Mental ill-health imposes a significant burden on individuals and societies, with mild-to-moderate depressive symptoms affecting one in five adults in OECD and EU27 countries. If left untreated, these symptoms can escalate to mental illnesses, increasing societal costs. This chapter summarises key findings and policy recommendations following a review of 11 interventions aimed at promoting mental well-being and preventing symptom deterioration.
Mental Health Promotion and Prevention
Best Practices in Public Health
Abstract
Mental ill-health has a large burden on population health, well-being and the economy. One in five adults across OECD and EU27 countries experience mild-to-moderate symptoms of depression and anxiety, conditions that affect more individuals than any other mental health disorder. If left untreated, milder symptoms may progress into moderate functional impairments and even major depression. Mental ill-health often emerges early in life and is exacerbated by vulnerabilities and socio‑economic disadvantage, particularly among the unemployed, low-income and less-educated populations, resulting in substantive societal costs, including increased demand for health and social services, and reduced workforce productivity.
As part of the work on OECD Best Practices in Public Health, this report identifies and assesses proven best practice interventions designed to prevent and manage mental ill-health. The selected interventions focus on promoting good mental health and preventing mild-to-moderate symptoms of depression and anxiety from deteriorating into more serious disorders, as well as preventing suicide. Informed by submissions from countries and the EU Best Practices portal, 11 promising and best practices were identified, aligning with the prevention priorities outlined in the OECD Benchmark for mental health performance (OECD, 2021[1]).
The selected best practice interventions cover the following priorities: making schools mental health-friendly environments that build resilience (e.g. Icehearts, This is Me and Zippy’s Friends); improving mental health literacy and enabling front-line professionals to recognise and help an individual with mental distress (e.g. Mental Health First Aid); preventing suicide (e.g. Suicide Prevention Austria and VigilanS); and making mental health care system easy for individuals to seek help (e.g. Belgium’s Mental Health Reform, @Ease, iFightDepression® Tool, Prompt Mental health care and Next Stop: Mum).
Preventing and treating early symptoms of depression and anxiety improve people’s health, educational and labour market outcomes. Evidence shows that interventions that provide prompt access to mental health care and support reduce symptom severity and duration by up to 87%. Programmes such as Mental Health First Aid and Zippy’s Friends, strengthen protective factors for mental well-being and mental resilience. Interventions, such as @Ease, Icehearts and the Belgian mental health reform, also demonstrated tangible improvements in school attendance and reduced work absenteeism, with reported gains ranging from 50% to 61%.
This report uses OECD modelling analysis, based on the Strategic Public Health Planning for Non-Communicable Disease model, to assess the effectiveness and cost-effectiveness of scaling-up promising and best practices in OECD and EU27 countries. The analysis shows that implementing four key interventions – Prompt Mental health care, iFightDepression® Tool, Next Stop: Mum and VigilanS – could prevent 26.2 million cases of mental disorders in OECD countries and 9.1 million in EU27 countries, over the 2025‑2050 period (1.4% of the new annual cases of depression and anxiety in OECD countries). These interventions have the potential to deliver health benefits at affordable costs, making them cost-effective. For example, scaling up interventions like Prompt Mental health care could generate 35 Disability-Adjusted Life Years (DALYs) gained per 100 000 population per year on average across countries, compared with 56 DALYs lost per 100 000 population due to bullying-related depression in Canada. Estimated per capita annual savings could reach EUR 4.7 in health expenditure, and EUR 3.8 in labour market costs, with healthcare savings exceeding intervention costs in nearly one‑fifth of countries studied.
The assessment of the transferability of the interventions from the origin country to other countries indicates that 47% of OECD and EU27 countries have organisational arrangements, political support, and economic conditions in place to implement the selected promising and best practice interventions. In the remaining countries, key gaps include, among others, a limited number of psychologists per capita and lower spending on prevention and health promotion.
Analyses of the 11 interventions have also identified three key areas that deserve a special attention in the design, scaling up and transferring best practices promoting good mental health.
First, individuals with mental health care needs face both health system-related and stigma-related barriers to access treatment. The cost of treatment, long travel distances and waiting times to see a mental health professional are major barriers for people from seeking help for mental ill-health. On average, two‑thirds of individuals who need mental health care are estimated to lack access to treatment in OECD and EU27 countries. Taboo and stigma surrounding mental health care cause additional personal barriers, discouraging people from talking and seeking help. Among those with mental health needs, one in five young people and one in seven adults fear to be judged by their peers if they seek mental health support. To address access barriers, it is crucial to:
Increase the availability of and facilitate access to low-threshold and specialised mental health care across regions and local settings, including online tools. For instance, the Belgian reform establishes networks of mental health professionals across schools, workplace, and social services. Additional measures include teleconsultations and online tools that improve access for individuals with mild-to-moderate symptoms (e.g. Prompt Mental health care and iFightDepression® Tool).
Reduce access barriers by reimbursing the cost of psychological therapies either in part or in full, as illustrated in Prompt Mental health care and Belgium’s reform. For instance, in Belgium, where people were recently entitled to reimbursement for a specified number of consultations with a psychologist, nearly 40% of patients using the service reported that they had to forgo care when the cost was not reimbursed.
Support programmes to communicate on mental health to normalise mental ill-health, remove stigma-related barriers and to enhance mental health literacy in the population (e.g. Mental Health First Aid, Zippy’s Friends).
Roll out peer-based programmes to train students and front-line professionals (such as teacher) to help individuals with mental distress (e.g. @Ease and Mental Health First Aid). While the treatment of mental illnesses relies on healthcare professionals, these programmes can reduce stigma, encourage people to talk and seek help, and prevent early symptoms from worsening.
Second, the evidence base of interventions is generally of moderate or weak quality and requires strengthening. While 80% of the interventions have strong-quality data collection methods and 40% have strong-quality study design, several selected interventions have a lack of relevant data and proven effectiveness. The indicators used to assess intervention effectiveness are heterogeneous. The evidence‑base of mental health interventions can be strengthened by implementing actions to:
Encourage experts and professionals to agree on and use standard frameworks for data collection and programme evaluation, such as the OECD Benchmark for mental health performance (OECD, 2021[1]). For example, in England, the National Health Service Talking Therapies has implemented an outcome monitoring system that collects symptom scores from 98% of users.
Incentivise programme leaders and assessors to consistently apply these standards across programme evaluations and ensure sufficient long-term monitoring of patients. For instance, in Finland, the Icehearts programme has its own follow-up tool that systematically collects data, including mentors’ assessment of child’s progress twice a year and parents’ and children’s self-assessment once a year.
Third, transferring interventions needs to be thoroughly planned and resourced. The OECD’s transferability analysis has identified several countries with strong potential to adopt and implement the 11 selected interventions. However, practical attempts to transfer these interventions have encountered difficulties related to differences in national and local contexts, integrating mental health programmes in various sectors of the government, and gaps in mental health workforce capacity. Policy options to facilitate the transfer of policies include:
Encourage implementers to share knowledge and experience and apply established implementation strategies to support the transfer of best practices across countries, as illustrated by the transfer of the Belgium’s mental health reform and Suicide Prevention Austria to other EU countries through the EU Joint Action ImpleMENTAL.
Foster cross-governmental co‑ordination for coherent and sustained action. For example, seven Norwegian ministries have collaborated on the National Mental Health Strategy; the Ministries of Health, Culture, Children and Equality, Labour and Social Affairs, Education, Local Government and Modernisation, and Justice.
Ensure that there is sufficient capacity in the mental health workforce, by planning for the future, and by creating roles for existing professions, such as midwife‑led postpartum depression diagnosis in Next Stop: Mum, or new professions, such as orthopaedagogues in the Belgian reform.
Major depression and generalised anxiety disorders are the most diagnosed mental disorders in OECD countries. On average across OECD countries, around 3% of the population lived with major depression and 5% with generalised anxiety disorders in 2019 (IHME, 2020[2]). The prevalence of major depression was higher in women (3.9%) than in men (2.1%), and it varied with age. The highest rates were found among individuals aged 20‑24 followed by those aged 35‑44. Individuals suffering from major depression experience depressed mood or a loss of pleasure or interest in activities for most of the day, while individuals with anxiety disorders experience excessive fear and worry. The symptoms of both conditions result in significant distress or significant impairment in social and occupational functioning. The severity and the duration of symptoms are key factors of the clinical diagnosis of mental disorders (Box 1.1).
Different instruments are used to identify and diagnose mental ill-health.1 This box provides an overview of the two most common alternatives: structured interviews, that allow the diagnosis of mental disorders as per internationally recognised psychiatric classification systems; and screening tools, designed to identify individuals at risk of conditions which should then be clinically assessed. In line with the remaining of the report, examples focus on depression and anxiety related mental-ill health, responsible for a large burden worldwide.
Structured interviews for clinical diagnosis of major depression
The Diagnostic and Statistical Manual (DSM) is used by medical doctors to establish diagnostic criteria for mental disorders, such as major depression. Patients are diagnosed with major depression if they report five or more depressive symptoms, including at least one of the symptoms “depressed mood” and/or “loss of interest or pleasure”. The list of symptoms include:
Depressed mood most of the day
Loss of interest or pleasure in activities most of the day
Significant weight loss or weight gain, or decrease or increase in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings worthless or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of suicide.
Comparable diagnostic criteria are also defined for generalised anxiety disorder.
Patients reporting less than five symptoms do not fulfil the diagnosis of major depression but may be considered in the “subclinical depression” category. While there is significant heterogeneity in the conceptualisation of subclinical depression, a systematic review found that most studies define subclinical depression as having two to four symptoms including depressed mood or loss of interest (Rodríguez et al., 2012[3]).
Screening tools for depressive and anxious symptoms
Screening tools are designed to capture a continuum of mental ill-health and to identify symptoms of different severity. Among the most used tools:
The Patient Health Questionnaires (PHQ) are scales validated by research to assess the severity of depressive symptoms (OECD, 2023[4]; Kroenke et al., 2009[5]). The PHQ‑9 is composed of nine questions referring to the previous two weeks. In each question, the frequency of the symptom is associated with a number of points: not at all (0 point), several days (1), more than half the days (2), nearly every day (3). The total score ranges from 0 to 27, with higher score indicating greater severity of symptoms. The score cut-offs used to define the severity of symptoms are shown in Table 1.1. A shorter version of the questionnaire, the PHQ‑8, removes the final question of PHQ‑9, which focusses on suicidal ideation, and scores 0‑24 points. A positive screening result is considered when scoring 10 or more, in both PHQ‑8/9.
The Generalised Anxiety Disorder scale (GAD‑7) is a tool to assess anxiety symptom severity (Spitzer et al., 2006[6]). The GAD‑7 is composed of seven items capturing the presence of anxiety symptomatology, each with four categories of response (similarly to the PHQ). The sum of the seven items ranges between 0 and 21 points and allows for the identification of one of the four categories of symptom severity (Table 1.1). A positive screening result is considered when scoring 10 or more in GAD‑7.
Source: Kroenke et al. (2001[7]), “The PHQ‑9: Validity of a brief depression severity measure”, https://doi.org/10.1046/j.1525-1497.2001.016009606.x; Spitzer et al. (2006[6]), “A brief measure for assessing generalised anxiety disorder”, https://doi.org/10.1001/archinte.166.10.1092.
Symptom screening tools have been increasingly incorporated into national health surveys to measure population mental health. PHQ‑8 is applied in more than 60% of OECD countries (OECD, 2023[4]), for example through the European Health Interview Survey (EHIS), the Korea Community Health Survey, and the United States National Health Interview Survey. Estimates of mental disorders prevalence in the population are likely to differ depending on the type of instrument used to measure them. Compared with diagnostic interviews, screening tools are likely to overestimate population level prevalence, as these tools were designed to identify individuals at risk for conditions – some of whom may not meet the criteria for a confirmed diagnosis.
1. Mental ill-health is used as an umbrella term encompassing both subclinical experiences (e.g. distress, subclinical symptoms) and diagnosed conditions (e.g. major depression, anxiety disorders).
Mild-to-moderate depressive symptoms affect one in five adults across OECD and EU27 countries and, too often, remain undiagnosed and untreated
The proportion of people experiencing mild-to-moderate symptoms is large. OECD analysis of survey data from OECD and EU27 countries found that nearly one in five people aged 15 and above reported having mild-to-moderate symptoms of depression in 2019. Specifically, 15% of respondents reported having mild symptoms of depression, 4% had moderate symptoms, while 2% had moderately-severe and severe symptoms (Figure 1.1). More than 25% of the population aged 15 and above report mild-to-moderate symptoms in Luxembourg, the Netherlands, Iceland and Estonia, compared to less than 15% in Poland, Korea, Italy, Ireland, Czechia, the Slovak Republic, Bulgaria and Greece. In all the studied countries, the mild and moderate symptoms represent the bulk of depressive symptoms: 90% of individuals with mental health symptoms had reported mild-to-moderate symptoms. Individuals with mild-to-moderate symptoms, not fulfilling the diagnostic of major depression, have lower quality of life, poor health perception, higher level of disability and well-being, impairment in physical functioning (Rodríguez et al., 2012[3]).
Note: Age 15+. In the United States, the moderately-severe and severe are grouped.
Source: OECD analysis based on EHIS, 2019, and national survey data for Korea (Korea Community Health Survey 2019), the United Kingdom (European health interview survey 2019) and the United States (National Health Interview Survey 2019).
Mild and, often, moderate depressive symptoms are less likely to be diagnosed because they do not meet the clinical criteria. If symptoms are milder or less persistent, patients are more likely to remain undiagnosed. OECD analysis based on survey data from 22 OECD countries, confirms that the likelihood of receiving a diagnosis of depression increases with the severity of symptoms (Figure 1.2). Specifically, about 8% of the surveyed population reported to have been diagnosed with depression in the last 12 months. This proportion increases with the severity of symptoms: the share of those with a diagnosis is 20% in those with mild symptoms, 47% in those with moderate symptoms, 67% in those with moderately-severe symptoms, and 77% in those with severe symptoms. As more than half of individuals with mild and moderate symptoms are undiagnosed, there is a potential for prevention and early interventions targeting those with mild and moderate symptoms.
Note: Age 15+.
Source: OECD analysis based on EHIS, 2019, including data for the United Kingdom.
If left untreated, mild symptoms can turn into mental illnesses. People with mild and moderate symptoms are significantly less likely to receive a mental health therapy or treatment compared to those with severe symptoms (Evans-Lacko et al., 2018[8]). However, if milder symptoms are left untreated, they can deteriorate to mental disorders. Evidence shows there is a 10% to 20% risk that subclinical depression deteriorates to major depression (Teepe et al., 2023[9]). In addition, subclinical depression poses a 33% to 50% risk of patients developing moderate functional impairments.
The burden of mental ill-health is possibly increasing, although more data are needed to confirm this trend. Previous OECD analysis showed that population mental health fluctuated during the COVID‑19 pandemic, typically worsening during periods of infection and movement restriction (OECD, 2023[10]). As the pandemic receded, population mental health has improved, although level of mental ill-health has remained elevated. In about half of the OECD countries with available data, the proportion of people reporting depressive symptoms decreased in 2022 compared to 2020 levels, but this proportion remains at least 20% higher than pre‑pandemic levels. Several factors can explain the persistent high level of mental distress, such as the cost-of-living crisis, climate crisis, conflicts, as well as increased awareness and changing language around mental health that reduced the stigma of this health issues making it easier to speak and seek support.
As the prevalence of mental ill-health has increased, rates of suicidal ideation (suicide thoughts) have increased too, especially among young people. In the three OECD and EU27 countries for which data is available, up to a quarter of young people reported having had suicidal ideation during the COVID‑19 crisis, which was five times higher than pre‑pandemic levels (OECD/European Union, 2022[11]). However, in most countries, this trend did not translate into an increase in deaths by suicide. In 2020 and 2021, death by suicide represented 11.2 deaths in 100 000 people, compared to 11.3 in 2018 and 11.1 in 2019, on average across OECD countries. Between 2001 and 2021suicide rates across OECD countries reduced by 34% for males and 24% for females.
The burden of mental ill-health varies across population groups. Women experience 62% higher rates of depression than men, while men face much higher suicide rates. Mental ill-health often begins at early ages, with 75% of adult disorders starting before adulthood. Vulnerability increases during life transitions, such as adolescence, pregnancy and postpartum, or migration, and is heightened by negative events such as unemployment or death of a relative or friend. The uneven distribution of mental health conditions has a particularly detrimental impact on people in low income and/or with low education. Socio‑economic disadvantages such as unemployment and income loss, exacerbate mental health issues.
Mental ill-health carries a significant economic burden, including spending on healthcare and social services, and lost labour productivity
Mental ill-health carries a significant cost to the society. The cost of mental ill-health was estimated at 4% of gross domestic product (GDP) across the 28 EU countries in 2015 (OECD/European Union, 2018[12]). This equates to more than EUR 600 billion, equivalent to twice the health budget of France. This cost includes 1.3% of GDP in direct spending on health systems, 1.2% of GDP on social security programmes, and a further 1.6% of GDP in indirect costs related to lower employment and work productivity. It has been suggested that this cost may be under-estimated because several additional costs could not be included due to data limitations. For instance, it does not account for social spending related to mental health problems, such as higher social assistance benefits and higher work-injury benefits, costs within the criminal justice system, and the higher cost of treating a physical illness if the patient also has a mental illness.
The cost of mental illness varies according to the severity of symptoms and treating symptoms in their early stages would prevent more costly healthcare later. Medical cost of treating mental illnesses may vary up to 20‑fold by level of severity. A German study found that in 2019, the 6‑month treatment cost of mental disorders was estimated at EUR 511 for mild symptoms, EUR 2417 for moderate symptoms, EUR 7 624 for moderately-severe symptoms and EUR 10 485 for severe symptoms (König et al., 2023[13]). This finding suggests that interventions at an early stage of the disease are likely to prevent higher costs when mental health symptoms deteriorate to more severe conditions.
Mental health symptoms, even milder forms, have negative labour market outcomes, suggesting that preventing a deterioration of the disease can increase employment and productivity. Mental ill-health is associated with lower employment and higher absenteeism from work. The strength of the association varies by the severity of symptoms. Previous OECD analysis based on 31 countries found that individuals with moderate mental distress were 15% less likely to be employed compared to those with no mental distress, while the risk increases to 36% for individual with severe mental distress (OECD, 2021[14]). An Australian study found a significant and positive association between the level of depressive symptoms and the number of mental health-related work absence in the previous four weeks (Johnston et al., 2019[15]). Individuals with mild depression symptoms had about 0.5 absence day whereas those with moderate symptoms had around 1 absence day, and those with severe symptoms had more than 3 absence days.
Eleven candidate promising and best practices were examined
OECD and EU27 countries have various policy interventions at their disposal to prevent mental ill-health and promote good mental health. The OECD Framework for Mental Health Performance recommended six policy areas for addressing mental ill-health prevention and promoting good mental health (OECD, 2021[1]). Policy areas include strengthening suicide prevention, improving mental health awareness and literacy, making schools mental health-friendly environments, ensuring that workplaces foster good mental health, enabling front-line professionals to recognise and respond to mental health symptoms, and improving access to care and support by making it easy for individuals to seek help.
Eleven candidate promising and best practices were identified and assessed. Interventions were identified with the help of member countries of the OECD Expert Group on the Economics of Public Health and through the European Commission Best Practice portal (European Commission, n.d.[16]). Six of the selected interventions aim to facilitate access to mental health care and support for individuals with mild-to-moderate symptoms by expanding low-threshold services (e.g. supportive material and talking groups) and specialised care services. Three case studies relate to education-based programmes developing children’s skills enabling good mental health. Two case studies focus on suicide prevention, and three case studies focus on training for front-line professionals such as midwives and teachers to help individuals with mental distress or in a crisis (Table 1.2). Some of the interventions can cover multiple policy areas at the same time. The population target of the selected interventions is diverse, including children, adolescents, adults, perinatal women, and individuals with mild-to-moderate mental health symptoms, and those with more severe symptoms and suicidal ideation. The geographic representation covers more than 11 countries since some interventions were implemented in several countries. The selected case studies include various ways of delivering the intervention, such as healthcare settings, web-based tools, peer-to-peer programme, and school settings.
Each intervention was assessed against a standard methodology common to all the analyses part of the OECD series on best practices in public health. The approach was co-developed by delegates to the OECD Expert Group on the Economics of Public Health and assesses interventions against five best practice criteria including effectiveness, efficiency, equity, quality of evidence base and extend of coverage, as well as an assessment of the intervention’s transferability potential. For further methodological details, see Annex A.
While this report focusses on early intervention and prompt access to care for highly prevalent mental disorders, such as depression and anxiety, this focus is not intended to diminish the importance of addressing other disorders, including psychotic disorders, bipolar disorder, and substance use disorders. Instead, the report supports the view that improving access to care and support across the spectrum of mental health conditions must be an overarching policy priority.
Scaling-up early interventions for mild and moderate symptoms of depression and anxiety can have broad public health benefits, including reducing stigma and strengthening mental health literacy, which may indirectly benefit those with other severe mental disorders. For instance, a population trained in mental health support and exposed to destigmatising conversations around mental ill-health (e.g. Mental Health First Aid) may also acquire skills to better support individuals with complex conditions, encouraging them to seek help earlier.
However, there is a risk that disproportionate focus on mild and moderate symptoms could lead to resource shifts or a lack of policy attention to services addressing other mental health needs. For example, if workforce and funding are primarily channelled into prevention and early intervention programmes, specialised services such as intensive case management could face shortages, reducing the quality and accessibility of care.
To mitigate this risk, it is essential that policy efforts to promote good mental health also include measures for people with severe mental disorders. This may include tailored health promotion and prevention measures as well as specific resources to specialised care. For instance, interventions improving access to mental health support for individuals with mild-to-moderate depressive symptoms (e.g. Prompt Mental health care, @Ease) also serve as a gateway to secondary healthcare services or to general practices for individuals with more severe mental health conditions.
Most interventions facilitate access to people with mild-to-moderate symptoms, such as free consultations with mental health professionals, walk-in centres for youngsters, and guided self-help online tools
Six of the 11 case studies were designed to provide individuals with mild-to-moderate symptoms with easy and prompt access to low-threshold and psychological care. Evaluation studies show that these interventions are effective in facilitating access to care and improving individuals’ mental health status. The following case studies fall in the category of interventions facilitating access to care:
Prompt Mental Health Care (PMHC) provides individuals with mild-to-moderate symptoms of depression and anxiety with a facilitated and prompt access to diagnosis and talking therapy. Evidence from a randomised controlled trial (RCT) study shows that 59% of the individuals who received PMHC treatment had recovered from the symptoms of mild-to-moderate depression or anxiety after six months, compared to 32% of those who received treatment as usual. In addition, PMHC increases recovery by 83% at six‑month follow-up compared to treatment as usual.
iFightDepression® (iFD Tool) is a web-based, self-management tool for people with mild-to-moderate depressive symptoms, that uses the principle of cognitive behavioural therapy and is guided by a health professional. iFD Tool offers free‑of-charge training and exercises to do at home. It complements psychological therapy, rather than replacing it. The intervention is effective in shortening the time a person lives with the symptoms of depression and anxiety. Evidence from a RCT study shows that the intervention reduces the symptoms by 40% on an 84‑point scale after six weeks and three months, and it increases remission after eight weeks.
@Ease are walk-in centres where young people who experience mental distress can come, seek help and talk with a young adult. The intervention reduces psychological distress and improves social and occupational functioning among adolescents. It also reduces school absence. Among the youngsters who received the intervention, the proportion of those who were absent from school at least once in the last three months decreased from 44% to 17% between the first and third visit to the walk-in centre.
This is Me consists of two different interventions. It offers an online information and counselling service (#Tosemjaz) available at any time and at no cost for adolescents with mental distress, as well as a school-based workshop programme, that systematically addresses the development of social and emotional competencies and realistic self-evaluation of students in primary and lower secondary education. The #Tosemjaz website offers a repository of questions-answers by theme (e.g. self-image; love and obsession; drugs and addiction, etc.) and has a chat function that adolescents can use anonymously to exchange with psychologists and other health professionals. The website receives about 180 000 unique visitors, more than 260 000 visits and 1 000 000 page views each year. The school-based workshops are complemented by a self-help manual for adolescents aged 15 and over, widely made available to students as well as to education and health professionals in Slovenia.
Belgium’s mental health reform has created a network based on multidisciplinarity and intersectionality to enable prompt and free‑of-charge access to psychologists. Specifically, the reform entails the creation of networks of mental health professionals (e.g. psychologists and “orthopedagogues”) at the regional and local levels, and the reimbursement of both low-threshold and specialised psychological care, covering up to eight and 20 psychological sessions per patient per year, respectively, among others. An evaluation study shows that in the group of individuals who got access to a psychologist through the network, the prevalence of mental health disorders has decreased by 10% on average, six months after their enrolment.
Next stop: Mum is a postpartum depression screening programme with targeted support for women at high risk. The programme aims to inform women on postpartum depression, train midwives to screen postpartum depression in perinatal women and refer those with higher risk to psychological consultations. The programme expanded the potential for screening postpartum depression, reaching about 10% of the target population. A higher likelihood of screening then increases the likelihood of treatment and recovery.
Four interventions specifically target children and young people, three being school-based programmes (Icehearts, Zippy’s Friends and This is Me) and one being a peer-based programme (@Ease). This is Me and @Ease are described just above.
Icehearts uses team sports to provide long-term mentoring support to socially vulnerable children and adolescents. Support is provided both in and outside of schools. An evaluation study found that at 4‑year follow-up, 49% of Icehearts participants showed improved prosocial behaviour, whereas 34% showed a worsening. No evidence is found for emotional and conduct problems. Icehearts also reduces school dropouts with a 50% reduction in the number of children being not in employment, education, or training (NEET).
Zippy’s Friends is a social and emotional learning programme for school-based children aged 5‑7 years. The programme improves social-emotional skills and coping strategies, providing children valuable tools to navigate challenges through adolescence and into adulthood. Negative attitudes such as opposition and withdrawal were reduced by 9% and 15% (respectively) compared to the control group.
Two interventions aim to support suicide prevention. Each intervention has a different focus and breadth. One is a nationwide strategy, while the other is a programme dedicated to individuals who had a first suicide attempt.
Suicide Prevention Austria (SUPRA) is national strategy for suicide prevention, including a gatekeeper programme (e.g. front-line professionals trained to listen to people at risk of suicide and provide essential support), safeguarding hotspots for suicide attempts (e.g. bridges, railways), and reducing access to means of suicide (e.g. firearms, substances). The global effectiveness of SUPRA has not been evaluated, although its components have shown to be effective in reducing suicides.
VigilanS is a prevention programme for individuals who were hospitalised after a suicide attempt. The intervention aims to provide information and involves follow-up phone calls and postcards six month after hospital discharge. The programme reduces the risk of suicide attempt repetition by 24% within one year.
Three interventions aim to train front-line professionals such as teachers and midwives, in order to provide recognise and support to a person experiencing mental distress or in a crisis. Next Stop: Mum and SUPRA are described above. The third intervention is described below.
Mental Health First Aid (MHFA) is a training programme that teaches front-line professionals how to recognise, understand and help someone experiencing mental distress or a crisis. MHFA increases mental health literacy, helping-behaviour and confidence in helping people with mental health problems.
Early interventions of mental ill-health prevent the development of more severe mental disorders and improve health and economic outcomes. The selected case studies show positive effects on three key domains: enabling factors for good mental health, health outcomes, and educational and occupational outcomes (Table 1.3), with some interventions reporting evidence on multiple dimensions. Five of the selected interventions show to improve factors supporting mental well-being such as social-emotional skills, coping strategies, interpersonal relationships, and health literacy. Five of the selected interventions also improve clinical outcomes, such as reduced symptoms, faster recovery, less time spent with mental distress, and increased screening of postpartum depression. Finally, four interventions show positive effects on educational and occupational outcomes, including improved school attendance and reduced absenteeism from work.
Note: The effectiveness of Suicide Prevention Austria (SUPRA) has not been assessed.
OECD simulations indicate selected interventions would yield significant health and labour market savings while being affordable for many health systems
The OECD Strategic Public Health Planning for Non-Communicable Diseases (SPHeP-NCD) model was used to assess the effectiveness and cost-effectiveness of scaling-up selected promising and best practices in OECD and EU27 countries. This analysis focusses on four of the 11 interventions (PMHC, iFD Tool, Next Stop: Mum, and VigilanS), based on data availability and quality. Results from the model show that implementing all interventions would yield a significant health impact – preventing 26.2 million and 8.1 million cases of mental health disorders in OECD and EU27 countries, respectively, between 2025 and 2050. This represents about 1.4% of the annual cases of depression and anxiety in OECD countries. Furthermore, across the four interventions, between 0.3 and 35 disability-adjusted life years (DALYs) per 100 000 population would be gained in OECD countries over the period 2025‑2050 (0.3 and 33 DALYs gained in EU27 countries, respectively) (Figure 1.3). For comparison, depression attributable to bullying in Canada results in a loss of 56 DALYs per 100 000 population (IHME, 2020[2]).
Note: PMHC = Prompt Mental health care, iFD = iFightDepression®, NSM = Next Stop: Mum.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Interventions can generate both health expenditure savings and improvements in workforce productivity, although the magnitude of benefits varies across countries. OECD simulations show that transferring PMHC – an intervention that provides timely access to effective mental health care – to OECD and EU27 countries would lead to significant savings in health expenditure, due to reduction in symptoms severity and shorter disease duration. Specifically:
Scaling up PMHC would result in average annual savings of EUR 4.7 per person in OECD countries and EUR 3.57 across EU27 countries.
Scaling-up a postpartum depression screening programme such as Next Stop: Mum improves early detection and diagnosis and supports timely access for psychological care, thereby reducing time spent with the disease and preventing symptom deterioration. This leads to better health outcomes alongside reduced healthcare costs on the long term in all studied countries.
The transfer of iFD Tool and VigilanS would also yield health expenditure savings in 19 and 17 countries, respectively, although with no cost reductions in remaining countries. For VigilanS – a suicide reiteration prevention programme – health expenditure savings are offset by the cost of treating future chronic diseases. As suicide‑related deaths are avoided, the cost of treating certain diseases is expected to increase over the years, as captured by the model’s dynamics. However, VigilanS produces significant gains in workforce participation and productivity.
Across all the four interventions studied, the reduction of mental health symptoms increases both labour force participation and work productivity. For example, the PMHC intervention would save OECD countries up to EUR 3.8 per person per year in labour market costs (EUR 3.5 in EU countries).
Interventions are cost-effective in all countries studied, and even cost saving in some countries. Analysis of cost per DALY gained over the period 2025‑2050 shows that scaling-up PMHC would be cost saving in 19% of countries studied and cost-effective1 in the remaining countries (Figure 1.4). Expanding the Next Stop: Mum screening programme – assuming that the programme covers up to three psychological support consultations- would be cost saving in 28% of countries studied and cost-effective in remaining countries. Scaling-up iFD Tool would be cost saving in 7% of countries, cost-effective in 79% and potentially cost-effective at higher threshold2 in 12% of countries. The scale‑up of VigilanS is consistently found cost-effective in all countries except one country where the health impact is non-significant.
Note: Cost per DALY gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2021‑2050. An intervention is considered cost-effectiveness when the cost per DALY is below the average cost-effectiveness threshold applied in European countries (i.e. EUR 50 000 based on (Vallejo-Torres et al., 2016[17]). For iFD Tool, the average cost per DALY is below EUR 50 000, but in a few countries, the confidence interval for the cost-effectiveness ratio crosses the threshold of EUR 50 000 per DALY.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Analyses of the 11 case studies have identified three main challenges and several solutions to guide policymakers in designing, scaling up or transferring interventions to prevent mental ill-health and promote good mental health. These three challenges are discussed in the reminder of this Chapter, and are summarised as follows:
Barriers to access and use mental health care and support services can be addressed by increased availability and affordability of mental health care and support services, investments to increase the level of mental health literacy in the population and by developing peer-based support programmes.
Moderate or poor quality evidence on the effectiveness of interventions can be addressed by using standard frameworks and validated clinical tools to build the evidence base and by incentivising programme assessors to consistently apply these standards.
Difficulties in previous transfers due to contextual variability, suboptimal cross-sector co‑ordination, and limited capacity of the mental health workforce highlight the need to share knowledge, apply established implementation strategies, involve different parts of the government and invest in workforce planning and development.
People in needs of mental health care face financial, organisational, geographical barriers as well as knowledge and stigma-related barriers to access treatment
The levels of unmet needs for mental health care are high in OECD countries. On average, two‑thirds of individuals in OECD and EU27 countries who need mental health care are estimated to lack access to treatment, based on OECD analysis (see Chapter 2). The gap in mental health support and treatment varies with the severity of mental ill-health: individuals with mild and moderate symptoms are significantly less likely to receive a mental health therapy or treatment than those with severe symptoms (Evans-Lacko et al., 2018[8]).
There are various reasons explaining high level of unmet needs for mental health care. These include, but are not limited to, financial, organisational and geographical barriers, such as out-of-pocket payments for psychological therapies, long waiting times to access psychological therapy, shortage of providers, and long distance to travel. Health system characteristics, such as the availability of healthcare services and the health benefit basket covered by national health insurance, are key determinants of healthcare access (Paris et al., 2016[18]).
Cultural, social and knowledge barriers, such as the lack of mental health literacy and stigma around mental illness, are other important determinants of access to mental health services. Mental health literacy is the capacity to find, understand and use information and services to inform decisions and take actions related to mental health problems. Low levels of mental health literacy result in people not having sufficient resource to deal with mental health problems and not seeking care. Four in 10 people reported difficulties to find information on how to handle mental health problems, on average across 16 OECD countries, in 2019-2021 (Figure 1.5). This proportion varies from 19% in Slovenia to 50% or more in Bulgaria and Germany.
Note: Due to the wide variety of sampling and data collection procedures across countries, country differences should be interpreted with caution.
Source: The HLS19 Consortium of the WHO Action Network M-POHL (2021[19]), International Report on the Methodology, Results, and Recommendations of the European Health Literacy Population Survey 2019-2021 (HLS19) of M-POHL, https://m-pohl.net/sites/mpohl.net/files/inline-files/HLS19%20International%20Report.pdf.
Stigma around mental illness, and in particular stigma about seeking help for mental ill-health, creates additional barriers to access mental health care. Perceived stigma (or self-stigma) is an individual’s perception that they will be treated differently by other people if they seek mental health treatment. A US study focussing on college students found that self-stigma was a major barrier to seek care for one in five students with unmet needs for mental health (Eisenberg, Golberstein and Gollust, 2007[19]). In another US study, one in seven adults with mental health needs did not seek treatment because they feared to be judged by their neighbours (Mason et al., 2013[20]). Interestingly, personal stigma (i.e. the perception that one has about someone seeking mental health treatment) is less of a problem. When asked about stigma around mental health care, college students generally reported greater perceived stigma than personal stigma (Pedersen and Paves, 2014[21]). This result suggests that communication around mental health interventions can help change perception and reduce self-stigma, which may have a positive impact on care‑seeking for mental health problems.
Policy recommendations
In response to high levels of unmet needs in mental ill-health, the following section outlines policy recommendations to remove barriers to access low-threshold and psychological treatment.
Increasing the availability of mental health care services is a top priority to facilitate timely management of mental ill-health. For example, this would include policies to ensure prompt mental health care services, with mental health professionals delivering both low-intensity mental health care (e.g. support group) and specialised care such as psychological therapy, across regions and local settings. Increasing provision of low-threshold and specialised treatment would have implications on the mental health workforce. For example, both PMHC and the Belgian reform are best practices to improve access to care for people with mild-to moderate symptoms. Besides, the Belgian network of mental health professionals spreads across various settings (such as schools, workplace, and social services) to reach a wider group of individuals who might not seek care on their own and to ensure integration of mental health care with other services. When such services cannot be deployed across the entire territory, tele‑consultation and online tools should be used to facilitate access for individuals with mild-to-moderate symptoms. In an experimentation of PMHC video teleconsultations, users reported that video treatment was more accessible, as they did not have to travel to and from to the service, or as they appreciated being able to sit at home in a safe environment and talk about difficult issues. Online services have the potential to increase the programme coverage and reduce waiting times. Evidence from Next Stop: Mum – a screening programme of postpartum depression in perinatal women- show that in the regions in which the intervention was deployed, the programme covered 5% of the target population in its in-person version, while the coverage was doubled (10%) when using both in-person and virtual screening versions. The online iFD Tool – a guided self-help tool- is a best practice to reduce the time on waiting list, as it provides the patient with information and exercises to address mental health challenges, while waiting for an appointment with a mental health professional.
Enhancing the affordability of mental health care by removing financial barriers can also substantially improve access to services. Cost of psychological therapies should be reimbursed, either partially or in full. In 2020, 24 of 25 countries responding to the survey had psychological therapies delivered by a psychologist covered in full or in part by basic health coverage (OECD, 2021[1]). Among countries reimbursing the service, more than half (13) covered it in full by basic health coverage (Figure 1.6). While having significant costs for governments, removing the financial barriers is a key lever for seeking mental health care. For instance, both PMHC and the Belgian reform removed the cost barrier, partly or in full. PMHC is totally free‑of-charge for patients, and the Belgian reform entitles patients to reimbursement for a specified number of free consultations with a psychologist. In Belgium, nearly 40% of users of the new scheme reported that they previously had to forgo care when cost was not reimbursed. This suggests that 40% of the users of the new scheme would have forgone psychological treatment if the cost was not covered.
Note: N/A not available.
Source: OECD, (2021[1]), A New Benchmark for Mental Health Systems, https://doi.org/10.1787/4ed890f6-en.
Effective communication should contribute to normalise mental health symptoms and promote care seeking. For example, interventions such as MHFA and This is Me promote discussion about mental health problems and the identification of solutions. In addition, school-based interventions, such as Zippy’s friends, Icehearts and This is me, teach basic essential skills to deal with emotional and mental issues, providing solutions to mental health problems in children and adolescents.
Efforts should be made to enhance mental health literacy among the population, including young people, workers, and the whole community. Interventions such as MHFA that train front-line professionals can raise the level of mental health literacy in various settings, such as schools, higher education institutions, workplaces, and communities. In the workplace, MHFA training is crucial for creating mentally healthy environments where employees feel supported, valued, and confident in talking openly about mental health. In Australia, a specialised MHFA course trains adults to deliver an intervention specifically designed for Aboriginal and Torres Strait Islander communities, taking into consideration cultural sensitivities.
Peer-based programmes may be implemented to train students and front-line workers (such as teachers) to provide support to a person with mental distress or in a crisis. While treatment of mental illnesses should remain with healthcare professionals, these programmes can help lift the taboo off mental illnesses and can encourage people to discuss their problems and seek help. These interventions can also avoid that early symptoms worsen to more severe conditions. Interventions such as @Ease and MHFA rely on individuals (peers) who are trained to listen and guide a person experiencing mental distress or crisis.
There are gaps in the evidence base of mental health promising and best practices
Only half of the case studies present proven effectiveness on mental health outcomes and/or enabling factors for good mental health. The OECD Benchmark report identified that it is extremely difficult to assess the efficiency and the evidence‑base of the mental health systems because of their loose conceptualisation of efficiency, an heterogeneity in service design and a lack of data (OECD, 2021[1]). The lack of relevant data and proven effectiveness is also one of the main limitations identified during the analysis of the case studies. Although the evidence base is one of the criteria used to select the candidate interventions, just about half of the analyses present proven effectiveness on mental health outcomes and/or enabling factors for good mental health. Three interventions found mixed or no proven effectiveness of the programme. Two interventions did not – or only partially – evaluate the programme effectiveness on the key indicators described in Table 1.3.
There is a large heterogeneity in the indicators used to measure the interventions’ effectiveness. The original studies evaluating the intervention effectiveness use a large variety of indicators, with low level of consistency across the case studies. These indicators can be classified into three groups of outcomes as mentioned above (i.e. enabling factors for good mental health, mental health outcomes, and educational and occupational outcomes). Yet, there is a large heterogeneity in the indicators used within each group of outcomes.
Enabling factors for good mental health include a variety of measures of social-emotional skills, coping and resilience skills, and social isolation. At least eight different scales were used to measure children’s social-emotional skills, such as Strengths and difficulties questionnaire, Kidcope checklist, Social skills improvement system rating scale, among the others.
Health outcomes include symptom severity and duration, incidence and remission of mental disorders, suicide attempts, and screening of postpartum depression. The two studies evaluating symptoms relied on different instruments: one used PHQ‑9 and the other one the Inventory of Depressive Symptomatology self-rating scale. Other studies used indictors about patient satisfaction, quality of life, and general mental well-being, with no consistency in the selected indicators.
Educational and occupational outcomes are also heterogenous: they include school attendance, school dropout, classroom climate, and work absenteeism. Each original study uses a different indicator from the other original studies.
The evidence base of the selected interventions is generally of moderate or poor quality, with the exception of the data collection methods which are of strong quality. The quality of the evidence supporting the selected interventions was assessed against the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project, 1998[22]). This tool evaluates the internal validity of studies using six criteria: selection bias; study design; controlling for confounders; blinding; data collection methods; and withdrawals and dropouts. For each criterion, a study is awarded either a “strong”, “moderate” or “weak” score. Figure 1.7 presents a summary of the evidence quality assessment of the selected interventions. Most selected interventions (i.e. 90% of the interventions) have weak assessments regarding “blinding”, while “reducing selection bias” was rated as moderate in 60% of cases and weak in 40% of cases. The quality of the “study design” is relatively more balanced, with 60% of the case studies showing a moderate quality study design and 40% with a strong study design (e.g. random controlled trial). The evidence base of the interventions is often calculated on observational studies that compare the evolution of outcomes before and after the intervention. Although informative, this type of studies may not be sufficiently reliable to assess the intervention effectiveness. Higher quality evidence is obtained when the intervention effectiveness is assessed by comparing the group that received the intervention with a control group that received treatment as usual (as for example, PMHC and iFD Tool). Finally, strong quality assessment is granted for 40% of the interventions regarding “controlling for cofounders” and for 30% of interventions regarding “reducing withdrawals and dropout”. Most interventions have strong quality “data collection methods”, with 80% of the interventions using both valid and reliable methods.
Note: Results reflect findings from the selected interventions. “NA” = not applicable.
Source: OECD analyses based on the methodology in: Effective Public Health Practice Project (1998[22]), “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14.
Policy recommendations
The key findings summarised above on the quality of the evidence base highlight gaps in data collection and quality that may hinder transferring and scaling-up mental health interventions. Recommendations to strengthen the evidence base of mental health interventions include the following ones.
Experts and professionals should be encouraged to agree and use standard frameworks for data collection, such as the OECD framework for mental health system (OECD, 2021[1]). The OECD Framework outlines a set of indicators for continuous mental health surveillance, including those related to prevention and promotion, which countries can collect to advance the mental health policy agenda, Experts and professionals should also be encouraged to establish standards for programme evaluations, such as requesting that programme assessors systematically include the measurement of mental health symptoms. In England, the outcome monitoring system of the National Health Service Talking Therapies collects symptom scores from 98% of users, which serves to assess the programme performance. In addition, experts and professionals should be encouraged to agree on validated clinical tools to measure symptom severity and the enabling factors for good mental health. These recommendations help prioritise mental health preventive actions and focus on subclinical conditions.
Programme leaders and assessors should be incentivised to consistently apply these standards across programme evaluations. For example, funding for programmes can be linked to the standards and tools used in evaluations. It is also important to ensure sufficient long-term monitoring of patients to assess programme effectiveness and sustainability, particularly when the programme targets children and young people. For instance, for interventions such as Icehearts and @Ease, programmes and outcomes are repeatedly measured and monitored. Specifically, Icehearts in Finland has its own follow-up tool that systematically collects data, including mentors’ assessment of each child’s progress twice a year, parents’ and children’s assessment once a year. It is essential to conduct follow-up studies until participants reach adulthood to evaluate the long-term effects of the programme. Finally, it is crucial to carefully monitor the impact of mental health interventions, not only to assess their effectiveness but also to guard against potential unintended consequences such as overdiagnosis or shift attention away from patients with more complex needs. This will help ensure that scaling-up interventions leads to equitable and effective improvements in mental health.
Transferring interventions is a complex task that requires a well-designed implementation strategy
Transferring promising and best practices from one country to another is generally a difficult task, as highlighted in previous OECD analyses (OECD, 2022[23]). Transferring practices on mental health also presents complexities. Specifically, at least three specific issues were identified in the transferring of promising and best practices on mental health.
Attempts to transfer the best practices have encountered difficulties due to cross-national differences in contexts and needs. Countries have different characteristics, and their mental health care system differs, which may facilitate or hinder the transfer. For instance, adopting walk-in centres for young people is relevant in areas with good public transport so that young people in need can go to the centres on their own. In countries where a significant share of the population lives in rural and remote areas, online support and teleconsultation may be more suitable. Another example is the implementation of prompt mental health care services and networks of mental health workers in local settings such as social services, schools, and hospitals. These interventions are particularly relevant in countries where psychological therapies can be obtained without a referral from a general practitioner as direct access to a psychologist removes one of the key barriers to care access.
The second specificity of the mental health practice transfer is the need for the integration of mental health promotion and prevention programmes into other related domains such as schools, unemployment and social services. Most selected interventions require interprofessional and inter-sectoral collaboration, and effort to engage multiple stakeholders. For instance, the transfer of school-based interventions requires to involve education actors such as teachers and school directors, as well as pupils and their parents. The delivery of these interventions is facilitated by small class size and teacher motivation relating to their perception on their ability to influence the development of children. Another example is a suicide prevention programme, such as Suicide Prevention Austria, that requires the collaboration with the Ministry of Transport to safeguard hotspots for suicide such as bridges, highways or railways.
The third difficulty that can hinder successful transfer of mental health interventions is the country’s mental health workforce capacity. Interventions that aim to facilitate access to mental health care rely on mental health care workers, such as psychologists and mental health nurses. In most selected interventions, psychologists play a prominent role. Countries with shortages in mental health professionals may experience difficulties in adapting these interventions in their local context. A number of OECD countries report shortages in mental health professionals, although data is not systematically collected, and when it is collected it is specific to some professions (OECD, 2021[1]). For instance, the number of psychologists per 1000 population varies hugely across countries, from 0.02 in Hungary and Korea to 1.40 or above in Norway and Denmark (WHO, 2024[24]).
Despite the difficulties outlined above, the evidence shows the case studies can be successfully scaled-up and transferred if adapted to the local context. Six of the promising and best practices were, or are being, scaled up nationally, and eight practices were, or are being, transferred from the “owner” country to another “target” country (Table 1.4). In many cases, the promising and best practices are transferred to multiple “target” countries. For instance, MHFA was, or is being, transferred to 29 countries, while Zippy’s Friends to 18 OECD and EU countries. The European Union financially supports the transfer of promising and best practices related to mental health across EU/EEA countries. For example, the EU-funded EAAD-Best project supported the transfer of iFightDepression® Tool to 8 EU countries. Another example is the EU-funded Joint Action ImpleMENTAL that helps countries to transfer and implement two selected best practices: Suicide Prevention Austria transferred to 17 EU/EEA countries, and the Belgian mental health reform transferred to 14 EU/EEA countries (Box 1.2).
Source: OECD analyses.
The EU-funded Joint Action ImpleMENTAL was a 3‑year project, ending in 2024. The work of the Joint Action aimed to support countries in transferring and implementing two selected best practices: Suicide Prevention Austria transferred to 17 EU/EEA countries, and the Belgian mental health reform transferred to 14 EU/EEA countries.
The Joint Action ImpleMENTAL supported participating countries in the implementation process, such as assessing the situation and needs in the target countries, establishing local networks for mental health, sharing knowledge, setting achievable goals, fostering stakeholder engagement and advocacy, and building capacity for mental health care services.
The Joint Action has used the CHRODIS Plus implementation strategy, which consists in three phases. The pre‑implementation phase is crucial to analyse the context of the target countries, assess the feasibility of the implementation and set action plans for the pilots testing the intervention. The implementation phase aims to monitor progress of implementation and collect data, while the post-implementation aims to evaluate the success of the intervention and report lessons learnt. A similar three‑step strategy is also recommended in the OECD Guidebook on best practices in public health. Based on the Plan-Do-Study-Act framework, the OECD recommends identifying and assess the transfer feasibility to a different context (Step 1), prepare and implement (Step 2); and monitor and evaluate (Step 3) (OECD, 2022[25]).
Source: JA-ImpleMENTAL website, https://ja-implemental.eu/.
Nearly half of OECD and EU27 countries have already in place many of the elements needed to transfer the identified best practices to their own country. OECD developed a methodology to cluster countries based on their potential to transfer selected case studies to their own countries. High-level methodological details are in Annex A, with further details available in (Wiper et al., 2022[26]). The section below summarises key findings from the analyses assessing the potential for countries to transfer and implement the interventions described in the case studies in this report:
Countries in cluster one comprise 20 OECD and EU27 countries – representing 47% of the studied countries- that have organisational, political, and economic conditions in place at the national level to support the implementation of the mental health interventions (Table 1.5). For example, these countries typically have good level of accessibility to healthcare services and a higher number of psychologists. These countries also have national policies to prevent suicide, improve mental health awareness and literacy, and a strategy or an action plan that guides the implementation of the mental health policy.
Countries in cluster two – 14 OECD and EU27 countries – have national policies in place supporting the implementation of mental health interventions. However, they may not have the arrangements in place to provide access to mental health services, and they have a lower budget available to implement the interventions. In addition, the number of psychologists per capita is relatively smaller than in countries part of cluster one, and they also tend to show lower score for the healthcare accessibility index suggesting the presence of barriers to access healthcare services. Spending on prevention is relatively lower than in cluster one.
Countries in cluster three – 9 OECD and EU27 countries – are less likely to have organisational, political, and economic conditions supporting the implementation of mental health interventions, although all countries have the opportunity to tailor the promising and best practices according to their specific needs, resources and contexts. Countries in this cluster on average score lower on the healthcare accessibility index than countries in cluster one, and the number of psychologists per capita is smaller than countries in clusters one and two. In addition, countries in cluster three may not have an action plan to guide the implementation of their mental health policy, a suicide prevention strategy or programmes to increase mental health literacy. The average spending on prevention is also relatively lower than for countries in cluster one.
Source: OECD analyses.
It is important to note that there are limitations with this analysis, most importantly:
It should not be assumed that the transfer of the mental health interventions will fail in countries where it is recommended to consider challenges related to population, political and/or economic feasibility (e.g. clusters 2 and 3). Rather, the results indicate areas to which countries should pay particular attention, but which are not necessarily pre‑requisites for transferral.
The analysis relied on publicly available data that covered many OECD and EU27 countries. Therefore, the analysis is high level and may rely on simplifications and not capture all the relevant indicators and factors to assess the potential for transferability.
The data used for the analysis is collected at the national level and therefore does not consider regional differences within countries.
Policy recommendations
The key findings summarised above on scaling-up and transferability highlight the barriers associated with transferring and scaling-up best practices on mental health prevention. Based on the analysis of the case studies, the following policies were identified to assist policymakers in scaling-up interventions within countries as well as transferring them to other countries.
Implementers should be encouraged to share knowledge and experiences from previous transfers. Building on previous transfers is essential to learn from past experiences and improve future transfer. It is also crucial that implementers have at their disposal guidelines and standards to facilitate the transfer and implementation process. For instance, the Joint Action ImpleMENTAL uses the established implementation strategy developed by the Joint Action CHRODIS Plus (Box 1.2). Lessons learnt from CHRODIS Plus have supported the development of ImpleMENTAL, for instance in carrying out of a country’s situation analysis and an assessment in the early phases of the implementation. In turn, lessons learnt from ImpleMENTAL may help future transfers. For instance, ImpleMENTAL identified that along with achievable and sustainable goals, it is motivating to have “quick wins” producing positive results soon after the implementation of the intervention.
A cross-governmental approach should be used to implement mental health interventions. Mental health prevention and promotion activities span across many different sectors such as health, school, work, social services and justice. It is essential that governments co‑ordinate mental health strategies and that collaboration between multiple ministries is improved in order to effectively implement policies. In 2021, 19 OECD countries reported that multiple ministries, in addition to the Ministry of Health, were in charge for implementing mental health interventions (OECD, 2021[1]). Ten countries also reported that ministries other than the Ministry of Health (e.g. ministries of social affairs, families, employment) had a dedicated mental health budget. For example, Norway has developed the National Mental Health Strategy with seven ministries, including the Ministries of Health, Culture, Children and Equality, Labour and Social Affairs, Education, Local Government and Modernisation, and Justice.
Careful planning and, when necessary, increasing the capacity of the mental health workforce are crucial to support an effective implementation of the identified best practices. Efforts to collect data on the workforce capacity should be made, reflecting the diversity of the professions including psychologists, mental health nurses, general practitioners, psychiatrists, social workers and occupational therapists. Where necessary, policymakers can also increase the workforce capacity by creating new roles for existing professions, such as midwife‑led postpartum depression diagnosis in Next Stop: Mum, or new professions such as orthopaedagogues in the Belgian reform. At the same time, it is important to ensure integrating these new roles with established, traditional roles across healthcare and other sectors, such as the social sector. Finally, mental health workforce projections should also be carried out and used to plan for future mental health needs of the population. For instance, England’s 2020/21 mental health workforce plan emphasised expanding the diversity of staff roles and established a significant number of new professions. These included “traditional” staff such as nurses, occupational therapists or doctors, and new roles such as peer support workers, personal well-being practitioners, or call handlers (Health Education England, 2017[27]). As of 2025, the UK Government recruited more than 6 700 additional mental health workers and developed mental health support teams in schools and colleges, now being accessible to more than half of pupils in England.
References
[22] Effective Public Health Practice Project (1998), Quality Assessment Tool for Quantitative Studies, https://www.ephpp.ca/quality-assessment-tool-for-quantitative-studies/ (accessed on 28 July 2021).
[19] Eisenberg, D., E. Golberstein and S. Gollust (2007), “Help-seeking and access to mental health care in a university student population”, Medical care, Vol. 45/7, pp. 594-601, https://doi.org/10.1097/MLR.0B013E31803BB4C1.
[16] European Commission (n.d.), EU Best Practice Portal on Public Health, https://webgate.ec.europa.eu/dyna/bp-portal/ (accessed on 4 October 2021).
[8] Evans-Lacko, S. et al. (2018), “Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys”, Psychological Medicine, Vol. 48/9, pp. 1560-1571, https://doi.org/10.1017/S0033291717003336.
[27] Health Education England (2017), Stepping forward to 2020/21: The mental health workforce plan for England.
[2] IHME (2020), GBD Compare | IHME Viz Hub, https://vizhub.healthdata.org/gbd-compare/ (accessed on 22 December 2021).
[15] Johnston, D. et al. (2019), “The relationship between depression symptoms, absenteeism and presenteeism”, Journal of Affective Disorders, Vol. 256, pp. 536-540, https://doi.org/10.1016/J.JAD.2019.06.041.
[13] König, H. et al. (2023), “Excess costs of mental disorders by level of severity”, Social psychiatry and psychiatric epidemiology, Vol. 58/6, pp. 973-985, https://doi.org/10.1007/S00127-022-02298-8.
[7] Kroenke, K., R. Spitzer and J. Williams (2001), “The PHQ-9: Validity of a brief depression severity measure”, Journal of General Internal Medicine, Vol. 16/9, pp. 606-613, https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
[5] Kroenke, K. et al. (2009), “The PHQ-8 as a measure of current depression in the general population”, Journal of affective disorders, Vol. 114/1-3, pp. 163-173, https://doi.org/10.1016/J.JAD.2008.06.026.
[20] Mason, M. et al. (2013), “Perceived mental health treatment need and substance use correlates among young adults”, Psychiatric services (Washington, D.C.), Vol. 64/9, pp. 871-877, https://doi.org/10.1176/APPI.PS.201200159.
[10] OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/7a7afb35-en.
[4] OECD (2023), Measuring Population Mental Health, OECD Publishing, Paris, https://doi.org/10.1787/5171eef8-en.
[25] OECD (2022), Guidebook on Best Practices in Public Health, OECD Publishing, Paris, https://doi.org/10.1787/4f4913dd-en.
[23] OECD (2022), Healthy Eating and Active Lifestyles: Best Practices in Public Health, OECD Publishing, Paris, https://doi.org/10.1787/40f65568-en.
[1] OECD (2021), A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/4ed890f6-en.
[14] OECD (2021), Fitter Minds, Fitter Jobs: From Awareness to Change in Integrated Mental Health, Skills and Work Policies, Mental Health and Work, OECD Publishing, Paris, https://doi.org/10.1787/a0815d0f-en.
[11] OECD/European Union (2022), Health at a Glance: Europe 2022: State of Health in the EU Cycle, OECD Publishing, Paris, https://doi.org/10.1787/507433b0-en.
[12] OECD/European Union (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris/European Union, Brussels, https://doi.org/10.1787/health_glance_eur-2018-en.
[18] Paris, V. et al. (2016), “Health care coverage in OECD countries in 2012”, OECD Health Working Papers, No. 88, OECD Publishing, Paris, https://doi.org/10.1787/5jlz3kbf7pzv-en.
[21] Pedersen, E. and A. Paves (2014), “Comparing perceived public stigma and personal stigma of mental health treatment seeking in a young adult sample”, Psychiatry Research, Vol. 219/1, pp. 143-150, https://doi.org/10.1016/J.PSYCHRES.2014.05.017.
[3] Rodríguez, M. et al. (2012), “Definitions and factors associated with subthreshold depressive conditions: a systematic review”, BMC psychiatry, Vol. 12, https://doi.org/10.1186/1471-244X-12-181.
[6] Spitzer, R. et al. (2006), “A Brief Measure for Assessing Generalized Anxiety Disorder”, Archives of Internal Medicine, Vol. 166/10, p. 1092, https://doi.org/10.1001/archinte.166.10.1092.
[9] Teepe, G. et al. (2023), “Development of a digital biomarker and intervention for subclinical depression: study protocol for a longitudinal waitlist control study”, BMC Psychology, Vol. 11/186, https://doi.org/10.1186/s40359-023-01215-1.
[17] Vallejo-Torres, L. et al. (2016), “On the Estimation of the Cost-Effectiveness Threshold: Why, What, How?”, Value in Health, Vol. 19/5, pp. 558-566, https://doi.org/10.1016/j.jval.2016.02.020.
[24] WHO (2024), Psychologists working in mental health sector (per 100,000), https://www.who.int/data/gho/data/indicators/indicator-details/GHO/psychologists-working-in-mental-health-sector-(per-100-000).
[26] Wiper, O. et al. (2022), “Cluster analysis to assess the transferability of public health interventions”, OECD Health Working Papers, No. 133, OECD Publishing, Paris, https://doi.org/10.1787/a5b1dcc1-en.
← 1. An intervention is considered cost-effectiveness when the cost per DALY is below the average cost-effectiveness threshold applied in European countries (i.e. EUR 50 000 based on Vallejo-Torres et al. (2016[17])).
← 2. The average cost-effectiveness ratio falls below the cost-effectiveness threshold, but the confidence interval for the ratio crosses the threshold.