Mental Health Care

In Belgium, as in most industrialised countries, the mental healthcare sector has undergone several reforms since the end of the 20th century. The purpose of these reforms was to bring, as much as possible, people with mental disorders back to their native environments and social communities. The focus was therefore on types of care that were increasingly incorporated into people’s living environment, and no longer on mental hospitals (de-institutionalisation).

In Belgium, the mental healthcare situation is fairly complex, as this responsibility has been de-federalised. For instance, the Federal bodies are responsible for paying psychiatrists and psychiatry services within hospitals, while the federated entities are in charge of organising and funding outpatient mental health services. As for independent clinical psychologists, most of them are covered neither by one system, nor the other. Due to this fragmentation of responsibilities, there is no single, standardised source of data that would cover the entire mental healthcare system. In particular, the absence of a unique patient identifier means that these patients cannot be followed throughout the mental healthcare landscape, especially as regards their outpatient care. Therefore, it remains very difficult to assess the performance of the mental healthcare sector.

In this report, we have selected 11 indicators related to mental health. They therefore provide only a partial picture of the performance of the mental healthcare sector. Two of these are contextual indicators (Suicide rate for Belgium and Number of hospitalisation days in a psychiatric unit), and the other indicators can be presented under specific dimensions of our conceptual model:

  • Accessibility, measured by the number of practising psychiatrists and the waiting time before obtaining an appointment in a mental health facility;
  • Quality of care, particularly appropriateness of care, according to the number of forced hospitalisations in psychiatry units and the number of visits to hospital emergency departments for reasons of mental health, and based on an analysis of antidepressant prescriptions;
  • Continuity of care, based on the number of repeated hospitalisations within 30 days of discharge from a mental hospital. 
Summary of the indicators on mental health
(ID) indicatorScoreBELYearFlaWalBRUSource

EU-15 mean

Health Status
MH-1 Deaths due to suicide (/100 000 pop) red empty 16.6 2015 16.0 19.8 10.2 (a) SPMA/ 10.2 (1)
Accessibility of care
MH-2 Practising psychiatrists (/1000 pop) 0.17 2016 - - - RIZIV-INAMI 0.19 (1)
MH-3 Waiting time longer than 1 month for first contact in ambulatory mental health centre (% of pop in contact with ambulatory mental health centre) red deteriorating - 2017 44 - - VAZG -
Appropriateness of care
MH-4 Rate of involuntary committals in psychiatric hospital wards (/10 000 pop) 7.3 2016 7.1 6.3 10.3 MPG-RPM -
MH-5 ER visits for social, mental or psychic reason (% of admissions in ER in general hospitals) orange stable 1.6 2016 1.7 1.5 1.4 MPG-RPM -

MH11
NEW 2019

Proportion of readmissions within 30 days in psychiatric hospitals (in the same hospital, %) orange empty 14.1 2016 14.7 11.1 11.1 (a) MZG-RHM -
Appropriateness of prescribing pattern in ambulatory patients
MH-6 Use of antidepressants(total DDD/1000 pop/day) 79.0 2016 71.8 98.6 62.3 Farmanet 70.2 (1)
MH-7 Use of antidepressants (% of adult population, at least once in the year) 13.1 2016 11.9 16.2 11.2 Farmanet -
MH-8 Percentage of patients with short duration (< 3 months) of antidepressants treatment (% of pop on antidepressants) red improving 42.6 2016 43.2 41.3 43.7 IMA-AIM -
Safety of prescribing pattern in ambulatory patients
MH-9 Patients (65+ years old) prescribed antidepressants with anticholinergic effect (>80 DDD, %)  red improving 12 2016 10 15 14 IMA-AIM -
Contextual indicator
MH-10 Number of hospitalisation days in psychiatric hospital wards (/1000 pop) 351 2016 381 293 261 MPG-RPM -

(a) underestimated, (1) OECD Health Statistics 2018

Death due to suicide (MH-1)

Suicide can be the result of a combination of extremely variable psychological, social and demographic factors, such as crisis periods due to disruptions in personal relationships (separation, mourning), but also to alcohol and drug abuse, unemployment, depression or other forms of mental illness. For this reason, the suicide rate is often used as an indirect indicator for a population’s mental health status, but it remains controversial due to its instability and measurement difficulties. Moreover, this indicator is often criticised for the lack of relationship between suicides and the quality of care provided. This contextual indicator must therefore be interpreted as part of a broader context, in combination with other mental health indicators. However, some improvements are clearly possible, for example with regard to patient monitoring.

RESULTS
  • The suicide rate has slightly decreased in Belgium between 2000 and 2015: it was at 21.3 per 100,000 population in 2000 and reached 16.6 in 2015.
  • Suicide rates are higher in Wallonia (19.8% in 2016) than in Flanders (16.0%) and Brussels (10.2%), and this difference has remained consistent over time. However, there is also a lot of variability within each region (Figure 1). The surprisingly low rate in Brussels could be due to data artefacts.
  • The suicide rate is higher in Belgium than in other European countries.
Figure 1 - Age-adjusted suicide rate per 100 000 inhabitants (2000-2015)
Data source: Sciensano (SPMA: Standardized Procedures for Mortality Analysis – Belgium)
Note: Brussels decrease is partly an artefact.

Figure 2 - Age-adjusted suicide rate per 100 000 inhabitants per province (2015)
Data source: Sciensano (SPMA: Standardized Procedures for Mortality Analysis – Belgium)
Note: Brussels decrease is partly an artefact.

Age-adjusted suicide rate per 100 000 inhabitants per province (2015)
Figure 3 - Suicide Premature mortality in Men (1-74 year) (2003-2009)
Data source: Renard et al., 2015
Suicide Premature mortality in Men (1-74 year) (2003-2009)
Figure 4 - Mortality rate due to suicide (per 100 000 population): international comparison (2000-2015)
Data source: OECD Health Statistics 2018
Mortality rate due to suicide (per 100 000 population): international comparison (2000-2015)
Figure 5 - Mortality rate due to suicide (per 100 000 population): international comparison (2015)
Data source: OECD Health Statistics 2018
Mortality rate due to suicide (per 100 000 population): international comparison (2015)

  Link to technical datasheet and detailed results

Number of practising psychiatrists (per 1,000 population) (MH-2)

People who are confronted with mental health problems can receive help from various kinds of professionals, but international indicators are primarily about psychiatrists due to their pivotal role in the mental healthcare system, and also because the availability of data about other players, such as psychologists, is more limited.

The term ‘psychiatrist’ means a physician who has completed a specialisation in psychiatry; they may also have additional training in a sub-specialty of psychiatry (e.g. child and adolescent psychiatry). Neuropsychiatrists and neurologists are not included.
The number of practising psychiatrists is a reflection of accessibility of mental healthcare. 

RESULTS
  • In 2016, there were 1958 practising psychiatrists in Belgium, i.e. 0.17 psychiatrist per 1000 population. This density figure has been stable since 2000.
  • The density of psychiatrists is higher in Brussels (0.33/1000 population) than in Flanders (0.15/1000) or Wallonia (0.16/1000). However, these figures are based on psychiatrists’ residential addresses, which provides little information about their actual places of work.
  • The number of practising psychiatrists in Belgium is lower than the European average (0.19/1000 in 2016).
Figure 6 - Density of active psychiatrists: number of active psychiatrists per 1000 inhabitants (2016)
Data source: INAMI – RIZIV (based on the home address of the psychiatrist)
Density of active psychiatrists: number of active psychiatrists per 1000 inhabitants (2016)
Figure 7 - Number of practising psychiatrists per 1000 pop: international comparison (2000-2016)
Data source: OECD health statistics 2018
Number of practising psychiatrists per 1000 pop: international comparison (2000-2016)
Figure 8 - Number of practising psychiatrists per 1000 pop: international comparison (2016)
Data source: OECD health statistics 2018
Number of practising psychiatrists per 1000 pop: international comparison (2016)

Link to technical datasheet and detailed results

Waiting time for a first face-to-face contact in a centre for ambulatory mental health (MH-3)

Long waiting times are an important sign of accessibility of care issues. Whenever mental health is involved, excessive waiting time can have an impact on the person’s psychological state, or even increase the risk of hospitalisation or suicide. It is also a known fact that the longer the waiting time, the less patients actually attend their appointments. Speed of access to mental healthcare services may therefore be considered as a key element in improving the mental healthcare system.

As explained previously, there is no uniform source of data on mental healthcare due to the division of responsibilities between the Federal authorities and the federated entities. In this report, we use the data published for Flanders (Agentschap Zorg en Gezondheid, the Flanders Agency for Care and Health). The 20 centres for mental healthcare (Centrum voor Geestelijke Gezondheidszorg) which are under the responsibility of the Flemish authorities are required to submit twice per year a collection of data based on their electronic patient records; waiting times are part of this data.

RESULTS
  • Nearly half of the patients had to wait one month or more for a first contact (44% in 2017), a percentage which has increased over time (30% in 2009). (data for Flanders only)
  • On average, the longest waiting time is for mental health services for mentally disabled people, and for children and adolescents; the shortest waiting time is for mental health services for the elderly.
Figure 9 - Waiting time for ambulatory mental health centres in Flanders, first contact (2013-2017)
Data source: EPD 2013-2017 (Agentschap Zorg en Gezondheid)
mnd: month, onbekend: unknown

Waiting time for ambulatory mental health centres in Flanders, first contact (2013-2017)
Figure 10 - Waiting time for first contact in ambulatory mental healthcare centres in Flanders, by type of care (2017)
Data source: EPD registration data, 2017 (Agentschap Zorg en Gezondheid)
Waiting time for first contact in ambulatory mental healthcare centres in Flanders, by type of care (2017)

Link to technical datasheet and detailed results 

Involuntary committal in psychiatric hospitals (MH-4)

Involuntary committal (or placement under observation, also  known as forced admission) is subject to specific conditions which are stated in the Law of 1990: the person must be suffering from a mental illness, he/she must constitute a danger for him/herself or for society, and there can be no other treatment option, such as voluntary admission or treatment at home.

A key objective of the mental healthcare system is to offer appropriate treatment, support and protection to individuals with serious mental illnesses, while maintaining unnecessary involuntary committals to a minimum. Involuntary committal is indicative of a crisis episode, but it can also help understand whether the mental healthcare system is able to provide alternative forms of care to more complex patients. In addition, it is a known fact that the risk of involuntary committals is higher among people belonging to ethnic minorities.

In order to better protect psychiatric patients, most European countries have reformed their laws on mental patient protection and revised the criteria for involuntary committal. Despite these reforms, differences can still be observed between countries and between regions with regard to how this method is used. In some Western European countries, the figures are rising, yet this cannot be explained by an increased prevalence of serious mental disorders.

A high rate of involuntary committals should be considered as a sign of lack of appropriateness of mental healthcare.

RESULTS
  • The rate of forced admissions per 10,000 population in mental hospitals has increased between 2002 and 2014, changing from 4.85 to 7.19.
  • There were more forced admissions in men (9.25/10,000) compared to women (5.21/10,000).
  • Differences between regions are significant (2014 figures): 9.26/10,000 in Brussels; 7.28/10,000 in Flanders; 5.90/10,000 in Wallonia.
Figure 11 - Rate of Involuntary Committals per 10 000 inhabitants (2000-2016)
Data source: SPF SPSCAE – FOD VVVL

Link to technical datasheet and detailed results

Proportion of visits to the Emergency Rooms in general hospitals for mental health related problems (MH-5) 

The use of emergency departments for reasons related to mental health and/or social problems is considered as an indicator of poor coordination of care and failure of community mental health services. Indeed, if people having difficulties had access to outpatient care and could begin treatment before reaching a crisis situation, emergency rooms would no longer be used as a rescue solution. The excessive use of emergency rooms for mental, social or psychological problems is also a concern due to the level of saturation which this entails in these departments, meaning lower quality of care and an increased risk of medical errors.

Emergency departments need to have specialised staff that is able to address psychological and/or social crisis situations, or, at a minimum, every citizen needs to have an option to access immediate mental healthcare services at any time.

A high rate of visits to emergency rooms for mental and/or social health reasons should be considered as a sign of lack of appropriateness of mental healthcare.

RESULTS
  • Out of 3 506 831 admissions to emergency rooms recorded in 2016, 7374 were for suicide attempts (0.2%) and 55 164 for social, mental or psychiatric reasons (1.6%). These percentages have been relatively stable over time (2012-2016).
  • In Wallonia, admissions for suicide attempts are relatively more numerous (0.4% compared to Brussels (0.1%) and Flanders (0.1%)), while the percentage of admissions for social, mental or psychological problems is highest in Flanders (1.7%), followed by Brussels (1.6%) and Wallonia (1.4%).
Figure 12 - Proportion (%) of visits in emergency rooms for social, mental or psychic reasons or suicide attempts by district (2016)
Data source: National feedback on the use of emergency services
No data for the following districts: Bastogne, Diksmuide, Philippeville, Virton and Waremme.

Proportion (%) of visits in emergency rooms for social, mental or psychic reasons or suicide attempts by district (2016)

Link to technical datasheet and detailed results

Antidepressant medication (MH-6, MH-7, MH-8)

Based on global level figures (WHO), it is estimated that 4 to 10% of people are affected by depression at one time or another of their lives. Women are 1.5 to 2.5 times more often affected than men. 

Antidepressants are medicines that are effective for treating severe depression, panic and anxiety disorders, and obsessive-compulsive disorders (OCDs), but in order to be effective, they must be taken for at least 6 months, ideally in combination with psychotherapy. Theoretically, they are not indicated for light depression.

An increase in antidepressant prescriptions can be observed throughout Europe, but the Belgian figures are generally higher than the average for other European countries, while the causes for this situation are somewhat unclear. Several Belgian studies report inappropriate use of medicines (poor indication, inappropriate duration of treatment, poor choice of medicine).

Four indicators have been selected to assess the relevance of antidepressant prescriptions:

  • Total volume of antidepressants prescribed per 1,000 population per day, expressed as Defined daily dose
  • Proportion of adults who took antidepressants during the past year (MH-7)
  • Proportion of antidepressant treatments taken for (too) short periods (<3 months) (MH-8)

One should also bear in mind the fact that antidepressants can also be prescribed for reasons other than depression, including obsessive-compulsive disorders (OCDs), anxiety disorders, social phobia, post-traumatic stress disorder, or certain forms of chronic pain.

RESULTS
Total prescribed volume (MH-6)
  • The total prescribed volume per 1000 population per day has changed from 42 DDD in 2002 to 79 DDD in 2016, with significant differences between regions (higher in Wallonia than in Brussels and Flanders).
  • The same upward trend can be observed in all European countries. Belgium, however, is above the European average, which is 70 DDD/1000 population/day.
Figure 13 - Defined Daily Doses (DDDs) of antidepressants per 1000 inhabitants per day, by patient region (2008-2016)
Data source: Pharmanet (INAMI-RIZIV)
Figure 14 - Consumption of antidepressants (Defined Daily Doses (DDDs) per 1000 inhabitants per day), by district (2013)
Data source: Pharmanet (INAMI-RIZIV)
Defined Daily Doses (DDDs) of antidepressants per 1000 inhabitants per day, by district (2013)
Figure 15 - Consumption of antidepressants: international comparison (Defined Daily Doses (DDDs) per 1000 inhabitants per day, 2000-2017)
Data source: OECD health statistics 2018
Figure 16 - Consumption  of antidepressants: international comparison (2000-2017)
Figure 16 - Consumption of antidepressants: international comparison (Defined Daily Doses (DDDs) per 1000 inhabitants per day, 2016)
Data source: OECD health statistics 2018
Figure 16 - Consumption  of antidepressants: international comparison (2016)
Proportion of adults who took antidepressants during the past year (MH-7)
  • The percentage of adults who took antidepressants during the past year has increased proportionally less, changing from 12.3% in 2006 to 13.1% in 2016. However, there are major differences between regions: 11.2% for Brussels; 11.9% for Flanders; 16.2% for Wallonia.
  • This percentage clearly increases with age, with more than 20% of adults treated by antidepressants in the age groups over 75 years. The percentage is particularly high in elderly people (aged 65+ years) receiving long-term care: 48.6% in nursing facilities and 37.5% in care at home, versus 16.6% in elderly people who do not require care. In addition, these antidepressants often have anticholinergic effects, whose side effects are higher in elderly people (risk of falling) – see ELD-10 and MH-9 below.
Proportion of antidepressant treatments taken for (too) short periods (MH-8)
  • A high percentage of people (42.6% in 2016) receive antidepressant treatment for too short periods (<3 months), but this situation seems to be improving as the number was 49.3 in 2007.

Link to technical datasheet and detailed results

Volume of anticholinergic antidepressants prescribed for patients over 65 years of age (MH-9)
  • Prescriptions of antidepressants known to have anticholinergic side effects (a potential cause of falls) in elderly people have remained at 12% for the country average (Flanders: 10%, Wallonia 15%, Brussels 14%).
Figure 17 - Proportion of the population aged 65 years or more prescribed antidepressants drugs with anticholinergic effects (>80 DDD/year) : evolution (2011-2016)
Data source: Pharmanet (INAMI-RIZIV)

Link to technical datasheet and detailed results

Number of hospitalisation days in psychiatric hospital wards per capita (MH-10)

In Belgium, as in many other Western countries, the mental healthcare sector has undergone a number of profound reforms. As a very brief summary, these reforms have been aimed at evolving from a model based on ’large isolated institutions (asylums)’ towards one where care is provided as close as possible to the patient’s natural living environment. A decreasing tendency should therefore be expected in the number of hospitalisation days in psychiatry hospital wards.

This contextual indicator helps determine this change, although, evidently, the number of hospitalisations in hospital psychiatry wards represents only a relatively small proportion of the total number of people requiring mental health services.

RESULTS
  • Despite the efforts of the mental healthcare system reform aimed at treating people as close as possible to their natural living environment, the number of hospitalisation days in psychiatry units has increased between 2000 and 2016, from 305/1000 population in 2000 to 351/1000 in 2016.
  • Differences between regions are noticeable, with a strong increase in Flanders (+19% from 2000 to 2016), a slight increase in Wallonia (+7%), and a decrease in Brussels (-11%).
Figure 18 - Number of hospitalisation days in psychiatric hospital or in psychiatric services in general hospital per 1000 capita, by patient region (2000-2016)
Data source: RPM – MPG

Link to technical datasheet and detailed results

Rate of unplanned re-admissions for mental illness (MH-11)

The rate of re-admissions within 30 days to a psychiatry unit is regularly used as an indirect indicator of the number of relapses or complications after a stay in a mental hospital; it can indicate premature discharge, lack of coordination with outpatient care, or poor continuity of care. However, because Belgium does not use patient unique identifiers, patients who are discharged from a mental hospital (or a psychiatry ward) and re-hospitalised in another mental hospital (or psychiatry ward) will not be counted as re-admissions.

RESULTS
  • The rate of re-hospitalisations for mental health problems within 30 days is 14.1% (2016 figure), comparable to the level of other similar countries.
  • The highest rate is in Flanders (14.7%), compared to Wallonia (11.1%) and Brussels (11.1%). 
Figure 19 - 30 days readmission rate in Psychiatric hospital or in Psychiatric services in general hospital, by patient region (2010-2016)
Data source: RPM-MPG
Figure 20 - Unplanned readmission rate for adults in mental healthcare: international comparison
Data source: NHS Benchmarking Network 2018
NZE: New Zealand, AUS: Australia, SCO: Scotland, WAL: Wales, ENG: England, NLD: the Netherlands, NIR: Northern Ireland.

Unplanned readmission rate for adults in mental healthcare: international comparison

Link to technical datasheet and detailed results