Abstract
Background
It remains unclear what role depression screening plays in routine ambulatory orthopedic care. The purpose of this study was to determine (1) the floor and ceiling effects of the Patient-Reported Outcomes Measurement Information System Depression (PROMIS-D) form, (2) the prevalence of positive PROMIS-D screening forms across an orthopedic service line, and (3) the prevalence of previously diagnosed depression and interventions among a representative sample of patients.
Methods
This retrospective study analyzed 58,227 patients who presented to ambulatory orthopedic clinics across an orthopedic service line between January 1, 2019 to December 31, 2021. All patients completed a self-administered PROMIS-D form as part of the ambulatory encounter. Scores were analyzed with respect to patient characteristics including age, gender, and presenting orthopedic complaint. A sample of 1000 patients was evaluated for prevalence of depressive symptoms and formal psychiatric diagnosis and interventions in the 5 years preceding the clinic visit.
Results
PROMIS-D displayed a negligible ceiling effect (<0.001 %) but a large floor effect (19.0 %). PROMIS-D scores indicating depressive symptoms were highest among patients presenting with spine complaints (42.8 %) and lowest among patients presenting to orthopedic pediatric clinics (28.6 %). Women and those in the lowest quartile median household income (MHI) were more likely to report depressive symptoms. Among the 1000 patient sample, 31.3 % exhibited depressive symptoms. Of these, 39 % had previously received some form of mental health treatment, including 33.2 % who were prescribed antidepressants.
Conclusions
PROMIS-D is a useful screening questionnaire for patients in the orthopedic clinic, although there is a consistent floor effect. There are a number of patients who present to the orthopedic clinic who have depressive symptoms but have had no interaction with behavioral health. Given the impact depression can have on outcomes, screening for depressive symptoms should be considered as part of routine orthopedic practice.
Keywords: Patient-reported outcomes, PROM, PROMIS, Depression, Mental health
1. Introduction
Depression is a significant cause of morbidity and mortality.1 Greater than 21 million adults experienced depressive episodes in 2020 alone.2 Depression and mental health is increasingly recognized as important to the success of orthopedic care. Multiple studies have demonstrated that those with a diagnosis of depression or other psychiatric disease have worse outcomes after routine orthopedic procedures.3, 4, 5, 6, 7, 8, 9 Patients with depressive symptoms preoperatively have also been shown to have significant improvement in their depressive symptoms following orthopedic intervention.5,10,11
The U.S. Preventative Services Task Force (USPSTF) recommends that all adolescents and adults be screened for depression12,13 but provides minimal guidance about which depression screening questionnaire to use or in which setting these questionnaires should be administered. Some of the most commonly used screening tools include the Patient Health Questionnaire (PHQ)-2 and PHQ-9.14 In 2003, the National Institute of Health created the Patient-Reported Outcomes Measurement Information System (PROMIS).15 The PROMIS questionnaires include a depression screening form – PROMIS Depression (PROMIS-D). Though less widely used as a depression screening tool, PROMIS-D has demonstrated similar validity and responsiveness as the PHQ-2 and PHQ-9.16 It has also demonstrated validity across orthopedic populations.17, 18, 19, 20
Despite the known relationship between mental health and outcomes following orthopedic procedures, it remains unclear what role depression screening has in routine ambulatory orthopedic clinic visits. The purpose of this study was to determine (1) the ceiling and floor effects of PROMIS-D, (2) the prevalence of positive PROMIS-D forms across an orthopedic service line, and (3) the prevalence of previously diagnosed depression and interventions among those with positive screens. The study authors hypothesized that PROMIS-D would be an adequate screening form for use in orthopedic care with a low ceiling effect but historically relevant floor effect, that social deprivation would be a risk factor for a positive screen, and that PROMIS-D would provide a means by which orthopedic surgeons could identify patients who may require multidisciplinary behavioral health interventions.
2. Methods
This study was approved by the institutional review board prior to data collection. Data was collected retrospectively from all patients 14 years or older presenting to the orthopedic service line between January 1, 2019 and December 31, 2021 who had completed a PROMIS-D questionnaire. The orthopedic service line at this institution consists of the following divisions – Musculoskeletal Oncology, Foot and Ankle, Hand, Joint Replacement, Pediatrics, Physical Medicine and Rehabilitation (PM&R), Spine, Sports Medicine, and Trauma.
In this institution's ambulatory orthopedic clinics, all patients complete the self-administered NIH PROMIS-D CAT version 2.0 questionnaire upon check-in at their initial clinic visit or annually as a returning patient. PROMIS surveys are completed on a tablet or via MyChart (Epic Systems Corporation, Verona, WI) prior to a patient's clinic visit. Patient scores are automatically uploaded to the electronic health record (EHR). If a patient had multiple PROMIS-D scores during the study inclusion period, the score corresponding to the earliest clinic visit was included. PROMIS questionnaires are scaled to a population mean score of 50 with a standard deviation (SD) of 10 points.21 In this study, major depressive symptoms were classified as a PROMIS-D score >60 and minor depressive symptoms as a PROMIS-D score of 55–60.
Demographic data including age, sex, race and ethnicity, body mass index (BMI), and presenting orthopedic division was also extracted from the EHR. Median household income (MHI) was calculated based upon patient zip code using a database available for the institution's area. A patient's MHI quartile was determined by the following income thresholds – 1st quartile $0-$42,545.85; 2nd quartile $42,545.85-$54,021.01; 3rd quartile $54,021.01-$69,595; 4th quartile $69,595 - $133,438. A representative sample of 1000 patients was selected based upon the distribution of minor and major depression across the orthopedic divisions. A manual chart review of those with positive PROMIS-D screening scores in the sample was conducted for a history of psychiatric diagnoses and behavioral or psychiatric interventions in the 5 years preceding the date associated with the patient's included score.
2.1. Statistical analysis
Ceiling and floor effects are the proportion of respondents with the lowest (floor) or highest (ceiling) possible scores for a questionnaire. The calculation of ceiling and floor effects can help determine the validity of a test.22,23 Concerning ceiling and floor effects are usually classified previously in the literature as >15 %22 but some have recommended a goal of less than 5–10 %.24,25 Ceiling and floor effects for PROMIS-D were determined by calculating the percentage of the lowest and highest scores for the entire cohort of patients. An exploratory analysis was then performed for clinically relevant differences in PROMIS-D scores according to various patient characteristics. Descriptive statistics were generated for all variables. Continuous data was analyzed using independent samples t-tests or analysis of variance (ANOVA) as appropriate.
3. Results
There were 58,227 patients who presented to ambulatory orthopedic clinics and completed a PROMIS-D questionnaire during the study period. Orthopedic patients were predominantly female (58.7 %), white (67.3 %), and an average of 53.8 ± 19.0 years old. Patient demographics are reported in full in Table 1.
Table 1.
Characteristics of ambulatory orthopedic patients by presenting orthopedic division.
| Overall | Oncology | Foot/Ankle | Hand | Joint | Pediatrics | PM&R | Spine | Sports | Trauma | |
|---|---|---|---|---|---|---|---|---|---|---|
| Age (SD) | 54.7 (18.1) | 55.9 (18.5) | 55.0 (18.1) | 52.8 (18.0) | 61.1 (14.8) | 23.8 (15.3) | 53.6 (18.2) | 55.8 (16.1) | 50.5 (19.1) | 50.9 (20.0) |
| Sex, % male | 41.3 % | 42.0 % | 37.4 % | 42.4 % | 39.0 % | 42.7 % | 36.7 % | 44.4 % | 44.9 % | 45.7 % |
| Race, % | ||||||||||
| White | 63.9 % | 62.2 % | 56.4 % | 72.0 % | 70.9 % | 48.6 % | 50.5 % | 65.4 % | 60.4 % | 43.5 % |
| Black | 25.4 % | 24.3 % | 32.9 % | 18.5 % | 21.0 % | 30.5 % | 34.3 % | 24.1 % | 26.9 % | 43.3 % |
| Asian | 2.2 % | 2.2 % | 2.1 % | 2.0 % | 1.4 % | 2.7 % | 2.6 % | 1.5 % | 3.3 % | 1.8 % |
| Hispanic | 2.9 % | 2.4 % | 3.3 % | 3.1 % | 2.1 % | 4.1 % | 3.5 % | 3.3 % | 2.7 % | 5.9 % |
| Other | 3.4 % | 4.0 % | 3.7 % | 3.1 % | 2.8 % | 5.0 % | 5.3 % | 3.6 % | 3.6 % | 6.1 % |
Abbreviations: PM&R, Physical Medicine and Rehabilitation.
The average PROMIS-D score for the entire orthopedic service line was 48.9 ± 10.1. Rates of minor (PROMIS-D score 55–60) and major depression (PROMIS-D score >60) were 17.9 % and 12.6 %, respectively. Overall, PROMIS-D displayed a negligible ceiling effect (<0.001 %) but a large floor effect (19.0 %). This trend was consistent across all divisions within the orthopedic service line with ceiling effects ranging from 0.0 to 0.2 % and floor effects ranging from 13.0 to 28.9 % (Table 2).
Table 2.
Forest plot of the floor and ceiling effects of PROMIS-D within the ambulatory orthopedic population overall and by presenting department. The width of the bar represents floor or ceiling effect.
| Dept | Patients, N | PROMIS-D, mean (SD) | Major Depression, N (%) | Minor Depression, N (%) | Floor Effect (%) | Ceiling Effect (%) | Floor Effect | Ceiling Effect |
|---|---|---|---|---|---|---|---|---|
 |
||||||||
| Overall | 58,227 | 48.9 (10.1) | 7370 (12.6 %) | 10,504 (17.9 %) | 18.6 % | 0.0 % | ||
| Oncology | 452 | 49.1 (10.2) | 64 (14.2 %) | 73 (15.9 %) | 19.3 % | 0.22 % | ||
| Foot/Ankle | 8844 | 48.4 (9.9) | 977 (11.0 %) | 1558 (17.4 %) | 19.7 % | 0.03 % | ||
| Hand | 7876 | 48.2 (10.0) | 875 (13.9 %) | 1381 (15.8 %) | 20.8 % | 0.09 % | ||
| Joint | 15,471 | 49.3 (10.1) | 2140 (13.8 %) | 2881 (18.6 %) | 17.0 % | 0.01 % | ||
| Pediatrics | 220 | 48.2 (10.3) | 44 (15.0 %) | 55 (13.6 %) | 5.45 % | 0.45 % | ||
| PM&R | 2395 | 50.4 (10.2) | 389 (16.2 %) | 464 (19.4 %) | 15.0 % | 0.13 % | ||
| Spine | 2211 | 51.8 (10.7) | 472 (21.4 %) | 474 (21.4 %) | 13.0 % | 0.05 % | ||
| Sports | 17,379 | 48.1 (9.8) | 1810 (10.4 %) | 2969 (16.9 %) | 19.8 % | 0.05 % | ||
| Trauma | 2127 | 50.6 (10.9) | 408 (19.0 %) | 410 (19.2 %) | 17.5 % | 0.09 % | ||
Abbreviations: PM&R, Physical Medicine and Rehabilitation; PROMIS-D, Patient-Reported Outcome Measurement Information System Depression.
When PROMIS-D scores were compared across the 9 orthopedic divisions, average PROMIS-D score was highest among patients presenting to spine providers (51.8 ± 10.7) and lowest among patients presenting to sports medicine clinics (48.1 ± 9.8). Rates of major and minor depression were also highest patients presenting to spine clinics (21.4 % and 21.4 %, respectively). Overall rates of depression were lowest among pediatric patients, age 14–17 years old (28.6 %). A detailed depiction of scores by orthopedic division can be visualized in Table 2.
Average PROMIS-D scores (45.1–49.9) remained consistent across multiple demographic cohorts (age, sex, race, and MHI quartile). However, the prevalence of scores indicating minor or major depression did vary considerably depending on the demographic cohort (Fig. 1, Fig. 2, Fig. 3, Fig. 4). Minor and major depression had a bimodal distribution related to age, with those aged ≥80 years old (11.9 % and 19.4 %) and aged 39–59 years (14.4 % and 18.9 %) having the highest rates of positive screening questionnaires. Female patients were 1.4 times more likely to score exhibit depressive symptoms than male (33.5 % vs. 26.1 %, p < 0.001). Patients who identified their race as “white” or “other” had the highest rates of minor depression (18.1 % and 18.4 %, respectively). Patients of Hispanic descent were most likely to score in the range indicating major depression (16.6 %). Patients of Asian descent had significantly lower PROMIS scores (average score 47.3; p < 0.001) and were least likely to screen positive for either minor or major depression (p < 0.001).
Fig. 1.
A) Average PROMIS-D scores across different age groups. (B) Rates of major (score >60) and minor (score 55–60) depression across different age groups.
Fig. 2.
A) Average PROMIS-D scores for male and female patients. (B) Rates of major (score >60) and minor (score 55–60) depression among male and females.
Fig. 3.
A) Average PROMIS-D scores by race/ethnicity. (B) Rates of major (score >60) and minor (score 55–60) depression by race/ethnicity.
Fig. 4.
A) Average PROMIS-D for each MHI quartile. (B) Rates of major (score >60) and minor (score 55–60) depression in each MHI quartiles. MHI quartiles were calculated using patient zip codes from the available mean and median household income database for the institution's area. Quartiles are as follows: 1st quartile $0-$42,545, 2nd quartile $42,545-$54,021, 3rd quartile $42,545-$69,595, 4th quartile $69,595-$133,438.
When MHI quartile was examined, 35.0 % of patients in the lowest quartile had scores 55 or higher. Scores indicating major depression were nearly double among patients in the lowest MHI quartile (16.1 %) compared to the highest MHI quartile (8.7 %). There was a very significant correlation between household income and PROMIS-D scores in that, as PROMIS-D scores improved (i.e. decreased), household income increased (p < 0.001).
Of the 1000 patients selected as a representative sample, 313 (31.3 %) had positive screening scores (13.2 % scored >60, 18.1 % 55–60). Only 117 (37.3 %) had been formally diagnosed with depression. 122 (39.0 %) had received some form of behavioral or psychiatric treatment in the 5 years preceding their orthopedic clinic visit, leaving 191 (61.0 %) untreated.
4. Discussion
In this retrospective cohort study of all patients 14 years or older presenting for ambulatory orthopedic care across an orthopedic service line, 58,227 patients completed a PROMIS-D questionnaire at time of clinic presentation with 30.5 % with scores indicating minor or major depression. When ceiling and floor effects were calculated, PROMIS-D exhibited a negligible ceiling effect (<0.001 %) but a large floor effect (19.0 %). A positive PROMIS-D screening form was most common among those age 39–59 years old (33.3 %), those identifying as female (33.5 % vs. 26.1 %, p < 0.001), and those in the lowest quartile MHI (35.0 %, p < 0.001). Of 1000 patients randomly sampled across the orthopedic service line, 313 patients (31.3 %) exhibited depressive symptoms at presentation. Only 39.0 % (122/313) had previously received some form of behavioral or psychiatric treatment.
PROMIS-D exhibited a negligible ceiling effect (<0.001 %) but a large floor effect (19.0 %) which was generally consistent across all service line divisions. These findings are similar to what has been previously reported throughout the literature. In an analysis of patients with symptomatic knee osteoarthritis, PROMIS-D demonstrated a floor effect of 24 %.26 In a related study of approximately 3000 knee and shoulder patients, PROMIS-D exhibited a ceiling effect of 0 % but a floor effect of up to 19 %.27 As with this study, Bernstein et al. also demonstrated the consistency of large floor effects across subspecialties.28 The reasons for the consistently large floor effect across studies is unknown but may be attributed to a number of factors. It has previously been shown that patients who score low on PROMIS-D typically complete the questionnaire the fastest.28,29 These patients may not feel that mental health is necessary to discuss in conjunction with their musculoskeletal complaints. They may also not be willing to discuss their mental health symptoms with a physician they feel may lack the formal training to manage behavioral health. Despite the large floor effect, practically if patients are provided with the PROMIS-D questionnaire in conjunction with other PROMIS forms, it remains a reasonable mental health screening tool to use.
To the study authors’ knowledge, this is the first study to assess the prevalence of depressive symptoms across an entire orthopedic service line. In this cohort of patients, patients exhibiting depressive symptoms were most likely to be age 39–59 years old (33.3 %), identify as female (33.5 %), and in the lowest quartile MHI (35.0 %) with an income-dependent decrease in depressive symptoms with increasing MHI (p < 0.001). These findings are representative of that of the general population. In 2020, 17 % of adults aged 18–25 experienced at least one major depressive episode, the highest among all age groups.2 Though this study did find that patients aged 39–59 most commonly experienced depressive symptoms, 31.2 % of patients 18–29 years also screened positive on PROMIS-D for depression with 13.6 % scoring >60, indicating major depression symptoms. That those identifying as female were more likely to experience depressive symptoms is something that is highlighted throughout many studies on depression. Salk et al. in 2 meta-analyses on gender differences in depression, synthesized data from samples that included 1.7 million men and women to calculate an odds ratio for gender differences in diagnoses of major depression.30 Women were 1.95 times more likely to be diagnosed with depression than men. This study also reinforces the impact that socioeconomic status (SES) has on mental health. Multiple studies have demonstrated that lower SES (with low income as a marker for low SES) increases the risk of depressive symptom onset as well as the risk of persistent depression.31, 32, 33, 34, 35
Among the representative sample of 1000 patients, 31.3 % scored >55 on PROMIS-D indicating that, at the time of their visit, they were experiencing depressive symptoms. What is more striking is that upon further review of those 313 patients, only 117 (37.3 %) had been formally diagnosed with depression in the 5 years prior to PROMIS-D screening, and 122 (39.0 %) had received some form of mental health treatment. It is known that patients with a diagnosis of depression, particularly untreated depression, have worse outcomes following orthopedic procedures.3, 4, 5, 6, 7, 8, 9,36,37 Certainly some patients in this cohort without a history of depression may have screened positive on PROMIS-D given the effect musculoskeletal conditions were having upon their daily lives with symptom improvement following orthopedic intervention.10,11 But, these findings also indicate that there is room for growth when it comes to identifying and treating patients with potential mental health conditions prior to operative intervention.
The results of this study highlight several important findings for the orthopedic clinician. First, despite a large floor effect, PROMIS-D has shown favorable validity and responsiveness when compared with the PHQ-2/9.16,38 If PROMIS scores in other domains are already being collected as standard practice in an orthopedic clinic, the addition of PROMIS-D is an acceptable form of mental health screening. Second, this study has shown that the prevalence of depression among orthopedic patients is quite similar to that of the general population. The orthopedic clinician should, thus, be able to recognize those patients that may be at higher risk of depression with a low threshold for additional screening or referral for multidisciplinary mental health care. Third, there is likely a significant gap in diagnosis and treatment for patients exhibiting depressive symptoms. The orthopedic clinic may be the first time a patient has been screened for mental health symptoms, particularly for patients who do not routinely obtain preventative health services. It can be argued that, if the intention is to provide true patient-centered care, mental health screening should be considered for all orthopedic practices.
4.1. Limitations
This study does have its limitations. First, only English-speaking patients were included in this study. Second, all PROMIS-D questionnaires were administered via a computer through MyChart or on an iPad which may have excluded patients that are older or who have limited understanding of how to use technology. Third, there was a small discrepancy in the numbers of patients from the representative sample who had a prior diagnosis of depression and those who had received some form of mental health treatment. This is likely due to the fact that some patients had been placed on antidepressants or were receiving behavioral therapy for diagnoses other than depression which could not be differentiated upon chart review. Fourth, while the EHR used at the study institution does have access to some medical records from outside institutions, a subset of patients may have had a diagnosis of depression or received behavioral health treatment at an institution whose records were unattainable through the EHR. Lastly, only the patients who screened positive for depression on PROMIS-D in the representative sample were reviewed for a history of depression and depression treatment. There are likely patients who had normal or mildly elevated PROMIS-D scores with a history of depression and/or mental health treatment who were missed. Evaluating the rate of treated and untreated depression in patients with normal or only mildly elevated PROMIS-D scores should be an area of future investigation.
5. Conclusions
PROMIS-D is a useful screening questionnaire for patients in the orthopedic clinic, though there is a consistent floor effect. There are a large number of patients who present to the orthopedic clinic who screen positive for depressive symptoms but have never had behavioral health interventions. Given the outcomes depression can have on orthopedic outcomes, screening for depressive symptoms and initiating discussions in the clinic should be incorporated into orthopedic practice.
Funding/sponsorship
The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Guardian/patient's consent
This study was approved by the institutional review board (Retrospective Review of Prospective Patient-Reported Outcome Measures Collection in an Orthopedic Clinic, #13787). No guardian or patient consent was necessary to obtain for this study. There was no direct contact with any patients. The study was conducted in accordance with the ethical principles mentioned in the Declaration of Helsinski (2013).
Ethical statement
This study was conducted in accordance with the ethical principles mentioned in the Declaration of Helsinski (2013).
CRediT authorship contribution statement
Mary E. Hennekes: Conceptualization, Formal analysis, Supervision, Writing – original draft, Writing – review & editing. Stanley Li: Data curation, Writing – original draft. Justin Bennie: Data curation, Formal analysis, Writing – original draft. Eric C. Makhni: Conceptualization, Methodology, Visualization, Supervision, Writing – review & editing.
Acknowledgements
The study authors have no additional acknowledgements to make with regards to the preparation of this manuscript.
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