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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)

-1 5

-1 4

-1 3

-1 2

-1 1

-1 0

-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9

Social Phobia Panic GAD Agorahobia Specific Phobia Major Depression Alcohol dependency Intestinal disorders Diabetes Cardiovascular disorders no mental disorder

-50 -40 -30 -20 -10 0 10 20 30 40 50 60 70 80

average number of days with disability per month

% of persons with > 1 day per month

(2)

Type and meaning of work

you work to live ? - you live to work ! Hand – Head – Haste !

Early retirement by diagnosis

Deutsche Rentenversicherung, 1996–2008

0 10000 20000 30000 40000 50000 60000 70000 80000 90000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

mental dis + addiction musculoscelettal oncology cardiology

(3)

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

(4)

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:

94.921 97.336 103.715 119.949

135.727 140.514

129.845 124.953 126.539 123.428 138.722

148.130

49.702 50.823 52.831 58.439 64.330 65.832 62.194 60.857 60.748 58.914 66.967 70.025

45.219 46.513 50.884 61.510

71.397 74.682

67.651 64.096 65.791 64.514 71.805 78.105

0 20.000 40.000 60.000 80.000 100.000 120.000 140.000 160.000

total male female

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

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

(5)

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

(6)

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

0 10 20 30 40 50 60 70 80 90

admission by insurance specialist treatment long term psychotherapy inpatient psychiat care application for retirement problems at work sick leave > 1/4 year

%

inpatient day care

(7)

Complaints / Symptoms

Diagnostic Algorithm

ICD-10-Diagnosis

Illness Status

Medical Episode Treatment

ICD ICF

Medical Rehabilitation

ICF impairment of function

Mini-ICF-APP ICF limitations of capacity

ICF barriers of context

ICF restrictions in participation

Social Support (e.g. sick leave, pension)

+

0% 20% 40% 60% 80% 100%

PTSD (N=4) Adjustment Disorder (N=45) Specific Social Phobia (N=39) Unspecific Social Phobia (N=13) Situational Anxiety (N =46) Hypochondriac Anxiety (N=23) Insufficiency Anxiety (N=61) Generalized Anxiety (N=70) Work Place Phobia (N=39)

no problems with participation short time absence

long term sick leave change or loss of job

Special Diagnoses: Percentage of patients with sickness absence in relation to different types of work related anxiety

(8)

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

Mental Functions Capacities Participation

(Psychopathology) („Activities“) (Role fullfillment)

Restrictions in Capacity and Sick Leave

***

*

**

***

***

**

*

***

*** ***

**

***

0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 2

degree of disability

total score mobility self maintenance non work activities intimacy public exposure contact to others assertiveness endurance competency flexibility structuring of tasks adherence to regulations

sick leave working

(9)

– 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

Special Treatments:

Therapeutic Interventions for work related problems

Medical rehabilitation by general practitioners

0 10 20 30 40 50 60 70 80 90 100

% Pat.

special diagnosis treatment

additional treatments

institutional contacts

social activities

done earlier done now recommended

(10)

Percentage of patients on early retirement 2 years after inpatient rehabilitation

German Federal Pension Agency, 2005

0 5 10 15 20 25

% pts. F 3, affective dis

F 4, neurotic dis.

F 5, eating dis F 5, personality dis

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

0 5 10 15 20 25 30 35 40

Teltow fulltime Teltow daycare

(11)

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

References

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