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Mental health status found to impact patient reported THR outcomes as much as age
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BERLIN — Researchers from Boston and Sweden have identified preoperative antidepressant use as a significant risk factor of poorer patient reported outcomes 1 year after total hip replacement.
“Patients using antidepressants were less satisfied with their treatment, and the risk factors for less satisfaction were female gender, higher age, Charnley class C and antidepressant usage,” Meridith E. Greene, BA, of Massachusetts General Hospital, Boston, said during her presentation at the 13th EFORT Congress 2012.
To determine the impact of a patient’s mental health status inferred by preoperative antidepressant use on patient reported outcome measures, Greene and colleagues from the University of Göteborg and Karolinska Institute studied data for 13,261 patients with osteoarthritis entered into the Swedish Hip Arthroplasty Register from 2006 to 2007. They crossed their findings with a national database of prescription drug purchases from 2005.
Antidepressant use analyzed
“The use of antidepressants in this population was defined as the purchase of antidepressant medication up to 3 years before surgery,” Greene said.
Meridith E. Greene
Greene and colleagues excluded patients who underwent reoperation within 1 year of total hip replacement (THR) from the study and surveyed participants preoperatively and at 1-year follow-up for Charnley classification, health-related quality of life using the EuroQol-5D (EQ-5D) and pain on a 100-point Visual Analog Scale (VAS).
Patients also reported their satisfaction with surgery at 1-year postoperatively using a 100-point VAS.
The investigators discovered that 13% of patients used antidepressants.
“These patients had poor health-related quality of life and higher levels of pain before and after THR surgery,” Greene said. “They also had less satisfaction with treatment. But, despite starting and ending with lower scores, antidepressant patients improved, on average, at a similar rate as those not using antidepressants.”
Screening for psychological distress
A linear regression analysis revealed that male gender, older age, Charnley class C and antidepressant use significantly decreased any change in the patients’ overall impression of health as noted in the EQ VAS.
“However, unlike the EQ VAS, the liner regression analysis found male gender, older age and Charnley class C but not antidepressant usage significantly decreased the change in the EQ-5D index,” Greene said.
In addition, another liner regression analysis showed older age, Charnley class C and antidepressant use decreased the percent change in the pain VAS.
“Our findings add knowledge to the preoperative risk assessment,” Green said. “Understanding a patient’s mental health before surgery may play a key role in the management and education of patients before THR. A patient on antidepressants and at risk for poorer outcomes may be identified through a review of their medical records. Antidepressant usage, gender, age and Charnley classification could all play a part in predicting patient reported outcomes after THR, and clinicians should be encouraged to actively review and screen osteoarthritis patients for psychological distress before surgery.” – by Gina Brockenbrough, MA
Reference:
- Greene ME, Rolfson O, Gordon M, et al. Does the use of antidepressants predict outcomes following total hip replacement surgery? Paper #12-1930. Presented at the 13th EFORT Congress 2012. May 23-25. Berlin.
For more information:
- Meridith E. Greene, BA, can be reached at Massachusetts General Hospital, Harris Orthopaedic Laboratory, 55 Fruit St., Boston, MA 02114; email: megreene@partners.org.
- Disclosure: Greene has no relevant financial disclosures.
Perspective
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William R. Beach, MD
Patients with depression are, by my experience, seldom identified by the orthopedic surgeon or orthopedic process. Rarely do we refer patients for counseling or therapy. It is not surprising that those patients do less well. Curiously however, what is the estimated number of patients that are either on antidepressants or are clinically depressed while undergoing total joint arthroplasty (TJA)? How difficult would it be to determine the number of patients that are depressed and not on medication? Should all patients who are to undergo TJA be screened for depression and, if so, what is the least invasive/easiest way to do that? The SF-12, EuroQual-5D (EQ-5D) or similar tool could be used. But, if the incidence is low, the majority of patients will be “required” to complete a survey that is not applicable to them. Lastly, what is the protocol for patients who are identified as clinically depressed?
These are exactly the questions the payers would like us to answer. How can we coordinate care to maximize outcomes and maximize our investment in appropriate treatments? If we are able to better coordinate care, facilitate different services in the realm of medicine and, as importantly, collect the data, we should be able to determine the incidence of many disorders and the best modes of treatment for each, in isolation or when combinations of morbidities are present. The hope of modern medicine is to collect data and base treatment on the best available evidence, realizing the best available evidence will often be expert consensus equal to expert opinion.
Perspective
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Robert S. Namba, MD
The association of mental health and total joint replacement outcomes has previously been published. Specifically, a mental component score of the SF-36 score of less than 50 predicted poorer outcomes 6 months after a total joint procedure. From a practical standpoint, however, most patients undergoing total joint replacement do undergo an SF-36 evaluation.
The presentation by Greene and colleagues is promising because antidepressant use is readily available for all patients. Their finding that use of antidepressant was a significant risk factor for poorer patient reported outcomes after total hip replacement will help identify patients at risk. It was not reported whether the patients had satisfactory management of depression, only that medication was purchased. Efficacy of management would provide insight into whether depression is a modifiable risk factor that could be optimized before surgery.
Reference:
- Ayers DC, Franklin PD, Trief PM, Ploutz-Snyder R, et al. Psychological attributes of preoperative total joint replacement patients: Implications for optimal physical outcome. J Arthroplasty. 2004;19(7):125-130.
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