Editorial Commentary: Clinically Depressed Patients Show Worse Outcomes After Anterior Cruciate Ligament Reconstruction Than Situationally Depressed Patients and Patients Without Mood Issues

The impact of psychological factors on outcome after orthopaedic surgery is increasingly well reported. Specific to anterior cruciate ligament (ACL) reconstruction, prior authors have reported that psychological factors influence return-to-sport outcome. The role of depression, however, has not been as well studied with regard to ACL reconstruction.

In their study “Clinically Depressed Patients Having Anterior Cruciate Ligament Reconstruction Show Improved but Inferior Rate of Achieving Minimum Clinically Important Difference for Patient-Reported Outcomes Measurement Information System Compared With Situationally Depressed or Nondepressed Patients,” Schaffer, Kuhns, Reuter, Sholtis, Karnyski, Goldblatt, Bronstein, Maloney, Baumhauer, and Mannava assessed whether the preoperative diagnosis of depression predicted worse postoperative outcomes specifically physical therapy compliance, return-to-sport, and patient-reported outcomes after ACL reconstruction. The authors differentiated between clinical depression, situational depression, and absence of depression. Clinical depression was defined as a prior diagnosis of depression whereas situational depression was defined as meeting the clinical threshold for mild depression on the PROMIS without an established diagnosis of depression. The authors found that clinically depressed patients had a higher rate of physical therapy noncompliance and a lower postoperative PROMIS Physical Function score compared to patients without clinical depression. Situationally depressed patients, however, had lower preoperative physical function with no differences in postoperative outcomes scores compared to the nondepressed cohort. Interestingly, 90.5% of situationally depressed patients had postoperative resolution of their depressive symptoms.

These findings point to the notion for the first time that not all depression is the same. Specifically, there can be situational depression as a result of injury, which can be unrelated to an underlying clinical mood disorder (i.e., clinical depression). With this in mind we are called on to take a more nuanced interpretation of depression—one that does not call for a singular snapshot of mood/affect but rather a longitudinal and multicentric approach which takes into account situational triggers and pre-existing conditions. Thus, for clinical investigators who believe that screening tests for depression are warranted to risk-stratify outcomes, perhaps a deeper dive is needed. Not only should we screen for the current state of depression, but we should also understand whether the current low mood is new in onset or whether it has been a persistent issue (i.e., for patients screening in for low mood), we need to take a whole person assessment and review their clinical psychological background.

Beyond the retrospective review for depression (in search for a diagnosis of clinical depression), there is a need for prospective tracking of psychological status. How do things change with time? The authors note that 10% of participants indeed do not resolve their depression. This subgroup analysis opens up a potential pandora box: Do these 10% have persistently worse outcome? Do these 10% have persistent low mood due to their poor outcome (and NOT vice versa)? If we resolve low mood in the 10%, can we reach an even higher level of clinical success after ACL reconstruction? The answers to these questions are likely myriad and not readily apparent, but what the questions themselves highlight for us is that we should renew our focus on investigating the psychological predictors of success after ACL reconstruction.