Germany: Mental health patients face uphill battle for help

Around 17.8 million adults, roughly one in three, are affected by mental illness every year in Germany, according to the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN). Of those, only 18.9% seek treatment each year. Nia* is one of them. "It's not that easy to ask for help. It's not that easy to admit to yourself that you have problem," she says of her struggle to find a therapist amid a depressive episode.

Nia, who lives in Berlin, started looking for therapist to treat her recurrent depressive disorder in 2023. After months of phone calls, emails and two initial consultations with therapists who had no availability, Nia gave up. In 2024, she decided to try again. But the situation had worsened. Nia went for four initial consultations with therapists who ultimately had no capacity to take her on as a patient.

"I basically broke down during the process because every time I would go for an initial consultation I would tell them my story and I would cry my heart out and it would always finish with, 'Yes, absolutely you need help but I cannot give it you," Nia told DW. "I think I was traumatized by the experience."

She was eventually admitted to psychiatric clinic for inpatient care as her symptoms worsened and she began to have suicidal thoughts. She is out of the clinic now, and pays for online therapy with a psychotherapist in another EU country where the rates are cheaper than in Germany. "I eventually decided to go abroad on my own, out of my own pocket," Nia says. "It felt like life or death."

As well as reaching for psychotherapy abroad, studies have shown that more people are turning to artificial intelligence for therapy. Last year, a study by the Berlin-based online therapy platform It's Complicated found that just over 50% of clients had used AI tools such as ChatGPT. Around 70% of the therapists surveyed said they had concerns about the accuracy and safety of the advice given by AI tools.

Cutting therapist fees despite high demand 

Demand for psychotherapists is high in Germany, with waiting times for a first appointment of over a year in many areas. The situation could significantly worsen if planned cuts to psychotherapists' fees take effect in April. In early March, the Extended Assessment Committee (E-BA), a body of the joint self-governing system in the German healthcare sector, decided that psychotherapy fees paid by public health insurance providers should be cut by 4.5%. 

The National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) says that the legally mandated fees for psychotherapists have increased disproportionately compared to other specialized medical branches.

The Berlin Chamber of Psychotherapists has accused the E-AB, under pressure from the GKV, of "cost-cutting at the expense of the most vulnerable." The Berlin Chamber is now calling on the Health Ministry, headed by Nina Warken of the conservative Christian Democrats (CDU), to object to the planned cuts. 

The outcry over the planned cuts has been huge and the National Association of Statutory Health Insurance Physicians intends to take legal action. Demonstrations have already taken place in cities across the country, and a nationwide day of protest is also planned to take place on Saturday, March 28.

Impact on patients and the economy

Speaking to DW, Enno Maass, chairman of the German Association of Psychotherapists (DPtV), described the cuts as a "truly disastrous sign" that statutory health insurers would come to regret. "There are huge reserves throughout the healthcare system where savings could be made, but to cut back on mental health care and psychotherapy right now, to interfere with our good outpatient care, I really can't understand that," he said.

Maass is a practicing psychotherapist with a medical clinic in the small town of Wittmund in rural Lower Saxony close to Germany's northwestern coast. He says demand is extremely high, with people often waiting a year or longer to begin treatment.

"With today's psychotherapy practices, we are only able to treat a fraction of those suffering from mental illness in Germany," he told DW. "The need is so great andmental illness is, quite literally, a widespread epidemic."

Apart the "immense suffering" of patients who are stuck waiting for treatment, Maass emphasised the potential negative impact on the economy. Mental illnesses are one of the most frequent causes of reduced ability to work, reduced earning capacity and early retirement. "And on top of that, there are all the personal struggles: family conflicts, difficulties, job loss because one might no longer be able to function properly at work, and friendships," he said.

Psychotherapists cutting the number of appointment slots for publicly insured patients to make way for more lucrative privately insured clients would be "inevitable," according to Maass. It would also result in more patients requiring significantly more expensive acute impatient care, he added.

Public healthcare system under threat

The fee for a 50-minute session with a publicly insured patient was around €120, compared to €170 for those who pay out of their own pocket, according to the GVK. These rates can change depending on the type of therapy and the level of urgency.

The legally mandated fees for psychotherapists have risen by 52% since 2013, according to the GKV. It argues that is disproportionate when compared to other specialized medical branches where fees have risen on average by 33% in the same period.

The GKV also says that the legally mandated fees are reassessed annually to adjust for changes in the cost of things like staff, rent and energy bills. Psychotherapists, at least according to the GKV, have disproportionately benefited from this increase because their personnel costs are significantly lower than in other specialized medical branches.

The decision was not based on cost-saving for the public health insurance system, the GVK insists. It said that the public health insurance providers had made more than €500 million in additional funding available for psychotherapeutic care in recent years, which now totals €4.6 billion annually.

"Although the number of psychotherapists is constantly increasing and the volume of services is expanding, we are not seeing any improved care or shorter waiting times," the GKV said in a statement.

In Germany, the so-called "needs assessment" determines how many psychotherapists with public health insurance accreditation can work in a region. Many regions are classed as "oversupplied" with psychotherapists despite the lack of appointments. The Federal Chamber of Psychotherapists (BPtK) says these calculations are based on figures from the 1990s, and has warned they do not reflect true demand on the ground. 

The BPtK estimates there is an overall shortage of 7,000 treatment places in Germany's public healthcare system. It has warned that number of people seeking psychotherapy is likely to increase by 23% by 2030 — by which time one-third of today's practicing psychotherapists will have reached retirement age.

*Name changed to protect anonymity.

Edited by: Rina Goldenberg.

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