Behavioral Health in Surgical Settings

Gregory M. Borst, MD

Trauma/Acute Care Surgery Fellow

University of Colorado Anschutz Medical Campus

Denver Health Medical Center

Christine E. W. Borst, PhD, LMFT

Clinical Assistant Professor

Doctor of Behavioral Health

Arizona State University

Disclosures

• No financial disclosures

• Any opinion given by Dr. Greg Borst represents his own opinions and is not necessarily representative of the opinions of the University of Colorado or Denver Health Medical Center

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify ways in which behavioral health affects surgical patients

• Review benefits of pre- and post-operative management of behavioral concerns

• Describe the potential roles behavioral health practitioners may play in the care of surgical patients

The Stereotypical Surgeon

• Cold

• Egotistical

• Short-tempered

• Moves at a rapid pace

• Fixes things

• Pays little attention to emotional issues

• Doesn’t care/doesn’t have time for behavioral or psychiatric issues

Cases to Consider

Case One

• A 25 year-old police officer shot in chest during training exercise. Undergoes chest operation for massive bleeding and does well, walks out of the hospital 5 days later.

• Heals well without physical disability

• Severe PTSD, unable to work in law enforcement, disability

• Alcoholism, substance abuse, depression

• Divorce

Case Two• 65 year-old man with depression

and colon cancer undergoes a routine colon resection for a cancerous polyp.

• Post-operative pain control issues and won’t participate in physical/occupational therapy, does not breathe deep or cough

• Respiratory failure, pneumonia, tracheostomy

• 24 day length of stay

• 3 readmissions within 9 months (pneumonia, GI bleed, fall)

• Dies 10 months post-op

Case Three

• A 19 year old man is shot in the abdomen and left arm. Sustains a left humerus fracture and no major intraabdominal injuries

• Does not cooperate with police; anger issues in hospital

• Elopes from hospital

• Suspected in shooting in following weeks

• Dies in shootout with police attempting to arrest him

• One police officer injured

Theoretical Foundation

Biopsychosocial-Spiritual Model

• Biopsychosocial model – George Engel (Mayo Clinic psychiatrist), 1977

• Spiritual aspect added later• Theory of health

• Bio – pathophysiological processes of health

• Psycho – psychological, mental, and behavioral issues contributing to health and how health is experienced

• Social – societal, family, cultural influences on health

• Spiritual – religion/spirituality influencing views of health and disease

(Engel, 1977)

Health Affects Behavior

• Chronic medical problems are associated with higher rates of depression

• Increased duration of illness correlates with increased rates of depression

• Substance abuse frequently co-occurs with chronic illness

(Simon, 2002)

Behavior Affects Health• Stress

• Drug use

• Alcohol use

• Smoking

• Diet

• Exercise

• Compliance

• Preventative medicine

(IOM, 2001)

Behavior Affects Health

(Schroeder, 2007)

Behaviors Impact Need for Surgery

• Behavior leads to surgical indication• Traumatic injury

• Lung cancer, cardiovascular disease

• Morbid obesity

• Medication non-compliance

• Behavior may affect outcome post-operatively• Wound healing

• Length of stay

• Pain control

(Gouin & Kiecolt-Glaser, 2011)

Family/Social Influences on Health

• Social support for recovery

• Married individuals have less morbidity and mortality from cancer, heart attacks, and following surgeries

• Family/relationship stress slows healing

• Cultural influence

(Kiecolt-Glaser et al., 2005)

Spirituality and Health

• Provides coping mechanism

• Provides social support

• Meditation and relaxation

• Provides hope for the future

(Contrada et al., 2004)

Rethinking Care

• Stigma of mental illness

• Incorrect beliefs/assumptions re: behavioral health by medical professionals • Patients with a mental illness diagnosis are not the only ones who would

benefit from behavioral health consultation

• It’s “normal” to have: • Dysfunctional thought patterns

• Dysfunctional behaviors

• Dysfunctional relationships

Rethinking Care

• Surgery/Trauma is not a “normal” experience• Grief

• Pain

• Depression/Anxiety

• PTSD

• Psychosocial distress

• Interventions post-surgery/trauma may help improve coping and possibly circumvent maladaptive behavior

• Can help patients understand when actions/thoughts/behaviors become maladaptive and worrisome

Integration is More Than a Psych Referral

• Integration provides tools to patients to aid in: • Adaptation

• Insight

• Problem-solving

• Coping

• Resolving conflicts

• Expectations

Application to Surgery

Depression Affects Inflammatory Response

• IL-1β, IL-6, TNF-α – important markers for inflammation and mediators of local and systemic inflammatory responses

• Correlation between major depressive disorder and high levels of circulating inflammatory mediators

• Inflammation can increase the occurrence of major depressive episodes in animal models

• IL-6 and TNF-α significantly decrease when treated with an anti-depressant

• Despite high levels of systemic inflammation, the local inflammatory response is impaired in depressed individuals

(Soledad Cepada, Stang, & Makadia, 2016)

Behavior Affects Biology

• 16 sessions of psychotherapy

• Significant decrease in depressive symptoms

• Significant decrease in serum IL-6 and TNF-α

(Del Grande da Silva et al., 2016)

Stress Affects Wound Healing

• 13 volunteers who care for a family member with Alzheimer’s vs 13 age-matched healthy volunteers as control

• 3.5 mm punch biopsy of the skin

• Control group healed 9 days faster than did the caregivers

• WBC from control group produced more IL-1

(Kiecolt-Glaser, Marucha, Malarkey, Mercado, & Glaser, 1999)

Depression Affects Wound Healing

• 183 healthy volunteers at UCLA

• Beck Depression Inventory

• 3.5 mm wound hard palate

• High depression score predicted slow wound healing

(Bosch, Engeland, Cacioppo, & Marucha, 2007)

Stress and Surgery

• 47 adults undergoing open inguinal hernia repair

• Preoperative questionnaire about stress and worry about the operation

• 30 volunteers had fluid aspirated from wound following surgery

• High perceived stress –> lower IL-1 in wound aspirates

• Higher worry • Higher pain

• Slower recovery

• Worse overall recovery

(Broadbent, Petrie, Alley, & Booth, 2003)

Behavioral Health Affects Wound Healing

• Blisters of women with high stress had lower levels of inflammatory mediators

• Punch biopsies in men showed that fast healers had high optimism

• Burn victims with higher stress scores healed more slowly

• Patients with concurrent diabetes and depression were twice as likely to have a diabetic foot ulcer

(Christian, Graham, Padgett, Glaser, & Kiecolt-Glaser, 2006; Kiecolt-Glaser et al., 2005)

Relationships Affect Wound Healing

• Physically healthy couples with high hostility healed at 60% of the rate of couples with low hostility

• Local IL-6, TNF-α and IL-1β lower following marital conflicts

• High hostility couples produced larger increases in plasma IL-6 and TNF-α following conflict

(Kiecolt-Glaser et al., 2005)

Behavioral Health in Various Surgical Populations

Bariatric Surgery

• Preoperative evaluation of mental health is the standard of care• 2/3 surgery applicants have lifetime history of psychiatric disorder• 65-70% receive recommendation to proceed with surgery

• Reasons for denying or delaying surgery:• Significant psychopathology (bipolar, psychosis)• Untreated/undertreated depression• Lack of understanding of surgery and post-operative expectations• Active substance abuse• Eating disorder• Severe personality disorder• Psychosocial factors

(Walfish, Vance, & Fabricatore, 2007)

Bariatric Surgery

• Number of pre-surgery psychiatric hospitalizations• increased in complication

• increased distress

• decreased satisfaction

(Beaulac & Sandre, 2015; Gade et al., 2015; Himes et al., 2015)

• Binge eating behaviors predict poorer weight loss and long-term outcomes

• Higher divorce rate in 3 years following bariatric surgery

Bariatric Surgery• Pre-op CBT

• Assess goals and understanding of the procedure

• Weight/dieting history

• Binge eating and psychopathology

• Assess family/relationship factors

• Recommend less invasive options

• Post-operative CBT• Improves psychological distress

• Decreased perceived life difficulty and depressive symptoms

• Improved weight-related adjustment

• Less emotional overeating and relationship anxiety

• Long-term Adjustment• Prevent re-gain

• Maintain healthy behaviors

(Beaulac & Sandre, 2015; Gade et al., 2015; Himes et al., 2015)

Trauma

• Study of patients with facial trauma

• Poor outcomes associated with:• Hospital days

• ICU days

• Surgical procedures

• Major complications

• Age

• Recurrent injury

• Inadequate information

• 1/3 of patients reported depression

• 1/3 of patients reported PTSD

• *Zero patients sought mental health follow up for PTSD/Depression*

(Sluys, Haggmark, & Iselius, 2005)

Trauma• Mental health outcome directly

influences:• General health

• Work status

• Satisfaction with recovery

• No patient returned to baseline by 12 months

(Michaels et al., 2000)

Trauma

• Pain intensity related to:• Catastrophizing

• Depressive symptoms

• Depressive symptoms associated with poor physical health and pain interference with activity

• Higher pain predictive of eventual disability

• High fear of movement was not associated with disability

Both responsive to CBT

(Archer, Abraham, & Obremeskey, 2015)

Cardiac Surgery

• 67 women post CABG

• Patients with major depression:• Had lower NK cell cytotoxicity

(NKCC)

• Had higher rate of infectious illness in 6 months following surgery

• Depressed patients:• Higher rate of post-op fever

• Higher infectious illness rate

• CBT moderate to large effects• Improved NKCC

• Decreased IL-6

• Decreased CRP

• Decreased infectious illness

(Doering, Cross, Vredevoe, Martinez-Maza, & Cowan, 2007; Doering, Martinez-Maza, Vredevoe, & Cowan, 2008)

Cardiac Surgery• Patients with depression

• Risk factor for delirium• Predictor of participation/completion of cardiac rehab• Twice as likely to have a cardiac event at 1 year• Increased risk of cardiac mortality • Increased unplanned readmissions• Poorer quality of life• Higher rate of arrhythmia and angina at 5 years

• Preoperative anxiety• Greater all-cause mortality with CABG• Greater rate of post-op atrial fibrillation• Increased risk of in-hospital stroke, MI and renal failure

(Tully & Baker, 2012)

Spine Surgery

• 90 patients

• Significantly improved quality-adjusted life years

• Significantly larger disability reductions (3 & 6 months, not 1 year)

• No difference in cost

• 86 patients

• Significant decreases • Back and leg pain

• Disability

• Significant improvement• General health

• Mental health

• Faster improvement in PT exercises

(Archer et al., 2016; Rolving et al., 2016)

Behavioral Interventions

Potential Interventions

• Pain and symptom management

• Motivational interviewing• PT/OT participation• Compliance with treatment

• Treating pre-existing depression/anxiety

• Preventing PTSD, adjustment disorders, depression

• Improving family interactions and support

• Preparing for discharge

Cognitive Behavioral Therapy

• Effective in management of chronic low back pain

• Adjunctive treatment in fibromyalgia

• Early CBT can prevent post-partum depression in high-risk mothers

• Can prevent PTSD in patients at high risk following a trauma

(Cho, Kwon, & Lee, 2008; Thys, Coulter, & Hudson, 2016; Vinci, Coffey, & Norquist, 2015)

Mindfulness

• Inflammatory bowel disease• Mindfulness vs. control• Significant improvement in

depression, anxiety, quality of life• Maintained improvements for at least

6 months

• Ulcerative Colitis • Lower stress levels during flares• Prevented drops in QOL during flares• No overall reduction in flare

frequency• Reduction in frequency in high-stress

individuals

(Schoultz, Atherton, & Watson, 2015)

Benefits to Patients

• Reduced postoperative pain

• Decreased length of stay

• Improved functional recovery

• Increased communication

• Improved follow-up

• Increased patient satisfaction

• Improves quality of care

(DiGiola, Greenhouse, & Levison, 2007: Petrie & Zatzick, 2010; Rollman& Belnap, 2011)

Other Borst Collaborations

Questions/Comments

References

• Archer, K.R., Abraham, C.M., & Obremeskey, W.T. (2015). Psychosocial factors predict pain and physical health after lower extremity trauma. Clinical Orthopedics and Related Research, 473, 3519-3526.

• Archer, K.R., Devin, C.J., Vanston, S.W., Koyama, T., Phillips, S.E., George, S.Z., McGirt, M.J., Spengler, D.M., Aaronson, O.S., Cheng, J.S., and Wegener, S.T. (2016). Cognitivie-behavioral-based physical therapy for patients with chronic pain undergoing lumbar spine surgery: A randomized control trial. Journal of Pain, 17(1), 76-89.

• Beaulac, J., & Sandre, D. (2015). Impact of a CBT psychotherapy group on post-operative bariatric patients. Springerplus, 4, 764-768.

• Bosch, J.A., Engeland, C.G., Cacioppo, J.T., Marucha, P.T. (2007). Depressive symptoms predict mucosal wound healing. Psychosomatic Medicine, 69(7), 597-605.

• Broadbent, E., Petrie, K.J., Alley, P.G., & Booth, R.J. (2003). Psychological stress impairs early wound repair wound repair following surgery. Psychosomatic Medicine, 66(5), 865-869.

• Cho, H.J., Kwon, J.H., & Lee, J.J. (2008). Antenatal cognitive behavioral therapy for prevention of postpartum depression: A pilot study. Yonsei Medical Journal, 49(4), 553-562.

• Christian, L.M., Graham, J.E., Padgett, D.A., Glaser, R., & Kiecolt-Glaser, J.K. (2006). Neuroimmunomodulation, 13(5-6), 337-346

• Contrada, R.J., Goyal, T.M., Cather, C., Rafalson, L., Idler, E.L., & Krause, T.J. (2004). Psychosocial factors in outcomes of heart surgery: The impact of religious involvement and depressive symptoms. Health Psychology, 23(3), 227-238.

• Del Grande da Silva, G., Wiener, C.D., Barbosa, L.P., Araujo, J.M.G., Molina, M.L., San Martin, P., Oses, J.P., Jansen, K., Dias de Mattos Souza, L., & Azevedo da Silva, R. (2016). Pro-inflammatory cytokines and psychotherapy in depression: Results from a randomized clinical trial. Journal of Psychiatric Research,75, 57-64.

• DiGiola, A., Greenhouse, & Levison, T.J. (2007). Patient and family-centered collaborative care: An orthopaedic model. Clinical Orthopedics & Related Research, 463, 13-19.

References

• Doering, L.V., Martinez-Maza, O., Vredevoe, D.L., & Cowan, M.J. (2008). Relation of depression, natural killer cell function, and infections after coronary artery bypass in women. European Journal of Cardiovascular Nursing, 7, 52-58.

• Doering, L.V., Cross, R., Vredevoe, D., Martinez-Maza, O., & Cowan, M.J. (2007). Infection, depression, and immunity in women after coronary artery bypass: A pilot study of cognitive behavioral therapy. Alternative Therapies, 13(3), 18-21.

• Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196 (4286), 129-136.

• Gade, H., Friborg, Ol, Rosenvinge, J.H., Smastuen, M.C., & Hjelmesaeth, J. (2015). The impact of a preoperative cognitive behavioural therapy (CBT) on dysfunctional eating behaviours, affective symptoms and body weight 1 year after bariatric surgery: A randomized controlled trial. Obesity Surgery, 25(11), 2112-2119.

• Gouin, J.P., & Kiecolt-Glaser, J.K. (2011). The impact of psychological stress on wound healing: Methods and mechanisms. Immunology and Allergy Clinics of North America, 31(1), 81-93.

• Himes, S.M., Grothe, K.B., Clark, M.M., Swain, J.M., Collazo-Clavell, M.L., & Sarr, M.G. (2015). Stop regain: A pilot psychological intervention for bariatric patients experiencing weight regain. Obesity Surgery, 25(5), 922-927.

• Institute of Medicine Committee on Health and Behavior: Research, Practice, and Policy. (2001). Health and behavior: The interplay of biological, behavioral, and societal influences. Washington, DC: National Academies Press.

• Kiecolt-Glaser, J.K., Loving, T.J., Stowell, J.R., Malarkey, W.B., Lemeshow, S., Dickenson, S.L., & Glaser, R. (2005). Hostile marital interactions, proinflammatory cytokine production, and wound healing. Archives of General Psychiatry, 62, 1377-1384.

• Kiecolt-Glaser, J.K., Marucha, P.T., Malarkey, W.B., Mercado, A.M., Glaser, R., (1999). Slowing of wound healing by psychological stress. Lancet,346(8984), 1194-1196.

• Petrie, M., & Zatzick, D. (2010). Collaborative care interventions in general trauma patients. Oral Maxillofacial Surgery Clinics of North America, 22(2), 261-267.

References

• Petrie, M., & Zatzick, D. (2010). Collaborative care interventions in general trauma patients. Oral Maxillofacial Surgery Clinics of North America, 22(2), 261-267.

• Michaels, A.J., Michaels, C.E., Smith, J.S., Moon, C.H., Peterson, C., & Long, W.B. (2000). Outcome from injury: General health, work status, and satisfaction 12 months after trauma. Journal of Trauma, 48(5), 841-850.

• Rollman, B.L., & Belnap, B.H. (2011). The Bypassing the Blues trial: Collaborative care for post-CABG depression and implications for future research. Cleveland Clinic Journal of Medicine, 78 Supplement 1, S4-S12.

• Rolving, N., Sogaard, R., Nielsen, C.V., Christensen, F.B., Bunger, C., & Oestergaard, L.G. (2016). Preoperative cognitive behavioral patient education versus standard care for lumbar spinal fusion patients: Economic evaluation alongside a randomized controlled trial. Spine, 41(1), 18-25.

• Schoultz, M., Atherton, I., & Watson, A. (2015). Mindfulness-based cognitive therapy for inflammatory bowel disease patients: Findings from an exploratory pilot randomized controlled trial. Trials, 16, 379-391.

• Schroeder, S.A. (2007). We can do better – improving the health of the American people. The New England Journal of Medicine, 357(12), 1221-1228.

• Simon, G.E. (2002). Treating depression in patients with chronic disease. Western Journal of Medicine, 175(5), 292-293.

• Sluys, K., Haggmark, T., & Iselius, L. (2005). Outcome and quality of life 5 years after major trauma. Journal of Trauma, 59(1), 223-232.

• Soledad Cepada, M., Stang, P., & Makadia, R. (2016). Depression is associated with high levels of c-reactive protein and low levels of fractional exhaled nitric oxide: Results from the 2007-2012 National Health and Nutrition Examination Surveys. Journal of Clinical Psychology, 77(12), 1666-1671.

• Thys, S., Coulter, L., & Hudson, J. (2016). Is cognitive behavioral therapy (CBT) an effective treatment for fibromyalgia? Evidence Based Practice, 19(7), 9.

• Tully, P.J., & Baker, R.A. (2012). Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: A contemporary and practical review. Journal of Geriatric Cardiology, 9, 197-208.

• Veysman, B. (2005). Physician, know thyself. British Medical Journal, 331, p. 1529

• Vinci, C., Coffey, S.F., & Norquist, G.S. (2015). When to recommend cognitive behavioral therapy. The Journal of Family Practice, 64(4), 232-237.

• Walfish, S., Vance, D., & Fabricatore, A.N. (2007). Psychological evaluation of bariatric surgery applicants: Procedures and reasons for delay or denial of surgery. Obesity Surgery, 17, 1578-1583.