Background

Of the 54.4 million Americans with osteoarthritis, more than one third endorse coexisting symptoms of depression and/or anxiety [1,2,3]. This is more than double the prevalence of depressive and anxious symptoms compared to Americans without osteoarthritis [1], and this same phenomenon of highly prevalent comorbid mental health conditions has been established across numerous musculoskeletal diagnoses [4,5,6,7,8]. Furthermore, depressive and anxious symptoms negatively impact physical function and recovery after a wide variety of orthopedic procedures [5, 9,10,11,12,13,14], and there is a continuing shift in the United States to allow for innovative financial structures to facilitate clinicians, regardless of specialty, to address patients’ whole-person health [15, 16].

As a result, orthopedic clinicians are increasingly motivated to offer mental health resources to their patients as part of a comprehensive musculoskeletal treatment plan [17,18,19,20,21,22,23,24,25,26,27,28,29,30]. Nevertheless, barriers and knowledge gaps are interfering with widespread changes to clinical orthopedic practice [27,28,29,30]. For instance, mental health interventions can be delivered via a variety of modalities such as digital, printed, and/or in-person, and a knowledge gap remains in identifying which modalities are simultaneously: (1) feasible for orthopedic teams to deliver efficiently, (2) acceptable to patients and clinicians, and (3) scalable to deliver across diverse orthopedic practice models. Furthermore, it is essential to learn about unique factors that influence whether orthopedic patients and clinical teams are willing to contribute to clinical trials to identify the most effective mental health interventions that are suitable to deliver in an orthopedic setting.

The primary purpose of this study was to understand orthopedic patients’ and clinical team members’ perceptions and preferences regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of musculoskeletal care. A second purpose was to understand these stakeholders’ perspectives regarding the feasibility and acceptability of participating in mental health related research trials in the context of musculoskeletal care.

Methods

This single-site qualitative study was approved by the Washington University IRB. Participants gave written or verbal consent, and they received a $40 stipend for participating. Participants were enrolled between January and May 2022, and data analysis was completed in September 2022.

Participants

Participants from two stakeholder groups were recruited. The first group consisted of adult (18 years or older) patients who presented to a Washington University orthopedic specialist for treatment of ≥ 3 months of neck or back pain. This population was chosen because among patients who seek care for a musculoskeletal condition, people with chronic neck or back pain have a particularly high comorbid prevalence of depression and anxiety [31,32,33,34]. Potential participants were identified by pre-screening orthopedic clinic schedules, and patients were purposively sampled to include: (1) adults across the age spectrum, (2) at least 50% of participants who self-identified as a woman and 25% who self-identified with a racial/ethnic minority group, and (3) patients who reported no, mild, and severe symptoms of depression and/or anxiety on the clinic’s standard care Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) Depression and Anxiety measures [35,36,37]. All patients who met the eligibility criteria and whose inclusion would contribute to, or at least not compromise maintenance of, our purposive sampling targets were invited to participate. The study was introduced to patients via a pre-visit phone call or in-person at their visit.

The second participant group consisted of Washington University orthopedic clinical team members including clinicians and support staff. Purposive sampling was used to ensure the group included: (1) clinicians from all adult orthopedic subspecialties, (2) early, mid, and late career physicians, (3) operative and non-operative specialists, (4) members of all clinical support roles present in the clinic (i.e., nurses and medical assistants who worked with operative and non-operative specialists), and (5) team members who self-identified as women and with racial/ethnic minority groups. The relative over-representation of White men in our orthopedic department heavily dictated which team members could be invited to participate while simultaneously honoring our purposive sampling goals. The study was introduced to team members via e-mail.

Interviews

After completing a demographic survey [38, 39], stakeholders participated in a one-on-one, approximately 30-minute interview in which they were asked to share their perceptions and preferences regarding various modalities through which mental health intervention could be delivered as part of musculoskeletal care. Interviews with patient stakeholders were conducted by a research coordinator with formal qualitative research training who has worked with orthopedic patients for 18 years (MAA). Interviews with clinical team members were conducted by a medical student with masters-level training in qualitative research (AJL). The lead researcher, who is a sports medicine physiatrist and manages chronic spine conditions (ALC), also participated in the initial interviews until the other research team members became acquainted with the clarifying and follow-up interview questions which were of interest to the lead researcher. All interviewers were overseen by a researcher with extensive qualitative methods experience (JA). Interviews were audio and video recorded and were conducted in person or via secure video conferencing technology, per the participant’s preference.

The interviews were informed by semi-structured interview guides that were drafted by the lead researcher (ALC) and then revised based on feedback from research team members including orthopedic surgeons and qualitative researchers (RPC, CJD, JA) (Additional file 1). The guides were pilot tested prior to the stakeholder interviews and were iteratively revised based on participant responses during the interviews.

All stakeholders were asked to describe their perceptions and preferences of feasibility, acceptability, and usability regarding modality options for mental health interventions that could/should be offered in the context of orthopedic care. They were specifically asked to at least comment on digital, printed, and in-person options. They also provided feedback regarding specific examples of one digital and one printed intervention.

The digital intervention, called Wysa for Chronic Pain, is an evidence-based mental health app that addresses the interplay between mental health and chronic pain [19, 20, 40]. It is a multi-component intervention that delivers cognitive behavioral therapy, mindfulness training, and sleep tools (e.g., meditations, sleep hygiene education) via a digital chatbot and real-time, text-based communication with human counselors. The printed intervention is a mental health resource guide developed by the research team. It was designed to maximize usability for older adults and people with limited literacy, and it was iteratively refined from stakeholder feedback provided during this study. The final guide is two double-sided pages and is titled, “Wellness Resource Guide.” The guide uses icons to assist users in quickly identifying resources which are in person, virtual/online, free, reduced cost, and/or a crisis hotline. Resources mirror the tools offered by Wysa for Chronic Pain, and some are intentionally inclusive and welcoming of people from diverse backgrounds. Each resource is accompanied by a brief description, physical and online contact information, and a QR code that links users to the resource’s primary online information site.

Patient stakeholders also completed usability testing for these digital and printed interventions. During this time, they were given access to the actual interventions and were asked to explore them and provide feedback on the intervention content and design. For the digital intervention, patients were also asked to complete onboarding and schedule a session with a counselor. For the printed intervention, they were also asked to demonstrate how to engage with a resource on the guide which appealed to them. As needed, the research coordinator assisted patients with the usability tasks. Next, the patients provided qualitative feedback and rated each intervention on the System Usability Scale (SUS), which is scored 0-100 with higher scores being favorable and scores above 80.3 interpreted as receiving an “A” [41, 42]. Because usability testing is not as applicable to human-human interactions, stakeholders were instead asked to comment on their preferred workflow(s), if any, for delivering in-person mental health support (e.g., referral versus real-time support in the orthopedic clinic, performed by a licensed counselor versus psychologist versus psychiatrist, etc.). Finally, all stakeholders described factors which would influence whether they would contribute to a randomized controlled trial related to a mental health intervention introduced during musculoskeletal care.

Data analysis

A preliminary codebook was developed by the lead researcher (ALC) using a deductive coding approach based on the dimensions of feasibility, acceptability, and usability. Next, using inductive coding, the codebook was refined and finalized by two team members (ALC and MAA (patient interviews), or ALC and AJL (clinical team interviews)) after they reviewed a sample of interview transcripts. All transcripts were independently coded by those two team members. Participant recruitment continued from each stakeholder group until thematic saturation was reached. Coding was completed with NVivo 12 software (QSR International; Doncaster, Australia). Group discussion was used to resolve coding discrepancies and organize codes into final themes.

Results

Of 85 patients approached, 30 (35%) participated (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White, median (range) pain duration 3.3 (0.5–40) years) (Table 1). Of 25 clinical team members approached, 22 (88%) participated (11 (50%) women, 6 (27%) non-White, 18 (82%) clinicians) (Table 2). Of the three team members who declined to participate, two were clinicians, and one was a support staff member.

Table 1 Characteristics of orthopedic patient stakeholders (N = 30)
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Table 2 Characteristics of orthopedic clinicians and support staff stakeholders (N = 22)
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Digital mental health intervention

Clinical team members perceived delivery of a digital mental health intervention to be feasible and appealing (Table 3). They especially expressed optimism that if patients experience improved mental health and ability to cope with pain, they may not rely as heavily on the clinical team to address these challenges, which many team members did not feel well-equipped to manage. However, team members and patients also voiced possible implementation challenges, including out-of-pocket costs for patients and the concern for increased workload and medicolegal liabilities for orthopedic team members if they offer an intervention that is outside their current scope of practice (e.g., receiving follow-up questions regarding mental health, becoming liable if a patient carries out an act of self-harm). The digital modality was largely acceptable to patients, but patient-reported interest varied based on their self-described tech-savviness and whether, at any given time, they felt a need for intervention and perceived benefit from using it. To be an acceptable intervention, orthopedic clinicians often expressed a need to first be presented rigorous evidence of effectiveness. For successful implementation, patients and team members also recommended: (1) providing patients with a printed “Getting started” informational handout, (2) offering a telephone support line to assist patients with app onboarding if needed (rather than relying on the clinical team for assistance), and (3) developing clear medicolegal policies and support paths which ensure orthopedic team members understand and work within their certified scope of practice. Patients scored the digital intervention with a median SUS score of 81.3, IQR 61.3–95.0, range 0-100 (n = 30). They demonstrated varied proficiency in navigating the intervention, and although not uniformly true, older patients frequently had more difficulty than younger patients with independently completing usability tasks. The most common usability barrier was that iOS (Apple iPhone) users often could not recall their App Store password, which interfered with their ability to download the app (even though the download was free). Six of the 30 purposively sampled patients had to complete usability testing on the research coordinator’s mobile device, four of whom because they could not remember their App Store passwords, and two because they did not own smartphones.

Table 3 Themes regarding use of digital intervention to address mental health in the orthopedic care setting
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Printed mental health resource guide

Compared to a digital intervention, team members expressed relatively greater feasibility to incorporate delivery of a printed mental health intervention into their existing clinic flow (Table 4). Patients and team members also expressed strong enthusiasm for a printed intervention to better meet the needs of patients who are generally not “tech users” and of patients who particularly prefer tangible resources for mental health related matters. To ensure acceptability and successful implementation of a printed intervention, some patients and team members suggested that the intervention be offered in a variety of methods during the orthopedic encounter (e.g., in the waiting room, on patients’ online portals, directly from clinical teams, etc.). However, many patients expressed they would be most likely to engage with a printed intervention if, as part of discharge instructions, a clinical team member highlights the intervention components that the orthopedic clinician perceives would be most relevant for them. Regarding usability, patients scored the printed resource guide similarly to the digital intervention, with a median SUS score of 87.5, IQR 65.6–92.5, range 45–100 (n = 30). Patients overwhelmingly perceived the final guide to be easy to use, but they also suggested: (1) creating an electronic version with active URLs to listed resources, and (2) de-emphasizing QR codes on the paper version of the guide so patients who are not familiar with QR codes do not feel overwhelmed.

Table 4 Themes regarding use of printed intervention to address mental health in the orthopedic care setting
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In-person mental health support

Although orthopedic patients and team members perceived that in-person support from a mental health specialist would be the ideal intervention modality for some patients (e.g., with more severe psychological distress and/or a preference for in-person intervention), many team members expressed skepticism regarding the current financial and logistical feasibility of providing in-person support as part of musculoskeletal care (Table 5). If feasibility could be achieved, clinicians expressed various acceptable implementation options, such as: (1) incorporation of an in-person social worker into orthopedic clinics, or (2) preferred referral-based access to mental health clinicians who offer affordable, prompt appointment availability for patients referred from the orthopedic teams. The ideal method of incorporating in-person support was felt to vary depending on the patient population. Team members who more frequently manage chronic, life-changing (e.g., major traumatic or oncologic), and/or spine conditions expressed more interest in incorporating a mental health clinical team member into the orthopedic clinic (rather than relying on expedited referrals).

Table 5 Themes regarding incorporation of in-person support to address mental health in the orthopedic care setting
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Research considerations

Orthopedic patients and team members expressed overall feasibility and acceptability of conducting randomized controlled trials of mental health interventions delivered in the orthopedic clinic setting (Table 6). Although team members agreed that a brief introduction of the study by a clinical team member would increase patient recruitment for the study, clinicians expressed variable amounts of time (from none to essentially as much as needed) that they and their team members would be interested in and able to contribute. Patients generally expressed interest in participation in order to help other people and to access free, potentially helpful resources for themselves. Patients anticipated that barriers to sustained study participation could include: (1) episodes of reduced motivation and engagement with daily activities due to depressive and/or anxious symptoms, and (2) excessive study-related burden. Most patients expressed willingness to be randomized, although many patients also expressed a preference for one intervention over the other (e.g., digital or printed). Offering all study interventions to each patient by the end of the study increased patients’ enthusiasm for participating in a randomized trial.

Table 6 Themes regarding considerations for conducting mental health related research in the orthopedic care setting
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Discussion

In this study, we found that digital and printed modalities are both anticipated to be feasible and acceptable methods of delivering mental health intervention in the context of musculoskeletal care. Although implementation considerations slightly favored the printed modality, available evidence of intervention effectiveness currently favors the digital modality [43,44,45]. Therefore, we anticipate that digital intervention can play a key role in facilitating delivery of mental health related therapeutic content to orthopedic patients, especially for patients who are younger and/or consider themselves to be proficient with and enjoy using mobile apps. At this time, also offering an accessible, inclusive printed intervention will likely be key to feasibly delivering content to a subset of often underserved patients, including many older patients, patients from rural communities with limited internet access, and those who cannot independently navigate mobile devices. Despite the feasibility challenges related to facilitating in-person mental health intervention, innovation and dissemination of successful models regarding care delivery to make this option possible will likely be most important for patients who are experiencing the most severe symptoms of depression, anxiety, and related impairment.

It is encouraging that orthopedic team members reported positive perceptions regarding the feasibility and acceptability of a digital intervention because: (1) this modality can provide at-home access to mental health tools when a patient’s mobility is limited due to a musculoskeletal condition, (2) there is growing evidence of effectiveness of digital mental health interventions, sometimes comparable to in-person mental health intervention [46, 47], and (3) there is increasing momentum for third party payers to subsidize digital interventions. Although some clinicians voiced medicolegal concerns related to offering a digital mental health intervention, the COVID-19 pandemic has accelerated the national push to facilitate seamless prescription of effective digital therapeutics, and we anticipate these concerns will lessen as clarity from governing bodies is achieved [48,49,50,51]. As these system-level considerations are addressed, incorporating an evidence-based digital mental health intervention into orthopedic care has the potential to meaningfully contribute to the treatment plan for a substantial subset of orthopedic patients. However, a “digital divide” still exists, and offering only a digital intervention will not yet be an equitable solution. Many patients who are already at increased risk of poor outcomes, such as older adults and people from rural locations with less internet access, are those who are least likely to successfully engage with a digital mental health intervention [52, 53].

Although patients and team members expressed somewhat favorable feasibility and equity of a printed intervention compared to a digital intervention, there is currently weaker evidence regarding the clinical effectiveness of printed mental health interventions. So far, self-guided interventions have achieved small, yet still significant mean effects on mental health symptoms (meta-analysis d = 0.23, Number Needed to Treat (NNT) of 6.4) [45, 54]. A subset of people have demonstrated high engagement with self-guided interventions, and low-intensity resource referral interventions have been shown to improve awareness and use of existing community resources [55]. Given the feedback from our stakeholders, we hypothesize that offering a well-designed printed resource referral intervention to the subset of orthopedic patients who voice a preference for a printed rather than a digital intervention could: (1) improve the previously identified NNT, and (2) improve quality of life for this subset of patients, relative to what they would have achieved if they were offered an intervention with which they would not be able to engage at all [56]. Nevertheless, orthopedic clinicians have expressed a desire for strong evidence regarding the effectiveness of a mental health intervention prior to incorporating it into their clinical practice [30]. Therefore, we propose that future investigation related to mental health interventions in the context of orthopedic care should include an intentional focus on the effectiveness of printed mental health interventions.

Although our stakeholders also strongly favored the option of in-person, one-on-one mental health support for some patients, perceived financial and logistical barriers still substantially tamper enthusiasm for current feasibility. Orthopedic practices could circumvent clinic-facing financial barriers to in-person mental health support by developing a “preferred access” referral list to mental health clinicians in the community. However, due to restrictive third party payer policies and the nationwide shortage of mental health clinicians, patients would still face the same financial and wait-time barriers to accessing care that they currently face when independently seeking mental health support [57,58,59]. One-on-one telehealth psychotherapy could be considered an alternative “in-person” support option. However, telehealth does not necessarily address the “digital divide” barrier, patient-facing financial barriers, or the widespread shortage of mental health clinicians. Telephone based support is another alternative modality that preserves the “human connection,” but this modality has not been well-received by subpopulations of orthopedic patients [23].

Limitations

A limitation of this study is that all stakeholders were recruited from a single institution in a single metropolitan region. Therefore, some of the mental health resources listed on the printed intervention that we tested may not be available elsewhere, although many of the included resources are widely available virtually. Similarly, the feasibility of incorporating in-person mental health support will somewhat vary based on regional resources, although the shortage of mental health clinicians is a widespread problem nationally and globally [57,58,59]. Also of note, all patients in this study presented for treatment of chronic neck or back pain. External validity of our patient-related findings needs to be assessed in other orthopedic patient populations who may have unique sociodemographic distributions and patterns of mobile device use (e.g., major orthopedic trauma, sports medicine, etc.).

Conclusions

In this study, we found that orthopedic patients and clinical team members perceive distinct advantages and challenges related to integrating digital, printed, and in-person modalities of mental health intervention into the orthopedic care setting. Digital intervention may currently have a favorable balance of feasibility and evidence of effectiveness compared to the other modalities, but an important, often underserved, subset of patients will not currently be reached using exclusively digital intervention. To reach as many patients as possible and to particularly engage patients who are older, from rural communities, and/or otherwise cannot meaningfully engage with a digital intervention, we propose that mental health intervention in the orthopedic setting cannot be a one-size-fits-all approach. Multiple intervention modalities are needed. The next step will be to build on this stakeholder feedback and conduct rigorous clinical trials to identify interventions that are feasible, acceptable, scalable, and effective at improving mental and physical health outcomes in orthopedic patients.