Advertisement
Editor’s Choice| Volume 46, ISSUE 2, P99-105, February 2021

Download started.

Ok

Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients

Published:December 01, 2020DOI:https://doi.org/10.1016/j.jhsa.2020.10.012

      Purpose

      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.

      Type of study/level of evidence

      Symptom prevalence study II.

      Key words

      In 2017, 17.3 million U.S. adults had at least 1 major depressive episode.
      The National Institute of Mental Health Information Resource Center
      Major depression. 2019.
      Depression can impart considerable individual morbidity and accounts for substantial societal medical resource consumption.
      • Katon W.
      • Lin E.H.
      • Kroenke K.
      The association of depression and anxiety with medical symptom burden in patients with chronic medical illness.
      ,
      • Kang H.J.
      • Kim S.Y.
      • Bae K.Y.
      • et al.
      Comorbidity of depression with physical disorders: research and clinical implications.
      Depression is also increasingly recognized as having a negative impact on treatment results and surgical outcomes among patients with musculoskeletal conditions.
      • Bot A.G.
      • Menendez M.E.
      • Neuhaus V.
      • Ring D.
      The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty.
      • Buller L.T.
      • Best M.J.
      • Klika A.K.
      • Barsoum W.K.
      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.
      • Werner B.C.
      • Wong A.C.
      • Chang B.
      • et al.
      Depression and patient-reported outcomes following total shoulder arthroplasty.
      • Garcia G.H.
      • Wu H.H.
      • Park M.J.
      • et al.
      Depression symptomatology and anterior cruciate ligament injury: incidence and effect on functional outcome—a prospective cohort study.
      • Stone A.H.
      • MacDonald J.H.
      • King P.J.
      The effect of psychiatric diagnosis and psychotropic medication on outcomes following total hip and total knee arthroplasty.
      • Ellis H.B.
      • Howard K.J.
      • Khaleel M.A.
      • Bucholz R.
      Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population.
      • Weinberg D.S.
      • Narayanan A.S.
      • Boden K.A.
      • Breslin M.A.
      • Vallier H.A.
      Psychiatric illness is common among patients with orthopaedic polytrauma and is linked with poor outcomes.
      • Singh J.A.
      • Lewallen D.
      Age, gender, obesity, and depression are associated with patient-related pain and function outcome after revision total hip arthroplasty.
      • Martin R.L.
      • Christoforetti J.J.
      • McGovern R.
      • et al.
      The impact of depression on patient outcomes in hip arthroscopic surgery.
      • Crijns T.J.
      • Bernstein D.N.
      • Ring D.
      • Gonzalez R.M.
      • Wilbur D.
      • Hammert W.C.
      Depression and pain interference correlate with physical function in patients recovering from hand surgery.
      Depression affects 20% to 30% of orthopedic patients.
      • Rahman A.S.
      • Aziz A.
      • Jamal Q.
      • Siddiqui M.A.
      • Riaz M.
      • Ali R.
      Prevalence of recognised and unrecognised depression among medical and surgical patients in a tertiary care hospital.
      • Jang B.
      • Bhavsar D.R.
      The prevalence of psychiatric disorders among elective plastic surgery patients.
      • Esteghamat S.S.
      • Moghaddami S.
      • Esteghamat S.S.
      • Kazemi H.
      • Kolivand P.H.
      • Gorji A.
      The course of anxiety and depression in surgical and non-surgical patients.
      • Oflazoglu K.
      • Mellema J.J.
      • Menendez M.E.
      • Mudgal C.S.
      • Ring D.
      • Chen N.C.
      Prevalence of and factors associated with major depression in patients with upper extremity conditions.
      Comorbid depression increases postoperative pain and mortality and impairs perceived physical function.
      • Bot A.G.
      • Menendez M.E.
      • Neuhaus V.
      • Ring D.
      The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty.
      • Buller L.T.
      • Best M.J.
      • Klika A.K.
      • Barsoum W.K.
      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.
      • Werner B.C.
      • Wong A.C.
      • Chang B.
      • et al.
      Depression and patient-reported outcomes following total shoulder arthroplasty.
      • Garcia G.H.
      • Wu H.H.
      • Park M.J.
      • et al.
      Depression symptomatology and anterior cruciate ligament injury: incidence and effect on functional outcome—a prospective cohort study.
      • Stone A.H.
      • MacDonald J.H.
      • King P.J.
      The effect of psychiatric diagnosis and psychotropic medication on outcomes following total hip and total knee arthroplasty.
      • Ellis H.B.
      • Howard K.J.
      • Khaleel M.A.
      • Bucholz R.
      Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population.
      • Weinberg D.S.
      • Narayanan A.S.
      • Boden K.A.
      • Breslin M.A.
      • Vallier H.A.
      Psychiatric illness is common among patients with orthopaedic polytrauma and is linked with poor outcomes.
      • Singh J.A.
      • Lewallen D.
      Age, gender, obesity, and depression are associated with patient-related pain and function outcome after revision total hip arthroplasty.
      • Martin R.L.
      • Christoforetti J.J.
      • McGovern R.
      • et al.
      The impact of depression on patient outcomes in hip arthroscopic surgery.
      • Crijns T.J.
      • Bernstein D.N.
      • Ring D.
      • Gonzalez R.M.
      • Wilbur D.
      • Hammert W.C.
      Depression and pain interference correlate with physical function in patients recovering from hand surgery.
      ,
      • Skeppholm M.
      • Fransson R.
      • Hammar M.
      • Olerud C.
      The association between preoperative mental distress and patient-reported outcome measures in patients treated surgically for cervical radiculopathy.
      • Goebel S.
      • Baumann B.
      • Steinert A.
      • Reppenhagen S.
      • Faller H.
      Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor [in German].
      • Vranceanu A.M.
      • Jupiter J.B.
      • Mudgal C.S.
      • Ring D.
      Predictors of pain intensity and disability after minor hand surgery.
      • Lozano Calderon S.A.
      • Paiva A.
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • London D.A.
      • Stepan J.G.
      • Boyer M.I.
      • Calfee R.P.
      The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions.
      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.
      • Crijns T.J.
      • Bernstein D.N.
      • Ring D.
      • Gonzalez R.M.
      • Wilbur D.
      • Hammert W.C.
      Depression and pain interference correlate with physical function in patients recovering from hand surgery.
      ,
      • Skeppholm M.
      • Fransson R.
      • Hammar M.
      • Olerud C.
      The association between preoperative mental distress and patient-reported outcome measures in patients treated surgically for cervical radiculopathy.
      • Goebel S.
      • Baumann B.
      • Steinert A.
      • Reppenhagen S.
      • Faller H.
      Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor [in German].
      • Vranceanu A.M.
      • Jupiter J.B.
      • Mudgal C.S.
      • Ring D.
      Predictors of pain intensity and disability after minor hand surgery.
      • Lozano Calderon S.A.
      • Paiva A.
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • London D.A.
      • Stepan J.G.
      • Boyer M.I.
      • Calfee R.P.
      The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions.
      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.
      • Pilkonis P.A.
      • Choi S.W.
      • Reise S.P.
      • et al.
      Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
      The PROMIS Depression scores, and the legacy measures against which they have been validated,
      • Purvis T.E.
      • Andreou E.
      • Neuman B.J.
      • Riley III, L.H.
      • Skolasky R.L.
      Concurrent validity and responsiveness of PROMIS health domains among patients presenting for anterior cervical spine surgery.
      ,
      • Purvis T.E.
      • Neuman B.J.
      • Riley III, L.H.
      • Skolasky R.L.
      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.
      • Bevans M.
      • Ross A.
      • Cella D.
      Patient-Reported Outcomes Measurement Information System (PROMIS): efficient, standardized tools to measure self-reported health and quality of life.
      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.
      • Yost K.J.
      • Eton D.T.
      • Garcia S.F.
      • Cella D.
      Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
      Similar MCID values have been proposed on other PROMIS assessments in patients with musculoskeletal conditions.
      • Steinhaus M.E.
      • Iyer S.
      • Lovecchio F.
      • et al.
      Minimal clinically important difference and substantial clinical benefit using PROMIS CAT in cervical spine surgery.
      • Kazmers N.H.
      • Hung M.
      • Bounsanga J.
      • Voss M.W.
      • Howenstein A.
      • Tyser A.R.
      Minimal clinically important difference after carpal tunnel release using the PROMIS platform.
      • Sandvall B.
      • Okoroafor U.C.
      • Gerull W.
      • Guattery J.
      • Calfee R.P.
      Minimal clinically important difference for PROMIS Physical Function in patients with distal radius fractures.
      • Lee D.J.
      • Calfee R.P.
      The minimal clinically important difference for PROMIS Physical Function in patients with thumb carpometacarpal arthritis.
      Therefore, we set 4 points as our threshold for a clinically important difference in PROMIS Depression scores between groups.
      The PROMIS Depression CAT measures persistent negative mood, affect,
      • Pilkonis P.A.
      • Choi S.W.
      • Reise S.P.
      • et al.
      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.
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      The PHQ-9: validity of a brief depression severity measure.
      ,
      PROsetta Stone
      Linking Patient-Reported Outcome Measures.
      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.
      • Yost K.J.
      • Eton D.T.
      • Garcia S.F.
      • Cella D.
      Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
      ,
      • Kazmers N.H.
      • Hung M.
      • Bounsanga J.
      • Voss M.W.
      • Howenstein A.
      • Tyser A.R.
      Minimal clinically important difference after carpal tunnel release using the PROMIS platform.
      • Sandvall B.
      • Okoroafor U.C.
      • Gerull W.
      • Guattery J.
      • Calfee R.P.
      Minimal clinically important difference for PROMIS Physical Function in patients with distal radius fractures.
      • Lee D.J.
      • Calfee R.P.
      The minimal clinically important difference for PROMIS Physical Function in patients with thumb carpometacarpal arthritis.
      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).
      Table 1Diagnoses Established in Patients
      Diagnoses
      Patients may have more than 1 diagnosis.
      n (%)
      Carpal tunnel syndrome94 (27)
      Cubital tunnel syndrome72 (21)
      De Quervain tenosynovitis64 (18)
      Trapeziometacarpal osteoarthritis67 (19)
      Distal radius fracture60 (17)
      Metacarpal/phalangeal fracture58 (17)
      Patients may have more than 1 diagnosis.
      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 thumbnail gr1
      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 thumbnail gr2
      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.
      • Saragoussi D.
      • Christensen M.C.
      • Hammer-Helmich L.
      • Rive B.
      • Touya M.
      • Haro J.M.
      Long-term follow-up on health-related quality of life in major depressive disorder: a 2-year European cohort study.
      ,
      • Wang G.
      • Si T.M.
      • Li L.
      • et al.
      Cognitive symptoms in major depressive disorder: associations with clinical and functional outcomes in a 6-month, non-interventional, prospective study in China.
      Among 598 Chinese outpatients treated for 6 months, 65% of patients’ depression was in remission.
      • Wang G.
      • Si T.M.
      • Li L.
      • et al.
      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.
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      The PHQ-9: validity of a brief depression severity measure.
      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.
      • Mitchell A.J.
      • Yadegarfar M.
      • Gill J.
      • Stubbs B.
      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.
      • Pratt L.A.
      • Brody D.J.
      • Gu Q.
      Antidepressant use among persons aged 12 and over: United States, 2011–2014.
      • Moore T.J.
      • Mattison D.R.
      Adult utilization of psychiatric drugs and differences by sex, age, and race.
      • Petty D.R.
      • House A.
      • Knapp P.
      • Raynor T.
      • Zermansky A.
      Prevalence, duration and indications for prescribing of antidepressants in primary care.
      • Harris T.
      • Carey I.M.
      • Shah S.M.
      • DeWilde S.
      • Cook D.G.
      Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales.
      • Shevlin M.
      • Rosato M.
      • Boyle S.
      • Boduszek D.
      • Murphy J.
      Rates and predictors of anti-depressant prescribing in Northern Ireland 2011–2015: a data linkage study using the Administrative Data Research Centre (NI).
      • Boissonnault W.G.
      Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: a multicentered study.
      • Movig K.L.
      • Janssen M.W.
      • de Waal Malefijt J.
      • Kabel P.J.
      • Leufkens H.G.
      • Egberts A.C.
      Relationship of serotonergic antidepressants and need for blood transfusion in orthopedic surgical patients.
      • Patterson R.W.
      • Li Z.
      • Smith B.P.
      • Smith T.L.
      • Koman L.A.
      Complex regional pain syndrome of the upper extremity.
      • Mojtabai R.
      • Olfson M.
      Proportion of antidepressants prescribed without a psychiatric diagnosis is growing.
      Antidepressants are generally understood to be efficacious for Major Depressive Disorder,
      • Ostuzzi G.
      • Benda L.
      • Costa E.
      • Barbui C.
      Efficacy and acceptability of antidepressants on the continuum of depressive experiences in patients with cancer: systematic review and meta-analysis.
      • Cortese S.
      • Adamo N.
      • Del Giovane C.
      • et al.
      Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.
      • Davies C.
      • Radua J.
      • Cipriani A.
      • et al.
      Efficacy and acceptability of interventions for attenuated positive psychotic symptoms in individuals at clinical high risk of psychosis: a network meta-analysis.
      but the magnitude of their effect and the population for whom they are most beneficial remain unclear.
      • Cameron I.M.
      • Reid I.C.
      • MacGillivray S.A.
      Efficacy and tolerability of antidepressants for sub-threshold depression and for mild major depressive disorder.
      ,
      • Moncrieff J.
      What does the latest meta-analysis really tell us about antidepressants?.
      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.
      • Serrano M.J.
      • Vives M.
      • Mateu C.
      • et al.
      Therapeutic adherence in primary care depressed patients: a longitudinal study.
      • Sansone R.A.
      • Sansone L.A.
      Antidepressant adherence: are patients taking their medications?.
      • Samples H.
      • Mojtabai R.
      Antidepressant self-discontinuation: results from the collaborative psychiatric epidemiology surveys.
      • Degli Esposti L.
      • Piccinni C.
      • Sangiorgi D.
      • Fagiolini A.
      • Buda S.
      Patterns of antidepressant use in Italy: therapy duration, adherence and switching.
      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.
      • Lunn M.P.
      • Hughes R.A.
      • Wiffen P.J.
      Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia.
      • Sindrup S.H.
      • Otto M.
      • Finnerup N.B.
      • Jensen T.S.
      Antidepressants in the treatment of neuropathic pain.
      • Uhl R.L.
      • Roberts T.T.
      • Papaliodis D.N.
      • Mulligan M.T.
      • Dubin A.H.
      Management of chronic musculoskeletal pain.
      • Shen F.H.
      • Samartzis D.
      • Andersson G.B.
      Nonsurgical management of acute and chronic low back pain.
      • Konno S.
      • Oda N.
      • Ochiai T.
      • Alev L.
      Randomized, double-blind, placebo-controlled phase iii trial of duloxetine monotherapy in Japanese patients with chronic low back pain.
      • van den Driest J.J.
      • Bierma-Zeinstra S.M.A.
      • Bindels P.J.E.
      • Schiphof D.
      Amitriptyline for musculoskeletal complaints: a systematic review.
      • Richards B.L.
      • Whittle S.L.
      • Buchbinder R.
      Antidepressants for pain management in rheumatoid arthritis.
      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.
      • Bot A.G.
      • Menendez M.E.
      • Neuhaus V.
      • Ring D.
      The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty.
      • Buller L.T.
      • Best M.J.
      • Klika A.K.
      • Barsoum W.K.
      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.
      • Werner B.C.
      • Wong A.C.
      • Chang B.
      • et al.
      Depression and patient-reported outcomes following total shoulder arthroplasty.
      • Garcia G.H.
      • Wu H.H.
      • Park M.J.
      • et al.
      Depression symptomatology and anterior cruciate ligament injury: incidence and effect on functional outcome—a prospective cohort study.
      • Stone A.H.
      • MacDonald J.H.
      • King P.J.
      The effect of psychiatric diagnosis and psychotropic medication on outcomes following total hip and total knee arthroplasty.
      • Ellis H.B.
      • Howard K.J.
      • Khaleel M.A.
      • Bucholz R.
      Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population.
      • Weinberg D.S.
      • Narayanan A.S.
      • Boden K.A.
      • Breslin M.A.
      • Vallier H.A.
      Psychiatric illness is common among patients with orthopaedic polytrauma and is linked with poor outcomes.
      • Singh J.A.
      • Lewallen D.
      Age, gender, obesity, and depression are associated with patient-related pain and function outcome after revision total hip arthroplasty.
      • Martin R.L.
      • Christoforetti J.J.
      • McGovern R.
      • et al.
      The impact of depression on patient outcomes in hip arthroscopic surgery.
      • Crijns T.J.
      • Bernstein D.N.
      • Ring D.
      • Gonzalez R.M.
      • Wilbur D.
      • Hammert W.C.
      Depression and pain interference correlate with physical function in patients recovering from hand surgery.
      ,
      • Skeppholm M.
      • Fransson R.
      • Hammar M.
      • Olerud C.
      The association between preoperative mental distress and patient-reported outcome measures in patients treated surgically for cervical radiculopathy.
      • Goebel S.
      • Baumann B.
      • Steinert A.
      • Reppenhagen S.
      • Faller H.
      Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor [in German].
      • Vranceanu A.M.
      • Jupiter J.B.
      • Mudgal C.S.
      • Ring D.
      Predictors of pain intensity and disability after minor hand surgery.
      • Lozano Calderon S.A.
      • Paiva A.
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • London D.A.
      • Stepan J.G.
      • Boyer M.I.
      • Calfee R.P.
      The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions.
      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
        Major depression. 2019.
        (Available at:)
        • Katon W.
        • Lin E.H.
        • Kroenke K.
        The association of depression and anxiety with medical symptom burden in patients with chronic medical illness.
        Gen Hosp Psychiatry. 2007; 29: 147-155
        • Kang H.J.
        • Kim S.Y.
        • Bae K.Y.
        • et al.
        Comorbidity of depression with physical disorders: research and clinical implications.
        Chonnam Med J. 2015; 51: 8-18
        • Bot A.G.
        • Menendez M.E.
        • Neuhaus V.
        • Ring D.
        The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty.
        J Shoulder Elbow Surg. 2014; 23: 519-527
        • Buller L.T.
        • Best M.J.
        • Klika A.K.
        • Barsoum W.K.
        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: 165-170
        • Werner B.C.
        • Wong A.C.
        • Chang B.
        • et al.
        Depression and patient-reported outcomes following total shoulder arthroplasty.
        J Bone Joint Surg Am. 2017; 99: 688-695
        • Garcia G.H.
        • Wu H.H.
        • Park M.J.
        • et al.
        Depression symptomatology and anterior cruciate ligament injury: incidence and effect on functional outcome—a prospective cohort study.
        Am J Sports Med. 2016; 44: 572-579
        • Stone A.H.
        • MacDonald J.H.
        • King P.J.
        The effect of psychiatric diagnosis and psychotropic medication on outcomes following total hip and total knee arthroplasty.
        J Arthroplasty. 2019; 34: 1918-1921
        • Ellis H.B.
        • Howard K.J.
        • Khaleel M.A.
        • Bucholz R.
        Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population.
        J Bone Joint Surg Am. 2012; 94: e84
        • Weinberg D.S.
        • Narayanan A.S.
        • Boden K.A.
        • Breslin M.A.
        • Vallier H.A.
        Psychiatric illness is common among patients with orthopaedic polytrauma and is linked with poor outcomes.
        J Bone Joint Surg Am. 2016; 98: 341-348
        • Singh J.A.
        • Lewallen D.
        Age, gender, obesity, and depression are associated with patient-related pain and function outcome after revision total hip arthroplasty.
        Clin Rheumatol. 2009; 28: 1419-1430
        • Martin R.L.
        • Christoforetti J.J.
        • McGovern R.
        • et al.
        The impact of depression on patient outcomes in hip arthroscopic surgery.
        Orthop J Sports Med. 2018; 6 (2325967118806490)
        • Crijns T.J.
        • Bernstein D.N.
        • Ring D.
        • Gonzalez R.M.
        • Wilbur D.
        • Hammert W.C.
        Depression and pain interference correlate with physical function in patients recovering from hand surgery.
        Hand (N Y). 2019; 14: 830-835
        • Rahman A.S.
        • Aziz A.
        • Jamal Q.
        • Siddiqui M.A.
        • Riaz M.
        • Ali R.
        Prevalence of recognised and unrecognised depression among medical and surgical patients in a tertiary care hospital.
        J Pak Med Assoc. 2015; 65: 1320-1324
        • Jang B.
        • Bhavsar D.R.
        The prevalence of psychiatric disorders among elective plastic surgery patients.
        Eplasty. 2019; 19: e6
        • Esteghamat S.S.
        • Moghaddami S.
        • Esteghamat S.S.
        • Kazemi H.
        • Kolivand P.H.
        • Gorji A.
        The course of anxiety and depression in surgical and non-surgical patients.
        Int J Psychiatry Clin Pract. 2014; 18: 16-20
        • Oflazoglu K.
        • Mellema J.J.
        • Menendez M.E.
        • Mudgal C.S.
        • Ring D.
        • Chen N.C.
        Prevalence of and factors associated with major depression in patients with upper extremity conditions.
        J Hand Surg Am. 2016; 41 (e1–e7): 263-269
        • Skeppholm M.
        • Fransson R.
        • Hammar M.
        • Olerud C.
        The association between preoperative mental distress and patient-reported outcome measures in patients treated surgically for cervical radiculopathy.
        Spine J. 2017; 17: 790-798
        • Goebel S.
        • Baumann B.
        • Steinert A.
        • Reppenhagen S.
        • Faller H.
        Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor [in German].
        Schmerz. 2010; 24: 54-61
        • Vranceanu A.M.
        • Jupiter J.B.
        • Mudgal C.S.
        • Ring D.
        Predictors of pain intensity and disability after minor hand surgery.
        J Hand Surg Am. 2010; 35: 956-960
        • Lozano Calderon S.A.
        • Paiva A.
        • Ring D.
        Patient satisfaction after open carpal tunnel release correlates with depression.
        J Hand Surg Am. 2008; 33: 303-307
        • London D.A.
        • Stepan J.G.
        • Boyer M.I.
        • Calfee R.P.
        The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions.
        J Bone Joint Surg Am. 2014; 96: 806-814
        • Pilkonis P.A.
        • Choi S.W.
        • Reise S.P.
        • et al.
        Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
        Assessment. 2011; 18: 263-283
        • Purvis T.E.
        • Andreou E.
        • Neuman B.J.
        • Riley III, L.H.
        • Skolasky R.L.
        Concurrent validity and responsiveness of PROMIS health domains among patients presenting for anterior cervical spine surgery.
        Spine (Phila Pa 1976). 2017; 42: E1357-E1365
        • Purvis T.E.
        • Neuman B.J.
        • Riley III, L.H.
        • Skolasky R.L.
        Discriminant ability, concurrent validity, and responsiveness of PROMIS health domains among patients with lumbar degenerative disease undergoing decompression with or without arthrodesis.
        Spine (Phila Pa 1976). 2018; 43: 1512-1520
        • Bevans M.
        • Ross A.
        • Cella D.
        Patient-Reported Outcomes Measurement Information System (PROMIS): efficient, standardized tools to measure self-reported health and quality of life.
        Nurs Outlook. 2014; 62: 339-345
        • Yost K.J.
        • Eton D.T.
        • Garcia S.F.
        • Cella D.
        Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
        J Clin Epidemiol. 2011; 64: 507-516
        • Steinhaus M.E.
        • Iyer S.
        • Lovecchio F.
        • et al.
        Minimal clinically important difference and substantial clinical benefit using PROMIS CAT in cervical spine surgery.
        Clin Spine Surg. 2019; 32: 392-397
        • Kazmers N.H.
        • Hung M.
        • Bounsanga J.
        • Voss M.W.
        • Howenstein A.
        • Tyser A.R.
        Minimal clinically important difference after carpal tunnel release using the PROMIS platform.
        J Hand Surg Am. 2019; 44: 947-953.e1
        • Sandvall B.
        • Okoroafor U.C.
        • Gerull W.
        • Guattery J.
        • Calfee R.P.
        Minimal clinically important difference for PROMIS Physical Function in patients with distal radius fractures.
        J Hand Surg Am. 2019; 44: 454-459.e1
        • Lee D.J.
        • Calfee R.P.
        The minimal clinically important difference for PROMIS Physical Function in patients with thumb carpometacarpal arthritis.
        Hand (N Y). 2019; (1558944719880025)
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • PROsetta Stone
        Linking Patient-Reported Outcome Measures.
        (Available at:)
        • Saragoussi D.
        • Christensen M.C.
        • Hammer-Helmich L.
        • Rive B.
        • Touya M.
        • Haro J.M.
        Long-term follow-up on health-related quality of life in major depressive disorder: a 2-year European cohort study.
        Neuropsychiatr Dis Treat. 2018; 14: 1339-1350
        • Wang G.
        • Si T.M.
        • Li L.
        • et al.
        Cognitive symptoms in major depressive disorder: associations with clinical and functional outcomes in a 6-month, non-interventional, prospective study in China.
        Neuropsychiatr Dis Treat. 2019; 15: 1723-1736
        • Mitchell A.J.
        • Yadegarfar M.
        • Gill J.
        • Stubbs B.
        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.
        BJPsych Open. 2016; 2: 127-138
        • Pratt L.A.
        • Brody D.J.
        • Gu Q.
        Antidepressant use among persons aged 12 and over: United States, 2011–2014.
        NCHS Data Brief. 2017; 283: 1-8
        • Moore T.J.
        • Mattison D.R.
        Adult utilization of psychiatric drugs and differences by sex, age, and race.
        JAMA Intern Med. 2017; 177: 274-275
        • Petty D.R.
        • House A.
        • Knapp P.
        • Raynor T.
        • Zermansky A.
        Prevalence, duration and indications for prescribing of antidepressants in primary care.
        Age Ageing. 2006; 35: 523-526
        • Harris T.
        • Carey I.M.
        • Shah S.M.
        • DeWilde S.
        • Cook D.G.
        Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales.
        J Am Med Dir Assoc. 2012; 13: 41-47
        • Shevlin M.
        • Rosato M.
        • Boyle S.
        • Boduszek D.
        • Murphy J.
        Rates and predictors of anti-depressant prescribing in Northern Ireland 2011–2015: a data linkage study using the Administrative Data Research Centre (NI).
        Ir J Psychol Med. 2020; 37: 32-38
        • Boissonnault W.G.
        Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: a multicentered study.
        J Orthop Sports Phys Ther. 1999; 29 ([discussion: 520–525]): 506-519
        • Movig K.L.
        • Janssen M.W.
        • de Waal Malefijt J.
        • Kabel P.J.
        • Leufkens H.G.
        • Egberts A.C.
        Relationship of serotonergic antidepressants and need for blood transfusion in orthopedic surgical patients.
        Arch Intern Med. 2003; 163: 2354-2358
        • Patterson R.W.
        • Li Z.
        • Smith B.P.
        • Smith T.L.
        • Koman L.A.
        Complex regional pain syndrome of the upper extremity.
        J Hand Surg Am. 2011; 36: 1553-1562
        • Mojtabai R.
        • Olfson M.
        Proportion of antidepressants prescribed without a psychiatric diagnosis is growing.
        Health Aff (Millwood). 2011; 30: 1434-1442
        • Ostuzzi G.
        • Benda L.
        • Costa E.
        • Barbui C.
        Efficacy and acceptability of antidepressants on the continuum of depressive experiences in patients with cancer: systematic review and meta-analysis.
        Cancer Treat Rev. 2015; 41: 714-724
        • Cortese S.
        • Adamo N.
        • Del Giovane C.
        • et al.
        Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.
        Lancet Psychiatry. 2018; 5: 727-738
        • Davies C.
        • Radua J.
        • Cipriani A.
        • et al.
        Efficacy and acceptability of interventions for attenuated positive psychotic symptoms in individuals at clinical high risk of psychosis: a network meta-analysis.
        Front Psychiatry. 2018; 9: 187
        • Cameron I.M.
        • Reid I.C.
        • MacGillivray S.A.
        Efficacy and tolerability of antidepressants for sub-threshold depression and for mild major depressive disorder.
        J Affect Disord. 2014; 166: 48-58
        • Moncrieff J.
        What does the latest meta-analysis really tell us about antidepressants?.
        Epidemiol Psychiatr Sci. 2018; 27: 430-432
        • Serrano M.J.
        • Vives M.
        • Mateu C.
        • et al.
        Therapeutic adherence in primary care depressed patients: a longitudinal study.
        Actas Esp Psiquiatr. 2014; 42: 91-98
        • Sansone R.A.
        • Sansone L.A.
        Antidepressant adherence: are patients taking their medications?.
        Innov Clin Neurosci. 2012; 9: 41-46
        • Samples H.
        • Mojtabai R.
        Antidepressant self-discontinuation: results from the collaborative psychiatric epidemiology surveys.
        Psychiatr Serv. 2015; 66: 455-462
        • Degli Esposti L.
        • Piccinni C.
        • Sangiorgi D.
        • Fagiolini A.
        • Buda S.
        Patterns of antidepressant use in Italy: therapy duration, adherence and switching.
        Clin Drug Investig. 2015; 35: 735-742
        • Lunn M.P.
        • Hughes R.A.
        • Wiffen P.J.
        Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia.
        Cochrane Database Syst Rev. 2014; 1: CD007115
        • Sindrup S.H.
        • Otto M.
        • Finnerup N.B.
        • Jensen T.S.
        Antidepressants in the treatment of neuropathic pain.
        Basic Clin Pharmacol Toxicol. 2005; 96: 399-409
        • Uhl R.L.
        • Roberts T.T.
        • Papaliodis D.N.
        • Mulligan M.T.
        • Dubin A.H.
        Management of chronic musculoskeletal pain.
        J Am Acad Orthop Surg. 2014; 22: 101-110
        • Shen F.H.
        • Samartzis D.
        • Andersson G.B.
        Nonsurgical management of acute and chronic low back pain.
        J Am Acad Orthop Surg. 2006; 14: 477-487
        • Konno S.
        • Oda N.
        • Ochiai T.
        • Alev L.
        Randomized, double-blind, placebo-controlled phase iii trial of duloxetine monotherapy in Japanese patients with chronic low back pain.
        Spine (Phila Pa 1976). 2016; 41: 1709-1717
        • van den Driest J.J.
        • Bierma-Zeinstra S.M.A.
        • Bindels P.J.E.
        • Schiphof D.
        Amitriptyline for musculoskeletal complaints: a systematic review.
        Fam Pract. 2017; 34: 138-146
        • Richards B.L.
        • Whittle S.L.
        • Buchbinder R.
        Antidepressants for pain management in rheumatoid arthritis.
        Cochrane Database Syst Rev. 2011; 11CD008920