Missed Opportunities for Identifying Mental Health Needs Among Patients in Primary & Wound Care Settings

Healthcare providers in all settings should be assessing and evaluating the mental health status of their patients and referring them for specialty care as needed. This article will help wound care clinicians gauge the signs and symptoms of mental health conditions associated with chronic wounds.

Healthcare providers face an arduous task of providing quality treatment in an efficient manner.^1,2 A vast majority of people living with mental health disorders, including severe mental illness, view primary care as the cornerstone of the healthcare system.³ For any healthcare provider caring for an ever-growing society of individuals who manage multiple comorbidities, having the time, knowledge, and/or comfort level to address a patient’s mental health needs is going to be challenging. However, the greatest clinical challenges are set to arise when mental health is not addressed appropriately within a patient’s plan of care, including for those patients in the outpatient wound clinic setting. This article will educate wound care clinicians on a slate of mental health conditions that could impact anyone among the outpatient population, as well as some signs and symptoms that should not be ignored. 

Missed Opportunities For Mental Health 

Mental health conditions are one of the leading causes of disability in the world. Primary care professionals are the first level of contact for individuals, families, and the general community.⁴ Mental health disorders are highly prevalent in primary care populations,^5,6 cause significant morbidity,^7-9 and are associated with increased primary care visits.^10,11 Patients living with depressive symptoms are more likely to seek primary care for their symptoms than to self-identify to mental health professionals. This trend relates to the stigma associated with all facets of mental health treatment, ranging from inpatient to outpatient mental health services. Stress-related defects related to wound repair can have important clinical implications in terms of recovery from surgery. One study examined wound healing-related complications following surgery that provided evidence of the impact of psychological stress on wound repair.¹² Patients living with lower leg wounds were followed to assess speed of wound repair. Patients who experienced the highest levels of depression and anxiety were four times more likely to be categorized in the delayed healing group.¹²

Early Detection & Eliminating Stigma 

Normalizing mental health treatment in primary care settings has been an ongoing need in treating the patient. A recent movement brings mental health to the forefront and confirms that assessment and treatment of other medical conditions, such as diabetes and hypertension, is as critical as ad-dressing mental health concerns. Molecular genetics has shown that mental health conditions, just as with most health conditions in general, are the result of complex interactions between the brain, body, genes, and environment.^13-16 By integrating mental health with each patient interaction, healthcare providers can help reduce the stigma of mental illness so that it can be addressed routinely.  

The need to improve detection and treatment of mental health problems is vital to integrative healthcare and positive outcomes. Primary care physicians and specialty clinicians in fields such as wound care, pulmonology, cardiology, and other areas of care must be able to assess for and recognize the potential for mental health conditions and help patients seek treatment just as with common medical comorbidities. Any practical and holistic treatment plan is going to consider the impacts on mental health and the appropriate education needed to connect patients to the needed resources. There are many signs and symptoms that can be exhibited across the spectrum in many mental health diagnoses that also affect healthcare outcomes. Specifically related to wound care, causes of disruption in the healing processes may include sleep disturbance, weight gain or weight loss due to compromised nutritional intake, feelings of hopelessness and helplessness, increased anxiety, medication noncompliance, poor hygiene, social isolation, and mood disturbance. Co-occurring disorders, which refer to the existence of both a mental health and a substance-use disorder, compound the barriers for effective medical treatment and compliance to such treatment. According to the Substance Abuse and Mental Health Services Administration’s 2014 National Survey on Drug Use and Health, approximately 7.9 million adults lived with co-occurring disorders in 2014.¹⁷ 

_________________________________
RELATED CONTENT
Health-Related Quality of Life & Chronic Wounds
Facility in Focus: Taking a Psychosocial Approach to Wound Care at Orlando Health
_________________________________

Mood Disorders & Barriers to Treatment

Mood disorders are a category of mental health diagnoses that cause a disruption or change in mood (eg, major depressive disorder, anxiety, bipolar disorder, cyclothymia, seasonal affective disorder). Two of the most common mood disorders are major depressive disorder and bipolar disorder. Depression, the most common serious mental health condition among primary care patients, has been the subject of several studies addressing the relationship between detection and severity of illness,^18-20 showing that more severely affected patients are more likely to be undetected. Undiagnosed depression can lead to poor healthcare outcomes and decreased function among those affected. A study in three outpatient healthcare facilities indicates that “patients with either current depressive disorder or depressive symptoms in the absence of a disorder tended to have worse physical, social, and role functioning; worse perceived current health; and greater bodily pain than did patients with no chronic conditions.”⁷ The study uncovers that the poor functioning linked with depressive symptoms was comparable with (or worse than) that linked with multiple significant chronic medical conditions. The authors continue: “For example, the unique association of days in bed with depressive symptoms was significantly greater than the comparable association with hypertension, diabetes, and arthritis. Depression and chronic medical conditions had unique and additive effects on patient functioning.”⁷ Bipolar disorder is a chronic mental illness that causes dramatic shifts in a person’s mood, energy, and ability to think clearly. People living with bipolar disorder have high and low moods known as mania and depression, which differ from the typical “ups and downs” most people experience. If left untreated, the symptoms usually worsen.²¹ Patients living with bipolar disorder also often have strained familial and/or supportive relationships due to the often extreme cycle of mood fluctuations. Risky behaviors and adherence to treatment are often associated with this mental illness as well.

Psychosis & Barriers to Treatment

Identifying psychotic disorders in primary and subspecialty care can be challenging, as the patient’s trust in his or her healthcare provider may be limited and take extended time to establish. According to the Diagnostic and Statistical Manual of Mental Disorders, diagnostic criteria for schizophrenia include symptoms persisting for at least six months and significant difficulty in one or more functional capacities.²² Patients living with primary psychiatric disorders are more likely to have auditory hallucinations, prominent cognitive disorders, and complicated delusions.²³ Ruling out medical conditions that could contribute to a patient experiencing psychosis or delirium is critical in establishing effective treatment.

Cognitive Disorders & Barriers to Treatment

Cognitive disorders represent a category of disorders that primarily affect memory, learning, perception and problem-solving. They are classified in the mild, moderate, and severe ranges. Psychosis and delirium can cloud an individual’s sensorium. Once this is treated effectively, the patient can be alleviated of an assortment of psychiatric conditions that compound the dementia itself. Recognizing cognitive disorders in the primary or subspecialty care setting and establishing a strong connection with family and caregivers is key. Family involvement and including a significant support system (with the patient’s permission) is important to improving the therapeutic effort of the treatment team, especially when cognitive disorders are assessed. 

What’s the Solution?

An agreement between the patient and the healthcare provider on a plan of care and treatment is vital. The patient’s opinion and preference for treatment should be of primary concern to the healthcare provider so that he or she can feel more engaged in their own care. Patients may lack insight into medical comorbidities and complex drug regimens, and the course of illness may be complicated by tobacco or other substance use.²⁴

Developing insight into the link between wound care treatment and mental wellness can ultimately improve overall treatment outcomes in a more cost-effective approach. Physicians, nurses, and support staff may recognize issues with adherence to the plan of care, including:

• lack of motivation or commitment to treatment,
• missing scheduled appointments,
• medication/wound care supplies not being used, 
• extended wound healing time, 
• complications/chronic infections,
• inability to follow directives, and  
• reported changes in eating and/or sleep patterns.

Conclusion

The need to improve detection, assessment, and treatment for mental illness in primary care and subspecialties is widely recognized.^25-29 Observing and being aware of these issues can alert staff to potential mental health concerns that are impeding or prolonging the treatment process. Understanding the importance that patient engagement plays in detection of mental health issues is key to obtaining optimal patient outcomes. Detection and integration of mental health treatment in the initial stages of wound care treatment planning increases engagement and adherence to treatment goals, which ultimately can affect outcomes in a positive way. 

Amy Bienvenu is a licensed clinical social worker, a board-approved clinical supervisor by the Louisiana State Board of Social Work Examiners (LABSWE), and a mental health counselor serving Natchitoches, LA. Sandra Wiggins Long is director of psychiatric services at Natchitoches Regional Medical Center, a licensed clinical social worker, and a board-approved clinical supervisor by the LABSWE.

References

1. The World Health Report 2001 – Mental Health: New Understanding, New Hope. World Health Organization. 2001. Accessed online: www.who.int/whr/2001/en

2. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370(9590):859-77.

3. Lester H, Tritter JQ, Sorohan H. Patients’ and health professionals’ views on primary care for people with serious mental illness: focus group study. BMJ. 2005;330(7500):1122-6.

4. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. World Health Organization. Accessed online: www.who.int/publications/almaata_declaration_en.pdf

5. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45(12):1100-6.

6. Kamerow DB, Pincus HA, MacDonald DI. Alcohol abuse, other drug abuse, and mental disorders in medical practice. Prevalence, costs, recognition, and treatment. JAMA. 1986;255(15):2054-7.

7. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA. 1989;262(7):914-9. 

8. Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community. JAMA. 1992;267(11):1478-83.

9. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days and days lost from work in a prospective epidemiologic survey. JAMA.1990;264(19):2524-8.

10. Shapiro S, Skinner EA, Kessler LG, et al. Utilization of health and mental health services. Three epidemiologic catchment area sites. Arch Gen Psychiatry. 1984;41(10):971-8.

11. Unützer J, Patrick DL, Simon G, et al. Depressive symptoms and cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA. 1997;277(20):1618-23.

12. Cole-King A, Harding KG. Psychological factors and delayed healing in chronic wounds. Psychosom Med. 2001; 63(2):216-20.

13. Collins FS. The case for a US prospective cohort study of genes and environment. Nature. 2004;429(6990):475-7.

14. Dick DM, Latendresse SJ, Lansford JE, et al. Role of GABRA2 in trajectories of externalizing behavior across development and evidence of moderation by parental monitoring. Arch Gen Psychiatry. 2009;66(6);649-57.

15. Kandel ER. In search of memory: the emergence of a new science of mind. New York, NY. W.W. Norton & Company Inc.; 2006.

16. Shanahan MJ, Hofer SM. Social context in gene-environment interactions: retrospect and prospect. J Gerontol B Psychol Sci Soc Sci. 2005;60(1);65-76.

17. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. SAMHSA. 2014. Accessed online: www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

18. Mullan E, Katona P, Dath P, Katona C. Screening, detection and management of depression in elderly primary care attenders. II: Detection and fitness for treatment: a case record study. Fam Pract. 1994;11(3):267-70.

19. Garrard J, Rolnick SJ, Nitz NM, et al. Clinical detection of depression among community-based elderly people with self-reported symptoms of depression. J Gerontol A Biol Sci Med Sci. 1988;53(2):M92-101. 

20. Banazak DA. Late-life depression in primary care. How well are we doing? J Gen Intern Med. 1996;11(3):163-7.

21. Bipolar Disorder. National Alliance on Mental Illness. Accessed online: www.nami.org/learn-more/mental-health-conditions/bipolar-disorder

22. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC. American Psychiatric Association; 2013.

23. Levenson JL. Psychosis in the medically ill. Primary Psychiatry. 2005;12(8):16-8.

24. Planner C, Gask L, Reilly S. Serious mental illness and the role of primary care. Curr Psychiatry Rep. 2014;16(8):458.

25. Ormel J, Koeter MW, van den Brink W, van de Willige G. Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry. 1991;48(8):700-6.

26. Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW. Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry. 1988;10(5):317-21.

27. Perez-Stable EJ, Miranda J, Munoz RF, Ying YW. Depression in medical outpatients. Under-recognition and misdiagnosis. Arch Intern Med. 1990;150(5):1083-8.

28. Katon W, von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30(1):67-76.

29. Wells KB, Katon W, Rogers B, Camp P. Use of minor tranquilizers and antidepressant medication by depressed outpatients: results from the medical outcomes study. Am J Psychiatry. 1994;151(5):674-700.