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 Groningen
University 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 1
Need and care for mental problems from
population to specialized mental health care
Goldberg & Huxley model of help seeking for
mental disorder
SPEC.
MENTAL
HEALTH
CARE
Referral
DIAGNOSED BY GP
Recognition
VISITORS GENERAL PRACTICE
Help seeking
POPULATION
Goldberg & Huxley model of help seeking for
mental disorder: the Dutch situation in 2009
SPEC.
MHC: 4.4%
PC sychologist:
0,4%
Referral
DIAGNOSED BY GP: 12.4%
Recognition
VISITORS GENERAL PRACTICE
Help seeking
Sources:
De Graaf et al. 2011
Van Dijk et al. 2013
Verhaak et al. 2012
POPULATION: 18%
Part 2
Primary 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
Mental health care
defined within
primary care
Emphasis on
Secondary Mental
health Care
No info on mental
health care
Stong Primary
Care
Less strong Primary
Care
Estonia
UK
Netherlands
France
Ireland
Sweden
Belgium
Spain
Italy
Poland
Romania
Germany
Switzerland
Part 3
Need for and provision of mental health care
in different European countries
Reognition: % GP visitors with distress and
% that got a psychological diagnosis
30
25
20
15
10
5
0
Source: Verhaak 2009
% distressed
% with a psychological
diagnosis
GP treatment: GP’s perceived position in 1st contact
for psychosocial problems (1: seldom, 4: always)
UK
Switzerland
Sweden
Spain
Romania
Poland
Netherlands
Italy
Ireland
Germany
France
Estonia
Belgium
Source: Boerma 1999
0
0.5
Strong PC/MHC in PC
Strong PC/ 2nd MHC
1
1.5
2
2.5
3
3.5
Less strong P/ MHC in PC
Less strong P/ 2nd MHC
4
Ratio GP-treatment: Mental Health Care treatment
10
% of pre
valent cases
that is
treated
5
0
Treated by GP
Source:
WHO 2004
Wang 2007
Treated by Mental Healt Care
Part 4
Example 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 GP
Own initiative
other primary care
2nd MHC
school/work
Bron: LINEP 2012
Symptoms presented to primary care
psychologists in 2012
Interpersonal problems
Adjustment problems
Affective problems
Anxiety problems
Working problems
Symptoms children
Other
Identity problems
Psychosomatic symptoms
Addiction
0
Bron: LINEP 2012
5
10
15
20
25
DSM-IV diagnoses made by primary care
psychologists in 2012
Adjustment
Depression
Anxiety
Other axis 1
Interpersonal (axis
4)
Work problem
(axis 4)
0
Bron: LINEP 2012
10
20
30
%
40
50
60
Referrals of GP to Primary care psychologist, social
work and specialist mental health care
Bron: LINEP 2012
Number of treatment sessions
16
14
12
10
%
8
6
4
2
0
1
2
3
4
5
6
7
8 9 10 11 12 13 14 15 16 >16
N of sessions
The future organisation of Mental health care
in the Netherlands
DSM categorized
Psychiatric
Disorder
Consultation
Emental
health
General Practice
Mental health
Practice nurse
Generalist
Basic
Mental
Health
Care
Complicated
Psychiatric
Disorder
Special.
Mental
health
Care
What is covered by generalist
basic Mental Health care
Light
Moderate
Severe
Chronic
Low severity
Low risk
Singular problem
Persisting complaints
Moderate Severity
Low-moderate risk
Singular problem
Persisting complaints
conforming standard
High severity
Low-moderate risk
More complex problem
Persisting complaints
conforming standard
Low-moderate
risk
Stable 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