Annual report 2012 by Trimbos-instituut

DUCTION

INTROJan Walburg

Chair of the Board, Trimbos Institute What kinds of ideas do we have about people who are admitted to psychiatric institutions? That is a pertinent question, because these are the very ideas that determine policy on psychiatric patients. Are they people who are virtually incapacitated, or who may even be potentially dangerous to themselves and those around them? In other words, are we fixated on their illness? Or are they people who, beyond their impairments, can make the most of their potentials and opportunities if we assist them in doing so? If we pose the same questions to people who have been in residential institutions, we learn that they are indeed aware of their problems, but that they are searching above all for purpose and meaning in life, for relations with others, for employment and personal development. The Trimbos Institute’s regional mental health care monitoring schemes can bear this out with statistics. Desires for companionship, for orientation and recovery, for daytime activities, for psychological well-being and for paid employment jostle for places in the top five unmet needs. When we speak of community living for people with mental health issues, we should consider first of all how to support them as they try to fulfil these needs. Assertive community treatment (ACT) is the intervention approach that is currently at the forefront in the process of psychiatric deinstitutionalisation. An authoritative work edited by Niels Mulder and Hans Kroon has distinguished four phases in the evolution of ACT in the Netherlands:

• • • •

Small-scale initiatives Expansion to other sectors ACT and the broader-ranging FACT Specialisation for different client groups.

I would like to suggest three additional points to consider here, focusing in particular on the unmet care needs. I see, or rather hope for, several other developments that I believe will be vital to the success of the psychiatric deinstitutionalisation process. 1. Community living or deprofessionalisation. Psychiatry could concentrate more strongly on supporting community participation. That would include help in finding and keeping paid jobs, planning meaningful daily activities, getting physical exercise, strengthening purpose in life, and improving well-being. 2. Application of positive psychology, with a stronger focus on a client’s potentials. Psychiatric patients have low levels of psychological well-being. That is linked not

We have long been aware that physical exercise enhances both mood and health status. only to their mental illness, but perhaps in greater measure to their self-attributions and to their stigmatisation into the ‘helpless patient role’. Methods have been developed in positive psychology to promote the strengths of the individual. Mental health services in the province of North-Holland have already gained experience with this approach. Positive psychologists have also developed interventions that facilitate people in acquiring general life skills such as goal setting, positive and optimistic thinking, social interaction and physical exercising. 3. More emphasis on physical health. Although we have long been aware that physical exercise enhances both mood and health status, this awareness is not yet adequately integrated into psychiatric health care. The same applies to comorbid physical health problems. It is well known that psychiatric symptomatology is often accompanied by chronic illnesses such as diabetes, cardiovascular disease and addictions, yet integrated treatments are still only marginally available. I am convinced that psychiatric deinstitutionalisation, and the recent cooperative agreement concluded by the Dutch health ministry, mental health care providers and health insurance companies, have created a unique opportunity to ensure that people with psychiatric problems are given more latitude and support for developing their lives within the ambitions and capabilities they have. This will need to be complemented by professional knowledge and skills based on integrative psychiatry, which combines neurosciences with behavioural and social sciences. Yet it is equally important to make optimal use of each patient’s own personal knowledge, which is rooted in their own experiences with their illness and in their awareness of their own talents and potentials. This goes beyond the mere treatment and management of mental health symptoms and the care for patients or clients. It means encouraging people and developing their strengths.

Community living is a broad mandate to the whole of society. It requires well planned arrangements and a clearly articulated roadmap whose final destination is social inclusion.

Frank van Hoof, MSc and Sonja van Rooijen, MSc Senior Researchers, Trimbos Institute Reintegration Programme. Sources Trendrapportage GGZ 2012 (Mental Health Care Trend Report 2012, in preparation); ‘Bedden tellen: Afbouw van de intramurale ggz’ (Counting beds: The scaleback of inpatient psychiatric care), Maandblad Geestelijke Volksgezondheid MGv (Dutch Journal of Mental Health), September 2012, pp. 298-309). INTRODUCTION Psychiatric bed reduction currently tops the mental health policy agenda. A successful process of deinstitutionalisation will require well considered arrangements, a clear roadmap and a comprehensive knowledge agenda. DISCUSSION In 2012, there were nearly 40,000 inpatient beds in Dutch mental health care institutions. About 60% of mental health expenditures went to inpatient facilities, making the Netherlands the European front runner in inpatient psychiatric care. The Administrative Agreement concluded by the health ministry, mental health care providers and health insurance companies in 2012 provides for a drastic reduction in beds. It is now crucial to ensure that bed reduction will not turn into an end in itself, but that it will improve the quality of care and the social inclusion of people with serious mental illnesses.

DEINSTITUTIONALISATION

NEEDS KNOWLEDGE

AGENDA KNOWLEDGE CENTRE

AND A

ANNUAL

JANUARY

REVIEW

The website www.zelfhulpwijzer.nl, launched in January, gauges the severity of users’ mental health symptoms and problems and makes recommendations to them about self-help opportunities available on the Internet. They

Online guide gives advice about web-based self-help

first perform a self-test that measures stress, depression, anxiety and problem alcohol use, and they then receive an indication of how serious the problems are, whether web-based self-help might bring relief and, if so, which programme would be suitable. Referrals by the self-help guide are made exclusively to online courses with demonstrated effectiveness.

By 2020, the sector will have to make do with only half of its current inpatient capacity. As a result, people with severe and persistent psychiatric problems will have to receive treatment and care as far as possible within their own living and working environments. That will not necessarily be cheaper, but it will generate many benefits: people with mental illness will be participating again. That is both a social return and a community gain. People with persistent mental health conditions want to stand on their own two feet, just as other people do. Many of them need help in doing so. Yet people have a wealth of personal experience at their disposal in terms of what they need to survive, to keep working and to preserve maximum control over their lives. The pivotal focus in the community-based care of the future will be on these individual desires, experiences and capabilities of people with mental illness. People with psychiatric illnesses can find their own routes to participation, self-direction and empowerment. Their relatives, neighbours and friends can facilitate that. Mental health professionals can provide support to clients as well as to their personal environment. Employers, educational and training institutes, housing associ-

Khat use by Somalis in the Netherlands There are growing signs of the problem use of khat by Somali people living in the Netherlands. The nature and scale of the use of the drug was assessed in a report entitled Qat gebruik onder Somaliërs in Nederland: Studie naar de invloed van qat op de sociaaleconomische situatie en de gezond-

ations, local authorities and health insurers all have important roles to play. Community living is a broad mandate to the whole of society. It requires well planned arrangements and a clearly articulated roadmap whose final destination is social inclusion. The roadmap should specify what resources are necessary to optimally develop clients’ own strengths and those of their personal networks. It should also make clear what contributions other people, including mental health professionals, can make; what conditions are needed to achieve effective cooperation amongst all stakeholders; how officials in mental health and other sectors can create the necessary conditions; what systemic incentives can persuade stakeholders to commit themselves to the shared goal of social inclusion for people with mental illness. CONCLUSION: CALL FOR A KNOWLEDGE AGENDA Some parts of the roadmap are already clear, but there are still many gaps and blind spots. A knowledge agenda for deinstitutionalisation could help define the itinerary and ensure its sustainability. It would guide the development and implementation of knowledge in support of: • Treatment and care provision: fostering experiential expertise and self-management, developing effective forms of community-based care and employment support, and determining the required competences and skills of professionals • Organisation: coordination of care, regional and neighbourhood cooperation (community support systems) • Policymaking and implementation: facilitation and encouragement of partners in the field, monitoring the progress of deinstitutionalisation, its cost-effectiveness and its benefits to the community. Particularly important for a successful deinstitutionalisation process with broad support in the community will be the cohesion between these three elements of the knowledge agenda. That could be achieved by consolidating forces in a Deinstitutionalisation Knowledge Centre.

heid van Somaliërs (Khat use by Somalis in the Netherlands: A study of how it influences their socioeconomic and health situations), which appeared in January. It was commissioned by the Health, the Security and Justice and the Interior ministries of the Netherlands.

FEBRUARY Addicted to you The project Verslaafd aan jou (‘addicted to you’), conducted by the Alcohol and Drugs Information Line that has been operating for 15 years, was in the news twice in 2012. The project focuses on the problems faced by partners, friends and relatives of people with substance

LATE-

MOVER ADVANTAGE

Often we open a drawer and are tempted to close it again straightaway. But that drawer may contain a wealth of information, if we just dare to look.

Jolande Tijhuis, MSc Chair of the Board, Vincent van Gogh Institute for Psychiatry. Source Contribution to debate at Mental Health Care Knowledge Day on Deinstitutionalisation, 7 February 2013.

LATE-MOVER INSPIRATION Things are moving again. In many respects, the mental health sector must make a great leap forward, and our Vincent van Gogh Institute is no exception. We’re very well-off in the Netherlands, and Dutch mental health care is of high quality. Perhaps that’s why I see insufficient ambition and vision to make the leap. We’ll be needing to reinvent ourselves, because our health system and our ways of addressing social issues will be unsustainable in the long run. There’s an acute need to develop new patterns of health care provision, by approaching the transition to community living not just from the angle of mental health expertise, but by drawing on the full range of experience that can help patients recover. We can learn from experiences abroad and from those in other sectors. It’s always difficult to make a leap forward on your own initiative, especially when you’ve

dependencies. On 13 February, the day before St Valentine’s, a live all-day webchat was organised for people in the target group. On 1 November the project held the premiere of a short, interactive film, launched a dedicated project website www.verslaafdaanjou.nl and published a new information brochure. The film production was supported by funding from the Nuts

already achieved so much. That’s why the mental health sector needs the dynamism of the business world, the youth services, the probation services, the housing associations and the education sector. There lie the answers for ensuring that sufficient high-quality services remain available, in dialogue with local authorities and health insurance companies. The staff of the Vincent van Gogh Institute explore every possible means of connecting with people in other organisations such as local councils, health care services and social welfare organisations, as well as engaging patients, to ensure selfdetermination and quality care. In conjunction, we also seek to mobilise the strengths and potentials of individuals and their personal environments. Our guiding principles are patient self-determination, self-reliance and problem-solving in the patient’s own context.

Ohra Foundation and from several Dutch addiction services.

Open and Alert launches website On 1 February, Open and Alert started its own website: www.openenalert.nl. Open and Alert is a programme for strategy and policy development and professional expertise enhancement to improve substance use prevention in

at-risk settings. Different versions of the website are online, designed for people working in residential youth services, young offender institutions, youth welfare services and facilities for people with mild intellectual disabilities – environments where alcohol and drug use is widely prevalent.

OPEN MIND I move ahead of the current: I act and don’t wait. As an executive in a public service institution, I feel I have an obligation to society as well as to my organisation. This begins with myself and with the Vincent van Gogh Institute: ‘Be the change you want to see in the world.’ This means we are working with a broad-based team to prepare the organisation for change, to restructure it as a network-centric organisation and to implement deinstitutionalisation and community living. In doing so, I think it’s important to form coalitions both local and nationwide and to look across the fence. I believe this approach can produce remarkable, sustainable solutions to seemingly intractable problems. We should pull out the stops, open every drawer, stick our necks out and learn something in the process.

Well-being on prescription The manual entitled Welzijn op recept (‘well-being on prescription’) was published in February. It describes a method for referring people with psychosocial problems from GP practices to activities for personal well-being. De Roerdomp Health Centre in Nieuwegein began a pilot project to facilitate collaboration between the

If we probe into the causes of the challenges we face, into our own roles and obstructions, and if we explore these in the light of different interests and perspectives, we will make progress. That will give us a foothold for the great leap forward. We’ve grown accustomed to the established order of things and our own statuses and privileges. Letting go of these can be unsettling, or it can even seem ‘dodgy’. In our management team we’re fully aware that things can’t remain as they are. Our message to ourselves and our staff is, ‘Take a good look around you, take a look at yourself and try seeking advice in other departments or other disciplines.’ Start from your own strengths and talents, but be open to your colleagues. Talk to them and encourage one another to reach new solutions. Professionalism, Leadership and Entrepreneurship is the word.

health care and the well-being sectors. In consultation with GPs, several ‘well-being packages’ have been designed, suitable for addressing various psychosocial problems that people present to their GPs with.

the Trimbos Mental Health Care Innovation Programme, was awarded a Harkness Fellowship to do research in the United States for a one-year period starting in September.

Ionela Petrea Harkness Fellowship for Gerdien Franx In February, Gerdien Franx, head of

Ionela Petrea of the Trimbos programme International Policy and Mental Health was awarded her doctoral

Clearly the digital contact must be complementary to face-to-face contact; at present there is no question of fully replacing in-person contacts.

Ina Boerema, MSc Researcher, Trimbos Institute Mental Health Care Innovation Programme. Lex Hulsbosch, MSc Researcher, Trimbos Institute Reintegration Programme. Sources Presentations at Mental Health Care Knowledge Day, 7 February 2013; and breakfast session, Zorg & ICT Trade Fair, 13 March 2013; Boerema I., de Leeuw J.R.J, Evaluatie van de eerste ervaringen met Eigen Regie (Evaluation of initial experiences with Personal Control in Rehabilitation), Trimbos Institute (2012); de Leeuw J.R.J., van Splunteren, P.T., Boerema I., Personal Control in Rehabilitation: An Internet platform for patients with schizophrenia and their caregivers (2012); Hulsbosch, L., Tamis-ten Cate, P., Nugter, A., & Kroon, H., Zorg op afstand in de langdurende geestelijke gezondheidszorg: Een randomised controlled trial naar telezorg bij GGZ Noord-Holland-Noord (Care at a distance in long-term mental health care: A randomised controlled trial of telecare in the North-Holland-North Mental Health Services) (2011).

FOR

CARE A DISTANCE

PEOPLE WITH

PSYCHOTIC 6

VULNERABILITY

degree in February by the London School of Hygiene and Tropical Medicine. Her thesis was entitled Institutional Discrimination in Mental Health Services: A Comparative Analysis of Schizophrenia and Diabetes in Romania. The primary conclusion was that people with schizophrenia suffer more discrimination in terms of both legislation and treatment opportunities

than diabetes patients.

MARCH Jan Spijker, Professor for Chronic Depression As from 1 March, Jan Spijker, senior researcher in the Trimbos Mental Health Care Innovation Programme, was appointed Professor for Chronic

Depression at Radboud University Nijmegen. This endowed chair was established on the initiative of the Pro Persona Foundation and the Trimbos Institute, both of which have identified chronic depression and depression care as priority focuses and have maintained long-standing collaborations with the Radboud Departments of Clinical Psychology and Psychiatry.

INTRODUCTION Community living for people with psychotic vulnerability can be supported using e-mental health applications. Examples of resources now available are the Internet platform Personal Control in Rehabilitation (PCR; the Dutch name is Eigen Regie) and a telecare application using image communication. PCR has been specially developed for people with psychotic vulnerability, their friends and relatives, and their carers and care providers. Image communication telecare is a broadly based technology suitable for use in long-term psychiatry. The Trimbos Institute has tested and assessed the image communication telecare application in cooperation with the North-Holland-North Mental Health Services (GGZ NHN) and PCR in cooperation with the Julius Centre for Health Sciences and Primary Care at Utrecht University together with the mental health organisations GGZ Breburg and Western North-Brabant Mental Health Care (GGZ WNB). DISCUSSION PCR and image communication telecare were both received positively by clients. These enabled them to communicate with their service providers and carers at times convenient to the clients themselves. Another positive feature was the overview they could obtain of their treatment and support plan. Although the service providers likewise expressed positive attitudes about the use of modern media in their jobs, some found it awkward to integrate e-mental health into their daily routines. Because clients could make digital contact on their own initiative and when it suited them, the role of the service providers shifted from a supervisory to an

Tibor Brunt Tibor Brunt of the Trimbos Drug Monitoring Programme received his PhD on 2 March for his thesis entitled Monitoring Illicit Psychostimulants and Related Health Issues. It demonstrated how efficient monitoring of recreational drug use enables timely warnings when dangerous drugs appear on the market.

advisory one. One obstacle to the successful implementation of e-mental health tools such as these lies in technical snags during the developmental stage. CONCLUSION Internet applications such as image communication telecare and PCR seem useful tools in support of the care and treatment of people with psychotic vulnerability, including those in long-term care. Our pilot studies indicated they are well able to judge whether and when they can use such tools. Clearly the digital contact must be complementary to face-to-face contact; at present there is no question of fully replacing in-person contacts. In the pilot stage, it was not yet possible to fully assess the effectiveness of the intervention. The project is still in development, and a key stage has now been reached: implementation. RECOMMENDATIONS The intervention will not function optimally until it has been carefully implemented. Hendy et al. (2012) have provided clear instructions. An intervention needs to be implemented in a stepwise fashion and at a pace that suits the organisation in question. Further points to remember are: • Involve all stakeholders, including IT experts, in the project at the earliest possible stage. • Ensure that the tasks of the various partners are clearly defined. • Be alert to any resistance from people involved and respond to it promptly; clear communication is essential.

Harry Michon, Professor for Sustainable Employment On 16 March, Harry Michon, senior researcher in the Trimbos Institute Reintegration Programme, took up his chair of Sustainable Employment and Vocational Rehabilitation at the Fontys University of Applied Sciences in Eindhoven. His inaugural lecture, entitled Op zoek naar nieuwe krachten

(In search of new strengths), was a critical review of the existing knowledge and included a discussion of effective and productive models for helping people with long-term psychiatric problems to find and hold down jobs.

The first mental health support app for women with breast cancer In March we began developing an app

LIVING

Health care providers with good proposals for transforming part of their service package into community-based innovative care can count on long-range support.

COMMUNITY

Diana Monissen, MSc Chair of the Board, De Friesland Health Insurance Company.

INTRODUCTION ’In future I want to stand on my own two feet without mental health care. Everybody’s surprised how I’m doing now, since I had such a long way to go. The psychiatrist said, “If everybody was like you, I’d practically be out of work.” So I must’ve done something right.’ That was Frank, a client of GGZ Friesland Mental Health Care Service, who now lives independently with community care support after a stay in a psychiatric hospital. In cooperation with GGZ Friesland, a 30% reduction of inpatient psychiatric beds in the province of Friesland has been achieved in one year’s time. The beds have been replaced by innovative community care with an e-health component. Bed reduction is not an end in itself. Quality of life for the clients is the paramount issue – quality of life in the community. Community care is a crucial part of that.

ENHANCED VALUE FOR

that will provide mental health support to women during the diagnostic and treatment phases of breast cancer. The first-ever app of its kind, it is funded by the international organisation Pink Ribbon. It will use exercises derived from positive psychology, cognitivebehavioural therapy and mindfulness. The app will be available in 2013.

CLIENTS

AND SOCIETY

APRIL Mad pride documentary film

The Trimbos programme Towards Recovery, Empowerment and Experiential Expertise (TREE) produced a documentary film entitled Gekkenwerk – HEE in de psychiatrie (Mad pride: TREE in psychiatry), which premiered on 3 April. It portrays recovery, empower-

ment and experiential expertise in people with mental health impairments. Five TREE instructors, all of them experts-by-experience as psychiatric patients, and two prominent psychiatrists give accounts of the psychiatric sector and their experiences in it. Wilma Boevink, initiator of the TREE team, provided the key impetus for the documentary, which received funding

REORGANISATION OF CARE If we fail to change course in the Netherlands, health care may become prohibitively expensive. In the Friesland Voorop (‘Friesland up front’) programme, we are working to recast health care provision in the province, with quality and affordability carrying equal weight. We work together with patient advocates and health care providers, given our shared responsibility for high-quality affordable care, now and in the future. In the mental health sector we call the programme Friesland Vooruit (‘Friesland forwards’). The deinstitutionalisation of clients has already begun. We purchase integrated treatment and care packages and work with service providers to ensure quality basic mental health care in conjunction with primary care services. PARTICIPATION The mental health sector also needs to reorient itself, developing new concepts of care based on clients, quality and affordability. The transition from inpatient beds to community care is a very welcome development, as bed reduction promotes affordability, whilst community

from the Netherlands Organisation for Health Research and Development (ZonMw), the Utrecht Foundation for Supervised Accommodation (SBWU), the Hanze University of Applied Sciences in Groningen, Rehabilitatie ‘92 and Maastricht University.

care promotes quality of life. Community care concentrates on the client’s life in society, at home in the community. Proactive mental health teams can provide clients with optimal support in that setting, enabling them to take part in the community according to their own abilities. SELF-RELIANCE De Friesland Health Insurance Company believes in cooperation. Health care providers with good proposals for transforming part of their service package into community-based innovative care can count on long-range support. We are therefore now working together with GGZ Friesland on the basis of a business case under which 100 of the 300 Frisian inpatient psychiatric beds covered by the Dutch Health Care Insurance Act (ZVW) have been phased out and replaced by innovative outpatient care. GGZ Friesland has community teams that visit clients at home, in their own environment and personal context. The focus is on promoting the clients’ self-reliance and self-direction. Our experience with health care in general is that a quality-centred approach leads to cost reduction over time. In view of the positive outcomes achieved on the basis of this business case, we are now convinced that the approach will also be effective in the mental health sector, in terms of both the treatment and the care services. ENHANCED VALUE A remarkable trend is underway in mental health care. Clients are returning to society and reassuming their place as citizens. As one client recently reflected, ‘I’m trying to fully reclaim the way I am.’ Mental health services have a crucial role in supporting that client in her own community. In a concerted effort involving service providers, health insurers and other partners such as local health authorities and housing associations, we can further enhance the value of mental health care in the years to come – and demonstrate that value to the clients and to society.

Completion of the Depression Initiative A report published on 26 April concluded that the Depression Initiative had greatly improved the nationwide efforts to combat depression. It had elucidated the distinction between mild and severe depression and clarified why that distinction is important. People with depressive symptoms now receive appropri-

ate treatment more promptly in GP practices and are less likely to be given medication. The Depression Initiative began in 2006 under auspices of the Trimbos Institute and with funding from the Health Care Innovation Fund of the Dutch health insurance industry. Cooperating partners included mental health services, GP practices, hospitals, universities and the European Alliance Against Depression (EAAD).

Aafje Knispel, MSc Researcher, Trimbos Institute Reintegration Programme. Source Trendrapportage GGZ 2012, deel 1: Organisatie, structuur en financiering (Mental Health Care Trend Report 2012, part 1: Organisation, structure and funding).

N IO AT IS

U L T I A T FROM N SO NTI I E To ensure well informed decisions, we need clarity about the costs and benefits that community living will have for society.

D 10

Social consequences of addiction How common are addiction-related public nuisance, violence, acquisitive crime, road accidents and work absenteeism? How can we prevent or combat these social consequences? These questions were addressed in a report entitled Verslaving: Maatschappelijke gevolgen (Addiction: Social consequences) appearing in April. The report

further identifies knowledge gaps in this field and asks which research questions could lead to a clearer understanding of these social consequences and the approaches needed to deal with them.

The role of CBD in hashish and marijuana Does cannabidiol (CBD) counteract

some of the detrimental effects of THC? That is the key focus of the literature review entitled THC, CBD en de gezondheidseffecten van wiet en hasj: Recente inzichten (THC, CBD and the health effects of marijuana and hashish: Recent insights), presented in April. In responding to the increased demand for cannabis dependence treatment, it is important to know whether CBD

INTRODUCTION Many choices have to be made in the process of deinstitutionalising psychiatric care. What community services need to be expanded and further developed, which clients need the most attention, how much inpatient capacity can be scaled back, and how rapidly can these changes be made? One key focus in the process is how to achieve the optimum balance between client interests and community interests. What role does community participation play? To ensure well informed decisions, we need clarity about the costs and benefits that community living will have for society. What knowledge is available so far?

As an international literature study has shown, there is not yet enough systematic evidence to enable precise conclusions about the societal impact of deinstitutionalisation. Only a few studies have embraced the full range of costs and benefits to society, and they have aggregated various cost and benefit domains, such as the costs of mental health care, other health care sectors, social services and law enforcement, or the benefits of ameliorating mental health symptoms, physical symptoms, daily functioning, work productivity and the supportive capacity of the patients’ environments. Findings broadly indicate a more favourable cost-benefit

A SOCIETAL PERSPECTIVE DISCUSSION In evaluating the impact of modifications in services, we must take various stakeholders and differential outcomes into account. Any service innovation will have consequences not just for clients, but for the surrounding community and the whole of society as well. Adopting a ‘societal perspective’ in evaluating such innovations means weighing the costs and benefits to society as well as those for individual clients, specific organisations, target populations or particular government bodies, such as a single ministry. Moreover, indirect costs and returns, such as changes in labour productivity, need to be taken into account alongside the direct care-related expenditures and savings. If we allow for all the players, sectors and stakeholders involved as well as the direct and indirect costs and gains, we will minimise the risk of overlooking major costs or benefits and of making inefficient decisions. This approach can also shed light on costs and benefits that shift between the various sectors.

might have protective effects against mental health symptoms associated with THC. Although no firm proof has been obtained, enough evidence is now available to conclude that imported hashish is probably less harmful to users than the Dutch-grown ‘netherweed’. Because most studies so far have been conducted in clinical settings rather than among recreational users,

relationship for community-based as opposed to residential care in comparable populations. Yet there is still too little evidence to draw rigorous conclusions about which specific domains may contribute the greatest societal returns. Improvement in the work participation of people with serious mental problems appears to be one important gain, but more research on that is definitely needed. CONCLUSION The current wide-reaching changes in the Dutch field of mental health offer excellent opportunities to identify benefits that deinstitutionalisation can generate for society as a whole. Such information could be vitally important in community care implementation both at home and abroad.

more research is now needed on the latter groups. Our study was commissioned by the Dutch public health ministry.

NEMESIS 2: Netherlands has high and rapid uptake rates for mental health care Dutch people with mental health conditions are more likely than those in other

Western countries to contact a mental health service, and they do so sooner after the onset of symptoms. Those were conclusions from a study published in April, based on data from NEMESIS 2, the second Netherlands Mental Health Survey and Incidence Study. That was a representative study of 6646 adults aged 18-64 from the general Dutch population. Little was

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previously known about the length of time between disorder onset and initial service contacts, nor about the percentages of people deriving benefit from treatment. That information is now available after analysis of the NEMESIS 2 data.

Primary mental health care: More health gains, same budget A wide array of measures are conceivable to ensure better mental health without increases in funding. These include brief treatment modalities, fewer pills when depressive symptoms do not amount to full major depression, broader-scale self-management, more efforts to ensure treatment adherence,

and more services delivered by practice nurses in response to minor symptoms. These were some of the potential courses of action that emerged from a strategic exploration entitled Optimalisatie van de basis-GGZ (Optimising primary mental health care), which we carried out in cooperation with the Netherlands Institute for Health Services Research (NIVEL) at the

Local authorities can help to enable community living by aligning their purchases of care services with those of the health insurance companies.

Victor Everhardt, MSc Portfolio Holder for Welfare, Social Support and Public Health, City of Utrecht. Source Article based on contribution to the debate at the Mental Health Care Knowledge Day, 7 February 2013. INTRODUCTION Increasing emphasis is being put on strengthening the self-reliance of clients in mental health care. The basic assumption is that people feel most comfortable in their own homes and environments. Care in the community can help to improve the quality of life of people with serious mental health conditions. DISCUSSION In ideal situations, people with mental illness receive treatment and support whilst maintaining control over their own lives. If possible, they live independently or in supported living environments. The Dutch Social Support Act (WMO) provides for additional support via the local authorities. Such support is focused on opportunities, the assumption being that every individual has talents to develop. Clients are expected to contribute to society. All support must be tailored to the individual client, for every client has a different symptom profile and different care needs. For many people with severe psychiatric conditions, specialist care will always be necessary. In some cases it will be based on medication, in other cases on intensive treatment and care. An essential prerequisite for deinstitutionalisation is a focus by treatment and care providers on the strengthening of self-reliance. In practice, this includes helping clients to build social networks, to improve daily living skills and to manage money. Such will entail a culture shift, both for health workers and clients. Crisis response services will still have to be in place for clients who are temporarily unable to cope; consistent with community living, however, this should not involve crisis admission to an institution, but support close to home, near familiar social and care networks.

request of the ministry of public health.

MAY Psychosocial care not routinely available in long-term physical illness People with chronic physical health conditions are relatively likely to suffer psychosocial problems such as depres-

It goes without saying that local authorities will require sufficient wherewithal to arrange the necessary support, employment and day care services. Spatial planning measures will also be needed, given the shortage of appropriate and affordable housing for this complex group. Local authorities can help to enable community living by aligning their purchases of care services with those of the health insurance companies. They can also facilitate initiatives to improve the integration of these vulnerable individuals into the community. In addition, local government policy can do more to promote positive perceptions of people with mental illness, in order to discourage stigmatisation. CONCLUSION If mental health care deinstitutionalisation is to succeed, the self-reliance of clients must be strengthened. This will require a culture shift for treatment providers, carers, clients and local authorities alike. People with serious mental illness must be enabled to participate in the community to the best of their abilities. It is a justified concern to ask whether the necessary conditions are sufficiently in place at this time. Should that not be the case, the transition process may not go well for the most vulnerable groups, resulting in a new influx of homeless people. To avoid that, further research is needed to determine whether the expectations for the least selfreliant clients are realistic. The partners involved in the deinstitutionalisation process must develop a joint agency protocol to address implementation and infrastructure. Local government has been engaged too little in this process so far.

sion, anxiety or difficulties with work resumption, and this has serious consequences for individuals and society alike. Although effective interventions are available, psychosocial care is not a standard component of the health care these patients receive. Our report entitled Naar een integrale aanpakâ&#x20AC;Ś (Towards an integrated approach...), published in May, summarises a range

of options to better integrate psychosocial care into the conventional treatment pathways for chronic physical illnesses. The report, produced during preparations for the Mental Health Care Trend Report, focuses on three health conditions with heavy burdens of illness: coronary heart disease, type 2 diabetes and chronic obstructive pulmonary disease (COPD).

DEINSTITUTIONALISATION

The monopoly that the mental health sector now holds over the treatment and support of people with mental health problems needs to be broken. Marjan Heuving interviewing Marianne van Bakel, MSc, Project Leader, TREE (Towards Recovery, Empowerment and Experiential Expertise), Trimbos Institute. Background and expertise The project entitled Towards Recovery, Empowerment and Experiential Expertise (TREE, or HEE in Dutch) provides effective methods and strategies that people with mental health vulnerabilities have developed in order to help themselves. These also help them raise their voices to reorient mental health care towards recovery support. The TREE team is comprised of about 50 facilitators who are experts-byexperience. Working mainly with mental health services throughout the Netherlands, they support the recovery and empowerment of clients by offering a broad range of expertise.

AS A

CHANCE

BREAK OPEN THE MENTAL HEALTH SECTOR

Implementation plan and conference for suicidal behaviour guidelines ‘Making Contact!’ is the slogan of the National Implementation Plan for the Dutch multidisciplinary diagnosis and treatment guidelines for suicidal behaviour. The implementation plan was presented at a well attended conference on the guidelines that was held on

22 May. The guidelines describe many options for carefully considered responses that practitioners can make to clients with suicidal thoughts. Current practice still lags behind what is needed, however, and the gap between standard and optimal care will not be bridged automatically. The Dutch public health ministry therefore commissioned the development of this

nationwide plan to get the guidelines systematically and fully implemented, and to ensure that the empirically validated insights are promptly integrated into the work of practitioners.

MGv goes cross-media In the spring of 2012, the Maandblad Geestelijke Volksgezondheid (Dutch Public Mental Health Monthly) was

INTRODUCTION In the process of deinstitutionalising mental health care, too little use is being made of the knowledge and expertise possessed by experiential experts and the clients themselves. The risk is that psychiatric care will simply be superimposed onto the community, bringing the care closer to home but changing very little. DISCUSSION Long before the term ‘deinstitutionalisation’ (re-)entered the picture, the TREE team was promoting alternatives to long-stay psychiatric admissions. If possible, such alternatives are to be provided at home, in the client’s own surroundings, or, if a temporary crisis precludes that, in a home-like environment. That is something entirely different from ‘crisis intervention beds’ as we know them in the Netherlands. The alternatives might resemble the crisis house I once visited in New Zealand – quite an ordinary house, which happened to be nestled in the sand dunes, with a well stocked fridge, a cat and two people that were simply there for you if you needed it. The crucial element was devoted support for a brief period. In the current debates and developments surrounding deinstitutionalisation in the Netherlands, we unfortunately see too many people still thinking in terms of the existing relationships in the mental health system. Basically they seem to be saying, ‘Close down institutions and shift them to the community.’ If the upshot of that is to continue the medicalisation of psychiatry in a small-scale as opposed to a large-scale setting, then there is little to be gained. Existing treatment structures will merely be superimposed onto the community. Instead, the deinstitutionalisation process should be seized on as an opportunity to explore an entirely new conception of mental health care. Care should be truly grounded in the personal strengths and needs of the

recast as a cross-media journal, henceforth entitled MGv. MGv now appears bimonthly in paper format, supported by the website www.mgv-online.nl, which was launched in May. New features are journalistic contributions, a debate section, interviews on topical issues on the website, and the online-only publication of authors’ contributions on

people who use it. It should give the individual patients (if indeed that term is applicable) a voice in their care and treatment pathways, just as in the physical health care sector. At present, the chief worry is to fit everything into the existing frameworks of an institution or system. Everything is defined and labelled in terms of the imperfections diagnosed by professionals. That leaves little room for self-determination and self-direction on the part of the individual clients. That could improve if mental health care were to attune itself more to people’s ‘ordinary’ lives, to what is happening in their social or community environments, rather than just extending the present institutional provisions over the region. A further consequence of the latter approach would be to preserve the mental health sector as a separate distinct world vis-à-vis conventional medicine. The major challenge now facing mental health services in the deinstitutionalisation process is to bring up the courage to let go – not only to let go of ‘their’ patients, but to relinquish their budgets, control and authority as well. The monopoly that the mental health sector now holds over the treatment and support of people with mental health problems deserves to be broken. The critical guideposts in that process are the wishes and preferences of the people who need the care. TREE is a keen discussion partner that can bring together those voices and the available expertise for those who want to work with it. CONCLUSION TREE and its experts-by-experience will judge the deinstitutionalisation process as successful if, and only if, the transition to community living is used to break open the mental health dominion – integrating mental health care into ‘ordinary’ life, into the lives of people who have health problems of whatever kind.

http://mgv.boomtijdschriften.nl. MGv is a joint publication of Uitgeverij Boom, Amsterdam, and the Trimbos Institute.

JUNE

Master Your Mood online: Effectiveness demonstrated The e-health intervention Grip op je dip (Master Your Mood) has been shown

effective in reducing symptoms of anxiety and depression. That was one outcome of the first-ever Dutch randomised controlled trial of a web-based group intervention for young people with depression, the results of which were announced in June. Participants also reported a greater sense of control over their lives. Improvements were maintained at six-month follow-up.

ORGANISATION

PATIENT

Peers who set good examples are the walking proof that a variety of social roles are still possible after the psychosis.

Grip op je dip is an online group course based on cognitive-behavioural therapy for youth aged 16 to 25 with depressive symptoms.

JULY Roma and school absenteeism Why are Roma girls often absent from secondary school? How do local educa-

tion authorities respond to this and what more could they do? In cooperation with the Triana Foundation, Trimbos researchers interviewed 27 Roma girls and their fathers or mothers, as well as 20 parent support advisers and school attendance officers from the eleven Dutch towns and cities where the most Roma families live. A number of factors that affect school attendance

by Roma girls emerged from the interviews and the accompanying literature review. The findings were published in July.

AUGUST Dedicated voting advice application for mental health care The Dutch website Kies voor GGZ

IMPLEMENTS

DECISION

SUPPORT

Maarten Muis, MSc Project Leader, Anoiksis Association and Amsterdam Clients’ Interest. Sources Projects entitled Regie- en empowermentbevorderende benaderingen bij schizofrenie: Implementatie via cliëntenorganisaties (Approaches to promoting self-direction and empowerment in schizophrenia: Implementation via client organisations), Trimbos Institute/Anoiksis, 2011/12; and Meer dan dat…10 portretten van mensen met schizofrenie (More than that...: Ten portraits of people with schizophrenia), Tobi Vroegh, 2011. INTRODUCTION Most people that receive a diagnosis of schizophrenia did not present to mental health institutions for the first time on their own initiative. Ironically, such patients are expected to find the exit by themselves after a show of common sense. Deinstitutionalisation intensifies such expectations towards patients. Recovery-oriented therapy can help, because it assists patients in reclaiming a maximum amount of control and direction over their lives. That is not feasible without the smart use of experiential knowledge. DISCUSSION For twenty years now, the Anoiksis Association has shown how peer-to-peer contact forms a fruitful basis to access, articulate and share experiential knowledge. Self-help organisation by people with a schizophrenia diagnosis creates abundant opportunities for individual empowerment. The implementation of the Dutch website Schizophrenia Decision Support (www.keuzehulpen.nl) via Anoiksis hence formed a logical next step. This decision aid tool helps patients to discover that people with a schizophrenia diagnosis are able to take control back into their own hands. It makes them aware of where personal initiative begins and what people or resources can help them build on it. The seed was planted as we were training active Anoiksis members to organise meetings on the topic of self-direction. A valuable outcome of this working method has been to create an atmosphere surrounding the Schizophrenia Decision Support website that encourages people who have the diagnosis to start using the decision tool on their own initiative. Another

(‘vote for mental health care’, www.kiesvoorggz.nl), which opened on 1 August, provides information about political parties in specific relation to mental health. It was launched in the run-up to the Dutch parliamentary elections of 12 September. Parties were questioned on issues including their future visions for mental health care, the importance of mental health pro-

result is that a group of forty trained experts-by-experience now act as ambassadors for the website. In the mental health sector, there is a broad consensus that an effective practice of empowerment is essential for people with a schizophrenia diagnosis. Peer support can be a key part of this. In the relative safety of peer contact groups, people can discover their possibilities. Peers who set good examples are the walking proof that a variety of social roles are still possible after the psychosis. That can inspire and motivate people. That is why we have portrayed ten extraordinary people in our book (in Dutch) entitled More than that...: Ten portraits of people with schizophrenia. CONCLUSION The coming years will show whether the use of experiential knowledge in mental health care can make a qualitative leap forward. Community living poses challenges, demanding that more psychiatric patients recover more rapidly outside the institutions. At an earlier stage than previously, they will be expected to integrate into a sport club, community centre or creative arts group. Expertsby-experience can advise and support them in such efforts. One essential condition is the continued availability of peer contact groups where new experts-by-experience can be recruited and trained in a relatively safe atmosphere. In Anoiksis, people that are vulnerable to psychosis make progress in different steps and at unequal paces. End points may also differ. Yet for many people with schizophrenia, the outcome has been an acceptance of the limitless potentials.

motion, co-payments for mental health care, and community participation and stigmatisation of people with mental illness. Kies voor GGZ was created in collaboration with GGZ Nederland (the professional association of the mental health and addiction sector), the Landelijk Platform GGZ (the national alliance of client and family organisations in mental health), the Dutch Psy-

chiatric Association (NVVP), the Dutch Association of Psychologists (NIP) and the Phrenos Knowledge Centre.

COPMI resource guide for local health authorities In August, a resource guide was presented for local authorities for assistance to children whose parents have mental health or addiction

EMPLOYMENT FOR PEOPLE PERSISTENT WITH

MENTAL ILLNESS

problems (COPMI). The purpose is to underline the importance of supporting such children and to give local officials more ready access to the existing range of interventions and other resources. They can now obtain correct, up-todate information about children in those situations and about the appropriate available services. The information may also be of use in preparing

local policy documents.

Effectiveness of IPS demonstrated In cooperation with the Rob Giel Research Centre (RGOC) at the University Medical Centre Groningen (UMCG), we published a report in August entitled Effectiviteit van individuele plaatsing en steun in Nederland: Eindverslag van een

One of the obstacles is that policymakers and health insurers have still not agreed on a unitary, well functioning system of funding.

Harry Michon, PhD Senior Researcher, Trimbos Institute Reintegration Programme; and Professor of Sustainable Employment and Vocational Rehabilitation, Fontys University of Applied Sciences, Eindhoven. Sources Psychisch Gezien panel; unpublished paper by Jaap van Weeghel, 2013; Trendrapportage GGZ 2012 (Mental Health Care Trend Report 2012, in preparation); van Busschbach et al. 2011; Burns et al. 2007. INTRODUCTION People with severe and persistent psychiatric illnesses want to be part of the community. In this sense they are no different from other people. Yet their situation on the labour market is far weaker. Whilst about 70% of the entire labour force is in paid employment, the score for people with psychiatric illnesses is no higher than 15%. That figure can definitely be improved. DISCUSSION A large percentage of the people with persistent mental health problems would like to have paid jobs. In our large advisory panel called Psychisch Gezien (‘psychologically regarded’), about one third of the members explicitly say so. In concrete figures, that means that 70,000 of the estimated 240,000 Dutch adults with persistent mental health issues desire paid employment. This group may actually be larger, as research shows that many do not even venture to hope for a job, fearing prejudice, stigmas, rejection or hollow hopes. If, however, they notice that their peers do have opportunities, their interest, motivation and courage for finding work grows. Obviously unemployment is high at present, and that makes it no easier for job seekers with impairments. Yet opportunities are also increasing. More and more employers now understand the added benefits of diversity in their workforce. The Dutch Participation Act, which requires that employers with more than 25 staff hire a quota of 5% or more employees with a work impairment, is another positive factor. Appropriate individual support is necessary in many such cases. The most effective approach currently is the individual placement and support (IPS) model. IPS is a method for people with long-term mental health conditions who desire support in finding and keeping

gerandomiseerde gecontroleerde effectstudie (Effectiveness of individual placement and support in the Netherlands: Final report of a randomised controlled trial). It assessed the effectiveness of the individual placement and support (IPS) model, which assists people who are in treatment for persistent mental health conditions in finding and keeping jobs

in the competitive labour market. The study found that IPS results in higher percentages of people in paid employment than conventional vocational rehabilitation, a difference of 44% to 25%.

Happy Drinks at the Olympic Games Athletes, visitors and guests at the Holland Heineken House at the London

competitive employment. Some differences between IPS and traditional vocational rehabilitation are that IPS focuses solely on contacting mainstream employers and seeking competitive paid jobs, provides a minimum of preparatory training prior to the employment mediation, and arranges training and coaching as much as possible after the client is hired. It also works intensively with psychiatric services. In 2012, a nationwide effectiveness study of IPS was completed in the Netherlands which found that it produced better results than the more conventional approach. Beyond the positive influence that employment has on the lives of the individuals involved, improved work participation by people from this group is also expected to have financial advantages for society, in the form of reduced expenditures for provisions such as social benefits and health care costs. A European study has shown that IPS participants were significantly less likely to be admitted or readmitted to psychiatric hospitals than those who received conventional vocational rehabilitation. CONCLUSION Achieving increased work participation by people with persistent mental illnesses will require much time and patience. A positive development is that GGZ Nederland (the professional association of the Dutch mental health and addiction sector) and UWV (the employee insurance administration agency) have explicitly endorsed the targeted and broad-scale implementation of IPS. But there is also a host of obstacles. One of these is that policymakers and health insurers have still not agreed on a unitary, well functioning system of funding. The time has now come to eliminate such barriers and take the employment expectations of people with mental health conditions seriously.

Olympics could order special Happy Drinks – alcohol-free cocktails with a special buzz and twist. The Dutch chef Pierre Wind was commissioned by the Trimbos Institute to develop Happy Drinks, in order to widen the availability of alcohol-free beverages and to offer bar patrons tasty and intriguing alternatives to alcoholic drinks.

SEPTEMBER Striking the right tone: Dealing with aggressive and substance-related nuisance What influence do drink and drugs have on aggressive behaviour? And how should public-service workers and professionals deal with people that exhibit such aggression? These questions were tackled

THE NETHERLANDS

CHANGE

in a study published in September in cooperation with Bureau Beke, a crime and safety consultancy, and commissioned by the Research and Documentation Centre (WODC) of the Netherlands Ministry of Security and Justice. The study provides an up-to-date review of the available knowledge about aggressive and violent behaviour that occurs under the influence of alcohol and/or drugs.

Moniek Vlasveld

Moniek Vlasveld, researcher in the Trimbos Public Mental Health Programme, was awarded her PhD on 12 September at the VU University Medical Centre in Amsterdam. Her thesis analysed factors in job absenteeism and work resumption, as well as the clinical and costeffectiveness of a collaborative care treatment model for absence-prone

LESSONS

WHY

employees. The study was conducted as part of the Depression Initiative.

An eye for carers A report was published in September that studied six organisations in Leiden as they were gaining experience with a method called Preventieve Ondersteuning Mantelzorgers (POM, ‘preventative support to carers’).

Relatively intensive psychiatric care is widely available, whilst comparatively little mental health care is provided in the primary care sector.

FROM THE REST OF EUROPE Matthijs Muijen Mental Health Programme Manager, WHO Regional Office for Europe.

Source ‘Netherlands: Why Change?’, a presentation at the 2013 Mental Health Care Knowledge Day, 7 February 2013, Beurs van Berlage in Amsterdam. INTRODUCTION Considerable progress has already been made by Dutch mental health care services in providing community based services, although the number of inpatient beds remains high. High-quality community services and expertise are now available. Yet this also presents an obstacle to change, as no sense of urgency exists. A unique feature of the present deinstitutionalisation process in Dutch mental health care is that it coincides with a large-scale austerity operation. DISCUSSION Policy aims for mental health care in the Netherlands are now prioritising inpatient bed reduction. The present number of beds is among the highest in Europe. Preconditions for such a reduction are favourable in a number of respects. In comparison with other EU countries, the Netherlands has generous numbers of beds, psychiatrists and nurses. Surprisingly, the number of admissions is low. The annual number per hospital bed is 12 in England and Denmark, but only 5 in the Netherlands. It is also worth noting that the Dutch rate of GPs per capita is only half the EU average. The treatment gap, the difference between the numbers of people requiring treatment and those receiving it, is relatively narrow as compared to other countries. One key problem, however, involves targeting and efficiency. Relatively intensive psychiatric care is widely available, whilst comparatively little mental health care is provided in the primary care sector. Some 20% of Dutch people with psychiatric problems now receive treatment from specialised mental health services and only 22% from GPs. In the UK, as many as 90% of people with mental health problems can expect to be treated by GPs, including 50% of those with severe mental disorders. This relieves the pressure on community services, enabling early discharge and follow-up. The shortage of

POM facilitates the early detection of carer strain and focuses on strengthening personal and social resources and on overcoming inhibitions to seeking and accepting help. The aim is to prevent carer distress. This pilot study identified promising components of the POM method that were feasible for delivery by health care and social welfare agencies.

primary care capacity in the Netherlands may also explain why Dutch patients remain in treatment settings rather long; few are transitioned to self-help modalities or informal support from personal networks. Considering the high investment in mental health care, there are opportunities for improvement. The Administrative Agreement concluded in 2012 among stakeholders in the mental health sector could be a powerful impetus. International comparisons have shown that local initiatives and national-level policies and models of care, combined with financial incentives, can be key inducements to innovation. The administrative agreement largely satisfies those conditions. Caution is also needed. A major liability is that the deinstitutionalisation process cannot rely on supplementary investments, but will be accompanied by funding cutbacks. Another problem is that bed reduction has been on the agenda for such a long time that many people believe it has already happened. Nor does any real sense of urgency exist, because many aspects of care are currently functioning well in the mental health sector, and there is a reluctance to take risks. A final difficulty is that no national model has been set out for the reforms; wide latitude has been provided for regional differentiation. That makes the process more difficult to manage. CONCLUSION Many stakeholders in the mental health sector have endorsed the commitment to deinstitutionalisation. However, since all of them have a great deal to lose, and because no national model exists and the reforms coincide with funding cuts, ambitions may not be easy to fulfil. Much will depend on national leadership and the political will to keep the process high on the agenda.

Renewal of Trimbos Supervisory Board In September, the Supervisory Board of the Trimbos Institute bade farewell to Mieke Bot as well as to its chair, Huub Hannen, both of whom had served on the board for ten years. Three new members were appointed: Joke van Lonkhuijzen, supervisory board member of the Achmea insurance group and

former board of directors chair of the GGZ inGeest mental health service in Amsterdam; Bernard Welten, special adviser to the Amsterdam-Amstelland regional police force and to the national police; and Wouter Vlasblom, human resources manager at Siemens Netherlands.

SOCIAL DISCONTENT

ABOUT

Anne Margriet Pot, PhD Programme Head, Trimbos Institute Programme on Ageing; and Professor of Geropsychology, VU University, Amsterdam.

DEINSTITUTIONALISATION

ELDERLY CARE

OCTOBER

Bridging the Gap: Early-onset psychosis and quality of life People who have suffered a psychosis at an early age have the same hopes for the future as their peers, but they experience considerable impairment in fulfilling those hopes. That is one conclusion of Bridging the Gap, a broad-

scale research study in Dutch on the quality of life and the ambitions of young people with psychotic experiences, which was presented on 16 October. The study was conducted in cooperation with Redmax IT developers and funded by Janssen Pharmaceuticals. On 12 December, the findings were discussed in a public debate in The Hague, planned in consultation

It may be the first-ever broad-ranging debate on issues such as: What kinds of care am I willing to provide to my parents or neighbours?

INTRODUCTION The Dutch government has begun an effort to deinstitutionalise the care of the elderly. As from 2015, residential or nursing home care will no longer be available to people with a level-4 ‘care intensity package’ (ZZP 4), meaning that only those with ‘intensive’ care needs (ZZP 5) will be eligible. Care is to be arranged instead in the individual’s own surroundings, relying first and foremost on relatives and friends. These developments have touched off considerable unrest in Dutch society. Yet there are positive sides to the discussion. DISCUSSION First of all, we should be clearly aware that only a limited range of older people will be affected by deinstitutionalisation. Contrary to widespread perceptions, most elderly people already live independently. If I ask students during lectures what percentage of older people live in institutions, I am overwhelmed by the estimates. Some students believe that as many as three out of four elderly people live in homes, whereas a realistic estimate is one in twenty. A large proportion of those residents have needs levels higher than 4. The fact remains that independent living poses a considerable burden for many people at needs level 4. A person with dementia living at home puts tremendous strain on informal carers, who are not always adequately equipped for the task themselves and whose own ability to cope may also be limited. Nor are informal carers (that is, partners, offspring or friends) always available, and not every older person feels comfortable receiving care from friends and family. One precondition for deinstitutionalisation is therefore the availability of quality home support at the earliest possible stage, not just for the person with care needs, but also for the carers. Digital support for both carers and people with dementia, via the Internet or other new communication channels, has opened a range of opportunities. These novel

with Phrenos Knowledge Centre and the Dutch Early Psychosis Network.

Online self-help parenting course for parents with psychiatric or addiction problems As from October, parents who are in treatment for psychiatric or addiction problems can take part in a web-based self-help course called KopOpOuders

(‘Chin-up, parents!’), which provides low-level parenting support. When parents have mental health or addiction issues, these often hinder them in devoting sufficient attention to their children. The parents’ symptoms may also make themselves felt in the children’s’ development. The content of this KopOpOuders self-help course is based on the certified and theoreti-

assistive devices can count on an enthusiastic reception, as we discovered in a pilot project testing GPS technology for people with Alzheimer’s disease and in a trial of Mastery over Dementia (www.dementiedebaas.nl), an e-health intervention for carers of people with dementia. Since few other such services are currently available, there is a world to be gained. Other possibilities focus on creating a safe environment for people who need care, in which the neighbourhood, as well as the family, plays a part. The Dutch local council of Gemert-Bakel, for instance, is experimenting with small-scale community-oriented care. Community care officers ensure that residents get the care they need. We should not underestimate people’s willingness to provide lots of help to one another, and the Internet and social media offer many low-threshold ways to facilitate and support such mutual aid. Older people have no trouble using the new techniques. Beyond these new opportunities, there are also positive sides to the current discussion. It may be the first-ever broad-ranging debate on issues such as: What kinds of care am I willing to provide to my parents or neighbours? What would I want myself if I needed help; what kinds of care would I feel comfortable with? Rather questionable, on the other hand, is the growing emphasis being put on health promotion and support to informal carers, whilst the local health authorities have lost a quarter of their funding for the elderly. Moreover, many local councils are not yet sufficiently equipped for the new tasks assigned to them. CONCLUSION Deinstitutionalisation in the elderly care sector has heightened the urgency of ensuring support both for older people with care needs and for their carers. Notwithstanding the promising developments in the Internet and the social media, too little use is being made of such resources so far, nor has enough investment been made. There is still a world to be won.

cally well grounded online group course of the same name.

Website on alcohol and drugs for youth with mild learning disabilities The website www.bekijkhetnuchter.nl (‘take a sober look’), launched in October, offers a low-threshold, visualised approach to informing youth

and adults with mild intellectual disabilities about alcohol and cannabis use. It forms part of the substance use prevention programme Open and Alert, one component of which is specially focused on people with mild learning impairments. The website was developed in cooperation with the Steffie Foundation and was funded by the Fonds Verstandelijk Gehandicapten,

Whether clients live independently, in sheltered housing or in a community residential facility, each client has their own key worker to contact.

FROM

the Dutch fund for persons with intellectual disabilities.

NOVEMBER Quality seal for e–mental health An assessment service called Onlinehulpstempel (‘seal of approval for web-based help’) was introduced on 1 November, where consumers can

obtain clarity about the quality of various Internet services for psychological help. It was developed at the request of the Dutch ministry of public health. The quality seal provides indicators to consumers, patients, mental health providers, government and health insurance companies for gauging quality in a virtual world where new psychological help services are launched almost daily.

ITY

HOSPITAL

Fewer restrictive measures in dementia care The average numbers of restrictive measures for people with dementia in residential care decreased from 2009 to 2011, mainly due to the declining use of bedrails and restraining sheets. Seventy per cent of the 140 accommodations assessed were no longer using restraining straps in 2011, as against

Roberto Mezzina, MD Director, WHO Collaborating Centre for Research and Training; and Trieste Mental Health Department, Italy. Source ‘The Deinstitutionalisation Process in Europe: The Experience in Trieste’, a presentation at the 2013 Mental Health Care Knowledge Day, 7 February 2013, Beurs van Berlage in Amsterdam. INTRODUCTION The last dedicated psychiatric hospital in Italy closed its doors in the year 2000, after a process set in motion by the national psychiatry reform act of 1978. The purpose of the legislation was to integrate psychiatric treatment into the community, in close proximity to the people who needed it. Trieste anticipated that process from 1971 to 1980 and inspired the reform; it has since then become an archetype for the whole of Europe when it comes to the deinstitutionalisation and community participation of people with mental illness. DISCUSSION In 1971, Trieste (then with 310,000 inhabitants) had 1200 beds in psychiatric hospitals. The annual costs of mental health care had risen to €28 million in today’s currency. By 2011, there were only 26 psychiatric beds in four community mental health centres, open 24/7 for the short-term accommodation of people in crisis, plus 45 beds in sheltered housing. Mental health care expenditures had dropped to €18 million a year. Since the passage of the reform act, Italian mental health care has been organised into mental health departments for average populations of 300,000. Trieste Healthcare Agency has four health districts, each serving 60,000 residents, with three separate sections for mental health, addiction and health promotion. Dedicated psychiatric hospital facilities no longer exist as such, but a small emergency unit has six acute psychiatric beds available. Services for people with psychiatric problems in criminal justice settings are provided by the community mental health centres. A rehabilitation service coordinates all NGOs involved in supported living, vocational training and job placement. Thirteen social cooperatives, which work according to market principles and compete with mainstream companies, employ people both with and

fifty per cent in 2009. Policy shifts, campaigns and interventions in recent years thus appear to have had some impact, although there is still room for improvement. The new findings were announced in November by the Dementia Housing Monitoring System, funded by the public health ministry and the Alzheimer Nederland Foundation.

without psychiatric problems. They operate in virtually all sectors, ranging from transport, cleaning, catering, museums, archives, administrative services and art to the repair and design of technical devices or furniture. The aim is to ensure that people with mental illness can work and function normally in the community. Currently, a total of 215 professional mental health care providers are employed in Trieste (about one per 1000 residents). They include 26 psychiatrists, 9 psychologists, 130 nurses, 10 social workers and 6 psychosocial or reintegration workers. Each of the four community mental health centres offers an open-door policy, assertive and proactive care, home treatment, and day-night accommodation services on site. The team approach ensures continuity of care. Whether clients live independently, in sheltered housing or in a community residential facility, each client has their own key worker to contact. To the greatest extent possible, treatment and social participation are integrated and coordinated. The basic premise is to provide lowthreshold, accessible, demand-driven care without appointments or waiting lists. Clients live as independently as possible, but assistance is available around the clock to those who need it. CONCLUSION Every year, 900 professionals from throughout the world come to Trieste to learn about its experiences in deinstitutionalising psychiatric patients. Although legislation such as the 1978 Italian reform act can help initiate the deinstitutionalisation process, a paradigm shift is indispensable: from focusing on illness and custodianship to responding to the needs of the person. Emphasis is not simply on health care, but above all on community participation and support.

More drunkenness in bars where ‘anything goes’ A report on characteristics of nightlife drinking venues published by four European research institutes in November found higher levels of intoxication in bars with relatively permissive atmospheres and high toleration of antisocial behaviours. A total of sixty bars and dance clubs in Utrecht, Liverpool,

Palma de Mallorca and Ljubljana were studied, each of which received four observation visits.

ZonMw Pearl for Zicht op Evenwicht On 1 November, Agnes van der Poel, researcher in the Trimbos Public Mental Health Programme, was awarded a ZonMw Pearl by the Netherlands

Organisation for Health Research and Development for the successful implementation of Zicht op Evenwicht, an adaptation of A Matter of Balance, a course for older adults developed in the United States. Zicht op Evenwicht has also received the highest Dutch rating for interventions to address fear of falling and avoidance behaviours in elderly people. Participants develop

AND

OPPORTUNITIES

THE PRIMARY CARE SECTOR

PREVENTIVE

TRANSFERRING

MENTALCARE HEALTH FROM THE SECONDARY TO

RISKS

more control over their fears of falling, become more active and self-reliant, and suffer fewer falls. Intensive cooperation with Maastricht University and the Orbis Healthcare Group ensured that the course was consistent with the working methods of health care, home care and mental health care agencies. The course was also found to be exemplary for a successful cycle of innovation

– the thorough implementation of an effective intervention in response to the expressed needs of practitioners.

Twinning project in Montenegro A ‘twinning light’ project between the Netherlands and Montenegro was awarded funding by the European Commission. Ionela Petrea of the Trimbos programme International Policy

One example might be a combination of online preventative interventions, self-management methods and personal support from a general practice nurse in a community health centre.

Brigitte Boon, PhD Programme Head, Trimbos Institute Public Mental Health Programme. Sources Research on transferring preventative mental health care from secondary to primary care, developing symptom-oriented mini-interventions for primary care, an e-learning course on recognising depression, and the primary care implementation of the Dutch Standards of Care for Depression. INTRODUCTION Much of the focus in the deinstitutionalisation of mental health care lies on long-term care and self-management for people with persistent conditions. Equally important, though, are investments in preventative care and in interventions to keep mild mental health symptoms from exacerbating. Such services have long been provided effectively in the secondary care sector, but they are now being transferred in large part to primary care. Much is to be gained from this transition, as it enables the earlier detection and treatment of mild mental health problems. Yet there is also something to be lost, in view of the many effective therapies now available. Now that swifter and briefer intervention is required, can we preserve such effective treatments using fewer sessions? DISCUSSION The Dutch secondary care sector offered a well structured range of high-quality preventative mental health care. This included empirically validated interventions shown effective for large categories of people with mental health conditions like anxiety and depression, as well as for their relatives and friends, such as informal carers or children whose parents have mental illnesses or addictions. Now that preventative care is being shifted to the primary sector, it is uncertain whether the high quality can be maintained, in particular because health insurance companies cover fewer sessions in primary care and the funding for such services is still unclear. The concern is justified, because the transition from secondary care to generalist primary care providers means that the primary sector will now be responsible for more of these mental health care tasks than was previously the case. The primary care sector is already working hard to implement preventative mental health care. Several consultation forums have been set up to expedite this and to make more substantive arrangements for provision. The Trimbos Institute is supporting the process by

and Mental Health is to further develop the proposal in cooperation with other mental health care experts from the Altrecht Institute for Mental Health Care and the North-Holland-North Mental Health Services. Twinning projects are cooperative undertakings in which experts from one European Union country provide expertise in support of another European country. This smaller-scale

developing interventions to facilitate preventative mental health care delivery by primary care providers. For depression prevention, a reasonable range of interventions is already available; web-based preventative programmes for delivery by GP practices are being implemented, and symptom-oriented mini-interventions for primary care have been developed. There is also an e-learning course for community nurses, general practice nurses, social workers and advisers to the elderly to teach such professionals to recognise depression and motivate their clients to accept preventative interventions. Such practitioners often work with categories of younger or older adults that are at risk for depression. A number of pilot projects are also underway for introducing the Standards of Care for Depression into the primary care sector. An additional study entitled Depressievrij (‘depression-free’), focusing on self-management and relapse prevention, is being conducted with the University of Groningen. Because primary care often works with briefer interventions than secondary care, it is important to consider more blended forms of prevention and treatment. One example might be a combination of online preventative interventions, self-management methods and personal support from a general practice nurse in a community health centre. CONCLUSION To ensure that preventative mental health care becomes firmly embedded in the primary care sector, we need to invest more in developing new, effective interventions of briefer duration. To safeguard effectiveness, more investment in research is needed. Knowledge gaps must also be identified, possibly through a research implementation agenda that would indicate what primary care services are needed to ensure an effective range of provision, including brief therapies for people with incipient mental health problems.

twinning light project will promote professional development for staff in the Montenegrin mental health sector.

DECEMBER Alcohol and health portals launched in four countries On 6 December, innovative portals were opened in Belarus, Brazil, India and

Mexico on the topic of alcohol and health. The portal was an initiative of the World Health Organization, the Trimbos Institute and collaborating partners in the four countries. The project is based on the Trimbos-developed intervention MinderDrinken.nl (‘drinking less’), the world’s most rigorously tested webbased self-help tool for problem alcohol use. Each of the four pilot countries

CENTRE FOR

NETHERLANDS

(NET) top-ranking international knowledge centres on tobacco control, as well as with the World Health Organization (WHO), of which the Trimbos Institute is a collaborating centre.

In January 2012, the Trimbos Institute was granted Dutch government funding earmarked for research on tobacco control. Expertise relating to tobacco, alcohol and drugs has since been concentrated in a single highlevel knowledge centre specialised in substance use. It supports government, schools, companies, institutions and local authorities in their policymaking and health promotion activities.

The purpose of NET is to monitor trends, develop and test interventions, disseminate Dutch and international research knowledge on tobacco control, conduct smoking prevention activities targeted particularly at young people, and promote innovation in policies and health interventions. Some specific NET activities will be: • Reports on trends in tobacco use among youth and adults • A research agenda for developing effective policies and interventions to prevent and treat tobacco use and addiction and to encourage healthy lifestyles • Development of innovative interventions and evaluation of their effectiveness • Proactive dissemination of tobacco-related knowledge, tailored to the needs of individuals and organisations • A particular focus on youth, building further on the smoking resilience campaign entitled More Fun with Self-Control, conducted jointly with the Stivoro knowledge centre in 2011.

Established by the Trimbos Institute, the Netherlands Centre for Tobacco Control Research (NET) will engage the ministry of health as well as other ministries, funding bodies and health insurance companies in an effort to develop new health interventions and new policies to curb tobacco use. It will deliver recommendations on request or on its own initiative. Intensive cooperation will be maintained with the Lung Foundation Netherlands, the Dutch Cancer Society (KWF), the Netherlands Heart Foundation, the Netherlands Smoke-Free Alliance and the Stop Smoking Partnership. NET will also work with

NET will investigate determinants of tobacco use and addiction and develop effective interventions to curb problem use and detrimental health effects. It will bring together, develop and share new knowledge relating to tobacco. Innovative strategies will be implemented using social media. The ultimate aims of NET are the prevention, treatment and management of tobacco addiction and the promotion of healthy lifestyles. The key focus will be on strengthening the personal resilience of young people and adult smokers in order to reduce their vulnerability to the risks of tobacco.

TOBACCO CONTROL RESEARCH

has tailored the portal to its own needs and preferences. If evaluations are positive, the portal will also be made available for adaptation to other interested countries. The Dutch government provided partial funding.

Knowledge Centre for Economic Evaluation The Kenniscentrum voor Economische

Evaluatie, established in 2011, published several reports in 2012. It conducted projects for the World Health Organization, the Dutch ministry of public health, the Netherlands Organisation for Health Research and Development (ZonMw) and the government of India, and it collaborated with universities in the Netherlands and abroad. The number of health economics publications

has grown steadily. Examples are a costeffectiveness study of the mental fitness course PsyFit in cooperation with the University of Twente, a cost-effectiveness study on relapse in depression entitled DepressieVrij (‘depression-free’) in cooperation with the University of Groningen, and several economic modelling studies commissioned by the Dutch health ministry.