The association between psychiatric disorders, most notably depression and anxiety, and pain is well established. However, mental health professionals, and especially psychiatrists, are still often excluded from treating patients with pain as many of our non-psychiatrist physician colleagues still often believe that there is little for them to do in the care of patients with pain unless it is clearly secondary to a psychiatric disorder. The results of two new studies highlight the importance of addressing mental health problems in patients with pain.
Total knee arthroplasty
The first study examined the effects of MDD on the outcomes for 260 patients who underwent total knee arthroplasty (TKA).1 Patients completed baseline measures before the surgery that included the Patient Health Questionnaire to evaluate the presence of MDD and others to evaluate pain, level of functioning, and overall quality of life. The testing was repeated at a year following the surgery.
The patients were divided into four groups:
1) Those who didn’t suffer from MDD either at baseline or follow-up
2) Those who suffered MDD at baseline but not at follow-up
3) Those who didn’t suffer MDD at baseline but did at follow-up
4) Those who suffered MDD both at baseline and follow-up
At baseline there were no significant differences between the groups with regard to knee function. However, there were significant differences between them at one-year follow-up. Patient with MDD at both baseline and follow-up were found to have significantly less net improvement than patients in the other three groups. Patients who did not have MDD at baseline but did at follow-up also had less improvement than patients who never had MDD or those with MDD that had resolved by follow-up. Patients in the latter two groups had similar levels of improvement.
Visser and colleagues conclude that patients with MDD can still benefit from TKA. They emphasize that the presence of the psychiatric disorder is not a contraindication to the surgery, but it is important to at least begin to treat symptoms before patients undergo TKA. Moreover, it is important to monitor the mental health of patients who have undergone the surgery to determine whether depression is developing and needs to be treated. Also noted was the difficulty in determining whether the psychiatric disorder caused the reduction in benefits from the surgery or if the reason for continuing or new-onset depression was the lower level of improvement following the surgery.
Dr King is in private practice in Philadelphia.
1. Visser MA, Howard KJ, Elli HB. The influence of major depressive disorder at both the preoperative and postoperative evaluations for total knee arthroplasty outcomes. Pain Medicine. 2019;20:826-833.
2. Oliveira DS, Mendonça LVF, Sampaio RSM, et al. The impact of anxiety and depression on the outcomes of chronic low back pain multidisciplinary pain management: a multicenter prospective cohort study in pain clinics with one-year follow-up. Pain Medicine. 2019;20:736-746.