A New Benchmark for Mental Health Systems

Tackling the Social and Economic Costs of Mental Ill-Health

Report

OECD Health Policy Studies

8 June 2021

3. Accessible, high-quality mental health services

Abstract

A system that provides accessible, high-quality mental health services includes services that are safe and evidence‑based, delivered in a timely, continuous manner, while being developed close to the community and taking into account individual needs and preferences. High-quality mental health services outcomes and experiences, and support people to recover from, or better manage, mental health conditions. OECD countries have been making efforts to improve their services, including to improve accessibility and quality. However, this chapter shows room for improvement remains, as unmet need for mental health care remains high, and high rates of emergency care use, repeat admissions to inpatient care and high suicide rates after discharge points to key gaps in quality of care. This chapter identifies some policies and practices that can be implemented to improve access to and quality of mental health services, while calling for improvements in data availability to better measure how effectively mental health services are delivering improved outcomes for service users.

Introduction

In many countries, there have been significant efforts to increase availability of mental health services in recent years, more and more services are delivered in community settings (outside of hospitals) and efforts are ongoing 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.

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. There are still significant limitations in available data on quality and outcomes in mental health care, but available indicators point to shortcomings. People with severe mental illness have a mortality rate markedly above the general population, there are challenges around continuity of care after inpatient discharge, with around 10% of people with acute mental health needs are regularly appearing in emergency care settings.

Countries need to keep focusing on strengthening their mental health care systems and aim for accessible, high quality service that are able to meet the needs of all people in their support and treatment for mental health. These services should range from preventative measures for maintaining mental health to high quality, more intensive treatments for people with severe mental ill-health. One way is to provide low-intensity, low threshold services as a way to promote well-being and prevent worsening for severe mental ill-health. Additionally, systems must focus on creating safe mental health services that are developed in a continuous, integrated manner.

Building high-performing mental health services

What are accessible and high-quality mental health services?

Mental health conditions affect mood, cognition, motivation and all aspects of life including employment, relationships, housing and personal care, and represent a growing burden of disease worldwide (Ride et al., 2020[1]). In 2016, mental ill-health affected more than 1 billion people globally, mental health conditions caused 7% of all global burden of disease as measured in disability-adjusted life years (DALYs) – closer to 10% if substance use disorders are included – and 19% of all years lived with disability (Institute for Health Metrics and (IHME), 2020[2]). Depression was associated with most DALYs for both sexes, with higher rates in women as all internalising disorders whereas other disorders such as substance abuse had higher rates in men (Rehm and Shield, 2019[3]).

Access to high quality mental health services can transform individuals’ experience of mental health conditions. For some people, access to effective and high-quality services can contribute to a full recovery from a mental health condition. For others, effective treatment can mean improved functioning, return to work or education, and an increase capacity to participate in activities that are meaningful, even as some symptoms continue. For others still, effective mental health care helps alleviate and manage symptom burden and promote the highest quality of life and functioning possible, even if full recovery is not possible (Mind, 2017[4]; American Psychiatric Association, 2018[5]; NAMI, 2020[6]; Mental Health America, 2020[7]). Access to effective mental health services has individual and social benefits, as well as economic benefits, contributing to reducing the costs of lost productivity, higher levels of disability, and even higher costs of treating physical health conditions such as diabetes (Sporinova et al., 2019[8]; Hutter, Schnurr and Baumeister, 2010[9]; Ducat, Philipson and Anderson, 2014[10]).

That a high performing mental health system “Has accessible, high-quality mental health services” is one of the six principles of a high-performing mental health system established by the OECD Mental Health Performance Framework (OECD, 2019[11]). Accessible and high-quality mental health services are the foundation of a high performing mental health system, and mean that people experiencing mental distress can get the help and support they need. In particular, accessible and high-quality services should:

Be evidence‑based (see Chapter 7);
Be developed close to the community;
Be provided in a timely manner;
Account for and respect the unique needs of vulnerable groups;
Ensure continuity of care;
Deliver improvement of individual’s condition;
Be safe.

How accessible and high-quality are mental health services in OECD countries?

Are services accessible and provided in a timely manner?

Historically, rates of unmet need for mental health care have been high

Countries have been struggling with meeting the needs of people with mental ill-health. The ‘treatment gap’ for mental health services has long been acknowledged and estimated to exceed 50% worldwide (Kohn et al., 2004[12]; Patel et al., 2018[13]). It is estimated that between 76% and 85% of people in low- and middle‑income countries receive no treatment for their mental disorder (Wang et al., 2007[14]; WHO, 2020[15]).

In OECD countries, available indicators point to an enduring gap in need for treatment and access (Figure 3.1). There is a clear variability in accessibility: in some countries reported unmet needs for mental health care for financial reasons were far higher than for other health needs; in Iceland 8.1% of respondents reported financial barriers to accessing medical services, compared to 33.1% for mental health services. 2018 data from Canada also suggests 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 were more likely to report unmet needs (Statistics Canada, 2019[16]). In addition, recent analysis from the Canadian Institute for Health Information suggests that Canadians with mental health conditions were more likely to report cost barriers to care and financial distress (CIHI, 2021[17]).

Figure 3.1. Share of people with unmet needs due to financial reasons, wait times or transport, 2016 or latest year

Unmet needs for mental health care

In some countries, it appears that the COVID‑19 crisis has increased unmet need for mental health care. 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[19]).

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 from 25 to 80%, demand for treatment dropped between 10 and 40%; billable hours have decreased 5‑20%; bed occupancy dropped 9%. 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 (Fund, 2020[20]). In the United States, a survey undertaken across 2020-21 found that 9.2% of surveyed adults reported that they needed counselling or therapy but did not get it in the four previous weeks in August 2020, while in 2019 4.3% of adults they could not receive needed counselling or therapy due to cost in the past 12 months (Centers for Disease Control and Prevention, 2020[21]). In the phases of the survey (Phase 3 and 3.1) in late 2020 and early 2021, the rate of adults who reported they needed counselling or therapy but did not get it in the four previous weeks ranged from lows of 9.7% to a high of 13.0% (ibid).

In some countries residential and long-stay mental health care were significantly disrupted, and negative impacts on quality of care were reported. A review of the impact of the COVID‑19 pandemic on long-stay mental health care institutions in Europe, which included care homes, psychiatric hospitals and other forms of residential institution, found that institutions struggled to implement the necessary protective measures in already over-stretched settings, and that “providing individualized person-centred care and support under crisis conditions is significantly more challenging to deliver in large‑scale institutions than in community settings or at home” (WHO Europe, 2020[22]). In the Czech Republic, an assessment of the pandemic and the state of emergency in the Czech Republic which lasted from 12 March to 17 May 2020 on long-stay institutions found a high prevalence of poor mental health outcomes amongst both clients (46% poor well-being, 58% depression, 45% anxiety) and staff (17% poor well-being, 22% depression, 14% anxiety) (Guerrero et al., 2021[23]). Delivery of care was also disrupted, along with the admissions and discharge process, and isses including lack of clear information, lack of protective equipment, lack of activities for pateints, and an increase in use of restrictive practices were reported (ibid).

Coverage of mental health services varies across countries

The availability of services covered by basic health coverage, or the requirement to pay for services in part or full out of pocket, are important factors that influence the access to mental health services. Costs such as out-of-pocket payments for mental health care services can also be a barrier for access to care (Paris et al., 2016[24]; Auraaen et al., 2016[25]). Countries vary in the extent to which mental health services are fully or partly covered by basic health care (Figure 3.2). Alcohol, drug or substance abuse counselling, and mental health outpatient services are covered in most OECD countries (24, out of 29 respondents) while psychological therapies delivered by a psychologist are also covered in full or part in most countries. Counselling or psychological therapy services delivered by a professional other than a psychologist are covered in fewer countries and are more likely to be covered only in-part.

Figure 3.2. Mental health services covered in full or in part by basic health coverage

In some countries, where services are covered in part, a fixed co-payment is required which in turn can be deducted through additional health insurance coverage, such as in Norway and the Netherlands (OECD, 2020[26]). Coverage can also depend by type of services, with some countries (for instance the Netherlands) covering treatment of severe mental health in full and requiring additional out of pocket payments for less acute mental health support such as care provided by General Practitioners (OECD, 2020[26]).

Some countries have provided additional coverage for vulnerable populations. In Iceland, all services for children are free of charge and fully covered, whereas adults pay a small fee for services. Canada covers mental health services for populations at higher risk of mental ill-health such as indigenous people and veterans (OECD, 2020[26]). Countries also have a range of gatekeeping requirements regarding accessing mental health services in order to access services and/or for services to be reimbursed, for example requiring a referral from a General Practitioner such as in Australia and the United Kingdom, or requiring that services are provided by certain accredited professionals or in certain health settings such as in Canada and France (CAMH, 2021[27]; SANE Australia, 2019[28]; NHS, 2019[29]; Aide-Sociale.fr, 2019[30]).

Average waiting times for mental health services decreased in countries tracking them

That services “Be provided in a timely manner” is included as one of the sub-principles in the OECD Framework, and one of the most important principles in the OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy (OECD, 2019[11]; OECD, 2015[31]). Delayed care for mental ill-health can be related to poorer outcomes, for example for people with first-episode depressive illnesses (Davey and McGorry, 2019[32]) or psychotic episodes (Fusar-Poli, McGorry and Kane, 2017[33]). Tracking waiting times can also be a way to track whether access to services is consistent across geographical areas or service type (OECD, 2020[34]).

Denmark, Finland, Ireland, Lithuania, the Netherlands, New Zealand, Norway, some regions in Spain (including Baleares, Navarra), Sweden and the United Kingdom (England, Wales, Scotland) have a waiting times target or guarantee in at least one area of mental health care, most of which aim to provide treatment or a first service contact within 1‑3 months (OECD, 2020[34]; OECD, 2020[26]). Several countries (Finland, Ireland, New Zealand, Norway, Sweden, Scotland, and Wales) report separate waiting times guarantees for mental health services for children and adolescents. In Norway the wait time for children (40 days) is slightly shorter than for adults (45 days) while in Sweden the wait time target is much shorter for children and young people (30 days) than for adults (90 days).

Where data is available over time, the proportion of patients who have been assessed or treated within the maximum waiting times targets appears to have increased and average waiting times decreased for mental health (OECD, 2020[34]). In Denmark, Finland and Norway the percentage of persons seen within set mental health waiting times increased in recent years, although the percentage of people seen within the waiting times guarantee fell in Estonia (Figure 3.3). The waiting times target set in Denmark stands out in particular, where the waiting time for a first appointment and assessment is 30 days Denmark, a target met for 95% of people in 2018. Many countries continue to struggle with waiting times for people in need of mental ill health. In the Netherlands, targeting the issues behind waiting times is currently a top priority to ensure access to care, as people with severe mental ill-health have to wait over 4 months and sometimes up to 24 months to access a mental health care specialist (Box 3.1).

Figure 3.3. Percentage of persons seen within mental health waiting times target set in each country

Although policy discussions are not always framed in terms of reducing mental health wait times, or meeting maximum wait time targets, policies appear to be focused on better meeting demand through increased service volumes or scope, rather than managing demand. Countries also identify shorter wait times for accessing services as a way to reduce the risk of deterioration in health, and improve outcomes from treatment (Helsedirektoratets Norway, 2019[35]; NHS England, 2015[36]). For example, when England introduced maximum wait time targets for mental health services, this included an injection of funding of GBP 80 million to increase service capacity. This included GBP 40 million of recurrent funding to support increased capacity in order to meet the 2 week wait time target for early access to psychosis services. GBP 10 million was provided as implementation funding for psychological therapies services, which was to be used to confirm the accuracy of existing waiting lists, and enhance capacity to provide assessment and treatment (NHS England, 2015[36]).

Box 3.1. Addressing long wait times for mental health services for severe mental illness in the Netherlands

Long waiting lists for mental health care, especially, especially for people with severe mental ill-health, have been a major source of concern in the Netherlands in recent years. In 2020, the Court of Audit in the Netherlands estimated that 27% of people with a severe mental health condition were waiting 4 months or longer before their treatment started, compared to 8% of people considered to have mild-to-moderate mental health conditions.

The Court of Audit found main drivers for these long waiting lists:

Financial incentives that are in place make it more attractive for care providers to concentrate on patients with less-severe disorders. Mental health care institutions have agreed on average prices with their insurers for the all mental health care they provide. The average price is above the costs to treat people with milder care needs but too-low to cover costs of more intensive treatments;
The number of beds in the Netherlands has declined by 20% in recent years, with an ambition that this shift would be offset by increasing availability of outpatient care. However, outpatient care has not been scaled up sufficiently to meet levels of need for care for severe mental illness;
There is a shortage of staff; psychiatrists, psychologists, clinical psychologists, specialist nurses and nurse practitioners. This is partially because working in an integrated mental health institution is not attractive to staff because of many night, weekend and evening shifts. Additionally, the Court of Audit found a heavy administrative burden in these roles, and comparatively low wages.

To overcome these challenges, the State Secretary has put in place an action plan. Because of the decentralised mental health system in the Netherlands, the Ministry of Health has implemented regional taskforces that work with local stakeholders to analyse challenges and come up with solutions. Possible solutions include enhancing visibility of people on the waiting list, imposing a temporary stop for admission at care institutions where waiting time are exceeded, increasing accessibility to care by providing care alternatives within the social domain and preventing unnecessary overtreatment. As of January 2021, these taskforces were still grappling with the challenge of finding effective ways to reduce long waits for persons with complex mental health conditions.

Source: Netherlands Court of Audit (Rekenkamer) (2020[37]), No Place for Big Problems – Tackling specialist mental healthcare waiting lists, https://english.rekenkamer.nl/publications/reports/2020/06/25/no-place‑for-big-problems.

Are services developed close to the community?

In recent decades countries have increasingly adopted a community-based approach to mental health care, shifting care away from inpatient care settings. Historically, mental health systems in OECD countries were heavily inpatient-based, and often highly restrictive, with ‘patients’ spending long periods in institutional settings (Hewlett and Moran, 2014[38]). From the late 1960s onwards, the ‘deinstitutionalisation’ movement which started in Trieste, Italy, moved more and more mental health care into community-based settings (Hewlett and Moran, 2014[38]; Forti, 2014[39]). At the same time, the organisation of mental health care within OECD countries remains highly heterogeneous - inpatient beds per population varied more than 50-fold across countries – and some countries began the shift to community-based services much later than others, or have chosen to retain a more hospital-centric system.

Community-based care is now recognised as the preferred approach for the significant majority of mental health care – with a smaller number of inpatient services focused on very acute or crisis care – and has advantages for the service users’ experience, for quality and outcomes, and can have economic advantages, too (WHO, 2013[40]; OECD, 2019[11]). A strong community-based care system should result in improved quality of care, with potential benefits including reduced hospital admission rates, improved medication adherence, greater care involvement of service users in their own care, early detection of relapse, and reduced emergency department visits (Thornicroft, Deb and Henderson, 2016[41]; Clausen et al., 2016[42]; Aagaard, Tuszewski and Kølbæk, 2017[43]). Additionally, providing mental health services through community centres is considered a less costly approach to inpatient care (Winkler et al., 2018[44]).

Inpatient psychiatric beds are declining in almost all OECD countries

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 (OECD, 2019[11]) and other international strategies, notably the WHO Mental Health Action Plan (WHO, 2013[40]). Between 2000 and 2018 the average number of psychiatric beds per 1 000 population fell from 0.9 to 0.68 in OECD countries, 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) (Figure 3.4). The number of beds rose only in Norway, Germany and Korea. This could indicate an overall increase in service availability, both through inpatient care and community care.

Figure 3.4. Psychiatric beds per 1 000 population, 2000 and 2018 or nearest year

The Norwegian system of mental health services is characterised by extensive decentralisation of both outpatient and inpatient care, with still-existing traditional central psychiatric hospitals alongside newer locally-organised psychiatric services in “District Psychiatric Centers” (DPCs). There is a difference in organisation in care between these centres, with some offering care in outpatient services combined with centralised regional hospitals, while others have a local institution-based model; increasingly inpatient services are offered at smaller local institutions while integrating the psychiatric beds in local DCPs with the outpatient clinics (OECD, 2014[46]). Studies in Norway comparing the use of mental health care of both centralised and local institutions models, showed that inpatients in local institution models make more use of GP and specialist outpatient care in combination with a longer inpatient stay at the local centres, compared to people receiving care through the centralised care models. Additionally, having beds available at small local institutions led to a decrease in acute admissions (Myklebust, Sørgaard and Wynn, 2017[47]; Myklebust and Lassemo, 2020[48]).

In Japan, the number of psychiatric beds is nearly four times higher than the OECD average. Japan has not reformed the system towards a deinstitutionalised system, mainly because of a lack of funding. Privately funded hospitals were not able to receive public funding to shift long-term care beds towards care in the community. The 2004 Vision for Reform of Mental Health and Welfare of the Japanese Ministry of Health, Labour and Welfare (MHLW) articulated an aim to reduce the number of long-term care beds. Since then, the MHLW has aimed to remove 70 000 psychiatric care beds across 10 years (Okayama et al., 2020[49]). However, changes have been very slow, and in the 12 years from 2004 to 2018 bed numbers fell by only 25 000 beds, with a reduction from 356 000 to 330 000. Japan is still facing significant barriers to moving towards a community-based model including weak insurance coverage of community care, a fee schedule incentive structure that still supports inpatient care and high bed occupancy, and high levels of stigma towards mental illness (Kasai, 2017[50]; OECD, 2015[51]; Okayama et al., 2020[49]).

The use of inpatient mental health services varies across countries

Admissions to inpatient care vary across countries (Figure 3.5). Countries with very few inpatient beds (Italy, Mexico, Turkey, the United Kingdom tend to have very small numbers of admissions to inpatient care both in terms of total number of admissions, and number of individual patients admitted to inpatient care. Countries with higher numbers of inpatient beds tended to have higher rates of inpatient admission. It is unclear whether this trend is driven by a greater concentration of mental health services in the inpatient sector and fewer non-hospital alternatives, or because of a tendency to ‘use available beds’.

Figure 3.5. Admissions to inpatient care across OECD countries, 2019 or latest year

Data collected from 11 countries by the IIMHL/NHS Benchmarking Project – Australia, Canada, England, Ireland, New Zealand, Northern Ireland, the Netherlands, Japan, Scotland, Sweden and Wales – appears to confirm that bed availability is a key driver of inpatient admission rates. In general psychiatry average bed occupancy rates were 87% on average, and that there was relatively little variation in occupancy rates between countries despite significant difference in bed numbers, with a range of 70‑90% occupancy (NHS Benchmarking Network, 2019[52]).

The majority of countries report hospital stays between 10 and 40 days for people with ‘mental and behavioural disorders’. Spain, Greece and Korea are outliers, with respectively an average of 56, 96 and 176 days stay in inpatient settings.

Figure 3.6. Average length of inpatient stay, mental and behavioural disorders, 2018 or latest year

In Korea, hospital treatment remains the foremost option in mental health care, and inpatient care is far more prevalent than outpatient or community care. This is reflected as well in the increase of psychiatric beds of the last decades, which has showed an increase over 200% (Figure 3.4). In Korea, the payment system is one of the main factors driving high rates of admission are of psychiatric patients, with reimbursements for inpatient higher and more attractive to providers (Kim, 2017[53]).

About 80% of all psychiatric admissions are involuntary in Korea, with admissions completed under the Mental Health Act, often submitted by family members (Kim, 2017[54]). There are some signs that involuntary admissions that are medically unjustifiable have been frequently reported in Korea. In 2008, only 4.8% of patients who requested to be discharged only obtained the permission to discharge and more than half of the patients were admitted again, with half of those readmitted within a day after discharge (Kim, 2017[53]). In 2016, Korea began revising the Mental Health Act, which aims to promote human dignity, human rights and recovery-based practice environment (Chung and Yang, 2020[55]). Over the last decade, Korea has also increasingly made a shift towards community mental health care, for example under the Third 5-Year National Mental Health Plan 2016‑2020 prioritises the development of community-based mental health facilities. In 2017 the existence of more than 300 mental health rehabilitation centres were reported, and number of mental health welfare reached over 200 nationwide (Ministry of Health and Welfare, 2017[56]).

Community-care capacity for mental health varies more than 30-fold between OECD countries

It is 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; only 7 countries were able to report the number of individuals under the care of community teams, and 15 the number of individuals attending outpatient clinics (Figures 3.7 and 3.8). There are also longstanding challenges around comparability of mental health services across countries, as outpatient and community services can play quite different roles from one country to another; for example, in some countries outpatient clinics may include services for intellectual disabilities or dementia, or substance mis-use including or excluding alcoholism, while others may not.

A limited amount of data does point, again, towards significant variation in available resources (Figures 3.7 and 3.8). In Mexico (0.04 individuals per 1 000 population under mental health care in community teams in 2017, 0.2 per 1 000 population attending outpatient clinics) and Greece (0.5 individuals per 1 000 population attending outpatient clinics), for example, it appears that community care through outpatient clinics or community teams are very limited.

Figure 3.7. Individuals under mental health care in community teams, 2018 or latest year

Figure 3.8. Individuals attending mental health outpatient clinics, 2018 or latest year

Is continuity of care assured?

Community-based mental health care demands good care co‑ordination

While evidence suggest that moving away from inpatient settings and increasing community-based services will improve quality and accessibility of care, the shift in the mental health systems leads to additional challenges, with countries struggling to provide strong community-based services, and to co‑ordinate care across multiple settings (Abdulmalik and Thornicroft, 2016[57]). Mental health problems are complex and often require multiple interventions and approaches, involving different care institutions and sectors (Doran and Kinchin, 2019[58]). Poor co‑ordination of care is associated with poor outcomes, such as increased risk of suicide, homelessness and criminal justice involvement (Beadles et al., 2015[59]; Ilgen et al., 2008[60]; Van Dorn et al., 2013[61]). Especially people with severe mental illnesses are at risk to fall into gaps between inpatient and community care (MacDonald et al., 2019[62]). Not only continuity of care between care settings but also longitudinal continuity of care is important, which refers to the capacity of professionals and services to provide care across longer periods of time, while maintaining a good quality of patient-provider relationship (MacDonald et al., 2019[62]).

Assessing the provision of continuity care delivery is a challenge given the complexity of mental health care systems and above all due to shortcomings in data availability. Data on ‘continuity of care’ across countries is limited, but available evidence points to ongoing challenge of providing high quality, consistent care.

In 2020, six OECD countries (Australia, Israel, Italy, Lithuania, New Zealand, Norway, Turkey, the United Kingdom [England]) were able to report on the percentage of service users who received a follow up within the nationally mandated or nationally recommended period following discharge from inpatient care (e.g. within 7 days, within 14 days, depending on national guidelines). The percentage of service users who were received a follow-up ranged from 37.4% in Italy within 14 days in 2018, to 98.80% within 7 days in England in 2018, although this only covers the proportion of patients on ‘Care Programme Approach (CPA)’ (OECD, 2020[26]) Table 3.1. The Care Programme Approach delivers community mental health services for those diagnosed with mental illness and with complex needs, with the individual’s health and social services needs assessed and addressed in a written care plan, patients are allocated a care co‑ordinator, and their care plan is regularly reviewed.

	Percentage of patients who received a follow up within the mandated or recommended period following discharge from inpatient care	Nationally mandated or recommended period following discharge from inpatient care
Australia	75.2%	7 days
Israel	85%	Percentages where outpatient appointment was set (no time limit specified).
Italy	37.4%	Within 14 days
Lithuania	56.9%	Unspecified
Norway	70%	Within 30 days
New Zealand	66.50%	Within 7 days
Sweden¹	22%	7 days or 8 days, depending on county
Turkey	79.2%	Rate reported for within 14 days, but ideal time for follow up is set at 7 days.
United Kingdom (England)	95.80%	Patients on Care Programme Approach (CPA) who were followed up within 7 days after discharge

Notes: ¹Data only reported by 1/3 of the Swedish counties.

Source: OECD (2020[26]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires.

Emergency care visits and repeat admissions to inpatient care point to gaps in care co‑ordination between inpatient and community care

Repeat visits to emergency care for mental health conditions, and repeat inpatient admissions, can be signs of poor care co‑ordination for people with mental health conditions (Lay, Nordt and Rössler, 2011[63]; Brännström, Strand and Sand, 2018[64]; Kalseth et al., 2016[65]; Hewlett and Moran, 2014[38]; Berchet, 2015[66]). Reporting in the Netherlands suggested that 15% of the involuntary admissions were repeated admissions, and 80% of the people that are being admitted are already receiving care within psychiatric care settings (De Volkskrant, 2020[67]). Monitoring repeat emergency care contacts for psychiatric illness can point to individuals in need of mental health support, as well as gaps in access to care (CIHI, 2020[68]; Sirotich, Durbin and Durbin, 2016[69]; Slankamenac, Heidelberger and Keller, 2020[70]). Although evidence is mixed, there are studies that indicate timely follow up after discharge (for example within 30 days) result in less frequent visit emergency department and re‑hospitalisations (Beadles et al., 2015[59]; Durbin et al., 2019[71]).

In countries reporting data, an average of 10% of patients were repeatedly admitted to inpatient care for mental health in a year; repeat admissions can be part of a care plan, but can also point to poor community-based follow-up care, or repeated crisis events (Figure 3.10). Twelve OECD countries were able to report data, which showed a range of 5 to 35% in repeated admission between countries, with Denmark reporting the highest number of people admitted to inpatient care at least three times in a year.

Repeated emergency department visits for mental health reasons can be another signal of gaps in community care coverage (Figure 3.9). In Denmark and Israel approximately 10% of people who attended the emergency department for mental health reasons, attended at least 4 times in 2018. In New Zealand this number was even higher and has increased over the years with currently 16% of the people visiting emergency departments visiting at least four times in 2018. In New Zealand, emergency department use is used as a quality measure across the health service; like for mental health emergency department visits, the overall volume of emergency department visits has seen an upward trend in recent years (Ministry of Health New Zealand, 2016[72]; Tenbensel et al., 2017[73]). The Māori population in New Zealand have high emergency department use (Curtis et al., 2019[74]); in 2018 17% of the Māori population attended emergency departments at least four times for a mental health reason, higher than the 16% population average (OECD, 2020[26]).

Figure 3.9. Repeat admissions to inpatient care, 2019 or latest year

Percentage of people admitted to inpatient care at least three times in a year

Figure 3.10. Repeat emergency department visits, 2019 or latest year

Percentage of people who attend the emergency department for mental health reasons, who attended at least four times in a year

Services after discharge – suicide following discharge inpatient admissions

With the shift to deinstitutionalised care settings, community settings are given the priority for psychiatric care delivery and in OECD countries inpatient hospital settings focus more on acute care needs (Hewlett and Moran, 2014[38]). Continuity of care has become one of the key issues in mental health care provision, with challenges remaining in continuing care for people with severe mental illnesses. There are some key points in mental health care delivery where continuity of care is critically important, one of which is immediately following discharge from inpatient care. Managing the transition from inpatient care to community-based support for ongoing mental health management, to support the service user at a clinically vulnerable moment, to improve long-term outcomes, and to ensure that service users are connected with services to meet their ongoing mental health needs (Tyler, Wright and Waring, 2019[75]; Lynch et al., 2020[76]).

Looking at outcome indicators such as suicide rates after hospital discharge can indicate the quality of care in the community, as well as co‑ordination between inpatient and community settings (OECD, 2019[77]). The first week, and the first month, after discharge from inpatient care are periods of acute suicide risk for psychiatric patients (Chung et al., 2019[78]); patients with less contact with mental health services after discharge have been found to be more likely to die by suicide (Large et al., 2011[79]). Across OECD countries, suicide rates among patients who had been hospitalised in the previous year was as low as 1 per 10 000 patients in Iceland and the United Kingdom but higher than 50 per 10 000 in the Netherlands, Slovenia and Lithuania (Figure 3.11). In England, which has one of the lowest rates of suicide following hospitalisation for a psychiatric disorder, post-discharge period has nonetheless been found to be a period of peak suicide risk; in the period 2002‑2012 deaths by suicide in the first three months after discharge represented 18% of all patient suicides (University of Manchester, 2014[80]). Recognition of the high risk of suicide immediately after discharge in England has led to a clinical guideline for follow-up within 7 days of discharge from psychiatric inpatient care, and within 48 hours if suicide risk has been identified (Bojanić et al., 2020[81]; NICE, 2016[82]).

Figure 3.11. Suicide following hospitalisation for a psychiatric disorder, within 30 days and one year of discharge, 2017 or nearest year

Do services deliver improvement of individual’s condition?

OECD countries are focusing on on delivering care that provide meaningful improvements of an individual’s condition. To deliver care that helps to maintain and improve health and well-being of populations, measures to evaluate health system delivery need to bring insights into outcomes of care, and go beyondindicators such as volume of service or rate of resources which have been more commonly available. Better data on inputs and processes is still sorely lacking in mental health systems, but, this information does not always provide sufficient information whether health systems are also improving an individual’s condition, which can result in patients receiving health care that is not necessarily tailored to achieve the outcomes they prioritise.

The OECD publishes international benchmarking data on a number of mental health indicators, including on excess mortality, which 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, 2020[45]).

On a national level, OECD countries are increasingly focusing on quality and outcome indicators of mental health. According to the OECD Policy Questionnaire 17 out of 29 countries reported the use of some sort of outcomes framework (OECD, 2020[26]). In 2016, Denmark set national goals to ensure better health care quality by focusing on monitoring quality by looking at outcomes of care by adopting the Danish Healthcare Quality Programme. This national programme aims for better continuity of care, stronger management of chronically ill and elderly patients, higher survival rate and improved patient safety, high quality treatment, quick assessment and treatment, greater patient involvement, additional healthy life years and more efficient health care systems. To better understand the outcomes of an individual’s condition, Denmark uses a framework of indicators, which includesindicators that measure the outcomes of people suffering from mental ill-health, such as “acute somatic/psychiatric readmissions within 30 days”, “mental illness and excess mortality” and “patients satisfaction with somatic and psychiatric care”. A measure used frequently on in international level to assess health and social function of people who use mental health services, is the Health of the Nation Outcome Scales (HoNOS). It covers symptoms, functioning, social relationships and environmental issues. The scale has been adopted in a number of countries as a quality and outcome measure, notably in Australia, New Zealand and the United Kingdom.

While countries are struggling to implement measures that give valuable information on outcomes of care, the use of patient-reported measures of health care provides an opportunity to shed light on how health care systems impact an individual’s condition. As of 2018, a survey from the OECD showed that only five of the 12 countries surveyed (Australia, Israel, the Netherlands, Sweden, the United Kingdom) regularly use patient-reported measures in mental health care.

In 2017 the OECD launched the Patient-Reported Indicators Surveys (PaRIS) to accelerate patient-reported measures to make systems more people‑centred (see also Chapter 2, Chapter 7). Its aim is to systematically collect data on what matters most to patients. As part of the PaRIS initiative, the OECD launched the PaRIS Working Group on Patient-Reported Measures for Mental Health in May 2018. The main objective is to develop PREM and PROM data collection standards in mental health for international benchmarking of patient-reported outcomes, with first results expected in 2021.

Are services safe?

Alongside the patient safety risks seen across the health system, such as medication error or failures in communication (Slawomirski, Auraaen and Klazinga, 2017[83]; Auraaen, Saar and Klazinga, 2020[84]; de Bienassis, Llena-Nozal and Klazinga, 2020[85]; de Bienassis et al., 2020[86]), there are some safety risks that are specific to mental health settings, including higher rates of suicide and self-harm, and stigma around mental illness. Some forms of mental health care delivery can also be high-risk to patients’ safety, such as the use of restraint and seclusion. In addition, issues such as stigmatisation of people suffering from ill-health or the lack of listening to the patient’s voice in mental health services can jeopardise the safety of a patient (Brickell and McLean, 2011[87]; Berzins et al., 2018[88]).

Inpatient suicides point to shortcoming in OECD countries

Looking at the incidences of adverse advents can help us understand a patient’s safety when using mental health services. The OECD indicators on inpatient suicide and suicide after discharge 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 (Figure 3.12).

Figure 3.12. Inpatient suicide among patients with a psychiatric disorder

Countries have tried to identify factors related with inpatient suicide and come up with strategies to lower inpatient suicide, however evidence and effectiveness has been inconclusive. For example, Australia’s Fifth National Mental Health and Suicide Prevention Plan (Fifth Plan) agreed by all Australian Governments has identified ‘Making safety and quality central to mental health service delivery’ as a priority area for attention, while ‘Safety’ is also a domain in Australia’s National Mental Health Performance Reporting Framework and the broader Australian Health Performance Framework, and has repeatedly been identified as a key area of concern for consumers and carers.

Denmark, too, has been focused on lowering the suicide rate. Inpatient suicide in Denmark increased since 2009, following a decling trend up until 2009, and then an annual 7.5% increase of inpatient suicides. Inpatient suicides and post-discharge suicide constitute a substantial part of the total number of suicides in Denmark (Madsen, Erlangsen and Nordentoft, 2017[89]; Madsen et al., 2020[90]). Initiatives taken by Denmark have included removing harmful objects such as plastic bags and sharp objects as well as a systematic risk assessment by time of admission and discharge (ibid).

Seeing to reduce inpatient suicides in the United States, the Department of Veteran Affairs has developed a checklist to check the safety of acute psychiatric units which has shown to be effective at decreasing inpatient suicides (Watts et al., 2017[91]). The checklist consists of 134 questions that focus on structural and special changes. Clinicians at the mental health centres can use this checklist to signal environmental hazard points and look to remove or decrease the hazards to improve safety wards. The checklist has been used since 2007 and has led to a decrease of 5 inpatient suicides per 100 000 admissions to 1 inpatient suicide per 100 000 admissions (Watts et al., 2017[91]).

Coercion in contemporary mental health care

Coercive measures, such as seclusion or restraint of a person in patient care, are used psychiatric settings to prevent harm towards the service user or others. Use of coercive measures might occur in response to or to prevent aggression or violence, or when a service user is not able, or refuses, to accept treatment. Restrictive interventions should be seen as a last resort, and any action taken to restrict a person’s freedom of movement must be the least restrictive option that will meet the need; coercive measures should never be a form of routine care, or used as a ‘punishment’.

Four main methods of coercion are used in contemporary mental health care: physical restraint; mechanical restraint; chemical restraint; and seclusion. Coercive measures may occur in different settings and concerning different population groups, such as psychiatry wards targeting adults and children with psychiatric illness (NICE, 2017[92]; Gooding, 2019[93]; Völlm and Nedopil, 2016[94]; Völlm and Nedopil, 2016[94]). Seclusion and restraint are controversial techniques in contemporary mental health systems, highlighting risk for physical and psychological trauma, while adding to the organisational costs of mental health facilities. Use of coercive measures can result in lasting psychological harm to service users, and in some cases physical harm, especially if appropriate safety steps are not taken (NICE, 2017[92]; Care Quality Commission, 2020[95]).

The United Nations’ 2007 Convention on the Rights of Persons with Disabilities (CRPD) pushed towards alteration change in the use of coercive measures in mental health systems, underlining the rights and need for equality in all aspects of life for people with disabilities, while respecting dignity, autonomy and independence, although there is clear evidence that a gap between the principles of the CRPD and its implementation in practice (Winkler et al., 2020[96]; Mahomed, Stein and Patel, 2018[97]; Steinert et al., 2016[98]) Evidence of efficacy of coercion is fragmented and there is little research in this area that focus on interventions and outcomes (Barbui et al., 2020[99]; Madsen, Erlangsen and Nordentoft, 2017[89]).

Coercive practices are increasingly regulated or restricted by a variety of standards and facility policies, and recommendations and guidelines from professional and trade organisations are progressively being developed (Völlm and Nedopil, 2016[94]). Across OECD countries, while there is an overall commitment to the safe and reduced use of coercive measures, there is also significant diversity in the ‘preferred’ forms of coercion. In some countries certain types of coercion are prohibited while these measures are very common in other countries (Table 3.2). This difference appears to be mainly based on cultural preferences around which methods present least harm to the service user; for example, seclusion is usually not allowed in Denmark for ethical reasons, while it is the preferred technique in the Netherlands. Secondly, mechanical restraint is prohibited in the United Kingdom, with a (relative) preference for the use of physical restraint and chemical (pharmaceutical) restraint. Germany considers chemical restraint as a last resort treatment and is perceived as very invasive. Up until 2013 chemical restraint was prohibited in Germany, and is now currently allowed again only under very strict conditions and as a last resort (Gooding, 2019[93]; Martin et al., 2007[100]; Steinert, Noorthoorn and Mulder, 2014[101]; Völlm and Nedopil, 2016[94]).

Both data collected by the OECD and literature on the use of coercive measures shows a wide variation in incidence and duration between countries, which in addition to significant differences between countries in regulation and clinical guidelines over coercive measures, makes it difficult to compare the use of coercive measures across countries. Additionally, there are considerable difference between countries with regards how they report coercive measures. In most countries there is currently no centralised agency collecting, analysing and publishing data on use of coercive measures. Countries differ in how they report their coercive practices, which care settings are included and which institutions are in charge of reporting which makes it difficult to compare to what extent coercive practices are used (Lepping et al., 2016[102]).

Country	Techniques used in order of preference	Comments
Belgium	1. Mechanical restraint 2. Seclusion	Physical restraint is not used.
Denmark	1. Medical restraint 2. Physical restraint	Seclusion not allowed in Denmark.
Finland	1. Mechanical restraint 2. Seclusion 3. Physical Restraint	Physical restraint is rarely used, only used in child psychiatry when parents agreed.
France	1. Physical restraint 2. Seclusion 3. Mechanical restraint
Germany	1. Mechanical restraint 2. Seclusion 3. Medication	Until 2011, the use of mechanical restraint was widely accepted, since then considerable change in opinion, for example coercive medication is approvable again only under strict conditions
Iceland	1. Seclusion 2. Physical restraint	Mechanical restraint has not been used as a routine measure for decades.
The Netherlands	1. Seclusion 2. physical restraint	Mechanical restraint is rarely used. Since 2005, the Dutch Government has launched a programme to reduce use of seclusion, since a 2004 international study showed increased use of seclusion compared to other European countries.
Norway	1. Physical restraint 2. Seclusion 3. Mechanical restraint.
Sweden	1. Physical restraint 2. Seclusion 3. Mechanical restraint.
United Kingdom	1. Physical restraint and medication 2. Seclusion	Mechanical restraint is not allowed. Staff is highly is trained in the use of physical restraint techniques, seclusion is rarely used.
United States	1. Mechanical restraint 2. Seclusion 3. Medication	The use of involuntary medication is restricted.

Source: Bak and Aggernæs (2012[103]), “Coercion within Danish psychiatry compared with 10 other European countries”, https://doi.org/10.3109/08039488.2011.632645; Kaltiala-Heino et al. (2003[104]), “Reasons for using seclusion and restraint in psychiatric inpatient care”, https://doi.org/10.1016/s0160‑2527(02)00210‑8; Raboch et al. (2010[105]), “Use of coercive measures during involuntary hospitalization: Findings from ten European countries”, https://doi.org/10.1176/ps.2010.61.10.1012; Steinert, Noorthoorn and Mulder (2014[101]), “The Use of Coercive Interventions in Mental Health Care in Germany and the Netherlands. A Comparison of the Developments in Two Neighboring Countries”, https://doi.org/10.3389/fpubh.2014.00141; Völlm and Nedopil (2016[94]), “The use of coercive measures in forensic psychiatric care: Legal, ethical and practical challenges”, https://doi.org/10.1007/978‑3‑319‑26748‑7.

OECD-collected data shows countries have reported little data on the use of coercive practices, and available data shows international difference in seclusion and restraint practices (Figure 3.13). Although it is difficult to infer conclusion based on these numbers, it implies that countries make different use of coercive measures, with is reflected in the number reported. Japan shows high rates of seclusion and restraint. Compared to other countries, Japan has fewer psychologists and higher bed number (WHO, 2018[106]). One of the possible barriers mentioned for reducing seclusion and restraint is staffing ratios, however, data remains inconclusive. The United Kingdom shows high rates of restrain, and much less use of seclusion, which is in line with their national policy on the use of coercive measures (Table 3.2).

Variations in the use of coercive measures are supported by findings in literature. The mean duration of restraint in German psychiatric hospitals was found to be 10 hours compared to 49 hours in Switzerland (Martin et al., 2007[100]). In Finland, one study found a mean total time of 19 hours (Kaltiala-Heino et al., 2003[104]). The longest duration was reported in a Japanese study which found durations of being restrained could vary from under 24 hours to over 30 days (Odawara et al., 2005[107]). A comparative study in Germany, Bulgaria, Czech Republic, Greece, Italy, Lithuania, Poland, Spain, the United Kingdom and Sweden shows on average 38% of the patients in inpatient settings were exposed to some sort of coercive measures, with a variability between countries, from 21% in Greece to 59% in Poland (Kalisova et al., 2014[108]).

Figure 3.13. Countries reporting different annual rates of seclusion and restraint, 2019 or latest year

Do mental health services account for and respect the needs of vulnerable groups?

Certain population groups can have both higher risk of mental ill-health, such as the LGBTQ+ community, Indigenous populations, refugees, and children and youth (Kuyper and Fokkema, 2011[109]; Mitrou et al., 2014[110]; Sijbrandij et al., 2017[111]). For example, in New Zealand in 2016‑17, Māori adults were 1.1 times as likely to have mild or greater anxiety, depression or somatic symptoms, and Māori children were 1.5 times as likely to have emotional or behavioural problems, than non-Māori adults and children (Ministry of Health New Zealand, 2020[112]). In Australia, Aboriginal and Torres Strait Islander people die by suicide at a rate double that of non-Indigenous Australians; in the period 2014‑18 there was an increase in the age standardised rate of suicide deaths amongst Aboriginal and Torres Strait Islander populations from 20.2 per 100 000 person between 2009 and 2013 to 23.7 per 100 000 persons between 2014 and 2018, compared to 12.3 suicide deaths amongst non-Indigenous Australians (Australian Institute of Health and Welfare, 2020[113]).

The population groups at particular risk of mental ill-health vary across countries, and population groups not necessarily inherently ‘vulnerable’ to mental health condition; population group characteristics such as ethnicity, race, gender identity or sexual orientation intersect with social, historical, and economic trends such as discrimination, poverty, inequality or unemployment (Mental Health Foundation, 2019[114]).

Just as the key population groups with particular mental health risks differ across countries, the service needs of these groups differ across and within countries. Key population groups may need more, or different, mental health services (see also Chapter 2, for discussion of adapting and co-creating services for different key population groups). Across OECD countries, relatively few countries were able to report mental health service use patterns by population group; in 2020 five countries were able to provide some broken-down data on mental health service use and/or outcomes such as death by suicide, Australia (indigenous Australians receiving specialist or community care, suicide), Canada (six key groups receiving specialist services, and suicide), Turkey (over 65s, under 18s, contact with specialist services, outpatient services, repeat emergency department contacts), and the United Kingdom (England) (five population groups by ethnicity, contact with specialist services) (OECD, 2020[26]). New Zealand was able to break down a significant amount of its mental health data to show contact rates for the Māori population, including rate of receiving specialist, outpatient, community care, repeat emergency contacts, rate of inpatient admissions, repeat admissions, rate of seclusions and involuntary admissions, and deaths by suicide. The data shows service use is higher for the Māori population compared to the general population use (OECD, 2020[26]) (Figure 3.14).

Figure 3.14. Service use in New Zealand of Mãori and general population, 2019

The service use patterns for key population groups are not consistently predictable. Some key groups may have a higher rate of mental health service use than the general population, or be disproportionately represented in some service settings such as inpatient care. Some groups may have higher mental health service use, but when adjusted to the burden of mental health conditions, mental health service use is in line with or even below expected needs. Monitoring different service use patterns by population group can help to identify where access to services is not being ensured – for instance high rates of or repeat inpatient care or emergency department contacts in a group may point to problems with access to community services – or where the service model is not reflecting different needs or preferences of that group – for instance higher rates of coercive practices, or involuntary admissions, may point to a failure of services to adapt to a group’s specific needs. For example, the Black Caribbean population in England who are estimated to have a risk of psychosis nearly seven times higher than in the White population, and the Black Caribbean population has a higher rate of mental health service contact than the White population (Mental Health Foundation, 2019[114]). Detention rates under the Mental Health Act was four times higher for Black or Black British populations than for White populations in 2017‑18, and from 2006 to 2010 Black population groups had higher than average inpatient admission and detention rates (Quality Commission, 2011[115]; Mental Health Foundation, 2019[114]). These patterns could point to difficulties in delivering appropriate and high quality services in community settings for Black populations in England.

In recognition of the different mental health service needs of key population groups, most OECD countries aim to make mental health services more accessible or appropriate for key groups who may have particular mental health risks. Thirteen countries have implemented services specifically designed for these key populations in at least some settings, and a further three countries have at least a number of pilots for specific groups (Figure 3.15). Five countries – Austria, Canada, Italy, Japan, and Korea – report that there are many widely available services for key population groups in place. For example, Canada fully covers mental health services for Indigenous populations and has developed additional strategies and services to meet the needs of these populations and ensure quality of care. Other countries have more specific services developed for vulnerable populations such as mental health initiatives for the Traveller community in Ireland, where mental health initiatives that focus on promoting mental health and reducing death by suicide by travellers, through training and educational programs (OECD, 2020[26]).

Figure 3.15. Services specifically designed for key populations

Improving the accessibility and quality of mental health services

Providing high quality and accessible mental health services remains a challenge among OECD countries, and available data points out the need for improvement. High rates of emergency care use, repeated admissions to inpatient care and high suicide rates after discharge point out there is a need to strengthen continuity of care. OECD countries should focus on providing strong integrated care systems, with a primary focus on enhancing care systems in the community.

Community care has been proven beneficial for the service user outcomes and less costly compared to inpatient care. However, available data shows OECD countries practice various levels of community care, which is reflected by the number of inpatient beds, admissions of inpatient care and people under care of community teams. Mental health systems continue to struggle with delivering safe services. People using mental health services are exposed to specific risks, and data on inpatient suicides points to shortcomings in OECD countries.

Additionally, there is still a lot that remains unclear about the state of health systems among OECD countries, because relatively little data is available.Contemporary mental health systems have tried to prioritise delivering services that provide improvements rather than focusing solely on the volume of services in place, and even if key gaps in understanding quality and outcomes of services remain, there is clearly scope for further. There is still more that remains to be done, and data systems should focus on integrating measures that shed light on how care is delivered for the individual. Patient-reported measures are a way forward and will help to provide the insights that are needed to delivered effective care; patient-reported indicators can also point to gaps between what matters to service users in service delivery and design, and what matters to policy makers or practitioners.

Strengthening community services by developing early intervention approaches and accessible services such as talking therapies

The prevalence of mild-to-moderate mental health conditions, and in particular mild-to-moderate cases of anxiety and depression, is significant. The mental health burden is high, and in Europe alone tens of millions of people suffer from a mental illness during a certain point in their life, and tens of thousands of people dying each year because of suicide or death related to mental illness. Although countries are taking actions to prevent and treat mental illnesses, as discussed across the chapters of this report, unmet need for care including for mild-to-moderate mental health conditions, remains high. For people with mild-to-moderate ill health, low-intensity, low threshold services are a way to promote well-being and prevent worsening for severe mental ill-health. Psychological therapies are a treatment of choice for these disorders (Thornicroft, 2018[116]).

Countries have been focusing on increasing access to talking therapies, especially for mild-to-moderate disorders. In particular, there has been significant activity around increasing services including psychological therapies, counselling, group therapy, and general advice for example provided by General Practitioners or available online. All respondents to the OECD Policy Questionnaire (OECD, 2020[26]) 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. In addition in 12 countries primary care practitioners are providing some form of talking therapy, for example brief psychological therapy. 62 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. As an example, Lithuania now has more than 100 mental health centres that work alongside with general practitioners and are the first point of contact for people with mental health disorders. These centres consist out of a psychiatrist, psychologist and social workers (OECD, 2020[26]). In Slovenia, community mental health centres are being established (currently there are 10 for adult populations and 11 for child and adolescent populations), at a primary care level, where interdisciplinary work with multiple professionals (psychiatrists, psychologists, social workers, speech therapists, occupational therapists, nurses) are working together.

Figure 3.16. Talking therapy provided by primary care providers, 2020

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.

In Denmark, the health care system includes an opportunity for psychological treatment. According to Section 69 of the Health Care Act, specific vulnerable groups of patients have the opportunity of being referred by the local GP to psychological treatment and partly reimbursed for the costs; up to 12 consultations may be granted. In some cases a person may be referred to treatment twice and thereby be offered another 12 consultations with partly reimbursement of the costs. The subsidy covers 60% of the cost and is granted by the regional council whereas the remaining 40% is paid by the patient. Additionally patients who are between 18‑21 years old can receive psychological treatment due to depression or anxiety disorders for free. From the second half of 2021, this entitlement was expanded to include all patients between 18 and 24 years. 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 (Box 3.2).

Box 3.2. Scaling-up access to talking therapies in England and France

The Increasing Access to Psychological Therapies (IAPT) programme in England has significantly transformed access to talking therapies, and continues to stand out internationally as a game‑changing programme. IAPT began in 2008 to provide talking therapies for adult anxiety and depression, and has steadily increased the number of people who access services year-on-year, with more than a million people using IAPT services in 2018 alone. The programme originally began with a significant focus on cognitive behavioural therapies, and has since expanded to include a wider range of therapies found to be clinically effective by NICE (e.g. counselling, brief psychodynamic therapy, interpersonal psychotherapy), and a wider range of health conditions (phobias, OCD, PTSD, body dysmorphic disorder, irritable bowel syndrome, chronic fatigue syndrome).

IAPT stands out for its significant reach in terms of the number of people who are accessing services, but also for at least three other reasons: systematically including only therapies assessed as effective by NICE; the use of a stepped-care model with lower intensity services delivered by a specifically trained non-psychologist workforce, notably by ‘psychological well-being practitioners’; and the integration of outcomes measures for all services. All IAPT services collect outcome measures at least at the start, middle, and end of treatment, including symptom measures (mostly using PHQ‑9 or GAD‑7), measures of disability (using WSAS). The measure of disability includes the extent to which a person’s mental health problem interferes with their functioning at work, at home, at leisure, socially and with their family. At the beginning of the IAPT programme a target of 50% recovery was set for the services, which was reached in 2017‑18 with a recovery rate of 50.8% (NHS Digital, 2019[117]; NHS Digital, 2019[118]).

Figure 3.17. IAPT recovery rates (select therapies), 2018-19

In France, mild-to-moderate mental disorders are typically managed by GPs, with antidepressants the main treatment available to them; psychological therapies provided by psychologists have not been reimbursed under basic health insurance. In 2018, the French health insurance began a pilot project in three regions to reimburse psychologist-provided psychological therapies (Gandré et al., 2019[119]; L’Assurance Maladie, 2018[120]). Unlike the approach taken by IAPT, these pilots did not create a new system or protocol for the type of psychological therapies to be delivered. Rather, the pilots introduced standardised protocol for referral and reimbursement of a range of psychologist-provided therapies. To benefit from reimbursed therapies recipients must be referred by their GP after following common referral guidelines and tools, after which an assessment is undertaken by a psychologist, and if appropriate the person is referred for ten sessions of supportive psychotherapy. After ten sessions the GP is able to refer for a further ten sessions if necessary. Psychologists delivering services are reimbursed directly, based on fixed tariffs. An evaluation of the pilots was due to begin in early 2020; initial findings suggest that the pilots have been extremely popular, with high demand for services from the population.

Early intervention techniques can effectively target adolescents or young adults

A system that wants to focus on proactive and accessible mental health services should also strengthen services for young people. The majority of mental health disorders often occurs in adolescence or young adulthood with 50% of mental disorders emerging by the age of 14 years, and 75% by the age of 24 years. When left untreated, there is a high rate of recurrence and increased chances of negative outcomes for the individual possible resulting in severe mental illness (Hetrick et al., 2017[121]). This makes it crucial for mental health systems to intervene during early stages of mental distress.

However, the process of early intervention, early diagnosis and timely access can still be a challenge. Many services are fragmented, while providing care that is strictly age based and with low levels of integration by being focused on specific diagnosis or comorbidities. This has led to lack of early intervention for people in need of mental health care (Hetrick et al., 2017[121]; Parabiaghi et al., 2019[122]; Malla et al., 2018[123]).

Internationally there has been a response to these challenges that includes reforming youth mental health into more integrated care models. Among others, Australia, Canada, France, Ireland, Israel, Italy, the United Kingdom and the United States have all taken certain steps to move towards to integrated youth mental health care by implementing initiatives based on integrated care models (Cocchi et al., 2018[124]; Hetrick et al., 2017[121]), with significant leadership in this area coming from Australia. Initially, these early intervention models developed in Australia focused on young individuals at risk for developing psychosis because of the prevalence of behaviour identified as possible prodromal phase in the development of psychotic disorders (McGorry, Killackey and Yung, 2008[125]). However, transdiagnostic perspectives have been presented later on, expanding towards a general understanding of “at-risk” mental states and other signs of psychological distress as cues, with youth potentially at risk for developing multidimensional psychopathologies. Australia’s commitment to providing comprehensive mental health support for young people has led to the development of ‘headspace’ centres which provide a ‘one‑stop shop’ for mental health, physical health (including sexual health), alcohol and other drugs or work and study support, and are in place in more than 130 communities across Australia. The Australian Government also funds the Early Psychosis Youth Services (EPYS) Program, which leverages off the headspace platform to provide early intervention treatment and support to young people aged 12 to 25 years who are at ultra-high risk of, or actively experiencing, their first episode of psychosis. The EPYS Program aims to reduce the incidence and severity of psychosis within the community through prevention, early detection, and co‑ordinated care delivery, and currently operates in 14 headspace centres in six locations across Australia.

In Ireland, too, integrated mental health support for young people has been prioritised, with the ‘Jigsaw’ programme now reaching hundreds of thousands of young people, while in Canada programmes such as the ‘ACCESS Open Minds’ have sought to transform mental health services for young people aged 11 to 25 years (Box 3.3). Canada’s ACCESS Open Minds programme aligns with the ‘Common Statement of Principles on Shared Health Priorities (CSOP)’, a statement of intent in which Health Ministers agreed on the importance of promoting mental wellness, and of addressing gaps in mental health and addiction services and recovery, including for children and youth. From 2017, and for at least the ten following years, this CSOP constituted a commitment from Health Ministers to improve access to evidence‑supported mental health and addiction services and supports for Canadians and their families. Specifically, actions identified that should be pursued included expanding access to community-based mental health and addiction services for children and youth (age 10‑25), recognising the effectiveness of early interventions to treat mild to moderate mental health disorders.

Box 3.3. Ireland’s ‘Jigsaw’ mental health early intervention programme for young people and ‘ACCESS Open Minds’ in Canada

Jigsaw in Ireland

To improve early intervention in mental health care in 2014, Ireland has responded to transform youth mental health services through the development of Jigsaw. This project aims to transform mental health services for young people aged 12 to 25 years and support young people across Ireland in close collaboration with statutory, voluntary and community mental health and related services.

Jigsaw is now established in ten communities with a reach of 150 000 to 250 000 people. The centres are staffed by a multi-disciplinary teams or health professionals, who work in a brief and solution, while basing their treatments on CBT principles.

The core objectives identified to transform services are:

1. To ensure young people have access to youth-friendly, integrated mental health support in their community.

2. Build capacity in front-line workers and volunteers to support young people’s mental health

3. Promote community awareness around mental health.

A review of the effectiveness of the services in 2015 highlighted more than 8 000 young people have received a service from Jigsaw. The study showed that there was a gender balance between the youth receiving support, which was seen as a strength, considering males do not seek help as frequently as females. The most common presenting issue was anxiety. People reported high levels of psychological distress pre‑intervention and significantly lower levels post intervention (O’Keeffe et al., 2015[126]).

‘ACCESS Open Minds’ in Canada

To improve early intervention in mental health care, in 2018, Canada has responded to transform youth mental health services through ACCESS (Adolescents/young adult Connections to Community-driven, Early, Strengths-based and Stigma-free services) Open Minds.

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[123]).

Integrated continuous community care to improve mental health for people with severe mental health conditions

Data shows mental health systems are not yet able to deliver the care that people with severe mental illness need, while showing high numbers of readmissions, repeated emergency visits and suicide after discharge. Severe mental ill health is a complex condition, and people with severe mental ill health are often dependent on receiving long term care, while being highly vulnerable to future episodes and experiencing persisting symptoms (Rodgers et al., 2018[127]; Austin et al., 2013[128]).

Outpatient care models have been developed for people with severe mental ill health to serve their complex care needs. These models been associated with reduced hospital admissions, including involuntary admissions (Aagaard, Tuszewski and Kølbæk, 2017[43]; Burns, Tomita and Kapadia, 2014[129]). Assertive Community Treatment (ACT) and Case Management (CM), and Intensive Case Management (ICM) are all models that have been used or are currently used in care settings. These approaches are delivered by a multidisciplinary team of professionals, who offer services in community settings, by helping with a broad range of services which can include medication management, housing, finances and everyday problems in life. Intensive Case Management evolved from ACT and CM, where ICM emphasises the importance of a small caseload (fewer than 20) and high intensity input (Bond et al., 2001[130]; Dieterich et al., 2017[131]).

Continuous, open ended, integrated care treatments could provide people with severe mental ill-health the care they need to improve in illness severity and overall functioning, while preventing worsening of their condition. In 2006, Germany has developed the ACCESS-model which is an integrated care treatment based on ACT for patients with schizophrenia-spectrum disorder (SSD), while providing continuous and open-ended treatment. The ACCESS-model was incorporated into clinical routine as a time‑unlimited care model and delivered to a sample of severely ill patients, primarily for people with multiple‑episode schizophrenia-spectrum disorder and people with bipolar disorder with psychotic features, thus very complex treatment needs. Between May 2007 and December 2013, 115 patients were treated within the ACCESS care model over a continuous 48 months. Patients in the ACCESS received high frequent face‑to-face contacts, with a mean of 2.0‑2.4 contacts per week. Care was provided by a multidisciplinary team of psychiatrists, psychologists, nurses and social workers. This rate remained stable of the 4 years. Moments of contact focused on assertive engagement and shared decision making, while frequently involving family or significant others. The ACCESS treatment had positive outcomes, leading to improvement in patients’ psychopathology, illness severity, functioning and quality of life. Service disengagement rate of 48 months remained low at 8.7% overall, a very low hospitalisation rate and a much lower rate of involuntary admissions compared to 2 years before involvement in ACCESS-care, respectively 7.8% in 4 years to 34.8% in the 2 years before. It is assumed that the continuously high rate of outpatient contact in ACT was a key component in stabilising patients’ psychopathology (Schöttle et al., 2018[132]; Schöttle et al., 2019[133]). Given the success of this model, it has since been modified and extended to severely ill early psychotic adolescents and young adults between 12 to 29 years (Lambert, 2016[134]).

Ongoing efforts must also focus on improving services and therapeutics for people with serious mental illness, and this should include accelerating innovation and research in this area (see also Chapter 7). Innovation in service delivery for serious mental illness could include interventions which deliver better outcomes (e.g. symptom reduction, improved physical health outcomes), which have a higher rate of adherence, or which offer a better experience to service users for instance because of fewer side effects, or because the care model is more compatible with other social or professional objectives. In Norway, and in some other countries, efforts to explore drug-free treatments are one example of an alternative treatment model for severe mental health conditions (Box 3.4). While such an approach may not be the right one for all settings or all service users, it is critical that efforts to develop a diversity of different approaches to management of severe mental health conditions continue.

Box 3.4. Alternative treatment models for serious mental illness – exploring drug-free treatment in Norway

Treatment of severe mental illness with psychiatric medications remains the treatment of choice. However, there are ongoing challenges around the use of psychiatric medication, including adherence, and significant side effects. Side effects of anti-psychotic treatment can include mental and physical side effects such as concentration problems, emotional deregulation, weight gain, constipation and sexual dysfunction, all of which undermine adherence (Kasper and Resinger, 2003[135]; Iversen et al., 2018[136]). While newer, second generation psychiatric medication are found to have fewer side effects, the effects can still be significant. In particular, people were found to be a risk for weight gain and developing diabetes (Sernyak et al., 2002[137]).

Innovations to improve outcomes and experience in treatment of severe mental illness should be prioritised. There is an increased desire to explore medication free treatment of psychotic disorders. Studies have shown promising results, with successful outcomes in drug-free treatment. As an example, a study by Francey et al. (2020[138]), found young people with early-stage psychosis have experience reduced symptoms and improved functioning without antipsychotic medication, when they were provided with psychological interventions and comprehensive case management. Another study by Morrison et al. (2018[139]) examined outcomes between cognitive behavioural therapy and antipsychotic drugs, and a combined therapy of both cognitive behavioural therapy and antipsychotic drugs, which resulted in similar outcomes in people with psychosis.

Countries are increasingly exploring other ways to provide the treatment for people with severe mental illness and looking at possibilities for drug-free treatments. In a response to service users, Norway does now offer drug free treatment for people with psychosis. Demand for it rose due to an increase of negative experiences with psychiatric medication and led to Norway to adopt drug free treatment in 2016. While it is an option to receive drug-free treatment in some other countries, Norway is the first to embed it in their national mental health system. The University Hospital in Tromso has most of their patients to abate anti-psychotic drugs and the first signs point to positive outcomes. However, drug-free treatment remains controversial and data on outcomes remain scarce, and reassessment is needed to shed light of the use of drug-free treatments (BBC News, 2021[140]).

Creating safe inpatient settings while reducing coercive measures

Although countries are continuously working towards a model where care is provided in community settings, inpatient psychiatric care remains an integral part – albeit to differing extents – of OECD mental health systems. Countries have been focusing on creating safe inpatient settings, which concerns both patients and staff and is crucial in the process towards recovery from mental illness. However, inpatient suicides remain high, and countries are trying to identify the factors that contribute to unsafe inpatient facilities. Incidences such as assault, aggressive behaviour towards staff and patients, and the use coercion are among factors that could influence patient safety on inpatient wards. Lack of patient engagement, insufficient ward activities and lack of staff involvement have been pointed out as factors that aggravate aggression and violence (Janner and Delaney, 2012[141]; Polacek et al., 2015[142]).

From an international perspectives there have been attempts to reduce the use of coercive measures, and research has tried to identify the factors that influence the use of coercive measures. These factors concern both the causes for the destructive and aggressive behaviours from the patients, and secondly the frequency of the use of coercive measures by staff. Governments and mental health organisations are making attempts to reduce the use of coercive measures to a minimum required. To do so, several initiatives have been implemented. In some cases, strategies have been proven effective and are promising in reducing the use of coercive measures. These strategies often relate to open door policies, ward culture and staff/patient ratios and models that have been developed combining several strategies (Bak & Aggernæs, 2012b; Gooding, 2018; Janssen et al., 2011; Cibis et al., 2016; Fan et al., 1994; Steinert et al., 2008; Sullivan et al., 2004). A frequently used model is the Six Core Strategies for Reduction of Seclusion and Restraint (6CS) (Box 3.5).

Box 3.5. The Six Core Strategies for Reduction of Seclusion and Restraint (6CS) – a model to reduce coercive practices

The Six Core Strategies for Reduction of Seclusion and Restraint (6CS) is a strategy model developed by the NASMHPD National Technical Assistance Centred in the United States. This is a synthesis of strategies, shown to be effective in reducing the use of seclusion and restraint (Gooding, McSherry and Roper, 2020[143]; NASMHPD, 2006[144]). The strategies in this model include;

1. ‘Leadership towards organisational change’ – promoting a climate of care which focused on reduction of coercive measures

2. ‘Using data to inform practice’ – Using empirical data to examine patterns of seclusion and constraint

3. ‘Workforce development’ – developing procedures and training, based on mental health recovery

4. ‘Use seclusion and restraint reduction tools’ – training programme for staff for de‑escalation tools and techniques

5. ‘Consumer roles in inpatient settings’ – including patients and clients to manage their own behaviour

6. ‘Debriefing techniques’ – conducting an analysis of why the coercive measure occurred and evaluating its impact on individuals with the lived experience.

These strategies have been used in the United States, Canada, Australia and New Zealand. Several studies examined the use of the Six Core Strategies approach and all reported a significant decrease in the use of seclusion and restraint. In a study by Wieman et al. (2014[145]), out of the 28 facilities that had a stable implementation of the model, nine achieved reductions in overall population secluded, with an average reduction of 17%. Fifteen facilities reduced the amount of seclusion with 19%, respectively 1 000 hours. Nine facilities achieved reductions in the percentage of patients who were restrained, with an average reduction of 30%.

When coercive measures are inevitable, care facilities should strive for using the least intrusive measures possible

In cases when containment measures seem inevitable, it is important to apply the measures which are least harmful and safest for the patients and staff. Many organisations such as the World Health Organization, have passed statements that only the least restrictive measure should be applied (WHO, 2019[146]). What is considered as the least restrictive measure is difficult to define, given the cultural and historical geographical differences. Qualitative approaches consider human rights and medical ethics to determine what approach is most preferable. According to medical ethics, a procedure should lead to benefits, while physicians avoid harm and respect the patient’s autonomy and act under aspect of fairness. This is line with the human rights perspective based on the CRPD, which states that individuals should maintain the highest level of autonomy and independence. These rights are difficult to respect as in cases of coercion, patients’ autonomy is severely restricted. Some studies consider the restriction in autonomy is less when staying in a seclusion room, than being immobilised by the use of bed belts. However, there is no unified opinion about which measure is least restrictive (Völlm and Nedopil, 2016[94]).

Another perspective is to consider the amount of distress a coercive measure evokes, by using a technique which minimises the harm done to an individual. An instrument has been developed to measure subjective distress and impairments of human dignity during coercive measures; the Coercion Experience Scale (CES) (Bergk, Flammer and Steinert, 2010[147]). A study by Bergk et al. (2011[148]) compared the use of seclusion and mechanical restraint, which showed patients who experienced mechanical restraint experienced more distress in retrospect. The same instrument was used in a study comparing the use of involuntary medication to seclusion. The study showed that people who were exposed to seclusion experienced more distress, and the people who receive both involuntary medication and seclusion experienced highest levels of distress (Georgieva et al., 2019[149]).

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