Emily Hewlett, OECD Health Division
Winston Churchill famously called it the ‘black dog’. “It is that absence of being able to envisage that you will ever be cheerful again. The absence of hope. That very deadened feeling, which is so very different from feeling sad,” said JK Rowling. “I don’t want to see anyone. I lie in the bedroom with the curtains drawn and nothingness washing over me like a sluggish wave… I am inadequate and stupid, without worth. I might as well be dead” wrote Margaret Atwood, in Cat’s Eye.
They were talking all about depression.
Across the world, millions of people are struggling with their own black dog. The OECD estimates that one in two people experience a mental illness in their lifetime, and some 20% of the working-age population is experiencing mental ill-health at any given time[i]. According to the WHO, depression is now the leading cause of ill-health and disability worldwide; globally, more than 300 million people are living with depression[ii]. While some people experience depression only briefly, others find themselves battling the black dog for long periods, or find it returning again and again. And when people are suffering from a mental disorder, it has big consequences across their lives: when people are living with mental ill-health they have poorer educational outcomes and a higher risk of dropping out of school[iii]; they are more likely to be dismissed from work and 2-3 times more likely to be unemployed[iv]; and in serious cases depression can lead to people harming themselves, or even dying from suicide[v].
The good news is that there are some very effective ways to help prevent mental illness and promote mental wellbeing, to treat depression and other disorders, and to support people who are living with mental ill-health. For instance, actions to prevent depression and anxiety can bring life-long economic benefits to mothers and children, while certain workplace interventions could reduce the cost of lost productivity – notably sickness absence and presenteeism – by up to a third[vi]. We know, too, that evidence-based services – like psychological therapies, early intervention approaches, or pharmacological therapies – can facilitate and speed-up recovery from depression. And we know that if employers and workplaces can provide a supportive environment, and thoughtfully facilitate return to work after a sickness absence for depression, then this can be good for the individual’s mental health and good for workplace productivity.
However, places where these effective, evidence-based policies have been rolled out are the exception, not the norm. People with depression too often face unsupportive or disengaged schools or workplaces, find inadequate treatment provision or long-waits to get help, and are still weighed down by a heavy burden of stigma. Today, on World Health Day, policy makers across the world must commit to putting care for depression and mental illness at the centre of their health systems, and their health policy priorities. More needs to be done.
We need better information, to understand what works, and where countries are falling short; at OECD, we are particularly keen to further improve, international benchmarking of data and policies so as to drive improvements across countries. We need innovation to find the effective, novel, adaptable and affordable policies that work, for depression and for all mental disorders. And we need implementation, so that better policies for depression can already start transforming peoples’ lives.
More needs to be done, and we should start today.
[i] OECD (2015), Fit Mind, Fit Job: From Evidence to Practice in Mental Health and Work, Mental Health and
Work, OECD Publishing, Paris. http://dx.doi.org/10.1787/9789264228283-en
[v] OECD (2015), Health at a Glance 2015: OECD Indicators, OECD Publishing, Paris. http://dx.doi.org/10.1787/health_glance-2015-en
[vi] OECD (Forthcoming, 2017), Understanding Effective Approaches to Promoting Mental Health and Preventing Mental Illness.
“Mental health issues exact a high price on individuals, their families, employers and the economy,” said OECD Secretary-General Angel Gurría, “Policymakers have been too slow to act. Strong political leadership is needed to drive reform and tackle this issue.”
Winston Churchill, Virginia Woolf and millions of others have suffered in the past or still live with mental illness. As many as half of all people in OECD countries can be expected to suffer from mild to moderate mental ill-health at some point during their lives. And yet despite the scale of the problem, mental illness is still too often a second thought for health systems, and a forgotten issue for policy makers. For too long the widespread worldwide burden of mental illness has done little to galvanise a policy response: those suffering from mental ill-health often experience prejudice and fear, struggle to get the treatment they need, and are more likely to experience unemployment, inactivity and physical ill-health than the rest of the population.
The OECD has long been shedding light on the unacceptably high personal, societal and economic burden of mental ill-health. For several years, we have recommended policies countries need to introduce to tackle mental illness, to give those affected the care and services they deserve. In OECD’s Making Mental Health Count we show that there are unacceptable treatment gaps for mental illness, even in the most advanced countries. Too many people go without treatment or wait too long for treatment and are unable to access the most appropriate treatment. Evidence-based treatment for mild and moderate mental illness is often unavailable, patients have to wait a long time, or face high costs. For severe illnesses, comprehensive treatment plans tailored to patients’ needs are few and far between. The outcomes tend to be, as one could expect, poor. OECD data show that in Denmark, New Zealand, Norway, Sweden and Korea, individuals with bipolar disorder or schizophrenia have a mortality rate some 4 to 6 times higher than the general population.
Mental illness does not just reduce the wellbeing of affected people and their entourage. The economic costs of mental-ill health are high, too, as they can exceed 4% of GDP. The OECD report Fit Mind, Fit Job suggests that people with poor mental health are much less likely to be in work, and, when employed are more likely to be absent from work. Depending on the severity of the mental illness, the employment gap can be 15 to 30 percentage points relative to the rest of the population. Not surprisingly, people suffering from mental ill-heath face a risk of poverty that is 30% to double that of the total population.
There are better ways to tackle mental ill-health. Evidence-based services – like psychological therapies, early intervention approaches, or pharmacological therapies – should be made more easily and quickly accessible. We need front-line public servants – GPs, nurses, teachers, social workers – to understand how to spot the signs of mental illness, and to know where to direct people to get help. Employment and health care services ought to act fast – and work together – when mental health problems are recognised or diagnosed. We need better policies to allow those affected by mental ill-health to find jobs, to be fully productive at work and avoid protracted periods on sick leave when they would do better on the job.. Public policy, while essential, is not enough: we need to involve employers and social partners in the required actions to make the labour market inclusive for people with mental ill-health. And we need to act early because the onset of mental health problems is typically during youth and adolescence. Young people seek help even less than others but their education success suffers significantly thereby further impacting on their labour market chances later in life.
It is encouraging to see that policy makers are finally grappling with these challenges. Besides its analyses and striking statistics, the OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy provides a set of policy principles that help countries address, through an integrated approach, the impact of mental health problems on health, education, employment and social outcomes. This Recommendation, to which all OECD members countries have adhered, sends a very clear message: that mental health must be at the heart of health, employment, education and social policy making, giving countries the impetus to make this commitment a reality. Mental health is finally moving to the top of the global agenda, too. Political leaders, international leaders, thought leaders, and policy makers worldwide are slowly waking up to decades-old cries of campaigners, patients, families, and sufferers, and looking for ways to bring mental health care out of the shadows.
The status quo on mental health is no longer acceptable. The message is clear: we must all step up, together, to tackle mental ill-health. Now, it is the time to do it.
Across the OECD an estimated 20% of the working-age population suffer from mental ill-health, and the social and economic impacts of this burden of illness are huge, according to the OECD’s recent publication Making Mental Health Count. Together, the direct and indirect costs of mental ill-health can exceed 4% of GDP across the OECD, driven by expenditure on medical needs and social care costs, as well as higher rates of unemployment and more absences from work. According to OECD’s Sick on the Job report, people with severe mental illness are 6 to 7 times more likely to be unemployed, while those with a mild-to-moderate illness are 2 to 3 times more likely to be unemployed.
World Mental Health Day should also be a time to look beneath these striking statistics, and think about the millions of individuals living with mental ill-health across the OECD, and worldwide.
The reality of mental ill-health is often a grim one. Mild and moderate mental illnesses such as depression or anxiety are estimated to affect around 50% of people in their lifetime. For society and economies the costs are clearly significant, but for individuals the strain can be crippling. The heavy weight of depression and anxiety can stop individuals reaching their full potential in education or at work and put huge strain on relationships with loved ones. If untreated, individuals suffering from depression or anxiety can quickly find themselves out of work and dependant on sickness or disability benefits. Sick on the Job shows that after long periods of sickness absence, individuals find it harder and harder to return to work. Furthermore, the stigma around mental illness can lead people to hide their suffering, leaving them to struggle alone.
Individuals with severe mental illnesses, like bipolar disorder or schizophrenia, experience symptoms such as hallucinations and big swings in mood, which are hard to understand and tough to control. In too many instances, treatment is restricted to ‘what’s available’, rather than the care that best suits the individual’s needs or preferences. Individuals with severe mental illness also have poorer physical health, and higher rates of cardiovascular disease, diabetes and cancer. For health systems this means higher spending on services, and for individuals having a physical and a mental illness together can mean dying up to 20 years earlier than the average for people born around the same and in similar circumstances to them.
What, then, needs to be done?
The high social and economic costs of mental ill-health demand a more robust policy response. Individuals with mental ill-health should be offered care that is timely and appropriate for their needs, which puts them at the centre of care delivery, and makes treatment choice a reality. Sick on the Job stresses the importance of making employment a core desired outcome for mental health care and the need for employment services to address widespread mental health needs among jobseekers. With appropriate training, guidance and resources, the ability of teachers and managers to provide support with mental health problems can make a huge difference to individual wellbeing, and can be decisive in whether a student or worker stays in education or work or not.
The structure of mental health services, how they are set up, funded, and delivered to the individuals who need them, needs to be strengthened. Even as national pressures, costs and priorities bear down, OECD mental health systems need enough services, enough investment, enough evidence-based care, and enough cleverly designed service delivery to make patient-centred high quality care a reality for every individual that needs it.
Making mental health a policy priority would have significant and economic benefits, but most importantly it would enhance people’s lives. We can hope that by the next World Mental Health Day we are further along the road to societies where all individuals with mental health needs get the treatment, care and support that they need.
Depressing depression: mental illness at work OECD Insights
Work-life imbalance OECD Insights
Dementia: a modern killer OECD Observer
Former US President, Harry Truman, once said: “It’s a recession when your neighbour loses his job; it’s a depression when you lose yours.” This rings particularly true right now, when in some countries it might not just be your neighbour but your whole street, you included, that has lost their job. In fact, being unemployed has a large negative effect on your physical and mental health, as well as on how happy you are with your life.
There have been many indications that rates of anxiety and depression have been rising since the economic crisis. Europeans reported feeling “more negative” in 2010 than in 2005-06, and one study even linked the rise in suicides to the 2008 downturn, with nearly 5000 suicides above the expected level in the following year. This has severe consequences on the population’s well-being, with mental health being a key determinant of how healthy people are and how satisfied they are with their life. For instance, over the four years to 2012, average life satisfaction declined by more than 20% in Greece and by around 12% in Italy and 10% in Spain, all countries that experienced big rises in unemployment. Looking at the OECD Better Life Index, we see that these three countries now all do poorly in life satisfaction, with Greece coming last.
The OECD’s Making Mental Health Count tells us that mental health has a huge impact on economic productivity. Not only are people with severe mental illness more likely to die younger (up to 20 years), but they are more likely to be unemployed and poor. This translates into very high costs for countries, with the total costs – direct and indirect – of mental ill-health reaching an estimated $2493 billion in 2010. In England, the overall lost earnings due to depression were estimated at £5.8 billion in 2007, and is projected to rise to £6.3 billion by 2026. Being mentally healthy is defined by the World Health Organization (WHO) as “a state of well-being in which the individual realises his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” But if you don’t have a job and you’ve more chance of being depressed, and if you are depressed you probably don’t have job. So what’s the solution?
Unfortunately, despite the enormous health, social and economic costs created by mental illness, mental health care is still not a priority in most countries. Although there has been an initiative by many countries to move people out of mental hospitals towards care in the community, which is better, there is still plenty of room for improvement. The amount of money spent on mental health care is very small. For example, mental illness is responsible for 23% of England’s total burden of disease, but only receives 13% of National Health Service health expenditures. This low spending is mainly due to lack of information on the amount of care provided and the outcomes care produces. This is because mental health problems are completely different from physical problems, and much harder to understand and measure.
This is a big issue for the well-being of countries, as around 20% of the working-age population suffers from a mental disorder. Being mentally unwell has a major impact on your quality of life, and your ability to be productive at work. Conversely, work organisation and workplace relationships can have a profound effect on your well-being and mental health. So much so, that one of Britain’s leading doctors, John Ashton, has called for the country to switch to a four-day week to reduce high levels of work-related stress, let people spend more time with their families or exercising, and reduce unemployment.
Fortunately, there are initiatives which are trying to shine a light on this hidden issue and improve the services provided in the workplace for mental health problems. One example is the prevention and reintegration services offered by Helsana, the largest private health insurer in Switzerland. They offer companies support to develop a healthy work environment through the assessments of risk factors (including factors that can generate mental health problems) and the development of a prevention plan, as well as helping sick employees return to work. However, despite these initiatives, much more must be done.
In the meantime, if this article has made you depressed, try taking a leaf out of Edgar Allan Poe’s book, when he says: “I do not suffer from insanity, I enjoy every minute of it”.
Mental health and work This series of country reports offers both a general overview of the main challenges and barriers to better integrating people with mental illness in the world of work, as well as a close look at the situation in specific OECD countries.
If you’re fretting, chafing, sighing, grieving, complaining, finding faults, repining, grudging, weeping, vexing, disquieted in mind, with restless, unquiet thoughts, then you’ve probably been eating cabbage, which as you should know by now, sends black vapours up into the brain, provoking melancholy. It’s not the only cause, of course, and you should also avoid sorrow, fear, shame, disgrace and any other emotion as well as too much exercise, too much study, poverty, scoffs, pleasures immoderate and werewolves.
You’ll find all this and more in the hundreds of pages of Robert Burton’s 1621 masterpiece Anatomy of Melancholy, where he describes the causes and symptoms of psychiatric disorders and discusses possible cures, ranging from herbal teas to drilling holes in the head. What he doesn’t mention is work, except to say that hardworking servants have no time for such ladylike maladies.
That’s where the OECD steps in. Sick on the Job? Myths and Realities about Mental Health at Work says that on average, one in five workers in OECD countries suffers from a mental illness, such as depression or anxiety. From a third to a half of all new disability benefit claims are for mental health reasons, and that figure rises to 70% for young adults. The report highlights the “considerable lack of awareness, non-disclosure and under-treatment among adolescents and young adults, with the gap before the first treatment of a mental illness on average being about 12 years”.
As a result, many young people struggle to get through school, and once they leave they are unfit for work and go straight onto disability benefit. The human cost is appalling, and the economic cost is considerable too – around 3% to 4% of the EU’s GDP according to the International Labour Organisation.
As the subtitle implies, Sick on the Job tackles some of the myths about mental ill-health, and notably the idea that prevalence is increasing. It’s not, but there is much more public awareness of mental disorders, less stigma, and better assessment tools. Unfortunately, at the same time, that’s also meant that more people suffering from mental disorders have been excluded from work, perhaps because many jobs now require social skills or cognitive competencies that workers with mental health problems don’t have.
The problem could get worse though, as working conditions grow harsher and job insecurity grows. The share of workers exposed to work-related stress, or job strain, has increased in the past decade all across the OECD. And in the current economic climate, more and more people are worried about their job security (a rising fear among the employed according to this poll).
What can be done to improve the well-being of people suffering from mental disorders? The OECD report argues for a “three-fold policy shift will be required thereby giving more attention to common mental disorders and also sub-threshold conditions; disorders concerning the employed as well as the unemployed; and preventing instead of reacting to problems””
How about Burton? Apart from cutting down on the cabbage, what did he have to propose? In OECD jargon, we’d say a holistic approach to increasing overall well-being accompanied by timely, targeted interventions aimed at the most vulnerable.
But let’s hear him argue for a welfare state, pensions, social security and justice in his own, magnificent, words: “If they be impotent, lame, blind, and single, they shall be sufficiently maintained in several hospitals, built for that purpose; if married and infirm, past work, or by inevitable loss, or some such like misfortune cast behind, by distribution of corn, house-rent free, annual pensions or money, they shall be relieved, and highly rewarded for their good service they have formerly done; if able, they shall be enforced to work. For I see no reason why an epicure or idle drone, a rich glutton, a usurer… should live at ease, and do nothing, when a poor labourer… that hath spent his time in continual labour…, and without whom we cannot live, shall be left in his old age to beg or starve, and lead a miserable life worse than a jument.”
Cheers you up, doesn’t it?