Ontwikkelingen op het gebied van integrale zorg: een internationaal perspectief

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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
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Wat doen C-L psychiaters?

• Grote variatie tussen praktijken
• Consultatieve psychiatrie is
• Reactief
• Gebaseerd op de behoeften van dokters
• en verpleegkundigen
• Liaison is theorie maar geen praktijk
• CONSULTATIEVE ACUTE
• is gelijk aan
• PSYCHIATRIE PSYCHIATRIE

11 Europese landen 56 C-L PCDs 14.700 patienten
Huyse e.a. Gen Hosp Psychiatry 23(3)124-132, 2001
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DepressionA Major Cause of Disability
Worldwide DALYs2000 and 2020
Rank 20001 2020
(Estimated)2 1 Lower respiratory
infections Ischemic heart disease 2 Perinatal
conditions Unipolar major depression 3 HIV/AIDS Ro
ad traffic accidents 4 Unipolar major depression
Cerebrovascular disease 5 Diarrheal diseases
Chronic obstructive pulmonary disease
1.World Health Report 2001. Mental Health New
Understanding, New Hope. Geneva, World Health
Organization, 2001.2. Murray CJL, Lopez AD, eds.
The Global Burden of Disease. Boston Harvard
University Press 1996. DALYsdisability-adjusted
life-years.
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Prevalence of Mental Disorders in Non-Psychiatric
Setting
Community Primary Care General Hospital
Setting Major 5.1 5-14
gt15 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
2 x
Carthesian solutions Kathol 2002
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Ontwikkelingen in de gezondheidszorgSomatiek uit
GGZPsychiatrie uit AGZ

• 1970
• splitsing neurologie/psychiatrie
• Geen systematische somatische opleiding
• Deinstitutionalisering
• Somatiek verdwijnt uit GGZ
• 1990
• MFE vorming
• PAAZ verdwijnt uit algemeen ziekenhuis (gt50)
• AWBZ
• Financiering voor consulten en comorbiditeit
  verdwijnt

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

• USA/Canada
• Duits
• Denemarken

• Stepped/shared care modellen
• Psychosomatische model
• The Extended Reattribution Model

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HAMILTON MODEL
SHARED CARE

• Nick Kates
• Models of integrated care
• APM Frt Myers 2005

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The Hamilton Model

• 80 Family physicians
• 40 practices 1-6 physicians in each
• Funded by capitation
• Each has a counsellor permanently attached
• 1 full time counsellor / 8,000 patients
• Psychiatrist visits each practice
• ½ day of psychiatrist time per family physician a
  month

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The Hamilton Model Training Residents

• McMaster University
• 5 year program
• 1st year general medical training
• 30 residents in program
• Program includes
• Seminars during training
• Visits to primary care
• Participate in seminars with family medicine
  residents

Somatiek geïntegreerd interdisciplinaire vorming
gegarandeerd
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The Hamilton Model Training Residents

• Primary 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

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Benefits to residents

• Learn about primary care
• See collaboration modelled
• Develop specific consultation skills
• Appreciation of how the rest of the world sees
  psychiatry
• Can follow-up cases after a consultation

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Outcomes

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

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Kenmerk Hamilton model

• Psychiatrie in de huisartsen praktijk
• Shared care gebaseerd op effectiviteit van
  psychiatrische behandelingen

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

• Kurt Kroenke MD
• Regenstrief Institute
• Indiana University School of Medicine

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DepressionA Major Cause of Disability
Worldwide DALYs2000 and 2020
Rank 20001 2020
(Estimated)2 1 Lower respiratory
infections Ischemic heart disease 2 Perinatal
conditions Unipolar major depression 3 HIV/AIDS Ro
ad traffic accidents 4 Unipolar major depression
Cerebrovascular disease 5 Diarrheal diseases
Chronic obstructive pulmonary disease
1.World Health Report 2001. Mental Health New
Understanding, New Hope. Geneva, World Health
Organization, 2001.2. Murray CJL, Lopez AD, eds.
The Global Burden of Disease. Boston Harvard
University Press 1996. DALYsdisability-adjusted
life-years.
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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 20201
• In US women, depression is the second highest
  source of disability (DALYs)2
• Antidepressant nonresponders are among the
  heaviest utilisers of healthcare resources3

1. Murray CJL, Lopez AD, eds. The Global Burden
of Disease 1996. 2. Michaud CM, et al. JAMA.
2001285(5)535-539.3. Pearson SD, et al. J Gen
Intern Med. 199914(8)461-468.
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Depression Is Often Underdiagnosed and
Inadequately Treated

• Less than 1/2 of patients with major depression
  are explicitly recognized as being depressed1
• Only about 1/2 of all depressed patients receive
  some form of therapy for their illness2
• Only about 1/4 of depressed patientsreceive an
  adequate dose and durationof antidepressant
  treatment3

1. AHCPR. Rockville, Md US Dept of Health and
Human Services 1993. Publication 93-0550. 2.
Lepine JP, et al. Int Clin Psychopharmacol.
199712(1)19-29. 3. Katon W, et al. Med Care.
199230(1)67-76.
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Depression Remission, not Just Response 1
HAM-D17 Scores
Depression
15

• Response/Partial Response
• 50 reduction in baseline HAM-D score or HAM-D
  ?15
• Remission HAM-D Score ?7 2
• lower risk of relapse3
• improved physical and social functioning4

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1. Ballenger. J Clin Psychiatry. 199960(suppl
22)29-34 Nierenberg et al. J Clin Psychiatry.
199960(suppl 22)7-11. 2. Fawcett et al. J. Clin
Psychiatry. 199758 (suppl 6)32-38. 3. Paykel et
al. Psychol Med. 1995251171-1180. 4. Doraiswamy
et al. Am J Geriatr Psychiatry. 200194423-428.
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Simon GE
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Stepped/shared care modellenbij patienten met
onbegrepen klachten en depressiviteit

• Kurt Kroenke MD
• Regenstrief Institute
• Indiana University School of Medicine

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Stepped Care

• Patient self-management
• Primary care provider
• Care manager
• Collaborative care
• Indirect (TCM) MHS supervises CM
• Direct MHS sees pt in consultation
• Referral to Mental Health Specialist

PC
MH
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Clinical Roles
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PHQ-9

• A New Depression Tool

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Measuring DiseaseCommon Metrics
DISEASE MEASURE
Hypertension Sphygmomanometer
Diabetes Glucometer
Asthma Peak flow meter
Depression PHQ-9
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PHQ-9 Depression Measure

• Consists of the 9 DSM-IV depressive symptoms,
  each scored 0 to 3
• Validated in 6000 patients (3000 primary care and
  3000 ob-gyn)
• Diagnostic, severity, monitoring tool
• Widely used in research clinical care
• PHQ-2 version valid for screening

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More than half the days
PHQ - 9
Not at all
Nearly all days
1. Over the last 2 weeks, how often have you
been bothered by the following problems?
Several days
0
1
2
3
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 . . .
Subtotals 3 4 9
TOTAL 16
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PHQ-9 as Severity Measure

• Cutpoints proposed on PHQ-9 for depression
  severity are
• ? 5 mild
• ? 10 moderate
• ? 15 moderately severe
• ? 20 severe
• Response to therapy 5 point ?
• Remission score lt 5

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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
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Stepped Care

• Patient self-management
• Primary care provider
• Care manager
• Collaborative care
• Indirect (TCM) MHS supervises CM
• Direct MHS sees pt in consultation
• Referral to Mental Health Specialist

PC
MH
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Stepped/shared care modellen
Wayne Katon Hackett award lecture APM San Diego
2003
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Depression Impact in Patients with Medical
Illness

• Wayne Katon, M.D.

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Major Depression PrevalenceChronic Medical
Illness

• Heart Disease 15 to 23
• Diabetes 11 to 12
• COPD 10 to 20

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Prevalence of Major and Minor Depression in
Patients with Diabetes

• 14.2 major depression, 8.7 minor depression
  (2059 females)
• 9.2 major depression, 8.3 minor depression
  (2166 men)
• Totals
• 12 major depression
• 8.5 minor depression

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Depression and Chronic Medical Illness

• Increased prevalence of major depression in the
  medically ill
• Depression amplifies physical symptoms associated
  with medical illness
• Comorbidity increases impairment in functioning
• Depression decreases adherence to prescribed
  regimens
• Depression is associated with adverse health
  behaviors (diet, exercise, smoking)
• Depression increases mortality

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Relationship of Major Depression to Diabetes
Symptoms Odds Ratios
Diabetes Symptoms
0
1
2
3
6
4
5
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Depression and HbA1C

• Meta-analysis of 24 studies showed a significant
  association between depression and HbA1c
• Effect sizes were in the small to moderate range
  (0.17, 95 CI 0.13 0.21)

Lustman et al, Diabetes Care, 2000
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Diabetes self-care and depression
Self-care activities (past 7 days) No Major depression Major depression Odds ratio 95 CI
Healthy eating lt1 week 8.8 17.2 2.1 1.59-2.72
5 servings of fruit/vegetables lt1 week 21.1 32.4 1.8 1.43-2.17
High fat foods gt6 times week 11.9 15.5 1.3 1.01-1.73
Physical activity (gt30min) lt1 week 27.3 44.1 1.9 1.53-2.27
Specific Exercise Session lt1 week 45.8 62.1 1.7 1.43-2.12
Smoking Yes 7.7 16.1 1.9 1.42-2.51
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Adverse Bidirectional Interaction

• Medical illness at earlier age
• Poor symptom control
• ? functional impairment
• ? complications of medical illness

• Smoking
• Sedentary lifestyle
• Obesity
• Lack of adherence to medical regimens

Major Depression
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Stepped Care Models 3 Assumptions
Von Korff et al., 1999

• Different people require different levels of care
• Finding the best level of care depends on
  monitoring outcomes
• 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

Wayne Katon Hackett award lecture APM San Diego
2003
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Modellen Katon Seattle group

• Shared en stepped care gestuurd door behandel
  uitkomsten
• Focus naast depressie op compliance met therapie
  voor somatische ziekte
• The Pathways StudyKaton ea Arch Gen Psychiatry
  2004611042-1049

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Psychosomatische model
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Successful models of integrated care the
psychosomatic model in the German speaking
countries
EACLPP
EACLPP

• Wolfgang Söllner (Nuremberg/Germany),
• Thomas Herzog (Göppingen/Germany)

Academy of Psychosomatic Medicine November 2003,
San Diego
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Special development in Germany

• Own specialization Psychosomatic medicine and
  psychotherapy
• Special health care units
• Special training for students, doctors with other
  specializations and nurses
• Research focus on the interface between
  physiology and psychology

• Why Germany?
• Theoretical foundation (paradigm)
• Historical and socio-economic development
• Empirical research

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1 Counter-movements against the biotechnological
paradigm

• The biotechnological paradigm Machine-model of
  the body
• 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 physician
• ? meets anthropological medicine psychiatry
  stood aside

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2 The legacy of national socialism

• Necessity to cope with terrible crimes and
  inhuman practices in medicine during NS.
• Intellectual isolation and paralysis after 1945.
• Alexander Mitscherlich Medicine without
  humanity
• Loss of empathy should be compensated. Holistic
  approaches supported.

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Development of psychosomatic medicine in the
60-ies

• The holistic paradigm of psychosomatic medicine
  (Thure von Uexküll)
• 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)
• The Dührssen study Implementation of C-L
  services psychosomatic wards in the GH

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Aims of psychosomatic medicine

• Patient care
• bio-psycho-social diagnosis
• Detect and treat psych. co-morbidity
• emphasis on psychotherapeutic treatment for the
  medically ill
• Research
• focus on the interface between physiology and
  psychology
• Education
• enhance the psycho-social attitudes and skills of
  medical students, physicians and nurses (holistic
  approach)

Patient care
Education
Research
C-L
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Integrated inpatient models (e. g. Nuremberg)
Outpatient services
C-L service
Liaison
General hospital
Day clinic
Psycho- somatic ward
C-L
General psychiatry
Rehabilitation
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Inpatient models type A Integrated psychosomatic
ward

• Two models
• A1 Head representing both disciplines (e.g.
  Heidelberg, Stuttgart)
• 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

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Education of physicians Basic psychosomatic
care

• 80-hour courses
• 30 hrs communication skills training and
  relaxation techniques
• 20 hrs psychosomatic theory
• 30 hrs Balint group
• mandatory 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)

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Evaluation of courses

• Self-assessment Visual Analog Scales
  0completely incompetent to 100most competent
  open questions
• pre-post, 1-year follow-up

• Expert rating Independent experts evaluate
  blinded video-taped routine doctor-patient-interac
  tions (Roter Langewitz method)
• After training physisiancs provide better
  emotional support for patients

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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