Monday, April 11, 2016

The effect of anxiety and depression

Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression

These authors conducted a review of 86 patients undergoing arthroscopic acromioplasty. Their inclusion criteria were patients with isolated 'subacromial impingement (SI)' aged between 25 and 75 years with shoulder pain on overhead activity or in the mid arc of abduction, a positive Hawkins test result on repeated examination, pain relief of a minimum of 2 weeks after subacromial steroid injection, and radiologic evidence of impingement (sclerosis, cysts, or osteophyte at the grater tuberosity and acromion). They state that "rotator cuff tears were excluded", but cuff imaging findings of the included patients are not provided.  Patients with other concurrent shoulder diseases were excluded, including "SI" accompanied by rotator cuff tear (partial or full thickness) on preoperative ultrasound scan, acromioclavicular arthritis, calcific tendinitis, calcific bursitis, adhesive capsulitis, labral tear, biceps tendinitis, superior labral anteriorposterior  tear, and instability. It is unclear how they excluded diagnosis of frozen shoulder or glenohumeral arthritis.

Patients were analyzed in 2 groups defined by Hospital Anxiety and Depression Scale (HADS) scores, group A being depressed and group B nondepressed. Both groups had less pain and improved Oxford Shoulder Score (OSS) at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction.

Comment: As the authors point out, "subacromial impingement" is frequently used as an indication for acromioplasty. In this paper it is difficult to know exactly what pathology was being treated in these patients with an age span of 50 years. It has been suggested that we can stop using the term "impingement syndrome" now that a clear understanding of cuff pathology is available through a good history, physical exam and MRI as is explained in this post.

With respect to the HADS, anxiety and depression are each rated by assigning a value from 0-3 to each of seven items:

The items on the questionnaire that relate to anxiety are:
I feel tense or wound up
I get a sort of frightened feeling as if something bad is about to happen
Worrying thoughts go through my mind
I can sit at ease and feel relaxed
I get a sort of frightened feeling like butterflies in the stomach
I feel restless and have to be on the move
I get sudden feelings of panic

The items that relate to depression are:
I still enjoy the things I used to enjoy
I can laugh and see the funny side of things
I feel cheerful
I feel as if I am slowed down
I have lost interest in my appearance
I look forward with enjoyment to things
I can enjoy a good book or radio or TV program

So that the anxiety score can range from 0-21 and the depression score can range from 0-21. Apparently these to scales were added so that the maximal value for anxiety+depression was 42.
The relationships between the HADS and three different outcome metrics are shown below

While these effects are significant, it is apparent that a relatively small percentage of the variation on the outcome is associated with the preop HADS score: the respective coefficients of determination (see this link) for the three outcomes were 39%, 7% and 25%.

This study is important because it highlights the fact that many factors, including the patient's emotional heath, can affect the result of a treatment.

There are many different instruments for assessing emotional health. Our practice is to use the SF 36 which includes these three questions about depression:

When we suspect that a patient is depressed or over-anxious we try to explain that these conditions may interfere with the success of treatment and seek whether specialist help may be in order before proceeding with surgery.


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