Is Europe’s mental health still in crisis?

Mary McCaughey (00:00:24:22 - 00:01:03:16): Good morning and welcome to this edition of #EurofoundTalks. Today, Eurofound talks mental health. It has become a regular topic of discussion over the past decades, but perhaps unsurprisingly, in today's world with the various challenges happening at both the global and indeed national and European levels, things are not good for many of our citizens.

Mary McCaughey (00:01:03:18 - 00:01:57:06): Since the COVID-19 pandemic, we have seen an upsurge in mental health issues. There has been an increase in anxiety and depression. It has levelled off, but poor mental health does seem to have become a ubiquitous part of our society today. So to explore this topic, I'm joined by senior research manager, Hans Dubois. Hans has joined us previously on other issues, not least on the issue of housing, which perhaps he will be able to say, 'Has that got some level of input and contribution to the issue of mental health across Europe?' And we're going to look at the picture in the European Union and maybe look at some of the solutions that we could put to use. So Hans, it's a very difficult subject for us to deal with today, but it is one that we need to explore.

Mary McCaughey (00:01:57:07 - 00:02:18:03): So you're very welcome. We actually experienced the kind of crisis that we seem to believe we are in terms of statistics for mental health. It has a dramatic impact on human lives, but also in terms of cost. Mental health can certainly be seen as a crisis. However, we have looked at a whole range of data.

Hans Dubois (00:02:18:09 - 00:02:41:09): You compared the situation before the pandemic and after. We have not found a dramatic increase during the pandemic. Yes, there has been clearly an increase in the number of people with poor mental health, and this emphasises how important the context is, because obviously, due to the circumstances of the pandemic, there was a sudden increase in mental health problems.

Mary McCaughey (00:02:41:12 - 00:03:13:04): So what you're saying is that we have seen since COVID, of course, we have seen the rise during COVID, but we're not seeing a spike in the way that we would have thought from what we're hearing in the media. Is that correct?

Hans Dubois (00:03:13:06 - 00:03:36:22): Yes, our data suggests, through the data that we put together from all kinds of different sources, that after the pandemic, the levels for mental health have quickly levelled off again. Okay, but it is still very common in a way that perhaps it wasn't prior to the COVID pandemic. And we're seeing that in particular areas. Can you indicate to me what those areas are? I mean, you talked earlier in some of your key findings from this report about older men and younger women. Are those the groups that are most affected?

Mary McCaughey (00:03:36:22 - 00:03:57:01): Are younger people more affected than older people? Can you just give us a broad picture of what we're looking at in terms of the different groups?

Hans Dubois (00:03:57:01 - 00:04:22:21): Yes, absolutely, and you point to the right groups. While overall it seems to have similar levels to where mental health is at the moment before the pandemic, you have seen a clear increase among young girls, for instance, and younger women, and also among older men. And do we know why that is, Hans? For young girls, there could be a relation with increased social media usage, for instance. And among the oldest men, there could be a relation with increased loneliness among this group.

Mary McCaughey (00:04:22:24 - 00:04:44:23): And when you talk about social media usage, because in fact, that's the sort of the default explanation for younger women a lot of the time. But our understanding is that young men are equally active on social media. So what is that related to? Is it about insecurities to do with your body, with your appearance, with your performance, your career?

Hans Dubois (00:04:44:23 - 00:05:12:12): What is it for women in particular? Do we know that? Yeah. So we draw on data looking at problematic social media usage. And there has been a big increase among girls aged 11, so very young. Yes, indeed. For boys, there's a larger proportion of problematic gaming, which also comes with mental health issues.

Hans Dubois (00:05:12:14 - 00:05:56:21): However, the use as such of social media is not always leading to mental health problems. It's not always negative. But there is a group for whom it is problematic, and that's particularly young girls in this case. Yeah. And those girls, as you talked about earlier, they have a higher level of reporting, so that when they are feeling anxious or depressed or suffering from mental health issues to some degree, they do report this, or there's an increase in their reporting. In general, the pandemic seems to have reduced a little bit the stigma on mental health. People are more likely to speak about it, in particular younger generations, and probably also to seek help. And so that is certainly the pandemic's doing. This increased attention for mental health is certainly one of the reasons for that. So there's a positive aspect in fact to this, which is perhaps not so clear when we see the statistics in terms of a rise. But it could also be that there is a general greater awareness of the need to report.

Hans Dubois (00:05:56:21 - 00:06:21:19): Absolutely. However, there are still a lot of stigma and discrimination against people with poor mental health, and that needs to be addressed because that's a large barrier in addressing their situation. And Hans, talk to me about the older men because, again, we would have a narrative of older men perhaps suffering greater degrees of loneliness. Would that be some element of the mental health struggles that they're facing?

Hans Dubois (00:06:21:21 - 00:06:48:16): Yes. So there's a problem. On the one hand, we have data which is about service usage. And when you see an increase in certain usage of treatment for depression, well, that can mean two things: that people actually have more depression, but it can also be caused by people seeking care more quickly. And it can be because of improved access and decreased stigma, etc.

Hans Dubois (00:06:48:18 - 00:07:13:11): So you cannot really know whether it's because of increased prevalence of poor mental health. Now, when you look at survey data, there are also all kinds of biases. People may be more inclined to report, as we just spoke about. Now, for older people, and loneliness is a particular problem for older people, in poorer mental health more generally, that's in surveys very often the oldest age groups are not well represented, so they exclude people who are in nursing homes.

Hans Dubois (00:07:13:11 - 00:07:45:27): They exclude groups of older people. It may not be so easy to include in the surveys. And so when you look at one of the rare surveys which includes people over the age of 50, very well, that's the SHARE survey, then you see actually people, both men and women over 80 are much more likely to be at risk of depression. Okay. Than younger groups in that age group.

Hans Dubois (00:07:45:27 - 00:08:14:07): So the oldest people over 80 are much more likely to be at risk of poor mental health. So that more generally. Then, about loneliness: so we looked at whether single households are more likely to be at risk of poor mental health. That's true mainly also for single parents, by the way. Many of these single households are indeed more likely to be at risk of depression, for instance.

Hans Dubois (00:08:14:10 - 00:08:41:14): However, it is only the case if they have no confidants. So a single household which actually are on a daily basis in touch with other people, are active, are not so much at risk of poor mental health. So I wouldn't generalise or stereotype people living alone. However, in several countries and in the EU overall, you can see that in particular the oldest group of men and in particular in rural areas are more often at risk of poor mental health.

Mary McCaughey (00:08:41:14 - 00:09:15:27): Okay. And tell me, in terms of trends, what have we seen, because you talked there about COVID, but over the past decade, for example, what kind of trends have we seen? What would you be able to tell me about the increases or indeed stagnation or decreases?

Hans Dubois (00:09:15:29 - 00:09:41:10): I think it's important to see the groups which are most at risk of poor mental health, which they include. To answer your question, and that includes a group of workers, which is those working in health and social work. That's a big group. And 1 in 5 women in employment actually works in that sector. That's health care, that's long-term care, that's childcare. Now they are at particular risk of poor mental health.

Hans Dubois (00:09:41:17 - 00:10:09:16): 1 in 4 of them reports that they feel emotionally drained after their working day. Now education's also high, for instance, with one fifth of workers reporting that. So that's the sector which is most at risk of poor mental health. It grew tremendously over the past decades. Okay. By one third, and they're mostly women who work in that sector. So that is, for instance, a clear trend which increased among a certain group at risk.

Mary McCaughey (00:10:09:18 - 00:10:35:13): But are you also picking up those who don't have jobs, who are unemployed? And you would assume that unemployment would also be a factor?

Hans Dubois (00:10:35:15 - 00:11:01:25): Absolutely. So by focusing on workers, you risk ignoring that people who are unemployed are actually at the biggest risk of poor mental health. And there comes a problem when we compared data across time, because we are in a period of relative low unemployment.

Hans Dubois (00:11:01:25 - 00:11:28:04): So things may look better than they would have looked. So we're at similar levels of unemployment as in the more distant past. So that is key. And you see that's very interestingly among persons with disabilities. Persons with disabilities are more often at risk of poor mental health, but not because they have a disability, but because they face all these barriers and discrimination in society.

Mary McCaughey (00:11:28:04 - 00:11:51:07): And one of them is not being in employment. So if you look at people with disabilities in employment, then their rates are lower. But likewise, as you talked about for older people, their lack of engagement is what determines their mental health, rather than the age per se. And the same with the disability. It's the lack of access or ability to participate or engage.

Hans Dubois (00:11:51:07 - 00:12:27:27): And that engagement often comes from work. But I think as a retired person, it's also important to look at engagement beyond employment alone for older people, for instance. And in terms of countries, have we got similar rates across the European Union and indeed Norway, or are we seeing pockets of different countries that have higher rates? Of course, it's always tricky to compare countries when you look at survey data, how likely people are to report poor mental health, for instance, there's a lot of societal context as well, cultural context with respect to all of that.

Hans Dubois (00:12:27:27 - 00:12:58:11): Yeah, stigma differs per country. However, if you look at a very clear and prominent risk factor, it's related to unemployment, but not alone. It's having lower socioeconomic status. It can be education, that can be income. Then you are much more likely to be at risk of poor mental health. And this situation, facing difficulties making ends meet, etc. is much more common in certain countries in Europe. So in these countries, you also tend to see poor mental health.

Mary McCaughey (00:12:58:11 - 00:13:21:21): So making ends meet, there's a correlation with poor mental health. Yes. Or not being able to make ends meet. So therefore we look at the countries that have particular difficulties, perhaps higher levels of unemployment, economic issues at play. And we can expect to have higher rates of mental health reporting. I mean, one of the issues that you raised in the report, which I find particularly troubling, is the issue of suicide. And although you were saying earlier that there isn't the spike that perhaps people perceive in mental health issues, in terms of reporting and in terms of people accessing, suicide is a very stark indicator, and here you have seen that there is concern about a growing level of suicide.

Mary McCaughey (00:13:21:23 - 00:13:56:13): And here, particularly young people, I read that from those in the bracket of 15 to 29. It's the leading cause of death for this group. Well, what is happening here, Hans?

Hans Dubois (00:13:56:15 - 00:14:25:18): I think when we speak about suicide, the first thing to acknowledge is that there has been a dramatic drop in suicides since the 80s, and the drop has been very, very large. The explanation for this drop can be that in general, living conditions improved in the EU and in particular in the countries where the drop has been largest in post-communist countries, but also better care for people with mental health problems, but also better health care. So fewer suicide attempts leading to death. So there's been an incredibly large drop in suicides.

Hans Dubois (00:14:25:20 - 00:14:52:20): It's been really a success in the European Union. During what period? From the 1980s up until late in this century. So, only since the last few years, there has been a stabilisation at these much lower levels. And in the last few years, there has been a small increase and the increase was largest in the latest data available.

Hans Dubois (00:14:52:20 - 00:15:18:12): And that's from 2021 to 2022. But there has been indeed a small increase. And we see from more recent national data that it doesn't seem to be going the other way, but it just seems to be further small increases. And when they say small, they're small compared to the large decrease which has occurred. But they're still about human lives.

Mary McCaughey (00:15:18:12 - 00:15:43:16): And, and when you say the last few years, can we pinpoint when we would have seen that sort of stagnation of the decline in suicide rates and now the small incremental increases? Where did that start?

Hans Dubois (00:15:43:18 - 00:16:11:04): Yeah, it was before the COVID pandemic. It wasn't since more or less 2017. And a clearly bigger increase happened now with the recent data that's from 2021 to 2022. But there was already an increase before in terms of certain groups. And there, we can see that young girls, and the oldest men, so, 85 and over, there we saw increases in suicides.

Mary McCaughey (00:16:11:06 - 00:16:37:24): But your research is showing also that men are three times more likely than women. Do we know why that is?

Hans Dubois (00:16:37:24 - 00:16:59:27): So there are different reasons for that. Firstly, I think it's important to highlight that in general, women are more at risk of poor mental health. You can see that in the surveys. You can see that from primary health care usage data. Okay. You can still say, 'Well, maybe women are more likely to report it.' That may be partly true.

Hans Dubois (00:17:00:00 - 00:17:32:09): Women are certainly more likely to seek care on average. However, there are clear explanations for this. Women face larger negative inequalities at work. They face inequalities in their profession and in housework at home, and they face more often domestic violence than men do. So, they have all kinds of risk factors which indeed make them more likely to suffer from poor mental health.

Hans Dubois (00:17:32:09 - 00:17:58:18): But they are more likely than men to seek help on average, and other things. So, for instance, we see a survey that said, may still be about a relatively small group, actually, many men, or more than women, are in care for substance abuse or alcohol abuse. And that's maybe one of the expressions of not having sought care for mental health problems, for instance.

Hans Dubois (00:17:58:18 - 00:18:25:23): Of course, these relations are complex, but that clearly could be one of the examples. And also, it's important to note that the data are very clear about deaths from suicide. Few countries have data from attempted suicides. We do map some of these data in the reports. And there the picture is different. So there, it's hard to measure.

Hans Dubois (00:18:26:00 - 00:18:48:17): Usually it's hospitalisations and the reasons for that are being used. And there we see more equal levels of women and men. Okay.

Mary McCaughey (00:18:48:19 - 00:19:17:05): I mean, you referred earlier to the stigma, the issue of stigma, and that that has improved to some degree across the European Union and that sort of fear of reporting has perhaps diminished a little. But the the access to care which comes with reporting, are there significant differences between member states in terms of that access, or is there a rural-urban divide? Is there a very visible difference between northern Europe and southern Europe in these things?

Hans Dubois (00:19:17:05 - 00:19:40:13): So in terms of access to care, there is in general, and I was myself surprised about it. And we mapped so the entitlement to mental health care across the European Union and actually is pretty good. Most people are entitled to free or low-cost mental health care if they need it across the European Union, and in particular for the for the most urgent types of needs. However, we already spoke about stigma and discrimination, which is a big issue.

Hans Dubois (00:19:40:17 - 00:20:06:00): So that makes it so many people do not seek the care they need. And second, yes, many people are entitled to this mental health care, but capacity is very low. In certain areas in Europe, and we see that waiting lists are a key problem in this area. So many people who need the care cannot access it due to waiting lists.

Hans Dubois (00:20:06:00 - 00:20:32:09): And this is particularly in rural areas. Access to mental health care is very problematic because of these capacity limitations. And in general, it's in many countries noticed that it's particularly problematic for child and adolescent mental health care needs.

Mary McCaughey (00:20:32:09 - 00:21:00:13): And what does that mean for people's perception of mental health care in their country or in their community?

Hans Dubois (00:21:00:13 - 00:21:34:02): So maybe I should add one more thing before it it it's so these are about urgent need. But for more mild or moderate forms of poor mental health, coverage is less often. Sometimes it is available publicly, but it's really impossible to access due to all these capacity limitations. So people may need to buy them on the private market. These services. This is very expensive to buy the service of a private psychologist or psychiatrist. We map these, these costs in the report. In most member states you would need one monthly minimum wage to cover 10 sessions, for instance. And it's not accessible for everybody. I assume that the report also looks at what the outcomes would be when people do access this care, and that I'm assuming, perhaps incorrectly, that the outcomes are improved.

Hans Dubois (00:21:34:05 - 00:21:59:20): Yes. And there's one country with a very nice example, Italy. They implemented the entitlements for people with low incomes to access these, this type of support for people with mental health problems, access to a psychologist for people with low incomes. And you see, indeed, that this has a positive impact on these groups' mental health. And so in general, yes.

Hans Dubois (00:21:59:22 - 00:22:34:22): But overall, that relates to your previous question. There's it's really a very stark finding of the report, also that of people who experience emotional or psychosocial problems. Nearly half of them rate mental health care services at four or below out of ten. They may have used it or not, but it may be a barrier for them to use it because they don't know any mental health care provider which they trust, or which they think the quality is good enough, and those who use it are not always satisfied with it.

Mary McCaughey (00:22:34:22 - 00:23:15:04): So yes, one thing is providing the services, and the other thing is providing the services that are needed that have the kind of impact that we would wish. Yeah. And and when we look at all of this, Hans, I mean, you've talked about the sort of development and evolution of trends over the last few decades. Clearly, what we have seen from what your report shows is that things were improving, particularly with respect to mental health issues and suicide rates up until more or less 2017. Prior to COVID, things have declined.

Mary McCaughey (00:23:15:07 - 00:23:38:23): There hasn't perhaps been the same spike that we thought or that we understand, but that we are seeing an incremental rise in mental health issues in terms of both reporting. But more worryingly, perhaps entirely, is in terms of suicide rates. So that's up until today. And I assume with what's going on in the world, things are not likely to improve anytime soon.

Hans Dubois (00:23:38:25 - 00:24:08:18): But do you have an idea of what kind of trends we could see coming down the tracks over the next decade or so? The COVID pandemic, actually, as the Great Recession did, it made it very clear that very quickly the situation can deteriorate if the context allows for that to deteriorate. So very clearly, the pandemic and the situation caused a lot of poor mental health.

Hans Dubois (00:24:08:21 - 00:24:34:15): So it's highly context-specific. So if the future gives us peace, prosperity and no pandemics, I think we're likely to see a reversal of that trend. Yes. Or almost as radically as we see the increase. Yeah, but if that's not the case, then a recession hits, more expense, if there's another pandemic, then many more people will face poor mental health again.

Mary McCaughey (00:24:34:16 - 00:24:58:20): And I assume also we're not even talking at the absolute, you know, macro level. We're also talking about housing. We're talking about economic insecurity. We're talking about labour markets. We're talking about unemployment. I mean, these are also things that are impacting directly on people's mental health as a sort of a more micro, if you like, level.

Hans Dubois (00:24:58:23 - 00:25:22:23): Yes. And people worry about climate change. It's another one, about housing. Indeed. We saw that many young people in particular worry about the housing situation and reported that that impacts their mental health. Not only that, also people facing housing insecurity, which was during the Great Recession, a key problem that people needed to leave their house.

Hans Dubois (00:25:22:25 - 00:25:56:27): Now that causes a lot of mental health problems. So these issues are maybe easier to address than the bigger macro issues. Such as, one can do things to reduce loneliness and one can do things to improve the housing situation. And importantly, one can do things to address discrimination because there are many groups which are more likely to face discrimination, and due to that are more likely to face mental health problems.

Hans Dubois (00:25:57:00 - 00:26:43:07): It does include LGBTQ+ for instance. So it's also disabled people and importantly, also people who have poor mental health or who have had poor mental health in the past. So one thing which our report also argues is that people who have had poor mental health in the past are often pointed at as being more likely to have poor mental health in the future, and that is a reason, for instance, for them to be discriminated against in insurance policies, which makes their life more difficult, which is kind of a self-fulfilling prophecy, because all these difficulties in life, which they face because they are discriminated, because they have had mental health problems in the past,

Hans Dubois (00:26:43:09 - 00:27:19:00): make them more obviously more likely to face mental health problems in the future. And so it's a very complicated multidimensional issue, this one. And it's certainly not one that we have a quick fix for at the end of a podcast. But having carried out this research and having become fairly expert in this area over several years, if you were to talk to me in three, what would be your three main policy recommendations to address some of the issues that we've discussed today?

Hans Dubois (00:27:19:03 - 00:27:46:00): Now, the first one is that I think it's key to make sure people can access support when needed, and that requires addressing stigma and discrimination. People with poor mental health. It also requires to work through places where people spend most of their time in schools. It's work more generally in society to raise awareness so people recognise problems and are more likely to seek support when needed.

Hans Dubois (00:27:46:03 - 00:28:11:06): It also requires engaging with professionals who are more likely to be in contact with people who face poor mental health, like GPs. They are made more aware and medical specialists in other fields, like gynaecologists, for instance, that they're more aware of the risk of poor mental health. Second, it's key that support also actually meets people's needs.

Hans Dubois (00:28:11:12 - 00:28:41:24): To achieve this, it is important to involve people who've had poor mental health or are experiencing poor mental health, to involve them in the design of policies and in the design of services to make sure they will meet the needs of people with poor mental health. And the third one, I think the most important one, and that's to take a step back when you narrowly focus on care services, it's addressing problems of people who already have poor mental health, which of course is Europe.

Hans Dubois (00:28:41:24 - 00:29:07:29): We would like to prevent these problems. And we see that the type of mental health problem, if we looked at depression, anxiety, is very often having causes which you can prevent. As we spoke about during this interview, they all come down to improved working and living conditions in Europe and to ensure employment inclusion. But also social inclusion.

Mary McCaughey (00:29:07:29 - 00:29:47:29): Yeah. So inclusion is a big part of the response to this. Certainly across all elements. Hans, thank you for today's discussion. It is sobering, there is no doubt. And as we leave today, I suppose we're very aware that there are perhaps people who are listening to this podcast who would be looking to access mental health care or support, and that they should find those services and will find them online, certainly accompanying this podcast. Should you wish to know more about this, please feel free to contact us here at Eurofound.

Mary McCaughey (00:29:47:29 - 00:30:22:02): And Hans is one of our experts on this particular topic. If you're also interested in issues which we've discussed in passing, such as equality, inclusion, working conditions, housing, labour markets, we have, of course, topic pages and much more research available for you to peruse on our website, so feel free to do so. In the meantime, you can follow us on our social media, on Facebook, on X and LinkedIn.

Mary McCaughey (00:30:22:02 - 00:30:40:24): And wherever you access your podcast, you can find us on Spotify or elsewhere. So thank you for listening today. I hope this has been informative and useful. Until next time when Eurofound talks to you.