9.1 Psychosocial wellbeing and mental health conditions

9. Connected health issues

Some health issues are commonly connected with having an amputation. Because these health issues are so common among people with an amputation, the person should be carefully monitored for these health issues throughout all phases of the support pathway. Sometimes these are called secondary conditions (refer to the Glossary). We do not include all the possible health issues below, but describe the common issues identified (from research and experiential knowledge) during development of the guidance.

9.1 Psychosocial wellbeing and mental health conditions

Psychosocial wellbeing, quality of life, body image and sexuality are connected. Psychosocial adjustment after a limb amputation is complex, with interplay between individual psychological and environmental factors [125, 126]. Frequently, people experience anxiety and depression before and after the amputation [127, 128]. Traumatic injury-related amputation is a risk factor for the person also experiencing post-traumatic stress disorder [129]. Post-traumatic stress is also associated with more mental health disorders of anxiety and depression, and poorer outcomes with activities and participation [130]. The presence of phantom limb pain after amputation is also a risk factor for depression, poor psychosocial adjustment and withdrawal from social activities [130]. The research is clear that early assessment and psychological treatment, before and after surgery (because of the association with adjustment) and also for some months after the amputation (some suggest up to 12 months after), facilitate the person’s psychosocial adjustment [126].

The person’s response to limb amputation will be influenced by a range of personal and contextual factors [126]. Psychosocial adjustment varies between people. Some people perceive the limb amputation as devastating, and others perceive the major life-changing event as a challenge and find a new meaning and purpose in life. There are three overlapping patterns related to the coping styles that people use in their psychosocial adjustment [130]:

1. active/confrontative (direct planning, taking action, problem solving) versus passive/avoidant (dependence on others, avoiding adjustment issues) 2. optimistic/positivistic versus pessimistic/ fatalistic (challenge for personal growth versus surrender to a sick role) 3. social/emotional (seeking social support, seeking audience for venting, asking for help) versus cognitive (internal self-examination, working on acceptance, denial).

Strategies people use to cope and adjust to an amputation can influence their outcomes. If the person actively problem solves, tends to be optimistic and proactively seeks support, their psychosocial adjustment will be positive. If the person avoids treatment and rehabilitation, and is not engaged in their own self-management, more severe emotional distress and poor psychosocial adjustment is likely [130]. Adjustment may be relatively immediate but, for many people, the emotional adjustment can be delayed. They may then experience possible triggers later when confronted with changed circumstances, such as prosthetic fitting, resuming activities and participation, or other personal or environmental factors [130, 131]. Some people think they will get better on their own, and do not need psychosocial support services [132]. However, they may still be at risk of experiencing depression many years later [133]. One large study noted that people with an amputation after a traumatic injury were more satisfied with their activities and participation than people with dysvascular amputations [134]. Better mental health and satisfaction has also been shown to be higher for people with limb amputation who return to work after the amputation [132, 135].

Counselling and psychological support should be offered and made available to the person and their family before (where possible) and again after the amputation, throughout the care pathway when needed, and at key life events such as the first anniversary of the amputation [24, 136]. Psychological treatment via telehealth is a realistic and established option when there are barriers to face-to-face treatment.

Recommendations

23 If a psychologist is not currently involved, the person should be regularly screened for psychosocial issues by the treating health professionals using a validated tool (PHQ-2 and GAD-2; refer to Resources box 8)

24 The person should be referred by the treating doctor (monitored by the case manager) to be assessed for psychosocial concerns before the amputation.

25 Within the first three months after the amputation, the person should be assessed to determine their need for psychosocial support (e.g. in terms of adjustment, need for peer support, treatment for anxiety and depression, medication review).

26 The case manager should encourage the person to maintain contact with their GP for monitoring and referral for appropriate supports (e.g. psychosocial) as required. (Refer to recommendation 16)

27 All multidisciplinary team members and the funding body are responsible for monitoring the person throughout the support pathway, and advising the case manager and GP if there are concerns.

(Refer to Section 8.9 regular screening and Section 8.11 Lifelong monitoring) Grade

A

BQ

BQ

Consensus

Consensus

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