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.
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