Recently, a friend had outpatient surgery. Once home, he was surprised that he burst into tears. Luckily, this was transient; but that’s not always the case.
Over the years, I’ve worked with patients and family caregivers to co-design resources for surgery, and one story repeated: even when people were looking forward to something like a joint replacement so they could be more active again, they were often confounded to find themselves depressed in the days, weeks, and even months after surgery.
As one woman explained, “I was relieved to finally have a hysterectomy and stop bleeding. I definitely didn’t want to have more kids. But after surgery, I was seriously depressed. I even had suicidal thoughts. I couldn’t understand why. But I felt like I was going crazy.”
People expect pain and other challenges during recovery, but for those who also experience depression, not knowing this can happen creates confusion, embarrassment, and isolation. And it makes it much more difficult to participate in the recovery process.
Both patients and their care partners don’t realize how common post-op depression is, Or, in the case of something like an implantable defibrillator, that it’s common to experience new, persistent anxiety or PTSD. While the device is meant to protect people from sudden cardiac death by shocking the heart, having a device in your body that can deliver a shock can be profound. In fact, some studies note younger people, especially those who haven’t had a near-death experience due to heart issue may be more likely to have anxiety for a year or longer. [1, 2]
However, depression has been documented after many procedures: coronary artery bypass graft, joint replacement, and bariatric, brain, and colon surgery. While it may be more common after certain procedures, there’s a risk with any surgery. And getting comfortable with identifying and addressing it can only improve patient experiences, engagement and outcomes.
People often don’t think about it, but their body has been through a trauma — even if it’s a planned and expected trauma. Plus, there are the effects of anesthesia, a post-op let-down effect, opioids, poor sleep, and pre-existing depression or anxiety that may become worse.
Unfortunately, not knowing depression can occur makes it less likely people will recognize what’s going on and reach out for help.This makes it difficult for them to participate in their recovery and rehab. It lowers their threshold for pain. It can create a pain-depression feedback loop. And it increases morbidity and mortality. [3, 4]
Prevention and Post-op Checks
Studies recommend screening everyone for depression before procedures. This could also be used as an opportunity to broach the topic and normalize it. [5] We also need to educate patients and family caregivers about post-op depression so they can recognize it, report it, and put it in perspective.
And it helps to make sure people understand what happens during surgery and set realistic expectations about recovery. Knowing what to expect gives people a sense of control. And helps them understand what their body will go through. Plus knowing instead of guessing what will happen can help reduce anxiety. And less anxiety before surgery may mean less anxiety afterward.
There are also simple ways to check for depression during follow-up visits and calls, or through chatbots and interactive voice response phone calls. Many people are more comfortable disclosing things like depression or anxiety when they see those questions as a normal part of care. And people often feel safer honestly disclosing this type of information in a virtual setting, like an automated call or text, where they don’t feel judged by another human.
Family Caregivers also get depressed and overwhelmed
It’s also essential to make sure family caregivers and care partners are doing okay. Our health system increasingly relies on family caregivers to help patients take meds, change bandages, do any physical therapy, and move through recovery or deal with new diagnoses and care plans.
When working with a team to create a hospital-to-home transition program for heart failure, we found it was important to include a monthly screener to see if the family caregiver felt depressed or overwhelmed. When the pilot team got that data, they said: this is the first time we’ve been able to know a care partner was depressed and act on it. A simple call to check in with them seemed to go a long way. And in other cases they were able to help arrange respite or additional in-home help.
We know people can only participate in their recovery or care for a family member when they have energy. Unfortunately, depression robs people of the energy to engage. It’s hard to do physical therapy exercises if the weight of depression makes it hard to get out of bed. So, including this as part of patient and family education can help people identify it, de-stigmatize it, and get help.
1. Bostwick JM, Sola CL. An updated review of implantable cardioverter/defibrillators, induced anxiety, and quality of life. Psychiatr Clin North Am. 2007 Dec;30(4):677-88. doi: 10.1016/j.psc.2007.07.002. PMID: 17938040.
2. Habibović M, Denollet J, Pedersen SS; on behalf of the WEBCARE investigators. Posttraumatic stress and anxiety in patients with an implantable cardioverter defibrillator: Trajectories and vulnerability factors. Pacing Clin Electrophysiol. 2017 Jul;40(7):817-823. doi: 10.1111/pace.13090. Epub 2017 Jun 1. PMID: 28432794.
3. Guerini F, Morghen S, Lucchi E, Bellelli G, Trabucchi M. Depressive symptoms and one year mortality among elderly patients discharged from a rehabilitation ward after orthopaedic surgery of the lower limbs. Behav Neurol. 2010;23:117–21. doi: 10.1155/2010/365341. [PMC free article][PubMed]
4. Thombs BD, de Jonge P, Coyne JC, Whooley MA, Frasure-Smith N, Mitchell AJ, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA. 2008;300:2161–71. doi: 10.1001/jama.2008.667.
5. Ghoneim, M. M., & O’Hara, M. W. (2016). Depression and postoperative complications: an overview. BMC surgery, 16, 5. doi:10.1186/s12893-016-0120-y
Excellent advice, Geri. Both the idea of normalizing some level of post-op depression as a normal part of recovery for many people, but also the idea of checking in with a patient’s personal caregivers to make sure that they, too, are not suffering from depression and/or burn-out. I know my dad struggled a lot, as my mom’s illness got worse and worse. Trying to find support and intervention for him took some doing.