We need better treatment for post-surgical depression

The first time I had surgery, I was startled by something that happened afterward: I was tired all the time for a while, which made sense given that I was still processing the anesthetic, but also, I was deeply depressed. I didn’t understand why  I was experiencing such intense suicidal ideation when circumstantially, things were going fairly well for me, and my mental illness was at the time reasonably well controlled with medications and therapy. To abruptly swing from feeling fairly stable to mental health crisis made absolutely no sense to me — when medications aren’t working and things are going wonky it’s usually a more gradual slide — but I was flung so deep into the depths that I felt incapable of reaching out to ask for help.

A doctor friend of mine happened to ask how I was doing and I mentioned it, and she said ‘oh, yeah, post-surgical depression happens all the time, no one really knows why.’ I was astonished. No one has mentioned that it might be a complication before I went into surgery or during any of my consultations. It wasn’t discussed at followups. I wasn’t screened for it or advised to look out for warning signs — like fatigue, which I only learned was a depression indicator years later. Especially given my history of mental illness, I would have been an especially at-risk candidate, but no one thought to be proactive about the problem. Being tired for weeks after surgery had nothing to do with the afterlife of the anesthetic and everything to do with the fact that I was deeply depressed.

She wasn’t the only one who mentioned it when I delved into the rabbit hole. Eventually, with some medication adjustments and time, my utterly imbalanced brain chemistry stabilised. And when I had surgery again, I remembered my post-surgical depression from the previous time and tried to anticipate it — ultimately, I did in fact develop extreme depression, but this time, I had better tools to fight it and an awareness that my brain hadn’t just abruptly broken, that something else was going on.

Post-surgical depression is quite common, but it’s not a subject of conversation very often. Doctors are certainly aware of it as are some members of the public — as for example the people who asked me how I was doing after my surgery. But the topic remains taboo, as with other mental health issues, and that leaves patients in the dark. Not only are they unprepared, but they think they’re alone, freakish, isolated outliers. They don’t identify what’s happening and they don’t ask for help because culturally, mental illness is considered a sign of weakness and a failing, rather than a fact of life for some people that’s best addressed by treatment, not shame.

Earlier this year, public health officials announced support for depression screening in pregnant and post-partum patients, as well as the general population, since depression is “the leading cause of disability” in people over 15. They noted that accurate screening, diagnosis, and treatment helps people get care earlier, get the right kind of care, and achieve the best clinical outcomes. Their recommendations will likely be buried, as any mental health recommendations are, until another mass shooting, at which point society will collectively decide that maybe it cares about mental illness again and ought to Do Something unless it costs money, in which case, Let’s Not.

But the fact is that some groups are at higher risk of depression, and it’s critical both to educate them and conduct regular screenings to make sure that interventions come sooner, rather than later. As I fought my brain chemistry without understanding why I was having such a difficult time, I joined the ranks of over 50 million people in the US who have surgery every year — and some of us most definitely come out of the OR with transitive, situational depression, or with exacerbations of existing depression. The way to deal with that isn’t to pretend it doesn’t happen, but to engage directly with it.

Surgeons and support staff should know well enough by know to discuss the risks of post-surgical depression, how to identify risk factors, and what to do with their patients, especially if they have mental health conditions. Certainly patient charts should be flagged to stress when and where surgery occurred to make health care providers aware that patients reporting depression symptoms may be experiencing issues related to surgery. While there’s some awareness that certain procedures can come with a greater risk of mental health concerns that warrant therapy — like cancer-related mastectomies or hysterectomies, where patients are experiencing emotionally traumatic surgeries that will change their lives forever — many other procedures apparently aren’t considered a risk. Why would a cosmetic surgery make you sad? Knee replacement is pretty routine and will improve quality of life, so why should it be a cause for concern?

Medically, we need to research post-surgical depression to learn more about its mechanisms and identify patients who are most at risk, as anecdotal experience and limited research clearly isn’t enough to ensure that patients have access to the care they need after surgery. Meanwhile, we need to be educating providers about how to prepare surgical patients and their families for the risk of depression — there’s nothing shameful or wrong about experiencing depression, but there is something shameful about failing patients and leaving them in a dark wood wandering when they are already experiencing acute mental distress.

Image: UCD School of Medicine, Flickr