Availability of psychological treatment in Sweden

Mental illness is increasing! We've heard it many times by now. But how is it, really? And if it is so serious - how does it affect access to treatment as a patient?

Mental illness in Sweden

According to Folkhälsomyndigheten's (the Public Health Agency's) latest survey, roughly between 5-10% of the Swedish population exhibits severe mental stress (Folkhälsomyndigheten, 2022). Across all age categories, however, young adults report almost a doubled prevalence - 10-20%. Women are overrepresented in all categories, but especially women aged 16-29 and aged 85+, the difference is particularly large. An estimate is therefore that around 800,000 people in Sweden report severe mental stress. In the last 8 years, this percentage has risen alarmingly and steadily in the national public health survey.

In Sweden today there are 9,158 employed clinical psychologists (https://www.socialstyrelsen.se). The proportion of clinical psychologists has increased by 14% in the last 8 years. How many patient treatments are completed varies by psychologist, but for a full-time clinical psychologist at the primary care level, an approximate estimate is that one performs approximately 40 full-scale 10-session treatments (KBT i Primärvården) in a business year.

Although cognitive behavioral therapy has robust scientific evidence and is considered the most researched form of treatment for mental illness (Mechler & Holmqvist, 2016), the treatment results for psychological therapy do not praise the market. Approximately one in two patients undergoes treatment without improvement (Hofmann et al., 2012) (David et al., 2018).

Based on these data points, a number of assumptions can be made:

• There are approximately 90 people in Sweden with severe mental stress, per clinical psychologist.

• A clinical psychologist who works full-time with treatment - which not everyone does - probably does not treat more than about 40% of the coverage rate of patients per psychologist.

• Although the number of psychologists is increasing, so is the number of people with mental illness. It is therefore unlikely that the ratio patient: psychologist will change.

• Of the full-scale treatments that are carried out, half of these probably lead to the mental illness not persisting over time. That is about 22% of the coverage rate.

From a purely data perspective, it therefore does not appear that all people with severe mental stress can be treated for their problems with psychotherapy. This doesn't necessarily have to be that remarkable. Some problems can be greatly influenced by either medical or other external environmental reasons, and pure therapy cannot solve it all. At the same time, it is clear that there is a structural problem in both outcomes and availability of what we call evidence-based treatment.

International perspective

If it looks like this in Sweden - what is it like internationally?

In a socioeconomically similar country like Germany, it looks very similar (Bundespsychotherapeutenkammer, 2018). It takes an average of 4.5 months to start psychological treatment and about 50% of patients do not improve after that.

If we broaden our view to developing and emerging economies such as Nigeria, Brazil and Turkey, the picture looks even bleaker. The estimated prevalence of mental illness does not differ significantly, and between 8 - 16% of the total disease burden is made up of mental illness (Rathod et al., 2017). In Nigeria, for example, there is 1 psychologist per 1,600,000 people. With a comparable prevalence of severe mental stress, there is 1 psychologist per 128,000 patients. This is an extremely low availability of psychological treatment - approximately 1,422 times as great a shortage.

Alternative routes to treatment

What routes are there to take if you want to receive psychological treatment in Sweden today? How do you meet a psychologist?

Public care

Public care accounts for the majority of the Swedish infrastructure for the treatment of mental illness. The care is tax-financed and budgeted on a regional basis. Care is divided into primary care for simpler cases, and secondary care for more difficult cases that require referral.

Here, the visits are mostly subsidized, and patients pay a low sum per visit, up to a high-cost cover of SEK 1,300 per year for outpatient care (Sveriges Kommuner och Regioner, 2023).

Public care via private care providers

Private healthcare providers can also sign healthcare contracts with regions. This means that they can provide care on behalf of public services. Different regions sign different types of agreements.

Private Primary Care

As a patient, you can register at a private primary care center, such as KRY or Doktor.se. These care providers are generally paid per listed patient. The visits are covered by high-cost coverage for the patient.

Referred Psychotherapy

Some regions also sign agreements with psychotherapists to manage certain psychological treatment - referred from primary or secondary care. These visits are also covered by high-cost coverage for the patient.

Private Psychotherapy

Patients can also seek private psychotherapy. These psychologists may have specific specializations or niches. Here, patients pay out of their own pockets, and the market price is between SEK 1,000 - 1,500 per session.

iKBT

As a patient, you can also work with internet-based treatment. Then you get to work from your browser with various forms of modules, over several weeks, and often have some contact with a psychologist who helps patients through the modules. Examples of such solutions are the state system Support and Treatment, which is procured in many regions, or private actors such as Livanda. Access to these treatments is relatively good, but actual contact with a psychologist is very scarce.

Occupational health care

You can also get access to psychotherapy from your employer through occupational health care. Corporate health care such as Feelgood specializes in prevention and rehabilitation, and often has access to a psychologist. In more serious cases, however, referrals are usually made to primary or secondary care, which carries out actual treatment.

Insurance company

Companies can also take out insurance with companies such as If. These in turn can offer contact with a psychologist if needed as part of the employee's insurance. Just over 14% (Svensk Försäkring, 2022) of able-bodied Swedes currently have health insurance.

Children and Young People

For children and young people, there is no regulated responsibility for treatment within primary care, but the national coordination support First Line Children and Young People with Mental Illness (FLBUP) acts as a receiving structure for children and young people with mild to moderate mental health problems (Uppdrag Psykisk Hälsa). This takes place according to various emerging models, but the majority of the regions' models for FLBUP take place in primary care centres. BUP is responsible for specialized care for more serious cases of mental illness in young people.

Accessibility to care

Availability of psychological treatment varies. The majority of these segments are basically about receiving treatment through public services, either through private healthcare providers who sign agreements with regions, or through public services. The availability of these activities is regulated by the national care guarantee. Among other things, an initial medical assessment must be carried out within 3 days within primary care. You must also have had a first visit to a specialized clinic within 90 days, and treatment should begin within 90 days.

Fulfillment of the care guarantee

Primary care

For public healthcare providers, only 49% of patients get contact with a psychologist in the first 3 days. For physical visits, that number is as low as 32%. For remote visits, however, the number is almost twice as high - 71%.

For private healthcare providers, the availability of an initial medical assessment in primary care is a little better. 71% of patients receive an assessment within 3 days. For physical visits, however, the number is 40%, while the number for remote visits is as much as 90%.

For all forms of ownership, 59% receive an initial assessment within 3 days. For regions like Sörmland, Gävleborg, or Västernorrland, the problem is very big - between 20 - 30% get a first contact when they should. But for other regions such as Kalmar or Västra Götaland, the figure is upwards of 80-95%.

Secondary care

For public specialized care, a first contact with a psychologist takes an average of 109 days (Svensk Försäkring, 2022). 70% of all first visits take place within 90 days. A first treatment with a psychologist is carried out on average after 191 days, which is a little more than six months. Only 49% of all teatments are started within 90 days.

For private specialized care, accessibility is significantly better. 95% of first visits are made within 90 days. The average waiting time is thus only 45 days. However, a first intervention with a psychologist only takes place in 49% of cases within 90 days and it takes an average of 145 days until a treatment is started.

For all forms of ownership, the average waiting time is 79 days and 79% of cases occur within the care guarantee.

Children and young people - First line (FLBUP)

For children and young people, there is no regulated responsibility for treatment within primary care, but the national coordination support First Line Children and Young People with Mental Illness acts as a receiving structure for children and young people with mild to moderate mental health problems (Uppdrag Psykisk Hälsa). This takes place according to various emerging models, but the majority of the regions' models for FLBUP take place in primary care centres.

For first-line services, 71% of children and young people receive a first contact with a psychologist within 3 days within public services (Sveriges Kommuner och Regioner). However, only 9% receive a first visit, while 96% receive a telephone call, within the time period.

Within private businesses, only 23% get in touch with a psychologist within three days. However, 100% of patients are contacted by phone, while only 16% receive a first visit within 3 days.

For all forms of ownership, 57% of children and young people receive a first contact with a psychologist in FLBUP within 3 days.

Children and youth psychiatry (BUP)

According to the enhanced care guarantee, a first medical assessment must be made within 30 days, and a first investigation or treatment must begin within 60 days (Sveriges Kommuner och Regioner).

For public services, 59% of patients receive an initial medical assessment within 30 days. 22% begin an investigation with a psychologist within 60 days, and 32% begin treatment within 60 days.

For private practices, 92% of patients receive an initial medical assessment within 30 days. 37% begin an investigation within 60 days, and 44% of all patients begin treatment within 60 days.

Summary

In both primary and secondary care for both adults and children and young people, it is clear that the care guarantee for seeing a psychologist is not fulfilled. For adults, there is a clear difference between public and private businesses, with private businesses fulfilling the care guarantee to a greater extent. Within secondary care, however, the availability of an initial assessment is good within private facilities, but there is no difference between private and public facilities for starting an investigation or treatment.

For children and young people in the first line, between 9-16% receive a first visit within 3 days, but the majority receive a telephone call during the time period. For BUP, accessibility is slightly better for private healthcare providers, but a minority of patients receive an examination or treatment within the enhanced care guarantee. A first medical assessment is often done within 30 days in private practices, and over half get it in public practices.

Swedish digitization to increase access to psychological treatment

Sweden has been a pioneering country when it comes to the digitization of public activities. In 2020, a vision was set to be a world leader in digitization in healthcare. According to E-health 2025 (https://ehalsa2025.se/), one of the stated goals was to increase accessibility to healthcare. As part of this digitization, the company Inera - owned by Sweden's Municipalities and Regions - has designed a number of care services that have been procured by various regions within the architecture for 1177.se.

During the 2000s, Sweden has also been a leader in the development of Internet-based CBT (Andersson et al., 2019). Much research has been published on this form of CBT, with largely good results in studies. Characteristic of Swedish Internet-based CBT are modular web-based programs via browsers, where the patient is guided through blocks. There is a therapist view and a patient view, and an encrypted chat functionality to allow the psychologist to provide feedback on the patient's activity. The treatment is largely self-guided and involves a lot of reading and reporting through the portal. Normally, the psychologist does not meet the patient physically.

Inera's Support and Treatment program is adapted to include the architecture necessary to allow regions to build their own treatment programs with the support of research, and is used to varying degrees in all of Sweden's regions. The use of SaT has increased significantly in the last years (Inera). Currently, approximately 70,000 treatment modules are active since March 2023. However, this is for a range of digital care programs that are not necessarily related to mental illness.

Looking at reasons for cancellation - 160,000 cancellations are "unknown" and only 70,000 treatments are closed because the patient reached treatment goals.

Through the treatment register Siber (https://siber.registercentrum.se/), standardized outcomes are reported for iKBT. If you look at the treatment results for these programs (mostly SaT), an improvement at the end of treatment is recorded in 40% of cases. In 46% of the cases there was no improvement and for the rest there was no reporting. Some regions perform worse than others. In Västernorrland, a positive outcome was indicated for only 17% of all treatments. Nationally, adherence to treatment was reported to be completed in 62% of cases.

Summary

Sweden has invested large resources in treatment programs for Internet-based CBT. Although we see that good outcome measures are seen in research, and that the adoption of these programs is steadily increasing, in clinical everyday life we do not see optimal outcome measures. This may be due to a variety of reasons, and some hypotheses may be that ease of use is limited for many patients. For research purposes, patients who already have a higher level of literacy are recruited to a greater degree - which is helpful due to the large amounts of text within these platforms - but also patients who are already motivated to test this form of treatment. Comorbidity and other aggravating circumstances are also screened out to a greater extent in research, although not specifically for studies of Internet-based treatment.

Conclusion

Both in Sweden and internationally, we see a high prevalence of severe psychological stress. We also see that there are probably a large number of people in Sweden experiencing these symptomss without getting psychological treatment. Even if all Swedish clinical psychologists were to work full-time clinically, it would probably not be possible to treat all potential patients. Internationally, in similar economies but also in developing countries, we can see even larger, almost impossibly large patient populations to treat.

To come into contact with psychological treatment today, there are several routes to take, but the majority is through public or semi-public activities as part of the regions' responsibility for providing health care.

For both young people and adults, the availability of care within high-cost cover is regulated by the care guarantee or the enhanced care guarantee. Within both private and public operations, Sweden does not meet the care guarantee for virtually any region, or any measures for both primary and secondary care. Availability is slightly better for private businesses, but not for all data points. For children and young adults, the availability of first line or secondary care is generally even worse.

Sweden's large digitization investments in iKBT have not yet borne fruit. It remains to be seen what adjustments will be made in the future.

References

Andersson, G., Titov, N., Dear, B. F., Rozental, A., & Carlbring, P. (2019). Internet-delivered psychological treatments: from innovation to implementation. World Psychiatry, 18(1), 1-116. https://doi.org/10.1002/wps.20610

Bundespsychotherapeutenkammer. (2018). Ein Jahr nach der Reform der Psychotherapierichtlinien. Wartezeiten 2018

David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Front Psychiatry, 9. doi: 10.3389/fpsyt.2018.00004

Folkhälsomyndigheten. (16 november 2022). Statistik psykisk hälsa: vuxna 30-44 år. https://www.folkhalsomyndigheten.se/livsvillkor-levnadsvanor/psykisk-halsa-och-suicidprevention/statistik-psykisk-halsa/statistik-psykisk-halsa-vuxna--30-44-ar/

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.

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Mechler, J., & Holmqvist, R. (2016). Deteriorated and unchanged patients in psychological treatment in Swedish primary care and psychiatry. Nordic Journal of Psychiatry, 70(1), 16-23. 10.3109/08039488.2015.1028438

Rathod, S., Pinninti, N., Irfan, M., Gorczynski, P., Rathod, P., Gega, L., & Naeem, F. (2017). Mental health service provision in low- and middle-income countries. Health Serv Insights, 10, 1-7. 10.1177/1178632917694350

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