Hip Dysfunction and Psychological Distress: The Value and Challenges of Screening

Commentary The study by Willey et al. highlights an important concern in the young adult hip clinic: the prevalence of psychological distress among adolescents and young adults with hip pain. Their findings that 10.6% of patients exhibited moderate or greater depression symptoms and 26.9% demonstrated severe psychological distress underscore the mental health challenges facing this population. These data, complementary to previous researchers' findings, make a strong case for routine screening when implementational and interventional challenges are addressed. The association between psychological distress and greater hip dysfunction, as measured by lower International Hip Outcome Tool (iHOT) scores, is particularly noteworthy. Patients with severe psychological distress scored a median of 24.5 points lower than those with no or mild distress, a clinically important difference for this instrument. This correlation raises important questions about the directionality of the relationship: Does psychological distress exacerbate hip dysfunction, or does prolonged hip pain contribute to declining mental health? The answer likely involves bidirectional influences and, in this light, may add weight to the call for more integrated care approaches for our patients dealing with sometimes quite severe pain. The researchers' use of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool may itself represent a methodological advancement over single-domain assessments of mental health. Although infrequently used, the OSPRO-YF tool captures 11 distinct psychological domains, including often-overlooked factors like kinesiophobia (present in 74.5% of patients in this study) and pain catastrophizing. It may provide a more relevant understanding of psychological distress in this population than screening for depression symptoms alone. However, the implementation of screening without clear clinical pathways for intervention raises ethical considerations. Psychological screening for issues such as self-harm is not unique to the tool used in this study, but it presents challenges that are perhaps less familiar to many orthopaedists. Willey et al. acknowledge this, noting that "orthopaedic clinics must have an efficient pathway to refer patients to a psychiatrist or to the emergency room." Although the authors established protocols for referral, many orthopaedic practices lack similar resources. Several identified risk factors for psychological distress offer potential targets for enhanced monitoring. The comprehensive nature of the OSPRO-YF screening may be particularly beneficial, as evidence-based interventions exist for certain psychological factors that it identifies, such as pain catastrophizing1. Further, young adults' higher risk of depression symptoms compared with that of adolescents suggests that prolonged experience with hip dysfunction may contribute to psychological deterioration over time, emphasizing the importance of timely diagnosis. For clinicians considering implementing a more comprehensive psychological screening program, this study highlights both the potential value and the challenges that such a program presents. Willey et al. provide useful insight both into the relationship between psychological distress and hip dysfunction in general and into which patients with hip conditions may be more likely to experience outsized psychological stress in particular. Without clear protocols for addressing their issues, however, screening alone is likely to fall short of improving their care.