Commentary and Perspective
The study “Depression and Patient-Reported Outcomes Following Total Shoulder Arthroplasty” makes good use of a prospective registry that recorded diagnosed major depressive disorder and also measured patient-reported outcomes. A recorded diagnosis of major depressive disorder was associated with less improvement and lower final scores on questionnaires measuring symptoms and limitations in a comparison of matched cohorts. These findings match our intuition that even people with lower mood appreciate amelioration of pathophysiology and that the happier you are, the more comfortable and capable you are able to be in spite of disease.
This type of study may simply put numbers on common sense: the happier you are, the less things bother you. However, such studies draw attention to the potential benefits of attention to stress, distress, and less effective coping strategies. I think that we can take better advantage of opportunities to help to coordinate care that optimizes both pathophysiology and resiliency (an ability to recover from or adjust to misfortune or change): comprehensive care.
For every patient with a diagnosed major depressive disorder, there are likely one or more additional patients with an undiagnosed major depressive disorder and several others with substantial symptoms of depression. Such a diagnosis implies patient insight and active treatment. To get a sense of the magnitude of potential missed opportunities, consider the recent study of 46,417 people who had depression screenings in primary care: 8.4% of adults met a threshold for a potential diagnosis of major depressive disorder, with only 28.7% receiving treatment, and among all adults under treatment for major depressive disorder, only 29.9% had depressive symptoms above the threshold used to estimate diagnosis1. In other words, major depressive disorder is either overdiagnosed or inadequately treated in many patients, and thousands of others have underappreciated and undertreated major depression. This is consistent with a study in my upper-extremity surgery practice that found that about 1 in 8 patients met criteria for an undiagnosed major depressive disorder2.
It may be time for a different approach. Labeling people as depressed or not depressed seems arbitrary, artificial, and counterproductive. We can all attest that symptoms of depression and anxiety occur on a continuum. Labels can stigmatize and shame and may decrease the appeal of working on resiliency. There are many advantages to addressing resiliency on its continuum.
Symptoms do not bring a person to the doctor. We seek care when a symptom becomes a concern. It seems safe to assume that everyone seeking our care is somewhat unsettled. Evidence is mounting that everything that we do to normalize and ameliorate those feelings enhances resiliency, which then reduces symptoms and limitations, thereby optimizing health.
We talk a lot about patient expectations, but when a person is dissatisfied with a surgical procedure, is that not more likely due to an error in diagnosis? I think that dissatisfaction belies undiagnosed and undertreated stress and distress and less effective coping strategies. These are missed opportunities for improved resiliency and improved health. In this context, talking about patient expectations feels uncomfortable. It seems as if we are blaming the patient for the illness.
Counseling depressed patients that they may not do as well as non-depressed patients sounds like something that we do for ourselves. I would like to stay focused on how can we help people to get and stay healthy. It was no surprise that total knee arthroplasty outperformed nonoperative care in a recently published randomized trial3 comparing the two. The surprise was how much people in the nonoperative group improved. The ability to improve without intervention is the manifestation of the power of resiliency. Resiliency is the embodiment of all of the nontechnical things that we do for people: taking genuine interest in them; restoring meaning, purpose, and hope; and motivating them to return to their daily routine. With time for reflection and revitalized self-efficacy, people need a lot less treatment to achieve comparable health, and they recover more rapidly after injury or a surgical procedure.
1. Olfson M, Blanco C, Marcus SC. Treatment of adult depression in the United States. JAMA Intern Med. 2016 Oct 1;176(10):1482-91.
2. Oflazoglu K, Mellema JJ, Menendez ME, Mudgal CS, Ring D, Chen NC. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016 Feb;41(2):263-9.e1-7. Epub 2015 Dec 24.
3. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015 Oct 22;373(17):1597-606.