The Psychological Impact of Surgical Procedures: Pre- and Post-Operative Considerations
Surgery is not only a physical event but also a significant psychological stressor. Patients often experience a range of emotional responses before and after an operation. For healthcare professionals, understanding these psychological factors is crucial, as mental states can influence surgical outcomes, recovery, and long-term well-being. This article provides a comprehensive, evidence-based overview of the psychological impact of surgical procedures, covering pre-operative anxieties and decision-making difficulties, post-operative issues like depression and PTSD, and the role of interdisciplinary teams in mitigating these challenges. We draw on the latest research and psychological theories to highlight how addressing patients’ mental health needs can improve surgical readiness, compliance, recovery outcomes, and quality of life. The tone is professional yet accessible, aiming to inform surgeons, physicians, nurses, and allied professionals about best practices in perioperative psychological care.
Pre-operative Psychological Challenges
Anxiety and Stress Before Surgery
It is common for patients to experience anxiety and stress in the days and weeks leading up to surgery. In fact, systematic reviews indicate that roughly one in two surgical patients globally report significant pre-operative anxiety. This anxiety can stem from various fears: concerns about anaesthesia and intraoperative awareness, potential complications or pain, loss of control, or uncertainty about outcomes. Psychological theory (e.g., the Transactional Model of Stress) suggests that surgery is appraised as a threatening event, triggering a stress response. Research shows that pre-operative stress levels often rise as the surgery date approaches (peaking ~2 days before) and are associated with autonomic arousal – elevated heart rate, blood pressure, sweating – all signs of the body’s “fight-or-flight” response. While mild anxiety can motivate patients to prepare and follow instructions, high levels of anxiety are generally maladaptive, leading to emotional distress and cognitive perturbations that may interfere with coping.
Importantly, anxiety before surgery isn’t only an emotional experience; it has physiological correlates. High anxiety activates the sympathetic nervous system and HPA (hypothalamic–pituitary–adrenal) axis, resulting in increased cortisol and inflammatory markers. These changes can affect surgical readiness – for example, patients may have trouble sleeping before surgery, come in with elevated blood pressure, or require higher doses of induction agents to achieve anaesthesia. Indeed, studies have found that highly anxious patients often need more intraoperative anaesthetic and post-operative analgesia to achieve the same comfort levels as calmer patients. One prospective study in gynaecologic surgery patients showed those with high pre-op anxiety had worse post-op pain and required significantly more opioid analgesics, and they experienced more nausea and dizziness post-operatively than patients with low anxiety. Clearly, pre-operative anxiety and stress are not benign; they can directly impact the perioperative course.
Decision-Making Difficulties and Fear
Beyond general anxiety, many patients struggle with decision-making when facing surgery. The choice to undergo an operation (especially elective or high-risk procedures) can provoke a form of decisional conflict, often fuelled by fear of the unknown. A recent study on surgical fear found that patients who felt confused about the surgery decision or ambivalent had markedly higher fear levels. Patients may second-guess whether surgery is truly needed or delay scheduling due to dread of pain or poor outcomes. This can be compounded by information overload or misunderstanding of risks and benefits, leading to paralysis in decision-making. High anxiety appears to reinforce this decisional conflict; for example, in a cohort of thoracic surgery patients, those with greater anxiety about surgical risks had more uncertainty and conflict about proceeding with surgery. This is a critical point for providers to recognise: an anxious patient might nod along during informed consent, yet internally they could be struggling to process information or reach a comfortable decision.
Fortunately, evidence suggests that involving patients in a shared decision-making (SDM) process can help. SDM interventions, where surgeons and patients collaboratively discuss options, have been shown to reduce patient anxiety and decisional conflict. In one meta-analysis, surgical patients who engaged in shared decision-making reported greater satisfaction and felt more sure of their choices, with lower pre-op anxiety, compared to those receiving standard consent processes. Thus, clear communication, allowing time for questions, and decision aids can mitigate the psychological burden of decision-making. From a theoretical lens, enhancing a patient’s sense of control and understanding can reduce fear – aligning with self-efficacy theory, which posits that confidence in managing a situation (in this case, undergoing surgery) lowers perceived stress.
Impact of Pre-operative Distress on Readiness and Physiological Responses
Psychological distress before surgery can have tangible effects on a patient’s readiness for surgery, cooperation with medical instructions, and even physiological functioning during the perioperative period. High levels of anxiety or depression may lead to non-compliance or suboptimal preparation – for example, an extremely anxious patient might inadvertently skip meals against fasting instructions (due to nausea or distraction) or fail to follow pre-op medication guidelines. Additionally, anxious patients often experience insomnia before surgery, arriving fatigued and less resilient. This can impair their concentration when listening to pre-op instructions and reduce overall readiness.
From a physiological perspective, stress and anxiety initiate a “surgical stress response” even before any incision is made. The release of stress hormones (adrenaline, cortisol) can cause immune and inflammatory changes that potentially influence healing. There is robust evidence from psychoneuroimmunology that psychological stress can slow wound healing and increase susceptibility to infection. In surgical patients, those who are highly distressed pre-operatively might have higher intraoperative cortisol levels and blood pressure, which could complicate anaesthetic management. Elevated cortisol and catecholamines can impair immune cell function, theoretically raising the risk of post-op complications such as infections. Supporting this, a 2022 study of 400 surgical patients found that pre-operative anxiety (STAI score ≥40) was associated with a higher incidence of post-operative complications, particularly in major surgeries. In a high-risk subgroup, 45% of anxious patients had complications vs 31% of non-anxious patients – a significant difference. After adjusting for other factors, pre-op anxiety carried about twice the odds of post-op morbidity. These findings reinforce that psychological distress is not merely an epiphenomenon; it can directly impact surgical outcomes through both behavioural and biological pathways.
Furthermore, anxiety can heighten patients’ perception of pain (lowering pain thresholds via increased sensory sensitivity). This heightened pain can trigger stronger physiological stress responses (a vicious cycle) and potentially delay mobilisation after surgery. Patients who are extremely nervous may also require heavier sedation or anxiolytics pre-operatively, which could have side effects or influence intraoperative haemodynamics. In summary, severe pre-operative distress can compromise the ideal physiological equilibrium we aim for in elective surgery – it primes the body for a rockier perioperative course, with poorer sleep, higher analgesic needs, and possibly more complications.
Mitigating Pre-operative Psychological Challenges: An Interdisciplinary Approach
Given the clear impact of pre-op psychological state on outcomes, the healthcare team plays a pivotal role in mitigating these challenges. Surgeons, anaesthetists, primary care physicians, nurses, and mental health professionals must collaborate to prepare the patient both physically and mentally for surgery. Early identification of at-risk patients is key. Tools like the Amsterdam Preoperative Anxiety and Information Scale (APAIS) or Hospital Anxiety and Depression Scale (HADS) can be used in clinic to screen for high anxiety or depressive symptoms. Notably, despite evidence of benefit, routine mental health screening is still not standard in many pre-surgical assessments. As healthcare moves toward patient-centred care and values long-term outcomes, experts suggest incorporating psychological screening into pre-op workups to flag those who might need extra support.
Physician communication is one of the first lines of intervention. Surgeons and their teams can reduce anxiety by providing clear, empathetic education about the procedure. A well-structured pre-operative education session (verbal counselling, possibly supplemented with written materials or videos) helps correct misconceptions and set realistic expectations. Numerous studies show that pre-operative education can significantly reduce patient anxiety and stress. For example, a systematic review found that in most trials, educational interventions (even a single dedicated session by a nurse educator) led to lower anxiety scores pre-surgery and improved post-op recovery parameters (like pain control or earlier discharge). Education works on the principle of reducing uncertainty, which is a major driver of fear.
Beyond education, evidence-based psychological interventions have proven effective. Relaxation techniques are among the simplest to implement: guided imagery, breathing exercises, meditation, or even music therapy can allay anxiety in the pre-op holding area. One randomised trial reported that guided imagery relaxation significantly decreased pre-operative anxiety compared to control. Similarly, playing calming music or providing noise-cancelling headphones while waiting for surgery has been shown to reduce anxiety levels and even attenuate the rise in blood pressure before induction. Cognitive-behavioural strategies can also be introduced, especially for patients with phobias or extreme fears (for instance, cognitive reframing of catastrophic thoughts like “I won’t wake up from anaesthesia”). For patients with profound anxiety or a history of psychological issues, a pre-operative referral to a psychologist for a short course of Cognitive Behavioural Therapy (CBT) or stress management training may be beneficial. Although research on pre-op CBT is still emerging, some studies with cancer surgery patients have used multi-session CBT-based coaching and observed reduced distress and even improved immune markers post-op.
The anaesthesiology team plays a role as well. Anaesthetists can meet patients pre-operatively to build rapport and answer anaesthesia-specific questions – alleviating the common fear of “anaesthesia awareness” or post-op pain. In cases of debilitating anxiety, short-term pharmacological anxiolysis can be considered (e.g., a low dose benzodiazepine the night before or morning of surgery). However, medication should complement, not replace, psychological support. Often, non-pharmacologic methods are sufficient and avoid sedative side effects.
An interdisciplinary concept gaining traction is prehabilitation, which includes a psychological component in the weeks before surgery. Prehab traditionally focuses on exercise and nutrition, but programs now often incorporate stress reduction techniques or counselling. The idea is to optimise mental resilience just as we optimise physical status. Though robust evidence is still being gathered, prehabilitation addresses anxiety and builds coping skills, potentially translating to smoother recoveries. As Levett and Grimmett (2019) note, pre-operative anxiety, depression, and low self-efficacy are consistently linked to worse surgical outcomes and lower postoperative quality of life, which has led to the inclusion of psychological intervention as a “third pillar” of prehab alongside physical training and nutrition.
In practice, many hospitals now use integrated care pathways for major surgeries that involve mental health professionals. For instance, bariatric surgery programs often require a psychological evaluation and counselling pre-surgery, recognising the importance of mindset in outcomes. Similarly, some orthopaedic centres offer stress management workshops for patients awaiting joint replacement. Even a simple intervention like a pre-op hospital tour or meeting a recovered patient (peer support) can reduce fear of the unknown. The interdisciplinary team approach – surgeon, anaesthetist, nurse, psychologist, social worker – ensures that while one team member optimises the medical aspects, another can focus on the patient’s emotional state, thereby holistically preparing the patient for surgery.
Post-operative Psychological Issues
After surgery, patients face new psychological challenges that can range from transient mood swings to serious mental health conditions. The post-operative period is a time of physical stress (pain, limitations, potential complications) and life adjustment, and it’s common for emotional difficulties to surface or worsen at this stage.
Post-operative Depression and Anxiety
Depressive symptoms are notably common after major surgery. Patients may feel a sense of let-down after the adrenaline of the surgery has passed, or frustration if recovery is slower than expected. Pain and temporary loss of function (e.g., being bed-bound) can also precipitate depressed mood. Studies have documented significant rates of new-onset depression in the year following surgery. For example, an analysis of over 700,000 surgical patients (various major procedures) found post-op depression incidence as high as 16–19% in some surgery types. Hip fracture patients had the highest risk (nearly 1 in 5 developed depression within a year), followed by thoracotomy (~16%) and cardiac surgery (~13%). Even in less invasive procedures like laparoscopic cholecystectomy, about 9% developed new depression, which is above baseline population rates. These figures underscore that depression is a frequent complication of the post-op course – whether due to biological stress responses, inflammation, psychosocial factors, or a combination. Patients with a prior history of depression are at even greater risk, but importantly, many who become depressed had no history prior to surgery.
Clinically, post-op depression may manifest as persistent sadness, loss of interest in rehabilitation activities, feelings of hopelessness about recovery, or even cognitive changes like difficulty concentrating. It’s crucial for healthcare providers to differentiate normal transient “post-op blues” from a major depressive episode that warrants intervention. If unrecognised, depression can impede recovery by reducing a patient’s motivation to participate in physical therapy or adhere to medication and wound care regimens. Indeed, depression has been linked to poorer functional outcomes at discharge. In spinal surgery patients, those with depression (either pre-existing or new) experienced worse post-op pain control and functional scores compared to non-depressed patients. Moreover, a recent meta-analysis in spine surgery found depressed patients had significantly higher rates of medical and surgical complications – including nearly double the odds of issues like infections, thromboembolism, and even higher rates of reoperations. The authors concluded that depression contributes to “suboptimal outcomes” and emphasised addressing psychiatric aspects as part of comprehensive surgical care. In short, post-operative depression is common and consequential.
Anxiety can also persist or emerge post-operatively. Some patients remain anxious about their health (“Will the surgery cure my problem or will it come back?”), or develop health-related anxiety especially if recovery has any complications. Others might experience acute anxiety episodes in the ICU or hospital, sometimes related to delirium or the stressful environment. It’s not unusual for patients to have vivid nightmares or disturbed sleep after major surgery, which can feed anxiety. Post-operative delirium, though primarily a cognitive issue, often has an anxiety component – the patient may feel confused and frightened. Prompt management of pain and assuring orientation can help reduce this acute anxiety. Persistent anxiety post-op can overlap with PTSD symptoms (discussed below) when related to traumatic recall of the surgical or ICU experience.
Post-traumatic Stress Disorder (PTSD)
While PTSD is often associated with combat or assaults, it can and does occur after medical events, including surgery. The concept of post-operative PTSD has gained recognition as research shows a subset of patients develop clinically significant traumatic stress symptoms after invasive procedures. A narrative review in 2019 estimated that about 20% of surgery patients experience postoperative PTSD symptoms. Certain surgeries carry higher PTSD risk – notably emergency surgeries or trauma surgeries (where the event leading to surgery was itself traumatic), cardiac surgeries (some patients report vivid awareness or near-death feelings), and any case with complications like unexpected ICU stays. Risk factors for developing PTSD after surgery include a sense that the experience was life-threatening or uncontrollable, a prior psychiatric history, severe post-op pain, and delirium or ICU sedation experiences that cause hallucinations.
Patients with post-surgical PTSD might report intrusive memories or flashbacks of being in the operating room or ICU, nightmares about the hospital, avoidance of follow-up care due to distress, and hyperarousal (e.g., feeling on edge, easily startled). Unlike typical anxiety, PTSD involves re-experiencing and avoidance behaviors that can significantly hinder recovery if not addressed. For instance, a patient who had a traumatic emergency surgery might avoid cardiac rehab appointments because just entering a medical facility triggers panic. Or they may under-report symptoms to avoid any consideration of another surgery.
It’s worth noting that PTSD after surgery can sometimes manifest in ways distinct from classic PTSD. Patients might not immediately link their irritability or sleep problems to the surgery, and clinicians may overlook the connection. Thus, awareness is key. Screening tools like the PTSD Checklist (PCL-5) can be used in follow-up visits for those at high risk. Early identification of acute stress reactions in the hospital (e.g. severe nightmares, refusal to engage in care due to fear) should prompt involvement of mental health specialists, since brief interventions might prevent progression to chronic PTSD.
Body Image and Self-Identity Concerns
Many surgical procedures result in changes to the body that can affect a patient’s body image and sense of identity. This is especially true for surgeries that remove or alter body parts (mastectomy, limb amputation, colectomy with stoma, prostatectomy, etc.), or any procedure that leaves significant scarring or disfigurement. Body image disturbances are a well-documented psychological outcome, particularly in areas like oncologic surgery. For example, women who undergo mastectomy for breast cancer frequently report body image distress, which can include feelings of loss of femininity, reduced attractiveness, and discomfort with seeing themselves in the mirror or being seen by others. This distress is not trivial; it is strongly associated with higher rates of depression and anxiety and with reduced quality of life. One study noted that body image distress after mastectomy correlated with impaired sexual functioning and intimate relationship strain.
Even when reconstructive surgery is performed (such as breast reconstruction or prosthetics for amputations), patients may still face adjustment issues. The psychological processing of a changed body can take time and often requires support. Patients might experience grief for the part of the body lost, or shame and social withdrawal due to scars or functional devices (like an ostomy bag). For instance, an ileostomy patient might avoid social outings for fear of leakage or smell, impacting their social confidence. In the absence of support, these feelings can progress to clinical depression or social anxiety.
Encouragingly, interventions like immediate reconstruction or advanced prosthetics can alleviate some body image concerns. Studies have found that women who undergo immediate breast reconstruction tend to have better body image and lower depression/anxiety levels in the aftermath compared to those who have mastectomy alone. This suggests that medical teams should, when possible, discuss reconstructive options or refer patients to specialists who can help restore appearance or function. Additionally, peer support groups (such as groups for breast cancer survivors, amputees, etc.) allow patients to share experiences and coping strategies, which often helps normalise their feelings and improve self-acceptance.
Prolonged Rehabilitation and Psychological Strain
Recovery from surgery can be immediate or can stretch into weeks or months of rehabilitation. Long rehabilitation periods – for example, after orthopedic surgeries (joint replacements, spinal surgeries), neurological surgeries (stroke, brain injury), or major trauma – present their own mental health challenges. Patients in prolonged rehab often ride an “emotional rollercoaster.” Initially, there may be optimism (“I survived surgery, and I’ll work hard to get better”), but as the hard work of rehab sets in, frustration, burnout, and demoralisation can occur. Setbacks like a flare-up of pain or slower-than-expected progress can trigger feelings of defeat. It’s not uncommon for such patients to develop adjustment disorders or depressive symptoms a few weeks into rehab when they realise the journey is long.
Depression in the rehabilitation phase is particularly concerning because it can create a self-fulfilling cycle: a depressed patient has low motivation, leading to poor participation in therapy, which then leads to worse functional outcomes, reinforcing feelings of failure. For example, a patient recovering from spinal surgery who feels depressed may skip therapy appointments or not put full effort into exercises; as a result, their mobility improves slowly, and they remain in pain longer, which deepens the depression. This interplay between mood and physical recovery means that psychological support is just as important in rehab as medical support.
Patients may also experience anxiety during rehabilitation, particularly fear of re-injury (“If I walk on my new hip, will it break again?”) or fear of pain. Such anxiety can cause them to avoid pushing themselves in therapy, again hindering progress. In long-term rehab, cognitive burnout can occur – patients get tired of the hospital environment, of being dependent on others, and this can manifest as irritability or withdrawal.
Interdisciplinary rehab teams often include psychologists or counsellors for this reason. Strategies like motivational interviewing by therapists, setting small achievable goals, celebrating incremental progress, and involving family in rehab can all help maintain a patient’s morale. In some cases, pharmacotherapy (e.g., a short course of antidepressants) might be indicated if a patient shows signs of major depression that aren’t lifting with support alone.
Influence of Psychological Distress on Recovery Outcomes
The psychological well-being of patients after surgery has a profound influence on their recovery trajectory and ultimate outcomes. Mental distress can negatively impact key factors such as treatment adherence, functional recovery, quality of life, and even healthcare utilisation and costs.
Adherence to Treatment: Patients who are depressed or anxious are less likely to adhere to post-operative regimens. This can include poor adherence to medication schedules (e.g., skipping antibiotics or pain meds), neglecting wound care, or not following dietary/exercise recommendations during recovery. They may also miss follow-up appointments or therapy sessions. Depression often saps the energy and executive function needed to manage complex care routines. One can imagine a patient recovering from cardiac bypass who, due to depression, fails to do their daily walking exercise or quits cardiac rehabilitation early – potentially undoing the benefits of the surgery. In contrast, patients with better emotional well-being are generally more engaged in their care plans. Empirical research supports this: emotional well-being correlates with higher rates of adherence and faster resumption of normal activities, whereas distress correlates with compliance issues and setbacks.
Physical Recovery and Function: Psychological distress can directly slow physical recovery. As discussed, depression can limit participation in rehab, leading to prolonged disability. Anxiety can heighten pain perception, making mobilisation more difficult. Furthermore, stress responses can interfere with wound healing. Chronic stress and depression are associated with slower tissue repair and higher inflammation, which might prolong the time it takes for incisions to heal or bones to fuse. In orthopaedic patients, those with depressive symptoms often report more pain and worse functional scores for months after surgery compared to non-depressed patients, even when the surgical outcome (e.g., x-ray of a healed fracture) is the same. This suggests a link between mental state and subjective recovery – pain and disability are perceived as worse when mental health is poor.
Quality of Life: Long-term quality of life (QOL) is increasingly recognised as an essential outcome of surgery. Even if a surgery is “technically” successful, a patient’s life satisfaction and daily functioning define the true success in many ways. Psychological distress can dramatically lower post-operative quality of life. For instance, persistent PTSD symptoms or body image issues might cause social withdrawal, unemployment, or sexual dysfunction, all of which diminish QOL. Anxiety and depression can reduce one’s enjoyment of activities and social relationships. Levett et al. noted that pre-operative psychological factors predicted postoperative quality of life – patients with more anxiety or depression tended to report poorer QOL after surgery. The same likely holds for post-operative emergent distress: a patient who becomes depressed after surgery often experiences a diminished quality of life even if the surgical problem (say, back pain from a herniated disc) was fixed. Conversely, patients who get adequate psychological support and remain mentally well tend to rate their post-surgery life much higher.
Healthcare Costs and Utilisation: There is also a health economics dimension. Patients with psychological complications often end up using more healthcare resources. Depression and anxiety have been associated with longer hospital stays, higher likelihood of readmission, and more frequent calls/visits to providers after surgery. For example, the meta-analysis on depression in spine surgery showed depressed patients had higher rates of non-routine discharges (need for rehab facility instead of home) and nearly double the odds of readmission within 30 days. Each of these events carries significant costs. Readmissions or prolonged rehabilitation place financial strain on healthcare systems and can incur penalties for hospitals in some healthcare models. Moreover, managing poorly controlled pain or complications exacerbated by non-adherence may require additional medications, home health services, or interventions (e.g., treating a wound infection that might have been avoided with proper self-care). All told, psychological distress can indirectly raise the cost of care and resource use. On the flip side, proactive mental health care can be cost-saving: one study found that providing psychiatric liaison support to surgical patients reduced length of stay by a couple of days, translating into substantial cost savings for the hospital. This implies that investing in psychological support is not just ethically sound but economically prudent.
Strategies and Protocols for Psychological Support Across the Surgical Journey
Addressing psychological distress in surgical patients requires a continuum of care that spans the pre-operative, intra-operative, and post-operative phases. Below, we review successful strategies and protocols at each stage, highlighting interdisciplinary and evidence-based approaches.
Pre-operative Interventions
1. Routine Screening: As mentioned, implementing routine screening for anxiety, depression, or extreme distress in pre-surgical evaluations can identify patients who need help. Simple questionnaires (STAI for anxiety, PHQ-9 for depression) can be administered in surgical clinics. Patients with high scores can then be flagged for extra interventions (such as pre-op counselling or psychiatric consultation) before surgery.
2. Patient Education and Coaching: Structured pre-operative education programs are widely recommended. These can be one-on-one sessions or group classes (“pre-surgery class”) where patients learn about what to expect before, during, and after the procedure. Emphasis is on empowering the patient with knowledge (e.g., walking through the surgery day timeline, explaining postoperative pain management, etc.). Many hospitals now provide printed booklets or online videos as part of this education. Education not only reduces anxiety by resolving uncertainties, but also improves compliance (patients who know the rationale behind fasting or exercising pre-op are more likely to do it). Some programs incorporate health coaching, where a nurse or health coach calls the patient weekly in the month before surgery to check on preparation progress and address concerns. Studies in cardiac surgery have shown that such personalised coaching reduces pre-op anxiety and even shortens ICU stays post-op.
3. Psychological Prehabilitation: This may involve referral to a psychologist or use of relaxation and mental training techniques as part of a formal “prehab” protocol. Interventions like cognitive behavioural therapy (brief format) targeting surgery-related fears, or mindfulness meditation training to improve stress coping, have shown promise. For example, Hanalis-Miller et al. (2022) found that across various studies, pre-operative psychological interventions (psychoeducation, relaxation training, etc.) consistently improved immediate post-op psychological and physiological outcomes. Although long-term outcome data are still needed, these interventions can reduce acute stress and possibly improve immune function around the time of surgery. Even a single session of guided relaxation the day before surgery can be beneficial. Some institutions have created “Mind-Body” pre-op clinics where patients learn deep breathing, imagery (e.g., visualising a positive recovery), or even get a chance to discuss fears with a therapist.
4. Shared Decision-Making (SDM) Protocols: Incorporating SDM into the consent process is a strategy to reduce decisional conflict and anxiety. This might involve decision aids (pamphlets or interactive software that explains options and asks patients about their values) and longer consultation times for high-stakes surgeries. By ensuring patients feel heard and that the decision aligns with their preferences, SDM protocols make patients more psychologically comfortable going into surgery. Some hospitals measure decisional conflict as a quality metric and aim to keep it low via such protocols.
5. Family Involvement: Allowing or encouraging patients to bring a family member to pre-op appointments can be helpful. The family member can provide emotional support and also learn how to aid the patient in the prehab and post-op process. Knowing a loved one is informed and involved can ease patient anxiety.
Intra-operative and Peri-operative Support
Though the patient is often unconscious during surgery, the period immediately before and after (and in some cases during, for those under regional anesthesia) is critical for psychological support.
1. Pre-induction Calming Techniques: In the pre-operative holding area and as the patient is brought into the OR, maintaining a calm environment is key. Simple measures like warm blankets, a quiet room, and having the anesthesiologist or nurse calmly talk the patient through what’s happening (“We are giving you medicine to relax now, you might feel sleepy… we’ll be right here with you”) can prevent panic. Some centers allow patients to listen to calming music of their choice via headphones up until anesthesia induction – this has been associated with lower anxiety and even lower anesthetic requirements.
2. Anaesthetic Techniques: Certain anaesthesia approaches might reduce psychological stress. For example, using adequate pre-medication for anxiolysis (midazolam or similar) can prevent the patient from experiencing intense fear in the OR. If regional anaesthesia is used and the patient is awake, ensuring they have sedation or at least a screen so they don’t see the surgical field is important to avoid distress. Additionally, avoiding traumatic experiences like intraoperative awareness (where patients recall surgery) is critical – strictly adhering to protocols to prevent awareness will avert one potential cause of post-op PTSD. Good pain control with regional blocks or epidurals can also reduce the stress response (patients who wake up in severe pain can develop fear of pain and trauma associations).
3. Interpersonal Support: The OR and PACU (post-anaesthesia care unit) staff can provide human support by offering reassurance as patients go to sleep and wake up. A kind word on emergence (“The surgery is over and it went well, you’re in recovery now, you’re safe”) can orient and comfort a patient, reducing emergence delirium or panic. Some hospitals have implemented protocols for a “soft landing” in PACU – minimising loud noises and bright lights as the patient wakes, and ensuring a nurse is immediately present to explain the situation. This can prevent confusion and terror upon waking in an unfamiliar place. If a patient emerges in an agitated state, prompt use of calming techniques (verbal reorientation, medication if needed) can prevent a memory of extreme distress.
4. Family in the PACU: Where feasible, allowing a family member to visit in the PACU for a brief period can alleviate anxiety in patients who are awake and stable. Seeing a familiar face soon after surgery has been shown in some studies to reduce stress and pain ratings.
5. Early Psych Assessment for High-Risk Patients: For patients who had intra-operative complications or an especially traumatic course (e.g., massive hemorrhage, or an unexpected ICU transfer), involving a psychiatric or psychological consultation early (even while in ICU) can be beneficial. Acute stress disorder can be addressed at this stage with trauma-informed care (for instance, short-term use of trauma-focused therapy or even medication like beta-blockers being researched to reduce memory consolidation of trauma). While such interventions are still being studied, the principle is to not wait until discharge – address acute psychological trauma in real-time.
Post-operative Interventions
1. Pain Management: Effective pain control is a cornerstone of post-op care that also serves psychological well-being. Uncontrolled pain is a major risk factor for delirium, PTSD, and depression. Using multimodal analgesia to keep pain at tolerable levels helps patients stay engaged in recovery and prevents the demoralising effect of constant pain. For example, patient-controlled analgesia (PCA) allows patients some control over pain relief, which can reduce anxiety compared to feeling helpless and waiting for a nurse to administer doses.
2. Early Mobilisation and Autonomy: Enhanced recovery protocols emphasise early mobilisation. Getting patients out of bed and doing self-care tasks as soon as possible not only has physical benefits but also psychological ones – it combats feelings of helplessness and restores a sense of normalcy. Each small victory (sitting in a chair, taking a few steps) can boost confidence. Nurses and physical therapists play a motivational role here, celebrating these achievements with the patient.
3. Emotional Support and Counselling: Hospitals with robust programs may have psychologists or social workers round on post-op floors, especially surgical ICUs or oncology units. Brief counselling or supportive therapy can be provided in the hospital to patients who exhibit distress. Simply having a professional listen to a patient’s fears or mood complaints can be therapeutic. Techniques such as normalisation (“Many people feel a bit down after surgery… it’s okay, and it usually improves”) and encouragement (“You are doing the best you can in recovery”) help validate the patient’s experience and provide hope. For patients who had extremely adverse events (like nearly dying on the table or awakening with an unexpected ostomy), more focused trauma counselling may begin in the hospital.
4. Peer Support and Consultation: Bringing in a peer visitor – someone who has undergone the same surgery and recovered – can be a powerful intervention. For example, a breast cancer survivor volunteer can visit a new mastectomy patient to share her story of recovery and body image acceptance, providing the patient with a relatable role model. Likewise, an amputee support program can connect new amputees with mentors. Peer support normalises the emotions (fear, grief) and shows that a fulfilling life after surgery is possible, thereby reducing isolation and hopelessness.
5. Family Education: Post-op psychological support often involves the family. Educating family members about the patient’s potential emotional needs is important. Families might misinterpret a patient’s irritability or apathy as “laziness” or personal affront, when it could be depression or pain. Guiding families to be patient, to encourage without pressuring, and to assist in care routines can improve the home atmosphere for recovery. Family presence itself is supportive, but they may need coaching on how to best support (for instance, understanding that the patient might not bounce back immediately and avoiding statements that convey disappointment).
6. Pharmacotherapy for Mental Health: If a patient is diagnosed with a specific condition like major depression or PTSD post-op, appropriate pharmacological treatment should be initiated, often in coordination with psychiatry or primary care. Antidepressants or anxiolytics can be useful adjuncts to therapy and support. Caution is needed with sedatives if the patient is still on opioids or has respiratory risk, but SSRIs (selective serotonin reuptake inhibitors) are generally safe to start in the hospital for depression or significant anxiety, with follow-up arranged.
7. Follow-Up Calls/Visits Focused on Mental Health: Some surgical teams have started post-discharge phone call programs. Nurses call patients within a week of discharge not only to check on wound or physical issues, but also to ask about mood, coping, and any signs of psychological struggle. If concerns are raised, they can expedite referral to a mental health professional. This proactive approach ensures issues are caught early rather than waiting for the first routine surgical follow-up where the focus might be primarily on the incision or physical function.
Long-Term Psychological Support and Follow-Up
The duty to care for a patient’s psychological health does not end at hospital discharge or even the six-week post-op visit. Many mental health effects of surgery can surface or persist in the long-term, months or even years later. Therefore, establishing a long-term support plan is advisable, especially for patients who underwent life-altering surgeries or experienced severe complications.
1. Scheduled Mental Health Screening: Incorporate mental health check-ins at key recovery milestones. For instance, at the 3-month and 1-year post-surgery marks, patients can be asked to complete brief screening tools for depression (PHQ-9) and PTSD (PCL-5) as part of their routine follow-up questionnaires. This is increasingly feasible as many follow-ups use electronic patient-reported outcome surveys. If a patient screens positive or indicates problems (e.g., “I’m feeling very down” or “I keep reliving the ICU”), the provider can then dig deeper or refer appropriately. Given that routine pre-op depression screening is not yet standard, it’s not surprising that post-op screening is also under-utilised, but awareness is growing. For example, cardiac surgery guidelines in some countries now recommend depression screening during recovery due to the known link between depression and poorer cardiac outcomes.
2. Continuity of Psychiatric Care: For patients with known psychiatric history or those who were started on psychotropic medications in the hospital, ensure continuity of care. This might mean arranging an appointment with a psychiatrist or psychiatric APRN soon after discharge, or coordinating with the patient’s primary care physician to take over medication management and monitoring of mental health symptoms. It’s often helpful for the surgeon or surgical team to communicate to the primary care provider about the psychological issues encountered, so they know to keep an eye on it. Integrated care models, where mental health professionals are embedded in primary care, can seamlessly pick up the care of these patients.
3. Support Groups and Rehab Programs: Encourage patients to engage in community or online support groups. Many organisations (e.g., the Amputee Coalition, cancer survivor networks, cardiac rehab support groups) provide ongoing support resources. Some rehabilitation programs for cardiac or pulmonary patients include not just exercise sessions but also educational/psychosocial sessions – for example, discussing stress management, relaxation, and coping strategies. Long-term attendance in such programs correlates with better maintenance of lifestyle changes and mood.
4. Counselling/Therapy: Patients who continue to struggle with body image, PTSD, or depression long-term should be offered formal psychotherapy. Cognitive-behavioural therapy (CBT) has strong evidence for treating depression and anxiety, including health-related anxieties. Trauma-focused therapies like EMDR (Eye Movement Desensitisation and Reprocessing) or trauma-focused CBT can be used for persistent PTSD symptoms related to surgery or ICU experiences. Sometimes, short-term therapy post-op can help a patient process the meaning of the surgery in their life narrative (this is a more psychodynamic approach – making meaning of “losing a body part” or “surviving a near-death experience”). For example, a young athlete who had a leg amputation might benefit from counselling to grieve the loss and eventually mentally reframe their identity with a prosthetic. The healthcare team should destigmatise these referrals by framing them as a routine part of comprehensive recovery (“just as you need physical therapy for your body, many people find therapy for their emotional recovery very helpful”).
5. Monitoring and Managing Chronic Pain: A known long-term issue after some surgeries is the development of chronic post-surgical pain (CPSP), which can itself perpetuate psychological distress. There is a reciprocal relationship: patients with higher pre-op anxiety or catastrophising are more likely to develop CPSP, and having CPSP can lead to depression/anxiety. Multidisciplinary pain management, including psychological strategies like pain coping skills training or acceptance and commitment therapy (ACT), might be necessary for these patients. By addressing chronic pain in a biopsychosocial manner, we also mitigate its impact on mental health.
6. Involving Primary Care and Community Services: Ultimately, when the surgical team’s involvement tapers off, the patient’s primary care physician (PCP) often becomes the key medical contact. It’s important for surgeons to hand off the information about any psychological challenges to the PCP, along with recommendations for monitoring. Community resources, such as home nurse visits or occupational therapy, can also be leveraged to keep an eye on the patient’s mental state (for example, a home health nurse noting that the patient seems withdrawn and notifying the doctor).
7. Cost-Benefit Advocacy: At an administrative level, healthcare institutions should note the cost implications of unaddressed psychological distress (as discussed earlier) and support the development of protocols and teams to provide long-term psychological follow-up. This might include setting up specialised clinics (like a Post-ICU clinic for survivors of intensive care, which often includes mental health evaluation) or ensuring insurance coverage for needed mental health services after surgery. The goal is to make psychological care an integrated part of surgical aftercare, not an afterthought.
Conclusion
The journey through surgery is as much an emotional passage as it is a physical one. Pre-operative anxiety, if unaddressed, can cascade into physiological stress and decisional difficulties, potentially compromising surgical outcomes. Post-operative psychological issues – from the blues to clinical depression or PTSD – can significantly colour the patient’s recovery experience and effectiveness. For healthcare professionals, being attentive to these psychological factors is part of delivering holistic, high-quality care.
By applying psychological theories of stress and coping, we can better empathise with what patients are experiencing and implement interventions that empower them. Interdisciplinary teamwork is crucial – when surgeons, anaesthetists, nurses, psychologists, and others coordinate, patients receive consistent messages of support and practical help in managing their emotions. The research is clear that such efforts pay off: patients who are less anxious and more supported have smoother surgeries, faster recoveries, and better long-term outcomes. Moreover, attending to mental health is part of ethical patient-centred care; it respects the patient’s whole being, not just the surgical site.
In summary, the psychological impact of surgery spans from pre-operative anxiety and decision-making challenges to post-operative depression, PTSD, body image concerns, and rehab-related stress. Each phase offers opportunities for intervention – whether it’s allaying fear with education, preventing trauma in the OR, or counselling a patient through recovery. Healthcare professionals should employ evidence-based strategies such as screening, relaxation techniques, cognitive-behavioural interventions, shared decision-making, peer support, and long-term follow-up to mitigate psychological distress. By doing so, we not only improve clinical outcomes and reduce costs, but we also help our patients emerge from surgery not just alive, but mentally resilient and on a path to regaining a fulfilling life.
References
Akutay, S., & Ceyhan, Ö. (2023). The relationship between fear of surgery and affecting factors in surgical patients. Perioperative Medicine, 12(1), 22. DOI: 10.1186/s13741-023-00316
Bedaso, A., Mekonnen, N., & Duko, B. (2022). Prevalence and factors associated with preoperative anxiety among patients undergoing surgery in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open, 12(3), e058187. DOI: 10.1136/bmjopen-2021-058187
Hanalis-Miller, T., Nudelman, G., Ben-Eliyahu, S., & Jacoby, R. (2022). The effect of pre-operative psychological interventions on psychological, physiological, and immunological indices in oncology patients: A scoping review. Frontiers in Psychology, 13, 839065. DOI: 10.3389/fpsyg.2022.839065
Kassahun, W. T., Mehdorn, M., Wagner, T. C., Babel, J., Danker, H., & Gockel, I. (2022). The effect of preoperative patient-reported anxiety on morbidity and mortality outcomes in major general surgery. Scientific Reports, 12(1), 6312. DOI: 10.1038/s41598-022-10302-z
Levett, D. Z. H., & Grimmett, C. (2019). Psychological factors, prehabilitation and surgical outcomes: evidence and future directions. Anaesthesia, 74(S1), 36–42. DOI: 10.1111/anae.14507
Gu, X., Zhang, Y., Wei, W., & Zhu, J. (2023). Effects of preoperative anxiety on postoperative outcomes and sleep quality in patients undergoing laparoscopic gynecological surgery. Journal of Clinical Medicine, 12(5), 1835. DOI: 10.3390/jcm12051835
Kaneda, H., Nakano, T., Utsumi, T., & Murakawa, T. (2024). Decisional conflict scale for elective thoracic surgery. Shanghai Chest, 8, 8. DOI: 10.21037/shc-23-9
El-Gabalawy, R., Sommer, J. L., Pietrzak, R., et al. (2019). Post-traumatic stress in the postoperative period: current status and future directions. Canadian Journal of Anesthesia, 66(11), 1385–1395. DOI: 10.1007/s12630-019-01418-4
Weingarden, H., Ladis, I., Austen, W. G. Jr., & Wilhelm, S. (2022). Body Image After Mastectomy Scale: A new measure of body image behaviors and beliefs in women following mastectomy. Journal of Women’s Health, 31(1), 416–424 (issue date Jan 2022). DOI: 10.1089/jwh.2020.8915
Aghajanian, S., Shafiee, A., Teymouri Athar, M. M., Mohammadifard, F., Goodarzi, S., & Elsamadicy, A. A. (2024). Impact of depression on postoperative medical and surgical outcomes in spine surgeries: a systematic review and meta-analysis. Journal of Clinical Medicine, 13(11), 3247. DOI: 10.3390/jcm13113247
O’Gara, B., Espinosa Leon, J. P., Robinson, K., Schaefer, M., Talmor, D., & Fischer, M. (2023). New onset postoperative depression after major surgery: an analysis from a national claims database. BJA Open, 8, 100223. DOI: 10.1016/j.bjao.2023.100223
Strain, J. J., Lyons, J. S., Hammer, J. S., et al. (1991). Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. American Journal of Psychiatry, 148(8), 1044–1049. DOI: 10.1176/ajp.148.8.1044