Impact of mental health on outcomes after total shoulder arthroplasty

Anxiety and depression are the 2 most commonly diagnosed psychiatric disorders in the United States. The effect of these disorders on total shoulder arthroplasty (TSA) outcomes must be appreciated. The purpose of this study was to examine the correlation between a preoperative diagnosis of anxiety and depression and postoperative outcomes after TSA. The secondary goals were to determine whether patients contemporaneously treated with medication for their mental health diagnosis fared better than a cohort treated without medication and to examine the degree to which Patient-Reported Outcomes Measurement Information System Mental Health (PROMIS-MH) scores correlate with patient outcomes. Our hypothesis was that a history of anxiety and/or depression would negatively impact patient outcomes after TSA.

We performed a retrospective analysis of a prospectively collected cohort at a single institution. Patients undergoing anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) with anxiety and/or depression were identified and compared with a cohort of patients without a mental health diagnosis enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant types, range of motion, adverse events, and clinical outcome metric scores-PROMIS-MH score, American Shoulder and Elbow Surgeons score, Constant score, Shoulder Arthroplasty Smart Score-were recorded. Outcomes between cohorts were analyzed using conventional statistics, as well as stratification by the minimal clinically important difference and substantial clinical benefit thresholds where applicable.

The study comprised 218 patients (114 rTSA and 95 aTSA patients) with a diagnosis of either anxiety and/or depression and 378 patients (153 rTSA and 217 aTSA patients) with no history. Although both cohorts achieved the minimal clinically important difference and substantial clinical benefit thresholds for the postoperative American Shoulder and Elbow Surgeons score, the cohort with anxiety and/or depression showed lower postoperative outcome scores (P < .05), higher AE rates, and significantly lower preoperative-to-postoperative differences in all variables when compared with the cohort without anxiety and/or depression. There were no differences in outcome scores after rTSA or aTSA between patients being treated for anxiety and/or depression and those not receiving treatment. The PROMIS-MH score was positively correlated with postoperative outcomes and patient satisfaction.

This study shows that patients with anxiety and/or depression who underwent TSA had inferior postoperative outcomes and higher rates of AEs compared with a cohort without a mental health diagnosis. In addition, patients taking medication for treatment of depression and/or anxiety did not gain any significant benefit in terms of their postoperative shoulder outcomes or satisfaction rate compared with those with this diagnosis but not taking medication. Additionally, we found that, independent of a patient's underlying shoulder pathology or psychiatric diagnosis, lower PROMIS-MH scores were correlated with worse postoperative outcomes.