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Researchers Identify Risk Factors for New-Onset Depression, Anxiety After Orthopedic Surgery

Researchers at Hospital for Special Surgery (HSS) have identified risk factors for new-onset depression and anxiety after certain types of orthopedic surgery, and have made recommendations for identifying at-risk patients.

Although uncommon, the development of depression and anxiety after surgery has been documented across various surgical cohorts and can potentially cause long-term health issues or even disability. However, there is limited research on this topic in orthopedic surgery.

Researchers from HSS led by anesthesiologist Stavros G. Memtsoudis, MD, PhD, MBA, are presenting three studies on this topic at the 2019 American Society of Anesthesiologists (ASA) Annual Meeting.

“Anesthesiologists have to keep in mind that what we do in the operating room or in the hospital may affect long-term outcomes, and anxiety and depression are issues that have been coming up more and more,” Dr. Memtsoudis said. “There are many causes, but having or developing chronic pain is one of the reasons why patients may not fulfill their expectations of what their life should be like after surgery.”

It is well known that acute pain that is not effectively managed has the potential to develop into chronic pain.

“If patients can’t return to their normal lives because they continue having pain, or if they develop anxiety or depression, then we haven’t really achieved our goal,” he added. “This research helps to remind us that what we do surrounding surgery may really affect things down the line, and we need to take more responsibility for those complications that happen perhaps not right away but weeks later.”

The three studies investigated potential risk factors for new-onset depression and anxiety after spine surgery, including posterior lumbar fusion (PLF) and anterior cervical discectomy and fusion (ACDF), and joint replacement, including total hip arthroplasty (THA) and total knee arthroplasty (TKA). They also examined whether obstructive sleep apnea (OSA) affected occurrence of new-onset depression or anxiety or risk factors.

The researchers analyzed patients who underwent surgery between 2012 and 2015 and who were identified with the Truven Health MarketScan database (which includes inpatients and outpatients from various hospitals across the United States).

New-Onset Depression and Anxiety after Spine Surgery

There were 16,277 patients who had PLF or ACDF procedures between 2012 and 2015 without coding or prescriptions indicating depression or anxiety before spine surgery.1 After surgery, 12.3% of patients (n=2,006) experienced either new-onset depression (n=563), anxiety (n=1,251) or both (n=192).

Risk factors included younger age, female sex, previous history of psychoses/neurological disorders, chronic opioid use and higher income.

New-Onset Depression and Anxiety after Total Joint Replacement

There were 106,260 total joint replacements identified in the database between 2012 and 2015 (34.3% TKA, 65.7%THA).2 Researchers found that 3.6% of patients (n=2,642) developed new-onset depression and 4.8% of patients (n=3,886) developed new-onset anxiety.

New-onset depression and anxiety were also significantly more likely after TKA compared with THA; patients undergoing TKA experienced 20% greater odds of new-onset depression and 40% greater odds of new-onset anxiety compared with patients undergoing THA.

“The reasons why new-onset depression and anxiety are more prevalent after TKA compared with THA are speculative, because with these database studies, we can’t determine causality,” Dr. Memtsoudis explained. “However, TKA is commonly a more painful procedure. It doesn’t quite replace a joint as physiologically as a hip replacement. So increased pain and not meeting expectations as well may underlie that finding.”

Chronic opioid use was associated with significantly higher odds of developing depression or anxiety after surgery. The strongest relationship was between chronic postoperative opioid use and new-onset depression and anxiety: Those who chronically used opioids after surgery had 2.4 times greater odds of developing new-onset depression and 2.9 times greater odds of developing new-onset anxiety compared with those who did not use opioids chronically after surgery.

“There are multiple reasons why chronic opioid use might be a risk factor for new-onset depression and anxiety after surgery,” Dr. Memtsoudis said. “One has actually been shown to happen on a molecular level, which is opioids interacting in the brain in a way that can produce anxiety.”

“On the other hand, it may not be current opioid use that causes depression in patients,” he continues. “Do people start getting depressed because they have chronic pain, or do they start having chronic pain when they’re depressed? Either way, I think that disrupting the cycle by finding patients at increased risk will at least allow us to screen for these problems and perhaps treat them early enough to prevent long term complications.”

Obstructive Sleep Apnea and New-Onset Depression and Anxiety after Surgery

Although trends were similar between patients with and without OSA, more significant results were found in patients without OSA, suggesting that OSA has a limited effect on new-onset depression and anxiety after surgery.3

Researchers found that in patients with or without OSA undergoing either spine surgery (PLF or ACDF) or total joint replacement (TKA or THA), risk factors for new-onset depression and anxiety six months after surgery included peripheral vascular disease, hyperthyroidism, paralysis, drug abuse and psychoses. Chronic opioid use increased the risk for complications. Higher income level was also associated with higher anxiety risk: Patients without OSA had 3% higher odds for developing new-onset anxiety if their annual household income was between $45,000-$60,000, and 19% higher odds if their annual household income was greater than $60,000.

“I think that there are multiple explanations for why higher income might be an increased risk factor for new-onset depression and anxiety,” Dr. Memtsoudis said. “It has been described in other fields that patients with higher income often have better access to healthcare. So someone who develops a problem is probably more likely to seek medical advice. So it may just be bias, a surrogate marker of access to better access to healthcare.”

“Additionally, patients with higher income may be more worried about potential loss of that income. Alternatively or additionally it may also be that patients who make more money have higher expectations,” he added.

Because of the observed relationship between chronic opioid use and new-onset depression and anxiety after surgery (particularly in patients whose chronic opioid use begins after surgery), Dr. Memtsoudis and colleagues recommend closely monitoring these patients to ensure they receive adequate and appropriate pain treatment.

“The most important takeaway is that this problem does exist. We need to find out if there is a causal relationship and who is at risk,” he said. “We also need to screen for these problems. It would be beneficial to put protocols in place that allow us to identify as early as possible patients who might develop depression, and find a mechanism to treat it. This may require better expectation management before surgery, or teaching patients coping skills or even referral to a specialist to identify the best course of treatment.”


1. Megan Fiasconaro MS, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Janis Bekeris MD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Postoperative depression and anxiety in posterior lumbar fusion and anterior cervical discectomy and fusion.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

2. Megan Fiasconaro MS, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Janis Bekeris MD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA FCCP. “New onset anxiety and depression as a function of chronic opioid use following total joint arthroplasty.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

3. Janis Bekeris MD, Lauren Wilson MPH, Jiabin Liu MD PhD, Jashvant Poeran MD PhD, Megan Fiasconaro MS, Stavros G. Memtsoudis MD PhD MBA FCCP. “OSA depression anxiety.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

About HSS

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In addition, HSS will be opening a new facility in Florida in early 2020. In 2018, HSS provided care to 139,000 patients and performed more than 32,000 surgical procedures, and people from all 50 U.S. states and 80 countries travelled to receive care at HSS. There were more than 37,000 pediatric visits to the HSS Lerner Children’s Pavilion for treatment by a team of interdisciplinary experts. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is the world’s leading provider of education on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.