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behavioral patterns of patients with mental disorders in hospitals differ from those of the general population.12) This may require medical personnel to have different communication approaches and attitudes towards patients than they used to. For example, patients with mental disorders may feel that they are being ignored by the medical staff or that they are being treated differently from other patients. In addition, they often try to seek unproven treatment methods and actively intervene in treatment protocols. Although they sometimes feel grateful to medical staff, the feeling of ignorance may be expressed in violent behavior. Thus, medical staff who will be working with patients before and after surgery should obtain important information through preoperative psychosocial evaluation, such as specific behavioral patterns and activities associated with mental disorders.9) THE PURPOSE OF PSYCHIATRIC ASSESSMENT The purpose of psychiatric assessment is to identify the state of mental illness and provide useful information to patients to help them stay without problems during hospitalization, while creating a better condition for surgery, establishing a plan to control postoperative mental illness, and ensuring good clinical outcomes of surgery.7) Various methods, such as the Beck Depression Inventory, Quality of Life Inventory, patient-reported outcomes measurement information system Anxiety, Depression, Physical Function, and Pain Interference computer adaptive tests, Hamilton anxiety scale, and Hamilton depression scale, are suggested as assessment tools (Table 1). However, the most important assessment method is a clinical interview with a psychiatrist, and the role of an orthopedic surgeon may not appear to be significant. Nevertheless, orthopedic surgeons must try to additionally discover various risk factors that affect the patient’s condition after surgery. SIX CONSIDERATIONS FOR PREOPERATIVE PSYCHIATRIC EVALUATION It is reported that psychiatrists must check the following six issues for patients considering surgical treatment before preoperative consultation with surgeons (Fig. 1).8) The first is to find out whether there is a major mental illness. The most common mental illness is mood disorders, and surgery can trigger mood episodes. Thus, these patients should be educated on the early symptoms of mental illness and behaviors that require treatment. Also, surgeons should present a treatment plan in advance. If symptoms are not well controlled and social support is not sufficient, proceeding to surgical treatment is not recommended. The second is to find out if the patient has an addiction to a substance or an active mental disorder. Surgery is not recommended until the patient is treated for drug addiction or active mental disorder, and a plan to prevent recurrence after surgery should be considered. 157 Yoo et al. Mental Disorder in Orthopedic Patients Clinics in Orthopedic Surgery • Vol. 14, No. 2, 2022 • www.ecios.org The third is to find out if the patient can understand the surgery and treatment process and make decisions. If the patient is incapable of understanding the process of treatment or making decisions, the risks and benefits of the treatment or surgery should be considered. For example, under conditions of uncertainty, individual differences in the weighing and estimation of information or circumstance have the potential to strongly influence patient’s behavior.13) Thus, because of these individual differences, anxiety and depression are associated with difficulties in decision making. Fourth, the patient’s treatment should be assessed. Patients may need special medication after surgical treatment, and sometimes they may need lifestyle modifications. Therefore, it can be an important issue whether the patient will be able to adhere to future treatment plans. It is also useful to check whether compliance with treatment was good in the outpatient office or to obtain information about the patient’s condition from a guardian or caregiver. The fifth issue is to check the patient’s defense mechanism against stress. If a primitive defense mechanism, such as psychotic denial, delusional projection, distortion, fantasy, projection, and passive aggression, was shown through questions about methods of coping with stress in the past, the patient may have a personality disorder. For patients with a personality disorder, surgical treatment is not recommended. The sixth is to assess the risk of suicide. Patients with suicidal ideation should be cautioned, because the stress of surgery can trigger suicidal behavior. In particular, patients who have attempted suicide or self-harm in the past could have a possibility of depressive disorder and require psychiatric evaluation and further treatment. CLINICAL RESULTS OF ARTHROSCOPIC SURGERY IN PATIENTS WITH MENTAL DISORDERS Jacobs et al.14) investigated factors influencing preoperative symptoms in 64 patients who underwent hip arthroscopic surgery for labral tears. Interestingly, the patient’s symptom severity was more related to the mental health status than either the size of the labral tear or femoroacetabular impingement (FAI) deformity. Also, patients with FAI and depression had higher pain levels and lower self-reported function than those without depression on initial assessment. Martin et al.15) analyzed the effects of
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