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Abstract:
Background:
Treating orthopaedic patients with psychiatric illness is challenging
as they pose many salient and complex problems that may
affect choice of treatment option and outcome. These problems
need to be addressed in order to render appropriate treatment
and prevent complications. A prospective observational study on
problems associated with this subset of patients with
psychiatric disorders was undertaken.
Methodology: Patients with psychiatric illness who were admitted for orthopaedic
problems and those who developed psychiatric disorders following
admission for orthopaedic treatment were enrolled into the
study. The problems associated with orthopaedic treatment of
these patients as regard to contributing factors to the outcomes
were noted.
Results: Poor family support was encountered in 42.5% of the patients; 40%
showed poor insight to their orthopaedic problems. More than
half of the patients (58%) defaulted follow-up and 45% had poor
compliance to therapy. The infection rate was high in the
operative trauma cases.
Conclusion:
Subset
of orthopaedic patients with psychiatric disorders poses many
salient problems that may affect choice of treatment. To ensure
good treatment outcome, full evaluation of the patient, liaison
with the family members, psychiatric services and the
rehabilitation therapist are the keystones.
J.Orthopaedics 2007;4(3)e19
Keywords:
Psychiatric
patients; mental affliction; problems encountered; compliance
Introduction:
Individuals
with psychiatric background represent a minor subset of
orthopedic patients. The problem of recognition of this subset
of patients remains difficult owing to social attitude of hiding
rather than unveiling the afflicted patients. Society typically
demonstrates a poor understanding and even less sympathy for
those afflicted by psychiatric problems.
Treating
this subset of patients may perhaps compounded by multifaceted
problems. Terry and Hayashi pointed out that there are stresses
in the treating doctors when working with the mentally ill
patients1. Problems such as obtaining history,
validity of consent for treatment, post-hospitalization care and
compliance to therapy and rehabilitation can influence treatment
decision-making. These problems may lead to suboptimal treatment
and poor overall outcomes.
Poor
compliance on the patient’s part can be a main obstacle toward
satisfactory outcome. It is imperative to provide mentally
afflicted patients a pattern of effective care so that an early
return to mobility and function is possible. Unfortunately for
this group of patients, they are often neglected before or after
seeking medical attention, and not uncommonly, they may present
again only with complication of their initial complaints or
treatment. Lange et al
in their study of orthopedic in-patients with psychosomatic
disorders showed that 30% of them had difficulty coping with
their illness attributed partly by the nature of the disease and
consequences of difficult psychosocial adaptation to orthopedic
problems or complication2. There is still lack of
consensus on how to address mental illness.
Whilst
the issue of post-traumatic disorder in orthopedic patients has
been frequently addressed, attention on problems specifically
associated with general psychiatric individuals continued to be
lacking. How do psychiatric patients fare to orthopedic
treatment remained difficult to be answered.
The
aims of the study are to identify the problems associated with
orthopedic treatment of the psychiatric patients as regard to
its treatment morbidities and outcomes, and to propose possible
interventional strategies for such problems.
Material and Methods :
Patients
included in this study were those who presented to the
Orthopaedic Department of a public hospital with orthopaedic
related soft tissue infection or trauma, who were either with
known psychiatric disorders or newly diagnosed to have
psychiatric disorders during their hospitalization. Patients who
developed post-operative delirium, post-hospitalization
psychiatric disorder on follow-ups, or patients with
musculoskeletal pain were excluded from this study. All were
prospectively follow-ups and evaluated. The issues that were
looked into include type of psychiatric affliction, pre-injury
status of dependency, orthopedic treatment, and problems
encountered during hospitalization and on follow-ups, and
outcomes of orthopaedic treatment.
The
history was obtained from the patients and their caregivers. The
diagnosis was classified into either traumatic or infective in
origin. All patients were reviewed and assessed by the
psychiatric team of the hospital during their admissions.
Patients with a known psychiatric disorder were reassessed to
confirm the diagnosis. Those who showed clinical features of
psychiatric illness were referred to the psychiatric team for
assessment. They were considered as newly diagnosed cases.
Categorization of patients into three diagnostic groups of
psychiatric disorders, namely schizophrenic, affective, or
schizoaffective was then made. Patient dependency in activities
of daily living (ADL) was assessed and an institutionalized
patient was considered as dependent. The psychiatric team
managed treatments and follow-up of their psychiatric problems.
Problems
encountered by the patient and the treating doctors throughout
the patients’ hospital stays were noted. These include delayed
presentation, barrier to communication and cooperation of the
patient, patient’s insight to the injury or illness, consent
for surgical treatment, payment for treatment or implant or
orthoses, and family support.
Consent
for surgical treatment was obtained from the patient with
reasonably sound mental status. If the patient was deemed unfit
for consent as declared by the treating surgeon or psychiatrist,
the authority to consent is transferred to the patient’s
eligible guardian. In the case of emergency where it was
impossible or impracticable to obtain consent from the patient
or the eligible guardian, both an orthopaedic surgeon and a
psychiatrist will be required to authorize the consent for
treatment.
The
patients were reviewed and followed-up in the orthopaedic
outpatient clinic after their discharge. The problems evaluated
during follow-ups at the orthopedic outpatient clinic include
compliance to treatment plan, complications related to treatment
particularly wound infection, re-fracture, and plaster cast
related consequences. Defaulters are defined as those who fail
to attend necessary follow-ups after attempts were made to
contact them via phone or mail and a home visit failed.
Results :
Forty
patients were admitted in the study over the twenty months
period, with 20 males and 20 females. Their ages ranged from 15
to 85 years with a mean age of 42 years (Figure 1)
Of
the 40 patients, 30 (75%) patients were admitted due to
traumatic injury and the remaining 10 (25%) were due to
infection (Table 1).
Upon
psychiatric reviews, 24 patients were having schizophrenia; 12
were categorized as affective disorder such as depression and
anxiety disorder; and another 4 as schizoaffective disorder.
Patients with known psychiatric disorders accounted for 80% of
the patients but only 62.5% of them were under psychiatric
follow-ups. The other had defaulted psychiatric treatment. The
remaining 20% of the patients were newly diagnosed cases. Of the
total 40 patients, 5 patients were dependent on their caregivers
with 3 of them were institutionalized.
On
evaluation of the problems faced by the patients and the
treating surgeons during hospitalization, several issues were
raised (Table 2). Poor family support appeared to be the main
problem faced by the patients. This is followed by poor
doctor-patient communication and a lack of insight in
patient’s part to the illness or injury.
On
follow-up of these patients after they were discharged from the
hospital (Table 3), 23 (57.5%) of them defaulted along the
follow-up. 18 (45%) of the patients had poor compliance to the
prescribed treatments.
Of
the 23 patients who defaulted follow-ups, 7 (30%) patients did
not attend the first appointment, 6 (26%) came to the follow-up
clinic once. Of 15 patients contacted by telephone, 11(73%)
cited transportation problem as the reason for not attending
follow-up. The remaining were satisfied with their conditions,
hence rendered further check-up unnecessary. Eight patients were
not contactable.
Of
the 23 defaulters, 22 (96%) were independent in their ADL. Of
the 17 patients who had poor family support, 13 (76.5%) ended
defaulting follow-up, compared to 43% from patients with good
family support (p=0.037). 66% of the affective disorder patient
defaulted follow-up, as compared to 54% from the schizophrenia
group and 50% from the schizoaffective group.
There
were 17 operative trauma cases in the study, of which 10 (59%)
were complicated by infection. During the follow-up, there were
overall 24 cases complicated by infection. Of these cases, 11
also has problem of poor family support.
Apart
from the 23 patients who were loss in the follow-up, 14 (35%)
patients recovered from their orthopaedic problems. There was
one case of osteomyelitis due to infected implants.
Discussion :
The
key issues in this study are to identify various problems
related to the management of psychiatric patients with
orthopedic injuries and infections, and to provide possible
interventional suggestions to encounter them.
The
major problems in treating these mentally afflicted patients are
poor compliance to their treatments and defaulting follow-ups.
This can be attributed to poor insight and poor family support
which were found in more than one third of the study subjects.
The
term "poor insight" has a very broad definition. The
most widely accepted definition of insight, as documented in
current studies on the subject, include three recurring aspects:
a general recognition of mental illness, the capacity to
correctly attribute symptoms to the pathology of said illness,
and the ability to recognize the benefits of (and consequently
cooperate with) treatments3. 37.5% of the subjects in
this study group have shown an unawareness of their own illness.
Such poor insight has profound consequences for treatment
compliance, disease prognosis, and general quality of life.
From
this study, the patients with poor family support are more
likely to default treatment (p<0.05). More than half of the
defaulters have poor family support.
This finding is in agreement with the observations in the
literatures4,5. Poor family support is a major
concern as it leads to poor supervision on the treatment
compliance and disruption of rehabilitation. Problem of getting
transport to the hospital has been identified as the main reason
for defaulting follow-up. Without the support from the family
members, these patients who are usually apprehensive of their
mobility will face difficulty getting public transport to the
hospital.
This
study has shown that there is a significant higher infection
rate in patients who underwent surgical intervention (58.8%).
Many inter-related factors have been identified as the possible
causes which include delayed treatment, poor insight, poor wound
care, poor compliance on medication and wound dressing
instruction. A lack of supervision is suggested in these
patients as a majority of them also facing the problem of poor
family support.
Improvement
in many aspects is needed to provide a better care for this
subset of psychiatric patients:
a. Knowledge in
Psychiatry and Clinical Ethics
A
better understanding of psychiatry and psychological medicine
should be the basis for an improved ability to recognize
co-morbid psychiatric disorder in orthopaedic patients. Improved
recognition of symptoms referable to psychiatric disorders and
the recognition that psychiatric treatment may on occasion be
necessary will lead to a reduction in waste of treatment time.
Knowing the natural history of the disorders should also help
the orthopedic surgeon to cope with clinical problems arising
within this area and to produce realistic orthopedic treatment
plans, which tailor to the patients’ needs and be able to
communicate with the members of the psychiatric support
services.
Orthopedic
surgeons who are involved in the care of patients with
psychiatric disorders should become familiar with the ethical
issues that may complicate the provision of care to these
patients. The knowledge in clinical ethics should be explored
and improved. Wenger
found that there was
poorer understanding of proper ethical conduct with
regard to informed consent and recommended that ethics must be
taught in training programs in orthopaedic surgery6.
b.
Improve Patient’s Compliance
Non-compliance
in the patient’s part, especially in the case of outpatient is
a substantial obstacle to the achievement of therapeutic goals.
Treatment, which is complex, prolonged, expensive, inconvenient,
or disruptive of the patient’s lifestyle, is least likely to
be followed. There is considerable scope for restructuring
treatment regimes to minimize these features, such as giving
clear and simple instructions, trying to predict non-compliance
and determine its causes, informing the patient of the dire
consequences which will certainly occur if the advice is not
followed, and above all, enlisting family support.
c. Family Support
The
family is considered an important social institution in our
culture. Family support can thus be regarded as an “inevitable
health care system” which constitutes the core long-term care
provider, providing day-to-day routine physical care, supplying
emotional support, and supervising daily tasks. However it
requires tremendous commitment and is a physically demanding
role that can lead to emotional backlashes, restriction of
social life, and a financial drain for the caregiver. To prevent
this informal care system from collapsing, there is a need to
identify caregivers who experience difficulties and are
vulnerable. Therefore a good and efficient community support is
imperative.
d. Community Support
The
service of community or home care nurses cannot be
over-emphasized and should be an essential member of the
multi-disciplinary team which manages for the after-care of the
patients following discharge. Their visitations include working
directly with the mentally afflicted patients and their
caregivers, providing continuous care in promoting mental health
and be equally ready to provide assistance to the orthopaedic
plan of care such as wound dressing and supervision to
rehabilitation program. The community nurses can offer more
systematic follow-up as well as be of great assistant in
defaulter tracing. Other services such as providing patient
transport should be looked into.
e. Liaison with
Psychiatric Services
There
should be a close liaison between the orthopedic surgeon and
psychiatrist if the overall treatment is to succeed. . The
multidisciplinary setting should be established as it allows
joint assessment and management in a co-coordinated treatment
planning. Such a regime should provide improved results both in
the short and long term. There can be a more rapid response to
the acute problems. If the underlying psychopathology can be
identified and treated, the orthopedic problem can be managed
more effectively.
f. Orthopaedic Treatment
Options
The
principles of orthopaedic management should be held true in the
treatment of all orthopaedic patients, regardless the background
of mental affliction. Surgery, if consented, should be performed
if clearly indicated. The higher infection rate in surgically
managed cases in this study should not deter an orthopaedic
surgeon to opt for conservative management in the mentally
afflicted patients if surgical intervention is indicated.
Conversely, the surgeon should be more meticulous in his
operation. The importance of wound care needs to be emphasized.
The surgeon should take the initiative to liaise with the home
care service to help supervision and wound dressing if
necessary. Alternatively, extended hospitalization should be
considered to ensure continuous supervision as regard to wound
care as well as compliance to medication and rehabilitation in order to achieve uncomplicated healing.
g. Rehabilitation
Rehabilitation
in mentally afflicted patients presents numerous challenges for
the doctors involved in their care. Mentally afflicted patients
may already have disorder-related conditions that may interfere
with physical performance and safety. The general goal of
rehabilitation is to return each patient to the pre-morbid
functional level of mobility and self-care, ensuring that the
patient is discharged to a safe environment and reduce the risks
of further trauma. Orthopaedic surgeons, with the collaboration
of the psychiatrists and the interdisciplinary rehabilitation
team, should prescribe a comprehensive treatment program that
offers these patients the best opportunity to improve physical
skills and functions, decreasing social isolation and
deterioration of their mental condition.
Conclusion:
Orthopaedic
surgeons cannot and should not ignore the value on the virtue of
complete patient care, including the mentally afflicted patients
and their well-being. Accurate identification of orthopaedic
patients with mental affliction can lead to better overall
clinical management and to the effective use of psychiatric
intervention. Because of the complexities involved in treating
these mentally afflicted patients, it is suggested that their
care should be comprehensive and integrated, provided by teams
of health-care personals working in dedicated units.
This
study has its own limitation as regard to the size of the sample
and non-comparable nature of the study. The sample size was
small. A large sample would enable more weighting to be placed
on the statistical results. The data may not be from a
representative sample that is generalized to all orthopedic
patients with mental affliction. The significance of the
findings in this study must be balanced against the limitations
inherent within it. Performing in-depth interviews with the
patients to explore their perceptions, although it may be
difficult in view of their mental states, could have enhanced
the qualitative elements of this study.
Much
is still to be learned. Effort should be made to strengthen and
co-ordinate services on a local level as primary healthcare
services, and links to the hospital system and to rehabilitation
services. An integrated system should be formed to ensure
efficient services delivered to the patients, whose chance for
an improvement in the quality of life very much depends on the
adequacy of the service they are able to obtain.
It
is hoped that the emphasis of this study will lend support to
the introduction of further liaison psychiatry into orthopaedic
management. This issue surely deserves both enthusiasm and
caution. This clarification enhances a greater understanding of
mental health in orthopaedic practice and how it can impact on
improved health outcomes for patients within a general hospital
environment.
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Terry K, Hayashi C. Occupational therapy issues in the
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Lange C, Heuft G, Wetz HH. Psychiatric co-morbidity in
patients of technical orthopaedic units. Orthopaedic. 2001; 30(4): 236-41.
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Kemp RA, Lambert TJR. Insight in schizophrenia and its
relationship to psychopathology. Schizophrenia Research
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18: 21
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King SA. Snow BR. Factors for predicting premature
termination from a multidisciplinary inpatient chronic pain
program. Pain
1989; 39: 281-7.
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Basler H, Rehfisch HP. Follow-up results of a
cognitive-behavioral treatment for chronic pain in a primary
care setting. Psychology
and Health 1990; 4: 293-304.
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Wenger
NS
, Lieberman JR. An assessment of orthopaedic surgeons’
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