Facing major surgery is stressful, but for older adults, unaddressed anxiety and depression can impede physical recovery.
A clinical trial led by researchers at Washington University School of Medicine in St. Louis has found that starting an intervention before surgery — one that combines mental health coaching with optimization of medications that may increase risks for older adults — reduces post-surgery anxiety and depression.
“The time around surgery is a window of both risk and opportunity,” said the study’s first author Joanna Abraham, PhD , a professor in the Department of Anesthesiology at WashU Medicine. “The stress of surgery can worsen anxiety and depression symptoms and affect patients’ recovery and overall health, but it also offers a critical opportunity to identify these concerns proactively and connect patients with the support they need.”
The study, published Sept. 9 in JAMA Network Open, supports including mental health care and medication optimization into routine pre-surgical care.
“We recognize the importance of getting the body into shape before surgery, but preparing the mind and the brain is just as important,” said the study’s senior author Eric J. Lenze, MD , the Wallace and Lucille K. Renard Professor of Psychiatry and head of the WashU Medicine Department of Psychiatry. “Patients undergoing major surgery hope for a better life afterward, and our study shows that taking care of emotional well-being and optimizing medications can help deliver that outcome.”
Addressing emotional distress, high-risk medications
Up to 33% of older surgical patients in the U.S. experience depression, and 22% experience anxiety before surgery. In addition, older patients are frequently on multiple drugs that affect the brain, including sedatives, muscle relaxants or over-the-counter sleep aids. Without routine re-evaluation for safety or necessity, these prescriptions can accumulate and increase risks such as sedation, confusion and falls, and high-risk medications can also raise an older patient’s odds of post-surgery confusion, dangerous falls and long-term physical pain.
Traditional perioperative care — the care patients receive before, during and after surgery — focuses on physical healing, often leaving emotional distress untreated, explained Lenze. To close this gap, the researchers designed and tested a practical care model for older adults facing surgery. They conducted the clinical trial through WashU Medicine’s Center for Perioperative Mental Health , whose mission is to integrate holistic mental health care and medication optimization into routine surgical medicine.
“The results of this trial suggest that anesthesiology and psychiatry can unite to treat surgical patients more holistically, pioneering a practical blueprint that hospital systems nationwide can use to improve recovery after invasive procedures.”Michael S. Avidan, MBBCh, WashU Medicine
The study analyzed 306 adults aged 60 and older who were scheduled for cardiac, oncologic or orthopedic surgery in hospitals across the BJC HealthCare system. Screened patients who reported mild to moderate symptoms of depression and anxiety were enrolled in the study.
The patients were randomly assigned to one of two groups. In addition to receiving educational materials on mindfulness, sleep and brain health, the intervention group talked with a dedicated wellness coach — a trained mental health professional such as a social worker or mental health counselor — over eight to 12 phone sessions. They also received a personalized review by pharmacists and doctors to safely optimize doses of high-risk medications. The control group only received the self-help materials to read independently, which is the standard approach to pre-surgical care.
The researchers found that three months after surgery, patients receiving the intervention experienced a 2.2-to-2.5-point greater reduction in symptoms of depression and anxiety compared with patients given educational materials alone, using a 48-point scale. Older adults undergoing cancer surgery experienced the strongest mental health improvements, scoring nearly 5 points lower than the control group.
Furthermore, patients reported positive experiences with the extra care, both from the wellness providers and the pharmacists who worked to eliminate unnecessary medications.
“What makes this care model so promising is that it’s practical to deliver,” said Abraham. “Patients and healthcare providers found the program manageable and easy to integrate into existing surgical workflows. Proactive mental health care doesn’t have to burden the hospital system.”
However, making that shift requires clinical specialties to break out of traditional silos to coordinate care before surgery.
“Today’s perioperative care models do not adequately address mental health needs and challenges faced by older adults,” added Michael S. Avidan, MBBCh , the Dr. Seymour and Rose T. Brown Professor of Anesthesiology, who serves as the Center’s co-director with Lenze. “The results of this trial suggest that anesthesiology and psychiatry can unite to treat surgical patients more holistically, pioneering a practical blueprint that hospital systems nationwide can use to improve recovery after invasive procedures.”
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