Актуальність: Важливими проблемами при психічних та поведінкових розладах є медична, соціальна та професійна оцінка хворих та розробка реабілітаційної програми. Але, недостатнє урахування основних принципів медико-соціальної експертизи призводять до планування і проведення не завжди адекватних потребам пацієнта реабілітаційних заходів.
Мета: є дослідження сутності та розуміння поняття “обмеження життєдіяльності” та “соціальної ізоляції” в практиці психіатричної допомоги та реабілітації.
Матеріали і методи: теоретичний аналіз та узагальнення наукових першоджерел з питань медико-соціальної реабілітації психічно хворих, які мають обмеження життєдіяльності та соціальну ізоляцію.
Результати: У статті викладені погляди на розуміння виникнення обмежень життєдіяльності та соціальної ізоляції у психічно хворих. Розглянуто аспекти застосування даних категорій у практики медико-соціальної допомоги та реабілітації.
Висновок: на теперішній час спостерігається загальна тенденція, притаманна як зарубіжним так і українським науковцям, що зазначають необхідність будувати надання медико-соціальної допомоги на підході визначення обмеження життєдіяльності та соціальної ізоляції.
In modern medical research on issues of medical and social assistance, in the context of determining vital activity limitations (VAL) and social isolation in psychiatric patients, attention is paid to the scientific analysis of these categories from the point of view of the disability of psychiatric patients. The results of this analysis (most of which are from expert medical-social commission (EMSC)) are used to develop measures to improve expert and rehabilitation assistance . However, effective medical and social assistance to patients is only possible in the consideration of the principles of international approaches to the definition of VAL and SI evaluation in practice.
The researchers point out that scientific study of the problem of determining VAL and SI in the field of psychiatry is mostly theoretical. Thus, focusing of research on medical institutions or expert needs only leads to controversy between them and complexity of their practical use. Research on the study of disability indicators in terms of their impact on the development of VAL and SI are isolated [2, 3, 4] and mainly are EMSC’s reporting, which, according to the organization and operation of specialized EMSC standard approved by the Ministry of Health of Ukraine, have to contain analysis of structure, dynamics, disability causes etc. The results of these studies correspond to the needs of the EMSC and are not suitable for correction of Individual Rehabilitation Program (IRP) for disabled persons in psychiatric institutions. Thus, according to the results of scientific studies [5, 6, 7, 8, 9], it is determined that there are seperate comprehensive studies on disability indicators from the point of view of their influence on the formation of VAL and SI in psychiatric patients nowadays in Ukraine. Thee is no any systematic study of this problem in psychiatric or rehabilitation institutions or in EMSC. The studies are focused on expert or medical institutions, therefore their results can not be widely apllied for the purpose of SI prevention.
Important problems in mental behavioral disorders are the medical,social and professional assesment of patients and the development of a rehab program . However, insufficient consideration of the main principles of MSE leads to the planning and implementation of rehabilitation measures that are not always adequate to the patient’s needs. Patients’ rehabilitation is often reduced to fixing the patient’s problems, whereas their real solution is possible only when the definition of VAL and SI will be an integral part of the conclusion of EMSC and will be determined on the basis of sound methodological support . It can be noted that one of the main tasks of EMSC is to increase social functionig (SF) level and quality of life in psychiatric patients. However, this taskis not fully implemented.
The purpose of the research is to study the essence and understanding of the concept of «vital activity limitations» and «social isolation» in the practice of mental health care and rehabilitation.
Objectives of the study: to study the concept of «vital activity limitations» in psychiatric practice using the biopsychosocial approach.
Materials and methods of research
Domestic and foreign research in questions of medical and social rehabilitation of psychiatric patients with vital activity limitations and social isolation.
Methods of research: theoretical analysis and generalization of scientific sources on the studied issues.
Presentation of the main research material
In the world the study of the problem of VAL and SI are based on provisions of the modern VAL concept presented in International Classification of Functioning, Disability and Health (ICF) and concept of consequences of the illness [11, 12]. Accordingly, to ICF VAL is defined as a biopsychosocial category and is a «consequence or result of a complex relationship between the change in the health of the individual, personal and external factors that represent the conditions in which the individual lives». The ICF outlines and theoretically substantiates standardized approaches to the assessment of the effects of health changes, which are manifested by the restrictions of "activity" and "participation". The presence of a detailed list of individual spheres of life and a unified scale of violations in the ICF allows it to be used as a methodological tool for the study of VAL and SI. However, the use of ICF in the EMSC for some diseases has not yet been achieved in practice. In particular, there is a need to study and develop specific criteria for VAL and SI in mental disorders. The ICF, taking into account the social aspects of disability, does not consider disability only as a "medical" or "biological" dysfunction at the same time. Inclusion of contextual factors in the ICF, which also include environmental factors, allows you to record the impact of the environment on the functioning [10, 11, 12, 13].
It is known that the ICF complements the 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10) and contains information on diagnosis and state of health, but it is bypassing the human functional state. ICD-10 and ICF are the main classifications that are part of the WHO's international classifications. Functioning and disability are considered as a complex interconnected state of health of individuals and contextual factors of the environment, as well as personal factors. The ICF considers these aspects as integrative and dynamic rather than linear and statistical. Formulations of the ICF adopted a neutral position in relation of the etiology, it focuses on the function, not on condition or disease [11, 12]. Thus, the ICF takes into account the social aspects of disability and reveals the mechanism of influence of social and physical environment on human functioning. In the ICF, all medical and social conditions are considered on an equal footing, regardless of the reasons they were caused. Such a neutral approach allowed to equalize mental illness with physical illness [11, 12]. The new language of the ICF has become a landmark event, which has led to a strengthening of rehabilitation positions within the medical community, changes in professional attitudes and relationships, and improved communication between patients and professionals in the field of medical, social, occupational and occupational rehabilitation .
Scientific research [13, 14, 15, 16, 17, 18, 19, 20] has proved that the approach proposed in the ICF is an instrument for identifying and assessing the effectiveness and efficiency of rehabilitation services through a functional approach and orientation assessment interventions. In this way, the ICF is an international scientific tool for defining the concept of human activity and disability for clinical research, policy development in the field of state assistance to patients.
It should be noted that ICD-10 provides standard formulation and serves as a basis for describing health and related conditions. In turn, the ICF describes the functioning of three points of view: the body, personality and society and organizes information in two parts. The first is devoted to the functioning and disability, the second covers the related factors. The components of functioning and disability are subdivided into component organs: functions and anatomical structures. Problems in the organ, function, or structure are considered an impairment. The second component is the type of activity. In this case, the component of the activity is understood as the fulfilment of the task (actions) by individuals, and their participation in the activity is determined by assessing participation in life situations. Difficulties at the level of the person are marked as limitation of activity, and at the level of society - limitation of participation. The component of contextual factors is an independent and integral element of classification and is divided into environmental and personal factors. In this case, environmental factors impact the components of functioning and disability, and personal factors are not classified in the ICF. Consequently, the concept of the ICF makes it impossible to understand the concept of disability without consideration of environmental factors .
In accordance with international approaches in psychiatric practice in Ukraine, the issue of determining the presence of an impairments, VAL and its degree has become special. Separately, the SI is considered in the form of an assessment of social insufficiency and the formation of an expert opinion on this basis.
The medical and social and expert documentation indicates that the EMSC determines the level of life limitation (LLL), establishes the cause, time of occurrence, disability group, promotes effective measures for the prevention of disability, the rehabilitation of the disabled, and their adaptation to public life. Also, EMSC identifies the compensatory and adaptive capabilities of a person implementation of which will promote functional, psychological, social, vocational rehabilitation and adaptation of the disabled.
According to the legislative and regulatory framework in Ukraine, livelihood is defined as day-to-day activities that ensure the existence of a person, the existence of other members of society and society as a whole through learning, communication, orientation, movement, self-service, control over their behaviour, participation in work. It is indicated that livelihood represent the integration of physical, psychological and social functions of a person. In turn, VAL is the inability to perform daily activities in a way that is common to humans, which creates barriers in the social environment, places person in an awkward position in comparison with healthy people and manifests itself in a partial or complete loss of self-service, movement, orientation, communication, education, control over behaviour, as well as significant restrictions on the amount of available employment, decrease of qualifications and leads to social maladaptation .
Currently, in Ukraine, SI is viewed in accordance with international approaches [14, 15, 16, 17, 18, 19, 20] as a consequence of limiting the ability to move, orientation, self-service, control over behaviour, communication, work, learning. At the same time, specialists do not have the same criteria for Ukraine for assessing SI and the determination of VAL in mental disorders [9, 16].
Thus, the results of scientific studies indicate lack of knowledge on the issues of defining the components of the medical criteria for VAL and SI in patients with mental disorders . The medical documentation does not adequately cover the components of the medical criterion, and the conclusion about the SI is complicated by the lack of an algorithm for determining the indicators of the medical criteria for VAL. It is known that the clinical criteria of VAL include clinical and psychopathological symptoms, which creates a kind of closed circle of problems. On the one hand, it is a provocative factor, and on the other hand, it results from the deterioration of the mental state, which leads to the SI in society. The analysis of a medical criterion should be based, first of all, on a comprehensive study of the components that lead to VAL and SI. On the basis of this criterion, measures are being developed for medical rehabilitation.
In turn, the study of the social criterion of VAL shows insufficient coverage in the medical documentation and the complexity of the analysis of its indicators which are limiting livelihood, as well as the formation of the conclusion on the patient’s SI on their basis [17, 20]. This situation is due to the fact that the establishment of indicators SI is not systematically ensured, which leads to ignoring them in the experts’ conclusions . The study of indicators of professional activity and professional criterion of VAL also indicates the complexity of the formation of the conclusion about their impact on the development of the SI on their basis [12, 20].
Approaches to assessing work status are based on international criteria for the definition of VAL . However, according to scientific studies in Ukraine, the current situation in different. Theoretical developments and regulatory framework far outweighed the possibility of their implementation in medical and expert practice. The main reason of such a situation is the lack of methodological support and appropriate tools for the practical implementation of new technologies .
In the studies of foreign and domestic scientists, the definition of VAL and SI is considered as social diagnosis, which is understood as an analysis of social and living conditions of existence and environment, as well as the professional capabilities of the patient. The study of social factors in medical and social rehabilitation should include assessment of: family status; living conditions; financial position; social and personal adaptation of the person; dependence of the patient from other persons; ability to independent existence, independent living, including self-service, self-movement, orientation, communication, control of behavior .
When determining the SI, as a part of social diagnostics, the concept of socio-professional status is observed and includes assessment of the: level of education (general and vocational), main profession (specialty), qualifications, professional knowledge and skills, professional route, general work experience, professional stereotype, profession in which the person works at the time of the survey, conditions and organization of work, rationality of employment, as well as compliance with the psycho-physiological requirements of the main profession, health an individual .
Medical and social diagnostics are aimed at a comprehensive assessment of the medical, biological, psychological and social components, which makes it possible to judge the existence of sustainability and the degree of limitation of certain categories of vital activity and SI in the patient. The clinical doctrine of the prognosis of functioning in society and the performance of the patient in psychiatry develops on the general theoretical basis for all medicine. For example, the classification of the degree of disability is not based on the anatomical principle and not on the basis of the mechanical calculation of the percentage of disability, but on the basis of the actual ability to perform one or another work without harm to health. Thus, scientists determined that the basis of the medical and social conclusion is the clinical picture compared with the requirements of society, the conditions of life and profession to the mental functions of man.
Summarizing the aforementioned theoretical analysis and generalization of scientific sources, it can be noted that at present, there is a general tendency that is common to both foreign and Ukrainian scholars to study the problem of provision of medical care from the point of view of VAL and SI. Different aspects of this problem are considered, where in general the necessity of construction of the provision of medical and social help to psychiatric patients in the approach of defining VAL and SI is indicated.
- Derezjuk A, Orlova H. Stan medyko-social’noi’ dopomogy hvorym na psyhichni rozlady ta obg’runtuvannja mozhlyvostej i’i’ vdoskonalennja. 2005.
- Prib G. Osnovy zabezpechennja medyko-social’noi’ reabilitacii’ hvoryh na psyhichni rozlady. Arhiv psyhiatrii’. 2014;20(2):6-10.
- Prib G. Pryncypy, struktura ta tehnologija medyko-social’noi’ reabilitacii’ psyhichno hvoryh. Arhiv psyhiatrii’. 2014;20(3):8-13.
- Prib G. Social’na psyhiatrija i narkologija. Kyiv: IPKDSZU; 2016.
- Ipatov A, Sergijeni O, Vojtchak T. Standart organizacii’, struktury ta funkcionuvannja specializovanyh psyhiatrychnyh medyko-social’nyh ekspertnyh komisij ta kryterii’ vyznachennja obmezhen’ zhyttjedijal’nosti hvoryh z rozladamy psyhiky ta povedinky. Dnipro: Porogy; 2004.
- Ipatov A, Sergijeni O, Petrashenko P. Pytannja optymizacii’ organizacii’ ta pidvyshhennja efektyvnosti naukovyh doslidzhen’ z problem medyko-social’noi’ ekspertyzy ta reabilitacii’ invalidiv. Dnipro: Porogy; 2005.
- Smychek V. Rukovodstvo po ocenke ogranychenyj. 2003.
- Nykiforuk R. Medyko-social’na dopomoga v psyhiatrychnoi’ praktyci. Psyhichne zdorov’ja. 2005;(1):59-61.
- Sergieni E, Bashmakov A, Vojtchak T. Pytannja optymizacii’ organizacii’ ta pidvyshhennja efektyvnosti naukovyh doslidzhen’ z problem medyko-social’noi’ ekspertyzy ta reabilitacii’ invalidiv. Dnipro: Dnipro-VAL; 1997.
- Entoni V. Psyhiatrychna reabilitacija. Kyiv: Sfera; 2001.
- Korobov M, Shostka G, Rjasnjanskij V. Mezhdunarodnaja klassifikacija funkcionirovanija, ogranichenija zhiznedejatel’nosti i zdorov’ja. 2001.
- Nakaz MU №183. Іnstrukcіja pro vstanovlennja grup іnvalіdnostі, zatverdzhena. Kyiv: Nakaz MOZ Ukrajiny; 2004.
- Polozhennja pro іndivіdual’nu programu reabіlіtacії іnvalіda. Kyiv: Postanova Kabіnetu Mіnіstrіv Ukrajiny; 2007.
- Vojtenko R. Social’naja psihiatrija s osnovami mediko-social’noj ekspertizi i reabalitalogii rukovodstvo dlja vrachej i psihologov. SPb: Foliant; 2002.
- Jurjeva L, Phidenko S, Jerchkova N. Medyko-social’na ekspertyza psyhichnyh ta povedinkovyh rozladiv navch-metod posib dlja likariv-psyhiatriv, narkologiv, likariv med-soc ekspertnyh komisij i likariv-interniv. Dnipro: Intertehnodruk; 2005.
- Derezjuk A. Ekspertna ocinka efektyvnosti medyko-social’noi’ dopomogy kontyngentam hvoryh z hronichnymy psyhichnymy rozladamy. Visn Vinnyc derzh med universytetu. 2000;5(1):242-3.
- Prib G. Dyferencijovana kompleksna systema vyznachennja obmezhennja zhyttjedijal’nosti ta social’noi’ nedostatnosti u pacijentiv z psyhichnymy rozladamy pry provedeni medyko-social’noi’ ekspertyzy j reabilitacii’. Arhiv psyhiatrii’. 2015;21(1):23-5.
- Dmitrieva T, Krasnova V, Neznanova N, Semke V, Tiganova A. Psihiatrija, Nacional’noe rukovodstvo, Kratkoe izdanie. Moskva: GJeOTAR-MEDIA; 2012.
- Prib G. Medyko-social’na ekspertyza zhyttjedijal’nosti u psyhichno hvoryh. Kyiv: Monografija; 2012.
- Sonnyk G, Naprjejenko O, Skrypnikov A. Psyhiatrija i narkologija pidruchnyk. Kyiv: Medycyna; 2015.