When a patient walks into an orthopedic spine clinic, most providers are focused on one thing: the back. But after over a decade of caring for patients with chronic pain, I noticed something deeper lurking behind the disc herniation and spinal stenosis: depression. And it was not being addressed.

That is why I launched a quality-improvement (QI) project focused on integrating depression screening into the routine evaluation of orthopedic spine patients. What I found was both alarming and enlightening, and it revealed a path toward better, more complete care.

Chronic back pain does not just impair movement; it impacts mood, energy, sleep, and even hope. And yet, depression is rarely screened for in orthopedic settings. According to recent studies, as many as forty percent of spine patients may have undiagnosed depression, which can worsen surgical outcomes, slow recovery, and lead to prolonged opioid use.

Still, in many specialty clinics, depression is not on the radar. There is a perceived divide between mental health and musculoskeletal care, a divide that is costing lives.

In an outpatient spine clinic, I implemented the PHQ-9 depression screening tool as a standard part of intake for new patients. My goal was simple: Catch depression early, and intervene before it complicates recovery.

But change in a busy clinical environment is not easy. So I used Kotter’s Change Model and the Plan-Do-Study-Act (PDSA) cycle to design and refine a sustainable process.

Here is what we did:

• Educated the team, from front desk staff to physical therapists, about the importance of depression screening.
• Integrated the PHQ-9 into our intake forms using Epic, making it easy for patients to complete before seeing the provider.
• Created a simple referral workflow: If a patient scored above ten, they were flagged for a mental-health consult or follow-up with their primary care provider.

Over a twelve-week period, our clinic saw a significant increase in depression screening rates, from zero percent baseline to eighty-two percent. More importantly, we identified multiple patients who would have otherwise gone untreated for depression.

Patients told us they felt seen, not just for their pain, but for their emotional well-being. Staff appreciated having a formal tool to guide sensitive conversations. And our providers felt more confident managing complex, chronic pain cases with a behavioral health component.

This is not just about one clinic or one screening tool. It is about shifting culture in specialty care. Depression and chronic pain are often intertwined, and we cannot keep treating them in silos.

Here is what we learned:

• Screening tools like PHQ-9 are simple, validated, and underused.
• With the right implementation strategy, even small clinics can adopt mental health screening without adding time or burden.
• Nurse practitioners are uniquely positioned to lead quality initiatives that cross traditional specialty lines.

The spine is not isolated from the brain. Depression screening should be as routine as taking a blood pressure or checking a reflex.

If you work in orthopedics, neurology, or pain management, consider this your invitation to screen for depression. Patients are often silently suffering, and your clinic could be the first to notice.

This project reinforced my passion for quality improvement and health equity. As a nurse practitioner and Doctor of Nursing Practice (DNP), I believe our profession must lead the way in integrating mental health across all specialties.

We cannot fix the spine without also supporting the spirit.

Shabeena Hirani is a board-certified nurse practitioner with extensive experience in internal medicine, pulmonology, and sleep medicine. A graduate of Quinnipiac University, she is affiliated with Catholic Health Physician Partners and currently practices at Queens Pulmonary Medical Services. Dr. Hirani is passionate about evidence-based care, quality improvement, and interdisciplinary collaboration. She has led initiatives in chronic disease management and mental health screening, and co-authored a peer-reviewed article on type 2 diabetes management in The Nurse Practitioner. Known for her patient-centered approach and dedication to mentoring, she works closely with health care professionals to improve outcomes and promote compassionate, holistic care.