CORR Insights®: Is There an Association Between Psychiatric Disorders and Adolescent Idiopathic Scoliosis? A Large-database Study

Where Are We Now? During the time period that a young person might develop adolescent idiopathic scoliosis (AIS), his or her normal development would include large—sometimes dramatic—social, emotional, and psychological changes. An analysis of the 2016 National Survey of Children’s Health [4] showed that among children aged 3 to 17 years, 7.1% had current anxiety problems, 7.4% had a current behavioral/conduct problem, and 3.2% had current depression; the prevalence of each disorder increased with older age. Suicide remains the second leading cause of death among adolescents [6], a statistic that underscores the importance of these concerns. As one would expect, adding a serious musculoskeletal diagnosis to the story doesn’t make that life stage any easier. In the current study, Lee et al. [5] provide a unique “big data” perspective on the relationships between AIS and teen mental health. The study, based on diagnoses linked to billing claims, was made possible by the use of data from the National Health Service of the Republic of Korea. Although the validity of the data itself is well defended in the paper, the authors acknowledge that this methodology did not allow consideration of curve severity or treatment. Despite demographic and social differences, adolescent stress may manifest in surprisingly similar ways among industrialized nations. Lee et al. [5] found that the prevalence of confirmed psychological diagnoses in adolescents without identified AIS was reasonably comparable to statistics in the United States. Disorder prevalence for patients with AIS was somewhat higher, both in aggregate and in each year studied. While this may be in agreement with anecdotal observations expressed by US clinicians, published numbers are not directly comparable. The preponderance of published US studies relies on voluntary databases that are focused toward AIS treatment, as noted in the current study [5]. Nevertheless, this Korean model makes it obvious that there is much that could be done to enhance comprehensive care for scoliosis patients and their families. Where Do We Need To Go? A necessary prerequisite for improving patient care is that we all remain mindful of the mental health challenges faced by these rapidly developing individuals. Surgeons frequently are criticized for wanting to treat the deformity rather than the patient. While this is most often untrue and unfair, the trend toward delegating much of a patient’s preoperative and postoperative care to others may reinforce that misconception. It is important that the patient and family know that they have an empathetic surgeon leading their scoliosis treatment team. It bears repeating that the responsibility for identifying patients with emotional distress frequently falls to the orthopaedic surgeon. Beyond physician acumen, standardized tools are available. Validated patient-reported outcome (PRO) questionnaires are already part of patient visits at most scoliosis centers, and those of us not currently using such tools should consider doing so. Selected domains of the Scoliosis Research Society Outcomes Questionnaire (SRS-22) and Patient-reported Outcomes Measurement Information System (PROMIS) are relevant, but further refinement of PRO tools is still needed, especially as relates to perceived cosmesis. Comparisons between the Spinal Appearance Questionnaire and the SRS-22 [2], as well as between the PROMIS and SRS questionnaires [1], are steps in this direction. Pathways for appropriate intervention should be more easily available to young patients identified as at risk for mental health dysfunction. Healthcare in the Republic of Korea is essentially a single-payor situation, while the United States’ healthcare system is notoriously uneven with variable administrative regulations among the states, even under the umbrella of federal programs such as Medicaid. The system in the Republic of Korea boasts easy patient access to specialists and has consistently been first in the world with respect to number of yearly per capita physician visits for the last decade: Statistics compiled by the Organisation for Economic Co-Operation and Development record an average of 16 physician visits per person during 2019 [7]. Most US clinicians could provide a long list of challenges to subspecialty referral, many relating to approval processes that differ according to payor source, provider participation in various insurance plans, and the uneven distribution or frank unavailability of subspecialty care. Obviously, children and adolescents neither choose their own healthcare providers nor do they vote. They need effective advocates in order to improve access. It would be ideal to extend similar research to include the changes or improvements to patient mental health that might accrue from referral and intervention. The methodology of such research, especially big data research, may depend on future database development. As relates to this study by Lee et al. [5], the Republic of Korea has a population of approximately 51 million, with a relatively uniform ethnic and social base. By contrast, the United States has a diverse population of some 360 million, characterized by a high degree of mobility in terms of geography, employment, and healthcare providers. Whether it is possible, or even desirable, to develop a comprehensive all-inclusive healthcare database is open to debate. How Do We Get There? The number of recent publications [4, 5, 8, 9] relating spinal deformity to mental health attests to the awareness that physicians, orthopaedic surgeons, and scoliosis surgeons in particular already have regarding this issue. This material should continue to be presented in lectures and teaching exercises as part of the overall management of the scoliosis patient. As with most of the orthopaedic curriculum, awareness and empathy modeled by experienced practicing physicians is the best teacher. Lee et al. [5] conclude that patients with AIS and their families should be counseled about the increased risk of deteriorating mental health. There is no better place to begin this discussion than the surgeon’s office. The idea that the overall well-being of the patient will be of concern, not only the deformity of the spine, should be part of the general broad-brush information provided to patients and families at an initial visit, whether verbal, written, or web-based. Importantly, the PRO tool should be reviewed with the patient and his or her family at each visit. So long as these steps are a matter of office routine, patient embarrassment or feelings of intimidation would likely be minimal. Residents could be included in such routine sessions, particularly junior residents who still retain lessons pertaining to mental health learned during medical school rotations in primary care or psychiatry. However, if mental health concerns are actually uncovered, or even sensed, respect for the patient would argue that persons other than the attending, the patient, and the most immediate family be excused. It is often best for the attending physician to discuss even the most difficult issues directly with the patient, parent, or guardian present of course, as he or she represents a caring authority figure without entanglements at the family home. Much of the current research justifiably uses a “big data” approach [3]. In the United States, there is no database comparable to those accessed by Lee et al. [5]. Specialty registries and databases supported by professional organizations such as the American College of Surgeons are mostly voluntary, and many are narrowly focused on treatment outcomes. A specific diagnosis of interest is the point of entry into most of these databases; it is difficult to imagine how such databases could be expanded to provide meaningful longitudinal information, either for “normal” outcomes or across specialties. This currently leaves the state or federal government, primarily through the federal Centers for Medicare & Medicaid Services, to house the largest and most comprehensive patient databases. As healthcare consolidates toward multispecialty cradle-to-grave options, the Kaiser Permanente and Geisinger systems being possible examples, proprietary databases may provide excellent information from valid cross-sections of the population.