Reviewed by Kay Funke-Kaiser
Psychotherapists from 20 European countries met in Berlin on the 23rd of February at the invitation of the Federal Chamber of Psychotherapists in Germany. At the conference “Psychotherapy in Europe – Disease Management Strategies for Depression”, around 60 experts and healthcare politicians used the example of depression in order to discuss the status quo of the provision of care, guidelines, and good-practice models for psychotherapeutic care. The European Parliament quite clearly called on its member states in 2009 to ensure a sustained increase in awareness of the major importance of good mental health.
According to the European Commission’s Green Paper on Mental Health, more than 27 percent of adult Europeans are estimated to experience at least one form of mental ill health during any one year. Forms of mental illness are the main cause for the 58,000 suicides per year and thus result in more deaths in Europe than road traffic accidents. The most widespread illnesses are anxiety disorders and depression. Mentally ill people continue to be stigmatised. Mentally ill people and those with mental disabilities encounter rejection and prejudice, which increase their personal suffering and exacerbate their experience of social exclusion. From an economic point of view, the costs generated by mental illness are estimated to constitute between three and four percent of the European gross national product, largely as a result of loss of productivity and the costs incurred by the social and educational systems as well as the criminal and justice system. Considerable discrepancies exist between the various member states of the European Union with regard to the provision of care for mentally ill people.
Mental health is a fundamental human right, as the President of the German Chamber of Psychotherapists Prof. Dr. Rainer Richter reiterated in his welcoming speech. The goal of the conference was to show the situation in the various European health systems of the provision of psychotherapeutic care. It is important for psychotherapy to learn from the experiences of the other European states, as the European Member 0f parliament Dr. Peter Liese explained in his written message of greeting. In addition to the economic savings that would arise from an improvement in the treatment and diagnosis of mental disorders, the issue is above all that of the health and wellbeing of the citizens. In the process, the differences in life expectation and health that exist both within and between the member states must be reduced.
The European Commission also sees an urgent need to act in order to improve the mental health of the population, as Johanna Schmidt from the EU Commission’s Representation in Germany made clear. According to the Eurobarometer “Mental Health” that was published last year, every seventh person in Europe seeks professional help for a mental health problem within the course of a year, and during the same period of time seven percent of Europeans are prescribed anti- depressants. The European Pact for Mental Health and Wellbeing that was made in 2008 under the leadership of the Commission has already left some initial traces. The Federal Chamber of Psychotherapists in Germany has provided strong support from the start for the work being done at the European level. In order for the EU to achieve its strategy goals for 2020 of more intelligent, sustained and integrative growth, however, further measures for promoting mental health are necessary.
Depression is a central challenge of the 21st century
Prof. Dr. Hans-Ulrich Wittchen (Dresden University of Technology, Germany) gave an overview of the epidemiology of mental illnesses in Europe and the current care situation. Using the example of depression, he demonstrated that there is a wide gap between the need for treatment and the reality of the provision of care. In the European Union seven Percent of the population suffer from uni-polar depression every year, but only a half to a third of sufferers are treated. Between three and eight percent were treated pharmacologically or at least with a minimum of psychotherapy, but often only after much too great a time delay. Psychotherapy was received by only two to three percent of patients.
Prof. Wittchen saw the provision of care for depression as a central challenge for Europe in the 21st century. He called for concerted action in order to make effective psychotherapy available to all sufferers as quickly as possible after the outbreak of illness. Care guidelines would play an important role here in order to set the right course in terms of health politics. This would however necessitate an increase in the number of qualified professionals, whereby an increase in the number of psychiatrists could not be counted upon. It would be more realistic to continue to draw on the potential of psychological forms of therapy.
Short presentations were held outlining national provision of care structures and innovative care concepts for people with depression in Austria, Finland, France, Germany, Italy, the Netherlands, Poland. Portugal and the United Kingdom. An increasing need for treatment was reported by all European countries, especially for young people. In none of these countries do the opportunities for psychotherapeutic treatment available come even close to being sufficient. In this way, with reference to the professions, their qualifications, powers and involvement in the health system as well as the psychotherapy methods applied, a Europe- wide overview emerged.
Faster and broader access to psychotherapy
Provision of care models are being sought in several European states that could ensure faster access to psychotherapy, independent of age and social class. In order to achieve this, “Stepped Care” concepts are being put into practice which offer patients a range of treatment options depending on the severity and complexity of the illness. Prof. Dr. Glenys Parry (University of Sheffield, UK) presented the results of an evaluation of the programme “Improving Access to Psychological Therapies (IAPT)” which is in the meantime on offer throughout England. With this programme, therapy has become available more quickly. The proportion of patients treated by means of psychotherapy has in the meantime increased six fold. Inability to work because of mental illness has also sunk. There is, however, dissatisfaction among patients as a result of the length of treatment, which they judge as being too short.
Prof. Dr. Pim Cuijpers (Free University of Amsterdam, the Netherlands) compared the effects of low- and high-intensity therapy within the framework of Stepped Care models. According to this under certain conditions, low-intensity measures such as self-help conducted and supervised on an internet basis can be effective on a level similar to psychotherapy “face-to-face”. He described internet-based therapies as an innovation in the care of mentally ill people, whose success, however, depended on the individual needs and resources of the patients. Low-intensity care and treatment programmes cannot and should not fully replace face-to-face psychotherapy. One should however make use of them because there will never be enough treatment on offer from qualified practitioners for traditional psychotherapy in relation to the demand for care.
Prof. Dr. Jaakko Seikkula (University of Jyvaskyla, Finland) reported on investigations in Finland into the effects of a need-adjusted treatment model for the treatment of depression. Originally developed for the care of schizophrenia, the need-adapted treatment promises to be successful in treating depression, too. He demanded more flexibility in the care of depression instead of restriction by means of treatment guidelines in order to make a better fit possible between treatment methods, therapist characteristics and patient needs; this could for example translate into differing levels of involvement in treatment for family members.
The contributions by the scientists regarding possible innovations in psychotherapeutic care and the descriptions of the actual care situation in Europe gave rise to three central questions during the podium discussion, which was led by Andrea Mrazek, M.A., M.S. (boardmember of the Federal Chamber of Psychotherapists in Germany).
The first question was concerned with the nature of psychotherapy. A comparison of the development of psychotherapy with that of the industrial revolution served as a provocative key metaphor. As in the industrial revolution, psychotherapy will undergo a development from an individualised cottage industry to a standardised replicable product with minimal differences in quality. But, can ten sessions of manualised short-term therapy, which is what is being offered in the way of services by some health care systems, actually be described as psychotherapy, and above all, is it effective? One position held with regard to this was that psychotherapy is evidence-based treatment. As such, internet-based interventions are psychotherapy if they can show a corresponding effect. On the other hand, the position was held that psychotherapy is defined by its mechanism of action and as such is characterised by the psychotherapeutic relationship, the competence of the psychotherapist, and the fit between the treatment offered and the individual needs of the patient. Effects reveal themselves here in particular in long-term outcomes.
The second central question concerned the profession of psychotherapists. Which competencies should a psychotherapist have and what is his task? The various positions on the nature of psychotherapy were naturally reflected in the answers that followed. For the one person a psychotherapist is someone who is comprehensively trained for the job of conducting evidence-based psychotherapeutic treatment. This does not rule out, it was stated, that psychotherapeutic treatment can be conducted in other professions such as nurses. For other people only someone who is competent to ensure treatment that is oriented towards the individual patient’s need can be a psychotherapist.
Finally, the third question was concerned with how it can be possible to use the strengths of intensive psychotherapy, in particular for people with severe and complex limitations to their health, while at the same time providing for the growing need for treatment despite limited human and financial resources. It was in addition established that only two of the three criteria “fast”, “cheap” and “good” could be achieved at the same time in relation to the provision of psychotherapeutic care and never all three together. The resources available would dictate which strategies for providing care for mentally ill people could or should be used. These could for instance also justify low-threshold interventions and interventions via new media and/or in largely standardised form.
The search for the best strategies for the provision of psychotherapeutic care – and in this the participants in the podium discussion were united – will concern all European health systems equally, for it must be their goal to offer quality-assured care for mentally ill people and to no longer accept the existing gaps in care provision. In order to include psychotherapeutic expertise sufficiently in the process, those who are employed in the field of psychotherapy in Europe should work more closely together in future.
The desire for greater cooperation was at the centre of Prof. Richter’s concluding words: the conference showed how psychotherapy’s potential could be employed to an even greater extent in the provision of care. At the same time, however, one had to conclude that psychotherapy does not occupy the place within the political initiatives for the improvement of mental health in Europe that it should have according to current scientific findings.
Prof. Richter proposed the setting up of a network for psychotherapeutic care in Europe, with the purpose of giving psychotherapy a voice and an address. A network of this nature should be able to profit from the experience and expertise of all those who are largely or exclusively employed in psychotherapy within their health care systems. The first step to be taken towards forming this network could, he suggests, be the creation of a mailing list by means of which all those being interested can communicate about the arrangement of the network, further initiatives, and hopefully also a follow-up conference. In the name of the Federal Chamber of Psychotherapists in Germany as the organisers of this conference, he offered to take the initiative in setting up this network: a suggestion that was very much welcomed by the participants.
Contact: Kay Funke-Kaiser
Phone: ++49 30 2787850