Ontwikkelingen op het gebied van integrale zorg: een internationaal perspectief

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 • 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 PCD’s 14.700 patienten Huyse e.a. Gen Hosp Psychiatry 23(3):124-132, 2001

4. Depression—A Major Cause of Disability Worldwide DALYs—2000 and 2020 Rank 20001 2020 (Estimated)2 1 Lower respiratory infections Ischemic heart disease 2 Perinatal conditions Unipolar major depression 3 HIV/AIDS Road traffic accidents 4 Unipolar major depressionCerebrovascular 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. DALYs=disability-adjusted life-years.

5. Prevalence of Mental Disorders in Non-Psychiatric Setting Community Primary Care General Hospital 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% 2 x Carthesian solutions Kathol 2002

7. 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 (>50%) • AWBZ • Financiering 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 modellen • Psychosomatische model • The Extended Reattribution Model • USA/Canada • Duits • Denemarken

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Kenmerk Hamilton model • Psychiatrie in de huisartsen praktijk • Shared 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 2020 Rank 20001 2020 (Estimated)2 1 Lower respiratory infections Ischemic heart disease 2 Perinatal conditions Unipolar major depression 3 HIV/AIDS Road traffic accidents 4 Unipolar major depressionCerebrovascular 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. DALYs=disability-adjusted life-years.

19. 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. 1997;12(1):19-29. 3. Katon W, et al. Med Care. 1992;30(1):67-76.

20. 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 7 1. Ballenger. J Clin Psychiatry. 1999;60(suppl 22):29-34; Nierenberg et al. J Clin Psychiatry. 1999;60(suppl 22):7-11. 2. Fawcett et al. J. Clin Psychiatry. 1997;58 (suppl 6):32-38. 3. Paykel et al. Psychol Med. 1995;25:1171-1180. 4. Doraiswamy et al. Am J Geriatr Psychiatry. 2001;9:4:423-428.

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

23. 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

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

25. PHQ-9 A New Depression Tool

26. Measuring DiseaseCommon Metrics

27. 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 Kroenke, JGIM 2001; Kroenke & Spitzer, Psychiatric Annals 2002

28. 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

29. 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 < 5

30. Translating PHQ-9 Scores into Action

31. 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

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

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

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

35. 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

36. 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

37. 1.93 Cold hands & feet 1.98 Numbness in hands & feet 2.23 Pain in hands & feet 2.24 Polyuria 2.66 Excessive hunger 3.30 Abnormal thirst 3.53 Shakiness 3.42 Blurred vision 4.00 Feeling faint 4.96 Daytime sleepiness Relationship of Major Depression to Diabetes Symptoms Odds Ratios Diabetes Symptoms 0 1 2 6 3 4 5

38. 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

39. Diabetes self-care and depression

40. 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

41. 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

42. Modellen Katon “Seattle group” • Shared en stepped care gestuurd door behandel uitkomsten • Focus naast depressie op compliance met therapie voor somatische ziekte • “The Pathways Study”Katon ea Arch Gen Psychiatry 2004;61:1042-1049

43. Psychosomatische model

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

45. 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 Special development in Germany

46. 1Counter-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 • Ψ meets anthropological medicine; psychiatry stood aside

47. 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.

48. Development of psychosomatic medicine in the 60-ies • The holisticparadigm 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 Dührssenstudy: Implementation of C-L services & psychosomatic wards in the GH

49. 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

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