Report from Rogier Hoenders, MD, PhD, on Integrative Psychiatry in the Netherlands

Rogier Hoenders, MD, PhD Rogier Hoenders, MD, PhD (pictured), is the founder of the Center for Integrative Psychiatry (CIP) based in an outpatient clinic at the University of Groningen in the Netherlands  (pictured below). Hoenders contacted the Global Integrator recently with news of the Center and its related work. The Center began operations in 2007. On staff are 20 therapists “who treat about 500 psychiatric outpatients with severe mental illness,” according to Hoenders. The staffing is a mix of professionals. Included are psychiatrists, psychologists, nurses specializing in integrative mental health, psychiatry residents, a physical therapist and “an expert in mind-body medicine.”

The Center is also described on an international integrative mental health site as “the hub for a national Dutch network of integrative clinicians.” The loose network reportedly includes some 50 psychiatrists, 50 psychologists, 30 family physicians, and “many Master’s level therapists.” In March 2015, CIP held their sixth biennial conference. The meeting was entitled (Mental) Health in Crisis and drew more than 400 attendees. The attendee total was down from as many as 900 in the event’s early years. Hoenders attributes the decline to changes in the economy. Useful descriptions of all six meetings are here. A seventh conference is planned for 2017.

University of Groningen in the NetherlandsHoenders shared two significant documents with the Global Integrator. One is the work his team was required to perform to open the Center: namely, create the “The Dutch CAM Protocol” for inclusion of complementary and alternative modalities in psychiatric care. The protocol lists treatments, including certain herbs and mind-body approaches deemed to have quality biomedical evidence, which thus could be offered. Other therapies didn’t meet their standard—homeopathy and Reiki are mentioned. Under the protocol, these can be offered offsite “to patients through referral under strict conditions.” The centerpiece is a flowchart for decision processes.

The second document was a research publication on outcomes at the Center based on a novel “routine outcome modeling (ROM)” data strategy. The paper describes challenges with the methodology, including a significant problem in gathering posttreatment data. They noted, for instance, that “subtle variations in analytic strategies influenced effect sizes substantially.” While offering qualifications, the team concludes, “Mixed-model analysis showed significant improvement in symptomatology, quality of life, and autonomy, and differential improvement for different subgroups. Effect sizes were small to large, depending on the outcome measure and subgroup.” In addition, “We illustrate how problems inherent to design and analysis of ROM data prevent drawing conclusions about (comparative) treatment effectiveness.”

INIMHTo a question from the Global Integrator about whether his group had a formal association, Hoenders responded, “Not yet. I am working on starting an association. About 50 psychiatrists seem interested, but there is also a lot of opposition from old dogmatic MDs.” Asked if he was aware of the New Jersey, USA–based International Network of Integrative Mental Health, Hoenders shared that he was a cofounder and continues as a member of the board of the directors. In fact, “it was during one of our conferences that the idea of starting an international network for integrative mental health was born!”  He and James Lake, MD, took the lead.

Comment: I felt a kinship immediately on reading into the protocol that Hoenders and his team developed. They led off by directly addressing an elephant in the room: “Table 1. Prejudices against Complementary and Alternative Medicine (CAM).” His team describes 8 such prejudices followed by a “Refutation.” Better yet, the team and its protocol show balance. There follows “Table 2. Prejudices for Complementary and Alternative Medicine (CAM).” The pro-CAM prejudices also get their refutation. Example: “Prejudice: 1. If it does not work, at least it will not harm. Refutation: 1. Some supplements or herbs can cause severe side-effect or interactions.”

I shared with Hoenders my own version of such a table, from a contracted paper for a 1996 US National Institutes of Health invitational meeting entitled “Complementary and Alternative Medicine: Issues Impacting Coverage Decisions.” My table on page 45 was entitled “Bilateral Prejudice as an Operational Issue in Limiting the Integration of Complementary and Conventional Health Care.” It is fitting that this short piece on this ambitious and influential work in integrative psychiatry should conclude with recognition that among us human beings the twin high horses of “evidence-based medicine” and “medicine without side effects” can often be creatures with fur matted and stinking with residue of where the critter slept last night.

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