* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Figure 1: Lifetime, 12-month and and 30
Survey
Document related concepts
Separation anxiety disorder wikipedia , lookup
Treatments for combat-related PTSD wikipedia , lookup
Outpatient commitment wikipedia , lookup
Munchausen by Internet wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Mental disorder wikipedia , lookup
Diagnosis of Asperger syndrome wikipedia , lookup
Intellectual disability wikipedia , lookup
Child psychopathology wikipedia , lookup
Drug rehabilitation wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Externalizing disorders wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Transcript
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