Henriëtte van der Horst VUmc Head of Department of General Practice and Elderly Care Medicine

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1 MUS and psychiatry in primary care Henriëtte van der Horst VUmc Head of Department of General Practice and Elderly Care Medicine

2 Double Dutch: two topics Major changes in the mental health care organisation in the Netherlands Dutch Guideline Medically Unexplained Symptoms

3 Organisation of mental health care now 1. Mental health care provided by GP (and mental health nurse practitioner) and psychologists in primary care setting (psychosocial problems, mild depression, work related problems etc.) 2. Specialist mental health care (simple, but more persisting mental disorders, severe and complex mental disorders, but sometimes also psychosocial problems, mild depression, work related problems etc.)

4 Organisation of mental health care in Mental health care provided by GP and mental health nurse practitioner 2. Generalist (basic) mental health care 3. Specialist mental health care

5

6 Organisation of mental health care in Mental health care provided by GP and mental health nurse practitioner Consists of - Early identification (of mild depression, relapse, deterioration) and early intervention - Stimulation of self-management (PST, e-health)

7 Organisation of mental health care in Mental health care provided by GP and mental health nurse practitioner Consists of - Diagnosis, and if necessary (DSM disorder) referral to general or specialist mental health care - Treatment of psychosocial problems, work-related problems, mild depression, etc.

8 Organisation of mental health care in Generalist mental health care, provided by psychologists, psychotherapists, psychiatrists, mental health care nurses Treatment of - Mild simple though persisting disorder, low risk - Moderately severe disorder, singular or low complexity, low to moderate risk - Severe disorder, singular or low complexity, low to moderate risk - Chronic disorder, stable, low to moderate risk

9 Organisation of mental health care in Specialist mental health care, provided by (teams of) psychologists, psychotherapists, psychiatrists Treatment of Complex severe disorder, problems in many domains, high risk (self negligence, suicide, child abuse) 80% of all patients currently treated in secondary care fulfil these criteria

10 Two goals 1. More effective health care (& less medicalisation): - Stepped care (using objective criteria for referral) - Webbased mental health care interventions (depression, anxiety, substance abuse selfmanagement) - Psychiatrists providing consultations in primary care 2. Reducing/containing costs

11 Dutch guideline MUS starts with exploring the symptoms: S omatic dimension C ognitive dimension E motional dimension B ehavioural dimension S ocial dimension

12 A careful exploration results in A patient feeling understood, taken seriously A doctor having some real clues where to start Doctor and patient sharing common ground

13 Determination of the severity of MUS Mild MUS slight functional limitations; and one or several MUS within one or two symptom clusters (gastro-intestinal, cardiopulmonary, musculoskeletal, general non-specific i.e. fatigue, headache, dizziness).

14 Severity of MUS Moderate MUS moderate functional limitations; and several MUS in at least three symptom clusters; and/or duration of symptoms longer than expected, depending on normal course of relevant symptom.

15 Severity of MUS Severe MUS severe functional limitations; and MUS in all symptom clusters; and/or duration of symptoms longer than three months.

16 Step I. Mild MUS, treatment by GP Shared definition of problem, based on exploration of symptoms (5 dimensions) Education and advice explanation and education; discussion of factors that inhibit recovery; advice.

17 Step I. Mild MUS, GP Formulation of a shared time-contingent plan. Follow-up monitor progress of plan and repeat exploration of symptoms if recovery stagnates; if symptoms change, repeat exploration of symptoms and perform targeted physical examination and additional investigations if necessary.

18 Step 2. Moderate MUS, GP and other primary care health care providers (partly generalist mental health care) Collaboration with/referral to: (psychosomatic) physiotherapist or exercise therapist; mental health nurse practitioner in primary care; primary care psychologist trained in cognitive behavioural therapy.

19 Step 3. severe MUS, GP in collaboration with secondary care providers (mostly specialized mental health care, but also rehabilitation medicine) Collaboration with/referral to: multidisciplinary teams/treatment centres.

20 The past??

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