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