- Email: [email protected]
Depression Treatment Is Not Associated With Improved Patient-Reported Outcomes Following Total Joint Arthroplasty
The Journal of Arthroplasty xxx (2019) 1e4
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Depression Treatment Is Not Associated With Improved Patient-Reported Outcomes Following Total Joint Arthroplasty Mohamad J. Halawi, MD a, *, Christian Gronbeck b, Lawrence Savoy a, Mark P. Cote, DPT a, Jay R. Lieberman, MD c a b c
Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT University of Connecticut School of Medicine, Farmington, CT Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 May 2019 Received in revised form 4 August 2019 Accepted 4 August 2019 Available online xxx
Background: The objective of this study was to investigate if there were differences in disease-specific, overall health, and activity outcomes after total joint arthroplasty (TJA) between treated and untreated depressed patients. Methods: Patients who underwent primary, elective, unilateral TJA were divided into 3 groups based on self-reported history of depression and treatment at the time of surgery: 1) patients without depression, 2) patients with treated depression, and 3) patients with untreated depression. The primary outcomes were the differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA activity rating scale up to 12 months postoperatively. A secondary outcome was the effect of depression treatment on patients’ perception of experiencing limitation in their activities due to depression. Univariate and mixed-effects model analyses were performed to control for potential confounding factors. Results: The prevalence of depression was 189/749 (25%). Compared to patients with treated depression, untreated patients had lower baseline SF-12 MCS (P < .001) and were more likely to have Medicaid insurance (P < .001). After controlling for potential confounding factors, there were no differences in either the absolute scores or net changes in any of the assessed outcomes at 12 months postoperatively among depressed patients regardless of treatment (P > .05). In addition, depression treatment did not affect patients’ perception of activity limitation (P ¼ .412). Conclusion: Although it is clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment does not necessarily imply resolution of depressive symptoms. Future studies should explore alternative interventions to reduce the health-related consequences of depression to optimize the outcomes of TJA. © 2019 Elsevier Inc. All rights reserved.
Keywords: depression arthroplasty patient-reported outcomes treatment mental health
The role of depression in total joint arthroplasty (TJA) has garnered significant attention in recent years as a risk factor for suboptimal surgical outcomes. The prevalence of depression in patients undergoing TJA is estimated between 22% and 25% [1,2], a trend that appears to be on the rise [3]. Among the reported
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.08.010. * Reprint requests: Mohamad J. Halawi, MD, Department of Orthopaedic Surgery, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030. https://doi.org/10.1016/j.arth.2019.08.010 0883-5403/© 2019 Elsevier Inc. All rights reserved.
adverse effects of depression in TJA are increased rates of postoperative opioid consumption [4], complications [5,6], nonroutine discharge [6], and 90-day hospital readmission [7]. Depression has also been shown to lower patients’ perception of improvement after surgery as assessed by patient-reported outcome measures [8e10]. These patient-reported outcome measures are becoming increasingly important in arthroplasty practice as greater emphasis is placed on value of care and patient satisfaction. To date, while there is an established association between depression and diminished post-TJA outcomes, it remains unknown whether depression treatment attenuates this negative relationship. A review of literature identified a single report on this topic. Kohring et al [11] retrospectively reviewed 280 primary TJA cases with a minimum 1-year follow-up. The study found that
2
M.J. Halawi et al. / The Journal of Arthroplasty xxx (2019) 1e4
despite experiencing a lower magnitude of change in their physical function (PF), patients with untreated depression had similar final postoperative PF scores compared to treated patients. The purpose of this study is to assess the effect of depression treatment on patient-reported outcomes (PROs) in patients undergoing elective, primary, unilateral TJA. The specific study questions were the following: (1) Is there an association between depression treatment and a patient’s baseline general health, disease-specific symptoms, and activity rating? (2) Does depression treatment influence the clinical response to TJA as measured by PROs? Materials and Methods Institutional review board approval was obtained. We queried our prospectively collected institutional joint database for all primary total hip and knee arthroplasties (THA and TKA) with a minimum of 12-month follow-up. Exclusion criteria were simultaneous bilateral, nonelective, and tumor-related procedures. Additionally, in order to avoid any confounding effects, patients who underwent a second arthroplasty within 12 months were excluded. Finally, 749 procedures met the aforementioned criteria. All procedures were performed by fellowship-trained arthroplasty surgeons. Patient characteristics collected were age, sex, body mass index, American Society of Anesthesiologists physical classification system, educational attainment (primary/secondary vs college/university), smoking status (never/former vs active), race/ethnicity (white, black, or Hispanic), marital status (married/living with a
significant other vs single/divorced/widowed/separated), and insurance type (Medicaid, Medicare, or commercial). In addition to demographic variables, PROs were measured preoperatively during joint class and again at 6 and 12 months postoperatively. PROs included the Short Form-12 physical and mental component summaries (SF-12 PCS and SF-12 MCS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and University of California Los Angeles (UCLA) activity level rating. Three groups were compared: (1) patients without depression (control), (2) patients with depression receiving treatment, and (3) patients with depression not receiving treatment. At the time of enrollment into the database, patients were asked “Do you have depression?” Those who indicated that they had depression were then asked 2 questions: (1) Are you receiving treatment? (2) Does depression limit your activities? Information regarding treatment was not collected. A retrospective chart review was performed on patients who endorsed depression to elucidate whether they received a diagnosis of depression and/or pharmacologic treatment. The primary outcomes of the study were differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA scores at baseline postoperatively. A secondary outcome was whether patients’ perception of activity limitation due to their depression was altered by treatment. Descriptive statistics, including mean ± standard deviation for continuous variables and frequency/proportion for categorical variables, were calculated to characterize the study groups. Mixed effects linear regression was used to examine change in outcome scores throughout the postoperative period. All effects were
Table 1 Baseline Characteristics of the Study Cohorts. Variable Demographic Factors Age Gender Male Female Body mass index (kg/m2) ASA classification Diagnosis Nonprimary osteoarthritis Primary osteoarthritis Education Primary/secondary school College/university Smoking status Never/former Active Race/ethnicity White Black Hispanic Marital status Married/living with significant other Single/divorced/widowed/ separated Payer type Commercial Medicare Medicaid Patient-Reported Outcome Measures SF-12 MCS SF-12 PCS WOMAC UCLA
Group 1: No Depression (N ¼ 561)
Group 2: Untreated Depression (N ¼ 41)
Group 3: Treated Depression (N ¼ 148)
61.3 ± 11.9*2,3
55.8 ± 14.0*1
57.9 ± 11.2*1
284 (51%) 277 (49%) 30.9 ± 5.7 2.2 ± 0.5*3
21 (51%) 20 (49%) 28.9 ± 4.4 2.3 ± 0.5
60 (41%) 87 (59%) 30.9 ± 5.6 2.4 ± 0.5*1
130 (25%)*2 391 (75%)*2
14 (41%)*1 20 (59%)*1
44 (32%) 93 (68%)
251 (47%) 285 (53%)
20 (51%) 19 (49%)
78 (56%) 61 (44%)
483 (89%)*3 60 (11%)*3
33 (85%) 6 (15%)
103 (74%)*1 37 (26%)*1
445 (83%)*2,3 67 (12%)*2,3 27 (5%)*2,3
25 (64%)*1 8 (21%)*1 6 (15%)*1
108 (75%)*1 17 (12%)*1 19 (13%)*1
287 (53%)*3
14 (36%)
41 (30%)*1
253 (47%)*3
25 (64%)
98 (71%)*1
181 (33%)*2,3 203 (37%)*2,3 170 (31%)*2,3
6 (15%)*1 9 (22%)*1 26 (63%)*1
20 (14%)*1 55 (38%)*1 69 (48%)*1
58 ± 112,3 27 ± 9 59 ± 20*2,3 4.3 ± 1.8*2,3
39 ± 12*1,3 26 ± 6 71 ± 17*1 3.3 ± 1.6*1
P Value .0004 .101
.0946 .0007 .042
.142
<.0001
.001
45 ± 15*1,2 26 ± 7 70 ± 20*1 3.3 ± 1.3*1
<.0001
<.0001
<.0001 .3957 <.0001 <.0001
Values are presented as mean and standard deviation or as frequency and percentage. (*) and associated numbers indicate significant intergroup differences. For categorical variables, overall P values are obtained from Pearson’s chi-squared test. For continuous variables, overall P values are from an overall F test of 1-way analysis of variance. ASA, American Society of Anesthesiologists physical classification system; SF-12 MCS, Short Form-12 mental component summary; SF-12 PCS, Short Form-12 physical component summary; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los Angeles activity level rating.
M.J. Halawi et al. / The Journal of Arthroplasty xxx (2019) 1e4
evaluated with age, sex, body mass index, American Society of Anesthesiologists physical classification system, diagnosis, smoking status, race, marital status, and payer type as covariates in the models. The alpha level for all statistical tests was set at 0.05. All statistical analyses were performed using Stata 15 (StataCorp. 2017. Stata Statistical Software: Release 15.0. College Station, TX: StataCorp LLC). Results A total of 749 TJA procedures were included in the analysis (398 THAs and 351 TKAs). Patients with depression were more likely to be younger (P < .001), have Medicaid insurance (P < .001), and belong to a nonwhite race (P ¼ .001). Patients without depression had better baseline SF-12 MCS (P < .001), WOMAC (P < .001), and UCLA (P < .001) scores compared to those without depression. Among patients with depression, those in the treatment group had higher SF-12 MCS compared to untreated patients (P < .001). There were no differences in baseline SF-12 PCS among the 3 groups. Table 1 summarizes the preoperative demographic and clinical characteristics. Among patients with depression who were receiving treatment, 81 of 144 (56%) indicated they were limited by their depressive symptoms whereas 63 of 144 (44%) denied any limitations (P ¼ .412). Clinical documentation of depression and/or antidepressant treatment was verified in 170 of 189 (90%) patients who reported depression. In addition, among patients with verified depression who endorsed treatment, antidepressant medications were verified in all their records. Mixed effects linear regression showed a significant postoperative improvement in SF-12 MCS among patients with depression, which was higher in the untreated group during the first 6 months only (13.2 vs 4 points, P < .001). By 12 months postoperatively, the net SF-12 MCS gains between treated and untreated depressed patients became similar (P > .05). In contrast, patients without depression (control group) did not experience any change in their SF-12 MCS at any time interval. For SF-12 PCS, there were no differences in the net gains between treated and untreated groups. However, patients with depression, with or without treatment, had lower gains in their SF12 PCS compared to patients without depression (P < .001 at 6 and 12 months). The changes in WOMAC and UCLA scores were similar from baseline to 6 and 12 months postoperatively in all 3 groups. Table 2 summarizes the adjusted changes in outcome scores over time for the study cohorts. Regardless of the postoperative time interval assessed (6 or 12 months), patients without depression had higher absolute scores across all outcomes compared to those with depression (P .002 and <.001 at 6 and 12 months, respectively). Among patients with depression, there were no differences between treated and untreated groups in any of the measured outcomes by 12 months postoperatively. Table 3 summarizes the adjusted absolute outcome scores over time for the study cohorts. A subanalysis between patients with self-perceived depression (N ¼ 19) and confirmed depression (N ¼ 170) did not show any differences in PROs at baseline (P ¼ .984, .848, .298, and .325 for SF-12 MCS, SF-12 PCS, WOMAC, and UCLA, respectively) or 12 months postoperatively (P ¼ .079, .431, .265, and .335 for SF-12 MCS, SF-12 PCS, WOMAC, and UCLA, respectively). Discussion While it is established that depression adversely affects PROs following TJA [8e10], the role of depression treatment remains unclear. In this study, we found that patients with either untreated
3
Table 2 Adjusted Mixed Linear Regression Comparing the Changes in Patient-Reported Outcomes Over Time for the Study Cohorts. PatientReported Outcome Measure
Follow-Up Period (mo)
Group 1: No Depression (N ¼ 561)
Group 2: Untreated Depression (N ¼ 41)
Group 3: Treated Depression (N ¼ 148)
P Value
SF-12 MCS SF-12 PCS
6 12 6 12 6 12 6 12
0.2*2,3 0.3*2,3 17.6*2,3 18.9*2,3 43.2 47.6 1.4 1.5
13.2*1,3 7.0*1 10.5*1 12.6*1 46.3 45.9 1.4 0.8
4.0*1,2 4.1*1 13.3*1 12.4*1 44.0 43.1 1.2 1.1
<.0001 .003 .0003 .0001 .8029 .3902 .4235 .2164
WOMAC UCLA
Values are presented as marginal means from the mixed effects regression and refer to changes in outcome score compared to baseline. (*) and associated numbers indicate significant intergroup differences. Negative changes in WOMAC indicate improvement. SF-12 MCS, Short Form-12 mental component summary; SF-12 PCS, Short Form-12 physical component summary; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los Angeles activity level rating.
or treated depression had lower improvement in PF and lower scores across all assessed outcomes compared to those without depression at any given time interval. There were no differences in both the net improvement and absolute scores in overall physical health, osteoarthritis symptoms, or activity levels between patients with treated depression. Furthermore, patients’ perceptions of activity limitations due to their depressive symptoms were not influenced by whether they were receiving treatment or not. To our knowledge, only one previous study has explored the effect of depression treatment on PROs. Kohring et al [11] retrospectively reviewed 280 primary TJA patients with a minimum of 1-year follow-up. Diagnosis and treatment of depression were extracted from their institution’s electronic medical record system. Patients with limitations secondary to other musculoskeletal problems were excluded. The primary outcome was the change in Patient-Reported Outcomes Measurement Information System PF. The prevalence of depression was 33% in that study. While the authors found statistically smaller PF gains in untreated patients with depression, the difference was not clinically significant and the absolute postoperative PF scores were similar regardless of treatment. We found similar results in our study with respect to the
Table 3 Adjusted Mixed Linear Regression Comparing the Absolute Patient-Reported Outcome Scores Over Time for the Study Cohorts. PatientReported Outcome Measure
Follow-Up Period (mo)
Group 1: No Depression (N ¼ 561)
Group 2: Untreated Depression (N ¼ 41)
Group 3: Treated Depression (N ¼ 148)
P Value
SF-12 MCS SF-12 PCS
6 12 6 12 6 12 6 12
58.3*2,3 57.8*2,3 44.8*2,3 46.2*2,3 16.1*3 11.7*2,3 5.7*2,3 5.8*2,3
51.9*1 45.7*1 39.0*1 41.1*1 23.3 23.7*1 4.9*1 4.3*1
49.3*1 49.4*1 41.0*1 40.1*1 23.7*1 24.6*1 4.6*1 4.5*1
<.0001 <.0001 .0004 <.0001 .0020 <.0001 <.0001 <.0001
WOMAC UCLA
Values are presented as marginal means from the mixed effects regression and demonstrate absolute outcome scores at 6 and 12 months. (*) and associated numbers indicate significant intergroup differences. Lower WOMAC scores indicate better disease-specific symptoms. SF-12 MCS, Short Form-12 mental component summary; SF-12 PCS, Short Form-12 physical component summary; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los Angeles activity level rating.
4
M.J. Halawi et al. / The Journal of Arthroplasty xxx (2019) 1e4
prevalence of depression and the absolute outcome scores. However, when assessing the preoperative to postoperative gains in PF, we observed no advantage for treatment when using the SF-12 PCS as the measure of PF. Whether the benefits of TJA extend to modulating depressive symptoms is a subject of debate. Duivenvoorden et al [10] prospectively followed 282 patients undergoing primary TJA up to 12 months postoperatively. Using the Hospital Anxiety and Depression Scale, the authors found that the prevalence of depressive symptoms decreased from 33.6% to 12.1% and 22.7% to 11.7% at 12 months for patients who underwent THA and TKA, respectively. Despite the reduction in their depressive symptoms, patients with preoperative depression still had worse outcomes postoperatively as measured by Knee injury and Osteoarthritis Outcome Score and Hip disability and Osteoarthritis Outcome Score questionnaires [10]. An interesting finding in this study was that 2.5% of patients reported that they suffered from depression despite absence of established clinical diagnosis or treatment in their medical records. While the prevalence of unrecognized or undiagnosed depression among arthroplasty patients is unknown, a few reports have called for higher awareness of undiagnosed psychiatric disorders among surgical patients. In a disease-specific survey of 108 hospitalized general surgery patients, 10 of 14 patients (71%) who were identified to have depression were not receiving any pharmacological antidepressant treatment [12]. In another survey of 96 surgical patients using the Hospital Anxiety and Depression Scale, the prevalence of undiagnosed depression was 12.5% [13]. The main limitation of this study is it is a retrospective review from a single institution. Second, no conclusions can be made regarding the duration of pharmacological treatment or use of nonpharmacological modalities. Third, we were not able to confirm the diagnosis of depression in 19 of 189 (10%) patients who selfreported themselves to have depression. However, a comparison of those patients to others with confirmed depression did not show differences in any of study outcomes preoperatively or postoperatively. Essentially, patients with self-reported depression were clinically identical to patients with confirmed depression. It is possible that those patients were receiving their psychiatric care outside our health system and hence were not captured by your chart review. Nonetheless, our results are consistent with previous reports on the prevalence and adverse effects of depression in patients undergoing TJA. Multivariable analyses were also performed to control for a wide range of baseline patient characteristics. In conclusion, while it is very clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment may
not necessarily imply resolution of depressive symptoms. Large prospective studies are needed to better confirm our findings and to explore whether there is any differential effect by treatment type (pharmacological vs behavioral). Until such information becomes available, patients with depression should be counseled about their potential of experiencing lower perceived clinical benefits. This study also adds further evidence that the outcomes, and thus the value of TJA, can be impacted by patient factors that may or may not be modifiable.
References [1] Halawi MJ, Cote MP, Singh H, O'Sullivan MB, Savoy L, Lieberman JR, et al. The effect of depression on patient-reported outcomes after total joint arthroplasty is modulated by baseline mental health: a registry study. J Bone Joint Surg Am 2018;100:1735e41. [2] Riddle DL, Wade JB, Jiranek WA. Major depression, generalized anxiety disorder, and panic disorder in patients scheduled for knee arthroplasty. J Arthroplasty 2010;25:581e8. [3] Oh C, Slover JD, Bosco JA, Iorio R, Gold HT. Time trends in characteristics of patients undergoing primary total hip and knee arthroplasty in California, 2007-2010. J Arthroplasty 2018;33:2376e80. [4] Etcheson JI, Gwam CU, George NE, Virani S, Mont MA, Delanois RE. Patients with major depressive disorder experience increased perception of pain and opioid consumption following total joint arthroplasty. J Arthroplasty 2018;33: 997e1002. [5] Browne JA, Sandberg BF, D'Apuzzo MR, Novicoff WM. Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. J Arthroplasty 2014;29:481e3. [6] Buller LT, Best MJ, Klika AK, Barsoum WK. The influence of psychiatric comorbidity on perioperative outcomes following primary total hip and knee arthroplasty; a 17-year analysis of the National Hospital Discharge Survey database. J Arthroplasty 2015;30:165e70. [7] Gold HT, Slover JD, Joo L, Bosco J, Iorio R, Oh C. Association of depression with 90-day hospital readmission after total joint arthroplasty. J Arthroplasty 2016;31:2385e8. [8] Perez-Prieto D, Gil-Gonzalez S, Pelfort X, Leal-Blanquet J, Puig-Verdie L, Hinarejos P. Influence of depression on total knee arthroplasty outcomes. J Arthroplasty 2014;29:44e7. [9] Lindner M, Nosseir O, Keller-Pliessnig A, Teigelack P, Teufel M, Tagay S. Psychosocial predictors for outcome after total joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord 2018;19:159. [10] Duivenvoorden T, Vissers MM, Verhaar JA, Busschbach JJ, Gosens T, Bloem RM, et al. Anxiety and depressive symptoms before and after total hip and knee arthroplasty: a prospective multicentre study. Osteoarthritis Cartilage 2013;21:1834e40. [11] Kohring JM, Erickson JA, Anderson MB, Gililland JM, Peters CL, Pelt CE. Treated versus untreated depression in total joint arthroplasty impacts outcomes. J Arthroplasty 2018;33:S81e5. [12] Vaeroy H, Juell M, Hoivik B. Prevalence of depression among general hospital surgical inpatients. Nord J Psychiatry 2003;57:13e6. [13] Ni Mhaolain AM, Butler JS, Magill PF, Wood AE, Sheehan J. The increased need for liaison psychiatry in surgical patients due to the high prevalence of undiagnosed anxiety and depression. Ir J Med Sci 2008;177:211e5.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Depression Treatment Is Not Associated With Improved Patient-Reported Outcomes Following Total Joint Arthroplasty Mohamad J. Halawi, MD a, *, Christian Gronbeck b, Lawrence Savoy a, Mark P. Cote, DPT a, Jay R. Lieberman, MD c a b c
Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT University of Connecticut School of Medicine, Farmington, CT Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 May 2019 Received in revised form 4 August 2019 Accepted 4 August 2019 Available online xxx
Background: The objective of this study was to investigate if there were differences in disease-specific, overall health, and activity outcomes after total joint arthroplasty (TJA) between treated and untreated depressed patients. Methods: Patients who underwent primary, elective, unilateral TJA were divided into 3 groups based on self-reported history of depression and treatment at the time of surgery: 1) patients without depression, 2) patients with treated depression, and 3) patients with untreated depression. The primary outcomes were the differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA activity rating scale up to 12 months postoperatively. A secondary outcome was the effect of depression treatment on patients’ perception of experiencing limitation in their activities due to depression. Univariate and mixed-effects model analyses were performed to control for potential confounding factors. Results: The prevalence of depression was 189/749 (25%). Compared to patients with treated depression, untreated patients had lower baseline SF-12 MCS (P < .001) and were more likely to have Medicaid insurance (P < .001). After controlling for potential confounding factors, there were no differences in either the absolute scores or net changes in any of the assessed outcomes at 12 months postoperatively among depressed patients regardless of treatment (P > .05). In addition, depression treatment did not affect patients’ perception of activity limitation (P ¼ .412). Conclusion: Although it is clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment does not necessarily imply resolution of depressive symptoms. Future studies should explore alternative interventions to reduce the health-related consequences of depression to optimize the outcomes of TJA. © 2019 Elsevier Inc. All rights reserved.
Keywords: depression arthroplasty patient-reported outcomes treatment mental health
The role of depression in total joint arthroplasty (TJA) has garnered significant attention in recent years as a risk factor for suboptimal surgical outcomes. The prevalence of depression in patients undergoing TJA is estimated between 22% and 25% [1,2], a trend that appears to be on the rise [3]. Among the reported
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.08.010. * Reprint requests: Mohamad J. Halawi, MD, Department of Orthopaedic Surgery, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030. https://doi.org/10.1016/j.arth.2019.08.010 0883-5403/© 2019 Elsevier Inc. All rights reserved.
adverse effects of depression in TJA are increased rates of postoperative opioid consumption [4], complications [5,6], nonroutine discharge [6], and 90-day hospital readmission [7]. Depression has also been shown to lower patients’ perception of improvement after surgery as assessed by patient-reported outcome measures [8e10]. These patient-reported outcome measures are becoming increasingly important in arthroplasty practice as greater emphasis is placed on value of care and patient satisfaction. To date, while there is an established association between depression and diminished post-TJA outcomes, it remains unknown whether depression treatment attenuates this negative relationship. A review of literature identified a single report on this topic. Kohring et al [11] retrospectively reviewed 280 primary TJA cases with a minimum 1-year follow-up. The study found that
2
M.J. Halawi et al. / The Journal of Arthroplasty xxx (2019) 1e4
despite experiencing a lower magnitude of change in their physical function (PF), patients with untreated depression had similar final postoperative PF scores compared to treated patients. The purpose of this study is to assess the effect of depression treatment on patient-reported outcomes (PROs) in patients undergoing elective, primary, unilateral TJA. The specific study questions were the following: (1) Is there an association between depression treatment and a patient’s baseline general health, disease-specific symptoms, and activity rating? (2) Does depression treatment influence the clinical response to TJA as measured by PROs? Materials and Methods Institutional review board approval was obtained. We queried our prospectively collected institutional joint database for all primary total hip and knee arthroplasties (THA and TKA) with a minimum of 12-month follow-up. Exclusion criteria were simultaneous bilateral, nonelective, and tumor-related procedures. Additionally, in order to avoid any confounding effects, patients who underwent a second arthroplasty within 12 months were excluded. Finally, 749 procedures met the aforementioned criteria. All procedures were performed by fellowship-trained arthroplasty surgeons. Patient characteristics collected were age, sex, body mass index, American Society of Anesthesiologists physical classification system, educational attainment (primary/secondary vs college/university), smoking status (never/former vs active), race/ethnicity (white, black, or Hispanic), marital status (married/living with a
significant other vs single/divorced/widowed/separated), and insurance type (Medicaid, Medicare, or commercial). In addition to demographic variables, PROs were measured preoperatively during joint class and again at 6 and 12 months postoperatively. PROs included the Short Form-12 physical and mental component summaries (SF-12 PCS and SF-12 MCS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and University of California Los Angeles (UCLA) activity level rating. Three groups were compared: (1) patients without depression (control), (2) patients with depression receiving treatment, and (3) patients with depression not receiving treatment. At the time of enrollment into the database, patients were asked “Do you have depression?” Those who indicated that they had depression were then asked 2 questions: (1) Are you receiving treatment? (2) Does depression limit your activities? Information regarding treatment was not collected. A retrospective chart review was performed on patients who endorsed depression to elucidate whether they received a diagnosis of depression and/or pharmacologic treatment. The primary outcomes of the study were differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA scores at baseline postoperatively. A secondary outcome was whether patients’ perception of activity limitation due to their depression was altered by treatment. Descriptive statistics, including mean ± standard deviation for continuous variables and frequency/proportion for categorical variables, were calculated to characterize the study groups. Mixed effects linear regression was used to examine change in outcome scores throughout the postoperative period. All effects were
Table 1 Baseline Characteristics of the Study Cohorts. Variable Demographic Factors Age Gender Male Female Body mass index (kg/m2) ASA classification Diagnosis Nonprimary osteoarthritis Primary osteoarthritis Education Primary/secondary school College/university Smoking status Never/former Active Race/ethnicity White Black Hispanic Marital status Married/living with significant other Single/divorced/widowed/ separated Payer type Commercial Medicare Medicaid Patient-Reported Outcome Measures SF-12 MCS SF-12 PCS WOMAC UCLA
Group 1: No Depression (N ¼ 561)
Group 2: Untreated Depression (N ¼ 41)
Group 3: Treated Depression (N ¼ 148)
61.3 ± 11.9*2,3
55.8 ± 14.0*1
57.9 ± 11.2*1
284 (51%) 277 (49%) 30.9 ± 5.7 2.2 ± 0.5*3
21 (51%) 20 (49%) 28.9 ± 4.4 2.3 ± 0.5
60 (41%) 87 (59%) 30.9 ± 5.6 2.4 ± 0.5*1
130 (25%)*2 391 (75%)*2
14 (41%)*1 20 (59%)*1
44 (32%) 93 (68%)
251 (47%) 285 (53%)
20 (51%) 19 (49%)
78 (56%) 61 (44%)
483 (89%)*3 60 (11%)*3
33 (85%) 6 (15%)
103 (74%)*1 37 (26%)*1
445 (83%)*2,3 67 (12%)*2,3 27 (5%)*2,3
25 (64%)*1 8 (21%)*1 6 (15%)*1
108 (75%)*1 17 (12%)*1 19 (13%)*1
287 (53%)*3
14 (36%)
41 (30%)*1
253 (47%)*3
25 (64%)
98 (71%)*1
181 (33%)*2,3 203 (37%)*2,3 170 (31%)*2,3
6 (15%)*1 9 (22%)*1 26 (63%)*1
20 (14%)*1 55 (38%)*1 69 (48%)*1
58 ± 112,3 27 ± 9 59 ± 20*2,3 4.3 ± 1.8*2,3
39 ± 12*1,3 26 ± 6 71 ± 17*1 3.3 ± 1.6*1
P Value .0004 .101
.0946 .0007 .042
.142
<.0001
.001
45 ± 15*1,2 26 ± 7 70 ± 20*1 3.3 ± 1.3*1
<.0001
<.0001
<.0001 .3957 <.0001 <.0001
Values are presented as mean and standard deviation or as frequency and percentage. (*) and associated numbers indicate significant intergroup differences. For categorical variables, overall P values are obtained from Pearson’s chi-squared test. For continuous variables, overall P values are from an overall F test of 1-way analysis of variance. ASA, American Society of Anesthesiologists physical classification system; SF-12 MCS, Short Form-12 mental component summary; SF-12 PCS, Short Form-12 physical component summary; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los Angeles activity level rating.
M.J. Halawi et al. / The Journal of Arthroplasty xxx (2019) 1e4
evaluated with age, sex, body mass index, American Society of Anesthesiologists physical classification system, diagnosis, smoking status, race, marital status, and payer type as covariates in the models. The alpha level for all statistical tests was set at 0.05. All statistical analyses were performed using Stata 15 (StataCorp. 2017. Stata Statistical Software: Release 15.0. College Station, TX: StataCorp LLC). Results A total of 749 TJA procedures were included in the analysis (398 THAs and 351 TKAs). Patients with depression were more likely to be younger (P < .001), have Medicaid insurance (P < .001), and belong to a nonwhite race (P ¼ .001). Patients without depression had better baseline SF-12 MCS (P < .001), WOMAC (P < .001), and UCLA (P < .001) scores compared to those without depression. Among patients with depression, those in the treatment group had higher SF-12 MCS compared to untreated patients (P < .001). There were no differences in baseline SF-12 PCS among the 3 groups. Table 1 summarizes the preoperative demographic and clinical characteristics. Among patients with depression who were receiving treatment, 81 of 144 (56%) indicated they were limited by their depressive symptoms whereas 63 of 144 (44%) denied any limitations (P ¼ .412). Clinical documentation of depression and/or antidepressant treatment was verified in 170 of 189 (90%) patients who reported depression. In addition, among patients with verified depression who endorsed treatment, antidepressant medications were verified in all their records. Mixed effects linear regression showed a significant postoperative improvement in SF-12 MCS among patients with depression, which was higher in the untreated group during the first 6 months only (13.2 vs 4 points, P < .001). By 12 months postoperatively, the net SF-12 MCS gains between treated and untreated depressed patients became similar (P > .05). In contrast, patients without depression (control group) did not experience any change in their SF-12 MCS at any time interval. For SF-12 PCS, there were no differences in the net gains between treated and untreated groups. However, patients with depression, with or without treatment, had lower gains in their SF12 PCS compared to patients without depression (P < .001 at 6 and 12 months). The changes in WOMAC and UCLA scores were similar from baseline to 6 and 12 months postoperatively in all 3 groups. Table 2 summarizes the adjusted changes in outcome scores over time for the study cohorts. Regardless of the postoperative time interval assessed (6 or 12 months), patients without depression had higher absolute scores across all outcomes compared to those with depression (P .002 and <.001 at 6 and 12 months, respectively). Among patients with depression, there were no differences between treated and untreated groups in any of the measured outcomes by 12 months postoperatively. Table 3 summarizes the adjusted absolute outcome scores over time for the study cohorts. A subanalysis between patients with self-perceived depression (N ¼ 19) and confirmed depression (N ¼ 170) did not show any differences in PROs at baseline (P ¼ .984, .848, .298, and .325 for SF-12 MCS, SF-12 PCS, WOMAC, and UCLA, respectively) or 12 months postoperatively (P ¼ .079, .431, .265, and .335 for SF-12 MCS, SF-12 PCS, WOMAC, and UCLA, respectively). Discussion While it is established that depression adversely affects PROs following TJA [8e10], the role of depression treatment remains unclear. In this study, we found that patients with either untreated
3
Table 2 Adjusted Mixed Linear Regression Comparing the Changes in Patient-Reported Outcomes Over Time for the Study Cohorts. PatientReported Outcome Measure
Follow-Up Period (mo)
Group 1: No Depression (N ¼ 561)
Group 2: Untreated Depression (N ¼ 41)
Group 3: Treated Depression (N ¼ 148)
P Value
SF-12 MCS SF-12 PCS
6 12 6 12 6 12 6 12
0.2*2,3 0.3*2,3 17.6*2,3 18.9*2,3 43.2 47.6 1.4 1.5
13.2*1,3 7.0*1 10.5*1 12.6*1 46.3 45.9 1.4 0.8
4.0*1,2 4.1*1 13.3*1 12.4*1 44.0 43.1 1.2 1.1
<.0001 .003 .0003 .0001 .8029 .3902 .4235 .2164
WOMAC UCLA
Values are presented as marginal means from the mixed effects regression and refer to changes in outcome score compared to baseline. (*) and associated numbers indicate significant intergroup differences. Negative changes in WOMAC indicate improvement. SF-12 MCS, Short Form-12 mental component summary; SF-12 PCS, Short Form-12 physical component summary; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los Angeles activity level rating.
or treated depression had lower improvement in PF and lower scores across all assessed outcomes compared to those without depression at any given time interval. There were no differences in both the net improvement and absolute scores in overall physical health, osteoarthritis symptoms, or activity levels between patients with treated depression. Furthermore, patients’ perceptions of activity limitations due to their depressive symptoms were not influenced by whether they were receiving treatment or not. To our knowledge, only one previous study has explored the effect of depression treatment on PROs. Kohring et al [11] retrospectively reviewed 280 primary TJA patients with a minimum of 1-year follow-up. Diagnosis and treatment of depression were extracted from their institution’s electronic medical record system. Patients with limitations secondary to other musculoskeletal problems were excluded. The primary outcome was the change in Patient-Reported Outcomes Measurement Information System PF. The prevalence of depression was 33% in that study. While the authors found statistically smaller PF gains in untreated patients with depression, the difference was not clinically significant and the absolute postoperative PF scores were similar regardless of treatment. We found similar results in our study with respect to the
Table 3 Adjusted Mixed Linear Regression Comparing the Absolute Patient-Reported Outcome Scores Over Time for the Study Cohorts. PatientReported Outcome Measure
Follow-Up Period (mo)
Group 1: No Depression (N ¼ 561)
Group 2: Untreated Depression (N ¼ 41)
Group 3: Treated Depression (N ¼ 148)
P Value
SF-12 MCS SF-12 PCS
6 12 6 12 6 12 6 12
58.3*2,3 57.8*2,3 44.8*2,3 46.2*2,3 16.1*3 11.7*2,3 5.7*2,3 5.8*2,3
51.9*1 45.7*1 39.0*1 41.1*1 23.3 23.7*1 4.9*1 4.3*1
49.3*1 49.4*1 41.0*1 40.1*1 23.7*1 24.6*1 4.6*1 4.5*1
<.0001 <.0001 .0004 <.0001 .0020 <.0001 <.0001 <.0001
WOMAC UCLA
Values are presented as marginal means from the mixed effects regression and demonstrate absolute outcome scores at 6 and 12 months. (*) and associated numbers indicate significant intergroup differences. Lower WOMAC scores indicate better disease-specific symptoms. SF-12 MCS, Short Form-12 mental component summary; SF-12 PCS, Short Form-12 physical component summary; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los Angeles activity level rating.
4
M.J. Halawi et al. / The Journal of Arthroplasty xxx (2019) 1e4
prevalence of depression and the absolute outcome scores. However, when assessing the preoperative to postoperative gains in PF, we observed no advantage for treatment when using the SF-12 PCS as the measure of PF. Whether the benefits of TJA extend to modulating depressive symptoms is a subject of debate. Duivenvoorden et al [10] prospectively followed 282 patients undergoing primary TJA up to 12 months postoperatively. Using the Hospital Anxiety and Depression Scale, the authors found that the prevalence of depressive symptoms decreased from 33.6% to 12.1% and 22.7% to 11.7% at 12 months for patients who underwent THA and TKA, respectively. Despite the reduction in their depressive symptoms, patients with preoperative depression still had worse outcomes postoperatively as measured by Knee injury and Osteoarthritis Outcome Score and Hip disability and Osteoarthritis Outcome Score questionnaires [10]. An interesting finding in this study was that 2.5% of patients reported that they suffered from depression despite absence of established clinical diagnosis or treatment in their medical records. While the prevalence of unrecognized or undiagnosed depression among arthroplasty patients is unknown, a few reports have called for higher awareness of undiagnosed psychiatric disorders among surgical patients. In a disease-specific survey of 108 hospitalized general surgery patients, 10 of 14 patients (71%) who were identified to have depression were not receiving any pharmacological antidepressant treatment [12]. In another survey of 96 surgical patients using the Hospital Anxiety and Depression Scale, the prevalence of undiagnosed depression was 12.5% [13]. The main limitation of this study is it is a retrospective review from a single institution. Second, no conclusions can be made regarding the duration of pharmacological treatment or use of nonpharmacological modalities. Third, we were not able to confirm the diagnosis of depression in 19 of 189 (10%) patients who selfreported themselves to have depression. However, a comparison of those patients to others with confirmed depression did not show differences in any of study outcomes preoperatively or postoperatively. Essentially, patients with self-reported depression were clinically identical to patients with confirmed depression. It is possible that those patients were receiving their psychiatric care outside our health system and hence were not captured by your chart review. Nonetheless, our results are consistent with previous reports on the prevalence and adverse effects of depression in patients undergoing TJA. Multivariable analyses were also performed to control for a wide range of baseline patient characteristics. In conclusion, while it is very clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment may
not necessarily imply resolution of depressive symptoms. Large prospective studies are needed to better confirm our findings and to explore whether there is any differential effect by treatment type (pharmacological vs behavioral). Until such information becomes available, patients with depression should be counseled about their potential of experiencing lower perceived clinical benefits. This study also adds further evidence that the outcomes, and thus the value of TJA, can be impacted by patient factors that may or may not be modifiable.
References [1] Halawi MJ, Cote MP, Singh H, O'Sullivan MB, Savoy L, Lieberman JR, et al. The effect of depression on patient-reported outcomes after total joint arthroplasty is modulated by baseline mental health: a registry study. J Bone Joint Surg Am 2018;100:1735e41. [2] Riddle DL, Wade JB, Jiranek WA. Major depression, generalized anxiety disorder, and panic disorder in patients scheduled for knee arthroplasty. J Arthroplasty 2010;25:581e8. [3] Oh C, Slover JD, Bosco JA, Iorio R, Gold HT. Time trends in characteristics of patients undergoing primary total hip and knee arthroplasty in California, 2007-2010. J Arthroplasty 2018;33:2376e80. [4] Etcheson JI, Gwam CU, George NE, Virani S, Mont MA, Delanois RE. Patients with major depressive disorder experience increased perception of pain and opioid consumption following total joint arthroplasty. J Arthroplasty 2018;33: 997e1002. [5] Browne JA, Sandberg BF, D'Apuzzo MR, Novicoff WM. Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. J Arthroplasty 2014;29:481e3. [6] Buller LT, Best MJ, Klika AK, Barsoum WK. The influence of psychiatric comorbidity on perioperative outcomes following primary total hip and knee arthroplasty; a 17-year analysis of the National Hospital Discharge Survey database. J Arthroplasty 2015;30:165e70. [7] Gold HT, Slover JD, Joo L, Bosco J, Iorio R, Oh C. Association of depression with 90-day hospital readmission after total joint arthroplasty. J Arthroplasty 2016;31:2385e8. [8] Perez-Prieto D, Gil-Gonzalez S, Pelfort X, Leal-Blanquet J, Puig-Verdie L, Hinarejos P. Influence of depression on total knee arthroplasty outcomes. J Arthroplasty 2014;29:44e7. [9] Lindner M, Nosseir O, Keller-Pliessnig A, Teigelack P, Teufel M, Tagay S. Psychosocial predictors for outcome after total joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord 2018;19:159. [10] Duivenvoorden T, Vissers MM, Verhaar JA, Busschbach JJ, Gosens T, Bloem RM, et al. Anxiety and depressive symptoms before and after total hip and knee arthroplasty: a prospective multicentre study. Osteoarthritis Cartilage 2013;21:1834e40. [11] Kohring JM, Erickson JA, Anderson MB, Gililland JM, Peters CL, Pelt CE. Treated versus untreated depression in total joint arthroplasty impacts outcomes. J Arthroplasty 2018;33:S81e5. [12] Vaeroy H, Juell M, Hoivik B. Prevalence of depression among general hospital surgical inpatients. Nord J Psychiatry 2003;57:13e6. [13] Ni Mhaolain AM, Butler JS, Magill PF, Wood AE, Sheehan J. The increased need for liaison psychiatry in surgical patients due to the high prevalence of undiagnosed anxiety and depression. Ir J Med Sci 2008;177:211e5.