Health Psychology Past, Present, and Potential Cynthia D. Belar, Ph.D., ABPP ◊ Historical Perspectives ◊ Growth of Education and Training ◊ Growth of Research ◊ Growth of Professional Practice/Applications ◊ Potential (and preparation) Health Psychology The aggregate of the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health; the prevention and treatment of illness; the identification of etiologic and diagnostic correlates of health, illness and related dysfunctions; and the improvement of the health care system and health policy formation. (Matarazzo, 1980, 1982, 2001) Key Features of Health Psychology ◊ Breadth ◊ Biopsychosocial model ◊ Focus on prevention and health promotion as well as illness and rehabilitation ◊ Focus on cost-effectiveness ◊ Interdisciplinary collaboration ◊ Clinical Health Psychology professional practice of health psychology ◊ Behavioral Medicine interdisciplinary field to which health psychologists contribute Historical Perspectives ◊ Ancient Greece ◊ Middle Ages ◊ Renaissance 18th Century “the reason why a sound body becomes ill, or an ailing body recovers, very often lies in the mind” (Gaub, cited in Lipowski, 1977) 19th Century ◊ “psychosomatic” (Heinroth) ◊ Benjamin Rush ◊ Sigmund Freud ◊ Walter B. Cannon ◊ Ivan Pavlov 20th Century Formalization as a Field of Inquiry Two major frameworks: psychodynamic and psychophysiologic ◊ ◊ ◊ ◊ ◊ ◊ ◊ 1938 – Psychosomatic Medicine 1942 – American Psychosomatic Society Helen Flanders Dunbar Franz Alexander Harold G. Wolff Edmund Jacobson Hans Selye 20th Century ◊ “Comprehensive Medicine” (Guze, ◊ ◊ ◊ ◊ Matarazzo, & Saslow, 1953) “Biopsychosocial Model” (Engel, 1977) Neal Miller (1969) Wilbert Fordyce (1976) Robert Ader (1974) Landmark Events in Organized Psychology 1969 - The Role of Psychology in the Delivery of Health Services (Schofield) 1975 - Section on Health Research in APA Division of Public Service 1977 - Yale Conference on Behavioral Medicine 1978 Growth of Education and Training ◊ Early 1980’s – opportunities for E&T in HP • 42 doctoral (Belar, Wilson & Hughes, 1982) • 48 internships (Gentry, Street, Masur & Asken, 1981) • 43 postdoctoral (Belar & Siegel, 1983) ◊ 1983 - Arden House Conference defines education and training in Health Psychology Core Knowledge Domains ◊ Biological bases of health, disease and behavior (basic anatomy and physiology, pathophysiology, pharmacology, psychoneuroimmunology, psychophysiology, neuroendocrinology) ◊ Cognitive-affective bases of health, disease and behavior (how learning, memory, perception, cognition, thinking, motivation and emotions influence health behaviors, are affected by physical illness/injury/disability, and can affect response to illness/injury/disability) Core Knowledge Domains ◊ Social bases of health, disease and behavior (impact of relationships [including physician-patient relationships], social support, culture, religion, workplace, health policy and organization of health care delivery systems on health and help-seeking) ◊ Psychological bases of health,disease and behavior (behavioral risk factors for disease/injury/disability and nonadherence to medical regimens; relationships among stress,coping and health outcomes; developmental issues in health and illness; impact of psychopathology on illness and treatment; issues of diversity and health,e.g., gender, sexual orientation) Core Domains of Knowledge & Skill ◊ Health research methods ◊ Health assessment, consultation, and interventions • individual, families, groups, organizations, communities • primary, secondary and tertiary prevention ◊ Program development and evaluation ◊ Management and supervision ◊ Ethical, legal and professional issues ◊ Interdisciplinary collaboration ◊ 1990 – health psychology was the most frequently noted area of faculty research in APA accredited clinical psychology doctoral programs ◊ 2004 – 3 APA accredited postdoctoral programs in clinical health psychology Growth in Research ◊ 1979 - U.S. Department of Health, Education and Welfare. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. ◊ 1982 - Institute of Medicine. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (50% of mortality from the 10 leading causes of death in the U. S. can be traced to behavior/lifestyle factors) Establishment of Journals 1978 – Journal of Behavioral Medicine 1982 – Health Psychology 1986 – Journal of Psychology and Health Behavior in Medical Journals (Suls and Rothman, 2004) ◊ NEJM, Lancet, JAMA, Annals of Internal Medicine ◊ “behavior” doubled from 1974-2001 (total # of articles increased by 3%) ◊ BUT – increase is from .002% of total articles to .004% (starting in 1986-89) 2001 Growth of Professional Practice 1984 - American Board of Health Psychology incorporated (ABHP) 1991 - Board certification recognized by American Board of Professional Psychology (ABPP) 1997 - APA Council of Representatives recognizes Clinical Health Psychology as a specialty 1998 - ABHP renamed as American Board of Clinical Health Psychology Service Areas for Health Psychology 1. Prevention of illness/injury 2. Coping with illness 3. Preparation for stressful medical procedures 4. Adherence to medical regimens 5. Management of physical symptoms 6. Management of psychophysiological disorders 7. Problems of health care providers and health care systems. 8. Mental health disorders There are a variety of service areas for the application of knowledge in health psychology. Interventions can occur at a variety of levels. ◊ Individual/Family ◊ Health Care Provider ◊ Health Care System ◊ Population ◊ Health Policy #1 Prevention of illness/injury Traumatic Injuries ◊ Reckless driving ◊ Poor body mechanics ◊ Falls ◊ Seatbelts/helmets ◊ Toxic storage ◊ Interpersonal violence Behavioral Risk Factors ◊ Tobacco use ◊ Diet ◊ Exercise ◊ Unsafe sex ◊ Alcohol and substance use #2 Coping with illness Social Support ◊ Post MI survival (Berkman, 1995) ◊ Hemodialysis survival (Christensen et al., 1994) Myocardial Infarction ◊ depression increases risk of mortality independent of cardiac disease severity ◊ impact of depression is as great as previous MI and impaired left ventricular ejection fraction ◊ anxiety and anger directed inward also increase risk Frasure-Smith et al., 1995 Recovery from Illness Acute Myocardial Infarction ◊ patients with high anxiety in the 48 hours after AMI had 4.9 times risk for developing complications ◊ risk independent of clinical indicators Moser & Dracup, 1996 Interventions are more than health education. ◊ Social support ◊ Emotional support ◊ Systematic behavior change ◊ Increased self-efficacy #3 Preparation for stressful medical procedures Recovery from Surgery Meta-analysis ◊ N = 191 studies, major and minor surgery ◊ Interventions • information • skill-building • support ◊ Outcome • 79-84% of studies reported beneficial effects • length of stay decreased by an average of 1.5 days Devine, 1992 #4 Adherence to Medical Regimens ◊ 1 out of 6 hospitalizations of seniors (GAO, 1995) ◊ 10% of all hospital admissions (DHHS, 1990) ◊ 2/3 not taking therapeutic dose of BP medication (JAMA, 1989) ◊ 50% of 1.6 billion prescriptions taken incorrectly #5 Management of Physical Symptoms ◊ Asthmatic episodes ◊ Dyspnea ◊ Pain ◊ Headache ◊ Fecal incontinence ◊ Muscle spasms ◊ Anticipatory nausea ◊ Insomnia ◊ Vasospasms ◊ Cramping/diarrhea COPD Rehabilitation Program 7 6 5 4 Pre Post 3 2 1 0 Inpatient Days Talcott et al., 1996 Outpatient Visits ER Visits Arthritis Self-Management N = 401 Physical Disability 9% Increase Visits to Physicians 43% Decrease Pain 20% Decrease Sense of Self-efficacy Significant Increase Lorig et al., 1993 Fecal Incontinence ◊ 1.2% over age 60 ◊ 2nd most common reason for institutionalizing the elderly ◊ BF is treatment of choice when caused by nerve injuries resulting in weakness of external anal sphincter or impaired ability to detect rectal distention (est. 60-70% of adult patients) ◊ 72% of patients obtain at least 90% reduction Whitehead et al., 1996 #6 Psychophysiological Disorders ◊ Irritable Bowel Syndrome ◊ Migraine Headache ◊ Tension Headache #7 Problems of health care providers and health care systems. Medical Decision-Making ◊ Surgery (pain, ICD) ◊ Organ transplantation ◊ Complex management (home dialysis, home ventilator) ◊ Fertility treatments Needs of Other Health Professionals ◊ Education and Training ◊ Physician-Patient Communication ◊ Implementation of Practice Guidelines ◊ Burnout Prevention Needs of Health Care Organizations ◊ Self-Help Programs ◊ Program Development • disease management • staff development • community outreach • Infection control Diabetes ◊ n = 11 studies, self-management training ◊ FBS level improvement ◊ Reduction in diabetes-related hospitalizations ◊ Reduction in serious foot lesions ◊ Reduction in diabetes-related health care costs ◊ Need: • extensive use of behavior change strategies • integrated team Clement, 1995 #8 Mental health disorders U.S. Surgeon General Reports 1999, 2000, 2001 ◊ 1 in 5 American adults experience a mental disorder in a given year ◊ 1 in 10 children and adolescents ◊ 1 in 5 older persons Most Americans seek mental health care from their family physician. ◊ 50% of all individuals with a mental disorder go to primary care providers ◊ 80% of psychotropic medication is prescribed by primary care providers ◊ Patients have long-standing relationships with primary care providers Problem 50-66% of mental health problems are not detected by primary care providers • lack of knowledge • lack of training and experience • poor interviewing skills • lack of time Need for Integration of Psychological Services in Primary Care ◊ Acknowledges the defeat of mind-body dualism ◊ Facilitates dealing with high comorbidity of medical and psychological problems • pain-depression • COPD-anxiety ◊ Reduction in overall health care costs Why has there been such growth in Health Psychology? ◊ Deficiencies in biomedical model ◊ Increased maturity of behavioral science ◊ ◊ ◊ ◊ ◊ research and practice Increased disease burden from chronic disease HIV/AIDS epidemic Focus on prevention Increased concern with quality of life Increased cost of health care Why is there such potential for Health Psychology? ◊ Deficiencies in biomedical model ◊ Increased maturity of behavioral science ◊ ◊ ◊ ◊ ◊ research and practice Increased disease burden from chronic disease HIV/AIDS epidemic Focus on prevention Increased concern with quality of life Increased cost of health care Healthy People 2010 10 Leading Health Indicators ◊ responsible sexual ◊ ◊ ◊ ◊ ◊ substance abuse ◊ mental health ◊ environmental behavior tobacco use injury and violence quality physical activity ◊ immunization obesity ◊ access to health care Drivers of Health Policy ◊ To Err is Human (IOM, 1999) ◊ Crossing the Quality Chasm (IOM, 2001) ◊ Health Professions Education Summit (IOM, 2002) ◊ Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medial School Curriculum (IOM,2004) Competencies for Quality Health Care 2002 Health Professions Education Summit ◊ Informatics ◊ Interdisciplinary Teams ◊ Evidence-Based Care ◊ Quality Improvement ◊ Patient-Centered Care Preparing to reach our potential: ◊ Changing demographics ◊ Context Competence (e.g., culture, race/ethnicity, history, religion, politics, economics, community, discrimination) Health Informatics ◊ Communication (e.g., email) ◊ Knowledge management (e.g., evidence-based databases) ◊ Decision support Telehealth Need more attention to: ◊ Clinical decision-making ◊ Practice guidelines ◊ Dissemination of guidelines Need increased attention to: ◊ Genetics ◊ Organ and tissue transplantation ◊ Assisted reproductive technology ◊ Primary care Globalization Environment Advocacy ◊ Graduate Education & Training ◊ Research ◊ Health Policy There is great potential for psychologists in health research and care. ◊ Research ◊ Psychological ◊ Health promotion and disease prevention ◊ Assessment and triage ◊ Consultation (case centered and systems centered) ◊ ◊ ◊ ◊ ◊ interventions Program development Administration Team building Supervision Education and Training