Introduction
Public mental health (PMH) has been defined as a population approach to improve coverage, outcomes and coordination of interventions to treat mental health conditions (MHCs), prevent associated impacts, prevent MHCs, and promote mental well-being and resilience [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1]. This leads to efficient, equitable and sustainable reduction in MHCs and promotion of mental well-being across populations. The European Psychiatric Association’s PMH Section has adopted this definition [2], and PMH is one of the six priority areas of the 2025–2027 EPA Action Plan [3, Reference Fiorillo4].
This policy article outlines the impact of MHCs and mental well-being, relevant risk and protective factors, higher-risk groups and PMH interventions. It then highlights the scale of PMH implementation failure across the European region and reasons for this. Drivers and required actions to support PMH implementation are set out.
Mental health conditions and associated impacts
Proportion of global disease burden due to mental health conditions (MHCs) has increased so that MHCs are now the leading cause of global Years Lived with Disability (YLDs) [Reference Santomauro, Miller, Shadid, Hanson, Vo and Roy5], although has been consistently underestimated [Reference Vigo, Thornicroft and Atun6, Reference Arias, Saxena and Verguet7]. Furthermore, the increased burden of MHCs over the last decade is in contrast with physical health conditions [8]. Proportion of disease burden due to MHCs across the European Region is 21% (YLDs) [9] with burden (DALYs) varying from 22.5% in Western Europe to 16.4% in Central Europe and 18.1% in Eastern Europe [Reference Arias, Saxena and Verguet7]. Mental health conditions are the leading cause of disability among young people in most European countries [Reference Castelpietra, Knudsen, Agardh, Armocida, Beghi and Iburg10].
Several reasons account for the large proportion of disease burden, including high prevalence of MHCs which varies by country [Reference Castelpietra, Knudsen, Agardh, Armocida, Beghi and Iburg10, Reference Sacco, Camilleri, Eberhardt, Umla-Runge and Newbury-Birch11], with subthreshold MHCs having additional impact. Furthermore, the majority of lifetime MHCs arise before adulthood [Reference Solmi, Radua, Olivola, Croce, Soardo and Salazar de Pablo12] and then impact across the life course. The broad range of impacts occurs across health (health risk behaviors, physical illness, premature mortality, suicide) and other sectors including education, employment, and criminal justice [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1]. Estimated annual economic costs of MHCs as a proportion of GDP vary from 4% across European countries [13] to 6.5% in Western Europe, 6.0% in Central Europe and 7.7% in Eastern Europe [Reference Arias, Saxena and Verguet7]. The term “mental health condition” is used in this article instead of “mental disorder” since it is the preferred term by the World Health Organization and people with lived experience.
Mental well-being
Mental well-being has a broad range of impacts across different sectors [Reference Campion14]. Various definitions exist [Reference Fusar-Poli, Salazar de Pablo, De Micheli, Nieman, Correll and Kessing15] which vary by culture. Mental well-being can be described as affective well-being (present-state satisfaction, pleasure and mood) and evaluative well-being (broader, longer-term aspects including meaning and development).
Mental health conditions and well-being are inter-related. The single continuum model has MHCs and well-being at opposite ends of a single dimension, while the dual continuum model has two related yet distinct continua since MHCs do not preclude mental well-being and vice versa, while good mental well-being is associated with reduced risk of MHCs and MHCs are associated with lower mental well-being.
Risk and protective factors
Various factors increase risk of different MHCs which are important to inform prevention and early intervention strategies [Reference Arango, Díaz-Caneja, McGorry, Rapoport, Sommer and Vorstman16, Reference Arango, Dragioti, Solmi, Cortese, Domschke and Murray17]. In particular, adverse childhood experiences (ACEs) account for a large proportion of MHCs [Reference Arango, Dragioti, Solmi, Cortese, Domschke and Murray17, Reference Bellis, Hughes, Ford, Rordriguez, Sethi and Passmore18] and other health conditions [Reference Carr, Duff and Craddock19] as well as broader impacts. Furthermore, the impact of different types of ACE is transdiagnostic and results in an increased risk of several MHCs [Reference Arango, Dragioti, Solmi, Cortese, Domschke and Murray17]. Parental MHCs result in increased risk of developing any MHC in offspring [Reference Uher, Pavlova, Radua, Provenzani, Najafi and Fortea20].
Decisions about which risk factors to focus on can be informed by the proportion of the population affected by such factors and proportion amenable to intervention. A review of potentially modifiable risk factors to prevent MHCs found the largest global population attributable fractions were for ACEs and schizophrenia spectrum disorders (38%), tobacco smoking and opioid use disorders (25%), job strain and depression (18%), insufficient physical activity and Alzheimer’s disease (15%), childhood sexual abuse and depressive disorders (13%), clinical high-risk state for psychosis and any non-organic psychotic disorders (12%), three metabolic factors and depression (10%), cannabis use and schizophrenia spectrum disorders (10%), and maternal pre-pregnancy obesity and ADHD (9%) [Reference Dragioti, Radua, Solmi, Arango, Oliver and Cortese21].
Certain factors have overarching impacts on other risk and protective factors and therefore are also important to address [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Campion14]. These include socioeconomic inequalities [Reference Kivimäki, Batty, Pentti, Shipley, Sipilä and Nyberg22, Reference Patel, Burns, Dhingra, Tarver, Kohrt and Lund23], conflict [Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena24], disasters [Reference Newnham, Mergelsberg, Chen, Kim, Gibbs and Dzidic25] and humanitarian emergencies, pandemics [Reference Newnham, Mergelsberg, Chen, Kim, Gibbs and Dzidic25], stigma and discrimination [Reference Thornicroft, Sunkel, Alikhon Aliev, Baker, Brohan and El Chammay26, Reference Emmer, Dorn and Mata27], and environmental factors such as pollution [Reference Radua, De Prisco, Oliva, Fico, Vieta and Fusar-Poli28] and climate change [Reference Radua, De Prisco, Oliva, Fico, Vieta and Fusar-Poli28–Reference Brandt, Adorjan, Catthoor, Chkonia, Falkai and Fiorillo30]. Commercial determinants (products and practices of some commercial actors) are responsible for escalating rates of avoidable ill health, planetary damage, social and health inequity [Reference Gilmore, Fabbri, Baum, Bertscher, Bondy and Chang31, 32], as well as MHCs, self-harm, and suicide [Reference Dun-Campbell, Hartwell, Maani, Tompson, van Schalkwyk and Petticrew33]. Commercial determinants including tobacco, alcohol, processed food, fossil fuels, and occupational practices account for 2.7 million deaths annually across the European Region [32].
Higher risk groups
Risk factors cluster in particular groups, making them at much higher risk of MHCs and poor mental well-being [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Campion14]. Examples include people in some minority ethnic groups, carers, homeless, those with intellectual disabilities, LGBTQI+, new mothers, children of parents with MHCs, people with certain genetic traits [Reference Provenzani, Damiani, Bersano, Singh, Moschillo and Accinni34], offenders, older people in care homes, those with sensory impairment, unemployed, young women, people in humanitarian emergencies, refugees and asylum seekers, and conflict-affected populations.
Public mental health interventions
Evidence-based public mental health interventions exist and can be categorized in two ways. The first category includes treatment of MHCs, prevention of associated impacts, prevention of MHCs, and promotion of mental well-being and resilience. Another category includes prevention of MHCs and promotion of mental well-being at primary, secondary, and tertiary levels (Table 1).
Public mental health interventions [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Campion14]
Table 1 Long description
The table consists of two columns. The first column lists the intervention category, and the second column details the Level of prevention or promotion.
* Prevention of MHCs
- Primary: Prevention of MHCs from arising.
- Secondary: Early intervention for MHCs and associated impacts, including to prevent further MHCs and impacts.
- Tertiary: Prevention of relapse and associated impacts.
* Promotion of mental well-being
- Primary: Promotion of protective factors for well-being.
- Secondary: Early promotion for those with recent well-being deterioration.
- Tertiary: Promotion in those with longstanding poor well-being.
* Promotion of resilience
- Primary level: Promotion of resilience.
- Secondary level: Early promotion of resilience in people with recent adversity.
- Tertiary level: Promotion in people with previous or longstanding adversity.
More targeted approaches are required for groups at higher risk of MHCs and poor mental well-being highlighted in the previous section, in order to prevent widening of inequalities. Selective prevention and promotion refers to interventions targeting those at higher risk of developing MHCs and poor mental well-being while indicated prevention refers to early intervention for those with a subthreshold MHC.
Various PMH interventions are delivered by a range of providers across different sectors including health (primary care, secondary mental health care), social care, public health, schools, employers, housing, criminal justice, voluntary and non-government organizations (NGO’s), and others. This highlights the complexity of provision but also opportunities for cross-sector coordination and integration.
Public mental health implementation gap across the European region
The size of PMH implementation gap varies across the 53 countries of the European region, with wide variation in the responsiveness of different European countries to their population mental health needs [Reference Arango, Fiorillo, Dom and Lopez-Morinigo35].
Only a minority of people with MHCs except psychosis across the European region receive any treatment, with wide coverage variation between countries [Reference Barbui, Alonso, Chisholm, Evans-Lacko, Keynejad and Lazeri36,37] and with much lower coverage of effective treatment [Reference Barbui, Alonso, Chisholm, Evans-Lacko, Keynejad and Lazeri36,Reference Vigo, Stein, Harris, Kazdin, Viana and Munthali38]. The largest treatment gaps across the European region were found for higher-risk groups including refugees, homeless, and sexual minorities [Reference Barbui, Alonso, Chisholm, Evans-Lacko, Keynejad and Lazeri36]. Treatment coverage was far lower in low- and middle-income countries (LMICs) compared to high-income countries (HICs) [37]. Coverage of interventions to prevent associated impacts of MHCs was even less, with negligible coverage of interventions to prevent MHCs or promote mental well-being and resilience. Proportion of European region countries with a stand-alone or integrated suicide prevention strategy was 59% [37].
Results of the PMH implementation failure across the European region include preventable population-scale human suffering, broad impacts and associated economic costs. The implementation gap breaches the right to health and statutory legislation in some countries not to discriminate against people with MHCs as well as to protect children, families, and employees. Understanding the causes of this implementation failure is important to inform required actions (Table 2).
Causes of public mental health implementation gap
Table 2 Long description
The table is organized into two columns: the cause category on the left and specific details on the right.
* 1. Insufficient right to mental health: Absence of legal rights to evidence-based PMH interventions. Only 12% of constitutions globally include a right to mental health.
* 2. Insufficient political will: Lack of resource allocation by decision makers linked to poor PMH understanding and stigma.
* 3. Insufficient PMH knowledge and training: Lack of knowledge among professionals regarding relevance, interventions, and economic benefits. Includes insufficient training.
* 4. Insufficient policy: Content does not reflect evidence or scale of need. 13% of European countries have no PMH policy, and 30% are not human rights compliant.
* 5. Insufficient data: Lack of standardized monitoring. Only 21% of European countries compiled specific data in the last 2 years.
* 6. Insufficient resource: Mental health expenditure is only 4.5% of health spending in Europe. Only 23% of countries have full financial allocation for plans.
* 7. Insufficient workforce: Low numbers of specialists per 100,000 population. For adults: 9.9 psychiatrists and 28.4 nurses. For children: 1.3 psychiatrists and 1.7 nurses per 100,000 population.
* 8. Specific causes of MHC treatment gap: Includes poor literacy, stigma, poor treatment quality, and staff burnout.
Required actions to address public mental health implementation failure
Public mental health has been defined as a population approach to improve coverage, outcomes, and coordination of PMH interventions, which leads to efficient, equitable, and sustainable reduction in MHCs and promotion of mental well-being across populations [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1]. The European Psychiatric Association’s PMH Section has adopted this definition [2] and PMH is one of the six priority areas of the 2025–2027 EPA Action Plan [3, Reference Fiorillo4]. However, PMH is also relevant to the other priority areas of the 2025–2027 EPA Action Plan which are treatment delivery, determinants of brain development and mental health, whole person health, and stigma and discrimination, including protection of minorities health.
Several important drivers to support PMH implementation are already in place including rights-based and United Nations initiatives, legislation, PMH prioritization by WHO, advocacy by people with lived experience, the economic case and leadership by key organizations (Table 3).
Drivers to support public mental health implementation
Table 3 Long description
The table consists of six rows.
* Row 1. Rights-based initiatives. Includes the right to health, national adoption of constitutional rights to mental health, and legislation supporting population access to PMH interventions.
* Row 2. United Nations initiatives. Includes Sustainable Development Goals for universal health coverage and political declarations for an integrated approach to noncommunicable diseases and mental health.
* Row 3. Public mental health prioritization by WHO. Includes the Comprehensive Mental Health Action Plan 2013 to 2030, the European Framework for Action 2021 to 2025, Mental Health in All Policy (MHiA P,) the Pan-European Mental Health Coalition, and the Health Resilience in the Eastern Partnership programme.
* Row 4. Advocacy by people with lived experience. Includes collaboration with organizations like Gamian Europe and integrating lived experience into healthcare and social care.
* Row 5. Economics. Includes the cost of the PMH implementation gap, investment cases, financing, integration into insurance schemes, and the Prague Agreement calling PMH a high-yield investment.
* Row 6. Leadership by organizations. Includes the EPA PMH Section and Action Plan, the European Commission’s comprehensive approach, WPA Action Plans, the Royal College of Psychiatrists PMH Implementation Centre, and the World Federation of Public Health Associations PMH Working Group.
Building on these foundations, the following ten urgent actions are required to address the causes of PMH implementation failure (Table 2) and support the required scale up of PMH implementation across the European region (Table 4).
Required actions to scale up public mental health implementation across the European region
Table 4 Long description
The table contains ten numbered rows outlining strategic actions for PM H.
1. Making the PMH case by PMH needs assessment, coordinated advocacy and PMH economics.
2. PMH practice: Use of PMH needs assessment to inform: a) Choice of PMH interventions, coordinated policy and strategy development, ways to scale up implementation, transparent decisions about agreed coverage and operationalisation; b) Implementation of PMH interventions at agreed population level; c) Regular evaluation of coverage and outcomes of PMH interventions.
3. Coordinated PMH surveillance and data collection by different sectors.
4. Use of human rights approach and legislation.
5. Public mental health training and population literacy.
6. Maximizing existing resources.
7. Settings-based and integrated approaches.
8. Digital technology to support delivery of PMH interventions and PMH training.
9. Prioritization of interventions with large population impact.
10. Public mental health implementation research.
1. Making the public mental health case
Making the case at national, regional, and local levels is an important first step and requires a coordinated approach, which includes a focus on key decision makers [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1]. This includes conducting PMH needs assessment, coordinating advocacy with leadership from different sectors and people with lived experience, as well as demonstrating the economics of PMH implementation failure and improved coverage. Effectively communicating the PMH case is important for different stakeholders, such as psychiatrists and people with lived experience.
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a) Public mental health needs assessment
The size of the PMH implementation gap varies by region, country and locality. Assessment of the PMH gap is an important first step and should include the following information [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Campion14]: Estimated prevalence of MHCs and well-being; levels of risk and protective factors; estimated number from different higher risk groups; coverage and outcomes of evidence based PMH interventions including for higher risk groups; quality of implementation according to evidence; views of people with lived experience and families; estimated size, impact and cost of the PMH implementation gap; expenditure on different types of PMH interventions and estimated impact and associated economic savings from improved coverage.
Public mental health needs assessments can be carried out at regional and national levels as well as for particular MHCs, different higher risk groups such as intellectual disability [Reference Campion, Roy and Baker73], various settings such as schools and workplaces, and different stages of life such as early years [Reference Lamb and Campion74]. Psychiatrists and other professional groups across the European region have important roles in PMH needs assessments, which require relevant training (see part 5 “Public mental health training and population literacy” below).
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b) Coordinated advocacy with leadership from different sectors and people with lived experience
The WHO Comprehensive Action Plan 2013–2030 [55] highlights that it is important to convene, engage with and solicit consensus from all relevant sectors and stakeholders when planning, developing and implementing policies, laws and services relating to health, including sharing knowledge about effective mechanisms to improve coordinated policy and care across formal and informal sectors.
Coordinated PMH advocacy and leadership by a range of stakeholders and organizations (Table 3) is supported by transparent agreement about acceptable population coverage of PMH interventions, which informs decisions about the size of required resources to meet agreed coverage targets. Stakeholders include people with lived experience of MHCs and associated organizations such as the European Federation of Associations of Families of People with Mental Illness (EUFAMI) and Gamian Europe, people from higher risk groups, community, health providers including secondary mental health care and associated organizations such as the European Psychiatric Association, public health and associated organizations such as the European Public Health Association, European Commission, voluntary sector and non-government organizations (NGOs), education, employment, social care/services, criminal justice, policymakers, ministries of health and finance, and key decision makers.
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c) Economics of PMH implementation failure and improved coverage
As a proportion of GDP, estimated annual economic costs of MHCs are as high as 6.5% in Western Europe, 6.0% in Central Europe and 7.7% in Eastern Europe [Reference Arias, Saxena and Verguet7] while ACEs, which are responsible for a significant proportion of MHCs, result in annual costs of US $581 billion across Europe [Reference Bellis, Hughes, Ford, Rordriguez, Sethi and Passmore18].
Many evidence-based PMH interventions also result in economic savings even in the short term [Reference Campion14, Reference Le, Esturas, Mihalopoulos, Chiotelis, Bucholc and Chatterton75]. Overall local/national savings related to the level of population coverage can be estimated. For instance, scale implementation of nine PMH interventions across England was estimated to result in net savings £43 billion [Reference Campion and Knapp63], while 10% reduction in ACEs across Europe was estimated to result in annual savings of $49 billion [Reference Bellis, Hughes, Ford, Rordriguez, Sethi and Passmore18]. Table 3 outlines various associated economic drivers. Therefore, advocacy and relevant economic PMH information needs to be directed to ministries of finance and key decision makers across the European region to support sustained improved funding and political commitment.
2. Public mental health practice
This involves the following three steps [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1]:
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a) Use of PMH needs assessment to inform the regional and national:
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• Choice of implementable evidence-based PMH interventions provided by different sectors informed by best review-level evidence graded according to quality
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• Coordinated policy and strategy development by different sectors supporting mental health in all policy
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• Ways to scale up implementation of different PMH interventions
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• Transparent decisions about acceptable level of provision, implementation timeframes and required resources made with broad range of stakeholders including people with lived experience [62]. Such decisions should take account of the population scale preventable human suffering, broad impacts and economic costs of implementation failure; impacts and economic savings of improved coverage; the right to mental health including treatment, prevention and promotion; the legal duty not to discriminate against people with MHCs; and the UN SDG of universal health coverage
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• Communication to different sectors and wider population, including people with lived experience
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• Commissioning, operationalization and inter-sector coordination/integration.
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b) Implementation of evidence-based PMH interventions by different sectors at agreed population scale and timeframes.
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c) Regular evaluation of coverage and outcomes of PMH interventions including for higher risk groups as well as reasons for implementation outcomes.
Public mental health practice is supported by setting up a functional mental health unit or coordination mechanism in ministries of health, with an allocated budget and responsibility for strategic planning (including situational analysis, needs assessment, and inter-ministerial and multisectoral coordination and collaboration) to help ensure the development and implementation of effective national policy and legal frameworks [55]. A forthcoming survey of EPA Member Psychiatric Associations conducted by the EPA PMH Task Force will further explore how to support PMH practice and implementation.
3. Coordinated public mental health surveillance and data collection
Improved surveillance through coordinated data collection by different sectors is required to understand the prevalence of MHCs, associated impacts and risk factors as well as the coverage and outcomes of PMH interventions by different sectors, including for higher risk groups. This is important since 48% of countries across the European region had conducted a national mental health survey in the previous 10 years although only 62% of these included use of services [37]. Furthermore, only 21% of countries across the European region compiled mental health-specific data for the public and private sector in the previous 2 years, while 41% of countries compiled mental health-specific data for just the public sector [37].
Therefore, PMH-relevant, high-quality data needs to be routinely collected and integrated into existing health and other sector information systems [55], which is facilitated by providing better support and training in mental health information management [56]. In countries where such PMH data is absent, regional surveys or estimates can be used [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1].
4. Use of human rights approach and legislation
The right to health includes the right to mental health and evidence based PMH interventions, particularly for higher-risk groups, as well as the right to quality care for people with MHCs. Article 3 of the EU Charter of Fundamental Rights [51] protects the physical and mental integrity of every person while Article 35 recognises the right to healthcare. Furthermore, the European Pillar of Social Rights grants everyone the right to timely access to good quality, affordable, preventive, and curative health care [52]. However, although the constitutional right to mental health supersedes other laws, only 12% of constitutions covering 3.5% of the global population have a constitutional right to mental health [Reference Ni, Candi, Wan, Campion, Gill and Galea39].
Legislation can also support PMH implementation through the protection of children and young people from ACEs, the promotion of workplace safety, and reduction in availability of alcohol and tobacco although there is no one single European law which protects mental health in all circumstances.
Various opportunities exist to harness a human rights approach and legislation to scale up PMH implementation [Reference Ni, Candi, Wan, Campion, Gill and Galea39]. A coordinated rights and legal approach across the European region is therefore important to ensure scale up of PMH intervention coverage and associated resources, as well as the protection of the rights of people with MHCs. The EPA made the right to PMH interventions a central part of its 2024 EU Election Manifesto [67].
5. Public mental health training and population literacy
Public mental health training and skills support making the case for PMH and delivering effective PMH practice in order to scale up PMH implementation at local, regional, and national levels. Public mental health training should include several important areas such as impacts of MHCs and well-being; prevalence of MHCs and mental well-being; risk and protective factors; higher-risk groups; effective PMH interventions delivered by different sectors, including associated cost-effectiveness; assessment of size, impact, and cost of the PMH implementation gap, including for higher-risk groups; estimation of impact and associated economic benefits of improved coverage of PMH interventions; use of PMH needs assessment to inform policy and decision making at national and local levels; scaling up of interventions according to population need; and communication and leadership skills [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Campion14, Reference Campion76]. This should include a critical appraisal of the strength of evidence for different aspects of PMH. Public mental health training in different countries also needs to take account of the cultural context.
Public mental health training is relevant for a wide range of disciplines including psychiatrists, primary care, public health, social services, education and employment settings, policymakers [55], implementers, and advocates, including people with lived experience. This training needs to be both broad and practical regarding scaling up PMH implementation as well as specific to particular more senior roles or PMH intervention. Guidance about specific PMH policy and strategic actions across different government sectors is also important [58].
Given the insufficient availability of PMH training across the European region, increased access to such training is required to reflect disease burden of MHCs [Reference Pinto da Costa, Mulcahy and Campion41], including through digital delivery given the number requiring such training [Reference Campion76]. Public mental health is included among the topics of the EPA European Board Exam with the plan to include more comprehensive detail. The EPA should also support PMH training during medical school [Reference Puri and Campion77], residency and CME activities.
There is an absence of PMH roles in psychiatry or public health. Creation of such funded roles is required and supported by job descriptions linked to required activities, skills, and training [71]. The EPA PMH Task Force will develop such a job description with the EPA PMH Section.
Improved knowledge and literacy about mental health is also important for the general population, people with lived experience and higher risk groups. Public mental health training and improved mental health literacy are also important for particular groups, including health professionals, trainees, and medical students [Reference Puri and Campion77], given their higher rate of MHCs compared to the general population [Reference Puri and Campion77, Reference Frajerman, Morvan, Krebs, Gorwood and Chaumette78].
6. Maximizing existing resources
This is supported by PMH needs assessment and includes support from family, carers and friends, self-management (self-help and digital-based interventions), liaison between less and more experienced practitioners, use of brief interventions [Reference Frajerman, Morvan, Krebs, Gorwood and Chaumette78], collaborative care, task-sharing, improving treatment quality and concordance, complementary and alternative approaches, and facilitating service user involvement in PMH policy development and evaluation [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1]. Protecting the health of the workforce is also important through scaling up treatment and prevention of MHCs among health staff [Reference Almeida-Meza, Ledden, Dempsey, Smith, Croak and Bhundia47–49] and undergraduates [Reference Puri and Campion77, Reference Frajerman, Morvan, Krebs, Gorwood and Chaumette78] which requires specific actions as well as monitoring of coverage and outcomes.
Supporting the implementation of guidelines is also important [Reference Pereira, Silva, Carvalho, Zanghelini and Barreto80] such as the WHO Mental Health Gap Action Programme guideline [81, Reference Brohan, Chowdhary, Dua, Barbui, Thornicroft and Kestel82].
7. Settings-based and integrated approaches
Implementation is supported by setting-based approaches, including preschools and schools, workplaces, prisons, and care homes [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Campion14].
Integrated approaches include both within and between sectors. For instance, 48% of countries across the European region demonstrated functional integration of mental health into primary care [37]. Integration is facilitated by PMH needs assessments.
8. Digital technology
Digital technology can support delivery of both PMH interventions [Reference Campion, Javed, Lund, Sartorius, Saxena and Marmot1, Reference Crocamo, Palpella, Cavaleri, Nasti, Piacenti and Morello83–Reference Schäfer, von Boros, Schaubruch, Kunzler, Lindner and Koehler85], lifestyle behaviours [Reference Singh, Ahmed, Staiano, Gough, Petersen and Vandelanotte86] and smoking cessation [Reference Li, Li, Xu, Tao, Sun and Yang88], and PMH training [Reference Campion76]. Healthcare professionals of 83% of countries across the European region delivered services through communication technology [37].
9. Prioritisation of interventions with large population impact
Particular PMH interventions result in large population impact if implemented to scale by relevant sectors (Table 5).
Examples of PMH interventions with large potential population impact
Table 5 Long description
The table consists of two columns: Public mental health intervention and Population impact.
* Row 1: Parental MHC treatment and prevention; Improves child and adolescent mental health.
* Row 2: Address and prevent ACEs; Improves child and adolescent mental health since responsible for large proportion of MH Cs.
* Row 3: Parenting programmes; First-line recommended intervention for some child MHCs that also prevent AC Es.
* Row 4: Smoking cessation; Reduces depression and anxiety and improves physical health and life expectancy.
* Row 5: Addressing socioeconomic inequalities; Underlie many other risk factors and are also impacts of MHCs. Poverty alleviation.
* Row 6: Addressing commercial determinants of mental health; Includes increases in price and stricter regulation of alcohol, tobacco, unhealthy food, and sugar-sweetened drinks, which reduce demand.
* Row 7: Physical activity promotion; Supports recovery from and prevents MH Cs.
* Row 8: Labour market regulation and active labour market policies and programmes; Supports job seekers including those with psychosocial, mental health or other disabilities.
* Row 9: Stigma and discrimination; Address mental health-related stigma and discrimination.
10. Public mental health implementation research
Most evidence-based interventions are not implemented to scale, representing a critical gap between what is known to work and what is delivered in practice. Therefore, research focus is required on how to scale up implementation of existing evidence-based PMH interventions. This includes rigorous, systematic implementation evaluation as well as empowerment of practitioners and researchers to assess, learn from and continuously improve PMH implementation.
Conclusions
Implementation failure of effective PMH interventions breaches the right to health and results in population scale preventable suffering, broad impacts and associated economic costs. Public mental health involves a population approach to improve coverage, outcomes and coordination of PMH interventions. Public mental health needs assessment informs PMH practice, including choice of implementable evidence-based PMH interventions by different sectors, coordinated policy development across different sectors, integrated approaches between different sectors, transparent decisions about acceptable level of provision and required resources, implementation to agreed scale, and regular monitoring of coverage and outcomes including for higher risk groups. Other required actions to scale up PMH implementation include using a human rights approach and legislation, PMH training to different sectors and improved population PMH literacy, maximizing existing resources, settings-based and integrated approaches, use of digital technology, prioritization of interventions with large population impact, and research focused on scaling up implementation. Scaled up PMH implementation supported by collaboration with people with lived experience results in broad population scale impacts, achievement of a range of policy objectives across sectors, sustainable reduction in impact of MHCs, and promotion of population health. The associated economic savings make PMH practice an essential part of sustainable economic development.
Data availability statement
Data cited in this document can be accessed through publications outlined in the reference section, all of which include relevant weblinks.
Acknowledgments
All authors except A.F. and M.P.C. are members of the European Psychiatric Association Presidential Task Force on Public Mental Health. C.A. was supported by the Spanish Ministry of Science and Innovation, Instituto de Salud Carlos III aISCIII, co-financed by the European Union, ERDF Funds from the European Commission, “A way of making Europe,” financed by the European Union – NextGenerationEU (PMP21/00051), PI19/01024. PI22/01824 CIBERSAM, Madrid Regional Government (B2017/BMD-3740 AGES-CM-2), European Union Structural Funds, European Union Seventh Framework Program, European Union H2020 Program under the Innovative Medicines Initiative 2 Joint Undertaking: Project PRISM-2 (Grant agreement No. 101034377), Project AIMS-2-TRIALS (Grant agreement No. 777394), Horizon Europe, the National Institute of Mental Health of the National Institutes of Health under Award Number 1U01MH124639-01 (Project ProNET) and Award Number 5P50MH115846-03 (project FEP-CAUSAL), Fundación Familia Alonso, and Fundación Alicia Koplowitz.
Financial support
No funding received for this article.
Competing interests
J.C. has carried out public mental health needs assessments for regions in England covering several million people for which his employer received payment. C.A. has been a consultant to or has received honoraria or grants from Abbott, Acadia, Ambrosetti, Angelini, Biogen, BMS, Boehringer, Carnot, Gedeon Richter, Janssen Cilag, Lundbeck, Medscape, Menarini, Minerva, Otsuka, Pfizer, Roche, Rovi, Sage, Servier, Shire, Schering Plough, Sumitomo Dainippon Pharma, Sunovion, Takeda and Teva. G.D.: None. G.C.: None. K.B.: None. A.M.-S.: None. M.P.C. is funded by the UK Department for Science, Innovation and Technology (DSIT), the National Institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre (BRC), and the NIHR Applied Research Collaboration (ARC) London.
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