The need for rehabilitation teams in endocrinology

Important psychiatric morbidity (particularly depression and anxiety) has long been recognized and consistently reported in endocrine disorders [1]. In recent years, there has been increasing awareness of the unsatisfactory degree of remission that current therapeutic strategies entail in a variety of endocrine disorders. More recently has been the interest in impaired quality of life, which stems from the fact that measures of disease status alone are insufficient to describe the burden of illness and that the subjective perception of health status (e.g., lack of well-being, demoralization or difficulties fulfilling personal and family responsibilities) is as valid as that of the clinician in evaluating the outcome [2]. Difficulties that patients encounter in coping with endocrine illness and its often severe psychological consequences have led to the development of several patients’ associations. The psychosocial impairment that is associated with incomplete remission from endocrine illness requires novel modalities of clinical interventions, as we have recently outlined be introducing the concept of rehabilitation in endocrinology [3]. In other branches of internal medicine it has been well established and implemented.

Psychiatric disturbances and impaired quality of life, which were present in the acute phase of illness, were often found to improve upon correction of hormonal imbalances [1,3]. Examples are provided by the favorable effects of steroid synthesis inhibitors upon depression in Cushing’s syndrome, or of anti-thyroid agents on anxiety in hyperthyroidism. However, disappearance of psychiatric symptoms and amelioration of quality of life are not always the case. This has been observed in recent studies concerned with patients with either pituitary disease at large or with individual conditions, such as pituitary-dependent Cushing’s disease, acromegaly, hyperprolactinemia, nonfunctioning pituitary adenoma, hypopituitarism and adult growth hormone deficiency [4–6], or with nonpituitary endhocrine disorders, such as thyroid disturbances, primary hyperparathyroidism, polycystic ovary syndrome and adrenocortical insufficiency [4,7,8].

There may be different reasons for a delayed or impaired process of recovery. Hormone alterations are frequently associated with affective disturbances, which do not always remit upon normalization of blood parameters, as was found to be the case in Cushing’s syndrome, thyroid disorders and growth hormone abnormalities [1,4,6]. Unrealistic hopes for ‘cure’ may foster discouragement and apathy. Hormone replacement may not fully restore optimal endocrine balance and subtle dysfunctions may still exert their influences on psychological states [9]. Currently, the average endocrinologist is unfamiliar with the psychosocial aspects of patient care and lacks an adequate background, both in terms of personal skills and organizational structure. A broader competence, however, including psychosomatic and psychoneuroendocrinology issues, would be crucial for facilitating the process of recovery.

Rehabilitation units and activities have achieved wide currency in many areas of medicine (e.g., cardiology, pneumology, rheumatology and neurology). Clinical endocrinologists are increasingly recognized as an important component of rehabilitation teams involved with traumatic brain injury due to the high frequency of pituitary impairment, but have not, as yet, developed their own rehabilitation services. Rehabilitation of endocrine patients is defined here as the sum of activities required to ensure the best physical, mental and social conditions, so that they may progress toward an optimal state of health [3]. It would be indicated in clinical situations, such as delayed recovery after appropriate treatment, discrepancy between endocrine status and current functioning, and the persistence of important comorbidity with special reference to psychiatric symptoms (e.g., association between depression and menstrual disturbances, binge eating and progression of diabetes, and anxiety and pheochromocytoma). Problems with life style, risk behavior and attitudes toward illness would also be good indicators.

The interdisciplinary team approach has emerged as the mainstay of rehabilitation processes. The endocrine rehabilitation team should, ideally, include a trained clinical endocrinologist, a physical therapist and a psychologist, with opportunities for consultations by different specialists.

The operational characteristics of a rehabilitation endocrinologist would depart from the current standard approach implimented in an endocrine clinic. In clinical endocrinology, there is often the tendency to rely exclusively on ‘hard data’, preferably expressed in the dimensional numbers of work-up results and hormone measurements, excluding ‘soft information’, such as disability and well-being. This soft information can now, however, be reliably assessed [2]. The evidence that has accumulated on the treatment of growth hormone deficiency [6] should lead endocrinologists to a multidimensional assessment of treatment effects, also encompassing psychosocial parameters. For instance, the differential effects on quality of life that are entailed by differences in replacement therapy are frequently acknowledged in the newsletters of patients’ associations, but have received only scanty research attention.

The physical therapist may supervise gradual physical activity and devise appropriate strategies for contrasting physical and functional decline, since inactivity is a big enemy of the post-surgical recovery process. Patients may postpone their participation in usual activities. However, avoiding situations that induce undue discomfort and anxiety initially relieves the distress; however, this subsequently results in its further increase and perpetuation. Thus, it is important for the patient to go back to all previous activities with a graded schedule and under guidance, if necessary.

The role of the psychologist is essential for a more precise definition of a patient’s psychological symptoms (e.g., depression, anxiety disorders and irritable mood), for understanding coping difficulties and for modifying risk behavior (e.g., smoking). Brief forms of individual psychotherapy may be indicated in selected cases. Group therapy for patients sharing similar disorders (e.g., pituitary disease) might also be helpful. The patient would then be encouraged to put into words his/her feelings about the endocrine disease and its feared consequences. Emotional sharing, reassurance, the provision of information (with the endocrinologist participating in some sessions) and planning for the future would encourage the patient to think in terms of adaptive coping, rather than brood about the past (“I am no longer the person I used to be”) and the potential dangers and disabling effects of his/her condition. The psychologist may also offer advice and support to the spouses and family members of the patients during the various phases of illness.

Sources of referral for the service do not only encompass endocrinology, neurosurgery and surgery divisions, but may extend to primary-care physicians, other specialists and patients’ associations. Thus, an endocrine rehabilitation service would have the potential to substantially increase the frequency of interactions between endocrinology and other medical fields.

The evidence that has accumulated on the psychosocial aspects of endocrine disease and on its process of recovery provides factual support to the concept of endocrine rehabilitation and to the introduction of such a service. A dedicated, interdisciplinary rehabilitation team may provide a comprehensive and coordinated approach to ensure adequate communication, education and support, to help the patient and his or her family achieve optimal coping with endocrine illness, and to implement gradual physical activity, with the aim of obtaining full recovery. Indeed, a biopsychosocial mode of intervention [10] would have the potential of reducing residual symptomatology and increasing the level of remission in a significant proportion of patients.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.