Download Figure 1: Lifetime, 12-month and and 30

Mental Health, Disability and Work:
Inpatient Medical Rehabilitation
Prof. Michael Linden
Head of the Rehabilitation Center Seehof of the German
Pension Fund and Director of the Department of Behavioral
Medicine, Teltow/Berlin
Director of the Research Group Psychosomatic Rehabilitation
at the Charité University Medicine, Berlin
Disability in relation to
different disorders
(Bundesgesundheitssurvey 98)
% of persons with > 1 day per month
80
70
60
50
40
30
20
10
0
-10
-20
-30
-40
-50
Social Phobia
Panic
GAD
Agorahobia
Specific Phobia
Major Depression
Alcohol dependency
Intestinal disorders
Diabetes
Cardiovascular disorders
no mental disorder
-1 -1 -1 -1 -1 -1 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9
average number of days
5 4 3 2 1 0
with disability per month
www.oecd.org/els/disability
1
Type and meaning of work
Hand – Head – Haste !
you work to live ? - you live to work !
Early retirement by diagnosis
Deutsche Rentenversicherung, 1996–2008
90000
80000
70000
60000
mental dis + addiction
50000
musculoscelettal
oncology
40000
cardiology
30000
20000
10000
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
www.oecd.org/els/disability
2
Health Care for Mental Disorders in Germany
(80 Mio. inhabitants)
individual outpatient practice
• 14.986 ambulatory psychological psychotherapists
• 2.985 ambulatory specialists for psychosomatic medicine and psychotherapy
• 2.724 ambulatory specialists for neurology and psychiatry
• 2.207 ambulatory specialists for psychiaty and psychotherapy
• 60.000 ambulatory physicians with special training in basic psychosomatic
care (mostly general practitioners)
• 14.173 non-medical practitioners (Heilpraktiker)
outpatient clinics
• appr. 300 outpatient clinics (appr. 1.200 physicians and psychologists)
• 12.487 psychosocial counselling institutions (60.000 counsellors)
• 155 outpatient psychotherapy training institutes (appr. 4.000
psychotherapists)
= 162275 therapists/counsellors = 1 / 493 inhabitants
= 28.102 psychiatric-psychotherapeutic specialists = 1 / 2847
hospital care (pts per year)
• 638.538 pts. in psychiatric hospitals
• 23.220 pts. in psychosomatic hospitals
• 30.273 pts. in child and adolescent psychiatry hospitals
• appr. 160.000 pts. in general hospitals
• appr. 200.000 pts. in inpatient rehabilitation hospitals
Forms of Rehabilitation
• Participation Rehabilitation
– prothesis
– barrier free architecture
• Job Rehabilitation
– education in jobs which can be done in spite of existing
impairment
– formation of special jobs for persons with impairment
• Medical Rehabilitation
– diagnosis and treatment of chronic illnesses (> ½ year)
– treatment of illness course
– support for self-management of chronic illnesses
www.oecd.org/els/disability
3
Medical Rehabilitation:
Medical specialty for the diagnosis and treatment
of disability and chronic illnesses
SGB IX, § 26
•
Goals:
– prevention of chronicity
– treatment of chronic illnesses
– compensation of chronic illnesses
– prevention of illness deterioration
– prevention of negative illness consequences
•
Interventions:
– care by physicians
– medication
– psychotherapy
– etc.
Inpatient medical rehabilitation for mental disorders
German federal pension agency, 1997– 2008:
total
male
148.130
16 0 .0 0 0
135.727
14 0 .0 0 0
12 0 .0 0 0
female
140.514
138.722
129.845
124.953
126.539
123.428
67.651
64.096
65.791
64.514
119.949
94.921
97.336
103.715
10 0 .0 0 0
8 0 .0 0 0
6 0 .0 0 0
4 0 .0 0 0
71.397
74.682
64.330
65.832
62.194
60.857
60.748
58.914
2001
2002
2003
2004
2005
2006
61.510
71.805
78.105
50.884
45.219
46.513
49.702
50.823
52.831
1998
1999
58.439
66.967
70.025
2007
2008
2 0 .0 0 0
0
1997
2000
total
94.921
97.336 103.715 119.949 135.727 140.514 129.845 124.953 126.539 123.428 138.722 148.130
m ale
49.702
50.823
52.831
58.439
64.330
65.832
62.194
60.857
60.748
58.914
66.967
70.025
fem ale 45.219
46.513
50.884
61.510
71.397
74.682
67.651
64.096
65.791
64.514
71.805
78.105
www.oecd.org/els/disability
4
Inpatient Psychosomatic Rehabilitation
in Germany
•
•
•
•
•
•
•
•
25.000 beds (0,3 beds per 1000 inhabitants)
200.000 patients per year (0,25%)
costs are payed by the pension or health insurance
patients and their physicians can send applications together with
case reports to the insurance which are then reviewed by physicians
patients with prolonged times of sick leave are seen by physicians of
the insurance and then send involuntarily to inpatient rehabilitation
patients who ask for early pensions are first send to inpatient
rehabilitation (rehab first!)
there is a fixed number of days admitted by insurance, which can be
changed if necessary
patients are send by the insurance to rehabilitation centres
nationwide which are specialised for the problem at hand
Why Inpatient Treatment:
Therapeutic Milieu
•
•
•
•
•
•
•
•
•
•
•
Intensified diagnosis
Intensified treatment
Shelter
Relieve of demands
Structuring of the day
Therapeutic demands
Practice field
Motivation
Model-Learning
Contact with others
More reliabel observation and sociomedical
judgements on illness state, prognosis and ability to
work
www.oecd.org/els/disability
5
Diagnoses in
Inpatient Psychosomatic Rehabilitation
Dep. of Behavioral Medicine, Rehabilitation Centre Seehof Teltow/Berlin
ICD10-Diagnoses
F0
F1
F2
F31
F32
F33
F34
F40
F41
F42
F43
F45
F48
F50
F51
F54
F60/61
F8
%
Organic Disorders
Abuse of Psychotropic Substances
Schizophrenia
Bipolar Depression
Depressive Episode
Recurrend Depressive Episode
Chronic Depressive Episode
Phobic Disorder
Panic, GAD
OCD
Adjustment Disorders
Somatoforme Disorders
Neurasthenia etc.
Eating Disorders
Sleep Disorders
Psychological Reactions to Somatic Disorders
Personality Disorders
Developmental Disorders
3,1
1,3
0,4
2,2
11,9
9,2
3,8
15,3
10,1
2,0
29,2
9,7
2,2
0,7
0,7
0,2
8,1
0,2
Patients of the Department of Behavioral and Psychosomatic
Rehabilitation at the Rehab Center Seehof
of the German Federal Pension Agency
sick leave > 1/4 year
problems at work
application for retirement
inpatient psychiat care
long term psychotherapy
specialist treatment
admission by insurance
0
10
20
30
40
50
60
70
80
90
%
inpatient
day care
www.oecd.org/els/disability
6
ICD
ICF
ICF impairment of function
Complaints / Symptoms
Diagnostic Algorithm
Mini-ICF-APP
ICF limitations of capacity
ICD-10-Diagnosis
+
ICF barriers of context
Illness Status
Medical Episode Treatment
ICF restrictions in participation
Social Support
(e.g. sick leave, pension)
Medical Rehabilitation
Special Diagnoses: Percentage of patients with sickness absence
in relation to different types of work related anxiety
Work Place Phobia (N=39)
Generalized Anxiety (N=70)
Insufficiency Anxiety (N=61)
Hypochondriac Anxiety (N=23)
Situational Anxiety (N =46)
Unspecific Social Phobia (N=13)
Specific Social Phobia (N=39)
Adjustment Disorder (N=45)
PTSD (N=4)
0%
20%
40%
60%
no problems with participation
80%
100%
short time absence
long term sick leave
change or loss of job
www.oecd.org/els/disability
7
Mental Functions
Capacities
Participation
(„Activities“)
(Role fullfillment)
(Psychopathology)
Vigilance
Orientation
Memory
Concentration
Formal Thinking
Content of Thoughts
Ego-Disorders
OCD and Anxieties
Affect
Drive
Attitude
Somatoform symptoms
1. adjustment to routines
2. structuring of time
3. flexibility
4. competeny
5. endurance
6. assertiveness
7. public roles
8. contact to others
9. family roles
10. leisure activities
11. Self Care
12. move around
nurse
architect
physician
baker
workman
truck driver
carpenter
plumber
postman
accountant
salesman
others
Restrictions in Capacity and Sick Leave
adherence to regulations
structuring of tasks
flexibility
competency
endurance
assertiveness
contact to others
public exposure
intimacy
non work activities
self maintenance
mobility
total score
***
**
***
***
***
*
**
***
***
**
sick leave
*
working
***
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
2
degree of disability
www.oecd.org/els/disability
8
Special Treatments:
Therapeutic Interventions for work related problems
– Individual psychotherapy for the improvement of self
efficacy, reduction in anxiety etc.
– Group psychotherapy for the improvement of self efficacy,
decrease of anxiety etc.
– Competency training by occupational therapists
(concentration, endurance, functional training)
– Group therapy: management of conflicts at the work place
– Group therapy: management of time at the work place
– Group therapy: Work an self-development
– Internet search
– application for jobs with support
– Couseling for occupational rehabilitation
– Individual counseling for work related problems
– Contacts with the employer
– Work exposure
– Follow up counseling
Medical rehabilitation by
general practitioners
100
90
80
70
60
% Pat.
done earlier
done now
recommended
50
40
30
20
10
0
special diagnosis
treatment
additional
treatments
institutional
contacts
social activities
www.oecd.org/els/disability
9
Percentage of patients on early retirement
2 years after inpatient rehabilitation
German Federal Pension Agency, 2005
25
% pts.
20
F 3, affective dis
F 4, neurotic dis.
F 5, eating dis
F 5, personality dis
15
10
5
0
Percentage of patients who have been on sick leave
longer than ½ year and who have not been on early retirement
during the next two years
German Federal Pension Agency
40
35
30
25
Teltow fulltime
Teltow daycare
20
15
10
5
0
www.oecd.org/els/disability
10
Summary and Conclusions
• Chronic (mental) disorders have special
characteristics in respect to functions, capacities
and participation in work or life in general
• Chronic (mental) disorders pose special
problems in respect to diagnosis and treatment
and need special medical care (medical
rehabuilitation, social psychiatry)
• Specialized centers for medical rehabilitation can
help to identify problems and offer targeted
treatment in the course of chronic illnesses
• Additional to the diagnosis of syndromes
diagnoses of course are needed and especially
of criteria for course dependent interventions
• Assessment, prediction, and treatment of chronic
(mental) disorders has to focus on the relation
between capacity and context
www.oecd.org/els/disability
11