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Orthopedic Surgeons Must Be Aware of Psychiatric Issues in Subset of Patients
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Posted on: 11/28/2007
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Although patients with psychiatric illnesses make up only a subset of orthopedic patients, orthopedic surgeons need to be aware of the issues involved in caring for patients with psychiatric illnesses.
The authors of this study wanted to identify problems associated with orthopedic treatments for patients who are mentally ill. To do this, the researchers studied 40 patients (24 with schizophrenia, 12 with depression and/or anxiety disorder, and 4 with schizoaffective disorder) who were receiving treatment for soft tissue infection or trauma. The group, aged from 15 to 85 years, was split evenly among men and women.
After obtaining histories from the patients and/or their guardians, and a psychiatric assessment at admission, patients who required surgery either signed themselves if they were considered to be competent, or their guardians signed for them. If an emergency arose and the patient was not competent and a guardian was not available, the orthopedic surgeon and the psychiatrist could sign consent if they were in agreement. The majority of the patients (80 percent) were known to have a psychiatric disorder, but only 62.5 percent were under treatment, with the remaining patients with known psychiatric illness not receiving follow-up care. The remaining 20 percent of patients were newly diagnosed.
The patients were watched for any problems that may have been encountered between the patient and the treating doctors. This included patients not appearing for follow-up appointments, non-compliance with treatment, and complications from treatment (including infection, re-fracture or incidents with the cast).
The researchers found that the main problem faced by the subjects was a lack of or poor family support, followed by poor doctor-patient communication, and then the patients' lack of insight into the problems. After discharge from the hospital for their orthopedic treatment, over half (57.5 percent) did not follow up for further care and 45 percent were not compliant with their treatments.
When the researchers analyzed the patients who defaulted, or did not participate in follow up, they found that 30 percent did not attend the first appointment following discharge, 26 percent did attend the follow-up clinic once. The staff was able to contact 15 patients by phone; 11 of the patients said that transportation difficulties kept them from attending the clinic while the other 4 felt that further visits were not necessary. The staff was not able to contact the remaining 8 patients.
Of the 23 patients who did not appear for follow up, 22 of them were independent. Seventeen patients had a poor family support and of them, 13 did not appear for follow up - accounting for a 76.5 percent rate, compared with those who did have good family support, of whom only 43 percent did not appear for follow up. Again, among the 23 lost to follow up, only 14 patients or 35 percent recovered from their orthopedic problem.
The study authors wrote that the major issues that present when treating patients with psychiatric disorders are those of compliance and defaulting on follow up. They noted that those patients with poorer family support had a higher likelihood of defaulting, and they also found that this group had a higher rate of infection following surgery (almost 59 percent of patients). The authors suggested 7 aspects in which care could be improved for patients with psychiatric patients who need orthopedic treatment:
1 - A better understanding of psychiatric and psychological medicine
2 - Restructuring treatment to minimize patient non-compliance, such as providing easy-to-understand instructions and good patient teaching about patient outcomes if the patient is non-compliant
3 - Encouraging family support
4 - Recruiting community support, such as community or home care nurses
5 - working with psychiatric services
6 - Adapting orthopedic treatment options to fit each case
7 - Working with rehabilitation
In conclusion, the authors say that the orthopedic surgeons must take into account total patient care in order to provide proper care for patients with psychiatric illness who have orthopedic problems.
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References:
Khai O. Ng, BC Se To, and H Shakur. Treating Orthopaedic Patients with Psychiatric Illness and their Outcomes. In Journal of Orthopedics. December 2007. Vol. 4. No. 3. e19.
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