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Treating Orthopaedic Patients With Psychiatric Illness And Their Treatment Outcomes

  Khai O Ng*, BC Se To**, H Shukur***

* Orthopaedic Surgeon, Department of Orthopaedic and Traumatology, Penang General Hospital , Penang , Malaysia .

** Consultant Orthopaedic Surgeon and Head, Department of Orthopaedic and Traumatology, Penang General Hospital , Penang , Malaysia .

*** Professor and Head, Department of Orthopaedic and Traumatology, Hospital Universiti Kebangsaan Malaysia , Kuala Lumpur , Malaysia .

Address for Correspondence:

Khai O Ng
Department of Orthopaedic and Traumatology, Penang General Hospital ,
Jalan Residensi,
10450 Penang , Malaysia .
Phone: +614 06 527 473


Background: Treating orthopaedic patients with psychiatric illness is challenging as they pose many salient and complex problems that may affect choice of treatment option and outcome. These problems need to be addressed in order to render appropriate treatment and prevent complications. A prospective observational study on problems associated with this subset of patients with psychiatric disorders was undertaken.  

Methodology: Patients with psychiatric illness who were admitted for orthopaedic problems and those who developed psychiatric disorders following admission for orthopaedic treatment were enrolled into the study. The problems associated with orthopaedic treatment of these patients as regard to contributing factors to the outcomes were noted.  

Results: Poor family support was encountered in 42.5% of the patients; 40% showed poor insight to their orthopaedic problems. More than half of the patients (58%) defaulted follow-up and 45% had poor compliance to therapy. The infection rate was high in the operative trauma cases.  

Conclusion: Subset of orthopaedic patients with psychiatric disorders poses many salient problems that may affect choice of treatment. To ensure good treatment outcome, full evaluation of the patient, liaison with the family members, psychiatric services and the rehabilitation therapist are the keystones.

J.Orthopaedics 2007;4(3)e19

Psychiatric patients; mental affliction; problems encountered; compliance


Individuals with psychiatric background represent a minor subset of orthopedic patients. The problem of recognition of this subset of patients remains difficult owing to social attitude of hiding rather than unveiling the afflicted patients. Society typically demonstrates a poor understanding and even less sympathy for those afflicted by psychiatric problems.  

Treating this subset of patients may perhaps compounded by multifaceted problems. Terry and Hayashi pointed out that there are stresses in the treating doctors when working with the mentally ill patients1. Problems such as obtaining history, validity of consent for treatment, post-hospitalization care and compliance to therapy and rehabilitation can influence treatment decision-making. These problems may lead to suboptimal treatment and poor overall outcomes.  

Poor compliance on the patientís part can be a main obstacle toward satisfactory outcome. It is imperative to provide mentally afflicted patients a pattern of effective care so that an early return to mobility and function is possible. Unfortunately for this group of patients, they are often neglected before or after seeking medical attention, and not uncommonly, they may present again only with complication of their initial complaints or treatment. Lange et al in their study of orthopedic in-patients with psychosomatic disorders showed that 30% of them had difficulty coping with their illness attributed partly by the nature of the disease and consequences of difficult psychosocial adaptation to orthopedic problems or complication2. There is still lack of consensus on how to address mental illness.  

Whilst the issue of post-traumatic disorder in orthopedic patients has been frequently addressed, attention on problems specifically associated with general psychiatric individuals continued to be lacking. How do psychiatric patients fare to orthopedic treatment remained difficult to be answered.  

The aims of the study are to identify the problems associated with orthopedic treatment of the psychiatric patients as regard to its treatment morbidities and outcomes, and to propose possible interventional strategies for such problems.

Material and Methods :

Patients included in this study were those who presented to the Orthopaedic Department of a public hospital with orthopaedic related soft tissue infection or trauma, who were either with known psychiatric disorders or newly diagnosed to have psychiatric disorders during their hospitalization. Patients who developed post-operative delirium, post-hospitalization psychiatric disorder on follow-ups, or patients with musculoskeletal pain were excluded from this study. All were prospectively follow-ups and evaluated. The issues that were looked into include type of psychiatric affliction, pre-injury status of dependency, orthopedic treatment, and problems encountered during hospitalization and on follow-ups, and outcomes of orthopaedic treatment.  

The history was obtained from the patients and their caregivers. The diagnosis was classified into either traumatic or infective in origin. All patients were reviewed and assessed by the psychiatric team of the hospital during their admissions. Patients with a known psychiatric disorder were reassessed to confirm the diagnosis. Those who showed clinical features of psychiatric illness were referred to the psychiatric team for assessment. They were considered as newly diagnosed cases. Categorization of patients into three diagnostic groups of psychiatric disorders, namely schizophrenic, affective, or schizoaffective was then made. Patient dependency in activities of daily living (ADL) was assessed and an institutionalized patient was considered as dependent. The psychiatric team managed treatments and follow-up of their psychiatric problems.  

Problems encountered by the patient and the treating doctors throughout the patientsí hospital stays were noted. These include delayed presentation, barrier to communication and cooperation of the patient, patientís insight to the injury or illness, consent for surgical treatment, payment for treatment or implant or orthoses, and family support.  

Consent for surgical treatment was obtained from the patient with reasonably sound mental status. If the patient was deemed unfit for consent as declared by the treating surgeon or psychiatrist, the authority to consent is transferred to the patientís eligible guardian. In the case of emergency where it was impossible or impracticable to obtain consent from the patient or the eligible guardian, both an orthopaedic surgeon and a psychiatrist will be required to authorize the consent for treatment.  

The patients were reviewed and followed-up in the orthopaedic outpatient clinic after their discharge. The problems evaluated during follow-ups at the orthopedic outpatient clinic include compliance to treatment plan, complications related to treatment particularly wound infection, re-fracture, and plaster cast related consequences. Defaulters are defined as those who fail to attend necessary follow-ups after attempts were made to contact them via phone or mail and a home visit failed.

Results :

Forty patients were admitted in the study over the twenty months period, with 20 males and 20 females. Their ages ranged from 15 to 85 years with a mean age of 42 years (Figure 1)

Of the 40 patients, 30 (75%) patients were admitted due to traumatic injury and the remaining 10 (25%) were due to infection (Table 1).

Upon psychiatric reviews, 24 patients were having schizophrenia; 12 were categorized as affective disorder such as depression and anxiety disorder; and another 4 as schizoaffective disorder. Patients with known psychiatric disorders accounted for 80% of the patients but only 62.5% of them were under psychiatric follow-ups. The other had defaulted psychiatric treatment. The remaining 20% of the patients were newly diagnosed cases. Of the total 40 patients, 5 patients were dependent on their caregivers with 3 of them were institutionalized.  

On evaluation of the problems faced by the patients and the treating surgeons during hospitalization, several issues were raised (Table 2). Poor family support appeared to be the main problem faced by the patients. This is followed by poor doctor-patient communication and a lack of insight in patientís part to the illness or injury.

On follow-up of these patients after they were discharged from the hospital (Table 3), 23 (57.5%) of them defaulted along the follow-up. 18 (45%) of the patients had poor compliance to the prescribed treatments.

Of the 23 patients who defaulted follow-ups, 7 (30%) patients did not attend the first appointment, 6 (26%) came to the follow-up clinic once. Of 15 patients contacted by telephone, 11(73%) cited transportation problem as the reason for not attending follow-up. The remaining were satisfied with their conditions, hence rendered further check-up unnecessary. Eight patients were not contactable.      

Of the 23 defaulters, 22 (96%) were independent in their ADL. Of the 17 patients who had poor family support, 13 (76.5%) ended defaulting follow-up, compared to 43% from patients with good family support (p=0.037). 66% of the affective disorder patient defaulted follow-up, as compared to 54% from the schizophrenia group and 50% from the schizoaffective group.  

There were 17 operative trauma cases in the study, of which 10 (59%) were complicated by infection. During the follow-up, there were overall 24 cases complicated by infection. Of these cases, 11 also has problem of poor family support.  

Apart from the 23 patients who were loss in the follow-up, 14 (35%) patients recovered from their orthopaedic problems. There was one case of osteomyelitis due to infected implants.

Discussion :

The key issues in this study are to identify various problems related to the management of psychiatric patients with orthopedic injuries and infections, and to provide possible interventional suggestions to encounter them.  

The major problems in treating these mentally afflicted patients are poor compliance to their treatments and defaulting follow-ups. This can be attributed to poor insight and poor family support which were found in more than one third of the study subjects.  

The term "poor insight" has a very broad definition. The most widely accepted definition of insight, as documented in current studies on the subject, include three recurring aspects: a general recognition of mental illness, the capacity to correctly attribute symptoms to the pathology of said illness, and the ability to recognize the benefits of (and consequently cooperate with) treatments3. 37.5% of the subjects in this study group have shown an unawareness of their own illness. Such poor insight has profound consequences for treatment compliance, disease prognosis, and general quality of life.  

From this study, the patients with poor family support are more likely to default treatment (p<0.05). More than half of the defaulters have poor family support.  This finding is in agreement with the observations in the literatures4,5. Poor family support is a major concern as it leads to poor supervision on the treatment compliance and disruption of rehabilitation. Problem of getting transport to the hospital has been identified as the main reason for defaulting follow-up. Without the support from the family members, these patients who are usually apprehensive of their mobility will face difficulty getting public transport to the hospital.  

This study has shown that there is a significant higher infection rate in patients who underwent surgical intervention (58.8%). Many inter-related factors have been identified as the possible causes which include delayed treatment, poor insight, poor wound care, poor compliance on medication and wound dressing instruction. A lack of supervision is suggested in these patients as a majority of them also facing the problem of poor family support.  

Improvement in many aspects is needed to provide a better care for this subset of psychiatric patients:  

a.   Knowledge in Psychiatry and Clinical Ethics

A better understanding of psychiatry and psychological medicine should be the basis for an improved ability to recognize co-morbid psychiatric disorder in orthopaedic patients. Improved recognition of symptoms referable to psychiatric disorders and the recognition that psychiatric treatment may on occasion be necessary will lead to a reduction in waste of treatment time. Knowing the natural history of the disorders should also help the orthopedic surgeon to cope with clinical problems arising within this area and to produce realistic orthopedic treatment plans, which tailor to the patientsí needs and be able to communicate with the members of the psychiatric support services.  

Orthopedic surgeons who are involved in the care of patients with psychiatric disorders should become familiar with the ethical issues that may complicate the provision of care to these patients. The knowledge in clinical ethics should be explored and improved.  Wenger found that there was poorer understanding of proper ethical conduct with regard to informed consent and recommended that ethics must be taught in training programs in orthopaedic surgery6.                                                         

b.   Improve Patientís Compliance

Non-compliance in the patientís part, especially in the case of outpatient is a substantial obstacle to the achievement of therapeutic goals. Treatment, which is complex, prolonged, expensive, inconvenient, or disruptive of the patientís lifestyle, is least likely to be followed. There is considerable scope for restructuring treatment regimes to minimize these features, such as giving clear and simple instructions, trying to predict non-compliance and determine its causes, informing the patient of the dire consequences which will certainly occur if the advice is not followed, and above all, enlisting family support.  

c.   Family Support

The family is considered an important social institution in our culture. Family support can thus be regarded as an ďinevitable health care systemĒ which constitutes the core long-term care provider, providing day-to-day routine physical care, supplying emotional support, and supervising daily tasks. However it requires tremendous commitment and is a physically demanding role that can lead to emotional backlashes, restriction of social life, and a financial drain for the caregiver. To prevent this informal care system from collapsing, there is a need to identify caregivers who experience difficulties and are vulnerable. Therefore a good and efficient community support is imperative.  

d.   Community Support

The service of community or home care nurses cannot be over-emphasized and should be an essential member of the multi-disciplinary team which manages for the after-care of the patients following discharge. Their visitations include working directly with the mentally afflicted patients and their caregivers, providing continuous care in promoting mental health and be equally ready to provide assistance to the orthopaedic plan of care such as wound dressing and supervision to rehabilitation program. The community nurses can offer more systematic follow-up as well as be of great assistant in defaulter tracing. Other services such as providing patient transport should be looked into.  

e.   Liaison with Psychiatric Services

There should be a close liaison between the orthopedic surgeon and psychiatrist if the overall treatment is to succeed. . The multidisciplinary setting should be established as it allows joint assessment and management in a co-coordinated treatment planning. Such a regime should provide improved results both in the short and long term. There can be a more rapid response to the acute problems. If the underlying psychopathology can be identified and treated, the orthopedic problem can be managed more effectively.  

f.  Orthopaedic Treatment Options

The principles of orthopaedic management should be held true in the treatment of all orthopaedic patients, regardless the background of mental affliction. Surgery, if consented, should be performed if clearly indicated. The higher infection rate in surgically managed cases in this study should not deter an orthopaedic surgeon to opt for conservative management in the mentally afflicted patients if surgical intervention is indicated. Conversely, the surgeon should be more meticulous in his operation. The importance of wound care needs to be emphasized. The surgeon should take the initiative to liaise with the home care service to help supervision and wound dressing if necessary. Alternatively, extended hospitalization should be considered to ensure continuous supervision as regard to wound care as well as compliance to medication and rehabilitation in order to achieve uncomplicated healing.  

g.   Rehabilitation

Rehabilitation in mentally afflicted patients presents numerous challenges for the doctors involved in their care. Mentally afflicted patients may already have disorder-related conditions that may interfere with physical performance and safety. The general goal of rehabilitation is to return each patient to the pre-morbid functional level of mobility and self-care, ensuring that the patient is discharged to a safe environment and reduce the risks of further trauma. Orthopaedic surgeons, with the collaboration of the psychiatrists and the interdisciplinary rehabilitation team, should prescribe a comprehensive treatment program that offers these patients the best opportunity to improve physical skills and functions, decreasing social isolation and deterioration of their mental condition.


Orthopaedic surgeons cannot and should not ignore the value on the virtue of complete patient care, including the mentally afflicted patients and their well-being. Accurate identification of orthopaedic patients with mental affliction can lead to better overall clinical management and to the effective use of psychiatric intervention. Because of the complexities involved in treating these mentally afflicted patients, it is suggested that their care should be comprehensive and integrated, provided by teams of health-care personals working in dedicated units.  

This study has its own limitation as regard to the size of the sample and non-comparable nature of the study. The sample size was small. A large sample would enable more weighting to be placed on the statistical results. The data may not be from a representative sample that is generalized to all orthopedic patients with mental affliction. The significance of the findings in this study must be balanced against the limitations inherent within it. Performing in-depth interviews with the patients to explore their perceptions, although it may be difficult in view of their mental states, could have enhanced the qualitative elements of this study.  

Much is still to be learned. Effort should be made to strengthen and co-ordinate services on a local level as primary healthcare services, and links to the hospital system and to rehabilitation services. An integrated system should be formed to ensure efficient services delivered to the patients, whose chance for an improvement in the quality of life very much depends on the adequacy of the service they are able to obtain.  

It is hoped that the emphasis of this study will lend support to the introduction of further liaison psychiatry into orthopaedic management. This issue surely deserves both enthusiasm and caution. This clarification enhances a greater understanding of mental health in orthopaedic practice and how it can impact on improved health outcomes for patients within a general hospital environment.

Reference :

  1. Terry K, Hayashi C. Occupational therapy issues in the treatment of long term mentally ill. Canadian Journal of Occupational Therapy 1985; 52: 105-11.

  2. Lange C, Heuft G, Wetz HH. Psychiatric co-morbidity in patients of technical orthopaedic units. Orthopaedic. 2001; 30(4): 236-41.

  3. Kemp RA, Lambert TJR. Insight in schizophrenia and its relationship to psychopathology. Schizophrenia Research 1995; 18: 21 -28.

  4. King SA. Snow BR. Factors for predicting premature termination from a multidisciplinary inpatient chronic pain program. Pain 1989; 39: 281-7.

  5. Basler H, Rehfisch HP. Follow-up results of a cognitive-behavioral treatment for chronic pain in a primary care setting. Psychology and Health 1990; 4: 293-304.

  6. Wenger NS , Lieberman JR. An assessment of orthopaedic surgeonsí knowledge of medical ethics. The Journal of Bone and Joint Surgery (Am)1998; 80: 198-206.

This is a peer reviewed paper 

Please cite as : Khai O Ng: Treating Orthopaedic Patients With Psychiatric Illness And Their Treatment Outcomes

J.Orthopaedics 2007;4(3)e19





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