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Corresponding author: Ryan P. Calfee, MD, MS, Department of Orthopaedic Surgery, Washington University, 660 South Euclid Ave., Campus Box 8233, St. Louis, MO 63110.
We aimed to test the utility of screening for depressive symptoms in the hand surgical office focusing on chances of heightened depressive symptoms in patients with no history of diagnosed depression and by quantifying ongoing depressive symptoms among patients diagnosed with depression accounting for antidepressant use. The clinical importance of this study was predicated on the documented negative association between depressive symptoms and hand surgical outcomes.
Methods
This cross-sectional study analyzed 351 patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. Adult patients completed self-administered Patient-Reported Outcomes Measurement Information System (PROMIS) Depression computer adaptive tests at registration. Health records were examined for a past medical history of diagnosed depression and whether patients reported current use of prescription antidepressants. Mean PROMIS Depression scores were compared by analysis of variance (groups: no diagnosed depression, depression without medication, depression with medication). Four points represented a clinically relevant difference in PROMIS Depression scores between groups and Depression scores greater than 59.9 were categorized as having heightened depressive symptoms.
Results
Sixty-two patients (18%) had been diagnosed with depression. Thirty-four of these patients (55%) reported taking antidepressant medications. The PROMIS Depression scores indicated greater current depressive symptoms among patients with a history of diagnosed depression when not taking antidepressants (11 points worse than unaffected) and also among patients taking antidepressants (7 points worse than unaffected). Heightened depressive symptoms were detected in all groups but were more prevalent among those diagnosed with depression (36% with no medication, 29% with antidepressant medication) compared with unaffected patients (7%).
Conclusions
Depression screening for heightened depressive symptoms identifies 1 in 14 patients without diagnosed depression and 1 in 3 patients diagnosed with depression as having currently heightened depressive symptoms. Hand surgeons can use PROMIS Depression screening in all patients and using this to guide referrals for depression treatment to ameliorate one confounder of hand surgical outcomes.
Depression is also increasingly recognized as having a negative impact on treatment results and surgical outcomes among patients with musculoskeletal conditions.
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.
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.
Most studies have explored the orthopedic implications of depression via patient-reported depressive symptom questionnaires or reported histories of depression, without examining the impact of antidepressant medications.
The Patient-Reported Outcomes Measurement Information System (PROMIS) is unique among outcome measures used in hand surgery because it offers assessment of mental and social health in addition to physical function. The PROMIS Depression Computer Adaptive Test (CAT) screens patients for depressive symptoms in the 7 days before presentation.
Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
Discriminant ability, concurrent validity, and responsiveness of PROMIS health domains among patients with lumbar degenerative disease undergoing decompression with or without arthrodesis.
are independent of any formal diagnosis of depression. Patients formally diagnosed with depression may receive pharmacological treatment and could potentially present with average, or below-average, levels of depressive symptoms.
The main goal of this study was to clarify the utility of depression screening in the hand surgical office. We aimed to determine whether PROMIS Depression scores differ (mean and prevalence of heightened depression) between hand patients who either have or do not have a formal diagnosis of depression. We planned to further categorize patients diagnosed with depression according to their use of antidepressants.
Methods
This cross-sectional study analyzed data from 351 adult patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. These patients were randomly selected for this study’s manual record review from a dataset of 3,524 patients who newly presented to our hand surgeons for 1 of 6 common hand conditions (carpal tunnel syndrome, cubital tunnel syndrome, de Quervain tendinitis, trapeziometacarpal joint arthritis, distal radius fracture, metacarpal/phalanx fracture). The larger dataset had already excluded patients younger than 18 years of age, those with other diagnoses, and any who did not complete PROMIS assessments.
Upon check-in, patients completed the self-administered PROMIS Depression, Anxiety, Pain Interference, and Physical Function CATs on a computer tablet and had their scores automatically uploaded to their electronic health record. The PROMIS tests are validated patient-reported health domain surveys scaled to a population mean score of 50, with an SD of 10 points.
Higher scores indicate more of each health domain. For example, a PROMIS Depression score of 60 would indicate depressive symptoms 1 SD greater than the normative population. A minimal clinically important difference (MCID) of 3.0 to 4.5 points on the PROMIS Depression measure has been proposed in oncology patients.
Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
and self-views. Linkage tables relate PROMIS Depression scores to legacy measures. A PROMIS Depression score of 59.9 correlates to a Patient Health Questionnaire 9 (PHQ-9) score of 10, which has the greatest specificity and sensitivity for predicting a diagnosis of major depression.
A score greater than 10 on the PHQ-9 indicates moderate depression. Therefore, we classified a PROMIS Depression score of greater than 59.9 as indicative of a patient experiencing heightened depressive symptoms.
Electronic health records were manually reviewed to identify any history of diagnosed depression and reported antidepressant use. Specifically, patient self-report intake questionnaires were queried to establish any diagnosis of depression and use of antidepressant medication. On these questionnaires, patients reported their regularly used medications and the reason for the medication. Based on this information, we divided patients into 3 groups: no prior diagnosis of depression or antidepressant use (unaffected), diagnosed depression without antidepressant use, and diagnosed depression with antidepressant use.
Statistical analysis
Descriptive statistics were generated for patient demographics. One-way analysis of variance was performed to compare mean PROMIS Depression scores between patient groups with Tukey B pairwise testing. Between-group differences were also assessed as clinically relevant or not based on the MCID threshold of 4 points.
The proportion of patients affected by heightened depressive symptoms (PROMIS Depression score > 59.9) according to patient group was analyzed by chi-square testing.
An exploratory analysis examined for clinically relevant differences (4 points based on several MCID publications) according to the patient groups and the mean value of other PROMIS scores: Anxiety, Pain Interference, and Physical Function.
Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
No statistical testing was used for these exploratory examinations.
An a priori sample size calculation was completed relevant to our primary analysis, which was the difference in PROMIS Depression scores between the 3 patient groups. This indicated the need for at least 66 patients overall to detect an effect size of 0.4 on Depression scores (4 point difference, SD 10 points) with an alpha of 0.05 and power of 0.80. Understanding that our patient groups would have uneven numbers, we aimed to collect enough patients to have at least 22 patients in our smallest patient group.
Results
Of the 351 patients analyzed, 209 (60%) were female. Patients averaged 53 (SD ± 17) years of age. Two hundred ninety-five patients (84%) described themselves as Caucasian with 42 (12%) identifying as Black. Two hundred forty patients (68%) presented with nontraumatic conditions (Table 1).
Sixty-two of 351 patients (18%) had been formally diagnosed with depression. Thirty-four of these patients (55%) reported using a prescription antidepressant. Significant (P < .05) differences existed in PROMIS Depression scores according to the patient group (no depression diagnosis, depression diagnosis with medication, and depression diagnosis without medication) (Fig. 1). Pairwise testing confirmed that patients without a history of diagnosed depression had significantly lower PROMIS Depression scores than those with diagnosed depression whether or not medications were prescribed (P < .05). The between-group differences in PROMIS Depression scores were deemed clinically relevant because unaffected patients averaged 11 points lower than those with diagnosed depression but not taking antidepressant medication and 7 points lower than those taking antidepressant medication for depression. There was no statistically significant difference in the PROMIS Depression scores among those patients with a history of diagnosed depression based on antidepressant use (P > .05) although the difference in mean score was exactly 4 points, which was our threshold for clinical relevance.
Figure 1Mean PROMIS Depression scores according to patient group.
Thirty-nine of the 312 patients (11%) demonstrated heightened depressive symptoms. This included patients in every category, although patients diagnosed with depression were more commonly affected (P < .05). Among patients with no history of depression, 19 of 270 (7%) had heightened depressive symptoms. For patients diagnosed with depression, 10 of 28 (36%) of those not on medication and 10 of 34 (29%) of those taking antidepressants reported heightened depressive symptoms (Fig. 2).
Figure 2Percentage of patients with heightened depressive symptoms according to patient group.
In exploratory qualitative analysis, PROMIS Anxiety scores demonstrated clinically relevant differences between the groups with the lowest anxiety levels among patients without depression (mean, 51 ± 11) followed by patients prescribed antidepressants (mean, 55 ± 10) and then patients diagnosed with depression but not on medication (mean, 59 ± 10). The PROMIS Pain Interference scores varied similarly, but only patients with depression and no medication (mean, 64 ± 8) demonstrated increased pain interference without clinically relevant differences between the other groups (mean, 60 ± 7 for no depression; mean, 59 ± 6 for depression with medication). The PROMIS Physical Function scores indicated less perceived function for those patients with depression and no medication (mean, 37 ± 9), whereas the other groups were not clinically distinct (means, 43 ± 8, 44 ± 10).
Discussion
In our sample, depression screening identified that 11% of our patient population reported currently heightened depressive symptoms. This included 1 in 14 patients with no history of depression and 1 in 3 patients with diagnosed depression. We view these data as supporting the value of depression screening and not presuming that patients on antidepressants have their depression controlled. Likewise, a lack of diagnosed depression does not rule out substantial active depressive symptoms.
Even when reporting antidepressant use, patients with a prior diagnosis of depression report more current depressive symptoms than unaffected patients. Large-scale cohort studies indicate that use of a new antidepressant results in people having improved quality of life and less depressive symptoms but not an elimination of all depressive symptoms.
Cognitive symptoms in major depressive disorder: associations with clinical and functional outcomes in a 6-month, non-interventional, prospective study in China.
Cognitive symptoms in major depressive disorder: associations with clinical and functional outcomes in a 6-month, non-interventional, prospective study in China.
Our findings were comparable in that 29% of our patients on antidepressants still reported heightened depressive symptoms. Our data indicate that patients medicated for depression are, on average, still going to report ongoing depressive symptoms that exceed those experienced by patients without a history of depression. Therefore, even when treated for depression, surgeons may be well served by exploring with patients whether they are still experiencing ongoing depressive symptoms that could benefit from reassessment by the physician managing their depression.
A prior diagnosis of depression was associated with worse PROMIS Depression scores. This indirectly supports the existing concept that patient health questionnaires are adequate when screening for depression.
However, it raises concerns that many patients diagnosed with depression are still experiencing relevant depressive symptoms. At the same time, it was also clear that patients without diagnosed depression can present for treatment while experiencing heightened depressive symptoms. Notably, legacy questionnaires such as the PHQ-9 and PHQ-2 are shown to effectively screen for depressive symptoms, but not establish a clinical diagnosis of depression.
Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies.
This is a helpful distinction to explain to patients reluctant to answer survey questions about depressive symptoms fearing that they will be diagnosed with depression.
The prevalence of depression and antidepressant use in both general and surgical populations is substantial and growing.
Rates and predictors of anti-depressant prescribing in Northern Ireland 2011–2015: a data linkage study using the Administrative Data Research Centre (NI).
Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.
Efficacy and acceptability of interventions for attenuated positive psychotic symptoms in individuals at clinical high risk of psychosis: a network meta-analysis.
Adherence to antidepressant medication is considered a major barrier to effective treatment of Major Depressive Disorder in psychiatry, with estimates of acceptable adherence ranging from 80% to as low as 37% for some groups.
That said, outpatients in primary care settings are most likely to adhere to their treatment regimen, and the current study determined antidepressant use from patient self-report of medications used as opposed to physician-generated records. This should have minimized bias associated with miscategorizing patients as taking antidepressants when they are not complying with that medication. However, patient noncompliance is still possible. Noncompliance would have biased our PROMIS scores toward underestimating the treatment effect of these medications. Importantly though, our observational study findings should be generalizable because most surgeons presume self-reported outpatient medication lists are accurate and indicate treatment of the relevant comorbidity.
Antidepressant medication did not eliminate the differential depressive symptoms reported by patients with and without depression. However, when examining Pain Interference and Physical Function, the patients on antidepressants more closely approximated those patients without any history of depression. This may have occurred because certain antidepressants alleviate musculoskeletal or nerve-related pain.
Because our examination of these other PROMIS domains was an exploratory analysis, this will require further dedicated study.
This study has several inherent limitations. As noted earlier, our cross-sectional study cannot quantify how antidepressant medication use may have altered depressive symptoms in individual patients. We chose to base our patient categorization (depression history, medication use) on self-report intake forms. Although patient omission and errors risk misclassification, we felt the intake forms would best capture diagnoses and treatments from any provider even if outside of our health system. Also, these forms have places to mark for no medical problems and no medications used, which allowed us to distinguish negative histories from inadvertent skipping sections. All patients in this study presented for treatment of a symptomatic hand condition. It is likely that these individuals were experiencing increased pain or impaired function, which can be a psychological stressor. Therefore, the depressive symptoms measured may reflect a combination of baseline depressive symptoms as well as depressive symptoms produced by their upper extremity condition. Finally, our cross-sectional study was not designed to collect outcome data following treatment. Therefore, we relied on the body of literature demonstrating the negative association between depressive symptoms and surgical outcomes to presume that it is important to detect depressive symptoms.
This study offers insight into the utility of depression screening for the hand surgeon and the assessment of patients with diagnosed depression who are now seeking hand surgical care. Depression screening has value in detecting heightened depressive symptoms in patients with and without diagnosed depression. It is well documented that comorbid depression is associated with worse surgical outcomes.
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.
Our data suggest that a diagnosis of depression remains relevant even when a patient reports treatment with an antidepressant. Thus, we see depression affecting hand surgical patients as a comorbidity that surgeons cannot presume is eliminated by medication. Therefore, in patients with diagnosed depression, surgeons may be well served to screen patients for ongoing depressive symptoms even when the patient is taking an antidepressant. If a patient reports active depressive symptoms and hand surgery is not urgent, we would recommend that the surgeon facilitate further treatment (either return to, or discussion with, mental health provider or primary physician) because this may improve the ultimate functional outcome. Future research appears warranted to determine the effects of psychotropic medications and treating depression on hand surgical outcomes.
References
The National Institute of Mental Health Information Resource Center
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.
Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
Discriminant ability, concurrent validity, and responsiveness of PROMIS health domains among patients with lumbar degenerative disease undergoing decompression with or without arthrodesis.
Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
Cognitive symptoms in major depressive disorder: associations with clinical and functional outcomes in a 6-month, non-interventional, prospective study in China.
Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies.
Rates and predictors of anti-depressant prescribing in Northern Ireland 2011–2015: a data linkage study using the Administrative Data Research Centre (NI).
Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.
Efficacy and acceptability of interventions for attenuated positive psychotic symptoms in individuals at clinical high risk of psychosis: a network meta-analysis.
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