the psychosomatic approach and its contribution to medical...

The Psychosomatic Approach

and its Contribution to

Medical Care

Matthias Rose

Department of Psychosomatic Medicine

Charité Universitätsmedizin Berlin, Germany

Department of Quantiative Health Sciences

University of Massachusetts, USA

Life Expectancy

Quality of Life

Medical

Condition

Medical

Treatment

Health Outcomes

1980 – 2010

+5 years

European average

76 years

Latvia

72 years

European Health Report 2012 - World Health Organization Regional Office for Europe

Life Expectancy Gain

Life Expectancy

Quality of Life

Medical

Condition

Medical

Treatment

Health Outcomes

Disease Burden

Fries J, Ann Intern Med. 2003, Am J Clin Nutr. 1992, Milbank Q. 1989

Compressing Morbidity

71 55

76 64 64

76 60

? 76 55

years with

disease burden

Vos et al. The Lancet 2013

Global Years Lived with Disability

Global Burden of

Disease Study 2010

YLD = years lived with disability

Fries J, Ann Intern Med. 2003, Am J Clin Nutr. 1992, Milbank Q. 1989

Compressing Morbidity

71 55

76 55

76 64 64

76 60

What are the

burdening conditions ?

Lost of Healthy Life Years (World) Change in Disease Adjusted Life Years (DALY)

De

pre

ssio

n

Dia

be

tes

Ne

ck P

ain

Ba

ck P

ain

HIV

Global Burden of Disease Study - The Lancet 2013

1990-2010

He

art

Dis

ea

se

Str

oke

Ca

nce

r

Mu

scu

losce

lata

l

Years Lived with Disability (World)

Vos et al. The Lancet 2013

in relation to 1990

disorders with major mental or

behaivioral component

Top 10

Disease Burden Ranks in Different Regions

Vos et al. The Lancet 2013 YLD = years lived with disability

European Health Report 2012 - World Health Organization Regional Office for Europe

Attributed Causes for Lost of Healthy Life Years

Disease Adjusted Life Years (DALY)

Main Health Challenges in Europe

Mental Disorders

Behavior Related Disorders

Rise of Non-Communicable Diseases

Obesity and Diabetes mellitus

Depression

Anxiety

Pain

Are These Distinct Phenomena ?

depression

unhealthy diet

little exercise obesity

diabetes

pain

Simplified Example of an Interactive Pattern

coronary heart disease

Knol ... Snoek, Powers, Diabetologica 2006

risk for the development of a type 2 diabetes of a otherwise health patient with depression 37%

prospective studies controlled for obesity, physical activity, smoking, alcohol und family disposition

4-6 year follow up period

Depression and Diabetes Type 2 Development

Depression, Diabetes and Mortality

Egede LE, et al. Diabetes Care 2005

Mortality n = 10.025

follow-up 12 Jahre

HR 2.50 (2.04–3.08 p<0.001*

* Multivariate controlled for age, gender, ethnicity, income, education, family status, smoking,

physical activity, BMI, NSAR medication, co-morbidity (CHD, hypertension, cancer, stroke)

Depressive

Non-Depressive

Depressive

Patients with Diabetes

Non-Depressive

Patients with Diabetes

depression

unhealthy diet

little exercise obesity

diabetes

pain

Assumptions of a System Medicine

coronary heart disease

External Demands health would

mean

successfully

maintaining

the systems

integrity

Mc Ewen, New York, „allostatic load“

What’s the difference ?

Life Expectancy Chronic

Condition

Medical

Treatment

Psychosomatic Approach

Disease Burden

Disease Burden

Psychosomatic Approach

Psychological

Disposition Coping, Personal Goals,

Conflicts, Structure

Disease-oriented Medicine

Social Disposition Working Conditions

Family Situation

Culture

Biological

Disposition

Life Expectancy

Patient-centered Care

Wilbert-Lampen, N Engl J Med 2008; 358: 475-483

Germany - Portugal

Germany- Italy

Germany- Argentina

Germany- Sweden

Example Cardiovasular Events

FIFA Soccer

World Cup 2006

1 0,9 0,9

1,4

2,2

0

0,5

1

1,5

2

2,5

0 1 2 3 4 oder

mehr

number of adverse childhood experiences

Mental Health and Disease Development

Risk for the Development of Coronary Heart Disease

or more

Center for Disease Control and Prevention ACE Study, Felitti 1998

n=17,000

Marmot, M.G. Shipley, M.J. Whitehall II Study, BMJ 1996

Social Status and Disease Development

25 years follow-up

Job Control predicts Coronary Heart Disease 10,308 civil servants

Need for Integrated Care

400 b.c.

Plato

Integrated Care Integrated Care

Greek

„The cure of many diseases is unknown to the

Physicians of Hellas, because they disregard the

whole, which ought to be studied also, for the part can

never be well unless the whole is well."

„The cure of many

diseases is unknown

to the Physicians of

Hellas, because they

disregard the whole,

which ought to be

studied also, for the

part can never be well

unless the whole is

well."

400 b.c.

Plato

„Should the physician devote all of his

effort to the body alone, an take no

account of the mind, his curative

endeavor will pretty often be less than

happy."

1763

Gaub

Integrated Care Integrated Care

Greek Dutch

Physician

„The cure of many

diseases is unknown

to the Physicians of

Hellas, because they

disregard the whole,

which ought to be

studied also, for the

part can never be well

unless the whole is

well."

400 b.c.

Plato

„Should the physician

devote all of his effort

to the body alone, an

take no account of

the mind, his curative

endeavor will pretty

often be less than

happy."

1763

Gaub

1894.

C.H. Hughes

„We are approaching

an era when the whole

patient is to be treated,

no more only a part or

organ solely."

Integrated Care Integrated Care

Greek Dutch British

Neurologist

„The cure of many

diseases is unknown

to the Physicians of

Hellas, because they

disregard the whole,

which ought to be

studied also, for the

part can never be well

unless the whole is

well."

400 b.c.

Plato

„Should the physician

devote all of his effort

to the body alone, an

take no account of

the mind, his curative

endeavor will pretty

often be less than

happy."

1763

Gaub

1894.

C.H. Hughes

„We are

approaching an

era when the

whole patient is

to be treated, no

more only a part

or organ solely."

K. Goldstein

1939

“There are innumerable facts

which demonstrate how the

functioning of a field is changed

by its isolation.”

Integrated Care

Greek Dutch British German

Neuologist

„The cure of many

diseases is unknown

to the Physicians of

Hellas, because they

disregard the whole,

which ought to be

studied also, for the

part can never be well

unless the whole is

well."

400 b.c.

Plato

„Should the physician

devote all of his effort

to the body alone, an

take no account of

the mind, his curative

endeavor will pretty

often be less than

happy."

1763

Gaub

1894.

C.H. Hughes

„We are

approaching an

era when the

whole patient is

to be treated, no

more only a part

or organ solely."

R. Dubos

1968

K. Goldstein

1939

„The understanding of disease

requires that the body-mind complex be

studied in its relations to external

environment."

“There are

innumerable

facts which

demonstrate

how the

functioning of a

field is changed

by its isolation.”

Integrated Care Integrated Care

Greek Dutch British French

Pathologist

German

Lipowski Psychosomatic Medicine 1984

Integrated Care Integrated Care

Is it naïve to believe the medical

system will change to

an integrated care model ?

Would it make sense ?

Yes

Yes

Integrated Care Time for an Integrated Care Model ?

Monocausal diseases, like infectious disease, and

mortality rates are declining

Instead non-communicable, chronic diseases become

decisive for the overall disease burden today

If a multi-factorial origin of chronic conditions is assumed,

including biological, psychological and social factors, a

reductionistic treatment – mental or medical – does not

seem adequate

Among them, mental status and behavior associated

disorders, like obesity, are playing prominent roles

Integrated Care Time for an Integrated Care Model ?

New methods also aiming of a

personalized medicine emerging

Neighboring disciplines are also

approaching a more integrated view

Computational power will allow to

analyze large interactive patterns

Geno- mics

Transcripto- nomics

Proteo- mics

Metabolo- mics

Compu- tational

Sciences

Large Scale Data

Systems Biology

to treat mental disorders as rigously

as medical disorders

Psychosomatic Approach

it is NOT just …

but also …

to appreciate mental and medical

conditions as an integral part and indicator

of a patient’s health status

Thank you.