Research Article: Persistence of Psychological Distress in Surgical Patients with Interest in Psychotherapy: Results of a 6-Month Follow-Up

Date Published: December 5, 2012

Publisher: Public Library of Science

Author(s): Léonie F. Kerper, Claudia D. Spies, Maria Lößner, Anna-Lena Salz, Sascha Tafelski, Felix Balzer, Edith Weiß-Gerlach, Tim Neumann, Alexandra Lau, Heide Glaesmer, Elmar Brähler, Henning Krampe, Jerson Laks.


This prospective observational study investigated whether self-reported psychological distress and alcohol use problems of surgical patients change between preoperative baseline assessment and postoperative 6-month follow-up examination. Patients with preoperative interest in psychotherapy were compared with patients without interest in psychotherapy.

A total of 1,157 consecutive patients from various surgical fields completed a set of psychiatric questionnaires preoperatively and at 6 months postoperatively, including Patient Health Questionnaire-4 (PHQ-4), Brief Symptom Inventory (BSI), Center for Epidemiologic Studies Depression Scale (CES-D), World Health Organization 5-item Well-Being Index (WHO-5), and Alcohol Use Disorder Identification Test (AUDIT). Additionally, patients were asked for their interest in psychotherapy. Repeated measure ANCOVA was used for primary data analysis.

16.7% of the patients were interested in psychotherapy. Compared to uninterested patients, they showed consistently higher distress at both baseline and month 6 regarding all of the assessed psychological measures (p’s between <0.001 and 0.003). At 6-month follow-up, neither substantial changes over time nor large time x group interactions were found. Results of ANCOVA’s controlling for demographic variables were confirmed by analyses of frequencies of clinically significant distress. In surgical patients with interest in psychotherapy, there is a remarkable persistence of elevated self-reported general psychological distress, depression, anxiety, and alcohol use disorder symptoms over 6 months. This suggests high and chronic psychiatric comorbidity and a clear need for psychotherapeutic and psychiatric treatment rather than transient worries posed by facing surgery.

Partial Text

Few studies have investigated psychological distress in surgical patients. With the exception of two earlier large-scale investigations [1], [2] research is mostly based on small samples, distinct surgical fields and specific psychological factors. Taken together, there is some evidence that psychological distress is high in surgical patients during the pre- and perioperative period regarding depression, e.g. [3]–[7], anxiety, e.g. [1], and alcohol use disorders, e.g. [8], [9]. However, it is not clear to which extent elevated self-reported symptoms of preoperative psychological distress reflect either clinically significant psychiatric symptoms or transient worries posed by facing surgery. O’Hara et al (1989) found in a large sample study that the rate of patients with clinically significant psychological distress was even higher 3 months after surgery than at the day before surgery [1]. Recent investigations of smaller samples and with follow-up times ranging from 3 days to 3 to 5 years show a differentiated picture: Some studies confirmed the increase of psychological distress [10], [11], others found no significant change [12]–[14], a significant decrease [15]–[18], patterns of no significant change and decrease [19], [20], or patterns of both increase and decrease [21], [22]. In a recent study, we examined N = 4,568 surgical patients in the preoperative anesthesiological assessment clinic and found a rate of clinically significant preoperative psychological distress of up to 38% [23]. Independently of surgical field or physical health, interest in psychotherapy was significantly associated with the intensity of self-reported symptoms of general psychological distress, depression, anxiety and substance use disorders. However, only a prospective longitudinal investigation will provide data to clarify whether elevated symptoms remain stable over time or decrease after patients have overcome the hospital stay.

Out of all 1,157 participants, 193 patients (16.7%) were interested in psychotherapy, and 964 (83.3%) were not interested. Patients with interest in psychotherapy were statistically significantly younger (p<0.001), were more likely to be female (p = 0.012) and less likely to live with a partner (p<0.001). However, there was no significant difference regarding surgical field (p = 0.731) and ASA classification (p = 0.122) (Table 3). To the authors’ knowledge, this is the first long-term study on psychological distress in surgical patients that included interest in psychotherapy as a group factor. The results revealed that (1) patients with interest in psychotherapy differed considerably from patients without interest in psychotherapy; (2) there were no substantial changes of distress between preoperative assessment and 6-month follow-up in both patient groups. The most important finding is that interested patients showed consistently high distress at both baseline and month 6 regarding all of the assessed psychological measures of general distress, depression, anxiety, subjective health, and alcohol use disorder symptoms. This remarkable persistence suggests high and chronic psychiatric comorbidity and a clear need for psychotherapy rather than transient worries posed by facing surgery. These results might be considered as unsurprising in a setting of psychosocial health care. However, data were collected in preoperative anesthesiological assessment clinics where surgical patients are examined by an anesthesiologist to clarify anesthesia related risks of the intended surgery and to evaluate the patients’ individual level of risk. In this setting, patients prepare to undergo surgery and both patients and clinicians do not expect psychological screening programs. Clinically significant preoperative psychological distress may be misinterpreted by anesthesiologists and surgeons as transient worries about somatic diagnoses and the forthcoming surgery. Thus, it is important to provide evidence that patients with high preoperative psychological distress and interest in psychotherapy do not easily improve after having overcome surgery and the hospital stay. From a psychotherapeutic perspective it makes sense to treat chronic psychiatric comorbidity in surgical patients who are motivated for therapy. But also from a medical perspective this implication becomes comprehensive: Recent studies provided evidence that untreated depression, anxiety and substance use disorders are associated with perioperative complications and increased morbidity and mortality, leading to worse surgical outcomes and higher health care costs of surgical patients [3]–[9], [34]–[38]. In order to properly assess and treat psychological distress in surgical patients, cost-efficient approaches are needed that are based on interdisciplinary collaboration of clinicians from anesthesiology, surgery and psychology. A stepped care program may fulfil both clinical and economical demands of such an approach [23]: Screening for psychological distress, brief motivational interventions, as well as early supportive interventions for transiently elevated perioperative distress can be performed by psychologically trained nursing staff. After the screening, those patients who wish to be visited by a psychotherapist may communicate their interest to the nursing staff to arrange a first appointment. Non-confrontational brief advice should be offered to patients who show clinically significant distress but lack motivation for therapy. The data of the present study suggest that patients with both clinically significant preoperative psychological distress and the explicit interest in psychotherapy are at an increased risk to have persistently high distress after 6 months. As a consequence, for these patients, the therapeutic steps after the screening should comprise detailed psychological assessment, clarification of psychiatric diagnoses according to ICD-10, first psychotherapy sessions including motivational interviewing, and, if required, the initiation of longer psychosocial treatment options. Source: