Saturday, August 15, 2020
How common is new onset depression and anxiety after spinal fusion?
Baseline depression and anxiety are very common among spine surgery patients and are well-known risk factors for worse post-operative outcomes. There is a complex interrelationship between depression and chronic pain, and both seem to predispose to the other. Less well-studied is whether spine surgery is a risk factor for developing depression and anxiety post-operatively. To study this question, Dr. Bekeris and colleagues from the Hospital for Special Surgery used the Truven MarketScan database that includes large amounts of claims data from employer sponsored health plans across the United States. They identified approximately 39,000 patients who underwent ACDF or posterior lumbar fusion from 2012-2015 and who had data for at least a year prior to and after surgery. Approximately 16,000 had no diagnosis of or prescription for depression or anxiety for the year prior to surgery, and these patients formed the cohort of those at risk for de novo depression or anxiety post-operatively. Of these patients, 12% received either a diagnosis or prescription for depression or anxiety within 6 months after surgery, not including prescriptions for antidepressants or anxiolytics received within 1 week of surgery as those may have been part of the routine post-operative regimen. A baseline diagnosis for psychosis (less than 3% of patients had this diagnosis) was the most powerful risk factor for developing new post-operative depression or anxiety (OR 3.6). Chronic obstructive pulmonary disease (OR 1.17) was also associated with new onset depression or anxiety. Chronic opioid use either pre- or post-operatively was also strongly associated with a new diagnosis of depression or anxiety, with those starting chronic opioid use post-operatively at highest risk (OR 2.9). Lower age (OR 0.99), female sex (OR 1.35), and living in a zip code with a median household income over $60,000 (OR 1.46) were also associated with increased risk. While type of procedure (ACDF vs. lumbar fusion) and number of vertebrae fused were not risk factors, length of stay was (OR 1.08).
This is a novel study in that it identified a relatively high proportion of patients (12%) who developed novel depression or anxiety within 6 months of spinal fusion. While a high proportion of spinal fusion patients have a baseline diagnosis of depression or anxiety (59% in this study), surgeons are not generally aware of patients being at increased risk for developing these conditions de novo after surgery. This study benefits from the huge number of patients available for analysis in administrative claims databases but also suffers from the limitations inherent in this kind of study. The diagnosis of depression or anxiety relied on diagnostic coding or prescription data, not traditional psychiatric criteria for making these diagnoses. Many patients may have had depression or anxiety at baseline without a diagnostic code or prescription for the condition. Conversely, some patients not meeting the traditional diagnostic criteria for these conditions may have received a diagnostic code or a prescription. For example, many surgeons use diazepam or other benzodiazepines as muscle relaxants post-operatively, and some patients may have received prescriptions for these medications beyond the 1 week point as part of a post-operative analgesia regimen without having a diagnosis of anxiety. The reported risk factors for developing depression or anxiety post-operatively are not surprising. Opioid use is strongly associated with depression and anxiety. It is interesting that patients who started chronic opioid therapy post-operatively were at greatest risk for developing depression or anxiety. Further research would be necessary to know if the chronic opioid use predisposed them to the mental health condition or vice versa. Younger age and female sex are established risk factors for depression and anxiety. The finding of increased risk among those from zip codes with higher household income is interesting and suggests that patients with higher socioeconomic status were either at greater risk for these conditions or were more likely to seek care for them. This paper is eye opening in that it shows that spine surgery is a risk factor for new onset depression and anxiety. Surgeons and primary care physicians should be vigilant in screening for this and also do their best to avoid chronic opioid use post-operatively.
Please read Dr. Bekeris's article on this topic in the August 15 issue. Does it surprise you that spine surgery resulted in new onset depression or anxiety in over 10% of patients?
Adam Pearson, MD, MS
Associate Web Editor