Strategier for udviklingen mod en evidensbaseret vård for mennesker med skizofreni i Danmark

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Simone Groth
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1 Strategier for udviklingen mod en evidensbaseret vård for mennesker med skizofreni i Danmark 11 Community Mental Health Conference i Lund Anne Lindhardt

2 Konklusion af udvikling Skift mod ambulant psykiatri Få men sikre modeller for effekt evidens? Mere specialisering Nå flere patienter med samme ressourcer Gode kvalitetsdatabaser Nationale indikatorprojekt God medicinalstatistik Meget mere fokus på patientindragelse patient som samarbejdspartner Og på minimering af tvang Psykiatriudvalg regeringsnedsat

3 Denmark 5 health regions Mental health part of health regions population: mio Organised in separate units Virtual psychiatric hospitals on many adresses 98 local communities Division of tasks: Asessment and treatment in regions Prevention and rehabilitation in local communities Financing: State financed. No local tax 3

4 Values Fair and equal treatment 24 hours accessability GP as filter for referrals Stepvise model GP Secundary care Specialised care 4

5 Organisation Step care model GP as gatekeeper Hospital beds ( 3.100/ )(0.56/ ) 90% admittances are acute Community mental health teams (caseload: 1: 25/30) Often including ACT and early intervention teams ( caseload: 1:12) Specialised teams for outpatients non psychotic disorders treatment programmes persons treated every year in secundary services 25% as inpatients and thus 75 % as outpatients only 5

6 Pressing themes Ressources lacking behind somatics Stigma High mortality Cohesion Continuity Workforce lack of specialist in psychiatry High unemployment amongst persons with a psychiatric disorder Growing number of private practising psychiatrists and psychologists Psychiatry has a political focus 6

7 Data sources National registers on psychiatry and mortality National Indicator project (Quality) National guidelines Data on health economics Patients and carers satisfaction Accreditation the danish quality model 7

8 Trends in development In ten ys. Psychiatry has treated 50% more persons with almost same ressources / (affective and anxiety disorders) Shift from inpatients to outpatients More focus on metabolic syndrome, and high mortality Difficulties with transitions from hospital to social sector Economic crisis New public management belief in change as the answer to all problems Evidens based treatment - Ethics and values in focus ( reaction) 8

9 Change in absolute number of outpatients 9

10 Changes in absolute number of inpatients 10

11 Klik for at redigere i master Andet niveau Tredje niveau Fjerde niveau Femte niveau 11

12 12

13 Skizofreni- impact Øget dødelighed Øget sygdomsbelastning Øget kriminalitet Øget stofmisbrug Antal personer med en skizofrenidignose i DK estimeres til ca Antal nysyge estimeres til ca per år

14 Initiativer To store studier påbegyndtes i 1990erne DNS OPUS Indførelse af Team efter ACTmodellen OPUS modellen fik stor gennemslagskraft dokumenterede at ambulant behandling efter tidlig intervention var mere effektiv end hospitalsbehandling

15 Initiativer Behandling: SST vejledende retningslinier for behandling for skizofreni SST vejledende retningslinier for behandling med antipsykotika (2008) Dansk Psykiatrisk selskab: god socialpsykiatrisk standard i behandling af unge og voksne med skizofreni (2001)

16 kvalitetsdatabase Det nationale indikatorprojekt Skizofreni 2001 og frem

17 National indicator project - schizophrenia 10 ys. Focus points: Asessment of psychopathology and cognitive functions, need for social support Psychopharmacologica treatment, effect and adverse affect monitored Contact after discharge to relatives psychotherapy Psychoeducation Follow up Suicidal risk 17

18 National Indicator Project Schizophrenia results % had BMI>30 (Denmark: 18 %) 59 % had waist circumference above 88cm (women) 102 cm (men) (Denmark: 30 %) 20 % had elevated blood sugar (Denmark 16 %) 61 % had increased blood lipids (Denmark 35 %) 62 % had blood pressure >130/85 32 % fulfilled criteria for metabolic syndrome (Denmark 22 %) 18

19 Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 2005 Apr;62(4): There are two sharp peaks of risk for suicide around psychiatric hospitalisation, in the first week after admission in the first week after discharge 19

20 Neuro-psychiatric conditions Europe: Years lived with disability Ranking 1st Unipolar depressive disorders 13.7% Ranking 2nd Alcohol use disorders 6.2% Ranking 7th Alzheimer and other dementias 3.7% Ranking 11th Schizophrenia 2.3% Ranking 12th Bipolar disorders 2.2%

21 Kriminalitet og psykisk sygdom I en registerundersøgelse fandt man at 74 procent af de personer med skizofreni, som fik en dom til psykiatrisk behandling, ikke havde været i kontakt med psykiatrien før de begik (første) den kriminelle handling [Munkner et al., 2003]

22 Kriminalitet og skizofreni De aller fleste med skizofreni er ikke farlige Risiko associeret til ubehandlede vrangforestillinger 374 dræbt af mennesker med biler (3,7 per biler) max 5 af mennesker med skizofreni (max 3,3 per patienter) Risikoen for at et tilfældigt menneske bliver dræbt af et menneske med skizofreni er som at blive ramt af et lyn Gruppen af unge mænd er farligere Stigma holder mennesker fra at søge behandling Nordentoft 2011

23 NEDBRINGELSE AF TVANG gennembrudsprojekt

24 Aktuel organisering Adgang: henvisning fra egen læge til central visitation Psykiatrisk akutmodtagelse Tidlig opsporing og intervention som princip ikke realitet OPUS Opsøgende teams til kroniske patienter fungerer i tre af de fem regioner

25 Two major clinical trials on first episode psychosis The Danish OPUS Trial: A two-site randomised clinical trial of assertive specialised psychiatric treatment The Danish National Schizophrenia Project DNS: A prospective, longitudinal, multi-centre investigation. Investigating supportive psychodynamic psychotherapy (SPP) vs. TAU 25

26 DNS - Preliminary results - 5 years outcome Psychodynamic therapy (SPP) vs. TaU GAF (function) is significantly improved by SPP, and this is positively correlated with having friends, being in work and not abusing drugs/alcohol, at inclusion The differences between for SPP og TaU is nonsignificant for: GAFsymptom, PANSSnegative and PANSSpositive WAIS tests of similarities, picture completion, picture arrangement, and bloc design all improve significantly over time. However, the SPP-group did better than the TaU, but not significantly better. 26

27 OPUS - Conclusion: Psychotic and negative symptoms and substance abuse was significantly better after two years of intervention. Difference disappeared when patients in OPUS treatment were transferred to standard treatment after two years 27

28 OPUS Conclusion: Significant more satisfaction with treatment in OPUS-team treated group after two-years Significantly better adherence in OPUS-team treated group Low dose strategy succesfully implemented in OPUS (20 percent lower dosage antipsychotic medication) 28

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