The Relationship of Unemployment and Depression with History of Spine Surgery
Winter 2011 - Volume 15 Number 1
Background: Chronic back pain is a known risk factor for unemployment, disability, and depression. This paper discusses the interaction of unemployment, depression, and history of prior spine surgery.
Unemployment is one of the major distresses that can strike a human being. Unemployment rates in the general population surge during economic recessions, but unemployment may also occur to individuals as a sequela of physical injury or disease. People losing their jobs are very likely to experience psychological tension, mainly depression and anxiety, which negatively affects their health, their family's security, and society's stability in general.
Chronic back pain is a known risk factor for unemployment, disability, and depression.1,2 In a difficult period of economic restraint brought on by the recession that began in 2008 and with the US experiencing approximately $30 billion in lost productivity from chronic back pain each year,3 it is relevant to investigate the interaction of unemployment and depression and their relationship with a history of spine surgery.
Materials and Methods
We retrospectively reviewed the charts of 629 patients who underwent spine surgery between 2005 and 2008 and who were between the ages of 25 and 65 years. We collected data on their employment status, history of depression, and history of prior spine surgery, which were coded as nominal variables (yes or no). Three types of spine surgery were included in the study:
The χ2 and Fisher exact tests were used to determine significant differences between the rates of unemployment, depression, and prior spine surgery. Statistical analysis and graphing was accomplished using Excel (2003; Microsoft, Redmond, WA) and SPSS Statistics (version 16; IBM, Somers, NY).
Approximately 29% (183) of the 629 patients were unemployed, and 32% (200) had a history of depression. Unemployment was 36% in the LDF group, 28% in the ACDF group, and 23% in the LMD group, which was statistically different (p < 0.05). Similarly, the percentage of those with a history of depression was highest in the LDF group (35%), with 33% in the ACDF group and 27% in the LMD group having such a history, which was not statistically significant (p > 0.05). The average ages in the LDF, ACDF, and LMD groups of working age patients were 51 years, 50 years, and 48 years, respectively (Figure 1).
Unemployment was most common among depressed patients (44% vs 27%; p < 0.001), and depression was most common among unemployed patients (41% vs 24%; p < 0.001). A history of depression was most common in unemployed women in all types of spine surgery. A history of depression was reported by 34.62% of unemployed women in the LMD group, by 49.02% of those in the ACDF group, and by 60.00% of those in the LDF group (Figure 2). The difference was significantly different (p < 0.05) between the male members of the ACDF group and the female members of the LDF group.
A history of prior spine surgery was most prevalent in unemployed women with a history of depression: in 66.67% of unemployed women in the LMD group, 48.00% of those in the ACDF group, and 59.26% of those in the LDF group (Figure 3). In the ACDF group, the rates for a history of prior spine surgery were significantly different (p < 0.01) between depressed and nondepressed, employed men and between depressed and nondepressed, unemployed women.
Unemployment depression, which particularly affects middle-aged persons, may manifest with physical symptoms such as headache, irritability, stomachache, and sexual dysfunction in its early stages.4 More serious symptoms may eventually arise, including fatigue, sluggishness, loss of interest in life pleasures, and, worst of all, suicidal thoughts, plunging individuals who lose their job into a vicious cycle of frustration and defeat that makes it even harder for them to find a new job.4 Our study shows that unemployment and depression are common among those who have had spine surgery, with depression being more common among unemployed patients. Women admitted for spine surgery who are unemployed and report a history of depression are more likely than other patients to have had spine surgery in the past.
Recent studies document a dramatic 220% increase in the rate of spinal-fusion surgery, yet Deyo et al note that these increases "have not been accompanied by population-level improvements in patient outcomes or disability rates."5 Our study sheds light on an important factor that may be behind this lack of better spine surgery outcome: the duo of unemployment and depression. A model can be suggested where unemployment causes depression, which worsens back problems via pain-threshold modification, leading to additional spine surgeries6,7 (Figure 4). Furthermore, depression strongly affects the ability of patients to achieve a good surgery outcome with significant improvement in symptoms, disability score, and walking capacity, as demonstrated recently by Sinikallio et al.8
With an ongoing economic recession and with soaring health care expenditures, it is important to quantify efforts to improve hospital efficiency and decrease hollow overuse of health care resources.9 In view of our findings, it may be extremely useful to perform a randomized, controlled trial involving social workers and cognitive-behavioral specialists who will work with the spine-surgery population to decrease the risk of "failed back syndrome"10 by performing the right operation on the right patient, which should supposedly improve the patient's clinical outcome, quality of life, and depression symptoms.11 It would also be useful to incorporate length of stay, consumption of hospital resources, and change in employment status in the outcome analysis of these patients.
It is important to note, however, that the discovered association between employment status, depression, and the number of spine interventions in US patients may not apply to other countries that have different health care resources and treatment protocols. More research is still needed into spine surgery cost-effectiveness, patient psychological markers, and sex-related differences in outcome.
The author(s) have no conflicts of interest to disclose.
The views expressed are those of the authors and do not represent the policies or opinions of the Medical Center of Central Georgia or Kuban State Medical University.
Katharine O'Moore-Klopf, ELS, of KOK Edit provided editorial assistance.
1. Watson PJ, Booker CK, Moores L, Main CJ. Returning the chronically unemployed with low back pain to employment. Eur J Pain 2004 Aug;8(4):359–69.