Het Tekort van het Teveel

Het Tekort van het Teveel (The shortcomings of too much) by Damiaan Denys offers a critical perspective on mental healthcare. The main thesis is that we want to do too much, for too many people. We should focus our efforts on those who are suffering the most, whilst limiting the public investments into helping people who are doing so-so. Going broader than this, Damiaan (or at least my interpretation) argues that we shouldn’t try and solve everything, we should be able to sit with our pain and live with discomfort.

Read: 1x | First: June 2021

We were in the jungle. There were too many of us. We had access to too much money, too much equipment. And little by little we went insane.” – Francis Ford Coppola (quoted at the start of the book, director of Apocalypse Now, describing the situation in Vietnam

Summary Review of ‘Het Tekort van het Teveel’

1. The Paradox

  • One in four people will develop mental health issues during their lifetime (WHO, 2001)
  • Those suffering from mental health issues have double the chance of dying from cardiovascular diseases
  • 90% of suicides are accompanied by mental health issues
  • 60% of those in need don’t receive mental healthcare, leading to 13,5 million deaths per year (The Lancet, 2018)
  • The estimated lost productivity and Disability-Adjusted Life-Years (DALY’s) lost between 2011 and 2030 is estimated at 16.300 billion
  • The investment, per person, on mental health care is but 2,5 dollar per year (between 0,1 to 21,7 dollar, Knapp & Wong, 2020)
  • Many experts are calling this a ‘global mental health crisis’

Damiaan identifies three problems underlying the crisis:

  1. The incompetence of governments
    • More than 40% has no mental health care policy, 30% no program, 25% no laws on this (WHO, 2001)
    • No government is able to provide adequate funding (though, see his later points on this, Andrews & Henderson, 2000)
    • In developing countries, there is a severe lack of access to mental health care (The Lancet, 2018)
  2. The inability of current science
    • Psychiatry itself is in crisis (Gardner & Kleinman, 2019)
    • There haven’t yet been much progress in the understanding of mental health disorders
    • (me: I would say that some therapies including those with psychedelics are paving a way forward here)
  3. The immense scale of psychological suffering
    • It’s estimated that 1 billion people are suffering from mental health issues (alas no source given)
    • 14% of lost (happy) years is due to mental health issues (no source)
      • From Rehm & Schield (2019);
      • 1 billion people living with mental and addictive disorders in 2016
      • 7% of global burden of disease as measured in DALYs
      • 19% of all years lived with disability
    • Since 1990, there have been no improvements in mental health globally (The Lancet, 2019)
    • Although there is the same prevalence (number of people with X), the need/demands on care keeps rising (MHF and other sources)
    • Those living in wealthy (WEIRD) countries are impacted more and are more vulnerable for psychological suffering

The subtitle of the book is ‘The Paradox of Mental Health Care’ and it’s explained as follows:

  1. The first paradox is that you would expect richer countries to do better, not worse
  2. The second paradox is that (in the current system) it’s unsolveable as the actions taken have the opposite effect of what is wanted

The Netherlands

  • 5th place on world happiness ranking (39)
  • 89% thinks they are psychologically health (40)
    • 95% of kids between 12 and 16
  • 40% will develop a mental health issue during their lifetime (42)
  • In each year (year incidence) this is 20%
    • 21% mood disorders
    • 20% anxiety disorders
    • 19% addiction
    • 9% attention & behaviour issues
  • The Netherlands spends 7,3 billion euros on health care (43)
    • 4 billion of this on curative (to cure)
    • 1,7 billion on protected living
    • 1 billion on youth mental health care (‘jeugd-GGZ)
    • 0,6 billion on long-term care (44)
  • The percentage of the budget going to mental health care is the highest in the EU (45)
  • This care is being done by 19.000 professionals (49)
    • 3.500 psychiatrists
    • 15.000 psychologists
    • 24.000 nurses
  • The Netherlands is the best place to go crazy.”
  • Between 1980 and 1997, there was a doubling in the number of intakes (51)
  • Between 2000 and 2010, the costs rose from 2,9 billion to 6,1 billion (57)
  • Between 2003 and 2018, the number of psychiatrists rose from 2400 to 3700 (59)
  • Or in other words, the number of personell or the abundance of money aren’t the problems here
    • More health care institutes are filing for bankruptcy (61) WHY?
    • Waiting lists are becoming longer and work pressure is rising (FIND SOURCE)
    • At the moment of writing, more than 90.000 people each year are on waiting lists (per year or at any moment???)
    • It takes about 8 weeks to be referred somewhere
    • The work pressure is leading to many health care professionals wanting to leave the field

The rest of the book will dissect this paradox by looking at the three components in this system, 1) the health care system, 2) the care offer, and 3) the care demand.

2. The Health Care System


3. Care Offer


4. Care Demand


5. The (ab)Normality


6. The Paradox


7. The Shortcomings of Too Much


8. Epilogue