COVID-19 has reinforced deficits in psychotherapeutic care in the EU
NPCE Event 2021The Network for Psychotherapeutic Care in Europe (NPCE) discussed the challenges and implications for psychotherapeutic care during the COVID-19 pandemic. The event was hosted by Dr Nikolaus Melcop, Vice President of the BPtK, and Dr Jorge Gravanita, President of the Portuguese Society for Clinical Psychology (SPPC), and took place on 24 June 2021. Given the Portuguese EU Council Presidency, a focus was laid on Portugal and possible spill-over effects of the national mental health reform plans.
After one and a half year living with the pandemic, it becomes more and more evident that the pandemic also affects mental health. It is well known from psychotherapy research, that the longer a crisis, a conflict, and a life-threatening event lasts, the more likely it is that the psychological resistance and regeneration will be overwhelmed and result in mental disorders. Existential fears, work at home, closed schools, the fear of infection, illness or even the loss of family members, but also the overwhelming situation for healthcare professionals in hospitals can endanger mental health. However little has been done at the EU level to address this issue. The European Commission aims at building a European Health Union which should allow a better and common response to a crisis and should ensure access to vaccination or face masks. This is important, for sure. But it neglects the psychological burden of the pandemic to the European societies. With an initiative, the NPCE has pointed out that the European Centre for Disease Control and Prevention (ECDC) should analyse and identify mental health issues due to COVID-19 with the aim that national health systems can respond to emerging risks or a higher need in treatment. This has been supported by Members of the European Parliament and has been introduced to the on-going parliamentary negotiations. However, the EU needs to do more. Health in all policies is a well-known maxim, however Mental Health in All Policies must be underlined.
Case study PortugalAn ad-hoc study on the social effects of the pandemic in Portugal revealed that children and young people, students, but also older people, low-income families, as well as women and single mothers are particularly suffering from the COVID-19 pandemic. Dr Rita Gouveia, post-doc researcher in sociology with a focus on families from the Institute of Social Sciences of the University of Lisbon, supervised the multidisciplinary survey and presented the result. The survey revealed a narrative of fatigue. While mental health was considered an issue, it became a present issue during the confinement. Anxiety, insomnia, unhappiness, the feeling of isolation, emotional draining, and issues to manage emotions and a lack of privacy were reported. Besides this, the survey revealed a correlation between the political trust in decision makers and the acceptance of confinement measures: the less the trust, the less political measures were accepted.
Dr Isabel Prata, Intervention Service in Additive Behaviours and Dependencies (SICAD) & SPPC Vice-President, reported that helplines were often contacted to receive psychotherapeutic care since services were not available during the pandemic. During the confinement or when the feeling of loneliness was strong, the inquiries increased. With regards to addiction disorders, for those who already showed problematic consumer behaviour before the pandemic, the behaviour was reinforced during the lockdown measures. Among the elderly, gambling in form of scratch cards was observed. Also, prevention services in schools and on the streets had to be paused. In her view, a higher demand for psychotherapeutic care will very soon be noticeable.
Dr Miguel Xavier, Director of the National Mental Health Program in Portugal, reported that even before the pandemic, psychotherapeutic care was not adequately secured since there was a lack of capacities and funding. Also, it is worrying that the numbers of healthcare professionals, psychotherapists included, in Portugal has not been increased over the last 10 years resulting in a shortage of care givers that impacts the provision of care. In his view, the mental health challenges due to the COVID-19 pandemic need to be tackled with a holistic public health approach. “Mental Health in All Policies” must be taken in account in all measures. For example, health promotion, prevention, digital solutions, risk group-specific measures, but also the number of psychotherapists should be strengthened. Portugal had in the past contributed to strengthening mental health at EU level, but the implementation of existing recommendations for action in the Member States was deficient.
Jeopardized access to psychotherapeutic care
That the demand for psychotherapeutic care has been risen, but at the same time access to psychotherapy was not always given, was noticed in other countries as well.
In Italy, too few psychotherapists are involved in public care. This leads to the fact that the patients suffer unnecessarily long. About three quarters of the people who need psychotherapy are not granted access. Those who urgently need support have the worst access to psychotherapy and cannot always afford it. In addition, patients would be prescribed medication too quickly, even though they actually needed psychotherapeutic care. Although the Italian government is working to increase the number of psychotherapists in the public health system, implementation will take time. In order to cover the increased need for care, some private psychotherapy schools offer inexpensive care to bridge the gap. At the same time, this would have the advantage that the psychotherapists in training could gain practical experience. Besides this, a focus should be placed on the rehabilitation of people with mental illnesses.
In Germany, the psychological stress caused by the pandemic has increased. Children and young people suffer particularly from the measures taken to combat the pandemic. Children from low-income families were also more at risk than children from wealthy families. The demand for psychotherapeutic treatment is increasing and exacerbating the existing problem of a lack of therapy places: The psychotherapy practices received 40 percent more inquiries, the demand in child and adolescent psychotherapy practices rose by 60 percent. Psychotherapy via video is not suitable for all patients, but still, it could allow to provide psychotherapy during the pandemic for some patients. Fortunately, people with mental illnesses and psychotherapists were given priority access to the COVID-19 vaccination. Nonetheless, concrete policy measures to strengthen mental health and psychotherapeutic care that solve existing care problems remain overdue.
Call for Action
So far, the EU has not considered the psychological stress caused by the pandemic in its measures, although mental illness was the third most common cause of illness in Europe before the COVID-19 pandemic. The NPCE has therefore adopted a position paper in which it calls on the EU and the Member States to act together: Data on the psychological consequences of the pandemic must be improved to develop European recommendations for mental health promotion, prevention and care, which Member States should implement, but also support the access to psychotherapeutic care in Europe.
Reports from other countries
By Máté Kapitány-Fövény
As part of an international online study of the Mental Health Sector of the Scientific Research Institute of the Pan-Hellenic Medical Association, the Hungarian research team assessed 738 adults (both healthy controls and respondents with mental disorders) during the pandemic (between 30.06.2020-12.09.2020), and reported especially severe anxiety and depression symptoms, increased smoking and increased use of sedatives among mental disorder patients as well as a significant reduction in physical activity within this time interval among the same subgroup as compared to healthy controls. In May 2020, a research group of the University of Szeged assessed a non-representative sample of Hungarian adults in the time of the national quarantine situation (n= 431). 34.1% of the respondents showed depression symptoms, while 36.2% were characterized by elevated levels of anxiety. Between 4th March and 25 May 2020 (during lockdown) Eötvös Loránd University launched a specialist online counselling program to provide crisis mental health support for all university members. The program consisted of one to three sessions (altogether 47 clients received this support). According to the observations of the counsellors involved in this program, the clients main psychological problems encompassed the fear from the virus, anxiety, fatigue, addictive behaviours and symptoms of depression or psychosis. Three key features of online counselling were identified: 1) the need of a problem-oriented approach; 2) the challenges of building rapport online; 3) the frames of online counselling and the difficulty of controlling them. Similar online programs were implemented in many other locations/institutes. An online Pro Bono Counselling Project was provided by many Hungarian psychologist during the lockdown (Spring, 2020) to reach those clients in need who otherwise could not afford psychotherapy or counselling. As a response to the public health concern regarding post-Covid syndrome, a special outpatient clinic was opened (2th of April 2021) in the National Institute of Mental Health, Neurology and Neurosurgery (Budapest, Hungary) which is currently one of Hungary’s main psychiatric centres. The primary goal of this clinic is to provide help for those clients who struggle with the mental symptoms of post-Covid syndrome. The Hungarian Psychiatric Association has recently held its XXIV. itinery congress focusing on the major mental health correlates of peri and post Covid situation and condition, including both the individual (e.g. psychiatric symptoms of patients and health care workers, neuropsychiatric characteristics of post-covid syndrome, etc) and the organizational (e.g. cutting the availability of inpatient psychiatric beds, redeployment experiences) levels. The Hungarian Academy of Sciences – as requested by the Hungarian Government - has started to develop a post Covid strategy in the Spring of 2021, alongside with working on a medium-term national pandemic plan.
By Veronica Defièbre, member of the board and vice president of the “Assoziation Schweizer Psychotherapeutinnen und Psychotherapeuten” ASP
During the first lock down during the COVID-19 pandemic the Swiss Department for Health (BAG) which is part of the Federal Department of Internal Affairs (EDI) of which one of the Swiss Federal Council members Alain Berset is the head of, was certainly confronted with a quite new and challenging task. They had a lot to cope with and we understood that the situation of the psychiatrists and psychological psychotherapists was not their first concern, but it isn’t handled satisfactory until now.
Firstly, I would like to bring to your attention the situation of psychological psychotherapists in Switzerland: They can reimburse the costs of their psychotherapies only by the general health insurance if they work together with a psychiatrist in the so called delegating system. The psychiatrist is responsible for everything the psychotherapist does in his or her psychotherapy, but the exact way how they are working together, apart from having to work in the same practice, is not clearly regulated. Therefore, there is a lot of misuse, for example psychiatrist, who charge their delegated psychotherapist up to 80% of his or her income as part of the delegation contract.
Apart from this system the psychological psychotherapists can work in their own practice and reimburse their psychotherapy costs via the private health insurance or the patients can pay themselves. This kind of psychotherapy isn’t regulated that strictly as the delegated one. Delegated psychotherapists for instance are not allowed to perform psychotherapy online and the sessions via phone are limited to 240 minutes per 6 months.
In the following I’m only referring to the psychological psychotherapists who are working in the delegating system and who are very important especially for patients with low income who cannot afford a private health insurance or pay for their psychotherapy by themselves.
In the beginning of the first lockdown the psychological psychotherapists had the same regulations as the psychiatrists. They were allowed to perform online-sessions with their patients or talk to them on the phone and could charge it as a face-to-face session. But after a few weeks of this practice the BAG returned to the usual regulations, that psychological psychotherapists are limited to 240 minutes per 6 months for psychotherapy on the phone, but also permitted online therapy via a video conference system, which was prohibited before. The psychiatrists were still allowed to continue the practice of charging phone and video calls as face-to-face sessions and were thus free either to see their patients in the practice or do it online or via phone. The psychotherapist associations such as the ASP intervened and required even together with the associations of the psychiatrists that psychological psychotherapists should be unlimited as well, because they otherwise could either be in contact with their patients rather rarely or the patients would be forced to go to the practices and endanger themselves and the psychotherapists of being infected by the corona virus. The reaction was that the BAG raised the permitted 240 minutes of psychotherapy via phone up to 360 minutes per 3 months for psychological psychotherapists. This was extended until 1st of July 2021 and has just finished this month. In spite of all protest of the associations the BAG is not prepared to change the law and permit online therapy even though the COVID-19 pandemic is still going on.
The only other effort that was made was a hotline the BAG planned to install in the beginning of the pandemic. The psychotherapy associations supported the BAG and organized psychotherapists who would be working on this hotline, but in the end the BAG gave up this project due to difficulties they had technically.
But apart from these frustrating aspects the psychotherapy associations have achieved an important goal: The Swiss Federal Council has agreed to abolish the delegation system which will be replaced by the so called “Anordnungsprinzip” which is still not ideal but certainly an improvement. We are still negotiating with the EDI and Alain Berset the exact terms of it. It ist planned, that all general practitioners and psychiatrists will be able to order 15 hours of psychotherapy sessions. After 15 hours the ordering doctor has to receive a report of the psychotherapist in case the patient wishes to continue the psychotherapy. After another 15 hours a psychiatrist has to decide if more sessions are necessary and, in case he should agree, the doctor has to write a report for the health insurance. Neither the psychotherapist associations nor the associations of the psychiatrists support this involvement of the psychiatrists. It makes the whole process unnecessarily complicated. The associations think the BAG is still trying to limit the independence of the psychotherapists and have them under the control of doctors because they don’t trust them to be competent enough. The fact that the doctors have to write the report and not the psychotherapists has in our opinion the same reasons. In the daily practice the psychotherapists will do it as they already are doing it in the delegating system: They will write the reports in the names of others, even though in the present system it should be the psychiatrists who are writing the reports for the health insurances, which takes away the responsibility from the psychotherapists. Certainly, another important aspect of and reason for these restrictions are the health costs which the EDI wishes to limit as much as possible. We are trying to change these terms of the “Anordnungsprinzip” and hope that we will succeed, but don’t know yet. Apart from that the change in general is welcome as the psychotherapists are able to work in their own practices and are no longer obliged to work so closely together with psychiatrists. We think that this change was made possible because of the COVID-19 pandemic. It has shown how important psychotherapy is in such a crisis and how even more important is an easy access to it.
The new system will start on the 1st of July 2022.