Key Considerations In Treating Patients With Mental Illnesses
Podiatric physicians provide interventions to improve the quality of life and physical activity of patients, but the emotional health of patients can be a key component in determining the outcome and quality of these treatments.
Research in numerous areas including spine, trauma, sports medicine, joint reconstruction and upper extremity surgery has shown a link between the emotional status of patients and functional outcomes. When patients are affected by mental illness, there is often a divide between subjective disability versus objective impairment that we can better explain by mood, stress and coping ability than by a pathologic process.
We need to consider several factors in the treatment of patients with mental illness. These factors include the specific psychiatric disorder, disorder severity, psychiatric treatment, medical comorbidities, potential drug interactions, perioperative management if surgical treatment is necessary and psychosocial considerations.
Medical comorbidities. Patients with severe mental illness, namely severe bipolar disorder and psychotic illness, have increased mortality rates with the leading cause of death being cardiovascular disease.1 Other common medical conditions of patients with severe mental illness include metabolic disorders, chronic pulmonary disease, gastrointestinal disorders and obesity.2,3 Obesity, metabolic syndrome and diabetes also frequently occur in patients with mental illness due to a combination of poor lifestyle choices, weight gain from medications and inadequate access to quality care.1,4
Pharmacologic considerations. While numerous non-pharmacological treatment options are available for mental illnesses, the majority of mentally ill patients take one or more psychoactive medications. In 2010, antidepressants were the third most common class of prescription drugs in the United States with reported use by 8.7 percent of the population.5 Interactions with other medications can increase or decrease the effectiveness of the psychoactive medication, or cause toxic effects. Cytochrome P450 metabolizes many psychoactive medications so caution is necessary with co-administration of other medications.6
Perioperative considerations. Psychiatric illness is a very important component of the perioperative management of patients. Psychiatric patients have an increased risk of perioperative complications due to impairment of their biologic response to stress.7
Depending on the type and severity of mental illness, preoperative considerations can include assessment of a patient’s decision making capacity and ability to obtain informed consent, his or her ability to follow pre- and postoperative instructions, coping mechanisms and social support. Additionally, podiatric physicians must consider the potential impact of psychoactive medications and other medical comorbidities during the perioperative period. Always consider psychiatric consultation for input regarding perioperative management of those with psychiatric illnesses and their current medications as well as assessment of the patient’s medical decision-making capacity and ability to give informed consent.
Psychosocial considerations. Depending on severity, mental illness can compromise a patient’s ability to adhere to treatment regimens and to continue follow-up care. Ng and colleagues performed a prospective observational study of patients with psychiatric disorders (schizophrenic, affective or schizoaffective disorders) undergoing orthopedic surgery.8 The authors found that 58 percent of patients defaulted for follow-up care and 45 percent had poor adherence with therapy regimens.
Poor adherence can lead to unsatisfactory outcomes and potentially serious postoperative complications. In this study, the authors also found poor family support and poor insight of patients into their condition, factors that can also contribute to poor adherence with treatment and follow-up care.8 Evaluating a patient’s understanding of his or her condition and treatment plans, as well as active involvement of the patient’s family in providing support and adherence with treatment and follow-up care is extremely important in the management of lower extremity injury in patients with mental illness.
References
1. McIntyre RS. Overview of managing medical comorbidities in patients with severe mental illness. J Clin Psychiatry. 2009;70(6):e17.
2. Jones DR, Macias C, Barreira PJ, Fisher WH, Hargreaves WA, Harding CM. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatr Serv. 2004;55(11):1250-1257.
3. Susce MT, Villanueva N, Diaz FJ, de Leon J. Obesity and associated complications in patients with severe mental illnesses: a cross-sectional survey. J Clin Psychiatry. 2005;66(2):167-173.
4. McIntyre RS. Managing weight gain in patients with severe mental illness. J Clin Psychiatry. 2009;70(7):e23.
5. National Center for Health Stastistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD. 2014.
6. Tanaka E, Hisawa S. Clinically significant pharmacokinetic drug interactions with psychoactive drugs: antidepressants and antipsychotics and the cytochrome P450 system. J Clin Pharm Ther. 1999;24(1):7-16.
7. Attri JP, Bala N, Chatrath V. Psychiatric patient and anaesthesia. Indian J Anaesth. 2012;56(1):8-13.
8. Ng KO, To SB, Shukur H. Treating orthopaedic patients with psychiatric illness and their treatment outcomes. J Orthopaedics. 2007;4(3):e19.
Editor’s note: This DPM Blog is an excerpt from Dr. Hoffman’s upcoming cover feature, “Managing Lower Extremity Conditions In Patients With Mental Illness,” which will appear in the April 2016 issue of Podiatry Today.
