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

Belgium

Estonia

German

y

Netherl

ands

Poland

Roman

iaSpa

in

Sweden

Switzerl

and UK

0

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 PCStrong 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

AddictionPsychosomatic symptoms

Identity problemsOther

Symptoms childrenWorking problemsAnxiety problems

Affective problemsAdjustment 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

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