Joint Surgery May Be Worse for Those with Mental Illness

Individuals with psychiatric diseases like bipolar disorder and schizophrenia often face obstacles to their medical care. While the continued social stigma of mental illness can discourage some from seeking treatment, some symptoms of mental illness also make it difficult to keep track of medications and appointments, and to stay on top of one’s general health. A recent examination of medical data suggests that the problems may run even deeper, and that mental illness may be affecting how well patients recover from joint surgery.

The Mental Effects of Joint Surgery

A study recently published in the Journal of Arthroplasty investigated the outcome of total hip replacement surgery in patients with diagnosed psychiatric disease, and found that in general those patients faced more frequent and more severe post-surgical complications than a matched control group.

Researchers analyzed Medicare data collected between 2005 and 2011 and found nearly 90,000 patients with psychiatric disease who had undergone total hip replacement surgery. The mental illnesses were varied, but the most common diagnoses in the group were depression (95%), bipolar disorder (6%), and schizophrenia (4%). A number of patients were diagnosed as having two or more mental illnesses at once, which is why the numbers add up to more than 100%.

The joint replacement patients with mental illness diagnoses were, on average, younger than the control group, with a higher proportion of them receiving hip replacements in their 50s and early 60s.They were also more likely to be female and to have other complicating illnesses prior to the surgery. These “comorbidities” included heart disease, pulmonary disease, hypertension and diabetes.

Even though those comorbidities are so common in the general population that they surely also affected several in the control group, it seems that adding psychiatric disease to the equation means a tougher surgery and recovery. The study authors concluded that the outcomes of the surgeries of patients with mental illnesses were considerably worse than those of the control group. They were almost twice as likely to suffer post-operative infections requiring antibiotics or surgical intervention, and twice as likely to break or dislocate their new artificial hip joint in the first 90 days after surgery. They were also more likely to acquire secondary illnesses during their hospital stay, including pneumonia and respiratory failure, and to need blood transfusions to correct post-surgical anemia.

How Joint Surgery Affects Psychology

The study authors suggest that the problem is twofold, involving both the physical and the psychological.

A patient struggling with depression, for example, may have a difficult time focusing on recovery and taking all prescribed medications. Forgetting to take antibiotics or blood thinners can create a risk of surgical site infection or systemic blood clots. In the case of joint surgery, postoperative physical therapy is extremely important to regaining useful mobility, and to strengthen muscles around the new joint. If a patient is experiencing mental illness symptoms during recovery, important follow-up physical therapy appointments could be forgotten or skipped. Impaired mobility and continued weakness are risk factors for falls, injuries, and dislocation.

Meanwhile, the higher prevalence of serious comorbidities in the population being treated for psychiatric disease means that these patients are often in unhealthier states as they go into surgery, making their recovery more difficult. Heart disease and respiratory disease, in particular, make anesthesia and surgery more dangerous.

Clearly, data collected in this study suggests that both a patient’s preoperative health and psychological state will affect postoperative outcomes. So how can physicians minimize risk to patients with mental illness as they approach a necessary joint surgery?

Physicians must take the time to assess whether the patient is compliant with mental health treatments and medications. Presurgical psychological screening would be helpful in identifying patients at highest risk, who could then be followed more closely through the postoperative period. A severely depressed patient, or one whose schizophrenia is not well managed, may not be as receptive to medical instructions given post-surgery. Clear instructions on pre-surgical preparation and post-surgical care must be given both to the patient and any family members or caregivers present, and should also be given in writing so that a distracted or depressed patient won’t forget important details.

That said, doctors might not always think to ask. Patients with diagnosed mental illnesses, and their families, should feel comfortable speaking up during pre-surgical consultations to ask what can be done to minimize the risks of the surgery. Be honest about lifestyle, medical conditions, and treatments, and about any worries that might impede recovery. A frank discussion about mental health and how it might affect an individual’s surgery and recovery is the best way to be sure everyone is paying attention to all the risks.