Health Psychology Past, Present, and Potential

1. Health PsychologyPast, Present, and Potential Cynthia D. Belar, Ph.D., ABPP

2. Historical Perspectives • Growth of Education and Training • Growth of Research • Growth of Professional Practice/Applications • Potential (and preparation)

3. 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)

4. 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

5. Clinical Health Psychology professional practice of health psychology • Behavioral Medicine interdisciplinary field to which health psychologists contribute

6. Historical Perspectives • Ancient Greece • Middle Ages • Renaissance

7. 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)

8. 19th Century • “psychosomatic” (Heinroth) • Benjamin Rush • Sigmund Freud • Walter B. Cannon • Ivan Pavlov

9. 20th CenturyFormalization 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

10. 20th Century • “Comprehensive Medicine” (Guze, Matarazzo, & Saslow, 1953) • “Biopsychosocial Model” (Engel, 1977) • Neal Miller (1969) • Wilbert Fordyce (1976) • Robert Ader (1974)

11. Landmark Eventsin 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

12. 1978

13. 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

14. 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

15. 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 Knowledge Domains

16. 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 Core Domains of Knowledge & Skill

17. 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

18. 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)

19. Establishment of Journals 1978 – Journal of Behavioral Medicine 1982 – Health Psychology 1986 – Journal of Psychology and Health

20. 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)

21. 2001

22. 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

23. 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 Service Areas for Health Psychology

24. 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

25. #1Prevention of illness/injury

26. Reckless driving Poor body mechanics Falls Seatbelts/helmets Toxic storage Interpersonal violence Traumatic Injuries

27. Behavioral Risk Factors • Tobacco use • Diet • Exercise • Unsafe sex • Alcohol and substance use

28. #2Coping with illness

29. Post MI survival (Berkman, 1995) Hemodialysis survival (Christensen et al., 1994) Social Support

30. 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 Myocardial Infarction Frasure-Smith et al., 1995

31. patients with high anxiety in the 48 hours after AMI had 4.9 times risk for developing complications risk independent of clinical indicators Recovery from Illness Acute Myocardial Infarction Moser & Dracup, 1996

32. Social support Emotional support Systematic behavior change Increased self-efficacy Interventions are more than health education.

33. #3Preparation for stressful medical procedures

34. Recovery from SurgeryMeta-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

35. 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 #4Adherence to Medical Regimens

36. Asthmatic episodes Pain Fecal incontinence Anticipatory nausea Vasospasms Dyspnea Headache Muscle spasms Insomnia Cramping/diarrhea #5Management of Physical Symptoms

37. COPD Rehabilitation Program 7 6 5 4 Pre Post 3 2 1 0 Inpatient Days Outpatient Visits ER Visits Talcott et al., 1996

38. 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

39. 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 Fecal Incontinence Whitehead et al., 1996

40. #6Psychophysiological Disorders • Irritable Bowel Syndrome • Migraine Headache • Tension Headache

41. #7Problems of health care providers and health care systems.

42. Surgery (pain, ICD) Organ transplantation Complex management (home dialysis, home ventilator) Fertility treatments Medical Decision-Making

43. Education and Training Physician-Patient Communication Implementation of Practice Guidelines Burnout Prevention Needs of Other Health Professionals

44. Self-Help Programs Program Development disease management staff development community outreach Infection control Needs of Health Care Organizations

45. 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

46. #8Mental health disorders

47. 1 in 5 American adults experience a mental disorder in a given year 1 in 10 children and adolescents 1 in 5 older persons U.S. Surgeon General Reports1999, 2000, 2001

48. 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

49. 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

50. 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