Mental Health: A key challenge for Europe in the 21st century

This issue of Eurohealth is dedicated to the 2013 European Health Forum Gastein. The articles specifically focus on the theme of the 2013 conference “Building resilient and innovative health systems for Europe”, and will give readers an insight into some of the topics addressed in the various conference sessions.  David McDaid is a Senior Research Fellow in Health Policy and Health Economics LSE Health and Social Care and European Observatory on Health Systems and Policies at the London School of Economics and Political Science. His article “Mental Health: A Key Challenge For Europe in the 21st Century” is a fascinating insight into this field.

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Mental Health: A key challenge for Europe in the 21st century

By: David McDaid

David McDaid is Senior Research Fellow in Health Policy and HealthEconomics, LSE Health and Social Care and European Observatory on Health Systems and Policies, London School of Economics and Political Science, UK.


The impacts of poor mental health are well documented. Increased awareness of these human and economic costs has not gone unnoticed but the challenge of translating policy plans and goals into actions across Europe remains. Innovative actions to promote and protect mental health need to go beyond health care systems. They can harness resources, goodwill and mutual interests of other sectors. One key area for greater collaboration is in the workplace. Europe’s workforce will need protection to help it retain its competitive advantage in terms of knowledge and skills. It will need to respond to changing dynamics in the global economy. Good mental health will be vital if Europe is to compete effectively with the rest of the world. This means tackling issues such as stress, depression and alcohol harm in the workplace.


The impacts of poor mental health are well documented. Globally, major depressive disorders are the second leading cause of years lived with disability1. They affect about 150 million people,  including 33.4 million people in the World Health Organization (WHO) European region. The costs are substantial; costs for depression alone in 30 European countries were estimated to be €92 billion in 2010, with costs for all anxiety disorders accounting for a further €74 billion2. The majority of these costs are due to lost productivity from work and other economic activity.

Increased awareness of these human and economic costs has not gone unnoticed in many policy-making circles. It is now nearly a decade since the WHO’s Mental Health Declaration for Europe in 2005 acknowledged the need for more attention to be paid to mental health and psychological wellbeing. The European Commission subsequently published its Pact for Mental Health and wellbeing in 2008, which in turn has been followed up by the recent launch of a Joint Action on Mental Health and Wellbeing in 2013. There have been further significant developments in mental health policy in some European Union (EU) Member States, including a welcome increased interest in the benefits of prevention and actions to promote mental wellbeing.

In the workplace the European Strategy on Health and Safety at Work 2007–2012 encouraged member States to incorporate specific initiatives aimed at preventing mental health problems and more effectively promoting mental health into their national strategies, in combination with Community initiatives on the subject. Two autonomous framework agreements were also signed and implemented by the EU social partners: the 2004 Framework Agreement on work-related stress and the 2007 Framework Agreement on harassment and violence at work.

Notwithstanding these positive developments, the translation of policy to practice has proceeded at an uneven pace. Moreover, the economic landscape has changed dramatically since most of these policy initiatives were conceived. The European economy is only now beginning to emerge from its deepest recession in decades; a crisis that has dramatically affected the working and living conditions of many people in the EU. In June 2013, 26.4 million people were still unemployed, with the impacts on young people being most pronounced in those countries hardest hit by the crisis.

We know economic shocks have immediate impacts on mental health and psychological wellbeing, including  potentially increased risks of suicidal behaviour and inter-personal violence3. Unemployment is one major risk factor for mental health, but it is not just about those excluded from work; those fortunate enough to be in work still may have a greater fear of reduced hours or job loss in both the public and private sectors. These changing economic circumstances merit further attention on protecting and promoting mental health, including at the workplace. Innovation in mental health systems at a time of austerity and financial crisis is therefore critical. The current economic crisis in Europe presents an opportunity to carefully consider the structure of services to support mental health in Europe.

This topic is also one of the main themes for discussion at this year’s European Health Forum Gastein, a gathering which for many years has provided an opportunity for leading policy makers, professionals and thinkers to debate key directions in health policy in Europe. This forum will aim to analyse the value of targeted measures and the different components of integrated policy approaches to mental health. Participants will be invited to analyse how to integrate mental health promotion and management of mental health problems into broader health and employment policies in order to effectively tackle both current and future social and economic challenges. For instance, can health work with different sectors more easily to achieve mental health related goals? What more can be done to work with employers to protect mental health at work? How cost-effective are preventive strategies? What role can the EU play in this process?

Protecting mental health at work

Work makes a contribution to our wellbeing. We simply cannot leave our mental health and wellbeing at the door of the workplace. Employment in a good working environment is beneficial to physical and mental wellbeing. Moreover, for people who have experienced poor mental health, maintaining or returning to employment can also be a vital element in the recovery process, helping to build self esteem, confidence and social inclusion. However, overall satisfaction with working conditions has declined over five European Working Conditions Surveys since 19914. Less than 20% were ‘very satisfied’ with their working conditions in 2010; in 1991 this rate was closer to 30%.

While some levels of stress and high demands at work can be good for health, a poor workplace environment can have an adverse impact on health and lead to excess levels of psychological distress, which in turn can lead to the development of poor mental and physical health. Vulnerabilities to psychosocial stress, burnout and mental health problems are becoming more challenging as the nature of work continues to change, moving away from traditional occupations towards service sector jobs with high levels of demand and work intensity. The boundaries between home life and work are also becoming blurred, especially in the service sector.

New working practices, such as increased use of temporary and short-term employment contracts, perhaps intended to help adapt economies to the challenges of competing in a global marketplace, may increase feelings of job insecurity; for instance, where there is a possibility of outsourcing tasks to external locations. This fear is also an important risk factor for psychosocial stress and mental health problems. Restructuring can also increase job demands and workload which increases the chances of burnout and depressive disorders5.

Even very minor levels of depression are associated with productivity losses6. Where there is a loss of highly skilled workers due to depression, additional recruitment and training costs may be incurred by employers. Businesses also have to contend with ‘presenteeism’: poor performance at work due to excess stress and mental health problems. The Impact of Depression in the Workplace in Europe Audit (IDEA) surveyed more than 7,000 people in seven European countries in 2012. It highlighted that common symptoms of depression such as poor concentration, indecisiveness and forgetfulness have significant adverse impacts on work functioning thus contributing to presenteeism. Yet awareness that these factors are symptoms of depression is poor and managers responding to the survey reported a lack of support to help them to assist their employees7.  Presenteeism is difficult to measure, but its impact may be as much as five times greater than the costs of absenteeism alone8.  Presenteeism is also a strong predictor of future poor mental and physical health9,  which itself may imply additional costs when employers are responsible for paying the health care costs of their employees.

Another reason for investing in measures to protect and promote wellbeing is due to the spillover impacts of poor mental wellbeing to other workers: there can be a detrimental impact on those working in teams. Sickness absence may lead to an increased workload on remaining team members, with consequences for work-related stress. There will also be adverse impacts on workers’ families.

There are also reputational and legal consequences of having an unhealthy workplace. If a business is perceived to have high levels of absenteeism due to stress and depression it may potentially have an adverse impact on its standing. This might be seen, rightly or wrongly, by both the general public and potential future recruits, as a signal of the low priority that a company places on having a healthy workforce. Potentially, it might lose customers and procurement contracts. Within the workforce there can be a detrimental impact on morale and staff loyalty. Poor mental health and excess work-related stress can also increase the risk of accidents due to human error; this in turn could lead to litigation and compensation claims in some circumstances.

Investing in mental health at work

Better mental health at work therefore has benefits both for business and for health systems. The workplace can provide a healthy culture and environment that is psychologically supportive to the workforce, helping to foster and maintain wellbeing. It is not just about avoiding mental health problems. Not only are improved levels of psychological and physical wellbeing associated with better workplace performance, but they can also help improve the level of staff retention, improve employee-employer dialogue, encourage greater levels of creativity and innovation that are vital to dynamic businesses, and enhance the reputation of the workplace10.

From a public health perspective the workplace is an important location for mental health promotion and the early identification and management of depression and other mental health problems. This public health approach means that action in the workplace should be about much more than simply focusing on the prevention of mental health problems and poor wellbeing that may be linked to a poor work environment; it is also about those non work-related problems that may become visible and sometimes exacerbated within some working environments. About one third of all the costs of depression and anxiety disorders fall on health care systems; actions at the workplace to address these issues can reduce the need for health care interventions, strengthening the economic arguments for action. In addition, health care systems are themselves major employers whose performance can be improved through better staff mental health.

Alcohol, mental health and work

Alcohol and its impact on the workplace is another important issue. One review of the impact of alcohol on the workplace and on productivity found “little doubt that alcohol and heavy drinking can negatively impact on the workplace and the productivity of the European Union as a whole”11.  One report estimates that 29% (€45 billion) of the total societal costs of alcohol in the EU in 2010 were due to absenteeism and unemployment alone12.

Increased levels of alcohol consumption have been associated with greater rates of sickness absence13  and early retirement14.  In general, individuals with alcohol problems are vulnerable at work as alcohol addiction is not well protected under workplace discrimination laws. This also means the individuals are reluctant to disclose any alcohol problems that they might have. There is also some limited evidence supporting an association between greater levels of work-related stress and heavy rates of alcohol consumption. While alcohol consumption may be a reaction to stressful working conditions, alcohol may also increase inefficiencies, leading to greater rates of work-related stress15.

One of the benefits of effective policies to reduce the harms of alcohol, such as the use of taxation and restrictions on advertising and sales to reduce access and limit consumption, may be a reduction in productivity losses associated with depression and stress-related sickness absence and poor performance at work. While the EU alcohol strategy recognises the workplace as a key setting, few measures have been implemented directly in the workplace. Moreover, there are still only a few studies that have evaluated their impact11.  Nonetheless, one review concluded from the limited literature that “brief interventions, interventions contained within health and life-style checks, psychosocial skills training and peer referral may all have the potential to produce beneficial, although rather small, results14.”   There are also probable benefits to business and the wider economy, but they still need to be analysed.


Despite all the evidence on risks to mental health and psychological wellbeing, services for mental health can be an easy target for cost cutting measures during times of austerity. Cuts to mental health budgets may be seen as a lesser evil compared to cuts in budgets for physical health problems where illness and premature death are very visible. Mental health may be emerging from the shadows but it is still not as visible in the public consciousness; yet mental health impacts are felt early during a time of economic shock and can be long lasting. They also increase risks to physical health.

Budgets are inevitably tight and tough choices have to be made. This makes it even more important that innovative actions to promote and protect mental health go beyond health care systems. They need to harness the resources, goodwill and mutual interests of other sectors. One key area for greater collaboration is in the workplace. Europe’s workforce will need protection to help it retain its competitive advantage in terms of knowledge and skills. It will need to respond to changing dynamics in the global economy. Good Mental health will be vital if it is to compete effectively with the rest of the world. This means tackling issues such as stress, depression and alcohol harm in the workplace.


1 Vos T, Flaxman A, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380: 2163–96.
2 Olesen J, Gustavsson A, Svensson M, et al. The economic cost of brain disorders in Europe. European Journal of Neurology 2012; 19:155–62.
3 Wahlbeck K, McDaid D. Actions to alleviate the mental health impact of the economic crisis. World Psychiatry 2012; 11(3):139–45.
4 European Foundation for the Improvement of Living and Working Conditions. Changes over time – first findings from the fifth European Working Conditions Survey. Dublin: European Foundation for the Improvement of Living and Working Conditions, 2010.
5 Kieselbach T, Nielsen K, Triomphe C. Psychosocial risks and health effects of restructuring. Brussels: Commission of the European Communities, 2010.
6 Beck A, Crain A, Solberg L, et al. Severity of depression and magnitude of productivity loss. Annals of Family Medicine 2011; 9(4):305-11.
7 European Depression Association. IDEA Survey Press Release. Brussels, October 1, 2012.
8 Sanderson K, Andrews G. Common mental disorders in the workforce: recent findings from descriptive and social epidemiology. Canadian Journal of Psychiatry 2006; 51(2):63-75.
9 Taloyan M, Aronsson C, Leineweber L, et al. Sickness presenteeism predicts suboptimal self-rated health and sickness absence: a nationally representative study of the Swedish working population. PLoS ONE 2012; 7(9):e44721.
10 Dornan A, Jane-Llopis E. The Wellness Imperative: creating more effective organisations. Geneva: World Economic Forum, 2010.
11 Alcohol Work and Productivity. Opinion of the Science Group of the European Alcohol and Health Forum. Brussels: European Commission, 2011.
12 Rehm J, Shield K, Rehm M et al. Alcohol consumption, alcohol dependence and attributable burden of disease in Europe. Toronto: Centre for Addiction and Mental Health, 2012.
13 Heikkila K, Nyberg S, Fransson E, et al. Job strain and alcohol intake: a collaborative meta-analysis of individual-participant data from 140,000 men and women. PLoS ONE 2012:7(7): e40101.
14 Anderson P.  Alcohol and the workplace. A report on the impact of work place policies and programmes to reduce the harm done by alcohol to the economy. Prepared for the Focus on Alcohol Safe Environment (FASE) Project, 2010.
15 Skogen J C, Knudsen A K, Mykletun A, Nesvåg S, Øverland S. Alcohol consumption, problem drinking, abstention and disability pension award. The Nord-Trøndelag Health Study (HUNT). Addiction 2012;107(1): 98–108.


Tip: More up to date educational events dealing with “Mental Health” can be found online on the Education Database »medicine & health«.

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