Should Optimization for Elective Surgery Include Mental Health Optimization?

Commentary Domb and colleagues performed a case-control study evaluating the intermediate-term outcomes of hip arthroscopy in patients with depression and/or anxiety compared with those without. The authors should be commended for tackling this important topic. The impact of depression and anxiety on the outcomes of orthopaedic surgery has previously been investigated for many procedures, including hip and knee arthroplasty, lumbar fusion, and anterior cruciate ligament reconstruction1–3. Results have been mixed, with some studies showing worse outcomes and increased complications in patients with depression and/or anxiety and others showing no outcome differences. For example, Vajapey et al., in a systematic review of total joint arthroplasty in patients with depression, found that patients with depression are at higher risk for persistent pain, dissatisfaction, and complications after total joint arthroplasty, despite experiencing equivalent gains in function postoperatively1. These types of data are critical in counseling patients prior to orthopaedic interventions and should be part of any conversation regarding the risks, benefits, and alternatives of a proposed operation4. In my personal experience, many patients with orthopaedic injuries and conditions are also being treated for concomitant anxiety or depression, and the incidence has been increasing in recent years. Patients with underlying depression and anxiety present unique challenges, both in the preoperative period and during surgical recovery. Because of these concerns, many surgeons may shy away from surgical intervention in this population or proceed with trepidation related to fears of management challenges postoperatively. However, this study by Domb and colleagues provides evidence of successful outcomes with hip arthroscopy in this potentially difficult patient population. Domb and colleagues performed a case-control study in which 125 patients with depression and/or anxiety were compared with 125 patients without depression and/or anxiety. The authors found that, while the depression/anxiety cohort started with lower patient-recorded outcome measures, their magnitude of improvement was comparable with that for patients without depression and/or anxiety. Nonetheless, the depression/anxiety cohort ended up with lower outcome scores at intermediate-term follow-up and had a lower rate of achievement of patient-acceptable symptom state (PASS) thresholds. These data are critically important to the hip arthroscopist in perioperative counseling of patients considering hip arthroscopy. This study had many strengths, including the relatively large number of patients in each cohort and intermediate-term outcomes with a minimum 5-year follow-up. The study also had several limitations that the reader should consider. The authors utilized a variety of patient-reported outcome measures, including the modified Harris hip score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), and International Hip Outcome Tool (iHOT-12), and not all patients completed all outcome measures studied. Additionally, the depression/anxiety cohort was generated on the basis of patient self-reports on intake forms. Thus, not all patients in this cohort may have a clinical diagnosis of depression and/or anxiety, and they may not have been receiving formal treatment for those conditions. It is also possible that patients in the control cohort were being treated for depression and/or anxiety but did not self-report those conditions. Finally, as with any single-institution study, the results may not be generalizable to other patient populations. Patient optimization for elective surgery is an essential premise for orthopaedic surgery. We focus on medical optimization and often seek recommendations for perioperative optimization from other medical specialties, including cardiology, pulmonology, and others, to help manage medical comorbidities. With the goal of getting a patient “cleared” for surgery, the focus on medical optimization often ignores psychiatric and behavioral health concerns. Studies like this one shed light on the risk of inferior surgical outcomes for patients with depression and/or anxiety and highlight the potential need for behavioral health optimization prior to elective orthopaedic surgery. While I am not suggesting avoiding or canceling surgical procedures because a patient has a history of depression or anxiety, there may be a role for discussing these comorbidities with a patient’s primary care provider or behavioral health specialist preoperatively in order to ensure that patients are truly optimized in all aspects of their health care prior to proceeding with elective orthopaedic surgery. A thorough discussion of the risks, benefits, and alternatives is an essential component of all operations, and this study provides an important perspective on the expected outcomes of hip arthroscopy in patients with depression and/or anxiety.