1. 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

2. 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

3. Part 1 Need and care for mental problems from population to specialized mental health care

4. Goldberg & Huxley model of help seeking for mental disorder POPULATION Help seeking VISITORS GENERAL PRACTICE Recognition DIAGNOSED BY GP Referral SPEC. MENTAL HEALTH CARE

5. 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. 2011 Van Dijk et al. 2013 Verhaak et al. 2012

6. Part 2 Primary care in Europe and the position of mental health care within this system

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Stong Primary Care Less strong Primary Care Mental health care defined within primary care Estonia UK Netherlands France Ireland Sweden Emphasis on Secondary Mental health Care Belgium Spain Italy Poland Romania No info on mental health care Germany Switzerland

14. Part 3 Need for and provision of mental health care in different European countries

15. Reognition: % GP visitors with distress and % that got a psychological diagnosis Source: Verhaak 2009

16. GP treatment: GP’s perceived position in 1st contact for psychosocial problems (1: seldom, 4: always) Strong PC/MHC in PCLess strong P/ MHC in PC Strong PC/ 2 nd MHC Less strong P/ 2 nd MHC Source: Boerma 1999

17. Ratio GP-treatment: Mental Health Care treatment Source: WHO 2004 Wang 2007

18. Part 4 Example of a comprehensive system of primary mental health care: the Netherlands

19. 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

20. Who referred client to PCP Bron: LINEP 2012

21. Symptoms presented to primary care psychologists in 2012 Bron: LINEP 2012

22. DSM-IV diagnoses made by primary care psychologists in 2012 Bron: LINEP 2012

23. Referrals of GP to Primary care psychologist, social work and specialist mental health care Bron: LINEP 2012

24. Number of treatment sessions

25. The future organisation of Mental health care in the Netherlands Symptoms, complaints, feelings of distress, worries, social conflicts General Practice Mental health Practice nurse E- mental health Consul- tation Generalist Basic Mental Health Care Special. Mental health Care DSM categorized Psychiatric Disorder Complicated Psychiatric Disorder

26. What is covered by generalist basic Mental Health care LightModerateSevereChronic 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 30% consultation100% consultation

27. 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

28. 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