Psychiatric Patients Need Care, Too!

Lynne Boone, DO

This is a recap of the psychiatry lecture at the annual meeting, in which we discussed how to address the multi-faceted needs of psychiatric patients.  It is important to better understand this population, as the presence of a psychiatric comorbidity is independently associated with an increased risk of morbidity and mortality. Surgical interventions themselves carry risks of worsening of psychiatric illness as well as PTSD from the procedure itself, to say nothing of the interactions between psychotropics and other medications.

It is interesting to note that the highest risk of increased morbidity and mortality is with patients who have anxiety and depression. Depression carries risk of serotonin syndrome as well as neuroleptic malignant syndrome (NMS) in the perioperative period, as often patient are being treated with  antidepressants, augmented with antipsychotics.  Bipolar patients can often experience mood fluctuations during this stressful period and mood stabilizers may require adjustments with volume fluctuations, such as pregnancy.

For patients who are being treated with antipsychotics, the very real possibility of NMS must be considered with any patient who develops fever, has muscle rigidity and altered mental status. Sometimes, there is also autonomic instability. Early recognition of this condition is critical, and requires external cooling measures and supportive care.

Psychiatric patients can often be difficult and demanding, which results in counter-transference, leaving the physician to deal with the feelings that they evoke while attempting to provide the best care.  It is often difficult to respond with empathy to a severely personality-disordered patient, for example. Empathy barriers can be anxiety (which is usually related to time pressure) as well as difficulty recognizing patients' emotional needs as a core aspect of illness and care.  Often, it is important to realize that the patient who is making a routine task much more difficult is only recreating the trauma that they are experiencing within.

One of the most difficult patient populations are those with the diagnosis of substance use, especially Opioid Use Disorder (which is sometimes comorbid with Anxiolytic Use Disorder).  It is important to distinguish between the three types of opioid users. Some patients have  Opioid Use Disorder in Full Sustained Remission (these patients are often worried about relapse), some  are on maintenance treatment (buprenorphine or methadone), and some  are actively abusing the substance. This categorization will helps to define thei patients’ goals of care, which are very different per category. It is important to verify the patient’s last methadone dose and day of administration so that they do not miss a dose and precipitate withdrawal. It is also important to be aware that there is an extended-release formulation of buprenorphine, administered into the subcutaneous abdominal fat. This must be surgically excised if the patient were to be in a traumatic accident within the first two weeks after administration, in order to allow for adequate pain control. Since this is relatively new on the market, it is important to raise awareness of this modality and verify (if possible) whether an Opioid Use Disorder patient on agonist therapy is actually receiving this long-activing injectable medication.

We concluded our discussion by spending some time on Borderline Personality Disorder’s high comorbidity with Opioid Use Disorder. These difficult patients, who often have little or no internal locus of control, can exhaust their care team with multiple demands.  It is important to maintain firm boundaries with these patients. It is also helpful to involve as many hospital services as possible,  such as psychology and chaplaincy, to provide support and empathy to the patient.  The patient’s level of physical discomfort/pain is often intensified by the accumulation of trauma that they have endured throughout their lifetime as well as a lack of adequate coping skills.