How Depressive Disorder May Affect Outcomes of RSA

Depression is one of the most common mental health disorders in the US. The National Institute of Mental Health estimates that in 2020, approximately 21 million adults had at least 1 major depression episode.

Studies have shown that depressive disorder can lead to poor health, mortality, and substance abuse, and there is an established link between depressive disorder and higher complication rates following shoulder arthroplasty.

These studies, however, either grouped all shoulder arthroplasty procedures together or did not evaluate the effects of depression on primary reverse shoulder arthroplasty (RSA), an increasingly common type of shoulder arthroplasty. As a result, surgeons have little information on the role depressive disorder plays in outcomes of RSA for glenohumeral osteoarthritis (OA).

A large-scale study, presented at the 2022 Annual Meeting of the American Academy of Orthopaedic Surgeons, sought to fill this gap by evaluating the impact of depressive disorder on in-hospital length of stay (LOS), medical complications, and healthcare costs in patients undergoing RSA for glenohumeral OA.

Study Findings

Using a private payer database, the researchers identified primary RSA patients with depressive disorder who had surgery between January 1, 2010, and October 31, 2020. These patients were matched 1:5 with RSA patients who did not have depression based on age, sex, and comorbidities in the Elixhauser-Comorbidity Index.

A total of 28,410 patients were included in the study: 4084 in the study cohort and 24,326 in the comparison cohort.

Depression was found to significantly affect outcomes in patients who underwent primary RSA for glenohumeral OA:

  • Patients with depressive disorder had significantly longer LOS than the comparison group: 3 days vs 2 days, respectively (P=0.0007).
  • These patients had higher frequency and odds of developing complications after RSA: (47.40% vs 14.67% (P<0.0001).
  • Complications included:
    • Pneumonia (10.04% vs 1.79%; P<0.0001)
    • Cerebrovascular accident (3.13% vs. 0.72%; P<0.0001)
    • Myocardial infarction (1.98% vs. 0.43%; P<0.0001)
    • Venous thromboembolism (2.15% vs. 0.55%; P<0.0001)
    • Acute kidney injury (11.17% vs. 2.32%; P<0.0001)
    • Transfusion of blood products (4.39% vs. 1.20%; P<0.0001)
    • Surgical site infection (4.38% vs. 2.35%; P<0.0001)
  • Cost of care was significantly higher in patients with depressive disorder: $19,363.10 vs $17,927.55 (P<0.0001).

In summary, depressive disorder was associated with longer LOS, higher rates of medical complications, and increased healthcare costs for patients undergoing RSA for the treatment of glenohumeral OA.

Mental Health and RSA

“Mental health and how it affects patients has become a greater area of concern for healthcare professionals,” said Keith Diamond, MD, lead author and an orthopaedic surgery resident at Maimonides Medical Center in Brooklyn.

“RSA aims to improve the functionality of the shoulder; however, mental health can have a great effect on the outcomes. There were several significant outcomes of this study, including increased LOS and cost, that demonstrate a need to educate patients when considering primary RSA.”

Co-author Anthony A. Romeo, MD, seconded the importance of being aware of a patient’s mental health before surgery.

“Screening should be a part of preoperative care. If a patient’s depression is not well controlled, they may want to delay surgery until it is,” said Dr. Romeo, who is Executive Vice President of the DuPage Medical Group’s Musculoskeletal Institute.

“Unfortunately, some parts of the depressive disorder may be directly related to the pain and impairment of the shoulder arthritis, inhibiting a good response to the preoperative treatment. Additionally, a patient’s mental state may be in a good place before RSA, but postop, they could have pain and limited mobility, which can affect their depression.

“It is equally important to consider methods to assess and guide treatment for mental health as a part of the postoperative care plan for patients with depressive disorder.”


Diamond K, Gordon AM, Roth E, Conway C, Vakharia R, Romeo AA, Choueka J. How Does Depressive Disorder Impact Outcomes in Patients with Glenohumeral Osteoarthritis Undergoing Primary Reverse Shoulder Arthroplasty? (Paper 426). Presented at the American Academy of Orthopaedic Surgeons’ 2022 Annual Meeting, March 22-26, 2022, Chicago, Illinois.

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