Depression and Cardiac Surgery: Underrecognized and Undertreated

“Psychological Depression and Cardiac Surgery: A Comprehensive Review” (1) is a welcomed invitation to explore the mutual impact major depression and cardiac surgery have on each other.

Addressing the depressed patient has traditionally not been a priority in the management of cardiac surgical patients despite the fact that a disproportionate number of patients in the cardiac surgery population suffer from depression. The focus is more likely on other aspects of the care of this group of patients such as the conduct of cardiopulmonary bypass, anatomic challenges, increasing age and acuity of patients, and, more, all in the setting of demanding schedules. There is much concern about neurocognitive abnormalities and neurological outcomes and very little conversation about the depressed patient. Tully’s review (1) is important and invites the reader to think further on the impact of major depressive disorders on medical conditions, in this case the recovery from cardiac surgery.

Often the patient in the cardiac surgeon’s consulting room is suffering from depression, which can lead to a lack of self-care and to physiological changes. Weight gain, insomnia, inactivity, smoking, alcohol consumption, and noncompliance with treatments such as antihypertensives, statins, and insulin are common in patients who suffer from major depression. In the operating room, depression-driven physiological changes such as hypercortisolemia, elevated catecholamine levels, abnormal platelet activation, increased inflammatory markers, and endothelial dysfunction have real and immediate consequences.

Major depression is predictive of developing cardiac disease and of adverse outcomes among patients with existing cardiac disease and surgery (2). Coronary artery bypass graft (CABG) surgery leads to a 25% incidence of major depression (3) and up to a 75% incidence of adjustment disorder with depressed mood. Screening patients for depression during the preoperative work-up may reap benefits for the patient with regard to the smoothness of the postoperative recovery.

Depressed patients experience more fatigue, pain, insomnia, and anorexia during the postoperative period. Symptoms such as these that can easily be attributed to the effects of surgery might also be caused by major depression. A Geriatric Depression Scale score of 10 or more is more predictive of poor functional improvement after CABG than such traditional measures of disease severity as previous myocardial infarction, heart failure on admission, history of diabetes, and left ventricular ejection fraction (3). Although these patients may be often dismissed as being needy or annoying, their depression could be a signal for poor outcomes and is a risk factor for postoperative delirium.

Studies have shown that there is a delay in getting psychiatric consultations for depressed patients on inpatient units (4). Delayed treatment results in a significant increase in length of stay (5,6), because the symptoms of major depression influence functional recovery post-CABG. Detecting ongoing major depression in a patient who will undergo cardiac surgery will allow the surgical team to get a preoperative psychiatric consult for the patient. Timely psychiatric intervention and follow-up will result in a speedier recovery and a shorter length of stay in this group of patients. Depression impacts outcomes in cardiac surgery and depression management needs to take its proper place on the preoperative cardiac surgery checklist along with such things as glucose management, kidney injury, and blood management.