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FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Academy of Psychosomatic Medicine USA.

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Presentatie over: "FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Academy of Psychosomatic Medicine USA."— Transcript van de presentatie:

1 FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Academy of Psychosomatic Medicine USA UMCGGroningen Integrale zorg een blijvende ontwikkeling NFZP Universitair Medisch Centrum Utrecht

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3 Hoofdstuk 6 Complexe patienten Huyse Slaets de Jonge

4 Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine THE FUTURE OF CONSULTATION-LIAISONPSYCHIATRY Keynote speaker Anual meeting Dutch Psychiatric Association Maastricht The Netherlands 2005

5 CONCLUSIONS Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem Development of a seamless web of pre- admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy Development of a seamless web of pre- admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy

6 %Verzekerden Kosten/ Verzekerde Kosten/ VerzekerdeBeleid Type patiënt Zorg coördinatie in relatie tot zorgbehoefte BezorgdheidBezorgdheid Voorbijgaande ziekteVoorbijgaande ziekte Minder ernstige acute ziekteMinder ernstige acute ziekte Vraag gestuurd Low Zorg coördinatie Ambulant`/Klinisch Chronische ziekteChronische ziekte Matig tot ernstige acute ziekteMatig tot ernstige acute ziekte Ziekte gestuurd Medium High Complexe medische patiënten Multi-morbiditeit, waaronder psychiatrische Meerder hulpverleners Psychologische, sociale en financiële ontregeling Cartesian Solutions Kathol 2002 Wie?Hoe?

7 Results of ECLW Collaborative Study patients 56 hospitals 11 countries Consultation psychiatry Consultation psychiatry Rate 1% of all admissions Rate 1% of all admissions Reactive (wait and see) Reactive (wait and see) Doctors and nurses needs driven Doctors and nurses needs driven Liaison Liaison Theory not practice Theory not practice Huyse, Herzog, Lobo, Malt e.a. Gen Hosp Psychiatry 23(3): , 2001 CONSULTATION EMERGENCY CONSULTATION EMERGENCY equals equals PSYCHIATRY PSYCHIATRY PSYCHIATRY PSYCHIATRY

8 General hospital population Consults; psychiatric, psychological, social work Consults; psychiatric, psychological, social work

9 Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine THE FUTURE OF CONSULTATION-LIAISONPSYCHIATRY Keynote speaker Anual meeting Dutch Psychiatric Association Maastricht The Netherlands 2005

10 CONCLUSIONS Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem Development of a seamless web of pre- admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy Development of a seamless web of pre- admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy

11 Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine THE FUTURE OF CONSULTATION-LIAISONPSYCHIATRY Keynote speaker VJC NVvP Maastricht 2005

12 CONCLUSIONS 1 Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan. Huyse NRC mei 2005: Geef psychiaters in ziekenhuizen de ruimte

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14 “De ziekenhuispsychiatrie kan mijns inziens een belangrijke rol vervullen. In dit opzicht sluit ik mij aan bij het standpunt van de heer Huyse. De stelselwijziging in de zorg die nu plaatsvindt, is mede bedoeld om de “ontschotting” van de lichamelijke en psychische zorg te verwezenlijken. …”

15 CONCLUSIONS 2 The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem. Huyse FJ, van der Mast RC, Boenink AD: De psychiater als medisch specialist: de psychiatrie een zorg? Tijdschrift voor Psychiatrie 44: , 2002

16 CONCLUSIONS 3 Development of a seamless web of pre- admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy. Integrated care for the complex medically ill. Editors Huyse FJ, Stiefel FC Medical clinics of North America Elsevier Juli 2006

17 Crossing the Quality Chasm “Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” Trying harder will not work: changing systems of care will! a new HEALTH system for the 21 st century (IOM, 2001)

18 The Crossing the Quality Chasm Series To Err is Human (1999) Crossing the Quality Chasm - A New Health System for the 21 st Century (2001) Leadership by Example (2002) Fostering Rapid Advances in Health Care (2002) Priority Areas for National Action (2003) Health Professions Education (2003) Keeping Patients Safe – Transforming the Work Environment of Nurses (2004) Patient Safety – Achieving a New Standard for Care (2004) Quality through Collaboration – the Future of Rural Health (2005) Improving the Quality of Health Care for Mental and Substance-use Conditions (2005)

19 19 Improving the Quality of Health Care for Mental and Substance-Use Conditions A Report in the Quality Chasm Series Commission of Quality of Care, Institute of Medicine, USA Ensure that multiple providers’ care Ensure that multiple providers’ care of the same patient is coordinated of the same patient is coordinated Plea for integration and removal of Plea for integration and removal of dysfunctional barriers dysfunctional barriers

20 Six Aims of Quality Health Care 1.Safe – avoids injuries from care bijvoorbeeld psychopharmaca en electieve chirurgie 2.Effective – provides care based on scientific knowledge and avoids services not likely to help bijvoorbeeld Pathway- (diabetes and depression) en IMPACT-studies (ouderen met somatische ziekten en depressies) 3. Patient-centered – respects and responds to patient preferences, needs, and values bijvoorbeeld algemeen ziekenhuis setting en geen RIAGG Crossing the Quality Chasm a new HEALTH system for the 21 st century (IOM, 2001)

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23 De berg naar Mohammed of …………

24 ……… of de psychiatrie naar de AGZ !

25 Six Aims (cont.) 4.Timely – reduces waits and sometimes harmful delays for those receiving and giving care bijvoorbeeld geïntegreerde consulten bij onbegrepen klachten poli interne UMCG; gelijktijdig consult internist en psychiater 5. Efficient – avoids waste, including waste of equipment, supplies, ideas and energy bijvoorbeeld rechtstreekse verwijzing naar collega; “snuffel- consult” 6.Equitable – care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status) bijvoorbeeld psychiatrische patient heeft gelijke toegang tot somatische zorg vv Crossing the Quality Chasm a new HEALTH system for the 21 st century (IOM, 2001)

26 Ten Rules for Achieving the Aims Old Rules 1. Care is based on visits 2. Professional autonomy drives variability 3. Professionals control care 4.Information is a record 5.Decisions are based upon training and experience New Rules 1. Care is based upon continuous healing relationships 2. Care is customized to patient needs and values 3. The patient is the source of control 4. Knowledge is shared and information flows freely 5. Decision making is evidence- based Crossing the Quality Chasm a new HEALTH system for the 21 st century (IOM, 2001)

27 Ten Rules for Achieving the Aims Old Rules 6.“Do no harm” is an individual clinician responsibility 7.Secrecy is necessary 8.The system reacts to needs 9.Cost reduction is sought 10.Preference for professional roles over the system New Rule 6.Safety is a system responsibility 7.Transparency is necessary 8.Needs are anticipated 9.Waste continuously decreased 10.Cooperation among clinicians is a priority Crossing the Quality Chasm a new HEALTH system for the 21 st century (IOM, 2001)

28 Achieving Aims and Rules Requires News ways of delivering care Effective use of information technology (IT) Managing the clinical knowledge, skills, and deployment of the workforce Effective teams and coordination of care across patient conditions, services and settings Improvements in how quality is measured Payment methods conducive to good quality Crossing the Quality Chasm a new HEALTH system for the 21 st century (IOM, 2001)

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

30 Mental health services in the general hospital 1. Emergency services a.Attempted suicide b.Acute behavioral disturbances a.Deliria b.Withdrawal 2. Integrated services a.Screening and integrated assessment b.Patient tailored multidisciplinary care (horizontal integration) and care trajectories (vertical integration)

31 Arie Querido ( ) A Dutch psychiatrist: his views on integrated health care. Boenink AD, Huyse FJ. J Psychosom Res Dec;43(6):551-7.

32 Visie Querido 1935: Psychiatrie d’urgence –Naast gestichtspsychiatrie moet ambulante psychiatrie ontwikkeld worden tbv voor en nazorg –Dit is de motor achter de RIAGG vorming (70er jaren) en zorgcircuitgedachte (negentiger jaren) geweest 1955: Integrale geneeskunde –Populatie gebaseerde studie in Weesperplein ziekenhuis waarin hij als een van de eersten aantoonde dat PS- comorbiditeit leidt tot slechte uitkomsten van somatische zorg

33 Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied

34 Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus

35 Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus 2004:Ziekenhuispsychiatrie subspecialisatie in USA

36 Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus 2004:Ziekenhuispsychiatrie subspecialisatie in USA Nederland 2006:Geen hoogleraren ziekenhuispsychiatrie 2010: Kernhoogleraren psychiatrie zijn ziekenhuispsychiaters

37 General hospital population Screening for complexityIndicator-INTERMED Nurse specialist Nurse specialist Multidisciplinary careIntegrated assessment Psychiatrist/geriatrician Nurse specialist psychiatry Psychologist Social work MPU MPU Multidisciplinary care Physical: High acuity/intensity no artificial respiration no artificial respiration Psychiatric: High acuity no severe behavioral dist no severe behavioral dist MPU = Medical-Psychiatric-Unit

38 Chronische ziekte en depressie Verhoogde prevalentieVerhoogde prevalentie Versterkt de symptomen van de somatische ziekteVersterkt de symptomen van de somatische ziekte Vergroot de functionele beperkingenVergroot de functionele beperkingen Vermindert de compliance met somatische behandelingVermindert de compliance met somatische behandeling Gaat gepaard met negatief gezondheidsgedrag (dieet, lichamelijke oefening, roken)Gaat gepaard met negatief gezondheidsgedrag (dieet, lichamelijke oefening, roken) Gaat gepaard met een verhoogde mortaliteitGaat gepaard met een verhoogde mortaliteit

39 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 After Katon Physical illness

40 SYSTEMATIC REVIEW OF ANTIDEPRESSANTS IN THE PHYSICALLY ILL  N of RCTs = 18  Adverse reactions:  No differences of placebo  No difference between drugs  Number needed to treat 4 DOES TREATMENT of the DEPRESSED MEDICALLY ILL HELP ? Gill and Hatcher Cochrane Review 2001

41 Behavioral change can be considered according to a hierarchy of behavioral challenge, ranging from those that are least difficult (i.e., the initiation of new practices in which there is no preexisting habit that needs to be broken) to the most difficult (i.e., breaking addictive habits which satisfy physiological drives). Rozanski: Psychosom Med 2005; 67 [Suppl 1]: s67-s73

42 MODELLEN VOOR INTEGRALE ZORG

43 Depressie en somatische ziekte Depressie en somatische ziekte

44 Gerrity et al, J Gen Intern Med 2004 (abstract) Multifactorial Interventions for Depression in Primary Care Literature synthesis 12 RCTs involving 6,274 patients Most trials had 3-4 components All 12 had care management; 7 had augmented mental health 10 studies → improved outcomes

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46 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

47 More than Nearly Not Several half the every at all days days day 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... Over the last 2 weeks, how often have you been bothered by the following problems? Subtotals : TOTAL = 16

48 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

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

50 The Pathway Study RCT: depressie en diabetes mellitus –Verbetert diabetes door verbeterde depressie zorg? Intervention: stepped care Tx depression –N=329 (int: 164; CAU 165) –9 primary care klinieken Outcomes: –Verbetering depressie 6 en 12 mnd –Verbetering algemeen gevoel na 6 en 12 mnd –Meer satisfactie met type zorg na 6 en 12 mnd –HBA-1C gelijk in interventie en controle groep Katon, Von Korff (2004) Arch Gen Psych 61:

51 IMPACT Improving Mood – Promoting Access to Collaborative Treatment for Late-Life Depression Funded by John A. Hartford Foundation California HealthCare Foundation California Geriatric Education Center (via the Bureau of Health Professions, HRSA) 1801 depressive elderly (>/60 years) 18 clinical practices 8 healthplans Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA 2002;288(22):

52 IMPACT Improving Mood – Promoting Access to Collaborative Treatment for Late-Life Depression Funded by John A. Hartford Foundation California HealthCare Foundation California Geriatric Education Center (via the Bureau of Health Professions, HRSA) 1801 depressive elderly (>/60 years) 18 clinical practices 8 healthplans Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA 2002;288(22): chronic conditions

53 In the IMPACT study the patients had 3.8 chronic conditions in addition to depression e.g. cardiac e.g. cardiac diabetes diabetes parkinson parkinson

54 In the IMPACT study the patients had 3.8 chronic conditions in addition to depression e.g. cardiac e.g. cardiac diabetes diabetes parkinson parkinson What about patients with psychiatric co-morbidities? As comorbidity is rather the rule then the exception! Kroenke and Rosmalen Symptoms, syndromes and psychiatric diagnosis in Huyse and Stiefel “Integrated care for the complex medically ill”

55 In the IMPACT study the patients had 3.8 chronic conditions in addition to depression e.g. cardiac e.g. cardiac diabetes diabetes parkinson parkinson - add anxiety anxiety substance abuse substance abuse somatization somatization xx xx - managers! What about patients with psychiatric co-morbidities? As comorbidity is rather the rule then the exception! Kroenke and Rosmalen Symptoms, syndromes and psychiatric diagnosis in Huyse and Stiefel “Integrated care for the complex medically ill”

56 Chronic Disease Focused Depression Care: New Grant Nurse will provide depression, heart disease and diabetes case managementNurse will provide depression, heart disease and diabetes case management Behavior intervention-especially exercise, positive life activitiesBehavior intervention-especially exercise, positive life activities Optimize medication for depression, heart disease and diabetesOptimize medication for depression, heart disease and diabetes Supervision of nurses by psychiatrists and PCPsSupervision of nurses by psychiatrists and PCPs Katon and Unutzer

57 Chronic Disease Focused Depression Care: New Grant Nurse will provide depression, heart disease and diabetes case managementNurse will provide depression, heart disease and diabetes case management Behavior intervention-especially exercise, positive life activitiesBehavior intervention-especially exercise, positive life activities Optimize medication for depression, heart disease and diabetesOptimize medication for depression, heart disease and diabetes Supervision of nurses by psychiatrists and PCPsSupervision of nurses by psychiatrists and PCPs Katon and Unutzer = Complexity management

58 MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte Depressie en somatische ziekte Ziekte specifiek Ziekte specifiek

59 MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte Depressie en somatische ziekte Ziekte specifiek Ziekte specifiek Complexiteit Complexiteit

60 MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte Depressie en somatische ziekte Ziekte specifiek Ziekte specifiek Complexiteit Complexiteit Generiek Generiek

61 INTERMED c PROGRAM GROUP RESEARCH COORDINATOR Groningen Peter De Jonge PARTICIPATING CENTERS LausanneFritz Stiefel GroningenFrits Huyse Groningen Joris Slaets NürnbergWolfgang Söllner CONSULTANTS John LyonsChicago Corine LatourAmsterdam Roger KatholBurnsville C Huyse, Lyons, Stiefel, Slaets, De Jonge ea Gen Hosp Psychiatry 21:39-48, 1999 Gen Hosp Psychiatry 21:39-48, 1999

62 Step wise method for detection and assessment of COMPLEXITY

63 = filter = Possible indicators: Excess utilization Non-Compliance Non-Compliance Questionnaires Questionnaires COMPRI) 1 COMPRI) 1 Groningen Frailty Groningen Frailty Index Index Type of illness Type of illness Transplant Transplant Cancer Cancer Research Research Etcetera Etcetera

64 Step wise method for detection and assessment of COMPLEXITY = Integrated health risks and needs

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68 Intervention studies Pre/post internal medicine IP (NL) –Reduction of LOS in elderly (16 -> 11 days) –Improvement in psychological functioning RCT prevention readmission post discharge (NL) –No effects; restricted funding and lack of cooperation/integration

69 Intervention Study Internal Medicine Vumc Effect on QoL: specifically Mental Health (SF36) –P 0.03(Z -2.17) Effect on LOS: specifically in elderly –P 0.05(Z -1.95) from 16 to 11.5 days Costs of the intervention –1 nurse specialist –1/4 C-L psychiatrist de Jonge P, Latour CH, Huyse FJ. Implementing psychiatric interventions on a medical ward Psychosom Med Nov-Dec;65(6):

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71 Intervention studies Pre/post internal medicine IP (NL) –Reduction of LOS in elderly (16 -> 11 days) –Improvement in psychological functioning RCT prevention readmission post discharge (NL) –No effects; restricted funding and lack of cooperation/integration RCT depression and DM or Rheuma (SU) –In analysis; positive effects on most outcomes

72 A randomised psychiatric intervention in complex medical patients: Effects on depression Stiefel F, Bel Hadj B, Zdrojewski C, Boffa D, (announcement poster) de Jonge P Dorogi Y, Miéville JC, Ruiz J, So A. J Psychosomatic Res 2004,56:578-9 de Jonge P Dorogi Y, Miéville JC, Ruiz J, So A. J Psychosomatic Res 2004,56:578-9 Outpatients of department of Outpatients of department of endocrinology and rheumatology University center University center Complexity screen with INTERMED; inclusion > 20 Complexity screen with INTERMED; inclusion > 20 Assessment of depression with MINI and CES-D Assessment of depression with MINI and CES-D Randomisation Randomisation Intervention based on risks and needs Intervention based on risks and needs as assessed with the INTERMED

73 SampleNoINTCAU Age 50.9 (14.1) 53.1 (15.3) INTERMED 24.6 (3.7) 26.1 (4.6) EuroQuol 44.7 (22.2) 45.1 (21.2) CES-D 27.1 (11.4) 27.5 (10.8) SF-36 physical 31.8 (10.9) 29.6 (10.0) SF-36 mental 34.8 (11.6) 35.4 (10.4) Female sex 58.3%57.5% Major depression 60.5%55.8% No significant differences Stiefel,..., So Lausanne Suisse

74 SampleNoINTCAU Age 50.9 (14.1) 53.1 (15.3) INTERMED 24.6 (3.7) 26.1 (4.6) EuroQuol 44.7 (22.2) 45.1 (21.2) CES-D 27.1 (11.4) 27.5 (10.8) SF-36 physical 31.8 (10.9) 29.6 (10.0) SF-36 mental 34.8 (11.6) 35.4 (10.4) Female sex 58.3%57.5% Major depression 60.5%55.8% No significant differences Stiefel,..., So Lausanne Suisse

75 Intervention (N=120) Psycho education 43.3% 43.3% Emotional expression 72.6% 72.6% Psychodynamic 47.2% 47.2% Pragmatic 70.8% 70.8% # of Follow-ups (median) 7 Stiefel,..., So Lausanne Suisse

76 Effects on general health perception (Euroqol)

77 Effects on physical health (SF-36)

78 Effects on prevalence (%) of major depression (MINI) T=3: P=0.06 T=6: P=0.12 T=9: P=0.15 T=12: P=0.01

79 2 zorgverzekeraars hebben interesse 9 praktijken in Minnesota hebben interesse oa huisartsen geneeskunde Univ of Mineapolis RCT in voorbereiding 7 talen: Engels, Nederlands, Frans, Duits, Spaans, Italiaans, Turks Jaarlijkse Cursussen NL Wenckebach Groningen NL Wenckebach Groningen EU EACLPP satelite EU EACLPP satelite USA Chicago CANS satelite USA Chicago CANS satelite

80 Developments Several studies on their way and in preparation –TransplantMC outcome prediction studyEurope –MC RCT in oncologyGermany –Preassessment in elective surgeryGroningen –RCT depression and rheuma/diabetes Minneapolis USA –RCT Functional neurologic complaintsAMC NL –Touchscreen module for patient self assessmentGroningen INTERMEDFoundation January 2006 INTERMED BV Beginning 2007 webbased training webbased training webbased clinical support webbased clinical support

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83 Staatsecretaris voor Integrale zorg

84 Na regen komt zonneschijn!


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