Implementing Routine PHQ-2 Screening in POPS to Identify Persistent Low Mood Before and After Surgery

Abstract
Perioperative Care of Older People undergoing Surgery (POPS) clinics provide multidisciplinary optimisation for older adults with frailty undergoing surgery. While physical recovery following surgery is well documented, psychological outcomes are less consistently addressed within perioperative pathways. Analysis of patient-reported outcome measures (PROMs) from patients undergoing elective joint replacement identified a disparity between improvements in physical recovery and persistent low mood post-operatively. This quality improvement project aimed to identify gaps in psychological recovery and introduce structured depression screening within the POPS clinic to enable earlier recognition and intervention for low mood.

Methodology
PROM data were analysed from patients attending a POPS clinic for pre-operative assessment prior to elective joint replacement surgery at East Kent Hospitals University NHS Foundation Trust. Patients completed questionnaires before surgery and six months post-operatively assessing mobility, self-care, usual activities, pain, and anxiety/depression on a five-point scale. Ninety patients with complete paired responses were included, with a mean Rockwood Clinical Frailty Scale score of 4.

Pre- and post-operative scores were analysed using JASP to calculate mean changes, confidence intervals, and effect sizes. Findings informed a quality improvement intervention introducing routine depression screening using the PHQ-2 within the POPS clinic. The PHQ-2 is a brief validated screening tool assessing depressed mood and anhedonia over the preceding two weeks. Screening was embedded within clinic templates to allow real-time assessment and escalation where scores ≥3 triggered discussion, safety-netting, and signposting to primary care or psychological support. Uptake and feasibility were evaluated through a Plan–Do–Study–Act cycle reviewing consecutive clinic consultations.

Results
PROM analysis demonstrated significant improvements in physical and functional outcomes following surgery. The total PROM score excluding the anxiety/depression domain showed a moderate to large effect size (95% CI for Cohen’s d 0.514–0.994; p<0.001), indicating meaningful improvements in mobility, pain, and daily functioning.

In contrast, anxiety and depression scores showed no statistically significant change following surgery (95% CI −0.171 to 0.265; p=0.672), suggesting psychological wellbeing remained largely unchanged despite physical recovery. Baseline data showed a substantial burden of mood symptoms, with 39% of patients reporting moderate to extreme anxiety or depression pre-operatively.

Following implementation of the intervention, PHQ-2 screening was completed in 100% of POPS clinic consultations reviewed. Of those screened, 20% scored ≥3, prompting further discussion and signposting for psychological support or communication with primary care.

Conclusion
PROM data suggest that improvements in physical recovery following surgery in older adults with frailty do not necessarily translate into improvements in psychological wellbeing. Routine PHQ-2 screening within the POPS clinic proved feasible and achieved high uptake, enabling systematic identification of patients with possible depression and facilitating earlier intervention. Embedding structured mood screening within perioperative assessment may help address an important but under-recognised component of recovery in frail surgical patients and supports a more holistic POPS pathway