The GGZ is in trouble. The House of Representatives wanted to know from the field what is going on and what possible solutions are. Conclusion: market forces have failed. And not every client needs a professional counselor.
A series of plagues is plaguing mental health care, it seems. Dramatic increase in the number of patients/clients. Long waiting lists. Institutions that are not financially strong. Last week, the House of Representatives invited ten experts by experience, professionals from the field and scientists, to shed light on the causes and possible solutions to these problems. Why has the number of people with a mental disorder increased so much? And how can an even greater demand on mental health care be prevented?
Waiting for care
There was little discussion about the figures. Between 2009 and 2021, the mental health care budget grew by 11 percent, but the number of people with mental disorders seeking mental health care increased by 53 percent. Waiting lists are the result: in May last year, more than 80 thousand people were waiting for psychological help, of which more than 41 thousand longer than the treek norm. The percentage of adult Dutch people with a mental disorder according to the DSM-5 has increased sharply over the past 12 years. From 17 percent in 2007-2009 to more than 26 percent in 2019-2022, according to the latest so-called Nemesis study. Thirteen years ago it was 1.9 million people, now there are 3.3 million.
Much of this increase leads to a rush to POH mental health care and basic mental health care. The strong increase is mainly visible among young adults. Figures for specialist mental health care remain about the same. According to the Trimbos Institute, mental disorders lead to dysfunction in work, family or self-care in 8 percent of adults (± 900 thousand). Some 538 thousand adults receive specialist mental health care. An additional issue is the staff shortage: at the beginning of 2018 there were 3.6 thousand vacancies in the mental health care sector, in the third quarter of 2022 there were almost twice as many.
Pressure to perform at school and at work, being ‘on’ 24/7, poverty and debt problems, quantitative and qualitative housing shortages, an increasingly complex society with major socio-economic differences, an excessive amount of digital stimuli, and less social cohesion – also about the causes mentioned during the meeting of the increase, there was great unanimity. When asked, Bauke Koekkoek, epidemiologist, social scientist and crisis service nurse, and one of the consulted professionals, says that he still has doubts about the premature conclusions that are attached to the recent figures. ‘If you really want to know what is going on in our society that causes so many more people to experience psychological distress, then you have to consult people who try to understand developments in society more broadly. Social scientists, for example, but also “ordinary” streetwise people or entrepreneurs from small and medium-sized enterprises, for example, who we expect to employ people with psychological distress.’
More concretely, he criticizes the measurement method of the Nemesis study: ‘It is based on a structured interview and on algorithms that lead to conclusions such as: ‘no disorder’, ‘depression’ and ‘ADHD’ via the inventory of problems and complaints.’ But without context, he says: ‘When someone becomes gloomy because of a destructive relationship with a partner, the approach is really different than when it’s because of a heavy loss or a hopeless life. Only after a thorough analysis can you say something about an approach – which is much less often ‘treatment in mental health care’ than after taking a problem-oriented questionnaire without context.’ According to professor of psychiatry Jim van Os, it often concerns ‘social and existential care needs’ and, according to him, you need ‘recovery academies and community centres, the church, self-management centres, contact with other people, debt counselling.’ So not necessarily professional helpers.
In this context, professor of psychiatry Damiaan Denys summed up ‘three uncomfortable truths’ in the House of Representatives: the introduction of regulated market forces in 2006, as a result of which mental suffering has since been seen as a ‘commercial’ product. The impossibility of the professional to unequivocally and objectively validate psychological suffering – as requested by health insurers – and the increasing illusion of absolute manipulability, in which normal suffering no longer has a place, but is quickly psychologized and medicalized.
This does not mean that the use of DSM-5 would play a role in the problems in mental health care – a point that is often made. Psychiatrist/professor Christiaan Vinkers says: ‘A DSM classification does not detract from someone’s story and wishes.’ As far as he is concerned, abolition is not an option: ‘A global, common language is necessary and useful in the treatment of psychological complaints. Otherwise you reopen the door to treatments of which it is not clear whether they have an effect, as happened too often in the pre-DSM era.’ In addition, a disorder listed in DSM-5 does not necessarily lead to insured care. After all, the Zorginstituut uses additional criteria for this: necessity, effectiveness, cost-effectiveness and feasibility.
According to the Dutch Association for Psychiatry (NVvP), ‘decompartmentalization and better cooperation with the social domain’ is one of the best ways, certainly at regional level, to cope with the huge influx to mental health care. According to psychiatrist Marja van ‘t Spijker, vice-chairman of the NVvP, there is still a lot to be researched about effective and cost-effective forms of collaboration and good indications such as the exploratory interview, mental health centers and all kinds of regional initiatives. Jim van Os also advocates ‘intensive regional cooperation based on shared values’. ‘Let health insurers buy in on that basis and the NZa make a payment title.’ He is already putting this ‘Mental Health Ecosystem’ into practice in five regions (Deventer, Doetinchem, Harderwijk, Groningen and Amsterdam-Zuidoost), in which the social domain, recovery academies, general practitioners, GGD, alternative healers, informal care and others work together. . He sees a lot in population-based funding, because ‘the postal code is the best predictor of a demand for mental health care. We know that most mental health care is purchased in certain neighbourhoods.’
The biggest concern of the NVvP, according to Marja van ‘t Spijker the day after the meeting, is that the increase in the number of people with what Van Os calls ‘social and existential care needs’ is displacing care for patients with serious problems. ‘We certainly don’t want to play down the suffering of the first, large group, but a perverse incentive has crept into the current system to serve the second, more expensive group less. Moreover, there is underfunding of this care, which is also apparent from Trimbos research; mental health care institutions are therefore faced with major shortages or are even on the verge of collapse. That must change soon. Parties are now pointing fingers at each other: institutions say they cannot afford this care, insurers say that institutions have been given a budget that should be sufficient and the NZa believes that insurers and institutions should work it out together. We believe that politicians should intervene and take more control and direction. As a professional group, as doctors, we are primarily there to treat the sickest group.’ Market forces have also led to incorrect financial incentives in the case of this group of seriously ill people, she says. Making it more rewarding to treat singular problems. The result: complex patients with, for example, anorexia and autism are sent from pillar to post. Van ‘t Spijker: ‘We must also apply the decompartmentalization that we are calling for in the social domain within specialist mental health care.’ She does want to say that her profession is not giving up. On the contrary: ‘We want things to improve in mental health care, and believe that this is possible, but something has to be done now.’