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
-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 5 4 3 2 1 0 average number of days 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
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
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 female
148.130 160.000 140.514 135.727 138.722 129.845 124.953 126.539 140.000 119.949 123.428
120.000 103.715 94.921 97.336 100.000 78.105 71.397 74.682 71.805 67.651 65.791 80.000 61.510 64.096 64.514 50.884 60.000 45.219 46.513 66.967 70.025 64.330 65.832 62.194 58.439 60.857 60.748 58.914 40.000 52.831 49.702 50.823 20.000
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
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 male 49.702 50.823 52.831 58.439 64.330 65.832 62.194 60.857 60.748 58.914 66.967 70.025 female 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 Organic Disorders 3,1 F1 Abuse of Psychotropic Substances 1,3 F2 Schizophrenia 0,4 F31 Bipolar Depression 2,2 F32 Depressive Episode 11,9 F33 Recurrend Depressive Episode 9,2 F34 Chronic Depressive Episode 3,8 F40 Phobic Disorder 15,3 F41 Panic, GAD 10,1 F42 OCD 2,0 F43 Adjustment Disorders 29,2 F45 Somatoforme Disorders 9,7 F48 Neurasthenia etc. 2,2 F50 Eating Disorders 0,7 F51 Sleep Disorders 0,7 F54 Psychological Reactions to Somatic Disorders 0,2 F60/61 Personality Disorders 8,1 F8 Developmental Disorders 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
Complaints / Symptoms ICF impairment of function
Diagnostic Algorithm
Mini-ICF-APP
ICD-10-Diagnosis ICF limitations of capacity + ICF barriers of context Illness Status
Medical Episode Treatment ICF restrictions in participation
Social Support Medical Rehabilitation (e.g. sick leave, pension)
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% 80% 100% no problems with participation short time absence long term sick leave change or loss of job
www.oecd.org/els/disability 7 Mental Functions Capacities Participation (Psychopathology) („Activities“) (Role fullfillment)
Vigilance 1. adjustment to routines nurse Orientation 2. structuring of time architect Memory 3. flexibility physician Concentration 4. competeny baker Formal Thinking 5. endurance workman Content of Thoughts 6. assertiveness truck driver Ego-Disorders 7. public roles carpenter OCD and Anxieties 8. contact to others plumber Affect 9. family roles postman Drive 10. leisure activities accountant Attitude 11. Self Care salesman Somatoform symptoms 12. move around 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 * sick leave mobility working total score *** 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. 50 done earlier done now 40 recommended 30 20 10 0 special diagnosis additional institutional social activities treatment treatments contacts
www.oecd.org/els/disability 9 Percentage of patients on early retirement 2 years after inpatient rehabilitation German Federal Pension Agency, 2005
25
20
15 F 3, affective dis F 4, neurotic dis.
F 5, eating dis % pts. % 10 F 5, personality dis
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 20 Teltow daycare 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