Depression And Hip Fracture

In his recent article “Depression and Hip Fracture Risk: The NHANES I Epidemiologic Follow-Up Study” (Public Health Reports, January/February 2005, pages 71–75), author Michael E. Mussolino documents his research about whether depression is predictive of fracture risk. The study concluded that “an association between high depressive symptomatology and hip fracture risk was observed. This study has the advantage of being based on a representative sample that included a relatively large number of subjects with depression compared to other studies; thus the results may be more generalized than those of previous studies” (p. 75).

Accounting for psychosocial ramifications is as important in health care intervention as the individual’s physical condition. This notion has been demonstrated and reinforced throughout my college career in occupational therapy at Utica College. While reading Mussolino’s article, I realized that health care practitioners, such as occupational therapy clinicians, must be sensitive to antecedent diagnoses as well as the current ones; in Mussolino’s study it is depression to hip fracture. Mussolino considered other risk factors: age at baseline, gender, bone mineral density (BMD), smoker, alcohol consumption, and recreational physical activity (p. 73). My experience as a clinician and researcher has also provided insight into the importance of risk factors, past medical history, and current lifestyle choices such as the ones Mussolino outlined.

This article is informative, yet it suggests further studies. Another study that may extend Mussolino’s work could evaluate the level of depression (high, intermediate, or low) after treatment (for example, follow-up studies of the level of depression of individuals who have experienced a hip fracture). An additional study could focus on depression in individuals with total hip replacements to determine the effectiveness of medical intervention on secondary or antecedent diagnoses. This would also provide evidence-based research for administrators or clinicians. Level of depression could be examined using the General Well-Being Schedule (GWB-D)—the same tool Mussolino used—pre and post surgery and intervention. Conclusions could then be drawn on the effectiveness of health care services in treating psychosocial concerns such as depression in an individual with an orthopedic impairment.

Another study could consider if pain is interrelated with depression. Mussolino cites studies supporting evidence of association between depression and BMD (p. 72). For clinical research it would be valuable to identify if individuals who experience pain pre or post surgery due to osteoarthritis, osteoporosis, or degenerative bone mass changes have increased levels of depression. Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”1 One might conclude that an individual who experiences chronic pain from degenerative bone mass changes could have higher levels of depression pre and post surgery, compared to that of an individual who has acute pain due to a hip fracture. In addition, the findings of this study would add to evidence-based practices for occupational therapy practitioners and health care providers. Sound research in this arena would provide the information needed to incorporate the relativity of pain and depression into intervention planning. This could also provide information for clinicians, such as occupational therapy professionals, to manage and treat pain within this diagnosis while assisting administrators with employee education and training on pain, depression, and the probable relationship and impact on intervention.

Determining the level of depression in individuals who suffer hip fractures compared to that of individuals undergoing total hip replacement surgery could be the focus of yet another study. This study could examine differences between the levels of depression in individuals with acute sustained fractures and those patients undergoing elective total hip replacement. (One might conclude that an elective surgery, although invasive, is less traumatic to an individual due to the decision process, while an individual with an acute fracture would be affected by higher levels of depression for a more prolonged period due to a possible longer recovery phase.)

The limitations of Mussolino’s study include, in his words, confounding by variables that were not measured, in particular use of antidepressant medications. The study also suffered a loss of follow-up studies within the sample size (5.2%), resulting in a possible bias due to cohort exclusions (p. 74). Mussolino reported that another potential source of bias, incorrect diagnosis of hip fracture, “is unlikely on medical records, but may be more of a concern for death certificates” (p. 75). Quintana, Arostegui, Azkarate, and Goenaga concluded through their research of four hospitals that 13.7% out of 216 participants undergoing total hip replacement surgery were considered to have been treated inappropriately or misdiagnosed by their physician.²

Pain was another confounding variable the study did not take into account. According to Verma and Gallagher, “depression is more likely to co-occur with chronic pain than with chronic illnesses without pain.”¹ Mussolino’s work also does not consider the etiology of hip fracture, resulting in another limitation. The American Occupational Therapy Association reports that one out of three Americans over the age of 65 sustain a fall each year.³ In 2001, more than 1.6 million seniors were treated in emergency departments for fall-related injuries and nearly 388,000 were hospitalized.⁴

Additional studies in this arena will expand evidence-based research on depression, pain, hip fractures, and total hip replacements. This research will also inform evidence-based practice (from the expert, consumer, and research) that could substantiate or challenge the existing research. Further research might provide a means for change in practice framework and best practice theories for allied health professionals in ways to treat depression and/or pain. Increased research could be gathered on the validity and reliability of assessment tools such as the GWB-D or Randall Chronic Pain Scale.⁵

Further studies would raise awareness of the importance of co-morbid diagnoses such as depression, while creating more evidence-based research. As Mussolino emphasizes, it is essential to determine whether depression is predictive of a fracture, as it could change the outlook of intervention.