Prof dr. Peter FM Verhaak Netherlands Institute for Health Services Research University Groningen

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 thispresentation • Need and care formentalproblemsfrompopulation to specializedmental health care • Primary care in Europe and the position of mental health care withinthis system • Needfor and provision of mental health care in different European countries • Example of a comprehensive system of primarymental health care

3. Part 1Needand care formentalproblemsfrompopulation to specializedmental health care

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

5. 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 POPULATION: 18% Sources: De Graaf et al. 2011 Van Dijk et al. 2013 Verhaak et al. 2012

6. Part 2Primarycare in Europe and the position of mental health care withinthis 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 countrieswith 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 secondarymental health care institutions • Belgium • Italy • Poland • (some services are provided in primarycare) • Romania • Spain • (althoughmention is made of mental health care beingfullyintegrated 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

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

15. Reognition: % GP visitorswithdistressand% thatgot a psychological diagnosis Source: Verhaak 2009

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

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

18. Part 4Exampleof a comprehensive system of primarymental 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 byprimary care psychologists in 2012 Bron: LINEP 2012

23. Referrals of GP toPrimary care psychologist, socialwork and specialist mental health care Bron: LINEP 2012

24. Number of treatment sessions

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

26. What is coveredby generalist basic Mental Health care

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. ConclusionsChallengesforthis 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