Perspectives of patients with depression and chronic pain about bone health after a fragility fracture: A qualitative study

Abstract Background Compromised bone health is often associated with depression and chronic pain. Objective To examine: (1) the experience of existing depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and pain. Design A phenomenological study guided by Giorgi's analytical procedures. Setting and Participants Fracture patients who reported taking prescription medication for one or more comorbidities, excluding compromised bone health. Main Variables Studied Patients were interviewed within 6 weeks of their fracture, and 1 year later. Interview questions addressed the recent fracture and patients' experience with bone health and their other health conditions, such as depression and chronic pain, including the medications taken for these conditions. Results Twenty‐six patients (5 men, 21 women) aged 45–84 years old with hip (n = 5) and nonhip (n = 21) fractures were recruited. Twenty‐one participants reported depression and/or chronic nonfracture pain, of which seven reported having both depression and chronic pain. Two themes were consistent, based on our analysis: (1) depression and chronic pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain. Conclusion Experiences with depression and pain take priority over bone health and may worsen as a result of the fracture. Health care providers treating fragility fractures might ask patients about depression and pain and take appropriate steps to address patients' more general emotional and physical state. Patient Contribution A patient representative was involved in the study conception, data interpretation and manuscript writing.


| INTRODUCTION
Compromised bone health is often associated with depression and chronic pain. There is evidence to suggest a bidirectional relationship between bone health and depression. Specifically, researchers have suggested deleterious effects of depression on bone health through bone loss and increased fracture risk. 1 The causal mechanism is unclear but possibly due to depression altering concentrations of many hormones that affect bone formation and/or resorption, such as cortisol. 1 Medications taken for depression may also be detrimental to bone. [2][3][4] For example, serotonin can influence bone metabolism as serotonin receptors and transporters are present in osteoblasts and osteoclasts. 4 At the same time, fragility fractures often precede the onset of depression. 5,6 In one cohort study, 10% of individuals reported depressive symptoms after a hip fracture. 6 There is also evidence of a bidirectional relationship between bone health and chronic nonfracture pain. Medications taken for chronic pain, such as nonsteroidal antiinflammatory drugs (NSAIDs) and opioids, including codeine, can have negative bone health effects, including increased fracture risk, increased risk of falling and decreased bone mineral density. 2,7,8 The mechanism underlying this effect is unclear. 7,8 Fragility fractures, such as vertebral fractures, can also result in long-term pain at the site of the fracture, 9,10 which is thought to be due to physiological changes in the spine and loss of height. 11,12 Other types of fractures have also been shown to result in reports of long-term pain at the site of the fracture, 13,14 possibly due to the development of arthritis at the fracture site. 15,16 Little is known about whether fragility fractures have an effect on chronic pain conditions unrelated to the fracture.
Few researchers have examined the co-occurrence of depression and chronic nonfracture pain in patients who have had a fragility fracture, and what factors may worsen these conditions. In one randomized controlled trial of patients with a wrist fracture, the most common reported comorbidities included osteoarthritis (34%-42%) and depression (11%-15%). 17,18 Although not determined in that study, it is expected that reports of chronic joint pain would have been common in most of the patients reporting osteoarthritis. Kelly-Pettersson and colleagues reported that approximately 22% of hip fracture patients reported depressive symptoms at baseline, 19 but it is unclear whether the depressive symptoms existed at the time of hip fracture or occurred after the hip fracture was sustained.
Our purpose was to examine experiences of depression and chronic nonfracture pain in patients who presented with a fragility fracture and other comorbidities. A fragility fracture is one that occurs after a slip, trip or fall from standing height or less. 20 This is distinct from high-trauma fractures, which typically result from motor vehicle crashes and falls from greater than standing height. 21 Fragility fractures are a sign of poor bone quality and a predictor of future fractures. 22,23 A Fracture Liaison Service is a model of care that identifies individuals over the age of 50 years who present to a hospital with a fragility fracture to ensure they receive a fracture risk assessment and bone health treatment according to current clinical practice guidelines. 24 Treatment includes pharmacological and nonpharmacological treatment, such as vitamin D supplementation, adequate calcium intake, and exercise. 25 Pharmacological treatment has been shown to reduce refracture [26][27][28] and mortality rates. 28 We anticipated that our investigation might partially contribute to our understanding of the modest uptake of bone health recommendations after a fragility fracture, such as taking bone active medication. 29,30 In one systematic review, less than 35% of individuals initiated medication after a postfracture intervention. 31 Depression has been shown to be associated with poor adherence to bone active medication. 32 Using a qualitative approach and relying on patients' perspectives, we sought to understand the complexity and meaning of bone health in comparison to that of chronic pain and depression. Previous qualitative studies in bone health have demonstrated that patients have limited knowledge of bone densitometry and bone health 33 and are unclear about testing and treatment recommendations. 34,35 Studies have shown that the circle of care for those with fragility fractures is disrupted at vital communication junctures 36 and that patients perceive inconsistent messages within, and across, primary care providers and bone specialists. 37 One qualitative synthesis demonstrated that individuals create meaning of an osteoporosis diagnosis based on self-perceived risk, self-perceived severity of osteoporosis and self-perceived health. 38 Authors have also reported that patients do not connect their fractures to bone health, 39,40 that many patients classified as 'high risk for future fracture' do not believe they are high risk, 41 and that having caregiving responsibilities affect the management of fragility fractures. 42 Specifically, our objectives were to examine: (1) the experience of depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and chronic pain.

| METHODS
This study was part of a larger study examining bone health management in patients with a fragility fracture who reported one or more comorbidities. It involved a 2-year qualitative investigation guided by phenomenology as conceptualized by Giorgi and Wertz (the 'Duquesne school'). [43][44][45] Phenomenology was relevant to our study design as it emphasizes the importance of direct experiences, perceptions and actions. 46,47 Ethical approval for the study was received by Unity Health Toronto (REB#: 14-301).
We recruited patients from a Fracture Liaison Service serving approximately 430 patients annually in a Canadian urban hospital. 48,49 Consistent with phenomenology, we employed criterion sampling 50 where eligible individuals were English-speaking men and women, 45+ years old, who self-reported currently taking prescription medication for at least one additional chronic health condition (bone health could not be the only chronic condition for which patients were taking medication). To aid with recruitment, we created a list of eligible chronic health conditions, such as arthritis and high blood pressure, from two Canadian sources 51,52 and expanded it to include other conditions such as those causing secondary bone loss.
Participants were not eligible if they only reported conditions on the list of excluded conditions (see Table 1). Patients who exhibited cognitive difficulties that might compromise their ability to give informed consent or participate in an interview were not approached. as depression and conditions that might be associated with chronic pain, including the medications taken for these conditions. For example, we asked patients about the condition(s) of concern to them at the moment and about the importance of bone health in comparison with their other health conditions. We also asked how bone health recommendations might affect the management of these other conditions. The second interview focused on changes, if any, to patients' experiences with bone health and their other health conditions as well as any changes in medication regimens (see Table 2). • What changes, if any, has your fracture had on your overall health?
• For example, do you have any ongoing pain as a result? 2 What were you told about your bone health after your fracture?
• What do you understand about your bone health?
• Did you have any tests (e.g., a BMD test) for bone health? Describe. What did these tests tell you?
• What did the fracture clinic/your family doctor/your specialist say?
• What recommendations did you receive from the fracture clinic/your family doctor/your specialist?
• How does your bone health affect your life (e.g., mobility, personal care, participation in social and recreational activities)?
• Is your bone health a serious issue for you? Why/why not?
• How does your bone health condition make you feel? 3 We would like to know about your overall health. What other conditions are you being treated for? Tell me about them (if the participant has more than one condition, go through each condition) • Do you currently have any symptoms for [condition(s) mentioned]? Explain.
• Who have you seen for [condition(s) mentioned]?
• What has your family doctor or specialist told you about [condition(s) mentioned]?
• What motivates you to take care of [condition(s) mentioned]?
• What kinds of tests have you had for [condition(s) mentioned]?
• What did these tests tell you?
• • Tell me about any supplements/medications that you are taking?
• What else are you doing to look after [condition(s) mentioned], for example, exercises?
• How often do you forget to follow recommendations for your [condition(s) mentioned]?
• What makes it easy/difficult for you to follow these recommendations for [condition(s) mentioned]?
• Do your other medications/conditions affect your ability to include bone health in your daily routine? Why/why not?
• What would make bone health more or less serious in relation to your [condition(s) mentioned]?

Second interview
1 Tell me about your fracture since I last interviewed you.
• How is your fracture now?
• • How have these changes impacted your general health?
• Do you anticipate that these changes will impact your general health?
In phenomenological studies, the outcome is a description of the essence, or structure, of what is perceived and experienced across individuals. 44 Iterative analyses of the data began after the first two baseline interviews were conducted. Preliminary codes were identified and then revised as more interviews were conducted. Two individuals (J. E. M. S., L. F.) with qualitative expertise analysed the transcripts independently and met regularly to develop and finalize a coding template, which was then applied to all transcripts using NVivo. 53 To promote a comprehensive examination of the data, 54 all transcripts were coded by the two coders. The analysis was guided by Giorgi's procedures. 43 To organize the data, meaning units, or codes, were documented in the margins, and codes relevant to our objectives were grouped together. We reflected on the relationships among the codes and developed themes that were supported by direct quotations from participants. 55 Discussions regarding analysis and interpretation of the data were reviewed by the study team as data collection and analysis progressed. Multiple thematic possibilities were considered by the team (a critical appraisal strategy referred to as imaginative variation 44,45 ) and a consensus was sought on the final themes based on the relevance, 56 novelty and clinical significance of the findings. Cases that did not fit with our general findings were discussed and reported to promote transparency in the research process. 57 Consistent with GRIPP2-SF, 58 a public contributor was a formal part of the research team from the beginning of the study. He was involved in the grant-writing process, which included the drafting of the interview guide and refining the focus of the research questions.
Along with all team members, this individual was involved in discussions about the data and the findings reported (see Table 3).

| RESULTS
We recruited 26 patients ( • Have your other health conditions impacted your ability to implement these new changes or recommendations? Explain.
• What has made it difficult for you to make these changes?
3 <If no changes in bone health/bone health recommendations/ actions regarding bone health>Tell me about what is going on with your bone health these days?
• What is your understanding of it?
• What are you doing about your bone health? 4 Have there been any changes in your [other condition(s) mentioned in the previous interview] since [date of the last interview]?
• Tell me about it/them.
• Have you had any new tests related to this/these conditions? If so, what did the test results say?
• What are you currently doing about this/these conditions?
• Have you been hospitalized for any of these conditions? Please explain.
• • Tell me about it/them?
• Have you had any tests related to these conditions? If so, what did the test results say?
• What has your family doctor or specialist told you about this condition(s)?
• What are you doing for this/these new health condition(s)? For example, are you taking any new medications?
• How easy or difficult has it been to incorporate this new condition, and treatment for it, into your daily life?
• Has this condition(s) caused you to make any general changes in your life?
• How do you feel about your bone health in light of your new condition(s)?
• How important is [all current and new conditions mentioned] compared to your bone health? Why?
depression or chronic pain reported giving up physical and social activities due to these conditions.
Two themes were consistent, based on our analysis: (1) depression and chronic nonfracture pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain. We did not observe any differences between men and women, or in participants having different comorbidities or other characteristics, related to these two themes.

| Depression and chronic nonfracture pain overshadowed attention to bone health
Participants reported experiencing depression and/or chronic nonfracture pain for 15 years or longer. These conditions were described as allconsuming and they were prioritized over bone health (see Table 4).

| Depression was more important than bone health
Participants talked about their depression as being more important than their bone health. In fact, many participants reported they could only take care of other health conditions, including bone health, when T A B L E 3 Patient and public involvement in the study using GRIPP2-SF Aim We sought to examine: (1) the experience of depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and chronic pain.

Methods
We recruited one public contributor to the research team from the beginning of the study. The public contributor was involved in the grant-writing process, which included drafting the interview guide and refining the focus of the research questions. This individual was involved in the analysis and interpretation of the deidentified data. He participated in edits to the final paper and is a coauthor.

Study results
The public contributor assessed the relevance of the findings and helped the team to develop the themes reported.
Discussion and conclusions By participating in the study from its inception (writing the grant), the public contributor helped shape the research questions and the topic areas in the interview guide. There were limitations to the public contributor's participation. Due to research ethical concerns, this individual did not have access to the transcripts and could only comment on the deidentified data presented by the analysts.
Reflections/critical perspective The public contributor has worked with our research team since 2010. The team's relationship with the public contributor has strengthened over the years, highlighting the importance of sustaining long-term collaborations with public contributors. The public contributor was not trained in qualitative research, so could not comment on the methodological aspects of the study.

| The fracture exacerbated reported experiences of existing depression and chronic pain
Most participants described their recent fracture as exacerbating their existing depression and/or chronic pain (see Table 5). Participants talked about how the recent fracture affected their depression. Participant #4 reported that the fracture worsened her The stiffness of arthritis is one of the biggest, biggest problems. When you get up in the morning, it takes you five minutes to just stand up and walk from the bed to the bathroom because you're just so, so stiff…we were walkers…and I'm just not able to do that. So for me, [the rheumatoid arthritis pain] is a priority because it has impacted on our quality of life that way' (Female, 71 years old)

22
'I'm not going to worry about diet and bone health right now…I'm trying…to get the whole gastrointestinal system, right down to the bowel, under control before I start experimenting with diets for other aspects of my health' (Male, 62 years old)

23
'I would say pain is my biggest enemy because I have had so much of it for so many years…I think the osteoporosis is being looked after…. but the pain of the arthritis is hard to get away from' (Female, 80 years old) SALE ET AL.

| DISCUSSION
In our study of patients with a fragility fracture and other health conditions, most patients reported depression or chronic nonfracture pain and several lived with both depression and chronic pain. These two conditions were considered to be all-consuming and were prioritized over bone health. Patients also indicated that the fragility fracture had worsened their depression and chronic pain. Our results overall suggest that depression and chronic pain are often present in the setting of fragility fracture, that they have important consequences, and that they may be under-recognized and undertreated, especially chronic pain.
Our qualitative study was not designed to assess prevalence, and may have inadvertently selected for individuals at risk for mental health conditions (to be eligible, participants had to report one or more comorbidities in addition to compromised bone health).
Nevertheless, the high proportion of patients in our study reporting depression is worrisome because depression has been associated with poor adherence to osteoporosis medication 32 and increased falls. 59 The experience of sustaining a fracture has been documented to precede depression, 5,6 so it is not surprising that existing depression may be exacerbated by the fracture. However, our results suggest that the potential implications of these relationships may be Older adults with chronic pain often alter or reduce their social and physical activities in some way to avoid pain. 60 This is a rational response to prevent further pain but it might paradoxically result in deconditioning and social isolation. 60 A reduction in physical activity has implications for postfracture recovery, which often involves physiotherapy exercises. As demonstrated by our findings, social isolation may also aggravate existing depression. Various safe medication treatments exist for chronic pain in older adults but less than one-half of patients with chronic pain in our study reported taking medication for their pain. This is perhaps not surprising, given that older adults are reluctant to take pain medication for conditions such as osteoarthritis, and when they do, they take the pain medication at a lower dose or frequency than prescribed. 61 We did not ask participants if they had declined offers of pain medication or if they had not been offered medication for their chronic pain so cannot comment on why less than one-half reported taking medication for their pain.
Future studies are needed to examine in detail changes in pain and pain medication. Chronic pain is not easily treated and treatments may be- The main limitation of our study is that the downstream effects of the fragility fracture on depression and pain remain unclear as we did not follow patients for longer than 1 year. We did not collect information on adherence to bone health recommendations so cannot comment on whether pain and depression affected the uptake of these recommendations. We also did not collect information on body mass index so cannot comment on the link between it and bone health. Further, we did not ask whether patients were depressed or had chronic pain before previous fragility fractures. A diagnosis of depression and chronic pain was based on self-report. We did not measure depression (or depressive symptoms) or pain and we did not determine the course of symptoms so cannot comment on the severity of these conditions. However, the reported prescriptions for medication in patients with depression and chronic pain suggest these conditions were diagnosed by a health care provider and the quotes we have provided demonstrate the apparent impact of these conditions. We conclude that these quotations support the findings and promote that the study maintains a patient perspective.
Another strength of our study was the use of a phenomenological approach, which was well-suited to our objectives to collect data on patient's experiences. Finally, two independent qualitative researchers coded and analysed the data and we drew on the expertise of the research team, some of whom have previously