Depression before knee and hip replacement leads to poorer outcomes after surgery

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

We often see patients after a joint replacement surgery who are still having problems with pain and function in that joint. There may be nothing wrong with the joint hardware, there may be nothing showing up on an MRI or x-ray, there may be no obvious cause of their problems, yet here they are with an unstable, weak, and painful joint. To be fair, joint replacement can be an extraordinary life-changing event for many people, helping them get out of pain and giving them function again. This article will focus on the patients who had challenges after their joint replacement. The challenges of this article’s focus will be depression and anxiety and how depression and anxiety can delay, stunt, hamper, and suppress healing.

A patient will come in with a painful knee. They had had a knee replacement a few weeks or a few months prior. They are not healing. They are in our office, many times, not for the problems of the joint that was replaced but for another joint problem, the hip on the side that the knee replacement was done, or the ankle, for instance, It seems that those joints were made worse after the knee replacement. When we ask this person, “what’s going on?,” we may hear something like this:

My knee replacement is okay I guess but I don’t want to go through another joint replacement, I am hoping that I can avoid a hip replacement. After my knee replacement, I suffered terrible anxiety and depression. I was stuck in my house because I was afraid to leave. I had a terrible fear that I would fall. It got so bad for me that I stopped taking care of myself. I would not wash, I would not eat, I lost a lot of weight and became very weak.

My home care therapists were concerned and recommended to my doctor that I see a psychiatrist, I was even afraid of that. The worse my situation got the more pain pills I was given.

The reason I was able to get myself here is that I have bad hip pain and I do not want that surgery. I had a lot of people helping me get to this appointment today.

There are many things that happen to some people following a joint replacement that one should be aware of before the surgery

The surgery is a major impact on your life. The surgery and the recovery can be exhausting, physically demanding, emotionally draining events.
Even patients who had limited mobility, fear of movement, fear of falling, BEFORE the surgery found these fears worse after surgery
Desperation and depression set in as even caregivers can get frustrated with these people for the failings to take care of themself, inability to use bedpans or potty chairs that come with their own special humiliation and despair.

Patients with depression or anxiety undergoing joint replacement experienced more complications after surgery

In our clinics, we offer non-surgical options. We try to help patients avoid joint replacement surgery with injections that stimulate the natural repair of damaged joints. We also see many patients with depression and anxiety from the physical limitations that their painful joints are causing them, and, because some of them feel that they have become a “burden” on their loved ones. We tell these people that we are confident we can help them, but they must have a strong supportive family or friends and they must MOVE.

In December 2020, researchers writing in the medical journal Clinics in Orthopedic Surgery (1) suggested the need for “precise assessment of preoperative mental health and psychological determinants” which may be useful in identifying patients at risk for poor postoperative knee replacement outcomes.

In their study of 52 patients, this research team found that patients with less depressive symptoms and higher baseline mental and physical scores (simply a better outlook) had significantly greater improvement in quality of life after surgery. The only independent factor affecting the physical, mental, and functional outcome was depression.

The burden of surgery

Where we offer non-surgical options, others opt for joint replacement. When a patient has a major depressive disorder (MDD), healing and recovery from surgery can be more challenging. Doctors at the Rothman Institute at Thomas Jefferson University recognized these challenges and found that patients with depression or anxiety undergoing joint replacement experienced more complications. They caution that doctors and health care providers should counsel these patients before the surgery to prevent MDD related complications.

The actual focus of this study was on post-surgery expenses. The researchers wrote that all efforts need to be invested to minimize joint replacement complications INCLUDING the additional monetary costs of recovery experienced by the patients. (2) Costs that may include the need for prolonged pain medications.

Prolonged pain medications – are doctors treating depression and anxiety with painkillers?

In April 2018, surgeons from the Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, and the Cleveland Clinic published these findings in The Journal of Arthroplasty, (3):

Pain in the immediate postoperative period following total joint arthroplasty (replacement) is influenced by various patient factors, including major depressive disorder.
This study aimed to compare the patient perception of pain and opioid consumption between patients with and without major depressive disorder who received either a total knee replacement or total hip replacement. Specifically, we compared:
- (1) pain intensity,
- (2) lengths of hospital stay,
- (3) opioid consumption, and
- (4) patient perception of pain control.
RESULTS: Patients with a major depressive disorder who received a total hip replacement or total knee replacement demonstrated a higher mean pain intensity score when compared to those without major depressive disorder; however, this was not statistically different. YET, patients with major depressive disorder who received a total hip replacement or total knee replacement consumed more opioids when compared to those without a major depressive disorder.

In other words:

Patients with major depressive disorder consume more opioids compared to patients without major depressive disorder despite both groups having the same pain scores. One may speculate or ask, are doctors treating depression and anxiety with painkillers?

This was the subject of research from European doctors writing in the medical journal Acta Orthopaedica. (4) In their October 2016 study, these doctors made these observations:

Recent studies suggest that patients with psychiatric disorders tend to do worse than patients without a psychiatric diagnosis when undergoing total hip replacement or total knee replacement. Whether this is due to their psychiatric condition, pharmacological treatment, a combination of the two, or something else has not been thoroughly analyzed—and there are no internationally accepted guidelines for perioperative management of psychiatric patients.
The distinction between the psychiatric disease itself and the side effects of psychotropic drugs is a challenge when evaluating perioperative outcomes, raising the question of the relative importance of disease-related factors and drug-related factors and their independent effects on surgical outcome.
The use of psychopharmacological drugs may be prevalent but this is seldom considered in preoperative assessment. Furthermore, there are no evidence-based guidelines for psychotropic drugs in the perioperative period, and there is little documentation.

In other words:

If you are on medications for depression and anxiety before you have joint replacement, doctors are unsure, even uninformed of how your depression and anxiety symptoms will respond after the joint replacement.

Occasionally a patient will be in our examination room and they will talk about their post-op stress. They say things like this:

During the physical therapy for my hip (which was replaced) I started to have terrible knee pain. I knew my knee was bad but it was secondary to how bad my hip felt. What stressed me out the most was my doctor telling me that he/she was cutting off my pain medications. I told my doctor that I need the medications for my knee now. The pain medications I was told were for my hip, not for my knee and I would have to address that problem by itself. Continued use of pain medication may make my hip not heal.

I also told my doctor about the anti-depressants I was taking. He/she told me I need to go back to my psychiatrist to discuss the continued usage or increase in usage of these medications. When I went to my psychiatrist he/she asked me “what did your surgeon say?” I said, “they told me to ask you.”

That is why I came in to see you, I don’t want another joint replacement.

Depression before joint replacement, depression after joint replacement

In the May 2017 issue of the prestigious British Journal of Surgery, (5) researchers at the University of Manchester wrote about patients who underwent hip replacements, knee replacements, hernia repairs, varicose vein operations.

Patients with moderate anxiety or depression had an increased probability of wound complications after a hip replacement.
Patients were more likely to be readmitted for a wound complication and had increased duration of hospital stay by 0·19 days. Estimated associations between anxiety/depression and surgical complications were consistent across all four types of operations and for each measure of anxiety and/or depression.

Joint replacement does not reduce mental health concerns

It is somewhat assumed that a patient with significant joint pain will have a happy disposition once that joint pain is alleviated. This is not the case for many patients. Now doctors are trying to figure out the cause and effect and one thing they are finding is that joint replacement does not reduce mental health concerns.

Research in the medical journal Aging and Mental Health says: “Total Joint Replacement patients did not show any clinically meaningful reductions in symptoms of depression or anxiety, following surgery.“(6)
- Here is a situation where an adult age child will send an aging mother or father to joint replacement with the hopes that the replacement will make them a “happier person.” Sometimes this does happen, sometimes it does not, it makes mom and dad worse.

Doctors in Serbia examined factors associated with severe postoperative pain in patients with total hip replacement. Patients with severe anxiety, depression, and Type D personality (tendency to worry or lack self-assurance) appear to be at risk of developing severe postoperative pain. In addition, being female and the intensity of pain immediately after the procedure was found to be important risk factors as well. (7)

In the medical journal Pain, doctors found a significant connection between postsurgical anxiety and acute pain, and this was confirmed by showing the relevance of psychological factors, over and above other potential clinical predictors that may lead to excessive or acute pain after surgery. It was recommended that doctors should target interventions aimed at acute postsurgical pain and anxiety management following major joint replacement. (8)

A multi-national study including doctors from the US, Germany, and Sweden found that 10% of patients in their study used antidepressants and these patients had poorer Quality of Life and higher levels of pain before and after surgery. The study concluded preoperative antidepressant use was independently associated with low patient-reported outcomes one year after total hip replacement. Clinicians are encouraged to screen for antidepressant use preoperatively. (9)

We do realize that many people reading this article are not the people who are suffering from depressive or anxiety episodes after a joint replacement. You may be the adult age caregiver of a mom or dad or a loved one and you are looking for some help. Earlier in this article, we mentioned that for our treatments to be most successful there has to be a good support structure in place. If you are part of that support structure your loved one already has a much better chance of achieving treatment goals.

If you are the person suffering from these challenges you have more than likely logged countless hours on the internet looking for help or answers.

In our clinics are goals are to help people avoid surgery, many times an unnecessary surgery. It is also our goal to help when surgery may not have provided the benefits that were hoped for, in this case, a painful joint following joint replacement.

As shown in the literature anxiety and depression are key factors in preventing patients from healing. We cover this subject further in these articles.

Would you like to ask a question about this article?
Get help and information from our Caring Medical staff.

References for this article Depression before joint replacement, depression after joint replacement

1 Moghtadaei M, Yeganeh A, Hosseinzadeh N, Khazanchin A, Moaiedfar M, Jolfaei AG, Nasiri S. The Impact of Depression, Personality, and Mental Health on Outcomes of Total Knee Arthroplasty. Clinics in Orthopedic Surgery. 2020 Dec 1;12(4):456-63. [Google Scholar]
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8 Pinto PR, McIntyre T, Ferrero R, Almeida A, Araújo-Soares V. Predictors of acute postsurgical pain and anxiety following primary total hip and knee arthroplasty. J Pain. 2013 May;14(5):502-15.[Google Scholar]
9 Greene ME, Rolfson O, Gordon M, Annerbrink K, Malchau H, Garellick G. Is the use of antidepressants associated with patient-reported outcomes following total hip replacement surgery? Acta Orthop. 2016 Oct;87(5):444-51. [Google Scholar]

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