Lillian Banyacski, 90, of Somerset, NJ, had an aortic heart valve replaced and the first question she asked after the surgery in the recovery room was, “When can I go to the casino?” as this was her favorite recreational activity. This remark was from the same woman who outlived the surgeon who performed a quadruple bypass on her in 2005 and another orthopedic surgeon who replaced three hips on Lillian. Juxtapose her recovery and positive upbeat attitude with that of my husband who at 82 had the same aortic heart valve replacement a month ago but is still sullen, tired, languishing, lethargic, unusually quiet and lacks his usual pep and vitality. What’s going on here?
Granted that feeling bad emotionally and physically often go hand in hand, but the big problem is that many people don’t identify what they are feeling as depression and think they are only feeling the effects of physical illness. It’s hard to differentiate what happens between recovery from surgery and depression. Many of the symptoms such as fatigue and irritability are common when someone is depressed and especially during recovery from surgery and the symptoms of depression take on a myriad of forms.
What is most common are discomfort, ongoing health problems, getting used to a change in routine, impatience with the recovery rate, poor attention and information processing, sadness, a sense of hopelessness and despair, mood swings, fatigue and memory issues such as forgetting appointments, names of people and simple recall. There are also feelings of melancholy, eating more or less, and a sense of feeling worthless and that life has little meaning. Decision making may be impaired, there might be a difficulty in concentrating, sleeping more or less, and frequent resting during the day.
Many experience a loss of interest or pleasure in activities they formerly enjoyed which is termed anhedonia. They may feel guilty that they are a burden to others and have persistent negative thoughts that they can’t stop. They are slower in speech and in movement, have a loss of motivation and increased feelings of anxiety, guilt, stress, despair and hopelessness with no specific cause. The fatigue of depression can make the person feel as if they are always tired and so, they may experience insomnia.
Sadly, depression can increase the risk of physical illness and delay recovery. Any irritability or anger issues are visible more in males and some symptoms can be present before surgery as the patient feels anxiety and stress which may make the surgery less likely to be effective. If depression continues, it may even reach a catatonic sate where one does not speak or appears in a daze for some time and may be silent or motionless with no response to what is happening around them. Mutism can result where one feels low, sad or hopeless and can be due to brain structure changes, a family history of mental conditions, or a dopamine depletion.
In my husband’s case, there were signs of anxiousness a month before the procedure. He caused three small fender-benders on our new car, got lost going to familiar places and had small instances of forgetfulness. That’s when I knew he was worried and stressed.
Granted, some factors of depression are hard to distinguish from the aftereffects of surgery since surgery can affect sleep, appetite and energy, but those that affect the emotions should trigger an assessment. People with family or a personal history of depression may be more likely to develop depression in times of stress or illness. Fatigue or feeling low on energy usually improves as recovery progresses, but symptoms caused by depression are not typically improved with recovery after surgery.
Two weeks is more than long enough to determine if the symptoms are improving with the passage of time or if they are lingering and some can occur up to one year after surgery. Antidepressant medication or therapy may be needed. One researcher found that some, even when their surgeons told them they were doing well, were also more likely to be depressed.
How does this happen?
So, why does this depression occur at all? Some factors that increase post-op depression are reactions to anesthesia, the effect of antibiotics, discomfort while recovering, reactions to some pain relievers, the physical, mental and emotional stress resulting from surgery, and concerns about the impact on one’s quality of life in the future.
Post-operative cognitive impairment is a relatively serious complication of anesthesia and major surgery for those over 60 years of age. Early cognitive decline during the first week post-surgery in about 30-50% of patients is followed by a persistent decline in 10-20% at three months postoperatively which may lead to problems with learning, memory, attention, and concentration which may also affect one’s daily activities. Disorientation, medications, changes to daily routine, stress, expectations about the surgical outcome, and a sense of losing mobility or independence may also be factors.
Some surgeries are more closely associated with post-operative depression such as cardiac-like coronary artery disease, plastic surgery, cancer, spinal, bariatric and other procedures on elderly patients like hip replacements. The prevalence of depression for patients with coronary artery disease, despite successful surgery, can approximate between 30 and 40% and increases the risk of morbidity, mortality and the incidence of cardiac events. The interaction of depression and anesthesia and surgery especially after coronary artery bypass surgery can even be evident one year after surgery and increases the likelihood for new coronary artery events. Fifteen percent of patients who undergo surgery are at a high risk of complications.
Depressive symptoms are associated with poor emotional and physical recovery and an impaired quality of life. One 2007 study found that women can experience depression for up to three years following a mastectomy for breast cancer in spite of a good long-term outlook. The elderly, particularly, fear losing mobility, and cardiac patients are frustrated that they may have to reduce their physical activities. The longer depression goes untreated, the worse for the patient.
Other procedures that are more likely to lead to depression are for those especially who have pain, undergo treatments like chemotherapy, experience long recovery times, or face reduced mobility long-term. Other contributing factors for a higher risk of depression are for those with diabetes, those who experience longer times in intensive care, those with early Alzheimer’s but no previous symptoms, and those over 60 years of age. The post-operative cognitive decline can affect memory, attention span and the ability to focus.
One theory is that failing to warn patients about post-operative depression might be a self-fulfilling prophecy. Depression certainly disrupts healing making for a longer recovery time so therapy and medication may be the best help. Even assessing the patient’s anxiety symptoms prior to surgery is recommended as depression prior to surgery was correlated with post-operative pain measurements and certainly impacted post-surgery recovery.
Decreasing post-op depression
So, what can one do to lessen possible post-op depression? First, be aware of what to expect and find out how long recovery is likely to take. Understand the medications and side effects. It may be tempting to sleep a lot following surgery, but some routine needs to be established and one needs to socialize and enjoy others again. Eating healthy and regularly and with others is helpful too. Exercise is necessary to strengthen your body and improve your mood and energy level. Maintain a regular sleep routine and avoid daytime naps.
Find a suitable way to express anger, sadness and frustration and if such feelings persist, a doctor may have to recommend a therapist or counselor. Set realistic improvement goals to help you focus on how far you’ve come, rather than how far you have to go. Avoid alcohol or illegal drugs and employ stress management techniques. Your caregiver should ask for a doctor’s help if necessary, offer support and understanding to you by reducing stress at home, getting you outdoors, preparing nutritious meals and inviting you to events and outings so you can interact with others.
A warning for spouses and female caregivers like me: men don’t talk as much as we do, so ask for help, go to doctor’s appointments with them and be the mouthpiece, remembering that their physical well-being is connected to their emotional health. Post-operative depression needs to be addressed for patients who are experiencing mood changes, feel isolated and stressed and need the help of us spouses and caregivers, no matter that they deny it. Caring for those with depression can improve their quality of life and be lifesaving.
Remember, too, that post-op depression is common but not commonly talked about. According to a 2017 study by the British Journal of Surgery, depression and anxiety can actually disrupt physical healing. “It doesn’t matter how large or small the operation is,” said Amy Vigliotti, PhD, founder of Self Works, a therapy professional and former supervising psychologist at Jacobi Medical Center in New York City. “It’s perfectly normal to have an emotional reaction to an operation on your body. Putting your health in the hands of a surgeon makes you extremely vulnerable and can trigger an array of strong emotions, including depression.”
“And surgery is an invasion of a person’s body which can be quite traumatizing, whether they realize it or not,” Vigliotti explains. “Depression may come on because of pain or discomfort, a lack of mobility, or increased dependency on others. We all have a certain amount of invincibility. We’re physically well and then all of a sudden, our bodies let us down and it surprises people. That brings a lot of feelings about physical well-being, mortality and our vulnerability in the world. We need to focus more on emotional needs so remember that recovering from surgery can take time, even anti-depressants can take several weeks, but most post-op patients return to a full life even if some accommodations have to be made.”