The role of psychological support in cardiac surgery: initial experience

The scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. From January 2009 until June 2010, 15 patients scheduled for cardiac surgery were enrolled. The patients were assessed by psychological evaluation either in the hospital stay either in the rehabilitation period with the aim of identifying their emotional condition (sentiments about the onset of the disease, support received from family and friends) even by means of preformed tests for anxiety and depression (tests of Stay and Back). Thus, in our preliminary experience, the psychological evaluation failed to detect the occurrence of postoperative complications. Conversely, the psychological evaluation is very effective in detecting a poor emotional state and the psychological support decreases the degree of anxiety and depression with positive effects on postoperative outcome. In conclusion, a standardize test for anxiety and depression should be used for patients at hospital admission to detect who may benefits by psychological support.


Introduction
The studies of Dunbar have identified a relationship among behavior and cardiovascular diseases, since personality ambitious, disciplined, determined and stressed has an increased risk of coronary artery disease. In 1959, Friedman and Rosenman have characterized the type A coronary-prone behavior associated with an increased level of blood cholesterol and clotting time, leading to a higher risk of coronary artery disease. However, type A research has largely fallen out of favor since 1990's and cannot be applied nowadays.
Recently, the scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. [1][2][3]

Study presentation
The relationship between the emotional conditions and the complications after surgery has been already shown in the national guidelines on cardiac rehabilitation and prevention for the cardiovascular diseases, 4 highlighting that pain, depression and anxiety impair the postoperative outcome and delay recovery.
The aims of this study would be to identify the role of psychological support in cardiac surgery populations: can the psychological support reduce the degree of anxiety and depression improving postoperative outcome and should it predict the occurrence of complications? We report our experience.

Material and Methods
From January 2009 until June 2010 15, patients scheduled for cardiac surgery were enrolled. The patients were assessed by psychological evaluation either in the hospital stay either in the rehabilitation period with the aim of identifying their emotional condition (sentiments about the onset of the disease, support received from family and friends) even by means of preformed tests for anxiety and depression (tests of Stay and Back) as shown in Tables 1 and 2. Four interviews were administered: three over the hospital stay and the last one two months later: i) First meeting: psycho-diagnostic investigation and test administration; ii) Second (preoperative) and third interview (postoperative): psychological support to detect anxiety, fears, experiences and hopes after surgery; test administration; iii) Fourth interview (two months later): conclusions and verification of the tools used; test administration. Several matters were discussed during the interviews (Table 1): illness -onset and sentiments; religion-belief and faith; network of social support received from family and friends; lifestyle (hobbies, emotions and experiences), hopes.
Eight patients were females with a mean age of 61.9±16.7 years. Ten patients were married, 3 patients were widows and 2 patients were singles. 12 patients had soon. Ten patients had a primary school graduation and 5 patients had a high school graduation. Thirteen patients have a job, 1 patient was a housewife and 1 patient was a student. Fourteen patients were catholic and 1 was of waldensian religion: 7 patients usually pry and participate to religious activities. All of them had prayed before operation. Three patients had previous cardiac operation (2 aortic valve replacement and 1 mitral valve replacement) whereas 1 patient had a previous percutaneous coronary angioplasty (PTCA). Six patients had a previous general surgery operation. The cardiac procedures were: 6 mitral valve operations (repair or replacement), 5 aortic valve replacements, 3 aortic root replacements (2 Bentall and 1 David procedure), 1 mitro-aortic valve replacement associated to tricuspid repair and ascending aorta replacement. The mean duration of hospital stay was 13.6±10.5 days and 5 patients had significant postoperative complications (2 pace maker implantations for complete atrio-ventricular block, 3 bleedings). One patient had a prolonged intensive care unit stay for respiratory failure requiring a tracheotomy. One patient required a re-operation 6 months later.
After hospital discharge, all patients participated voluntary in cardiac rehabilitation to achieve a complete recovery.

Results and Discussion
Recently, the scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. [1][2][3] The relation between depression and complications after surgery has been already shown even by the Italian guidelines on cardiac rehabilitation and prevention for the cardiovascular diseases, 4 highlighting that pain, depression and anxiety impair the postoperative outcome and delay recovery. The possible relationship between --Widow for many years and no longer wanted to marry. emotional state, support by family and other factors (i.e., religiousness, hopes) is the matter of interest of this paper. The data collected are not resumable as a number since they are qualitative and belong to the emotional area (Tables 1 and 3). All patients showed a great concern and anxiety regarding the operation even though almost all of them minimized and denied any fear, relying to the surgeon and to the department. Patients with a primary school graduation were usually less informed about the operation and the risk of complications, because they did not collect any information personally. Usually, they were afraid for the risks of anesthesia and the possibility of permanent disability affecting postoperative outcome.
Patients with an higher school degree were usually more informed and their concerns belongs mainly to the risks of complications after surgery (bleeding, re-operation, organ dysfunction and infection) with less concerns related to the anesthesia. Regardless of the instruction degree, the fear and the anxiety were strictly related to the exhaustiveness of the information received: when accurate, the degree of fear and anxiety was lower.
The sentiments described after initial diagnosis were: confusion; fear and uncertainty about the decision-making. In case of lack of symptoms, patient had a more complicate acceptance of the disease and usually preferred delaying surgery. On the contrary, symptomatic patients decided for a prompt surgical treatment to avoid worsening of the clinical conditions. The role of patient in the organization of familial structure had several effects on hopes after surgery: in case of a busy life with several interests and responsibilities, patients were more determined to a prompt recovery and participated all the activities proposed. However, patients with many familial responsibilities showed several difficulties in communicating to relatives sentiments, fears and hopes because they were usually a referent and not a burden. As a result, there was a lack of communication of the emotional state to the family leading to an un-useful relation characterized by practical organization without emotional support; such as they received by the psychologists.
The age is related to the degree of the support received: in case of young patients, they had significant support from parents, relatives and friends with a variable reaction to the disease, ranging from careless to panic. Conversely, the older patients had usually less way to be supported and the family is the caregiver. At the follow up evaluation, all the patients confirmed they were very concerned and afraid awaiting the operation, with a great support by the psychological evaluation in describing their fears and hopes after surgery. In fact, many patients had serious difficulties of communication with the family in order to avoid the onset of anxiety to relatives.
However, all the patients have prayed before surgery. As previously reported, 5 negative outcomes as depression and anxiety were partially reduced when patients employ prayer before surgery. A lower degree of depression was noted in patients using praying, with optimism and positive hope after surgery. Subjective religiousness, marital status and support by family may reduce the degree of anxiety postoperatively.
All patients described the psychological support as very useful even though the older patients had serious difficulties in completion the tests of STAI and Beck for a too long procedure reducing the degree of concentration. Thus in case of older patients with a poor instruction, we used the Self-Assessment Scale of Zung for Anxiety and Depression that was easier to be understood. However, a significant reduction in terms of anxiety and depression was noted over the investigation for all patients treated by psychological support. Patients had a more positive impact respect to the surgery with a greater motivation for a Very afraid and Great concern and support Support by Yes Yes 8/63 High state anxiety Waldensi anxiety and low community trait anxiety 5

Brief Reports
No fear Great concern Support Yes Yes 12/63 High state anxiety 6 No fear Great concern and support Not involved No Yes 2 /63 No 7 Very afraid and Great concern Support Yes Yes 50/63 Low state anxiety anxiety 8 Very afraid and Great concern and support Support Yes Yes 43/63 Mild state anxiety anxiety 9 Very afraid and Great concern and support No friends Low Yes 49/63 Low state anxiety anxiety 10 No fear Great concern and support Support Yes Yes NP No 11 Very afraid and Great concern and support Support [page 221] complete and prompt recovery. Despite the utility of the psychological support described by patients, all of them failed the study completion (voluntary last interview) for the fear to come back to the hospital after surviving cardiac operation. In fact, the psychological support was believed as useful preoperatively even though the last interview was thought only a research purpose and just two patients came back to the hospital for the last assessment in case of late complications.

Conclusions
As reported by other researches in this field and by the national guidelines on cardiac rehabilitation and prevention, the presence of anxiety and depression are major warning signs, worsening the postoperative problems. [4][5][6] However, the structure of personality and emotional state are quite complicated matters to debate and they cannot be summarized by numbers or sentences. Thus, in our preliminary experience, the psychological evaluation failed to detect the occurrence of postoperative complications. Conversely, the psychological evaluation is very effective in detecting a poor emotional state and the psychological support decreases the degree of anxiety and depression with positive effects on postoperative outcome.
In conclusion, a standardize test for anxiety and depression should be used for patients at hospital admission to detect who may benefits by psychological support. The major limitations of Beck and Stay test are their complexity and length. Thus, a less specific test as Zung rating scales may be the standard evaluation at hospital admission.