Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective

Abstract

This study sought to explore the impact of the psychological variables anxiety and depression, on pain experience over time following surgery. Eighty-five women having major gynaecological surgery were assessed for anxiety, depression and pain after surgery. To gain further understanding, 37 patients participated in a semi-structured taped telephone interview 4–6 weeks post-operatively.

Pre-operative anxiety was found to be predictive of post-operative anxiety on Day 2, with patients who experienced high levels of anxiety before surgery continuing to feel anxious afterwards. By Day 4 both anxiety and depression scores increased as pain increased and one-third of the sample experienced levels of anxiety in psychiatric proportions whilst under one-third experienced similar levels of depression.

These findings have significant implications for the provision of acute pain management after surgery. Future research and those managing acute pain services need to consider the multidimensional effect of acute pain and the interface between primary and secondary care.

Introduction

Admission to hospital and the prospect of surgery is accepted as extremely anxiety-provoking (Speilberger et al., 1973; Johnson et al., 1978; Teasdale, 1995; Shuldham et al., 1995; Caumo et al., 2001) resulting in behavioural and cognitive sequelae which can have far reaching effects on recovery (Wilson-Barnett and Batehup, 1988; Kiecolt-Glaser et al., 1998). Numerous studies have demonstrated positive relationships between anxiety and pain, with those less anxious patients experiencing less pain (Seers, 1987; Thomas et al., 1995; de Groot et al., 1997).

Studies exploring the relationship between psychological factors and post-operative pain have predominantly focused on anxiety, leaving depression relatively unexplored (Boeke et al., 1991; Shuldham et al., 1995). Boeke et al. (1991) examined the ability of ‘anxiety’ to predict post-operative pain in 111 patients with gallstones. In the paper they repeatedly wrote about ‘psychological stress’ and ‘psychological variables’ rather than anxiety, suggesting that anxiety represented a range of psychological variables rather than a discrete construct.

Anxiety has been defined as ‘a state of uneasiness or tension’ (Collins Dictionary of the English Language, 1999, p. 64) which Speilberger et al. (1973) suggest relates to two components; state anxiety (A-State) which is associated with a dangerous situation and trait anxiety (A-Trait) which reflects anxiety proneness. Depression has been defined as an emotion dominated by sadness and associated with feelings of hopelessness and gloom (Watson et al., 1995). Boyer et al. (2000) view depressive symptomology as having three discrete phases of symptom clusters: anxiety (irritability, disturbances in sleep-waking rhymn); depressive (mood tone, alertness and concentration) and hedonic (renewed interest, making plans and restored self-image). It has been suggested that the traditional diagnostic systems do not adequately describe the nature, range and aetiology seen with comorbidity of physical illness (Clarke et al., 2003). They suggest that anxiety and depression could be identified as common syndromes of distress in the medically ill.

A review of 97 research reports dealing with peri-operative care identified anxiety as a main focus of research but no mention was made of depression (Leinonen and Leino-Kilpi, 1999). The narrow focus on anxiety neglects depression, which has been studied extensively in patients with cancer pain (Noyes and Kathol, 1986; Massie and Holland, 1990; Carroll et al., 1993; White et al., 1997), chronic pain populations (Bukberg et al., 1984; Magni et al., 1990; Hitchcock et al., 1994) and sickle cell pain (Pallister, 1992; Thomas et al., 2001) but remains a minority interest in acute pain.

Predictive roles of anxiety and depression have been reported using the Hospital Anxiety and Depression Scale (HADS) in cancer patients, before and after treatment as well as for evaluations of mental health in long-term survivors (Hammerlid et al., 1999; Hopwood and Stephens, 2000). The few researchers examining depression in the surgical pain population are Taezner et al. (1986); Gammon and Mulholland (1996); Gillies et al. (1999). Taezner et al. (1986) explored the influence of a number of psychological factors on pain, including anxiety and depression, following elective cholecystectomy ($n=40$). Using the Beck Depression Inventory (Beck et al., 1961), they found that high levels of pre-operative depressive symptoms correlated with all the post-operative pain measures, whilst pre-operative anxiety was unrelated.

A different pattern of the depression–pain relationship was observed by Gillies et al. (1999) who studied 351 adolescents undergoing elective surgery. They found that although depression on the HADS was less than 4% pre-operatively, it rose to 29% post-operatively, and patients with depression were significantly more likely to experience moderate to severe pain post-operatively.

Interventions that enhance personal control appear to have modifying effects on both anxiety and depression; for example, a small study evaluating the effect of preparatory information prior to total hip replacement on psychological coping outcomes (Gammon and Mulholland, 1996). They found that the intervention group experienced significantly less anxiety and depression, which was negatively correlated with their view of their own ability to cope. Generalisations from these findings should be cautious, as no account was taken of personality and situational factors, but they suggest that depression may be involved with the experience of post-operative pain through its ability to influence coping.

In summary, this brief review points to the important predictive roles of anxiety and depression on post-operative pain. Pain has been viewed as a multidimensional experience with sensory, motivational and affective components (Melzack and Wall, 1988). Concerns about psychological morbidity in the surgical population have been highlighted by the publication of a report from the Royal College of Surgeons of England & the Royal College of Psychiatrists pertaining to the psychological care of surgical patients (1997). A lack of psychological care in hospital has precipitated the call for practitioners to have skills to identify psychological problems, offer psychological care and know when and how to refer for psychiatric help (House et al., 1995). Whilst there have been many studies exploring anxiety, and to a lesser extent depression, in the surgical population, few studies have sought to gain an understanding of factors contributing to these findings. This study sought to explore the impact of psychological variables anxiety and depression on pain experience over time following surgery.