The first prospective study analysing the impact of depressive symptoms in surgically-treated severe adult spinal deformity patients on health-related quality of life outcomes has found that, whilst depressed patients began with “significantly worse absolute health-related quality of life scores”, the magnitude of their improvement was similar to that of the control group over a two-year follow-up period. Their results were presented by Amit Jain, (Johns Hopkins University, Baltimore, USA) at the Scoliosis Research Society Annual Meeting (SRS; 21–24 September 2016, Prague, Czech Republic).
Researchers from Johns Hopkins University (Baltimore, USA) have used data from the ScoliRisk-1 study to “investigate the impact of depression on health-related quality of life” in patients treated surgically for adult spinal deformity. The ScoliRisk-1 study includes data from patients with “severe” deformities, enrolled from 2011–2012. Jain told Spinal News International, “The ScoliRisk-1 study is a great example of a successful multi-institution collaborative effort. Under leadership of Larry Lenke (Columbia University, New York City, USA) and Khaled Kebaish (Johns Hopkins University, Baltimore, USA), patients were enrolled from 15 institutions across three continents. The study attempts to answer important questions regarding surgical treatment and outcomes of patients with severe adult spinal deformities, which is a very challenging area of spinal surgery.”
Hypothesising that surgically-treated adult spinal deformity patients with depressive symptoms would experience less improvement than those without depression, the research team began by defining a cut-off point for poor mental health and symptoms of clinical depression. Jain told Spinal News International, “Patients with adult spinal deformity are some of the most challenging patients in spinal surgery. They have a disease that severely impacts their quality of life. In addition to physical pain, adult spinal deformity is also known to have impact on self-image and mental health.” The authors used the Short Form-36 (SF-36) Mental Component Summary score of ≤35 to categorise patients as experiencing clinical depression symptoms. Of 260 patients who completed SF-36 instrument, the researchers identified 78 (30%) as exhibiting depressive symptoms, with the remaining 182 (70%) used as controls. Looking at the demographics of patients in the study population (age, gender, smoking status and race), only age was significantly associated with depressive symptoms (p=0.001). The average age of the control group was years, whilst the depression group was older: 60.7±11.9, with an average age of 54.9±16.1.
The researchers recorded the Oswestry Disability Index, and an SRS-22r SubScore for each group at baseline, six weeks, six months and two years of follow-up. The baseline Oswestry Disability Index scores were dramatically different at baseline between the control and depression group (39.2 and 60.5, respectively). Both groups’ results had improved at six months—the control group’s Oswestry Disability Index score had fallen to 31.8, while the depression group’s score had fallen 44.7. At two years’ follow-up, the Oswestry Disability Index scores were 27 for the control group, and 46.6 for the depression group.
The researchers developed a measure to compare the differences in SRS-22r scores between the two groups, called the SRS SubScore. This excluded responses to the mental health-related questions of the SRS-22r survey, looking solely at functional outcomes, pain and self-image. Both groups’ sub-scores improved from baseline (2.7 in the control group and 2 in the depression group) to two years (3.6 in the control group and 2.8 in the depression group).
One of the study’s limitations was its failure to use the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders as a source for defining depression. Jain explained this decision to Spinal News International, stating, “We were interested not only in depression, but in general, in patients with poor mental health at baseline. This could be from depression, anxiety, mood disorder etc.”
“At enrolment and at final follow-up, depressed patients had significantly worse absolute health-related quality of life scores,” Jain concluded. However, “The magnitude of health-related quality of life improvement in the depressed versus control group was similar over the two-year follow-up. While patients with poor mental health (at baseline) do not achieve equivalent absolute improvement compared to patients with good mental health in health-related quality-of-life (HRQoL) outcomes, they do make significant improvements. We hypothesise that these improvements persist over time.”
Future efforts should be made “to longitudinally follow these patients to see if their improvements in HRQoL persist over time,” Jain said.
Expanding on the context of the team’s research, Jain told Spinal News International, “Among surgeons, patients with poor mental health at baseline are frequently perceived to be poor candidates for surgery due to the unsubstantiated belief that these patients may not improve with surgery. Using the data from ScoliRisk-1 multicentre, international collaborative, we actually found quite the opposite. Patients with adult spinal deformity with poor mental health at baseline and those with clinical symptoms of depression did indeed make significant improvements in their HRQoL outcomes as a result of surgical intervention.”