the psychosomatic approach and its contribution to medical...
TRANSCRIPT
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.