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Mental health and well-being of children and young adults

Report | Doc. 15829 | 22 September 2023

Committee
Committee on Social Affairs, Health and Sustainable Development
Rapporteur :
Mr Simon MOUTQUIN, Belgium, SOC
Origin
Reference to Committee: Doc. 15223, Reference 4565 of 19 March 2021. 2023 - Fourth part-session

Summary

Young people’s mental health and well-being are impacted by a world with multiple crises and much uncertainty. Good mental health is a cornerstone for achieving many goals under the 2030 Agenda for Sustainable Development.

The report welcomes the shift to a human rights-based approach to mental health. It encourages the integration of mental health into national health systems, especially primary and community-based health services. The healthcare provided must be holistic and encompass both mental and physical health, as well as socio-economic and environmental factors that can impact a person’s overall well-being.

The report recommends to member States to strengthen mental health care for children and young adults and their well-being, as well as that of their carers, in normal times and in crisis situations. Mental health services should be free of charge and accessible to everyone, regardless of factors such as socio-economic status, sexual orientation and gender identity, legal status, ethnic background or disability. The report recalls that mental health care must be provided on a voluntary basis respecting the autonomy of the person receiving care, and calls on the Committee of Ministers to take any decisions in line with the United Nations Convention on the Rights of Persons with Disabilities.

A Draft resolutionNote

1. The fulfilment of the right to health, as recognised by numerous international and regional instruments such as the International Covenant on Economic, Social and Cultural Rights and the European Social Charter (ETS No. 35), is fundamental for the well-being of every human being. This right also encompasses, as an essential component, the right to mental health: a state of mental well-being which allows the individual to realise their potential, cope with the normal stresses of life, work and participate in their community.
2. Children and young adults today face a world characterised by multiple crises and much uncertainty. The Covid-19 pandemic had a devastating effect on their mental health and well-being. However, challenges to their mental health and well-being were already present before the pandemic: Today’s young generation has, in addition, lived through the global financial crisis and its repercussions (including misguided austerity measures), a cost-of-living crisis, uncertainties on the job market (inter alia linked to advances in machine learning and artificial intelligence), and a war in Europe. Moreover, global transformations such as the ever-intensifying climate crisis, the ageing of populations, digitalisation and rising inequalities have created significant uncertainties about the future young people and unborn generations can expect.
3. The imposition of restrictions related to Covid-19 adversely influenced the mental health of many individuals. The main victims, however, are reported to have been children, adolescents, and young adults, who were disproportionately affected by the disruption in education, social isolation, economic instability, and general uncertainty about the future. Their well-being and life satisfaction steeply declined during this period, thus putting them at a higher risk of developing mental health problems. Within this group, children and young people from disadvantaged socio-economic backgrounds, persons with disabilities, LGBTQI+, minorities, refugees and undocumented migrants, undoubtedly suffered the most. The surge in mental health problems which occurred during the pandemic uncovered long-standing deficiencies in the way that mental health systems are organised, managed, and funded at national levels.
4. Against this background, the Parliamentary Assembly believes that States should seize this opportunity to advance with regard to improving mental health and recalls that the right to mental health includes access to timely and appropriate mental health care and treatment for all. A key step in this regard is to integrate mental health into national health systems, especially primary and community-based health services. The healthcare provided must be holistic and focus on treating the person as a whole, including addressing mental health, as well as social, economic and environmental factors that can impact a person’s overall well-being, rather than just their physical symptoms. It is critical to raise awareness of these issues from a young age, also in order to “de-dramatise” problems related to mental health. Coercion in mental health must be phased out.
5. The Assembly welcomes the shift to a human rights-based approach to mental health and the recognition that there is “no health without mental health”. It applauds recent efforts by the World Health Organization, the United Nations and other influential global actors in recognising mental health as an integral component of health and a human rights development imperative. Good mental health is a cornerstone for the achievement of many goals in the 2030 Agenda for Sustainable Development. Moreover, the Assembly underlines the critical importance of reducing stigma and shame associated with mental health problems.
6. The Assembly recalls that human rights do not exist in a vacuum. As such, States’ obligations towards fulfilment of mental health includes both immediate obligations and requirements to undertake deliberate, concrete and targeted actions to progressively realise other obligations. The Assembly joins the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health in urging States to use appropriate indicators and benchmarks to monitor progress on mental health, with indicators to be disaggregated by factors including sexual orientation, gender identity, age, race, ethnicity, disability and socio-economic status.
7. In light of these considerations, the Assembly recommends that the Council of Europe member States:
7.1 build up strong health systems at national level and mainstream mental health across all policies by:
7.1.1 allocating the necessary funding to establish a well-functioning, human rights-compliant mental health system and ensure the appropriate training of mental health professionals;
7.1.2 decentralising health-care services, so that people get timely mental health care that meets their individual needs regardless of where they live;
7.1.3 implementing universal health coverage, thus removing financial barriers to mental health care, ensuring that everybody has access to these services, irrespective of their socio-economic status, ethnic background, sexual orientation, gender identity or legal status;
7.1.4 integrating mental health into primary and community-based services and treating mental health with the same attention and seriousness as physical health;
7.1.5 simplifying administrative procedures and bureaucratic processes to make them more user-friendly and provide better information to users and their carers on their rights;
7.1.6 offering holistic, multisectoral and low-threshold mental health care services, such as drop-in centres, community-based programmes, peer support, and phone and chat services;
7.1.7 implementing the necessary educational reforms and campaigns in order to end the stigma and misinformation associated with mental health issues, in collaboration with trusted persons and organisations in communities where this is the case;
7.1.8 providing appropriate mental health first-aid training in hospitals, schools and universities, workplaces, prisons and detention centres, and law enforcement;
7.1.9 designing targeted and inclusive health services that meet the needs of underserved communities, in particular refugees and migrants, persons with disabilities and LGBTQI+ youth;
7.1.10 providing appropriate and necessary information, training, support and relief to families of young people struggling with mental health problems, including siblings, parents and other carers;
7.1.11 providing educational resources related to mental health to children, adolescents and young adults, as well as to their parents or other carers, in order to ensure the timely detection of mental health problems and provide information on how to maintain good mental health;
7.1.12 quickly responding to crises and emergency situations, including, but not limited to, wars, forced displacements and natural disasters, and developing national strategies on how to best support the mental health and well-being of children and young adults in such circumstances;
7.1.13 performing vulnerability screenings of refugees and asylum seekers and following the United Nations High Commissioner for Refugees (UNHCR) handbook on interpretation in asylum interviews; children should never be made to interpret the traumata of their parents;
7.2 take action to address other concerns that impact the mental health and well-being of children and young adults by:
7.2.1 ensuring equitable access to quality education to children and young adults, and meaningful work for young persons;
7.2.2 reducing socio-economic inequalities and making the fight against extreme child poverty a priority;
7.2.3 empowering young people and including them in decision-making processes, taking their concerns seriously, including on issues such as the environment and racial discrimination, where young people are the stakeholders for the future;
7.2.4 taking measures to tackle young people’s financial and employment insecurity;
7.2.5 encouraging employers to ensure appropriate work-life balance, leaving employees, including young people, with enough flexibility and time to rest and pursue other interests;
7.2.6 taking measures to protect children and young people from being exposed to inappropriate and harmful content on social media;
7.3 take the necessary precautions to protect the mental health of children, adolescents and young adults in the event of a public health emergency or confinement period by:
7.3.1 keeping educational facilities open and functional for as long as this is possible, while taking into account the importance of protecting the population;
7.3.2 facilitating equitable access to necessary equipment and materials for at-home learning, in the event that the continuous operation of educational facilities is no longer feasible;
7.3.3 ensuring tailored follow-up and support to young persons with a history of mental health needs;
7.3.4 ensuring that all measures taken to tackle the public health emergency are transparent, proportionate, and in line with the best interests of the child;
7.3.5 consulting children and young adults with regard to any decision that may affect their rights, mental health and well-being;
7.3.6 disseminating information specifically targeted to a younger audience, as seen in the good practice example of Norway.
8. The Assembly believes that parliaments have a responsibility to ensure that children’s and young people’s voices are listened to and incorporated into legislative processes, in order to promote a more inclusive and representative democracy. By creating spaces for dialogue and collaboration in parliaments, we as parliamentarians, can foster an environment where children and young people feel valued and understood, and can effect change. As such, the Assembly recommends that parliaments within the Council of Europe member States frequently invite children and young people to parliamentary hearings, get to know their point of view on matters that affect them and empower them in policy-making processes.

B Draft recommendationNote

1. The Parliamentary Assembly refers to its Resolution … (2023) “Mental health and well-being of children and young adults”. It is convinced that this topic should be given higher priority in the Council of Europe member States and underlines the importance of empowering children and young adults in decision-making processes that relate to them, and in particular about their health and well-being.
2. The Assembly commends the work of the drafting group on developing a guide to child participation in decisions regarding their health (BIO/ENF-CP). In this regard, the Assembly recommends that the Committee of Ministers instruct the drafting group to co-ordinate closely with the World Health Organization (WHO) and other United Nations agencies working on this issue to ensure a harmonised and rights-based approach to mental health, especially for children and young adults.
3. The Assembly moreover recommends that the Committee of Ministers remind the Steering Committee for Human Rights in the field of Biomedicine and Health (CDBIO) of the firm position of the Assembly, the Commissioner for Human Rights of the Council of Europe, relevant United Nations agencies and mechanisms (including the Committee on the Rights of Persons with Disabilities (CRPD Committee) and WHO), and of independent experts and persons with lived experience against the use of coercion in mental health. Mental healthcare must be provided on a voluntary basis and must always respect the autonomy of the person receiving care. Any decisions of the Committee of Ministers should reflect this human rights imperative, and be taken in line with the United Nations Convention on the Rights of Persons with Disabilities, as interpreted by the CRPD Committee.

C Explanatory memorandum by Mr Simon Moutquin, rapporteur

1 Introduction

1. On 11 February 2021, I tabled, together with 29 other members of the Assembly, a motion for a resolution entitled “Taking into consideration the impact of the fight against the Covid-19 pandemic on the mental health of minors and young adults” (Doc. 15223). The motion called on the Parliamentary Assembly to study the link between the health measures taken during the pandemic and the increase in psychological disorders among children, adolescents and young adults and to advise States on the proportionality of restrictive measures in relation to mental health consequences. The motion was referred to the Committee on Social Affairs, Health and Sustainable Development (the committee) for report and I was appointed rapporteur on 12 April 2021.
2. The motion was tabled during a period with strict measures in place to contain the spread of the virus, and which consequently had a large impact on the mental health and well-being of people across the world. However, challenges to the mental health and well-being of adolescents and young adults were already present before the pandemic, such as the global financial crisis and its repercussions (including misguided austerity measures), rising inequalities, high expectations from society with regard to education, career and establishing a family, pressure from social media and peers, but also wars, conflicts and natural disasters. These have all contributed to significant uncertainties about the future young people and unborn generations can expect.Note Despite pressure from society, the many crises and turbulent events which have unfolded, there are few studies on their impact on the mental health and well-being of young people in general. In fact, the last report adopted by the Assembly on the issue of mental health and well-being was adopted in 2005. Thus, I propose to change the title of the report to better reflect the enlarged focus of the report and the challenges we are dealing with today.
3. There is no clear age definition of “youth”, but the United Nations, for statistical purposes defines those persons between 15 and 24 years old as youth, without prejudice to other definitions by member States. Some specialised agencies include persons up to the age of 32 in their statistics. The European Steering Committee for Youth (CDEJ) and the Advisory Council on Youth (CCJ) of the Council of Europe include persons up to the age of 30. For the purpose of this report, I have decided to focus on the age group between 15 and 32 years old, an age group that is often forgotten and which has suffered through a series of turbulent events during critical years for their development, as described above.
4. In November 2022, I undertook a fact-finding visit to Oslo (Norway) to learn more about the country’s efforts to lower barriers to access mental health care, but also the challenges young people in Norway face with the current system. During the visit, I had the pleasure to meet with representatives of NGOs, local mental health care services, the Norwegian Ministry of Health and Care Services, and the Norwegian Public Health Institute. I also met with two of colleagues from the Norwegian Delegation to the Assembly, Ms Lisa Marie Ness Klungland (ALDE) and Mr Morten Wold (EC/DA), for an interesting exchange of views on the topic. I would like to express my sincere gratitude to the Secretariat of the Norwegian Delegation who helped organise my fact-finding visit in short timeframe.
5. On 24 January 2023, the committee held an exchange of views with Anna Knobbout, member of the CCJ. Anna Knobbout highlighted the mental health struggles of many peers, in particular trans youth, who had to wait several years only to have a first session with a psychologist, also noted that while problems of youth and their needs were increasing, waiting lists were getting longer, and worried that this could lead to suicidal thoughts. It was noted that prevention and including mental health in school curricula was very important, including by having trauma-informed schools, both for refugees and for youth in general. Although public acceptance of mental health issues had improved, Anna Knobbout regretted that mental health was still not considered on an equal footing with physical health.
6. I believe it is urgent that the Council of Europe member States address the fault-lines in their health systems and the way they think about mental health and accelerate efforts to improve the mental health and well-being of minors and young adults. With the present report, I aim to formulate some practical policy recommendations to member States as to how that can be done.

2 The right to mental health

7. Mental health is an integral and essential component of health. The World Health Organization (WHO) recognises health as a state of complete physical, mental, and social well-being. Moreover, it is more than just the absence of mental health disorders or disabilities. Mental health is “a state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn well and work well and contribute to their community”.Note The increased acknowledgement that there is no health without mental health, indicates a shift in how “the right to a standard of living adequate for the health and well-being...” as enshrined in the Universal Declaration of Human Rights, which was adopted 75 years ago, is now understood.Note
8. The International Covenant on Economic, Social and Cultural Rights provides a legally binding framework for the right of everyone to the enjoyment of the highest attainable standard of [physical and] mental health in its Article 12.1. This is complemented by other United Nations (UN) legal standards, including the Convention on the Rights of Persons with Disabilities, the Convention on the Elimination of All Forms of Discrimination against Women, and the Convention on the Rights of the Child. At the regional level, the right to protection of health is recognised in Article 11 of the European Social Charter (ETS No. 35). Consequently, States parties have an obligation to “respect, protect and fulfil the right to mental health in national laws, regulations, policies, budgetary measures, programmes and other initiatives.”Note
9. The right to mental health is moreover understood as the belief that all individuals should have access to appropriate and effective mental health care and support, regardless of their socioeconomic status or other factors. The Office of the United Nations High Commissioner for Human Rights (OHCHR) emphasises that the right to mental health includes access to timely and appropriate mental health care and treatment. “Good mental health must be defined by the creation of environments where people can live their lives in dignity in the equitable pursuit of their full potential.”Note It is fundamental to our collective and individual ability to think, emote, interact with each other, earn a living, and enjoy life. On this basis, WHO underlines that the promotion, protection and restoration of mental health should be regarded as a vital concern of individuals, communities and societies throughout the world.Note
10. This new and holistic approach to mental health emerged at the end of the 20th century and contains a critical mass of new evidence on the importance of mental health and the effectiveness of integrated approaches.Note The former UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Dainius Pūras noted that we are standing before a unique momentum and opportunity to advance with regard to improving mental health. Recent efforts by the WHO and other influential global actors are proof that mental health is emerging at the international level as a human rights development imperative. This is supported by the 2030 Agenda for Sustainable Development where most of the development goals implicate mental health.Note

3 Challenges to the mental health and well-being of adolescents and young adults

3.1 An age of uncertainties

11. Young people face a world with multiple crises and much uncertainty. Adolescence is a crucial period for the development of social and emotional habits that are important for mental health and well-being. Half of all mental health disorders in adulthood start by age 14, but most cases are undetected and untreated.Note The consequences of not addressing adolescent mental health conditions extend to adulthood, impairing both physical and mental health and limiting opportunities to lead fulfilling lives as adults. One such challenge can be developmental changes, as the transition into adulthood can be a time of significant physical, emotional, and cognitive changes, which can be both overwhelming and stressful.
12. Adolescents and young adults face a variety of challenges to their mental health and well-being. The more risk factors young people are exposed to, the greater the potential impact on mental health. According to WHO, factors that can contribute to stress during adolescence include exposure to adversity, pressure to conform with peers and exploration of identity. Moreover, media influence and gender norms can exacerbate the disparity between an adolescent’s lived reality and their perceptions or aspirations for the future. Difficult living conditions, stigma, discrimination or exclusion, or lack of access to support and services can negatively impact the mental health and well-being of young people. These include young people living in humanitarian emergencies and fragile settings; young people with chronic illness, autism spectrum disorder, an intellectual disability or other neurological condition; pregnant adolescents, adolescent parents, or those in early or forced marriages; orphans; asylum seekers, refugees, and immigrant children and young people from minority ethnic or sexual backgrounds or other discriminated groups.Note
13. Compared to older generations, young people report more negative feelings such as losing purpose and motivation in life, often caused by having to meet never-ending high expectations from society related to education, work and career path, amongst other things. Moreover, the lack of involvement of young people in critical decision-making processes amplifies these feelings. Issues like climate change, LGBTQI+ rights, socioeconomic inequalities, and racial justice deeply resonate with them, yet they often find themselves side-lined from the discussions that shape their own future.
14. Children and young adults in Europe are reported to suffer more from mental health disorders than their peers in other continents.Note In Europe, suicide is sadly the second leading cause of death among young people. Despite alarming trends on their mental health and well-being, there are few studies on the state of mental health specifically for the age group of 15-32 years in our region. In 2021, UNICEF published a report titled “The State of the World’s Children 2021: On My Mind”Note. The report finds that depression and anxiety are two of the leading causes of illness and disability among adolescents in Europe. Almost one in five European boys aged 15 to 19 suffer from mental disorders, followed by more than 16% of girls the same age. However, mental health disorders among children and young people are often under-reported, due to the stigma around mental health issues. It is not clear why, in the high-income continent of Europe, mental disorders contribute a greater percentage to overall burden, despite evidence-based interventions and comparatively greater financial capacity to address these issues.Note
15. There is evidence to suggest that capitalism may be associated with poor mental health outcomes and that it exacerbates inequities.Note Some argue that the competitive and individualistic nature of capitalism as such can lead to high levels of stress, anxiety, and depression. The pressure to constantly strive for success and material wealth can create a sense of never-ending dissatisfaction and can lead to feelings of inadequacy and failure. Additionally, the emphasis on individualism and self-sufficiency within capitalist societies can make it difficult for individuals to ask for help or support, which can exacerbate mental health issues. Furthermore, the focus on consumerism and material possessions can make it difficult for individuals to find meaning and fulfilment in life, which can lead to feelings of loneliness. Consumerism has also been linked with increased feelings of depression and anxiety, emotional and behavioural problems, lower self-esteem, and parent-child conflicts.Note
16. Studies have also reported on the correlation between the use of social media and poor mental health. Notably, prolonged daily usage of social media has been associated with a higher risk of developing anxiety and depression, as well as body image issues, disordered eating behaviours, attention problems, feelings of exclusion, and poor quality of sleep. Additionally, while there is currently no available medical diagnosis of it, some researchers believe that excessive social media exposure can lead to brain changes comparable to an addiction.Note
17. Use of social media also increases the possibility of young people being exposed to inappropriate or harmful content, and of being subjected to cyberbullying or predatory behaviours. Vulnerable categories of young persons – such as racial or ethnic minorities, persons with disabilities or members of the LGBTQI+ community – are also more susceptible to being targeted or accidentally coming across hate-based content, which can significantly affect their mental health.Note
18. Lack of access to affordable healthcare, job insecurity and poverty can also contribute to poor mental health. Studies show that young people are over-represented in these statistics. Negative trends on the labour market disproportionately affect young people, including by reducing their opportunities for part-time work and work-based learning for students. Many recent graduates (and students who are soon to graduate) face difficulties finding and maintaining jobs, which negatively impacts their well-being and puts them at increased risk of developing mental health issues throughout the course of their lives.
19. The climate crisis is another contributing factor to increased levels of anxiety among young people today. Climate anxiety, or eco-anxiety, is distress related to worries about the effects of climate change.Note It is not a mental illness, but rather anxiety rooted in uncertainty about the future and reactions to a vision of a better future in jeopardy. Nevertheless, its detrimental effects should not be overlooked – climate anxiety may lead to rumination and difficulty in sleeping, and have adverse impacts on work, study, and family relationships.Note Additionally, high levels of climate anxiety are often correlated with high clinical symptoms of depression and anxiety.Note A survey published in the Lancet Planetary Health in 2021Note, revealed that among 10 000 children across 10 countries, more than 50% of them reported feeling sad, anxious, angry, powerless, helpless, and guilty about climate change. As many as 45% of the respondents indicated that their feelings regarding climate change have a negative impact on their daily life and functioning.
20. The impact that the climate crisis may have on young persons’ mental health transcends past climate anxiety: the effects of environmental disasters increase the already-high levels of uncertainty. Climate change can affect children’s physical environment, such as their home or school; parents’ or young adults’ places of work may also be damaged, as well as livestock and crops, thus leading to economic instability and, in turn, to a decrease in mental well-being. In the most nefarious of cases, climate disasters may lead to the forced migration of families, putting young persons at a higher risk of developing mental health issues.Note Additionally, living through an environmental disaster is a traumatic experience, which may leave long-term mental scars on young people.

3.2 The impact of Covid-19 on the mental health and well-being of adolescents and young adults

21. According to WHO, in the first year of the Covid-19 pandemic, global prevalence of anxiety and depression increased by 25%.Note Young people and women were the most affected. Concerns about mental health conditions have already prompted 90% of countries surveyed to include mental health and psychosocial support in their Covid-19 response plans, but major gaps remain.
22. A report on the “Impact of Covid-19 on young people in the EU”, indicates that young people were more likely than older groups to experience job loss, financial insecurity, and mental health problems due to the Covid-19 pandemic. Moreover, young people reported reduced life satisfaction and mental well-being associated with requirements to stay at home, and disruptions in education.Note Overall, the Covid-19 pandemic had a disproportionate impact on young people’s life satisfaction and their mental well-being, compared to older groups.
23. At least one in seven children globally have been directly affected by lockdowns. Key findings from a study conducted by UNICEF suggest that the pandemic had a substantial negative effect on child and adolescent mental health, mostly because of rising anxiety related both to the disease itself and the restrictive public health measures that were put in place to contain the virus.Note Social isolation, disruptions in daily life, family grief, and uncertainty about the future in the context of Covid-19 are all factors that put children and adolescents at higher risk for depression.
24. The economic and social impacts of the pandemic will have profound consequences for many years to come, resulting in a setback for the UN Sustainable Development Goals. Findings from a report by Save the Children show a correlation between income loss and decreased psychological well-being.Note The pandemic tends to magnify pre-existing social inequalities with respect to access to quality education, health care, and other services, resulting in an unequal impact on children and young adults from different socio-economic backgrounds.Note Children living in poverty are more likely to experience stress due to loss of income in the family. Unsurprisingly, children living in households that had lost more than half of their income since the outbreak of Covid-19 reported a higher level in the increase of negative feelings compared to children from other households.Note
25. Moreover, the Covid-19 pandemic has had a devastating effect on young people with a history of mental health needs, who reported aggravation of their condition and more difficulties when searching for help.Note The Norwegian Ministry of Health and Care Services, and the Norwegian Public Health Institute, whose mission is to produce, summarise and disseminate knowledge to support good health efforts and healthcare, have observed similar tendencies. The foundations of lifelong mental health are built in early childhood. This period is known by the increase in prevalence of many psychological symptoms and the emergence for the first time of psychological problems. The hardships of the pandemic severely undermined those foundations.
26. However, not all children and young adults have the same experience of the pandemic, and thus its impact on their mental health is different. For example, some young people have reported certain positive aspects of the pandemic alongside the negative ones, including discovering oneself, deepening family relationships, and sharing life at a distance.Note In particular, the amount of parental engagement during lockdown has made a significant impact on children’s wellbeing.Note However, the negative impacts of the pandemic clearly outweigh its positive aspects for most children and young adults.
27. Studies indicate that alcohol and substance abuse among adolescents and young people increased during the pandemic. Moreover, this was found to be associated with other negative mental health issues. Containment measures such as lockdowns and subsequent social isolation were found to be a risk factor for alcohol consumption.Note

4 Some challenges and good-practice examples to take away from the fact-finding visit to Norway

28. The Norwegian health system offers a high level of social and financial protection. Population coverage is universal (although regrettably with some exemptions such as undocumented migrants and persons whose asylum applications have been rejected) and includes essential mental health care. Public financing accounts for the majority (85%) of health expenditure. Various mechanisms, including exemptions and ceilings on out-of-pocket payments, limit the financial burden of care on individuals. For 2023, the ceiling for annual out-of-pocket user fees is 3 040 NOK (approximately 285 EUR). Once someone has reached this ceiling, they will receive an exemption card, and will not have to pay user fees for the remainder of the calendar year.
29. In Norway, health care policy is controlled centrally. However, responsibility for the provision of health care is decentralised. Primary mental health care services are financed and organised by local authorities at municipal level, and according to local demand. Specialised mental health services, on the other hand, are the responsibility of the regional health authorities. They are provided in highly specialised mental hospitals, community mental health centres, and in outpatient setting (treatment by privately practicing psychiatrists and psychologists under contract with the regional health authorities).
30. User fees for treatments by psychologists that specialise in clinical psychology, and have funding contracts with regional health authorities, count towards the ceiling for out-of-pocket fees and the exemption card for health services. Children and adolescents up to 18 years old do not have to pay any user fees for treatment by a psychologist. Patients need a referral either from a doctor, psychologist, or child welfare officer. However, the number of psychologists with funding contracts is limited. This has resulted in long waiting times, in extreme cases up to two yearsNote (although patients with urgent needs will normally skip the line and receive care faster). In 2020, nearly one in four patients with a referral were declined by the specialised mental health services.Note Patients who are declined by the specialised mental health services, or who find the waiting lists to be too long, will have to bear the full cost of private psychologists, without any reimbursement.
31. Local municipalities often have a wide range of mental health services available, depending on the demand and capacity. Municipalities are required to employ psychologists within their health and social care services. The municipality psychologists provide free short-term treatment for mild to moderate mental illnesses and disorders.
32. During my visit to Oslo, I met with representatives of “Health Clinics for Adolescents” (HFU), “UNG Arena” and “FACT Ung”. Health Clinics for Adolescents are free services for young people that offer help and advice from nurses, doctors, and psychologists. My interlocutors informed me that young people often come to them with questions regarding sexual and reproductive health, as well as mental health issues, ranging from school refusals and heartbreak to more serious problems that need long-term care. If the HFU finds that the latter is the case, they will often refer the person to UNG Arena, for follow-up on mental health. UNG Arena is a low-threshold mental health service offered to young people aged between 12 and 25 years old that was built together with young people and offers peer-support. FACT, which stands for Flexible Assertive Community Treatment, and draws inspiration from the Netherlands, aims to provide a holistic and co-ordinated service to young people with more serious mental health problems and disorders. It targets young people who should normally receive treatment within the specialised mental health services, but who for various reasons do not fit in, and thus try to accommodate their individual needs.
33. All three care services experienced a sharp increase of young people struggling with poor mental health both during the first stages of the outbreak of the pandemic, and post-confinement. Moreover, Gamle Oslo, the district where the three care services are located, has one of the highest percentages of children growing up in poverty in Norway, including a lot of refugees and immigrant children, who are often at increased risk of mental health problems, marginalisation, and stigma. My interlocutors were worried that despite the very high increase of young people seeking care, they were not able to reach out to some of the most vulnerable groups.
34. Another low-threshold treatment service that is provided by the municipality is “Urgent Mental Health Care”. It is offered to persons over 16 years old who are experiencing various types of anxiety together with mild or moderate depression. This service can also help with sleeping difficulties and incipient substance misuse problems.Note The service is free and provides direct assistance without the need for referral from a doctor. The aim is to ensure that young people can access support within one to two weeks so that the condition does not become more severe.
35. The NGOs that I met with in Oslo drew my attention to several other critical issues for vulnerable groups in Norway. In particular, the Norwegian Organisation for Asylum Seekers, pointed out that there is no vulnerability screening of asylum seekers and that immigration authorities are not trained in detecting mental health problems and disorders, which has resulted in fatal consequences for some individuals. On one occasion, it was detected long after the asylum interview that the asylum seeker, whose legal age was 24 years old, had an intellectual disability and had the intellectual level of a 12-year-old. Moreover, undocumented migrants and asylum seekers whose applications have been rejected, are only able to receive immediate assistance and healthcare which is absolutely necessary and cannot wait, despite the many traumas they may have lived through.
36. Queer Youth represents another group vulnerable to mental health problems. The mental health of many of their members has deteriorated since the mass shooting at locations associated with Oslo Pride, on 25 June 2022, with many receiving death threats and feeling unsafe. They underlined the need to decentralise health care services so that queer people could get adequate health care and support in their local communities. Queer Youth has phone and chat services that risk being defunded by the government. They experienced an increase in calls concerning suicide prevention in 2020 and 2021, and noted that people calling are getting younger, with 8 out of 10 being under 18 years old.
37. Lastly, Mental Health Carers Norway, an advocacy group solely working for the well-being and needs of mental health carers, underlined the importance of including carers and other family members in national strategies concerning mental health and well-being. I have integrated the additional learnings and good practice examples from my fact-finding visit to Norway in the chapter below.

5 Practical recommendations to member States

38. In a report to the UN Human Rights Council, the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health notes that “the right to mental health includes both immediate obligations and requirements to take deliberate, concrete and targeted action to progressively realize other obligations”.Note States are urged to use appropriate indicators and benchmarks to monitor progress, with indicators disaggregated by sex, age, race, ethnicity, disability and socio-economic status. Below, I will include some policy proposals that member States should consider in order to improve the mental health and well-being of young people.
39. In many member States, waiting lists have hit all-time highs and critical mental health services have been disrupted or halted in 93% of countries worldwide.Note The pandemic has highlighted the fragility of support systems for mental health in many countries and underlined how these hardships fall disproportionately on the most disadvantaged communities.Note Many member States have been forced to divert already overstretched health system resources away from mental health needs and towards the fight against the virus. In March 2022, the Director General of WHO, Dr Tedros Adhanom Ghebreyesus, warned that the numbers should serve as a wake-up call to all countries to step up mental health services and support.Note
40. After three years of pandemic disruption, it is time for governments to urgently allocate the necessary funding and take other steps to build stronger health systems. First of all, States must increase funding for mental health. This may include funding for community-based services, but also funding for research and training for mental health professionals. Despite the recognition that mental health is an integral and essential component of health, it has been continuously underfunded in all of our member States. In fact, spending on mental health stands at less than 10% of spending on physical health.Note
41. In 2023, the United Nations will hold a high-level meeting on Universal Health Coverage. Universal health coverage means that everyone, everywhere, should be able to access health services they need without suffering financial hardship. Regrettably, in many countries, there are high coverage gaps of care and services for common mental health conditions, such as depression and anxiety. Even when services are available, they are not necessarily rights-based, accessible and cost-effective.Note
42. The need for universal health coverage has never been clearer, and it is pivotal that mental health is an integral part of this. If we want to ensure the full success of the implementation of universal health coverage, mental health must be integrated into health systems, especially primary and community-based health services.Note There are several studies that suggest that integration of mental health in physical health programmes will improve the mental health outcomes of populations, as well as support the effective delivery of physical and mental health. This corresponds well with the understanding of WHO that there is no health without mental health. In fact, when integrated, the combined physical and mental health treatment contributes to better overall outcomes. Moreover, from a financial perspective, the overall care may also cost less.
43. Another important measure is to expand access to mental health care and treatment, to anyone within a State’s territory, regardless of legal status, and have in place targeted and holistic measures that meet the needs of underserved communities. Having mental health as an integral part of universal health coverage will increase access to mental health services by removing financial barriers, such as high out-of-pocket costs which may prevent individuals from seeking help. This is an important step to ensure that vulnerable groups, who are often disproportionally affected by crises, and in general may have poorer health, have easier access to necessary care and treatment.
44. Early detection and treatment are pivotal to addressing the challenges to the mental health and well-being of minors and young people. Member States can increase focus on mental health promotion and prevention by providing education and resources to help children, their carers, and young people maintain good mental health. Integrating mental health into universal health coverage would also increase early identification and treatment of mental health conditions. Moreover, having mental health and well-being as part of the school curriculum will help foster well-being and develop resilience, and may include talking about emotions, recognising signs of mental health illnesses, and practicing self-care.
45. Reducing stigma and shame associated with mental health problems is another critical step. We have a long way to go with regard to acceptance of mental health and well-being and treating it as equal to physical health in all population groups. However, there is no denying that mental health problems are more stigmatised in certain population groups. Member States could reduce stigma by improving the overall health literacy within the population and organising targeted campaigns towards certain groups by reaching out and collaborating with trusted organisations/people in their respective local communities. Moreover, universal health coverage can help reduce stigma associated with mental health problems by treating mental health as equal to physical health. This would also help reduce discrimination and marginalisation of people with mental health problems.
46. Finally, universal health coverage would provide a more holistic health care service overall. A holistic approach to healthcare focuses on treating the whole person, rather than just their physical symptoms, and includes addressing mental health, as well as social, economic, and environmental factors that can impact a person's overall well-being. Following the good practice example from Norway, where seven ministries are working together on a new escalation plan on mental health, a cross-sectoral approach that integrates mental health into other policy areas is necessary for the success of national strategies. For instance, education and access to meaningful work that is conducive to the mental health and well-being of young people, requires a multisectoral approach.
47. Offering a wide range of multisectoral and low-threshold care services will contribute to lowering barriers to seek help for mental health issues. Building on the good practice examples from Norway, this could include drop-in-centres, community-based outreach programmes, peer support and phone and chat services. It is an excellent way to reduce pressure on health systems, through early detection and prevention, so that people get the help they need before their condition develops into something more serious. Such services are also beneficial because they are less stigmatising than traditional mental health services and are more accessible to people who may not have the resources or support to access more traditional services. However, it cannot replace specialised mental health services.
48. Member States should also simplify administrative procedures and bureaucratic processes to make them more user-friendly and provide better information to users on their rights. Navigating complex bureaucratic systems can be overwhelming and confusing, leading to feelings of frustration, helplessness, and stress. All the NGOs I met with during my fact-finding visit highlighted that dealing with administrative procedures can be time-consuming and require a significant amount of paperwork, which can be burdensome and increase stress levels. Moreover, dealing with administrative procedures can be costly for people who may have financial difficulties, which can add to their stress levels.
49. Although priority should be given to children and young adults, the mental health of parents and other caregivers is pivotal for the well-being of the younger generations as well, as underlined by the advocacy group for mental health carers in Norway. The stress experienced by parents and caregivers can affect their ability to meet the children’s needs. It can also be transferred to younger generations and have a negative effect on their mental health.
50. As for the pandemic, disruptions in education had a negative impact on the mental health of children and young adults, and disproportionately affected the most vulnerable and marginalised within our communities. Many lacked access to internet and/or necessary equipment, as well as adult support and supervision. As pointed out by UNESCO, the pandemic and the following restrictive measures exacerbated already existing disparities within the education system.Note For this reason, UNICEF, UNESCO and WHO recommend that if and when restrictions are imposed to decrease transmission and control the spread of the virus, schools should be the last places to close and the first to reopen.Note
51. The pandemic has had a negative impact on the fulfilment of children’s rights and the transition into adulthood. As pointed out by my colleague, Mr Stefan Schennach (Austria, SOC), in his report on “Beating Covid-19 pandemic with public health measures” (Doc. 15444), it is of utmost importance that governments and decision makers are transparent and open on the reasons for imposing restrictive measures. In addition to ensuring that measures fulfil a legitimate aim and that they are proportionate, decision makers must assess and determine the best interests of the child, as well as consult children and young adults in all cases concerning them, in line with Resolution 2414 (2022) “The right to be heard – Child participation: a foundation for democratic societies”.

6 Conclusions

52. Mental health and well-being are fundamental components of a child’s healthy development and future. Failing to address mental health needs among youth can have profound consequences and extend into adulthood, including limiting young people’s opportunities to lead fulfilling lives, as well as societies’ pathways for upward growth.Note Young people with mental health conditions often face disproportionate challenges if they do not receive adequate support. They are more vulnerable to social exclusion, discrimination, stigma (which may affect their readiness to seek help), poor physical health and human rights violations. This may lead to the inability to continue education, unemployment, troubles with criminal justice systems, substance abuse, self-harm and suicide, and poor quality of life.
53. Despite the fact that mental health is increasingly acknowledged as a key component to children and young people’s development, greater recognition and promotion of mental health and well-being are needed. Social and cultural stigma attached to mental health still need to be addressed. Promotion, prevention, and early intervention strategies may produce the greatest impact. Recognising that mental and physical health are equally important for the well-being of children and young adults, more resources are needed for timely, integrated, and multidisciplinary interventions. This would limit the risk of poor long-term outcome, with potential benefits for health-care system costs.Note
54. It is urgent to ensure that mental health care services are free and accessible to everyone, regardless of socioeconomic status, sexual orientation and gender identity, legal status, ethnic background, disability, and other factors that may put minors and young people at increased risk of poor mental health and well-being.
55. I firmly believe that as parliamentarians, we have a responsibility towards children and young people to include them in policy-making processes and ensure their voices are heard on issues that matter to them. By incorporating young voices into legislative processes, we promote a more inclusive and representative democracy, which helps ensure that our policies are well-rounded and reflective of the diverse needs and interests of the entire population. By creating spaces for dialogue and collaboration in parliaments, we as parliamentarians can foster an environment where young people feel valued and understood. This in turn will lead to increased civic engagement and a stronger sense of belonging within a society.