Creating Barriers to Mental Health Care in the Netherlands

To the Editor: The article in the July issue by Bruwer and colleagues (1) described attitudinal and structural barriers to mental health care and predictors of treatment dropout in South Africa. The study found that the most commonly cited reason for not seeking care was a low perceived need for treatment and that lack of health insurance was an important reason for treatment dropout. Similar results were found by Sareen and colleagues (2) in a study that compared the United States, Ontario, and the Netherlands. Remarkably, fear of stigmatization was not frequently cited as a reason for not seeking care in the studies. However, it should be noted that these studies did not include persons with more severe psychiatric disorders, such as psychosis.

Currently, the Dutch government is planning what might be called a cynical experiment—to levy a considerable patient copayment for the treatment of mental disorders. Patients who are unable to pay may request financial compensation from the local council; however, under the current austerity policy, the councils have undergone severe budget cuts.

It may be expected that structural barriers to care will increase in the Netherlands among persons with severe mental disorders, most of whom are on the verge of poverty and lack insight into their illness. Because only patients who are involuntarily admitted to the hospital are exempt from this copayment, such admissions can also be expected to increase.

Other aspects of this austerity policy are the exclusion of adjustment disorders from coverage for treatment and a limit of five treatment sessions for persons with mental disorders in primary care. Such policies imply that these patients are simply whining and not suffering from a mental disorder. At the same time, several groups in the Netherlands have initiated campaigns against stigmatization of mental disorders.

We understand that economizing cannot be avoided, but it is difficult to understand why patients with mental illness are regarded as separate from those with general medical conditions. Choosing which patients should receive treatment on the basis of their illness is nothing less than discrimination. For individuals who have some historical consciousness, it brings to mind the first steps in the annihilation of psychiatric patients in the 1930s because they were considered inferior.