Mental health care in Primary care in Europe: Need and Performance
in different European countries
Prof dr. Peter FM Verhaak
Netherlands Institute for Health Services Research
University GroningenUniversity Medical Centre Groningen,
department of general practice
Content of this presentation
• Need and care for mental problems from population to specialized mental health care
• Primary care in Europe and the position of mental health care within this system
• Need for and provision of mental health care in different European countries
• Example of a comprehensive system of primary mental health care
Part 1Need and care for mental problems from
population to specialized mental health care
Goldberg & Huxley model of help seeking for mental disorder
POPULATION
Help seeking
VISITORS GENERAL PRACTICE
Recognition
DIAGNOSED BY GP
Referral
SPEC.MENTALHEALTH
CARE
Goldberg & Huxley model of help seeking for mental disorder: the Dutch situation in 2009
POPULATION: 18%
Help seeking
VISITORS GENERAL PRACTICE
Recognition
DIAGNOSED BY GP: 12.4%
Referral
SPEC.
MHC: 4.4% PC sychologist:
0,4%
Sources:De Graaf et al. 2011Van Dijk et al. 2013Verhaak et al. 2012
Part 2Primary care in Europe and the position of
mental health care within this system
Strength of primary care
• Structure– Governance– Economic Conditions of PC system– PC workforce development
• Process– Access to PC services– Comprehensiveness of PC– Continuity of care– Coordination of care
Source: Kringos 2013
European countries with strong and less strong Primary Care
• Strong PC– Belgium– Estonia– Netherlands– Spain– UK
• Less strong PC– France– Germany– Ireland– Italy– Poland– Romania– Sweden– Switzerland
Mental health care : trends in European countries
• General: Decrease in psychiatric beds since the 80’s• General: Introduction of ambulatory mental health
care institutions.• Different supply of psychiatrists and clinical
psychologists in private practices• Only in a few countries a systematic contribution of
primary care or general practice in mental health care is mentioned
Source: WHO: Health systems in transition
Development mainly on secondary mental health care institutions
• Belgium• Italy• Poland
– (some services are provided in primary care)
• Romania• Spain
– (although mention is made of mental health care being fully integrated in the health care network
Source: WHO: Health systems in transition
Movement of mental health towards primary care• Estonia
– Provision of services for e.g. depression by GPs has increased the past five years
• France: – many psychiatrists/psychologists in private practice.
However, no GP referral necessary – GPs have 16% of their workload by mental problems
• Ireland: – Increased mental health training for GPs, focused on
detection, assessment and training
• Sweden: – Minor mental health problems within primary care by
GPs and psychologists
Developments: towards integration of mental health care in primary care
• UK: – NHS target: 1000 new graduate primary mental health
workers to work with GPs– 500 community mental health staff to work with GPs
• Netherlands– Psychological treatments (up to 5 sessions) reimbursed
within general insurance
Stong Primary Care
Less strong Primary Care
Mental health care defined within primary care
EstoniaUKNetherlands
FranceIrelandSweden
Emphasis on Secondary Mental health Care
BelgiumSpain
ItalyPolandRomania
No info on mental health care
GermanySwitzerland
Part 3Need for and provision of mental health care
in different European countries
Reognition: % GP visitors with distress and % that got a psychological diagnosis
Belgiu
m
Estoni
a
Germ
any
Nether
lands
Polan
d
Roman
iaSpa
in
Sweden
Switzer
land
UK0
5
10
15
20
25
30
% distressed% with a psychological diagnosis
Source: Verhaak 2009
GP treatment: GP’s perceived position in 1st contact for psychosocial problems (1: seldom, 4: always)
BelgiumEstoniaFrance
GermanyIreland
ItalyNetherlands
PolandRomania
SpainSweden
SwitzerlandUK
0 0.5 1 1.5 2 2.5 3 3.5 4
Strong PC/MHC in PC Less strong P/ MHC in PC
Strong PC/ 2nd MHC Less strong P/ 2nd MHC
Source: Boerma 1999
Ratio GP-treatment: Mental Health Care treatment
Belgium France Germany Italy Netherlands Spain0
5
10
Treated by GP Treated by Mental Healt Care
% of prevalent cases
that is treated
Source: WHO 2004Wang 2007
Part 4Example of a comprehensive system of
primary mental health care: the Netherlands
Position of primary care psychologist (PCP) in Dutch health care system
• 1600 PCP (1: 10.000 population)• Collaboration with GPs• Covered in basic insurance for 5 sessions
(own contribution 20 €/session); • Graduated psychologists with post graduate
Health psychology
Who referred client to PCP
Referral by GPOwn initiativeother primary care2nd MHCschool/work
Bron: LINEP 2012
Symptoms presented to primary care psychologists in 2012
Addiction
Psychosomatic symptoms
Identity problems
Other
Symptoms children
Working problems
Anxiety problems
Affective problems
Adjustment problems
Interpersonal problems
0 5 10 15 20 25
Bron: LINEP 2012
DSM-IV diagnoses made by primary care psychologists in 2012
Work problem (axis 4)
Interpersonal (axis 4)
Other axis 1
Anxiety
Depression
Adjustment
0 10 20 30 40 50 60%
Bron: LINEP 2012
Referrals of GP to Primary care psychologist, social work and specialist mental health care
Bron: LINEP 2012
Number of treatment sessions
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 >160
2
4
6
8
10
12
14
16
N of sessions
%
The future organisation of Mental health care in the Netherlands
Symptoms,
complaints, feelings
of distress, worries,
social conflicts
Symptoms,
complaints, feelings
of distress, worries,
social conflicts
General Practice
Mental healthPractice nurse
E-mental health
Consul-tation
Generalist Basic
Mental Health
Care
Special.Mental healthCare
DSM categorizedPsychiatric
Disorder
ComplicatedPsychiatric
Disorder
What is covered by generalist basic Mental Health care
Light Moderate Severe Chronic
Low severityLow riskSingular problemPersisting complaints
Moderate SeverityLow-moderate riskSingular problemPersisting complaintsconforming standard
High severityLow-moderate riskMore complex problemPersisting complaints conforming standard
Low-moderate riskStable or instable chronic
Up to 5 sessions (eventually partly blended)
Up to 8 session (eventually partly blended)
Up to 12 sessions (eventually partly blended
10 sessions
10% consultation 10% consultation 30% consultation 100% consultation
Consequences
• Primary care psychologists have to compete with other providers
• Not-psychiatric disorders (such as symptoms of distress, relational problems, unexplained physical symptoms, social problems) have to be treated strictly within General practice or within other social care
Conclusions Challenges for this meeting
• There are many white spots regarding– Prevalence of common mental disorder in primary care
settings in different countries– The way these common mental disorders are treated in
these countries– The barriers faced by PC providers in the treatment of
these disorders– The opportunities existing in different countries for
GPs to collaborate with mental health care providers, such as social workers, psychiatric nurses, psychologists and psychiatrists