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An “Understandable” Complication | Harvard Magazine Jul-Aug 2000.

An “Understandable” Complication

Coming to terms with postsurgical depression

by John F. Lauerman

July-August 2000

A phrase that applies to just about every surgical procedure might be “This is going to get worse before it gets better.” Surgeons themselves often acknowledge the bloodiness of their work: an art that begins with the rending of flesh ends in rejoining, and leads ideally to quick and more or less permanent healing.

The advent of sterile techniques and anesthesia has made surgery far less ghastly than it was when patients were as likely to die from the procedure itself as from the condition precipitating it. But if we no longer need to coax patients into the surgical theater, nor physically restrain them as the cutting begins, considerable anxiety remains for many patients with surgery in their future.

Surprisingly, however, most people tend to prepare for and cope with

the emotions surrounding surgery itself quite well, observes psychologist Nicholas Covino, an assistant professor in the department of psychiatry who works at Beth Israel Deaconess Medical Center and has studied the emotional reactions men have to prostate cancer. Patients know that they will be asleep during surgery, they are confident that their pain will be controlled, and they hope the surgery will make them better. “Most often, people see surgery as a stressor to be managed and gotten over,” he says. “Everybody is apprehensive about it, and relieved when it’s over. It’s like doing your taxes: in the crisis, the crisis rules and getting through it becomes the task.”

But the risks and the many other issues that surround operations are sufficient to make most of us think hard before consenting to one. Although anesthesiologists keep us from discomfort during surgery, patients still face the prospect of limited function, or even severe pain, during recovery. There is also the possibility of complications. Not so long ago, a close friend died as the result of an infection acquired during a routine, elective, surgical procedure. The episode lingers like a bright-red warning light.

Other psychological issues crop up during the recovery period. When we’re healthy, we tend to think of our bodies as somehow intact, both inviolable and homogene-ous. Major surgery can shatter that image, and with it the concept of self-sustaining health. The feelings of mortality, of loss, and of vulnerability can be profound, and recognizing depression in surgery’s aftermath becomes very important.

“Depression is a serious thing,” says Bernard Vaccaro, instructor in psychiatry at Brigham and Women’s Hospital, “because it can impair the ability to cooperate with rehabilitation. Depressed patients have a significantly higher rate of complications. If you’re not able to participate in rehabilitation, if you’re not as active, the whole process of recovery just slows down.”

When a patient appears depressed immediately after surgery, Covino seldom attributes it to pain or a sense of loss; rather, he suspects hidden complications, perhaps a problem with anesthesia, an infection, or some other underlying cause. Delirium is another condition that can occur during the one or two days immediately following surgery, especially among older people. Doctors recognize what’s happening when patients become incoherent, disoriented, or hallucinatory. In certain patients, delirium may appear in-stead as subdued behavior—much like depression. Either way, it’s important to treat the underlying problems—anemia, hypoglycemia, or other deficiencies or imbalances.

Postoperative depression, on the other hand, is more likely to occur well after the crisis of surgery has ended and the patient is back at home or even at work. That can make it particularly difficult for patients to cope with feelings about what they’ve endured and what their future is likely to be, or for family members and physicians to see and understand their feelings. Stigma continues to surround depression, adds Vaccaro, and many patients may hide their state of mind from families and caregivers alike.

“Physicians are notoriously poor at recognizing depressive symptoms,” says associate professor of psychiatry Theodore Stern, chief of the psychiatric consultation service at Massachusetts General Hospital. Even among primary-care physicians, depression goes unrecognized about 50 percent of the time, Stern explains. “Many doctors don’t know the criteria, and don’t speak with patients long enough to establish whether they have the symptoms of depression. Sometimes, physicians believe that being depressed after surgery is ‘understandable’ and unworthy of diagnosis or treatment.”

Many patients naturally feel anxious about their course of recovery. Their sleep may be disrupted; they may be uncomfortable because of postoperative pain; they may lack some of their former energy; their appetite may fall off due to the discomfort of having organs manipulated or cut. But if some or all of these symptoms occur together and last for two weeks or longer, that may indicate depression—which should be treated, whether it’s “understandable” or not. “Our job is to recognize the symptoms and see if they’re part of the depression syndrome,” says Stern. “And if so, to treat it.” (Despite their reputation for shirking all but the most pressing patient needs, most HMOs would probably cover this kind of treatment.)

What may complicate matters for many physicians is the unpredictability of patients’ reactions to surgery, and the wide variety of meanings the experience may hold for patients once they begin to reflect on it. One patient may cope extremely well with something as invasive and traumatic as a hip replacement, while another may have difficulty coming to terms with a far less physically traumatic arthroscopic joint procedure.

Covino says there simply is no way of being able to predict beforehand whether patients will be able to manage their own short-term postsurgical feelings or whether they’ll have longstanding depression requiring treatment. “The patient might have been depressed before the surgery, or might have a depressive personality ‘style,’” he explains. “You don’t know the meaning that surgery has for a person, for instance, unless they tell you. Their subjective sense of the significance of surgery and the way they deal with important events in their lives is going to have a lot to do with how they deal with this event.”

The most important factor in how someone feels about surgery after the fact is probably not how well the procedure was performed, but how well the patient is prepared to think and feel about the entire process. Talking with a surgeon or mental-health professional about details of the surgery and recovery can help provide some of that preparation, but talking with friends and family about their hopes and fears can help, too. “The more patients can be proactive and ask doctors what they’re likely to experience after surgery, the more they read about it and communicate with others about it,” says Stern, “the better chance they have of putting the experience in its proper perspective.”

Even though surgeons strive to improve their techniques all the time—to make them less traumatic, less invasive, more reliable—there is still much about surgery that patients find painful and frightening. Preparing realistically for an operation will help patients start the process of healing even before they get to the hospital.

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