CHALLENGESINPRACTICE

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Prepared for: Athena Institute, Amsterdam Prepared by: BSc Tuğba Aydın, 2007991 Student: Master Management, Policy Analysis and Entrepreneurship in

Health and Life Sciences Specialization: Management and entrepreneurship Start date: October 2015 Version: Final version Supervisors: Dr. T.P. Groen Faculty of Earth and Life Sciences, VU De Boelelaan 1105 1081 HV Amsterdam t.p.groen@vu.nl MSc E.F. Maassen Faculty of Earth and Life Sciences, VU De Boelelaan 1105 1081 HV Amsterdam eva.maassen@vu.nl

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Summary Introduction: Bipolar disorder (BD), also called manic depression, is a mental disorder that is characterized with severe mood swings and for example changes in energy level, cognition and sleep. BD patients experience periods with a severe high mood state, which is called (hypo)mania, alternating with severe depressed episodes, in which patient are likely to commit suicide. The literature shows several difficulties in the diagnostic process of BD, which results in a high misdiagnosis (for example with unipolar depression) that can lead to needless suffering and medication use by the patient. This is a problem, because medication for unipolar depression can trigger a mania and delays in the correct and accurate diagnosis can lead to personal, social, and work-related problems. Due to the high rate of misdiagnosing, patients consult on average four doctors and it takes at least 7 years before receiving the correct diagnosis for BD, meaning that there are challenges in the diagnostic process of BD. The diagnostic process in mainly done in a multidisciplinary team (MDT), in which several disciplines work together to ensure the quality of the delivered care. MDT working has several benefits, it aims for example that all already achievable knowledge and expertise within a diagnostic team is compiled and used in an efficient manner, leading to a more accurate diagnostic process. However, achieving an efficient MDT, and with that, an efficient diagnostic process needs some core concepts and enablers. One of the important enabler is role clarification of the professionals involved in the diagnostics of BD. Multidisciplinary collaboration requires according to literature recognition of complementary roles in a team. In order to contribute to a more efficient diagnostic process, an insight of the current daily practice role division and the added value of the roles of the professionals in the MDT’s who are involved in the diagnostics seem to be necessary. Therefore, the aim of this study is to set out the challenges that are faced in practice by professionals who are involved in the diagnostic process of BD and besides that, to clarify the roles in the diagnostic process of BD of these professionals. Methodology: An explorative qualitative research method was used in this research, in order to get more insight in the perspectives of professionals about the challenges in the diagnostic process of BD and the added value of their and their colleagues’ role in the MDT. Interviews and focus groups are held at different locations with members of specialist bipolar teams. The participants are recruited based on pre-specified qualifications (professionals’ role in the diagnostic process) and their experience in the diagnostic process of BD, focussing on three professionals who are involved and experienced in the diagnostic process of BD: psychiatrists, psychologists and nurses. In total five focus groups and four interviews are conducted. The data is transcribed and analysed by a content analysis approach. Results: Professionals mentioned many challenges during the focus groups or interviews. An unreliable anamnesis can make the diagnostic process difficult. This can for example be caused by the memory of the patient to memorize their possible hypomanic episodes in the past or the choice to tell this to the professional. Besides, hetero-anamnesis seems also a challenging aspect, due to for example the unavailability of the family members. Furthermore, determining the difference between ‘what is normal for that particular patient’ and ‘what is hypomanic for that particular patient’ is sometimes very challenging. Almost all professionals mentioned co morbidity and symptom overlap as one of the most difficult aspects. Moreover, BD has aspecific symptoms that do not always fit in the criteria as described in the DSM. The unawareness of professionals outside the bipolar team can also lead to difficulties in an accurate diagnostic process of BD. Also, practical issues with the health insurance were mentioned. One of the controversies and challenge

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in the diagnostic process is that BD can evolve and develop in time, but the time for the diagnostic process is short. Psychiatrists fulfil an essential role in the MDT, as they have a broad medical psychiatric view, they are appointed to bear the final responsibility in the diagnostic process and formulate the diagnosis, signal physical problems and have an eye for medicines related problems. The nurses are almost at every location intakers. Furthermore, they are very practical, because of their relatively low cost. Besides that, they have an important psychosocial role, wherein a low threshold to the patient is an important aspect. Because of the longer and more personal contact with the patient, nurses have a functional view, as they can estimate the feasibility of a certain treatment and see the strengths of the patient. A psychologist is skilled in using measuring instruments, in getting a deeper insight about the personality of the patient for substantiated conclusions, is therapy oriented, pays special attention for co morbidity and set out the developmental stages of the disorder. Conclusion and discussion: This research aimed to get an insight in the challenges and role values of different disciplines in a MDT in order to achieve a more efficient diagnostic process of BD. Some challenges in practice endured by professionals can be mentioned: unreliable anamnesis, difficulties with hetero-anamnesis, character of the patient, great co morbidity and symptom overlap, vague DSM, course of disorder and time pressure and some practical issues. This research also showed that the added value of the psychiatrists in the MDT is their broad medical psychiatric view, their final responsibility, the knowledge about somatics and pharmacotherapy. The added values of the nurses, which differs per location, are identified as: being intakers, having an eye for the psychosocial aspect of the patient, having a functional view and being practical in the diagnostic process. In teams where psychologists are always available, nurses fulfil a less prominent role in the diagnostic process. The psychologists have an added value in using measuring instruments, having an eye for co-morbidity and the developmental stages of the disease, mapping personality of the patient, getting an overview and connecting all information about the patient. A specialised look and research to the broad personality aspect is indicated as a missing part, in case of no psychologist was available in the team. It is also remarkable that every location has at least subtle differences in their way of diagnostics, which can influence the perspective of team members about the added values of their selves and other disciplines. This research also identified that many professionals have comparable skills, however the responsibilities are different.

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Contents1. INTRODUCTION............................................................................................................................7

RESEARCH OBJECTIVE AND RESEARCH QUESTION..................................................................................82. CONTEXTUAL BACKGROUND................................................................................................9

2.1. WHAT IS BIPOLAR DISORDER...................................................................................................................9Aetiology of Bipolar disorder......................................................................................................................................9Bipolar disorder types..................................................................................................................................................9Bipolar spectrum.......................................................................................................................................................10

2.2. CONSEQUENCES OF BIPOLAR DISORDER..........................................................................................11Consequences of early onset......................................................................................................................................11Consequences of confusion and misdiagnosing.......................................................................................................11

2.3. DIAGNOSTICS OF BIPOLAR DISORDER...............................................................................................12Screening instruments...............................................................................................................................................12Challenges and perplexities in diagnosing..............................................................................................................13Diagnostic opportunities...........................................................................................................................................13

2.4. TREATMENT OF BIPOLAR DISORDER.................................................................................................14Long-term treatment.................................................................................................................................................14(Non) compliance of Bipolar disorder patients......................................................................................................14

2.5. DIAGNOSTIC TEAMS..................................................................................................................................153. THEORETICAL BACKGROUND...........................................................................................16

3.1. INTRODUCTION TO THE THEORETICAL FRAMEWORK...............................................................163.2. MULTIDISCIPLINARY COLLABORATION/TEAM..............................................................................16

Benefits of MDT working.......................................................................................................................................16MDT, timely diagnostics and positive clinical outcome.......................................................................................17Achieving an efficient MDT- phases......................................................................................................................18Achieving an efficient MDT- enablers...................................................................................................................19

3.3. ROLE CLARIFICATION IN THE MDT...................................................................................................203.4. THEORETICAL FRAMEWORK.................................................................................................................203.5. SUB-QUESTIONS..........................................................................................................................................21

4. METHODOLOGY.........................................................................................................................224.1. RESEARCH STRATEGY..............................................................................................................................22

Focus group and interview design............................................................................................................................224.2. RESEARCH APPROACH.............................................................................................................................234.3. RESEARCH ANALYSIS................................................................................................................................24

Validity......................................................................................................................................................................24Ethical consideration................................................................................................................................................25

5. RESULTS..........................................................................................................................................265.1. CHALLENGES IN THE DIAGNOSTIC PROCESS...................................................................................26

Unreliable anamnesis...............................................................................................................................................26Difficulties with hetero-anamnesis..........................................................................................................................27Character of the patient............................................................................................................................................27Co morbidity and symptom overlap........................................................................................................................29DSM.........................................................................................................................................................................30Practical issues..........................................................................................................................................................31Course of disorder and time pressure.......................................................................................................................32

5.2. ROLES OF PSYCHIATRISTS......................................................................................................................33Broad medical psychiatric view and DSM............................................................................................................33

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Final responsibility...................................................................................................................................................34Somatics.....................................................................................................................................................................34Pharmacotherapy......................................................................................................................................................35

5.3. ROLES OF NURSES......................................................................................................................................36Intake.........................................................................................................................................................................36Psychosocial aspect...................................................................................................................................................36Practical....................................................................................................................................................................37Functional view........................................................................................................................................................38

5.4. ROLES OF PSYCHOLOGISTS....................................................................................................................39Measuring instruments.............................................................................................................................................39Co morbidity.............................................................................................................................................................39Personality of the patient..........................................................................................................................................39Therapy orientation..................................................................................................................................................40Developmental stages................................................................................................................................................41Overview....................................................................................................................................................................41

6. CONCLUSION...............................................................................................................................426.1. CHALLENGES IN THE DIAGNOSTIC PROCESS OF BD.....................................................................426.2. ADDED VALUES OF PROFESSIONALS IN A MDT..............................................................................43

MDT functioning.....................................................................................................................................................437. DISCUSSION..................................................................................................................................45

7.1. REFLECTION ON THEORETICAL FRAMEWORK...............................................................................45Psychiatrists..............................................................................................................................................................45Nurses........................................................................................................................................................................45Psychologists..............................................................................................................................................................46Challenges.................................................................................................................................................................46

7.2. MULTIDISCIPLINARY TEAM COMPOSITION AND CONSEQUENCES..........................................477.3. STRENGTHS AND LIMITATIONS............................................................................................................47

Validity......................................................................................................................................................................487.4. FUTURE RESEARCH...................................................................................................................................48

REFERENCES.....................................................................................................................................50APPENDIX 1: FOCUS GROUP DESIGN...................................................................................55APPENDIX 2: ROLES OF PROFESSIONALS..........................................................................57

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1. Introduction Long before Kraepelin described ‘manic depressive insanity’ in the late 19th century, philosophers like Aristoteles, Plato and Socrates had recognized mania and associated it with creativity and ingenuity. Bipolar disorder (BD), also called manic depression, is a mental illness that brings severe mood swings. BD can be separated from unipolar depression by the occasion of abnormally high mood state, known as mania or hypomania, in combination with alternating depressed mood (Anderson et al., 2012). Besides severe high and low moods, bipolar disorder also brings changes in for instance energy, behaviour, cognition and sleep (Anderson et al., 2012). According to World Health Organization (WHO), mood disorders like bipolar disorder are relatively common in the Netherlands in comparison with other countries (Demyttenaere et al., 2004). From the Dutch population aged between 18 and 65, it is estimated that 91.100 adults suffers from BD (de Graaf et al., 2010), which can lead to high costs if accurate diagnosis is missing due to for example faces difficulties by professionals during the diagnostic process. Health professionals can face some difficulties in the diagnostic process of BD. First of all, the symptoms of BD can be confused with other diseases, like ADHD or unipolar depression. Hirschfeld describes in his research that 69% of BD patients were misdiagnosed with unipolar depression. The percentage, which was incorrectly diagnosed, consulted on average four doctors before receiving the correct diagnosis for BD. Many patients are mainly overlooked or misdiagnosed by physicians (Anderson et al., 2012), resulting in needless suffering and medication use by the patient. Besides the high percentage of misdiagnosis due to confusion of the symptoms of BD with other diseases, the lack of knowledge of the causes of BD is also challenging. Namely, BD has not a single cause. It appears that certain people are genetically predisposed to BD, yet there is not one gene that shows significant development of this disorder. Researchers suggest that many different genes are playing a complex role together with environmental factors (Muhleisen, 2014). Interestingly, a person with inherited vulnerability does not automatically develop the disorder (Xu et al., 2014), indicating BD is a multi causal illness. Hirschfeld and his colleagues reported in 2003 that patients with BD indicated that the disorder manifests itself at a young age but that accurate diagnosis lacked. Approximately 30 per cent had to wait 20 years or more for getting the accurate diagnosis, although they had reported manic symptoms earlier. Therefore many patients indicated as reason for the delayed diagnosis the lack of understanding of their physician about BD (Hirschfeld et al., 2003a). Indeed, according to Brickman many physicians do not screen for BD routinely, even though the patient has a depression history. A certain percentage of these people could meet the criteria for BD (Brickman et al., 2002). Researchers emphasize the duration of at least 7 years before receiving the right diagnosis, reproaching the poor screening (Mantere et al., 2004). The confusion with depression and the failure to diagnose BD accurately could have serious impact, since antidepressants without mood stabilizing drug may trigger mania (Ghaemi et al., 2001), which is an abnormally elevated mood. BD can impair the patient more and more if it is left undiagnosed and untreated, for example episodes could occur more severe or more frequent over time. Also, delays in the correct and accurate diagnosis- and treatment- can lead to personal, social, and work-related problems (Anderson et al., 2012). Therefore it is important that health

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professionals first of all diagnose BD correctly. The diagnostic of BD is done in a multidisciplinary team (MDT) with several disciplines, like psychiatrists, psychologists and nurses. Since the diagnosis of BD seems difficult, this research wants to get insight into the challenges in practice and the roles of involved health professionals in the diagnostic process of BD. Understanding the challenges and the added values of the roles can be used in practice for a more efficient multidisciplinary collaboration between the professionals, since role clarification is an important prerequisite of a well working multidisciplinary team, in which psychiatrists, psychologists and nurses play a role (Orchard et al., 2005).

Research objective and research question The aim of this study is to set out the challenges that are faced in practice by professionals who are involved in the diagnostic process of BD and besides that, to clarify the roles in the diagnostic process of BD of these professionals. Hence, the research question is defined as: What are the challenges in practice in the diagnostic process of BD faced by involved professionals and what are the added values of the roles of these professionals in the diagnostic process of BD?

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2. Contextual background This chapter will provide more context information and in-depth knowledge about BD, the consequences of it, the diagnostics and treatment of BD and the diagnostic teams.

2.1. What is Bipolar disorder

Aetiology of Bipolar disorder As indicated in the introduction, BD has no single cause. The development of BD seems to be a combination between nature and nurture. Some researches about brain imaging indicate physical changes in the brains of people with the disorder (Strakowski et al., 2005; Lagopoulos et al., 2007) while other studies steers to neurotransmitter imbalances as a cause. Also, a disturbed level of the stress hormone cortisol (Cole et al., 2011), circadian rhythm disturbances (Harvey, 2008) and an abnormal thyroid function (Kupka et al., 2002) are pointed as possible contributors to the emergence of BD. At the same time, a collaborative genome wide study indicates that ion channelopathies resulting from ANK3 and CACNA1C gene deficiencies are possibly involved in the pathogenesis of BD (Ferreira et al., 2008). The first signs of bipolar disorder is mainly seen in the teenage years, as first manic or depressive episode usually occurs in that period. According to Hirschfeld (2003), especially young adults and individuals with lower income are at higher risk for this disorder. Besides that, some studies have pointed out the differences between older and younger manic-depressive patients (Depp and Jeste, 2004). For example, an association between aging and longer depressive or manic episodes was found (Burt et al., 2000). It is also suggested that older patients with this disorder experienced a shorter interval between the episodes, which makes the disorder less manageable and recurrences more likely (Blazer and Koening, 1996)

Bipolar disorder types Patients with BD are mainly diagnosed by using guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, released in 2013). DSM is an American handbook that serves as a standard in most countries in the psychiatric diagnosis processes. The DSM was necessary to avoid international confusion about mental illnesses in the literature (Rockville, 2008). There are two types of assessment for diagnosing bipolar disorder: using retrospective self-reports (Merikangas et al., 2007) and clinician rated assessments (Furukawa, 2010). According to DSM-V, four basic types of BD can be distinguished: Bipolar I Disorder, Bipolar II Disorder, Bipolar Disorder Not Otherwise Specified (BP-NOS) and Cyclothymic Disorder (APA, 2013). Bipolar I Disorder last at least seven days with severe mixed or manic episodes. Depressive episodes last at least two weeks. Bipolar II Disorder is observable by others, but not severe enough for hospitalization. The primary symptom is depression alternating hypomanic episodes, which is less severe than mania (See Figure 1). If the patient show the symptoms of the disorder but does not meet the diagnostic criteria of neither Bipolar I disorder or Bipolar II disorder, the patient will be diagnosed with BP-NOS. A mild form of BD is Cyclothymia, in which the patient shows episodes of mild depression as well as hypomania for at least 2 years (APA, 2013).

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Figure 1: The difference between Bipolar I disorder and Bipolar II disorder in graphic (Anderson et al., 2012).

Besides the basic types, another term about the severity of BD can be distinguished, namely Rapid-cycling Bipolar Disorder. A person will be diagnosed with this severity within any type of BD when a person has at least four episodes within a year of mania, mixed states, depression and hypomania. Persons who experienced their first episode at a younger age are more likely to be diagnosed with rapid cycling. Besides that, this type of BD may affect more woman than men (Voderholzer et al., 2002).

Bipolar spectrum Besides the four basic type of bipolar disorder, scientists iteratively suggested a bipolar spectrum concept. According to Angst, the provision of more differentiated research for mood disorders could be realized by the initiation and improvement of a validated bipolar spectrum concept (Angst, 2007). This development may help reduce the underestimation and low recognition rate of bipolar disorder. To start with, a German scientist Kretschmer proposed a ranging concept (pathological to normal) for schizophrenia (schizophrenic-schizoid-schizothymic) in 1921 and Bleurer indicated the dimensional concept for affective disorder (manic-depressive disorder- cycloid `psychopathy'- cyclothymic temperament) in 1922. Remarkably, the term `spectrum' was first used by Kety and his colleagues in psychiatry for the schizophrenia spectrum (Kety et al, 1968). Thereafter, Akiskal first described the cyclothymic- bipolar disorder in 1977and subsequently Klerman postulated a mania spectrum in 1981. Hence, the bipolar spectrum covers a severity range of BD. This dimensional concept for classifying several mood disorders contributes to the alleviation of the problem in the under- and misdiagnosing of BD. Some psychiatrists find the bipolar spectrum concept to be ‘a useful framework for thinking about the driving force behind a wider range of mental health problems’

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(Akiskal et al., 1977), because the bipolar spectrum concept do not only refers to BD as traditionally defined, but also to related mood disorders, see Figure 2 (Angst, 2007).

Figure 2: Several mood disorders in dimensional bipolar spectrum (Angst, 2007).

2.2. Consequences of Bipolar disorder BD can have profound consequences according to Have and her colleagues. They show in their research that BD has a more negative effect on the lives of the patient than people with other mental disorder like anxiety disorder, substance use disorder and ‘other mood disorder’. People with BD have periods of bed rest and are more likely to be absent because of their emotional problems (Have et al., 2002). Besides that, BD patients are have more often attempted suicide in their life, and experience impairments in their social functioning, emotional role and vitality and thus a low quality of life. Emotional problems such as feeling depressed, nervous or less vital, can lead to difficulties in daily life and at work. The severity of the problems varied for each patient, however patients diagnosed with Bipolar I can experience more severe social and emotional consequences in daily life (Have et al., 2002).

Consequences of early onset Perlis and his co-workers investigated the early onset (<13 age) of the disease. In general, people with early onset of the disease are associated with a more severe disease course, since Perlis reports that they are more likely to have co morbidities and have more mood episodes. Besides that, they endure more depressed days and have a high likeliness for suicide attempts (Perlis et al., 2004), suggesting that these impairments have negative consequences for the quality of life of BD patients.

Consequences of confusion and misdiagnosing The confusion of BD with unipolar depression can also have consequences for the patient. According to Kato who compared these two mood disorders in his article, is depression much more dependent on environmental factors than on genetic factors in comparison with BD (Kato, 2007). The lifetime prevalence of depression is estimated on approximately 15%, while that for BD is approximately 0.8-2.6% (Kato, 2007). Antidepressant drugs are common used in the treatment of major depression, while mood stabilizer Lithium is marked as the most common in the pharmacological treatment of BD (Ikeda and Kato, 2003).

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Due to the higher lifelong recurrence and higher rate of co morbidity with psychiatric disorders like substance use and anxiety disorders could BD be a more distressful disorder than unipolar depression (Angst, 2007). Besides that, BD is associated with serious other diseases, like hypertension, Diabetes and cardiovascular disease (Weiner et al., 2011). This is related to the mortality rates (and suicide risk) of patients with BD, which is higher in comparison with depression (Osby et al., 2001). Therefore, an accurate diagnosis of BD is essential, as unrecognised or misdiagnosed BD mainly lead to higher costs than major depression. However, the cost can be reduced by early and correct diagnosis and the right treatment (McCombs et al., 2006)

2.3. Diagnostics of Bipolar disorder For the assessment of psychiatric disorders like BD, doctors mainly use five axes, which are mentioned in the DSM. These axes refer each to an information domain that contributes to the prognosis of treatment. The first three axes are relevant for the diagnosis, while the other two axes are relevant for the assessment of the feasibility of a certain treatment. Axis I encrypts all psychiatric disorders, except personality disorders and mental retardation. Axis II encodes the personality disorders and mental retardation. Axis III encodes the clinically relevant, general medical issues. Axis IV appoints clinically relevant psychosocial and environmental problems and axis V set out general psychological, social and occupational functioning of the patient (APA, 2013). A manner for the diagnostics of BD is making use of screening instruments.

Screening instruments Although BD cannot be diagnosed via a blood test or a brain scan, some screening instruments are available. Hirschfeldand his co-workers described a self-rated screening instrument for bipolar spectrum disorder, the Mood Disorder Questionnaire (Hirschfeld et al., 2000). It is based on clinical experience of the writers and DSM-IV criteria and screens for (hypo) manic symptoms in the lifetime history of the patient. Also researchers from Finland investigated the validity of the Mood Disorder Questionnaire as a screening instrument for bipolarity in psychiatric field (Isometsa et al., 2003), in which the questionnaire seems to be a practical method for the recognition of BD. However, the article refers also to the considerable amount of unrecognised Bipolar II disorder patients (Isometsa et al., 2013). Furthermore, several other methods are used, such as the semi-structured interview called Structure Clinical Interview for DSM-IV (SCID). The SCID consists of 10 different modules:mood episodes, psychological and related symptoms, psychotic disorders, mood disorders, substance use, anxiety disorders, somatoform disorders, eating disorders, adjustment disorders and optional disorders (such as acute stress disorder or hypomanic episode). The questions that relate to the criteria of the relevant clinical syndrome are scored from one to three on the presence of the symptom or a question mark (?) for missing or unclear information. At the end of the interview, the scores are counted for the final classification. It can be relatively time consuming. Besides that, Depue has designed the General Behaviour Inventory (GBI), which covers both the manic symptoms as the depressive symptoms in BD (Depue et al., 1981). However, Akiskal described that the most valid (and reliable) way for obtaining a diagnosis of BD is by using a structured interview by a trained clinician (Akiskal et al., 2002).

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Challenges and perplexities in diagnosing Some researchers suggest that the variety of types within BD and subtle differences between them may be an important reason of highly misdiagnosing this disorder (Anderson et al., 2012). Subsequently, persons with this disorder do not react accurately and do not seek help when they experience a hypomania or a mania, but mostly search for help when they are in a depressed mood (Belmaker, 2004). Identifying BD is difficult; since it is highly based on self reported symptoms of the patient (Merikangas et al., 2007). While depression is very perturbing and relatively easy to diagnose, a hypomania is mainly perceived as the normal behaviour of the person and will not be reported as much as the depression sides of BD. Therefore, identifying hypomania and subsequently diagnosing Bipolar II Disorder is difficult. As a result of this, unipolar depression in which hypomania or mania is absence, stays an uncertain diagnosing (Angst et al., 2007). Besides the confusion with unipolar depression, many other diseases have overlapping criteria with BD. For example, the recognition of BD in youth could be complicated, since psychiatric co morbidity and overlap of symptoms with more prevalent disorders are mainly seen. An example is the attention deficit of patients, called the hyperactivity disorder (ADHD) and is very common in youth (Birmaher et al., 2006). ADHD can be characterized with hyperactivity or distractibility, which is also present in paediatric BD (Axelson et al., 2006; Birmaher et al., 2006). Mood symptoms and severe irritability in ADHD are confusing factors, because they do not always meet full criteria for BD (Hazell et al., 2003). Other overlap of symptoms and co morbidities, such as anxiety has also been reported in youth with bipolar disorder (Biederman et al., 2004). According to Krishnan’s literature study, also alcohol and substance abuse can coexist with BD. Furthermore eating disorders and borderline personality disorder is identified as common coexisting diseases with BD (Krishnan, 2005). The symptom overlap with several diseases and possible co morbidities can delay the accurate diagnosis and treatment of BD, leading to an uncertain diagnosis and consequences for the daily life of the patient.

Diagnostic opportunities Besides the issues in diagnosing, also some opportunities for diagnosing BD can be mentioned. Some research has indicated that the prefrontal cortex is correlated with depression in BD (Ketter et al., 2001). Reductions in prefrontal cortical metabolism (which is associated with controlling impulsive behaviour) and an increase of Thalamus and Amygdala metabolism can be seen in bipolar depression (Ketter et al., 2001). Malhi and his co-workers suggest that these patterns could have potential diagnostic significance (Malhi et al., 2004). Furthermore an article of McClure suggests that patients with BD are making more often mistakes when they have to interpret the facial expressions of other people, at least in experimental setting (McClure et al., 2005). This finding was also present in children, who were not symptomatic during the study, suggesting that difficulties with the recognition of the expression in the faces of people are not a symptom, but a part of BD. Interestingly, this difficulty is even more negatively affected during mania (Altschuler et al., 2005)

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2.4. Treatment of Bipolar disorder The treatment of BD often consists of a combination of medication, psycho-education, psychosocial support and counselling and psychotherapy, and must be tailored as much as possible for each patient. In the Netherlands, the outpatient treatment is mostly given by psychiatrists, psychiatrists in training, social-psychiatric nurses and psychologists. Each of them serves a specific part of the treatment, and often a patient is treated simultaneously by more than one health professional. The treatment of Dutch psychiatric organizations is in general based on the latest insights and guidelines, which are issued by Centre for Bipolar disorders (in Dutch: Kennis centrum Bipolaire stoornissen) and organized according to the regional care program mood disorders. The main focus of the treatment is the stabilisation (euthymic mood) of the patient with depression or mania. The goal for a prolonged time is for example the prevention of relapse, the enhancement of occupational and social functioning and the minimization of sub threshold symptoms. A big issue in the treatment of mania and depression in BD is the complexity of the consequences. The same treatment that should alleviate the depression mood can cause (hypo)mania or rapid cycling, while the treatments that should reduce (hypo)mania could cause depressive episodes (Geddes and Miklowitz, 2013).

Long-term treatment The best long-term treatment for BD seems Lithium, a metal that was first introduced by John Cade in 1949. Although Lithium is in use for at least 50 years in clinical practice, Geddes and his co-workers presented a convincing long-term efficacy evidence of this drug in 2004. They performed a randomised clinical trial, in which Lithium was used as an active comparator (Geddes et al., 2004). The trials in their article indicated that Lithium could reduce the risk of depressive relapse with 28% and manic relapse even with 38%. Also, the risk of suicide is decreased of more than 50% as an effect of Lithium, which is the only known anti suicidal treatment with randomised evidence (Cipriani et al., 2005). Besides Lithium, antidepressants are widespread used to stabilize the depressive mood in BD. However, the evidence for efficacy of these medicines is scarce (Geddes and Miklowitz, 2013).

(Non) compliance of Bipolar disorder patients Interestingly, some studies show that patients with BD often do not take their medication as prescribed by their physician. An example is the 2-years study of Colom and his colleagues, in which they show that approximately 40% of euthymic BD patients were not adherent to their medication to some extent (Colom et al., 2000). Another study showed that 51% of the patients, who were hospitalized for manic episodes, were thereafter not compliant to their pharmacotherapy to some extent in a 1 year during follow up (Keck et al., 1997). There are several reasons that are mentioned by patients for non-adherence to medication, but the most common was denial of need. Others factors were associated with the feeling of that the mood is controlled by medication and the feeling of being diagnosed with a chronic illness. Also, feeling depressed and experiencing that taking medication regularly is a hassle were mentioned as reasons for non-compliance (Pope and Scott, 2003).

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2.5. Diagnostic teams There are two organizations that are important for this research, because the data is gathered mostly from these organizations. Therefore, this paragraph explains the diagnostic teams at these locations. GGZinGeest Bipolar and Altrecht Bipolar are both a specialised department of the psychiatric organizations GGZinGeest and Altrecht in Utrecht. Both organizations provide diagnostics, consultation and outpatient treatment to people with bipolar mood disorder. The departments participate in the Centre for Bipolar Disorders (in Dutch: Kenniscentrum Bipolaire Stoornissen). Patients are referred to these organizations if they are already diagnosed with BD or if there is a presumption for BD. The diagnostic Bipolar team consists of psychiatrists, physicians in training (to become psychiatrists), social-psychiatric nurses and psychologists. However, the psychologists who are available have not much working hours in a week. Altrecht Bipolar is a TOP-GGZ clinic, which is intended for patients with severe, complex and/or rare diseases who have insufficient results from the normal second line treatment. TOP-GGZ departments meet strict criteria in the areas of special diagnostics and treatment, scientific research, innovation and knowledge and are assessed by an independent review committee. GGZ inGeest clinics are an academic workplace for BD (in Dutch: Academische Werkplaats Bipolaire Stoornissen (AWBS)), which integrates ambulatory patient care by research and education. Besides regular second line care for the entire spectrum of patients with bipolar mood disorder, an AWBS offers third line care for complex patients, also in the form of consultation and second opinion. The diagnostic Bipolar team consists of psychiatrists, physicians in training (to become psychiatrists), social-psychiatric nurses and psychologists.

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3. Theoretical background For the deeper understanding of the scope of this research, this section presents necessary models and theories. The concepts in the model play a central role in this research and therefore the underlying theory and relevance in this research is described. Subsequently, these concepts are linked to each other through a newly created theoretical framework. Hence, the sub-questions are formulated from the theoretical framework.

3.1. Introduction to the theoretical framework As earlier mentioned in the introduction, the correct diagnosis of BD lasts at least 7 years and the disease is mainly confused with several other disorders, like unipolar depression or ADHD. The diagnostic process of BD seems to face challenges. In order to contribute to a more efficient diagnostic process, an insight of the current daily practice in role division of the professionals in the multidisciplinary teams (MDT’s) who are involved in the diagnostics seems to be necessary. All already achievable knowledge and expertise within a diagnostic team should be compiled and used in an efficient manner, leading to a more accurate diagnostic process. This process cannot be carried out by an individual but necessitates a multidisciplinary organizational level (Crossan et al., 1999), wherein the roles of different disciplines involved in the diagnostic process of BD are initially clarified and are known by each team member (Orchard et al., 2005).

3.2. Multidisciplinary collaboration/team A MDT is a team of several professionals or health care providers, in which the perspectives and the expertise of these professionals is recognized and valued. It enables ‘a partnership between a team of health professionals and a client in a participatory, collaborative and coordinated approach to share decision-making around health issues’ (Orchard and Curran, 2003), such as diagnostics. In recent years, various promoting models about health care teams are described by several authors (Mickan & Rodger, 2005; D'Amour & Oandasan, 2004; Orchard et al., 2005). However, there seems to be many challenging aspects in effectively implementing the suggested structures of the teams. The key aspects of multidisciplinary collaboration are according to Silen-Lippenon and co workers (2002): knowledge sharing, readiness to assume responsibility for outcomes of patient care, joint intellectual planning of tasks and non-hierarchical team decision. However, Henneman et al. (1995) indicated that collaboration is often lacking in the context of the team. Many literatures suggest that fear of the loss of professional identity (Atkins, 1998), differing value systems (Robinson & Cottrell, 2005), professional power imbalances (Orchard et al., 2005) interdisciplinary fragmentation (Mechanic, 2000) and role confusion (Henneman et al. 1995; Orchard et al., 2005), occurs within collaborative environments. For example, it is identified that specialist nurses feel difficulties with the cultures of other disciplines, although they understand very well patient knowledge and beliefs (Benner, 2001). Despite of the challenges in MDT working, also many benefits can be mentioned.

Benefits of MDT working A diverse composition of a team can increase the chance that each patient is offered the most appropriate diagnosis and treatment plan. This is because the plans will be based on a range of expert knowledge from the beginning, and all aspects that can influence the diagnosis and treatment options will be considered (Ruhstaller et al., 2006). This approach is especially

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important and essential in more complex cases, especially when the timing and choice of different diagnosis and treatment options is complicated, for example due to co morbidities. The open nature of peer review at a multidisciplinary meeting could make teams more accessible for change for delivering quality improvement initiatives (West et al., 2003). Besides the improved clinical outcomes, MDT working could also improve the coordination of services. Through regular meetings, team members will become more aware of avoidance of the duplication of examinations and investigations, efficient ways of diagnostics and treatment planning and simplification of referral processes between professionals (Ruhstaller et al., 2006). In addition, MDT working could also result in more consistent information for the patient, because each team member is aware of their own and other team members’ roles when they provide information to patients (Carter et al., 2003). Healthcare professionals could benefit in several ways too (Carter et al., 2003), for example, from a mutually supportive environment and reassurance from corporate decision making. This is important in especially complex cases where an appreciation of the specialist knowledge and different viewpoints of colleagues might be essential (Edwards, 1998).

MDT, timely diagnostics and positive clinical outcome Strong clinical consensus arising from the UK national survey supports the accumulating evidence for benefits of MDT working. Taylor and Ramirez show in their study that at least 90% of the participants assented that effective team working, such as a MDT, have improved clinical decision-making. It also lead to more evidence based treatment decisions and thus improved diagnostics and treatments, because an effective multidisciplinary team could deliver more coordinated patient care (Taylor and Ramirez, 2009). Also Chang et al. shows evidence that MDTs are linked with positive patient experience. He and his co-workers set out two observational studies in breast cancer and these studies indicated that MDTs indeed lead to more evidence based and timely diagnostics and treatment (Chang et al., 2001). Junor and his co-workers (1994) stated that that care by a MDT has the potential to significantly increase survival. Many other benefits can be mentioned from the literature, for example increasing resection rate of lung cancers (Davison et al., 2004), improving the health outcome of elderly inpatients after discharge (Caplan et al., 2004) and reducing medication variance (Sim and Joyner, 2002). In a US study, the initial treatment recommendation for women with breast cancer was changed following a second opinion of a multidisciplinary panel in 43% of the cases (Chang et al., 2001). Pfeiffer and Naglieri acknowledged already in 1983 that the multidisciplinary decision-making process is able to significantly reduce the wide variations in decisions made by professionals who are acting independently (Pfeiffer and Naglieri, 1983). Articles about multidisciplinary collaboration and teams in mental health care specifically are scarce, however articles about MDTs in cancer and diabetic care show the importance of this collaboration for positive patients outcome. Examples of cancer studies in which MDTs are linked with positive outcomes are mainly from the last decade. Studies from the UK show that MDTs can be associated with ameliorated five-years survival in colorectal cancer (Morris et al., 2006). It is also linked with improved five-years survival in oesophageal cancer (Stephens et al., 2006). Besides that Birchall showed an ameliorated two-years survival in head and neck cancer (Birchall et al., 2004). Interestingly, the improvements were highest in for example breast, colorectal and

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lung cancer, which are cancers for which MDTs were more established, in comparison with urological cancers where guides for MDT working was not published until 2002. Furthermore, one article showed significant improvement in amputations rate due to diabetes through MDT working and continuous audit (Krishnan et al., 2008).

Achieving an efficient MDT- phases Working in a MDT seems to have several benefits for both patients as professionals, since the professionals can experience for example an improved job satisfaction (Taylor and Ramirez, 2009). There are requirements that will lead to a successful collaboration, like the importance of a common purpose, conflict management, methodology, flexibility in meeting goals, guaranteed resources and leadership, communication processes and skills awareness (McPherson et al., 2001). Orchard and his colleagues described the process and identified some core concepts of an efficient MDT. He explains that achieving an efficient MDT needs different phases and enablers (see Figure 3). The phases are the sensitization, exploration, implementation and evaluation phases. In the sensitization phase of the process for establishing an efficient MDT power balances and varying values are challenged (Glenn, 1987). This phase creates awareness of the current practice in the team, since professionals explore the meaning of their roles and the daily decision-making process. This means that it is needed that tacit unaware knowledge must evolve in explicit aware knowledge of professionals about for example their added values of their roles. The process of creating explicit knowledge can be realized by reflective learning and is also explained in the research approach in the methodology section of this report. This ensues in the next phase; during the exploration phase all professionals explore their roles and seek clarification of the value they each bring to the team collaboration about for example the diagnostic process. Throughout the implementation phase, the team work with the patients to gain an insight or understanding of how each member’s role can be valued and how power can be shared in the team. In the last phase, evaluation, all professionals assess the effectiveness of their collaboration multidisciplinary teamwork on patient’s satisfaction with their participation. In this way, reflective learning can be realized and an MDT can be made iteratively more efficient, resulting a better diagnostics of BD. As indicated before, in the sensitization phase, some aspects or barriers are challenged. These barriers for an efficient MDT are identified as: organizational structuralism, power imbalances and role socialization. Organizational structuralism is about bureaucracy and requirements of authorities. The MDT has to convert these aspects in a positive environment, where professionals are supported in their work. Power imbalances can be caused by role conflict, like preconceptions that professionals have of their own role, overlapping competencies and responsibilities and stereotypic perceptions that professionals hold of members of their and other disciplines (Laschinger et al., 2003). Bringing different cultures together in a MDT is also challenging and professionals have to go through a socialization process (Clark, 1997). Therefore, health professionals must deal with the fact that the boundaries of practice are blurred and must trust each other and members of other disciplines in sharing the patient care (Clarke et al., 2002).

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Achieving an efficient MDT- enablers Figure 3 shows also several enablers of a MDT, including trusting relationships, power sharing, role clarification and role valuing. Orchard identified development of trusting relationships as where each member trusts the decision-making capacity, the knowledge, and the sense of ethics of each group member and power sharing where a willingness exists to facilitate joint power sharing within the group (Orchard et al., 2005). The last suggest that decision-making power must be shared with other members of the team. ‘Level of trust’ is described as a belief that other team members are accessible, dependable and acting with moral intent (Lindeke and Block, 1998). Trust is an important element in effective MDT and when it is lacking team effectiveness can be undermined (Orchard et al., 2005). Developing trusting relationships among MDTs creates synergy and tolerance of assertiveness, enhanced communication and shared decision-making about e.g. diagnostics (Laschinger et al., 2003). Another important aspect of a MDT is the role clarification of the involved professional, where this research focuses on. One of the challenges of MDT working is achieving clear definitions of the professionals’ roles and expectations with regard to shared care. This research’s scope is the allocation of roles within the MDT, because clearly defining practitioner roles and responsibilities will enhance the positive elements of the collaborative relations and reduce the possibility of ambiguity and misunderstanding regarding procedures, protocols, authority and responsibility (Paquette-Warren et al., 2004). Just as there is overlap in symptoms of BD and other disorders, there is much overlap in the tasks of the involved professionals. A clear task division in the diagnostic process could minimise misunderstandings between professionals and possible vagueness of roles within the MDT (Jenkins et al., 2001).

Figure3:theprocessofachievinganefficientMDT.(Orchardetal.,2005)

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3.3. Role clarification in the MDT An important reason of focussing on role clarification in the MDT is explained by Orchard and his co-workers. Namely, according to them role clarification and role valuing is one of the important enablers of multidisciplinary collaboration between professionals. The better the multidisciplinary collaboration, the more efficient the diagnostic process. The role clarification is defined as ‘gaining an understanding of both the roles assumed by each member of a group and their requisite knowledge in exercising the same’, while role valuing is defined as ‘respect shown for each other based on of each members knowledge and contribution to the team’ (Orchard et al., 2005, p.3). When each member of the MDT develops a clear understanding of the added values of each role and the contribution to the diagnostic process, respect will develop (Orchard et al., 2005). In addition the valuing of the roles in the MDT by the professionals will facilitate new ideas, sharing of responsibility and disagreement. A climate of respect and openness will be created in which expression of feelings and opinions is guaranteed, if professionals can value the contribution of each member in the MDT (Mariano, 1998). This research focuses on the role clarification part in the model suggested by Orchard, since the model suggests that role clarification comes at first in the exploration phase in order to go further in the process of achieving an efficient MDT. In addition, collaboration that is a interdependent relation, requires according to Makaram the recognition of complementary roles in a team (Makaram, 1995), suggesting that role clarification are the core of a successful MDT. By discussing the added values of the different professions and values and beliefs related to how the professionals wish to work together, they can develop a shared vision for a good collaboration (in order to get an more efficient team). An antecedent to formulating this shared vision is according to Ingersoll and Schmitt (2004) the establishment of what professionals’ expectations will be from each other and clarifying what each other’s roles and beliefs are about the MDT.

3.4. Theoretical framework The relation between the concepts and the theory explained above are gathered together in a theoretical framework as showed in Figure 4. The psychologists, psychiatrists and nurses collaborate in the diagnostic process of BD and constitute a multidisciplinary team (see methodology section). As summarized in the contextual background, several challenges are in the literature described as challenging during the diagnostic process. It is important to investigate whether and which challenges the professionals experience in practice. That is a good indication to have an insight in the diagnostic process in practice, and eventually optimize the diagnostic process of BD. Besides that, as mentioned before, one of the essential prerequisites of an effective multidisciplinary collaboration between the professionals is the clarification of the different roles in the diagnostic process of the members in the team. Thereby, it is essential that the professionals are aware of each other’s added values of their roles in order to compile the already achievable knowledge and expertise of the professionals. Clarifying the different roles in a MDT and creating explicit knowledge can contribute in making the diagnostic process of BD more efficient. The process at the left side of the model in Figure 4 is the process described by Orchard and his co-workers for achieving an efficient MDT. According to this model, this process starts with the awareness of the professionals of their roles, role clarification. Because of the importance of role clarification in this model and according to other articles described above, all other boxes are

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given a grey colour. These grey boxes are meant for creating a better understanding of the ‘role clarification’ concept and are not included in the research scope.

Figure 4: Theoretical framework (left part from Orchard et al., 2005)

3.5. Sub-questions The sub-questions are derived from the theoretical framework and are as follows:

1. What are the challenges in practice endured by professionals during the diagnostic process of BD?

2. What are the added values of the roles of the psychiatrists in order to get an efficient MDT for an efficient diagnostic process of BD?

3. What are the added values of the roles of the nurses in order to get an efficient MDT for an efficient diagnostic process of BD?

4. What are the added values of the roles of the psychologists in order to get an efficient MDT for an efficient diagnostic process of BD?

Efficientdiagnosticprocess

Efficientmultidisciplinaryteam

-Organizational

structuralism -Power imbalances

-Role socialization

-Role clarification -Role valuing

-Trusting relationships -Power sharing

-Team process

-Team member satisfaction

-Client outcomes

Evaluation

Sensitization

Exploration

Implementation

Challengesinpracticeindiagnostics

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4. Methodology This chapter describes the methods that are used for this research and is divided in three sections: the research strategy, research approach and the research analysis.

4.1. Research strategy This research aims to clarify the challenges in practice during the diagnostic process of BD and the added values of the roles of professionals in the MDT who are involved in the diagnostic process in order to make the multidisciplinary collaboration between them more efficient. For this purpose, an explorative qualitative research method was used, in order to get more insight in the perspectives of professionals. An exploratory research "seeks to find out how people get along in the setting under question, what meanings they give to their actions, and what issues concern them. The goal is to learn 'what is going on here?' and to investigate social phenomena without explicit expectations." (Schutt, 2014, p5.).In this research two types of data gathering methods were used: focus groups and interviews. A focus group method is very suitable in this research, since it is a type of qualitative research, in which the researcher obtains opinions of the group members (professionals) related to a specific topic (BD). The group members of these groups are recruited based on pre-specified qualifications (professionals’ role in the diagnostic process) and their experience in the diagnostic process of BD. Therefore, this research focuses on three professionals who are involved and experienced in the diagnostic process of BD: psychiatrists, psychologists and nurses. A big advantage of conducting a focus group in this research is creating a discussion that can produce insight that would be more difficult to generate without interaction in a group setting (Lindlof and Taylor, 2002). The memories, experiences and ideas of the professionals can be stimulated when they listen to each other’s verbalized explicit experiences and roles in diagnosing. This is the group effect in which the focus group members show a kind of ‘chaining’ or ‘cascading’ effect (Lindlof and Taylor, 2002, p.182). If available and achievable, focus groups were preferred. However, if the team consisted of just one professional with a specific profession, an interview was planned. An accessory advantage of interviewing professionals was the anonymity of the interviewee, whereby interviewees had the opportunity to be more on their ease.

Focus group and interview design The focus groups were designed as homogenous groups, because homogenous groups generally are more open and comfortable with each other and can create a higher degree of interaction and valuable data (Lindlof and Taylor, 2002, p.182). Therefore the focus groups in this research are designed with only one profession of the three professional types of nurses, psychologists and psychiatrists. Furthermore, almost all professionals are recruited from three locations: GGZ inGeest Bipolar Hoofddorp, GGZ inGeest Bipolar Amsterdam and Altrecht Bipolar in Utrecht. The professionals are an essential part of the bipolar team at these locations. Also two other organizations are contacted, because the absence of psychologists in the team of GGZinGeest Hoofddorp and Amsterdam. They are contacted via mailing and via previous connections and collaborations. The meetings lasted for about an hour and are planned at the work location of the professionals. The focus groups are planned in a time span of five months, September 2015 until January 2016.

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Figure 5 elaborates the gathered data within these five months. The nurses and the psychiatrists are all interviewed in a focus group setting. All psychologists are interviewed, there was only one focus group setting with two psychologists. In the end, a total of nine meetings with professionals were arranged.

Figure 5: Elaboration of five focus groups and four interviews. The numbers in parentheses are the amount of arranged meetings at the end of the data-gathering phase. Most interviews are held with psychologists (at different locations), due to their absence at GGZinGeest Bipolar in Amsterdam and Hoofddorp.

The focus group design can be found in the appendix. In this design, the challenging aspects of diagnosing a patient with BD are investigated (for each discipline). Initially, it is important to get an insight in the challenges of the diagnostic process of BD in practice. The literature shows us many challenges, however for making this research complete and implementable in practice, the challenges faced in practice by professionals of the MDT are included. To minimize these challenges and to contribute to a more accurate diagnostic process of BD an effective MDT is required. The professionals are asked to think about the challenges of diagnosing BD and to write them down on post its. All post-its are discussed and related topics are stuck together on an A3 blanch poster. Furthermore, the opinions/perspectives of each discipline about the added value of their discipline and the added value of their colleagues who are involved in the diagnostic process of BD are questioned. For this exercise, forms that group members could fill out, were made and printed beforehand.

4.2. Research approach In order to clarify the added values of the different roles within the multidisciplinary teams of the bipolar units of included locations, the reflective learning approach is used. Schön stated already in 1983, that reflective learning is all about the capacity to engage in a process of continuous learning and to reflect on actions or behaviour (Schön, 1983). According to Bolton (2010), reflective learning involves critical attention paying to the practical theories and values. These theories and values are about everyday actions. Paying critical attention to these everyday practices, like roles of several professionals in the diagnostic process of BD, increases the developmental insight (Bolton, 2010). Furthermore, reflective practice can be an important tool in practice based professional learning settings where people learn from their own professional experiences. It is also an important way to bring together theory and practice; through reflection a person is able to see and label forms of thought and theory within the context of his or each other’s work (McBrien, 2007). The act of reflection is seen as a way of promoting the development of autonomous, qualified and self-

• Psychiatrists (2)• Nurses (2) • Psychologists (1)

Focusgroups(5)

• Psychiatrists (0)• Nurses (1) • Psychologists (3)

Interviews(4)

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directed professionals, as well as a way of developing more effective healthcare teams (Ghaye, 2005). Engaging in reflective practice is associated with improved quality of care, stimulating personal and professional growth and closing the gap between theory and practice (Jasper, 2013) Medical practitioners can combine reflective practice with checklists, like SCID, to reduce diagnostic error (Graber et al., 2012) As said, for a better diagnostic process of BD, a MDT is required in order to get all expertise that are needed for the diagnostic process together. As this process is difficult due to several reasons (e.g. co morbidity), a clarification of different roles within the team and subsequently a more efficient collaboration between health professionals who are involved in the diagnostic process seems to be a prerequisite for achieving better results in BD. Reflective practice promises, as described above, several opportunities in order to minimise the diagnostic error in BD. In this research, reflective learning is used as an approach, in which giving feedback and getting aware of the added values of the roles of different disciplines important aspects. Especially focus groups create a platform in which professionals can discuss their roles and get aware of their unconscious (tacit) knowledge. In this research is tacit knowledge the roles in the MDT about the diagnostic process of BD. Clarifying and valuing the roles and recognizing and appreciating the added values of the colleagues will make this tacit knowledge explicit. This is important, because awareness of the roles can be the first essential step to eventually redesign or change some protocols in the multidisciplinary teams.

4.3. Research analysis The analysis phase of the research aims to find patterns that emerge from the gathered data. During the focus groups, a voice recorder was used to record all verbal data. All these data are transcribed in a document. After this step, ‘adding comments’ function was used to add comments in Word in the transcribed text about the themes, concepts or ideas that stand out. These themes are arranged in an Excel table to oversee the related themes or categories. In this way, a beginning of different themes or categories within the faced challenges in practices of the professionals and the added values of each other’s roles was made. The next step comprised sieving of the data by highlighting and sorting quotes. At this phase, the most important task is reducing the data by contrasting and comparing data via the overview of the table in Excel and rearranging similar quotes together and deleting unnecessary quotes. The data were then ready for the last phase of analysing: interpreting the data. In this phase, it was important to make sense of the individual quotes, but also to make an analytical translation to see the relationships between the quotes and the themes. The stages described above are called ‘open coding’, in which the formulated concepts and key words are reduced to a concise description (Strauss and Corbin, 1990). This is thus done by determining the key concepts and by formulating the essence of the relations between the key concepts.

Validity There are some artefacts that can affect a research design like maturation, sample selection and researcher bias. The type of people included in the focus groups and invited for interviews, also called the sample selection, is obviously very important. It is from high importance to ensure that the participants are homogenous in several aspects. In this research, the professionals are divided on their profession. The focus groups are arranged with only one profession in order to get a

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homogenous group, in which the focus group members are more likely to be comfortable with each other. All professionals of the bipolar team at the locations are invited indiscriminately. Maturation could be in focus groups when the respondents display signs of anxiety to be open or boredom. The responses of the participants are in that case not legitimate. In this research, the focus groups are conducted and guided by experienced researchers in order to minimize the maturation bias by signalling possible problems and give everyone approximately the same speaking time. Besides that, the interview setting gives the professionals the opportunity to be more open. Researcher bias can occur when the researcher (mostly unconsciously) influence the results of the research by mistakes in for example data recording, questioning and interpretation. The focus groups in this research are conducted or guided by experienced researchers. There are always multiple researchers present, which could have increased the detection of this bias by giving each other feedback.

Ethical consideration The ethical consideration in this research consists of several aspects: privacy and anonymity, confidentiality, data ownership and informed consent. The privacy and the anonymity of the group members are considered, since no names are mentioned in the research report. The meetings are recorded, after the researcher asked consent to all group members. The records are treated as confidential and copies were deleted from the disk when it was transcribed, where the original tapes are stored at a disk that requires personal codes. Only researchers who were involved in this research had the data ownership. It was not needed to sign an informed consent, since the participants are not asked to undergo a health care intervention.

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5. Results This chapter of the report is divided in two sections in which it sets out the results of the gathered data from focus groups and interviews with professionals. The first section presents the results about the challenges in the diagnostic process of BD, where the second session presents the results of the added values of the roles of several professionals who are involved in de the diagnostic process. The professionals are: the nurses, psychiatrists and the psychologists. Each subsection starts with a short summary in which the important aspects are underlined. These aspects are explained later on with illustrating quotes.

5.1. Challenges in the diagnostic process Professionals seem to face some difficulties in de diagnostic process, as the diagnosis of BD is not always accurate. After the analysis of the gathered data, seven main themes about these difficulties or challenges emerged: unreliable anamnesis, difficulties with hetero-anamnesis, character of the patient, co morbidity and symptom overlap, DSM, practical issues and course of disorder and time.

Unreliable anamnesis Some professionals mention the unreliable anamnesis as a big challenge. As reason for this, issues with the choice made by the patient about what they tell to the professional and the memory of the patient about the past episodes was mentioned. Also, patients can be familiar with the terminology of the disease and are able to use this during the intake with the professionals, which the professionals have to recognize and lance. Some patients are convinced that they have BD and search for it on Internet. Besides that, it is mentioned that the conditions of the patient during the intake can influence the anamnesis. Coming back to the choice of the patient: in some cases patients do not have the desire to mention their hypomania. That means that they choose deliberately to hide information for several reasons. On the other hand, some patients are not able to mention their hypomanic episodes even though they would like to report it. The memory of the patient leaves them in the lurch. An example is: ‘Years ago, I had a man with recurrent depression. We asked him out, even his environment (family), we did not note hypomania. But he felt better after Lithium was added to Notrilen. When I checked his dossier again, he simply had BD. I discussed his old dossier with him. And then he said: 'Yes, I do not want to know that.’ He was acting, and did his job well with the hypomania, he had the ability to learn everything by heart. He was very well focused, but not derailed. This proves that even if someone says: 'No, I have not had hypomania,' you cannot be sure.’ (Psychiatrists).1 Another point that makes the anamnesis unreliable according to the respondents is the use of terminology of the patient. Nowadays, patients can search the Web for diseases and have the possibility to find out the terminology of BD and use this terminology during the consult, which could be confusing for the professionals. Furthermore, the conditions (like emotions) of the patient during the consultation can have a negative effect on the anamnesis, as some respondents noticed. ‘For example, what also can be an issue is that somebody is already convinced of the fact that he has a BD and uses the terminology. That is also a difficulty.’ (Psychologists)2

1 Ik heb ooit, toen was ik nog in opleiding, had ik een man met recidiverende depressies. Er was goed gevraagd, ook trouwens bij de omgeving, 2Nou, weet je wat bijvoorbeeld ook meespeelt is dat als iemand zelf al wel overtuigd is van het feit dat hij een bipolaire stoornis heeft en iemand gaat ook de taal gebruiken die erbij hoort. Dat is misschien ook een moeilijkheidheid (Amsterdam, psychologists).

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Difficulties with hetero-anamnesis According to professionals, one of the important aspects of getting an overview of the (medical) history of the patient is the heteroanamnesis 3 , because this information is useful for the formulation of a suitable diagnosis. The professionals pointed two main challenges about the heteroanamnesis, first is the non-permission of the patient to consult the GP to gather information about the (medical) history. This is important, because the GP can make a contribution to the diagnostic process with the already gathered information about the medical history of the patient. Another one is the unavailability of the family members or other people who know the patient, examples of illustrating quotes are expounded below. Professionals marked the importance of a good hetero-anamnesis. They mention that conducting a good hetero-anamnesis will provide the professional with information, which can lack in a conversation with the patient alone, but which is information that can be very essential in the diagnostic process: ‘Especially with conditions such as hypomania, which is not mentioned by the patients themselves, a hetero-anamnesis is very important. During hypomania, they feel fantastic. On the other hand, with a mania, you encounter difficulties, but with a hypomania, they will never sign up themselves. Until the partner thinks there is something abnormal.’ (Psychiatrists).4 Sometimes, patients don’t give permission for retrieving more information about the patient at the GP or other related health professionals. This makes a good hetero-anamnesis challenging, the respondents said. ‘Availability of hetero-anamnesis is important. It is difficult if it is not allowed..., if the patient does not want you to contact the GP or other healthcare providers.’ (Psychiatrists)5 The second issue for conducting a good hetero-anamnesis according to the respondents was the unavailability of family members or other relatives of the patient for a conversation. Besides, the professionals do not always see the information from the heteroanamnesis about the patient in practice with the patient. The reliability of the heteroanamnesis is being questioned. ‘Well, sometimes someone just comes alone. We don’t literally ask for a relative in the invitation. It lacks in the invitation, but it also not possible later on. Because the partner is too busy with work, or because the patient doesn’t want it. Or because of a new relation or the parents have already passed away. There are various reasons.’ (Nurses)6

Character of the patient Unravelling the character traits of the patient is very important during the diagnosis. Since hypomania can be applied differently to each patient, professionals mentioned several times that determining the difference between ‘what is normal for that particular patient’ and ‘what is hypomanic for that particular patient’ is sometimes very challenging. Because of this, bipolar type

3 A heteroanamnesis is information gained by the professional by asking specific questions to people who know the patient and can give important and suitable information about the patient. 4Maar het is vooral de hypomanie die ze niet uit zich zelf melden, goede hetero anamnese daarom is heel belangrijk. Tijdens een hypomanie voelen ze zich fantastisch. Kijk manisch, dan loop je tegen dingen aan, maar hypomanie zullen ze nooit aan zichzelf melden. Tot die partner denkt dat hij zich anders gedraagt. (psychiatrists). 5Beschikbaarheid van heteroanamnese is belangrijk. Als het niet mag, als de patiënt het niet wil dat je met de huisarts zelf of met andere hulpverleners contact opneemt (psychiatrists). 6Nou ja, soms dan komt iemand per definitie zomaar alleen. Het is niet zo dat in de uitnodiging staat van: ‘we willen graag dat u iemand die je goed kent meeneemt.’ Dat staat niet in de uitnodiging, maar soms lukt het ook later niet omdat een partner werk voor wil laten gaan of dat de patiënt het zelf niet wil of dat... of er is pas een nieuwe relatie en ouders zijn overleden, nou ja. Diverse redenen. (nurses)

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2 is harder to diagnose, the respondents find. Also, the ‘hypomanic-like mood’ can be a logical result of the past events in the life of the patient. It is challenging but not less important that this distinction can be made from the character of the patient. Besides that, the countertransference is an aspect that needs attention during the diagnostic process. Illustrations are explained below. Because of hypomania is sometimes a great feeling for the patients, they think that a hypomanic episode is just like how they always strived to be in life. Therefore, many patients do not even notice it and don’t mention it during the consultation. It is up to the professional to see the difference between ‘what is normal’ and ‘what is abnormal’ for each patient, and that can be very challenging sometimes, they point out: ‘It can be a part of the character. Besides, the patients don’t sign for a hypomania because they think it is a part of them. How they always wanted themselves to be.’ (Nurses)7 Another illustrating quote of the consideration of the professionals whether a changed mood is a logical result of events or whether it is abnormal for the patient: ‘Is it really silliness or is it a logical consequence? Because very often, positive experiences can increase that sort of mood changes. Or just after a gloomy period, someone is recovering and feels free and fine, which is also quite normal (Psychologists).8 Because of this constant deliberation of the professionals and the manifestation of hypomania is not clear enough, especially bipolar type 2 is hard to diagnose, professionals said: ‘I think, especially bipolar type 2 is very hard to identify. Bipolar type 1 is often clear, because then, people become that much disordered that they must be hospitalized (Nurses).’ 9 Even the patients themselves can sometimes have difficulty with the distinction between their character and their hypomanic episode: ‘People find also themselves very troublesome when they have hypomanic symptoms. It is hard to make a distinction between their normal states and their hypomanic states. (Nurses)10 Another interesting aspect in the diagnostic process is the so-called ‘countertransference’. Countertransference is the influence of the patient on the unconscious feelings of the professional. For example, the expectations of a narcissistic patient can confuse the professional in the description of the right diagnosis. The professionals have to make a well-considered distinction between the character of the patient and the applicable criteria of BD. A respondents explains this as follows: ‘A narcissistic patient for example. Expectations of what you feel (from the patient), of what you need to do, or of what you are deemed to make a clear statement (about the disease), while you think there’re more issues to investigate.

7Dat het zo dicht bij het karakter ook kan liggen. De patiënt vindt een hypomanie vaak niet erg en vindt dat het bij hunzelf hoort. Hoe ze altijd al hadden willen zijn. (nurses) 8Is het nou echt gekkigheid of is het nou ja, een logisch gevolg? Want heel vaak zijn het natuurlijk ook positieve ervaringen die die stemmingen kunnen verhogen. Of juist na een sombere periode dat iemand zich juist weer helemaal vrij en lekker voelt, wat ook heel normaal is (psychologists). 9Ik denk dat met name de bipolaire 2 heel moeilijk te stellen is. Bipolaire 1 is vaak wel duidelijk met... als mensen zo ontregeld raken dat ze opgenomen moeten worden. (nurse) 10Mensen vinden het zelf ook heel lastig als ze bijvoorbeeld hypomane klachten krijgen dan vinden ze dat moeilijk los te koppelen, in mijn optiek, vaak wat hun normale ik is en wat hun hypomane ik is (GGZinGeest Amsterdam, nurses).

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It makes you kind of uncertain, uncertain is not the right word, but the intake is more uncomfortable.’ (Psychiatrists)11

Co morbidity and symptom overlap Almost all professionals mentioned co morbidity as one of the most challenging aspects in the diagnostic process of BD. Besides that symptom overlap with different other diseases makes diagnosing BD also very challenging. BD is a mental disorder, which is according to the professionals very related with other disorders, like: borderline personality disorder, autism, substance abuse (addiction) and ADHD. Professionals mention that these diseases can have symptom overlap with BD, but also can coexist at the same time with BD (co morbidity). Some professionals specifically mentioned Cluster B personality disorders, of which patients with BD can also be related with. Cluster B is a categorization of personality disorders and includes narcissism and borderline personality disorder. This category can either be co morbid with BD or have strong symptom overlap. Another confusion that makes diagnosis of BD challenging is according to many respondents that BD is also commonly misdiagnosed with recurrent unipolar depression, due to the hardly recognition and/or overlooking of hypomania (BD has great symptom overlap with unipolar depression). Another reason why professionals can see BD as recurrent depression is the likeliness that people only seek help when they are getting through a depression, while hypomania mainly does not lead to big problems in daily life, professionals said. Alcohol abuse, substance abuse and many more deficiencies can coexist with BD or have enormous symptom overlap with BD. It is up to the professionals to make a distinction whether a symptom is resulted from a BD or another disease, or whether it is both, professionals noted: ‘Alcohol and substance abuse, thus comorbid addiction, is a big problem. Because it has a lot of overlap in symptoms. It can get worse in depressive episodes or manic episodes. If you look at addictions, it has a great overlap. I think, that (co morbidity) is particularly the most challenging in diagnosing.’ (Psychiatrists).12 Distinguishing a particular disease or condition from others that have the same symptoms is also called differential diagnosis, as one professional mentions the challenging aspect of it: ‘I think, especially the co morbidity and differential diagnosis can sometimes be quite difficult to clearly distinguish from one another. So you count in symptom level, are the criteria for hypomania or mania met? If so, it is actually a BD, but sometimes we are a bit puzzling like: 'yes, but is this not a result of another disorder?’. Such as autism, such as personality disorders, such as ADHD’ (Psychologist).13 Making a distinction between symptom overlap and personality traits is very hard and is mentioned several times during the focus groups, like:

11Een narcistische patiënt bijvoorbeeld. Verwachtingen wat je voelt, wat je moet doen, of geacht wordt een duidelijke uitspraak te doen, terwijl je denkt volgens mij is er hier nog meer aan de hand. Waardoor je een soort van onzeker, onzeker is niet het goede woord, ongemakkelijker in de intake zit (GGZinGeest Amsterdam, psychiatrists). 12Alcohol en substanceabuse, dus co morbide verslaving, dat is een groot probleem. Omdat dat ook veel overlap geeft in symptomen. Het kan indrinken in depressieve episodes of manische episodes, als je naar verslaving kijkt, heeft dat een geweldige overlap (GGZinGeest Hoofddorp, psychiatrists). 13Ik denk vooral de co-morbiditeit en de differentiaal diagnostiek, die soms best wel lastig kan zijn om dat goed van elkaar te onderscheiden. Dus dat je dan op symptoomniveau wel telt van, ja, is aan de criteria van een hypomanie of een manie voldaan? Najah, dan heb je dus eigenlijk een bipolaire stoornis, maar dat soms wij een beetje zitten puzzelen van ‘ja maar komt dit eigenlijk niet voort vanuit een andere stoornis?’, zoals autisme, zoals persoonlijkheidsproblematiek, zoals ADHD (psychologist).

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‘It is also difficult to diagnose if someone has also comparable personality traits. It can overlap. And other diseases can manifest as well, which can coexist with the hypomania’ (Nurses).14 It is also mentioned that symptom overlap or the vague distinction between the character of the patient and the disease symptom can lead to difficulties with the ability to make retrospective look on the disease course: And cluster B, which is really inconvenient, whereby mood swings also play a role. There’s often so much going on. Therefore, you’re not always able to have a retrospective look: ‘was this a hypomania?’ or ‘was it a reaction to anything else?’ (Psychologists)15

DSM There are some challenging aspects about the DSM according to the respondents. Some mentioned that the DSM gives a definition of BD, which is sometimes controversial with the course of the disease. The professionals mentioned several times that despite of the essential role of the DSM in the diagnostics; some problems can occur. First of all, it is several time marked that the definition of BD is very vague and at the same time very strict, since a person with four days (hypo)manic symptoms already fits in the criteria. Concurrently, BD has aspecific symptoms that do not always fit in the criteria as described in the DSM, professionals said. They added that the group of people who are potential BD patients, are mainly very heterogeneous. To summarize, one professional used a metaphor and compared the DSM criteria with a baggy T-shirt, which does not fit in many cases: ‘Well, the classification consists out of a description of several symptoms… and mainly people do not fit in the description according to the ‘famous’ DSM classification. It is a little of this and also a little of that. It just does not fit. Like a baggy T-shirt, you can say.’ (Nurses) 16 When a patient has a four days hypomanic episode, the criteria for BD is met according to respondents, noting that the criteria are a difficult grey area. The difficulty of diagnosing BD following vague criteria in the DSM in a short time, while BD is a disease that evolves in time, is mentioned. ‘The diagnostic process is difficult, because according to the DSM, somebody has already BD when he had just four days mania of manic symptoms. It is a grey area, but at the same time it is very definitive to diagnose somebody with BD based on just a few days. Besides that, it is a disease that develops in time, so it a bit contradicting.’ (Nurses)17 Professionals find it sometimes difficult to put symptoms in a box of the DSM. This is according to the professionals due to the great symptom overlap with other diseases and the aspecific character of symptoms of BD. Despite of this the definition of BD in the DSM seems very clear, in practice it is very vague as respondents noted. This can make the diagnostic process very challenging.

14Wanneer het ook lastig is, vind ik, om een diagnose te stellen is als er iemand inderdaad persoonlijkheidstrekken doorheen heeft lopen. Dat overlapt elkaar. Andere ziektebeelden die er doorheen lopen (nurses). 15En die cluster B die is wel echt lastig. Waarbij die affectwisselingen ook wel heel erg spelen. Er is gewoon zoveel aan de hand vaak. Dat je ook niet altijd retrospectief echt kan aanwijzen ‘is het nou een hypomanie geweest’ of ‘was het een reactie op wat dan ook’? (psychologists) 16Nou ja, dat een classificatie, is een omschrijving van een aantal verschijnselen…en mensen passen eigenlijk heel vaak niet precies in de beschrijving zoals wij die voor .... hè officieel via de DSM de beruchte, beroemde DSM moeten doen. Dus dat maakt het ... denk je ja, het is een beetje dit en ook een beetje dat en het is ook wel dat en ja dan sta je beetje... Van ja, het past eigenlijk niet zo goed of het past net niet. Een beetje een ruim zittend T-shirt zal ik maar zeggen. (nurses) 17Wat lastig is om een diagnose te stellen is dat volgens de DSM iemand al een bipolaire stoornis heeft als die 4 dagen manisch is of manische symptomen heeft. Het kan nog een beetje grijs gebied zijn maar het is ook wel heel erg definitief gelijk hè, om iemand een diagnose bipolaire stoornis te geven op basis van een aantal dagen. En het is eigenlijk een beloopziekte, dus ik vind dat een beetje elkaar tegenspreken. (nurses).

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‘The symptoms (of BD) are often aspecific and the group of BD patients are very heterogeneous. So, you never know exactly which complaint is a consequence of which disease. In general it looks like BD is very clearly defined, however in practice that is very disappointing. Sometimes you think it a symptom linked to BD, but later on it is not.’ (Psychiatrists)18

Practical issues Besides the challenges about the anamnesis, the character of the patient and co morbidity, professionals mentioned also some practical issues, which professionals cannot influence. Firstly, professionals saw their specialisation in BD also as a pitfall because they will relate some symptoms too easily to BD, while the same symptoms may be induced by other disorders. Secondly, before the patient is referred to the bipolar specialised department, he or she sees other professionals like the GP, the professionals mentioned that the unawareness of professionals outside the Bipolar specialised team can also lead to difficulties in an accurate diagnostic process of BD. Additional to this, it is also noted that measuring instruments, like a MDQ could help in a GP office. As third, the lack of a standard practice of measuring instruments is marked once as a challenge, in a location without a psychologist in the team. Lastly, practical issues with the health insurance were mentioned. The respondents noticed the pitfall of professionals who are specialised in BD. Practically seen, the professionals are skilled in screening for BD and will indeed relate symptoms more easily to BD. This is mentioned as a pitfall, since there is a huge symptom overlap with other diseases and a symptom does not relate necessary to BD: ‘That's actually a bit like compartmentalised thinking. The police look at everyone as a criminal and we see everyone as someone with BD. So you're really going to look with those eyes and that's a huge pitfall of course. So we interpret every symptom to that direction.’ (Nurses).19 Another practical challenge is the unawareness of professionals outside the specialist team. The professionals in the specialist team do not have an influence on the colleagues outside the team. Still, it can be challenging that the colleagues who refer the patient to the bipolar team have more knowledge about the symptoms of BD. This could lead to more accurate diagnosis of BD, the professionals marked. ‘The lack of knowledge of people outside the specialist team is sometimes a problem. Thus, for example the GPs who don’t notice that a psychoses can be related with a mania or depression.’ (Nurses)20 One respondent answered that measuring instrument are underused in practice. This has to do with the policy of the department, where professionals don’t have always influence on. For example, a MDQ could be used in a GP practice to signal bipolar cases, but also at the specialist bipolar team it is not standardly used. ‘No usage of measuring instruments like MDQ. It is an additional instrument, especially in clinics with mood disorders, it is a good instrument. It is not used as a standard, only in anxiety disorders.’ (Psychiatrists) 21

18De symptomen zijn vaak aspecifiek en de groep van patiënten is vaak heel heterogeen. Dus je weet nooit precies welke klacht bij welke stoornis hoort Nou ja, dat is eigenlijk in het algemeen dat bipolaire stoornis lijkt een vrij duidelijk gedefinieerde stoornis, maar in de praktijk valt dat reuze tegen eigenlijk. Dat zit in die hoek van, dat is een symptoom en toch niet (psychiatrists). 19Dat is eigenlijk net zoiets als verkokerd denken. de politie ziet iedereen als misdadiger en wij zien iedereen als iemand met een bipolaire stoornis bij wijze van spreken. Dus je gaat inderdaad met die ogen ook kijken en dat is gewoon een enorme valkuil natuurlijk. Dus dan gaan we alle symptomen die richting in interpreteren (nurses). 20Maar het gebrek aan kennis buiten specialistische teams. Dus bijvoorbeeld huisartsen die niet helemaal in de gaten hebben dat een psychose bijvoorbeeld uit een manie of uit een depressie kunnen komen. (nurses)

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The health insurance plays a great role in the mental health care, professionals noticed. That’s a practical issue, which is decided outside the team. Especially when professionals have to give their second opinion, it is difficult to get this reimbursed, they said. But also, if a patient has already started a programme at another location, this can be a practical issue. The professionals marked this as a challenging aspect, which can put pressure on the diagnostic process. ‘Financially seen, it is difficult to get a reimbursement of the care for people who’ve already started the treatments for BD somewhere else. Thus, if we have to do a second opinion, but we can’t open a new file. I find this very difficult in the diagnostic process.’ (Psychiatrists)22

Course of disorder and time pressure One of the controversies and challenges in the diagnostic process of BD is that BD can evolve and develop in time, but the time for the diagnostic process is short, respondents stated. Professionals say that they have to base their diagnosis on just several conversations with the patient or on hetero-anamnesis. They therefore marked that the necessity that the team decide to follow the patient for half a year when it is an extremely complex case. Also, in case of providing second opinions, the time pressure is noticeable, many professionals mentioned. The majority of the professionals marked that the diagnostic process of BD can be ‘short’, since BD can have a course of years. Professionals has to rely sometimes on information coming from for example the hetero-anamnesis, not knowing whether it is completely true, they said: ‘You only see the patient once and not over a long time. It is hard to work based on one conversation, so we have to rely on what other say (about the patient), which is also extremely important, but actually we have to follow the patient for a longer time to say something meaningful.’ (Nurses) 23 The respondents have called the diagnostic process several times as pressing and they add that sometimes there are cases they even do not feel convinced about the diagnosis of BD: ‘Sometimes, we feel the pressure of the diagnosis of a patient, while we actually think it could be what has been diagnosed…we have to be careful. People can be stigmatized with a label. When I attend a meeting (with colleagues in the team), I sometimes think: ‘ok, fine.’ But I am still not convinced (that that person has BD).’ 24 Another professional noted that, because of the time pressure, the intake can be restless for her/him: ‘There is not much time for the second opinion. So I feel the time pressure in diagnostics, because you have to give a correct verdict. There are considerations that make an intake or a second opinion restless for me, like ‘are there more investigations needed or can a say something about the diagnosis?’’ (Psychiatrists)25

21Niet afnemen van meetinstrumenten, zoals MDQ. ja dat is toch een extra middel, zeker bij poliklinieken met stemmingsstoornissen, is het een goed meetinstrument. Wordt niet standaard gedaan, alleen bij angststoornissen (psychiatrists). 22Financieel gezien bij de diagnostiek dat wij ermee zitten als iemand elders al in zorg is voor een bipolaire stoornis hoe wij het vergoed gaan krijgen. Dus of het onder second opinion valt en dat we geen nieuwe DBC erop mogen openen. Dat vind ik op zich voor het proces van diagnostiek ingewikkeld (psychiatrists) 23Je ziet iemand eenmalig en niet over een langere tijd dus je kan zelf heel moeilijk op grond van één gesprek dan moet je inderdaad heel erg afgaan op wat die ander zegt. Wat overigens ook heel uiterst belangrijke informatie is, maar je zou het misschien graag wat meer zelf nog meer een beeld hebben en dat zou je eigenlijk over een langere tijd moeten zien wil je daar iets zinnigs over kunnen zeggen. (nurses) 24Je ziet ook weleens dat wij ons gedwongen voelen om een diagnose te geven terwijl we eigenlijk het liefst zeggen van nou we zouden ... we moeten daar voorzichtig mee zijn. Dat label wat mensen op krijgen hè? Maar ik zit nog weleens bij vergadering dat ik denk nou: ‘ok het zal wel’. maar dat is zelf niet per definitie overtuigd ben. (nurses) 25Omdat er niet veel tijd staat voor de second opinion. Ergens voel ik die tijdsdruk wel bij diagnostiek bij een second opinion, van dat je toch een uitspraak moet doen. Maar, dat zijn wel overwegingen die voor mij een intake of een second opinion onrustiger maken van ‘moet er een verlengd diagnostiek traject hebben?’. (psychiatrists)

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5.2. Roles of psychiatrists This section explains the second sub-question of this research and explains the added value of the roles of the psychiatrists in a MDT. According to the participants, the psychiatrists are indispensable when it comes to the diagnostic process of BD. It is many times mentioned that they fulfil an essential role, since they have years of experience behind during their education. As they have a broad medical psychiatric view, they are appointed to bear the final responsibility in the diagnostic process and formulate the diagnosis, signal physical problems and have an eye for medicines related problems, many professionals listed.

Broad medical psychiatric view and DSM According to respondents psychiatrists have a broad medical view, as they have studied many years about several aspects of mental health care. They are educated for years in clinical reasoning and DSM. They have knowledge on hand about the DSM and are used to classify symptoms within the borders of it, respondents noted. Due to their acquired skills and a broad medical view, they can describe and recognize the patterns in the symptoms very well. Besides that, when it becomes to a more complex case, like co morbidity or somatics, the psychiatrists have an essential task to identify and recognize the differences between disorders and formulate the right diagnosis at the end, the participants noticed. Almost all professionals mentioned the long and complicated education of the psychiatrists. Because of this education, psychiatrists are according to the respondents skilled in clinical reasoning (DSM) and having a broad medical psychiatric view. ‘I think psychiatrists are educated in clinical reasoning. The whole DSM is embedded. Much more attention is paid in their education (for DSM). So they are more experienced and have more knowledge on hand. While I sometimes have to check my DSM-book whether the case is ADHD or something else.’ (Nurses)’ 26 Because of the acquired broad medical psychiatric view, the psychiatrists are very skilled to describe the complete psychiatric research, respondents mentioned: ‘The psychiatrists have the knowledge to describe the whole research, the psychiatric research, very well. And he can set a diagnosis. The added value (of the psychiatrists) is therefore very important.’ (Nurse)27 Since the DSM is ingrained in the psychiatrists, they are able to recognize patterns and set a diagnosis based on these patterns, respondents mentioned. Furthermore, the psychiatrist is because of the knowledge on hand about the DSM and clinical reasoning skill more specialised in co morbid cases. He is mainly focused on Axis 1 and Axis 2, respondents answered. ‘If it is a questionable case, they look more specifically at the complaints of the patient. To see whether it is a BD or an ADHD or a borderline personality disorder. Or whether it is both. The psychiatrist is important in such cases. The psychiatrists are in particular focussed on Axis 1 and 2, I think. A psychiatrist can give good leads, where the GZ psychologist can build on.’ (Nurses) 28

26Ik denk dat psychiaters worden opgeleid om dat hele klinische redeneren. Van dat hele DSM dat wordt er bij hun helemaal ingepompt. Dus die zijn daar gewoon daar ja, veel meer in hun leertraject veel meer aandacht aan besteed. Dus daar zijn ze gewoon iets ervarener in en ze hebben gewoon, denk ik, wat meer parate kennis daarover. Terwijl ik soms nog m'n DSM-boekje erbij pakken van zou het nu toch niet ADHD zijn of zoiets. (nurses) 27De psychiater heeft natuurlijk de kennis om het hele onderzoek, het psychisch onderzoek, goed te beschrijven. En kan hiermee de diagnose stellen. De meerwaarde is daarom heel belangrijk. (nurse) 28Als het een twijfelgeval is: nog specifieker kijken naar de klachten. En die nog veel meer ja, zien of dat wel bipolair is of dat het misschien dan toch een ADHD of borderline persoonlijkheidsproblematiek is. Of dat het beiden is. In die gevallen is de psychiater belangrijk. De psychiaters zitten volgens mij met name op as 1, as 2 en dat goed beschrijven. Symptomen. Co morbiditeit natuurlijk. Persoonlijkheidsstructuur. Persoonlijkheidsdynamiek. Dan heb je het over as 2. Een psychiater die kan mooi aanknopingspunten geven waarop de GGZ psycholoog verder gaat. (nurses)

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Broad medical knowledge of the psychiatrist is very valued and is appealed by other professionals when they have patients with complex cases, in which mainly symptoms are aspecific. Like a professional mentioned. Almost all professionals agreed that psychiatrists are attempting to generalize and classify symptoms. ‘Well, I mostly need the psychiatrist when we have very complex cases, like: ‘is there a schizophrenic symptom development?’. Or when the symptoms are very aspecific. ‘What colour has that particular psychosis?’ That. I think, that is a big added value of the psychiatrist. Besides, doctors are more generalizing. They are more undoubtedly. I think a doctor is more likely to follow the criteria of DSM and base a diagnosis on that.’ (Psychologists).29

Final responsibility The respondents agreed unanimous that the psychiatrists have always the final responsibility about the diagnostics and are primary-treating practitioners in cases, as they have a more heightened understanding. This is mainly because of their education and experience, professionals said. Besides that, the participants mentioned that a psychiatrist has almost always the supervision and guards the consistency and the cohesion of all gathered information. He or she checks for example the nurses and makes addition if needed. The huge responsibility of the psychiatrists are noticed by psychiatrists their selves. They have to guard the cohesion of all achievable information, since they have the most extensive experience, they said. It is mentioned that because of this experience and knowledge, they are always involved in the diagnostic process. We have the final responsibility for the whole treatment process and diagnostic process. Psychiatrist has the most experience and he has to monitor the coherence of all gathered information (Psychiatrists).30 Psychiatrists are always primary treating practitioners. This is more a technical thing, not really content. Anyhow, therefore they are always involved (in the diagnostic process). (Psychologists)31 Since the psychiatrists monitor all achievable information about the patient, they can check the file of the patient and fill gaps eventually, professionals mentioned: If something is missing, the psychiatrists have the role of filling up that gap. Very often, if you read the intake again, he might think, ‘oh wait, we forgot to ask the family anamnesis’ for example. (Nurses)32

Somatics33 All interviewed professionals agree that somatics is a clear role of the psychiatrist, since the psychiatrist is unique in the team with his education in both physical as psychological aspects of the patient, as following quote illustrates:

29Nou ik denk waar ik de psychiater vooral heel hard bij nodig heb, is ook die hele ingewikkelde beelden van ‘zou er nou sprake zijn van een schizofrene ontwikkeling?’ of het symptoom wat atypisch zijn. ‘Hoe moet je.... ‘welke kleur heeft een psychose?’ Dat. Dus dat hele psychiatrische beeld eigenlijk. Daar vind ik de psychiater echt meerwaarde in hebben. Artsen zijn vaker generaliserend. Ze zijn wat stelliger van ‘ja manisch’, dus nu medicatie verhogen. Ik denk dat een arts sneller geneigd is de criteria van DSM te volgen en dat er dan een diagnose gesteld kan worden. (psychologists) 30Dat je uiteindelijk verantwoordelijkheid draagt voor het hele behandelproces en diagnostisch proces. Psychiater heeft de meeste ervaring en op zich moet hij de samenhang bewaken van alles wat aan informatie beschikbaar komt. (psychiatrists). 31En psychiaters zijn altijd hoofdbehandelaar. Ja, dat is natuurlijk meer een technische dingetje, dat is niet echt inhoudelijk. Maar goed, daardoor wordt hij wel altijd betrokken (psychologists) 32Wat de psychiater nog doet is nog de gaps invullen als er nog echt iets mist. Heel vaak als je die intake nog eens leest, kan je denken, o wacht, er is toch nog even vergeten om naar de familie anamnese te vragen. ik zeg maar wat. (nurses) 33 Psychosomatics is a medical field that focuses on diseases that mainly manifest physically, however have a clear psychological factor.

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Well, somatic problems. I believe that we are very well equipped to pay attention to additional somatic problems, which can for example lead to depression, thyroid gland problems and high blood pressure. (Psychiatrists)34

Pharmacotherapy A psychiatrist is also the pharmacotherapy specialist of the MDT. They are specialized in administering and prescribing medication, whereby extensive academic knowledge in pharmacotherapy is required. The pharmacotherapy aspect is very important in the diagnostic process, because the patient can for example already use medication. The psychiatrists can determine the effect of this medication. Of course the medical part is I think, that is the most important added value of a psychiatrist. So that knowledge about the influence of somatic complaints and influence of medication ... its impact. Now and in the history. I think it is a very important value. (Psychologists)35

34Nou, somatische problemen denk ik dat wij daar toch wel erg voor geëquipeerd zijn om goed te letten op bijkomende somatische problemen, die bijvoorbeeld aanleiding kunnen geven tot een depressie, schildkierproblemen, hoge bloeddruk. (psychiatrists) 35Natuurlijk het medische stukje is denk ik het belangrijkste meerwaarde van een psychiater. Dus echt die kennis over invloed van somatiek op klachten en invloed van medicatie... het effect daarvan. Nu en in de voorgeschiedenis. Ik denk dat het een heel belangrijke meerwaarde is. (psychologists)

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5.3. Roles of nurses This section explains the third sub-question of this research and explains the added value of the roles of the nurses in a MDT. The nurses are an interesting group in the MDT. Their tasks differ per location, where they have a quite essential role or a less prominent role within the diagnostic process, the focus groups has shown. The focus groups demonstrated also that the nurses are almost at every location intakers (they form mainly a duo with psychiatrists), while in teams where psychologists are always available; nurses fulfil a less prominent role in the diagnostic process. It is often mentioned that nurses are very practical, because of their relatively low cost. Furthermore, according to participants, they have an important psychosocial role, wherein a low threshold to the patient is an important aspect. The professionals added that because of the longer and more personal contact with the patient, nurses have a functional view, as they can estimate the feasibility of a certain treatment. They pay also attention to symptoms and co morbidity during the treatment, and can help to change the diagnosis by their input afterwards, some respondents noticed (in Dutch: beloopsdiagnostiek).

Intake According to the most participants, one of the important tasks of the nurses in the diagnostic process of BD is the selection of patients at the intake. Nurses filtrate the more complex cases and refer them to other professionals, they noticed. Besides that, it is mentioned that nurses have a role in the formation of a retrospective life chart during the intake. If the nurse doubts about the diagnosis BD or if it is a complex case, the psychiatrist will be informed by the nurse: ‘Actually, at the general intake we nurses are very skilled at selecting cases with BD, also cases of doubt. And the psychiatrist is more skilled for the complex cases, if we doubt, the psychiatrist will be informed.’ (Nurses) 36 During the intake, nurses pay attention for the course of events in the life of the patient until the consultation at that moment. They are not easily satisfied by the answers of the patient and question the (medical) history of the patient deeply. Therefore, a retrospective life chart is also made. ‘I think, imagine black on white, those people at the intake with depressive complaints say: ‘and then it goes well again.’ And everyone will think: ‘fine’. But we think: ‘how well?’. That.’ (Nurses) 37

Psychosocial aspect Nurses are well educated in relating social conditions of the patients to mental health. Because of their easiness to access for the patient (e.g. patients mainly see them more like their selves), they can dive into the daily life of the person and recognize events or symptoms that are possibly related to BD. It is noticed that they pay attention to for example: the financial situation, home situation, family relations and work place and relations. They make, as mentioned before, a retrospective life chart in order to get insight in the possible depression and (hypo)mania episodes of the patient, in which they in particular pay attention to the psychosocial aspect.

36Eigenlijk wat ik heb opgeschreven is bij algemene intake... bij mensen die aan de voordeur komen zijn wij heel goed in staat om verpleegkundigen bipolaire stoornis eruit te halen. Ook twijfelgevallen eruit te halen. En dan vind ik dat een psychiater er veel meer voor het complexe geheel is. Als wij twijfelen, psychiater erop. (nurses) 37Ik denk ook als, stel heel zwart-wit je hebt mensen in de intake met depressieve klachten en die zeggen dan: ‘en daarna gaat het weer goed’. En iedereen zal denken, fijn. Maar wij denken ja hoe goed? Dat. (nurses)

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It is noticed by the professionals that nurses have an essential role in sketching of the psychosocial aspect of the patient. The core areas, like the financial situation and relations are listed by the nurses during the intake. One professional called it the ‘environmental factors’, referring to the psychosocial aspect of the patient. Another interesting aspect, which is scrutinized by the nurses, is the strengths of the patient: ‘Psychosocial problems, we ask more for that. We ask mainly for financial things. Core areas. Much more than the psychiatrist. I think, we as nurses, pay more attention at ‘environmental factors’. How does the patient experience his life, what does he do, what is the background, how are his friends, his education etc. But also, we pay also attention at the strengths of the patient, which can support the treatment.’ (Nurses) 38 Many participants mentioned also that nurses are very important in mapping axis 4 of the DSM, referring to reporting of psychosocial and environmental stressors that may affect the diagnosis, treatment, and prognosis of BD. For this purpose, a self-management matrix is being used. Therefore, it is noticed that the nurses fulfil also an essential role in the descriptive diagnostics. ‘Well, the nurse has an added value in the diagnosis, because especially Axis 4 is mapped by them. Nowadays, we use a tool called self-management matrix. It easily maps out living, day filling, finance, support system, addiction, physical health (of the patient). And that is a very good addition to the diagnostic process. (Nurses)’ 39 They look more at axis 4. But then, it is not typical of BD alone, but how they operate now with those symptoms as a mother, as an employee, as a partner. Descriptive diagnosis actually. (Psychiatrists)40

Practical Another addition to an accurate diagnostic process delivered by the nurses is the ability to have more contact hours with the patient, several respondents noticed. Therefore the nurse can deliver more complete information about the patient, for example about the family support of the patient and follow the possible side effects of medication: ‘Well, the nurses see patients more often (than psychiatrists). So I think, for us (nurses) it is very important to see the supporting system (of the patient). And also to hear from the ‘supporting system’ (the family), how the patient is doing. In this way, we can keep it transparent and very concrete. We can also ask the family about their observations about the symptoms and features, psycho-indication. But also in particular the medication and the side effects.’ (Nurse) 41 Some nurses are specialised enough for creating an idea about the medication of the patient. Yet, they don’t decide, since it is the responsibility of the psychiatrists:

38Psychosociaal problematiek, dat we daar meer naar kijken. Je vraagt toch wel vaak uit van financiële dingen. Kerngebieden. Veel meer dan de psychiater. Ik denk dat we wat meer aandacht hebben voor meer de omgevingsfactoren, zal ik het maar noemen, van de cliënt. Dus ja hoe staat hij of zij in het leven, wat doet hij of zij, wat is de achtergrond van hij of zij, wat zijn z'n vriendenkring, opleiding heeft ie. Maar ook eruit halen misschien wat zijn sterke punten die een cliënt in een behandeling ook kunnen ondersteunen en zo. (nurses) 39Nou ja, de verpleegkundige heeft een meerwaarde bij de diagnostiek omdat met name As 4 in kaart wordt gebracht. En daar gebruiken we inmiddels een tool voor. Dat is een zelfmanagementmatrix. En dat brengt heel eenvoudig in kaart hoe het gesteld staat met nou ja, wonen, dag invulling, financiën, steunsysteem, verslaving, lichamelijke gezondheid. En dat is volgens mij een hele mooie aanvulling op het diagnostisch proces. (nurse) 40Ze kijken meer naar as 4. Maar dan gaat het niet typisch over bipolaire stoornis alleen, maar hoe functioneren ze nu met die symptomen als moeder, als werknemer, als partner. Beschrijvende diagnose eigenlijk. (psychiatrists) 41Nou ja, de verpleegkundigen zien de patiënt denk ik meer. Dus ik denk dat het voor ons ook heel belangrijk is om het steunsysteem vaak te zien. En ook te horen van het steunsysteem hoe zij het vinden gaan met de patiënt. Zo houd je het ook transparant denk ik en heel concreet. En, dan kunnen we ook de familie natuurlijk uitvragen over wat zij aan symptomen, kenmerken zien, psycho- indicatie. (nurse)

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‘As specialised as we are in this team we automatically have much experience about medication. However, we don’t decide, because it is the responsibility of the psychiatrist. But we (as nurses) discuss the medication with the patients. I also, can tell you things about antipsychotics and Lithium.’ (Nurses) 42 Nurses are also mainly associated with a practical aspect like the costs of the intake. Nurses are cheaper and simultaneously are skilled to analyse the psychosocial aspect in the diagnostics: ‘At the diagnostic phase the added value of the nurse is to collect good information. The nurses have an added value, because they are cheaper. I mean, process diagnostics is time consuming and they are cheaper than psychologists and psychiatrists. And they are better in assessing psychosocial situation. (Psychiatrists)43

Functional view Another role in the MDT is the functional view of the nurse. The nurses see, as mentioned, the patient over a longer time and have a good overview of the personal side of the patient. Therefore they can estimate the feasibility of the treatment, and take also the strengths of the patient into account. Besides that they can signal some symptoms of possible other disorders, and thus, have also an eye for co morbidity. In this way, they can help adjust the diagnosis of the patient. ‘I think the added value of nurses is often that nurses have prolonged contact with a client. Thus they know the client in many ways than when you see someone in a diagnostic process five times. And they can really see the difference in symptoms for that particular client. Process diagnostics actually. And what I think it is really good, is the attention paid to the strength of the client, much more than the psychiatrist and psychologist.’ (Psychologists)44

42Ja, nou goed, zo gespecialiseerd als wij zijn binnen dit team, dan weet je automatisch ook heel veel over medicatie. Alleen je hakt de knoop niet door, omdat dat de verantwoordelijkheid van de psychiater is. Maar je bespreekt het wel met patiënten. Ik kan ook dingen vertellen over antipsychotica en over Lithium (nurses). 43in de diagnostiekfase, dan denk ik dat de verpleegkundige meerwaarde heeft om goede informatie te verzamelen. De verpleegkundige heeft meerwaarde omdat ze goedkoper zijn. Ik bedoel, het is een tijdsintensief proces diagnostiek en zijn goedkoper dan de psychologen en de psychiater. En op zich kunnen ze de psychosociale situatie beter beoordelen. (psychiatrists) 44Ik vind de meerwaarde van de verpleegkundige vaak, dat verpleegkundige vaak al langer contact met een cliënt. En dus die cliënt op vele manieren kennen dan als je in een diagnostisch traject iemand vijf keer ziet. En dus ook de verschillen in beeld heel erg kunnen zien. Meer procesdiagnostiek. En wat ik echt heel goed vind is de zicht op de kracht van de cliënt, meer dan de psychiater en psycholoog. (pyschologists)

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5.4. Roles of psychologists This section explains the fourth sub-question of this research and explains the added value of the roles of the psychologists in a MDT. Despite of the essential complementary role of the psychologists, they are scarce in specialist teams of BD, some professionals complained. The respondents associated the psychologists particularly with more neuropsychological research of the patient. Mapping the personality and character features of the patient is an important factor and role in the diagnosis of BD, which is fulfilled by psychologists. Moreover, a specialised look and research to the broad personality aspect is indicated as a missing part by the professionals, in case of no psychologist was available in the team. A psychologist is skilled in using measuring instruments, in getting a deeper insight about the personality of the patient for substantiated conclusions, is therapy oriented, pays special attention for co morbidity and set out the developmental stages of the disorder, professionals noticed.

Measuring instruments The greatest added value of the psychologist in the MDT is his or her dexterity with measurement tools. A psychologist uses tools like SCID to gain a broader look of the personality of the patient. ‘Test research, memory research, intelligence research, which is more the area of the psychologist. ‘Does something more fit to BD or does it fit to autism spectrum disorder?’. Also conducting SCID2 for example, or a psychologist looks also whether a person meets the criteria of EMDR treatment or trauma treatment.’ (Psychologist)45

Co morbidity Due to the measuring skills, a psychologist can have a broader look to the disorder. Co morbidity, which is another challenge mentioned in previous section, is also scrutinized by a psychologist. Many professionals mentioned that psychologist approaches the patient from a different perspective, which can give them new insights that is overseen by other professionals during the diagnostic process. Co morbidity is an example of that. Mainly, the psychologist has a much broader view. We are very specialised in BD and the psychologist sees a lot of other things. Which are often of greater additional value. Beside the diagnosis, he also has an eye for the psychological mechanisms and things that play in the personality, so it is good to have him (the psychologist) around the table. We recognize autism never, they do. Psychodynamic things. So, they often have a very different perspective that adds on the diagnosis. (Psychiatrists)46 The psychologists are associated with their own expertise to see the broad picture about the patient. Anxiety disorder is called as an example of a co-morbid case. The psychologist also has his own knowledge and perspective. Particularly comorbid psychiatric images. For example anxiety complaints, which can play a role. He also sees the whole picture. (Psychologist)47

Personality of the patient Many professionals noticed that a psychologist is educated and skilled in several types of research. Neuropsychological research for example, can be of a high importance in the diagnostic process

45Testonderzoek, geheugenonderzoek, intelligentie onderzoek, dat is meer het ruim van de psycholoog. ‘Past iets nou meer bij bipolaire stoornis of autisme spectrum stoornis?’. Ook afname van SCID2 bijvoorbeeld, of of iemand voldoet aan de criteria van EMDR behandeling of trauma behandeling (psychologist) 46De psycholoog heeft vaak een veel bredere blik. Wij zijn heel erg verkokerd inmiddels op die bipolaire stoornis en die psycholoog die ziet heel veel andere dingen. Die vaak van grotere aanvullende waarde zijn. Los van de diagnostiek heeft hij ook oog voor de psychologische mechanismen en dingen die er spelen in de persoonlijkheid, dus dat is goed om die aan tafel te hebben. Autisme zien wij nooit, zij wel. Psychodynamische dingen. Dus die hebben vaak een hele aanvullende blik. (psychiatrists) 47De psycholoog heeft natuurlijk ook zijn eigen kennis en invalshoek. Dus ja, dan zijn het met name de co-morbide psychiatrische beelden. Bijvoorbeeld angst he, wat verder ook een rol kan spelen. Hij overziet ook het gehele plaatje. (psychologist)

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of BD, respondents marked. They added also that using these kinds of researches, a psychologist is more likely to get a more specified look of the personality of the patient and therefore contributes to a more accurate diagnosis and treatment of the disease. As earlier said in the previous section, one of the challenges of the diagnostic process of BD is the difference between ‘what is hypomania for a particular patient’ and ‘what is the normal character feature of the patient’. The psychologist has a great added value by using the measurement tools for the personality of the patient and is able to make the distinction between normal and abnormal for a particular patient, many professionals mentioned. ‘We need a specific diagnosis for treatment. What is disease, what is character, what is personality? Psychologists can see the difference. And they are able to notice anything in the personality that can affect the disease and subsequently the treatment. They can conduct neuropsychological research to see whether there are cognitive problems or anything else: more grip on the patient.’ (Nurses) 48 Another added value of the psychologist is the expertise to pay attention to the underlying personality traits of the patient. Professionals have mentioned that psychologist can see a cohesion of the factors and thus the whole image of the patient: ‘An added value of the psychologist is that they pay attention to the underlying dynamics and personality structure. Psychologists can make a distinction and also can see the coherence of personality traits and stress factors. I think, a psychologist can use those glasses very well, more than an average psychiatrist.’ (Psychologists)49 The distinction between ‘what is normal’ and ‘what is abnormal’ can be made by the psychologist because of the broader and different perspective to the personality of the patient, respondents noticed. ‘What is normal for this person?’ That's a question I often ask myself. ‘Does that person has a normal stable period or isn’t it there anyway?’ So, is he always like this? So that's a very important one. 'What is normal?’ and ‘do I really see a difference between the hypomanic episode and the normal period?’. (Psychologist)50

Therapy orientation Many professionals noticed that psychologists have a great added value in the treatment and eventually adjustment of the diagnosis of the patient. Personality traits, co morbidity, or the intelligence of the patient can be an obstacle in the treatment. The psychologist contributes to a complete image of the patient, seen in different perspectives, so that the treatment is best applicable one for that particular patient. If a treatment does not work the psychologist can have a value in the adjusting the diagnosis. ‘The psychologist is trained in making a diagnosis, but also in therapy types and areas, such as cognitive behaviour therapy. And also, what I have seen here is that the psychologist conducts proper research, which is also very important, I think. They have to exclude possible co morbidity, or whether it is autism, or borderline. And check the personality structure to set conclusions’ (Nurse) 51

48Er is voor behandeling natuurlijk ook weer specifieke diagnostiek nodig. Wat is ziekte, wat is karakter, wat is persoonlijkheid? Om daar een goede schifting in te maken. En zitten er dingen in die persoonlijkheid dwars die de hele ziekte ook dwarsbomen bijvoorbeeld? Kom je daarom niet verder met je behandeling. Die kunnen ook neuropsychologisch onderzoek doen. Kijken of er cognitieve problemen zijn en dergelijke. Meer grip rondom de patiënt verbeteren. (nurses) 49Wat ik een meerwaarde van de psycholoog vind is de dat ze kijken naar onderliggende dynamiek en persoonlijkheidsstructuur. Psychologen kunnen onderscheid maken en samenhang zien van persoonlijkheidskenmerken en stressfactoren. Ik denk dat een psycholoog goed met die bril kan kijken, meer dan een gemiddelde psychiater. (psychologists) 50‘Wat is normaal voor deze persoon?’ dat is een vraag die ik heel vaak stel, ‘heeft iemand wel een normale stabiele periode of is die er eigenlijk niet’, is ie altijd wel een beetje zo…ja, dus dat is een hele belangrijke ‘wat is normaal’ en ‘zie ik ook echt een duidelijk verschil nu, de hypomaan zou zijn of tussen de hypomanie en tussen die normale periode?’ (psychologist) 51De psycholoog heeft in die zin opleiding gehad in diagnostiek. Maar ook in therapievormen, -gebieden, cognitieve gedragstherapie. Ook met name met wat ik hier gezien heb en geleerd heb is dat de psycholoog gedegen onderzoek doet en dat vind ik heel belangrijk. Goed uitsluiten of er sprake is van co morbiditeit, is er sprake van autisme of toch borderline. En goed kijken naar de persoonlijkheidsstructuur om duidelijke conclusies te stellen (nurse)

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The psychologist has the expertise to search for reasons and do additional research about the patient in order to see what is an obstacle for the treatment. ‘Psychologists are also important when we start to think of questions like ‘why is the treatment not working?’. Do we have to do an intelligence research? Is there a risk of mental retardation? That could be a possibility why the treatment is not working. Or is someone not able to handle something for example.’ (Psychologist) 52

Developmental stages Many respondents noticed that the psychologist mainly map the development of the psychopathology (the developmental stages of the disease), if he or she is available in the team. This is a part of the ‘broader look’ to the personality performed by the psychologists in order to set substantiated conclusions in the diagnostic process, professionals said. For this purpose, psychologists try to properly identify the biography of the patient: ‘I think the added value of the psychologist, we do not have a psychologist at our disposal, I would like to know what the cognitive abilities of someone are. So what is the damage incurred by the episodes and to what extents can we react to that. I would like a psychologist that can determine this already in the intake phase. Psychologists often look at large contexts and developments. Psychopathology.’ (Psychiatrists)53

Overview Another important added value of the psychologist, according to the professionals, is the ability to connect all information from the psychiatrists and the nurses concerning the patient. Respondents also mentioned that psychologists are mainly involved in a later stage of the diagnostic process and have a fresh look on the case and the gathered information about the patient. This can lead to new insights and help formulate the correct diagnosis, professionals mentioned. ‘If we sit together with the psychologist, you notice that he often takes up the role of connecting the different elements (about the patient).’ (Nurse)54 ‘A psychologist is often involved later on in the diagnosis, to look at it with a fresh pair of eyes.’ (Psychologists)55

52Psycholoog is ook belangrijk als we denken:’ goh, waarom slaat de behandeling niet aan?’. Moet er een intelligentie onderzoek gebeuren? is er kans van zwakbegaafdheid? dat kan een mogelijkheid zijn dat behandeling niet aanslaat. Of is iemand niet voldoende capabel om iets aan te pakken bijvoorbeeld. (psychologist) 53Ik denk dat de meerwaarde van de psycholoog is, die hebben wij niet, ik zou willen weten wat de cognitieve mogelijkheden van iemand zijn. Dus wat de schade eigenlijk is van de doorgemaakte episodes en hoeverre we daar wat mee moeten. Dat zou ik graag in de intakefase door een psycholoog vastgesteld willen hebben. Psychologen kijken vaak naar grote contexten en ontwikkelingen. Psychopathologie. (psychiatrists) 54Als we dan bij elkaar zitten met de psycholoog, merk je dat hij vaak de functie kan hebben, dat het de verschillende elementen met elkaar verbindt zal ik maar zeggen. (psychologist) 55Een psycholoog wordt vaak pas later in de diagnose gevraagd, dat is toch een nieuwe frisse blik. (psychologists)

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6. Conclusion This research investigated the challenges in practice and the added values of different professionals in the diagnostic process of BD as the following research question was formulated: ‘What are the challenges in practice in the diagnostic process of BD faced by involved professionals and what are the added values of the roles of these professionals in the diagnostic process of BD?’ Focus groups and interviews were conducted, resulting in note worthy conclusions. This chapter is divided in two sections. The first one sets out the conclusions of this research regarding to the challenges endured by the professionals during the diagnostic process of BD. The second one elaborates the added values of the different professionals in a MDT who are involved in the diagnostic process of BD.

6.1. Challenges in the diagnostic process of BD The professionals mentioned many challenges, which they face during the diagnostic process of BD. First of all, an unreliable anamnesis can make the diagnostic process difficult. This can be caused by the memory of the patient to memorize their possible hypomanic episodes in the past or the choice to tell this to the professional. A hypomania does not always result in bothersome situations, but instead can be experienced as pleasant, as people have more energy and self-confidence. A second reason of an unreliable anamnesis can be the condition of the patient during the intake, as the emotion of the patients can influence the extent of expressing themselves about the disease. In the extension of unreliable anamnesis, this research has found that difficulties with hetero-anamnesis are another challenge during the diagnostic process. A hetero-anamnesis is one of the important aspects in the diagnostic process to get an overview of the medical history of the patient. However, sometimes patients do not give a permission to consult other professionals who also have seen the patient before (e.g. the GP who has referred the patient to the specialist bipolar teams). This information can be crucial, since it will make the information package about the patient complete and can give the team new insights. Besides that, a second issue was the unavailability of the family members or other persons who know the patient well. These persons can contribute to new insights about the patients, which the patient self does not notice. Furthermore, this research has found that unravelling the character traits of the patient is very important during the diagnosis, since hypomania means different to each patient. Determining the difference between ‘what is normal for that particular patient’ and ‘what is hypomanic for that particular patient’ is sometimes very challenging. Besides that, the countertransference is an aspect that needs attention during the diagnostic process. Almost all professionals mentioned co morbidity as one of the most challenging aspects in the diagnostic process of BD. Besides that symptom overlap with different other diseases makes diagnosing BD also very challenging. Other diseases like borderline personality disorder, autism, substance abuse (addiction) and ADHD can either be co-morbid with BD or have strong symptom overlap. Also the formulation of BD in the DSM can sometimes be troublesome, this research showed. First of all, it is several time marked that the definition of BD is very vague and at the same time very strict, since a person with four days (hypo)manic symptoms already fits in the criteria. Concurrently, BD has aspecific symptoms that do not always fit in the criteria as described in the

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DSM. They added that the group of people, who are potential BD patients, are mainly very heterogeneous. Moreover, some practical issues, which professionals cannot influence are sometimes challenging. Firstly, professionals saw their specialisation in BD also as a pitfall because they will relate some symptoms too easily to BD. Secondly, the unawareness of professionals outside the Bipolar specialised team can also lead to difficulties in an accurate diagnostic process of BD. As third, the lack of a standard practice of measuring instruments is marked once as a challenge. Lastly, practical issues with the health insurance were mentioned. One of the controversies and challenge in the diagnostic process of BD is that BD can evolve and develop in time, but the time for the diagnostic process is short. Professionals have to base their diagnosis on just several conversations with the patient or on hetero-anamnesis. Also, in case of providing second opinions, the time pressure is noticeable by the professionals.

6.2. Added values of professionals in a MDT This research showed that the psychiatrists fulfil an essential role, as they have years of experience behind during their education. As they have a broad medical psychiatric view, they are appointed to bear the final responsibility in the diagnostic process and formulate the diagnosis, signal physical problems and have an eye for medicines related problems. Psychiatrists have ingrained the DSM, are very well educated in recognizing symptoms and relate them more easily to disorders. Because of this reason, psychiatrists are also associated with a predisposition of generalizing symptoms and disorders. The added value of the nurses differs per location, where they have a quite essential role or a less prominent role within the diagnostic process. The nurses are almost at every location intakers. In teams where psychologists are always available, nurses fulfil a less prominent role in the diagnostic process. Furthermore, the nurses are very practical, because of their relatively low cost. Besides that, they have an important psychosocial role, wherein a low threshold to the patient is an important aspect. Because of the longer and more personal contact with the patient, nurses have a functional view, as they can estimate the feasibility of a certain treatment and see the strengths of the patient. They pay also attention to symptoms and co morbidity during the treatment, and can help to change the diagnosis by their input afterwards. Psychologists are not available in all teams, despite of the essential complementary role. The psychologists are associated particularly with more neuropsychological research of the patient. Mapping the personality and character features of the patient is an important factor and role in the diagnosis of BD, which is fulfilled by psychologists. Moreover, a specialised look and research to the broad personality aspect is indicated as a missing part by the professionals, in case of no psychologist was available in the team. A psychologist is skilled in using measuring instruments, in getting a deeper insight about the personality of the patient for substantiated conclusions, is therapy oriented, pays special attention for co morbidity and set out the developmental stages of the disorder.

MDT functioning This research identified little differences in the expectations of a discipline about their added values and what other disciplines expected about the added values of that discipline. Except, the difference that most stand out is the tasks of the nurses and the psychologists. For example, at locations where a psychologist is a member of the team, some psychologists had difficulties with

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mentioning the tasks in the diagnostic process of the nurses. They find that nurses have a prominent role in the treatment and not in the diagnostics. At teams without a psychologist, the psychosocial aspect about the patient and the deeper understanding about the character of the patient are determined by the nurses. However the role and the skills of the psychologists are not fully fulfilled, and are mainly identified as a great lack in the team. For example, at locations without a psychologist member in the team, tasks like measuring instruments are not used standardly. This research also identified that many professionals have comparable skills, however the responsibilities are different.

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7. Discussion In this chapter, the results are discussed by reflecting on the theoretical framework. Besides that, the strengths and limitations and the validity of the research are summarized. Also, possible future research about the topic of this research is summarized.

7.1. Reflection on theoretical framework The theoretical framework explains that an efficient MDT can lead to an efficient diagnostic process of BD. This is necessary, because the accurate diagnosis of BD can last for seven years. The framework also explains that the clarification of different roles, their added value, of the members of the MDT is an important aspect and will serve as an enabler of an efficient MDT. The psychologists, psychiatrists and nurses collaborate in the diagnostic process of BD and constitute a MDT. Thereby, it is essential that the professionals are aware of each other’s added values of their roles in order to compile the already achievable knowledge and expertise of the professionals. Clarifying the different roles in a MDT will create explicit knowledge, which is a first step to eventually change some aspects in a MDT in order to contribute to a more efficient diagnostic process of BD.

Psychiatrists Several added values of the psychiatrists are mentioned, however literature about the role clarification of these professionals is scarce. Most important, the psychiatrists are always leaders (mainly due to their education and experience) in the cases and the teams and have therefore always the final responsibility. The literature says that good functioning team leaders are the keystones for maintaining quality delivered to the patient. The sooner they get the support and the training that is needed for this task in the MDT, the better the quality of the care is likely to be (Firth-Cozens, 2001). Thus, despite of the existing medical experience and education, psychiatrists should be integrated in team working too in order to make the team more efficient. One of the greatest added values of the psychiatrist is the knowledge in somatics and the medicine related role. They are very well educated in the DSM, however other professionals are also extensively familiar with the DSM.

Nurses While nurses are mainly intakers, they are not educated in measuring instruments like psychologists. This can be a problem in teams without a psychologist, as nurses often have taken over the role of the psychologist in those teams. Some hierarchical problems were mentioned during this research. Professionals from other disciplines noticed that nurses mainly accept the diagnosis and does not make an attempt to change the diagnosis. However, nurses are in this research also associated with monitoring the treatment and having an alarming role in for example co-morbidities, as nurses are spending more time with the patient than other professionals. Leaders of teams, psychiatrists, must according to Atwall and Caldwell who has done research about this issue, ensure that they allow all members to contribute equally to the decision-making process and that all opinions are allowed to be expressed and debated if all already achievable information wanted to be used (Atwall and Caldwell, 2006). It is mentioned several times by professionals that nurses are very practical to use in the diagnostic process, since they are cheaper than the psychologists or the psychiatrists. However, one professional marked that cheaper professionals will not per se result in a more accurate diagnostic

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process. Mistakes that must be corrected or a diagnosis that has to be changed after years are more time consuming and leads to much higher costs. Though, nurses have an essential role in the psychosocial aspect of the diagnostics of BD. Indeed, Crowe and his co-workers investigated the role of the nurses in the psychosocial aspects of diagnostics and found that nurses play a critical role, since they are for example very well skilled in mapping the daily functioning of the patient (Crowe et al., 2010).

Psychologists The literature shows that the diagnostics and treatment recommendations made by MDTs do not always take into account the preferences and the wider social and psychological issues of the patients. Taylor and his co-workers analyzed that within upper gastrointestinal and colorectal cancer teams (in the UK), the decision-making were not implemented in 10-15% of diagnostics and treatment recommendations (Taylor et al., 2010). It was remarkable that patients mostly received more conservative treatments than initially planned, as the teams had not considered patient information such as co morbidity and patient preferences. At this point, the psychologist seems to play an essential role, since this research showed that a psychologist has a new perspective and pays extra attention to the personality of the patient and the possible co morbidities. This research also identified that the psychologists are an essential missing part if they are absent in a team. Nevertheless, in teams where psychologists were available, they were almost always involved in a later phase of the diagnostic process. They are often asked to have a broader look in complex cases, while some professionals noticed that the perspective of the psychologist should already be included in the intake phase in the diagnostic process of BD. Therefore, it is also suggested that a short and to the point questionnaire at the intake about the possible necessity and referral to the psychologist would be a valuable addition to the diagnostic process. In this way, the necessity of the psychologist can be noticed in the early phases of the diagnostic process and in addition the problems that would occur in the later phase are nipped in the bud.

Challenges A number of features of the disorder itself make BD challenging to diagnose. This research has found that a manic episode is usually preceded by one or more depressive episodes. Besides that, the diagnosis of bipolar disorder cannot be established until the first mania or hypomania has manifested itself. This is in concordance with the literature that shows that approximately 5 to 10% of the people with a depressive disorder end up developing BD (Bebbington and Ramana, 1995). Besides that, this research also found that professionals are challenged in practice because hypomanic episodes are difficult to distinguish from normal feelings and behavior of the patient and there is even a failure on the side of the patients to seek help on time (Belmaker, 2004), as they do not recognize hypomania as well. All such difficulties greatly increase the chance that BD at initial stage will not be promptly recognized and treated (Angst et al., 2007). This research also found conducting hetero-anamnesis can be challenging in practice for professionals. Interestingly, literature about hetero-anamnesis linked with BD is scarce. Another challenge in practice identified by this research is the definition and criteria of BD in the DSM, which can be very vague and simultaneously very strict. Also Vietta and Phillips (2007) identified similar issues about the DSM and BD.

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Furthermore, this research also found that co morbidity is a very challenging aspect in the diagnostic process of BD. Professionals mainly mentioned borderline personality disorder, ADHD, anxiety, addictions and autism as disorders that are likeable to co exist with BD. Much literature is affirmative and shows that co-morbidities are a big issue in the diagnostics of BD (Biederman et al., 2004; Hazell et al, 2003; Birmaher et al., 2006; Angst et al., 2007). Another study of Palkhivala from 2006 showed that the four features that have predicted a positive MDQ, which tests for BD, were a history of legal problems, a diagnosis of depression occurring in the previous five years, comorbid anxiety disorder and a family history of bipolar disorder. There was a 43% chance of scoring positive on the MDQ identified at patients with any three of the five predictive factors. Interestingly, a history of multiple antidepressant failures was not identified as a predictive factor for BD (Palkhvala, 2006).

7.2. Multidisciplinary team composition and consequences First, several aspects were remarkable about the teams at the locations. This research conducted focus groups at different locations and with different bipolar teams. One of the first remarkable aspects was the difference in the composition of the teams, wherein psychologists were not always present. The teams without psychologists (mainly because of financial problems) mentioned that they were missing the psychologist to have a more complete information package about the patient. Besides that, these teams filled that gap with the nurses, who have a more prominent role in the diagnostic process in comparison with teams consisting psychologists. It is also remarkable that the bipolar teams consisted of two types of nurses: specialist nurses and SPVs (in Dutch: Sociaal Psychiatrisch Verpleegkundige). The specialist nurse has also knowledge about medication. The employability of a mixture of nurse types can therefore possibly lead to confusions, less consistency and more possible faults during the diagnostic process. Also, the different team compositions at different locations ((un)availability of psychologists) can lead to less consistency and more problems in the diagnostic process, especially in cases where patients are referred from one location to another or in cases that professionals are asked to give a second opinion. A consistent team structure in all bipolar teams could lead to more awareness outside the team (because a consistent diagnosing process and information provision is known by health care providers) and a consistent way of information provision to the patient. Another point that could lead to confusion in the teams and the diagnostic process is that this research also identified that many professionals have comparable skills, however the responsibilities are different. It is essential that teams are aware of these skills and responsibilities in order to avoid duplication of efforts and ensure a consistent diagnostic process and formulate an accurate diagnosis.

7.3. Strengths and limitations Several strengths and limitation about this research can be noticed. First of all, this research enlarges our understanding of role divisions in a healthcare MDT. Moreover, all respondents are professionals who are experienced with the diagnostics of BD. The inclusion of different perspectives of several professionals is important for getting insight in the diagnostic process in practice and decreases bias. However, the amount of the professionals who are interviewed could be increased, in order to be able to generalize the data in more specialist bipolar teams. The generalization of the data is also limited by the difference of the composition of the teams and the

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daily practice of the teams at different locations. It is also remarkable that every location has at least subtle differences in their way of diagnostics, which can influence the perspective of team members about the added values of their selves and other disciplines. Furthermore, due to the bustling work planning of professionals, unfortunately not all planned focus groups are realized. In addition, sometimes some professionals were due to illness absent during the focus groups, which decreased the amount of participants in the focus group. On the other hand, despite of the absence of psychologists on initially planned locations, other psychologists involved in the diagnostic process of BD at other locations are recruited fluently. The diversity of the locations of the teams gave the opportunity to broaden the picture and have a more complete image about the diagnostic phase. This research has used two methods to gather the data: focus groups and interviews. An interview was planned when professionals where the only one team member with that particular profession, for example many psychologists are interviewed. A focus group setting can bring participants on ideas, because other participants memorize an aspect in the diagnostics. In that way, a focus group could help to gather more information. At the same time, interviews are anonymous in which the respondents could feel more on their ease. Besides that, the information gathering is done by different researchers, which can provide the research more insights, but also could have consequences for the consistency. Therefore, mainly two researchers were present during the focus groups or interviews.

Validity Besides the validity concerns in this research explained in the methodology section, this research also aimed to decrease the level of bias by including several locations that have different protocols about the diagnostic process of BD. In this way, it is aimed to get an overview about the diagnostics of BD as broad as possible. However, the professionals who are achieved are limited and the locations are narrowed to the area of Amsterdam and Utrecht. Despite of the valuable data in this research, more locations and professionals could be approached and questioned in order to a greater likeability to generalize the gathered data. Nevertheless, this research has achieved a good insight in the daily practice in the MDTs regarding to challenges and role values, since saturation of information was seen.

7.4. Future research While many issues about the diagnostic process of BD are raised in this research, still some future research is to be performed. This explorative research investigated the added values of different professionals by conducting focus groups and interviews, however there is not a consensus about the different roles reached. A Delphi study aims to reach a consensus on a particular issue within an organization. It can reach larger groups via emailing a questionnaire. Typically to the Delphi method is the low psychological threshold, because all respondents give his opinion anonymously and the study consists of several components. Furthermore, this research also found that psychologists are not always a part of the MDT in a specialist BD department. Therefore, measuring instruments that are used by psychologists are mainly missing or are not done standardly. An example was the MDQ, which is mentioned by one of the respondents. Future research can investigate which measuring instruments

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professionals in teams without a psychologist can use easily (and standard), in order to get a more efficient diagnostic process. Moreover, this research stressed the possible unawareness of instances and professionals outside the specialist team. Other professionals, like the GP, refer many patients with BD to the bipolar team. The first line care seems to be play an important role in the diagnostic process of BD. Therefore, more research can be done about how the awareness outside the specialist team can be increased. Beside the awareness, more research can be conducted about a fast check of BD at the GP.

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Appendix 1: Focus group design Benodigdheden

• Voice recorder • Flipover (2x) • Touw/tape om flipover op te hangen • Post-its • Stiften en pennen

Voorbereidingen

• Ophangen flipovers • Klaarleggen voor iedere deelnemer: post-its + pen/stift

Introductie (5 min)

• Voorstellen • Uitleggen wat we vandaag gaan doen

>Het diagnosticeren van een bipolaire stoornis kan moeizaam zijn. Het uiteindelijke doel is om sneller inzicht te krijgen in de problematiek van de patiënt door een efficiënter samenwerken van een multidisciplinair team. In deze sessie zullen we gaan kijken wat de moeilijkheden zijn bij het diagnosticeren van bipolaire stoornis en de meerwaarde van de verschillende rollen in het team. Wat is volgens jullie de rol van de verschillende disciplines in het stellen van de diagnose? Onderdeel 1 (15-20min):

• Leg de oefening uit o Bij deze oefening willen we een antwoord krijgen op de vraag: wat maakt het stellen van de

diagnose ‘bipolaire stoornis’ lastig? Jullie krijgen van mij 4 post its met de vraag om op elke post it 1 moeilijk aspect van het stellen van de diagnose te schrijven.

Onderdeel 2: meerwaarde rollen in het multidisciplinair team (15-20 min)

• Leg de oefening uit: o In deze oefening willen we jullie vragen de volgende vraag te beantwoorden en op te schrijven op

de kaartjes: de psychiater/psycholoog/verpleegkundige heeft een meerwaarde bij de diagnostiek

Doel:inzichtkrijgeninmoeilijkeaspectenvanhetstellenvandediagnose‘bipolairestoornis’.

Doel: inzicht krijgen in wat volgens psychiaters/psychologen/verpleegkundigen demeerwaardeisvandeanderedisciplinesbijhetdiagnosticerenvanpatiënten.

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omdat…… Vul het blauwe kaartje in over de psychiater, groen voor de psycholoog en rood voor de verpleegkundige. Op de achterkant staan verdiepende vragen die kunnen helpen bij het invullen van de vraag. Let op: de focus ligt op de diagnostiek

• Elke discipline vult het kaartje in voor de twee andere disciplines • Verzamel daarna de kaartjes en laat de deelnemers uitleggen wat ze bedoelen • Vraag hierbij ook door naar wat er anders is aan de bijdrage van die discipline ten

opzichten van hun eigen bijdragen. Oftewel, wat zouden we missen aan cruciale informatie als input vanuit deze discipline afwezig zou zijn?

o Zijn er duidelijk verschillende rollen? o Letten de disciplines echt op verschillende dingen? o Wat zouden de verschillen moeten zijn? o Wat is de overlap? o Wanneer moet je overschakelen naar een andere invalshoek?

Afronding/conclusie (5 min)

• Bedank de deelnemers voor deelname. Korte terugblik.

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Appendix 2: Roles of professionals

Takengemelddoor:PsychiatersGGZAmsterdam

SPVGGZHoofddorpSPVGGZAmsterdam

SPVAltrechtPsycholoogGGZAmsterdam

PsychiatersGGZHoofddorpPsycholoogAlkmaar

PsychologenPuntPPsycholoogAltrecht

TakenvanPsychiater>eindverantwoordelijkheid

>klinischeenbrederredeneren>neurologische,biologischeprocessen

>psychischonderzoekgoedbeschrijven

>meestekennisoversomatiek>medischpsychiatrischblik(breder)

>signalerenziekte>somatiek

>geneigdtegeneraliseren

>bewakensamenhangvanalleinfo>checkencomorbiditeit

>medicatie>bevoegdomdiagnosetestellen

>medicatie>somatiek

>medicatie>altijdhoofbehandelaar

>classificeertvolgensDSM

>meesteervaring>paratekennisoverDSM

>therapiegericht>as1en2goedbeschrijven

>besluitoveropnamevanpatientbv.

>oogvoormiddelengebruik>beloopsdiagnostiek

>complexebeelden>invloedmedicatie

>checkenvanwerkindiagnostiekverpl.

>somatiekuitvragen>checktenvultaan

>beteropgeleidomsymptomenteherkennen

>supervisie>isgetraindomsystematischtedenkenendifferentiaaldiagnostiektedoen.

>somatiek/labonderzoeken

>gewendomteclassificeren

>signaleertcomorbiditeit

>oogvoorsomatischeproblemen>eindverantwoordelijkmedicatie

>somatiek>comorbiditeit

>houdtoverzicht>oogvoorinvloedvanmedicijnen

>somatiek

>psychopathologie>geeftpsycholoogaanknopingspuntenvoorverderdieperonderzoek

>herkennenpatronen>pharmacotherapie

TakenvanPsychologen>persoonlijkheidsdiagnostiek

>neuropsychologischonderzoek

>beterbegripachtergrondenontwikkeling

>persoonlijkheidsstructuurvoorduidelijkeconclusies

>heeftandereinvalshoek,kijknaarcomorbidepsychiatrischebeelden(angst),cognitieveproblemen

>Bredereblikoppersoonlijkheid(dusookstijlvanpatient),isertraumabijpatient?

>schetsenonstaansgeschiedenis

>onderscheidensamenhangkunnenzienvanpersoonlijkheidenstressfactoren

>beschrijvendediagnose

>schadesopgelopendoorepisodes>belangrijkvoorvaststellentherapie,watzalerwerken

>kennisovertherapievormenengebieden

>overziethettotaleplaatje(socialeconsequenties,biopsychosocialemodel)

>Doenvanneuropsychologischonderzoek(NPO),ofmeetinstrumentenzoalsSCID

>oogvoorcomorbiditeit

>consulteertverschillendebronnen

>probeertniettegeneraliseren

>voorbereidingopbehandeling>persoonlijkheidsonderzoek

>cognitievegedragtherapie>verbindtverschillendeelementen(vanpsychiaterenspv)metelkaar.

>psycholoogstaptervaaklaterinenheefteenfrisseblik.

>testdiagnostiek(intelligentie,geheugen,SCID)

>hetero-anamnese>oogvoorwatisnormaalenwatishypomaan

>oogvoorpsychologischemechanismen

>creertmeerbegripoverpatient

>gedegenonderzoekdoen,uitsluitencomorbiditeit,kritischnauwkeurigonderzoekmetverschillendemeetinstrumenten.

>letop:watisernouechtaandehand.

>vooralhandigbijstagnatiebehandelingenpsychotherapie

>gebruikttestmateriaal>onderzoekcomorbiditeit

>brederbeeld>isgoedkoperdanpsychiater,kanrollenovernemen.

>psychopathologie>differentiaaldiagnostiek

>ontwikkelingsdynamiek>doetaanvullendonderzoekEM

CR,CGT.

>onderliggendedynamiekenpersoonlijkheidsstructuur

>verloopvanstemming

>veelmetenenonderbouwen,beschrijvendediagnostiek

TakenvanVerpleegkundige>signalerensymptomen

>beginintake,filtrerencomplexeregevallennaarpsychiater

>achtergrondpatient,lifestyle>as4,zelfmanagementmatrix

>vaakmeerpraktischedingen>makensignaleringsplan

>schetsenenbespreken(retrospectieve)lifechart

>kentpatientlanger>functionerenpatient

>kanprimadediagnostiekdoenalsptnwordtaangeleverdvanandereorg.metvermoeden

>vraagtdoornaarsymptomenenvoorgeschiedenis

>hetnemenvantijd>ogenvandepsychiater

>kanhuisbezoekendoen,extrainfooverpatientoverhoedieleefted.

>beloopziektevolgenenschetsen(ookbijcomplexegevallenvoorjuistediagnostiek)

>houdtcomorbiditeitindegaten

>ontwikkeltvertrouwensbad

>dagindelingensocialecontacten(systeem)

>goedkoperensimpelerindienalveelbekendisoverptn

>psychosociaalproblematiek>nietgefocustzijnopalleensymptomen

>psychosociaal,bijwerkingenmedicatie

>beschrijvendediagnose(as4)>procesdiagnostiek

>heeftoogvoorinhoeverrepatientdoorbipstoornisbeperktwordtindagelijksefuctioneren?

>meerervaringinpsychosocialeaspect

>sociaalmaatschappelijk>medeverantwoordelijkvoortransparantievaninfo

>hebbenlageredrempelenvrouwenkunnensomsmeerkwijtomdatverplvaakookvrouwis.

>ookinzichtindekrachtvandepatient

>financielemeerwaarde>snelleeersteintake

>kenthetsysteemvandepatienendeinvloedopdeklachten.

>functioneleblik:haalbaarheidbehandeling

>meerinformelesfeer,betertebereiken>retrospectivelifechart