacity.
· It was based on a clear needs’ assessment of some kind, ideally including the expressed needs of end users.
This list of criteria is not an exhaustive list.
Partners were asked to identify projects that aim to promote mental health and pre- vent depression and anxiety in children, adolescents and young people. Projects to be included in the review were defined as:
§ Projects that would specifically target and measure anxiety and depression in children, adolescents and young people
34
§ Projects that would work on wider mental health themes than just anxiety and de- pression, for example whole school health, prevention of bullying, maternal well being, but that would include measures of depression and anxiety in its outcomes;
§ Projects that would work on wider mental health aspects, for example whole school health, prevention of bullying, maternal well-being but that would not spe- cifically include any measurement on depression and anxiety in its outcomes;
§ Projects that would target known risk and resilience factors for mental health in individuals (for example self-esteem, self-efficacy, attachment, ability to make de- cisions)
§ Projects that would target known risk and resilience factors for larger groups, communities, regions or nations (for example poverty, levels of social capital) To collect and systematise the information gathered from each of the projects, the partners were provided with two questionnaires. These questionnaires had been drafted before the first partners’ meeting and were adapted and modified for the sector of children, adolescents and young people according to the suggestions of the experts and national partners.
Questionnaire I focused on outlining the broad approaches and the prevalence and burden caused by anxiety disorders and depressive disorders. Questionnaire II aimed at collecting detailed information of the projects and practices in each country.
The national partners were given six months to identify, select and describe the proj- ects from their country. The project Executive Committee and the experts evaluated the projects subsequently on the basis of a pre-determined system of evaluation and inclusion criteria as described in the next section.
3.3 MODELS OF BEST PRACTICE
Process and Methods
The Projects collected by the national partners of the sector “Children, adolescents and young people up to 24 years in educational and other relevant settings” ranged from relatively small-scale practical interventions through local and regional initiatives
