Mental Health Phenotypes and Patient-Reported Outcomes in Upper-Extremity Care
Pain is a remarkable and, at times, poorly understood concept. There has been extensive research showing that patients with the same conditions can experience pain differently and that pain and activity intolerance simply can’t be explained by biomedical factors alone. We have all seen examples in our own clinics as surgeons, how 2 individuals with the same pathology and treatment can have different perceived outcomes.
In the current issue of JBJS, Miner et al. explore this very topic in a prospective, cross-sectional study in which they used cluster analysis to identify mental health phenotypes (combinations of various types of misconceptions—unhelpful thoughts or cognitive biases—and symptoms of anxiety or depression) that could potentially help to direct care. A total of 137 adult patients seeking upper-extremity musculoskeletal care completed a survey that included demographics and mental health questionnaires (3 regarding unhealthy thoughts about pain and 2 addressing psychological distress) along with measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy.
Through a clustering algorithm, 4 mental health phenotypes were identified in the study population:
- Low misconceptions, low distress (77 patients)
- Notable misconceptions (36 patients)
- Notable depression and notable misconceptions (19 patients)
- Notable anxiety, depression, and misconceptions (5 patients)
The authors observed significant differences in activity tolerance, pain intensity, and pain self-efficacy based on mental health phenotype. Specifically, patients with low misconceptions and low distress had significantly greater activity tolerance and pain self-efficacy than those with notable misconceptions, notable symptoms of depression, and notable psychological distress. Patients with low misconceptions and low distress also had significantly lower pain intensity than those with notable symptoms of depression and notable symptoms of anxiety.
The authors did not find an association between phenotypes and socioeconomic status, as measured by participants’ zip code (used to calculate the home area deprivation index). In addition, they found no difference between phenotypes in terms of discrete traumatic conditions (35% of patients), discrete nontraumatic conditions (47%), and nonspecific diagnoses (18%), although they caution that they may not have had enough balance to detect differences based on diagnostic category.
As surgeons, we must consider psychological factors when counseling our patients. As the authors note, “musculoskeletal specialty and pre-specialty care units can benefit from strategies that anticipate mental and social-health opportunities.” As we increase our understanding of the interplay between mental and physical health, our patients stand to gain.
Co-author David Ring, MD, PhD shares his perspective on this study in the related Author Insights video, found here.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Better TKA Outcomes When Depression Is Addressed
In the past decade, we’ve learned through a multitude of studies that patient factors can have a substantial impact on the outcomes of orthopaedic interventions. Medical comorbidities, body habitus, and level of fitness are just a few factors we have evaluated. We also now better understand the impact of socioeconomic status and education level on access to care and the results of that care. And importantly, contemporary research is giving us a more complete picture of the relationship between a patient’s mental status and functional outcomes.
Geng et al. provide further insight into this relationship in a recent JBJS report. In a randomized controlled trial conducted at their institution in the People’s Republic of China, the authors investigated whether psychological intervention for patients with depression improved outcomes of total knee arthroplasty (TKA). Among 600 patients prospectively screened, 53 were identified with depressive disorders; 49 remained in the final analysis (24 randomized to standard TKA care and 25 randomized to perioperative psychotherapeutic interventions administered by a mental health professional). Those in the intervention group not only had a significantly higher rate of satisfaction compared with the control group, but they also showed greater improvements in functional outcome scores, range of motion, and scores on depression scales.
As Pablo Castañeda, MD emphasizes in a related Commentary on this article, “Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes.” I know that mental health concerns—especially depression—can be difficult to identify during all-too-brief orthopaedic consultations with patients. But they will reap important benefits if we learn to better recognize depression, engage patients in conversations related to mental health, and team with our mental health colleagues for referrals and support. The study by Geng et al. points to a model of care with potential for wider adoption. Considering our community of highly motivated orthopaedic surgeons who are dedicated to the holistic welfare of patients, I believe it is possible to raise our skills in this area close to the level of our ability to examine a knee radiograph.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Smoking, Depression Adversely Affect Outcomes after TAA
After some relatively poor results in the 1980s, there was a “reboot” with total ankle arthroplasty (TAA) in the late 1990s to improve outcomes so that TAA would provide a reliable treatment for patients with end-stage ankle arthritis. Advances in the understanding of the biomechanical requirements for ankle prostheses and which patients might benefit from them the most—plus the realization that TAA is a technically demanding surgical procedure that requires advanced education—have vastly improved the outcomes of these procedures. In fact, TAA has become reliable enough that we can now begin to tease out the patient variables that seem to affect outcomes.
In the February 6, 2019 issue of The Journal, Cunningham et al. use an extensive clinical TAA registry to identify patient characteristics that impact TAA outcomes. The good news is that, 30-plus years after the inauspicious outcomes of first-generation TAA, overall pain and function significantly improved among the patients in this study. However, current smoking was associated with poorer patient outcomes at the 5-year follow-up, as it seems to be with the vast majority of orthopaedic procedures. Also, at a mean 1- to 2-year follow-up, a previous surgical procedure on the ankle was associated with significantly smaller improvements in at least 1 patient-reported outcome. This makes sense because prior surgery leads to scarring and its attendant risk of infection and increased difficulty with exposure and the ideal placement of TAA components. Cunningham et al. also identified depression as being associated with worse TAA outcomes at all follow-up points, adding to our already ample body of evidence that patient psychological factors play a major role in orthopaedic surgical results.
Interestingly, these authors found that patients undergoing staged bilateral ankle arthroplasty did not do as well as those undergoing simultaneous bilateral TAAs. And somewhat surprisingly, the authors found obesity to be associated with better outcomes at the 5-year follow-up. This may be related to increased bone density and greater soft-tissue coverage, but this finding is still seemingly counterintuitive based on everything else we know about the negative associations between obesity and outcomes of other joint replacements.
As more surgeons and orthopaedic centers make use of TAA, it will be important for us to follow the lead of the total knee and total hip communities in providing large datasets to further clarify which factors—patient-related and surgical—lead to the best and worst patient outcomes. This study by Cunningham et al. provides a starting point upon which other research will hopefully build.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Better News for TJA Patients with Depression
Over the last 2 decades, research into how various “preexisting conditions” affect the outcomes of orthopaedic interventions has increasingly focused on the impact of mental health (a patient’s “state of mind” and coping abilities) and psychological diagnoses such as depression. The impact of mental health, depression, and personality characteristics on patient-reported outcomes following significant skeletal trauma has been well documented in the trauma literature. In addition, previous studies in knee arthroplasty have identified depression as a major factor in suboptimal patient outcomes.
In the October 17, 2018 issue of The Journal, Halawi et al. teased out the impact of depression and mental health—independently and in combination—on patient-reported outcomes following primary total joint arthroplasty (TJA) in 469 patients at a minimum follow-up of one year.
The authors used the validated SF-12 MCS instrument to assess patient baseline mental health at the time of surgery. They also used the widely accepted WOMAC score to assess joint-specific pain, stiffness, and physical function before and after surgery. Using these tools, the authors showed that, while depression alone may diminish some patient-reported gains obtained from arthroplasty, it does not seem to affect a patient’s overall outcome as much as poor mental health prior to surgery. In this study, patients with depression but good mental health achieved patient-reported outcomes comparable to those among normal controls. Still, patients without depression and in good mental health were found to have the most robust improvements after undergoing TJA.
Orthopaedic surgeons need to better understand the interplay between these complex psychological states and patient outcomes. These authors conclude that the effect of depression on patient-reported outcomes is “less pessimistic than previously thought,” but we welcome further studies examining the link between “the mind” and orthopaedic outcomes. Finally, we should be ready to refer patients to our mental health colleagues when we detect a potential underlying nonphysical condition that might adversely affect the magnitude of benefit from the treatments we offer.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Opioid-Tapering Plan May Help Prevent Prolonged Use after Trauma/Surgery
Addressing the opioid epidemic requires a concerted effort from all sectors of society, but the role of surgeons (orthopaedic and otherwise) cannot be ignored because they determine how best to manage postoperative pain for millions of patients. OrthoBuzz recently commented on two opioid-related studies from the July 18, 2018 issue of JBJS. In the August 1, 2018 edition of The Journal, Mohamadi et al. explain findings from a meta-analysis of 37 studies involving nearly 2 million patients that pinpoint several patient-related risk factors associated with opioid use beyond 2 months following surgery or trauma.
Using careful meta-analysis methods, the authors determined that about 4% of patients continued to use prescription opioids beyond 2 months after surgery or trauma. They also identified the following risk factors as being “among the most important predictors of prolonged opioid use” in these patients:
- Prior use of opioids or benzodiazepines
- Depression
- Long-duration hospital stay
- History of back pain
Mohamadi et al. also calculated a “number needed to harm” (NNH) from their data. NNH indicates the number of patients with a certain risk factor that is necessary to result in 1 person with prolonged opioid use beyond that of a patient population without that risk factor. They found that for every 3 patients with a history of opioid use, every 23 patients with a history of back pain, every 40 with depression, or every 62 with a history of benzodiazepine use, 1 patient will continue to use prescribed opioids for an extended time period.
Because this meta-analysis was derived from observational studies, the authors caution that “causal inferences could not be drawn for the proposed risk factors.” But they do offer a practical piece of advice gleaned from prior research: Provide patients with an opioid-tapering plan at the time of discharge to significantly reduce the likelihood of prolonged opioid use.
Pay Attention to Psychiatric Illness in Polytrauma Patients
Ample research has revealed that a patient’s psychological status influences the outcomes of many medical interventions. While orthopaedists treating patients with multiple-system orthopaedic trauma might not think first of the patient’s mental health, they should definitely take it into account, according to a prognostic study by Weinberg et al. in the March 2, 2016 Journal of Bone & Joint Surgery.
The study found that depression was an independent predictor of increased complications among 130 polytrauma patients who had preexisting psychiatric disorders. The authors also found that, relative to patients managed by a general trauma surgery service, those managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized and were less likely to receive instructions for mental-health follow-up upon discharge. The findings prompt the authors to encourage “awareness of [psychiatric] comorbidities during the treatment of orthopaedic conditions, the involvement of mental health-care providers in care, and the arrangement for meaningful mental health follow-up at the time of discharge.”
In her commentary on the Weinberg et al. study, Margaret McQueen, MD not only concurs with the authors’ admonitions, but adds that “we should control for psychiatric distress in our outcome measures to define the effect of surgical treatment more accurately.”
JBJS Editor’s Choice—Patient Pain: A Hurdle for All Orthopaedists
Ev
ery clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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