Posted on: Sat 10-10-2020

The International Council of Nurses (ICN) works to ensure quality holistic nursing care, encompassing mental and physical health and spiritual, cultural and social wellbeing. Mental health is a cornerstone of health and wellbeing for individuals, communities and societies and nurses play a crucial role in the promotion and maintenance of mental health and wellbeing. The World Health Organization (WHO) defines mental health as, “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her/his community”. 1 Conditions that promote the highest attainable standard of health are a human right and the stigma and discrimination associated with mental illness have detracted from that right for centuries.

The world is facing a global emergency in mental health. Around one in ten persons, approximately 792 million people, have a mental or substance use disorder, contributing 10% of the global burden of disease. 3 The most common disorders are anxiety and depression and rates of both are rising, especially in low-income countries. In recent decades, substance use disorders, a subset of mental health disorders, has contributed significantly to the rise in the global burden of disease. 4 Approximately half of mental health disorders first occur before age 14 and every 40 seconds someone dies by suicide; 80% of suicides occur in low- and middleincome countries.1,5 People with mental health disorders experience high rates of discrimination and abuse and are frequently denied basic human rights such as security and survival needs. This is especially true for those with severe mental health conditions and psychosocial disabilities. Despite the large global burden, countries spend on average only 2% of their health budgets on mental health and, in low- and middle-income countries, 76-85% of people with mental health disorders do not receive treatment.

Mental health is the product of social, biological and environmental factors throughout the life course. The social determinants of health, social norms and forces such as policy agendas, economic policies and political systems all sustain both risk and resilience in societies. Social inequalities are associated with increased risk of mental health disorders from factors including inadequate social safety nets; unstable or inadequate housing; racism; disasters including pandemics; discrimination based on gender and/or sexuality; educational disparities; the impacts of climate change; food insecurity and undernutrition; civil unrest; and risks within the physical environment.8 Converging sources of vulnerability increase the likelihood of poor mental health in certain population groups. These groups include women, Indigenous populations, older persons, sexually marginalised people, incarcerated and refugee populations, and children and young people, particularly those exposed to maltreatment and neglect and adolescents who are using substances. In addition to sharing risk with the general population, nurses experience risk factors such as workplace violence, high physical and psychological demands and burnout.

As an important contributor to global morbidity and mortality from non-communicable diseases (NCDs), mental disorders intersect with other NCDs.9 Approximately 80% of those with severe mental disorders are disproportionately affected by other physical diseases.10 Depression and anxiety commonly co-occur with acute and chronic illness and contribute to poor self-care and self-harm, including suicide.

The COVID-19 pandemic has severely worsened mental health and wellbeing in societies. It has magnified the existing mental health crisis and the need to urgently increase investment in mental health services. Frontline health workers, including nurses, are disproportionately affected and are experiencing high degrees of psychological distress due to COVID-19.

Mental health professionals number less than one for every 10,000 people, insufficient for consultation and direct care worldwide. 7 Few health professionals have specialist level mental health knowledge and all health services struggle with significant workforce challenges. The integrated care model supports treatment of most mental health disorders in general health care settings, but mental health specialists are primarily found in secondary and tertiary care settings. Investment in mental health and addiction specialty nurses and other professionals as well as efforts to destigmatise mental health providers and care recipients is needed. 11 Nursing shortages are exacerbated by the undervaluing of mental health/psychiatric nursing roles and insufficient mental health in nursing education for direct care provision, illness management, research and policy.

Three interventions of growing importance guide nursing care in mental health. Risk reduction is central to all early nursing interventions and health promotion, and specifically, risk reduction for NCDs. Harm reduction, which aims to reduce the health, economic and social consequences of legal and illegal substance use, and risks for NCDs, is supported by substantial empirical evidence and is consistent with ethical nursing practice.12 Increasingly, nursing practices are emphasizing the recovery model to help the individual attain a fulfilling and valued life based on restoration of maximal function.13 This model puts the individual at the centre of defining illness and deciding on treatment options. Nurse leaders in many countries are spearheading the development and implementation of ‘best practice’ policies, which not only support recovery, but also are aligned with international standards of psychiatric/mental health nursing.

ICN Position and Recommendations 

As the global voice of nursing, ICN:

• Endorses human rights as foundational to freedom from discrimination for those with mental and/or substance use disorders, a prerequisite to access high-quality, evidencebased treatment and linked to social services and basic survival resources to support recovery. 
• Believes that policy and practice approaches must be rooted in lived experiences of mental disorders and shaped by the unique knowledge of individuals and families with lived experience.
• Believes that the balanced care model, which considers low-, medium- and highresource settings, offers the optimal model for treatment and care for people with mental disorders and that access to affordable, high-quality, culturally-congruent mental health care across the lifespan, including psychiatric nursing care, can be attained through coordinated, continuous, inter-sectoral, community-based strategies.
• Advocates for policies in all sectors that address the social determinants of mental health and changes in social and political norms. 
• Endorses the WHO Mental Health Action Plan 2013-2020 which encourages governments to establish community-based service systems focused on the promotion of mental health, prevention of mental illness, early intervention, and home-based treatment, care and rehabilitation.
• Urges governments to place mental health at the centre of national COVID-19 pandemic response and recovery plans.
• Supports the WHO’s call for massive scale-up in investment in mental health, particularly in low- and middle-income countries. 
• Advocates for climate change issues and their impact on mental health to be addressed within the public health political agenda.
• Recognises that racism is significantly related to poor mental health and strongly supports actions at all levels to eliminate racial and ethnic disparities in the screening, diagnosis and care of people experiencing mental health or substance use disorders.
• Recognises the potential of digital technology as an additional tool to bridge the gap in mental health services including training providers; support screening, treatment and care; monitoring care; strengthening information systems; and promoting self-care.

ICN encourages national nurses’ associations (NNAs) in collaboration with their respective governments, to: 

• Lobby regional and federal agencies for greater investment in financial, human and technological resources for mental health and substance use disorder services, prioritising investment in services that address the developmental needs and mental health of vulnerable groups including women, children and youth, Indigenous populations, older persons, those living in poverty, and migrants and refugees. 
• Contribute to policy development through legislation and regulation to protect and improve mental health services using evidence-based, integrated, community-based mental health models of care which recognise the importance and ensure the active participation of individuals, families, caregivers, patient groups and communities in the policy process. 
• Contribute to national and international surveillance systems that regularly measure and report on mental health indicators and outcomes.
• Advocate for evidence-based policies and strategies to eliminate racial or ethnic disparities in the diagnosis and treatment of people experiencing mental health disorders. 
• Encourage and promote nursing organisations and nurses in mental health policy development at all levels of national health systems. 
• Undertake a multi-stakeholder campaign to reduce stigma, discriminatory attitudes and human rights violations occurring in relation to mental health including substance use. 
• Promote and protect the mental health and wellbeing of nurses and other health workers and ensure access to non-discriminatory and confidential mental health services. 
• Support the inclusion and participation of nurses in activities by national and international agencies responsible for the regulation, credentialing and promotion of national/international standards of practice for mental health. 
• Collaborate with civil society, ICN and humanitarian groups to advocate for the immediate and long-term physical and mental health needs of displaced persons, disaster survivors prioritising those of vulnerable groups, including victims of secondary trauma. 
• Urge the development of a competent and confident nursing workforce to address the growing burden of mental disorders. This will require strengthening the mental health component of nursing curricula for the development of generalist skills at pre-registration and specialist skills at post-registration and continuing education levels. 
• Promote the provision of mental health nursing care and services in selected populations, by recognising community and mental health nursing profiles such as school nurses, street nurses (working with people experiencing homelessness) or correctional/prison nurses.

ICN calls on individual nurses in their role as clinicians, educators, researchers, policy influencers and/or executives, to:

• Identify, educate and confront stigma and discrimination as determinants of marginalisation and poor quality of care for persons with all categories of mental disorders. 
• Advocate for policies designed to eliminate the stigma associated with mental health and prevent or eliminate abuses of those with mental and/or substance use disorders. 
• Contribute to the generation, promotion and dissemination of research findings in the field of mental health. 
• Work to eliminate racial or ethnic disparities in the diagnosis and treatment of people experiencing mental health disorders. 
• Recognise the nursing relationship as foundational to successful nursing interventions with individuals, families and communities. The development of the therapeutic use of self to support behavioural change toward health remains foundational to nursing in institutional, rehabilitation, home and community settings as every nursing action provides the opportunity to address mental health. 
• Support ongoing research and identification of models of care which reflect early intervention to screening/identification and recovery approaches in care/treatment, including greater patient education to inform decision-making on care/treatment programmes. 
• Educate students, providers, community members and families on people-centred health services, including self-care and self-care management to maximise holistic functions based on health literacy and informed decision-making. 
• Reflect on personal mental health and wellbeing and seek out support when needed. 
• Recognise and address the deleterious mental health effects of prolonged loneliness, and social isolation and support community actions that promote social connectedness. 
• Participate in planning and interventions to reduce the impact of eco-anxiety and other environmental and climate change-related issues, to support individual and social adaptation to climate change.

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