Psychiatric healthcare in the The Netherlands: a hidden crisis

By Phoebe Dodds

The Netherlands enjoys a good reputation internationally when it comes to healthcare: the country is often favourably compared to Scandinavia for the way it cares for it citizens. However, this reputation does not extend to all areas of medicine, and there is one field in particular , psychiatric healthcare, which is displaying worrying trends. New research conducted by the Vektis Care Information Centre has come to light, showing that the number of patients being treated for severe psychiatric disorders in the Netherlands has risen to over 220,000, an increase of 5000 from the previous year. Despite the growing number of patients suffering from this type of illness, reports further warn that many are not receiving the care they desperately need. If left untreated, the problem will worsen, leading to severe financial and social implications for the country.

What are serious psychiatric disorders?

The topic of mental healthcare has long been considered taboo in society, and therefore those suffering from the most severe types of psychiatric illnesses are often the victims of stigmatisation, ostracised to the edges of society. Regarding the majority of the studies conducted into the situation in the Netherlands, serious psychiatric disorders refer to those requiring more than the usual outpatient treatment, and which cause significant disruption to a person’s daily life. When severe mental illnesses are left untreated for extended periods of time, this can result in issues with work, relationships and personal finance. The stigma surrounding psychiatric disorders can then set off a negative snowball effect: if an employer is unaware of the intricacies of an employee’s mental illness, they are less likely to be understanding in providing the employee with the flexibility they may need. This could lead to unemployment and strains in the person’s interpersonal relationships, sometimes leading to homelessness and severe financial worries, which in turn make people less likely to see a specialist to seek the care they need.

Psychiatric disorders included in the recent Dutch studies include severe cases of depression, schizophrenia, personality disorders and suicidal tendencies, amongst others. The diverse range of severe psychiatric disorders means that they can affect a person’s daily life in very different ways, and similarly, the treatment options available vary widely. Schizophrenia, for example, is commonly diagnosed in those who experience a disconnect between reality and fantasy, leading to unusual and inappropriate behaviour. Similarly, personality disorders can also affect the way a person behaves in public, due to them suffering from an illness which causes difficulty for them in forming relationships with others. Certain traits in those who suffer from personality disorders, such as an inability to feel guilt, for example, can mean that they present a possible risk to public safety as they are unable to process their actions and behaviour in the way that others can.

What are the treatment options in the Netherlands?

As the symptoms and effects of psychiatric illnesses differ vastly, so too do the treatment options available. People for whom outpatient care is deemed sufficient are usually offered therapy, which may include psychoanalysis, cognitive therapy or behavioural therapy. Group therapy is commonly suggested for people struggling with mental illnesses such as addiction, while family therapy is offered to those struggling with interpersonal relationships at home, including children suffering from the separation of their parents. Patients suffering from severe psychiatric illnesses – those considered in the research by the Vektis Care Information Centre , can sometimes be placed in hospital if their behaviour is deemed to place themselves or others at risk. Included in this group are people with suicidal tendencies who are then admitted to hospital in order for specially trained doctors to monitor them and put into place an emergency treatment plan. Medical advances in the past half-century also mean that patients of psychiatric illnesses are sometimes able to opt for prescription drugs to help stabilise their condition. These drugs are frequently offered to patients with psychiatric illnesses caused by chemical imbalances in the brain, such as severe anxiety and depression.

The situation in the Netherlands

With so many treatment options available in the Netherlands, it would be easy to assume that patients of psychiatric illnesses in the country are well looked after and always receive the care they need. However, the data showing the rise in patients with serious psychiatric illnesses in the Netherlands demonstrates another concerning trend: that these patients are actually less likely to receive medical help than those with physical health problems. Three health groups, Landelijk Platform GGz, Patiëntenfederatie Nederland and Ieder(in), interviewed more than 10,000 patients during their research into the problem, and published their findings in January of this year. The group analysed the interviewees’ answers against a range of criteria, but the overwhelming trend showed that in every regard, people who suffer from psychiatric illnesses receive worse care than those with physical illnesses. When the patients were asked whether or not good care was available to them, almost 50% of the psychiatric patients responded that it was available either sometimes or never when needed. Only one in three in the group of patients with physical problems, on the other hand, gave the same answer. The research showed that the problem was even more prominent for those who suffer from complex psychological problems – those who may be considered to need to the most support.

The disparity between the two types of patients also trickles into other areas, including financial and social implications. The Dutch study showed that again, almost half of those with psychiatric illnesses are concerned about the high costs of their treatment, while only 30% of the patients with physical illnesses expressed the same worry. This financial strain also means that those with mental health problems are more likely to delay going to visit the doctor, while people with physical illnesses are more confident that they will receive financial support when needed and thus go to the doctor without fearing extortionate medical bills. For psychiatric patients, financial worries may mean they refrain from taking their prescribed medicine and from visiting their therapist, behaviours which risk worsening the symptoms of their illness. This in turn means this group is more likely to suffer from disruption to their daily life, creating a vicious cycle whereby psychiatric patients struggle to escape from the downwards spiral and receive the help they need.

A lack of understanding of psychiatric illnesses, even within the medical profession, does nothing to aid the issue, and causes further issues in the process of patients receiving appropriate care. This issue was also looked into by Landelijk Platform GGz, Patiëntenfederatie Nederland and Ieder(in), who found that waiting lists in Dutch hospitals and doctors’ surgeries tended to be far longer for psychiatric help than for physical treatment such as physiotherapy. According to the GGZ, patients with anxiety, autism and compulsive disorders are amongst those who suffer the most from these delays. In addition, it often takes far longer for those with psychiatric illnesses to be referred to specialists who are properly equipped to help them, which again can be attributed to insufficient knowledge about and understanding of these types of mental health problems. Researchers who are trying to analyse the reasons for the disparity in treatment for those with psychological versus physical conditions have touched upon a further potential cause in addition to the lack of understanding of this field.

The Trimbos Institute published findings in 2016 which demonstrated that outpatient care for psychiatric patients is being developed at a slower rate than the removal of beds is psychiatric wards, creating an imbalance where patients fall through the cracks. While identifying this issue might insinuate that the problem can be solved now researchers have found a clearly defined problem, the reality is more complex. The care of psychiatric patients is very cost-intensive, both for the patient themselves, and for the Dutch government. As reported by nu.nl, the total cost of care for psychiatric patients is €4.7 billion per year. This amounts to an average of €21,000 per patient, and with the national budget stretched as a long-term effect of the global financial crisis of the past decade, there is no clear solution in sight.

How does the Netherlands compare to the rest of Europe?

Comparing the situation in the Netherlands with the rest of Europe is a complex matter due to the differences between each country’s healthcare system. In the United Kingdom, for instance, citizens are entitled to free healthcare on the National Health Service system, although the stigmatisation of those with mental health issues still acts as a barrier to people receiving the help they require. Mental health is a prominent issue in Europe, with the World Health Organisation (WHO) conducting regular research into the different approaches taken by EU countries to combat the problem. Overall, while the problem in the Netherlands has been worsening in the past decade, the country still performs better in the area of mental healthcare than a number of its peers. In 2011, the WHO published a Mental Health Atlas, analysing psychiatric care in countries across the world. Their research showed that a number of European countries did not have a concrete, specially targeted mental health care plan in place, but rather included this area in their wider health care goals. The Netherlands was one of the countries which did present a specific plan, which included timelines for implementation, the allocation of funding and detailing the move from mental hospitals to community mental health facilities.

In terms of concrete data, the WHO stated that the Netherlands spent more than 10% of its total health budget on mental health expenditure, more than double that of Spain, who allocated only 5% towards this area. However, France allocated 13% of its total health budget to mental health care, one of the highest out of the European countries which release such data. Additionally, despite the Netherlands having a concrete mental healthcare plan in place in 2011, the research from Landelijk Platform GGz, Patiëntenfederatie Nederland and Ieder(in) published this year demonstrates that the plan has not been wholly successful.

Looking towards the future

In line with the GGZ’s findings that Dutch doctors are often lacking sufficient understanding of mental health issues, the World Health Organisation’s Europe division prioritises highquality information on mental health issues as one of its key pillars. Furthermore, the WHO also draws attention to the fact that people from low income households who suffer from mental health issues are at the highest risk of neglect, due to being unable to pay for bills related to their illness. This is something that a spokesperson for the the GGZ research group drew attention to in the Netherlands in particular, and providing financial assistance to low income mental health patients to ease their burden will be a priority in the country in 2018. With the recent publication of worrying statistics, the Dutch healthcare system is under pressure to put together an action plan. However, the GGZ has already spoken out against the speed with which action is being taken: municipalities were given a deadline of October 2018 by which time they should have plans laid out to improve mental healthcare in the Netherlands. This will be almost two years after the results of the research conducted by Landelijk Platform GGz, Patiëntenfederatie Nederland and Ieder(in) were published, with Ms Drost from the GGZ calling the late deadline “irresponsible and inhumane”. While the situation looks unlikely to change drastically and positively in the near future, the research has at the very least identified a number of concrete issues which can be dealt with by the relevant parties. Additionally, once one part of the existing vicious cycle of financial worries, unemployment and doctors’ lack of understanding and knowledge is broken, the situation should begin to improve, with patients of mental illnesses receiving better and faster care. While the rates of mental health issues are rising worldwide with increasing stress in the workplace and cuts to national budgets, more and more people are also educating themselves on mental health issues via social media.

Illnesses such as anxiety and depression are in the public eye now more than ever, thanks in part to celebrity spokespeople who share their own experiences and give sufferers the possibility to identify with them. With this shift, society as a whole is becoming more understanding of the suffering of people with psychiatric problems, and stigmatisation should decrease. When people with mental health issues feel like they will be listened to by their doctor without judgement, they are also more likely to seek the help they need on time, giving them the best chance of reducing the effects of their illness. Along with sufficient pressure from organisations such as the GGZ, the Dutch government will need to implement a mental healthcare strategy fast, to help maintain its reputation as a country who cares about the health and wellbeing of its citizens.