One in three patients having shoulder arthroplasty had depression or anxiety - what effect did this have on outcome and what should we do about it?

Anxiety and depression are the most commonly diagnosed psychiatric disorders in the United States, with a lifetime prevalence of about 29% and 17%, respectively. Thus, it is not surprising that a substantial percentage of patients considering shoulder arthroplasty (TSA) carry these diagnosis. Several questions arise:
(1) what are the effects of these mental health conditions on the outcomes of shoulder arthroplasty?
(2) can the adverse effects of depression and/or anxiety be modified (i.e are these risk factors modifiable)?
(3) how should the presence of depression and/or anxiety affect the decision to proceed with shoulder arthroplasty, recognizing the increased risk for suboptimal results and adverse outcomes?

The authors of the Impact of Mental Health on Outcomes After Total Shoulder Arthroplasty sought to examine the correlation between the preoperative diagnoses of anxiety and depression and their association with postoperative outcomes for TSA. A secondary goal was to determine whether patients on medication for their mental health diagnosis fared better than those not receiving medication.

In the authors' practice over one-third (37%: 218 patients (114 rTSA and 95 aTSA)) had anxiety and/or depression while 378 (153 rTSA and 217 aTSA) had no such history.

For patients having reverse total shoulder arthroplasty, the preoperative patient and shoulder characteristics of those without and with depression and/or anxiety were essentially the same. However, the postoperative comfort, function, satisfaction and adverse event rate were significantly worse for those with depression and/or anxiety.

For patients having anatomic total shoulder arthroplasty, the results were similar, but somewhat less striking.

Patients on medications for treatment of depression and/or anxiety did not have better postoperative outcomes or satisfaction rates compared to those who had depression and/or anxiety but who not on medication. However, it is not known (1) whether the patients on medication had more severe depression and/or anxiety than those not on medication and (2) whether the patients on medication would have had even worse outcomes had they not been medicated.

Poorer mental health correlated with worse postoperative functional outcomes, worse patient satisfaction, and higher rates of adverse events.

Comment: The high prevalence of anxiety/depression is striking. As emphasized in this study as well as in Shoulder arthritis: the relationship of function, depression and anxiety and Total shoulder - one in seven patients have depression; what difference does that make? poor mental health is associated with poorer outcomes following shoulder arthroplasty.

The authors suggest that preoperative identification of these mental health disorders may allow for treatment and "an opportunity to intervene and mitigate any deleterious effect". However it is not clear whether medical management of anxiety/depression mitigates their adverse effects on arthroplasty outcomes. To figure this out, it would be necessary to randomize patients with anxiety/depression to treatment and non-treatment groups prior to arthroplasty.

It is also not clear how surgeons should consider the patient with suboptimal mental health. Should they counsel these patients that they are more likely to get a poor result? Or should they consider not offering surgery to these patients to avoid the ramifications of bad outcomes for the patient and for the surgeons themselves?

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Total shoulder arthroplasty - the effect of mental health

The Influence of Mental Health on Outcomes Following Total Shoulder Arthroplasty

Anxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). These authors conducted an observational cohort study including 143 shoulders in 135 subjects undergoing total shoulder arthroplasty for glenohumeral osteoarthritis. The types of implants used and the methods used for addressing non-concentric glenoids are not specified.

Radiographs were reviewed for all 143 shoulders included. Advanced imaging was available for 60 shoulders. On initial review, there was 68.5% (99/143 shoulders) agreement on modified Walch glenoid morphology according to each subtype. Preoperative glenoid pathology was classed as either concentric wear (glenoid types A1 or A2) or eccentric wear (glenoid types B1, B2, B3, C, or D). When grouped as concentric vs. eccentric glenoids, initial review agreement improved to 86% (123/143 shoulders). 65 shoulders (45.5%) were graded as concentric and 78 shoulders (54.5%) were graded as eccentric following consensus analysis. Final Walch subtype classification included 26 shoulders graded as A1, 39 as A2, 8 as B1, 45 as B2, 23 as B3, and 2 as C. There were no glenoids graded as D.

Patients with anxiety and depression reported similar improvements in pain and function following TSA similar to those without depression or anxiety.

Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=.035) and were more likely to regret undergoing surgery.

The ASES scores were somewhat higher for the patients with non-concentric glenoid.

Comment: This article demonstrates an association between the degree of anxiety and depression with the preoperative and postoperative ASES scores. It does not suggest how this information might be used to improve the care of patients having shoulder arthroplasty. For example, how should patients undergoing TSA be screened for anxiety/depression? Should the presence of anxiety/depression influence the indications for surgery? Might the management of anxiety/depression preoperatively improve the outcomes of total shoulder arthroplasty?

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Shoulder arthritis: the relationship of function, depression and anxiety

The influence of mental health on Patient-Reported Outcomes Measurement Information System (PROMIS) and traditional outcome instruments in patients with symptomatic glenohumeral arthritis

These authors explored the influence of patients' mental health on their self-reported pain and function using the Patient-Reported Outcomes Measurement Information System (PROMIS) assessment. They performed a cross-sectional study of 284 shoulders in 276 patients presenting with isolated glenohumeral osteoarthritis. All patients completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Visual Analog Pain Scale (VAS), and PROMIS CATs at the time of presentation. 

Patients with scores corresponding to a diagnosis of anxiety or depression reported lower functional and higher pain scores compared to those with scores in the normal range (P < .001). The severity of anxiety and depression correlated with a lowering of function and with an increase in pain scores.

The relation of the degree of anxiety and depression to the Simple Shoulder Test score is shown below.

Comment:  As the authors point out, this analysis does not  determine whether worse mental health is related to more severe glenohumeral arthritis or whether the patients’ anxiety and depressive symptoms create a more intense perception of their limitations. In this regard, it would be of great interest to correlate the radiographic severity of arthritis with the severity of anxiety, the severity of depression and the patient self-assessed comfort and function using a metric such as the Simple Shoulder Test.

We are reminded of an important article from seven years ago, the abstract of which is reproduced below. We have been especially informed by the last part of the last sentence in this abstract.

Association Between Comorbid Depression and Osteoarthritis Symptom Severity in Patients with Knee Osteoarthritis

Background: We sought to investigate the reported association between depression and severity of knee osteoarthritis symptoms stratified by radiographic severity of osteoarthritis and to quantify the contribution made by depression to symptom severity.

Methods: Six hundred and sixty elderly Koreans (sixty-five years or older) were evaluated for radiographic severity of knee osteoarthritis on the basis of the Kellgren-Lawrence grading system and also for symptom severity on the basis of the Western Ontario and McMaster Universities Osteoarthritis Index scales. Patient interviews and a questionnaire that made use of a geriatric depression scale were conducted for the purpose of assessing depressive disorders. Regression analyses were performed to assess the relative contributions by radiographic severity and depression severity to Western Ontario and McMaster Universities Osteoarthritis Index scores and to explore any associations between radiographic severity and the presence of a depressive disorder with regard to the risk of symptomatic knee osteoarthritis. Symptomatic knee osteoarthritis was defined as a Western Ontario and McMaster Universities Osteoarthritis Index score of ≥39.

Results: The presence of a depressive disorder was found to be associated with an increased risk of symptomatic knee osteoarthritis (odds ratio = 5.87 [95% confidence interval, 3.01 to 11.44]). However, the influence of the presence of a depressive disorder was limited to subjects with a radiographic severity of minimal to moderate (Kellgren-Lawrence grade 0 to 3). The presence of a depressive disorder was not associated with the risk of symptomatic knee osteoarthritis in subjects with severe osteoarthritis (Kellgren-Lawrence grade 4).

Conclusions: This study indicates that the assessment and management of coexisting depression should be integrated with the assessment and management of knee osteoarthritis, particularly when radiographic changes of osteoarthritis in the knee joint are not severe.

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It's about the patient: the effect of depression and other psychiatric disorders on shoulder arthroplasty outcomes.

The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty

These authors sought to evaluate the influence of a preoperative diagnosis of depressive disorder, anxiety disorder, schizophrenia, or dementia on in-hospital (1) adverse events, (2) blood transfusion, and (3) nonroutine discharge in patients undergoing shoulder arthroplasty. They used the National Hospital Discharge Survey database, to identify 348,824 discharges having undergone partial or total shoulder arthroplasty from 1990 to 2007. 

They found that one in twelve patients receiving shoulder arthroplasty had some form of mental disorder: depression 4.4%, anxiety disorder, 1.6%; schizophrenia, 0.6%; and dementia, 1.5%. 

Depression, anxiety and dementia were associated with higher rates of adverse events.  Any preoperative psychiatric illness was associated with higher rates of nonroutine discharge.

Comment: We've put up many posts on the 4 Ps, emphasizing the importance of the patient in the outcome of shoulder arthroplasty. Paraphrasing Osler, "it is more important to know what patient the disease has than what disease the patient has".

It is apparent that individuals with emotional and psychiatric disorders can develop shoulder arthritis. It is also apparent that shoulder arthroplasty can improve the comfort, function, and overall well-being of a patient with shoulder arthritis. The questions becomes, should the presence of mental disorders change the indications for and the anticipated outcomes of shoulder arthroplasty?

In a prior post, we've pointed out that individuals with depression are more symptomatic with lesser degrees of radiographic arthritis. This suggests the possibility that surgeons may be urged to operate on arthritis in its earlier stages and may have less optimal outcomes.

Mental illness is an important co-morbidity, just like emphysema or chronic heart failure. Identifying these diagnoses before committing to surgery may help optimize decision making regarding the appropriateness of surgical treatment. In some cases these co-morbidities are modifiable, in which case their treatment should take place before the surgical treatment of arthritis. Adverse events and non routine discharge are costly to the patient and to the payers of health care.

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Rotator cuff repair and depression / anxiety

The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair

This important article investigated the prevalence of psychological distress and its effect on self-assessed pain, disability, and health-related quality of life in 107 patients scheduled for rotator cuff repair. Essentially 1 out of 4 patients had depression and 1 out of 4 had anxiety. The depression score positively correlated with a visual analog scale pain score and negatively correlated with self-assessed function. On multivariate analysis with a linear regression model, the depression score was an independent predictor of self-assessed function.

The bottom line is that both depression and rotator cuff tears are common entities. These authors have shown that in patients with cuff tears, self assessed comfort and function is worse when depression is present.

The authors state, "Our study is the first to show that depression and anxiety are contributing factors to the magnitude of preoperative self-assessed pain, functional disability, and HRQOL in patients undergoing rotator cuff repair." The question is, have they shown causation or association? See this.

The message is that while we cannot be sure of the cause and effect relationships, we need to be alert to the presence of depression in our patients along with its possible role in the comfort and function of the shoulder. We cannot assume that fixing a cuff tear will resolve the mood issue.

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Shoulder pain, depression and sleeplessness

Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance?

The authors evaluated patients who had had shoulder pain for 3 months or longer in comparison to healthy controls.  Shoulder pain group had abnormal values for the visual analog scale pain score, the American Shoulder and Elbow Surgeons Score, and the Korean Shoulder Scale.  In the pain group,  22.3% had depression, 19.2% had anxiety, and 81.5% had sleep disturbance. The authors concluded that shoulder pain for 3 months or longer was a strongest predictor of sleep disturbance and that there was a close relationship among depression, anxiety, and sleep disturbance in patients with shoulder pain for 3 months or longer.

These results indicate the need for us to consider the patient as a whole person had to evaluate and manage the depression, anxiety and sleep disturbances that may accompany their shoulder disorders.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.


See from which cities our patients come.


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