Addressing the mental health of Canadians waiting for elective surgery: a potential positive post-pandemic legacy

Summary

The impact of waiting for surgery on the mental health of patients usually receives little attention. Because of the coronavirus disease 2019 (COVID-19) pandemic, the waits for elective surgery have been lengthening, potentially inducing or exacerbating mental health burdens. Provinces’ health systems need to provide better support to assess not only patients’ physical health, but also their mental health, and provide them with timely access to care based on need. A stepped care approach is needed to mitigate negative mental health effects associated with prolonged waits for elective operations. To provide the best care possible, we need to recognize and address both the physical and mental health problems of our waiting patients.

The coronavirus disease 2019 (COVID-19) pandemic has strained many aspects of Canadian health care, especially access to elective surgery. With wait times already relatively long, surgeries for more than 100 000 Canadians have been either delayed or cancelled because of the pandemic. While the physical effects of these treatment delays are readily recognized and treated, the impact of waiting for surgery on the mental health of patients usually receives little attention.

About 20% of Canadians experience mental illness in any given year, and rates of anxiety, depression and substance abuse have increased since the start of the pandemic. Unfortunately, the further lengthening of waits for elective surgery may induce or exacerbate mental health burdens associated with COVID-19.^1–3 In Canada, the government of British Columbia is thus far alone in providing a general timeline in their prediction of the 17–24 months needed to add new capacity, catch up with the approximately 24 000 elective surgeries that were either cancelled or delayed, and restore prepandemic surgical case volumes.⁴ Mental health affects surgical outcomes and length of hospital stay.⁵ There is excellent evidence for physically optimizing patients before surgery through smoking cessation, physical activity and nutrition. Likewise, we also need to recognize the contribution of mental health and provide resources for patients’ whose symptoms and ability to self-care have been affected by the pandemic.

Equity is also a critically important issue, as people with mental illness are less likely to access surgery and their survival can even be affected. Indeed, the provinces of British Columbia, Alberta and Ontario recently released roadmaps for restarting elective operations, and they prioritize surgical access based on diagnosis. This means that surgeons must perform a manual over-ride to reflect patients’ symptom severity or pain. Better supports are needed to allow surgical teams to properly assess not only patients’ physical health, but also their mental health, and provide them with timely access to care based on need.

As Canadian hospitals are “ramping up” their elective operations, governments, hospital administrators, surgeons and referring doctors have limited evidence-based tools for prospectively prioritizing people who are waiting for surgery. However, since 2012 the Vancouver Coastal Health Authority, Providence Health Care and the University of British Columbia have partnered to survey patients awaiting elective surgery about their mental health and wellness. The results document that depression, anxiety, pain and insomnia are common in people waiting for an elective operation. This work may provide a template for other health regions on how patient-reported outcomes could be used to periodically screen the mental health of patients on surgical wait lists and selectively offer them further assessments and interventions. Surgical teams could also screen patients in their own practices to increase awareness of the impact of waiting on their patients’ mental health. In turn, this information could be used to help inform prioritization strategies. Further measures should also include improved communication and cohesion of teams based in facilities and communities so that primary care physicians, surgeons, allied staff and administrators can work together to bring needed mental health screening resources to their patients and communities.

Once mental health problems have been identified, low-intensity coping and mindfulness interventions that have been shown to be effective can be offered. An example is Ontario’s BounceBack program where coach-based telephone interventions are used under the supervision of clinical psychologists to monitor patients’ progress, offer resources and screen for symptoms of depression using the Patient Health Questionnaire-9 (PHQ-9).⁶ For patients who do not respond to low-intensity intervention, a stepped care approach can offer higher-intensity psychotherapy or psychiatric treatment to mitigate the negative mental health effects of prolonged waits for elective operations. Provincial or federal funding could be directed toward these low-intensity or coach-based interventions with required training, which takes less than 2 months.

Governments are understandably reluctant to expand publicly funded health care services during a time of economic uncertainty attributable to the pandemic. But the question for policy-makers is whether we can afford not to offer mental health services to individuals expected to experience prolonged wait times for their operations, as inaction will lead to higher costs later in the forms of human suffering, greater pressure on primary care physicians to manage progressing preoperative symptoms, and increased financial costs due to disability and utilization of medical services.

As we move through different phases of the COVID-19 pandemic, we need to consider that many surgeries labelled “elective” or “nonurgent” are crucial to the quality of life and function of the patients waiting for them. To provide the best care possible, we need to recognize, measure and address both the physical and mental health problems of our patients. With coordinated effort, we can work together so that “whole-person” preoperative care emerges as a positive legacy during Canada’s recovery from COVID-19.