Psychiatric illnesses before surgery associated with modest increased risk of death afterward

October 18, 2010

Individuals with co-occurring psychiatric illnesses, especially anxiety and depression, appear to have an increased risk of death within 30 days of surgery, according to a report in the October issue of Archives of Surgery, one of the JAMA/Archives journals.

Psychiatric illnesses occur along with physical complaints in an estimated 5 percent to 40 percent of hospitalized patients, according to background information in the article. Having a psychiatric condition is independently associated with an increased risk of illness and death. Previous studies of these conditions have largely been limited to patients admitted to the hospital for medical conditions, not surgical procedures.

Thad E. Abrams, M.D., M.S., of the Iowa City Veterans Affairs Medical Center and University of Iowa Carver College of Medicine, Iowa City, and colleagues studied 35,539 surgical patients admitted to intensive care units from Oct. 1, 2003, through Sept. 30, 2006. An existing psychiatric condition was identified in 8,922 (25.1 percent) of the patients, including 5,500 (15.5 percent) with depression, 2,913 (8.2 percent) with post-traumatic stress disorder, 2,473 (7 percent) with anxiety, 793 (2.2 percent) with bipolar disorder and 621 (1.8 percent) with psychosis.

Before adjustment, 30-day death rates were similar among patients with and without psychiatric illnesses (3.8 percent vs. 4 percent). However, after the researchers considered other factors in their analyses, 30-day death rates were higher for patients with psychiatric conditions.

In individual analyses, the risk of dying within 30 days was associated with depression and anxiety, but not with any other psychiatric condition. In addition, 30-day death rates among those with psychiatric conditions were higher for those undergoing respiratory or digestive system procedures but not procedures involving the circulatory, nervous or musculoskeletal system.

"Several potential mechanisms exist to explain these findings," the authors write. "First, studies indicate that patients with depression frequently do not adhere to medical recommendations for underlying medical conditions. It is therefore plausible that such undertreated conditions may affect postoperative care and outcomes. Second, patients with existing psychiatric comorbidity may be more likely to undergo surgery by a lower-quality surgeon or hospital. Third, pre-existing psychiatric comorbidity may serve as an indicator for greater severity of surgical risk."

The results suggest greater care should be taken among patients with a psychiatric illness who are undergoing surgery, the authors note. "Until further research is completed, we recommend that surgeons caring for patients with a history of anxiety or depression seek early involvement of multidisciplinary teams to help identify problematic areas in perioperative care processes, particularly regarding issues of surgeon-patient communication and adherence to post-surgical recommendations."
-end-
(Arch Surg. 2010;145[10]:947-953. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This research was supported by a grant from the Department of Veterans Affairs, Veterans Health Administration, through the Health Services Research and Development Service and through a post-doctoral fellowship award in Health Services Research to Dr. Abrams from the Office of Academic Affiliations. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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