The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 9

Scientific Articles | September 01, 2006

Depression in Orthopaedic Trauma Patients: Prevalence and Severity

Renn J. Crichlow, MD¹; Patricia L. Andres, MS, PT²; Suzanne M. Morrison, MPH³; Stephen M. Haley, PhD, PT²; Mark S. Vrahas, MD³

¹ Partners Orthopaedic Trauma Service, 305 West Fayette Street, Apartment 406, Baltimore, MD 21201
² Sargent College of Health and Rehabilitation Sciences, Boston University, 635 Commonwealth Avenue, Boston, MA 02215
³ Partners Orthopaedic Trauma Service, Massachusetts General Hospital, 55 Fruit Street, WACC 525, Boston, MA 02114. E-mail address for M.S. Vrahas: mvrahas@partners.org

View Disclosures and Other Information

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the Orthopaedic Trauma Association. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Sep 01;88(9):1927-1933. doi: 10.2106/JBJS.D.02604

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Abstract

Background: There is a known connection between physical injury and disability and emotional distress. Several investigators have shown a relationship between trauma, depression, and poor outcomes. The literature on trauma and depression is limited with regard to clarifying the relationship between the degree of injury and depression and the relationship between physical function of patients with less severe injuries and depression.

Methods: One hundred and sixty-one patients who presented to our orthopaedic trauma services were enrolled in the study and interviewed. We obtained information about patient demographics and administered several self-reported outcome measures: the Beck Depression Inventory (BDI), the Short Musculoskeletal Function Assessment (SMFA), and the Physical Function-10 (PF-10) subset of the Short Form-36 (SF-36). We documented the nature and severity of the injury or injuries and calculated correlations between the outcome measures and the BDI. Injury-specific factors such as the AO Fracture Classification, the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and the Gustilo and Anderson grade of open fractures were also examined.

Results: Fifty-five percent of the patients had minimal depression, as measured with the BDI; 28% had moderate depression; 13% had moderate-to-severe depression; and 3.7% had severe depression. When the somatic elements of the BDI were removed, the prevalence of moderate, moderate-to-severe, or severe depression was 26%. The SMFA scores had a strong negative correlation with the BDI (—0.75; p < 0.001). Of the injury-specific factors, only open factures were found to have an impact on the presence of depression, with an odds ratio of 4.58 (95% confidence ratio, 1.57 to 12.35).

Conclusions: The prevalence of clinically relevant depression approached 45% in a diverse cohort of orthopaedic trauma patients. Global disability is strongly correlated with depression. The presence of an open fracture may also increase the risk of depression.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

There is a defined association between physical injury and disability and emotional distress¹. There is an increasing awareness that patient outcomes following orthopaedic trauma surgery do not depend solely on the success of the operative procedure. Emotional distress has been shown to affect physical function, overall outcomes, and postinjury productivity levels^2-5. Depression rates as high as 42% have been reported in general trauma populations^5-8. Despite this, there has been very little research evaluating the specific psychological effects of musculoskeletal injury. High rates of depression have been documented in patients with severe lower-extremity injury⁵. However, patients with less severe injuries have not been evaluated with regard to their rates of depression, to our knowledge, and the relationship between injury severity and depression is not clear. In addition, little is known about the association between depression and functional disability in this context. The purpose of this paper was to evaluate the prevalence of depression in a general orthopaedic trauma population and to examine how instruments used to evaluate depression and functional outcome may be associated with one another.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

Data for this study were collected as part of a larger study that was being performed to develop a functional outcomes tool for evaluating patients who had sustained musculoskeletal trauma. This project involved developing outcomes instruments with use of item response theory and computerized adaptive testing. Our institutional review board approved the study. Patients, eighteen years of age or older, who presented to our orthopaedic trauma clinic for follow-up visits three to twelve months after an injury were approached for enrollment. Patients were excluded if they could not read English. Patients were enrolled from June 2002 through February 2004.

Procedures

After informed consent was obtained, each participant was asked to complete a 149-item questionnaire. A research assistant explained the questionnaire and was available to address difficulties; otherwise, the patients completed the forms independently. The 149 items included demographic questions as well as all of the items from the Beck Depression Inventory^9-12 (BDI), the Short Musculoskeletal Functional Assessment (SMFA)^13,14, and the Physical Function-10 (PF-10) subset of the Short Form-36 (SF-36)^15-17. All patients were recruited from orthopaedic trauma clinics staffed by senior orthopaedic trauma surgeons at the Brigham and Women's and Massachusetts General hospitals. With the exclusion of some upper-extremity fractures, all fractures that are seen at these institutions are managed in the clinics regardless of severity. The clinic days on which patients were recruited depended on the availability of research nurses. At each clinic in which a research nurse was available, all patients who were candidates were approached for enrollment. The refusal rate was not recorded.

Measurements

Depression

The BDI, an internationally recognized and widely used instrument in the assessment and detection of depression, was employed to evaluate depression in the study cohort⁹. The BDI has high internal consistency, has high content validity, has demonstrated validity in differentiating between depressed and nondepressed subjects, and is sensitive to change¹⁰. The instrument has twenty-one items: fifteen items evaluating emotional status and behavioral changes and six evaluating somatic symptoms. Each symptom is rated on a 4-point scale, and scores are added, for a total ranging from 0 to 63 points. Scores of <10 points indicate minimal depression, those from 10 to 18 points indicate moderate depression, those from 19 to 29 points indicate moderate-to-severe depression, and those of = 30 points indicate severe depression¹².

We were concerned that patients would score poorly on the physical function questions not because they were depressed but because of their injuries, pain, or narcotic dependence. To address this issue, we analyzed the BDI scores both with and without the six somatic (SS) questions. Thus, the maximum possible score on the full BDI was 63 points and the maximum possible score with the somatic scores removed (BDI — SS) was 45 points. Since there are no standards for the BDI — SS, we continued to use the standards for the full BDI to determine whether the patients were depressed.

Physical Function

We used the SMFA, a forty-six-item shortened version of the Musculoskeletal Function Assessment^13,14, to measure physical function in the study population. The SMFA was designed to describe the various levels of function of people with musculoskeletal disorders and to monitor change with time. It has been tested on patients with musculoskeletal disorders (the target population), and its psychometric properties suggest that it has value for monitoring either groups or individual patients^13,14. The reliability and validity of the SMFA have been demonstrated previously^13,14. The short form generates two main scores: the Dysfunction Index and the Bother Index. The Dysfunction Index (SMFA-DI) is comprised of four subscales: daily activities, emotional status, arm and hand function, and mobility. The Bother Index (SMFA-BI) adds a unique facet by evaluating the impact of the patient's symptoms and functional limitation.

Physical function was further evaluated with the PF-10 (SF-36). The validity of the PF-10 (SF-36) as a measure of physical function has been reported previously^15-17.

Injury Characteristics

Injury severity was evaluated with the Injury Severity Score (ISS), the Abbreviated Injury Scale (AIS), and the Orthopaedic Trauma Association (OTA) fracture classification^18-21. The Gustilo and Anderson classification was applied, on the basis of intraoperative findings, to open fractures²².

The AIS is a measure of injury severity based on anatomic descriptors for each body area. The score ranges from 1 to 6 points, with the most severe, fatal injuries given 6 points²³. A straightforward diaphyseal femoral fracture is assigned 3 points, and an ankle sprain is given 1 point.

The ISS evaluates severity in multiply injured patients. It is calculated by summing the squares of the highest AIS score for each of the three most severely injured body regions^18,19. The ISS and AIS score were calculated by trauma nurse coordinators at the time of admission and were recorded in the trauma registry. Only musculoskeletal AIS scores were used in this study. When patients had multiple musculoskeletal injuries and thus multiple musculoskeletal AIS scores, the highest AIS score was used.

Fractures were classified according to the OTA fracture classification by the attending surgeons at the time of admission²¹. Open fractures were classified according to the Gustilo and Anderson classification at the first débridement by the attending surgeon²².

Data Analysis

The relationship between depression and physical function as determined with the SMFA and the PF-10 (SF-36) and the relationship between depression and injury severity as determined with the ISS and the AIS (maximum musculoskeletal AIS for each patient) were analyzed with use of the Spearman correlation coefficient. The relationships between depression and the OTA fracture classification and the Gustilo and Anderson classification were calculated with use of odds ratio and relative risk analysis²⁴.

Each participant was asked to respond to 149 items; 7.4% of the items (2.5% to 11.2% items per patient) were not answered and were labeled as "missing." Rather than exclude patients who had completed the majority of items, we replaced missing values with use of the mean imputation method²⁵.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

Demographics

One hundred and sixty-one patients completed much of or the entire questionnaire. The mean age of the enrollees was 45.9 years, with a range of nineteen to eighty-four years. The majority of patients were male (66.3%).

Injuries

The average ISS (and standard deviation) was 10.3 ± 7.2 points, with 24% of the respondents having an ISS of =13 points. The average musculoskeletal AIS score was 2.74 ± 0.62 points. The distribution of AIS scores is presented in Table I. Seventy-eight percent of the patients had a lower-extremity injury, 4% had an upper-extremity injury, and 18% had multiple extremity injuries. Fifteen percent of the patients had an open fracture. The two most common injuries were tibial fractures (found in 43.5% of the patients) and ankle fractures (found in 16% of the patients). The distribution of fractures and their severity as measured with the OTA classification are presented in Table II.

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TABLE I Distribution of AIS Scores*

Maximum Extremity AIS Score for Each Patient	Injury	No. of Patients (N = 161)
1	Minor	2
2	Moderate	51
3	Serious	92
4	Severe	16
5	Critical	0
6	Unsurvivable	0

The Abbreviated Injury Scale is a measure of injury severity based on anatomic descriptors for each body area. The score ranges from 1 to 6 points, with the most severe, fatal injuries given 6 points²³.

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TABLE I Distribution of AIS Scores*

Maximum Extremity AIS Score for Each Patient	Injury	No. of Patients (N = 161)
1	Minor	2
2	Moderate	51
3	Serious	92
4	Severe	16
5	Critical	0
6	Unsurvivable	0

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TABLE II Injury Characteristics and Distribution

Anatomic descriptor	No. of Injuries
	AO Type	Total	A Type	B Type	C type	Open
Proximal humeral	11	5	2	3	0	0
Diaphyseal humeral	12	4	1	2	1	0
Distal humeral	13	2	0	1	1	1
Proximal ulnar	21	2	1	0	1	0
Forearm	22	4	1	2	1	1
Distal radial	23	6	0	3	3	1
Proximal femoral	31	10	7	3	0	0
Diaphyseal femoral	32	7	1	5	1	0
Distal femoral	33	12	2	4	6	3
Patellar		4	1	2	1	0
Tibia plateau	41	27	3	7	17	2
Diaphyseal tibial	42	34	14	10	10	13
Pilon/distal tibial	43	21	5	8	8	1
Ankle	44	31	7	20	4	8
Pelvic	61	6	2	2	2	0
Acetabular	62	20	5	12	3	1
Hindfoot	7	7	1	6	0	0
Forefoot	8	9	5	2	2	1
Total		211	58	92	61	32

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TABLE II Injury Characteristics and Distribution

Anatomic descriptor	No. of Injuries
	AO Type	Total	A Type	B Type	C type	Open
Proximal humeral	11	5	2	3	0	0
Diaphyseal humeral	12	4	1	2	1	0
Distal humeral	13	2	0	1	1	1
Proximal ulnar	21	2	1	0	1	0
Forearm	22	4	1	2	1	1
Distal radial	23	6	0	3	3	1
Proximal femoral	31	10	7	3	0	0
Diaphyseal femoral	32	7	1	5	1	0
Distal femoral	33	12	2	4	6	3
Patellar		4	1	2	1	0
Tibia plateau	41	27	3	7	17	2
Diaphyseal tibial	42	34	14	10	10	13
Pilon/distal tibial	43	21	5	8	8	1
Ankle	44	31	7	20	4	8
Pelvic	61	6	2	2	2	0
Acetabular	62	20	5	12	3	1
Hindfoot	7	7	1	6	0	0
Forefoot	8	9	5	2	2	1
Total		211	58	92	61	32

Depression Scores

The depression scores for the entire cohort and for the subgroups with the most frequent injuries are shown in Table III. There was a high rate of depression in the study population as a whole, with 45% of the patients having a BDI score indicating moderate, moderate-to-severe, or severe depression. The rate of moderate, moderate-to-severe, or severe depression was 73.9% for patients with an open tibial fracture, 32% for those with a closed tibial fracture, and 41.1% for those with a closed ankle fracture.

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TABLE III Prevalence of Depression in Cohort as a Whole and in Injury Subgroups

	Cohort (N = 161)	Open Tibial Fracture (N = 23)	Closed Tibial Fracture (N = 59)	Closed Ankle Fracture (N = 17)
Minimal depression (<10 points)	55.3%	26%	68%	59%
Moderate depression (11-18 points)	28.0%	61%	15%	18%
Moderate to severe depression (19-29 points)	13.0%	4%	14%	12%
Severe depression (=30 points)	3.7%	9%	3%	12%

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TABLE III Prevalence of Depression in Cohort as a Whole and in Injury Subgroups

	Cohort (N = 161)	Open Tibial Fracture (N = 23)	Closed Tibial Fracture (N = 59)	Closed Ankle Fracture (N = 17)
Minimal depression (<10 points)	55.3%	26%	68%	59%
Moderate depression (11-18 points)	28.0%	61%	15%	18%
Moderate to severe depression (19-29 points)	13.0%	4%	14%	12%
Severe depression (=30 points)	3.7%	9%	3%	12%

Scores on the BDI were recalculated with the questions related to somatic symptoms removed (BDI — SS), and the prevalence of depression was determined by comparing these scores with the standard BDI reference scale. The results are presented in Table IV. Even with the somatic subscale removed, 26% of the subjects had scores indicating moderate, moderate-to-severe, or severe depression.

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TABLE IV Prevalence of Depression with Somatic Subscale Removed*

Depression Level	Percentage of Cohort (N = 161)
Minimal or none	74%
Moderate	18.5%
Moderate to severe	6.8%
Severe	0.7%

The scores on the BDI were recalculated with the questions related to physical function removed, and the prevalence of depression was determined by comparing these scores with the standard BDI reference scale.

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TABLE IV Prevalence of Depression with Somatic Subscale Removed*

Depression Level	Percentage of Cohort (N = 161)
Minimal or none	74%
Moderate	18.5%
Moderate to severe	6.8%
Severe	0.7%

Functional Scores and Depression Index

There was a high correlation between the SMFA and the BDI (Spearman correlation coefficient, —0.75; p < 0.001). Thus, as functional outcome worsened, depression scores increased. Similarly, there was a high correlation between the SMFA-BI and the BDI (Spearman correlation coefficient, —0.77; p < 0.001). The SMFA-DI and the BDI were also highly correlated (Spearman correlation coefficient, —0.71; p < 0.001). There was moderate correlation between the scores on the PF-10 (SF-36) and the BDI (Spearman correlation coefficient, —0.63; p < 0.001). These correlations are shown in Table V.

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TABLE V Spearman Correlation Coefficients Between BDI Scores and PF-10 (SF-36) and SMFA Outcome Measures*

	SMFA
	PF-10 (SF-36)	Total	BI	DI
BDI
Total	-0.626 (p < 0.001)	-0.745 (p < 0.001)	-0.773 (p < 0.001)	-0.711 (p < 0.001)
Somatic index	-0.665 (p < 0.001)	-0.723 (p < 0.001)	-0.726 (p < 0.001)	-0.709 (p < 0.001)
Emotional index	-0.521 (p < 0.001)	-0.681 (p < 0.001)	-0.724 (p < 0.001)	-0.639 (p < 0.001)

In addition to the calculation of the correlations between the total scores, an attempt to clarify the relationships between depression, physical function, and outcomes was made by creating novel BDI subscales (the Somatic Index and the Emotional Index) and comparing them separately with the complete PF-10 (SF-36) and SMFA as well as with the SMFA subscales (the Bother Index and Dysfunction Index).

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TABLE V Spearman Correlation Coefficients Between BDI Scores and PF-10 (SF-36) and SMFA Outcome Measures*

	SMFA
	PF-10 (SF-36)	Total	BI	DI
BDI
Total	-0.626 (p < 0.001)	-0.745 (p < 0.001)	-0.773 (p < 0.001)	-0.711 (p < 0.001)
Somatic index	-0.665 (p < 0.001)	-0.723 (p < 0.001)	-0.726 (p < 0.001)	-0.709 (p < 0.001)
Emotional index	-0.521 (p < 0.001)	-0.681 (p < 0.001)	-0.724 (p < 0.001)	-0.639 (p < 0.001)

Injury-Specific Factors and Depression Index

We calculated odds ratios for several of the injury-specific markers in order to assess whether more severe injuries were more likely to be associated with depression. These results are shown in Table VI. An open fracture represented the only injury-specific factor to reach significance (odds ratio, 4.58 [95% confidence interval, 1.57 to 12.35]). OTA C-type fractures, lower-extremity fractures, upper-extremity fractures, and multiple fractures did not independently increase the risk of depression.

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TABLE VI Odds Ratios for Injury-Specific Factors*

	Odds Ratio	95% Confidence Interval
Open vs. closed fracture	4.58	1.57-12.35
AIS 4 vs. AIS 1-3	1.524	0.988-2.350
OTA C-type vs. OTA A and B-type fractures	1.142	0.581-2.246
Lower-extremity vs. upper-extremity and multiple fractures	0.761	0.356-1.626
Upper-extremity vs. lower-extremity and multiple fractures	0.609	0.108-3.423
Multiple fractures vs. upper and lower-extremity fractures	0.758	0.237-2.426

Odds ratios were calculated for several of the injury-specific markers in order to assess whether more severe injuries were more likely to be associated with depression. The presence of an open fracture was the only injury-specific factor to reach significance.

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TABLE VI Odds Ratios for Injury-Specific Factors*

	Odds Ratio	95% Confidence Interval
Open vs. closed fracture	4.58	1.57-12.35
AIS 4 vs. AIS 1-3	1.524	0.988-2.350
OTA C-type vs. OTA A and B-type fractures	1.142	0.581-2.246
Lower-extremity vs. upper-extremity and multiple fractures	0.761	0.356-1.626
Upper-extremity vs. lower-extremity and multiple fractures	0.609	0.108-3.423
Multiple fractures vs. upper and lower-extremity fractures	0.758	0.237-2.426

Correlations between the BDI and the injury severity as measured with the ISS, the AIS, the OTA grading system, and the Gustilo and Anderson system for grading open fractures were calculated to determine whether more severe injuries were correlated with more severe depression. The results are shown in Table VII. The correlation between the ISS and BDI scores was poor, with a Spearman correlation coefficient of 0.1 (p = 0.25). The correlation between the AIS and the BDI was also poor, with a Spearman correlation coefficient of 0.1 (p = 0.20).

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TABLE VII Spearman Correlation Coefficients Between BDI and Injury-Specific Scores

	BDI
ISS	0.07
AIS	0.14
Gustilo and Anderson grade of open-fracture severity	0.20
OTA classification of fracture severity	-0.06

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TABLE VII Spearman Correlation Coefficients Between BDI and Injury-Specific Scores

	BDI
ISS	0.07
AIS	0.14
Gustilo and Anderson grade of open-fracture severity	0.20
OTA classification of fracture severity	-0.06

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

The prevalence of depression in our sample was high, with 45% of our cohort screening positively for moderate, moderate-to-severe, or severe depression and 16.7% screening positively for moderate-to-severe or severe depression. These levels are extremely high relative to those in the population at large. The prevalence of depression in the general population ranges from 3.2% to 19.8%, depending on the instrument used for measurement and the study population^26-32. Similarly, the levels for our patients, who had sustained a fracture, were much higher than the estimated prevalence for comparative populations such as inpatient medical (34.4%), outpatient medical (2.2% to 12.2%), and cardiac populations (32%)^33-36.

These high levels of depression are consistent with findings in other studies documenting the prevalence of psychological distress following physical trauma. The incidence of psychological distress has ranged between 23% and 41% in a variety of studies with widely divergent populations and outcome instruments^2-8,33-38. In the Lower Extremity Assessment Project (LEAP) population (patients with severe lower-extremity injuries) the incidence of moderate-to-severe depression was 41.8% and the incidence of severe depression was 15.3%⁵.

Our findings are unique because they document and quantify depression separately from posttraumatic stress disorder, anxiety, or phobia. The trauma literature has yet to document the distribution of patients along a spectrum of mild-to-severe depression. Our stratification of patients according to three levels of depressive symptoms also allowed us to begin to determine which of these patients would qualify for potential interventions.

As a result of methodological differences, it is difficult to assess whether this diverse group of patients had more or less psychological morbidity than other populations studied to date. As mentioned, the LEAP results showed that the prevalence of moderate-to-severe depression was 41.8% and that of severe depression was 15.3%, but, since the measures of depression were different, our results cannot be directly compared. However, it is notable that, as a whole, the LEAP cohort (by design) had substantially worse injuries than did our cohort and yet the rates of moderate-to-severe depression were very similar in these two studies. This calls into question the widely held belief that less severe orthopaedic injuries are less likely to produce or unmask psychological distress. While the level of severe depression in our cohort differed from that in the LEAP group, these studies suggest that any orthopaedic injury places patients at substantial risk for moderate-to-severe depression.

Analyzing depression in patients with temporary physical disability can be difficult. Most depression-screening instruments involve questions that are directly related to physical status and vitality. Trauma patients, who by nature have difficulty with activities of daily living, chronic pain, or continuing narcotic requirements, may confound depression scores by scoring poorly on items related to vitality, energy, or sleep disturbance. Secondarily, there have been criticisms that the BDI overestimates the severity of depressive symptoms in patients with somatic symptoms³⁹. We attempted to address this issue by evaluating patient scores on the BDI with the items related to physical function (the somatic subscale) removed. Since there are no established norms for determining depression only on the basis of the emotion/mood-based portion of the BDI, we used standard BDI thresholds. The maximum possible score for the BDI is 63 points; with the somatic subscale removed, the maximum possible score is 45 points. While we expected that removing these physical components from the BDI would substantially lower the scores in general as well as lower the overall prevalence of depression, the prevalence of moderate, moderate-to-severe, or severe depression were still high (26%). Thus, the rate of substantial emotional distress remains elevated even when physical factors are ignored.

The functional outcome measures were closely correlated with the presence of depression. Poorer scores on the SMFA were associated with higher scores on the BDI as evidenced by the Spearman correlation coefficient. This was not unexpected, as the SMFA-DI and BI have questions specifically related to emotional status.

Intuitively, one would expect higher rates of depression in patients with more severe injuries. However, our data do not generally support that conclusion. We found no correlation between injury severity as measured with the AIS or ISS and depression as measured with the BDI (0.1 [p = 0.20] and 0.1 [p = 0.25], respectively). Similarly, we found no correlation between fracture severity and depression. On the other hand, we did find that patients with an open fracture were 4.58 times more likely to have moderate-to-severe depression than were those with a closed fracture (odds ratio, 4.58 [95% confidence interval, 1.57 to 12.35]). The severity of the injury as measured with the OTA fracture classification and a higher AIS score did not appear to be related to significant increases in the rate of depression. It may be that the presence of an open fracture is a more definitive indictor of severity than is any other index. For example, the AIS has been show to underestimate morbidity in patients with multiple musculoskeletal injuries⁴⁰. On the other hand, it may be that the etiology of depression is multifactorial and not simply dependent on the severity of the injury. The LEAP study group demonstrated that physical function was strongly associated with the likelihood of a psychological disorder⁵. However, they found inadequate social support, poverty, lack of self-efficacy, neuroticism, and a likely alcohol problem to be strongly associated as well⁵.

One of the strengths of our study is that we used the BDI to monitor depression. The BDI was designed specifically to diagnose depression and monitor treatment^9-12. Thus, the patients in our study whose score on the BDI indicated moderate-to-severe depression may benefit from standard treatments for depression, although it is yet to be determined whether patients who have depression associated with trauma will respond to standard treatments. Orthopaedic surgeons should be vigilant regarding symptoms of depression such as insomnia, anorexia, anxiety, poor concentration, and lassitude in order to make appropriate referrals⁴¹.

The results of our study should be considered in light of the following limitations. The lack of data on the preinjury levels of depression in this patient population limits the interpretation of the study results. The contribution of injury-related disability to the baseline level of psychological distress is unclear. It may be that these patients were involved in accidents as a result of baseline emotional distress and that the trauma and disability unmasked or exaggerated these preexisting conditions. The level of perceived depression and disability might also have been influenced by the patient's socioeconomic status, medical comorbidity, and health habits; however, such data were not collected. It has been shown that adequate financial and familial support can minimize the impact of injury on perceived physical and emotional disability⁴². Furthermore, we did not monitor the use of psychological counseling by the study patients. Access to and use of psychiatric interventions may have resulted in a lower rate of depression.

While we chose well-validated instruments, this study was also limited by the self-reporting method that was used. Clinical evaluation by mental health professionals would have increased the accuracy of diagnosis and allowed a greater understanding of the disease process. The self-reporting method also resulted in patients leaving some items blank. Although an established statistical method was used to account for missing data, there is some controversy regarding whether that method produces valid results.

Although all patients who met the inclusion criteria were approached for enrollment on selected clinic days, we did not attempt to enroll patients at every clinic during the study period. Similarly, although it was our impression that few patients refused enrollment, we did not record the actual number of patients who refused. Moreover, we do not know the number of, and did not collect data on, all patients with similar injuries. Without a true denominator, it is impossible to determine whether our findings apply to general fracture populations or to patients with specific injury patterns. Nevertheless, the range of patients studied was broad enough and the incidence was high enough to suggest that depression is an important problem deserving further study. Recognizing and treating depression can improve the patients' overall health and may lead to better outcomes. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors acknowledge Dr. Peng Sheng Ni at the Health and Disability Research Institute, Boston University, for his assistance with data analysis and Melissa Herman for her assistance with the preparation of the manuscript.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Topics

fracture ; depressive disorders ; fractures, open ; wounds and injuries ; depressed mood ; physical function

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Renn J. Crichlow, Patricia L. Andres, Suzanne M. Morrison, Stephen M. Haley, Mark S. Vrahas; Depression in Orthopaedic Trauma PatientsPrevalence and Severity. The Journal of Bone & Joint Surgery. 2006 Sep;88(9):1927-1933.

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