Patients with depression also had significantly lower satisfaction levels at 2 years for all assessed domains with the exception of pain, which approached, but did not reach, significance (p = 0.066) (Table III). Multivariable linear regression analysis determined that depression (p = 0.018) was an independent predictor of less improvement in ASES scores following total shoulder arthroplasty.
Depression is a highly prevalent comorbidity among patients seeking care for musculoskeletal pain, including those with upper-extremity and shoulder symptoms4,25-27. The impact of depression on clinical outcomes after total shoulder arthroplasty in the present study was significant, but did not reach clinical importance. Although patients with and without depression both experienced significantly and clinically important improvement in ASES scores after total shoulder arthroplasty, patients with depression had significantly less improvement in patient-reported outcomes and significantly lower levels of satisfaction following total shoulder arthroplasty compared with age and sex-matched controls, although these differences did not achieve clinical importance. However, patients with depression had significantly greater improvement in their mental health scores compared with controls. These findings highlight the importance of screening for depression in patients planned for total shoulder arthroplasty, and appropriately counseling patients with depression regarding likely functional improvements and expectations of the surgical procedure. Patients with depression can be counseled that they may have slightly less improvement after total shoulder arthroplasty than patient without depression, but the difference is not of clinical importance. Appropriate counseling preoperatively may help to improve the patient’s perception of his or her outcome.
It is important to note that the age and sex-matched study and control cohorts had similar baseline characteristics, including demographic characteristics and baseline ASES, SF-12 PCS, and Marx shoulder activity scores. Although depression appears to have a significant effect on postoperative improvement following total shoulder arthroplasty, the only major preoperative difference between age and sex-matched patients with and without depression was the SF-12 mental component, which is not a surprising finding. There were no significant differences in baseline shoulder function and activity as reported by the ASES and Marx shoulder activity scores between patients with and without depression.
One previous study has investigated the association of depression with perioperative complications following shoulder arthroplasty11. The authors utilized the National Hospital Discharge Survey database to examine the association between psychiatric comorbidities, including depression, and inpatient complications, length of hospital stay and discharge destination. Depression was found to have a significant association with higher rates of adverse inpatient events, blood transfusion, and non-routine discharge11. The authors were not able to comment on adverse outcomes outside of the initial hospitalization, such as long-term infection risk or revision risk, which is a notable limitation of discharge survey databases. Furthermore, and most notably, Bot et al. could not evaluate any association between depression and postoperative clinical or patient-reported outcomes in their study, which are often the outcome measures that are most negatively impacted by depression in studies of other orthopaedic procedures1,9,15,18,22,28,29.
Our findings were similar to that reported for lower-extremity arthroplasty. In a recent study of 202 patients who underwent total knee arthroplasty, Utrillas-Compaired et al. found that preoperative psychological distress, which included depressive symptoms, was significantly associated with poorer outcomes in patient-reported function and quality of life at 1 year postoperatively29. Ellis et al. compared outcomes after total knee arthroplasty for patients with psychopathology (n = 54), of whom 74% had a diagnosis of depression, with those for patients without any Axis-I diagnoses (n = 100)18. The authors found that patients with preoperative psychopathology had similar improvement in patient-perceived outcome scores, but lower final outcome scores, compared with patients without psychopathology at a minimum of 1 year postoperatively18. In contrast, we found lower final outcome scores and less improvement in outcome scores in patients with a preoperative diagnosis of depression compared with the matched controls.
Brander et al. reported minimum 5-year outcomes of 109 total knee arthroplasties in 89 patients and found that depression impacts long-term outcomes15. In addition to preoperative pain, depression was found to be predictive of lower Knee Society scores at 5 years postoperatively, mostly related to lower function subscores. Our results demonstrate that this association is important not only for lower-extremity arthroplasty, but also for total shoulder arthroplasty. Furthermore, as the volume of total shoulder arthroplasties performed in the United States has increased substantially over the past decade, from 8,154 performed in 1998 to 26,773 performed in 2008, representing an increase of >200% in annual total shoulder arthroplasty incidence, it has become increasingly important to identify risk factors for poor functional improvement to allow adequate preoperative patient counseling and management of patient expectations35,36.
In addition to patient-reported outcome measures, we also evaluated the effect of depression on patient satisfaction following total shoulder arthroplasty. Recently, practitioners have recognized that patients’ perception of their care is as important as objective measures of functional improvement. In addition to patient-reported functional outcomes, employers and hospitals are now directly incorporating patient satisfaction into compensation formulas28. Furthermore, insurers such as Medicare are using patient satisfaction as criteria for reimbursement. Lastly, satisfaction is also being used by accreditation agencies and licensing bodies to evaluate physician performance37. We found that depression was associated with significantly lower levels of satisfaction following total shoulder arthroplasty, most notably for the quality-of-life and activities subscales.
The present study had several limitations. First, this study was a retrospective review of a prospectively collected database and thus was subject to the typical biases of retrospective studies. The study may have been biased by the specific peculiarities of our patient population and may not translate to other patient populations. Although controls were matched to study patients by age and sex, there are numerous other factors that affect outcomes that were not included in the matching process but may have affected the results, including preoperative functional scores, preoperative range of motion, and glenoid deformity, among others. Additional factors were controlled for in the multivariable analysis, but the impact of all potential confounding variables could not be controlled. The statistical associations described in this study should not be interpreted as causative, as there was a possibility for confounding variables in this type of analysis. Although we included ASES scores, Marx shoulder activity scores, SF-12 scores, and patient satisfaction to determine clinical outcome, we did not have physical examination or range-of-motion measurements to include in our assessment. Our study population was a large cohort of patients undergoing anatomic total shoulder arthroplasty with a minimum 2-year follow-up, but factors that were not found to be significant could have been nonsignificant as a result of a lack of study power. This was a sample of opportunity from a registry database; thus, we could not add any more patients to improve our statistical power. Another limitation of the study design was that we defined depression as a categorical diagnosis, but mood is fundamentally a continuous variable. All patients entered into the registry were screened for a diagnosis of depression on the day of the surgical procedure, which mitigates this effect somewhat. Furthermore, baseline MCS scores demonstrate that patients in our depression cohort truly were experiencing lower levels of mental health compared with the control patients, and the SF-12 MCS has been demonstrated to be a valid measure of depressive symptomatology38. Another limitation was that we could not include hand dominance in the regression analysis; however, the effect of this limitation was mitigated by the fact that a recent study had found no correlation between hand dominance and clinical outcomes after total shoulder arthroplasty39.
Future prospective studies on this topic are needed to confirm the findings of the present investigation. We also do not know when the patients were diagnosed with depression or how long they had had depressive symptoms, which leave us unable to determine the difference between those patients with situational depression due to several years of shoulder pain and those patients with biological depression. We also do not have information regarding what medications, if any, patients were taking for depression perioperatively, which could influence the frequency and magnitude of depressive symptoms experienced. It is also unclear whether adequate recognition and treatment of depression can improve outcomes following total shoulder arthroplasty. Finally, we did not know what the status of the patients’ depression was at the time of the final follow-up, although we did note significant improvement in the SF-12 MCS from baseline.
In conclusion, patients with a diagnosis of depression should be counseled that they will experience a significant functional improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with depression from undergoing total shoulder arthroplasty.
Investigation performed at Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, New York, NY
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