Caring Medical - Where the world comes for ProlotherapyDepression before joint replacement, depression after joint replacement

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, PA-C

When a patient has major depressive disorder (MDD), healing and recovery from medical procedures 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 complication.

The actual focus of this study was on post-surgery expense. 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.(1) Costs that may include the need for prolonged pain medications.

Prolonged pain medications

A new study on patients age 55 and older appearing from doctors in the United Kingdom puts the incidence rate of depression at 17.1% of primary care patients and  and panic/anxiety disorders at 11.3%. (2)

As age 55 and older are the target ages for joint replacement, it becomes easy to speculate that many in this age group seek joint replacement alternatives because of anxiety, panic, and depressive episodes.

Now let’s explore an April 2018 study published in the The Journal of Arthroplasty. Here surgeons wrote of the problems of pain in the  immediate postoperative period following total joint replacement. Pain they suggest is influenced by various patient factors, including major depressive disorder.

  • This study compared 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, the doctors compared:
    • pain intensity,
    • lengths of stay,
    • opioid consumption, and
    • patient perception of pain control.

What they found was troubling:

  • Patients with major depressive disorder undergoing total joint replacement consume more opioids compared to similar patients without major depressive disorders during the immediate postoperative period.

Why patients should not consume more opiods is the focus of our current opined crisis in the United States and the focus of my article How narcotic pain medications can increase chronic pain.

Depression before joint replacement, depression after joint replacement

In May 2017 issue of the prestigious British Journal of Surgery, 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.
  • They were more likely to be readmitted for a wound complication and had an 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.(3)

It is somewhat assumed that a patient with significant joint pain will have a happy disposition once that knee pain is alleviated to their, the patient’s, satisfaction. 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.(4)

Doctors in Denmark all suggest that patients with psychiatric disorders tend to do worse than patients without a psychiatric diagnosis when undergoing total hip arthroplasty (replacement) or total knee arthroplasty (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.(5)

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 procedure were found to be important risk factors as well.(6)

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.(7)

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.(8)

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

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Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD

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

1 Rasouli MR, Menendez ME, Sayadipour A1 Purtill JJ, Parvizi J. Direct Cost and Complications Associated With Total Joint Arthroplasty in Patients With Preoperative Anxiety and Depression.J Arthroplasty. 2016 Feb;31(2):533-6.  [Google Scholar]

2 Etcheson JI, Gwam CU, George NE, Virani S, Mont MA, Delanois RE. Patients with major depressive disorder experience increased perception of pain and opioid consumption following total joint arthroplasty. The Journal of arthroplasty. 2018 Apr 1;33(4):997-1002. [Google Scholar]

3 Britteon P, Cullum N, Sutton M. Association between psychological health and wound complications after surgery. Br J Surg. 2017 May;104(6):769-776. doi: 10.1002/bjs.10474. [Google Scholar]

4 Scott JE, Mathias JL, Kneebone AC. Depression and anxiety after total joint replacement among older adults: a meta-analysis.  Aging Ment Health. 2016 Dec;20(12):1243-1254. [Pubmed] [Google Scholar]

5 Gylvin SH, rgensen CC, Fink-Jensen A, Kehlet H. Psychiatric disease as a risk factor in fast-track hip and knee replacement. Acta Orthop. 2016 Oct;87(5):439-43. doi: 10.3109/17453674.2016.1151292. Epub 2016 Feb 22 [Google Scholar]

6 Petrovic NM, Milovanovic DR, Ignjatovic Ristic D, Riznic N, Ristic B, Stepanovic Z. Factors associated with severe postoperative pain in patients with total hip arthroplasty. Acta Orthop Traumatol Turc. 2014;48(6):615-22. [Google Scholar]

7 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]

8 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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