Article Type : Research Article
Authors : Sayers JL and Stefanatou A
Keywords : Psychological outcomes after CABG; Women artery disease
Post-Traumatic Stress Disorder (PTSD)
symptomatology can complicate physical recovery from illness and surgery after
Coronary Artery Bypass Surgery (CABG). Especially women’s more challenging
recoveries from CABG could not be explained solely by the seriousness of their
illness or level of physical condition.
Post-Traumatic Stress Disorder (PTSD) symptomatology
can complicate physical recovery from illness and surgery after Coronary Artery
Bypass Surgery (CABG). Especially women’s more challenging recoveries from CABG
could not be explained solely by the seriousness of their illness or level of
physical condition. In the case of a patient who is exhibiting symptomatology
outside of symptoms consistent only with depression or anxiety, it is important
to consider the possibility of traumatic stress reactions, or comorbid
traumatic stress and depression. The psychological profile in women but also
the exploration of recent adversity is necessary. Numerous studies have
demonstrated the link between depressive symptoms and recovery from coronary
artery bypass grafting surgery (CABG), and how depression complicates physical
recovery. The estimate of patients suffering post-operative depression is in
the range of 30%- 40% of all CABG patients, with significant levels of anxiety
also present in this population [1].
Additionally, most patients have demonstrated to have some level of
anxiety and/or depression post-surgery.
Although most patients' symptoms resolved satisfactorily within 6
months, 28% of patients struggled with levels of depression that either
remained constant or worsened in that time period [2]. Because both depression
and anxiety are associated with poorer recovery and long-term outcomes,
understanding their relationship, and finding effective interventions can
impact the outcome trajectory of cardiac patients. Unfortunately, the
mechanisms by which psychological symptoms are correlated with physiological
outcomes are not clearly understood1, and as a result there is not a clearly
delineated or consistently applied method of diagnosing and treating patients
at risk for longer-term adverse effects.
Two potential outcomes that have not received as much
attention as depression in the literature are those of Post -Traumatic Stress
Disorder (PTSD) or Acute Stress Disorder (ASD), which are primarily
differentiated from each other by duration: ASD is considered to be a
short-term condition experienced directly after the traumatic event. Symptoms
are grouped in clusters, and some clusters, such as that of negative mood
symptoms can appear to be those of depression [3,4]. One study reported that a
significant number of patients in their sample met diagnostic criteria for PTSD
one month after myocardial infarction (MI) and that this number was higher
among women5. The circumstances of MI are different than those of CABG, in that
MI represents the type of sudden, traumatic, and life-threatening event
necessary for a diagnosis of PTSD [5], as opposed to a planned surgery. Under
some circumstances such sudden medical events can lead to traumatic stress
[4,6]. Panagopoulou [7] reported findings that pre-operative stress alone might
lead to symptoms of traumatic stress, albeit not at diagnostic levels for
either PTSD or ASD. Similarly, Doerfler [8] found notable (although not
statistically significant) levels of PTSD symptomatology above the diagnostic
threshold in a small sample of MI/CABG patients. Thus, in the case of a patient
who is exhibiting symptomatology outside of those symptoms consistent with
depression or anxiety, it is important to consider the possibility of traumatic
stress reactions, or comorbid traumatic stress and depression.
Consistent with the findings that a personality high
in neuroticism may experience more negative psychological impact after CABG,
studies have also found that some factors predict better outcomes, both in
terms of physical and psychological recovery. Both optimism and positive
expectations contributed to less pain and fewer distressing physical symptoms,
which might contribute to a smoother recovery [9]. These findings seem to be
consistent with elements of a theory of postoperative fatigue developed by
Salmon and Hall [10], which suggested that rather than defining postoperative
fatigue in purely physiological terms, it would be more accurate to
conceptualize this fatigue - which has an impact on rate of recovery - as
reflecting psychological dimensions as well. In this view, not only is
treatment for post-op depression and anxiety essential, but also the management
of the pre-op expectations of patients can reduce the period of recovery.
Although the exact mechanisms may not be fully explored, it is suggestive that
having an optimistic personality and positive outlook, perhaps enhanced by
pre-operative education to support realistic perceptions about the recovery
process and aid in problem-solving [11], can lead to a convalescence that is
characterized by appropriate levels of activity rather than depression,
anxiety, and prolonged fatigue. Other personal factors that have been shown to
influence successful recovery are the perception of personal control, with low
levels of perceived personal control predicting slower recovery [11,12] and
maladaptive coping style associated with higher levels of PTSD after MI [13].
In the latter study- which was examining MI rather than CABG but may hold
implications for patients after CABG - older adults who used maladaptive coping
strategies such as suppression and mental disengagement were much more likely
to meet the full diagnostic threshold for PTSD. This finding is consistent with
the DSM-5 risk factors for traumatic stress, which will be discussed in the
below section.
One area of significant environmental impact on
outcomes for patients after CAGB is tied to their ability to engage in adaptive
coping behaviours, that of level of external support. In review of studies [11]
examining quality of life after CABG, social support by a spouse predicted
lower levels of depression and anxiety. Various other types of support
(including financial assistance, emotional closeness, and belonging to a group)
were examined, the feeling of being cared for and respected by others had the
most beneficial effects on emotional recovery.
Risk factors for poor
emotional adjustment
Pre-operative anxiety and depression have been
demonstrated to predict post-operative anxiety and depression [14]. According
to the DSM V [3], risk factors for Major Depressive Disorder (MDD) include a
“neurotic personality/negative affect, a history of depression, first-degree
relatives who have experienced major depression, and a history of adverse
events in childhood” (p. 166). Neuroticism is also a significant predictor of
anxiety, as is related to behavioural inhibition and harm avoidance [3]. As for
either Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD),
neuroticism once again emerges as a significant risk factor for negative
traumatic stress-related psychological outcomes after surgery, as does an
avoidant coping style [3]. In related findings [15], causal attribution - or
the reason the patient believed they became ill -was a significant predictor of
depressive symptoms after CABG, with patients blaming themselves (personality
attribution), stress, and a belief that the illness was "destined"
suffering from more depressive symptoms.
Impact of emotional
adjustment on physical recovery
Ultimately, aside from the added distress that
emotional suffering can add to the pain and physical distress of recovering
from major surgery, disorders such as Major Depressive Disorder, Generalized
Anxiety Disorder, or Posttraumatic Stress Disorder - as well as subclinical
levels of depression, anxiety, and traumatic stress - can complicate physical
recovery from illness and surgery. For example, patients with higher levels of
depressive symptomatology were found to have more difficult recoveries based on
assessments of wound healing, levels of infection, levels of appetite and
energy, and ability to contribute to self-care [16]. They were also found by
the same study to be able to walk shorter distances both at the time of
discharge, and at 6 weeks post-op than non-depressed counterparts [16].
Further, in a review [1] of depression and anxiety and their impact on cardiac
outcomes, findings showed that depressed patients were less willing/able to
participate in cardiac rehabilitation after surgery and suggested that this
could lead to poorer long-term cardiac outcomes. Similarly, Connemey [17] found
that CABG patients meeting the criteria for MDD after surgery had a
significantly greater likelihood of experiencing another cardiac emergency
within a year (such as MI, cardiac arrest, and repeat CABG), and that they were
more than twice as likely to enter the hospital or die during the year
following surgery than nondepressed cardiac patients in the sample. Some of
the reasons suggested for this included their lower participation in
rehabilitative care, their lower rates of medication uptake, and less
willingness to modify their lifestyles [16,17]. In terms of traumatic stress,
especially when it is combined with depression, the outlook for long-term
recovery is similarly bleak. Dao [18]
discovered that comorbid depression and PTSD significantly increased the
mortality rate for patients after CABG, with the comorbid depression and PTSD
having mortality rates 4 times higher than those CABG patients who did not
suffer from these disorders. Interestingly, this study suggested that other
physiological factors associated with depression and/or PTSD, such as altered
activity in the autonomic nervous system or increased resting heart rate, might
be associated with the higher levels of mortality. These findings, especially
when taken together with findings that suggest that behavioural factors also
may play a part in higher mortality rates for patients suffering from
depression and PTSD, lead to a complex picture whereby - once again - it seems
obvious that identified patients are vitally in need of intervention, but there
is no clear mode of intervention that will necessarily provide for every
eventuality.
Gender differences
Virtually every study reviewed here used gender as a
unit of analysis when examining the prevalence of depressive symptomatology in
patients undergoing CABG. The outcomes associated with depression and/or
traumatic stress in these patients, and the recovery trajectory experienced by
all patients studied, including those with depression/anxiety/traumatic stress,
and those without. The study by Connerney [17] not only found greater levels of
additional cardiac events and/or mortality in patients meeting the diagnostic
criteria for major depressive disorder, but also found that female gender was
one of the predictive factors for future cardiac events and had higher levels
of post-operative morbidity and mortality overall. While this study looked at
women's recovery over the period of a year post-CABG, Vaccarino [19] examined a
sample both prior to surgery and again between 6-8 weeks after surgery and
found that not only did women report more depressive symptoms prior to surgery,
but they had higher rates of readmission after surgery, had increased
depressive symptomatology, and lower physical functioning post-op when compared
to men. Overall, this study found that women's more challenging recoveries from
CABG could not be explained solely by the seriousness of their illness or level
of physical condition. In general, higher levels of pre-operative depression
have consistently been found in women [1-12]. Women are not only more depressed
both before and after surgery, but they are more likely to make causal
attributions for their illness that are associated with depression [15], and
women are more likely to be unpartnered, which is itself associated with higher
rates of depression [2]. McKenzie [14] conducted a review of studies that
examined pre-CABG predictors of post-CABG depression and/or anxiety and
reported mixed results with regards to gender. They suggested that the greater
willingness of women to self-report depression might lead to skewed results in studies
using this method of determining depression. Similarly, Dao [18] did not report
significant differences in their study of mortality associated with depression
and PTSD. Whether or not individual studies vary in their findings due to
reporting differences, as mentioned above, it appears from the literature, when
taken as a whole, that women who have undergone CABG are at some level of
greater risk of poorer outcomes as associated with depression and anxiety. In
2018 a study [20] investigated the differences in disease experience and mood
between patients undergoing cardiac rehabilitation after CABG or after valve
replacement (VR). Scores in the psychosomatic concern scale were more frequent
in CABG than in VR patients. Anxiety and
depression scores did not differ between the two groups – no differences in
gender were reported. Results suggested providing psychological support for
anxiety and depression to both VR and CABG patients during cardiac
rehabilitation. Planning differentiated interventions of cardiac rehabilitation
and secondary prevention tailored to the specific psychological reactions of
CABG and VR patients could be the solution.
There are a number of factors associated with
psychological outcomes after CABG that were not mentioned here (or only briefly
mentioned). There is not a great deal of literature that addresses PTSD in
conjunction with CABG, but there is no doubt that the potential impact of this
diagnosis on long-term recovery is significant. The psychological profile in
women but also the exploration of recent adversity is necessary [21]. To
illustrate, a history of adverse childhood events coupled with
neurotic/negative affectivity and avoidant coping style would suggest that the
recovery, both physically and psychologically, could be difficult. On the other
hand, the demonstration of high levels of self-efficacy (a usual characteristic
in women’s functioning) may explain why the perceived loss of control over
health and medical decisions have such a strong negative impact on emotional
adjustment post-surgery. An intervention
that draws upon the patient’s own strength and social support, magnifies the
chance of a positive outcome in recovery.