The important thing in science is not so much to obtain new facts as to discover new ways of thinking about them.

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1 Innovatie = Verwondering Klinisch Redeneren, Shared Decision Making Jim van Os 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 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 Read, Runciman, Dillon, 2016 Read, Runciman, Dillon, 2016

2 Verwondering van de DSM-maker Verwondering van de Medicus Fluctuerende emoties Stemmen horen worden veroorzaakt door: BPD Schizofrenie Allen Frances, 2012 Medisch Contact, 2015 Verwondering over de Kennis Verwondering van de kennistheoreticus 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 Read, Runciman, Dillon, 2016 Trudy Dehue, Groene Amsterdammer, Febr Voor nogal wat aan de universiteit werkende psychiaters zijn mensen die dit soort kwesties aankaarten slechts antipsychiaters...

3 Verwondering van de User-Filosoof Open Science Collaboration Science, 2015 Niet weten is een vorm van weten 97% of original studies had significant results; 36% of replications had significant results Wat kies je? Do we need the Brain?

4 Verwondering van de Antropoloog Fundamental Attribution Error Extremely serious Mild Biological Psychosocial Woo-kyoung Ahn, 2009 Physical treatment Psychological treatment Devastating : Is it a cognitive illness? Cognition or Test-motivation? 2014 JAMA Psychiatr, 2014

5 Adversity and Cognition Verwondering van de verzekeraar: 300% variatie voorkomen angst/depressie? Mani et al, Science, Verwondering van de Verzekeraar: Bedden / 100,000 populatie 1 FACT Team (8-9 FTE) 50,000 population

6 Verwondering van de EBM crowd The Dodo. JAMA, 2010 Dodo & Psychopharmacology Is Clozapine Superior? All treatments must win Effect size medications: Peter Groot, 2015 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.

7 Percentage better 50% 35% n=1 approach: Daily variation in voices, paranoia, down and relaxed Treated Placebo Context Better A B C D Process Better E F G H I Worse Worse Bak et al, submitted N=1 Clinical Network Analysis: Rx Respons Effect of CBT for depression is falling Bak et al, submitted Johnson & Friborg, Psychological Bulletin, 2015

8 NNT Going Up Evolving Knowledge: Neglect as Usual Effect Cochrane Database 2000: Currently, for those with schizophrenia willing to receive CBT, access to this treatment approach is associated with a substantially reduced risk of relapse. Cochrane Database 2004: Currently, trial-based data supporting the wide use of CBT for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. Cochrane Database 2012: JAMA Psychiatry, 2014 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. Therapeutic Relationship Clinician Random Effect JAMA, % 5% Re-analysis NIMH Treatment of Depression Collaborative Research Program % variance BDI antidepressant % variance BDI psychiatrist McKay et al, 2006

9 How Does Placebo Work? We revealed a dysfunctional system that does not deliver the quality of treatment needed for recovery. Is this tolerable in the 21st century? BMJ, 2011 Verandering van binnen: Organisational Readiness T H E U. K. Lancet, 2013, Plos One, 2014

10 Ervaringskennis Twee Discours 1 Dominant 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 BMC Psychiatry, 2015 Klachten, ziekten, beperkingen Exacte diagnostiek GGZ Signalen, variatie, uitdagingen Vele wegen naar herstel SDS: Keeping the Balance Crisis: Opname Crisis: Activeren netwerkrelaties Evidence-based escaleren Group-based RCT s Contextuele, Fasegewijze Weerbaarheidsbevordering n=1 experimenten Handicap Persoon Delta T symptoom benchmarken Nieuwe doelen Minutenregistratie declaratie Populatiebekostiging (wijk) Slade & Longden, BMC Psychiatry, 2015

11 SDS: Keeping the Balance UK: Failure to Innovate Persoon Handicap Innovatie moet de default zijn,niet iets dat je er bij doet Beste manier om te innoveren jezelf obsoleet te maken Slade & Longden, BMC Psychiatry, 2015 Verandering vanuit de Status Quo: Top-Down Systeem- en Maakbaarheidsdenken 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) Large scale Small scale Uitvoering: Integrated Care Persoonsgericht Populatiebekostiging Wijkintegratie Relaties Hersteldenken

12 Van A naar B Kanteling: Verborgen Rijkdom GGZ=Integrated Wijkcommunity 100FTE Pilots disruptive change Verantwoordelijk voor KENNIS CENTRUM Kennis en Kunde Gaat Niet Verloren Professional Multideskundige Kennis Betrokkene Cliënt herstel coach Diagnosticus interventionist ervaringsdeskundige

13 100FTE: Multideskundige mix Acute / specifieke zorg Herstelgerichte zorg Consumer-run sociale economy Professional ED 80% 20% 50% 50% 20% 80% Ziektedenken symptomen problemen oplossingen behandelaar professionele distantie feiten beschrijving kennis verklaren oorzakelijke verbanden interventie behandeldoel focus op genezing beter worden evidence-based patiënt doen Hersteldenken signalen dilemma s keuzes en zingeving gesprekspartner professionele nabijheid verhalen, overtuigingen ervaring levenskunst en wijsheid begrijpen van betekenissen presentie open proces focus op veerkracht regie kunnen voeren lexperience-based persoon zijn Crisis = Netwerken Activeren & Empoweren Klinisch redeneren: Van escalatie naar contextuele behandeling Van escalatie-algoritmes naar procesmatige, contextgebonden, fasegewijze behandeling cq weerbaarheidsbevordering wonen opleiding werken relaties

14 ehealth 24% jaar prevalentie Zelfmanagement component ecommunities 1 op 1 zorg ehealth mhealth ecommunities mhealth 1 op 1 component 1 op 1 zorg Samen..betere verwondering Fin