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Changes in Anxiety and Depression Are Mediated by Changes in Pain Severity in Patients Undergoing Lower-Extremity Total Joint Arthroplasty
  1. Afton L. Hassett, PsyD*,
  2. Elizabeth Marshall, MD,
  3. Angela M. Bailey, MS*,
  4. Stephanie Moser, PhD*,
  5. Daniel J. Clauw, MD*,
  6. W. Michael Hooten, MD,
  7. Andrew Urquhart, MD§ and
  8. Chad M. Brummett, MD*
  1. *Departments of Anesthesiology
  2. Departments of Family Medicine, University of Michigan, Ann Arbor, MI
  3. Department of Anesthesiology and Pain Medicine, Mayo Clinic, Rochester, MN
  4. §Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
  1. Address correspondence to: Afton L. Hassett, PsyD, Division of Pain Medicine, Department of Anesthesiology, University of Michigan, 24 Frank Lloyd Wright Dr, Lobby M, Ann Arbor, MI 48106 (e-mail: afton{at}


Background Depression and anxiety are common comorbidities in chronic pain including osteoarthritis patients undergoing total joint arthroplasty (TJA). What is not clear is whether psychiatric comorbidity precedes the manifestation of painful states or represents a reaction to living with chronic pain and associated functional impairment. The objective of this research was to explore whether decreases in depressive and anxiety symptoms after lower-extremity TJA could be due to postsurgical reductions in pain.

Methods We conducted a secondary analysis of data from 1448 TJA patients enrolled in the Analgesics Outcome Study. Patients completed measures of pain intensity, functional status, and depressive and anxiety symptoms preoperatively and at 3 and 6 months postoperatively. Data were analyzed using a structural equation modeling approach.

Results We found that improvement in pain and physical function from baseline to 6 months postoperatively was associated with improvement in depression and anxiety symptoms. We also found that a change in overall body pain at 3 months after surgery significantly mediated changes in both the depression and anxiety scores at 6 months after surgery even when controlling for age, sex, baseline body pain, education, opioid use, and type of surgery.

Conclusions Presurgical affective symptoms not only have an effect on change in postsurgical pain, whereby lower preoperative scores on depression and anxiety were associated with lower postsurgical pain, but also postsurgical decreases in pain were associated with lower levels of depression and anxiety after surgery. Taking these points into consideration may prove useful in working toward better outcomes for TJA.

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  • The study was funded by R01AR060392 (co–principal investigators C.M.B. and D.J.C.) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (National Institutes of Health, Bethesda, MD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Arthritis and Musculoskeletal and Skin Diseases or the National Institutes of Health. Additional funding was provided by the Department of Anesthesiology, University of Michigan. The study sponsors had no role in the design, conduct, collection, analysis, or interpretation of this study or the preparation, review, or approval of the manuscript.

    A.L.H. has received research funding from Bristol-Myers Squibb (Princeton, NJ) and is a consultant for Happify, Inc (New York, NY). A.L.H. also receives salary support from the American College of Rheumatology as the president of the Association of Rheumatology Health Professionals. D.J.C. is a consultant for Pfizer, Inc (New York, NY); Johnson and Johnson (New Brunswick, NJ); Forest Pharmaceuticals (New York, NY); Merck (Whitehouse Station, NJ); Nuvo Research, Inc (Mississauga, Ontario, Canada); Eli Lilly, Inc (Indianapolis, IN); Grunenthal Pharma Ltd (Dublin, Ireland); and Jazz Pharmaceuticals, Inc (Palo Alto, CA). D.J.C. also receives research funding from Merck Pharmaceuticals, Cerephex, and Forest Pharmaceuticals. C.M.B. receives research funding from Neuros Medical Inc (Willoughby Hills, OH). The other authors declare no conflict of interest.