CORR Insights®: What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures

Where Are We Now?

It is reported that one of five Americans live with a diagnosed mental illness [6]. Most experienced arthroplasty surgeons will freely admit that patients who present with end-stage hip or knee arthritis as well as a major psychiatric disorder present a special challenge. Major psychiatric illness burdens those affected with many medical and social consequences that may complicate any attempt at surgical care, especially THA and TKA. Most orthopaedic surgeons are not familiar with the clinical features and management of major psychiatric disorders. In my experience, many affected patients often come from complex social situations and may have associated comorbidities related to smoking, illicit drug or alcohol use, or poor adherence to what would be considered routine medical care. As a result, it is challenging to properly prepare these patients and the entire orthopaedic team for what is usually a routine and uncomplicated procedure.

Hecht et al. [4] have exhaustively reviewed previous studies to provide a consensus about how psychiatric illness impacts the risk of complications, use of healthcare resources, and patient-reported outcomes after total joint arthroplasty. After reviewing a large number of published reports, they concluded patients with a confirmed psychiatric diagnosis are at a higher risk of complications, are less likely to be discharged home with a longer length of stay, and typically will achieve lower patient-reported outcome measure scores at 1 year of follow-up. The authors aptly concluded that psychiatric illness must be addressed when risk-stratifying patients, and they suggest future studies should examine how risk might be modified in these challenging patients. This study affirms major psychiatric illness is a frequent comorbidity in many patients undergoing THA and TKA, and special care pathways are required to prepare and treat these patients.

Where Do We Need To Go?

To better understand the risk imparted by a psychiatric diagnosis to patients undergoing total joint arthroplasty, the specific psychiatric diagnosis must be evaluated in the context of a patient’s overall health and socioeconomic context [5, 6]. Covariates such as psychiatric disease typically cannot be analyzed in isolation but must be evaluated as part of the whole picture relating to any given patient. Potentially harmful interactions between commonly used psychiatric medications and those used to manage postoperative pain must be clarified. Most psychiatric medications do not interact with pain medication or anesthesia [2], but as pointed out by the authors [4], an increased risk of bleeding from NSAIDs needs to be specifically assessed. Depression and anxiety often lead to substance abuse as a form of self-medication [1]. The presence of substance abuse must be tactfully sought in a preoperative evaluation. Specific strategies to better address pain, anxiety, depression, and anger in these patients need to be developed and validated. The role of psychiatric consultants and psychosocial professionals in the preoperative optimization scheme should be clarified as well. Additionally, there is evidence that specific preoperative interventions can reduce anxiety, pain, and anger postoperatively in patients undergoing orthopaedic surgery [7]. Specific preoperative interventions, perhaps tailored to specific diseases or illnesses, are needed.

How Do We Get There?

Future studies must address the role of specific psychiatric illness by considering the overall health and socioeconomic status of each patient to better clarify the unique risks associated with psychiatric disease. These studies should be based on large sources of data such as those of high-volume centers or national registries. These retrospective studies must incorporate multivariable analyses and should evaluate the effect of psychiatric diagnoses on all other comorbidities and risk factors. They should also provide for longer-term follow-up beyond the typically reported 90 days.

Any added risk of including NSAIDs and potentially COX-2 drugs in pain management regimens should be studied. Is this purported risk of true significance, and if so, can this bleeding risk be avoided with the use of particular NSAIDs such as COX-2 compounds? This question can initially be addressed by a retrospective review that could provide justification for randomized prospective drug trials.

The study by Hecht et al. [4] clearly confirms that screening tools for major psychiatric illness need to be routinely applied, but the best screening tools have not been determined [6]. Research is needed to develop these screening tools. Prospective studies that apply these screening tools to the initial evaluation of presenting patients and apply psychiatric interventions as indicated can determine whether interventions address the common complications associated with surgery in patients with psychiatric conditions.

In patients with psychiatric illness, modified clinical pathways must be applied. There are precedents for providing special care plans in specific clinical scenarios. For example, a study on the treatment of elderly patients with hip fractures illustrates the benefit of multidisciplinary care [3]. Comanaged care of a patient who has a psychiatric illness in which orthopaedic providers collaborate with psychiatric professionals may lead to fewer complications and readmissions, as well as better functional recovery. These interventions can be studied prospectively as has been done in the hip fracture setting, and compared with care pathways that don’t include a psychiatric team. The ideal approach will be to modify clinical pathways for patients with psychiatric illness and then assess specific interventions such as the routine use of preoperative psychiatric evaluations, special preoperative educational programs that improve communication and expectations, and more aggressive social work intervention before preparing for discharge. As interventions are trialed and evaluated, evidenced-based best practices will surely emerge.