Influence of Depression on Recovery After Major Noncardiac Surgery: A Prospective Cohort Study

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To determine the influence of patient depression (and anxiety) on postoperative outcome and surgeons’ consideration of it.


Patients’ mental state influences the course of nonpsychiatric diseases. Evidence in the surgical setting comes mainly from cardiac-surgery patients and no predictive-model of postoperative outcome considers this dimension.


This prospective multicenter study included patients undergoing liver resections, a model of major abdominal surgery, between September 2013 and September 2014 in 8 centers. The primary outcome was postoperative morbidity or mortality (assessed by the Clavien-Dindo grade and the Comprehensive Complication Index) and the postoperative length of stay (LOS). Depression and anxiety were assessed preoperatively with the Hospital Anxiety and Depression Scale and a validated cutoff. Surgeons were preoperatively asked to predict outcome. Multivariable mixed-effects Cox models were fitted to evaluate the influence of depression on actual and surgeon-anticipated outcome and on the difference between actual and surgeon-anticipated LOS.


Hospital Anxiety and Depression Scale identified 142 of 591 patients (24.0%) as depressed and 40.3% as anxious. Neither condition was independently correlated with morbidity or mortality, but depression was an independent risk factor for prolonged LOS (adjusted hazard ratio 0.65, 95% confidence interval 0.50–0.83, P = 0.001). Depression was not correlated with anticipated LOS. Three variables explained the gap between anticipated and actual LOS: depression (P = 0.003), associated surgical procedures in addition to liver resection (P = 0.007), and postoperative morbidity (P < 0.001).


Nearly 1 quarter of patients undergoing major abdominal surgery are depressed preoperatively. This depression is a strong independent predictor of prolonged LOS and partly explains surgeons’ failure to predict outcome accurately.

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