Psychological distress in a Department of Veterans Affairs spine patient population

doi:10.1016/j.spinee.2011.10.008

The Spine Journal

Volume 12, Issue 9, September 2012, Pages 798-803

https://doi.org/10.1016/j.spinee.2011.10.008 Get rights and content

Abstract

Background context

Purpose

To determine the prevalence of psychological distress among spine patients in a VA hospital and if higher levels of distress correlated with patient demographics and self-reported patient outcome scores.

Study design/setting

Cross-sectional evaluation of adult patients at a regional VA outpatient orthopedic spine surgery clinic.

Patient sample

One hundred forty-nine adult patients presenting for treatment of spine-related disorders.

Outcome measures

Patients were evaluated using the Distress and Risk Assessment Method (DRAM), a validated survey consisting of the Zung Depression Scale and the Modified Somatic Perception Questionnaire. In addition, self-reported pain, disability, and quality of life were assessed using the visual analog scale (VAS) for neck or back pain and the Neck Disability Index or Oswestry Disability Index (ODI) depending on the patient's location of pain.

Methods

The DRAM survey was used to determine the prevalence of psychological distress by classifying patients into normal, at-risk, and severe distress groups. Visual analog scale scores for neck and back pain, and self-reported disability scores, and demographic data including age, gender, combat experience, and use of antidepressant, anxiolytic, or narcotic medications were obtained at the time of enrollment.

Results

The DRAM survey identified 79.9% of patients as having some degree of psychological distress, whereas the remaining 20.1% were classified as normal. Among those with psychological distress, 43.6% of patients were categorized as severe distress. Compared with the normal group, a history of combat was more frequent in all distressed patient groups including the at-risk (p=.04) and severe distress (p=.009) groups. Those in the severe distress category more commonly reported the use of narcotics (p=.043) and antidepressant/anxiolytics medications (p=.0001). Those in the severe distress group had significantly higher ODI scores (p<.0001) and back pain VAS scores (p=.0360) compared with the normal group.

Conclusions

We identified a large number of patients (80%) with some level of psychological distress and 43% with severe distress. The percent of patients with severe psychological distress in the VA was double that previously reported in a non-VA patient setting. Patients with severe distress had higher ODI scores, back pain VAS scores, use of narcotics and antidepressants, and a reported history of combat when compared with those without distress.

Introduction

Evidence & Methods

A distressed psychological state is known to adversely affect spinal care outcomes for common degenerative conditions. It has been speculated that severe psychological distress, perhaps related to military service, may be more prevalent in a veteran population seeking spine care than those seen in non-veteran practices. This article aims to assess that hypothesis.

The authors found that 80% of the Veterans Affairs (VA) spine care population had some level of psychological distress and that 43% had severe distress. These rates were twice those reported in non-VA spine patients. Distressed psychological profiles were strongly associated with an exposure to combat in military service.

This study corroborates concerns regarding combat exposure and a primary factor known to exacerbate spinal disability and confound treatment efficacy. Limitations such as the cross-sectional methodology and relatively small numbers are noted; however, the extremely high rates of severe psychological distress in combat veterans (60%) with spinal disorders, if extrapolated to millions of recently deployed service personnel, suggests a looming public health problem.

—The Editors

A patient's perception of his or her disability is a reflection of his or her physical, mental, and social well-being. Patients with orthopedic conditions can present, for example, with similar radiographic and clinical findings yet may differ substantially in reported pain and functional ability. The biopsychosocial model of patient care takes into account this complex relationship of physical pathology with perceived disability, socioeconomic variables, medicolegal matters, and psychological distress [1].

Ultimately, these factors collectively influence the outcomes of treatment. Several studies have demonstrated the impact of psychological distress on patients undergoing treatment of spinal disorders [2], [3]. Individuals with significant psychological stress have been shown to be more likely to develop low back pain [4]. Distress has also been correlated with poorer outcomes after surgical treatment [5]. Orthopedic surgeons, although trained to recognize objective information from a physical examination or a radiographic imaging, are less equipped to identify psychosocial factors of patient care. In a recent study of 400 patients presenting for treatment of spine-related disorders, Daubs et al. [6] evaluated the ability of physicians to assess psychological distress. Compared with a validated questionnaire, physicians correctly identified severe distress only 29% of the time.

The veteran population presents a unique confluence of biopsychosocial factors in the treatment of spinal conditions. In addition to poorer health status and higher numbers of chronic medical conditions compared with the general population, previous reports have highlighted the high prevalence of psychological disorders within the Department of Veterans Affairs (VA) health system [7]. Kazis et al. [8] demonstrated a 28% prevalence of depression among over 1,600 participants in the Veteran's Health Study. Access to mental health services has become a priority for the VA health system, and spending increased from $2 billion in 2001 to $4 billion in 2008 [9]. Despite these efforts, Wagner et al. [10] reported a 3.8% per year increase in the prevalence of depression among VA patients from 2000 to 2007, ranking sixth among chronic medical conditions.

To our knowledge, no study has specifically evaluated psychological distress in patients with a spinal disorder within the VA health system. Given the known high prevalence of mental health disorders among the VA general patient population, we hypothesized that there would be a high prevalence of psychological distress among an outpatient spine patient population. Our primary objective was to determine the prevalence of psychological distress among spine patients using the Distress and Risk Assessment Method (DRAM) [11]. Our secondary objective was to determine if higher levels of distress, as measured by the DRAM, correlated with patient demographics and self-reported patient disability scores. Together, these findings might influence decision making in the management of VA spine patients.

Section snippets

Methods

The study design was a cross-sectional evaluation of patients presenting for treatment of spine-related disorders at a regional Veteran's Health Administration outpatient orthopedic spine surgery clinic. All established and new adult male and female patients aged 18 years and older were eligible for participation. Patients unable to complete the questionnaire were excluded from the study.

Demographic data including age, gender, combat experience, and use of antidepressant, anxiolytic, or

Results

One hundred forty-nine veterans were enrolled and completed our study. The mean age was 59.2±13.5 years. There were 132 men (88.6%) and 17 women (11.4%). Ninety-six percent (143/149 patients) were diagnosed with a degenerative spinal condition. Other conditions included deformity in one patient (0.7%), trauma in four patients (2.6%), and infection/tumor in one patient (0.7%). Forty-seven (31.5%) veterans complained of primarily neck and arm pain, whereas 102 (68.5%) complained of back and leg

Discussion

Patient outcomes in the treatment of spinal disorders are influenced by biological health, social factors, and psychological well-being. Several studies have shown that psychological distress, often unrecognized by physicians, can negatively affect a patient's perception of his or her function and disability after surgical treatment of lumbar radiculopathy or back pain [2], [3], [5], [6], [12]. Trief et al. [2] demonstrated that depression and somatic anxiety predicted lower return to work

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One-day Acceptance and Commitment Therapy workshop for preventing persistent post-surgical pain and dysfunction in at-risk veterans: A randomized controlled trial protocol
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Citation Excerpt :
Persistent post-surgical pain (PPSP) is a common and debilitating problem that impacts a significant number of patients following surgery [1–3]. Pain severity up to 12 months following surgery is highly correlated with adverse effects on physical functioning, recovery, and quality of life [3–10]. Disabling pain and reduced function also have a dramatic negative impact on mood, daily activities, sleep, cognitive functions, and social life [11,12].
Persistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning.
Described herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months.
The primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population.
The results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.
A retrospective cross-sectional survey of non-specific lower back pain among a cohort of Chinese army soldiers
2018, International Journal of Surgery
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A possible explanation for this finding is that respondents who have experienced LBP are familiar with the symptoms and are thus more sensitive to recurrence than those without a history of LBP. Many studies have reported that psychological factors, such as stress, anxiety, and depression, are correlated with the occurrence of LBP and are considered important risk factors [27–29]. Sleep quality and the frequency of nightmares reflect psychological tension to a certain extent, and poor sleep quality combined with nightmares can also indicate excessive psychological stress.
Nonspecific lower back pain (LBP) has been a major public health problem in western countries since the second half of the 20 t h century. The trend has expanded to non-western countries, and LBP is currently a significant cause of disability in the working population.
To investigate the prevalence of nonspecific lower back pain (LBP) and its risk factors among soldiers in the Chinese army.
A total of 2876 Chinese army soldiers were requested to complete a self-administered questionnaire on demographic, anthropometric factors, and their non-specific LBP symptoms. The LBP evaluation and risk factor analysis were based on the self-questionnaire survey.
The prevalence of non-specific LBP with physical state, one-child family, educational status, resident location and ethnicity were not associated (P > 0.05); while smoking, LBP history, LBP family history, nightmare frequency, sleep quality, and self-perceived fitness had significant effects on LBP (P < 0.05, Table 2). Multivariate logistic regression analysis showed that smoking (OR = 2.153,95% CI = 1.045–4.433), History of LBP (OR = 2.503,95% CI = 1.580–3.966), LBP family history (OR = 1.615,95%CI = 1.015–2.572), nightmare frequency (OR = 3.386, 95% CI = 2.047–5.603), sleep quality (OR = 2.391, 95% CI = 1.085–5.269) and self-perceived fitness (OR = 1.93,95%CI = 1.045–3.765) had significant effects on LBP (P < 0.05)) (Table 3).
Smoking, history of LBP, LBP family history, nightmare frequency, sleep quality, self-perceived fitness were important factors in the occurrence and persistence of LBP.
Clinical predictors of psychological distress in patients presenting for evaluation of a spinal disorder
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The finding of higher levels of distress correlating with higher ODI scores is consistent with the previously reported studies [15,19]. A recent study performed in a Veterans Affairs Hospital population found a similar correlation between higher levels of psychological distress and higher reported pain levels as recorded using the VAS [20]. Developing a model, using the data mining technique as described in our study, is unique to the spine literature.
Psychological distress has been shown to adversely affect the treatment outcomes of many spinal disorders. Most physicians do not routinely use psychological screening questionnaires. Additionally, physicians have not performed well when assessing patients for psychological distress while using clinical impression alone.
The purpose of our study was to evaluate the clinical factors that most accurately predict the presence of psychological distress in patients presenting for the evaluation of a spinal disorder.
This is a retrospective study.
Three hundred eighty-eight consecutive patients presented for an initial evaluation of a spinal disorder at a tertiary spine clinic.
Oswestry disability index (ODI), visual analog scale (VAS), and distress risk assessment method (DRAM).
Three hundred eighty-eight consecutive patients presenting for the evaluation of a spinal disorder with a completed DRAM, ODI, and VAS were evaluated. The DRAM was used to classify the patients' level of psychological distress. Clinical variables such as history of depression, use of antidepressants, use of other psychotropic medications, history of surgery, and history of chronic pain syndromes along with ODI and VAS scores were used to develop a model to predict a patient's level of psychological distress.
Our model was highly accurate (92%), sensitive (92%), and specific (95%) in predicting a patient's level of psychological distress. If patients' VAS is 4 or 5, their ODI is less than 45, and they are not on any psychotropic medications, they likely will fall into the normal group. Patients with a VAS greater than 7, currently taking antidepressants or other psychotropic medications, an ODI greater than 58, and a history of surgery are likely to fall into the higher distressed categories of distressed depressive or distressed somatic.
A patient's clinical history, ODI, and VAS scores can predict their level of psychological distress. In general, patients with higher VAS pain scores, higher ODI scores (>58), and those taking an antidepressant or another psychotropic medication were likely to have high levels of psychological distress. The predictive clinical factors noted in this study are readily available to most physicians treating spinal disorders and may be helpful in improving their ability to detect patients with psychological distress, counseling them on realistic outcomes, and possibly improve their treatment outcomes.
Commentary: The veteran: "a need to talk but no one wanted to hear about it"
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Marching home, again: Spine casualties, combat exposure, and the long wars
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: FDA device/drug status: Not applicable.

: Author disclosures: CMP: Nothing to disclose. MH: Nothing to disclose. BDL: Nothing to disclose. AAP: Nothing to disclose. AMW: Nothing to disclose. DSB: Royalties: Amedica (E), DePuy (G); Stock Ownership: Amedica (0.2%); Private Investments: Pioneer (<0.1%), Vertiflex (<0.1%); Consulting: Medtronic (B); Board of Directors: CSRS (None), FOSA (Executive board); Other Office: AOSpine (Education Committee); Fellowship Support: AOSpine (E). MDD: Royalties: Synthes Spine (F); Consulting: Synthes Spine (C); Grants: Stryker Spine (C, Paid directly to institution/employer).

: The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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Clinical StudyPsychological distress in a Department of Veterans Affairs spine patient population

Abstract

Background context

Purpose

Study design/setting

Patient sample

Outcome measures

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

The need for a new medical model: a challenge for biomedicine

Science

Prospective study of psychological predictors of lumbar surgery outcome

Spine

Emotional health predicts pain and function after fusion: a prospective multicenter study

Spine

Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors

Spine

Correlation of preoperative depression and somatic perception scales with postoperative disability and quality of life after lumbar discectomy

J Neurosurg Spine

Clinical instinct versus standardized questionnaire: the spinal surgeons ability to assess psychological distress

JBJS

Clinical Study
Psychological distress in a Department of Veterans Affairs spine patient population