Ontwikkelingen op het gebied van integrale zorg: Ontwikkelingen op het gebied van integrale zorg: een internationaal perspectiefeen internationaal perspectief

Frits Huyse, psychiaterFrits Huyse, psychiater

Afdeling Algemene Interne Geneeskunde UMCGAfdeling Algemene Interne Geneeskunde UMCGDeelaanstelling afdeling Psychiatrie VUmcDeelaanstelling afdeling Psychiatrie VUmc

NFZP Utrecht April 2005NFZP Utrecht April 2005

Wat doen C-L psychiaters?Wat doen C-L psychiaters?

• Grote variatie tussen praktijkenGrote variatie tussen praktijken• Consultatieve psychiatrie is:Consultatieve psychiatrie is:

• ReactiefReactief• Gebaseerd op de behoeften van dokters Gebaseerd op de behoeften van dokters en verpleegkundigenen verpleegkundigen

• Liaison is theorie maar geen praktijkLiaison is theorie maar geen praktijk

CONSULTATIEVE CONSULTATIEVE ACUTE ACUTEis gelijk aanis gelijk aan

PSYCHIATRIEPSYCHIATRIE PSYCHIATRIE PSYCHIATRIE

Huyse e.a. Huyse e.a. Gen Hosp Psychiatry 23(3):124-132, 2001Gen Hosp Psychiatry 23(3):124-132, 2001

11 Europese landen11 Europese landen

56 C-L PCD’s56 C-L PCD’s

14.700 patienten14.700 patienten

Depression—A Major Cause of Disability WorldwideDepression—A Major Cause of Disability WorldwideDALYs—2000 and 2020DALYs—2000 and 2020

1.World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva, World Health Organization, 2001.1.World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva, World Health Organization, 2001.2. Murray CJL, Lopez AD, eds. 2. Murray CJL, Lopez AD, eds. The Global Burden of DiseaseThe Global Burden of Disease. Boston: Harvard University Press; 1996.. Boston: Harvard University Press; 1996.DALYs=disability-adjusted life-years.DALYs=disability-adjusted life-years.

RankRank 2000 200011 2020 (Estimated) 2020 (Estimated)22

11 Lower respiratory infectionsLower respiratory infections Ischemic heart diseaseIschemic heart disease

22 Perinatal conditionsPerinatal conditions Unipolar major depressionUnipolar major depression

33 HIV/AIDSHIV/AIDS Road traffic accidentsRoad traffic accidents

44 Unipolar major depressionUnipolar major depression Cerebrovascular diseaseCerebrovascular disease

55 Diarrheal diseases Diarrheal diseases Chronic obstructive Chronic obstructive pulmonary disease pulmonary disease

Prevalence of Mental Disorders in Non-Prevalence of Mental Disorders in Non-Psychiatric SettingPsychiatric Setting

Community Primary Care General HospitalCommunity Primary Care General Hospital SettingSetting

Major Major 5.1% 5.1% 5-14% 5-14% >15%>15%DepressionDepression

Panic/GAD 4.2%Panic/GAD 4.2% 11% 11% 4.5%4.5%

Somatization 0.2%Somatization 0.2% 2.8%-5% 2.8%-5% 2%-9%2%-9%

Substance Substance 6.0% 6.0% 10%-30% 10%-30% 20%-50%20%-50%AbuseAbuse

Any DisorderAny Disorder 18.5% 18.5% 21%-26% 21%-26% 30%-60%30%-60%

Carthesian solutions Kathol 2002Carthesian solutions Kathol 2002 2 x2 x

Ontwikkelingen in de gezondheidszorgOntwikkelingen in de gezondheidszorgSomatiek uit GGZSomatiek uit GGZ

Psychiatrie uit AGZPsychiatrie uit AGZ

• 1970 1970 – splitsing neurologie/psychiatriesplitsing neurologie/psychiatrie

• Geen systematische somatische opleidingGeen systematische somatische opleiding

– Deinstitutionalisering Deinstitutionalisering • Somatiek verdwijnt uit GGZSomatiek verdwijnt uit GGZ

• 19901990– MFE vormingMFE vorming

• PAAZ verdwijnt uit algemeen ziekenhuis (>50%)PAAZ verdwijnt uit algemeen ziekenhuis (>50%)

– AWBZAWBZ• Financiering voor consulten en comorbiditeit verdwijntFinanciering voor consulten en comorbiditeit verdwijnt

Interdisciplinaire OpleidingenInterdisciplinaire Opleidingen

Een kans voor Interne Een kans voor Interne Geneeskunde en Geneeskunde en

Psychiatrie?Psychiatrie?

ROB Gans Hoogleraar Interne UMCG ROB Gans Hoogleraar Interne UMCG VJC VJC NNVvP VvP Amsterdam, Amsterdam,

April 4, 2003April 4, 2003

Thisbee en ….Thisbee en ….

INTERNATIONALE VOORBEELDENINTERNATIONALE VOORBEELDEN

• Stepped/shared care modellenStepped/shared care modellen

• Psychosomatische model Psychosomatische model

• The Extended Reattribution Model The Extended Reattribution Model

•USA/CanadaUSA/Canada

•DuitsDuits

• DenemarkenDenemarken

HAMILTON MODELHAMILTON MODEL

Nick KatesNick Kates

Models of integrated careModels of integrated care

APM Frt Myers 2005APM Frt Myers 2005

SHARED CARE

The Hamilton ModelThe 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 ½ day of psychiatrist time per family physician a

monthmonth

The Hamilton Model : Training ResidentsThe Hamilton Model : Training Residents

• McMaster UniversityMcMaster University– 5 year program5 year program– 11stst year general medical training year general medical training– 30 residents in program30 residents in program

• Program includes:Program includes:– Seminars during trainingSeminars during training– Visits to primary careVisits to primary care– Participate in seminars with family medicine residentsParticipate in seminars with family medicine residents

Somatiek geïntegreerd; interdisciplinaire vorming gegarandeerdSomatiek geïntegreerd; interdisciplinaire vorming gegarandeerd

The Hamilton Model : Training ResidentsThe Hamilton Model : Training Residents

• Primary care visitsPrimary care visits– Residents visit practices with their supervisorResidents visit practices with their supervisor– Usually 1-2 half days a week, during an out-patient Usually 1-2 half days a week, during an out-patient

rotation - can be child or geriatricrotation - can be child or geriatric– Observe their supervisor seeing casesObserve their supervisor seeing cases– Supervisor observes them seeing casesSupervisor observes them seeing cases– See collaboration between psychiatrist and family See collaboration between psychiatrist and family

physician being modelledphysician being modelled– See a broad range of cases – more than any clinicSee a broad range of cases – more than any clinic

Benefits to residentsBenefits to residents

• Learn about primary careLearn about primary care

• See collaboration modelled See collaboration modelled

• Develop specific consultation skillsDevelop specific consultation skills

• Appreciation of how the rest of the world Appreciation of how the rest of the world sees psychiatrysees psychiatry

• Can follow-up cases after a consultationCan follow-up cases after a consultation

OutcomesOutcomes

• Highly rated / popular rotationHighly rated / popular rotation

• Residents highly satisfied with time spent in Residents highly satisfied with time spent in primary careprimary care

• Residents also participate in research Residents also participate in research projects on primary mental health careprojects on primary mental health care

• Many graduates incorporate this as part of Many graduates incorporate this as part of their practicetheir practice

Kenmerk Hamilton modelKenmerk Hamilton model

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

psychiatrische behandelingen psychiatrische behandelingen

Stepped/shared care modellenStepped/shared care modellen

Wayne Katon Wayne Katon Hackett award lecture Hackett award lecture APM San Diego 2003APM San Diego 2003

Kurt Kroenke Kurt Kroenke MDMD

Regenstrief InstituteRegenstrief Institute

Indiana University School of MedicineIndiana University School of Medicine

Depression—A Major Cause of Disability WorldwideDepression—A Major Cause of Disability WorldwideDALYs—2000 and 2020DALYs—2000 and 2020

1.World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva, World Health Organization, 2001.1.World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva, World Health Organization, 2001.2. Murray CJL, Lopez AD, eds. 2. Murray CJL, Lopez AD, eds. The Global Burden of DiseaseThe Global Burden of Disease. Boston: Harvard University Press; 1996.. Boston: Harvard University Press; 1996.DALYs=disability-adjusted life-years.DALYs=disability-adjusted life-years.

RankRank 2000 200011 2020 (Estimated) 2020 (Estimated)22

11 Lower respiratory infectionsLower respiratory infections Ischemic heart diseaseIschemic heart disease

22 Perinatal conditionsPerinatal conditions Unipolar major depressionUnipolar major depression

33 HIV/AIDSHIV/AIDS Road traffic accidentsRoad traffic accidents

44 Unipolar major depressionUnipolar major depression Cerebrovascular diseaseCerebrovascular disease

55 Diarrheal diseases Diarrheal diseases Chronic obstructive Chronic obstructive pulmonary disease pulmonary disease

1. AHCPR. Rockville, Md: US Dept of Health and Human Services; 1993. Publication 93-0550. 1. AHCPR. Rockville, Md: US Dept of Health and Human Services; 1993. Publication 93-0550. 2. Lepine JP, et al. 2. Lepine JP, et al. Int Clin PsychopharmacolInt Clin Psychopharmacol. 1997;12(1):19-29.. 1997;12(1):19-29.3. Katon W, et al. 3. Katon W, et al. Med CareMed Care. 1992;30(1):67-76.. 1992;30(1):67-76.

Depression Is Often Underdiagnosed and Depression Is Often Underdiagnosed and Inadequately TreatedInadequately Treated

• Less than 1/2 of patients with major depression are Less than 1/2 of patients with major depression are explicitly recognized as being depressedexplicitly recognized as being depressed11

• Only about 1/2 of all depressed patients receive Only about 1/2 of all depressed patients receive some form of therapy for their illnesssome form of therapy for their illness22

• Only about 1/4 of depressed patientsOnly about 1/4 of depressed patientsreceive an adequate dose and durationreceive an adequate dose and durationof antidepressant treatmentof antidepressant treatment33

Depression: Depression: Remission, not Just Response Remission, not Just Response 11

HAM-DHAM-D1717

ScoresScores

1515

77

Response/Partial ResponseResponse/Partial Response• 50% reduction in baseline HAM-D 50% reduction in baseline HAM-D

score or HAM-D score or HAM-D 1515

Remission: HAM-D Score Remission: HAM-D Score 7 7 22

–lower risk of relapselower risk of relapse33

–improved physical and social improved physical and social functioningfunctioning44

Depression Depression

1. Ballenger. 1. Ballenger. J Clin PsychiatryJ Clin Psychiatry. 1999;60(suppl 22):29-34; Nierenberg et al. . 1999;60(suppl 22):29-34; Nierenberg et al. J Clin PsychiatryJ Clin Psychiatry. 1999;60(suppl 22):7-11.. 1999;60(suppl 22):7-11.2. Fawcett et al. 2. Fawcett et al. J. Clin PsychiatryJ. Clin Psychiatry. 1997;58 (suppl 6):32-38.. 1997;58 (suppl 6):32-38.3. Paykel et al. 3. Paykel et al. Psychol MedPsychol Med. 1995;25:1171-1180.. 1995;25:1171-1180.4. Doraiswamy et al. 4. Doraiswamy et al. Am J Geriatr PsychiatryAm J Geriatr Psychiatry. 2001;9:4:423-428.. 2001;9:4:423-428.

Effectiveness Studies of Depression in Primary Care

Tx Case ID/ Patient Physician Tracking Tx MH Effective

Guidelines Screening Educ Educ Systems Coord. Spec.

Schulberg + + + + + + ++++ Yes

Mynors-Wallis + + + + + + +++ Yes

Katon + + + + + + ++ Yes

Katzelnick + + + + + + ++ Yes

Rost + + + + + + +/- Yes

Hunkeler + + + + + + +/- Yes

Simon + + + + + + - Yes

Simon + + + + + - - No

Callahan + + + + - - - No

Goldberg + + + - - - - No

Dowrick + + - - - - - No

Simon GE

Stepped/shared care modellen:Stepped/shared care modellen:bij patienten met onbegrepen klachten bij patienten met onbegrepen klachten

en depressiviteiten depressiviteit

Kurt Kroenke Kurt Kroenke MDMD

Regenstrief InstituteRegenstrief Institute

Indiana University School of MedicineIndiana University School of Medicine

Stepped CareStepped Care1.1. Patient self-managementPatient self-management

2.2. Primary care providerPrimary care provider

3.3. Care managerCare manager

4.4. Collaborative careCollaborative care– Indirect (TCM) – MHS supervises CMIndirect (TCM) – MHS supervises CM– Direct – MHS sees pt in consultationDirect – MHS sees pt in consultation

5.5. Referral to Mental Health SpecialistReferral to Mental Health Specialist

MHMH

PCPC

Clinical RolesClinical Roles

Primary Care Diagnosis, treatment(s)

Care ManagerTelephone support: adherence,self-management, treatment response, physician feedback

Mental HealthCare Manager supervision,

informal advice

PHQ-9PHQ-9

A New Depression ToolA New Depression Tool

Measuring DiseaseMeasuring DiseaseCommon MetricsCommon Metrics

DISEASEDISEASE MEASUREMEASURE

HypertensionHypertension SphygmomanometerSphygmomanometer

DiabetesDiabetes GlucometerGlucometer

AsthmaAsthma Peak flow meterPeak flow meter

DepressionDepression PHQ-9PHQ-9

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

PHQ-9 Depression MeasurePHQ-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

PHQ - 9PHQ - 9

a.a. Little interest or pleasure in doing thingsLittle interest or pleasure in doing things

b.b. Feeling down, depressed, or hopeless Feeling down, depressed, or hopeless

c.c. Trouble falling or staying asleep, or sleeping too much Trouble falling or staying asleep, or sleeping too much

d.d. Feeling tired or having little energy Feeling tired or having little energy

e.e. Poor appetite or overeating Poor appetite or overeating

f.f. Feeling bad about yourself, or that you are a failure . . .Feeling bad about yourself, or that you are a failure . . .

g.g. Trouble concentrating on things, such as reading . . .Trouble concentrating on things, such as reading . . .

h.h. Moving or speaking so slowly . . .Moving or speaking so slowly . . .

i.i. Thoughts that you would be better off dead . . .Thoughts that you would be better off dead . . .

1.1. Over the Over the last 2 weekslast 2 weeks, how often have you , how often have you been bothered by the following problems?been bothered by the following problems?

SubtotalsSubtotals:: 33 4 4 9 9

TOTALTOTAL = = 1616

Not Not at allat all

Several Several daysdays

More More than than half half the the daysdays

Nearly allNearly alldaysdays

00 11 22 33

PHQ-9 as Severity MeasurePHQ-9 as Severity Measure

• CutpointsCutpoints proposed on PHQ-9 for proposed on PHQ-9 for depression severity are:depression severity are:

55 = mild = mild 1010 = moderate = moderate 1515 = moderately severe = moderately severe 2020 = severe = severe

• ResponseResponse to therapy = 5 point to therapy = 5 point ↓↓

• RemissionRemission = score < 5 = score < 5

Translating PHQ-9 Scores into ActionTranslating PHQ-9 Scores into Action

0 – 40 – 4 No action (community norms)No action (community norms)

5 – 95 – 9 Watchful waiting in mostWatchful waiting in most

10 – 1410 – 14 Education, counseling, active R/ based upon Education, counseling, active R/ based upon diagnosis, duration, impairment, patient preferencesdiagnosis, duration, impairment, patient preferences

15 – 1915 – 19 Active treatment in mostActive treatment in most

20 +20 + May need combination of R/’s and/or referralMay need combination of R/’s and/or referral

Stepped CareStepped Care1.1. Patient self-managementPatient self-management

2.2. Primary care providerPrimary care provider

3.3. Care managerCare manager

4.4. Collaborative careCollaborative care– Indirect (TCM) – MHS supervises CMIndirect (TCM) – MHS supervises CM– Direct – MHS sees pt in consultationDirect – MHS sees pt in consultation

5.5. Referral to Mental Health SpecialistReferral to Mental Health Specialist

MHMH

PCPC

Stepped/shared care modellenStepped/shared care modellen

Wayne Katon Wayne Katon Hackett award lecture Hackett award lecture APM San Diego 2003APM San Diego 2003

Depression: Depression: Impact in Patients with Medical IllnessImpact in Patients with Medical Illness

Wayne Katon, M.D.Wayne Katon, M.D.

Major Depression Prevalence:Major Depression Prevalence:Chronic Medical IllnessChronic 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%

Prevalence of Major and Minor Depression in Prevalence of Major and Minor Depression in Patients with DiabetesPatients with Diabetes

• 14.2% major depression, 8.7% minor depression 14.2% major depression, 8.7% minor depression (2059 females)(2059 females)

• 9.2% major depression, 8.3% minor depression 9.2% major depression, 8.3% minor depression (2166 men)(2166 men)

• Totals: Totals: – 12% major depression12% major depression– 8.5% minor depression8.5% minor depression

Depression and Chronic Depression and Chronic Medical IllnessMedical 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 Depression amplifies physical symptoms associated with medical illnessillness

• 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, Depression is associated with adverse health behaviors (diet, exercise, smoking)exercise, smoking)

• Depression increases mortalityDepression increases mortality

0 1 2 3 4 5

2.23

Cold hands & feet

Numbness in hands & feet

Pain in hands & feet

Polyuria

Excessive hunger

Abnormal thirst

Shakiness

Blurred vision

Feeling faint

Daytime sleepiness

1.93

1.98

2.24

3.30

3.53

3.42

4.00

4.96

2.66

6

Relationship of Major Depression to Diabetes Symptoms Relationship of Major Depression to Diabetes Symptoms Odds RatiosOdds Ratios

Diabetes SymptomsDiabetes Symptoms

Depression and HbADepression and HbA1C1C

• Meta-analysis of 24 studies showed a Meta-analysis of 24 studies showed a significant association between depression significant association between depression and HbAand HbA1c1c

• Effect sizes were in the small to moderate Effect sizes were in the small to moderate range (0.17, 95% CI 0.13 – 0.21)range (0.17, 95% CI 0.13 – 0.21)

Lustman et al, Diabetes Care, 2000

Diabetes self-care and depressionDiabetes self-care and depression

Self-care activities Self-care activities (past 7 days)(past 7 days)

No Major No Major depressiondepression

Major Major depressiondepression

Odds Odds ratioratio 95% CI95% CI

Healthy eating Healthy eating <<1 week1 week 8.8%8.8% 17.2%17.2% 2.12.1 1.59-2.721.59-2.72

5 servings of fruit/vegetables 5 servings of fruit/vegetables <<1 1 weekweek 21.1%21.1% 32.4%32.4% 1.81.8 1.43-2.171.43-2.17

High fat foods High fat foods >>6 times week6 times week 11.9%11.9% 15.5%15.5% 1.31.3 1.01-1.731.01-1.73

Physical activity (>30min) Physical activity (>30min) < <1 1 week week 27.327.3 44.144.1 1.91.9 1.53-2.271.53-2.27

Specific Exercise Session Specific Exercise Session <<1 1 weekweek 45.845.8 62.162.1 1.71.7 1.43-2.121.43-2.12

Smoking: YesSmoking: Yes 7.77.7 16.116.1 1.91.9 1.42-2.511.42-2.51

Adverse Bidirectional InteractionAdverse Bidirectional Interaction

Major Major DepressionDepression

• SmokingSmoking

• Sedentary Sedentary lifestylelifestyle

• ObesityObesity

• Lack of Lack of adherence to adherence to medical medical regimensregimens

• Medical illness Medical illness at earlier ageat earlier age

• Poor symptom Poor symptom controlcontrol

functional functional impairmentimpairment

complications of complications of medical illnessmedical illness

Stepped Care Models: 3 AssumptionsStepped Care Models: 3 Assumptions

1)1) Different people require different levels of careDifferent people require different levels of care

2)2) Finding the best level of care depends on Finding the best level of care depends on monitoring outcomesmonitoring outcomes

3)3) Moving from lower to higher levels of care based on observed Moving from lower to higher levels of care based on observed outcomes can increase effectiveness while lowering overall outcomes can increase effectiveness while lowering overall costscosts

CaveatsCaveats::Patient preferences and initial clinical complexity need to be taken Patient preferences and initial clinical complexity need to be taken

into accountinto account

Von Korff et al., 1999Von Korff et al., 1999

Wayne Katon Wayne Katon

Hackett award lecture Hackett award lecture

APM San Diego 2003APM San Diego 2003

Modellen Katon “Seattle group”Modellen Katon “Seattle group”

• Shared en stepped care gestuurd door Shared en stepped care gestuurd door behandel uitkomstenbehandel uitkomsten

• Focus naast depressie op compliance met Focus naast depressie op compliance met therapie voor somatische ziektetherapie voor somatische ziekte

• ““The Pathways Study”Katon ea Arch Gen The Pathways Study”Katon ea Arch Gen Psychiatry 2004;61:1042-1049Psychiatry 2004;61:1042-1049

Psychosomatische model Psychosomatische model

Successful models of integrated care: Successful models of integrated care: the psychosomatic model in the the psychosomatic model in the

German speaking countriesGerman speaking countries

Wolfgang SöllnerWolfgang Söllner (Nuremberg/Germany),(Nuremberg/Germany),

Thomas Herzog (Göppingen/GermanyThomas Herzog (Göppingen/Germany))

EACLPP

EACLPP

Academy of Psychosomatic MedicineNovember 2003, San Diego

Special development in GermanySpecial development in Germany

• Own specialization Own specialization „Psychosomatic medicine „Psychosomatic medicine and psychotherapy“and psychotherapy“

• Special health care unitsSpecial health care units• Special training for Special training for

students, doctors with students, doctors with other specializations and other specializations and nursesnurses

• Research focus on the Research focus on the interface between interface between physiology and physiology and psychology psychology

Why Germany?Why Germany?

• Theoretical foundation Theoretical foundation (paradigm)(paradigm)

• Historical and socio-Historical and socio-economic developmenteconomic development

• Empirical researchEmpirical research

11 Counter-movements against the Counter-movements against the biotechnological paradigmbiotechnological paradigm

• The biotechnological The biotechnological paradigm: paradigm: „Machine-model of „Machine-model of the body“the body“

• Holostic counter-movement Holostic counter-movement in internal medicine in internal medicine (Krehl, (Krehl, Siebeck, v. Bergmann, Siebeck, v. Bergmann, v. v. WeizsäckerWeizsäcker); ); „introduction of „introduction of the subject“the subject“

• Psychogenic counter-Psychogenic counter-movement: movement: Psychoanalysis Psychoanalysis introduced the subject of the introduced the subject of the physicianphysician

• ΨΨ meets anthropological meets anthropological medicine; psychiatry stood medicine; psychiatry stood asideaside

22 The legacy of national socialismThe legacy of national socialism

• Necessity to cope with Necessity to cope with terrible crimes and terrible crimes and inhuman practices in inhuman practices in medicine during NS. medicine during NS.

• Intellectual isolation and Intellectual isolation and paralysis after 1945.paralysis after 1945.

• Alexander MitscherlichAlexander Mitscherlich: : „Medicine without „Medicine without humanity“humanity“

• „„Loss of empathy“ should Loss of empathy“ should be compensated. Holistic be compensated. Holistic approaches supported. approaches supported.

Development of psychosomatic Development of psychosomatic medicine in the 60-iesmedicine in the 60-ies

• The The holisticholistic paradigm of paradigm of psychosomatic medicine psychosomatic medicine (Thure von Uexküll)(Thure von Uexküll)

• The The bio-psycho-socialbio-psycho-social paradigm paradigm (George Engel)(George Engel)

• Paradigm of Paradigm of object relationsobject relations in medicine: the key-role of in medicine: the key-role of the doctor-patient-the doctor-patient-relationship in medicine relationship in medicine (Michael Balint)(Michael Balint)

• The The DührssenDührssen study: study: Implementation of C-L Implementation of C-L services & psychosomatic services & psychosomatic wards in the GHwards in the GH

Aims of psychosomatic medicineAims of psychosomatic medicine

Research

Patient care

Education

Patient care:Patient care:• bio-psycho-social diagnosisbio-psycho-social diagnosis• Detect and treat psych. co-Detect and treat psych. co-

morbiditymorbidity• emphasis on psychotherapeutic emphasis on psychotherapeutic

treatment for the medically illtreatment for the medically illResearch:Research:• focus on the interface between focus on the interface between

physiology and psychology physiology and psychology Education:Education:• enhance the psycho-social enhance the psycho-social

attitudes and skills of medical attitudes and skills of medical students, physicians and nurses students, physicians and nurses (holistic approach)(holistic approach)

C-L

Integrated inpatient modelsIntegrated inpatient models (e. g. Nuremberg)(e. g. Nuremberg)

C-L service

Psycho-somatic

ward

Day clinic

Outpatient services

General hospital

Liaison

General psychiatry

Rehabilitation

C-L

Inpatient models type A:Inpatient models type A: Integrated Integrated psychosomatic wardpsychosomatic ward

Two models:Two models:

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

• A2: Interdisciplinary ward, A2: Interdisciplinary ward, 2 heads (Nuremberg)2 heads (Nuremberg)

Physicians: specialists and Physicians: specialists and residents in internal residents in internal medicine and in PSO medicine and in PSO

Common nursing staff Common nursing staff (special training)(special training)

Additional staff: Additional staff: physiotherapist, art physiotherapist, art therapist, social worker therapist, social worker

• Case conferences: Case conferences: common treatment plancommon treatment plan

• Balint groupBalint group

• Common further Common further educationeducation

Education of physicians:Education of physicians: „Basic psychosomatic care“„Basic psychosomatic care“

80-hour courses80-hour courses

• 30 hrs communication 30 hrs communication skills training and skills training and relaxation techniquesrelaxation techniques

• 20 hrs psychosomatic 20 hrs psychosomatic theorytheory

• 30 hrs Balint group30 hrs Balint group

• mandatory for residents in mandatory for residents in general/internal medicine general/internal medicine and obstet/gynecoland obstet/gynecol

• Supportive verbal Supportive verbal interactions and relaxation interactions and relaxation techniques are techniques are payed by payed by insurancesinsurances additionally if additionally if physicians performed physicians performed such training (maximum of such training (maximum of 12 sessions of 20 minutes 12 sessions of 20 minutes duration)duration)

Evaluation of coursesEvaluation of courses

• Self-assessment:Self-assessment: Visual Visual Analog Scales: 0=completely Analog Scales: 0=completely incompetent to 100=most incompetent to 100=most competent; open questionscompetent; open questions

• pre-post, 1-year follow-uppre-post, 1-year follow-up

• Expert rating:Expert rating: Independent Independent experts evaluate blinded video-experts evaluate blinded video-taped routine doctor-patient-taped routine doctor-patient-interactions interactions (Roter & Langewitz (Roter & Langewitz method)method)

• After training: physisiancs After training: physisiancs provide better emotional support provide better emotional support for patientsfor patients

0

10

20

30

40

50

60

70

80

90

pre post FU

Pat

Relat

Dying

Refer

Control

NV=Nonverb.; AZ=Akt.Zuhören; OF=Off.Fragen; VE=Verb.Emot

Wilcoxon Matched-Pairs RS-Test: *P<0.05

6,0

5,0

4,0

3,0

2,0

1,0VE_2VE_1OF_2OF_1AZ_2AZ_1NV_2NV_1

Like

rt-S

kala

1-5

The Extended Reattribution ModelThe Extended Reattribution Model

(TERM)(TERM)

Per Fink, MD, PhD, Dr.Med.Sc.Per Fink, MD, PhD, Dr.Med.Sc.The Research Unit forFunctional DisordersThe Research Unit forFunctional Disorders

Psychosomatics and CL psychiatryPsychosomatics and CL psychiatryArhus Univerity HospitalArhus Univerity Hospital

DanmarkDanmark