This chapter gives an overview of the main findings of the publication A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health. The chapter starts by recalling the significant social and economic costs of mental ill-health, and points to evidence that the burden of mental distress has risen during the COVID‑19 crisis. The chapter sets out, firstly, how the OECD Mental Health System Performance Benchmark can be used to bring new insights into the strengths and weaknesses of mental health systems. Second, the chapter summarises the main findings in terms of system performance across each of the six principles of the Benchmark, and highlights some of the innovative and effective ways that countries are already working to improve mental health system performance. Finally, this chapter points to some of the next steps for measuring mental health performance, and making the OECD Benchmark an even more valuable tool in the years to come.
A New Benchmark for Mental Health Systems
1. Key findings and recommendations
Abstract
Good mental health is essential for people to lead healthy, productive lives, and a cornerstone for strong economies. The burden of mental-ill health is significant; across the OECD countries, up to one in five people are living with a mental health condition at any time, and around one in two people will experience mental ill-health in their lifetime. The economic costs of mental ill-health, including investment in the mental health system, the costs of lower employment and productivity, are equivalent to to more than 4% of GDP (OECD, 2012[1]; OECD/European Union, 2018[2]). For many years in has been clear that mental health provision has not met demand, but overall levels of mental distress had not changed significantly across the past two decades. Data from the Institute for Health Metrics and Evaluation (IHME) and other international sources suggest that prevalence is fairly consistent, and the OECD average has been around 18% since 2002 (IHME, 2018[3]; OECD, 2015[4]).
The COVID‑19 crisis across the course of 2020 changed this trend. Overwhelmingly, surveys of OECD populations showed that mental health had worsened in March-April 2020 (Figure 1.1). In Australia 78% of respondents to a survey in late March and early April 2020 reported their mental health had worsened (Newby et al., 2020[5]); in Austria 43.5% of respondents to a survey reported the psychological impacts of the COVID‑19 outbreak as moderate or severe (Traunmüller et al., 2020[6]); in the United States 40.9% of 5 470 survey respondents in June 2020 reported an adverse mental or behavioural health condition (Czeisler et al., 2020[7]). Even in Korea and New Zealand, countries widely lauded for their success in containing and supressing the COVID‑19 outbreak, mental health status declined: in Korea 40% of survey respondents reported that their mental health had worsened (The Korea Herald, 2020[8]); in New Zealand a survey found that third of respondents experienced psychological distress during the country’s April 2020 lockdown (Every-Palmer et al., 2020[9]).
The worsening mental health status of the population across the course of 2020‑21 has made strong mental health system performance more important than ever. In many if not most OECD countries, in addition to the deleterious effect that COVID‑19 containment measures appear to have had on population mental health, the crisis has increased key risk factors – unemployment, financial insecurity, poverty – for mental illness. It is critical that governments take action to protect mental health, and put in place effective services to treat mental ill-health when it occurs. This report points to gaps where performance needs to be strengthened, but also highlights areas of strength and best practice.
Figure 1.1. The prevalence of anxiety and depression has increased significantly during the COVID‑19 crisis
Note: The survey instruments used to measure depression and anxiety differ between countries, and therefore are not directly comparable, and some surveys may have small sample sizes or not use nationally representative samples. Differences in the openness of populations to discussing their mental state also hampers cross-country comparability. To measure the prevalence of symptoms of anxiety, where possible surveys using the GAD 7 instrument have been selected. 2013 data for Sweden uses a cut-off of ‘8’ for the GAD 7, while most other studies use a cut off of ≥10. To measure the prevalence of symptoms of depression, where possible surveys using the PHQ‑9 instrument have been selected. 2020 data for Sweden uses a cut-off of ‘11’ for the PHQ‑9, while most other studies use a cut off of ≥10.
1. To the extent possible, 2020 prevalence estimates were taken from March-April 2020.
Source: OECD (OECD, 2021[10]), “Tackling the mental health impact of the COVID‑19 crisis: An integrated, whole‑of-society response”, https://doi.org/10.1787/0ccafa0b-en.
Box 1.1. Note on terminology and language
The OECD adopts the World Health Organization’s widely-accepted definition of mental health, referring to a state of well-being in which the individual realises his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.
This report aligns language with ongoing shifts that go hand-in-hand with efforts to raise awareness and address stigma, and to ensure, where possible, language is person-centred, strengths-based, and recovery-focused, and reflects the differing experiences of mental health issues from individual to individual. The broad term “mental ill-health” is used to describe mental and behavioural disorders but also include psychological or mental distress, i.e. symptoms or conditions that do not reach the clinical threshold of a diagnosis within the classification systems but which can account for significant suffering and hardship, and can be enduring and disabling. The terms ‘disorders’ or ‘conditions’ are used to apply to symptoms reaching the clinical threshold of a diagnosis according to psychiatric classification systems including disorders such as depression, anxiety, bipolar disorder and schizophrenia amongst many others.
This report recognises that the experience of mental health conditions can be highly fluid – an individual experiencing a moderate depressive episode can worsen and become “severe”, just as a severe episode can be stabilised with symptoms lessened or alleviated. This work does not explicitly exclude alcohol or substance abuse disorders, and covers these conditions when appropriate, but does not make these conditions a primary focus as the OECD’s current work programme includes relevant ongoing work, for example on preventing harmful alcohol use and opioids.
A framework for benchmarking mental health system performance
High-performing mental health systems have high quality and accessible services, are person-centred, innovative, and multi-sectoral
In 2018, the OECD convened more than 40 mental health experts from across OECD countries, constituting a diverse group of stakeholders with a wide range of experiences and perspectives. These policy makers, experts-by-experience, thought leaders, academics, business and union representatives, clinicians and civil society advocates came together to answer the question “when it comes to mental health, what matters?” Through a day of animated discussion, these experts determined six key principles of mental health performance and a series of sub-principles. These principles and subprinciples make up the OECD Mental Health Performance Benchmarking Framework (Figure 1.2).
Figure 1.2. OECD Mental Health System Performance Framework
Source: OECD (2019[11]), OECD Mental Health Performance Framework, https://www.oecd.org/health/health-systems/OECD-Mental-Health-Performance-Framework-2019.pdf.
It is clear from the Framework that OECD countries view mental health performance as extending beyond the traditional mental health system. A high-performing mental health system must include accessible and high quality services, as well as a person-centred, integrated and multi-sectoral approach, strong leadership, innovation and research, and services and policies that are culturally, age and gender appropriate. These are priorities that also affirm the ambitions of the OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy (Box 1.2).
Box 1.2. OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy
Recognising that mental ill-health demands interventions that are cross-sectoral in scope and complementary in nature, in 2015 the OECD Council adopted the OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy, that includes a detailed set of policy principles, with all OECD countries adhering to the Recommendation along with a number of non-members.
This recommendation is the recognition by OECD countries that good policies can make a significant difference when it comes to preventing mental illness at all ages, including in youth and adolescence, in supporting those experiencing mental illness to stay in the workplace and supporting those who have left employment to return to the labour market. The OECD Recommendation contains a detailed set of policy principles to address the impact of mental ill-health on employment, education, health and social outcomes. These policy principles encourage adherents to embrace approaches to mental health policy including seeking to “promote mental well-being, prevent mental health conditions, and provide appropriate and timely services which recognise the benefits of meaningful work for people living with mental health conditions”.
Source: OECD (2015[12]), Recommendation of the Council on Integrated Mental Health, Skills and Work Policy, http://legalinstruments.oecd.org.
Measuring mental health performance
At present, OECD countries lack the capacity to measure mental health system performance in many of the domains that matter – as identified in the OECD Mental Health Performance Benchmarking Framework (Figure 1.2). The OECD Mental Health Performance Benchmarking Project and data collection has made available new mental health indicators – for example follow-up after discharge, or repeat contacts with emergency departments. However, the range of available indicators still don’t tell us enough about the domains of performance that matter for mental health.
The OECD Mental Health System Performance Benchmark now includes 23 indicators, but only two – life satisfaction, and death by suicide – were available in more than 90% of OECD countries. There is still a big gap in terms of indicators that tell us about levels of stigma, about outcomes and functional improvement from treatments, about patient and carer experiences, about positive mental health, and about service coverage. In some cases (stigma, positive mental health, and experience measures) such data is available in some countries at a national level but not comparable internationally; in other cases such data is available in only a very few or even no countries, currently. For three indicators – patient-reported outcomes, attitudes towards mental health, and use of telemedicine to deliver mental health services – were included even though it is not possible, at this point, to report them in a consistent way across even a few countries, as these indicators would be critical for better understanding performance.
No OECD mental health system delivers excellent performance across the board
Tables 1.1, 1.2 and 1.3 present the OECD Mental Health System Performance Benchmark, including most recently available data at the time of publication. From the Benchmark, it is clear that no OECD country has a high-performing mental health system in all of the areas of the Benchmark. In some areas, even the countries which are doing best cannot really be considered to be delivering excellent performance; for example, even in the countries with the lowest rates of unmet need for mental health care, 30% or more of the population report some unmet need for mental health care. In all countries, though, it is clear from the available indicators to populate the Benchmark that both understanding and improving mental health performance are limited by a lack of relevant data. Though some countries stand out as having rich and relevant sources of mental health data – including Australia, England, Denmark, Ireland, the Netherlands, and Norway – there is a need to accelerate the use of outcome measures and patient-reported measures.
A close examination of the available data on mental health performance, an examination of mental health policies and practices, and a review of available academic literature reveals some key trends:
Mental health has been a long-neglected area, but this is beginning to change; significant attention from some governments and leaders – in Australia, in Canada, in New Zealand, in Norway, in the United Kingdom – is testament to global momentum around mental health. In some cases this has been accompanied by new high-level strategies or funding, in all instances such signals can be an important way to raise awareness and reduce stigma. However, despite growing attention to mental health, and in some cases increases in funding and service provision, OECD countries on average have not significantly increased funding for mental health;
Even before the COVID‑19 crisis, promoting good mental health and preventing mental illness was critical, but the rising levels of mental distress make it even more important for countries to ensure that policies are in place to support mental resilience, reduce mental health stigma and increase mental health literacy. Countries such as Finland and Iceland have been focusing on teaching social-emotional skills in schools, and online programmes are also being used to support youth mental health in Australia, Norway, and the Netherlands. More than half of OECD countries have national or regional mental health awareness programmes, and though few have been evaluated over time, where they have – for example England’s ‘Time to Change’ - a positive impact on attitudes to mental health was found;
In many countries there have been clear efforts to increase access to mental health services and reduce waiting times, especially for talking therapies. Digital technologies, including telephone and online talking therapies and app-based courses on mindfulness or coping skills, or self-management are a booming area further accelerated by COVID‑19, and can help reduce unmet need for mental health support, which is high. Many represent good value‑for-money;
Data on quality and outcomes of care, for example on excess mortality or repeat hospital admissions or emergency department contacts, point to shortcomings in continuity of care and ongoing difficulties with improving outcomes, especially for people with severe mental health conditions;
Person-centred and integrated policies and services are priorities in many OECD countries, but are proving harder to deliver in practice. In many respects, the mental health sector has led the way in prioritising voice, choice, and co-production for service users but more needs to be done to ensure that person-centred care is not tokenistic, and increased co-production – where service users contribute significantly to the design and even delivery of mental health services – stands out as one way to do this;
The COVID‑19 crisis has also reinforced the importance of integrated, multi-sectoral mental health policies, which focus on strengthening mental well-being. Young people, unemployed people, and people experiencing financial difficulties face significant mental distress. Mental health services will need to be scaled-up to meet this demand, but many people would benefit from low-threshold support such as app- or phone-based wellness activities, peer support or community group support structures, or exercise programmes as well as or even instead of medical care, and interventions in schools, workplaces, unemployment services, health care and social care institutions can be invaluable. It is clear from this work on Benchmarking, as well as from the Interim Report on the Implementation of the OECD Recommendation on Integrated Mental Health, Skills and Work Policy, that examples of initiatives to integrate services can be found across OECD countries, especially in youth support systems. Despite this, systematic inclusion of work or employment outcomes in mental health service delivery and of mental health outcomes in employment support services remains an exception, and not the norm;
Focusing on the future of mental health systems demands a dual focus on innovation, and on sustainability and improving existing services. Many countries are focusing on innovative ways – primarily using apps and other digital technologies – to increase access to mental health support. A sustainable mental health system also requires enough human resources, and mental health workers per capita vary significantly across OECD countries. Workforce innovation is a priority in some countries, with growing leadership by peer workers in Australia and New Zealand, and efforts across many countries to increase the mental health knowledge and skills of front line workers such as teachers, paramedics, and emergency department staff.
Table 1.1. OECD Mental Health System Performance Benchmark – Principles 1 and 2: Person-centred, high quality and accessible services
Note: Where data for at least nine countries was available, a colour-code is used in the tables to divide countries in three groups to indicate whether each country was above average (upper third), around average (middle third), and below average (bottom third). Above average performance is shaded in green, around average performance is shaded in orange, and below average performance is shaded in red. In the cases where categorical variables from the OECD Mental Health Performance Benchmarking Policy Questionnaire were used colour coding was not applied.
*England, ¹People with a mental health problem are people who responded ‘yes’ to adults who responded “yes” to “Have you ever been told by a doctor that you have depression, anxiety or other mental health problems”, hospitalisation is not necessarily for mental health reasons; ²Share of those with mental distress who wanted help, but could not get it due to financial or wait times or transport;
Source: ³OECD (2020[13]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires; ⁴OECD based on Commonwealth Fund International Health Policy Survey 2020 (forthcoming[14]) and (2016[15]), ⁵EHIS‑2, GEDA – see OECD (forthcoming[16]), Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation.
Table 1.2. OECD Mental Health System Performance Benchmark – Principles 3 and 4: Integrated and multi-sectoral, prioritises prevention and promotion
Note: Where data for at least nine countries was available, a colour-code is used in the tables to divide countries in three groups to indicate whether each country was above average (upper third), around average (middle third), and below average (bottom third). Above average performance is shaded in green, around average performance is shaded in orange, and below average performance is shaded in red. In the cases where categorical variables from the OECD Mental Health Performance Benchmarking Policy Questionnaire were used colour coding was not applied.
Source: ¹OECD (2020[13]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires; ²OECD (2020[17]), OECD Health Statistics; ³EHIS‑2, CCHS, SHS (2012), GEDA, INHIS‑3, GSS, NHIS (2013), CSLC, ENCAVI – see OECD (forthcoming[16]), Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation; ⁴OECD (2020[18]), Better Life Index.
Table 1.3. OECD Mental Health System Performance Benchmark – Principles 5 and 6: Mental health leadership and governance that prioritises innovation and sustainability
Note: Where data for at least nine countries was available, a colour-code is used in the tables to divide countries in three groups to indicate whether each country was above average (upper third), around average (middle third), and below average (bottom third). Above average performance is shaded in green, around average performance is shaded in orange, and below average performance is shaded in red.
In the cases where categorical variables from the OECD Mental Health Performance Benchmarking Policy Questionnaire were used colour coding was not applied.Source: ¹OECD (2020[13]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires; ²WHO (2018[19]), Mental Health Atlas 2017; ³National sources; ⁴OECD (2020[17]), OECD Health Statistics.
Principle 1. Person-centred approach: a policy priority that is not sufficiently implemented in routine care
Person-centred mental health is a policy priority in many OECD countries, but proving harder to deliver in practice
In many respects, the mental health sector has led the way compared to other parts of the health system in prioritising mental health service users’ voices. Mental health service users are represented in national groups in 85% of OECD countries, and the majority of countries (22 out of 27 responses) require involvement of service user or a representative in their mental health care (e.g. in designing their personal care plan) in at least some settings. Much more needs to be done to ensure that person-centred care is not tokenistic, and increased co-production, where service users contribute significantly to the design and even delivery of mental health services, stands out as one way to do this – Australia, Canada, England and Ireland stand out as countries leading the way in co-produced strategies, policies and services.
Service users of mental health care are increasingly involved in shared decision-making processes around their care, including through the use of personal care plans, engagement in discussion and decisions about how services are run, for instance through service user councils in inpatient settings. Personal mental health care plans with clinicians and service users working together to agree care and treatment decisions, while using evidence‑based practices, are one way of incorporating the service users’ preferences and values into their care (Slade, 2017[20]; Liverpool et al., 2020[21]), and are used in the majority of OECD countries. The degree of service user engagement also appears to differ.
Collecting patient-reported information on experiences of care is another way to focus attention on delivering person-centred care, and can garner information about how positive or otherwise experiences of care are for the care consumer. A number of countries have large‑scale national surveys of mental health service users, for example New Zealand’s ‘Ngā Poutama survey for consumers’ was administered in 2018. In countries including Australia, Canada, Denmark, Norway, Israel, and the United Kingdom service users are one of the principal assessors of whether care delivered is effective, safe, and high quality using tools such as Patient-Reported Experience Measures (PREMs) and Patient-Reported Outcome Measures (PROMS).
However, patient-reported measures show some signs of gaps between the widely held policy principle of person-centred mental health care, and the experience of mental health service users. In 2020, as in 2016, responses to the the Commonwealth Fund International Health Policy Survey in 11 countries showed that people who reported having a mental health problem were less likely to report being treated with courtesy and respect during a hospital stay than people without a mental health problem (includes hospital stays for any health condition, not only mental health care) (The Commonwealth Fund, forthcoming[14]). On average, there was a 10 percentage point gap between people who did not report a mental health problem and reported being treated with courtesy and respect, and people with a mental health problem. In Germany, the Netherlands, the United States, and Canada the gap exceeded 10 percentage points, and in the United Kingdom it was 20.3 percentage points. And while the majority of OECD countries required, or strongly recommended, service users’ involvement in care design of care plans, in many countries this is required in principle but does not always happen, or depends on the care setting. For example in Japan medical practitioners are obliged to draw up an inpatient-care plan and deliver it to the patient or the family with adequate explanation of care, which addresses a certain level of involvement but not an active role in decision-making processes.
Moving from consultation to co-production is key for increasing person-centredness of mental health policy and services
To secure more person-centred mental health systems, there is a need to move from light-touch consultation with service users, to leadership in the sector by mental health service users, working with people with lived experience in designing mental health services, and in delivering services. Countries including England and Ireland have begun this process, elevating the voices of mental health service users and promoting co-produced mental health services as a key way to enhance person-centredness. One acute mental health ward in England used a process of co-design between recent service‑users and health workers on the ward to change some key aspects of the way the ward was run, including the removal of an existing triage system and improving feedback from service users to staff (Springham and Robert, 2015[22]). After this process, the number of complaints on the ward dropped significantly, and were lower than two neighbouring wards. Ireland’s Health Services (HSE) recognises the value of personal lived mental health experience in developing more recovery oriented services, and has developed a structure – the office of Mental Health Engagement and Recovery – to engage service users and family members/carer’s in the design delivery and evaluation of services. A key part of this is the establishment of 35 service user local engagement service improvement forums to involve service users and family carers (OECD, 2020[13]; HSE, 2019[23]).
Experiences of and outcomes from mental health services don’t just vary between OECD countries, they also vary within them. Individuals’ age, gender, ethnicity, socio-economic status, and sexual orientation can all intersect with their mental health needs and service preferences, and can all have an impact on experiences and outcomes from mental health care. Though many countries may have strategies for priority population groups, the comparatively poor outcomes for such groups point to a need to further increase, or at least remain committed to, scaling-up appropriate support and services designed for and with minority and priority groups (see also, Principle 5).
Principle 2. Accessible and high-quality care: service availability has been scaled-up, but still doesn’t meet demand
Unmet need for mental health care is an enduring concern across countries, despite efforts to scale up services
Unmet need for mental health care is an enduring challenge across all OECD countries. The ‘treatment gap’ for mental health services has long been acknowledged, and estimated to exceed 50% worldwide. In OECD countries, available indicators point to an enduring gap in need for treatment and access to it. On average, 63.7% of working-age people in OECD countries who wanted to receive mental health care, indicated that they have difficulty accessing it for financial or geographical reasons, or because of long waits (Table 1.1).
Some countries reported unmet needs for mental health care for financial reasons were far higher than for other health needs, including in Denmark (13.3%), Portugal (31.1%), and Iceland (33.1%) (Eurostat, 2014[24]). In these countries the rates of unmet mental health care needs were double or even triple the average rates for all medical care; in Iceland 8.1% of respondents reported financial barriers to accessing medical services, compared to 33.1% for mental health services. More recent 2018 data from Canada also suggests some considerable unmet needs for care; only 50% of persons who reported needing counselling or therapy had their needs fully met, and people in the lowest income group were more likely to report unmet needs (Statistics Canada, 2019[25]). In some countries, it appears that the COVID‑19 crisis has increased unmet need for mental health care. In August 2020, 9.2% of surveyed adults in the United States reported that they needed counselling or therapy but did not get it in the four previous weeks, while in 2019 4.3% of adults reported that over the past year they could not receive counselling or therapy due to cost in the past 12 months (Centers for Disease Control and Prevention, 2020[26]).
During the COVID‑19 crisis, there have been significant disruptions to the delivery of mental health services. A WHO survey in Q2 2020 found that more than 60% of countries worldwide reported disruptions in mental health services: 67% saw disruptions to counselling and psychotherapy; 65% to critical harm reduction services; and 35% to reported disruptions to emergency interventions (WHO, 2020[27]). While many countries – 70% worldwide (ibid) – pivoted rapidly to delivering services through telemedicine formats, and maintained access to some critical in-person services, referrals into mental health services fell. For example, in the Netherlands in the first wave of the pandemic the number of referrals to mental health care fell between 25 and 80%, demand for treatment has dropped 10-40%; billable hours have decreased 5‑20%; bed occupancy has dropped 9% (GZZ Netherland, 2020[28]). The number of treatment hours for youth mental health care fell 20% in Q2 2020 (ibid). The crisis may have increased unmet need for mental health care; in a survey conducted in March-May 2020 by the Commonwealth Fund, 68% of adults in the United Kingdom and 69% of adults in the United States reported that they needed and wanted to get mental health care, but were not able to (The Commonwealth Fund, 2020[29]).
In many countries, there have been significant efforts to increase availability of mental health services in recent years, to deliver more and more services in community settings (outside of hospitals) and to deliver services in a timely manner. Countries have been increasing the volume of services, introducing targeted funds for priority services, and tracking time waited for services. Increasing access to talking therapies has been another way that countries have sought to better meet mental health needs, especially for common mental disorders such as depression and anxiety. In particular, there has been significant activity around services for mild-to-moderate conditions, including psychological therapies, counselling, group therapy, and general advice for example provided by General Practitioners or available online. Most respondents to the OECD Policy Questionnaire (OECD, 2020[13]) indicated that psychological therapies delivered by a psychologist were covered in full or part, and in most countries a range of other services were also covered in full or part (Table 1.1). In addition in 12 countries indicated that primary care practitioners are providing some form of talking therapy, for example brief psychological therapy. Sixty-two Norwegian municipalities have established ‘Rask psykisk helsehjelp – Prompt mental health care’ to improve access to psychological therapy by offering low threshold services without referral, cost or long waiting times, supported by the government with a grant scheme since 2013.
However, there is significant variation in type of mental health services available in countries: inpatient beds per population varied more than 50‑fold across countries, while rate of outpatient contacts varied more than 100‑fold. All OECD countries either already deliver the majority mental health services outside of inpatient settings, or have the transition to more community-based care models as a policy priority, in line with the OECD Mental Health Performance Framework and other international strategies, notably the WHO Mental Health Action Plan (WHO, 2013[30]). Between 2000 and 2017 the average number of psychiatric beds per 1 000 population fell from 0.9 to 0.68, with particularly significant falls in Ireland (1.41 to 0.34), Finland (1.03 to 0.39), the Netherlands (1.56 to 0.91) and Latvia (1.86 to 1.25) (OECD, 2020[17]). The number of beds rose only Norway, Germany and Korea. In Japan, the number of psychiatric beds is nearly 4 times higher than the OECD average, bed occupancy is 90%, and more than 60% of patients stay for a year or more (WHO, 2018[31]).
It is more difficult to understand the extent to which countries have replaced hospital-based services with care in the community, and how available and evidence‑based the care provided in community settings is. A limited amount of data does point, again, towards significant variation in available resources. In Mexico and Greece, for example, it appears that community care capacity either in outpatient clinics or through community teams is very limited.
Quality and outcomes of care remains a major challenge – both to measure, and to improve
Where data on mental health care quality and outcomes is available, it points to ongoing shortcomings in service delivery. The OECD indicators on inpatient suicide and suicide after discharge also point to shortcomings in many countries when it comes to safety in hospital settings, and continuity of care. Inpatient suicide is a “never” event, which should be closely monitored as an indication of how well inpatient settings are able to keep patients safe from harm. Most countries report inpatient suicide rates below 10 per 10 000 patients, but Denmark is an exception, with rates of over 10 (OECD, 2020[17]). Suicide rates after hospital discharge can be an indicator of the quality of care in the community, as well as co‑ordination between inpatient and community settings. Across OECD countries, suicide rates among patients who had been hospitalised in the previous year was as low as 10 per 10 000 patients in Iceland and the United Kingdom but higher than 50 per 10 000 in the Netherlands, Slovenia and Lithuania (OECD, 2020[17]).
Attempts to collect new information on care quality in the Data Questionnaire for this project included indicators on care continuity (follow-up after discharge), care in the community (repeat emergency department visits, repeat inpatient admissions) and quality of care in inpatient settings (use of seclusion, use of restraint). Only a few countries were able to report on each of these indicators.
However, even based on limited available data across countries there are signs of the ongoing challenge of providing high quality, consistent care. The proposed benchmarking indicator on ‘percentage of people admitted to inpatient care for mental health, who were admitted at least 3 times in year’ shows an average of more than 10% of patients were repeatedly admitted to inpatient care for mental health in a year (OECD, 2020[13]). Repeat admissions can be part of a care plan, but in many cases can point to repeated crisis events. Repeated emergency department visits for mental health reasons can be another signal of gaps in community care coverage; in Denmark and Israel approximately 10% of people who attended the emergency department for mental health reasons, attended at least four times in 2018, and in New Zealand this rose to 16%. Follow-up after discharge from inpatient care was reported by nine countries (Australia, Israel, Italy, Lithuania, Norway, New Zealand, Sweden, Turkey, the United Kingdom (England)). The percentage of patients followed up within the mandated period ranged from 34.7% in Italy to and impressive 95.8% in the United Kingdom, where follow-up within 7 days is required after discharge from some services.
Scaling-up available to mental health services is critical for increasing access
Talking therapies can be an evidence‑based intervention for a range of mental health conditions, from high prevalence disorders such as depression and anxiety, to conditions such as eating disorders, obsessive compulsive disorder, bipolar disorder and schizophrenia. Efforts to scale‑up access to talking therapies include stand-along schemes such as the IAPT programme in England, as well as trials to reimburse talking therapies in France (Coldefy and Gandré, 2018[32]; NHS Digital, 2019[33]; NHS Digital, 2019[34]; L’Assurance Maladie, 2018[35]).
For severe mental illnesses, for example psychosis, rapid intervention after the onset of symptoms can significantly change an individuals’ outcome in the short and long term. This approach can have a positive impact when intervention comes early in the disease pathway, as well as when it comes early in the life course; many severe mental illnesses begin in the late teens or early twenties, making timely support for young people particularly critical.
In the last decade, OECD countries have undertaken initiatives to implement projects that focus on early detection and intervention for people at risk to developed severe mental health disorders. Among others, Australia, Canada, France, Ireland, Israel, Italy, the United Kingdom and the United States have all taken steps to move towards to integrated youth mental health care by implementing initiatives based on integrated care models (Cocchi et al., 2018[36]; Hetrick et al., 2017[37]). To improve early intervention in mental health care one initiative that Canada has pursued, since 2018, is the ACCESS (Adolescents/young adult Connections to Community-driven, Early, Strengths-based and Stigma-free services) Open Minds programme. This pan-Canadian project aims to transform mental health services for young people aged 11 to 25 years and to evaluate the impact of this transformation on individual and system outcomes. The programme focuses on reducing unmet needs, through early identification of at-risk individuals, providing rapid access (within 72 hours) to an assessment, facilitating referral to an appropriate care service within 30 days (Malla et al., 2018[38]).
Principle 3. Integrated and multi-sectoral approach: in practice integration remains the exception, and not the norm
The COVID‑19 crisis calls for a re‑doubling of efforts to integrate mental health, work, and education policy
Cross-sectoral mental health policy, and especially integrated mental health, employment, education and skills policy, is even more critical in light of the COVID‑19 crisis. Across most OECD countries, people with mental health problems struggle more with education, and are less likely to be in employment, than the general population (Table 1.2). On average, the employment rate for persons with a mental health condition was 20% less than for those without, rising to 30% in Hungary, Norway, and the United Kingdom (OECD, forthcoming[16]). Across the OECD, students with mental health conditions are 35% more likely to have repeated a grade (ibid). This is not the case for all countries. In Slovenia, Portugal, Poland, and Colombia, this group of students is slightly less likely to have repeated a grade, while in the United Kingdom there is no difference between the two groups. On the other side of the spectrum, students with mental health conditions in Greece, Estonia, Denmark and Iceland are all at least 75% more likely to have repeated a grade (ibid).
Across all countries that are tracking population well-being across 2020 during the COVID‑19 crisis, mental health status amongst people who are unemployed, facing economic difficulties, and young people, has been markedly worse than the general population (OECD, 2021[10]). Often, the mental health of these population groups has worsened faster than the general population. At the same time as mental health status declined, there were significant disruptions to mental health support and services delivered in schools, workplaces, unemployment centres and other settings outside of specialist mental health care. Worldwide, 78% of countries reported at least partial disruptions to school programmes, and 75% to workplace mental health services (WHO, 2020[27]).
The COVID‑19 crisis underlines the importance of integrated mental health and somatic health care: early signs point to both possible lasting psychological impacts for COVID‑19 patients, especially those who experienced long hospitalisations or those living with ‘long COVID’, as well as increased risks of contracting COVID‑19 and experiencing complications for individuals living with severe mental illnesses. It was already clear that the health outcomes of people living with severe mental illness are significantly worse than the general population, in part due to increased risk of death by suicide, but also due to increased risk of cardiovascular disease, diabetes, and cancer. The OECD HCQO indicator on excess mortality for measures the difference between the mortality rate for the general population, and those who have had a diagnosis of schizophrenia or bipolar disorder. An “excess mortality” value that is greater than one implies that people with mental disorders face a higher risk of death than the rest of the population. In 2015‑17, excess mortality ranged from 1.3 in Lithuania to 6.1 in Norway for people who had lived with schizophrenia (OECD, 2019[39]). Inversely, people living with chronic diseases, such as cardiovascular disease or diabetes, are at increased risk of mental disorders such as depression (Holt, De Groot and Golden, 2014[40]; Glassman, 2007[41]).
Some impressive efforts to improve mental health knowledge of key front-line actors but inconsistent implementation
Broad and significant efforts exist to improve the mental health knowledge of key front-line actors, and to support connections between front line services such as police, emergency departments, and teachers, with mental health services. Provision of training for different front line actors is included as a performance indicator in Table 1.2. Training for front line actors can reduce stigma around mental health conditions, help actors spot signs of mental distress and react with sensitivity, and direct people in need towards appropriate mental health services. Many countries provide at least some mental health training for front line actors, in particular for teachers, GPs, and police, but less often for paramedics, the fire department, and unemployment counsellors or staff. Teachers, in particular, receive significant training in England, Canada, Latvia and Lithuania.
However, in response to the Policy Questionnaire, most countries indicated that only ‘some training’ was provided to these front line actors, and coverage tended to be through relatively ad-hoc courses, or depend on local or regional initiatives. For example in Australia some programmes are specific to States, such as a programme for teachers in Victoria or for Fire and Rescue workers in New South Wales. In England in 2016‑17 90% of schools and colleges offered training to at least some of their staff around how to support pupils’ mental health and well-being while 47% offered training to all staff (Marshall et al., 2017[42]; OECD, 2020[13]). In Canada, Yukon health professionals, including physicians, will receive education and training to provide compassionate and culturally sensitive transgender care, and the Mental Health Commission of Canada (MHCC) launched new mental health literacy training specific to police through a new agreement with the Ontario Provincial Police (OPP). There are also differences between the substance of the training that is provided to front line actors. For example in Latvia front line actors were mostly covered in general awareness raising campaigns, even if there were some targeted educational seminars for example on bullying and emotional welfare for teachers.
Integration of mental health, skills, and work policy is uneven, and tools to make integrated care more systematic could be more widely used
As of 2019‑20, five years after the introduction of the OECD Recommendation on Integrated Mental Health, Skills and Work Policy, the importance of a multi-sectoral, integrated approach to mental health performance is well-accepted amongst OECD countries (OECD, forthcoming[16]), Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation. The Interim Report on the Implementation of the Recommendation has found that in recent years, a number of Respondents have introduced mental health plans with a focus on mental health policies that are integrated with education, employment, social and health policy (OECD, forthcoming[16]). 19 of 26 respondents to the OECD Mental Health Benchmarking Policy Questionnaire have national programmes/strategies for developing integrated cross-government approaches to mental health governance, and in at least 24 countries Ministries other than the Ministry of Health have a dedicated mental health strategy, plan or work programme. In Denmark, the Ministry of Employment developed a broad political agreement from April 2019 on a new and improved working environment effort including initiatives to support improvement of mental health at work, from regulation on psychosocial risks at the work place, to a focus on education of managers and employees in how to take care of the psychosocial working environment. In England, the government has established an Inter-Ministerial Group for Mental Health which includes representatives from other government departments, and at least six government departments – from education to digital affairs to environment, food and rural affairs – have established strategies or actions covering mental health.
Good examples of initiatives to integrate services across sectors can be found across OECD countries, and across sectors. It is clear from the Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation report that reforms are being introduced to ensure that social protection systems, and mental health services, promote recovery and encourage return to work or education (OECD, forthcoming[16]). For example, Hungary, Latvia, Denmark and the United Kingdom have programmes or practices that support students to stay in school or transition to work. In Canada, Finland and Estonia changes are being made to work capacity assessments to facilitate partial return to work including after sickness leave with a mental health condition. Furthermore, Australia, Denmark, Ireland, Italy and New Zealand have been implementing or testing Individual Placement and Support (IPS), a proven evidence‑based practice in which multidisciplinary mental health teams including an employment specialist provide co‑ordinated health and employment support for jobseekers.
However, systematic inclusion of work or employment outcomes in mental health service delivery, or mental health outcomes in employment support services, is not the norm. Most countries did not include employment or labour market outcomes in mental health service outcomes frameworks, or only included them for some care settings. The lack of integration is most apparent in social protection systems despite the well-known high prevalence of mental ill-health among social benefit recipients and employment service users. Initiatives related to liaison services between services, and mental health support for people using unemployment services are more common. At the service user-level Australia and England collect information on employment through their service outcomes framework, the National Outcomes and Casemix Collection (NOCC) in Australia, and the NHS Outcomes Framework in England.
Denmark stands out as a country with strong integration of mental health and employment services, and outcomes, with a range of initiatives to bridge mental health and employment services, and the inclusion of “access to the workforce (for somatic and psychiatric patients)” as one of the eight national health care quality goals. The Danish Ministry of Health has established a partnership of 48 members ranging from employee and employer organisations from the private and public sector to participants from patient organisations. The partnership, ‘Sammen om mental sundhed’ (which roughly translates to ‘Together on Mental Health’), commenced in 2015 as a cross-sectoral effort, bridging the health and employment sectors, in order to pool knowledge and experience, and to create an overview of existing knowledge and tools within the field of mental health in the workplace.
Principle 4. Promoting mental well-being and preventing mental ill-health: the COVID‑19 crisis has highlighted the importance of good mental well-being, and gaps in support
Mental health policies should focus on promoting positive mental health
Some countries are also focusing on positive mental health, and building well-being, across the life course. In Canada, there are two frameworks for positive mental health – for adults and for adolescents – developed by the Public Health Agency of Canada (PHAC). The ‘Positive Mental Health Surveillance Indicator Framework’ framework addresses mental health from a strengths-based perspective, covering positive mental health outcomes, risks, and protective factors, furnished by data from ongoing Canadian surveys. For example, the framework uses indicators such as population rating of their own mental health and life satisfaction to measure positive mental health outcomes, as well as items on discrimination and stigma, on political participation, on school and neighbourhood environment, health status and physical activity (Government of Canada, 2020[43]; Orpana et al., 2016[44]; Public Health Agency of Canada, 2017[45]). In 2019 New Zealand announced the world’s first ‘well-being budget’, which focused on ‘taking mental health seriously’, improving child well-being, supporting Māori and Pacific populations, and building a productive nation. This ambition is backed with 445 million NZD for mental health services, 40 million NZD for suicide prevention, and commitments to put more nurses in secondary schools, tackle homelessness, and spend 320 million NZD addressing family and sexual violence.
Focusing on promoting good mental health amongst children and young people is particularly critical. Even prior to the COVID‑19 pandemic, reviews of available evidence have suggested some rising rates of self-reported mental distress, especially amongst adolescents (Choi, 2018[46]; Collishaw, 2015[47]; Blomqvist et al., 2019[48]). Studies have pointed towards higher rates of internalised mental health symptoms especially amongst girls, higher rates of teenagers reporting ‘feeling low’ in the international HBSC survey or reporting feelings of anxiety about school work in the OECD’s PISA study, and some instances of rising rates of self-harm and suicidal ideation (Choi, 2018[46]; OECD, 2018[49]; McManus et al., 2019[50]; OECD, 2017[51]; McManus et al., 2019[50]). More time spent online, and stresses and pressures arising from significant social media use, have also been pointed to as areas of new concern for children and adolescents’ mental health, even if academic evidence for these trends remains partial (OECD, 2018[49]; Kowalski et al., 2014[52]). Other literature suggests that an apparent increase in prevalence might be due to growing awareness and help-seeking behaviours children and young people and their parents, a broader classification of disorders, or more assiduous recording practices (Choi, 2018[46]; Comeau et al., 2019[53]). During the COVID‑19 pandemic, young people’s mental health has also worsened faster than that of the general population (OECD, 2021[54]).
Every year, a small number of children and some young people die by suicide. Based on data submitted to the OECD, and available in the WHO Mortality Database, there does not appear to have been an overall rise in deaths by suicide amongst children and young people in recent years. Between 2000 and 2015, the average number of death by suicides amongst young people aged 15 to 25 fell by 31%, but rose by 10% or more in a small number of countries (Australia, Luxembourg, Mexico, the Netherlands, New Zealand, Sweden, and the United States). In Australia, death by suicide are particularly high amongst young Aboriginal and Torres Strait Islander populations, for young people with serious and complex mental ill-health, and have been rising for females (Stefanac et al., 2019[55]; Orygen, 2016[56]). Data submitted to the OECD for the years 2009‑18 suggest that death by suicide amongst Australian adolescents (age 15‑19) rose across this time period, including in the most recent years (OECD, 2020[13]). Death by suicide amongst children and young people appears, as for adults, correlated with mental ill-health, access to lethal means, and previous suicide attempts, which point to a need for overall strengthening of access robust mental health care (McKean et al., 2018[57]; McKean et al., 2018[57]; Pettit, Buitron and Green, 2018[58]; Im, Oh and Suk, 2017[59]; McGillivray et al., 2020[60]). Some evidence also supports school-based interventions for suicide prevention; in ten European countries the Youth Aware of Mental Health (YAM) programme has been associated with a 55% reduction in incident suicide attempts and 50% fewer cases of severe suicidal ideation after 12 months, and is now being evaluated in Australia (McGillivray et al., 2020[60]).
Countries are focusing on promoting good mental health in early life
Many of the protective factors for good mental health go beyond the scope of mental health systems or programmes designed specifically to strengthen or protect mental health. Social, economic and cultural factors, such as employment status, income, physical health, experiences during childhood and adolescence, all have a significant impact upon mental health across the life course (Patel et al., 2018[61]). Interventions to improve socio-economic status, security, and reduce inequality, especially in childhood, can well be seen through a lens of building positive mental health. At the same time, programmes or interventions designed to promote mental well-being and prevent mental ill-health have also been shown to make a meaningful impact and represent good value‑for-money (McDaid, Hewlett and Park, 2017[62]).
Interventions to promote good mental-health and prevent mental ill-health are very effective, most cost-effective, in infancy, childhood, and adolescence (McDaid, Hewlett and Park, 2017[62]; Patel et al., 2018[61]; Knapp, McDaid and Parsonage, 2011[63]). Some interventions, such as the Penn Resiliency Program or Zippy’s Friends have been adapted across multiple countries or settings (Choi, 2018[46]; Wells, Barlow and Stewart-Brown, 2003[64]). Online programmes such as MoodGYM in Australia and Norway, the Netherland’s Master Your Mood Online, online stress prevention and coping skills training in Germany and In One Voice in Canada have been various associated with improvements in symptoms of depression and anxiety, improved mental health literacy and knowledge about stress and coping (Clarke, Kuosmanen and Barry, 2014[65]). In 2020 most OECD countries reported that programmes to build mental health literacy and well-being, reduce stigma, and advance social-emotional learning were in place in some or all schools. When asked what percentage of schools had some programme in place, or by age 15 what percentage of children had received at least two hours of mental health education, most countries were unable to answer but responses ranged from 100% of children in 100% of schools (in Iceland), to 60‑70% of schools (in England and Estonia) (OECD, 2020[13]).
Steps to promote mental resilience in the face of the COVID‑19 pandemic should be maintained
Across the course of 2020, it became increasingly clear that the COVID‑19 crisis was having a significant impact on population mental well-being. The rapidity and scope of the response by OECD countries, and the steps taken to protect mental well-being, were striking. There is ever reason to support the maintenance of some if not most of these new mental health resources well beyond the end of 2020 and the COVID‑19 pandemic.
OECD countries took rapid, concrete steps to make mental health support more available in 2020, especially through low-threshold resources such as internet and phone‑based information and support. Phone and online mental support service are available for the general population in most if not all OECD countries, including issuing specific mental health guidance, and setting up support phone lines, or online platforms (OECD, 2020[66]). In Australia, AUD 74 million over 2019‑20 and 2020‑21 is invested to bolster phone and online support services, digital peer-support, a mental health and well-being programme for frontline health workers, and expanding some existing services (Australia, 2020[67]). In France, a phone hotline where people can get psychological support is widely promoted, including in each COVID‑19 press briefing held by the government, and early 2021 the French government announced new entitlement to reimbursed sessions of psychological support. In New Zealand, three online mental health tools including a health journal app and an e‑therapy programme are available for free, while the government launched two additional mental health support programmes – Getting Through Together and Sparklers at Home – and a set of well-being activities and resources for parents to use with children at home (Government of New Zealand, 2020[68]).
Principle 5. Strong mental health leadership and governance: mental health has risen to the forefront of governments’ agendas, and investment improvements is now needed
Mental health is now a priority area for many governments, and has been prioritised in COVID‑19 responses
Attention to mental health from governments, society, news and media, has clearly increased over the past decade. Momentum has been building across OECD countries, and indeed globally, when it comes to mental health. In 2013, mental health was included in Goal 3 of the Sustainable Development Goals (SDGs); in 2015, OECD countries all signed up to the Recommendation of the OECD Council on Integrated Mental Health, Skills and Work Policy; in September 2018, at the Third UN High-level Meeting on Non-communicable Diseases, mental disorders were recognised by the WHO as one of the major drivers of death and disability; in October 2018, at the first Global Ministerial Mental Health Summit was held on 10 October 2018. Public figures and celebrities have increasingly been speaking out about their experiences of mental ill-health. Analysis from the United Kingdom shows that mentions of ‘mental health’ and related terms in The Guardian newspaper increased five‑fold in the 10 years up to 2017.
During the COVID‑19 crisis, too, governments have prioritised mental health as part of their COVID‑19 response plans. Action taken in Denmark, Norway and Canada are just three examples amongst many. In Denmark in April 2020 it was agreed that 215 million DKK would be used for initiatives for vulnerable groups, including mental health counselling, and in Norway mental health and psychosocial support were included as part of the national COVID‑19 response plan with a particular focus on vulnerable groups, and additional funded allocated to keep services and low-threshold services open for people with mental health problems while maintaining anti‑infection measures. From the first weeks of the pandemic, Canada has also prioritised mental health support, launching the online portal ‘Wellness Together Canada’ on 15 April 2020 to connect Canadians to peer support workers, social workers, and psychologists for confidential online or phone chats, promote self-assessment and other self-guided resources. Canada also allocated surge funding to the Canada Suicide Prevention Service and the Kids Help Phone distress lines, as well as including self-care advice in the Canada COVID-19 app used to record potential COVID-19 symptoms.
Overall mental health spending is increasing, but not significantly
There remain significant methodological challenges in collecting and comparing mental health spending, in particular scope of what services are included, whether all age groups are included, whether dementia is included, and whether government expenditure or all expenditure is included. Despite these methodological challenges the range in levels of mental health spending is clear; in 2018, mental health spending ranged from around 4% of total health spending (in Chile, Estonia, Greece and Poland) to 13.5% in Norway and 15% in France (OECD, 2020[13]; WHO, 2018[19]). Only five countries (United Kingdom, Canada, Germany, Norway, France) reported spending more than 10% of health spending on mental health.
A number of countries, including New Zealand, England (increase of GBP 1.4 billion between 2015/16 and 2017/18) and Australia (AUD 736.6 in 2019), have pointed significant increases in mental health funding in recent years (OECD, 2020[13]). National expenditure, reported in national currency, increased in all countries in the last decade, by with an average annual growth in mental health spending of more than 6% in Lithuania and Israel. However, overall government spending on health has also been increasing, and as a percentage of this total health spending the increases in resources for mental health have not been particularly significant. Generally spending on mental health as a percentage of total health spending has not increased significantly, and in some countries – Japan, Norway, New Zealand, the United Kingdom, Lithuania – declined.
Some reviews of spending have pointed to real-terms falls in mental health spending even when governments have publically committed to increasing investments. A 2018 review in England, where parity of esteem for mental health has been a guiding principle, funding gaps for NHS mental health providers and NHS acute providers appear to continue, and some mental health providers have seen funding fall (The King’s Fund, 2018[69]).
Decisive action to reduce stigma around mental illness is critical, but is infrequently measured
Greater awareness around mental health can help people experiencing non-specific mental distress to seek out ways to protect their mental well-being, for example through self-help or informal support networks, and those experiencing more acute or enduring mental distress to seek professional help (Patel et al., 2018[61]). The need to “foster mental well-being and improve awareness and self-awareness of mental health conditions” is also part of the OECD Council Recommendation on Integrated Mental Health, Skills and Work Policy.
Stigma – labelling, stereotyping thoughts, prejudice, and discrimination (Link and Phelan, 2001[70]) – includes stigmatising attitudes or behaviours in society towards those with mental health issues, as ‘self-stigmatisation’ or ‘internalised stigma’ whereby people may have a negative view of mental health conditions that reduces help-seeking and leads people to ‘hide’ their mental health condition. Indeed, stigma attached to mental health issues is one of the most significant barriers to help-seeking (Clement et al., 2015[71]; Thornicroft, 2008[72]). High levels of internalised stigma have also been found to reduce adherence to treatment and reduce openness to therapeutic interventions, and even reduce the efficacy of some treatments (Shrivastava, Johnston and Bureau, 2012[73]; Kamaradova et al., 2016[74]; Ansari et al., 2020[75]; Rüsch et al., 2009[76]). In Slovenia, for example, it is reported that only 41.5% of those with psychological problems had sought professional help, a treatment gap that may well be exacerbated by stigma around to mental health issues (Roskar et al., 2017[77]); in 2014, 88% of the working-age surveyed population in Slovenia also reported some unmet need for mental health care (Table 1.1). Population-level interventions such as stigma prevention, awareness raising and mental health literacy promotion are in place in many OECD countries; 19 out of 28 countries reported that they had at least one national programme that focuses on improving general population understanding or knowledge of mental health/mental illness, or reducing stigma (OECD, 2020[13]).
Reducing mental health stigma is a priority in OECD countries, but inconsistently measured over time. 22 countries reported that they have a national, regional or local survey to measure attitudes or level of stigma around mental health issues. However, each country has measured national stigmatising attitudes with different indicators, making comparison of levels of stigmatising attitudes across countries very challenging. Where multiple surveys have been undertaken over time, they can show changes in attitudes towards mental health. Australia’s national surveys of attitudes to mental health, which focused on mental health literacy, stigma, and perceived discrimination, have been performed three times since 1995 and have shown a fall in stigmatising attitudes and an increase in mental health literacy over time (Reavley, Too and Zhao, 2015[78]).
Some population groups are significantly more vulnerable to mental illness and mental health services must be tailored to support their unique needs
Multiple population groups have been identified as being particularly vulnerable to mental ill-health, and many have poorer experiences and outcomes of, and less access to, mental health care. Such population groups vary across countries, and include but are not limited to the LGBTQI+ community, indigenous populations, certain ethnic groups including ethnic minorities, older adults, and refugees (Mitrou et al., 2014[79]; Zehetmair et al., 2018[80]; Catalan-Matamoros et al., 2016[81]; Soysal et al., 2017[82]; McCann and Brown, 2017[83]; Meyer, 2003[84]; WHO, 2020[85]). Most OECD countries reported having mental health strategies or plans in place addressing the specific needs of nationally defined population groups. Strategies addressing children and young people are most common (15 countries), followed by older adults and LGBTQI+ communities (7 and 8 countries, respectively). The OECD Mental Health Performance Benchmarking Data Questionnaire included a data sheet requesting data broken down by population group, for example rate of service contacts for nationally defined population groups (OECD, 2020[13]). As of May 2020, only 4 countries (Australia, Canada, Japan, and the United Kingdom) were able to provide partial data covering a range of groups, including aboriginal populations, data by ethnic group, foreign-born population.
Though many countries have strategies for priority population groups, the comparatively poor outcomes for such groups points to a need to further increase, or at least remain committed to, scaling-up appropriate support and services designed for and with minority and priority groups. To take one pertinent example, in Australia, Canada, New Zealand and the United States and indeed worldwide indigenous populations have higher rates of suicide and psychological distress, suffering from symptoms of anxiety and depression (Hajizadeh et al., 2019; Hatcher et al., 2017). Indigenous Australians shows rates of anxiety and depression between 50% and three times as high compared to the non-Indigenous population (Anthony F Jorm Sarah J Bourchier, 2012[86]). Suicide rates are twice as high compared to the non-Indigenous population, and four times as high for youth (Tighe et al., 2017[87]). Suicide rates among the Inuit, one of the three distinct Indigenous groups in Canada, are among the highest in the world and up to ten times higher than the average suicide rate in Canada (Harder et al., 2012[88]; Kral, 2016[89]). At the same time, a 2019 paper examining suicide mortality among First Nations, Métis, and Inuit people in Canada found that there was considerable heterogeneity across communities; while suicide rates amongst some communities were high, just over 60% of First Nations bands had experienced no suicides between 2011 and 2016, and among the 50 Inuit communities, 11 communities had a suicide rate of zero between 2011 and 2016 (Kumar and Tjepkema, 2019[90]).
Furthermore, countries need to go beyond strategies focused on priority groups and towards accessible, co-produced services. Fostering a supportive community with focus on local culture, such as support by social or familial network, connection to culture, development of self-identity are all related with better mental health outcomes in Indigenous populations, resulting in less suicidal ideation (Harder et al., 2012[88]; Hatcher, Crawford and Coupe, 2017[91]; Tighe et al., 2017[87]). Canada has pursued this approach with “Culture as a Treatment””, where mental health agencies serve specific cultural practices such as talking circles, pipe ceremonies and smudging (Gone, 2013[92]). In Australia, Indigenous mental health policies focus on self-determination and community governance, reconnection and community life to enhance emotional well-being for Indigenous communities (Dudgeon et al., 2014[93]).
Principle 6. A future‑focused and innovative approach: COVID‑19 has accelerated mental health innovation, but workforce shortages are a limiting factors in improving mental health system performance
Data availability makes workforce planning and international comparisons very challenging
There is significant variation in the types of mental health resources that are available across OECD countries. For resources for which data is most easily available, which is proposed as a performance indicator – numbers of psychiatrists, psychiatric beds – show wide variation. The number of psychiatrists per 1 000 population in 2017 ranged from 0.01 in Mexico, 0.05 in Turkey, 0.08 in Korea or 0.09 in Chile, to 0.25 or more in Greece, Norway and Germany, and 0.52 in Switzerland (OECD, 2020[17]).
Other categories of mental health workforce play a critical role in delivering mental health services, including mental health nurses and psychologists, but also social workers, counsellors, General Practitioners or family doctors, occupational therapists, paramedics, and more. In many countries diverse teams of mental health professionals work together to deliver care. However, it is extremely difficult to collect workforce data for these diverse categories of mental health workforce; at the national level, this data is not routinely reported in all countries, and internationally there are significant comparability challenges. There are differences between countries in terms of how workforce data is reported (for example, full-time equivalent, all registered professionals, including or excluding private sector or non-hospital workers), as well as in terms of how mental health professionals are classified. For example, when it comes to psychologists there is significant variation in how psychologists are accredited, with some countries having single national accreditation systems for psychologists, and other countries having multiple accreditations or no nationally endorsed accreditation.
These comparability issues are a significant challenge for understanding the capacity and sustainability of the mental health workforce in OECD countries. However, given the diversity of different workforce categories involved in delivering mental health care, it is clear that reporting the rate of psychiatrists alone does not give a sufficiently good picture of the mental health workforce. Keeping in mind the comparability challenges, a scan of available workforce data, drawn from national sources and the WHO 2017 Mental Health Atlas, suggests wide variations. In 2017 estimated total mental health workers ranged from 0.09 in Chile to 2.15 in Australia per 1 000 population. Based on national sources, the number of psychologists per 1 000 population ranged from 0.03 or less in Hungary, the Czech Republic, Turkey and Japan, to 0.095 in Estonia, to 1.4 in Norway and more than 1.6 in Denmark (Association of Estonian Psychologists, 2019[94]; Statistics Norway, 2020[95]; The Ministry of Health, 2017[96]).
Use of digital tools increase access to services
Mental health is an area where innovation has been sluggish in recent decades; there has been quite widespread disengagement from the pharmaceutical sector, and investment in research has been low compared to other areas of disease. In Europe, the three year ROAMER project ran from 2015 to 2018 to create a roadmap for mental health, and found that mental health and well-being were under-represented both relative to the burden of disease in terms of DALYs, and to other health-related fields (Hazo et al., 2019[97]), a trend also identified in Australia and England (Christensen et al., 2011[98]; Department of Health, 2017[99]).
There are signs that some countries are investing more significantly in mental health research, across a range of areas from basic science to service development or service delivery. Under half of questionnaire respondents (11 countries) reported that they have a significant national or regional research agenda, including Denmark (Danish Government, 2015[100]), the United Kingdom (Department of Health, 2017[99]), Australia (Australian Government National Mental Health Commission, 2019[101]), and the United States (NIMH, 2020[102]). Non-government actors have established funds or platforms to boost innovation. The Duke and Duchess of Cambridge in the United Kingdom announced a 2 million GBP fund as part of their mental health campaign Heads Together, focused on digital tools for mental health in 2017 to develop new digital tools to help people have conversations about mental health. The first tool coming out of this fund was ‘Shout’, a free crisis service for people who feel they need immediate support, staffed by trained volunteers, and available 24 hours a day (Heads Together, 2019[103]). The American Psychiatric Association also launched the Psychiatry Innovation Lab in 2020, aiming to nurture early-stage ideas and ventures by investing in them with mentorship, education, funding and collaboration opportunities within our community of mental health innovators (American Psychiatric Association, 2020[104]).
In the last few years, there has indeed been considerable activity around finding innovative solutions to mental health challenges in recent years, much of which has been focused on better and broader deployment of digital tools including symptom tracking, self-help, and telemedicine (Wozney et al., 2017[105]; Gooding, 2019[106]; NHS, 2020[107]). In particular there has been an explosion in apps developed by private companies which range from tracking self-management of symptoms, for example Thrive or WorryTree for mood tracking, mindfulness apps such as Calm or Headspace, Beat Panic designed to help overcome panic attacks and anxiety or BlueIce to help young people manage their emotions (NHS, 2020[107]). Other apps, such as Ieso or Big White Wall in England or Talkspace in the United States connect people directly to licenced therapists, and in some cases access to these services are covered by employers or health insurance providers. In England, the National Institute for Health and Care Excellence (NICE) has been assessing digital therapies to be accepted under the Improving Access to Psychological Therapies Programme (IAPT) (NICE, 2020[108]).
The way that mental health services are delivered is changing, accelerated by the COVID‑19 outbreak
The COVID‑19 outbreak appears to have further accelerated both delivery of mental health services via telemedicine, and availability and use of internet- or app-based mental health tools. Multiple countries have lifted legislative or reimbursement limits on providing mental health services through telemedicine (OECD, 2020[66]). In Australia, the crisis rapidly accelerated use of telemedicine, and as of end‑April, 50% of psychology sessions were being provided online, although it remains to be seen whether this trend continues as the health crisis subsides. In England the psychological therapies service IAPT has moved massively towards delivery via telemedicine (Royal College of Psychiatrists, 2020[109]; EuroHealthNet, 2020[110]). In general the trend for mental health service contacts, including online, appears to be down.
There are signs that other mental health tools are being accessed more. In the United States, the online therapy company Talkspace saw an increase in clients of 65% between mid-February and end-April, a federal hotline for people in emotional distress say a 1 000% increase in April 2020 compared to April 2019, and use of elf-screening questionnaires on the website of the non-profit Mental Health America increased 60‑70% over the course of the outbreak (The Washington Post, 2020[111]). The COVID‑19 outbreak has also pushed governments to make more online or digital mental health resources available. In mid-April 2020 the Canadian Government launched a new portal for mental health resources, Wellness Together Canada, which offers no-cost wellness self-assessment and tracking, self guided courses, apps, and other resources, group coaching and community of support, and counselling by text or phone (Wellness Together Canada, 2020[112]).
The future of mental health performance measurement
At present, OECD countries are not able to comprehensively measure mental health performance across the domains that they identify as priorities
Tracking and comparing health system data across settings and services, across time, and across countries are powerful tools for understanding performance (OECD, 2019[39]; OECD, 2019[113]). Availability of mental health data, nationally and internationally, has long lagged behind broader health data development (Hewlett and Moran, 2014[114]). Over the past six years there has been a clear increase in availability, including at an international level, of mental health data. Since their introduction in 2013‑15, country coverage of the OECD’s three indicators on mental health care quality has increased markedly: from 7 countries reporting excess mortality in 2013 to 12 in 2019; 14 countries reporting inpatient suicide in 2015 and 21 in 2019; and 10 countries reporting suicide after discharge in 2015, to 14 in 2019 (OECD, 2020[17]). Responses to the OECD Mental Health Benchmarking Data Questionnaire were promising (OECD, 2020[13]). However, the majority of data that was available in 10 or more countries in 2020 covered inputs (beds, spending), or processes (length of stay, admissions, contacts with specialist care). For items which gave more insights into continuity of care, quality, or outcomes – such as repeat admissions, follow up after discharge, repeat emergency department visits – far fewer countries were able to report data.
There are a number of countries, including Australia, England, Denmark, Ireland, the Netherlands, and Norway, where extensive mental health data is available. In the Netherlands, mental health indicators include prevalence, service availability and contact rates as well as staff assessment of services, workforce flows, waiting times and absenteeism due to illness (Ministry of Health Netherlands, 2020[115]). In Norway, available indicators include experiences after a 24 hour inpatient stay, rate of individual care plans, involuntary admissions rates and waiting times (Directorate of Health, 2020[116]). Some countries – Australia, Canada, Denmark, England and New Zealand – also stand out as countries where there has been notable mental health data innovation, including patient-reported data to understand outcomes and recovery, capacity to track mental health outcomes across sectors, and data frameworks to understand mental health performance in a comprehensive way.
However, available mental health measures – especially at the international level – still do not map fully onto the domains of performance that matter to OECD countries. The OECD Mental Health Performance Benchmarking project began by asking mental health stakeholders from across OECD countries, ‘when it comes to mental health, what matters?’, and in answer to this question the OECD Mental Health System Performance Framework was developed (Figure 1.2). Having started by indentifying the performance principles that should be measured, rather than what already could be measured using available data, the gaps in available indicators were made clear. For example, it was not possible at even a single‑country level to identify measures that track the Framework Principles and Sub-Principles such as how effective the mental health system or services empower individuals to realise their own potential, or promote equity between population groups, or prioritise efficient and effective distribution of resources, or ensure that services are based on best available evidence.
More measures of quality and outcomes are warranted, even as important gaps in ‘input’ measures remain
In some areas of mental health system performance, with the input of experts participating in the Virtual Workshops on Mental Health Performance Benchmarking held in September 2020, indicators which would be important tools for understanding performance but are not yet available across multiple countries were identified. In particular, more robust indicators are needed on: on well-being, positive mental health and social cohesion; prevalence of mental ill-health, unmet need for care, and health care coverage; on mental health workforce and diverse care providers, and workforce training; on research; on integrated care including integration with somatic care, and physical health outcomes; and on disparities within national population groups. The COVID‑19 context, in which significant amounts of mental health care were moved to non face‑to-face formats, also highlighted the importance of indicators on changing care delivery methods, for example the rate of services delivered through telemedicine formats, preferably broken down by format (e.g. video, phone, app-based or chat-based).
Recognising some of these gaps, several indicators where data is not yet available across multiple countries, but where there is a critical importance for understanding mental health performance, were included in the Mental Health System Performance Benchmark (Tables 1.1, 1.2 and 1.3). Specifically, these are: patient-reported outcomes (PROMs), population attitudes towards mental health for example mental health literacy or levels of stigma, and use of telemedicine in mental health care. These are areas where further development of internationally comparable indicators is warranted,
Additionally, there is clear scope to continue to focus on strengthening the availability of internationally measures of mental health system quality and outcomes. Across the indicators included in the data collection for this project (OECD, 2020[13]), it was by far measures of ‘inputs’ – service contacts, admissions – that were the most consistently reported across countries, while expert stakeholders engaged with the project consistently stressed the importance of focusing on quality and outcomes as priorities for understanding performance.
There are some newly collected indicators – follow-up after discharge, repeat readmissions to inpatient care, repeat emergency department contact for mental health reasons – that bring more insights into care quality and processes, and which several countries were able to report, and could be considered for more routine collection. Other indicators which could have been promising, for example on restrictive practices (seclusion and restraint), or involuntary admissions, showed significant variation across countries in terms of definition and practice guidelines, and do not currently appear adept for routine international comparisons.
Patient-reported measures should be at the centre of policy making and service‑monitoring
The continuing gaps in availability of meaningful indicators of the dimensions of mental health performance that matter, as identified in the OECD Mental Health Performance Framework, underscore the importance of developing new measures. In particular, there is clearly space for more internationally comparable reporting on mental health service users’ experiences (PREMs) and outcomes (PROMs). At present, systematic patient reporting in mental health is in its infancy, and only an estimated eight OECD countries collect PREMs and/or PROMs on a regular basis in mental health settings. Only Australia, the Netherlands and England reported that they collected and routinely reported both.
Since May 2018, the OECD has been working with patients, clinicians and policy makers in a Working Group to develop mental health PREM and PROM data collection that enable international comparisons with 17 countries involved. The main objective is to develop PREM and PROM data collection standards in mental health for international benchmarking of patient-reported outcomes. Three domains which have international coherence have been identified for PREMs (respect and dignity, communication and relationship with health care team and shared decision making), and PROMs (relief of symptom burden, restoring well-being/social function and recovery support). The Working Group is looking towards a pilot PROM data collection, beginning with hospital care, focused on the domain of well-being, drawing on the OECD Guidelines on Measuring Subjective Well-being and the WHO‑5 Well-Being Index questionnaire that measures current mental well-being (time‑frame of the previous two weeks). For a pilot PREM data collection, again beginning with hospital care, the items already collected through the OECD’s HCQO’s regular PREM data collection is underway, with an additional item on courtesy and respect adapted from the Commonwealth Fund International Health Policy Survey. It is expected that some pilot data will be available to be reported in the OECD publication Health at a Glance 2021.
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