Patterns of depression screening, referral, and behavioral health follow-up after orthopaedic trauma

To evaluate baseline patterns of depression, behavioral health referral, and behavioral health treatment among orthopaedic trauma patients at a Level I trauma center.

Design: Retrospective Cohort, Secondary Analysis Setting: Single Level 1 Trauma Center Patient selection criteria: Adult orthopaedic trauma patients who completed an ambulatory postoperative visit between September 2024 and November 2025. Outcome measures and comparisons: Demographic variables, PHQ-9 screening results, injury characteristics, behavioral health referral patterns, and referral completion were extracted from institutional electronic health records. Primary outcomes were the proportion of patients screening positive for depression (PHQ-9 >10), with moderately severe to severe depression (PHQ-9 ≥15) triggering behavioral health referral, and subsequent referral completion rates. Secondary outcomes included referral patterns by injury mechanism and six-month orthopaedic complications or unplanned healthcare utilization.

Among 528 patients, 44.7% (236/528) screened positive for depressive symptoms, and 21.2% (112/528) demonstrated moderately severe to severe depression triggering a behavioral health referral. 33.9% (38/112) of referred patients completed a behavioral health visit compared with 67.6% (115/170) of referred non-trauma orthopaedic patients. The severe depression cohort was on average younger and more likely to be female, black, and have Medicare/Medicaid insurance status. Injury Severity Score did not differ significantly across depression categories. Patients with ballistic injury had significantly higher rates of positive depression screening (51.9% vs. 41.8%; P = 0.040) and behavioral health referrals (34.0% vs. 18.0%; P < 0.001) than non-ballistic patients, though referral completion did not differ significantly by mechanism (25.0% ballistic vs. 38.2% non-ballistic; P = 0.198). Infectious and wound complications and unplanned healthcare utilization, driven by emergency department visits for wound complications, were significantly higher among patients who screened positive and failed to complete their referral compared with those who screened negative for depression (P < 0.001).

Significant gaps exist in the depression care cascade for orthopaedic trauma patients. Referral completion rates were approximately two-fold lower than non-trauma orthopaedic subspecialties, and referral non-completion was associated with significantly higher rates of infectious complications and unplanned healthcare utilization. Targeted, navigation-based interventions addressing structural barriers at the point of care are needed to close the gap between depression identification and treatment engagement in orthopaedic trauma.

Level III.