Chronic diseases,psychological distress and coping -- challenges for psychosocial care in medicine

Due to the increase of chronic diseases within the last decades the need and demand for psychosocial treatment in medicine has been realized. This review focuses on the psychosocial aspects of chronic diseases and discusses selected topics of medical and rehabilitation psychology. Recent developments in quantitative and qualitative methods have allowed the systematic analysis of psychosocial distress and coping with chronic disease as well as the consequences on social relationships. The need for psychosocial treatment in acute care and rehabilitation can be diagnosed by differential assessment tools for coping and psychiatric morbidity. Specific approaches of psychology and psychotherapy for patients with somatic diseases have been developed and may be regarded as an integrative part of medical treatment in acute care and rehabilitation. In rehabilitation, the traditional individualistic view of psychotherapy has been broadened towards vocational integration and participation in social activities as outcome criteria. Evaluation research as well as the rehabilitation sciences have provided empirical data on psychosocial treatment of chronically ill patients. Under increasing financial restrictions and problems of the health care systems there is a need for quality assurance and the proof of scientific evidence to guarantee psychosocial treatment as an integrated part of medical care in the future.     

Cost-benefit aspects in psychosomatic rehabilitation

The active participation of patients in their healing process and early behavioral rehabilitation both cause a considerable and steady improvement of psychosomatic diseases. The results of a multicenter study show that patients become less ill, have shorter diseases and that their consumption of drugs decreases considerably following an inpatient behavior therapy. These changes also have an economical significance: Employers have to spend considerably less continued payments and health insurers have reduced expenses for medical treatments. The inpatient medical rehabilitation of psychosomatic disorders can cause a reduction of illness related costs of up to 2.5 billion DM annually.     

Psychosomatic medicine and psychotherapy in Austria

In present-day Austria, psychosomatic medicine and psychotherapy enjoy significantly more sociopolitical and cultural recognition perhaps as a heritage from the days of the Austrian monarchy -- than is reflected in their real presence. This development can be traced back to prewar times and the repudiation of the destructive national socialistic ideology. There is an immanent conflict between specialization in psychosomatic medicine and psychotherapy as an independent field of medicine and the integration of a psychosomatic basic approach into the general fields of medicine. The organization of psychotherapy is doubly anchored in the laws governing medical practice (PSY diploma) and the statutes governing the practice of psychotherapy; this, however, has not resolved the sensitive and only partially creative tension between the two. Austrian medical health politics are currently characterized by renewed efforts to organize the field of psychosomatic medicine. Should medical psychology and psychotherapy, internal medicine, psychiatry or general medicine provide the foundations for this new organization? This conflict is crucial since it will influence the further development of the entire medical field.     

The future of psychosocial treatments for elderly patients.

Geriatric psychiatric disorders usually occur in the context of medical illness, disability, and psychosocial impoverishment. Preliminary evidence suggests that psychotherapy can reduce not only psychopathology but also physical complaints, pain, and disability and that it can improve compliance with medical regimens. Psychotherapy has been found effective in treatment of depression related to bereavement and caregiver burden. Modification of available treatment strategies to address infirmity and life adversity may have a major impact on rehabilitation from psychiatric and medical disorders and may reduce utilization of nonpsychiatric health services. Most elderly patients with psychiatric problems prefer to be treated by their primary care physician. Models need to be developed and tested to integrate psychotherapy and other mental health services in primary care settings so that timely and appropriately targeted interventions can be provided.     

Somatische Morbidität bei psychisch Kranken

In addition to psychosocial impairment, patients with severe mental illness (SMI) are exposed to substantial risks with respect to physical health. Their life expectancy is significantly shortened in the range of 1–2 decades. Against this background common medical comorbidities of this important group of patients are discussed (e.g. cardiovascular, respiratory and metabolic disorders) with a focus on those clinical aspects most relevant for everyday psychiatric practice. Potentials for improvement of curative and preventive health care are outlined. Current scientific and clinical knowledge on somatic health of patients with SMI provides evidence of close interactions between physical and mental health. Meeting the challenge of compromised physical health in this particular group of patients might be a relevant topic for further conceptual development of psychiatry, psychotherapy und psychosomatic medicine.     

Current trends in medical rehabilitation and their significance for the field of psychosomatic rehabilitation

At present the process of serious restructuring can be observed in the system of medical rehabilitation in Germany. This paper focuses on recently initiated innovations and their consequences for psychosomatic rehabilitation. The patient's access to a psychosomatic rehabilitation system is analysed and examined to what extent innovations increase early detection of patients with psychosomatic disorders. Regarding the structure of psychosomatic rehabilitative offers, the initiated innovations such as an increase of flexibility, better transition and improvement of inpatient rehabilitative offers are described and discussed. Finally, the development of quality improvement programs and rehabilitation research in the field of psychosomatic rehabilitation is presented. Although many changes have taken place up to now, further relevant modifications in psychosomatic rehabilitation are predicted by the authors.     

Improving the psychosomatic competence of medical doctors in China, Vietnam and Laos-the Asia-Link Program

OBJECTIVE: The European Union is supporting a 3-year cooperation project coordinated by the Freiburg University Clinic for the development and promotion of psychosomatic medicine in China, Vietnam, and Laos. The main objective is the development and performance of post-graduate training for medical doctors to improve doctor-patient communication and to acquire psychosomatic knowledge, skills, and attitudes. METHOD: The project is based on contacts which have existed for several years with the Tongji University and the affiliated Tongji Hospital in Shanghai. Medical doctors in all disciplines are to learn to promptly recognize emotional disorders which frequently present in the primary care setting, to offer limited treatment themselves, and to cooperate with mental health specialists. RESULTS: In the first year of the project, 50 medical doctors from different medical fields were trained as future teachers. In the second year, we are starting a pilot curriculum which will include 60 hours of theory and psychosocial interventions, divided into three blocks. CONCLUSIONS: Future developments will involve setting up a psychosomatic network in Southeast Asia to establish advanced training in psychosomatic medicine and psychotherapy and to promote psychiatric and psychosomatic consultation and liaison services in the general hospitals.     

Inpatient psychotherapeutic health care services in northern Germany--Results of an expertise

In Germany health care services for patients with psychosomatic disorders are characterized by three specific features: A large amount of inpatient facilities, which have been developed outside psychiatric institutions and which are mainly rehabilitation clinics instead of acute clinics. We have tried to analyze whether (1) there is a sufficient number of inpatient facilities in Northern Germany, whether (2) the treatment of psychosomatic disorders should be conducted in large-scale outpatient clinics or in minor departments of community hospitals and (3) to what extent therapy should preferably be offered in acute rather than in rehabilitative settings. By means of different methodological approaches our analysis shows (1) a need for more facilities for the treatment of patients with psychosomatic disorders than legally established by the government, (2) the necessity to differentially allocate patients to appropriate clinics and (3) to encourage clinics to develop or to expand those therapeutic elements which aim more at rehabilitative or acute care.     

Medical and legal aspects of differentiation of inpatient psychotherapeutic treatment from psychosomatic rehabilitation

In the field of psychotherapeutic and psychosomatic medicine inpatient treatment is indicated in cases of instability of patients, comorbidity with severe organic disease, not yet clearly diagnosed and potentially dangerous symptoms, lack of understanding the nature of the psychosomatic illness and of motivation for psychotherapy and sometimes organizational reasons or the necessity to remove the patient from his private or professional conflicts. To differentiate between hospital treatment and psychosomatic rehabilitation is more difficult than in other medical settings. Medical and legal aspects of this indication problem are presented as well as solutions in way of networks of treatment processes.     

Teaching and training of the psychosomatic approach.

In the United States, teaching and training of the psychosomatic approach relies upon (1) the application of psychosomatic concepts, such as reaction to stress, life change and illness, and neuroendocrine influences on disease process to the delivery of mental health services to the sick and dying through liaison programs, and (2) the focussing upon relevant methodology of psychological care in the context of American medicine with its growing knowledge of social implications of health care. Such methodology includes the teaching of data collection, substantive psychiatric disorders in the medically ill, supportive therapy and crisis intervention, psychopharmacology, emotional reaction to illness, and management of obstacles to a psychosocial approach. The resistance of nonpsychiatrist personnel to psychological factors and of psychiatric personnel to medical factors are obstacles which require particular emphasis in graduate and postgraduate training in this clinical area.     

A modern therapeutic approach for chronically mentally ill patients--results of a four-year prospective study.

A 4-year prospective study was carried out on 53 chronically mentally ill patients living in a differentiated complementary residential complex. Our main question was how the lives of these patients develop, as reflected in their psychological wellbeing, working capacity, therapeutic requirements and any necessary periods of rehospitalization. At the end of a 4-year rehabilitation period, 50% of the patients were living in sheltered communities and about 25% on their own. Only 10% had returned to the psychiatric hospital as long-term patients. The psychological findings were characterized by apathetic, depressive and psycho-organic syndromes (AMDP system) and were subject overall to minimum variation. Very few patients succeeded in obtaining work on the general labour market, but the work available on the sheltered labour market was suitable for a large proportion (40%) of them. All patients were undergoing medical care after 4 years. Patients suffering from chronic mental disorders can be cared for in the community even after long-term hospitalization. Special success has been achieved with rehabilitation in the residential sphere. Adequate care implies numerous services to ensure that patients are integrated into the labour market, to help establish contacts and to enable chronically ill patients to take part in social and cultural life. Most patients retain a considerable degree of psychological disturbance and are permanently dependent on psychiatric therapy or psychosocial care. On the other hand, they benefit from the fact that their living circumstances are largely normal and that they have higher degree of personal autonomy.     

"Short and long-term therapies in psychosomatic disorders".

Narcoanalysis (narcosynthesis) as well as psychoanalytically oriented psychotherapy (psychoanalytic psychotherapy) are both, in my opinion, practical and useful short-term methods of therapy in psychosomatic disorders. Psychoanalytic psychoterapy may also be used as an alternative to narcoanalysis when the latter method decisively fails the therapist. In selecting candidates for psychotherapy in psychosomatic practice, 3 essential factors should be taken into consideration, viz. the time of onset of the illness, the patient's personality structure and his intellectual capacities.     

Post-hospitalization transitional care needs of depressed elderly patients: models for improvement

PURPOSE OF REVIEW: In the weeks immediately following psychiatric hospital discharge, severely depressed elderly patients are at risk of 'falling through the cracks' in a complex health care system: becoming lost to follow-up, receiving inadequate care, or requiring prompt readmission. The purpose of this review is to highlight recent literature on the comorbid physical health problems and complex care needs of elderly patients hospitalized for depression. This paper will also review recent initiatives to improve the quality of care transitions for elderly patients discharged from medical hospitals that may be adaptable to a severely depressed population. RECENT FINDINGS: Due to shorter hospital stays, comorbid physical health problems, and limitations in functional capacity, severely depressed elderly patients discharged from psychiatric hospitals have complex service needs, and numerous barriers to care, immediately following hospital discharge. There is a lack of research specifically addressing the transitional care needs of this population. Improvement interventions assigning transitional care providers to chronically medically ill elderly patients immediately after medical hospital discharge have shown decreased rates of rehospitalization and emergency services utilization, and appear to be cost-effective. SUMMARY: Further research is needed to adapt successful transitional care interventions targeting chronically ill elderly patients in medical hospitals to severely depressed elderly patients being discharged from psychiatric hospitals.     

Anxiety in medically III patients

Anxiety disorders and anxiety symptoms are highly prevalent in the general population and more so in the medically ill. They have a number of negative consequences for these patients and may worsen the outcome of the medical illness and increase health care utilization. In the evaluation of these patients, it is of paramount importance to identify the etiology of the anxiety and, in particular, to differentiate primary from secondary anxiety. Management includes medications (especially benzodiazepines and selective serotonin reuptake inhibitors) and psychotherapy (particularly cognitive-behavioral therapy).     

Preventive strategies and program evaluation methods for chronically mentally ill suicide attempters

In the course of defining treatment strategies and outcome criteria for a case management program serving the chronically mentally ill we reviewed the medical records of 282 patients admitted to University Hospital in Portland, Oregon following suicide attempts in 1979 and 1980. We found that these young people often had chronic psychiatric disorders, usually overdosed on medications, and spent a short time in the hospital—frequently in the intensive care unit. A substantial percentage of patients were clustered in the dowtown area of Portland and had not been treated previously at our hospital. Based on these findings we suggest a community based primary prevention program emphasizing case management for the chronically mentally ill. We also discuss a secondary prevention strategy in which overdose morbidity is minimized by adopting a cautious approach to dispensing psychotropic medications. We point out that readily available data on health care utilization following suicide attempts can be used to monitor such a program's effectiveness.     

Deinstitutionalization: a microcosmic perspective

Changes have taken place in caring for chronic patients due to deinstitutionalization, and these changes have affected the services rendered by the community mental health centers. Statistical data on dehospitalized patients treated in a community mental health center located in the South Central Bronx are examined to determine trends in service utilization by these patients. Demographic characteristics of this population are also examined. Issues surrounding treatment and rehabilitation of chronic mentally ill patients are critically explored and recommendations for changes in the care of the chronically mentally ill patient are offered.     

Health care of the chronically mentally Ill: The culture broker model

The chronically mentally ill tend to receive inadequate medical care for nonpsychiatric illnesses and to have poor health care status. Their medical problems lead to excessive morbidity and mortality and adversely affect their adjustment to psychiatric illness. The authors argue that many of the barriers to medical care for these patients can be overcome by using case managers as culture brokers—persons who provide bridges between the worlds of the chronically mentally ill and medical providers. This paper presents the culture broker model and its roots in anthropology, and illustrates its application to the medical care of the chronically mentally ill with case examples.     

Psychotherapy in psychosomatic disorders.

Published controlled studies of various psychotherapeutic techniques in psychosomatic disorders with adequate designs have formed the basis for the following conclusions: Psychotherapeutic techniques are effective in some patients with psychosomatic disorders. Some psychosomatic disorders, for example, bronchial asthma, peptic ulcer, and migraine headaches are perhaps more amenable to psychotherapy than others, for example, hypertension and ulcerative colitis. There is evidence to suggest that there are differences between the effectiveness of various psychotherapeutic techniques; a few patients differ perhaps from the rest in that they are helped most by the technique that is less effective for the majority.     

Treatment of depressive patients in private practice--empirical results, health political and social conditions and recommendations

Although depression and symptoms of depression belong to the most common disorders in private practice, affected patients are not always diagnosed as early as possible in Germany and often not sufficiently treated. In order to improve the care for persons with depression it is necessary that family doctors are prepared to guide these patients with empathy, treat them adequately pharmacologically both in respect to the depression and to all other somatic aspects and to refer them in time to specialists for psychiatry, psychosomatic medicine or psychotherapy. Political and social conditions that have pathogenic effects should be changed and the shortage of psychotherapy needs to be overcome. In future, the integrated care in ambulant and clinical settings will probably be successful, first trials and test setups have shown good results.     

Psychoanalysis and psychosomatics: a new synthesis.

The usefulness of psychoanalysis to psychosomatic medicine has been limited by the longstanding assumption that the psychological disorder in psychosomatic patients resembles the conflict-based psychopathology that Freud identified in psychoneurotic patients. Recent investigations of the alexithymia construct, and the discovery that social relationships can influence health over the entire life span, have challenged this assumption and created an opportunity for a new and active involvement of psychoanalysis with psychosomatic medicine. In this contribution, I offer a synthesis of contemporary psychoanalytic observations and theories with concepts and research findings from developmental psychology, developmental biology, and the biomedical sciences. The proposed synthesis is consistent with the view that living organisms are self-regulating cybernetic systems; it also extends an evolving new psychosomatic model that conceptualizes illnesses and diseases as disorders of psychobiological regulation. A modern psychoanalytic approach to physically ill and disease-prone individuals focuses less on the resolution of neurotic conflicts, and more on correcting deficits in these patients' self and object representations and capacity cognitively to process emotions.