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

Abstract

Background

Across virtually all orthopaedic subspecialties, symptoms of depression, anxiety, and unhelpful thinking are associated with worse patient-reported satisfaction with orthopaedic treatment and increased postoperative complications. In the orthopaedic community, there is growing interest in patients’ mental health in the orthopaedic care setting, but addressing mental health is still not a focus of orthopaedic clinical training. There is a persistent awareness gap about how to address mental health in orthopaedic care in a manner that is simultaneously feasible in a busy orthopaedic practice and acceptable to patients who are presenting for treatment of a musculoskeletal condition.

Questions/purposes

(1) What are orthopaedic patients’ and clinical team members’ current perceptions and motivators regarding addressing mental health as part of orthopaedic care? (2) What barriers do patients and clinicians face regarding addressing mental health as part of orthopaedic care? (3) What are facilitators for patients and clinicians related to addressing mental health as part of orthopaedic care? (4) What are practical, acceptable implementation strategies to facilitate addressing mental health as part of orthopaedic care?

Methods

This was a single-center, qualitative study conducted from January through May 2022 in the orthopaedic department of a large, urban, tertiary care academic medical center. Semistructured interviews were conducted with members of two stakeholder groups: orthopaedic patients and orthopaedic clinical team members. We interviewed 30 adult patients (of 85 patients who were eligible and approached) who had presented to our orthopaedic department for management of neck or back pain lasting for 3 or more months. By prescreening clinic schedules, patients were purposively sampled to include representatives from varied sociodemographic backgrounds and with a range of severity of self-reported symptoms of depression and anxiety (from none to severe on the Patient-Reported Outcomes Measurement Information System Depression and Anxiety measures) (mean age 59 ± 14 years, 70% [21 of 30] women, 60% [18 of 30] White, median pain duration 3.3 [IQR 1.8 to 10] years). We also interviewed 22 orthopaedic clinicians and clinical support staff members (of 106 team members who were eligible and 25 who were approached). Team members were purposively sampled to include representatives from the full range of adult orthopaedic subspecialties and early-, mid-, and late-career physicians (11 of 22 were women, 16 of 22 were White, and 13 of 22 were orthopaedic surgeons). Interviews were conducted in person or via secure video conferencing by trained qualitative researchers. The interview guides were developed using the Capability, Opportunity, Motivation, Behavior model of behavior change. Two study team members used the interview transcripts for coding and thematic analysis, and interviews with additional participants from each stakeholder group continued until two study team members independently determined that thematic saturation of the components of the Capability, Opportunity, Motivation, Behavior model had been reached. Each participant statement was coded as a perception, motivator, barrier, facilitator, or implementation strategy, and inductive coding was used to identify themes in each category.

Results

In contrast to the perceptions of some orthopaedic clinicians, most patients with orthopaedic conditions expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopaedic care plan. Motivation to address mental health was expressed the most strongly among orthopaedic clinical team members who were aware of high-quality evidence that demonstrated a negative impact of symptoms of depression and anxiety on metrics for which they are publicly monitored or those who perceived that addressing patients’ mental health would improve their own quality of life. Barriers described by patients with orthopaedic conditions that were related to addressing mental health in the context of orthopaedic care included clinical team members’ use of select stigmatizing words and perceived lack of integration between responses to mental health screening measures and the rest of the orthopaedic care encounter. Orthopaedic clinical team members commonly cited the following barriers: lack of available mental health resources they can refer patients to, uncertainty regarding the appropriateness for them to discuss mental health, and time pressure and lack of expertise or comfort in discussing mental health. Facilitators identified by orthopaedic clinical teams and patients to address mental health in the context of orthopaedic care included the development of efficient, adaptable processes to deliver mental health interventions that preferably avoid wasted paper resources; initiation of mental health–related discussion by an orthopaedic clinical team member in a compassionate, relevant context after rapport with the patient has been established; and the availability of a variety of affordable, accessible mental health interventions to meet patients’ varied needs and preferences. Practical implementation strategies identified as suitable in the orthopaedic setting to increase appropriate attention to patients’ mental health included training orthopaedic clinical teams, establishing a department or institution “mental health champion,” and integrating an automated screening question into clinical workflow to assess patients’ interest in receiving mental health–related information.

Conclusion

Orthopaedic patients want their mental health to be acknowledged as part of a holistic orthopaedic care plan. Although organization-wide initiatives can address mental health systematically, a key facilitator to success is for orthopaedic clinicians to initiate compassionate, even if brief, conversations with their patients regarding the interconnectedness of mental health and musculoskeletal health. Given the unique challenges to addressing mental health in the orthopaedic care setting, additional research should consider use of a hybrid effectiveness-implementation design to identify effective methods of addressing mental health that are feasible and appropriate for this clinical setting.

Clinical Relevance

Orthopaedic clinicians who have had negative experiences attempting to address mental health with their patients should be encouraged to keep trying. Our results suggest they should feel empowered that most patients want to address mental health in the orthopaedic care setting, and even brief conversations using nonstigmatizing language can be a valuable component of an orthopaedic treatment plan.

Introduction

The negative impact of symptoms of depression and anxiety on orthopaedic outcomes has become evident across orthopaedic subspecialties. The presence of these symptoms is associated with more-frequent postoperative complications and readmissions, higher levels of postoperative opioid use, poorer patient-perceived functional improvement, and lower levels of patient satisfaction after orthopaedic procedures including spine surgery, knee arthroplasty, hip arthroscopy, elective foot and ankle surgery, and rotator cuff repair [4, 7, 8, 11, 12, 27]. Furthermore, even among patients who do not meet the diagnostic criteria for depression or anxiety, unhelpful thought patterns such as catastrophization and kinesiophobia interfere with patients’ perceived musculoskeletal health, regardless of their structural musculoskeletal pathology [22].

As a result, in the orthopaedic community, there is growing interest in considering patients’ mental health in the orthopaedic care setting. This interest is evidenced by multiple mental health–related symposia in orthopaedic journals, in addition to the creation of the International Consortium for Mental and Social Health in Musculoskeletal Care [20, 24]. Some preliminary work has identified provider-perceived barriers and facilitators to addressing mental health, specifically in the setting of major orthopaedic trauma [18, 21, 23, 25]. However, the negative impacts of symptoms of depression and anxiety and related unhelpful thinking exist across virtually all subspecialties in orthopaedic care and are especially prevalent among patients with chronic spine conditions [2]. Furthermore, the perspective of orthopaedic patients regarding addressing mental health has not been examined in depth. An awareness gap persists regarding addressing mental health in the orthopaedic care setting in a manner that is simultaneously feasible in a busy orthopaedic practice and acceptable to patients who are presenting with an orthopaedic condition. A qualitative approach to explore this gap facilitates the identification of novel solutions that are proposed by stakeholders and have not been identified by researchers.

In this study, we sought to synthesize orthopaedic patients’ and clinical teams’ perspectives to answer the following questions: (1) What are orthopaedic patients’ and clinical team members’ current perceptions and motivators regarding addressing mental health as part of orthopaedic care? (2) What barriers do patients and clinicians face regarding addressing mental health as part of orthopaedic care? (3) What are facilitators for patients and clinicians related to addressing mental health as part of orthopaedic care? (4) What are practical, acceptable implementation strategies to facilitate addressing mental health as part of orthopaedic care?

Patients and Methods

Study Design and Context

This was a single-center, cross-sectional, qualitative study that used a thematic analysis approach to identify key themes repeatedly expressed by orthopaedic patient and clinical team stakeholders [1, 3]. It was conducted in the orthopaedic department of a large, urban, tertiary care academic medical center in the United States. Participant enrollment occurred from January 2022 through May 2022, and data analysis was completed in August 2022.

Participants

Participants from two stakeholder groups were recruited. The first group included adult patients who presented to the orthopaedic department for management of neck or back pain for 3 or more months (Table 1). This population was chosen because chronic spine conditions are among the leading causes of disability and physician visits nationwide, and symptoms of depression and anxiety are disproportionately prevalent in people with chronic neck or back pain [6, 9, 10]. Orthopaedic clinicians’ clinic schedules were prescreened to purposively approach and sample patients who spanned the adult age range (18 years and older) and included at least 25% (eight of 30) of participants who self-identified with a racial or ethnic minority group, as categorized by the United States government, and at least 50% (15 of 30) who self-identified as a woman. Patients were also selected to represent the full range of self-reported symptom severity on the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety measures [5, 16, 17], which all patients complete before each orthopaedic clinic visit at our institution. Including participants across this score continuum allowed us to collect perceptions from patients who could be experiencing unhelpful thought patterns, regardless of whether they met the full diagnostic criteria for a mental health disorder. Potentially eligible patients were identified via a review of upcoming orthopaedic clinic schedules. The study was introduced to patients via a telephone call before their visit or in person at their visit. Of the patients who were eligible, met our purposive sampling targets, and were approached, 35% (30 of 85) agreed to participate.

Table 1.

Demographic characteristics of orthopaedic patient stakeholders (n = 30)

Characteristic	Value
Age in years, median (IQR)	63 (46-70)
Gender, % (n)
Men	30 (9)
Women	70 (21)
Racea, % (n)
White	60 (18)
Black	33 (10)
Asian	7 (2)
Hispanic ethnicitya, % (n)	3 (1)
Healthcare coverage, % (n)
Private health insurance	30 (9)
Medicare/Medicare advantage	50 (15)
Medicaid/Medicaid replacement	23 (7)
Money available at the end of each month (for past 12 months), % (n)
Not enough to make ends meet	17 (5)
Just enough to make ends meet	17 (5)
Some left over	60 (18)
Prefer not to answer	7 (2)
Psychiatric history, reported in medical record, % (n)
Depression	30 (9)
Anxiety	23 (7)
Current mental health treatment, self-reported, % (n)
Medication	30 (9)
Psychiatrist, psychologist, and/or therapist	17 (5)
Self-management (such as meditation, mindfulness, deep breathing)	47 (14)
Support group	3 (1)
None	33 (10)
PROMIS scores, median (IQR)
Depression	52 (48-59)
Anxiety	60 (52-67)
Pain duration in years, median (IQR)	3 (2-10)
Orthopaedic diagnosis, % (n)
Spinal stenosis	37 (11)
Radiculopathy	37 (11)
Facet arthropathy	10 (3)
Spondylolysis	13 (4)
Scoliosis	7 (2)
Myofascial pain	10 (3)
Nonspecific/mechanical	9 (30%)

^aParticipants’ race and ethnicity data were collected from their self-report in their electronic medical record. PROMIS = Patient-Reported Outcome Measurement Information System.

The second stakeholder group included orthopaedic clinicians and clinical support staff across all adult subspecialty divisions in our orthopaedic department (Table 2). This group was strategically assembled to obtain perspectives from clinicians who treat all types of adult orthopaedic conditions and represent all clinical team roles. Clinicians were purposively sampled to include early-, mid-, and late-career physicians; operative and nonoperative specialists; and clinical team members who self-identified as women or with a racial or ethnic minority group. The study was introduced to clinical team members via email. Of the 106 team members in the department who were eligible to participate, 25 were approached, and 22 agreed to participate.

Table 2.

Demographic characteristics of orthopaedic clinicians and support staff stakeholders (n = 22)

Characteristic	Value
Clinical role
Orthopaedic surgeon	13 of 22
Nonoperative physician	3 of 22
Nurse practitioner	2 of 22
Nurse	2 of 22
Medical assistant	2 of 22
Physician rank
Assistant professor	8 of 16
Associate professor	5 of 16
Professor	3 of 16
Gender
Man	11 of 22
Woman	11 of 22
Race
White	16 of 22
Black	1 of 22
Asian	2 of 22
Other	2 of 22
Multiracial	1 of 22
Hispanic ethnicity	1 of 22
Average number of clinic patients per half-day
9 or fewer	2 of 22
10-15	10 of 22
16-20	4 of 22
21-25	3 of 22
26 or more	3 of 22

Participants’ demographic characteristics were self-reported.

Demographic information was collected from all participants. To minimize the burden on patients, information they had previously self-reported in their electronic medical record was directly extracted by the research team. All other information was collected via self-report in an electronic questionnaire using Research Electronic Data Capture.

Interviews

Semistructured, one-on-one interviews were conducted in person or via secure video conferencing technology (Zoom Video Communications, Inc), whichever the participant preferred. Before the interview, participants completed a brief demographic survey. Patient interviews were conducted by a research coordinator (MAA), who is a woman with formal qualitative research training and 18 years of experience working with patients who have orthopaedic conditions. Interviews with orthopaedic clinical team members were conducted by a man who is a medical student (AJL) with Master’s-level training in conducting qualitative research. The lead researcher (ALC) participated in the first several interviews for both stakeholder groups as well. She is a physical medicine and rehabilitation physician (physiatrist) with subspecialty board certification in sports medicine and a clinical practice that includes management of spine conditions. All interviewers were trained by a PhD-trained investigator (JA), who is a woman with qualitative methods expertise. The interviews lasted approximately 30 minutes and were audio and video recorded. Participants were fully informed of the purpose of this study and the research team’s personal experience and knowledge of existing evidence that mental health impacts patients’ responses to orthopaedic treatments.

Role-based interview guides were developed for orthopaedic patients and clinical team members (Supplementary Digital Content 1; http://links.lww.com/CORR/A999). The guides were developed using the Capability, Opportunity, Motivation, Behavior model of behavior change, which focuses on capabilities, opportunities, and motivators required to create a change in behavior (that is, addressing mental health in the orthopaedic setting) [15]. The Capability, Opportunity, Motivation, Behavior model was used as a framework for this study to systematically identify factors that contribute to whether productive discussion relating to mental health occurs during orthopaedic clinical interactions. Stakeholders were asked about their perceptions of how mental health currently impacts orthopaedic care; knowledge or experiences that would persuade them to want to address mental health during orthopaedic care (motivators); capabilities (skills) and opportunities (resources) that would be barriers or facilitators to addressing mental health during orthopaedic care; and feasible, acceptable methods of attaining required capabilities and opportunities to address mental health during orthopaedic care (implementation strategies). All guides were developed by the lead researcher (ALC) and reviewed by the research team, including two fellowship-trained, board-certified orthopaedic surgeons (RPC, CJD) and two experienced qualitative researchers (CJD, JA). Before initiating stakeholder interviews, the format, clarity, and flow of the guides was pilot tested. The guides were also iteratively revised in response to participant responses during the interviews.

Ethical Approval

Ethical approval for this study was obtained from the Washington University School of Medicine (IRB ID#: 202110165) before participant enrollment. Participants provided written or verbal consent before participation in the study. This research was performed in accordance with the ethical standards described in the 1964 Declaration of Helsinki and the relevant regulations of the United States Health Insurance Portability and Accountability Act.

Data Processing and Analysis

The interview recordings were transcribed, cleaned of transcription errors, and deidentified by the study team (AJL, MAA). The lead researcher (ALC) developed a preliminary codebook a priori using a deductive coding approach informed by the Capability, Opportunity, Motivation, Behavior framework. Next, the codebook was revised using an inductive coding approach after two team members (ALC and MAA for patient interviews or ALC and AJL for clinical team interviews) reviewed a sample of the first interview transcripts. The codebook was revised based on group discussion until team members reached 100% consensus. Using the final codebook, two team members (ALC and MAA for patient interviews or ALC and AJL for clinical team interviews) independently coded all interview transcripts. Transcripts were coded in tandem with ongoing participant interviews to identify preliminary themes and add additional prompts to the interview guides as needed. Additional participant recruitment and interviews from each stakeholder group continued until our minimum purposive sampling targets were met or surpassed and the two study team members independently determined that thematic saturation of the components of the Capability, Opportunity, Motivation, Behavior model had been reached, such that no new themes were emerging from coding of additional transcripts of these stakeholder groups. We coded transcripts with NVivo 12 software (QSR International). Group discussion was used to resolve coding discrepancies and organize the codes into final themes.

Results

Perceptions and Motivators

Although not anticipated by some orthopaedic clinicians, most orthopaedic patients perceived that the presence of depressive and anxious symptoms and related unhelpful thoughts negatively impacts musculoskeletal health and can interfere with the success of orthopaedic treatments (Table 3). Furthermore, orthopaedic patients said they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopaedic care plan. These findings were true among patients across different age, race or ethnicity, and gender groups. As one patient stated, “A physician should be worried about treating the whole person.” However, most orthopaedic clinicians reported they only discuss mental health if the patient broaches the topic or if they feel it is interfering with the patient’s response to orthopaedic treatment. Orthopaedic clinicians and clinical support staff reported varied perspectives regarding who on the team should address mental health concerns with patients, but regardless of orthopaedic subspecialty, physician rank, or clinical volume, orthopaedic clinicians said they would be (or are) the most motivated to address mental health in the context of orthopaedic care when they are aware of high-quality evidence that demonstrates the negative impact of symptoms of depression and anxiety and related unhelpful thoughts on metrics on which they are publicly monitored (such as patient satisfaction or surgical complication rate) and, perhaps even more importantly, the effectiveness of mental health intervention on improving those metrics (Table 4). As one physician stated, “If it's just a rehearsal and we’re just trying to see if we think it works but we don't know for sure, then that's a lot of time, energy, and effort put into something that doesn't have a clear outcome.” Some clinicians also expressed motivation from having copious personal experience managing patient care challenges they believe are related to a person’s mental health and coexisting musculoskeletal pain (such as difficulty for a patient to absorb information during the clinical encounter, frequent telephone calls to the office, or frequent requests for refills on pain medications) and a belief that addressing the patient’s mental health would reduce these challenges. Consistent with orthopaedic clinicians’ perceptions, orthopaedic patients said they would be motivated to engage in a mental health intervention if they believed it would improve their overall quality of life and if they received personal encouragement from their orthopaedic clinician, and possibly from a support staff member, that use of the intervention could improve their musculoskeletal health and be a key component of a holistic orthopaedic care plan.

Table 3.

Themes and representative quotes regarding current perceptions and practices regarding the role of mental health in orthopaedic care

Theme	Representative quotes
Negative impact: Most orthopaedic patients and clinical team members perceive that the presence of depressive and anxious symptoms and related unhelpful thoughts negatively impacts musculoskeletal health	“My mental health affects the pain, and the pain affects my mental health because it doesn't let me do my regular activities. So, for me, it’s both directions, and I believe there is a link between them.” (Patient, 30-year-old Asian man) “It's a challenge to appropriately address the surgical pathology and separate that out from the anxiety and depressive pathology. I think they're often intermingled and can play off of each other.” (Physician)
Desire for acknowledgment: Orthopaedic patients expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a holistic orthopaedic care plan	“I think, if they address that at the initial level, maybe the process of healing can be done faster than what is happening now.” (Patient, 30-year-old Asian man) “I like the idea of somebody coming and saying, ‘Hey, can we offer you some tools to help with the pain other than medicine or physical therapy?’” (Patient, 71-year-old White man) “A physician should be worried about treating the whole person.” (Patient, 62-year-old White man) “Just a check-in. ‘Hey, how are you feeling? I remember last time you weren't doing so well. How are you doing this time?’ That makes a big difference that someone cares to say that to you.” (Patient, 46-year-old White woman)
Added challenges: Orthopaedic clinicians and staff perceive that patients with symptoms of depression and anxiety and related unhelpful thoughts are more challenging to treat from an orthopaedic perspective and require more resources to treat effectively	“I think with a lot of orthopaedic conditions, especially the things that we deal with that are more chronic, it's going to be a process. I feel like if people are very depressed, they may not have the motivation to carry out some of our recommendations. They may not be as engaged.” (Physician) “Sometimes the patients [who] have mental health issues also have a pain control issue. It’s harder to treat their postoperative pain.” (Physician) “We have so many patients that don't really hear what you said or they're like, ‘Oh, you never told me that,’ or, ‘Oh, my God, I wasn't expecting it to be this bad.’ It’s when you spend an hour explaining everything, but they didn't hear any of it or they were so focused on the pain or so focused on the outcome that they didn't receive – mentally, they didn't absorb any of the information you gave them.” (Medical assistant)
Selective discussion: Orthopaedic clinicians expressed they only tend to discuss mental health if the patient broaches the topic or if they feel it is interfering with the patient’s response to orthopaedic treatment	“I'm sure I see many patients [who] have depression and/or anxiety that I just don't go down that pathway with. If they don't choose to open up, I don't dig it up.” (Physician)
Appropriate team member: Orthopaedic clinicians and clinical support staff reported varied perspectives regarding which team member(s) should address mental health concerns with patients	“I think it's best if the surgeon mentions it because that's part of the care.” (Physician) “I'm not sure [the staff] feel empowered to have that discussion because that discussion can change the dynamic between the patient and physician.” (Physician) “I count on my nurse and, to a certain extent, my therapists.” (Physician) “So, it usually is the nurse or nurse practitioner. Sometimes, it's the medical assistant. It’s just because we all do so much with the surgical patients. We talk to them so much and interact with them so much more. We tend to talk to them a lot more than the physicians do.” (Nurse)

Table 4.

Themes and representative quotes regarding motivators to addressing mental health, particularly in the orthopaedic care setting

Theme	Representative quotes
Orthopaedic clinical team members
Evidence: Orthopaedic clinicians expressed they are most motivated to address mental health in the context of orthopaedic care when they are aware of high-quality evidence that demonstrates: (1) the negative impact of depressive and anxious symptoms and related unhelpful thoughts on metrics on which they are publicly monitored (for example, patient satisfaction, surgical complication rate) and (2) the effectiveness of mental health intervention on improving those metrics	“If you find any association of any of the mental health outcome measures that can be studied and how they affect the outcome scores for patients and satisfaction after [orthopaedic surgery]... If their depression scores or their level of anxiety is directly correlated to a negative outcome after [surgery], no matter how you did the surgery. Well, man, that is a big area, a big gap in our knowledge of how do we improve our patients. And then that forges buy-in.” (Physician) “[Tell us], ‘Here are the areas that it is important and how interventions may benefit outcomes.’ Because at the end of the day, we all care most about our patients getting better. And if it's just a rehearsal and we’re just trying to see if we think it works but we don't know for sure, then that's a lot of time, energy, and effort put into something that doesn't have a clear outcome.” (Physician)
Personal experience: Some orthopaedic clinicians also expressed motivation to address mental health with their patients when they: (1) have copious personal experience managing patient care challenges which they believe are related to a person’s mental health and coexisting musculoskeletal pain (such as, it is difficult for a patient to absorb information during the clinical encounter, frequent phone calls to the office, frequent requests for refills on pain medications) and (2) believe that addressing the patient’s mental health would reduce these challenges	“Is there a part of this that's going to make my life easier? Well, that will get people to buy in.” (Physician)
Orthopaedic patients
Belief of impact and personal encouragement: Consistent with orthopaedic clinicians’ perceptions, orthopaedic patients endorsed they would consider engaging in a mental health intervention if: (1) they believed it would improve their overall quality of life and (2) they received personal encouragement from their orthopaedic clinician, and possibly from a support staff member, that use of the intervention could improve their musculoskeletal health and be a key component of a holistic orthopaedic care plan	“I think it's about tying it into recovery and into improvements and really focusing on what it gives people.” (Nurse practitioner) “I really think human nature is, if a doctor or an assistant one-on-one talked about it, I think you'd take it more seriously. I think something that's just laid out, people don't look at it.” (Patient, 64-year-old White woman)

Barriers

Among patients with orthopaedic conditions, most did not describe stigma as a barrier to addressing mental health in the orthopaedic care setting. However, the words, “mental health” and “depressed” were stigmatizing words for some patients and interfered with their openness to discussing the connection between physical and mental health. As one patient stated, “Right away my mind goes, ‘Nope.’ But when you bring up sleep, stressors—those are things that you struggle with whether you have pain or whether you have mental health issues or whatever. It’s something that can be helped across the board, and it's not, ‘You’ve got a mental health problem.’” Additionally, orthopaedic patients reported being less likely to answer honestly on mental health screening measures administered in the orthopaedic clinic when they were not told whether or how their responses on the screening measures would impact their orthopaedic care plan. With regard to addressing mental health in the context of orthopaedic care, the two barriers most commonly described by orthopaedic clinicians and clinical support staff were time pressure and a lack of expertise or comfort in adequately addressing mental health without offending patients (Table 5). Some orthopaedic surgeons, regardless of experience level or clinical subspecialty, also expressed uncertainty regarding whether they are the most appropriate person to address patients’ mental health, and some orthopaedic clinicians and clinical support staff members expressed hesitation about discussing mental health if they did not have access to affordable, timely mental health resources they could refer patients to. As one physician stated, “It's hard to talk about something and then tell your patient, ‘Okay, well, I know you have depression, but I don’t have any [available] resources for you.’”

Table 5.

Themes and representative quotes regarding barriers to addressing mental health in the orthopaedic care setting

Theme	Representative quotes
Orthopaedic patients
Stigmatizing words: Although most orthopaedic patients did not describe stigma as a barrier to addressing mental health in the orthopaedic care setting, the words, “mental health” and “depressed” were stigmatizing words for some patients that interfered with their openness to discussing the connection between physical and mental health	“Somebody who has struggled with mental health issues in the past ... I mean, I've attempted suicide four times. Anything that comes at you that says something about mental health, right away my mind goes, ‘Nope.’ But when you bring up sleep, stressors – those are things that you struggle with whether you have pain or whether you have mental health issues or whatever. It’s something that can be helped across the board, and it's not, ‘You’ve got a mental health problem.’” (Patient, 53-year-old White woman)
Lack of care integration: Orthopaedic patients reported being less receptive to answering honestly on automated mental health screening measures when they were not given an explanation of why the questions were being asked and they were not told how their responses would be used to guide clinical care	“My personal experience [as a healthcare professional] has been that when you look for a threshold with a questionnaire, many times, I don’t think I get the true answer. When you just give the questionnaire to every patient who walks in, they do it as a matter of fact and just go through clicks very fast … To get a better result on the screening questionnaire, just take a moment and explain to the patient, ‘Sit back, think about it…’ Make them aware, ‘This is not just something you are going to do so that you can do what you came for. It is to get your [orthopaedic problem] checked out.’ Personally, I have to admit that I did that. They just gave me the questionnaire, no explanation, and I’m sorry to say, but cynically, I looked at it like, ‘Ok … ’” (Patient, 71-year-old Asian man)
Orthopaedic clinical team members
Time pressure: Perceived time pressure for both clinicians and clinical support staff is a major barrier to addressing mental health in the context of orthopaedic care	“The question is, how much time do I spend on ‘nonorthopaedic’-related problems, whether that’s mental health–related or cardiac risk factor–related? All of these things fall into the same category for me of, ‘These are going to affect my outcomes.’ How much time do I have to spend on them before I get really behind in clinic?” (Physician) “If you’re looking at the timing of an office visit, if the medical assistant goes [into the patient room] and is there for maybe 10, 15 minutes, or even 5 minutes when you have your busier clinics, when the medical assistants are trying to get the patients roomed and to the doctors quicker, that could be a little bit of a hindrance.” (Medical assistant)
Lack of expertise or comfort: Many orthopaedic clinicians and staff members do not feel they have the expertise or comfort level to adequately address mental health with their patients, and they worry they will offend patients by asking about their mental health	“It’s not necessarily part of the background with our education in orthopaedic surgery residency—being taught how to approach patients about these sensitive subjects.” (Physician) “I don’t think we have proper protocols or … training for staff to learn how to address those situations as they arise. On our side of things, sometimes we need to address their mental health when we have them on the phone. There’s not really a way to address it other than just, kind of, talking through it and being compassionate and patient with them. Even in the call center, at times, it needs to be addressed.” (Nurse)
Uncertainty regarding appropriateness: Even if more training in mental health was provided to orthopaedic clinicians, some orthopaedic surgeons question whether they are the most appropriate person to address it in depth	“To some degree as a surgeon, I guess this is sort of half joking, but I kind of focus on the medical/surgical aspect of things, and then my nurse practitioner focuses more on the touchy-feely aspect of things. I think sometimes patients may potentially find a surgeon to be a little bit more intimidating. So, they may not feel as free to discuss some of those touchy-feely types of subjects as they may feel with a nurse.” (Physician)
Lack of resources: The perceived limited availability of affordable, timely mental health resources is reported to discourage orthopaedic team members from addressing mental health with their patients because they are hesitant to discuss a problem for which they cannot offer a tangible intervention	“It's hard to talk about something and then tell your patient, ‘Okay, well, I know you have depression, but I don’t have any resources for you.’” (Physician)

Facilitators

Our synthesis of orthopaedic clinical teams’ and patients’ reported needs and preferences revealed the following facilitators to address mental health in the context of orthopaedic care (Table 6):

• Compassionate, relevant mental health discussion, even if brief: Most patients expressed that mental health–related discussion in the orthopaedic setting can be brief, but it should be approached compassionately and in a manner that is relevant to the patient’s orthopaedic condition or secondary impairments, just as any other medical comorbidity would be discussed. Regardless of the orthopaedic team member who addresses mental health with patients, orthopaedic patients consistently expressed the team member should have established rapport with the patient before broaching the topic.

• Efficient, adaptable delivery of tangible interventions that preferably avoid wasted paper resources: Orthopaedic clinical team members consistently said the delivery of a tangible mental health intervention must not result in substantial added burden to clinicians or staff. Providing orthopaedic clinical teams with suggested, although not required, “best practice” workflows and facilitating preferred workflows may also increase the team’s likelihood of delivering the intervention (such as making pamphlets with mental health information available in the waiting room, posting flyers in examination rooms with telephone numbers and QR codes to obtain further information, sharing SmartPhrases or autotext to add information to patients’ electronic clinical visit summaries, or preparing printed copies of information in clinical team workrooms for patients who prefer a physical copy of information).

• Variety of interventions: Orthopaedic patients and clinical team members agreed that enabling patients to choose from a variety of mental health interventions is necessary to meet patients’ varied needs and preferences, but widespread affordability and timely access are essential for any intervention to be impactful.

Table 6.

Themes and representative quotes regarding facilitators to addressing mental health in the orthopaedic care setting

Theme	Representative quotes
Compassionate, relevant mental health discussion, even if brief: Most orthopaedic patients expressed they would be receptive to discussing mental health in the orthopaedic care setting if it is discussed in a way that: (1) relates the relevance of mental health back to their musculoskeletal health, (2) demonstrates concern for the patient as a whole person, and/or (3) focuses on the sequelae of mental health problems which can impact musculoskeletal health (such as, stress, sleep difficulty). Among orthopaedic clinicians who regularly address mental health with their patients, some find it is well received when mental health is approached similarly to any other medical comorbidity. Although orthopaedic clinicians had varied opinions regarding which orthopaedic team member should discuss mental health and when it should be discussed, a recurring theme among patients was that the team member should have established rapport with the patient before broaching the topic.	“A lot of times when people are in pain, they think you’re just placating them and giving them something else to look at when they’re really having another problem. The [orthopaedic problem] is real. But I would just give [the mental health resource] to them and explain, ‘This is going to help me help you.’ Even though you might not think it’s related to your pain, mental health is related to physical pain. And this is a tool to help us treat you better.” (Patient, 46-year-old White woman) “’Hey patient, this is going to be a painful process. We’ll do our best to moderate things, but you’re going to be in discomfort for some time in the future. This may be something that really helps you manage that, and helps you manage the anxiety.’” (Patient, 62-year-old White man) “I discuss it similarly to how I would discuss diabetes. I’m not treating the condition, but I ask them, ‘Is it well controlled, or is it poorly controlled?’ And usually they have family members, and they can also comment. And if it’s poorly controlled, then similar to any other medical condition, I tell them they need to be well controlled and I need to have confirmation from their psychiatrist who’s prescribing their medications. And then in that scenario, my nurse would then follow up prior to surgery.” (Physician) “Maybe I’ll say, ‘I see that you have fluoxetine on your prescription list. Just so you know, it’s normal for feelings of anxiety and depression to be heightened after surgery and in the postoperative period. Make sure that you’re staying on your medications or reaching out to whoever is prescribing them, and if you need help, reach out.’” (Physician) “It’s just honestly the trust and how the person interacts with you.” (Patient, 35-year-old Black woman)
Efficient, adaptable delivery of tangible interventions that preferably avoid the generation of wasted paper resources: Clinical team members expressed that any tangible mental health intervention in the orthopaedic setting, even if it is a referral to other resources, must be incredibly efficient to deliver and must not result in significant added burden to clinicians or staff. The method of intervention delivery must be flexible to adapt to each clinical team’s workflow and available personnel. However, providing orthopaedic clinical teams with suggested, although not required, “best practice” workflows and facilitating preferred workflows may also increase the team’s likelihood of delivering the intervention. Ideally, interventions and intervention delivery should be environmentally friendly such that they minimize the use of paper references unless specifically needed for a patient.	“If it’s an easy thing for us to talk about, there’s not a lot of work that we have to do to implement it or sign patients up, and it’s just offering patients the resource and we know it’s going to be beneficial, then I think it's an easier sell.” (Physician) “Every team runs differently, so I think to try to implement it in the same way across the board would probably not be effective. I think in the [joint replacement] service where they have ‘joint classes,’ I think that would be a great time for a brief overview of it. I think that on our service, we do individual preop teaching, and that would be a great time to buy into it for surgical patients.” (Nurse practitioner) “I think having a model workflow for them, so they don’t have to figure out how best to introduce this to patients.” (Physician) “I don’t want paper because it’s not environmentally friendly. If you have a clinic with 50 patients, imagine how much more printing we are going to do.” (Physician)
Variety of interventions: A variety of interventions is necessary to meet the varied needs and preferences of patients, but widespread affordability and timely access are essential for any intervention to be impactful.	“I think they’re all beneficial to some degree. I think it depends on the degree of the patient’s anxiety and depression and their previous experience with help. For patients who have relatively mild symptoms and have no previous history of having access to services, then having a handout or electronic resource or a mindfulness app or whatever it’s going to be, may be beneficial. I think for some patients, sometimes the persistent pain is one of the symptoms of anxiety and depression, and so having somebody in person may help there.” (Physician)

Implementation Strategies

Our synthesis of orthopaedic clinical teams’ and patients’ reported preferences and logistical considerations revealed the following practical implementation strategies to address mental health in the context of orthopaedic care (Table 7):

• Train orthopaedic clinical teams: Most orthopaedic clinical team members expressed interest in efficient training tailored to members of each role on the clinical team, with a focus on evidence of the effectiveness of a mental health intervention to reduce pain and improve physical function (especially for clinicians) and increasing proficiency and comfort to efficiently discuss mental health with patients. Other relevant topics requested included how to identify patients with clinically relevant symptoms of depression, anxiety, and unhelpful thoughts; refer them to appropriate resources; manage potentially emergent situations (for example, if a patient spontaneously voices thoughts of self-harm); and responsibly address mental health while respecting the boundaries of team members’ scope of practice such that they do not unintentionally become at risk for medicolegal liability. Ideally, training should be incorporated into an in-person, potentially preexisting learning forum (for example, grand rounds for clinicians). Clinicians expressed interest in training or updates no more frequently than yearly. Support staff members expressed they could benefit from training up to a few times per year, especially to practice acknowledging and addressing patients’ mental health concerns when appropriate and navigating patients’ mental health comorbidities to address their orthopaedic conditions efficiently and effectively.

• Establish a department or institution “mental health champion”: Effectively addressing patients’ symptoms of depression, anxiety, and unhelpful thinking requires the dedication of all clinical team members. However, with the expectation that available mental health resources will change over time, many team members expressed interest in establishing a “champion” in the organization to ensure clinical team members are aware of changes and that mental health–related information delivered to patients is updated regularly. This person could coordinate department- or institution-wide initiatives and might be a clinician or support staff member.

• Integrate an automated mental health screening question into clinical workflow: To efficiently identify patients who are interested in addressing their mental health as part of orthopaedic care, orthopaedic patients and clinical team members expressed nearly unanimous support for all patients to be asked an automated screening question, presuming the clinical team has reliable availability of a mental health resource that could be given to patients who voice interest. The following iteratively developed question was overwhelmingly well accepted by patients and clinical team members as being understandable, nonstigmatizing, and phrased to not introduce medicolegal concerns or to prohibit team members from discussing mental health in the future as the patient-clinician relationship develops: “Mental wellness can affect pain and function. Would you like more information on resources for stress, sleep trouble, or depressed or anxious feelings?” “Yes” or “Not right now”.

Table 7.

Themes and representative quotes regarding implementation strategies to address mental health in the orthopaedic care setting

Theme	Representative quotes
Train orthopaedic clinicians and clinical support staff: The overwhelming majority of clinical team members expressed interest in efficient, tailored training regarding how to approach mental health in the orthopaedic care setting. Primary topics of interest were learning the research surrounding the effectiveness of mental health intervention to reduce pain and improve physical function, and training to increase proficiency and comfort discussing mental health with patients. Secondary topics of interest included how to identify patients with clinically relevant symptoms of depression, anxiety, and unhelpful thoughts, refer them to appropriate resources, manage potentially emergent situations (for example, if a patient spontaneously voices thoughts of self-harm), and responsibly address mental health while respecting the boundaries of their scope of practice such that they do not unintentionally become at risk for medicolegal liability. Most team members expressed a preference for periodic in-person training via a preexisting learning forum.	“Some sort of hard data—if there was some sort of connection to improved outcomes, people would do it.” (Physician) “A set way to do things regarding verbiage—how to talk to people—because the way you say something has a big impact on what the patient perceives.” (Physician) “Modules online are very unattractive. I think it’s a passive way of learning. Probably at a grand rounds or a faculty meeting or something where we can say, ‘Hey, here’s the update on our mental health resources. If you have a patient with this problem, here’s who you call.’ And also make sure medicolegally that we’re covered so that when somebody does leave our clinics and we didn’t recognize it, we want to make sure that we are covered from that standpoint.” (Physician) “I think that all levels could use some training. I think there should be specific training for the call center, the medical assistants, and the nursing staff.” (Nurse) “A lot of times we’ll get patients [who] are crying on the phone with us. Sometimes it’s because of pain. Sometimes it’s because of anxiety. Maybe just some training to learn how to talk through those situations with patients, to find out what they really need, and then be able to refer them on to resources based on their needs.” (Nurse)
Establish a departmental / institutional “mental health champion”: Orthopaedic clinicians and clinical support staff perceive that a department “mental health champion” would facilitate their comfort with navigating the landscape of mental health resources because they expect available resources to change over time.	“Maybe even having a go-to person [who] was kind of the champion of this in the clinic. So, if people had questions, they knew who to ask. I think that might be helpful. Whether that’s the nurse manager of the division or if that’s one person in all of the departments—just having a go-to person would be nice. Like if something changes; kind of knowing that it’s up-to-date, too, that would be very helpful.” (Physician)
Integrate an automated screening question into clinical workflow: Orthopaedic clinical team members and patients consistently voiced interest in implementing an automated screening question to assess whether patients would like to be provided with mental health resources. Key implementation considerations described were: (1) phrasing the question in an understandable and nonstigmatizing way that does not introduce medicolegal concerns or prohibit team members from discussing mental health in the future as the patient-clinician relationship develops and (2) having reliable availability of a mental health resource that could be given to patients who do voice interest. Most orthopaedic clinical team members and essentially all patients believed all patients (not only those who screen positively on a mental health symptom measure) should be asked the screening question.	“What about having something on the [screening questionnaire] tablet just asking, ‘Are you interested in something for your mental health?’ Or something like that? If so, great, then I can talk to you about it in your appointment. Or if not, then we can just carry on with our day. That would save everyone a step. We could add this into the workflow without wasting someone's time.” (Nurse) “I think it makes a nice entry into that discussion for us, or at least the ability to provide that to patients without coming across as being presumptive or offensive to patients. Those who are really struggling and want help, it would allow us an opportunity to provide that without worrying that they’re going to be upset about it. I think it’d be great.” (Physician) “I think everybody should [be asked], because you could get a person [who] might not say something because you didn’t ask, and they’ll say, ‘Because you didn’t ask.’ ‘Why did you go try to kill yourself?’ ‘Well, you never asked.’” (Patient, 46-year-old White woman)

Discussion

The presence of depressive and anxious symptoms and related unhelpful thinking is independently associated with worse patient satisfaction and increased postoperative complications across a wide range of measures and musculoskeletal conditions [4, 7, 8, 11, 12, 27]. Despite increasing awareness of this phenomenon and early efforts to intervene [24, 26], addressing mental health in orthopaedic care still occurs as the exception, rather than the norm. In this study, most orthopaedic patients wanted their mental well-being to be acknowledged, if not addressed, as part of a person-centered treatment plan delivered by their orthopaedic care team. Organization-wide initiatives can facilitate the development and implementation of tangible mental health–related resources for screening and intervention, but patients expressed that compassionate conversations with their orthopaedic clinical team regarding the interconnectedness of mental health and musculoskeletal health, even if brief, can be therapeutic.

Limitations

First, all patients and clinical team members were recruited from a single institution that uses a standardized mental health screening process and likely has a partially shared culture regarding addressing mental health. Analogous stakeholders from other institutions, especially if they are in a different social or healthcare environment, may have expressed other themes that did not emerge in this study. Second, because of the nature of self-selection, patient stakeholders who participated in the study may have generally been more comfortable discussing mental health than patients who declined to participate, which could have affected the themes we identified regarding patients’ barriers related to discussing mental health in the orthopaedic setting. However, we believe this is unlikely because our patient stakeholders still provided insight regarding potential barriers, from both personal experience and interactions with loved ones. Bias related to self-selection is less likely to have occurred among clinical team members because we achieved a high recruitment proportion in this stakeholder group. Therefore, we believe it is unlikely that participants in this stakeholder group selectively shared our preconception that mental health should be addressed in the orthopaedic care setting. Third, demographic information collected about stakeholders’ race and ethnicity was limited to broad categories defined by the United States government, which limited our ability to capture diversity in each racial and ethnic group. A final limitation is that perspectives from patients with chronic neck or back pain are not generalizable to all patients with orthopaedic conditions. However, because this study focused on experiences shared across patients with all types of orthopaedic musculoskeletal conditions, we expect our findings are valid among other patients who seek care for other musculoskeletal conditions. Nevertheless, further work with other patient cohorts may identify unique subthemes—for instance, among patients who have sustained major orthopaedic trauma or have a musculoskeletal malignancy.

Perceptions and Motivators

Although some orthopaedic clinicians expressed uncertainty regarding the appropriateness of them addressing mental health with their patients [18], we found most orthopaedic patients want to be treated holistically and have their mental health acknowledged and, when appropriate, addressed in this setting. Many patients understood the time pressures and focused nature of orthopaedic clinicians’ expertise, but nevertheless, they conveyed the added value to healing, strengthening of the doctor-patient relationship, and motivation to address their own mental health when their orthopaedic clinician addresses the connection between musculoskeletal and mental health. Clinical team members who already recognized this sentiment in patients believed having the ability to address patients’ mental health would ultimately reduce their clinical workload (including clinic telephone calls and medication refill requests). Although orthopaedic clinical practices face seemingly competing pressures to provide care that is both outstanding and manages a high volume of patients, our findings are encouraging because orthopaedic clinicians who can inquire about a patient’s mindset and engage with patients’ thoughts and feelings as part of an orthopaedic evaluation and management plan may be improving the quality and efficiency of care they can provide.

Barriers

Despite reservations expressed by clinical team members that they are uncomfortable discussing a patient’s mental health because they do not have an “answer” regarding how to treat it [25], encouragingly, our patients did not expect orthopaedic clinicians to be mental health experts or “have all the answers.” However, many patients still wanted their mental well-being to be acknowledged (in an appropriate manner) in the orthopaedic care setting. Furthermore, some patients expressed that even a short conversation could motivate them to prioritize their own mental health as part of their orthopaedic treatment. Importantly, however, patients also expressed frustration when mental health screening measures are collected in the orthopaedic care setting but are not clearly integrated into the care plan. Therefore, coordinated implementation of a multicomponent plan to address patients’ mental health may be preferable to stepwise implementation in which, for instance, a mental health screening process is implemented before clinical team members feel prepared to discuss the purpose of the screening process and implications of the results. Orthopaedic clinicians who routinely collect mental health–related patient-reported outcome measures as part of surgical repositories should also consider integrating processes to ensure patients understand why these measures are collected and how the scores will be used (and not used) clinically and for research purposes.

Facilitators

One facilitator we identified is readily addressable by each orthopaedic team member. That is, a mental health–related discussion is well received by patients when it is approached in a manner that is compassionate and relevant to the patient’s overall well-being or musculoskeletal health, even if the discussion is brief. As Ring [19] describes, this discussion can be initiated by normalizing patients’ thoughts and feelings, guiding patients away from catastrophic thinking or an excessively worried mindset, redirecting patients toward hopeful thinking, and reassuring patients they are not alone in this journey. On a separate note, facilitating the equitable delivery of mental health interventions by having access to a variety of evidence-based mental health interventions that meet patients’ varied needs and preferences will require substantially more work from a research and policy standpoint in order to develop, test, and create widespread access to such resources. Nonetheless, some local and national resources exist [13, 14], and we encourage orthopaedic clinical teams to identify and share resources that are currently available to their patients. One potential resource is Mental Health America [13], which is a national nonprofit organization with local affiliates. Its website includes free educational resources, lists of nonaffiliated resources the organization endorses, databases of available mental health professionals, and contact information for local resources.

Implementation Strategies

The clinical implementation strategies we identified build on the strategies identified for orthopaedic trauma professionals to address psychosocial factors in a research context [21, 23]. Notably, in contrast to Sagar et al. [21], our clinical team stakeholders expressed a strong preference for mental health–related training to be performed in person rather than virtually through teleconferencing or prerecorded modules. Our clinical team stakeholders cited benefits to an in-person format including increased engagement, the opportunity for interactive demonstration, and the ability to ask questions. A grand rounds or society conference session could be used to train clinicians about how to acknowledge and discuss mental health efficiently and acceptably with patients, such as through motivational interviewing. Delivering content through either of these forums might generate more awareness and continued discussions to continue improving patient care. Specific to a clinical, rather than research, context, our stakeholders expressed great enthusiasm about integrating an automated screening question to assess whether patients would like more mental health–related information during their orthopaedic clinic visit, and patients thought such a question would increase the perception of relevance of screening questionnaires regarding mental health symptoms. Although an automated question cannot replace the importance of building relationships between patients and clinical team members, it can raise patient awareness regarding the connection between physical and mental health, serve as a component of a multilayered approach to address mental health in the orthopaedic setting, and may increase patients’ and clinical team members’ comfort in broaching the topic of mental health.

Conclusion

In this study, we found that in contrast to the perceptions of some orthopaedic clinicians, orthopaedic patients want their mental health to be acknowledged as part of a thoughtful orthopaedic care plan. Orthopaedic clinicians who have had negative experiences trying to address mental health with their patients should not be dissuaded from trying again. Rather, they can feel empowered that most patients want to address mental health in the orthopaedic care setting in a manner that is relevant to the patient’s musculoskeletal health or demonstrates interest in the patient as a whole person, and even brief conversations using nonstigmatizing language can be a valuable component of an orthopaedic treatment plan. The conversation may be therapeutic. To facilitate these conversations, orthopaedic clinical team members are interested in efficient training to specifically learn how to recognize and approachably discuss the manifestation and sequelae of unhelpful thoughts with their patients and to become aware of existing mental health resources they can refer patients to while still respecting the boundaries of their expertise and scope of practice as trained orthopaedic clinicians. The development and delivery of scalable training resources through existing orthopaedic organizations could expedite the evolution of orthopaedic care from a predominantly problem-focused approach to a person-focused approach. Department- and institution-wide initiatives can also facilitate clinical teams’ abilities to efficiently and effectively address the interconnectedness of mental health and musculoskeletal health with their patients. Given the unique challenges to addressing mental health in the orthopaedic care setting, additional research could consider use of a hybrid effectiveness-implementation design to identify mental health interventions that are both appropriate and feasible in this clinical setting.