Rehabilitation Psychiatry

Overview

Rehabilitation and rehabilitation hospitals aim to restore a patient's physical and mental function following serious illness or injury; when this is not possible, efforts focus on helping the patient to adjust to his or her condition and to function as well as possible in all important domains (including vocational, educational, social, psychological, and physical). In the US, many individuals undergo some type of rehabilitation. According to Schoenborn and associates, although about 7 out of every 10 persons reported excellent or very good health, about 31 million people (11%) had limitations in their usual activities due to one or more chronic health conditions, and about 3 million people (2%) required assistance with activities of daily living (ADLs).

Those physicians with specialty training in physical medicine and rehabilitation (commonly referred to as “PM & R”) are called physiatrists, and, according to the Association of Academic Physiatrists ( www.physiatry.org ), they provide services in three major areas of medical care: diagnosis and treatment of musculoskeletal injuries and pain syndromes; electrodiagnostic medicine (including electromyography [EMG] and nerve conduction studies); and rehabilitation of patients with severe impairments either caused by one or more medical conditions (e.g., stroke, myocardial infarction [MI], brain injury, and spinal cord injury) or that occur as a consequence of medical or surgical treatments (e.g., amputation, cardiac surgery, neurosurgery).

Because successful rehabilitation requires the cooperation of many professionals (e.g., physical therapists, occupational therapists, nurses, physicians, social workers, clergy, psychologists, speech-language pathologists), the physiatrist is likely to direct a unique, large, multi-disciplinary team that is expressly assembled to deal with the specific needs of each patient receiving PM & R care. Therefore, the psychiatrist asked to treat a patient undergoing rehabilitation must be prepared and willing to work closely with the entire team by doing the following: demonstrating his or her willingness to consult with any and all team members who feels his or her input might be important; understanding that each member of the team “holds different pieces” of the patient (e.g., because a physical therapist might spend a lot of time with a particular patient, he or she may have observed more depressive symptoms, witnessed more frequent fluctuations in attention, or had more frequent contact with family members, thereby making his or her observations and inferences essential to a better understanding of the patient); and appreciating and appropriately responding to patients receiving rehabilitation services who need psychiatric care and who may require more frequent contact with the psychiatrist than do other patients.

Good physical health is the norm for most adults. This is often not the case for a person in a rehabilitation hospital or for someone who is receiving rehabilitation services elsewhere (e.g., a skilled nursing facility [SNF]). Such an individual may be adjusting to a life-altering change (e.g., disfigurement following burn injuries, learning to walk [again] with one or more prosthetic devices after amputation, or trying to adapt to a progressive disease, such as cystic fibrosis).

Psychiatric Complications that Arise in the Context of Chronic Medical Illness and Rehabilitation

In the US, rapid discharge of patients from acute care facilities is the rule rather than the exception. Moreover, there is an increasing tendency to divert patients from acute care hospitals to other (lower-cost) facilities in order to cut costs. Thus, there is a growing need for appropriate aftercare following acute treatment. Many larger hospitals have rehabilitation facilities attached to them or close by; smaller hospitals often rely on distant rehabilitation centers to provide the specialized, long-term care that they cannot offer.

Many types of patients who require rehabilitation are at significant risk for the development of one or more psychiatric complications. For persons with traumatic brain injury (TBI), the prevalence of depression may be as high as 40%–50%, of fatigue, 43%–73%, and of anxiety, as high as 77% ; in those with cancer, rates of depression vary according to the type of cancer, with higher rates associated with cancer of the oropharynx (22%–57%), pancreas (33%–50%), and lung (11%–44%), whereas colon cancer (13%–25%) and lymphoma (8%–19%) have lower rates ; in those with multiple sclerosis (MS), depression ranges from 22% to 46%, and, for these and other conditions, diagnosis and treatment are often inadequate. In addition, thoughts of suicide are more common among those with chronic illnesses compared to those without such conditions; compared to those without chronic illness, people with cancer have suicide rates that are 15–20 times greater, those with spinal cord injuries, 15 times greater, and those with MS, 14 times greater.

Problems that May Occur During Rehabilitation

Patients who receive rehabilitative treatments tend to spend much of their time worrying about the future. They may anticipate (correctly or incorrectly) difficulties they will face while adjusting to their new (more medically compromised) lives. Some areas of worry include returning home, obtaining financial independence, driving, returning to work, adjusting to changes in appearance, socializing, dealing with stigmatization, engaging in sexual activities, and managing decreased functional capacity.

Rehabilitative services may be obtained in a rehabilitation hospital or as an outpatient and may continue for months or years, a span much longer than the acute treatment, and it may seriously disrupt one's usual schedules. During this phase of treatment, patients are usually exposed to a variety of new caregivers (including physiatrists, nurses, occupational therapists, physical therapists, social workers, vocational therapists, recreational therapists, psychologists, clergy, and psychiatrists). In addition, patients receiving rehabilitative treatments often undergo many new, uncomfortable, or painful procedures.

Rehabilitation psychiatrists must also be ready to deal with the potential long-term “fallout” of some medical conditions. For example, Mehnert et al. reported that fear of cancer reoccurrence (FCR) may be so severe that social functioning, well-being, and quality of life are significantly disrupted. They found that of 883 cancer survivors, roughly two-thirds had moderate FCR and 17.2% had high levels of fear 1 year after cancer rehabilitation treatment, and identified the presence of depression as a predictor of higher fear levels. Mutai and colleagues examined 153 stroke survivors (average age, 71.7 ± 11.3 years; 43.8% female) who were discharged home following inpatient stroke rehabilitation, with assessments carried out 1–3 years after discharge (average, 2.0 ± 0.6 years). Thirty-three patients scored ≥ 11 points on the Geriatric Depression Scale (GDS), yielding an estimated prevalence of depression of 21.6%. These findings suggest that psychiatric problems may endure for long periods among some rehabilitation patients following an “index” event that may itself be in remission or no longer acute but which still is responsible for “driving” the condition.

Sometimes challenges arise for clinicians and patients that may affect empathic connectedness. Cultural differences may play a role in this regard as it takes time to learn to trust a new consultant. Box 89-1 lists some characteristics of patients and caregivers to be considered when a clinician, especially a psychiatrist, tries to make an empathic connection with a rehabilitating patient.

The Rehabilitation Environment

Patients must adapt to many rehabilitation personnel and to the rehabilitation setting, which is often dramatically different from the acute hospital. Perhaps one of the most important issues for the rehabilitation patient is the possibility of physical displacement. With separation from loved ones, familiar objects, and surroundings, treatment received far from home for an extended time may be troublesome and may lead to depressed mood, apathy, or hopelessness.

Other problems may hinder timely and successful recovery and produce long-term negative effects for a recovering patient as a direct consequence of prolonged hospitalization or incapacity. Patients may also believe that they and their illnesses cause a financial or emotional burden for loved ones and they may feel guilty about the large blocks of time spent on them and the care they require.

Common Psychiatric Problems in Patients Undergoing Rehabilitation and in Those with Chronic Medical Illnesses

Any psychiatrist who provides care in a rehabilitation setting should expect to encounter the full spectrum of psychiatric conditions. However, certain psychiatric diagnoses and conditions (e.g., depression, cognitive dysfunction, adjustment disorders, behavioral problems) are more common than others.

Although diagnostic criteria for these conditions remain unchanged in the rehabilitation setting, it often is more difficult to obtain sufficient data to satisfy the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. Although many patients who receive rehabilitative care and are coping with chronic medical illnesses seem depressed, confused, or anxious, when widely used clinical assessment instruments are employed in hopes of reaching a less “biased” diagnosis, a large proportion of these patients do not meet diagnostic criteria for the suspected condition. This inability to reach a diagnostic threshold may be due in part to shared communication deficits between clinician and patient. Many of the conditions that afflict rehabilitating patients wreak havoc on their ability to communicate their most basic emotions. Likewise, clinicians may be fooled because the usual affective “music” associated with various mood states in healthy people may not sound the same in patients with chronic illness.

Therefore, we assert it is most appropriate to treat symptoms rather than diagnoses, and to treat them early and aggressively, as it is too often the case that more (and more severe) symptoms appear quickly rather than disappear, and are more difficult to manage once fully developed; it is far better to err on the side of too much treatment rather than too little treatment.

Delirium (see Chapter 18 ) is of particular importance in rehabilitation patients. This condition may occur during an acute hospitalization and may “follow” the patient to the rehabilitation facility; unfortunately, it may have gone undetected, or if detected, gone inadequately treated. Its presence may adversely affect prognosis and length of stay and may lead to nursing home placement or permanent disability.

Several important predisposing and precipitating risk factors for the development of delirium are often present among patients undergoing rehabilitation and with chronic illness (including visual or hearing impairment, cognitive impairment, history of stroke, presence of an intracranial lesion, chronic infection, regular use of psychotropic drugs, polypharmacy, and greater medical complexity).