Възстановяване от тежка психична болест и обслужването в хронични институции: характеристики, предиктивни фактори и добра практика
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Дата
2016-02-18
Автори
Спиридонов/Spyridonov, Спиридон Алексиев/Spyridon Alexiev
Заглавие на списанието
ISSN на списанието
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Издател
Резюме
Цел, задачи, материали и методика *****
1. Хипотеза ***
Профилът на обслужване в институциите за хронично боледуващи психиатрични пациенти влияе върху определени аспекти на тяхното функциониране и може достоверно да предскаже шансовете за възстановяване.
2. Цели на проучването ***
- Основната цел на представеното проучване е да анализира факторите на институционално обслужване на пациентите с хронични психични разстройства и влиянието им върху индивидуалното функциониране и шансовете за възстановяване.
- Да се дадат практически препоръки за подобряване на обслужването на пациентите с хронични психични разстройства ориентирано към възстановяване. *****
3. Задачи на проучването
- Да се събере извадка от пациенти с дълготрайни, хронично протичащи психични разстройства лекувани в три вида психиатрични институции– отделения в държавни психиатрични болници, домове за психично болни и служби в общността.
- Да се идентифицират демографските и клинико- социални характеристики на изследваната популация.
- Да се събере информация за профила на службите и практиките в обслужването на пациентите в тях.
- Да се изследват индивидуалните фактори на обслужването през призмата на субективната оценка на пациентите в съответните институции и да се направи обективна оценка на тяхното функциониране.
- Да се идентифицират корелации между различни социо- демографски и клинични показатели от една страна и субективната оценка на пациентите за обслужването и тяхното обективно измерено функциониране от друга.
- Да се изследват корелациите между компонентите на обслужването в съответната институция и субективната оценка на пациентите.
- Да се идентифицират предиктивни фактори в обслужването, имащи значение за функционирането и възстановяването от психичната болест.
- Да се изработят препоръки в съответствие с добрата практика за обслужване ориентирано към възстановяване. ****
4. Материали и методика ***
4.1. Обект на изследването
Обект на изследването са институциите за хронично психично болни и пациенти с дългогодишни, хронично протичащи психични разстройства пребиваващи в тях.
Институциите се дефинират като места за дългосрочно обслужване на лица с хронична психична болест. В нашата страна те биват три вида- отделения към психиатричните стационари, домове за психично болни и защитени жилища (служби в общността). ...... Summary:
Background: The study focuses on assessment of the living conditions, treatment, general care, respect for human rights and autonomy of mentally ill patients who need long-term interventions in psychiatric or social institutions, as well as assessment of the individual factors of care that are highly relevant for the recovery from the chronic disease. The prevalent part of these patients are diagnosed with schizophrenia. Contemporary epidemiological studies demonstrates a more favourable course of the illness for which the organization of care plays an important role. Recovery is complex in origin and its definition comprises both objective and subjective factors. In-depth studies on the effects of the institutional care on the patients is lacking in the country. Such research would be greatly conducive to introducing interventions of a better quality and greater effect.
Materials and methods: The principal aim of the proposed study is to analyze the factors of institutional care for patients with chronic mental disorders and their influence on individual functioning and on the chances for recovery. The research focuses on the institutions (hospital wards, community based services and residential homes) and the patients in them. This is a multi-center, randomized, cross-sectional, non-interventional study. It comprises 20 institutions in the country and 180 randomly chosen patients. The institutions were studied using a specially approved questionnaire for the purpose: Quality Indicator for Rehabilitative Care (QuIRC). The patients were assessed using a battery of questionnaires: Manchester Short Assessment of Quality of Life (MANSA), Markers of Recovery, Your Treatment and Care Questionnaire, Resident Choice Scale, Good Milieu Index, Client Socio-Demographic and Service Receipt Inventory, Global Assessment of Functioning (GAF), Personal and Social Performance scale (PSP). The statistical analysis was done using SPSS version 13.0.
Results: The study of the institutions revealed that many of them still operate on the basis of obsolete and insufficiently effective practices, they are located predominantly outside the towns, in most of them there is excessive number of beds, and they lack a key specialist involved in the treatment. Male patients prevail in the sample. Female patients are more frequently subjected to interventions by all professionals. A chronic disease is not equivalent to bad functioning: the average GAF sum for the sample is 63, which corresponds to mild functional impairment. The satisfaction with the quality of life demonstrates controversial trends and is not a function of the conditions offered by the institution. It can be reliably predicted that the introduction of occupational or art therapy in care programs results in a significantly better subjective assessment by the patients of the quality of treatment and care as a whole. Residential homes and community based services offer an environment protecting violence. The higher number of beds and inmates per room, as well as the increase in age, are predictors for reducing the opportunity for a personal choice. Meetings with a clinical psychologist and with an art therapist are a predictor of great personal choice. The older age of the patients and the interventions offered by an art therapist are prognostic landmarks for the overall satisfaction with the institution. It may be predicted that the functioning improves with diminishing the length of stay, with a higher monthly income and above all with interventions by a social worker.
In the seven domains of care studied, the lowest scores were found for self- management and autonomy and social inclusion. Community based services offer significantly better quality of care compared to the other institutions. Significant correlations and predictors were identified between the different domains of care in the institutions and the individual factors of recovery. No categorical consistency was found in the links between the quality of life and the individual domains. The data reveal negative correlations with almost all of them. The opportunity for a personal choice increases with the improvement of the conditions in all domains of care in the institution, whereby the strongest dependence is with the human rights domain. Satisfaction with the institution specifically increases with the rising of the domains living and therapeutic environment, self- management and autonomy, human rights and recovery based practice, the highest correlation being with the domain of recovery based practice. Functioning, measured objectively using GAF, demonstrated significant correlations, of a moderate degree, with the domains of therapeutic environment, treatment and interventions, self- management and autonomy, human rights and recovery based practice – most strongly with the therapeutic environment domain. The patients’ assessment of the treatment and care is influenced significantly positively by the higher score of the indicators for the domains of the living environment, social inclusion and recovery based practice, whereby the conditions of the living environment are of the highest significance. The absence of violence shows a significant positive correlation with all domains with the exception of treatment and interventions, above all with the domains of living environment, self- management and autonomy, and recovery based practice. Improvement of the living environment is of great prognostic significance for diminishing the probability of acts of violence against the patients in the respective institution. Personal choice is in direct significant predictive dependence on the organization of the therapeutic environment. The better therapeutic environment and the respect for human rights are the principal predictors for higher functioning.
Conclusion: A study on the institutional care for patients with longer term mental health problems and on its effect on the recovery from the mental illness has been conducted for the first time in the country. Correlation dependences and predictive relations have been identified between the profile and the organization of care in the institutions and the individual aspects of the functioning and chances for recovery of their patients. Evidence-based recommendations for improvement of care were made.
Описание
Дисертационен труд за присъждане на образователна и научна степен „Доктор по медицина” Научна специалност: 03.01.20- Психиатрия; Научен ръководител:
Проф. Д-р Георги Ончев, дм
Ключови думи
психиатрични пациенти; хронично болни; факторите на институционално обслужване; възстановяване , Mentally ill persons; Rehabilitation Centers--organization and administration; Rehabilitation