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Depression and the surgical patient

Glimpse of current and future literature

Ghoneim, Mohamed M.

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European Journal of Anaesthesiology (EJA): February 2015 - Volume 32 - Issue 2 - p 141
doi: 10.1097/EJA.0000000000000151
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Major depressive disorder or depression is a heterogeneous disease characterised by depressed moods, loss of interest and pleasure in normally enjoyable activities, loss of energy, difficulties in thinking and decision making, appetite and sleep disturbances, psychomotor disturbances and suicidal ideation.1 It is common in patients before and after major surgery, for example 47% of patients are depressed before cardiac surgery and this increases to 61% before discharge,2 and 25 to 50% of candidates for bariatric surgery are depressed.3 The disease may have significant effects in surgical patients, which fall under the jurisdiction of the anaesthetists as a peri-operative physician charged to achieve the best outcomes for the patients.

Depression prior to anaesthesia and surgery is significantly correlated with acute postoperative pain measurements and analgesic requirements4,5 which in turn are determiners of hospital stay and long-term outcome.6 Patients with chronic postoperative pain very commonly suffer from depression provoking worsening of both conditions.7 Depression is also an independent risk factor for postoperative delirium.8 About 28% of general ICU survivors suffer from depression.9 Also, there is an increase in surgical patients mortality.10

The above conclusions were driven mainly by relatively small studies which make chance findings more likely and prevent considering other possible contributing factors. They were mostly single-centre studies and are therefore subject to confounding, particularly when they are non-blinded, which was usually the case. It is not sufficient to simply demonstrate that poor clinical outcomes are more frequently associated with depression. A higher rate of psychiatric disorders in surgical than in non-surgical patients would suggest that anaesthesia and surgery contribute to the emergence of psychiatric morbidity. Unfortunately, such studies are uncommon. I am also not aware of direct evidence that screening before surgery and/or treatment of the disease lead to improved outcome of patients afterwards. Large multi-centre randomised controlled trials are needed for proof. To complicate matters more, peri-operative use of serotonin reuptake inhibitors which are used for treatment may contribute to adverse postoperative outcomes which include death, and similar other conditions.11 Future studies are also needed to determine whether they are patient factors or the drugs themselves (no new antidepressant has been developed in the last quarter century). Finally, it is interesting that risk-stratification tools for predicting morbidity and mortality ignore depression as a factor.12 I believe, together with others,13 that there is an urgent need for new and better tools to predict postoperative morbidity after major surgery, in addition to the call for better methodologies to investigate the interactions of depression with major surgery.

Acknowledgements relating to this article

Assistance with the letter: none.

Financial support and sponsorship: none.

Conflicts of interest: none.


1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed.Arlington, VA: American Psychiatric Publishing; 2013.
2. Burker EJ, Blumenthal JA, Feldman M, et al. Depression in male and female patients undergoing cardiac surgery. Br J Clin Psychol 1995; 34:119–128.
3. Wadden TA, Sarwer DB, Fabricatore AN, et al. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin N Am 2007; 91:451–469.
4. Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain 1986; 24:331–342.
5. De Cosmo G, Congedo E, Lai C, et al. Preoperative psychologic and demographic predictors of pain perception and tramadol consumption using intravenous patient-controlled analgesia. Clin J Pain 2008; 24:399–405.
6. Stundner O, Kirksy M, Chiu YL, et al. Demographics and perioperative outcome in patients with depression and anxiety undergoing total joint arthroplasty: a population based study. Psychosomatics 2013; 54:149–157.
7. Price DD. Psychological and neural mechanisms of the affective dimension of pain. Science 2000; 288:1769–1772.
8. Rudolph JL, Marcantonio ER. Postoperative delirium: acute change with long-term implications. Anesth Analg 2011; 112:1202–1211.
9. Davydow DS, Gifford JM, Desai SV, et al. Depression in general intensive care unit survivors: a systematic review. Intensive Care Med 2009; 35:796–809.
10. Abrams TE, Vaughan-Sarrazin M, Rosenthal GE. Influence of psychiatric comorbidity on surgical mortality. Arch Surg 2010; 145:947–953.
11. Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med 2013; 173:1075–1081.
12. Moonesinghe SR, Mythen MG, Das P, et al. Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: qualitative systematic review. Anesthesiology 2013; 119:959–981.
13. Kehlet H, Jørgensen CC. Predicting postoperative morbidity: in what procedures and what patients? Anesthesiology 2014; 120:1297.
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