This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to ServicesX. Psychoeducation for Three Categories of PatientsPsychoeducation, as explained earlier, is health education combined with behavioral counseling. The counseling component of psychoeducation deals with emotions, perceptions, coping, relaxation, and self-care. Psychoeducation is of value for three categories of patients: (1) Those with major chronic diseases; (2) persons scheduled to undergo surgical procedures; and (3) high users of health care services. Psychoeducation can help—
Patients, even with the best of intentions, rarely follow prescribed regimens of care perfectly—and often disregard them completely. For many aches, pains, and other distressing symptoms, medical science often offers either imperfect relief or therapy more distressing than the initial symptoms. Psychoeducation is an effective way to help close some of these gaps between the theoretical ideal and the reality each of us must live with on a daily basis. For some, it offers innovative ways to control pain and other distressing symptoms, and by doing so, speeds recovery and improves the quality of their lives. For others, it helps reduce the psychological and psychosocial barriers that inhibit effective adherence to prescribed regimens of care. A definition of psychoeducation on a Web site devoted to patients with psychiatric disorders and their families reads as follows:
Part of the problem is undiagnosed and untreated psychiatric disorders. Fulop et al. (Fulop, Strain, Fahs, Schmeidler, & Snyder, 1998) in a 1998 study explored the impact of psychiatric comorbidity on length of hospital stays of elderly medical-surgical inpatients. Of the 467 admissions included in the study, 208 (44 percent) met the standards for one or more DMS-III-R psychiatric diagnoses. Fifty-one (10.9 percent) had an anxiety disorder, 88 (18.8 percent) had a depressive disorder, and 126 (27 percent) had a cognitive impairment. Although no difference in length of stay was noted for those with and without anxiety or depression, those with cognitive impairments had significantly longer lengths of stay (14.6 versus 10.6 days). Part of the solution is mobilizing the resiliency and inner strength of human beings—and helping them more effectively help themselves to deal with painful and difficult circumstances. The literature demonstrating the need for and effectiveness of psychoeducation in patients with chronic disease, those scheduled for surgery, and those with a somatization disorder is reviewed briefly in each of the following sections of this report. Intervention The health care delivery system may wish to consider the following:
B. Psychoeducation for Patients With Chronic Disease In 1989, Spiegel et al. (1989) reported the results of what he called “psychosocial treatment” in a randomized controlled trial involving 86 patients with metastatic breast cancer. The cases and controls were similar in severity of illness and treatment modalities. The intervention consisted of 90- minute group meetings with a psychiatrist on a weekly basis for a year, with professional and group member support between the meetings. Mean survival time for the cases was 36.6 months postrandomization, compared with 18.9 months for the controls—a highly statistically significant difference—attributed by the authors to better patient and family coping skills, more effective relationships with the oncology staff, social support, and more effective control of anxiety, depression, and pain. In 1995, Devine and Reifschneider (1995) reported on a meta-analysis of 102 studies to determine the effects of psychoeducation on care of adults with hypertension. They concluded that substantial and statistically significant beneficial effects on blood pressure were due primarily to improved compliance with medication and improved compliance with health care appointments. In 1998, Roter et al. (1998) reported on a meta-analysis of 153 studies to assess the effectiveness of interventions to improve patient compliance. They concluded that the most substantial benefits were for chronic disease patients, including those with diabetes, hypertension, cancer, and mental health problems. Comprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions. In 1998, Clarkin et al. (Clarkin, Carpenter, Hull, Wilner, & Glick, 1998) reported the results of a randomized controlled trial of a psychoeducational intervention for married patients with bipolar disorder and their spouses. The intervention resulted in improved functioning and improved medication compliance but did not affect the symptom levels beyond that to be expected from the medication compliance. Similarly favorable results were reported by Miklowitz et al. (2000) in a randomized trial of familyfocused psychoeducation for bipolar disorder. In 1999, Dusseldorp et al. (1999) reported on a meta-analysis of 37 studies of the effects of psychoeducational (health education and stress management) programs for coronary heart disease patients. The results suggested that these programs yielded a 34 percent reduction in cardiac mortality, a 29 percent reduction in recurrence of myocardial infarction, and statistically significant positive effects on blood pressure, cholesterol, body weight, smoking behavior, physical exercise, and eating habits. The pattern of results by study suggested that the mortality and recurrent infarction end points were primarily related to the more proximal improvements in risk profiles. In 1999, Robinson et al. (Robinson, Faris, & Scott, 1999) reported on the results of a randomized controlled trial of a group psychoeducational intervention to improve compliance with prescribed regimens of vaginal dilatation for women undergoing radiotherapy for gynecological carcinoma. Such dilatation is required to maintain vaginal health and good sexual functioning, but compliance generally is low. The intervention was highly effective, especially in younger women in increasing vaginal dilatation and reducing fears about sex after cancer. The authors concluded that such women are unlikely to follow the recommendation to dilate unless given assistance in overcoming their fears and taught behavioral skills. In 2001, Lorig at al. demonstrated that a single, low-cost psychoeducational program can be used across a number of different chronic diseases, including heart disease, lung disease, stroke, or arthritis (Lorig, et al., 2001). In 2002, Mishel et al. (2002) reported on a randomized trial of a nurse-delivered psychoeducational intervention by telephone for 134 White men and 105 African- American men who had undergone surgery or radiation treatment for localized prostate carcinoma. They were enrolled either immediately after surgery or in the first 3 weeks of radiation therapy. The two interventions both consisted of weekly phone calls for 8 weeks. The intervention groups reported significantly better control of incontinence by 4 months postbaseline, fewer treatment side effects, and better sexual functioning. Levels of improvement were similar in the two racial groups. In each of the studies noted above, the psychoeducational intervention group was compared with a “usual care” group who received usual physician counseling, presumably with little or no psychoeducational content. The conclusions that can be drawn from the literature reviewed to date are limited by the lack of specific psychoeducational protocols and the presence of many studies of health education interventions where the studies do not include adequate description of the interventions to determine the presence or types of psychoeducational content. Although additional research should be done to proposed specific educational protocols by patient type and disease, the currently available literature clearly indicates that the efficacy of patient educational programming for chronic disease patients can be enhanced substantially by the inclusion of psychoeducational content. This enhancement of educational content should be seen as a desirable addition to the screening of all such patients for depression and mental health assessment of those with other evidence of behavioral disorders. C. Psychoeducation for Patients Scheduled for Surgical Procedures A number of studies have been published demonstrating the value of psychoeducational interventions for patients scheduled to undergo surgery. These studies, the oldest of which date back to 1964 (Egbert et al., 1964), present a very strong case for investment in specially trained staff to educate patients as to the nature of the surgical procedure, what they may anticipate in terms of pain and discomfort following the surgery, and techniques they can use to reduce pain, speed recovery, and reduce their postsurgical in-hospital convalescence. These same staff also can flag patients who might benefit from more definitive psychiatric consultation and intervention prior to the surgical procedure to further improve postsurgical recovery. In a 1964 study, Egbert et al. (1964) randomized 97 patients scheduled to undergo elective intra-abdominal surgery. The intervention consisted of expanded presurgical education by the anesthetist, including what to expect postsurgery, how best to relax, how to take deep breaths, and how to move to remain comfortable postoperatively. This simple intervention reduced the need for postoperative narcotic medication by half and reduced the average hospital stay by almost 3 days. In 1982, Mumford et al. (1982) published a meta-analysis of 34 controlled studies of surgical and heart attack patients and demonstrated an average 2-day reduction in what otherwise would have been a 10-day hospital stay for these patients. Although the protocols varied, most or all included general patient education coping techniques and interventions to address fear, pain, and psychological distress. In a similar metaanalysis published in 1983, which covered 49 studies, both controlled and uncontrolled, Devine and Cook (1983) showed very similar results. In 1988, Devine et al. (1988) conducted a controlled, but not randomized study of a nurse-based psychoeducational intervention in a post-DRG (diagnostic related group) managed-care-type setting in two rural hospitals owned by the same corporation. The primary intervention in the study hospital was a 3-hour, two-stage workshop for staff nurses to enhance their ability to provide educational and psychosocial support to patients undergoing abdominal and prostate surgery. This study showed that even in a managed care environment, supplemental psychoeducational services can cut the use of sedatives, antiemetics, and hypnotics by half, and shave another halfday off the hospital stay. In 1995, Jay et al. (1995) reported a clinical trial of cognitive behavioral therapy (CBT) versus general anesthesia for 18 patients with pediatric cancer (ages 3–12 years) undergoing bone marrow aspirations. The CBT children exhibited more behavioral distress for the first minute on the treatment table, but according to the parents, showed significantly better behavioral adjustment 24 hours following the procedure than the children who had been anesthetized. D. Psychoeducation for Patients With Somatization Somatization is a term used to describe true physical symptoms and true physical illness that are psychogenic in nature. The term “mind/body connection” is used to denote the role of the human mind in creating, exaggerating, minimizing, or totally eliminating symptoms and perceptions of pain in patients with and without diagnosable organic illness. By some criteria, 20–84 percent of patients in general medical settings have been estimated to show somatic complaints for which no organic cause can be found (Smith et al., 1995; Kellner et al., 1985; Kellner, 1965; Mayou, 1976, 1978). The preventive issue with somatization and mind/body connection relates to reduction in health care costs through effective management of these disorders. Somatization is common in primary care, and it is generally accepted that there is a connection between the mind and the body and that many diseases are caused by the mind-body connection. The problem, from the perspective of this report, is that few highquality studies demonstrating the efficacy of clinical interventions to address these disorders are available. This section is included in this report to alert health care managers to somatization and mind/body connection so they may consider possible education and intervention, and so that they may remain alert to further developments in these rapidly evolving fields. When somatization is fully developed, the proper diagnostic term is “somatization disorder” or “Birquet’s Syndrome” or “hysteria.” The full-blown syndrome is characterized by multiple physical complaints referable to several organ systems. Anxiety, panic disorder, and depression often are present. Polysurgery often is part of the history, and preoccupation with medical and surgical therapy becomes a lifestyle that excludes most other activities (Tierney et al., 2003). Although the full-blown syndrome is relatively uncommon, somatoform behavior that does not meet the full diagnostic criteria for somatization disorder is quite common, and quite costly in utilization of health care services. Recent reviews have estimated the prevalence of somatoform disorders in the range of 10–15 percent of primary care patients (Kroenke et al., 1998; Kirmayer & Robbins, 1991; Spitzer et al., 1994; Kellner et al., 1985) and have documented the impact of these disorders on both quality of life and health care utilization (Kroenke et al., 1998; Katon et al., 1991; Smith et al., 1986, 1995; Swartz et al., 1991; Kroenke et al., 1997; Escobar et al., 1989; Deighton, Nicol, 1985; Hiller et al., 1995). Effective management of these patients requires recognition of this possibility by the primary care practitioner and great sensitivity in approaching this issue to avoid suggesting that the patient is either “crazy” or faking the illness. Although management of full-blown somatization disorder tends to be frustrating for both patient and physician, there is at least one recent randomized study (Smith et al., 1995) and a recent review by the Lewin Group (Fifer et al., 2003) suggesting that recognition and intervention in patients with somatizing behavior not meeting the diagnostic criteria of full-blown somatization disorder may be of value in improving the patient’s quality of life and in reducing health care costs by reducing health care use. Although there are several studies suggesting that screening for somatization, followed by diagnosis and management of psychiatric illness and psychoeducational interventions are of value (Smith et al., 1995; Fifer et al., 2003), specification of exact screening and follow-up procedures are insufficient to suggest implementation of psychoeducational services for somatization as a “general” clinical preventive service. Summary of Psychoeducation Psychoeducation has been shown to improve health outcomes and reduce short-term health care costs for patients with major chronic diseases and for patients scheduled for surgical procedures. The literature has demonstrated the service’s ability to shorten the length of inpatient stay, to reduce pain, and to increase adherence to a regimen of care. Psychoeducation may also be of value for selected high-cost patients whose illnesses may be psychosomatic in origin. |
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