Dutch Mental Health Care Research Articles

Strategic market orientation in mental healthcare: A knowledge synthesis

System amendments, budget cuts and market forces have led to a deregulation of the Dutch (mental) healthcare system. Mental healthcare providers are forced to critically examine their strategic position, which increases the need for more knowledge on the strategic market orientation tools that are applicable in mental healthcare. The literature shows that a mental healthcare provider needs to develop knowledge within four domains of strategic market orientation: mental healthcare demand, mental healthcare supply, stakeholders, and the external environment. This article aims to answer the question as to which information and instruments are available for mental healthcare providers to develop this knowledge. Information was gathered via telephone interviews with policymakers and advisors of nine large mental healthcare providers in the Netherlands, complemented with the literature related to the four domains. This resulted in a knowledge synthesis on strategic market orientation in mental healthcare. This knowledge synthesis provides mental healthcare providers with a framework that needs to be operationalized in practice, leading to concrete guidelines for the development of a marketing function in mental healthcare organizations.

P04.60. The dutch complementary and alternative medicine (CAM) protocol: to ensure the safe and effective use of CAM within Dutch mental health care

Purpose Complementary and alternative medicine (CAM) is subject to heated debates and prejudices. Studies show that CAM is widely used by psychiatric patients, usually without the guidance of a therapist and without the use of a solid working method, leading to potential health risks. How can we use CAM alongside conventional psychiatry in an outpatient psychiatric clinic in a judicious and professional way?

Choosing to limit choice: Self-binding directives in Dutch mental health care

In certain cases of chronic mental illness (for example bipolar disorder) a self-binding directive or Ulysses contract may be a helpful intervention to prevent harm to the person him- or herself and/or others. By choosing such an arrangement, the patient can indicate when and how mental health professionals may intervene against his or her will and provide indicated care which may lead to an improvement of the patient's mental condition. In the Netherlands, since 2008 the Compulsory Admissions Act has been amended and now includes a paragraph on self-binding. Starting from the Dutch debate and statutory regulation of self-binding in mental health care, a number of issues with broader relevance are discussed, particularly as these pertain to the legal regulation and juridification of self-binding. It is argued that too many detailed rules are a threat to increasing patient empowerment.

Depressive disorder among Turkish women in the Netherlands: A qualitative study of idioms of distress

The provision of mental health services to immigrants in the Netherlands is hampered by difficulty in establishing valid diagnoses of psychiatric disorders. To improve the process of diagnosing depressive disorder among Turkish women in Dutch mental healthcare, we conducted a qualitative study of women with depression in Rotterdam. A bilingual Turkish-Dutch diagnostic interview was developed to explore Turkish women's idioms of distress. Interviews were conducted with 20 women with a disputed diagnosis of depression. Results showed that distress among the Turkish women was characterized by a wide range of somatic complaints, with anxiety and agitation occurring as frequently as depressive complaints. Because the range of complaints is so varied, major depression may be underdiagnosed in the Turkish immigrant population.

The Dutch Complementary and Alternative Medicine (CAM) Protocol: To Ensure the Safe and Effective Use of Complementary and Alternative Medicine Within Dutch Mental Health Care

Complementary and alternative medicine (CAM) is subject to heated debates and prejudices. Studies show that CAM is widely used by psychiatric patients, usually without the guidance of a therapist and without the use of a solid working method, leading to potential health risks. The purpose of this study is to facilitate the judicious use of CAM alongside conventional psychiatry in an outpatient psychiatric clinic. A search was made through scientific and legal articles and discussion in focus groups. In the Centre for Integrative Psychiatry (CIP) of Lentis in The Netherlands, some carefully selected CAM are offered under strict conditions, alongside conventional treatments. Because of the controversy and the potential health risks, Lentis designed a protocol that is presented. The CIP hopes, by using this protocol, to better serve and respect the individual needs and preferences of the diversity of psychiatric patients in our Dutch multicultural society, and better protect them from harm.

Training and employment of consumer provider employees in Dutch mental health care.

This article describes the results of a qualitative study on the training and employment of consumer provider employees in Dutch mental health care. The authors used semi-structured interviews with students, graduates/employees, teachers, team managers, colleagues and clients to assess their experiences with the college program. The college program succeeds in preparing the consumer students for their role as consumer provider employees in mental health teams. In the peer support and recovery program and supervision, students learn to develop their recovery story, to apply their experiences in practice, and to deal with challenges. Coaching and supervision are essential to help consumer providers in their specific role, to deal with dilemmas and to facilitate open dialogue. Teams need to be adequately prepared by informing them on the requirements of the college program and the role of consumer providers.

Three preparatory studies for promoting implementation of outpatient schema therapy for borderline personality disorder in general mental health care

ObjectiveThree studies were conducted to prepare for the implementation of Schema Therapy (ST) for Borderline Personality Disorder (BPD) in general mental healthcare settings. Two were surveys to detect promoting and hindering factors, one was a preliminary test of a training program in ST. MethodsIn 2004, a diagnostic analysis of factors promoting and hindering implementation of a new treatment for BPD was conducted among both managers (n = 23) and therapists (n = 49) of 29 Dutch mental healthcare institutes through a written survey (Study 1). Next, a training program, including a set of DVDs displaying the major therapeutic techniques, was developed and tested among eight therapists. The training program was evaluated by the participants. After the training, three independent raters evaluated therapists' adherence and competence, viewing videos of the therapists completing structured role-plays (Study 2). In 2008, a second written survey was conducted in 22 mental health institutes to study factors for future nationwide implementation of ST (Study 3). ResultsBoth surveys indicated that the situation in most institutes was favorable for implementing a new effective treatment, as participants were not satisfied with the existing treatments, had suitable professional backgrounds, worked in settings with (B)PD-oriented care programs, and expressed a need for change. The surveys yielded clear results for promoting or hindering successful implementation of ST. Promoting factors included scientific evidence for the effectiveness of the treatment, structural changes in the patient's personality, rapidly noticeable effects for the patient, low drop-out rates and a favorable cost-effectiveness. Possible barriers included implementation mandated unilaterally by management, choosing ST based on financial or organizational needs, extending implementation over a lengthy period of time and providing telephone support by therapists beyond office hours. The eight-day training program received very positive ratings. After the training, therapists were rated as sufficiently adherent and competent applying ST to treat BPD patients, with peer supervision and supervision recommended as a supplement to the training. ConclusionThis study showed that the situation in 2005 was advantageous to start implementation of ST. Evaluation of the training and the achieved competence scores of trainees concluded that the training program was a good basis for training therapists in ST. Outcome of the survey in 2008 demonstrated that there was a clear interest for implementation of ST for BPD patients in the future.

Sheehan disability scale as outcome measure in depressed out-patients

Dutch mental health care system to collaborate with primary care. This study evaluates the effectiveness of a collaborative care program (CCP) in a primary care setting for unselected common mental disorders compared to traditional referral to a primary or secondary mental health organisation (Care As Usual; CAU). Methods: In a cluster randomised controlled trial, 27 GPs were assigned to either CCP or CAU. The CCP condition refers to brief interventions with a maximum of 5 appointments in the GPs' office and, if indicated, followed by referral to specialised mental health care. The study included 165 patients. At baseline and after 3, 6 and 12 months, psychopathology and quality of life were assessed. Patients' and GPs' appreciation of mental health care and the number of mental health care appointments were assessed after 3, 6 and 12 months. The data were analysed with hierarchical linear models. Results: Patients' mean symptom score and quality of life significantly improved over time, with no significant differences between conditions. There was no significant difference in appreciation of mental health care between patients of both conditions. The CCP condition resulted in a significantly higher appreciation by GPs, significantly shorter waiting time, less number of appointments and shorter duration of treatment compared to CAU. Discussion: Collaborative care for patients with unselected common mental disorders seems to be as effective as CAU. However, the CCP condition was (much) more cost effective and collaborative care is also more appreciated by the GPs.

Effects and side-effects of integrating care: the case of mental health care in the Netherlands.

Description and analysis of the effects and side-effects of integrated mental health care in the Netherlands. Due to a number of large-scale mergers, Dutch mental health care has become an illustration of integration and coherence of care services. This process of integration, however, has not only brought a better organisation of care but apparently has also resulted in a number of serious side-effects. This has raised the question whether integration is still the best way of reorganising mental health care. Literature, data books, patients and professionals, the advice of the Dutch Commission for Mental Health Care, and policy papers. Despite its organisational and patient-centred integration, the problems in the Dutch mental health care system have not diminished: long waiting lists, insufficient fine tuning of care, public order problems with chronic psychiatric patients, etc. These problems are related to a sharp rise in the number of mental health care registrations in contrast with a decrease of registered patients in first-level services. This indicates that care for people with mental health problems has become solely a task for the mental health care services (monopolisation). At the same time, integrated institutions have developed in the direction of specialised medical care (homogenisation). Monopolisation and homogenisation together have put the integrated institutions into an impossible divided position. Integration of care within the institutions in the Netherlands has resulted in withdrawal of other care providers. These side-effects lead to a new discussion on the real nature and benefits of an integrated mental health care system. Integration requires also a broadly shared vision on good care for the various target groups. This would require a radicalisation of the distinction between care providers as well as a recognition of the different goals of mental health care.

Self‐Development and Civic Virtue: Mental Health and Citizenship in the Netherlands (1945–2005)

This article is about the development of mental hygiene and mental health care in the Netherlands from the Second World War to the present, aiming to explore its relation to social and political modernization in general and the changing meanings of citizenship and civic virtue in particular. On the basis of three different ideals of individual self-development, my account is divided into three periods: 1945-1965 (guided self-development), 1965-1985 (spontaneous self-development), and 1985-2005 (autonomous self-development). In the conclusion, I will elaborate some more general characteristics of Dutch mental health care in its sociopolitical context.

Cost-utility of brief psychological treatment for depression and anxiety

The cost-utility of brief therapy compared with cognitive-behavioural therapy (CBT) and care as usual in the treatment of depression and anxiety has not yet been determined. To assess the cost-utility of brief therapy compared with CBT and care as usual. A pragmatic randomised controlled trial involving 702 patients was conducted at 7 Dutch mental healthcare centres (MHCs). Patients were interviewed at baseline and then every 3 months over a period of 1.5 years, during which time data were collected on direct costs, indirect costs and quality of life. The mean direct costs of treatment at the MHCs were significantly lower for brief therapy than for CBT and care as usual. However, after factoring in other healthcare costs and indirect costs, no significant differences between the treatment groups could be detected. We found no significant differences in quality-adjusted life-years between the groups. Cost-utility did not differ significantly between the three treatment groups.

Deinstitutionalisation of mental health care in The Netherlands: towards an integrative approach.

The objective of this policy paper is to put recent developments in Dutch mental health reform in an international perspective and draw conclusions for future directions in policy. CONTEXT OF THE CASE: The practice of Western psychiatry in the second half and particularly in the last decade of the 20th century has fundamentally changed. Dutch psychiatry has traditionally been prominently bed-based and various policies in the last ten years have been intended to reduce the influence of the mental hospitals. Until the mid-1990s, this had not resulted in reducing the psychiatric bed rate in comparison to other countries. Since then, there have been rapid, dramatic changes. We summarised two recent national studies on this subject and placed them in a national and international context, using documents on psychiatric reforms, government and advisory board reports and reviews on deinstitutionalisation in different countries. The practice of psychiatry in the second half, and particularly in the last decade, of the 20th century has fundamentally changed. This has resulted in a spectacular decline in the number of beds in mental hospitals, increased admissions, decreased length of stay, closure of the large asylums and in community treatment away from asylums and in society, although this is a reform process. This article examines how the Dutch mental health care system has developed at the national level. The main topics cover the size, nature, aims and effects of the process of deinstitutionalisation and how alternative facilities have been developed to replace the old-fashioned institutes. There are two contrasting aspects of deinstitutionalisation in Dutch mental health care: the tendency towards rehospitalisation in relation to the sudden, late, but rapid reduction of the old mental hospitals and their premises; and a relatively large scale for community-based psychiatry in relation to building mental health care centres. Compared to other countries the bed rate in The Netherlands is still among the highest, although it is rapidly decreasing. Lessons from psychiatric reform in other countries emphasise the counterpart of deinstitutionalisation, especially issues such as the quality of alternative community treatment and increasing compulsory admission, while the closing down of old mental hospitals has caused a decrease in the availability of beds. In The Netherlands less attention has been paid to legislation, societal attitudes towards psychiatry, the roles of other care suppliers, the balancing and financing of care, the fate of psychiatric patients from old hospitals, the way to cope with the ever-increasing demand for psychiatric help and the actual quality of psychiatric help. A more integrative policy that includes all these aspects is desirable.

The Psychotherapist and the Sign Language Interpreter

Specialized psychotherapy for deaf people in the Dutch and Western European mental health systems is still a rather young specialism. A key policy principle in Dutch mental health care for the deaf is that they should receive treatment in the language most accessible to them, which is usually Dutch Sign Language (Nederlandse Gebarentaal or NGT). Although psychotherapists for the deaf are trained to use sign language, situations will always arise in which a sign language interpreter is needed. Most psychotherapists have the opinion that working with a sign language interpreter in therapy sessions can be a valuable alternative option but also see it as a second-best solution because of its impact on the therapeutic process. This paper describes our years of collaborationship as a therapist and a sign language interpreter. If this collaborationship is optimal, it can generate a certain "therapeutic power" in the therapy sessions. Achieving this depends largely on the interplay between the therapist and the interpreter, which in our case is the result of literature research and our experiences during the last 17 years. We analyze this special collaborative relationship, which has several dimensions and recurrent themes like, the role conception of the interpreter, situational interpreting, organizing the interpretation setting, or managing therapeutic phenomena during therapy sessions.

Repetition and Repertoires: The Creation of Cultural Differences in Dutch Mental Health Care

This paper explores how culture and cultural differences are created and used to maintain power of definition in mental health care. The author argues that although in mental health care an open approach in care for immigrants is stimulated, cultural differences are strategically used to maintain the status quo of mental health care and mental health professionals. The result is that such strategies keep immigrants in a marginal position. In mental health care, immigrants belong to a classificatory anomaly or, in processual terms, to liminal personae. The author concludes that interaction in mental health care is a manifestation and reproduction of larger class, racial, ethnic and gender conflicts in the broader society.

The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums, 1890-1920 (review)

Reviewed by: The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums, 1890-1920 Hans-Peter de Ruiter Geertje Boschma . The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums, 1890-1920. Amsterdam: Amsterdam University Press, 2003. 324 pp. Ill. $30.00, €25.75, £19.00 (paperbound, 90-5356-501-9). The Rise of Mental Health Nursing brings the reader back to Dickensian times. Geertje Boschma describes the complex forces that led the Dutch mental health care system to evolve at the turn of the century—changes that are, to a large extent, representative of events in most northern European countries as well as in the United States. Boschma's work is predominantly a result of researching the archives of four Dutch asylums. It covers the time when psychiatric patients started being seen as people with mental illnesses, rather than as people with "a loss of reason that supposedly kept the afflicted in a bestial stage and legitimized their enchainment" (p. 31). The author describes heart-wrenching cases of human suffering that resulted from the unscientific psychiatry of the day and a care system that was just starting to evolve. Both patients and staff, predominantly psychiatric nurses, had to endure many hardships. Forces within Dutch society as well as within the mental health institutions led to this situation. Some of the predominant societal forces on the mental health system were rooted in the belief systems of the Catholic and Protestant churches, both of which were trying to protect and expand their turf and were skeptical of evolving medicine. Political and social movements, changing gender roles, and the existing political and judicial system all played important roles in the development of a new mental heath system, as did the birth of scientific psychiatry, the lack of nursing education, staff with workloads exceeding their capabilities, and limited options for the treatment of patients. [End Page 727] The story of mental health nursing is brought to life by the multiple, powerful, and graphic descriptions of patients and caregivers during this period of change. Using data from patients' hospitalization records and institutional reports written during this period, Boschma makes clear that, in spite of improvements being made, it was still a time with many challenges for the mentally ill and their caregivers. For instance, a patient with delusions "heard voices scolding him, and he beat nurses, behaving aggressively for over a month . . . and often refused food. The nurses regularly force-fed him. He weakened . . . 5 months after his admission he caught pneumonia and died within a week" (p. 136). Another example occurred in "Veldwijk when an otherwise quiet patient impulsively attacked a housefather who came to pick up the patient from the carpentry workshop. The patient stabbed the father in the chest with a chisel, and he died several days later in the hospital" (p. 137). Boschma emphasizes that changing gender roles were an important factor in the development of mental health nursing. Women were considered the ideal caregivers because of their superior moral capabilities; this was at a time when the value of women to society was beginning to be acknowledged, thanks to the women's movement. During this same time, males began to enter the profession of mental health nursing, yet they were received with much skepticism and were at times marginalized and discriminated against, a fact that is well illustrated in the case of the nurse P. N. Bas. Bas's experiences motivated him to become one of the leaders in organizing mental health nurses—beginning with males, but later extending to all mental health nurses. Boschma's in-depth descriptions of the difficulties that male nurses had in obtaining recognition and a place in nursing is a welcome addition to the body of literature discussing gender equality in medicine and health care. This book is a great asset for historians of psychiatry, mental health nurses, and people interested in gender issues in health care. Hans-Peter de Ruiter University of Minnesota and Fairview University Hospital Minneapolis Copyright © 2004 The Johns Hopkins University Press

The importance of ethnic similarity in the therapist-patient dyad among Surinamese migrants in Dutch mental health care.

Empirical evidence is equivocal on whether ethnic matching in the therapist-patient dyad is preferred by ethnic minority patients and whether it leads to treatment satisfaction. The aim of this study was to establish the importance of ethnic similarity in mental health care among Surinamese migrants in the Netherlands. A convenience sample of Surinamese out-patients in community mental health care (N = 96) was interviewed. Data were analysed using logistic multivariate techniques. The majority of the Surinamese out-patients (in particular recently residing participants) rated ethnic matching as relevant; a considerable minority considered compassion and expertise to be more relevant than ethnic background. Most out-patients reported to be satisfied with the services, especially females and respondents treated by an ethnically similar therapist. Ethnic similarity in the patient-therapist dyad is a strong predictor for satisfaction with mental health care services. However, although it is preferred by many, ethnic matching per se is no must - empathy, expertise and world view sharing are reported to be of considerable importance as well.

Multidisciplinary guidelines in Dutch mental health care: plans, bottlenecks and possible solutions

This article describes the Dutch 'Multidisciplinary Guidelines in Mental Health Care' project and its first products (multidisciplinary guidelines on depressive and anxiety disorders). In the early 1990s, disciplines in Dutch mental health care formulated their first monodisciplinary guidelines, which disagreed on essential features. In 1998, the Dutch government invited representatives of the five core disciplines in mental health care (psychiatrists, general practitioners, psychotherapists (clinical), psychologists and psychiatric nurses) to start a joint project aimed at the development of new integrated multidisciplinary guidelines. The vision document, presented in 2000 by the five core disciplines, describes the directions for the development of new guidelines. The guidelines on depressive and anxiety disorders will appear in 2004. The first draft guidelines were presented in May 2003, in line with the vision document (2000). However, it is still not certain whether they will be authorised by all professional groups. Some disciplines do not recognise themselves in these guidelines. It is argued that these problems can be attributed at least in part to the evidence-based method that was used in drafting the guidelines. Interventions are compared on the basis of their 'level of evidence', the consequence of which is that cognitive behavioural therapy and drug treatment are almost always seen as the only appropriate interventions. Other interventions are excluded because of their lower level of evidence. The conclusion is that guidelines cannot be based on empirical evidence alone. It is argued that the collective sense of professions involved should also be integrated into the guideline, for example in relation to goal differentiation. It is finally argued that multidisciplinary guidelines must also offer a hierarchy between those goals, i.e. a vision of the appropriate type of care and the order in which the various care components should be administered.

Enforcing patient rights or improving care? The interference of two modes of doing good in mental health care.

New state laws are intended to bring about formal changes. These juridical activities inevitably interfere with the content of care of substantially changing health care practice. The case is argued by means of an analysis of ethnographic material gathered in the long-stay wards of two psychiatric hospitals in the Netherlands. The question raised by the ethnography is which 'mode of doing good', juridical or caring, is relevant to daily practice. A 'mode of doing good' is defined as a pattern of ideals, procedures, routines and knowledge that is oriented towards a specific form of 'good care'. The interference of these different modes of doing good explains the impact of recent juridical changes in Dutch mental health care. The potential tensions between juridical and caring traditions are accommodated in different ways. Either juridical and caring modes resonate and gradually merge into new patterns of day-to-day practice, or there is dissonance and they remain oppositional. Rather than securing patient rights, juridical measures change daily life and work on the wards in far more complex ways.

Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses?

The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses. On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality. Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire. The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales. The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.

Costs of deinstitutionalization in a rural catchment area in The Netherlands.

In contrast to many other countries, The Netherlands left the initiative in deinstitutionalizing mental health care to the traditional providers of mental health services. The goal of this study is to determine the effect of this policy on the allocation of mental health care resources to services. All 20- to 64-year old users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Service utilization was combined with the direct unit costs of these services for the 1999 price level. Changes in the population as to size and age were taken into account. In 1999 the direct costs of mental health care were Euro 268 per adult inhabitant of the register area, which is 9% higher than in 1990. Costs increased most in the early 1990s before deinstitutionalization policy took effect. From 1993 and onwards the reduced length of stay in the hospital was the main cause for the decreased costs of in-patient care. These savings equalled the increased expenditures for day-treatment, sheltered residences and home-treatment, even though the unit costs of these types of community care are much lower than the unit costs of admissions. This was not caused by an increasing number of new clients, but was a result of longer periods of care during a larger number of years. These findings are in accordance with Dutch mental health care policy, which aims at prolonged care and aftercare outside the hospital whenever possible.