The transversality of mental health in a “European Health Union”

Alessandra Silveira (Editor) and Maria Inês Costa (Master's student in Human Rights at University of Minho)

The Portuguese Presidency of the Council of the EU 2021 Program reinforces the need to strengthen cooperation between Member States in the field of health, to support actions needed to increase the responsiveness of health services to threats to public health.[1] In the debate regarding a “European Health Union” it is important to underscore that mental health is a transversal approach to all health policies. However, despite the many targeted resolutions covering urgent aspects of mental health,[2] the debate on this issue never found its way to a comprehensive European framework.[3] Indeed, it is critical to consider the impediments to mental healthcare, the costs of neglecting mental healthcare, and Covid-19 impact on increasing fatigue and its consequences on mental healthcare.[4]

Above all, it is important to ponder that many mental disorders are shaped, to a large extent, by social, economic, and environmental factors[5] – that is, many of the causes and triggers of mental disorders reside in the Europeans daily life conditions.[6] According to the World Health Organization (WHO), the response to social, environmental, and economic determinants of health requires multisectoral approaches anchored in a human rights perspective. Multisectoral action is central to the SDG (“sustainable development goals”) agenda because of the range of determinants acting upon people’s health – such as socioeconomic status, gender, and other social determinants.[7]

Hence, in October 2020, the Order of Portuguese Psychologists released a report on socio-economic impact and mental health,[8] according to which health depends, more and more, on a set of socioeconomic determinants that interrelate, sustain, and are sustained by social and economic inequalities, limiting citizens’ choices and the adoption of pro-health behaviors. Therefore, conceiving mental health and the budgetary resources allocated to it solely from a medical perspective – tending to the prescription of psychotropic medication in primary health contexts – leads to non-observance of the various determinants of health and well-being, underestimating the narrative and principles of human rights.[9]

In fact, good mental health is essential to individual well-being and is the structural basis for building happy, fulfilled, and productive lives.[10] This is the statement with which the first chapter of the 2018 OECD publication “Health at Glance” begins, under the main topic “Promoting mental health in Europe: why and how?”.  The report found that more than 1 in 6 people in EU Member States had a mental health problem in 2016, leading to deteriorating physical health and reduced resilience in all aspects of life. At the time, mental health problems affected around 84 million people in the EU,[11] being anxiety disorder and depression the main mental illnesses experienced by Europeans. One of the trends pointed out by the report – and of enormous relevance to the transversal and multisectoral perspective of mental health – is that, in the EU, individuals belonging to lower income groups are twice as likely to develop chronic depression than those belonging to high income groups.

In addition, the economic costs of mental health are substantial. According to the aforementioned OECD report, during the period under review, 1.3% of European GDP corresponded to direct expenditure on healthcare, 1.2% corresponded to expenditure on social security programs and 1.6% corresponded to indirect costs in the labor market, derived from lower employment rates and reduced productivity. The costs of mental health problems, in total, exceeded 4% of European GDP – which underlines the need to prioritize mental health on national and European policy agendas. These costs are also closely related with poor individual mental health, which leads to losses in productivity, increased absenteeism from work and, ultimately, loss of employment. Thus, the report exposed the vicious cycle according to which the longer people are without work, the more harmful the consequences for their mental health become. In addition, the data collected reveal that people who reported having chronic depression have lower employment rates than the rest of the population.

Poor mental health was already acknowledged as a serious problem globally before the year 2020. However, societies are facing a greater challenge nowadays, because the Covid-19 pandemic, by negatively impacting daily living conditions, acts as a catalyst for the deterioration of the population’s mental health, especially of the most vulnerable groups at the socioeconomic level, taking into consideration i) the isolation in the domestic sphere and lack of face-to-face contact; ii) the generalized phenomena of layoff and unemployment – and the consequent loss of income; iii) the distinct housing conditions and their impact on the well-being of individuals; iv) the physical and mental exhaustion of health professionals; v) the increasing lack of support given to informal caregivers, etc.

According to the report of the Portuguese Health Institute Doutor Ricardo Jorge on mental health in the Covid-19 context (October 2020), although the pandemic is, on a first level, a physical health crisis and a socio-economic crisis, if measures are not implemented in a timely manner, a serious mental health crisis may be on the horizon.[12] The results of this study indicate that some of the determinants analyzed, namely the maintenance of hobbies, daily routines, and physical activity, protect the general population from aggravated psychological suffering, anxiety, depression and, particularly notorious, from post-traumatic stress. Among the conclusions reached, it is worth mentioning that the unemployed and individuals with an income below € 1000 per month have a higher prevalence of psychological distress, as well as moderate to severe anxiety or depression.[13] This definitely shows the correlation between mental health and well-being and social and economic determinants. It is not exactly groundbreaking the realization that poverty is a key indicator for poor health. Poverty both causes and is a result of poor health.[14].

In 2011, the Council of the EU invited Member States and the Commission to set up a Joint Action on mental health and wellbeing under the EU-Health Programme. That Joint Action began its work in 2013 and it involved 25 Member States as well as Iceland and Norway, being its outcome the “European Framework for Action on Mental Health and Wellbeing”. The document emphasizes that the overall financial costs of mental disorders, including direct medical as well as indirect costs through care and lost productivity, amount to more than Euro 450 billion per year in the EU.[15] It also points out that many of the individual, family, and social determinants of mental health reside in non-health policy areas – namely, social policy, taxes, education, employment and community design.[16]

Despite efforts to date to improve the response to mental health problems, the lack of coverage of preventive interventions, as well as the inadequate treatment for mental disorders continued to prevail in Europe. Among the factors that can explain the lack of progress, the following are of enormous relevance: i) social stigma on the topic of mental health, which directly affects those who experience some type of mental disorder and delays their search for help; ii) permanence of outdated treatment and stigmatized institutional infrastructures, to the detriment of investment in community-based services; iii) lack of training of health professionals (in particular in primary care) on mental health; iv) lack of awareness and knowledge across society about mental health.[17]

In addition, according to WHO, people with disabilities need more healthcare or more specialized healthcare: there are more unmet health needs, compared to the rest of the population.[18] Persons with disabilities include those who have long-term physical, mental, intellectual, or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.[19] The human rights lens applied to mental health undoubtedly marks a position in defense of a social model of disability at the expense of a solely and outdated medical model of disability.[20] The social model does not separate the person with a mental disorder from society, aiming fundamentally at their integration and the fulfillment of their potential, bearing in mind the societal factors that may or may not contribute to that end – that is, against its stigmatization and marginalization.

On June 15, 2020, the Portuguese Offices of the Ministers of Justice and Health launched a joint Order[21] (no. 6324/2020) regarding the constitution of a working group to present a proposal to revise the Mental Health Law, capable of incorporating knowledge from different research fields and of rethinking the Portuguese legal mechanisms related to the problem of mental health. This may be a good sign of integrating a cross-cutting approach to mental health. Indeed, people with mental illness and cognitive disabilities generally do not have access to safe and affordable housing, are often excluded from employment and education, experience high levels of loneliness and social isolation, abuse, neglect, and continue to be exposed to the usage of continuous containment and confinement.[22]

Facing the seriousness of the mental health current scenario, it is of enormous relevance to reflect on the role the EU should play to tackle the severity of its consequences.[23] The EU has competence in public health matters shared with Member States (common safety concerns in public health matters, Article 4/2/k TFEU). Besides that, EU is competent to carry out actions to support, coordinate or supplement the actions of the Member States (protection and improvement of human health, Article 6/a TFEU). Article 168/1 TFUE states that a high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities. Thus, the Union action, which shall complement national policies, shall be directed towards improving public health, preventing physical and mental illness and diseases, and obviating sources of danger to physical and mental health. The dividing line between the EU’s shared and complementary competences on health matters is not always easily identifiable, and a careful analysis of the teleological and systematic elements that guide the division of competences is necessary in order to determine the scope of each of them.

In any case, Covid-19 pandemic will be brought under control sooner or later – and when the sanitary challenge passes, it is crucial that the mental resilience of European citizens shows to be greater than ever. By all means, a resilient Europe needs resilient citizens.[24]

[1] See 2021Portugal.EU, “Programa da Presidência Portuguesa do Conselho da União Europeia, 1 janeiro a 30 junho 2021”, 2021, 10,, accessed February 2, 2021.

[2] Regulation (EU) 282/2014 is the legal basis for the current EU Health Programme, the EU strategy for ensuring good health and healthcare, with the goal to support national health policy priorities, with a budget of €449.4 million. For more information see, accessed February 12, 2021.

[3] See Matteo Ciucci, “Mental health during the COVID-19 pandemic (Briefing)”, Policy Department for Economic, Scientific and Quality of Life Policies, Directorate-General for Internal Policies, European Parliament, 2020, 2,, accessed February 2, 2021.

[4] Matteo Ciucci, “Mental health during…”,.1.

[5] See World Health Organization and Calouste Gulbenkian Foundation, “Social determinants of mental health”, Geneva, World Health Organization, 2014, 12.

[6] World Health Organization and Calouste Gulbenkian Foundation, “Social determinants of mental…,.13.

[7] See WHO’S Thirteenth general programme of work 2019-2023, “Promote health, keep the world safe, serve the vulnerable”, 2019, 10,, accessed February 12, 2021.

[8] See Order of Portuguese Psychologists, “Crise económica, pobreza e desigualdades – Relatório sobre impacto socioeconómico e saúde mental em Portugal”, Lisboa, 2020,, accessed 12 February, 2021.

[9] See Faraaz Mahomed, “Addressing the problem of severe underinvestment in mental health and well-being from a human rights perspective”, Health and Human Rights Journal, 22(1), 35–49, 2020, 38.

[10] See OECD, “Promoting mental health in Europe: Why and how?”, in “Health at a Glance: Europe 2018, State of Health in the EU Cycle”, OECD Publishing, Paris, 2018, 19,, accessed January 24, 2021.

[11] OECD, “Promoting mental health,… 21.

[12] See Teresa Caldas de Almeida, et al., “Saúde mental em tempos de pandemia – SM-COVID-19: relatório final”, Lisboa, Instituto Nacional de Saúde Doutor Ricardo Jorge, IP, 2020, 205.

[13] Teresa Caldas de Almeida, et al., “Saúde mental”,.. 206.

[14] See Tamara Hervey, “Health equality, solidarity and human rights in European Union law”, Alessandra Silveira, Mariana Canotilho, Pedro Froufe (eds.), Citizenship and solidarity in the European Union – from the Charter of Fundamental Rights to the crisis, the state of the art, Peter Lang, Brussels, 2013. 341.

[15] See “European Framework for Action on Mental Health and Wellbeing – EU Joint Action on Mental Health and Wellbeing”, Brussels, 2019, 6,, accessed January 22, 2021.

[16] See “European Framework for Action on…”, p. 9.

[17]See “European Framework for Action on…”, p. 5.

[18] See World Health Organization, “Disability and health”, 2018,, accessed January 29, 2021.

[19] See Cláudia Monge, “Artigo 25.º – Saúde”, Joaquim Correia Gomes, Luísa Neto, Paula Távora Vítor (eds.), Convenção sobre os Direitos das Pessoas com Deficiência – Comentário, Imprensa Nacional-Casa da Moeda, Lisboa, 2020, 233ff.

[20] See António Araújo and Gonçalo Saraiva Matias, “Artigo 26.º – Integração das pessoas com deficiência”, Alessandra Silveira, Mariana Canotilho (eds.), Carta dos Direitos Fundamentais da União Europeia Comentada, Almedina, Coimbra, 2013.

[21] Joint Order towards the constitution of a working group to present a proposal to revise the Mental Health Law (no. 6324/2020),, accessed February 2, 2021.

[22] See Lisa Brophy, “Legal Provisions, Advocacy, and Empowerment”, Springer Nature Singapore Pte Ltd., Mental Health and Social Work, Social Work, 2019,7-8.

[23] See “EU Compass for Action on Mental Health and Well-Being”, a web-based mechanism used to collect, exchange and analyse information on policy and stakeholder activities in mental health, which includes the identification and dissemination of European good practices in mental health,, accessed February, 12, 2021.

[24] See “European framework for action on mental health and wellbeing – EU joint action on mental health and wellbeing”, Brussels, 2019, p. 6,, accessed January 22, 2021.

Picture credits: Wokanpix.

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