Reply to Letter to the Editor: What Are Orthopaedic Patients’ and Clinical Team Members’ Perspectives Regarding Whether and How to Address Mental Health in the Orthopaedic Care Setting? A Qualitative Investigation of Patients With Neck or Back Pain

To the Editor,

We thank Dr. Gu for his letter regarding our investigation into orthopaedic stakeholders’ perspectives regarding whether and how to address mental health in the orthopaedic care setting [4]. We are excited that our project has sparked further discussion, and we wholeheartedly support Dr. Gu’s proposal to adapt the Collaborative Care Model as a strategy for addressing patients’ mental health in the orthopaedic care setting.

The Collaborative Care Model is appealing for several reasons. First, it is a well-established, evidence-based intervention that effectively, simultaneously, and sustainably improves mental health, physical function, and overall quality of life [7, 8]. Second, it is a feasible strategy for delivering in-person mental health treatment directly within the orthopaedic care setting. Practically, an orthopaedic clinic could employ a social worker to serve as both the collaborative care program’s behavioral health manager and also as a resource to help patients navigate social barriers to care. Arguably, provision of both these services would generate a financial return on investment quickly by reducing the number of missed appointments in the clinic and post-procedure medical complications. Third, the Collaborative Care Model improves overall access and reduces racial and ethnic disparities related to accessing effective mental health treatment [1, 6]. Adapting the collaborative care Model in the orthopaedic clinic has the potential to make an especially meaningful societal impact because musculoskeletal conditions are among the most common reasons people seek medical care, and because people are more likely to engage with mental health treatment when it is integrated into their usual medical care rather than when treatment requires travel to another clinic that exclusively addresses mental health [2, 3, 5].

Nevertheless, we suspect that successfully addressing mental health in the orthopaedic care setting will not be a one-size-fits-all approach. Orthopaedic clinics have a wide range of personnel, administrative, and financial resources, so we are interested in identifying a synergistic array of treatment modalities and implementation strategies that effectively facilitate the delivery of evidence-based mental health treatment to patients with musculoskeletal problems. This kind of implementation-related research is in its infancy, but our preliminary work suggests that the orthopaedic community will most quickly adopt interventions that easily integrate into existing clinical workflows without considerable added resources. Integration of more resource-intensive interventions (such as collaborative care) will require more time, administrative buy-in, and logistical planning, but we believe this added effort would be worthwhile. The orthopaedic community has the opportunity to lead the medical field in delivering truly whole-person care within a busy, specialty clinic setting.

Ultimately, we believe that successfully addressing patients’ mental health in the orthopaedic care setting on a large scale will require a cultural shift within the orthopaedic community. Change may occur most efficiently if we work toward a multi-pronged approach to simultaneously implement low-resource, widely scalable interventions, as well as more robust interventions such as the Collaborative Care Model. If we can engage trainees in these efforts as Dr. Gu proposes, we hope that addressing mental health in the orthopaedic setting will become standard care within a generation, if not sooner.