A New Benchmark for Mental Health Systems

A multi-sectoral, integrated approach to mental health care means making mental health a priority in sectors beyond the mental health system – including the physical health system, and in education, employment, and societal settings and policies. Such an approach also means making sure that an integrated perspective is included within the mental health system, for example prioritising employment and education outcomes, and making meaningful links across sectors. As of 2019‑20, five years after the introduction of the OECD Recommendation on Integrated Mental Health, Skills and Work Policy, the importance of a multi-sectoral, integrated approach to mental health performance is well-accepted amongst OECD countries. Cross-government approaches to mental health are growing increasingly common, in particular in mental health strategies which regularly set out the importance of engaging actors beyond the specialist mental health system in efforts to promote good mental health, and reduce the burden of mental ill-health. This approach is also an economic necessity; the majority of the economic costs of mental ill-health are not driven by spending on care or treatment, and fall outside of the health system in spending on social security programmes, including paid sick leave benefits, disability benefits and unemployment insurance benefits.

However, this chapter – and the OECD Report Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation (OECD, forthcoming[1]) – find that more could still be done to strengthen the multi-sectoral policies, and above all working practices, when it comes to mental health. The employment and education outcomes of people with mental health conditions remain significantly poorer than the general population, and both the inclusion of employment and education outcomes as a goal of mental health services, and the integration of mental health support into social protection services, are ad-hoc at best. More systematic cross-sectoral mental health policy, and an integrated approach at the service‑delivery level, is now even more critical in light of the COVID‑19 crisis. Since the start of the COVID‑19 crisis, the growing burden of mental ill-health has weighed disproportionately on populations with a lower socio-economic status, people experiencing unemployment, and young people. In responding to the crisis, an integrated response that includes mental health support, should be prioritised.

Good performance in mental health is not only the responsibility of medical staff in hospitals and clinics, but rather must include a wide range of actors and sectors including teachers and schools, line managers and workplaces, as well as other community actors. Additionally, ‘high performance’ of mental health systems must extend beyond symptom treatment.

Principle 3 of the OECD Mental Health Performance Framework sets out that a high performing mental health system ‘Takes an integrated, multi-sectoral approach to mental health’, and that an integrated, multi-sectoral approach should:

• Pursue a ‘mental health in all policies’ approach;

• Ensure physical health needs are met;

• Involve social protection systems that promote recovery and encourage return to work or education;

• Enable front line actors to connect individuals to appropriate services.

Across the past decade, OECD work has highlighted the importance of cross-sectoral, integrated mental health policy for delivering good outcomes for people with mental health conditions, and for supporting good mental health for all.

Mental ill-health affects people of all ages, socio-economic groups, ethnicities, and identities, and intersects with peoples’ ability to lead the lives they want – in work, in schools, at home. OECD work has highlighted, first, the significant burden of mental ill-health amongst working-age and youth populations (OECD, 2012[2]; OECD, 2015[3]). Young people with a mental health condition are 35% more likely to have repeated a grade at school, and to leave school early, and working-age adults are 20% less likely to be in employment if they have a mental health condition (OECD, 2015[3]).

At the same time, most people with a mental health condition are in-work. And, being in-work (or in school) has a positive impact on mental health status. Indeed, for young people measures to address mental health problems are more effective if they are put in place while students are still in school, while mental health support is more effective at helping people stay in employment than it is at helping people return to work after unemployment or sickness absence (OECD, 2015[3]; OECD, forthcoming[1]). Integrated policies across sectors – health, youth, labour, and social policy – help meet people where they are – in work, in school, in their communities – to provide mental health support, and help people experiencing mental ill-health to return to or stay in work or education, which helps improve and secure mental health outcomes. Integrated support also goes both ways, including both the integration of mental health awareness and/or practices in work places, schools, or social support services, as well as an employment- or education-focus in mental health services.

Integrated mental health policies could also go beyond the health, employment, education and social affairs or social benefits sectors. For example, good quality housing or environmental planning that promotes access to green spaces can have significant positive impacts on population mental health, just as poor or insecure housing or lived environments can have a negative impact on mental health, or make mental health conditions harder to manage (Mind, 2017[4]; European Parliament, 2020[5]).

OECD member countries have, since 2015, committed to recognising the importance of integrated mental health policy and taking steps to strengthen it, in their adherence to the Recommendation of the OECD Council on Integrated Mental Health, Skills and Work Policy (2015) (OECD, 2015[6]) (see Box 4.1). In 2019, a process to follow-up on the progress made by countries in implementing this Recommendation began, some of the findings for which are discussed later in this chapter.

The economic costs of mental ill-health are distributed across multiple sectors, which is further motivation for an integrated, multi-sectoral approach to mental health policy and practices.

The economic costs of mental ill-health can exceed 4% of GDP in European countries (OECD, 2012[2]; OECD/European Union, 2018[7]). However, the majority of the economic costs of mental ill-health are not driven by spending on care or treatment. Direct costs outside of the health system – spending in many social security programmes, including paid sick leave benefits, disability benefits and unemployment insurance benefits – and indirect costs related to reduced labour market participation and productivity are significant. In European countries in 2015 the costs of mental ill-health outside the health sector accounted for more than half of the total economic costs – EUR 194 billion – of mental ill-health: disability benefits accounted for EUR 112 billion (or 0.76% of GDP); paid sick leave benefits related to mental health problems accounted for EUR 28 billion (or 0.19% of GDP); unemployment insurance benefits accounted for EUR 29 billion (or 0.20% of GDP) (OECD/European Union, 2018[7]). Indirect costs due to lower employment rates for people with mental health problems and reduced productivity due to higher absenteeism and lower productivity at work account for over EUR 240 billion (or 1.6% of GDP) (ibid) (Figure 4.1).

A significant proportion of short and long term sickness absence or disability claimants have mental health conditions, especially long term disability recipients. For example, mental health conditions have accounted for 29% of all sickness compensation in Sweden, according to Swedish Social Insurance Agency data, from 2015 to 2019 (OECD, 2020[8]). In Iceland, 32.1% of recipients of invalidity pension and 38.8% of recipients of rehabilitation pension had a mental health condition in 2019, and in the Netherlands 32.7% of long term absenteeism is for a mental health condition in 2017. In Norway, 16.9% of sickness absences, 42.9% of recipients of Work Assessment Allowance, and 35.8% of disability benefit recipients had a mental health condition as the major cause in 2019. In England, 59.5% of Employment Support Allowance claimants, 50% of ESA Support Group, and 35.77% of Personal Independence Payment claimants had a mental and behavioural disorder, based on 2019 data. In other countries, the percentage of sickness absences or disability payments for mental health conditions is far lower, for example in Luxembourg where mental health conditions accounted for 5.1% of sickness benefit claims in 2018, or Slovenia where 6/7% of compensated sick leave days were for a mental health condition, and 2.1% of total sick leave compensation in 2018 (ibid).

A range of national estimates already suggest that the economic costs of mental ill-health are as high across all OECD countries as they are in the European countries. For example, in Japan, the total costs of depression have been estimated at USD 11 billion, schizophrenia at USD 23.8 billion, and anxiety disorders at USD 20.5 billion (Sado et al., 2013[9]; Sado et al., 2013[10]), while estimates for the costs of mental ill-health in Canada have ranged from CAN 48‑50 billion (Mental Health Commission of Canada, 2016[11]), to up to CAN 65.3 billion (Jacobs, Knoops and Lesage, 2017[12]).

Estimates from Australia suggest that the total costs of mental ill-health amount to 4% of GDP, 45% of which is indirect costs (OECD, 2015[13]; Australian Government - National Mental Health Commission, 2016[14]). Since these estimates were made, a report by the Australian Productivity Commission Inquiry on mental health has pointed to the quality of life and economic benefits that reforms to the mental health system can bring – including focusing on promotion and prevention, improving access to care and integration of services, and promoting recovery (Australian Government Productivity Commission, 2020[15]). This report suggested that such reforms could bring quality of life improvements valued at AUD 18 billion annually, and increased economic participation valued at AUD 1.3 billion; the report also found that about 90% of the reforms, equivalent to AUD 17 billion, could be delivered through a number priority reforms which would require spending of AUD 2.4 billion but also generate savings of up to AUD 1.2 billion per year (ibid).

Cross-sectoral mental health policy, and especially integrated mental health, employment, education and skills policy, is even more critical in light of the COVID‑19 crisis. Across most OECD countries, people with mental health problems struggle more with education, and are less likely to be in employment, than the general population (OECD, 2015[3]; OECD, 2012[2]).

Across all countries that are tracking population well-being across 2020 during the COVID‑19 crisis, mental health status amongst people who are experiencing unemployment, facing economic difficulties, and young people, has been markedly worse than the general population. Longitudinal evidence from France (Figure 4.2) shows that individuals in employment have been less likely to report symptoms of depression and anxiety than unemployed people. Across the OECD, job retention or short-time work schemes were introduced or adapted to protect jobs, as these scheme allow employees to keep their contracts with the employer even if their work is suspended (OECD, 2021[16]). It is not always clear whether the mental health of these population groups has worsened faster than the general population – and general population mental health has declined in 2020 compared to previous years – or if these gaps mostly reflect differences in mental health status that pre‑date the pandemic. At the same time as mental health status declined, there were significant disruptions to mental health support and services delivered in schools, workplaces, unemployment centres and other settings outside of specialist mental health care. Worldwide, 78% of countries reported at least partial disruptions to school programmes, and 75% to workplace mental health services (WHO, 2020[17]).

The COVID‑19 crisis underlines the importance of integrated mental health and somatic health care: all signs point to both possible lasting psychological impacts for COVID‑19 patients, especially those who experienced long hospitalisations or those living with ‘long COVID’, as well as increased risks of contracting COVID‑19 and experiencing complications for individuals living with severe mental illnesses. It was already clear that the health outcomes of people living with severe mental illness are significantly worse than the general population, in part due to increased risk of death by suicide, but also due to increased risk of cardiovascular disease, diabetes, and cancer (see Figure 4.2), and COVID‑19 comes as an additional health risk that must be managed.

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[19]; OECD, 2012[2]; OECD, 2015[3]).The COVID‑19 pandemic has further underlined how inter-sectoral mental health status is: the COVID‑19 crisis has been acknowledged as an international mental health crisis, with risk factors for short- and long-term mental health being common during the COVID‑19 pandemic, specifically driven by social restrictions, unemployment, financial instability and school closures are amongst the several factors contributing to a worsened mental health outcome (WHO, 2021[20]; OECD, 2021[18]). This crisis has highlighted that our mental health is impacted by much more than factors related to the mental health system and emphasises the need for a cross-governmental approach of promoting and caring for mental health.

Already before the COVID‑19 pandemic, a cross-governmental approach in mental health has been receiving increased attention. OECD Countries endorsed the OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy in 2015, and committed to pursuing mental health policies and interventions that are cross-sectoral in scope and complementary in nature (Box 4.1). The Sustainable Development Goals defined by the United Nations, which recognises mental health as a fundamental human right, apply a multi-sectoral approach to promoting and protecting mental well-being and require a broad interdisciplinary perspective on mental health systems (Patel et al., 2018[21]). In a response, in 2019 the WHO has called for a multi-sectoral action on treating mental ill health. In this action, they defined mental health as physical and mental health and well-being. The action approached social progress by objective indicators of physical and mental health, health equity and well-being, including the conditions in which people are born, live and work, and called for the whole of government work together to achieve these goals in health and well-being (WHO Europe, 2019[22]).

A need for more cross-governmental working is not only a priority for mental health systems, but also other fields of policy making such as public health in general (Jenkins, 2005[23]). Countries have been trying to break down silos and working together between ministries to develop intersectional policies. In Austria, there are 10 ‘Health Targets’ which were developed and approved in 2012, with the aim to prolong the healthy life years of all people living in Austria within 20 years (until 2032). Health target #9 is “To promote psychosocial health in all population”, which has three impact goals: Health promotion/prevention/early detection; Care/rehabilitation/training; and Society/de‑stigmatisation (OECD, 2020[8]). The Targets are backed by more than 40 concrete measures have been started all over Austria by various initiatives, which include measures that target mental health in the workplace, such as a programme to boost mental health competencies at the work place for management and employees (“Gesundheitskompetenz für psychische Gesundheid fur Akteure im Betrieb”), and a trial project on patient-centred medical communication for medical doctors

Finland is widely recognised as having been a leader in the field of the “Health in All Policies” approach, which stresses that policies that are made outside traditional health policy making have a significant impact on health, such as transport, agriculture, education and employment. The Finnish Health in All Policies approach requires all government sectors to keep health problems at the forefront, to be held accountable for policies affecting health and health care, to prioritise inter-sectoral pro-health intervention, and to educate policy makers, lawmakers and the public in all sectors about how health and health services will be affected by their decisions. In Finland, this cross-sectoral focus originally started with a desire to enhance public health, focusing on improving nutrition, reducing smoking and reducing injuries. During the Finnish EU Presidency in 2006 when ‘Health in All Policies’ was adopted as the theme for health work. At the Finnish level, the work has evolved from tackling a single health issue to a wider scope such as programmes, policies and governmental inter-sectoral programs (OECD, 2019[24]).

To develop a high performing mental health system, it is important that governments approach mental health from a cross-governmental approach, with a co‑ordination on mental strategies and implementing policies while working with multiple ministries to address mental health. Nineteen OECD countries have reported they have mental health strategies that are being addressed by other ministries than the health ministry (Table 4.1). Fewer countries (Austria, Belgium, Iceland, Italy, Japan, the Netherlands, Norway, Slovenia, Switzerland, Turkey) reported that ministries other than the Ministry of Health had a dedicated mental health budget that they were able to identify. In countries with federated health systems or where regions and municipalities have particular responsibility for health care or education, for instance, efforts to work cross-sectorally are also undertaken at the sub-national level.

For example, Norway has developed the National Mental Health Strategy with seven ministries, respectively their Ministry of Health, Culture, Children and Equality, Labour and Social Affairs, Education, Local Government and Modernisation, and Justice. Norway has also applied a cross government approach while developing additional mental health strategies. Eight ministries have been involved in developing an escalation plan on children and young people, respectively the Ministry of Education, Employment, Social Affairs, Families, Justice, Local Government and Modernisation, Culture and Agriculture and Food. Additionally, the Norwegian Ministry of Employment and Social Affairs has a programme which aims for more inclusive labour markets including people with mental health and substance abuse problems. Similarly, in 2019, Denmark has as agreed on a political statement for an improved working environment with initiatives to support and improve mental health at work. This agreement focuses on gathering information on regulations of psychosocial risks as work, following up with increased inspections and actions to improve working environments by providing additional training for managers and employees to foster inclusive working environments that promote mental well-being (OECD, 2020[8]). In Costa Rica, work on mental health is carried out in an inter-institutional and inter-sectoral manner: the Ministry of Health, the Costa Rican Social Security Fund, the Ministry of Public Education, the Ministry of Youth, the National Children’s Trust, the Institute of Alcoholism and Drug Addiction, local governments, are involved in developing approaches, among others.

As of 2019‑20, five years after the introduction of the OECD Recommendation on Integrated Mental Health, Skills and Work Policy (OECD, 2015[6]) the importance of a multi-sectoral, integrated approach to mental health performance is well-accepted amongst OECD countries (henceforth, ‘the Recommendation’). The Monitoring Report on the Implementation of the Recommendation has found that in recent years, a number of respondents have introduced mental health plans with a focus on mental health policies that are integrated with education, employment, social and health policy (OECD, forthcoming[1]). In the follow-up on the implementation of the Recommendation, five years after its establishment, a significant number of Adherents to the Recommendation (‘Adherents’) had included educational, employment and social protection dimensions of mental health in their national strategies or plans for the first time. The most recent mental health plans in OECD countries appear to demonstrate a clear commitment to a cross-governmental approach, even if clear targets or outcome objectives can be absent (OECD, forthcoming[1]).

Nineteen of twenty-nine respondents to the OECD Mental Health Benchmarking Policy Questionnaire have national programmes/strategies for developing integrated cross-government approaches to mental health governance, and in at least 14 countries Ministries other than the Ministry of Health have a dedicated mental health strategy, plan or work programme (OECD, 2020[8]). In Denmark, the Ministry of Employment developed a broad political agreement from April 2019 on a new and improved working environment effort including initiatives to support improvement of mental health at work, from regulation on psychosocial risks at the work place, to a focus on education of managers and employees in how to take care of the psychosocial working environment. In England, the government has established an Inter-Ministerial Group for Mental Health which includes representatives from other Government Departments, and at least six Government departments – from education to digital affairs to environment, food and rural affairs – have established strategies or actions covering mental health.

The follow-up to the implementation of the Recommendation found that the extent to which countries had integrated mental health, skills and work policy was uneven – both across areas of policy, and across countries (OECD, forthcoming[1]). Policy development is highly uneven across the four thematic areas covered by the Recommendation (health systems, youth support systems, workplace policies, and social protection systems). Most OECD countries place growing importance on integrating mental health care with schools, workplaces and skills, but this emphasis has tended to be at the strategy level, and examples of working-level implementation are far fewer. OECD countries reported significant recognition in youth support systems of the need for an integrated approach includes responds to mental health and its impact on education and employment. There were some examples of integrated workplace and health policies that could be found. And there were relatively few examples where social protection systems – employment services and social benefits – are implemented systematically, and this sector seems to be lagging behind, despite the high prevalence of mental health conditions amongst benefit recipients and employment service users.

People with mental health conditions have long experienced poorer physical health care than the general population, driven by both a higher rate of physical health risks, and a poorer access to health care (Firth et al., 2018[25]; Teasdale et al., 2019[26]; Thornicroft, 2013[27]). People with mental health conditions have been found to be at a 1.4 to 2 times higher risk of obesity, diabetes and cardiovascular disease compared to the general population (Firth et al., 2019[28]). Additionally, studies have identified people with mental ill health to display behaviours that are risk factors for physical diseases at a higher rate, such as smoking, excessive alcohol consumption, dietary risks, physical inactivity and sleep disturbance (Teasdale et al., 2019[26]; Stubbs et al., 2018[29]; Firth et al., 2018[25]; Firth et al., 2019[28]). People with mental health conditions can also be at increased risk of physical ill-health because of the use of certain psychiatric medications; in particular, the use of antipsychotics has been consistently linked to cardiovascular and metabolic side effects (Ali, Jalal and Paudyal, 2020[30]; Westman et al., 2018[31]; Ösby et al., 2016[32]; Wahlbeck et al., 2011[33]; Pringsheim et al., 2017[34]; Solmi et al., 2017[35]).

Co-morbidity between mental health conditions and somatic conditions, especially non-communicable diseases, is extremely common. Mental ill-health is a risk factor for physical health conditions, just as some physical health conditions increase the risk of mental ill-health. A 2017 WHO report found that depression is two to three times more common in those with diabetes than those without, that depression is associated with a 60% increase in the disk for diabetes and type 2 diabetes is associated with a 15% increased risk for depression (WHO Regional Office for Europe, 2017[36]). The same report found that depression increases the risk of coronary heart disease by 1.6 to 1.9 times, and the risk of chronic obstructive pulmonary disorder (COPD) by 2.5 times, while people with COPD are more likely to have symptoms of anxiety disorder (10‑19% for people with stable COPD, and 58% of those recovering from acute episodes) (Ibid). The same report found that about 25% of people with cancer also have anxiety and/or depression. Co-morbid mental health and physical health conditions are also more difficult to manage, and can make it harder for people to adhere to treatments or engage in care for either their physical or mental health condition; co-morbid depression has been found to be associated with poorer glycaemic control for people with diabetes (type 1 or 2); depression has been found to worsen outcomes from cardiovascular disease by 2.4 times, and increase rates of re‑hospitalisation rates (ibid).

Mental health conditions, especially severe mental health conditions, are associated with high rates of premature mortality. The OECD indicator on excess mortality for measures the difference between the mortality rate for the general population, and those who have had a diagnosis of schizophrenia or bipolar disorder (Figure 4.3). An “excess mortality” value that is greater than one implies that people with mental disorders face a higher risk of death than the rest of the population. In 2015‑17, excess mortality ranged from 1.3 in Lithuania to 6.1 in Norway for people who had lived with schizophrenia (OECD, 2019[37]). Similar trends are found in other countries; in the Czech Republic a study comparing deaths in people with mental and behavioural disorders discharged from psychiatric hospitals with deaths in the general population found a mortality risk more than two times higher amongst people with mental disorders than in the general population (Krupchanka et al., 2018[38]). Inversely, people living with chronic diseases, such as cardiovascular disease or diabetes, are at increased risk of mental disorders such as depression (Glassman, 2007[39]; Holt, de Groot and Golden, 2014[40]).

Given the high rate of co-morbidity between mental health conditions and physical health conditions, integrated service deliver is key. This integration should include effective physical health care – including health promotion and prevention – for people with mental health conditions, as well as screening for physical health conditions and increased health risks for persons with mental health conditions, and for mental health conditions for persons with physical health conditions that present an increased risk for mental ill-health (see also Chapter 5, on promotion and prevention).

To improve the integration of mental health and physical health care, and to improve health outcomes for people with mental health conditions, countries are increasingly trying to take a multidisciplinary approach (Table 4.2). For example, Israel has undertaken periodic studies on physical health for people with mental ill-health, while looking at mortality numbers in psychiatric patients, and is currently in the process of linking both data from patients with a psychiatric hospitalisation with data on general hospitalisations, which should result in a more integrated approach (OECD, 2020[8]). In Denmark, one example of an initiative to support better physical health outcomes has been through the Steno Diabetes Center, under the supervision of the Danish Health Authority, which has developed a tool meant to be used by supported housing facilities for people with mental illness in order to prevent somatic illness. The tool can also be used as a guide for the staff in terms of speaking with residents about physical symptoms, general physical health and habits such as smoking, exercise, substance abuse and other risky behaviours (OECD, 2020[8]). In Norway in 2019, the government introduced patient pathways for mental health and substance abuse when patients are referred to specialised health care. One of the goals of introducing the pathways is to better maintain the somatic health of these patients, and the pathways include recommendations about somatic health care and checks (ibid).

However, room for improvement clearly remains. Only two OECD countries, Korea and the United Kingdom report routinely collecting information on access to physical health are for persons with mental ill-health, such as cholesterol checks, BMI measurements, smoking status or general physical health screenings.

In England and in Ireland, health checks have been being used to routinely monitor the physical health of people with mental health conditions. In Ireland, the Irish Mental Health Services have introduced a new physical health assessment proforma for all service users in acute adult approved centres on admission, and at six months. This proforma includes questions on lifestyle behaviours and was developed by practitioners and service users. The Irish Mental Health Services have also developed referral pathways to assist staff carrying out a brief intervention with making changes to lifestyle behaviours, as well as publishing guidelines on how mental health services can support services users to be more physically active (OECD, 2020[8]). In England, the short and long term mental health plans have set the ambition of 280 000 people with severe mental illness receiving a full annual physical health check by 2020/21, up to 390 000 people with an annual check-up 2023/24, carried out either by a General Practitioner or in secondary care (ibid). A comprehensive physical health check includes a weight or BMI, diet, nutritional and physical activity check, a cardiovascular status check (pulse and blood pressure), metabolic status, liver function, renal and thyroid check (NICE, 2018[42]).

Just as co-morbid mental health conditions and somatic conditions are common, so too are multiple or ‘co‑occurring’ mental health conditions. Co‑occurring mental health conditions demand particular attention to integration in services and policy models, in particular across often‑fragmented ‘mental health’ services and substance use or addiction services (Box 4.2).

The evidence on the impact of the COVID‑19 crisis on the mental health, and physical health, of people with existing mental health conditions is mixed. Some studies, and patterns of service user, seem to suggest that people with pre‑existing mental conditions are at higher risk not only of COVID infection and of developing poorer mental health during the pandemic (Moreno et al., 2020[55]). Other evidence, for example a study in the Netherlands, found that people without a mental health condition (depression, anxiety, obsessive compulsive disorder) prior to the pandemic saw a more negative impact on their mental health, while individuals with pre‑existing conditions did not experience increased symptom severity compared to pre‑pandemic levels (Pan et al., 2021[56])

A self-reported questionnaire in Australia in April with 5 070 adult participants, showed participants with self-reported history with a mental health diagnoses had significantly higher distress, health anxiety, and COVID‑19 fears than those with a prior mental health diagnosis (Newby et al., 2020[57]). A similar study with the purpose to assess psychological well-being in adolescents, while including 760 Australians between 12 and 18 years old, the study not only showed higher levels of sleep disturbance, psychological distress and health anxiety compared to normative examples, but effects on mental health were worse among those who reported a previous diagnosis in mental health (Li et al., 2020[58]). In Slovenia, monitoring telephone calls to a COVID‑19 helpline for psychosocial support showed that almost a third (31.3%) of callers reported having a pre‑existing mental illness, and 65.3% of them were taking antidepressants and/or benzodiazepines (EuroHealthNet, 2020[59]). Meanwhile, in Italy, 14% of community mental health centre was closed and one‑quarter of hours reduced for care. (Carpiniello et al., 2020[60]). In Norway, there are several phone and online mental support services and during the COVID‑19 pandemic these phone and online services received additional funding (approx. NOK 15‑20 million extra in 2020, through the budgets of the Ministry of Health and Care and the Ministry of Children and Families) to increase their capacity. The Norwegian Directorate of Health has also published information and made available free online tools in helsenorge.no to support mental well-being and resilience.

In the Netherlands, a case control study was conducted to assess perceived psychological impact related to COVID‑19 the few weeks after the national lockdown between April and May 2020. This shows that people with severe and chronic mental health issues, including anxiety disorders, depression, and obsessive‑compulsive disorders perceived greater psychological impact, stronger fear of COVID‑19, and more difficulty in coping with the pandemic, comparted to those without psychological issues. However, symptom severity amongst these populations did not increase, and in some cases people with the most severe or chronic mental health disorders even showed an average significant decrease in symptom severity. In this study, people with lifetime psychological issues are younger, women and lower educated, compared to people without a lifetime problem (Pan et al., 2021[56]). In France, the CoviPrev study that ran throughout 2020 found that amongst people with existing mental health problems levels of anxiety and depression were both higher than the general population across the year, but also levels of depression in particular amongst this population increased during the first (March-April) and second (November) lockdown periods (Santé Publique France, 2020[61]).

People living with severe mental illness are at a higher risk of severe cases of COVID‑19 (Wang, Xu and Volkow, 2021[62]; Siva, 2021[63]; Jeon et al., 2021[64]; Lee et al., 2021[65]). Persons with psychotic disorder, bipolar disorder, or severe depression are at increased risk of being hospitalised, and dying, from COVID‑19, with severity of outcomes for persons with severe mental illness are about double those without severe mental illness with outcomes comparable to persons with cardiac, pulmonary or autoimmune issues (Siva, 2021[63]). Some studies also found that persons with serious mental illness were at increased risk of contracting COVID‑19 (Taquet et al., 2021[66]). At the time of writing (early March 2021), amongst European countries, only four countries had included persons severe mental illness amongst priority populations for vaccinations (Denmark, Germany, the Netherlands, the United Kingdom) (De Picker et al., 2021[67]; Siva, 2021[63]).

Living with mental health problems has an impact on people’s daily lives, including on ability to work. Mental health problems often impede an individual’s ability to participate in the labour market which can lead to a “vicious circle” whereby the longer people are out of work, the more damaging the consequences are for their mental health. The OECD Mental Health Performance Benchmarking Framework includes ‘social protection systems tailored to promote recovery, return to education, or to work for people with mental health conditions’ as a key sub-principle. Equally, the OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy recommends that ‘Adherents seek to improve the responsiveness of social protection systems and employment services to the needs of people living with mental health conditions’ (Box 4.2).

Five years on from the introduction of the OECD Council Recommendation of the Council on Integrated Mental Health, Skills and Work Policy, and in a context where more and more countries are recognising – in strategies at least – the impact of mental health on good employment and education outcomes, people living with mental health conditions have consistently less good education and employment outcomes.

On average, the employment rate for persons with a mental health condition was 20% less than for those without, rising to 30% in Hungary, Norway, and the United Kingdom (OECD, forthcoming[1]) (Figure 4.4). In European countries, people living with chronic depression were significantly less likely to be in work; based on 2014 data, only about half of the population aged 25‑64 reporting chronic depression were in employment, compared with over three‑quarter (77%) among those who do not report chronic depression on average across EU countries (OECD/European Union, 2018[7]).

On average across the OECD, students with mental health conditions are 35% more likely to have repeated a grade (OECD, forthcoming[1]). This is not the case for all countries. In Slovenia, Portugal, Poland, and Colombia, this group of students is slightly less likely to have repeated a grade, while in the United Kingdom there is no difference between the two groups. On the other side of the spectrum, students with mental health conditions in Greece, Estonia, Denmark and Iceland are all at least 75% more likely to have repeated a grade. In all countries, persons with mental health conditions are less likely to complete higher education, with particularly significant gaps in Canada, the United States, the United Kingdom, Belgium, Chile, Luxembourg, and Iceland (Figure 4.4).

People with lower income are significantly more likely to report having chronic depression, while people with the lowest level of education are more likely to report having chronic depression than people with secondary education, who in turn are more likely to report depression than people with the highest level of education (Eurostat, 2014[68]). Some more limited but similar relationships between poverty and higher prevalence are also seen for severe mental illnesses such as bipolar disorder and schizophrenia, as well as for alcohol and substance use disorders (Hastings et al., 2019[69]; Burns, Tomita and Kapadia, 2014[70]; Werner, Malaspina and Rabinowitz, 2007[71]).

While mental health services for children and adolescents often have a link – which can vary between well integrated and quite fragmented – with schools and educational settings, a few OECD countries have dedicated initiatives to support young people with mental health conditions to stay in education or work.

A few initiatives exist that focus on young people transitioning to work or further education. In the United Kingdom, a taskforce in the Department of Education was set up in 2019 and focuses on supporting good mental health amongst university students (OECD, forthcoming[1]). Notably this taskforce has promoted good practices such as ‘Know Before You Go’, run by the charity Student Minds that focuses on young people’s mental health, which is an online guide for school leavers going to university that provides practical life advice and tips, with ideas about how to maintaining good mental health and seek help if needed embedded throughout the guide (Student Minds, 2018[72]).

Other initiatives link other services for young people across different sectors. Among these initiatives in Canada is the Youth Mental Health Count Program in Ontario (OECD, 2020[8]). The programme diverts youth from the justice system by providing comprehensive health and social rehabilitation supports. The Youth Mental Health Count Program provides support to 12 to 17‑year‑olds with identified mental health needs, and works as a bridge between the criminal justice system and mental health services, creating a plan based on the young person’s needs.

Good examples of initiatives to integrate services across sectors can be found across OECD countries, and across sectors. Some reforms are being introduced to ensure that social protection systems, and mental health services, promote recovery and encourage return to work, or return to school (OECD, forthcoming[1]). Initiatives range from preventing absence from work, promoting rapid return to work, providing concurrent or integrated mental health and employment support for job seekers or long-term unemployed, and developing appropriate work placements for people with serious mental health needs who require adapted working environments and/or tasks (OECD, 2012[2]; OECD, 2015[3]; OECD, forthcoming[1]). At the same time, when it comes to promoting good employment and education outcomes, taking a proactive approach to promoting good mental health and preventing mental ill-health and supporting people to stay in school or work should be a priority strategy, as also discussed in Chapter 5 of this report.

Some good examples of support for return-to-work, and reducing preventable sickness absences for mental health reasons can be found in OECD countries. For many workers, a flexible approach is key when returning to the labour market after a sickness absence. In Austria, a new model to promote part-time return to work (WIETZ) was introduced in 2017 which promotes a more flexible return-to-work model, with workers entitled to shorter working hours and financial protection during the reintegration period. Though the programme was not intended for mental health conditions alone, amongst applicants to the programme – of whom there have been more than 73 000 since 2017 – mental ill-health is the most common reason for prolonged absence (OECD, forthcoming[1]). In Denmark, a 2015 project led to the development of the ‘IBBIS’ (Integrated Mental Health Care and Vocational Rehabilitation to Individuals on Sick Leave Due to Anxiety and Depression) model, which connects people out of work who are identified through job centres, with integrated mental health and vocational rehabilitation services, including stepped mental health care intervention (Region Hovedstadens psykiatriske hospital, 2020[73]; Poulsen et al., 2017[74]). In a few countries, there are examples of incentives or requirements for employers to support return-to-work for employees after sickness absences, including the Netherlands, Norway, and Sweden where employers and their employees have to agree return-to-work action plans after around eight weeks of sickness absence (OECD, 2012[2]).

In some countries, reforms to rules and legislation in social benefits and employment services are helping encourage and incentivise job seekers with mental health conditions to return to employment (OECD, forthcoming[1]). In response to the Questionnaire on the Implementation of the OECD Recommendation on Integrated Mental Health, Skills and Work countries included Canada, Finland and Estonia indicated that they had made changes to their jobseekers programmes. Canada has made amendments to its Employment Insurance rules to extend maternity and sickness benefits, allowing claimants to work while claiming benefits, and gradually reducing benefits for each dollar earned. In Finland, a recently launched work ability programme will also adjust rules on partial working capacity, again allowing people with partial work capacity – including those on sickness absence for mental health conditions – to return to work gradually or part time while keeping part of their unemployment benefits. In Estonia, introduction of a of ‘partial work capacity’ to access unemployment benefits, and has helped identify pathways for specific employment roles, or training options.

However, systematic inclusion of work or employment outcomes in mental health service delivery, or mental health outcomes in employment support services, is not the norm. Most countries did not include employment or labour market outcomes in mental health service outcomes frameworks, or only included them for some care settings. The lack of integration is most apparent in social protection systems despite the well-known high prevalence of mental ill-health among social benefit recipients and employment service users (Table 4.1).

Initiatives related to liaison services between services, and mental health support for people using unemployment services are more common (Table 4.1). In England, the ‘job coaches’ working in the national unemployment services ‘Jobcentre Plus’ will, from 2021, all have received training on supporting claimants with health conditions, to build their expertise and provide the most effective support (OECD, 2020[8]). If the work coach knows the claimant has complex mental health issues then further safeguards are put into place for failure to attend interviews: two attempts at a home visit are made which, if not successful, is then referred for a management decision on next action to be taken. As of September 2019 over 10 000 job coaches had been given this training (ibid). Or, in an initiative which facilitates referrals from the health sector into the employment or vocational rehabilitation sector, in Iceland health care personnel can refer individuals to ‘Virk – Vocational Rehabilitation Fund’ which is a private foundation of which all the major unions and employers in the labour market in Iceland are member (OECD, 2020[8]). England is has also taken significant steps to integrate an employment-forward approach into its nationwide programme of Improving Access to Psychological Therapies (IAPT) services. IAPT services in 40% health regions in England now have employment advisers (OECD, 2020[8]).

In Lithuania, changes to the way that people with mental health are given labour market support is seen as a key part of the transition to a more community-based model of mental health care (Box 4.4). At the service user-level Australia and England collect information on employment through their service outcomes framework, the National Outcomes and Casemix Collection (NOCC) in Australia, and the NHS Outcomes Framework in England.

Denmark stands out as a country with strong integration of mental health and employment services, and outcomes, with a range of initiatives to bridge mental health and employment services, and the inclusion of “access to the workforce (for somatic and psychiatric patients)” as one of the eight national health care quality goals. The Danish Ministry of Health has established a partnership of 48 members ranging from employee and employer organisations from the private and public sector to participants from patient organisations. The partnership, ‘Sammen om mental sundhed’ (which roughly translates to ‘Together on Mental Health’), commenced in 2015 as a cross-sectoral effort, bridging the health and employment sectors, in order to pool knowledge and experience, and to create an overview of existing knowledge and tools within the field of mental health in the workplace.

This sub-principle is directly linked to the sub-principle ‘Enable front line actors to recognise and respond to mental distress’ included in Chapter 5 on preventing mental illness and promoting mental well-being. 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 this chapter.

Given the high prevalence of mental health problems across the OECD countries, there is an increasing demand for people who can identify mental health issues and have knowledge and skills to deal with them regardless of their professions. It often takes time even for individuals themselves to understand that they need mental health care, while the stigma around mental health conditions which can discourage people from seeking professional support.

There are certain key workers who are more likely to come into contact with people experiencing mental distress, or for whom having the capacity to identify mental distress could bring significant social benefits, including school teachers, line managers, co-workers, General Practitioners, emergency doctors, occupational doctors, pharmacists, and nurses. These front-line actors can play a critical role in raising awareness of mental health problems and improving the stigma around mental health problems. Line managers, for instance, would notice that co-workers have mental health problems when they show less productivity or they take frequent sick leave because those with mental ill-health often show presentees and absentees at work (OECD/European Union, 2018[7]). In another case, a pharmacist at a drug store could understand that a customer presenting with sleeplessness and appetite loss might be experiencing mental distress, and could be usefully directed towards appropriate support. Training programmes offer mental health knowledge, skills to deal with people with mental health problems depending on their professional and mental health training backgrounds.

Broad and significant efforts to improve the mental health knowledge of key front-line actors, and to support connections between front line services such as police, emergency departments, and teachers, with mental health services, and in some countries mental health training is provide for a significant number of front line actors (Table 4.4).

Training for front line actors can reduce stigma around mental health conditions, help actors spot signs of mental distress and react with sensitivity, and direct people in need towards appropriate mental health services. Many countries provide at least some mental health training for front line actors, in particular for teachers, GPs, and police, but less often for paramedics, the fire department, and unemployment counsellors or staff. Teachers, in particular, receive significant training in England, Canada, Latvia and Lithuania.

In Mexico, mental health training has been given to front line workers through the National Addiction Prevention Strategy ‘Together for Peace, which has as one of its objectives “to reduce the mental health care gap” through “improving the care of people with mental health problems and addictions in health services”. Among the actions contemplated for this point is “the training of first and second level health care providers through the WHO Mental Health Gap Action Program (mhGAP) and the Intervention Guide for Mental, Neurological and Substance Use Disorders of the World Health Organization (WHO)” so that first and second level health care personnel can identify and provide care for priority mental disorders in the population. To date, 3 683 first-level health care personnel have been trained. In Mexico the Ministry of Health, through the National Council of Mental Health and Psychiatric Care Services, is also looking to increase the availability of mental health services by promoting the National Program of Telementoring in Mental Health and Addictions. This programme brings together a group of specialists from various mental health institutions who establish virtual advisory groups to train and guide first and second level health personnel to provide timely and quality mental health care.

However, in response to the OECD Policy Questionnaire most countries indicated that only ‘some training’ was provided to these front line actors, and coverage tended to be through relatively ad-hoc courses, or depend on local or regional initiatives. For example in Australia some programmes are specific to States, such as a programme for teachers in Victoria or for Fire and Rescue workers in New South Wales. In England in 2016‑17 90% of schools and colleges offered training to at least some of their staff around how to support pupils’ mental health and well-being while 47% offered training to all staff (Marshall et al., 2017[76]; OECD, 2020[8]).

In Canada, Yukon health professionals, including physicians, will receive education and training to provide compassionate and culturally sensitive transgender care, and the Mental Health Commission of Canada (MHCC) launched new mental health literacy training specific to police through a new agreement with the Ontario Provincial Police (OPP). In Costa Rica, training for frontline actors who are not mental health specialists is due to begin, to raise awareness of mental health needs and improve person-centred approaches for people with mental health problems. There are also differences between the substance of the training that is provided to front line actors. For example in Latvia front line actors were mostly covered in general awareness raising campaigns, even if there were some targeted educational seminars for example on bullying and emotional welfare for teachers.

If front line actors are coming in regular contact with people with mental health needs, and are also being given the training and skills to identify mental distress, then this also gives front line actors an important gatekeeping role to identify when people are in need of further mental health service provision. However, studies report frontline workers might feel powerless when unable to access mental health services or being able to refer people in need of mental health care to necessary services (European Journal of Homelessness, 2016[77]), and without specialist support may struggle to identify the best course of action for someone showing signs of mental distress (Splett et al., 2019[78]). Increased training is necessary to stimulate collaboration between front line actors and further mental health services, while giving them the confidence to signal symptoms of mental ill-health and inform them about therapeutic interventions and possibilities to refer (European Journal of Homelessness, 2016[77]). It is important for front line actors, if they identify a case of mental distress, to be able to direct this person towards appropriate support. For example, police services having easy and direct contact for a psychiatric consultation, health services – including outside of emergency departments – having access to mental health for patients assessments as necessary, or teachers and schools being able to easily refer students to child and adolescent mental health service assessment.

Some front line services have been focusing on integrating and strengthening referral pathways within their services, by training front line actors and providing them with tools such as screening questionnaires to identify whether an individual is in need of additional care. As an example, in the United States, Massachusetts, the Gloucester police department has developed a police‑led addiction referral programme, with the aim to improve access to treatment systems for people with an opioid use disorder. Police officers were provided a brief set of questions for assessing any acute medical or psychiatric needs, asking about current drug use and time of last use, followed by calls to treatment programs. The programme was a success with a 94.5% direct referral rate, which exceeds hospital-based initiatives designed for detoxification and treatment. During the first year of the programme, from June 2015 through May 2016, 376 different persons presented for assistance, with a total of 429 times. The model has been adopted by 153 other police departments in 28 states (Schiff et al., 2017[79]).

Multi-morbidities require a multi-disciplinary approach, and an increase in efforts to integrate ‘physical’ and ‘mental’ health care. Given the significantly worse physical health outcomes for people with severe mental illness, as well as the high rate of comorbidity between mental health conditions and a range of physical health conditions, notably non-communicable diseases, efforts to increase co‑ordination are needed. There is clear scope, in almost all countries, for more initiatives that focus on different types of care to address the needs of the population, ranging from preventative measures for maintaining mental and physical health, to more intensified co‑ordination efforts for people with more acute or complex health needs who are in need of continuous care.

In Switzerland, the Federal Office of Public Health commissioned a review to identify models of good practice in the co‑ordination of acute psychiatry, and acute somatic medicine. The commission found a range of different initiatives that could be effective at increasing care co‑ordination and integration, including using systematic screening, transfer of patients from psychiatric to acute hospitals following a defined schema, training on integrated care for students, training for family doctors from psychiatrists or other relevant specialists, and the appointment of key liaison contact to respond to psychiatric questions within the acute hospital setting (Spiess and Ruflin, 2018[80]). The commission found that this range of models were effective, could be applied in heterogeneous settings, and improved service user outcomes directly or indirectly.

Evidence‑based lifestyle interventions have been found to result in positive outcome for people with mental ill-health and should be made available and implemented as a standard component of mental health care (Happell, Davies and Scott, 2012[81]). Introducing adapted lifestyle interventions for people with mental ill-health, that include exercise, diet and broader lifestyle interventions have been proven effective for people with mental illness while resulting in improved physical health and mental health (Richardson et al., 2005[82]; Czosnek et al., 2019[83]). Additionally, the use of lifestyle interventions can act as a low-threshold treatment, resulting in increased treatment adherence, especially for disengaged service users in more traditional mental health treatments (Firth et al., 2018[25]; Firth et al., 2019[28]). It is important to consider how these trainings programs are adapted to different settings and conditions, to make sure these interventions are delivered in an appropriate manner. Adapting these interventions to the population is crucial, as people with mental ill-health can face additional challenges to make and sustain lifestyle changes. Effects of psychiatric symptoms and consequences of these symptoms like social isolation are all potential barriers for the uptake of a healthy lifestyle (Yarborough et al., 2016[84]). As an example, an urban community health centre in southern New Hampshire has set up a 24‑week peer-group lifestyle intervention which consisted out of regular weight management sessions with two lifestyle coaches, exercise sessions with a fitness training, and mobile health technology and social media to increase motivation and facilitate self-monitoring and peer support. The training led to weight loss in 72% of the participants (Aschbrenner et al., 2016[85]).

Over the last decade, health professionals are increasingly working in multidisciplinary teams in integrated care settings, including disciplines such as physical activity, nutrition and behaviour change. Receiving training is important for both physical and mental health professionals to provide appropriate care and to learn how to work in an integrated manner. Mental health clinicians should receive training to enable them not to overlook somatic symptoms and to pay attention to physical complaints and lifestyle behaviours (Saxena and Maj, 2017[86]). Similarly, health practitioners should receive training on psychopathology and education on how to work with people with mental illness. From 2008, the WHO has developed the mental health Gap Action Programme Intervention Guide (mhGAP-IG) which provides evidence‑based guidance and tools on for the assessment of mental, neurological and substance use disorders in non-specialised health settings, which will help to strengthening the workforce for an integrated approach of health. The mhGAP-IG has been successfully used in different regions of the world and in various academic institutions, for example in the National Autonomous University in Mexico, where an evaluation showed young doctors have more knowledge in mental health and mental health disorders (Chaulagain et al., 2020[87]; WHO, 2020[88]; Mills and Lacroix, 2019[89]).

Good examples of initiatives to integrate services across sectors can be found across OECD countries, and across sectors. It is clear from the report Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation that reforms are being introduced to ensure that social protection systems, and mental health services, promote recovery and encourage return to work or education (OECD, forthcoming[1]).

Australia, Denmark, England, Ireland, Italy, the Netherlands, Norway and New Zealand have been implementing or testing Individual Placement and Support (IPS), a proven evidence‑based practice in which multidisciplinary mental health teams including an employment specialist provide co‑ordinated health and employment support for jobseekers (OECD, 2020[8]; Modini et al., 2016[90]). IPS have become widespread in OECD countries, and have demonstrated transferability between different systems and settings. However, IPS – which have been found to have a positive impact in helping individuals find and stay in employment or work (OECD, forthcoming[1]) – are nonetheless quite resource intensive, given the individualised level of support that they provide, and tend to focus on individuals with severe mental ill-health. IPS do show some promise in being able to be broadened to also be directed at individuals with mild-to-moderate mental illness. In England, IPS are being tested for people with a broader cohort of conditions beyond severe mental illness, in Australia a trial of IPS for young people run through the headspace programme found improvements to the employment and educational outcomes of young people. The programme was also found to be more cost effective than other employment programmes. In Australia this programme was due to be rolled out in a further 26 sites (in addition to the existing 24) (Department of Social Services, 2020[91]; Department of Social Services - KPMG, 2019[92]). Norway started implementing Individual placement and support (IPS) from 2013, supported by a grant scheme; IPS is specifically aimed at persons with severe mental health problems also in need for unemployment services and are now available in all counties of Norway.

Specific programmes supporting better employment or educational outcomes for people with mental health conditions are clearly a critical part of a high performing and integrated mental health system. Alongside these programmes, efforts to embed employment support in mental health services – for example IPS counsellors in mental health community teams in Ireland, or employment counsellors in psychological services in England – are a significant step towards integration. To make integration even more systematic, and to make good employment or educational outcomes a key expectation for mental health services, some health system outcome or monitoring frameworks now include employment outcomes for people with mental health (Box 4.6), but this approach could certainly stand to be used more widely.

A significant number of countries indicate that mental health training is provided to key front line actors. However, this training is inconsistent both across categories of front line actor – teachers are far more likely to receive training than unemployment counsellors, for example – and across countries (see Table 4.4). In addition, in many countries, whether front line actors receive mental health training depends on regional or local initiatives, or ad-hoc programmes, and is far from systematic or routine.

Mental health training for front line actors can help with both reducing stigma around mental health conditions and towards people living with mental health conditions and with directing people towards appropriate support. Programmes to increase mental health awareness and skills have shown good transferability across different settings, perhaps most notably the Mental Health First Aid programme which has been implemented in at least 20 countries worldwide (Box 4.7). Mental health training for front line actors can also stand to benefit the front line actors themselves, giving them the skills and knowledge to seek mental health help if they need it, and/or support their peers during periods of mental ill-health.

[30] Ali, R., Z. Jalal and V. Paudyal (2020), “Barriers to monitoring and management of cardiovascular and metabolic health of patients prescribed antipsychotic drugs: a systematic review”, BMC Psychiatry, Vol. 20/1, p. 581, http://dx.doi.org/10.1186/s12888-020-02990-6.

[85] Aschbrenner, K. et al. (2016), “A pilot study of a peer-group lifestyle intervention enhanced with mhealth technology and social media for adults with Serious Mental Illness”, Journal of Nervous and Mental Disease, Vol. 204/6, pp. 483-486, http://dx.doi.org/10.1097/NMD.0000000000000530.

[14] Australian Government - National Mental Health Commission (2016), Media Release: The Impact of Poor Mental Health: An Economic Issue, https://www.mentalhealthcommission.gov.au/news/2016/december/the-impact-of-poor-mental-health-an-economic-issue (accessed on 23 October 2018).

[15] Australian Government Productivity Commission (2020), Inquiry report - Mental Health Productivity Commission, https://www.pc.gov.au/inquiries/completed/mental-health/report (accessed on 15 May 2021).

[70] Burns, J., A. Tomita and A. Kapadia (2014), “Income inequality and schizophrenia: Increased schizophrenia incidence in countries with high levels of income inequality”, International Journal of Social Psychiatry, Vol. 60/2, pp. 185-196, http://dx.doi.org/10.1177/0020764013481426.

[60] Carpiniello, B. et al. (2020), “Mental health services in <scp>Italy</scp> during the <scp>COVID</scp> ‐19 pandemic”, Psychiatry and Clinical Neurosciences, Vol. 74/8, pp. 442-443, http://dx.doi.org/10.1111/pcn.13082.

[87] Chaulagain, A. et al. (2020), “WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG): The first pre-service training study”, International Journal of Mental Health Systems, Vol. 14/1, p. 47, http://dx.doi.org/10.1186/s13033-020-00379-2.

[83] Czosnek, L. et al. (2019), Health benefits, safety and cost of physical activity interventions for mental health conditions: A meta-review to inform translation efforts, Elsevier Ltd, http://dx.doi.org/10.1016/j.mhpa.2018.11.001.

[67] De Picker, L. et al. (2021), “Viewpoint | European COVID-19 exit strategy for people with severe mental disorders: Too little, but not yet too late”, Brain, Behavior, and Immunity, http://dx.doi.org/10.1016/j.bbi.2021.01.008.

[43] Department of Health (2009), Mental disorder comorbidity, https://www1.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-m-mhaust2-toc~mental-pubs-m-mhaust2-hig~mental-pubs-m-mhaust2-hig-men (accessed on 28 February 2021).

[91] Department of Social Services (2020), Individual Placement and Support Program (IPS Program), https://www.dss.gov.au/mental-health-programs-services/individual-placement-support-program (accessed on 28 February 2021).

[92] Department of Social Services - KPMG (2019), Final Report for the Evaluation of the Individual Placement and Support Trial, Department of Social Services, https://www.dss.gov.au/sites/default/files/documents/08_2019/individual-placement-and-support-trial-evaluation-report-june-2019.pdf (accessed on 28 February 2021).

[59] EuroHealthNet (2020), Local mental health support in Slovenia during COVID-19: setting up primary health care helplines, https://eurohealthnet-magazine.eu/local-mental-health-support-in-slovenia-during-covid-19-setting-up-primary-health-care-helplines/ (accessed on 22 February 2021).

[77] European Journal of Homelessness (2016), “European Journal of Homelessness 10th Anniversary”, Vol. 10/3, https://www.feantsaresearch.org/download/ehj10-3_-_full_pdf3109960603357939942.pdf (accessed on 12 March 2021).

[51] European Monitoring Centre for Drugs and Drug Addiction (2016), Comorbidity of substance use and mental health disorders in Europe, European Monitoring Centre for Drugs and Drug Addiction, https://www.emcdda.europa.eu/topics/pods/comorbidity-substance-use-mental-disorders-europe_en (accessed on 28 February 2021).

[5] European Parliament (2020), Climate change and its impact on mental health -Briefing requested by the ENVI committee, https://www.europarl.europa.eu/RegData/etudes/BRIE/2020/658210/IPOL_BRI(2020)658210_EN.pdf (accessed on 2 March 2021).

[68] Eurostat (2014), European Health Interview Survey (EHIS), https://ec.europa.eu/eurostat/cache/metadata/en/hlth_det_esms.htm (accessed on 7 May 2020).

[28] Firth, J. et al. (2019), “The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness”, The Lancet Psychiatry, Vol. 6/8, pp. 675-712, http://dx.doi.org/10.1016/s2215-0366(19)30132-4.

[25] Firth, J. et al. (2018), “Diet as a hot topic in psychiatry: a population‐scale study of nutritional intake and inflammatory potential in severe mental illness”, World Psychiatry, Vol. 17/3, pp. 365-367, http://dx.doi.org/10.1002/wps.20571.

[39] Glassman, A. (2007), “Depression and cardiovascular comorbidity”, Neuropsychiatry and Cardiovascular Disease, Dialogues in Clinical Neuroscience, Vol. 9/1, pp. 9-17, http://dx.doi.org/10.31887/dcns.2007.9.1/ahglassman.

[44] Grant, B. et al. (2004), “Prevalence and Co-occurrence of Substance Use Disorders and IndependentMood and Anxiety Disorders”, Archives of General Psychiatry, Vol. 61/8, p. 807, http://dx.doi.org/10.1001/archpsyc.61.8.807.

[81] Happell, B., C. Davies and D. Scott (2012), “Health behaviour interventions to improve physical health in individuals diagnosed with a mental illness: A systematic review”, International Journal of Mental Health Nursing, Vol. 21/3, pp. 236-247, http://dx.doi.org/10.1111/j.1447-0349.2012.00816.x.

[69] Hastings, P. et al. (2019), “Predicting psychosis-spectrum diagnoses in adulthood from social behaviors and neighborhood contexts in childhood”, Development and Psychopathology, pp. 1-15, http://dx.doi.org/10.1017/S095457941900021X.

[40] Holt, R., M. de Groot and S. Golden (2014), “Diabetes and Depression”, Current Diabetes Reports, Vol. 14/6, http://dx.doi.org/10.1007/s11892-014-0491-3.

[12] Jacobs, P., F. Knoops and A. Lesage (2017), “A Review of Measures of Aggregate Mental Health Costs in Canada Mesurer les coûts agrégés liés à la santé mentale au Canada : un examen de la question”, Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by, Vol. 36/4, http://dx.doi.org/10.7870/cjcmh-2017-032.

[23] Jenkins, R. (2005), Supporting Governments to Adopt Mental Health Policies, World Psychiatric Association, http://dx.doi.org/10.1108/13619322200500008.

[64] Jeon, H. et al. (2021), “Association of mental disorders with SARS-CoV-2 infection and severe health outcomes: nationwide cohort study”, The British Journal of Psychiatry, pp. 1-8, http://dx.doi.org/10.1192/bjp.2020.251.

[45] Kessler, R. et al. (1996), “The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization”, American Journal of Orthopsychiatry, Vol. 66/1, pp. 17-31, http://dx.doi.org/10.1037/h0080151.

[38] Krupchanka, D. et al. (2018), “Mortality in people with mental disorders in the Czech Republic: a nationwide, register-based cohort study”, The Lancet Public Health, Vol. 3/6, pp. e289-e295, http://dx.doi.org/10.1016/S2468-2667(18)30077-X.

[65] Lee, S. et al. (2021), “Correspondence COVID-19 in South”, The Lancet Psychiatry, Vol. 0366/21, pp. 5-6, http://dx.doi.org/10.1016/S2215-0366(21)00043-2.

[47] Lipari, R. and E. Park-Lee (2020), Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health.

[58] Li, S. et al. (2020), The impact of COVID-19 on the lives and mental health of Australian adolescents, medRxiv, http://dx.doi.org/10.1101/2020.09.07.20190124.

[50] Marel, C. et al. (2016), Guidelines on the management of Co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings SECOND EDITION - Australian Government, Department of Health, Centre of Research Excellence in Mental Health and Substance Use at NDARC (National Drug and Alcohol Research Centre) at UNSW Australia.

[76] Marshall, L. et al. (2017), Supporting Mental Health in Schools and Colleges Quantitative Survey.

[11] Mental Health Commission of Canada (2016), Investing in Mental Health, Mental Health Commission of Canada, Ottawa, ON, https://www.mentalhealthcommission.ca/sites/default/files/2016-06/Investing_in_Mental_Health_FINAL_Version_ENG.pdf. (accessed on 26 October 2018).

[75] Mental Sundhed (2020), Mental Sundhed - Sammen om mental sundhed, https://mentalsundhed.dk/ (accessed on 3 March 2021).

[46] Merikangas, K. et al. (1998), “Comorbidity of substance use disorders with mood and anxiety disorders”, Addictive Behaviors, Vol. 23/6, pp. 893-907, http://dx.doi.org/10.1016/s0306-4603(98)00076-8.

[89] Mills, C. and K. Lacroix (2019), “Reflections on doing training for the World Health Organization’s mental health gap action program intervention guide (mhGAP-IG)”, International Journal of Mental Health, Vol. 48/4, pp. 309-322, http://dx.doi.org/10.1080/00207411.2019.1683681.

[4] Mind (2017), Housing and mental health, mind.org.uk, https://www.mind.org.uk/information-support/guides-to-support-and-services/housing/housing-and-mental-health/ (accessed on 26 February 2021).

[93] Ministry of Health Denmark (2019), The National Goals of the Danish Healthcare System, https://sum.dk/Media/E/D/national-goals-of-the-danish-healthcare-system-2018.pdf (accessed on 28 February 2021).

[90] Modini, M. et al. (2016), “Supported employment for people with severe mental illness: Systematic review and meta-analysis of the international evidence”, British Journal of Psychiatry, Vol. 209/1, pp. 14-22, http://dx.doi.org/10.1192/bjp.bp.115.165092.

[55] Moreno, C. et al. (2020), “How mental health care should change as a consequence of the COVID-19 pandemic”, The Lancet Psychiatry, Vol. 7/9, pp. 813-824, http://dx.doi.org/10.1016/s2215-0366(20)30307-2.

[49] NAMI (2020), Substance Use Disorders, https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Substance-Use-Disorders (accessed on 28 February 2021).

[57] Newby, J. et al. (2020), Acute mental health responses during the COVID-19 pandemic in Australia, Cold Spring Harbor Laboratory, http://dx.doi.org/10.1101/2020.05.03.20089961.

[95] NHS Digital (2021), NHS Outcomes Framework 2020/21 Indicator and Domain Summary Tables, https://files.digital.nhs.uk/65/B59049/nhs-out-fram-feb-21-dash.pdf (accessed on 28 February 2021).

[94] NHS Digital (2021), NHS Outcomes Framework Indicators - February 2021 Release, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-outcomes-framework/february-2021 (accessed on 28 February 2021).

[42] NICE (2018), Quality statement 6: Physical health checks for people with serious mental illness | Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups, https://www.nice.org.uk/guidance/qs167/chapter/Quality-statement-6-Physical-health-checks-for-people-with-serious-mental-illness (accessed on 4 March 2021).

[52] NICE (2016), Coexisting severe mental illness and substance misuse: community health and social care services, https://www.nice.org.uk/guidance/ng58/chapter/Recommendations (accessed on 28 February 2021).

[16] OECD (2021), “Supporting young people’s mental health through the COVID-19 crisis”, OECD Policy Responses to Coronavirus (COVID-19), OECD Publishing, Paris, https://doi.org/10.1787/84e143e5-en.

[18] OECD (2021), “Tackling the mental health impact of the COVID-19 crisis: An integrated, whole-of-society response”, OECD Policy Responses to Coronavirus (COVID-19), OECD Publishing, Paris, https://dx.doi.org/10.1787/0ccafa0b-en.

[41] OECD (2020), OECD Health Statistics 2020, OECD Publishing, Paris, https://doi.org/10.1787/health-data-en.

[8] OECD (2020), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires, OECD, Paris.

[53] OECD (2019), Addressing Problematic Opioid Use in OECD Countries, OECD Health Policy Studies, OECD Publishing, Paris, https://dx.doi.org/10.1787/a18286f0-en.

[37] OECD (2019), Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris, https://dx.doi.org/10.1787/4dd50c09-en.

[24] OECD (2019), OECD Reviews of Public Health: Japan: A Healthier Tomorrow, OECD Reviews of Public Health, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264311602-en.

[3] OECD (2015), Fit Mind, Fit Job: From Evidence to Practice in Mental Health and Work, Mental Health and Work, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264228283-en.

[13] OECD (2015), Mental Health and Work: Australia, Mental Health and Work, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264246591-en.

[6] OECD (2015), Recommendation of the Council on Integrated Mental Health, Skills and Work Policy, http://legalinstruments.oecd.org.

[54] OECD (2014), OECD Reviews of Health Care Quality: Norway 2014: Raising Standards, OECD Reviews of Health Care Quality, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264208469-en.

[2] OECD (2012), Sick on the Job?: Myths and Realities about Mental Health and Work, Mental Health and Work, OECD Publishing, Paris, https://doi.org/10.1787/9789264124523-en.

[1] OECD (forthcoming), Integrated Mental Health, Skills and Work Policy: Implementation of the Council Recommendation, OECD, Paris.

[7] OECD/European Union (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris/European Union, Brussels, https://dx.doi.org/10.1787/health_glance_eur-2018-en.

[32] Ösby, U. et al. (2016), “Mortality trends in cardiovascular causes in schizophrenia, bipolar and unipolar mood disorder in Sweden 1987–2010”, The European Journal of Public Health, Vol. 26/5, pp. 867-871, http://dx.doi.org/10.1093/eurpub/ckv245.

[56] Pan, K. et al. (2021), “The mental health impact of the COVID-19 pandemic on people with and without depressive, anxiety, or obsessive-compulsive disorders: a longitudinal study of three Dutch case-control cohorts”, The Lancet Psychiatry, Vol. 8/2, pp. 121-129, http://dx.doi.org/10.1016/S2215-0366(20)30491-0.

[19] Patel, V. et al. (2018), “The Lancet Commission on global mental health and sustainable development”, Lancet (London, England), Vol. 392/10157, pp. 1553-1598, http://dx.doi.org/10.1016/S0140-6736(18)31612-X.

[21] Patel, V. et al. (2018), “The Lancet Commission on global mental health and sustainable development”, The Lancet, Vol. 392/10157, pp. 1553-1598, http://dx.doi.org/10.1016/S0140-6736(18)31612-X.

[74] Poulsen, R. et al. (2017), “Integrated mental health care and vocational rehabilitation to improve return to work rates for people on sick leave because of depression and anxiety (the Danish IBBIS trial): Study protocol for a randomized controlled trial”, Trials, Vol. 18/1, http://dx.doi.org/10.1186/s13063-017-2272-1.

[34] Pringsheim, T. et al. (2017), “Physical Health and Drug Safety in Individuals with Schizophrenia”, Canadian Journal of Psychiatry, Vol. 62/9, pp. 673-683, http://dx.doi.org/10.1177/0706743717719898.

[96] Public Health England (2021), Public Health Outcomes Framework - Wider determinants of health, https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data#page/3/gid/1000041/pat/6/par/E12000004/ati/302/are/E06000015/iid/10602/age/208/sex/4/cid/4/page-options/ovw-do-0_car-do-0 (accessed on 28 February 2021).

[73] Region Hovedstadens psykiatriske hospital (2020), IBBIS, www.psykiatri-regionh.dk, https://www.psykiatri-regionh.dk/Kvalitet-og-udvikling/udvikling/ibbis/Sider/default.aspx (accessed on 26 February 2021).

[82] Richardson, C. et al. (2005), Integrating physical activity into mental health services for persons with serious mental illness, American Psychiatric Publishing, http://dx.doi.org/10.1176/appi.ps.56.3.324.

[97] Richardson, R. et al. (2018), Mental Health First Aid as a tool for improving mental health and well-being, John Wiley and Sons Ltd, http://dx.doi.org/10.1002/14651858.CD013127.

[48] Rush, B. et al. (2008), “The interaction of co-occurring mental disorders and recovery management checkups on substance abuse treatment participation and recovery”, Evaluation Review, Vol. 32/1, pp. 7-38, http://dx.doi.org/10.1177/0193841X07307532.

[9] Sado, M. et al. (2013), “The cost of schizophrenia in Japan.”, Neuropsychiatric disease and treatment, Vol. 9, pp. 787-98, http://dx.doi.org/10.2147/NDT.S41632.

[10] Sado, M. et al. (2013), “Cost of anxiety disorders in Japan in 2008: a prevalence-based approach.”, BMC psychiatry, Vol. 13, p. 338, http://dx.doi.org/10.1186/1471-244X-13-338.

[61] Santé Publique France (2020), Covid-19 : une enquête pour suivre l’évolution des comportements et de la santé mentale pendant l’épidémie, https://www.santepubliquefrance.fr/etudes-et-enquetes/covid-19-une-enquete-pour-suivre-l-evolution-des-comportements-et-de-la-sante-mentale-pendant-l-epidemie (accessed on 25 November 2020).

[86] Saxena, S. and M. Maj (2017), Physical health of people with severe mental disorders: leave no one behind, Blackwell Publishing Ltd, http://dx.doi.org/10.1002/wps.20403.

[79] Schiff, D. et al. (2017), “A police-led addiction treatment referral program in Gloucester, MA: Implementation and participants’ experiences”, Journal of Substance Abuse Treatment, Vol. 82, pp. 41-47, http://dx.doi.org/10.1016/j.jsat.2017.09.003.

[63] Siva, N. (2021), “Severe mental illness: reassessing COVID-19 vaccine priorities”, The Lancet, Vol. 397/10275, p. 657, http://dx.doi.org/10.1016/S0140-6736(21)00429-3.

[35] Solmi, M. et al. (2017), Safety, tolerability, and risks associated with first-and second-generation antipsychotics: A state-of-the-art clinical review, Dove Medical Press Ltd., http://dx.doi.org/10.2147/TCRM.S117321.

[80] Spiess, M. and R. Ruflin (2018), Coordinated care at the interface (acute) psychiatry - acute somatic medicine (Koordinierte Versorgung an der Schnittstelle (Akut-)Psychiatrie – Akutsomatik, https://www.bag.admin.ch/bag/de/home/strategie-und-politik/nationale-gesundheitspolitik/koordinierte-versorgung/patientengruppen-und-schnittstellen-koordinierte-versorgung/menschen-mit-psychisch-somatischer-komorbiditaet-kov.html (accessed on 4 March 2021).

[78] Splett, J. et al. (2019), “Teacher Recognition, Concern, and Referral of Children’s Internalizing and Externalizing Behavior Problems”, School Mental Health, Vol. 11/2, pp. 228-239, http://dx.doi.org/10.1007/s12310-018-09303-z.

[29] Stubbs, B. et al. (2018), “Association between depression and smoking: A global perspective from 48 low- and middle-income countries”, Journal of Psychiatric Research, Vol. 103, pp. 142-149, http://dx.doi.org/10.1016/j.jpsychires.2018.05.018.

[72] Student Minds (2018), Know Before You Go, https://www.studentminds.org.uk/knowbeforeyougo.html (accessed on 28 February 2021).

[66] Taquet, M. et al. (2021), “Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA”, The Lancet Psychiatry, Vol. 8/2, pp. 130-140, http://dx.doi.org/10.1016/S2215-0366(20)30462-4.

[26] Teasdale, S. et al. (2019), Dietary intake of people with severe mental illness: Systematic review and meta-analysis, Cambridge University Press, http://dx.doi.org/10.1192/bjp.2019.20.

[27] Thornicroft, G. (2013), Premature death among people with mental illness, http://dx.doi.org/10.1136/bmj.f2969.

[33] Wahlbeck, K. et al. (2011), “Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders”, The British Journal of Psychiatry 199, pp. 453-458, http://dx.doi.org/10.1192/bjp.bp.110.085100.

[62] Wang, Q., R. Xu and N. Volkow (2021), “Increased risk of COVID‐19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States”, World Psychiatry, Vol. 20/1, pp. 124-130, http://dx.doi.org/10.1002/wps.20806.

[71] Werner, S., D. Malaspina and J. Rabinowitz (2007), “Socioeconomic Status at Birth Is Associated With Risk of Schizophrenia: Population-Based Multilevel Study”, Schizophrenia bulletin, Vol. 33, pp. 1373-8, http://dx.doi.org/10.1093/schbul/sbm032.

[31] Westman, J. et al. (2018), “Increased cardiovascular mortality in people with schizophrenia: A 24-year national register study”, Epidemiology and Psychiatric Sciences, Vol. 27/5, pp. 519-527, http://dx.doi.org/10.1017/S2045796017000166.

[20] WHO (2021), Mental health preparedness and response for the COVID-19 pandemic Report by the Director-General, https://unsdg.un.org/resources/policy-brief-covid-19-and-need-action-mental-health,.

[88] WHO (2020), Enhancing mental health pre-service training with the mhGAP Intervention Guide: experiences and lessons learned, https://www.who.int/publications/i/item/9789240007666.

[17] WHO (2020), The impact of COVID-19 on mental, neurological and substance use services, https://www.who.int/publications/i/item/978924012455 (accessed on 3 December 2020).

[22] WHO Europe (2019), Multisectoral action for Mental Health, WHO Europe, Copenhagen.

[36] WHO Regional Office for Europe (2017), Addressing comorbidity between mental disorders and major noncommunicable diseases, WHO Regional Office for Europe, https://www.euro.who.int/en/publications/abstracts/addressing-comorbidity-between-mental-disorders-and-major-noncommunicable-diseases-2017 (accessed on 3 March 2021).

[84] Yarborough, B. et al. (2016), “Improving lifestyle interventions for people with serious mental illnesses: Qualitative results from the STRIDE study”, Psychiatric Rehabilitation Journal, Vol. 39/1, pp. 33-41, http://dx.doi.org/10.1037/prj0000151.