Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: A qualitative analysis

Background: Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders’ perspectives regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care. Methods: This single-center, qualitative study was conducted within the orthopedic department of a tertiary care center. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders’ interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention. Results: Patients included 30 adults out of 85 approached (mean (SD) age 59 (14) years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during nonbusiness hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person mental health support into orthopedic care. Conclusions: Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients. Trial registration: Not applicable.


Background
Depressive and anxious symptoms negatively impact physical function and recovery after a wide variety of orthopedic procedures (1)(2)(3)(4)(5)(6)(7). Furthermore, there is a continuing shift in the United States to allow for innovative nancial structures to facilitate clinicians, regardless of specialty, to address patients' wholeperson health (8, 9). As a result, orthopedic clinicians are increasingly motivated to offer mental health resources to their patients as part of a comprehensive musculoskeletal treatment plan (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). Mental health interventions can be delivered via a variety of modalities such as digital, printed, and/or in-person, and a knowledge gap remains in identifying which modalities are simultaneously: 1) feasible for orthopedic teams to deliver e ciently, 2) acceptable to patients and clinicians, and 3) scalable to deliver across diverse orthopedic practice models. Furthermore, it is essential to understand unique factors that in uence whether orthopedic patients and clinical teams are willing to contribute to clinical trials to identify the most effective mental health interventions that are suitable to deliver in an orthopedic setting.
The primary purpose of this study was to understand orthopedic patients' and clinical team members' perspectives regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of musculoskeletal care. A second purpose was to understand these stakeholders' perspectives regarding the feasibility and acceptability of participating in mental health related research trials in the context of musculoskeletal care.

Methods
This single-site qualitative study was approved by the Washington University IRB. Participants gave written or verbal consent, and they received a $40 stipend for participating. Participants were enrolled between January and May 2022, and data analysis was completed in September 2022.

Participants
Participants from two stakeholder groups were recruited. The rst group consisted of adult (18 years or older) patients who presented to a Washington University orthopedic specialist for treatment of ≥ 3 months of neck or back pain. This population was chosen because among patients who seek care for a musculoskeletal condition, people with chronic neck or back pain have a particularly high comorbid prevalence of depression and anxiety (24)(25)(26)(27). Potential participants were identi ed by pre-screening orthopedic clinic schedules, and patients were purposively sampled to include: 1) adults across the age spectrum, 2) at least 50% of participants who self-identi ed as a woman and 25% who self-identi ed with a racial/ethnic minority group, and 3) patients who reported no, mild, and severe symptoms of depression and/or anxiety on the clinic's standard care Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) Depression and Anxiety measures (28)(29)(30). The study was introduced to patients via a pre-visit phone call or in-person at their visit.
The second participant group consisted of Washington University orthopedic clinical team members including clinicians and support staff. Purposive sampling was used to ensure the group included: 1) clinicians from all adult orthopedic subspecialties, 2) early, mid, and late career physicians, 3) operative and non-operative specialists, 4) members of all clinical support roles present in the clinic (i.e., nurses and medical assistants), and 5) team members who self-identi ed as women and with racial/ethnic minority groups. The study was introduced to team members via e-mail.

Interviews
After completing a demographic survey (31,32), stakeholders participated in a one-on-one, approximately 30-minute interview. Interviews with patient stakeholders were conducted by a research coordinator with formal qualitative research training who has worked with orthopedic patients for 18 years (MAA). Interviews with clinical team members were conducted by a medical student with masters-level training in qualitative research (AJL). The lead researcher, who is a sports medicine physiatrist and manages chronic spine conditions (ALC), also participated in the initial interviews. All interviewers were overseen by a researcher with extensive qualitative methods experience (JA). Interviews were audio and video recorded and were conducted in person or via secure video conferencing technology, per the participant's preference.
The interviews were informed by semi-structured interview guides that were drafted by the lead researcher (ALC) and then revised based on feedback from research team members including orthopedic surgeons and qualitative researchers (RPC, CJD, JA) (Additional le 1). The guides were pilot tested prior to the stakeholder interviews and were iteratively revised based on participant responses during the interviews.
All stakeholders were asked to describe their preferences and perceptions of feasibility, acceptability, and usability regarding modality options for mental health interventions that could/should be offered in the context of orthopedic care. They were speci cally asked to at least comment on digital, printed, and inperson options. They also provided feedback regarding speci c examples of one digital and one printed intervention. The digital intervention, called Wysa for Chronic Pain, is an evidence-based mental health app that addresses the interplay between mental health and chronic pain (12,13,33). It is a multi-component intervention that delivers cognitive behavioral therapy, mindfulness training, and sleep tools (e.g., meditations, sleep hygiene education) via a digital chatbot and real-time, text-based communication with human counselors. The printed intervention is a mental health resource guide developed by the research team. It was designed to maximize usability for older adults and people with limited literacy, and it was iteratively re ned from stakeholder feedback provided during this study. The nal guide is two double-sided pages and is titled, "Wellness Resource Guide." The guide uses icons to assist users in quickly identifying resources which are in person, virtual/online, free, reduced cost, and/or a crisis hotline. Resources mirror the tools offered by Wysa for Chronic Pain, and some are intentionally inclusive and welcoming of people from diverse backgrounds. Each resource is accompanied by a brief description, physical and online contact information, and a QR code that links users to the resource's primary online information site.
Patient stakeholders also completed usability testing for these digital and printed interventions. For the digital intervention, they were asked to complete onboarding and schedule a session with a counselor. For the printed intervention, they were asked to demonstrate how to engage with a resource on the guide which appealed to them. They provided qualitative feedback and rated each intervention on the System Usability Scale (SUS), which is scored 0-100 with higher scores being favorable and scores above 80.3 interpreted as receiving an "A" (34,35). Finally, all stakeholders described factors which would in uence whether they would contribute to a randomized controlled trial related to a mental health intervention introduced during musculoskeletal care.

Data Analysis
A preliminary codebook was developed by the lead researcher (ALC) using a deductive coding approach based on the dimensions of feasibility, acceptability, and usability. Next, using inductive coding, the codebook was re ned and nalized by two team members (ALC and MAA (patient interviews), or ALC and AJL (clinical team interviews)) after they reviewed a sample of interview transcripts. All transcripts were independently coded by those two team members. Participant recruitment continued from each stakeholder group until thematic saturation was reached. Coding was completed with NVivo 12 software (QSR International; Doncaster, Australia). Group discussion was used to resolve coding discrepancies and organize codes into nal themes.

Digital mental health intervention
Clinical team members perceived delivery of a digital mental health intervention to be feasible and appealing (Table 3). They especially expressed optimism that if patients experience improved mental health and ability to cope with pain, they may not rely as heavily on the clinical team to address these challenges, which many team members did not feel well-equipped to manage. However, team members and patients also voiced possible implementation challenges, including out-of-pocket costs for patients and the concern for medicolegal liabilities and non-orthopedic responsibilities out of the scope of practice for team members. The digital modality was largely acceptable to patients, but patient-reported interest varied based on their self-described tech-savviness and whether, at any given time, they felt a need for intervention and perceived bene t from using it. To be an acceptable intervention, orthopedic clinicians often expressed a need to rst be presented rigorous evidence of effectiveness. For successful implementation, patients and team members also recommended: 1) providing patients with a printed "Getting started" informational handout, 2) offering a telephone support line to assist patients with app onboarding if needed (rather than relying on the clinical team for assistance), and 3) developing clear medicolegal policies and support paths which ensure orthopedic team members understand and work within their certi ed scope of practice. Patients scored the digital intervention with a median SUS score of 81.3, IQR 61.3-95.0, range 0-100 (n = 30). They demonstrated varied pro ciency in navigating the intervention, and although not uniformly true, older patients frequently had more di culty than younger patients with independently completing usability tasks. The most common usability barrier was that iOS (Apple iPhone) users often could not recall their App Store password, which interfered with their ability to download the app (even though the download was free). Table 3 Themes regarding use of digital intervention to address mental health in the orthopedic care setting.

Theme
Representative quotes

Feasibility
Appealing: The ease of referring a patient to an app is appealing to orthopedic clinicians and clinical support staff, especially if the added resource reduces how much the patient needs to navigate mental health and pain challenges through the orthopedic o ce. Ideally, the app could be somewhat customized to the orthopedic patient population, even to the relevant body part or surgery (e.g., postoperative precautions, activity progression).
"I think an app like this would be amazing for a huge portion of the patients that we have." (Medical assistant) "I'm not saying to a patient, 'I'm treating your depression with this.' I'm telling the patient, 'This is a resource that we have, that we use as an option to help improve the patient's well-being.'" (Physician) "This, to me, would not be very di cult to discuss and just provide the information. Like, 'Here's an app. This is a platform you can use, and we highly recommend it. By no means do you have to use it.' I mean, it's a conversation piece. It's not like we've got to spend 30 minutes discussing this…And quite honestly, we spend a lot of time talking to patients about their pain and about how it's affecting their lifestyle. And it may even take some of that off of us because now they're using their app versus us." (Nurse) Persistent implementation concerns: Potential barriers to delivering a mental health app in the orthopedic care setting include: 1) out-ofpocket costs for patients, and 2) the concern for added medicolegal liabilities and responsibilities out of the scope of practice for orthopedic clinicians and team members.
"I'm on a xed income, so any increase in my healthcare cost, I've got to monitor pretty closely. I've seen people on social security who budget -they don't have an extra $5 to spare. "I think the app will be very helpful to have when it's late or when it's early morning and you're not getting any sleep or something." (Patient, 60-year-old White man) "For it to be here waiting for me, not having to try to navigate getting into a shrink and all of that nonsense with my primary -just any chance to introduce more mental healthcare, I think is good, honestly." (Patient, 44-year-old White man) Theme Representative quotes Tech savviness dependent: Orthopedic patients, clinicians, and clinical support staff agreed that digital interventions such as smartphone apps are preferred by many patients. They tend to be more preferred by young and middle-aged adults and less appealing to patients who are not "tech savvy," including many (but not all) older adults. Estimates for the proportion of clinicians' patient populations who might be interested in a digital intervention ranged from 5-70% and clustered around 20-25%.
" [Patients] are on their phones a lot more. Everything's going to their phones. Even when they're in pain or if they're miserable or something, their phones are a lot more accessible than a laptop or a piece of paper. I give them a whole packet and they'll say, 'I know you gave me some stuff and I wrote it down somewhere, but I don't know where I put it.'" (Medical assistant) "We have an online database for a particular surgery that we do, and I think 30% of my patients request paper surveys. Which is insanely high. For every other person in my division, it's like 5-15%. So, it just tends to be my geographic location, I think, because it's a lot of people from rural areas. They maybe don't really like using their smartphone, so it's a challenge. I think it's going to be less of a challenge, and there are more and more elderly people that are used to these things, but that's going to be your toughest population to hit with any kind of digital intervention -the elderly." (Physician) "I would give it a shot because, like I say, we're getting older, and we need to know how to mentally deal with our aches and pains. We really do. Evidence dependent: Before recommending a mental health app to patients, orthopedic clinicians want details on the content and delivery of the actual intervention, and they want to be reassured of the quality of the intervention and how patients will perceive it.
There is some concern regarding reliance on a chatbot to deliver an intervention.
"The big question that I would have is, 'How does this compare to seeing a 'real person'?'' But this is presumably going to be better than nothing." (Physician) "I feel like people still want to talk to people. I think having a licensed provider on the other end to chat with them is better than a bot." (Physician) Theme Representative quotes Facilitators for implementation: Facilitators reported by orthopedic patients and clinicians for delivering a mental health app to orthopedic patients include: 1) a printed informational "Getting started" handout for patients, 2) centralized phone support to assist patients in onboarding to the app, and 3) clear liability policies and a support path which does not lter mental health related questions or crises to the orthopedic clinician.
"It's not like [our staff] are going to go through it and help put the app on the patient's phone and go through that. Anything extensive like that might be like, 'Oh gosh, we don't have time to set it all up and to actually get them going with it and that type of thing.' So yeah, I think being able to have a printed 'How-to' thing -to give that to them would be, I think, helpful." (Nurse practitioner) As an older person, I learn more through visuals. I'm nding that if I hear and see it, I can retain it better. If somebody talks to me and tells me how to get through the app, then that would be better for me. The verbal, as well as the instructional handout, would be great." (Patient, 71-year-old Black woman) "I'm assuming there's a back-end to this app with someone monitoring it…We're treating the patient and they're putting information out there that we're not receiving or monitoring. And what happens if this app captures a problem?" (Physician)

Usability
Varied pro ciency: Although not universally true, some older and even middle-aged orthopedic patients expressed interest in using the app but had more di culty than they anticipated navigating through the app. In contrast, some patients had no di culty at all navigating to tools within the app, although these patients tended to be younger.
"It seemed pretty self-explanatory….Nothing was confusing." When asked to schedule a session with the human coach: "I wouldn't know how to get to that… I'm not sure how I got here, but I guess I just keep going back." (Patient, 78-year-old White woman) "It's actually pretty clear, pretty cut and dry, which is good." (Patient, 47-year-old Black woman) Password recall: The most common barrier to patients using the app was that many iOS (Apple iPhone) users could not remember their App Store password and therefore could not immediately download the app, even though the download was free.
"I think they want me to enter…my Apple ID? I think I will have to go home and check it." (Patient, 71-yearold Asian man) Printed mental health resource guide Compared to a digital intervention, team members expressed relatively greater feasibility to incorporate delivery of a printed mental health intervention into their existing clinic ow (Table 4). Patients and team members also expressed strong enthusiasm for a printed intervention to better meet the needs of patients who are generally not "tech users" and of patients who particularly prefer tangible resources for mental health related matters. To ensure acceptability and successful implementation of a printed intervention, some patients and team members suggested that the intervention be offered in a variety of methods during the orthopedic encounter (e.g., in the waiting room, on patients' online portals, directly from clinical teams, etc). However, many patients expressed they would be most likely to engage with a printed intervention if, as part of discharge instructions, a team member highlights the intervention components that are most recommended for them. Regarding usability, patients scored the printed resource guide similarly to the digital intervention, with a median SUS score of 87.5, IQR 65.6-92.5, range 45-100 (n = 30). Patients overwhelmingly perceived the nal guide to be easy to use, but they also suggested: 1) creating an electronic version with active URLs to listed resources, and 2) de-emphasizing QR codes on the paper version of the guide so patients who are not familiar with QR codes do not feel overwhelmed. Acceptability Sometimes preferred over a digital intervention: Orthopedic patients, clinicians, and clinical support staff agree that a printed resource option is more appealing than a digital intervention for some patients. The printed intervention was especially appealing to orthopedic patients who: 1) are not frequent mobile device users, 2) prefer "tangible" information, and 3) prefer local, in-person support for mental health matters. Estimates for the proportion of clinicians' patient populations who might be interested in a printed intervention was similar to estimates for the digital intervention.
"Someone like me that is not used to just looking at their smartphone or their iPad for everything -they might prefer [this guide] to the app." (Patient 78-year-old White woman) "Some people just like paper. In-person mental health support Although orthopedic patients and team members perceived that in-person mental health support would be the ideal intervention modality for some patients (e.g., with more severe psychological distress and/or a preference for in-person intervention), many team members expressed skepticism regarding the current nancial and logistical feasibility of providing in-person support as part of musculoskeletal care (Table 5). If feasibility could be achieved, clinicians expressed various acceptable implementation options, such as: 1) incorporation of an in-person social worker into orthopedic clinics, or 2) preferred referral-based access to mental health clinicians who offer affordable, prompt appointment availability for patients referred from the orthopedic teams. The ideal method of incorporating in-person support was felt to vary depending on the patient population. Team members who more frequently manage chronic, life-changing (e.g., major traumatic or oncologic), and/or spine conditions expressed more interest in incorporating a mental health clinical team member into the orthopedic clinic (rather than relying on expedited referrals). Table 5 Themes regarding incorporation of in-person support to address mental health in the orthopedic care setting.

Theme
Representative quotes Feasibility Skepticism: Many orthopedic clinicians questioned the nancial and logistical feasibility of in-person support from a mental health specialist within the orthopedic clinical environment.
"I think [a counselor or social worker] would be very helpful, but I don't see it happening in this day and age in healthcare." (Physician) "I don't think there are enough patients, at least in my practice, to make it work out." (Physician) Acceptability Ideal for some patients: Orthopedic clinicians, clinical support staff, and patients expressed that a subset of patients require and prefer one-on-one in-person mental health support.
"I think in-person options are going to be the key. "For a lot of patients, I've told them that they need to see or try to nd a psychiatrist, but they always have trouble nding one." (Physician) "I think it would be awesome to have a therapist that will come in and speak to you for maybe ve, ten minutes that can give pointers, things that you can do to help, say, if a person needs it. Considerations for various care models: Orthopedic clinicians proposed various models to integrate inperson mental health support into the orthopedic care plan. Compared to orthopedic teams that care for relatively acute and correctable conditions, clinicians and support staff who predominantly care for patients with chronic conditions, spine conditions, and/or life-altering (e.g., major traumatic or oncologic) conditions more frequently expressed that a departmental social worker or counselor would be an important resource, as opposed to referral to an outside resource.
"There are a couple applications for social workers that I think would be helpful. One would be mental health counseling. The other is for patients that are uninsured or underinsured to give them resources and help with things. So, I think there's utility for multiple roles that someone like a social worker can play, and I think that would be very bene cial. It can be one [social worker] at each clinical location. We're not asking them to take on all of our patients. It's a subset for sure." (Physician) "Just a list of names of people that maybe we have a relationship with -a psychiatrist that maybe we can refer them to would be nice. Maybe forming some relationships with some psychiatrists. I think that, and then maybe some psychologists, as well." (Physician) "I think it depends on the clinic. I mean, maybe in some ways you could consider having a 'complex patient' clinic and have more resources available there. Have longer appointment times, more resources available -like a psychologist or psychiatrist -at those visits." (Physician)

Research considerations
Orthopedic patients and team members expressed overall feasibility and acceptability of conducting randomized controlled trials of mental health interventions delivered in the orthopedic clinic setting (Table 6). Although team members agreed that a brief introduction of the study by a clinical team member would increase patient recruitment for the study, clinicians expressed variable amounts of time (from none to essentially as much as needed) that they and their team members would be interested in and able to contribute. Patients generally expressed interest in participation in order to help other people and to access free, potentially helpful resources for themselves. Patients anticipated that barriers to sustained study participation could include: 1) episodes of reduced motivation and engagement with daily activities due to depressive and/or anxious symptoms, and 2) excessive study-related burden. Most patients expressed willingness to be randomized, although many patients also expressed a preference for one intervention over the other (e.g., digital or printed). Offering all study interventions to each patient by the end of the study increased patients' enthusiasm for participating in a randomized trial. "I think just the presentationhaving them feel accepted and that this is really looking at an overall perspective for health and wellness…that we're on their side and they're not feeling, I guess, judged or bad. Taking a more positive approach to it. I think that delivery would be helpful for them to accept it." (Nurse practitioner) "If it were a lot of time or a lot of effort for anyone, they would not be okay with it." (Physician) Patient barriers to participation: Patients reported the following anticipated barriers to participation: 1) worsening of mental health such that the patient loses motivation and energy to participate in typical daily activities, or 2) excessive burden from the study. Acceptability of randomization: Generally, orthopedic clinicians believe patients would be willing to participate and be randomized to one of a variety of mental health interventions. While most patients expressed willingness to be randomized, many also expressed a preference for one intervention over the other (e.g., digital or printed). Offering all interventions by the end of the study period increased the appeal to many patients.
"I think patients are less likely to participate and be randomized into interventions where they have a vested interest and a clear prejudice for a certain outcome… Trying to get somebody to commit to a randomization for surgery is very di cult because they may have strong feelings, but for this, I don't think that they're going to feel strongly about it." (Physician) "To me, either one would be okay." (Patient, 71-year-old Black woman)

Discussion
In this study, we found that digital and printed modalities are both anticipated to be feasible and acceptable methods of delivering mental health intervention in the context of musculoskeletal care.
Although implementation considerations slightly favored the printed modality, available evidence of intervention effectiveness currently favors the digital modality (36-38). Therefore, we anticipate that digital intervention can play a key role in facilitating delivery of mental health related therapeutic content to orthopedic patients, especially for patients who are younger and/or consider themselves to be pro cient with and enjoy using mobile apps. At this time, also offering a printed intervention will likely be key to feasibly delivering content to a subset of often underserved patients, including many older patients, patients from rural communities with limited internet access, and those who cannot independently navigate mobile devices. Despite the feasibility challenges related to facilitating in-person mental health intervention, innovation and dissemination of successful models regarding care delivery to make this option possible will likely be most important for patients who are experiencing the most severe symptoms of depression, anxiety, and related impairment.
It is encouraging that orthopedic team members reported positive perceptions regarding the feasibility and acceptability of a digital intervention because: 1) this modality can provide at-home access to mental health tools when a patient's mobility is limited due to a musculoskeletal condition, 2) there is growing evidence of effectiveness of digital mental health interventions, sometimes comparable to in-person mental health intervention (39,40), and 3) there is increasing momentum for third party payers to subsidize digital interventions. Although some clinicians voiced medicolegal concerns related to offering a digital mental health intervention, the COVID-19 pandemic has accelerated the national push to facilitate seamless prescription of effective digital therapeutics, and we anticipate these concerns will lessen as clarity from governing bodies is achieved (41-44). As these system-level considerations are addressed, incorporating an evidence-based digital mental health intervention into orthopedic care has the potential to meaningfully contribute to the treatment plan for a substantial subset of orthopedic patients. However, a "digital divide" still exists, and offering only a digital intervention will not yet be an equitable solution. Many patients who are already at increased risk of poor outcomes, such as older adults and people from rural locations with less internet access, are those who are least likely to successfully engage with a digital mental health intervention (45,46).
Although patients and team members expressed somewhat favorable feasibility and equity of a printed intervention compared to a digital intervention, there is currently weaker evidence regarding the clinical effectiveness of printed mental health interventions. So far, self-guided interventions have achieved small, yet still signi cant mean effects on mental health symptoms (meta-analysis d = 0.23, Number Needed to Treat (NNT) of 6.4) (38, 47). A subset of people have demonstrated high engagement with self-guided interventions, and low-intensity resource referral interventions have been shown to improve awareness and use of existing community resources (48). Given the feedback from our stakeholders, we hypothesize that offering a well-designed printed resource referral intervention to the subset of orthopedic patients who voice a preference for a printed rather than a digital intervention could: 1) improve the previously identi ed NNT, and 2) improve quality of life for this subset of patients, relative to what they would have achieved if they were offered an intervention with which they would not be able to engage at all (49).
Although our stakeholders also strongly favored the option of in-person, one-on-one mental health support for some patients, perceived nancial and logistical barriers still substantially tamper enthusiasm for current feasibility. Orthopedic practices could circumvent clinic-facing nancial barriers to in-person mental health support by developing a "preferred access" referral list to mental health clinicians in the community. However, due to restrictive third party payer policies and the nationwide shortage of mental health clinicians, patients would still face the same nancial and wait-time barriers to accessing care that they currently face when independently seeking mental health support (50)(51)(52). One-on-one telehealth psychotherapy could be considered an alternative "in-person" support option. However, telehealth does not necessarily address the "digital divide" barrier, patient-facing nancial barriers, or the widespread shortage of mental health clinicians. Telephone based support is another alternative modality that preserves the "human connection," but this modality has not been well-received by subpopulations of orthopedic patients (16).

Limitations
A limitation of this study is that all stakeholders were recruited from a single institution in a single metropolitan region. Therefore, some of the mental health resources listed on the printed intervention that we tested may not be available elsewhere, although many of the included resources are widely available virtually. Similarly, the feasibility of incorporating in-person mental health support will somewhat vary based on regional resources, although the shortage of mental health clinicians is a widespread problem nationally and globally (50)(51)(52). Also of note, all patients in this study presented for treatment of chronic neck or back pain. External validity of our patient-related ndings needs to be assessed in other orthopedic patient populations who may have unique sociodemographic distributions and patterns of mobile device use (e.g., major orthopedic trauma, sports medicine, etc).
ALC supervised all aspects of the study's conduct. ALC, RPC, CJD, and JA conceived of the study design.
ALC, AJL, and MAA acquired and analyzed the data. ALC and AJL drafted the manuscript. All authors interpreted the data and critically revised the manuscript and approved the nal manuscript.