Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 6, 2003, pp. 475-479

Indian Journal of Surgery, Vol. 65, No. 6, November-December, 2003, pp. 475-479

Depression in surgery: An insight

Rajeev M. Joshi, T. S. Shetty, A. S. Khithani

Department of Surgery, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai Central, Mumbai, India.
Address for correspondence: Dr. Rajeev M. Joshi, Professor of Surgery and Unit Chief, Lokamanya Tilak Municipal General Hospital, Sion, Mumbai - 400022, India. E-mail: joshirm@vsnl.net

Paper Received: February 2003. Paper Accepted: June 2003. Source of Support: Nil.

How to cite this article: Joshi RM, Shetty TS, Khithani AS. Depression in surgery: An insight. Indian J Surg 2003;65:475-9.

Code Number: is03102

ABSTRACT

Depression is common in today's world and this article seeks to address issues relating to depression in surgical practise.Surgical situations and their effects on the patients, as well as depression in the family and the surgeon are highlighted.The solution is need for greater interaction with the caretakers of mental health.

Key Words: Depression, Surgery.

INTRODUCTION

Depression has become as ubiquitous in today's world as technological advances. It is so commonplace that it has been referred to as the "Common Cold of Psychopathology" The 21st century often termed as Age of Depression and global recession has seen anxiety and depression encompassing people in all walks of life. The need therefore arises to especially address issues relating to depression in clinical practice. More so, because the health care providers themselves are susceptible. The present article dwells on the issues relating to depression in surgery covering the patient undergoing surgery, the family members and the surgeon himself. (Figure 1)

DEPRESSION IN PATIENTS UNDERGOING SURGERY

The obvious reaction in any person informed of the need of a surgical procedure is that of anxiety. The term "Surgery" may evoke the idea of threat to life as in cardiac surgery, loss of vision as in ophthalmic surgery, disfigurement as with mastectomy or uncertainty to cope up with the challenges of survival and disability following oncosurgery. Other psychological factors may interplay and add to the anxiety like neurosis, stress and depression causing psychiatric co-morbidity in an already disease stricken patient. The Cincinnati series reports a 4. 5% incidence of depressive reactions in surgical patients, only second to delirium.^1,2

The diseased patient may become unco-operative by showing distinct lack of interest in his treatment and may compound the surgeons problem and impede his own recovery. The depressive reactions may be accompanied by physiological changes as well as functional and psychological symptoms. Moore et al demonstrated the effect of emotions on the Hypothalamo-Pituitary -Adrenal Axis during the immediate and subsequent post operative period like tachycardia, prolonged ileus etc. which can interfere with the clinical assessment of a surgical patient.³

The factors which modify the degree of depression in a surgical patient are manifold. Depression is seen to be more common in older age group, attributed to a blunted ability cope up with a surgical insult. The prevalence rate is almost double in females as compared to males and is related to increase in physiological stress and presence of gyaenacological disorders in females. Emotional strength and endurance of the patient are also important contributory factors.

Lack of finances causes and aggravates depression in the lower socio- economic group. Compromise in occupational skills due to loss of limb in a manual laborer or vocal cord palsy following a thyroid surgery in a professional singer may cause depression. Lack of support from family members and friends contributes to the trauma. A patient in a public hospital is more prone to depression than a private one. This may be related to a financial crunch, the surgical environment, a lack of rapport on a one to one basis with the operating surgeon and having little or no say in the choice of the surgeon.

Prolonged nature of the illness as in burns or a prolonged convalescence associated with orthopaedic and trauma surgery may precipitate depression. It may be interesting to note that the only specific tumor outside the nervous system, which has the reputation of presenting as depression is cancer of the Pancreas.⁴ The pancreatic neuropeptides have been incriminated as mediators in these patients. Others include tumors of the Pituitary, Parathyroids and those seen in Paraneoplastic syndromes.

Patients with depression often have high dependence on nicotine and alcohol which may aggravate prexisting illnesses as chronic pancreatitis and peripheral vascular disease. Modification of these behaviours may pose a problem in the presence of depression. The nature of the surgery, the chance of its success and the trust of the patient on the operating surgeon have tremendous bearing on the nature and course of depression.

SURGICAL SITUATIONS AND THEIR EFFECTS ON THE PATIENT

Listed below are various surgical situations having different effects on the patient.

Oncosurgery

It has been seen that cancer virtually disrupts every aspect of the patients life. Depression is furher compounded by the chronicity of the illness, the treatment involved, the pain, generalised lassitude and anorexia and the thought of impeding death. Buckberg found that depression increased along with levels of physical disability in cancer.⁵ The combination of the surgical procedure and the awareness of the implications of the illness strain the emotional stability of the patient. Depression is an appropriate response and stems from loss of health and physical integrity resulting from disease, disfigurement and discomfort, loss of finances resulting from cost of treatment and loss of job, rejection by friends and loved ones including seperation to receive treatment.

Sutherland and his associates are of the opinion that loss of a bodily part, valued activity or function is more depressing than fear or expectation of death.⁶ This is most commonly seen in surgeries performed for malignancies of the head and neck region and for breast cancer. Maguire series reports a 20% incidence of depression following mastectomy related to appearence and sexual dysfunction.^7,8 Since head and neck malignancies are highly related to abuse of alcohol and tobacco, these patients suffer increased anxiety related to substance withdrawal as well as pain and depression related to feelings of guilt and fantasies of suffering. In a patient with colostomy, depression occurs from sexual and social disability. The effect of various factors leading to depression in cancer patients is shown in Figure 2.

Possible Solutions

Free and open communication between the patient and surgeon, helps in overcoming the patient's fear for the disease and his emotional and mental difficulties. A healthy relationship is fostered by trust on part of the patient and interest on part of the surgeon. Since biological behaviour of cancer differs in different patients, rigid prognostification of the disease should be avoided as far as possible.

Psychological support and education are necessary in order to alleviate the patients' depression and fear to deal with disability resulting from the disease or the therapy. Examples include training in case of a colostomy by an Enterostomal therapist. Patients who require ostomies like a colostomy or ileostomy should be visited preoperatively by a stomal therapist and a member of the ostomy club who can share the feelings and concern of the patient. Patients with breast cancer treated by mastectomy may be helped to alleviate the problems of altered body image by referral to rehabilitation clinics. An important point especially in breast cancer and gynaecological surgery is that patient's spouse should be included as an active participant in all the discussions of the disease and treatment.

Laryngectomy patients can similarly be helped by speech therapists and patient's clubs. Patients recovering from amputations may benefit from meeting recovered amputees and physiotherapists before and after treatment.

Some incurable patients are unable to accept the realities of the situation. It hence becomes essential that a responsible family member be informed. The basic aim of a surgeon in caring for a patient inflicted with advanced cancer is to `prolong useful life and not useless suffering'. The patient should be permitted to die with dignity when active therapy can no longer be of benefit.

Neurosurgery

Depression in a neurosurgical patient may be attributed to physical incapacitation, temporal lobe lesions, brain damage following head injury and prolonged use of steroids.

Cardiac Surgery

In cardiac surgery the fear of death, prolonged convalescence and limitation of active life together with prohibitive costs of treatment contribute to the depression.

Paediatric Surgery

In paediatric practice depression is more commonly seen in parents than in children. In children, an anxiety like state may be precipitated by the shock of operation and the reaction is one of apprehension, dependency and defiance. The prevalence of death related depression in children is low because the concept of death as a permanent biological process usually does not develop until the age of nine years. However post surgical depression in children may manifest as irritability, excessive clinging to parents, rebellious behaviour and school phobia.

Genitourinary Surgery

Genitourinary surgery is often associated with depression arising out of sexual dysfunction. Lindemann noted that the preoccupation with depressive thoughts was greater after genitourinary surgery or pelvic surgery than after a cholecystectomy.⁹

Aesthetic Surgery

It involves the alteration of the body image in the hope of improving it. Depression is is due to high expectations of the patient and may lead to development of functional and psychological problems. It requires a proper preoperative counselling and a realistic approach.

Organ Transplantation

It involves the psyche of giving and receiving. The recipient is been shown to be aware of his own obligation to the donor and resents the dependency relationship. At times, feelings of shame, guilt and periods of severe depression are noted. With time even the donor may experience a sense of loss, at not being adequately supported or having been made a sacrificial lamb. With the legislation of a related kidney donor, question of family presures to donate a kidney and possibility of depression in family members must be considered.

Depression in the family

The family is the second facet in the triad of depression. Surgery poses a crisis for the family members and may have immediate as well as longstanding effects on the functioning of the family. Stress amongst family members is the key factor in the development of depression. Depression stems from the concern for a the patient's well being and financial losses, arising from illness. It may develop as early as diagnosis and may be aggravated by exhaustion of resources towards investigative procedures and subsequentely treatment. A study by Northhouse and Swain suggested that the level of stress experienced by family members is compatible to that of the patients.¹⁰ Plumb and Holland reported that patients and the next of kin were indistinguishable in terms of level of depression.¹¹ Parental reaction of surgery on the child especially a major surgery, resembles that of grief after the death of a near and a loved one. This may persist as depression when the child gets better. These events may have destructive effects on relationship between children and parents in the future course of the child's normal life.

Three situations are commonly encountered in the practise of oncology or terminal diseases viz; families who oppose patients knowing the diagnosis and outcome, the family wants the patient to be left alone but the patient wants to keep fighting and lastly the patient wants to be left alone to die with dignity but the family will not give up. These problems must be approached conjointly. It is an unpleasant task for the surgeon but preferable to the involvement in social and possibly legal disastersthese days. Surgeons should maintain an honest relationship and maximise the patients trust. The patient's family members may feel supported when the surgeon acknowledges the spiritual dimension and practical components of loss.

Depression in the surgeon

The surgeon is the third and often forgotten aspect of this triad. Surgery, like many other callings is stressful, but it is the attitude towards coping up to these stresses that ultimately affects the human system. Anxiety and depression, however transient, are common amongst surgeons. Emotional problems in the surgeons especially oncologists, superspecialists, frequently arise from exposure to failures and death, together with difficulty in coping with their own ageing. Often there is a feeling of being overwhelmed that few patients with advanced cancer can be cured. It also occurs when there is an increasing feeling of guilt for not being able to keep the patient alive, especially when death occurs on the operation table. Depression occurs when a feeling of helplessness sets in while treating terminally ill patients. These disturbances may lead to a transient loss of confidence, lack of concentration, indeciciveness or becoming inappropriately aggressive or optimistic in therapy often with a disastrous effect. This compounds the depression further. The solution is that the surgeons should learn to endure disappointment and failure and must always learn from his mistakes.

Depression is seen equally in both full time surgeons and in private practice. In a well analysed study published in the British Journal of Surgery, Green and co- workers showed that surgeons in private practice had to endure a greater stress than fulltime surgeons. This is related to sacrificing family life, pleasures, and self in the succesfull and lack of rewards in a not so successful. Depression in fulltime surgeons is attributed to financial constraints, administrative responsibilities and hurdles and patient overload.

A resident surgeon has to endure the stresses of training. He is first faced with depression while still an undergraduate student. While studying surgery, he feels that he has all the symptoms and while reading psychiatry he feels that his friends are typical examples. Along with health care workers in the surgical critical care unit or trauma ward, he may suffer from depression by having to attend to dying patients more often than others. It stems from a feeling of helplessness when attempting resuscitation in a gasping patient of polytauma or extensive burns.

AIDS, the new scourge of the 21st century, is a constant and a big threat to surgeons as it is to other heath care workers and may be a cuse for anxiety. The silver lining is that studies have shown surgeons to be the safest amongst health care personnelif adequate precautions are taken. In this era of medical "Peristroika", the lurking sword of consumer protection adds to the depression following a failure. However, even though the conduct of a surgical procedure involves multiple variables like the surgeon, assistant surgeon, the anaesthetist and theatre personnel, it is almost always the surgeon who is blamed for a failure even if other variables are responsible for it.

There is obviously a great stress in a surgeons life. Our only shock absorbers are character, competence and concern for the patient. Surgeons should have a clear head, a kind heart and awareness of the awesome responsibilities which a trusting patient places in thier hands.

CONCLUSION

The 17th century has been called the age of Enlightenment, the 18th, the age of Reason, the 19th the age of Progress, the 20th the age of Anxiety and the 21st century as the age of Depression or perhaps even antenatal depression. With the increasing stress and upsurging challenges of our times, it is becoming increasingly difficult for a surgeon to lead a meaningful and satisfying life Psychological approach towards the patient is the key in tackling depression in a surgical patient. This is as important as the surgeon's technical skill and like all other procedures practiced during training and refined over the years, dealing effectively and compassionately with patients, pre and post-operatively is a skill that can be nurtured. As Parkes stated, "Each time we succeed in helping someone else to face upto and cope with the awesome facts of life, we are indirectely helping ourselves."¹² There are a lot of ups and downs in a surgeon's life. To ensure that the final tally shows more ups than downs, one has to possess character, competence, concern for the patient and professional excellence.

Anticipation of the psychiatric disturbances may come as a triumph in the management of the patient and the disease. Thus an opportunity arises, to foster a close relationship between the two specialities of surgery and psychiatry. Psychiatrists and psychologists will have a greater role to play as we march further into the 21st century. Surgeons and psychiatrists will have to work in close conjunction if better patient care is to be administered. To quote, a famous author once said, "Too bad that all the people who know how to run the country are busy driving taxies and cutting hair." So very true. Here are surgeons who have some advise for Psychiatrists.

With the human genome being mapped, the immense possibilities of genetic manipulation and treatment `opening up' the future outlook of a depressed patient definitely looks brighter than before. With future advances it may be possible to prevent depression altogether perhaps antenatally.

REFERENCES

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2. Titchner JL, Levine M. Surgery as a human experience: The Psychodynamics of surgical practice. Oxford University Press; 1960.

3. Moore F, Steinberg K. Studies in surgical endocrinology. Ann Surg 1955;141:145.

4. Chaturvedi SK, Chandra P, Channabasavanna SM. NIMHANS Jr 1994;12:141-4.

5. Buckberg J, Penma C, Holland JC. Depression in hospitalized cancer patients. Psychomed 1984;46:199-212.

6. Sutherland A, Dyk R, et al. The psychological impact of cancer and cancer surgery: Adaptation to dry colostomy: Preliminary report and summary of findings. Cancer 1952;5:857-9.

7. Maguire P, Tait A, et al. The effect of counselling on psychiatric morbidity in elderly surgical patients. Br J Psychiatry 1981;138:17-8.

8. Maguire GP, Lee EG, Benington DJ. Psychitric problems in 1st year after mastectomy. BMJ 1980;1:963-5

9. Lindemann. E. Observation on psychiatric sequelae to surgical operations in women. Ann J Psychiatry 1941:98;132-7

10. Northhouse LL, Swain JA. Adjustment of patients and husbands to initial impact of breast cancer. Nurs Res1987;36:221-91.

11. Plumb MM, Holland J. Comparative studies of psychological function in patients with advanced breast cancer. Psychosom Med 1977;39:264-91.

12. Parkes CM. Bereavement. In: Kendrick T, Tylee A, Freeling P, editors. The prevention of mental illness in primary care. New York: Cambridge University Press; 1996. pp. 74-87.

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