Published 9/10/2025
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Leslie Schwindel, MD, FAAOS
Chronic pain and psychiatric disorders are common comorbidities in orthopaedic patients and often contribute to treatment outcomes regardless of the subspecialty. Within the field of orthopaedics, preexisting symptoms of depression or anxiety are associated with worse outcomes, such as increased postoperative opioid use, decreased return-to-work rates, worse patient-reported outcome measures, higher rates of complications, and longer length of stay. Despite the high rate of concomitant psychiatric disease, psychosocial interventions in the orthopaedic patient population are not widespread.
How psychological outcomes impact orthopaedic care
Symptoms of depression and anxiety can affect the perception of pain. In turn, pain can exacerbate or contribute to the development of mental health conditions after injury, potentially making treatment for both conditions less effective. In patients experiencing mental health symptoms in addition to musculoskeletal pain, traditional mental health treatments may fail to reduce psychological symptoms, and traditional orthopaedic treatments may provide less relief of physical symptoms than expected.
Trauma often sees the highest percentage of patients with mental health issues, with rates of psychiatric disorders reported in about 45% of patients. However, data on the mental health burden in trauma patients are underreported in the orthopaedic literature. From 2016 to 2018, only 3% of abstracts presented at the Orthopaedic Trauma Association Annual Meeting reported on patient mental health data, and 1% reported on substance use, although pain was more commonly assessed (10%). Only 16 of 942 abstracts described interventions to address psychosocial issues.
Mental health screening
Given the relationship between psychological and orthopaedic outcomes, it would stand to reason that mental health screening and appropriate intervention would improve postoperative outcomes, but there is limited reporting on this in the orthopaedic literature. According to a recent study in the Journal of Orthopaedic Trauma, only 45% of trauma surgeons indicated they are likely to formally screen patients for depression symptoms, and only 27% reported they would be likely to refer patients for psychological treatment.
Orthopaedic surgeons are exposed to psychiatry as medical students but are far from qualified to be a patient’s sole mental health provider. It has been suggested that adding a mental health screening tool into the orthopaedic clinic workflow would be a good starting point. Two such tools are the Patient Health Questionnaire (PHQ)-2 and PHQ-9; these are validated metrics for the identification of depression symptoms. These tools can be incorporated into electronic health record software and integrated into the workflow at a clinic or in a hospital. Positive findings could trigger referral to a psychiatrist or other mental health professional or to a primary care clinician in areas that lack access to psychiatric care.
Mental health applications using AI
Artificial intelligence (AI) solutions recognizing patterns in datasets have been explored in various areas of orthopaedic surgery. Using this technology specifically for mental health screening is another potential use, which may help decrease some of the barriers to implementation by more surgeons.
Screening must be paired with treatment to improve mental health outcomes in orthopaedic patients. Many areas lack robust resources for psychological treatment and care, or patients may not be able to access existing resources due to cost, transportation, time needed away from work, or stigma associated with these conditions. To combat this, there are several established mental health applications that utilize AI technology, including Happify, Rootd, Youper, and Calm, among others. Clinicians can refer patients to these digital resources, which are not limited by physical location, wait times, or privacy issues and can be performed outside of the orthopaedic setting.
One app, Wysa, has been reported in the media specifically for its use in orthopaedic clinics. Wysa is a mobile app that incorporates the principles of cognitive behavioral therapy, mindfulness, and motivational interviewing. It includes an AI-based “chatbot” conversational agent and text-based access to human “coach” counselors with master’s degrees in psychology.
A 2022 study published in JMIR Formative Research compared cohorts of orthopaedic patients receiving standard care with or without a mental health intervention, as well as a subgroup analysis comparing patients who received a digital or in-person intervention. The primary cohort of interest included patients who received two months of free access to the Wysa app along with their usual orthopaedic care. The researchers reported that patients who utilized the digital intervention showed greater improvements in mean depression, pain interference, and physical function scores after two months compared with patients who did not receive any intervention. Additionally, the digital intervention group demonstrated greater improvement in mean physical function scores and comparable improvements in depression, anxiety, and pain interference scores compared with patients who received in-person psychological counseling.
Orthopaedic patients are complex, and there are several factors beyond just treatment of their orthopaedic conditions that can influence their outcomes. Controlling pain, promoting injury healing, and reestablishing function in the setting of underlying chronic pain, psychological conditions, or treatment for substance use disorder — all while working within financial, social, and insurance constraints — are a delicate balancing act. Studies have shown improved outcomes in orthopaedic patients whose treatment strategies included mental health intervention, but there are barriers to implementing this for many clinicians. AI may provide an accessible new option for more efficient integration of mental health treatment during the course of orthopaedic care. Increased accessibility of mental health care may contribute to overall improvement in orthopaedic outcomes, which is the ultimate goal.
Leslie Schwindel, MD, FAAOS, is a general orthopaedic surgeon at Lake Cumberland Regional Hospital in Somerset, Kentucky, and a member of the AAOS Now Editorial Board.
References
- Henderson AP, Van Schuyver PR, Economopoulos KJ, Bingham JS, Chhabra A. The use of artificial intelligence for orthopedic surgical backlogs such as the one following the COVID-19 pandemic: a narrative review. JB JS Open Access. 2024;9(3):e24.00100. doi:10.2106/JBJS.OA.24.00100
- AI Mental Health Support Launched at Orthopedic Hospitals in Missouri, New York and California. BusinessWire. Oct. 10, 2023. Accessed July 21, 2025. https://www.businesswire.com/news/home/20231010591531/en/AI-Mental-Health-Support-Launched-at-Orthopedic-Hospitals-in-Missouri-New-York-and-California
- Leo AJ, Schuelke MJ, Hunt DM, Miller JP, Areán PA, Cheng AL. Digital mental health intervention plus usual care compared with usual care only and usual care plus in-person psychological counseling for orthopedic patients with symptoms of depression or anxiety: cohort study. JMIR Form Res. 2022;6(5):e36203. doi:10.2196/36203
- Wally MK, Hsu JR, Seymour RB. Musculoskeletal pain management and patient mental health and well-being. J Orthop Trauma. 2022;36(Suppl 5):S19-S24. doi:10.1097/BOT.0000000000002457