Guest Editorial: Hidden in Plain Sight

   The challenges of providing quality chronic wound care in today's healthcare environment have been well delineated by multiple authors. Generally, clinician authors concur that the chronic wound experience is multifactorial in nature and etiology.^1,2 What is striking is that the psychology of wound care - that is, the psychological hazards inherent in living with a pressure or vascular ulcer and the ability of wound care practitioners to comprehensively address those concerns - receives relatively little acknowledgment.

   Recently, I was discussing this topic with a psychiatric clinical nurse specialist colleague who has extensive experience in gero-psychiatric care and with whom I am conducting a research study on people with chronic wounds. His comments about the lack of concern for the psychological components of the wound experience were pithy, to say the least. Our continuing discussion has reminded me to look at the "other side" of a physical care focus for the wound patient and to ask, "How well am I addressing the psychiatric diagnoses that may be present?

   Most experienced clinicians would most likely agree that people with severe cardiac disease, poorly controlled diabetes, or renal insufficiency experience some degree of depression and compromised attitude. However, chronic wound patients may have these challenges plus an even more visible and permanent reminder of the failure of their bodily systems. One may even question if the best technology in topical wound therapy is not working because of the "sore" affecting the mind (eg, clinically significant depression). Have we been ignoring and/or underestimating the role of psychological care for chronic wound patients?

   It is generally accepted that pressure ulcers are best treated with pressure relief and moist wound healing; hence the humorous adage, "You can put many things on a wound except the patient." In the same way, we need to ask if the wound compromises the patient's outlook or if the mental health deficiency inflicts the physical wound.

   For those of us who may not have formal advanced mental health education, help is available in the literature and through continuing education conferences. We need to think about our current chronic wound care patient populations and ask, "Are we caring for the whole patient?" Considerations include:
   * Has the patient's mental status been screened recently? (Screening tools exist.)
   * Has the patient ever been screened for depression? (Multiple depression screening tools are available on databases such as the Health and Psychosocial Inventory [HAPI].)
   * What symptoms should arouse wound clinician suspicion? (Many articles target differential diagnosis.)
   * If mental health challenges are suspected, have we approached the appropriate practitioners to consult on our patients? (What practitioner supports are available in your system?)
   * How do we know if our patients are receiving the correct psychopharmacology for their psychiatric diagnosis? (Superb articles exist on electronic databases and even on the Internet.)

   Literature on chronic illness, palliative care, and gerontology offer significant assistance for people providing direct or indirect wound care in contemporary America.^3,4 Continuing education at national, regional, and local conferences may help us enhance our knowledge of mental health therapeutic interventions.

   I encourage everyone caring for wounds to take the time to better assess for adequate treatment of potential mental health challenges in their chronic wound patients. This scrutiny is especially needed in long-term and home care where patients may be geographically removed from the healthcare system. We need to ask, "Am I focusing on the wound bed, periwound skin condition, or type of wound exudate and missing the 'psychiatric sore' that is hidden in plain sight?" Holistic care may take on a fuller meaning as we heal both the injured integumentary system and the gash in the mind.

1. Beitz J. Overcoming barriers to quality wound care: a systems perspective. Ostomy/Wound Management. 2001;47(3):56-64.

2. Ennis W, Meneses P. Pressure ulcers: a public health problem, an integrated hospital's solution. Dermatology Nursing. 1997;9(1):25-30.

3. Beitz J. Chronic illness, aging, and palliative care: population-related trends with implications for long-term care nursing in the 21st century health care system. PADONA Journal. 2003;16(2):6-12.

4. Kissane DW, Clarke DM, Street AF. (2001). Demoralization syndrome - a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001;17(1):12-21.