More help needed for serious mental health problems 

World Mental Health Day pamphlet on the unspoken issues of mental health

Mental health is increasingly discussed publicly in Finland. Well-known people openly discuss their mental health experiences on social media platforms. In 2019, our Terapiatakuu citizens’ initiative campaign calling for immediate access to therapy turned the spotlight onto mental health policy in the Parliament. It is also becoming more and more common to hear a friend discuss the fact that they have sought help for burnout. 

It is great that it is becoming easier to talk about and seek help for mental health problems. But there are still discussions that we need to have. What to do when a co-worker tells us they have schizophrenia, when a friend is hospitalized because of bipolar disorder, or when severe self-destructive behaviour impacts everyday life?

As a mental health activist and member of Helsinki City Council, I have advocated for increasing the availability of low-threshold services in particular. Many people have approached me on the street to tell me that they have received help or even that they are still alive because of the walk-in mental health service Mieppi. I submitted a council initiative for these open and free clinics in 2017 when I noticed how difficult it was to access help. Now, there are three Mieppi units in Helsinki, and city has also made a commitment to implement the goals of the Terapiatakuu citizens’ initiative in 2022. Many more of these steps are still needed.

Easily accessible and timely brief therapy has been shown to be the most effective method for helping as many people as possible. A study conducted by Aino Kohtala found that just four brief therapy sessions were enough to halve symptoms of depression. Quick and easy access to help also reduces the strain on other services when issues can be addressed before they become magnified. 

But low-threshold services are not the solution to every issue. Neither is encouraging messaging on going to therapy in magazines or advertisements enough when many people are unable to access or afford it. In the public discourse in Finland as well, it is often easier to address less serious issues with simple solutions. Solutions than can be easily shown to be economically efficient. But this is not right in terms of our wellbeing or the society. 

One of the reasons why I began to advocate for mental health was that I had personally seen up close what severe mental health problems can do to those affected, whether directly or as a close friend or relative. Years ago, I tried to get help for a friend but instead we found ourselves going through a public healthcare process in Helsinki lasting more than a year and consisting of countless phone calls, visits to the emergency room, referrals, waiting, prolonged diagnosis, and finally effective specialized health care. The problems had time to exacerbate, as help was not available. Simple conversational therapy would not have been enough.

Since then, I have spoken to hundreds of people. I have listened to numerous experts, mental health organizations, and people living with mental health problems and those close to them. Many of the same issues that remain hidden are repeated in these statistics, studies, and stories. Most of this information comes from Finland, which is why I am mostly going to focus on the situation in my home country. I do however believe that many of my thoughts and suggestions could be applied more extensively, and at the end of this pamphlet I will discuss mental health issues on the EU level as well. 

Access to care is everyone's right 

In Finland, approximately 50 percent of people with mental health problems do not receive the care that they need. This is partially explained by the fact that seeking treatment is still associated with a significant social stigma, but another substantial reason is the difficulty of accessing care when compared to physical injuries, for example. 

In the case of mental health problems, severely affected people are required to have substantial reserves of strength to demand access to care. You have to find out where to turn to. You have to wait for letters and appointments and remain insistent. You have to endure endless referrals from one service to another as the operators try to avoid care responsibility in order to cut costs. And you have to keep trying to justify why you deserve treatment.

Sometimes care just is not available, even in case of severe problems. It is shocking to hear from different parts of the country how a person who has attempted suicide that day may not necessarily be admitted to a mental health unit for even a single night. The capacity is simply insufficient. The patient is monitored for only as long as is physically necessary, given sedatives, and sent home.  

The waiting times to access long-term care are also too long. Receiving a referral to psychotherapy can easily take up to one year. The patient is expected to have the energy to find the right therapist themselves. And the process of diagnosis preceding this can be long and arduous. On a general level, it makes more sense for a healthcare professional to spend ten hours on offering brief therapy instead of formulating a diagnosis. But severe mental health problems often require robust specialized health care, drug treatment, and inpatient care. These are not available to everyone.

Socially, we also often overlook the fact that receiving treatment may be quite difficult. Having been admitted for treatment, the diagnostic interviews, analyses, and experimentation with medication can be a tough process that affects the body mind, and self-image. At the same time, you are expected to have enormous reserves of energy to continue working or studying, applying for various benefits, filling forms, and paying bills. You have to be able to afford the medication and have close friends or family members to help you. Not everyone has these things. People who encounter severe mental health problems do not receive enough support in Finland.

The requirement to have the ability able to demand help is a dangerous one. Without help, mental health problems intensify, often quite quickly. Deterioration of mental health too often leads to traumatic experiences. Issues you would not typically recognize in yourself: substance abuse, self-destructiveness, despair, and even violent behaviour. It is absurd and irresponsible in terms of both personal wellbeing and the society to force people to wait until their problems begin to accumulate.

With these frank words, my intention is not to lay blame on health care workers. Many of them stretch their resources to the breaking point to help their patients. Instead, my words are aimed at the policymakers. Even though mental health has been discussed increasingly for years, actions have been few and far between. Fine words are not enough if the money required to offer treatment is not made available.

If policymakers wish to retain their credibility as regards mental health policy, the principles of immediate access to therapy must be adopted into the amendment to the Health Care Act concerning guaranteed access to treatment, which is in preparation at the Ministry of Social Affairs and Health. This would mean that the patient's need for care was assessed immediately, and the actual treatment commenced within one month. We must guarantee that everyone has access to the mental health support they need in a quick and comprehensive manner. At the same time, we must increase the availability of psychiatric resources at emergency units to ensure that acute problems can be addressed without delay by the correct professionals. Similarly, safe inpatient treatment options must always be available to people who are in danger.

No one should be left alone with mental health problems. In many municipalities, addiction psychiatry services have adopted an incomprehensible policy under which any substance abuse issues must be treated before addressing mental disturbances. However, mental health problems increase the likelihood of substance abuse, as many people have to rely on self-medication while waiting for help. Furthermore, substance abuse can exacerbate mental health problems. Thus, the two should be treated simultaneously.

Insufficient funds lead to insufficient services

The range of services pertaining to mental wellbeing is fragmented across a variety of outlets. This leads to the risk of falling through the gaps. And while mental health problems have been increasing for a long time, mental health services’ proportion of health expenditure in Finland has been decreasing throughout the 2000s. In the worst-case scenario, this leads to people being shuffled from one service to another, each of which will try to refer the person further due to lack of resources. This leads to prolonged problems. 

Cooperation between outpatient care and hospital services is inadequate. At worst, this will lead to people having to rely on more expensive hospital care time after time due to lack of support. According to a Finnish study published in 2019, 40% of patients returned to psychiatric hospital treatment within a year of having been discharged. A single outpatient care session was enough to significantly reduce the risk of this. 

When a person is discharged after treatment, this does not mean that they no longer require support. Many people feel that they have been discharged while their treatment was still ongoing. Such decisions cannot be based on cost-savings or performance targets, as they will come to nothing when the person returns to treatment in any case. Therefore, treatment should only end when the patient is ready for it. In some cases, this may never happen, and instead a safe patient care relationship must be maintained throughout the patient’s life.

The extensive social welfare and healthcare reform underway in Finland offers new opportunities for clarifying the clinical pathways, as different services are combined into wellbeing services counties. During the implementation of the reform, particular attention must be paid to how the cooperation between basic health care, specialized health care, and other authorities can be improved from the current situation. 

A mere restructuring will not guarantee quality care, and what mental health services actually need is financial investment. At the moment, many municipalities are refusing to implement immediate access to care because they wish to cut social welfare and healthcare costs and lack the courage to make the initial investment in care that could provide savings later. The situation requires both support from the government and the wisdom to see beyond the first step from regional policymakers.

Medication alone is not a sufficient form of treatment

The lack of resources can, for example, lead to the treatment of many mental health problems primarily through medication alone. Many people leave their first doctor's appointment holding a prescription without knowing where they could get the psychological support to go along with the medication. Furthermore, it is easy to neglect taking the medication if you receive no other forms of support or if you cannot afford the medication. It is also not guaranteed that the correct medication is identified immediately, leading to another arduous process where the patient would benefit from psychological support while the right medication is sought.

Medicines can be helpful to many people, aiding the management of symptoms. However, research shows that most people treated with medication would be significantly benefited by the addition of psychotherapy to support the drug therapy. And with some illnesses, therapy can be the most effective form of treatment. 

It is obvious that the use of medicinal products and the adverse effects occasionally caused by them can be substantially reduced through accessible psychotherapy and care contacts that are unbroken and sufficiently long. However, this is not often possible within the current health care system. This is why more mental health professionals, brief therapy practitioners, and psychotherapists should be recruited and trained free of charge.

Children and youths need support

It is particularly important to guarantee that children and youths are offered the necessary support and services. Up 50 percent of all mental health disturbances emerge before the age of 15, and three quarters before the age of 24. In addition to the fact that the problems emerge at an early stage, they often have far-reaching consequences in the future. This is why problems should also be identified and treated early.

Severe mental health problems among young people have quickly increased in Finland. The services have not been able to keep up. For example, institutional care is too difficult to access during an acute crisis, even when both the affected youth and their family would prefer it. This can be seen, for example, in the fact that the length of a stay in a psychiatric institute among 13–17-year-olds has reduced from 39 days to less than 19 days in 2008–2018. It is clear that more resources must be allocated for supporting children and youths. 

We should also support families, as unease and ill-health in a family has been shown to expose the family members to mental health problems. This can be addressed by preventing poverty among families with children, increasing the availability of support to close relatives of those affected by mental health issues, and by better integrating child and family services with mental health services starting from the children's health clinic.

Schools have a vital role in the mental wellbeing of children and youths. We should promote the mental health skills of the teaching staff and ensure that they have enough time and opportunities to provide support. This would allow us to react better to the symptoms displayed by children and youths. Children and youths should also be provided tools to recognize mental health challenges in themselves and their friends. This is why I submitted a council initiative for teaching mental health first aid skills in Helsinki: I had heard from teenagers that they were taught how to administer artificial respiration, but not how to help a friend experiencing a panic attack.

Unbroken, long-term patient care relationships are essential, particularly in the treatment of severe mental health problems. We should pay special attention to this with children and youths. We must be able to prevent people from falling through the gaps as they move from one level of education to the next, change cities, or transfer to secondary or tertiary education. 

This should also be a particular area of focus as school psychologists are moved from under municipal administration with the social welfare and healthcare reform in Finland. Without further investment, this may weaken the communication between health care providers and schools.

Health provides the basis for a good life   

It is not enough to discuss mental health if we do not address the root causes and social issues the lead to mental health problems. It is not enough to advocate for seeking therapy if the society treats people who encounter mental health problems in a discriminatory and even cruel manner.

Studies show without a doubt that insufficient income, inequality, and discrimination, for example, are all risk factors that increase the likelihood of mental illnesses. Poverty is often linked with stress, uncertainty, and experiences of insecurity, and in Finland the association with poverty and depression is the highest in EU. Lower income means lesser resources for basic daily needs, such as housing, food, or activities that can provide joy, for example.

Unfortunately, income is also strongly associated with how quickly the person can receive help. People with higher incomes have access to more services, private insurance, and occupational health care, and are thus more likely to receive help.

Low-wage earners are more likely to be affected by severe mental health problems, and the likelihood that these problems are prolonged is also higher. Critical situations where patients cannot afford the psychotropic medication prescribed by their doctor because of insufficient drug imbursement occur even in a welfare state such as Finland. Thus, the drug imbursement system and the practices of the Social Insurance Institution of Finland must be rapidly reformed. No one should have to choose between medicine and food.

Mental health problems also increase vulnerability to lower socioeconomic status in the longer term. The manner in which the society treats people affected by severe mental problems in particular is exclusionary. While general attitudes toward those affected by mental health problems have improved over the past decade, many stereotypes are still alive. Even according to a study published this year, nearly one in five Finnish people says that they would not want to live next door to a mental health rehabilitee. 

Nearly fifty percent of Finnish people, who have encountered mental health problems feel that they have been branded due to their illness, and they continue to face ignorance, prejudice, and discrimination. Discrimination occurs when searching for work, for example. A mental health diagnosis can also make it impossible to obtain insurance or a driver’s license or to adopt. 

Those affected by mental health problems also find themselves in an unequal position in terms of their physical health. The life expectancy of people affected by a severe psychiatric condition is often ten years shorter than that of the rest of the population. 

Universal basic income would be one of the best solutions available to preventing mental health problems and ensuring basic social security. When addressing mental health problems, we should also have the courage to discuss their root causes and attempt to find solutions to them, including income, work, and the prevention of structural discrimination.

The support and community offered by organizations, ethically arranged work during rehabilitation, and peer support are also extremely important for building good mental health. Services, such as various support chat rooms and the suicide prevention centre work empathically and effectively, primarily on a voluntary basis. Organizations are a source of indispensable help to those who encounter mental health problems. Policymakers should provide more support to them, instead of less.

Mental health is a joint challenge for the EU 

As an MEP and a co-chair of the Coalition for Mental Health and Wellbeing in the European Parliament, I believe that mental health is not only an issue in Finland but is instead endemic to the whole of Europe. More than one in six EU citizens have been diagnosed with a mental health disturbance and the economic impact of mental health problems on the EU level amounts to a minimum of 600 billion euros annually – more than 4% of the GDP.

The right of access to preventive healthcare and the right to benefit from medical treatment are in principle ensured by the European Union’s Charter of Fundamental Rights. However, these rights are not fully realized in any member state as regards mental health. Depending on the country, 33–70% of people affected by severe mental health problems do not get the help they need. 

The coronavirus situation has demonstrated the need for closer health cooperation. Mental health cannot be excluded from this development. We need an EU-wide mental health strategy that accounts for the impact of various policy areas on mental health (such as housing, education, labour, and the situation of minorities). Furthermore, work must continue particularly in areas where the EU already has jurisdiction, such as ensuring the rights of employees and developing labour legislation in a direction that promotes mental health. 

In the parliament, mental health problems are still tarnished by social stigma. When I have brought up my experiences with depression in public, many people advised me against doing so. One colleague also told me that it was great to see someone advocate for mental health issues, although mental health problems did not exist in their home country. Which, as research suggests, is a completely incorrect statement. Some EU member states have however identified good mental health practices that could be learned from. Methods already exists, we just need to utilize them.

Malta – Support for the LGBTQ+ community 

Malta was the first country in Europe to prohibit the dangerous and traumatic practice of conversion therapy targeting sexual and gender minorities. The largest LGBTQ+ organization in the country has also organized publicly financed professional support services to the LGBTQ+ community since 2013. This includes social assistance, individual and group therapy, support groups, and training offered to social and health care professionals. 

Belgium – Bringing the support to the people 

Since 2010, Belgium has been reforming their entire mental health system. The aim has been to bring services closer to the individual and the surrounding community, thus increasing the accessibility of care. The reform is based on multi-professional teams working in the field, outpatient care, basic health care, and housing and social services, among other things. As a result of the reform, improvements have been seen in the quality of care, rehabilitation and wellbeing of patients, and the quality of life of family members, although there is still plenty of work to be done.

Development of electronic services

The promotion of electronic services has become a particularly important issue during the coronavirus crisis, and research shows that these services can play a valuable role in tackling many mental health problems. Various electronic services were introduced in Finland last year, but awareness of the importance of this development has also increased elsewhere in the EU. One good example of this is the eMEN project funded by the EU, where new electronic services were trialled in the Netherlands, France, Belgium, and Ireland. As an MEP, I have also promoted a pilot project for remote psychotherapy, and while it has been difficult to gain support for the idea, I hope to see more progress here in the future.

France – Particular focus on inequality 

The French national health strategy for 2018–2022 takes into account the health inequalities caused by socioeconomic status and highlights the health impact of improving the social situation. The roadmap for mental health seeks to improve the inclusion of mental health rehabilitees in society. 

Slovenia – Mental health council to steer national activities 

Slovenia reformed its mental health policy in 2018, and as part of the reforms established a national mental health council that brings together ministries, local government, educational and research organizations, and the representatives of service providers, service users, and organizations. Such cooperation could prove useful in other parts of Europe as well.

Plenty of work remains

Mental health problems are discussed increasingly and more and more work is carried out in order to address and prevent them. 

But our work is still far from being finished. The failure to provide care is life threatening. Despite this, it is still far too common throughout Europe, and in Finland as well.

With this text I hope to open a debate on those questions as well that have been left unasked. On the actions required to treat the most serious crisis and mental health problems. And to prevent them in the first place. 

Mental health care and good life should be fundamental human rights. In your opinion, what can be done to promote this? I want to thank you for reading my thoughts. Your comments and wishes are very welcome!

Alviina Alametsä