Building Mental Health Policies into All Policies

It’s time our leaders stop treating mental health in a vacuum. It’s time to think about mental health in all the policies we build for the future.

By Sandrine Desforges

Even though the COVID-19 pandemic has shone a bright light on the alarming state of mental health around the world, the current global mental health crisis is far from new and has only been exacerbated in recent years. Yet, not one country seems to have found its remedy.

Analyses of the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) show that the prevalence of mental health disorders increased 48.1% between 1990 and 2019. While 25% of the population will be afflicted by a mental health condition at some point in their lives, the treatment gap remains upsettingly high. Globally, an average of 70% of people who need to receive treatment for a mental health condition do not have access to it, either from a lack of resources and trained health-care providers or stigma. This percentage is even higher within low- and middle-income countries. Mental health disorders have also risen from being the 13th leading cause of disability in 1990 to the 7th in 2019, and the World Health Organization (WHO) predicts that unipolar depression will become the leading cause of the global burden of disease by 2030.

In addition to the clear human cost of this global mental health crisis, there are substantial monetary costs to leaving it untreated. Estimations show that the cumulative global economic output loss related to mental health disorders will amount to $16.3 trillion between 2011 and 2030. The global financial burden of mental health conditions already surpasses those of cancer, chronic respiratory diseases, and diabetes.

Yet, despite numerous studies and reports highlighting the increasing prevalence of this crisis and making a case for urgent action, governments and non-state actors around the world continue to make the same flagrant mistake: addressing mental health as if it was produced in a vacuum.

The WHO defines mental health as

“a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in […] mental health is more than the absence of mental disorders.”

Based on this definition, it is rather obvious that mental health is dependent on various cognitive, emotional, and social skills that go beyond the scope of the health sector. The socioecological model effectively helps us understand how individual, interpersonal, organizational/institutional, cultural, political, societal, and even historical factors all come into play to determine one’s state of mental health and well-being. Therefore, effectively addressing mental health requires a whole-of-society approach: mental health considerations must be embedded into all sectors and policies that influence and regulate how people live their lives.

Figure I: Socio-Ecological Model for Mental Health and Well-Being (University of Minnesota’s School of Public Health, adapted from Dr. Bronfenbrenner’s original model)

For example, various policy areas can contribute to promoting protective factors for mental health and well-being, such as early child development, education, personal safety, protection of human rights, employment, access to housing, promotion of active lifestyles, and access to natural landscapes. Adversely, various types of inequalities, as well as precarious conditions (e.g. immigration challenges, employment or housing issues, racism, social exclusion, and abuse), can represent risk factors that can lead to the development of mental health challenges.

This is why the Organization for Economic Co-Operation and Development (OECD), in its 2015 Recommendation of the Council on Integrated Mental Health, Skills and Work Policy, set out policy guidelines and principles for a whole-of-government approach. Whilst non-binding, this OECD recommendation has been adhered to by the 38 OECD member countries. In 2017, the Mental Health in All Policies report by the European Union (EU) Joint Action for Mental Health and Well-Being again emphasized the importance of adopting a Mental-Health-in-All-Policies (MHiAP) approach to meaningfully tackle the ongoing mental health crisis.

Walking the Talk

A MHiAP approach would seek to promote mental health and well-being by expanding the scope of the efforts dedicated to improving population mental health to all policies – including non-health public policy areas – and increase the accountability of policy-makers for mental health impact at all administrative levels. Similar to a Health-in-All-Policies approach, a MHiAP would require all sectors to take into account the potential mental health implications of all decisions, with the goal that acting on these determinants will shift the need from late and costly interventions towards prevention of mental health disorders and an overall improved population mental health and well-being.

In its 2001 report Mental health: New understanding, new hope, the WHO had already put forward the role of non-health sectors – such as education, labor, welfare, law and non-governmental organizations – in improving the mental health of communities and had recommended the adoption of an intersectoral approach to effectively take an attempt at improving global mental health.

Over two decades later, why do these synergies remain lacking? 

It is more than time for the walk to follow the talk, especially for the 38 OECD adherents to the Recommendation of the Council on Integrated Mental Health, Skills and Work Policy. 

The Case for MHiAP

Incorporating MHiAP would require governments to include mental health in all health impact assessments or develop a stand-alone mental health impact assessment that could be used at all levels of government and governance. Following implementation, assessments of mental health impact of policy interventions and equity should also be conducted.

Successfully achieving a MHiAP approach would also require capacity building efforts. Firstly, there is a clear need to build literacy and understanding of mental health determinants amongst civil servants and decision-makers in all policy fields, across governments so they are better informed of how their work can potentially contribute to, or hinder, population mental health. A whole-of-government approach would also benefit from additional research on the correlation between non-health policy interventions and population mental health and well-being. A cross-sectoral coordination group to ensure conduction of assessments, as well as effectively share resources and tools between sectors could also contribute to achieving maximum impact.

While an MHiAP approach would hopefully yield increases in the overall mental health and well-being of the population, advantages to this approach are not limited to these improvements. A better understanding across government of the role mental health plays in general health – as well as overall stigma reduction – are to be expected. In addition, MHiAP has mutual benefits for many other sectors that also represent priorities for many governments across the globe, such as preventing suffering and increasing the general health of the population as well as life expectancy; reducing the economic burden on health systems; making available healthier and stronger workforces; and investing in a population that will then be able to invest back in the country’s economy. Systematically including mental health in all policy sectors, at all levels of government, is also extremely cost-effective, as it addresses the root causes of mental health concerns where they are created.

MHiAP in Practice

State-based models may serve as an example for how we can incorporate MHiAP on an international scale. In 2018, Slovenia’s national assembly adopted its National Mental Health Program 2018-2028, which clearly enunciates MHiAP as a core principle. Meanwhile, Finland’s National Mental Health Strategy 2020-2030 states mental health as a right that should be protected for all, and associates it with multiple other rights such as the rights to housing, studies, work, subsistence and social inclusion; the right to decide what things support coping with daily life and receiving support in line with these; the right to good and effective care when necessary; and the right of not being discriminated against. The Norwegian Public Health Act evokes mental health as a component of public health and recognizes that public health must be taken into consideration when forming initiatives and strategies in all sectors of society, not only health-related sectors. The Act acknowledges that “only by integrating health and its social determinants as an aspect of all social and welfare development through intersectoral action, can good and equitable public health be achieved.” Other examples include Austria’s health targets, which are based on the health-in-all-policies approach and include mental health targets. The 2017 EU Joint Action for Mental Health and Well-Being report also shares examples of good practices for incorporating mental health in education and labor policies.

Whilst quite simple to grasp as a concept, MHiAP continues to face many systematic barriers to its implementation, such as a lack of prioritization and incentives, a limited understanding of the concept of mental health, and a difficulty to implement cross-sectoral monitoring and collaboration and lack of coordination.

Despite some encouraging progress in recent years, it appears that until governments perceive the current mental health crisis for what it truly is – a crisis – achieving systemic change at the global level will continue to be an uphill battle.

Sandrine Desforges (she/her) is a Master of Public Policy candidate and McCall MacBain Scholar at the Max Bell School of Public Policy, McGill University. Passionate about mental health and well-being, she has experience working on post-secondary mental health at the Mental Health Commission of Canada and elaborating the National Standard on Mental Health and Well-Being for Post-Secondary Students. She also nourishes interest in educational policies and social policies, such as prevention of gender-based violence. She can be found on Twitter at @SandrineDforges.