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Ontwikkelingen op het gebied van integrale zorg: een internationaal perspectief Frits Huyse, psychiater Afdeling Algemene Interne Geneeskunde UMCG Deelaanstelling.

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Presentation on theme: "Ontwikkelingen op het gebied van integrale zorg: een internationaal perspectief Frits Huyse, psychiater Afdeling Algemene Interne Geneeskunde UMCG Deelaanstelling."— Presentation transcript:

1 Ontwikkelingen op het gebied van integrale zorg: een internationaal perspectief Frits Huyse, psychiater Afdeling Algemene Interne Geneeskunde UMCG Deelaanstelling afdeling Psychiatrie VUmc NFZP Utrecht April 2005

2 Wat doen C-L psychiaters? Grote variatie tussen praktijken Grote variatie tussen praktijken Consultatieve psychiatrie is: Consultatieve psychiatrie is: Reactief Reactief Gebaseerd op de behoeften van dokters Gebaseerd op de behoeften van dokters en verpleegkundigen en verpleegkundigen Liaison is theorie maar geen praktijk Liaison is theorie maar geen praktijk CONSULTATIEVE ACUTE CONSULTATIEVE ACUTE is gelijk aan PSYCHIATRIE PSYCHIATRIE PSYCHIATRIE PSYCHIATRIE Huyse e.a. Gen Hosp Psychiatry 23(3): , Europese landen 56 C-L PCD’s patienten

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4 Depression—A Major Cause of Disability Worldwide DALYs—2000 and World Health Report Mental Health: New Understanding, New Hope. Geneva, World Health Organization, Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; DALYs=disability-adjusted life-years. Rank (Estimated) 2 1Lower respiratory infectionsIschemic heart disease 2Perinatal conditionsUnipolar major depression 3HIV/AIDSRoad traffic accidents 4Unipolar major depression Cerebrovascular disease 5Diarrheal diseases Chronic obstructive pulmonary disease

5 Prevalence of Mental Disorders in Non- Psychiatric Setting Community Primary Care General Hospital Setting Setting Major 5.1% 5-14% >15% Depression Panic/GAD 4.2% 11%4.5% Somatization 0.2% 2.8%-5% 2%-9% Substance 6.0% 10%-30% 20%-50% Abuse Any Disorder 18.5% 21%-26% 30%-60% Carthesian solutions Kathol x

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7 Ontwikkelingen in de gezondheidszorg Somatiek uit GGZ Psychiatrie uit AGZ –splitsing neurologie/psychiatrie Geen systematische somatische opleidingGeen systematische somatische opleiding –Deinstitutionalisering Somatiek verdwijnt uit GGZSomatiek verdwijnt uit GGZ –MFE vorming PAAZ verdwijnt uit algemeen ziekenhuis (>50%)PAAZ verdwijnt uit algemeen ziekenhuis (>50%) –AWBZ Financiering voor consulten en comorbiditeit verdwijntFinanciering voor consulten en comorbiditeit verdwijnt

8 Interdisciplinaire Opleidingen Een kans voor Interne Geneeskunde en Psychiatrie? ROB Gans Hoogleraar Interne UMCG VJC NVvP Amsterdam, April 4, 2003 Thisbee en ….

9 INTERNATIONALE VOORBEELDEN Stepped/shared care modellenStepped/shared care modellen Psychosomatische modelPsychosomatische model The Extended Reattribution ModelThe Extended Reattribution Model USA/CanadaUSA/Canada DuitsDuits Denemarken Denemarken

10 HAMILTON MODEL Nick Kates Models of integrated care APM Frt Myers 2005 SHARED CARE

11 The Hamilton Model 80 Family physicians80 Family physicians 40 practices 1-6 physicians in each40 practices 1-6 physicians in each Funded by capitationFunded by capitation Each has a counsellor permanently attachedEach has a counsellor permanently attached 1 full time counsellor / 8,000 patients1 full time counsellor / 8,000 patients Psychiatrist visits each practicePsychiatrist visits each practice ½ day of psychiatrist time per family physician a month½ day of psychiatrist time per family physician a month

12 The Hamilton Model : Training Residents McMaster UniversityMcMaster University – 5 year program – 1 st year general medical training – 30 residents in program Program includes:Program includes: – Seminars during training – Visits to primary care – Participate in seminars with family medicine residents Somatiek geïntegreerd; interdisciplinaire vorming gegarandeerd

13 The Hamilton Model : Training Residents Primary care visitsPrimary care visits – Residents visit practices with their supervisor – Usually 1-2 half days a week, during an out-patient rotation - can be child or geriatric – Observe their supervisor seeing cases – Supervisor observes them seeing cases – See collaboration between psychiatrist and family physician being modelled – See a broad range of cases – more than any clinic

14 Benefits to residents Learn about primary careLearn about primary care See collaboration modelledSee collaboration modelled Develop specific consultation skillsDevelop specific consultation skills Appreciation of how the rest of the world sees psychiatryAppreciation of how the rest of the world sees psychiatry Can follow-up cases after a consultationCan follow-up cases after a consultation

15 Outcomes Highly rated / popular rotationHighly rated / popular rotation Residents highly satisfied with time spent in primary careResidents highly satisfied with time spent in primary care Residents also participate in research projects on primary mental health careResidents also participate in research projects on primary mental health care Many graduates incorporate this as part of their practiceMany graduates incorporate this as part of their practice

16 Kenmerk Hamilton model Psychiatrie in de huisartsen praktijkPsychiatrie in de huisartsen praktijk Shared care gebaseerd op effectiviteit van psychiatrische behandelingenShared care gebaseerd op effectiviteit van psychiatrische behandelingen

17 Stepped/shared care modellen Wayne Katon Hackett award lecture APM San Diego 2003 Kurt Kroenke MD Regenstrief Institute Indiana University School of Medicine

18 Depression—A Major Cause of Disability Worldwide DALYs—2000 and World Health Report Mental Health: New Understanding, New Hope. Geneva, World Health Organization, Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; DALYs=disability-adjusted life-years. Rank (Estimated) 2 1Lower respiratory infectionsIschemic heart disease 2Perinatal conditionsUnipolar major depression 3HIV/AIDSRoad traffic accidents 4Unipolar major depression Cerebrovascular disease 5Diarrheal diseases Chronic obstructive pulmonary disease

19 Impact on Society In 1990, major depression was the fourth highest source of lost disability-adjusted life years (DALYs) worldwide: it is projected to rise to #2 by the year In 1990, major depression was the fourth highest source of lost disability-adjusted life years (DALYs) worldwide: it is projected to rise to #2 by the year In US women, depression is the second highest source of disability (DALYs) 2In US women, depression is the second highest source of disability (DALYs) 2 Antidepressant nonresponders are among the heaviest utilisers of healthcare resources 3Antidepressant nonresponders are among the heaviest utilisers of healthcare resources 3 1. Murray CJL, Lopez AD, eds. The Global Burden of Disease ; Michaud CM, et al. JAMA. 2001;285(5): Pearson SD, et al. J Gen Intern Med. 1999;14(8):

20 1. AHCPR. Rockville, Md: US Dept of Health and Human Services; Publication Lepine JP, et al. Int Clin Psychopharmacol. 1997;12(1): Katon W, et al. Med Care. 1992;30(1): Depression Is Often Underdiagnosed and Inadequately Treated Less than 1/2 of patients with major depression are explicitly recognized as being depressed 1Less than 1/2 of patients with major depression are explicitly recognized as being depressed 1 Only about 1/2 of all depressed patients receive some form of therapy for their illness 2Only about 1/2 of all depressed patients receive some form of therapy for their illness 2 Only about 1/4 of depressed patients receive an adequate dose and duration of antidepressant treatment 3Only about 1/4 of depressed patients receive an adequate dose and duration of antidepressant treatment 3

21 Depression: Remission, not Just Response 1 HAM-D 17 Scores Response/Partial Response 50% reduction in baseline HAM-D score or HAM-D  1550% reduction in baseline HAM-D score or HAM-D  15 Remission: HAM-D Score  7 2 –lower risk of relapse 3 –improved physical and social functioning 4 Depression 1. Ballenger. J Clin Psychiatry. 1999;60(suppl 22):29-34; Nierenberg et al. J Clin Psychiatry. 1999;60(suppl 22): Fawcett et al. J. Clin Psychiatry. 1997;58 (suppl 6): Paykel et al. Psychol Med. 1995;25: Doraiswamy et al. Am J Geriatr Psychiatry. 2001;9:4:

22 Simon GE

23 Stepped/shared care modellen: bij patienten met onbegrepen klachten en depressiviteit Kurt Kroenke MD Regenstrief Institute Indiana University School of Medicine

24 Stepped Care 1.Patient self-management 2.Primary care provider 3.Care manager 4.Collaborative care –Indirect (TCM) – MHS supervises CM –Direct – MHS sees pt in consultation 5.Referral to Mental Health Specialist MH PC

25 Clinical Roles Primary Care Diagnosis, treatment(s) Care Manager Telephone support: adherence, self-management, treatment response, physician feedback Mental Health Care Manager supervision, informal advice

26 PHQ-9 A New Depression Tool

27 Measuring Disease Common Metrics DISEASEMEASURE HypertensionSphygmomanometer DiabetesGlucometer Asthma Peak flow meter DepressionPHQ-9

28 Kroenke, JGIM 2001; Kroenke & Spitzer, Psychiatric Annals 2002 PHQ-9 Depression Measure Consists of the 9 DSM-IV depressive symptoms, each scored 0 to 3Consists of the 9 DSM-IV depressive symptoms, each scored 0 to 3 Validated in 6000 patients (3000 primary care and 3000 ob-gyn)Validated in 6000 patients (3000 primary care and 3000 ob-gyn) Diagnostic, severity, & monitoring toolDiagnostic, severity, & monitoring tool Widely used in research & clinical careWidely used in research & clinical care PHQ-2 version valid for screeningPHQ-2 version valid for screening

29 PHQ - 9 PHQ - 9 a.Little interest or pleasure in doing things b.Feeling down, depressed, or hopeless c.Trouble falling or staying asleep, or sleeping too much d.Feeling tired or having little energy e.Poor appetite or overeating f.Feeling bad about yourself, or that you are a failure... g.Trouble concentrating on things, such as reading... h.Moving or speaking so slowly... i.Thoughts that you would be better off dead... 1.Over the last 2 weeks, how often have you been bothered by the following problems? Subtotals :3 4 9 TOTAL = 16 Not at all Severaldays Morethanhalfthedays Nearly all days 0123

30 PHQ-9 as Severity Measure Cutpoints proposed on PHQ-9 for depression severity are:Cutpoints proposed on PHQ-9 for depression severity are:  5 = mild  10 = moderate  15 = moderately severe  20 = severe Response to therapy = 5 point ↓Response to therapy = 5 point ↓ Remission = score < 5Remission = score < 5

31 Translating PHQ-9 Scores into Action 0 – 4 No action (community norms) 5 – 9 Watchful waiting in most 10 – 14 Education, counseling, active R/ based upon diagnosis, duration, impairment, patient preferences 15 – 19 Active treatment in most 20 + May need combination of R/’s and/or referral

32 Stepped Care 1.Patient self-management 2.Primary care provider 3.Care manager 4.Collaborative care –Indirect (TCM) – MHS supervises CM –Direct – MHS sees pt in consultation 5.Referral to Mental Health Specialist MH PC

33 Stepped/shared care modellen Wayne Katon Hackett award lecture APM San Diego 2003

34 Depression: Impact in Patients with Medical Illness Wayne Katon, M.D.

35 Major Depression Prevalence: Chronic Medical Illness Heart Disease 15 to 23%Heart Disease 15 to 23% Diabetes 11 to 12%Diabetes 11 to 12% COPD 10 to 20%COPD 10 to 20%

36 Prevalence of Major and Minor Depression in Patients with Diabetes 14.2% major depression, 8.7% minor depression (2059 females)14.2% major depression, 8.7% minor depression (2059 females) 9.2% major depression, 8.3% minor depression (2166 men)9.2% major depression, 8.3% minor depression (2166 men) Totals:Totals: –12% major depression –8.5% minor depression

37 Depression and Chronic Medical Illness Increased prevalence of major depression in the medically illIncreased prevalence of major depression in the medically ill Depression amplifies physical symptoms associated with medical illnessDepression amplifies physical symptoms associated with medical illness Comorbidity increases impairment in functioningComorbidity increases impairment in functioning Depression decreases adherence to prescribed regimensDepression decreases adherence to prescribed regimens Depression is associated with adverse health behaviors (diet, exercise, smoking)Depression is associated with adverse health behaviors (diet, exercise, smoking) Depression increases mortalityDepression increases mortality

38 Cold hands & feet Numbness in hands & feet Pain in hands & feet Polyuria Excessive hunger Abnormal thirst Shakiness Blurred vision Feeling faint Daytime sleepiness Relationship of Major Depression to Diabetes Symptoms Odds Ratios Diabetes Symptoms

39 Depression and HbA 1C Meta-analysis of 24 studies showed a significant association between depression and HbA 1cMeta-analysis of 24 studies showed a significant association between depression and HbA 1c Effect sizes were in the small to moderate range (0.17, 95% CI 0.13 – 0.21)Effect sizes were in the small to moderate range (0.17, 95% CI 0.13 – 0.21) Lustman et al, Diabetes Care, 2000

40 Diabetes self-care and depression Self-care activities (past 7 days) No Major depression Major depression Odds ratio 95% CI Healthy eating <1 week 8.8%17.2% servings of fruit/vegetables <1 week 21.1%32.4% High fat foods >6 times week 11.9%15.5% Physical activity (>30min) 30min) <1 week Specific Exercise Session <1 week Smoking: Yes

41 Adverse Bidirectional Interaction Major Depression SmokingSmoking Sedentary lifestyleSedentary lifestyle ObesityObesity Lack of adherence to medical regimensLack of adherence to medical regimens Medical illness at earlier ageMedical illness at earlier age Poor symptom controlPoor symptom control  functional impairment  functional impairment  complications of medical illness  complications of medical illness

42 Stepped Care Models: 3 Assumptions 1)Different people require different levels of care 2)Finding the best level of care depends on monitoring outcomes 3)Moving from lower to higher levels of care based on observed outcomes can increase effectiveness while lowering overall costs Caveats: Patient preferences and initial clinical complexity need to be taken into account Von Korff et al., 1999 Wayne Katon Hackett award lecture APM San Diego 2003

43 Modellen Katon “Seattle group” Shared en stepped care gestuurd door behandel uitkomstenShared en stepped care gestuurd door behandel uitkomsten Focus naast depressie op compliance met therapie voor somatische ziekteFocus naast depressie op compliance met therapie voor somatische ziekte “The Pathways Study”Katon ea Arch Gen Psychiatry 2004;61: “The Pathways Study”Katon ea Arch Gen Psychiatry 2004;61:

44 Psychosomatische model

45 Successful models of integrated care: the psychosomatic model in the German speaking countries Wolfgang Söllner (Nuremberg/Germany), Thomas Herzog (Göppingen/Germany ) EACLPP Academy of Psychosomatic Medicine November 2003, San Diego

46 Special development in Germany Own specialization „Psychosomatic medicine and psychotherapy“Own specialization „Psychosomatic medicine and psychotherapy“ Special health care unitsSpecial health care units Special training for students, doctors with other specializations and nursesSpecial training for students, doctors with other specializations and nurses Research focus on the interface between physiology and psychologyResearch focus on the interface between physiology and psychology Why Germany? Theoretical foundation (paradigm) Historical and socio- economic development Empirical research

47 1 Counter-movements against the biotechnological paradigm The biotechnological paradigm: „Machine-model of the body“The biotechnological paradigm: „Machine-model of the body“ Holostic counter- movement in internal medicine (Krehl, Siebeck, v. Bergmann, v. Weizsäcker); „introduction of the subject“Holostic counter- movement in internal medicine (Krehl, Siebeck, v. Bergmann, v. Weizsäcker); „introduction of the subject“ Psychogenic counter- movement: Psychoanalysis introduced the subject of the physicianPsychogenic counter- movement: Psychoanalysis introduced the subject of the physician Ψ meets anthropological medicine; psychiatry stood asideΨ meets anthropological medicine; psychiatry stood aside

48 2 The legacy of national socialism Necessity to cope with terrible crimes and inhuman practices in medicine during NS.Necessity to cope with terrible crimes and inhuman practices in medicine during NS. Intellectual isolation and paralysis after 1945.Intellectual isolation and paralysis after Alexander Mitscherlich: „Medicine without humanity“Alexander Mitscherlich: „Medicine without humanity“ „Loss of empathy“ should be compensated. Holistic approaches supported.„Loss of empathy“ should be compensated. Holistic approaches supported.

49 Development of psychosomatic medicine in the 60-ies The holistic paradigm of psychosomatic medicine (Thure von Uexküll)The holistic paradigm of psychosomatic medicine (Thure von Uexküll) The bio-psycho-social paradigm (George Engel)The bio-psycho-social paradigm (George Engel) Paradigm of object relations in medicine: the key-role of the doctor- patient-relationship in medicine (Michael Balint)Paradigm of object relations in medicine: the key-role of the doctor- patient-relationship in medicine (Michael Balint) The Dührssen study: Implementation of C-L services & psychosomatic wards in the GHThe Dührssen study: Implementation of C-L services & psychosomatic wards in the GH

50 Aims of psychosomatic medicine Research Patient care Education Patient care: bio-psycho-social diagnosisbio-psycho-social diagnosis Detect and treat psych. co- morbidityDetect and treat psych. co- morbidity emphasis on psychotherapeutic treatment for the medically illemphasis on psychotherapeutic treatment for the medically illResearch: focus on the interface between physiology and psychologyfocus on the interface between physiology and psychologyEducation: enhance the psycho-social attitudes and skills of medical students, physicians and nurses (holistic approach)enhance the psycho-social attitudes and skills of medical students, physicians and nurses (holistic approach) C-L

51 Integrated inpatient models (e. g. Nuremberg) C-L service Psycho- somatic ward Day clinic Outpatient services General hospital Liaison General psychiatry Rehabilitation C-L

52 Inpatient models type A: Integrated psychosomatic ward Two models: A1: Head representing both disciplines (e.g. Heidelberg, Stuttgart)A1: Head representing both disciplines (e.g. Heidelberg, Stuttgart) A2: Interdisciplinary ward, 2 heads (Nuremberg)A2: Interdisciplinary ward, 2 heads (Nuremberg) Physicians: specialists and residents in internal medicine and in PSO Common nursing staff (special training) Additional staff: physiotherapist, art therapist, social worker Case conferences: common treatment plan Balint group Common further education

53 Education of physicians: „Basic psychosomatic care“ 80-hour courses 30 hrs communication skills training and relaxation techniques30 hrs communication skills training and relaxation techniques 20 hrs psychosomatic theory20 hrs psychosomatic theory 30 hrs Balint group30 hrs Balint group mandatory for residents in general/internal medicine and obstet/gynecolmandatory for residents in general/internal medicine and obstet/gynecol Supportive verbal interactions and relaxation techniques are payed by insurances additionally if physicians performed such training (maximum of 12 sessions of 20 minutes duration)

54 Evaluation of courses Self-assessment: Visual Analog Scales: 0=completely incompetent to 100=most competent; open questionsSelf-assessment: Visual Analog Scales: 0=completely incompetent to 100=most competent; open questions pre-post, 1-year follow-uppre-post, 1-year follow-up Expert rating: Independent experts evaluate blinded video- taped routine doctor-patient- interactions (Roter & Langewitz method) After training: physisiancs provide better emotional support for patients

55 The Extended Reattribution Model (TERM) Per Fink, MD, PhD, Dr.Med.Sc. The Research Unit forFunctional Disorders Psychosomatics and CL psychiatry Arhus Univerity Hospital Danmark


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