Psychological Distress and Orthopaedic Trauma

第一作者:Margaret McQueen

2016-03-11 点击量:774   我要说

Over the past few decades, there have been many advances in the physical treatment of musculoskeletal injury, with improved outcomes and shorter hospital stays. More sophisticated methods of assessment of outcome have been developed, with an emphasis on patient rather than surgeon-oriented outcomes. Orthopaedic trauma as a specialty has become more team-oriented, with a bigger role for ortho-geriatricians, osteoporosis specialists, and paramedical practitioners. One omission in this list has been the psychiatrist or psychologist.

It has been recognized for some time that the patient’s psychological makeup has an influence on the outcome of treatment and perhaps should have an influence on the type of treatment recommended, but this has not been embraced by the orthopaedic community. In their article, Weinberg et al. highlight the high prevalence of psychiatric disorder in the polytrauma population (39.2%), the poor rate of detection of a preexisting psychiatric disorder by clinicians (69.2%), the low rate of home psychiatric medications restarted within twenty-four hours of admission (71.4%), and the lack of instruction to patients to follow up with their mental health practitioner at the time of discharge (39.2%). The performance of the orthopaedic trauma service was worse in all of these aspects compared with the general surgery trauma service, although, because of the retrospective nature of the study, numbers were small. The authors speculate that this difference may be due to orthopaedic surgeons being less focused on psychiatric issues. Furthermore, the authors found a significant association between depression and the risk of complications and, in their discussion, implicate both psychosocial factors and systemic pathophysiological effects of depression.

This article adds to the growing body of evidence of the importance and influence of the patient’s psychological state on many aspects of his or her assessment, treatment, and outcomes. Common sense alone dictates that the more confident, adaptive, and resilient the patients are, the better is their physical health and their perception of the outcome of their treatment. If we wish to achieve better care for our patients, both the available literature and common sense need to be harnessed to achieve a major attitudinal change in our specialty.

The authors conclude that this subject is an important one for collaborative research between mental health providers and orthopaedic traumatologists, a view with which I concur. A number of subjects should be addressed. First, the value of the involvement of a psychologist in the treating team should be assessed. There is an analogy to this in the detection and treatment of osteoporosis after fracture. Fracture liaison services for the detection and secondary prevention of osteoporosis have been shown to be effective, to save money, and to make good clinical sense. The same model could be applied to psychiatric disorders, including psychological support for those at risk, and could be tested to ensure its efficacy. Second, the effect of psychiatric disorders on the outcome of fracture should be studied in more detail to inform treatment selection and to allow us to assess our outcomes more accurately. Surgical treatment cannot alter the patient’s psychological status, so we should control for psychiatric distress in our outcome measures to define the effect of surgical treatment more accurately. Third, the effect of surgeon and patient expectations on the short-term and longer-term outcomes and patient satisfaction with treatment should be examined. The subject is complex because of the many different types of psychiatric or psychological disorders such as depression, anxiety, posttraumatic stress disorder, dementia, schizophrenia, and catastrophic thinking and the numerous ways of assessing them, but other specialties such as cardiology and neurology have studied this subject in some detail. Orthopaedic traumatologists should not be left behind.


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