JMIR Publications

ABSTRACT

Background:

Depression and anxiety frequently coexist with chronic musculoskeletal pain and can negatively impact patients’ response to standard orthopedic treatments. Nevertheless, mental health is not routinely addressed in the orthopedic care setting. If effective, digital mental health intervention may be a feasible and scalable method of addressing mental health in an orthopedic setting.

Objective:

To compare two-month changes in mental and physical health between orthopedic patients who received a digital mental health intervention in addition to usual orthopedic care, those who received usual orthopedic care only (without specific mental health intervention), and those who established in-person care with a psychologist as part of their orthopedic treatment plan.

Methods:

In this single-center, retrospective cohort study involving ancillary analysis of a pilot feasibility study, two-month self-reported health changes were compared between a cohort of orthopedic patients who received access to a digital mental health intervention (Wysa) and two convenience sample comparison cohorts: patients who received usual orthopedic care (without specific mental health intervention) and patients who established in-person care with a psychologist as part of their orthopedic treatment plan. All patients were 18 years or older and reported elevated symptoms of depression and/or anxiety at an orthopedic clinic visit (Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and/or Anxiety score ≥ 55). The digital intervention was a multi-component mobile app which used chatbot technology and text-based access to human counselors to provide cognitive behavioral therapy, mindfulness training, and sleep tools, among other features, with an emphasis on behavioral activation and pain acceptance. Outcomes of interest were between-cohort differences in the two-month longitudinal change in PROMIS Depression and Anxiety scores (primary outcomes) and PROMIS Pain Interference and Physical Function scores (secondary outcomes).

Results:

Among 153 patients (mean age 55 (SD 15) years, 128 (83.7%) female, n=51 patients per cohort), patients who received a digital mental health intervention made clinically meaningful improvements at two-month follow-up in all PROMIS measures assessed (mean longitudinal improvement 2.8-3.7 points, P≤.02). After controlling for age and body mass index, the improvements in PROMIS Depression, Pain Interference, and Physical Function were meaningfully greater than longitudinal changes made by patients who received usual orthopedic care (mean between-group difference |2.6-4.8| points, P≤.04). Improvements in PROMIS Physical Function were also meaningfully greater than longitudinal changes made by patients who received in-person psychological counseling (mean between-group difference 2.4 points, P=.04).

Conclusions:

In this retrospective analysis, patients who received a digital mental health intervention as part of orthopedic care reported greater two-month mean improvements in depression, pain interference, and physical function than patients who received usual orthopedic care. They also reported greater mean improvement in physical function and comparable improvements in depression, anxiety, and pain interference compared to orthopedic patients who initiated in-person psychological counseling. Clinical Trial: ClinicalTrials.gov NCT202005219