William Lawrence Bragg - ZonderZorg · 2018-09-03 · Klinisch Redeneren, Shared Decision Making...
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Klinisch Redeneren, Shared Decision Making Jim van Os Innovatie = Verwondering Innovatie = Verwondering The important thing in science is not so much to obtain new facts as to discover new ways of thinking about them. (William Lawrence Bragg) Introducing Psychiatry Introducing Psychiatry Read, Runciman, Dillon, 2016 Introducing Psychiatry Introducing Psychiatry Read, Runciman, Dillon, 2016 “While psychiatrists everywhere are doing their best to help people, their profession is in crisis. Psychiatry is struggling to reassert its future role. One possibility that is taboo for any profession to consider, however, is that it has little or no useful role”
Transcript of William Lawrence Bragg - ZonderZorg · 2018-09-03 · Klinisch Redeneren, Shared Decision Making...
Klinisch Redeneren,Shared Decision Making
Jim van Os
Innovatie = VerwonderingInnovatie = Verwondering
The important thing in science is not so much to obtain new facts as to discover new ways
of thinking about them.
(William Lawrence Bragg)
Introducing PsychiatryIntroducing Psychiatry
Read, Runciman, Dillon, 2016
Introducing PsychiatryIntroducing Psychiatry
Read, Runciman, Dillon, 2016
“While psychiatrists everywhere are doing their best to help people, their profession is in crisis. Psychiatry is struggling to reassert its future role. One possibility that is taboo for any profession to consider, however, is that it has little or no useful role”
Verwondering van de DSM-makerVerwondering van de DSM-maker
Fluctuerende emoties
worden veroorzaakt door:
Stemmen horen
BPD Schizofrenie
Allen Frances, 2012
Verwondering van de MedicusVerwondering van de Medicus
Medisch Contact, 2015
Verwondering over de KennisVerwondering over de Kennis
Read, Runciman, Dillon, 2016
“In terms of causation, psychiatry has focused predominantly on chemical imbalances, brain abnormalities and genetics. The failure to provide any findings of substance does not seem to matter. Merely engaging in this apparently scientific activity seems sufficient to sustain the ‘medical model’ ”
Verwondering van de kennistheoreticusVerwondering van de kennistheoreticus
Trudy Dehue, Groene Amsterdammer, Febr. 2016
“Voor nogal wat aan de universiteit werkende psychiaters zijn mensen die dit soort kwesties aankaarten slechts antipsychiaters...”
Niet weten is eenvorm van weten
Verwondering van de User-FilosoofVerwondering van de User-FilosoofOpen Science CollaborationOpen Science Collaboration
97% of original studies had significant results; 36% of replications had significant results
Science, 2015
Wat kies je?Wat kies je? Do we need the Brain?Do we need the Brain?
Verwondering van de AntropoloogVerwondering van de Antropoloog
Woo-kyoung Ahn, 2009
Extremely serious
Biological
“Physical” treatment
Mild
Psychosocial
“Psychological” treatment
‘Fundamental Attribution Error’
‘Devastating’: Is it a ‘cognitive’ illness?‘Devastating’: Is it a ‘cognitive’ illness?
2014
Cognition…or Test-motivation?Cognition…or Test-motivation?
JAMA Psychiatr, 2014
Adversity and CognitionAdversity and Cognition
Mani et al, Science, 2013
Verwondering van de verzekeraar: 300% variatie voorkomen angst/depressie?
020406080
100120140160180200
Verwondering van de Verzekeraar: Bedden / 100,000 populatie
Verwondering van de Verzekeraar: Bedden / 100,000 populatie 1 FACT Team (8-9 FTE)1 FACT Team (8-9 FTE)
50,000 population
Verwondering van de EBM crowdVerwondering van de EBM crowd
JAMA, 2010
The Dodo….The Dodo….
Effect size medications: 0.3‐0.4
“All treatments must win”
‘Dodo’ & Psychopharmacology
Peter Groot, 2015
Is Clozapine Superior?
Insufficient evidence exists on which antipsychotic is more efficacious for patients with treatment-resistant schizophrenia, and blinded RCTs-in contrast to
unblinded, randomized effectiveness studies-provide little evidence of the superiority of clozapinecompared with other second-generation antipsychotics.
Better
Worse
E F G
H I
Better
Worse
A B C
D
Percentage better 50%
35%
Treated Placebo
Context
Process
n=1 approach: Daily variation in voices, paranoia, down and relaxedn=1 approach: Daily variation in
voices, paranoia, down and relaxed
Bak et al, submitted
N=1 Clinical Network Analysis: Rx ResponsN=1 Clinical Network Analysis: Rx Respons
Bak et al, submitted
Effect of CBT for depression is fallingEffect of CBT for depression is falling
Johnson & Friborg, Psychological Bulletin, 2015
JAMA Psychiatry, 2014
NNT Going UpNNT Going Up Evolving Knowledge: “Neglect as Usual” Effect
Currently, for those with schizophrenia willing to receive CBT, access to this treatment approach is associated with a substantially reduced risk of relapse.
Trial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other - and sometime much less sophisticated - therapies for people with schizophrenia.
Cochrane Database 2000:
Cochrane Database 2012:
Currently, trial-based data supporting the wide use of CBT for people withschizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach.
Cochrane Database 2004:
Therapeutic RelationshipTherapeutic Relationship
JAMA, 2010
Clinician Random EffectClinician Random Effect
10%
5%
% variance BDI antidepressant
% variance BDI psychiatrist
McKay et al, 2006
Re-analysis NIMH Treatment of Depression
Collaborative Research Program
How Does Placebo Work?How Does Placebo Work?
BMJ, 2011
We revealed a dysfunctional system that does not deliver
the quality of treatment needed for recovery. Is this tolerable in
the 21st century?
THE
U.K.
THE
U.K.
Verandering van binnen: “Organisational Readiness”Verandering van binnen: “Organisational Readiness”
Lancet, 2013, Plos One, 2014
ErvaringskennisErvaringskennis Twee Discours – 1 DominantTwee Discours – 1 Dominant
BMC Psychiatry, 2015
“Two discourses exist in mental health research and practice. The first focuses on the limitations associated with disability arising from mental disorder. The second focuses on the possibilities for living well with mental health problems”
Exacte diagnostiek GGZ
Klachten, ziekten, beperkingen
Crisis: Opname
Evidence-based escaleren
Group-based RCT’s
“Delta T” symptoom benchmarken
Signalen, variatie, uitdagingen
Contextuele, FasegewijzeWeerbaarheidsbevordering
Crisis: Activeren netwerkrelaties
Vele wegen naar herstel
n=1 experimenten
Nieuwe doelen
Populatiebekostiging (wijk)Minutenregistratie declaratie
SDS: Keeping the BalanceSDS: Keeping the Balance
PersoonHandicap
Slade & Longden, BMC Psychiatry, 2015
SDS: Keeping the BalanceSDS: Keeping the Balance
HandicapPersoon
Slade & Longden, BMC Psychiatry, 2015
UK: Failure to InnovateUK: Failure to Innovate
Beste manier om te innoverenjezelf obsoleet te maken
Innovatie moet de defaultzijn,niet iets dat je er bij doet
Commissie Dekker (1987) ‘Bereidheid tot verandering’
De Swaan (1989) ‘Zorg en de Staat’
d‘Ancona & Simons (1990) ‘Werken aan zorgvernieuwing’
Landelijke Commissie Geestelijke Volksgezondheid (2002) ‘Zorg van
velen’
Bestuurlijk Akkoord ‘Toekomst GGZ’ (2011)
Commissie Dannenberg (2015) ‘Van beschermd wonen naar een
beschermd thuis’
De Werkagenda, Raad Volksgezondheid en Samenleving (2016)
De GGZ Agenda (2016)
Verandering vanuit de Status Quo: Top-Down Systeem- en Maakbaarheidsdenken
Verandering vanuit de Status Quo: Top-Down Systeem- en Maakbaarheidsdenken Uitvoering:
Integrated Care
Large scale
Small scale
PersoonsgerichtPopulatiebekostigingWijkintegratieRelatiesHersteldenken
Van A naar B
Pilots disruptive change
Kanteling: Verborgen RijkdomKanteling: Verborgen Rijkdom
100FTE
GGZ=Integrated Wijkcommunity
Verantwoordelijk voor 20.000
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
neighbourhood community (100FTE)
Kennis en Kunde Gaat Niet Verloren
KENNIS CENTRUM CliëntBetrokkeneProfessional
Diagnosti‐cus
interven‐tionist
herstelcoach
ervarings‐deskundige
Multideskundige Kennis
100FTE: Multideskundige mix100FTE: Multideskundige mix
80% 20%Acute / specifiekezorg
Herstelgerichtezorg 50% 50%
Consumer-run sociale economy 20% 80%
EDProfessional
Ziektedenken Hersteldenken
symptomenproblemenoplossingenbehandelaarprofessionele distantiefeitenbeschrijvingkennisverklaren oorzakelijke verbandeninterventiebehandeldoelfocus op genezingbeter wordenevidence-basedpatiëntdoen
signalendilemma’skeuzes en zingevinggesprekspartnerprofessionele nabijheidverhalen, overtuigingenervaringlevenskunst en wijsheidbegrijpen van betekenissenpresentieopen procesfocus op veerkrachtregie kunnen voerenlexperience-basedpersoonzijn
Crisis = Netwerken Activeren & EmpowerenCrisis = Netwerken Activeren & Empoweren
Van escalatie-algoritmes naar procesmatige, contextgebonden, fasegewijze behandeling cqweerbaarheidsbevordering
Van escalatie-algoritmes naar procesmatige, contextgebonden, fasegewijze behandeling cqweerbaarheidsbevordering
Klinisch redeneren: Van escalatie naar contextuele behandeling
Klinisch redeneren: Van escalatie naar contextuele behandeling
wonen
werken
opleiding
relaties
eHealth
1‐op‐1 zorg
mHealtheCom‐munities
24% jaarprevalentie
eHealth
mHealth
1‐op‐1 zorg
eCommunitiesZelfmanagementcomponent
1‐op‐1 component
Samen…..betere verwonderingSamen…..betere verwonderingFin
