Depression and anxiety are common in the United States, with a lifetime prevalence of 17% and 29%, respectively.1 Currently, 20.6% of Americans live with a diagnosed mental illness.2 Importantly, different populations of patients are disproportionately affected by mental health conditions. Significantly more women are diagnosed with any mental illness or serious mental illness.2 Racial and ethnic minorities experience disproportionate discrimination in the United States, and discrimination has been positively associated with depression, anxiety, and psychological distress.3,4 Moreover, once depressed, African American individuals are more likely than White individuals to be chronically or persistently depressed, have higher levels of impairment and more severe symptoms, and go without treatment.5 Lower socioeconomic status (SES) is also associated with, but not necessarily causative of, worse health outcomes, including more mental health illnesses and decreased mental well-being.6
These differences in health outcomes across different SES are a result of living and working conditions, access to health services, social relationships, and diversified lifestyles, all of which are unequally distributed across the social hierarchy.6
There also exist important racial and gender disparities in rates of osteoarthritis and their management with total hip and knee arthroplasty (collectively referred to as total joint arthroplasty [TJA]). Women,7 as well as African American and Hispanic individuals,8-10 are more likely to have osteoarthritis. However, it has been shown that TJA is underutilized by both men and women, but the underuse is more than 3 times greater in women than men,11,12 in African American and Hispanic individuals,13-16 and in those of low SES.17 Therefore, women, communities of color, and those of low SES are more likely to have a higher burden of mental health illness and to be considered inappropriate surgical candidates for elective TJA. Therefore, these patients may not have the opportunity to benefit from the known quality-of-life improvements of TJA, thus compounding existing disparities.
Clinical Implications of Mental Health Related to Total Joint Arthroplasty
Better preoperative mental health correlates with improved postoperative outcomes and lower preoperative disability. In a prospective study of 677 patients undergoing total hip arthroplasty using the mental health component of the short form 36 (SF-36) health survey, there was a strong correlation between improvement in Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores at 1 year and better preoperative SF-36 mental health scores (0.13; 95% confidence interval [CI] 0.06 to 0.2). WOMAC scores were negatively affected by age, obesity, back pain, and awaiting another joint arthroplasty.18 In a study of 2,279 patients enrolled in a total hip arthroplasty/total knee arthroplasty registry, patients with poor preoperative mental health based on Short Form Survey 12 (SF-12) scores were found to have worse functional outcomes at 1 year and 5 years postsurgery after primary TJA but still had equal improvement in functional outcomes. The authors found that the Pearson correlation coefficient for preoperative mental health scores and postoperative WOMAC scores was significant at both 1 year (r = −0.148, P < 0.01) and 5 years postoperatively (r = −0.118, P < 0.05). This study also found that after primary TJA, mental health scores improved markedly, which the authors postulate was likely due to a reduction in physical disability associated with arthritis.19
Other studies found that mental health disorders are associated with postoperative complications after orthopaedic surgery including psychosis, anemia, infection, and pulmonary embolism.20 The mental health disorders of depression, anxiety, dementia, or schizophrenia were also found to be associated with prolonged hospital stays and discharge to a skilled nursing facility.21 Specifically, in TJA, the presence of mental health conditions is linked to longer hospital stays,19 higher hospital charges, higher rates of nonroutine discharges, and an increased Charlson Comorbidity Index.22
Strategies to Optimize
Various proposals for preoperative assessment and management of mental health are currently being conducted by experts in the field of arthroplasty. We conducted 10 qualitative interviews with 14 members of the orthopaedic surgical care team across seven institutions: New York University, OrthoVirginia, Hospital for Special Surgery, Yale New Haven Health, Louisiana State University, Brigham and Women's Hospital, and Penn Medicine. These institutions and individuals were chosen because of their national reputations and peer-reviewed publications focused on improving access for vulnerable populations.
During the survey, every institution was asked, “Is mental health screening part of your preoperative process?” Only 1 of the seven institutions (Yale New Haven Hospital) had a formal process for preoperative screening of mental health, using the Patient-Reported Outcomes Measurement Information System (PROMIS-10) for screening and referring patients with a raw global mental health score of <8 (a maximum raw score of 20) for behavioral evaluation.23 The remaining institutions were asked, “Do you think your institution would benefit from including mental health screening?” to which all responded in the affirmative.
Primary screening for mental health disorders can be accomplished by the patient's primary care provider (PCP), a psychiatrist or other mental health professional, or a member of the surgical care team (if applicable to the institution) (Table 1). Primary screening seeks to identify high-risk patients. One possible initial tool is the PROMIS-10 screening tool as used by one institution in our survey, which produces global physical health and global mental health scores.24 The raw scores can be standardized to the general population by use of the “T-score,” with the average score for the US population at 50 points, a standard deviation of 10 points, a higher score indicating a healthier patient, and a score of 29 considered poor mental health.25 A poor PROMIS-10 Global Mental Health score alerts the clinician to the likelihood of depression or other mental health concerns. If a patient is identified as high-risk based on a low PROMIS-10 score or if the patient carries a current mental illness diagnosis, they can then be referred to their PCP or mental health professional for preoperative optimization and additional follow-up.
Table 1 -
Mental Health Optimization Strategies
|Primary screening personnel
| • Surgical care team, such as
| ◦ Nurse navigators
| ◦ Physician associates
| ◦ State-wide case managers
| ◦ Social workers
| ◦ Orthopaedic surgeon
| • Or PCP, psychiatrist, or other mental health professional
|Primary screening tool
| • PROMIS-10
|High-risk patient algorithm
| • Patients with low PROMIS-10 score or mental illness diagnosis referred to PCP or mental health professional for the following 6 elements:
| 1. Major mental illness (education surrounding surgeries acting as triggers for abnormal mood episodes and patients showing early signs of mental illness relapse)
| 2. Substance use (motivational interviewing to encourage the seeking of treatment and evaluation of support systems)
| 3. Capacity to make decisions
| 4. Treatment adherence (a history of compliance and understanding of the needed lifestyle changes, complicated medication schedules, and medical directives)
| 5. Coping style and strategy (patterns of primitive defense mechanisms to handle stress)
| 6. Safety (suicidal and/or homicidal ideation and trauma of surgery serving as a trigger)
PCP = primary care provider, PROMIS-10 = Patient-Reported Outcomes Measurement Information System
For high-risk patients, their PCP or mental health professional can follow a plan that includes six elements to be addressed before surgery detailed in Table 1.26 All of these elements emphasize an embedded plan of action and/or treatment plan that are created through shared decision-making and are understood by all involved. If necessary, it also emphasizes explicit involvement of support systems or caregivers.
Screening for mental health before TJA provides value if intervention before surgery can improve clinical outcomes. Although there are numerous studies showing the association between preoperative mental health and postoperative outcomes, the authors could not identify research related to the efficacy of structured preoperative mental health optimization programs for TJA. Nonetheless, it is logical to think that treatment of poor mental health should occur before surgery and be done by the PCP or nonorthopaedic provider. Although response to treatment with antidepressant medication therapy for patients with acute depression is generally estimated to occur in 4 to 6 weeks, treatment duration for patients with chronic depression may be 4 to 6 months after an initial response (or longer).27 Patients who have low activation levels may be particularly difficult to treat, highlighting the importance of an established, trusting relationship between the patient and their primary care provider. Routine screening for poor mental health by primary care providers will allow earlier treatment which may subsequently positively influence later TJA outcomes.
Although primary care providers ideally screen patients for poor mental health and start treatment if appropriate, orthopaedic surgeons should screen patients before TJA if this is not done by the PCPs. The opportunity for improved screening for poor mental health by orthopaedic surgeons is highlighted by the lack of a consistent approach to screening across the seven institutions surveyed in this study. Across the seven institutions interviewed, there was no consistent approach toward optimization for mental health. One institution used PROMIS-10 for screening, and the remainder did not have a formal screening process. However, those with no formal screening process identified this as a gap in their preoperative process and were engaged in addressing it. Therefore, this represents a vital area worthy of additional research to determine the most appropriate screening tool in these settings. Finally, no institution has a formalized process for assessing a patient's support system after TJA, although all institutions stated that this was routinely assessed during the clinical encounter. Given this lack of standardization, but universal commitment to assessment, it is important to make use of validated screening tools for such difficult topics. Such tools exist (eg, upstream risks screening tool and guide28) and can be used as part of a more standardized process to ensure that this vital screening is not missed.
Summary Take-home Message
Orthopaedic surgeons typically do not have the educational background or training to do more than a preliminary screening of TJA patients for mental health concerns such as with the PROMIS-10 Global Mental Health score. We propose, however, that such screening is a critical step in the preoperative optimization process because it facilitates identification of patients at risk who may not present with an existing diagnosis of a mental health condition. Given the lack of current research, additional research is vital in the future. Orthopaedic surgeons can then refer appropriate patients to mental health professional colleagues for mental health optimization before TJA. With a consistent approach to patients with mental health conditions, orthopaedic surgeons can be more confident of positive outcomes in TJA for patients with mental health conditions and improve disparities in TJA utilization particularly for women and individuals of color.
This article is part of a series on optimizing underserved patients for total joint replacement. The series was coordinated in collaboration with Movement is Life, a group of healthcare professions focused on the elimination of musculoskeletal disparities. The authors thank Daniel H. Wiznia, MD, member of the Movement is Life Steering Committee and an Assistant Professor of Orthopedics and Rehabilitation at Yale for his assistance with this article. He was instrumental in the creation and driving of this series.
References printed in bold type are those published within the past 5 years.
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