Behavioral Health in Surgical Settings - live-chs2.ws.asu.edu · Arizona State University ....
Transcript of Behavioral Health in Surgical Settings - live-chs2.ws.asu.edu · Arizona State University ....
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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
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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
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Learning Objectives
At the conclusion of this session, the participant will be able to:
• Identify ways in which behavioral 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
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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
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Cases to Consider
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Case One
• A 25 year-old police officer shot in chest during training exercise. Undergoes chest operation for massive bleeding and does well, walks out of the hospital 5 days later.
• Heals well without physical disability
• Severe PTSD, unable to work in law enforcement, disability
• Alcoholism, substance abuse, depression
• Divorce
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Case Two• 65 year-old man with depression
and colon cancer undergoes a routine colon resection for a cancerous polyp.
• Post-operative pain control issues and won’t participate in physical/occupational therapy, does 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
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Case Three
• A 19 year old man is shot in the abdomen and left arm. Sustains a left humerus fracture and no major intraabdominal injuries
• Does not cooperate with police; anger issues in hospital
• Elopes from hospital
• Suspected in shooting in following weeks
• Dies in shootout with police attempting to arrest him
• One police officer injured
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Theoretical Foundation
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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)
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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)
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Behavior Affects Health• Stress
• Drug use
• Alcohol use
• Smoking
• Diet
• Exercise
• Compliance
• Preventative medicine
(IOM, 2001)
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Behavior Affects Health
(Schroeder, 2007)
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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)
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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)
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Spirituality and Health
• Provides coping mechanism
• Provides social support
• Meditation and relaxation
• Provides hope for the future
(Contrada et al., 2004)
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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
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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
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Integration is More Than a Psych Referral
• Integration provides tools to patients to aid in: • Adaptation
• Insight
• Problem-solving
• Coping
• Resolving conflicts
• Expectations
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Application to Surgery
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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)
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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)
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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)
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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)
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Stress and Surgery
• 47 adults undergoing open inguinal hernia repair
• Preoperative questionnaire about stress and worry about the operation
• 30 volunteers had fluid aspirated from wound following surgery
• High perceived stress –> lower IL-1 in wound aspirates
• Higher worry • Higher pain
• Slower recovery
• Worse overall recovery
(Broadbent, Petrie, Alley, & Booth, 2003)
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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)
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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)
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Behavioral Health in Various Surgical Populations
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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)
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Bariatric Surgery
• Number of pre-surgery psychiatric hospitalizations• increased in complication
• increased distress
• decreased satisfaction
(Beaulac & Sandre, 2015; Gade et al., 2015; Himes et al., 2015)
• Binge eating behaviors predict poorer weight loss and long-term outcomes
• Higher divorce rate in 3 years following bariatric surgery
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Bariatric Surgery• Pre-op CBT
• Assess goals and understanding of the procedure
• Weight/dieting history
• Binge eating and psychopathology
• Assess family/relationship factors
• Recommend less invasive options
• Post-operative CBT• Improves psychological distress
• Decreased perceived life difficulty and depressive symptoms
• Improved weight-related adjustment
• 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)
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Trauma
• Study of patients with facial trauma
• Poor outcomes associated with:• Hospital days
• ICU days
• Surgical procedures
• Major complications
• Age
• Recurrent injury
• Inadequate information
• 1/3 of patients reported depression
• 1/3 of patients reported PTSD
• *Zero patients sought mental health follow up for PTSD/Depression*
(Sluys, Haggmark, & Iselius, 2005)
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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)
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Trauma
• Pain intensity related to:• Catastrophizing
• 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
Both responsive to CBT
(Archer, Abraham, & Obremeskey, 2015)
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Cardiac Surgery
• 67 women post CABG
• Patients with major depression:• Had lower NK cell cytotoxicity
(NKCC)
• Had higher rate of infectious illness in 6 months following surgery
• Depressed patients:• Higher rate of post-op fever
• Higher infectious illness rate
• CBT moderate to large effects• Improved NKCC
• Decreased IL-6
• Decreased CRP
• Decreased infectious illness
(Doering, Cross, Vredevoe, Martinez-Maza, & Cowan, 2007; Doering, Martinez-Maza, Vredevoe, & Cowan, 2008)
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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)
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Spine Surgery
• 90 patients
• Significantly improved quality-adjusted life years
• Significantly larger disability reductions (3 & 6 months, not 1 year)
• No difference in cost
• 86 patients
• Significant decreases • Back and leg pain
• Disability
• Significant improvement• General health
• Mental health
• Faster improvement in PT exercises
(Archer et al., 2016; Rolving et al., 2016)
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Behavioral Interventions
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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
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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)
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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)
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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)
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Other Borst Collaborations
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Questions/Comments
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References
• Archer, K.R., Abraham, C.M., & Obremeskey, W.T. (2015). Psychosocial factors predict pain and physical health after lower extremity trauma. Clinical Orthopedics and Related Research, 473, 3519-3526.
• Archer, K.R., Devin, C.J., Vanston, S.W., Koyama, T., Phillips, S.E., George, S.Z., McGirt, M.J., Spengler, D.M., Aaronson, O.S., Cheng, J.S., and Wegener, S.T. (2016). Cognitivie-behavioral-based physical therapy for patients with chronic pain undergoing lumbar spine surgery: A randomized control trial. Journal of Pain, 17(1), 76-89.
• Beaulac, J., & Sandre, D. (2015). Impact of a CBT psychotherapy group on post-operative bariatric patients. Springerplus, 4, 764-768.
• Bosch, J.A., Engeland, C.G., Cacioppo, J.T., Marucha, P.T. (2007). Depressive symptoms predict mucosal wound healing. Psychosomatic Medicine, 69(7), 597-605.
• Broadbent, E., Petrie, K.J., Alley, P.G., & Booth, R.J. (2003). Psychological stress impairs early wound repair wound repair following surgery. Psychosomatic Medicine, 66(5), 865-869.
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