Causes and Effects of Postoperative Depression

Surgery and anesthesia can lead to feelings of vulnerability, fear, and instability, even when the procedure is successful or comparatively noninvasive. Though a procedure may be intended to better the patient’s quality of life, depression can undermine it by lowering quality of life and even compromising surgical outcomes [1]. Moreover, post-operative patients may experience physical pain and self-doubt during their recovery period, both of which can cause depression [2]. While some degree of emotional turmoil is unavoidable, attending to preoperative mental health can reduce symptoms of postoperative depression.  

Patients with preoperative mental health symptoms are most likely to develop postoperative depression. However, procedures can sometimes alleviate pre-existing psychological symptoms by reducing medical stressors [3]. Nickinson et al. found that 50% of patients who underwent orthopedic surgery developed symptoms of major depression after their procedures [3]. McKenzie et al. found that patients diagnosed with clinical depression prior to undergoing coronary artery bypass procedures were at greatest risk of developing postoperative depression, making it difficult for them to reap the quality-of-life benefits of their surgeries [4]. At the same time, surgical procedures, when successful, can sometimes reduce pre-existing depression symptoms by improving physical health. In a survey of urethroplasty patients, Schober, et al. found that over half of those with preoperative depression reported a reduction or total elimination of psychological symptoms following surgery [5]. 

Regardless of risk factors, postoperative depression can have devastating outcomes for those who develop it. Depression leads to higher mortality and morbidity rates in physically ill patients, in part because symptoms of major depression, such as low energy, can impair patients’ ability to cope with a demanding recovery regimen. According to Schober et al., the 10% of patients who developed new depression symptoms were more likely to experience suboptimal surgical outcomes [5]. Similarly, a study of patients undergoing common surgical procedures like hip replacements found that those with moderate anxiety or depression were 17 times more likely to experience wound complications. They were also more likely to be readmitted to the hospital as a result [8]. 

Preoperative and postoperative depression are linked to substance reliance and abuse: depressed patients in recovery are more likely to smoke and drink alcohol [6]. O’Connell et al. found, with an odds ratio of 1.28, that patients with preoperative depression undergoing lumbar fusion were at an increased risk of chronic opioid use after their procedures [7]. This may be because pain and depression tend to be mutually reinforcing, with pain often worsening depression symptoms and depression, in turn, lowering an individual’s pain threshold [6]. 

Postoperative depression is a common problem, but the risk factors behind it are complex. Pain and anxiety surrounding surgery can worsen symptoms for patients with existing clinical depression, making preoperative depression a key predictor. At the same time, some patients find that surgery, and the quality-of-life improvements that follow, actually reduce psychological stress. In order to ensure that recoveries are not negatively affected by psychological symptoms, Nickinson et al. suggest addressing this problem through both pre- and post-operative mental health surveys, while McKenzie et al. suggest interventions for those with preoperative depression. These methods can mitigate the effects of depression on postoperative outcome and, in some cases, prevent it. 

References 

[1]. Lauerman, J.F. “An ‘Understandable’ Complication: Coming to Terms with Postsurgical Depression.” Harvard Magazine. 1 July 2000. 

[2]. Chowdhury, S.. “Why Some People Get Depressed After Surgery—Even If They’ve Recovered Just Fine.” Health. 6 Feb. 2019. 

[3]. Nickinson, R.S.J., Board, T.N. and Kay, P.R. (2009), Post‐operative anxiety and depression levels in orthopaedic surgery: a study of 56 patients undergoing hip or knee arthroplasty. Journal of Evaluation in Clinical Practice. 15: 307-310. doi:10.1111/j.1365-2753.2008.01001.x 

[4]. McKenzie, L.H., Simpson, J., & Stewart, M. (2010) A systematic review of pre-operative predictors of post-operative depression and anxiety in individuals who have undergone coronary artery bypass graft surgery. Psychology, Health & Medicine, 15:1, 74-93, DOI: 10.1080/13548500903483486 

[5]. Schober J.P., Stensland K.D., Breyer B.N., et al. Effect of Urethroplasty on Anxiety and Depression. Journal of Urology. 2018;199(6):1552-1556. doi:10.1016/j.juro.2018.01.074 

[6]. Ghoneim, M.M., O’Hara, M.W. Depression and postoperative complications: an overview. BMC Surgery. 16, 5 (2016). https://doi.org/10.1186/s12893-016-0120-y 

[7]. O’Connell C., Azad T.D., Mittal V., et al. Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes. Neurosurgical Focus. 2018;44(1):E5. doi:10.3171/2017.10.FOCUS17563 

[8]. Britteon, P., Cullum, N. & Sutton, M. (2017), Association between psychological health and wound complications after surgery. British Journal of Surgery 104:769-776. doi:10.1002/bjs.10474