Prevalence and characteristics of preoperative patients with depression

Abstract

Background: Within the perioperative period, depression-related diagnoses are associated with postoperative complications. We developed a perioperative depression screening programme to assess disease prevalence and feasibility for intervention.

Methods: Adult patients in multiple surgical departments at a single academic centre were screened for depression via the electronic health record patient portal or preoperative anaesthesia clinic before surgery, using the Patient Health Questionnaire (PHQ)-2 and -8. We utilised a broad method, screening all patients, and a focused method, only screening patients with a history of depression. Logistic regression was used to identify characteristics associated with clinically significant depression (PHQ-8 ≥10). Symptomatic patients were administered a brief psychoeducational intervention and referred for mental health services.

Results: A total of 3735 patients were identified by the broad and focused screens, of whom 2940 (79%) returned PHQ-2 data and were included in analysis. The broad screen (N=1216) found 46 (4%) patients who reported symptoms of moderate or greater severity. The focused screen (N=1724) found 242 (14%) patients with symptoms of moderate or greater severity and over all higher rates of depression across the symptom severity scale. Using the total screened pool, logistic regression identified a history of depression as the strongest associated patient characteristic variable but this did not capture most cases. Finally, we found that 66% of patients who were contacted about mental health services accepted referrals or sought outside care.

Conclusions: At least 4% of preoperative patients have clinically significant symptoms of depression, most of whom do not have a chart history of depression.

Keywords: Patient Health Questionnaire; depression; mental health services; perioperative; perioperative depression; preoperative depression screening; screening programme.

Fig 1

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram of patient flow in the Stanford Perioperative Mental Health Screening Program. Patients were identified by an electronic health record (EHR) report of patients with an ICD-10 coded depression diagnosis (left column; ‘Focused screen’) or from all patients presenting for major procedures (right column; ‘Broad screen’). PHQ, Patient Health Questionnaire. ∗Not contacted: See Methods for further detail.

Fig 2

Distribution of PHQ-8 scores amongst symptomatic patients with a history of depression and across the surgical departments. (a) Number of patients reporting each PHQ-8 scores (range 0–24) categorised as: none (3–4; blue), mild (5–9; purple), moderate (10–14; green), moderately severe (15–19; orange) or severe (20–24; red) depression. (b) Distribution of PHQ-8 scores, categorised by surgical department. PHQ-8 scores are categorised as asymptomatic (PHQ-8<5; blue), mild (PHQ-8=5–9; purple), and moderate or greater severity (PHQ-8>=10; green). (c) Proportional distribution of symptomatic patients within each surgical department. PHQ, Patient Health Questionnaire.

Fig 3

Distribution of PHQ-8 scores amongst symptomatic patients in the broad screen across surgical departments. (a) Number of patients reporting each PHQ-8 scores (range 0–24) categorised as: none (3–4; blue), mild (5–9; purple), moderate (10–14; green), moderately severe (15–19; orange) or severe (20–24; red) depression. (b) Distribution of PHQ-8 scores, categorised by surgical department. PHQ-8 scores are categorised as asymptomatic (PHQ-8<5; blue), mild (PHQ-8=5–9; purple), and moderate or greater severity (PHQ-8>=10; green). (c) Proportional distribution of symptomatic patients within each surgical department. PHQ, Patient Health Questionnaire.

Fig 4

Prevalence of depression in the perioperative patient population. (a) Prevalence of current symptoms of depression in patients with an ICD-10 code indicating a history of depression. Some 1456 (76%) had a PHQ-8<5 (teal), 126 (7%) had PHQ-8=5–9 (purple), and 261 (14%) had PHQ-8>10 (yellow); additionally 68 (4%) did not return a PHQ-8 (blue). (b) Prevalence of current symptoms of depression in patients without ICD-10 codes indicating a history of depression. A total of 974 (94%) had a PHQ-8<5 (teal), 19 (2%) had PHQ-8=5–9 (purple) and 27 (3%) had PHQ-8>10 (yellow); additionally 15 (1%) did not return a PHQ-8 (blue). PHQ, Patient Health Questionnaire.

Fig 5

Performance of a classification model to predict moderate or greater severity of depression symptoms (PHQ-8≥10). (a) Odds ratio of logistic regression mode with 95% confidence interval. (b) Coefficients used to build the logistic regression model with associated standard error. PHQ, Patient Health Questionnaire. P-values indicated at right (∗<0.05, ∗∗∗∗<1×10⁻⁶).

Fig 6

Referral outcomes among all symptomatic patients (PHQ-8≥5). Total number and proportion of patients in each referral outcome.