Mental Health and Orthopedics: Increasingly Relevant

A study by husband-and-wife team You Na and Michael Kheir quantifies the extent to which a patient’s mental health affects their large joint reconstruction surgery outcomes. Furthermore, the linkage, they found, was so relevant that orthopedists may do well to include pre-operative therapy and education to ensure that patients are psychologically fit for surgery.

According to a National Alliance on Mental Illness study, 1 in 5 adults experience mental illness during their lifetime, while only 44.8% of them receive treatment.

And while you didn’t choose to practice psychiatry, there is growing evidence that having a mental health professional inside or tied to an orthopedic practice could help these individuals, some of whom would otherwise never get help.

A 2018 study by a husband (orthopedic surgeon) and wife (psychiatrist) team addresses the overlap between mental illness and orthopedics. While OTW does not typically cover studies that are three years past their publishing date, we think that this research tackles an important issue, not only for the clinician but for the overall caregiver system.

You Na Kheir, M.D. is a child and adolescent psychiatrist. Her husband Michael Kheir, M.D. is an adult reconstruction and joint replacement fellow at Hospital for Special Surgery (HSS) in New York. Their study was conducted at the Rothman Institute under the guidance of Antonia Chen, M.D.

“Martin Luther King, [Winston] Churchill, and [Abraham] Lincoln were all people who changed the world,” said You Na Kheir to OTW. “And they did so despite their mental health issues. By shying away from troubled patients are we missing out on helping some brilliant individuals make major contributions to society?”

“I had heard anecdotes about poor outcomes in patients with different mental health conditions,” Michael Kheir explained, “and after talking with You Na, we decided to do a study focusing on patients with schizophrenia or bipolar disorder who had undergone total joint arthroplasty (TJA).”

Their study, “Increased Complications for Schizophrenia and Bipolar Disorder Patients Undergoing Total Joint Arthroplasty,” appeared in the May 2018 edition of The Journal of Arthroplasty.

“Our thought was that by examining schizophrenia and bipolar disorder, we may be able to see a more substantial statistical difference in outcomes compared to patients without these conditions than with, for example, depression,” explained Michael Kheir.

For their study, the researchers looked at 156 TJAs (125 primaries and 31 revisions) at the Rothman Institute from 2000 to 2015. Bipolar and schizophrenic patients were identified based on International Classification of Diseases, Ninth Revision codes or by active anti-psychotic medication status.

The research team found that patients with schizophrenia or bipolar disorder had an increased odds of developing peri-prosthetic joint infection at 90 days, 2 years, and at any time point. In addition, they had increased odds of aseptic and mechanical revisions at all endpoints (especially from dislocation), a higher number of postop ER visits, and were more likely to be discharged to a rehabilitation facility.

“Our findings agreed with the sparse prior literature indicating that patients with severe mental illness are at increased risk of surgical complications such as infection, instability, and overall revision,” Michael Kheir told OTW. “One thing we did not want the study to do was set up a roadblock for patients with mental conditions who are in need of surgery. Multiple studies have since come out indicating that patients with mental health disorders do improve significantly after surgery. We should not be avoiding them because of the increased risk of complications.”

A Pandora’s Box of Stigma

“Another reason for performing this study,” says Michael Kheir, “was that few people were talking about schizophrenia or bipolar disease. It’s still rather unaddressed, frankly, as these conditions are fairly stigmatized. An orthopedic surgeon and a patient are not very likely to talk about these diagnoses in detail or at all.”

And then there is the gaping hole of patient dissatisfaction.

Michael Kheir: “As orthopedic surgeons, we are constantly talking about optimizing medical comorbidities to improve outcomes and patient satisfaction. We muse over patients who are predisposed to infection or joint instability, but we typically don’t dive into mental health as far as preoperative optimization. In most cases, we screen for suicidal ideation, depression, and anxiety, but these are patient-reported, which doesn’t always work for more serious mental health problems.”

Not a Bridge Too Far

You Na Kheir told OTW, “In a pediatric practice you generally have a practice algorithm where appropriate follow-up care is available, such as social work assistance if the family is economically disadvantaged. But there is no such common model in orthopedics for patients with mental health illnesses.”

“Yes, some mental health disorders are screened for preoperatively because we know that these patients are at higher risk of infection/poor outcomes, but post-screening/preoperative psychiatric help is needed as well. If a hip patient has untreated depression or fibromyalgia then they are at higher risk for postoperative pain, something that can be addressed if there is a mental health professional co-located at the hospital or clinic. That way, we are offering a bridge between orthopedics and psychiatry.”

Progress

Michael Kheir told OTW, “While not long ago there was a paucity of research looking at mental health issues in orthopedic patients, if you now perform a PubMed search over the past five years you will find a surge in such studies. This is partly because our patient satisfaction rates have largely plateaued and orthopedic surgeons want to see what exactly we are missing to optimize our patients—especially given the bundled care environment.”

Shedding light on the psychiatric zeitgeist, You Na Kheir stated, “Traditionally, the medical realm has looked upon all things psychological as some sort of magic. Fortunately, the psychiatry and psychology professions are becoming more scientific. We are gaining an increased understanding of what is happening in the brain and there are more psychiatric medications available for patients.”

From their own research, said Michael Kheir, it seemed as if some of their findings were related to barriers to self-care.

“A lot of these patients went to a rehab facility because no one was at home to help them care for their wounds or help with activities of daily living, or help them to adhere to postoperative precautions, etc. Many of these patients who undergo elective joint replacement go to rehab with significant pain, trouble with ambulation, and concern about the quality of care in the facility. Our research also found a higher number of ER visits postop for this patient cohort, which could be a surrogate indicating lack of family support nearby. We think it also reflects the overall anxiety these patients have and that they are more likely to dislocate after total hip arthroplasty.”

The Brain Speaks

“Thanks to innovations such as the functional MRI and the discovery of biomarkers,” stated Michael Kheir to OTW, “we are starting to understand biopsychological conditions in a more profound way. For instance, there is evidence that in patients with psychiatric disorders there are elevated levels of inflammatory markers and cytokines throughout the body…so for whatever reason these individuals have an altered immune status. This is a vastly underexplored area.”

“We commonly talk about how stress affects the body and how increased cortisol levels leave us more prone to viruses and illnesses,” said You Na Kheir. “There are studies showing that encephalitic inflammation could cause psychotic symptoms including hallucinations among many others. We are only touching the tip of the iceberg when it comes to exploring a medical underpinning to psychological conditions.”

Tools

Michael Kheir told OTW, “While the screening tools we have now are not ideal for schizophrenia and bipolar disorder, they can still be helpful. The Patient Health Questionnaire (PHQ)-9 for depression is useful; the modified Patient Safety Indicator has only 13 questions and can give surgeons a decent picture of a patient’s mental health. Researching and adding more screening tools and mental health supports that are tailored to orthopedic patients may take more effort in the short-term, but over time will contribute to reduced complication rates and pain levels.”

So, what exactly should orthopedic surgeons be on the lookout for regarding schizophrenia and bipolar disorder?

You Na Kheir: “A hallmark of schizophrenia is a condition where reality testing is skewed so that there is disorganized thinking. This is often manifested in the way these patients talk, often involving visual or auditory hallucinations and delusions. The key is that the psychotic symptoms are under control pre- and postoperatively. When these patients are receiving good care and are taking their medications then they can be healthy; we should not think of them as being in some way compromised.”

“On the bipolar front, we typically see the appearance of a cluster of symptoms for 4-5 days that includes reckless behavior and grandiosity—as in, ‘I’m on top of the world!’ During this manic period the person doesn’t sleep and typically does things she or he wouldn’t otherwise do. Again, if they are taking the proper medication and have the appropriate support, then they can be healthy.”

Michael Kheir: “Studies show that these patients may also have impaired pain perception. While postoperatively some of these patients may have impaired insight attributable to their mental health, we also know that some of these patients have a higher pain threshold and believe they can do more than they safely can. Actually, that is one theory as to why these patients have more dislocations.”

You Na Kheir: “Ultimately, it’s not about adding another layer of service…another layer of tasks for orthopedic surgeons, and thus an extra barrier to care. We might take a cue from the world of bariatric surgery, where it takes months of preoperative preparation and includes therapy and education to ensure that the patient is psychologically fit. There is no reason why we can’t undertake such a protocol in orthopedic surgery.”