Why Aren’t We Talking About Postoperative Depression?

It’s a strange problem for people to forget to mention, because it’s not uncommon. In a 2000 feature for Harvard Magazine, surgeons described it as an “understandable complication.”

So why aren’t we talking about it? The answer is complex, and it involves a number of stops along a rabbit hole of twists and turns that leave patients unprepared for the emotional aftermath of surgery. While depression may be “understandable,” that doesn’t mean it should be ignored; and refusing to acknowledge that it’s a risk doesn’t resolve the problem.

It’s also very treatable. Prepared patients, particularly those with underlying mental health conditions, can be more proactive about managing it if they’re forewarned.

Clinical Health Psychologist Steven Tovian, who works at Northwestern University in Chicago in addition to maintaining a private practice, told Talkspace one reason postoperative depression falls by the wayside is limited research into the subject. Theories about what causes it may abound, but they aren’t backed by detailed, substantial research that explores the phenomenon and delves into ways to treat it.

Without that information, it’s both harder to treat and more difficult to convince surgical care teams that advising patients could be advantageous for recovery. Cultural attitudes within the medical profession also create a barrier to frank discussions about mental health for surgical patients, which is bad news for those at risk.

What is Postoperative Depression?

This form of situational depression can occur up to a year after surgery, Tovian said. Patients can experience symptoms like poor appetite, sleep disturbances, difficulty concentrating, lack of interest in formerly enjoyable activities, pessimism, and low self-esteem. It can become so severe that depression interferes with the ability to perform tasks of daily living — like going to work, or caring for children.

One challenge in diagnosing postoperative depression, Tovian said, is that it can be hard to distinguish from other emotional responses to surgery. For example, a patient diagnosed with cancer may develop similar symptoms because she’s frightened, stressed, or worried about the cancer — and the surgery may interact with those emotions.

June Pimm, a researcher who explores postoperative depression in cardiac care settings, told Talkspace that preexisting depression is a significant risk factor, as is a recent history of big life changes. Her research found that those who concentrated on the physical aftermath of surgery — even when their surgeons told them they were doing well — were also more likely to be depressed.

Tovian added that anesthesia, disorientation, medications used after surgery, pain, changes to a patient’s daily routine, traumatic stress, expectations about surgical outcomes, and a sense of losing mobility or independence may be factors as well. Many of these are common experiences for people who have surgery, highlighting this “understandable” complication as a common potential risk of surgery.

Some surgeries are also more closely associated with postoperative depression than others, including cardiac procedures, plastic and bariatric surgery, and procedures performed on elderly patients, like hip replacements. Many of these hit Tovian’s points — bariatric and plastic surgery patients, for example, may be struggling with self-esteem and their relationship with their bodies.

Elderly patients may fear losing mobility, while cardiac patients may be frustrated with postoperative care instructions that require a reduction in physical activities. In the case of some cardiac patients, he references “bypass bump,” a disruption in blood flow to the brain that happens when patients are taken on and off bypass during some surgeries on the heart — and one possible explanation for mood changes after surgery.

Whether the depression is exacerbated by the factors surrounding diagnosis and treatment or the surgery itself, though, it’s still treatable. But like any depression, the longer it goes untreated, the worse for the patient.

Why Aren’t We Talking About It?

Pimm had a theory: “Surgeons do not feel comfortable dealing with the emotional aspects of surgery.” Another issue could be pervasive on care teams, said Tovian: Failing to warn patients about postoperative depression for fear of creating a self-fulfilling prophecy.

Though we know surgery has a profound impact on mental health status, and that depression can actually disrupt healing, making for a longer recovery time, there’s a strange reluctance among surgeons to face this issue.

While a patient going into surgery may interact with a number of care providers, their focus is often on the surgery itself and potential physical complications. The mind/body duality in healthcare strikes again in these settings, as follow-up appointments may cover things like range of motion, activity levels, pain, and an inspection of the surgical site, without a discussion of the patient’s mood.

Tovian commented that better communication with patients could help to allay fears, worries, or confusion about surgery, helping patients understand why a procedure is recommended, what will happen in the OR, and what they can expect from recovery. Far from setting a patient up for depression, it could help patients feel like they’re in control.

Admitting that surgery may have a psychological toll can be a struggle for care providers who are used to working in the physical realm — and accustomed to handling patients who are asleep for the vast majority of their interactions. To create a tidal change in how we talk about surgery and mental health, Tovian and Pimm suggested, it’s necessary to change the way surgeons, nurses, and other care providers in surgical settings think about surgery and depression.

What Can We Do About It?

In the short term, there are options for managing postoperative depression. Educating patients is an important step for changing the healthcare landscape, as informed patients are in a better position to advocate for themselves. Especially for those with preexisting mental health conditions, talking with a counselor or therapist before surgery about the risks and warning signs, and creating a plan for treatment if postoperative depression does develop, can be an important part of preparing for surgery.

While surgeons can and sometimes do prescribe antidepressants and other psychiatric drugs, counseling is also critical for recovery. Because the root causes of postoperative depression may include aspects like body image issues and a loss of independence, an opportunity to process these emotions and experiences is important. With counseling, a patient has an opportunity to develop coping skills and work through complex feelings — though medication may help patients get stable so they can focus on that recovery.

Well-informed patients can also be supported by knowledgeable friends and family. Tovian commented that patients with a good support network tend to be less prone to depression after surgery. Supportive people don’t just cook meals, clean, or help out in other ways as someone recovers — they can also encourage people to get physically active after surgery, and keep an eye out for behavioral changes that might indicate a patient is struggling.

But participation from medical providers is also important. Just as surgeons warn patients to stop smoking, get active, and eat well before surgery, they should be discussing psychological issues and identifying patients most at risk. Nurses and others who interact with surgical patients should also be thinking about the psychological effects of surgery and taking mental health as seriously as a vital sign.

Tovian’s work focuses on providing mental health services to people in clinical settings. Yet, specialists like him aren’t necessarily available in every hospital, and that’s something surgery departments need to reevaluate. Clinical health psychologists work not only with surgical patients, but with people who have chronic illnesses, complex conditions, or traumatic medical issues. The specialty directly confronts myths about the mind/body duality by expressly connecting physical well-being with emotional health.

In the long term, the insufficient data on postoperative depression is a serious problem. Most studies are small, and focus on specific patient populations, which makes them difficult to apply more broadly. More research would legitimize the issue, potentially making it easier to break down barriers in the medical profession that make surgeons and others reluctant to talk about postoperative depression.

It would also provide insight into how and why postoperative depression occurs, paving the way to preventative measures. It would allow researchers to explore treatment options and discover the most effective mix for patients struggling with depression after surgery.

Patients who experience mood changes after surgery may feel isolated and stressed. Their depression isn’t a reflection of personal failure, however, and they’re far from alone. Hearing this might help patients recognize and seek treatment for postoperative depression much earlier, which might, in the end, improve their postsurgical prognosis.