5. Preventing mental illness and promoting mental well-being

Abstract

Policies to promote mental well-being and prevent mental ill-health have also been shown to make a meaningful impact on population health, and represent good value-for-money. Effective interventions to promote mental health, build mental resilience, and prevent mental ill-health can be found across the life course and in multiple settings. This chapter sets out some of the compelling reasons that promotion and prevention activities are a critical part of a high-performing mental health system, summarises the extent to which OECD countries have mental health promotion and prevention policies and interventions in place, and gives some recommendations of promising policies that could be used across OECD countries.

Introduction

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. However, 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.

Interventions to promote mental health, build mental resilience, and prevent mental ill-health can be found across the life course and in multiple settings. Interventions to promote good mental-health and prevent mental ill-health are particularly in infancy, childhood, and adolescence, and most OECD countries are taking steps to promote mental well-being for children in schools. Workplaces, too, are common sites where OECD countries are taking steps to protect against risks to mental health, and some are introducing mental health promotion programmes as well. Increasingly, mental health promotion and prevention is seen as a cross-government, multi-sectoral effort, which includes efforts such as promoting good mental health literacy, a focus on positive mental health, training for front line actors, as well as comprehensive approaches to preventing suicide.

This chapter starts by setting out some of the compelling reasons that promotion and prevention activities are a critical part of a high-performing mental health system, summarises the extent to which OECD countries have mental health promotion and prevention policies and interventions in place, and gives some recommendations of promising policies that could be used across OECD countries. There are strong links between the discussion in this chapter and many of the other chapters in this report, and in particular with Chapter 4 on multi-sectoral and integrated policies, and Chapter 6 on good governance and leadership, which includes efforts to reduce stigma around mental health conditions.

Why do mental health systems need to prevent mental illness, and promote mental well-being?

In the OECD Mental Health Performance Framework, a high-performing mental health system should prevent mental illness and promote mental well-being. Good prevention and promotion policies should:

Reduce the rate of suicide;
Ensure mental health literacy;
Make schools mental health-friendly environments that build resilience;
Ensure that workplaces foster good mental health;
Enable front line actors to recognise and respond to mental distress;
Make it easy for individuals to seek help.

Mental health exists on a spectrum – and includes both positive mental health and poor mental health

One in every two people in OECD suffer from mental health problems in their lives and the direct and indirect cost of mental illness are estimated to exceed 4% of GDP (OECD/European Union, 2020[1]). It is essential to support those with mental health issues by providing medical care, social support and financial aid. At the same time, preventing mental ill-health and promoting good mental well-being are critical parts of a high performing mental health system.

Mental health can be understood to exist on a spectrum, from positive mental health to poor mental health, and can also be conceptualised using the ‘dual continuum model’ for mental health, which sets out that mental illness and mental health are on related but different axes. Someone with a mental illness can have good mental health (i.e. be managing it well and experiencing good mental well-being), just as someone with no mental illness can experience poor mental health.

The purpose of health promotion and disease prevention programs is keeping people healthy, and improving people’s health. While disease prevention is a measure for reducing a risk of diseases and a severe condition of diseases. Both approaches are intended to result in increasing the quality of life and reducing the mortality of diseases.

Health promotion was discussed in the first International Conference on Health Promotion held in Ottawa in 1986 with a growing expectation for better public health. After 30 years of this conference, United Nations General Assembly adopted in 2015 “The 2030 Agenda for Sustainable Development”, aiming that all human being can fulfil their potential in dignity and equality in a healthy environment. One of the 17 goals of Sustainable Development Goals (SDGs) focus on ensuring healthy lives and promoting well-being for all people at all ages (WHO, 2017[2]).

Mental health promotion in this chapter includes ‘aiming to promote positive mental health by increasing psychological well-being, competence and resilience, and by creating supporting living conditions and environments’ (Saxena, Jané-Llopis and Hosman, 2006[3]). Mental ill-health prevention is includes ‘having as its target the reduction of symptoms and ultimately of mental disorders. It uses mental health promotion strategies as one of the means to achieve these goals’ (McDaid, Hewlett and Park, 2017[4]; Saxena, Jané-Llopis and Hosman, 2006[3]).Mental health promotion encourages positive mental health by increasing psychological well-being and creating supporting living conditions and environments. Mental disorder prevention has as its target the reduction of symptoms and ultimately of mental disorders (Saxena, Jané-Llopis and Hosman, 2006[3]).

Preventing mental ill-health and promoting mental well-being has taken on a new importance – and new complexity – in light of the COVID-19 crisis

Up until 2020, adult mental health status was largely stable but children and young people were showing signs of increased mental distress

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[5]; Collishaw, 2015[6]; Blomqvist et al., 2019[7]). 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[5]; OECD, 2018[8]; OECD., 2017[9]; McManus et al., 2019[10]). 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[8]; Kowalski et al., 2014[11]). 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[5]; Comeau et al., 2019[12]).

During the COVID-19 pandemic, young people’s mental health appears to have worsened faster than the general population. For example, young people in Belgium and France were more likely to be experiencing depression or anxiety than the all-age population average in 2020, while in a survey of young people in the United Kingdom 80% of respondents stated that the pandemic had made their mental health worse, with 41% stating it had made their mental health ‘much worse’ (Santé Publique France, 2020[13]; Sciensano, 2020[14]; Young Minds UK, 2020[15]). Young Minds UK undertook two mental health surveys, in September 2020 and June-July 2020: in September, just after schools had reopened, there was a slight rise in indicators such as the percentage of respondents feeling lonely or isolated, feeling anxiety (Young Minds UK, 2020[15]).

During 2020, population mental health status worsened across OECD countries

Overall levels of mental distress have not changed significantly across the past two decades. IHME data and other sources suggest that prevalence is fairly consistent, and the OECD average has been around 18% since 2002 (IHME, 2018[16]; OECD, 2015[17]). The COVID-19 crisis across the course of 2020 has changed this trend. Overwhelmingly, surveys of OECD populations showed that mental health had worsened: in Australia 78% of respondents reported their mental health had worsened (Newby et al., 2020[18]); in Austria 43.5% of respondents reported the psychological impacts of the COVID-19 outbreak as moderate or severe (Traunmüller et al., 2020[19]); 50% of Canadians reported worsened mental health since the start of the pandemic, and 6 in 10 said their mental health had worsened ‘a lot’ (CAMH, 2020[20]); in Luxembourg 37% reported their mental health had declined (Luxembourg Chronicle, 2020[21]); 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[22]).

For example, regarding the prevalence of people who experienced anxiety, national surveys showed that anxiety increased in all countries in 2020 compared to previous years. New Zealand conducted the research between 15 and 18 April 2020 and showed 15.6% of anxiety prevalence, which is much higher than in 2017 (Cabarkapa et al., 2020[23]; Ministry of Health NZ, 2020[24]). In Belgium, survey results point to significant increases in both self-reported anxiety (from 11% to 23%) and depression (from 10% to 20%) between 2018 and 2020 (Sciensano, 2020[14]). In Czech Republic, the prevalence of anxiety disorders significantly increased between 2017 and 2020 (Winkler et al., 2020[25]). Surveys in the United Kingdom and Denmark have also suggested that more people are feeling anxious and are having more difficulties staying upbeat (ONS, 2020[26]; Sønderskov et al., 2020[27]). In the United Kingdom, where anxiety levels increased significantly from 21% in 2019 to 50% in 2020, this could show particularly high levels of anxiety amongst the population, but may also be influenced by reporting factors such as a population more open to discussing their mental state or a more sensitive survey instrument. In Canada, a national poll by Mental Health Research Canada, found that as of December 2020, levels of high anxiety and high depression among Canadians were elevated. The proportion of Canadians reporting high levels of anxiety was four times pre-COVID levels, with a quarter (23%) reporting that they had high anxiety, up from 6% before the outbreak. The proportion of Canadians reporting high depression (15%) was more than double pre-COVID estimates (6%) (Mental Health Research Canada, 2020[28]).

While it is difficult to compare prevalence of mental distress, and changes in mental distress, between countries given the differences in survey instruments, self-reported stress, worry and anxiety were higher in some countries than others in mid-2020. A survey by the Commonwealth Fund in August 2020 found that at least 10% of adults reported experiencing stress, anxiety, or great sadness that was difficult to cope with alone since the outbreak started, with a particularly high percentage of adults experiencing this mental distress in Canada (26%), the United Kingdom (26%) and the United States (33%) (Figure 5.1).

Figure 5.1. Levels of mental distress were higher in some countries than others in August 2020

Investing in promotion and prevention in mental health makes good economic sense

The economic costs of mental ill-health are significant, and some of these costs could be offset by investment in more interventions to promote mental resiliency and well-being, prevent mental ill-health, and intervene early when mental health conditions occur.

A series of different reviews of the cost-effectiveness of promotion and prevention in mental health have found positive findings in terms of return on investment, and some programmes seem to hold potential to bring savings in health care costs, and/or improvements in productivity. In Australia, the National Mental Health Commission undertook a modelling exercise looking at ten promotion or prevention interventions in a range of different areas, including in schools, for women post-birth, for older age groups, and in workplaces (National Mental Health Commission, 2019[30]). All but one intervention demonstrated at least a modest positive return on investment. Some interventions – notably e-health interventions, and parenting interventions for preventing anxiety disorders in young people; e-health and educational interventions for reducing loneliness for older adults; and exercise programmes to prevent post-natal depression – showed a return on investment of more than 2.0.

In England, Public Health England also undertook a cost-effectiveness evaluation looking at effective mental health promotion and prevention programmes, and identified eight initiatives that demonstrated a positive return on investment (Public Health England, 2017[31]; Public Health England, 2017[32]). Initiatives that had potential to generate savings included social and emotional learning for children which was estimated to result in savings of GBP 5.08 for every GBP 1 invested over three years, a whole of school anti bullying programme, which was estimated to result in savings of GBP 1.58 for every GBP 1 invested across four years, a well-being programme in the workplace (savings of GBP 2.37 for every GBP 1 invested, over 1 year) and a debt and welfare service (GBP 1 invested leading to savings of GBP 2.60 over five years) (Public Health England, 2017[31]).

Are OECD mental health systems effectively preventing mental illness and promotion mental well-being?

Are countries reducing the rate of suicide?

Suicide rates are falling in OECD countries but still cause significant numbers of deaths every year

The rate of deaths by suicide varies nearly 10-fold across the OECD countries, with the lowest rates found in Turkey (2.6 per 100 000) and Greece (4 per 100 000), and the highest rates found in Lithuania (22.2 per 100 000) and Korea (23.0 per 100 000) (Figure 5.2).

Figure 5.2. Deaths by suicide 2018, or latest year

Deaths by suicide in OECD countries have been falling across recent decades; between 1997 and 2017 rate of death by suicide per 100 000 population fell or remained stable in all but six OECD countries (Korea, the Netherlands, Greece, the United States, Chile, Mexico) (Figure 5.3).

Figure 5.3. Change in rate of suicide 1998-2018, or latest year

In some countries – Estonia, Hungary, Lithuania, Luxembourg – the rate of suicide has fallen by more than half, albeit in some countries from an initially high rate. In Estonia, where the rate of death by suicide fell from 32.5 in 1997 to 13.6 in 2018, with the majority of this decline happening up to 2006, socio-political change across the period as well as changes to regulation around alcohol sales have been pointed to as significant drivers (Värnik et al., 2007[34]). Indeed, other countries in the region which underwent similar socio-political transformations after the end of the Soviet Union also saw significant declines in the rate of suicide, even if Estonia’s close neighbours Latvia and Lithuania have higher rates of suicide for most recently reported years.

In a few countries, suicide rates have remained fairly low for two decades or more, including Israel, Italy and Spain. In Greece, where the suicide rate is low compared to the OECD average (4 deaths per 100 000, compared to 11.1 OECD-wide), the rate of suicide saw an increase from 2011 onwards, possibly in part due to the prolonged economic crisis that Greece was facing (van Gool and Pearson, 2014[35]).

Korea is, and has been for some time, an outlier amongst OECD when it comes to deaths by suicide. Not only has suicide risen in Korea between 1997 and 2017 – from a rate of 8.8 to a rate of 23 – which runs against the overall average trend in OECD countries, but Korea also has the highest rate of deaths by suicide amongst all OECD countries, well above the OECD average of 11.1 deaths per 100 000 population in 2018. Korea has been seeking to reduce its suicide rate for many years – including introducing national suicide prevention campaigns, media guidelines on reporting on suicides, suicide prevention hotlines, reduction of access to lethal means and seeking to increase access to mental health care (Park et al., 2020[36]; Kim and Yoon, 2013[37]; Kim et al., 2015[38]; Paik et al., 2014[39]; Kim et al., 2019[40]). Korea’s current Master Plan for Prevention of Suicide includes 13 measures, including development of a counselling manual on suicide, tailored suicide prevention measures for each age group, promotion of mental health through management of depression and drug addiction, and follow-up management of people at risk of suicide or following a suicide attempt (OECD, 2020[41]).

Suicide had also been declining in Korea from 2012, where suicide rates reached a high of over 33 deaths per 100 000 in the period 2009-11. However in 2020, most recently available data points to worrying trends in Korea when it comes to suicide rates, and signs that the COVID-19 crisis may have contributed to an increase in deaths by suicide amongst young women in Korea. Korean data suggests that there was a 43% increase in deaths by suicides by women in their 20s in the first half of 2020 compared with the same period last year (The Washington Post, 2020[42]; The Economist, 2020[43]).

There are signs that the COVID-19 crisis is also having an impact on rates of death by suicide in Japan. A Japanese study recently found by using difference-in-difference estimate that overall suicide rate decreased by 14% during the ‘first wave’ (from February to June 2020) of the COVID pandemic, a time during which schools were closed, working hours were reduced for many people, and broad household financial support was provided by the governments. Analysis by the ‘Japan Suicide Countermeasures Promotion Center’ (JSCP), a research institute designated by the Minister of Health, Labour and Welfare, suggested that growing public anxiety may have stimulated people’s instinct to protect themselves, contributing to a decline in deaths by suicide (JSCP, 2020[44]). During the ‘second wave’ (July to October 2020), the suicide rate amongst Japanese women, children and adolescents increased by 37% and 49% respectively (Tanaka and Okamoto, 2021[45]). Suicide can be triggered by multiple factors, including psychiatric disorders, chronic medical conditions, alcohol or drug abuse, stressful life events, or social isolation (Mayo Clinic, 2021[46]), but the correlation of the significant rise in the suicide rate and psychological issues possibly related to the COVID-19 crisis is highly alarming.

Every year a small but concerning number of children and young people die by suicide

Every year, a small number of children and some young people die by suicide (Figure 5.4). 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. Between 2000 and 2015, the average number of deaths by suicide 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, the United States). In Australia, death by suicide are particularly high amongst young Aboriginal and Torres Strait Islander populations, for those with serious and complex mental ill-health. Rates of suicide are highest for those who have experienced child abuse and neglect (Stefanac et al., 2019[47]; Orygen, 2016[48]; Australian Institute of Health and Welfare, 2019[49]). Canada has also observed increases in the suicide rate in recent decades among females aged 10-24 and 45-64 years old (Varin et al., 2021[50]).

Figure 5.4. Death by suicide amongst young people age 15-25 in select countries, 2000-15 or nearest year

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[41]). 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[51]; McKean et al., 2018[51]; Pettit, Buitron and Green, 2018[52]; Im, Oh and Suk, 2017[53]; McGillivray et al., 2020[54]). 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[54]).

Are countries ensuring mental health literacy?

Good mental health literacy can reduce stigma, support self-management of mental distress, and encourage help-seeking

‘Health literacy’ includes an individual’s health knowledge, their capacity to understand and process information about health and health care, and their capacity to make decisions about their own health and their use of health services ( (Institute of Medicine, 2004[55]; Moreira, 2018[56]). Health literacy can support more people-centred care, supporting increased shared decision making, and a more egalitarian relationship between the care provider and consumer. Increased health literacy can also improve the care user’s capacity to manage their own health, for example managing a chronic disease, or seeking help in the event of ill-health (Paasche-Orlow and Wolf, 2007[57]). Some studies have found that health literacy contributes to improved self-reported health status, decrease in the frequency of health care service, and shorter the hospitalisations (Sørensen et al., 2012[58]).

Mental health literacy includes knowledge and skills related to mental health – both understanding of good mental health, and mental health problems and conditions –, improved attitudes and reduced stigma towards mental health conditions, and understanding of how to seek help in the event of mental ill-health (Wei et al., 2015[59]). At present, mental health literacy is not widely or consistently measured, and a range of different measurement tools exist. The most widely used approach to measuring mental health literacy is through questionnaires, which tend to measure either mental health knowledge, or stigma and attitudes (including self-stigma). Widely used measures of mental health knowledge include the Mental Health Literacy Questionnaire (MHLQ), the Mental Health Knowledge Schedule (MAKS), the World Psychiatric Association ‘Open the Doors” survey (WPA-OD), or condition-specific measures such as the Depression Literacy Scale (DLS), Knowledge about Schizophrenia Questionnaire (KASQ), or Schizophrenia Knowledge Questionnaire (SKQ) (Wei et al., 2015[59]).

Stigma, and efforts to reduce stigma, are also closely linked to mental health literacy, and are discussed in Chapter 4 of this report.

Efforts to improve mental health literacy are in place in many countries

The OECD questionnaire found that 16 out of 29 respondents countries have national and/or regional or local programmes that focuses on improving general population understanding or knowledge of mental health/mental illness (Table 5.1). These include programmes in Japan and Latvia, which have focused on increasing the level of information that the population has on mental health (OECD, 2020[41]). In Japan the Ministry of Health, Labor and Welfare (MHLW) has been operating a portal site called “Minnano Mental health” (Mental Health for Everyone), which provides useful information, including contact details of specialised medical institutions, support systems and national policies, as well as materials aimed to promote proper understanding of mental health conditions and reduce stigma. Municipal governments in Japan also organise seminars and other events to promote mental health understanding in a way that is tailored to local population needs, and Public Health Centers and Mental Health and Welfare Centers organise campaign events including an annual national conference on mental health care, during Mental Health Awareness Week in Japan. In Latvia, there is also a national platform, www.nenoversies.lv, which provides information and educational lectures about mental health conditions, and each year the ministry leads a particular push around mental health awareness in October, coinciding with World Mental Health Day on 10 October.

Table 5.1. National programme that focuses on improving general population understanding or knowledge of mental health/mental illness
At least one national programme that focuses on improving general population understanding or knowledge of mental health/mental illness
National campaign on mental health literacy	Australia, Canada, Czech Republic, England, Iceland, Ireland, Italy, New Zealand, the Netherlands, Poland, Slovenia, Switzerland
Regional or local campaign on mental health literacy	Belgium, Japan, Korea, Lithuania, Switzerland
Source: OECD (2020[41]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires.

Indeed, events and activities around World Mental Health Day appear to be a key part of countries’ efforts to increase mental health literacy, and to tackle stigma around mental health (see also Chapter 6). For example in Norway NGOs organise information and awareness campaigns on World Mental Health Day each year, while in Turkey key days such as 10 September which is Suicide Prevention Day and World Mental Health, public awareness seminars, panels, and conferences are organised on combating stigmatisation, including activities in primary care services, as well as the distribution of information brochures (OECD, 2020[41]).

During the COVID-19 crisis countries have increased public communication about mental health and staying mentally well

During the COVID-19 crisis, countries have prioritised communication with the public about mental health during COVID-19, including the increased risks to mental health during the pandemic, how to stay mentally healthy, and how to seek help for mental health problems if needed. Governments have also been regularly communicating about mental health issues in ‘COVID-19 briefings’, which have become regular and common place in OECD countries, for example sharing phone support numbers, or referring to latest data on mental health impacts of the crisis. Internet search activity has also shown increases in information-seeking related to mental health and emotional well-being during the COVID-19 crisis (Brodeur et al., 2021[60]).

Over the course of 2020, most OECD countries, and multiple international agencies such as the World Health Organization, the Inter-Agency Standing Committee (IASC), and the European Commission, have produced guidance on coping and staying in good mental health during the COVID-19 crisis. This mental health information, commonly shared online, has included advice for the general public, for health care workers, parents, children and young people, and mental health professionals. Materials include advice on steps to protect mental well-being, such as trying to limit news consumption, maintain social contact by phone or internet, undertaking physical activity at home, getting enough rest, eating healthily, and avoiding tobacco, alcohol or other drugs. Some materials produced by international agencies have been translated and used across hundreds of countries. For example the IASC developed an informational illustrated book, ‘My Hero is You’ for children coping during COVID, which has since been published in 137 languages (IASC, 2020[61]). In OECD countries, Ministries of Health, professional associations, and mental health associations have shared a diverse range of information on coping online. In Portugal, for example, the COVID-19 pandemic has meant that mental health has received more media coverage, and the government website on COVID-19 and mental health (https://saudemental.min-saude.pt/category/covid-19-e-saude-mental/) has been regularly consulted (OECD, 2020[41]). In Finland, the Institute for Health and Welfare has made information on strengthening coping through everyday routines, reducing risk and stress, supporting others and getting help for psychiatric symptoms via its website (THL, 2021[62]). In Turkey, the Psychiatric Association of Turkey has published a wide range of Turkish language resources, including guidelines for adults with existing mental health conditions, recommendations on sleep hygiene during the coronavirus pandemic, guidelines against burnout for health professionals, and the psychological effects of quarantine and means of prevention (European Psychiatric Association, 2020[63]). In Slovenia, the National Institute of Public Health (NIJZ) has published guidelines on promoting mental well-being during COVID-19, mental health first aid guidelines for general population, recommendations on how to talk about COVID-19 with children, how to talk about death and grieving during the COVID-19 pandemic.

Most OECD countries have also introduced mental health support phone lines during the COVID-19 crisis. For instance in Germany, a phone line staffed by volunteers from the Professional Association of German Psychologists (BDP eV) was opened from the end of March until the beginning of July 2020, and received over 12 000 calls (Berufsverband Deutscher Psychologinnen und Psychologen, 2020[64]). In Portugal, a free phone line with 24 hour psychological support from 63 mental health specialists (psychologists) has been created in partnership with the Ministry of Health, the philanthropic foundation Fundação Calouste Gulbenkian (donating EUR 300 million) and the charter of psychologists Ordem dos Psicólogos Portugueses (Servico Nacional de Saude, 2020[65]). In Costa Rica, an ‘Office of Psychological Support’ and more recently the Primary Psychological Support Center (CAPP) have been created by the College of Professionals in Psychology of Costa Rica, while the ‘Here I Am’ (Aquí estoy) phone line was established by the Ministry of Education. 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.

Are schools mental health-friendly environments that build resilience?

Promoting good mental health in early life is critical

A considerable number of children experience mental health problems which, unless they receive appropriate care and support, may have a lasting effect throughout their lives. Evidence suggests that many mental disorders begin at adolescence or even younger; roughly half of all lifetime mental disorders start by the mid-teens, and as many as three-quarters of lifetime mental disorders have their first incidence by age 24 (Kessler et al., 2007[66]; Kessler et al., 2007[67]). Children and adolescents with mental disorders, emotional, or behavioural problems are at higher risk of dropping school and struggling with finding stable jobs after leaving school (Hewlett and Moran, 2014[68]), and living with a mental health condition can also affect a child or adolescent’s interpersonal and family functioning (Wei et al., 2015[59]).

As many as 10% of boys and 14% of girls aged 11 reported ‘feeling low’ more than once a week in the last six months on average across 28 European countries which are members of the OECD. The share of children reporting feeling low increases quite sharply with age, and gender differences become even starker – as 11-year-olds, 14% of girls compared to 10% of boys felt low, but as 15-year-olds, this gap widened with 29% of girls feeling low compared with only 13% of boys (Figure 5.5).

Figure 5.5. Share of children reporting feeling low more than once a week, by age, 2016

Schools are a very good place to do mental health promotion and prevention

Schools are a very effective setting for mental health promotion and prevention activities. First, because almost all children and adolescents in OECD countries spend much of their week in educational settings, and second, because mental health promotion and prevention activities have found to be particularly effective when targeted at children and young people (McDaid, Hewlett and Park, 2017[4]; Union, 2018[69]; OECD, 2015[17]). Interventions delivered in school settings targeting mental health, social and emotional outcomes have been found to have benefits to mental health in the medium-to-long term, as well as having benefits such as a better school attachments, less risky behaviour, improved academic performance, and better resilience and cognitive skills (Durlak et al., 2011[70]; Weare and Nind, 2011[71]; McDaid, Hewlett and Park, 2017[4]).

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 (Figure 5.6), and 20 out of 29 respondents to the OECD Mental Health Performance Benchmarking Policy Questionnaire reported that teachers received some or a lot of mental health training (OECD, 2020[41]). Most countries (19) that were able to report whether they had a mental health education or awareness programmes in school in fact had multiple different programmes, either running at different points in the school year, for different age groups, or in different regions. Some of those countries which were unable to report whether they had specific mental health programmes in schools signalled that some mental health or socio-emotional education was nonetheless included in the school curriculum, for example in Denmark where primary school students all receive physical and mental well-being teaching as a compulsory subject Health, Sexual and Family education curriculum. Several countries – England, Ireland, and Norway – have made recent national commitments to embed mental health teaching in the school curriculum for students across age groups, while other countries – Denmark, Iceland, Finland – have taken such an approach for some time already (OECD, 2020[41]).

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[41]).

Figure 5.6. Mental health education or awareness programmes in schools

In some countries (notably Lithuania and Switzerland, and Denmark) a mental health focus in schools is expected, but teachers and schools are left to set their own teaching curriculum and approach and tailor it to student needs. In many countries, though, national programmes for mental health promotion in schools have been rolled out, either as part of the school curriculum delivered by teachers or as a specific initiative in schools.

Implementing mental health promotion programmes in schools typically requires close collaboration between the Ministry of Health and the Ministry of Education, and/or leadership by the Ministry of Education. In England, in July 2019, the Department of Education also announced a major new GBP 9.3 million ‘School Link Programme, joining up schools and the NHS by offering two whole-day workshops on mental health to all schools, colleges and alternative provision settings (OECD, 2020[41]). The Programme is designed to improve partnerships with professional NHS mental health services, raise awareness of mental health concerns and improve referrals to specialist help when needed. Schools Link Training began roll out to schools and colleges in October 2019 and will be delivered in phases over four years, being offered to up to 22 000 schools and colleges, including alternative provision settings. All the elementary and the secondary school have counselling offices with psychological professionals specialising in mental health prevention at school in Slovenia, which offer counselling to children, adolescents, and their parents. In addition, ‘This is Me’ is an online counselling web portal established by the Institute of Public Health Slovenia in 2001 to strengthen mental health among adolescents. The programme has offered adolescents online counselling service by professionals such as medical specialists, psychologists, social workers, and teachers, and helps adolescents with problem-solving efforts focusing on self-esteem, social and life skills.

England was also planning to introduce compulsory health education in all state-funded schools in England from September 2020 (OECD, 2020[41]). This change included statutory requirements and guidance passed by Parliament, and includes specific mental health content for all 5-16 year-olds. The aim is that this will improve quality and consistency of education on mental health, and provide a preventative benefit helping to stop problems developing and escalating, which including a support package for schools, with GPB 6 million earmarked this 2019/20 to help schools prepare for introduction of mental health education. This dual focus on including mental health in the school curriculum, and strengthening the link between schools and mental health support services is also found in Iceland. In Iceland the health services in primary school place an emphasis on mental health promotion and psychoeducation, and the Ministry of Health and the Ministry of Education and Culture are collaborating on promoting mental health of upper secondary school students via access to supportive services, education about mental health and access to psychological services. As part of England’s ‘Transforming Children and Young People’s Mental Health’ approach, the country is also looking to expand the support system around children, and around schools. This includes three key proposals: incentivising every school or college to identify and train a Senior Lead for Mental Health; creating new Mental Health Support Teams in and near schools and colleges; piloting a four-week waiting time for specialist NHS, so that there is swifter access to specialist NHS services for those children and young people who need it. The aim is that it will deliver early interventions for mental health issues, encourage a whole-school approach to positive mental health, and reduce waiting times for moderate-severe mental health needs services.

Norway, like England, has also recently introduced national commitments to ensure that students of all ages are getting mental health education in schools, and from August 2020 every school in Norway has to implement the subject ‘public health and life mastery’. Norway already has “Mental health in school”, a grant scheme to promote knowledge about mental health in schools, which offers support to many external programmes, and sits alongside a grant scheme about student’s mental health and substance use, aimed at universities and welfare organisations for students (OECD, 2020[41]).

In Ireland, a new national approach is also being pursued for schools, with the ambition that the promotion of well-being will be at the core of the ethos of every school and education setting. The Well-being Policy Statement and Framework for Practice 2018-2023 was launched by the Minister for Education and Skills in July 2018, and policy requires that a Well-being Promotion Process is developed and implemented, through the use of the School Self-Evaluation (SSE) process, in all schools by 2023 (OECD, 2020[41]).

In many countries, the regional or state governments are responsible for education and schools, including mental health programmes in schools. Despite this decentralised responsibility the national government, including the Department of Health, are still taking particular steps to support mental health programmes in schools in some countries. In New Zealand, schools are self-governing and choose the tools, resources and programmes that suit their needs. There are however a number of mental well-being programmes available for schools to uptake if they choose to do so, such as Sparklers, a well-being toolkit especially designed for classroom use with nearly 100 activities designed by child behavioural experts to support students with learning about their mental health and well-being (OECD, 2020[41]).

In Australia, the Australian Government also funds the Mental Health in Education Initiative, known as BeYou. BeYou is a national initiative supporting mental health promotion and prevention activities across education settings, ranging from early childhood learning through to secondary schools. BeYou seeks to ensure educators develop valuable mental health skills and knowledge, while also providing a model for implementing a whole-learning community approach to mental health and well-being. In addition, while states and territories are responsible under the Australian Constitution for school education, the Australian Government plays an important role in providing national leadership across important policy areas. The Australian Government’s Student Well-being Hub at www.studentwellbeing.edu.au provides a range of freely available information and resources for educators, students and parents to assist them to create and maintain a safe and supportive school environment (OECD, 2020[41]).

In Canada, where again mental health education and awareness programmes in schools are region specific, a range of different mental health programmes located in schools have been developed in different regions. Many of these efforts go beyond well-being education, and focus on providing mental health support directly to students. For example, Prince Edward Island has established Student Well-being Teams to cover all public schools in both official languages, giving students access to a team of mental health care professionals that are also able to provide social services supports, while British Columbia has established 24/7 mental health support for post-secondary students throughout the province. These services will include counselling and referral services to ensure students receive immediate, on-demand services or are able to be referred as appropriate (OECD, 2020[41]).

In Mexico, the Ministry of Public Education will create content in the curriculum that encourages and promotes healthy lifestyles, as well as health education, in the 2020-21 school cycle. A new school subject, ‘Healthy Life’ has been developed for preschool, elementary, middle, and high school students, and will also engage teachers and parents, and will include the promotion of mental health. This approach also promotes the implementation of a system of counselling and support for distance learning, to promote communication between teachers and students, in addition to the development of online seminars on socioemotional skills, as well as socioemotional resources using digital platforms.

Finland stands out as an OECD country that has not only implemented a significant evidence-based programme to support students’ socioemotional well-being in school across age groups (see Box 5.2), but has also made mental health a key part of the educational system’s objectives. Finland has a strong legal framework around school health and welfare, which has included embedding teams of health and welfare professionals in schools since 1966 (Coburn, 2019[72]). Further legislative changes were introduced in the early 2010s, strengthening efforts to identify children with social or emotional difficulties, and referring them to assessment and support either within or outside the school (ibid).

Do OECD workplaces foster good mental health?

Workplaces can be good, or bad, for mental health

Being in work has been shown to be good for mental health; non-employment generally is worse for mental health than working (OECD, 2008[73]; OECD, 2015[17]). A 2008 review of five countries found that mental health suffers when individuals move from employment to unemployment or inactivity, and non-employment is detrimental for mental health, and that individuals’ mental health tends to improve when they move from unemployment into having a job (OECD, 2008[73]); a 2016 systematic meta-review found that available evidence points to employment being good for employees’ well-being (Modini et al., 2016[74]).

At the same time, poor workplace environments can constitute a risk to mental health, and low-quality jobs or ‘non-standard’ jobs seem to have a weaker association with positive mental health for employees (OECD, 2008[73]). Previous OECD work (OECD, 2012[75]) has set out the multidirectional relationship between the work environment, and mental ill- health; job-related strain and a poor psychosocial work environment can cause mental ill-health; workers with mental health problems tend to work in lower-quality jobs and poorer work environments; and workers with mental health problems perceive their work situation more negatively because of their condition.

To support individuals to be in employment, and stay in employment, efforts are needed to ensure that workplaces don’t constitute a threat to employees’ well-being, and also contribute to improving mental health. The importance of implementing appropriate policies for workplace mental health promotion are underscored in the OECD Recommendation on Integrated Mental Health, Skills and Work Policy, which specifically requires that OECD countries – who are all Adherents to the Recommendation – “promote and enforce psychosocial risk assessment and risk prevention in the workplace”, “develop a strategy for addressing the stigma, discrimination and misconceptions faced by many workers living with mental health conditions at their workplace”, and “…[develop] guidelines for line managers, human resource professionals and worker representatives to stimulate a better response to workers’ mental health conditions” (OECD, 2015[76]).

Some countries have been focusing on reducing mental health risks in workplaces

OECD countries have been using workplace safety legislation to include provisions to protect employees’ mental health. Multiple countries, including Austria, Belgium, Finland, France, Norway, and the Netherlands, use labour legislation to require employees to reduce psychosocial workplace risks (OECD/European Union, 2020[1]).

In the follow-up to the implementation of the OECD Recommendation on Integrated Mental Health, Skills and Work Policy, several countries including Canada and Japan were found to have made recent amendments to labour regulations to add or strengthen provisions making it clear that employers had a responsibility for their employees’ mental health, as well as their physical safety, in the workplace (OECD, forthcoming[77]). In the EU-Compass for Action on Mental Health and Well-being, the 2017 focus was on mental health in school and work. As part of this activity, 70% of EU members states reported that addressing mental health in the workplace was a priority in policy or strategy documents, and more than half of countries had introduced programmes or policies to address mental health in the workplace (EU Compass for Action on Mental Health and Well-Being, 2017[78]).

Psychosocial risk assessment is a tool in place in a few countries, including Japan which has a mandatory ‘stress check’ for employees. In order to prevent mental health illnesses and reduce their burden in the Japanese labour force, and to encourage improved working conditions, employers with more than 50 employees are obliged to evaluate the stress level of workers (stress check) once a year (OECD, 2019[79]). This initiative was first introduced by the National Federation of Industrial Health Organization in Japan to its affiliated employers, and the central government then implemented this initiative nationwide in 2015. This stress test measures employees’ mental health through an online questionnaire which was developed based on the questionnaire designed by the National Institute of Occupational Safety and Health in the United States. It aims to make employees aware of their stress level so that they can try to prevent developing mental health problems, and also aims to promote changing the work environment based on stress check results.

In 2020, OECD (forthcoming[77]) pointed to Canada and the United Kingdom as taking a broader approach to workplace mental health than most countries, focusing on both reducing psychosocial risks, and promoting good mental health in workplaces. In the United Kingdom, the government along with other key actors such as employers’ associations, introduced a set of ‘Core Standards’, or ‘Management Standards, for employers. The Health and Safety Executive has developed a set of guidelines including risk identification, evaluation, monitoring and review, and actions, to reduce work-related stress. These standards cover a range of dimensions of workplace stress, including demand (workload, patterns, the working environment), how much control over their work an employee has and how much support they’re given, workplace relationships, and managing change. Canada also introduced a National Standard for Psychological Health and Safety in 2013, giving guidelines for employees on creating a healthy and safe working environment.

Workplace programmes can build mental health literacy, reduce stigma, build mental resilience, and direct people towards appropriate support

Promotion and prevention activities in workplaces do not just need to focus on reducing psychological risks and stress in the workplace. Workplace programmes can also proactively build mental health literacy, reduce stigma, build mental resilience, and direct people towards appropriate support.

Several workplace-based programmes have been found to be effective at improving mental health literacy, and reducing stigma, including the Mental Health First Aid programme (see Chapter 4), and some workplace programmes have been specifically tailored for certain professional groups. For example, ‘Beyond Silence’ in Ontario, Canada, is a two day course led by trained peer educators to support the mental health of health care workers (Beyond Silence, 2021[80]). The programme has also been expanded to a smartphone app, which gives information and support for managing mental health at work, and gives the option of a direct link to a peer support worker. An evaluation of the Beyond Silence programme found that while this programme – like many mental health literacy programmes – did not directly lead to an increase in help-seeking behaviours, it did improve increase mental health literacy, improve attitudes towards seeking mental health treatment, and was linked to sustained decreases in stigmatised beliefs (Moll et al., 2018[81]).

Some countries have programmes to reduce mental health stigma, and/or improve mental health literacy in workplaces, some of which are based on general awareness campaigns, and others on training for employees or employers. In Lithuania, legislation prohibiting certain jobs due to mental illness is currently under review, and in 2019 the Minister of Health established an order by which public health bureaus should organise trainings (40 hours in-length) in companies for employees and employers focusing on strengthening their mental health competences. During the trainings participants also acquire knowledge and practical skills on reducing psychosocial risks and work-related stress (OECD, 2020[41]).

Australia has taken steps to promote mentally healthy workplaces through the Mentally Healthy Workplace Alliance, which was established by the National Mental Health Commission; members include key representatives from business, union, government, workplace health and mental health sectors (The Mentally Healthy Workplace Alliance, 2018[82]; National Mental Health Commission, 2021[83]). The Mentally Healthy Workplace Alliance supports businesses through information and resources to encourage practical steps to strengthen mental health support in the workplace. The Australian Federal Government has supported the work of the Mentally Healthy Workplace Alliance with USD 11.5 million over four years provided in the 2019-20 Federal Budget for the National Workplace Initiative. This project will lead a nationally consistent approach to mentally healthy work and workplaces (Mentally Healthy Workplace Alliance, 2020[84]).

There is also clear scope for businesses and companies to take proactive steps to promote mental health in their workplaces, going beyond national guidelines or regulations. The American Psychiatric Association (American Psychiatric Association, 2017[85]) has pointed to the positive experience of several large employers, specifically the companies Garmin, HealthPartners and Unilever, which implemented company-wide mental health resilience programmes with positive effectives. These companies various used health behavioural assessments, emotional resilience coaching, health promotion programmes and brochures, training to managers and executives, and communication and education campaigns tailored to the specific workforce.

Can front line actors recognise and respond to mental distress, to connect individuals to appropriate services?

This sub-principle is directly linked to the sub-principle ‘Enable front line actors to connect individuals to appropriate services’ included in Chapter 4. An integrated and multi-sectoral approach to mental health. Equipping front line actors with the information and skills to identify and respond to mental distress are intrinsically linked, and important as part of both an integrated and multi-sectoral approach to mental health, and to good promotion and prevention practices. To maintain this link, the discussion of mental health knowledge, skills and ability to connect individuals to appropriate services has been brought together in Chapter 4 of this report.

Do OECD countries make it easy for individuals to seek help?

Improving mental health literacy, and reducing stigma around mental ill-health, are expected to contribute towards increase help-seeking behaviour if individuals are experiencing mental distress (Bonabi et al., 2016[86]; Henderson, Evans-Lacko and Thornicroft, 2013[87]; Schnyder et al., 2017[88]). If more people know where to go to seek help – be that low-threshold support such as mental health information, guidance, or self-help, or more intensive support from a trained professional – it should eventually mean that more people get help recovering from, or managing, mental health conditions when they occur. Along with stigma (including self-stigma), barriers to accessing mental health care can be financial or due to long wait times for services (see Chapter 3), and can also be related to lack of knowledge on where to seek help, or a shortage of available mental health support. For example, a 2017 study in the United Kingdom found that 35% of young adults experiencing emotional or mental health difficulties did not seek any formal or informal help, with stigma, or mental health literacy and a preference for self-reliance significant barriers to seeking help (Mitchell, McMillan and Hagan, 2017[89]).

Making services easily accessible can be one way of encouraging help-seeking for mental health needs. Amongst OECD countries, 26 reported that at least some services were accessible without previous referral (Figure 5.7).

Figure 5.7. Mental health that can be accessed directly, without referral

Many countries have online information, or phone lines, which can be accessed directly without referral, including Ireland, Lithuania, Slovenia, Portugal, Norway, Canada and New Zealand. In Ireland this includes the website ‘yourmentalhealth.ie’ and a signposting mental health telephone number, and Lithuania has a ‘hope line’, a women’s support line, and various other telephone support lines, and New Zealand has a range of web-based information and resources can be accessed directly. In addition, mental health and well-being telehealth services are available free of charge to all New Zealanders, including specific lines for youth, Māori, depression, alcohol and other drugs, gambling, and more. Portugal has both national and regional phone hotlines, as well as several websites giving information about how to access to services.

In England, a range of mental health advice and information is available online, including the NHS Apps library which includes apps for mental health which gives guidance on app-based mental health support tools that have been assessed to be effective for a range of different conditions or concerns (see also Chapter 7). In Canada, the Wellness Together Canada (WTC) online portal provides short-term mental health and substance use supports and services to Canadians, including access to immediate crisis support by phone. The WTC also includes a link to the Kids Help Phone web page, which provides resources for youth, including immediate access to counselling by phone/text/live chat. Another resource available to Canadians living in Ontario is a library hosted by the Centre for Addiction and Mental Health (CAMH). It provides access to a wide range of hard-copy and digital books, journals, research reports, government documents and videos relating to mental health and addictions. The broader CAMH website includes information on mental health and addictions that is accessible to all Canadians.

Amongst services that can be accessed without referral, all but one country (Portugal) reported that some self-referral directly into services was possible. However, self-referral tends not to be possible across all services. Several countries make self-referral possible for telephone services and/or online services. In Australia services that can be accessed directly include a wide range of telephone and online mental health services run by non-government organisations, funded by the Australian Government, which can be accessed directly or via the Government’s gateway to digital mental health services, Head to Health. This includes MindSpot, the Australian Government’s virtual clinic, a free service for Australian adults who are experiencing difficulties with anxiety, stress, depression and low mood, which provides assessment and treatment courses, and also helps clients find local services that can help. In Norway, many municipalities also offer digital courses and self-help programmes. The government has initiated a project to develop a digital tool treating milder forms of anxiety, depression and sleep issues – all municipalities should be able to use this tool when the project is finished.

In England, people may self-refer to some mental health services such as talking therapies through the ‘Increasing Access to Psychological Therapies’ (IAPT) programme. In Ireland, a number of voluntary agencies to provide services that are accessible without referral, including ‘Jigsaw’ and ‘Turn2Meonline’ counselling which are both for 12-25 year-olds. In Iceland, too, there are different NGOs that provide mental health support/counselling which can be accessed directly.

When it comes to accessing specialist mental health care, gatekeeping and referral pathways differ between countries. In Lithuania and Turkey, some specialist mental health care can be accessed without referral, including primary-level mental health centres in Lithuania, and primary, secondary and tertiary level services in Turkey. Additionally, in most countries some mental health services, notably psychological services such as psychological therapies delivered by a counsellor or a psychologist, can be accessed directly with out-of-pocket payment.

Strengthening prevention and promotion in mental health

An comprehensive approach to suicide prevention and harm reduction can reduce can reduce deaths by suicide

Most OECD countries have long had suicide prevention plans, either as stand-alone strategies, or as a key part of their mental health plans and policies (Hewlett and Moran, 2014[68]). A comprehensive approach to suicide prevention – which takes stock of the drivers of deaths by suicide, and their different distribution across population groups – is needed. A range of measures are recognised as effective in reducing suicide, including restricting access to lethal means, raising awareness of suicide and suicide risk, signposting to sources of help and protective measures in suicide “hotspots“ (Zalsman et al., 2016[90]), as well as improving access to mental health treatment, and tailored efforts to reduce suicide following hospitalisation, for example psychosocial assessment and good follow-up care (Hawton et al., 2016[91]).

While suicide should not be considered a proxy for mental illness, and mental ill-health is not the sole driver of suicide rates, many of the steps that can be taken to strengthen population mental well-being, capacity to seek appropriate help, and receive care when needed can also contribute towards broader suicide reduction. A comprehensive strategy to reduce suicide should be tailored to the national context – and start by identifying risk and protective factors – and then built out to include interventions that will work to respond to the specific problems identified (Figure 5.8).

Figure 5.8. A comprehensive approach to preventing suicide

Many OECD countries have either suicide prevention plans, or a suicide-prevention focus in their strategic mental health plans. These plans can also be a way to focus on the particular risks of suicide, and policy needs, of key vulnerable groups, as has been the case in Finland and New Zealand (Box 5.1).

Box 5.1. Taking account of key populations’ suicide risks in suicide prevention strategies – Finland and New Zealand

Finland

In Finland, the rate of suicide has fallen by over 50% over the past 30 years, in particular amongst young men aged 20-29. Suicide prevention campaigns in Finland began in the 1980s, and led to a series of national suicide prevention programmes that ran during the 1990s. Finland’s strategy identified depression, access to mental health care, substance and alcohol abuse, and access to lethal means as central features. Recognition that suicide was particularly high amongst young men led to the development of the “Time Out! Back on the track” (Aikalisä! Elämä raitelleen) initiative in 2004, which promoted social inclusion amongst vulnerable men. Two-thirds of participants reported that the participation in the programme was worthwhile, while about 60% considered it had improved their life situation.

In more recent years, Finland has moved towards integrating suicide prevention as part of its broader mental health policy planning, rather than having a stand-alone strategy. At the end of 2017, the Finnish Parliament allocated EUR 300 000 in 2018 to develop a new national strategy to prevent suicide, which will be included in Finland’s National Mental Health Strategy. This work will establish a network for co-ordinating suicide prevention, and improve the planning, implementation, monitoring and evaluation of suicide prevention measures.

New Zealand

In New Zealand, the ‘Every Life Matters – He Tapu te Oranga o ia Tangata: Suicide Prevention Strategy 2019-2029’, and the ‘Suicide Prevention Action Plan 2019-24 for Aotearoa New Zealand’ was published in 2019, which give a framework and targets for suicide prevention over the following ten years. The framework consists of:

a vision, setting the long-term aspiration for the strategy and suicide prevention in Aotearoa New Zealand
outcomes sought through the strategy to support the vision
focus areas, which describe actions needed to support the vision
collective ownership and shared ways of working that must underpin delivery of the vision.

A national Suicide Prevention Office was also established in New Zealand from November 2019. The Suicide Prevention Office is part of wider work to improve all aspects of mental health and well-being for people in New Zealand, in line with the direction set out in He Tapu te Oranga. To support He Tapu te Oranga and efforts to prevent suicide in New Zealand, the government allocated NZD 40 million over four years to a package of suicide prevention initiatives through Budget 2019.

In New Zealand, ensuring that Māori populations benefit fully from mental health policies and practices is a priority, and the same is true when it comes to suicide prevention. Lived experience and Māori advisory functions have also been established to support the work of the Suicide Prevention Office. The funding package for suicide prevention includes a NZD 12 million Māori and Pacific suicide prevention community fund, which will be used to support Māori and Pacific providers to design and deliver culturally responsive suicide prevention initiatives.

Source: OECD (2020[41]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires, OECD/European Union (2020[1]), Health at a Glance: Europe 2018: State of Health in the EU Cycle, https://doi.org/10.1787/health_glance_eur-2018-en.

Building good mental health for children and young people represents good value-for-money

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[108]). 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[4]). Interventions to promote good mental-health and prevent mental ill-health are most effective in infancy, childhood, and adolescence (McDaid, Hewlett and Park, 2017[4]; Patel et al., 2018[108]; Knapp, McDaid and Parsonage, 2011[109]). Interventions targeting children and young people, including universal programmes for example in schools, have also been found to demonstrate good return-on-investment in cost-effectiveness evaluations

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[110]). France, meanwhile, has included the development of mindfulness in schools as part of its National Strategy for mental health and psychiatry. A number of programmes have shown transferability across multiple countries, and/or have had a longstanding positive impact in school settings (Box 5.2).

Box 5.2. Evidence-based mental health promotion and prevention programmes in schools

Zippy’s Friends

Zippy’s Friends is a social and emotional learning programme for children around age 5-12 which is in place in around 30 countries, including Chile, the Czech Republic, Denmark, Ireland, Lithuania, the Netherlands, Norway, Poland, the Slovak Republic and the United Kingdom. Zippy’s Friends is a universal school-based programme, aiming to teach coping and emotional skills to children of all ages. The programme consists of a series of stories across 24 sessions, with modules covering feelings, communication, friendship, conflict, change and loss, and moving forwards. The programme helps children develop positive strategies to deal with problems, using learning approaches such as story telling, discussion, games, role-play and drawing (Partnership for Children, 2021[111]; European Commission - Employment, 2019[112]).

Multiple evaluations have found that Zippy’s Friends has a positive impact on children’s mental well-being. An evaluation in Norway found that the programme helped to improve the classroom atmosphere, reduce bullying, and improve academic scores (Holen et al., 2013[113]). An evaluation in Ireland also found that the programme had a positive impact on children’s coping skills, and that teachers reported that the programme had a positive effect in terms of raising their awareness about children’s emotional well-being (Clarke, Bunting and Barry, 2014[114]; Clarke and Barry, 2010[115])

KiVa anti-bullying programme

The KiVa anti-bullying programme began in Finland and uses online and in-person lessons for all students mainly focusing on bullying, as well as targetted actions for children and adolescents who have been involved in bullying as either perpetrators or victims. KiVa is a whole-school programme, with actions accessible for children age 7 to 15 years. KiVa has also been piloted in other OECD countries, including a pilot study in 3 schools in England and 14 schools in Wales, and pilots in Estonia and Italy, that have demonstrated the feasibility of implementation across countries (McDaid, Hewlett and Park, 2017[4]). In Finland, evaluations of both a randomised control trial (2007-09) and nationwide rollout (since 2009) have found positive impacts on children, including reduced bullying, increased empathy and self-efficacy to support victimised peers, and more positive feelings towards school (Salmivalli and Poskiparta, 2013[116]). The rollout in Finland has been across all schools – as of 2013 90% of Finnish comprehensive schools were using the programme – but the biggest impacts have been found for primary school age children (ibid). A range of evaluations, including in Finland and the United States, have also suggested positive changes in levels of anxiety and depression following the introduction of the programme (Williford et al., 2012[117])

KiVa was also recently introduced in 7 schools in New Zealand, and a year after implementation significant positive impacts across the 1 175 students surveyed were reported; positive impacts included reductions in self-reported rates of bulling and victimisation, and an increase in the number of children feeling safer at school (Green et al., 2020[118]).

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[119]; Orpana et al., 2016[120]; Public Health Agency of Canada, 2017[121]). Canada also has further mental health indicators that are collected nationally and/or at state level, tracking indicators including service use, quality and safety, emergency room visits, wait times and referrals (CIHI, 2019[122]).

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 NZD 445 million for mental health services, NZD 40 million for suicide prevention, and commitments to put more nurses in secondary schools, tackle homelessness, and spend NZD 320 million addressing family and sexual violence.

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 every 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 (see also Chapter 3, Chapter 7).

Phone and online mental support service are available for the general population in at least 20 OECD countries, including Australia, Austria, Canada, Chile, Costa Rica, the Czech Republic, France, Greece, Japan, Luxembourg, New Zealand, Portugal, Slovenia, the United States and the United Kingdom which have issued specific mental health guidance, set up support phone lines, or online platforms (OECD, 2020[123]). In Australia, the government has announced more than AUD 500 million in funding direct supports to respond to the mental health impacts of the COVID-19 pandemic.

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. France has also strengthened its National Strategy for Mental Health and Psychiatry with a number of key structural changes, including reimbursement of psychological therapies for children, students and adults, strengthening of emergency psychological support systems and offering treatment for psycho-trauma, the creation of a a national suicide prevention number and a range of targeted support for key vulnerable populations. 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[124]).

From the first weeks of the pandemic, Canada has 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. 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. As of 12 April 2021, over 1.1 million individuals across all Canadian provinces and territories had accessed the Wellness Together Canada (WTC) portal with 45% of registered users are under age 30. To date, the Government of Canada has invested USD 68 million in the WTC portal. Overall, through the 2021 Budget, the Government of Canada allocated an additional CAN 62 million for the portal so it can continue to support Canadians through 2021-22.

In April 2020, the Canadian Institutes of Health Research (CIHR) also launched the COVID-19 and Mental Health Initiative, in close collaboration with Health Canada, the Public Health Agency of Canada and others, to provide evidence to decision makers and practitioners on mental health and substance use responses in the context of COVID-19. To date, CIHR has launched three funding opportunities under this initiative, supporting a total of 101 projects for a total investment of CAN 13.5M from CIHR and partners.

Promoting strategies for mental health self-care – exercise, mindfulness, social connection

Not all mental health promotion, or illness prevention, has to be delivered by governments or specialist service providers. There are many steps that individuals can take to maintain or improve their own mental health, and OECD countries can take steps to point people towards effective self-care strategies for mental health. Indeed, not all mental distress requires specialist intervention, and some mental distress or mild mental health conditions can be managed by people on their own – often with support from their families or peers – if they have some key knowledge and tools. During the COVID-19 crisis, when mental distress increased across the population, individuals may not all need formal mental health support, but can still benefit from conscious steps to stay in good mental health.

There are some evidence-based ways to strengthen mental well-being which are highly accessible. Chief amongst them are exercise, and mindfulness, and social connection (Box 5.3). Guided self-help can also be a way for individuals to manage their own mental health, including both self-help books, as well as – increasingly – self-help apps. Apps, websites and books can include both tips and tools for managing moments of mental distress, symptoms of mental health conditions, or behaviours that might support mental well-being such as good sleep habits or eating habits (for more on mental health apps, see Chapter 7). For example, the Czech Republic has developed and launched a website (in Czech, English and Russian) through which people can: screen themselves for mental health problems; find evidence-based information on how to obtain and maintain a good mental health; and seek help if they need it (samopomo.ch, 2021[125]; Duševní zdraví, 2021[126]; My Mental Health Guide, 2021[127]).

Box 5.3. Social connection, exercise, and mindfulness – strategies for staying mentally healthy

Social connection

Strong social relationships, and social connectedness, have a positive impact on mental health; inversely, social disconnectedness and loneliness have a negative impact on mental health, and can increase the risk and/or severity of mental health conditions such as depression and anxiety (Newman and Zainal, 2020[128]; Saeri et al., 2018[129]). A longitudinal study using the New Zealand Attitudes and Values Survey looking at the bidirectional relationship between social connectedness and mental health concluded that “psychological resources conferred by social connectedness can act as a ‘social cure’ for psychological ill-health” (Saeri et al., 2018[129]). During the COVID-19 crisis, social distancing requirements made social connection more difficult across OECD populations; during this period, governments, international agencies such as the WHO, and non-government mental health agencies across OECD countries provided tips for staying mentally healthy and consistently included ‘connection with others’ as one key tip. People were encouraged to find ways of connecting, for example talking on the phone, connecting online, or spending time together outside, in a way that was safe and consistent with local COVID-19 guidelines (OECD Brief on Mental Health and COVID-19, forthcoming).

Exercise

Exercise has been established to have a significant positive effect on mental health, both boosting positive mental health and helping improve the symptoms of mental health conditions such as depression. Exercise can contribute to improved mood, improved self-esteem, lower stress levels, and lower levels of anxiety (Mikkelsen et al., 2017[130]; NHS, 2018[131]). In the United Kingdom, the NICE clinical guideline on mild-to-moderate depression includes a physical activity programme as one of three initial treatments (along with a self-help programme, and computerised cognitive behavioural therapy) based on best available evidence of effective interventions (NICE, 2009[132])

Mindfulness and mindfulness meditation

Mindfulness, or mindfulness meditation, is a type of meditation which tends to encourage focus on the present moment, and practicing being aware of thoughts, feelings and sensations without judgement. Mindfulness can be practiced in different ways, but might include focus on the breath, step-by-step awareness of the physical body, or a walking mediation paying particular attention to physical sensations and surroundings. Mindfulness exercises can be self-led, or followed guided tools such as audio supports. Other practices, such as yoga, tai chi, and qigong, can also bring some of the benefits of mindful meditation. Practicing mindfulness has been found to have benefits including reduced stress, less ruminative thoughts, improved focus, less emotional reactivity; mindfulness has been found in some studies to have benefits for persons living with mental health conditions including anxiety and depression (American Psychological Association, 2012[133]; Gu et al., 2015[134]; Goldberg et al., 2018[135]; Hofmann and Gómez, 2017[136]). App-based mindfulness support has been growing in population, and a number of studies suggest that for healthy adults regular app-based mindful meditation can improve psychosocial well-being (Bostock et al., 2019[137]; Economides et al., 2018[138]; Champion, Economides and Chandler, 2018[139]; Headspace, 2021[140]). Mindfulness can also be practiced in school or work settings; for example, in Estonia mindfulness-based programme ‘Minutes of Silence’ has been introduced in 100 schools as basic training, individual teachers have knowledge and skills of the technique in a further 300 schools (OECD, 2020[41]).

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