|
1
|
Giordano GM, Brando F, Pezzella P, De Angelis M, Mucci A, Galderisi S. Factors influencing the outcome of integrated therapy approach in schizophrenia: A narrative review of the literature. Front Psychiatry 2022; 13:970210. [PMID: 36117655 PMCID: PMC9476599 DOI: 10.3389/fpsyt.2022.970210] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/11/2022] [Indexed: 12/03/2022] Open
Abstract
The integration of pharmacotherapy with psychosocial interventions has an important role to play in the improvement of functional outcome of subjects with schizophrenia (SCZ), in all stages of the disorder. It is essential for the adequate management of unmet therapeutic needs, such as negative symptoms and cognitive dysfunctions which account for most of the functional impairment of subjects with SCZ and do not respond to available antipsychotics. Enhancing the knowledge on factors involved in the effectiveness of integrated treatment plans is an important step forward for SCZ care. This review aims to identify factors that might influence the impact of integrated treatments on functional outcome. Most studies on the impact of psychosocial treatments on functional outcome of subjects with SCZ did not control for the effect of prescribed antipsychotics or concomitant medications. However, several factors relevant to ongoing pharmacological treatment might influence the outcome of integrated therapy, with an impact on the adherence to treatment (e.g., therapeutic alliance and polypharmacotherapy) or on illness-related factors addressed by the psychosocial interventions (e.g., cognitive dysfunctions or motivational deficits). Indirect evidence suggests that treatment integration should consider the possible detrimental effects of different antipsychotics or concomitant medications on cognitive functions, as well as on secondary negative symptoms. Cognitive dysfunctions can interfere with participation to an integrated treatment plan and can be worsened by extrapyramidal or metabolic side effects of antipsychotics, or concomitant treatment with anticholinergics or benzodiazepines. Secondary negative symptoms, due to positive symptoms, sedation, extrapyramidal side effects or untreated depression, might cause early drop-out and poor adherence to treatment. Researchers and clinicians should examine all the above-mentioned factors and implement appropriate and personalized integrated treatments to improve the outcome of SCZ.
Collapse
Affiliation(s)
| | | | | | | | - Armida Mucci
- University of Campania Luigi Vanvitelli, Naples, Italy
| | | |
Collapse
|
|
2
|
Ashoorian DM, Davidson RM. Shared decision making for psychiatric medication management: a summary of its uptake, barriers and facilitators. Int J Clin Pharm 2021; 43:759-763. [PMID: 33515136 DOI: 10.1007/s11096-021-01240-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
The model of shared decision making with mental health patients and clinicians (doctors and pharmacists) harnesses the benefits of patients becoming partners in their own recovery through improved communication and greater self-advocacy. Shared decision making in mental health services is an emerging model of care which has not been well investigated, however it is seen as the way forward to achieving improved health outcomes for non-pharmacological and pharmacological therapy. Successful implementation of this model requires supporting the process through provision of information and training, use of decision aids, coaching in communication skills and inclusion of family and carers in the decision making process. This summary examines the application of the shared decision making model for psychiatric medication management, including barriers and facilitators.
Collapse
Affiliation(s)
- Deena M Ashoorian
- Pharmacy Division/ School of Allied Health, The University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.
| | - Rowan M Davidson
- Pharmacy Division/ School of Allied Health, The University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia
| |
Collapse
|
|
3
|
Pons EV, Salvador‐Carulla L, Calcedo‐Barba A, Paz S, Messer T, Paccardi B, Zeller SL. The capacity of schizophrenia and bipolar disorder individuals to make autonomous decisions about pharmacological treatments for their illness in real life: A scoping review. Health Sci Rep 2020; 3:e179. [PMID: 32782974 PMCID: PMC7415958 DOI: 10.1002/hsr2.179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIM Having decision making capacity is central to the exercise of autonomy in mental health care. The objective of this scoping review is to summarize the evidence on the capacity of people with schizophrenia or bipolar disorder to make decisions about their treatment in real life to support medical practice. METHODS Systematic search of observational studies on the assessment of capacity of patients with schizophrenia, psychosis, or bipolar disorder to make healthcare and treatment-related decisions, conducted in any clinical setting published up to January 31, 2020 was performed. Free text searches and medical subject headings in English were combined in PubMed, Scopus, CINAHL, and PsycInfo. Publications were selected as per inclusion and exclusion criteria. The Newcastle-Ottawa Scale for observational studies was used to assess the quality of publications. RESULTS Thirty publications were reviewed. According to the Newcastle-Ottawa Scale criteria, the publications reviewed were good quality. Findings showed that more than 70% of schizophrenia and schizoaffective disorder outpatients understood treatment options at the point of making decisions about their illness and healthcare. Patients treated voluntarily had considerably better scores for decisional capacity than those treated involuntarily. The burden of psychiatric symptoms could compromise decisional capacity temporarily. Decision-making capacity improved over time from admission to discharge from hospital, and with treatment among psychiatry inpatients. Schizophrenia and bipolar disorder patients could be as competent as nonpsychiatric individuals in making decisions about their treatments in everyday life. CONCLUSIONS This scoping review provides a body of evidence for healthcare professionals in need of assessing the capacity of schizophrenia and bipolar disorder patients for autonomously decide about their treatments. Decisional capacity judgements should consider variations in capacity over time and be based on the type of decision to be made, the severity of symptoms, and the specific phase of the mental disorder.
Collapse
Affiliation(s)
- Enric Vincens Pons
- Department of PsychiatryParc Sanitari Sant Joan de Déu, Sant Boi de LlobregatBarcelonaSpain
| | - Luis Salvador‐Carulla
- Centre for Mental Health ResearchResearch School of Population Health, College of Health and Medicine, Australian National UniversityCanberraAustralia
| | - Alfredo Calcedo‐Barba
- Department of Psychiatry, Hospital Gregorio MarañónMedical School at the Universidad Complutense de MadridMadridSpain
| | | | - Thomas Messer
- Department of PsychiatryDanuviusklinikPfaffenhofenGermany
| | - Bruno Paccardi
- Psychiatric UnitSanta Chiara University Hospital, University of PisaPisaItaly
| | - Scott L. Zeller
- Department of PsychiatryUniversity of CaliforniaCaliforniaUSA
| |
Collapse
|
|
4
|
Veshi D, Pupe E, Venditti C, Kalemaj I, Koka E, Biring-Pani M, Ruci H. End-of-Life Decisions in Albania: The Call for an Ethical Revision. THE LIVERPOOL LAW REVIEW 2020; 41:315-330. [PMID: 32836545 PMCID: PMC7312106 DOI: 10.1007/s10991-020-09251-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
While in Western European countries, the end-of-life decisions have become a matter of public policy, this paper provides a detailed analysis of end-of-life decisions in Albania by focusing on instructional medical directives. The manuscript investigates the Albanian legal system, the documents published by the National Ethics Committee and the National Committee of Health, as the two main advisory public bodies on health issues, as well as the national medical jurisprudence and the Code of Medical Ethics. After emphasizing the importance of instructional medical directives and considering the international literature that has underlined the ethical principle of patient autonomy, this paper provides some policy suggestions. In the conclusion, this contribution highlights the importance of ad hoc rules governing instructional medical directives as well as the ethical principles and international literature as an instrument to fill the gap in the national system. In addition, particular attention is given to the application of ethical principles in end-of-life decisions in the current pandemic situation.
Collapse
Affiliation(s)
- Denard Veshi
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| | - Ervin Pupe
- High Court of Albania, Rruga Deshmoret e 4 Shkurtit, Tirana, Albania
| | - Carlo Venditti
- University of Campania Luigi Vanvitelli, Via Mazzocchi, 68 - Palazzo Melzi, 81055 Santa Maria Capua Vetere, Caserta Italy
| | - Ilir Kalemaj
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| | - Enkelejda Koka
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| | | | - Hektor Ruci
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| |
Collapse
|
|
5
|
Contributions of community pharmacists to patients on antidepressants—a qualitative study among key informants. Int J Clin Pharm 2017; 39:686-696. [DOI: 10.1007/s11096-017-0502-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
|
|
6
|
Chakrabarti S. Treatment-adherence in bipolar disorder: A patient-centred approach. World J Psychiatry 2016; 6:399-409. [PMID: 28078204 PMCID: PMC5183992 DOI: 10.5498/wjp.v6.i4.399] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/31/2016] [Accepted: 11/22/2016] [Indexed: 02/05/2023] Open
Abstract
About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.
Collapse
|
|
7
|
De las Cuevas C, Peñate W, Sanz EJ. The relationship of psychological reactance, health locus of control and sense of self-efficacy with adherence to treatment in psychiatric outpatients with depression. BMC Psychiatry 2014; 14:324. [PMID: 25412702 PMCID: PMC4243370 DOI: 10.1186/s12888-014-0324-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 11/10/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although non-adherence to antidepressant medications is a significant barrier to the successful treatment of depression in clinical practice, few potentially modifiable predictors of poor adherence to antidepressant treatment are known. The aim of this study was to examine the relationship of psychological reactance, health locus of control and the sense of self-efficacy on adherence to treatment regimen among psychiatric outpatients with depression. METHODS One hundred and forty-five consecutive psychiatric outpatients suffering from depressive disorders were invited to participate in a cross-sectional study and 119 accepted. Patients completed a series of self-reported questionnaires assessing psychological reactance, health locus of control, self-efficacy, and adherence to prescribed medication in addition to socio-demographic and clinical variables. Logistic regression analyses were performed to determine which factors better correlate to treatment adherence. RESULTS Age was found to be the best correlate of adherence to prescribed treatment. As regards psychological dimension studied, medication adherence was negatively associated with both cognitive and affective psychological reactance; patients with higher psychological reactance were more likely to be noncompliant than patients showing a low level of psychological reactance. Regarding health locus of control, only the external dimension of doctor-attributed health locus of control was positively associated with medications adherence. No effect on adherence was observed for the self-efficacy scale. CONCLUSIONS Psychological reactance is an important correlate of adherence to treatment in patients with depressive disorders and this needs to be considered when giving clinical advice in order to avoid inducing reactance and thus non-adherence to prescribed treatments. Mental health professionals need to learn about communication techniques and counseling skills that enable them to deal with the psychological reactance of their patients.
Collapse
Affiliation(s)
- Carlos De las Cuevas
| | - Wenceslao Peñate
- Professor of Psychology, Department of Personality, Assessment and Psychological Treatments, University of La Laguna, Canary Islands, Spain.
| | - Emilio J Sanz
- Professor of Clinical Pharmacology, Department of Physical Medicine and Pharmacology, University of La Laguna, Canary Islands, Spain.
| |
Collapse
|
|
8
|
Perspective of community pharmacists on their practice with patients who have an antidepressant drug treatment: findings from a focus group study. Res Social Adm Pharm 2014; 11:e43-56. [PMID: 25443641 DOI: 10.1016/j.sapharm.2014.07.180] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 07/29/2014] [Accepted: 07/29/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Around 2/3 of patients with major depression discontinue their antidepressant drug treatment (ADT) prematurely. Community pharmacists can rely on their regular contacts with patients to identify and support those experiencing difficulties with their ADT. OBJECTIVE The aim of this study is to describe pharmacists' perceptions with respect to their practices related to patients having an ADT. METHODS A qualitative study was conducted based on 6 focus groups involving 43 community pharmacists in 5 regions of Quebec province, Canada. Verbatim transcripts of focus groups were analyzed using computer-assisted thematic analysis. RESULTS The discussions revealed three major aspects of the participants' pharmacy practice: convincing patients to initiate ADT, dealing with side effects in the first weeks of the treatment, and taking a reactive approach to managing the treatment for the remainder of the follow-up. Discussions also enabled participants to identify the challenges they face concerning their practice with patients who have an ADT, and voice their recommendations for improving pharmacy practice and ultimately patient adherence to ADT. CONCLUSIONS Pharmacists wishing to help their patients to adequately manage their ADT face important barriers. Potential solutions include tools designed to help pharmacists better detect and intervene in ADT-related problems. Study findings will guide the on-going development of training and tools to support pharmacists' practice in this context.
Collapse
|
|
9
|
Haron Y, Tran D. Patients' perceptions of what makes a good doctor and nurse in an Israeli mental health hospital. Issues Ment Health Nurs 2014; 35:672-9. [PMID: 25162189 DOI: 10.3109/01612840.2014.897778] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this study was to identify inpatients' expectations of their doctors and nurses in a mental health hospital setting. Individual interviews were conducted with 72 inpatients of a large mental health hospital in northern Israel. Our study produced three major results. First, most patients, whatever their emotional status, share similar expectations of staff, of which the most conspicuous is that they be respected as whole persons and that staff not treat them merely as cases of illness. Second, they expect to be involved in making decisions about their treatment, including being informed of reports and records referring to them. Third, patients expect all hospital staff, particularly nurses, to provide them with emotional support. The findings of this study can be used to facilitate improved care of mental health inpatients by both doctors and nurses. Structured and methodical examinations of inpatients' expectations at the time they are hospitalized can help adjust not only the professional aspect of health care but also the therapeutic communication approach to patients' individual needs.
Collapse
Affiliation(s)
- Yafa Haron
- Ministry of Health, Nursing Division, Jerusalem, Israel
| | | |
Collapse
|
|
10
|
Aggarwal NK, Glass A, Tirado A, Boiler M, Nicasio A, Alegría M, Wall M, Lewis-Fernández R. The development of the DSM-5 Cultural Formulation Interview-Fidelity Instrument (CFI-FI): a pilot study. J Health Care Poor Underserved 2014; 25:1397-417. [PMID: 25130248 PMCID: PMC4306341 DOI: 10.1353/hpu.2014.0132] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This paper reports on the development of the Cultural Formulation Interview-Fidelity Instrument (CFI-FI) which assesses clinician fidelity to the DSM-5 Cultural Formulation Interview (CFI). The CFI consists of a manualized set of standard questions that can precede every psychiatric evaluation. It is based on the DSM-IV Outline for Cultural Formulation, the cross-cultural assessment with the most evidence in psychiatric training. Using the New York sample of the DSM-5 CFI field trial, two independent raters created and finalized items for the CFI-FI based on six audio-taped and transcribed interviews. The raters then used the final CFI-FI to rate the remaining 23 interviews. Inter-rater reliability ranged from .73 to 1 for adherence items and .52 to 1 for competence items. The development of the CFI-FI can help researchers and administrators determine whether the CFI has been implemented with fidelity, permitting future intervention research.
Collapse
|
|
11
|
Johnston BJ. The role of patient experience and its influence on adherence to antidepressant treatment. J Psychosoc Nurs Ment Health Serv 2013; 51:29-37. [PMID: 24102841 DOI: 10.3928/02793695-20130930-04] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 07/12/2013] [Indexed: 11/20/2022]
Abstract
Major depression can be a very challenging illness and although antidepressant agents are shown to provide benefit, many patients do not adhere to antidepressant treatment guidelines. Multiple factors contribute to adherence, including the influence of patient experience. The purpose of this article is to conduct a systematic review on the influence of patient experience with depression and antidepressant agents on treatment adherence. Thirteen research articles were selected for the review and revealed that patient past experience with depression and antidepressant agents, vicarious experiences, beliefs and attitudes, and the treatment experience itself can impact adherence. It is important for providers to be vigilant with assessment and include patient experience when developing a plan of care. This approach encourages shared decision making and a patient-centered focus for improved management of depression.
Collapse
|
|
12
|
Salvador-Carulla L, Cloninger CR, Thornicroft A, Mezzich JE. Background, Structure and Priorities of the 2013 Geneva Declaration on Person-centered Health Research. INTERNATIONAL JOURNAL OF PERSON CENTERED MEDICINE 2013; 3:109-113. [PMID: 26146541 PMCID: PMC4487411 DOI: 10.5750/ijpcm.v3i2.401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Declarations are relevant tools to frame new areas in health care, to raise awareness and to facilitate knowledge-to-action. The International College on Person Centered Medicine (ICPCM) is seeking to extend the impact of the ICPCM Conference Series by producing a declaration on every main topic. The aim of this paper is to describe the development of the 2013 Geneva Declaration on Person-centered Health Research and to provide additional information on the research priority areas identified during this iterative process. There is a need for more PCM research and for the incorporation of the PCM approach into general health research. Main areas of research focus include: Conceptual, terminological, and ontological issues; research to enhance the empirical evidence of PCM main components such as PCM informed clinical communication; PCM-based diagnostic models; person-centered care and interventions; and people-centered care, research on training and curriculum development. Dissemination and implementation of PCM knowledge-base is integral to Person-centered Health Research and shall engage currently available scientific and translational dissemination tools such journals, events and eHealth.
Collapse
Affiliation(s)
- Luis Salvador-Carulla
- Centre for Disability Research and Policy, Faculty of Health Sciences, University of Sydney (Australia)
| | | | - Amalia Thornicroft
- Centre for Disability Research and Policy, Faculty of Health Sciences, University of Sydney (Australia)
| | | | | |
Collapse
|
|
13
|
McKay R, McDonald R, Lie D, McGowan H. Reclaiming the best of the biopsychosocial model of mental health care and 'recovery' for older people through a 'person-centred' approach. Australas Psychiatry 2012; 20:492-5. [PMID: 23099508 DOI: 10.1177/1039856212460286] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM The 'biopsychosocial', 'person-centred care' (PCC) and 'recovery' models of care can be seen as distinct and competing paradigms. This paper proposes an integration of these valuable perspectives and suggestions for effective implementation in health services for the elderly. METHOD An overview of PCC and recovery models, and their application for older people with mental health problems, is provided. Their overlap and contrast with the familiar 'biopsychosocial' model of mental health care is considered, together with obstacles to implementation. RESULTS Utilisation of PCC and recovery concepts allow clinicians to avoid narrow application of the biopsychosocial approach and encourages clinicians to focus on the person's right to autonomy, their values and life goals. CONCLUSIONS Service reform and development is required to embed these concepts into core clinical processes so as to improve outcomes and the quality of life for older people with mental health problems.
Collapse
Affiliation(s)
- Roderick McKay
- School of Psychiatry University of New South Wales, Sydney, NSW, Australia.
| | | | | | | |
Collapse
|
|
14
|
Abstract
This paper discusses an integrated approach to person-centred medicine and its role in the future of mental health care. The origins and current status of this emerging field are revised with special attention to the contributions made from psychiatry and to the implications for psychiatric diagnosis and evaluation of the three pillars of the Person-centred Integrative Diagnosis (PID) model: its conceptual domains (health status, experiences and contributors to ill and good health), the related evaluative procedures, the partnerships needed and the existing links and differences with people-centred care and personalised medicine. In spite of their striking complementarities person-centred medicine and personalised medicine do not yet have substantial bridges built between them. Knowledge transfer and coordination should be established between these two models which will cast medical evaluation and care in the upcoming future.
Collapse
|
|
15
|
Abstract
The development of evidence-based treat-to-target (T2T) recommendations alleviates decision-making for the rheumatologist and simultaneously promises substantial improvement of outcome for rheumatoid arthritis (RA) patients. For the office-based rheumatologist in Germany, however, implementation of T2T recommendations contains several difficulties. Limitations arise as a result of an insufficient number of rheumatologists as well as a lack of adequate remuneration both resulting in a lack of time for the individual RA patient. Furthermore budget limitations hinder the appropriate use of antirheumatic drugs and insofar counteract treating to the target of remission. Establishment of selective contracts for rheumatologists by health insurance funds might reduce many of these problems in future for the office-based rheumatologist in Germany.
Collapse
Affiliation(s)
- K Krüger
- Rheumatologisches Praxiszentrum St. Bonifatius, St.-Bonifatius-Str. 5, 81541, München, Deutschland,
| | | |
Collapse
|
|
16
|
Abstract
Full recovery from depression, as contrasted with symptom improvement, is a relatively new concept and therapeutic goal. It is an important goal, because the failure to achieve this goal leaves many patients with less productive and fulfilling lives, it leaves some children with lasting deficits, and it deprives families and societies of loved ones’ and employees’ care and investment. As a new therapeutic concept, recovery from depression is not as easy to define as it might seem; many or most patients were not euthymic before an episode of depression or have had some level of depression throughout their lives. There is no measurable definition of euthymia. In addition to definitional difficulties, we need to study and address other barriers to the achievement of recovery from depression. All the barriers to the diagnosis and treatment of depression are barriers against recovery: negative social and professional attitudes, comorbidity, lack of access to demonstrably efficacious professional and social services, and inability to match patients with the antidepressants most likely to help them. Efforts to address many of these knowledge and attitude gaps are already underway. Long-term studies are needed, both observational and experimental. Most published studies encompass only weeks or at best months of follow-up, but recovery must be sustained to be meaningful. As noted previously, there has been little or no attention to the developmental impact of depression. The restoration of premorbid function is not sufficient when depression has hindered a patient’s ability to form satisfying relationships and choose and perform satisfying work. We need to learn how to remediate patients whose history of depression has stifled their talents and aspirations. Studying these issues will not be easy, but millions of individuals with depression, and their physicians, will profit by it; it will be well worth the effort.
Collapse
Affiliation(s)
- Nada L Stotland
- Department of Psychiatry, Rush Medical College, 2150 Harrison Street, Chicago, IL 60612, USA.
| |
Collapse
|