Basem Attum MD1, and William Obremsky2 1 Department of Orthopedic Surgery, University of California, San Diego, CA, USA 2 Vanderbilt University Medical Center, Vanderbilt Orthopaedic Institute, Nashville, TN, USA Identifying the difference between these two psychological disorders is very important for the orthopedic surgeon to comprehensively treat patients. PTSD and depression have distinguishing characteristics and potentially affect outcome. Orthopedic injuries have a significant impact on society. In 2000, productivity losses from lower extremity injuries alone was $17.5 billion which is 75% more than the losses from nonfatal traumatic brain injuries, 50% more than the losses from nonfatal upper extremity injuries, and 600% more than losses from nonfatal spinal cord injuries.1 Treatment of orthopedic trauma injuries is multifaceted. What is often overlooked is the psychological component of recovery. Certain psychological factors such as depression, anxiety, and PTSD can affect outcomes. Zatzick et al. reviewed 101 trauma patients evaluated at admission and again at one year. In this study, PTSD had the strongest association with outcome. Patients with PTSD demonstrated worse outcomes in seven of eight domains of the 36‐Item Short‐Form Health Survey compared to patients without PTSD.2 The first step in management of these patients is to understand these disorders. Depression is a psychiatric disorder characterized by persistent sadness, decreased ability to experience pleasure, and decreased interest in usual activities.3 Depression can affect outcomes by reducing patient motivation to fully engage in rehabilitation activities.4 PTSD is a disorder secondary to a traumatic experience or a long‐term exposure to a traumatic stress which is characterized by re‐experiencing the incident, avoidance, and hypervigilance. The current diagnostic criteria for PTSD is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), and includes symptoms from the following categories: intrusion, avoidance, negative alterations in cognition and mood, alteration in arousal, and reactivity.5 Half of patients with PTSD go on to develop chronic progression and take approximately three years to remit. A third of the patients will suffer from PTSD‐related symptoms for more than 10 years.6 Clinical presentation and timing of onset is variable. deRoon‐Cassini et al. found that patients can present with PTSD symptoms as early as the initial hospital stay. At one to six months postdischarge, some patients developed worsening symptoms, others’ symptoms improved, and some had the same severity throughout.7 When identifying the stressor causing PTSD, patients reported a lack of control over the situation leading up to the traumatic event and/or death of a family member at the scene.8 Young age, female sex, poor education, lower socioeconomic class, alcohol abuse, drug abuse, and physical pain have been identified as risk factors for the development of PTSD.9,10 A study by Norman et al. on 115 patients evaluated by using the Visual Analog Scale (VAS) at a level one trauma center identified pain as a risk factor for the development of PTSD. An increase of half a standard deviation on the VAS was found to have a fivefold increase at four months and seven‐fold increase at eight months postdischarge of developing PTSD.11 Castillo et al. identified a recurring relationship between pain and associated psychological distress. It was determined that pain and psychological stress could be exacerbated by each other during the chronic stage of trauma. More specifically, it was discovered that pain influenced psychological distress early in the recovery process. At the one‐year mark, anxiety in turn affected the level of pain.12 Another variable in the development of PTSD is resilience. Clinically, resilience is healthy recovery from extreme stress and trauma.13,14 Patients have varying degrees of resilience with several factors involved with its development. Wilson et al. identified seven factors associated with resilience.13 These included: (i) locus of control (i.e. a sense of efficacy and determination), (ii) self‐disclosure of the trauma experience to significant others, (iii) a sense of group identity and sense of self as a positive survivor, (iv) the perception of personal and social resources to aid in coping in the post‐traumatic recovery environment, (v) altruistic or prosocial behaviors, (vi) the capacity to find meaning in the traumatic experience and life afterward, and (vii) connection, bonding, and social interaction within a significant community of friends and fellow survivors. King et al., studying Vietnam veterans and PTSD, found that hardy veterans coped better with life than less hardy veterans due to the hardy veterans seeking out and utilizing social support in their local environment to overcome stress.15 PTSD and depression are very common in the orthopedic trauma population and have been shown to affect outcome. PTSD and depression affect postoperative outcomes. By understanding the prevalence of these psychological disorders in the orthopedic trauma population, surgeons will be more aware of their presence and potentially more likely to screen patients. Psychological stress is common in the orthopedic population. In the Lower Extremity Assessment Project (LEAP) study, patients reported elevated levels of psychological distress compared to age‐ and sex‐matched cohorts. One‐fifth to one‐sixth of the patients reported severe levels of depression, phobia, and anxiety.16 The National Study on the Costs and Outcomes of Trauma, a multicenter prospective cohort study performed at 69 hospitals in 12 states on 2707 patients, had 20.7% of patients report symptoms of PTSD. Starr et al. used a Revised Civilian Mississippi Scale for Post‐traumatic Stress Disorder to measure PTSD symptoms in 580 persons at two level‐one trauma centers. Fifty‐one percent of these patients met the criteria for PTSD including 57% of those involved in motor vehicle accidents and 65% of the pedestrians struck by a motor vehicle.17
16 Post‐Traumatic Stress Disorder and Depression
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Question 1: What are post‐traumatic stress disorder and depression, and does their presence, in orthopedic patients, have an impact on postoperative outcomes?
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Question 2: How prevalent is PTSD and depression after acute trauma in the orthopedic trauma population?
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