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, • Identify ways in which behavioral the participant will be able to: 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 • Heals well without physical in chest during training exercise. disability Undergoes chest operation for • Severe PTSD, unable to work in massive bleeding and does well, law enforcement, disability walks out of the hospital 5 days later. • Alcoholism, substance abuse, depression • Divorce Case Two • 65 year-old man with depression • Post-operative pain control issues and colon cancer undergoes a and won’t participate in routine colon resection for a physical/occupational therapy, does cancerous polyp. 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 • Does not cooperate with police; abdomen and left arm. Sustains anger issues in hospital a left humerus fracture and no • Elopes from hospital major intraabdominal injuries • 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 • High perceived stress –> lower inguinal hernia repair IL-1 in wound aspirates • Preoperative questionnaire • Higher worry about stress and worry about • Higher pain the operation • Slower recovery • 30 volunteers had fluid aspirated • Worse overall recovery from wound following surgery

(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 • Binge eating behaviors predict psychiatric hospitalizations poorer weight loss and long- • increased in complication term outcomes • increased distress • Higher divorce rate in 3 years • decreased satisfaction following bariatric surgery

(Beaulac & Sandre, 2015; Gade et al., 2015; Himes et al., 2015) Bariatric Surgery • Pre-op CBT • Post-operative CBT • Assess goals and understanding of • Improves psychological distress the procedure • Decreased perceived life difficulty • Weight/dieting history and depressive symptoms • Binge eating and psychopathology • Improved weight-related • Assess family/relationship factors adjustment • Recommend less invasive options • 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 • 1/3 of patients reported trauma depression • Poor outcomes associated with: • 1/3 of patients reported PTSD • Hospital days • *Zero patients sought mental • ICU days health follow up for • Surgical procedures PTSD/Depression* • Major complications • Age • Recurrent injury • Inadequate information

(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 Both responsive to CBT • 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

(Archer, Abraham, & Obremeskey, 2015) Cardiac Surgery

• Depressed patients: • 67 women post CABG • Higher rate of post-op fever • Patients with major depression: • Higher infectious illness rate • Had lower NK cell cytotoxicity • CBT moderate to large effects (NKCC) • Improved NKCC • Had higher rate of infectious • Decreased IL-6 illness in 6 months following surgery • 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

• 86 patients • • 90 patients Significant decreases • Back and leg pain • Significantly improved quality- • Disability adjusted life years • Significant improvement • Significantly larger disability • General health reductions (3 & 6 months, not 1 • Mental health year) • Faster improvement in PT • No difference in cost 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

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