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Mental health disorders in children and adults increase postoperative complications

A mental health disorder or developmental disability increases the likelihood of complications after surgery, two studies find, raising important questions about how patients with these issues are prepared for procedures and followed up afterward.

Children with developmental disorders were more likely to experience a complication, a study presented at the 2018 Clinical Congress of the American College of Surgeons found, and had a longer lengths of stay following surgery.

“To our knowledge, no one has looked at outcomes in children with developmental delays undergoing surgery,” said study leader Charlotte Kvasnovsky, MD, PhD, MPH, clinical research fellow at Cohen Children’s Medical Center, Queens, NY. In fact, she believes that the effects of developmental delays such as autism on postoperative outcomes have not been specifically studied before in either adult or pediatric populations.

The researchers performed a retrospective study of the Maryland Health Services Cost Review Commission (HSCRC) database from 2009–2015. They assessed length of stay and complications for children (ages 2–18) who underwent at least one of the top 20 pediatric surgical procedures, excluding central line placement.

Of 139,850 eligible hospital admissions, 15,621 children (11.2 percent) underwent surgery, 6,118 of whom (1.1 percent) had a developmental disorder. Children with a developmental disorder were nearly twice as likely to experience a complication (20.4 percent versus 11.1 percent) than their peers. Children with developmental disorders also had longer average lengths of stay than children without such a disorder: five days versus three days.

Because children with developmental delays may have comorbidities that would contribute to postoperative complications and longer hospital stays, the researchers attempted to control for severity of illness, Dr. Kvasnovsky said.

The second study set out with a more general goal: to examine postsurgical health care use and identify characteristics of high use. There has been increased interest in high-cost patients because the top 5 percent of patients account for 50 percent of health care expenditures in any given year, said lead author Laura Graham, PhD, MPH, an advanced postdoctoral fellow at the Center for Innovation to Implementation at the VA Palo Alto Health Care System, Palo Alto, CA.

The researchers looked at hospital admissions within two years of inpatient surgery in the Veterans Health Administration between Oct. 1, 2007 and Sept. 30, 2014. Using group-based trajectory analysis, they identified a “high user” group that was compared to four other groups using bivariate statistics.

The researchers found that in 332,554 inpatient surgeries, high users were more likely to be older (average 63.7 years), male, African American and single or divorced at the time of surgery. They had more comorbidities and a strikingly higher burden of mental health diagnoses such as depression and bipolar disorder. The 30-day postoperative risk of readmission was highest among high users (25.7 percent versus. 8.5 percent) as was the 30-day postoperative risk of emergency department use (26.3 percent versus 14.2 percent).

The observation that mental health conditions are significantly associated with high health care use following surgery is important because one in five people has a mental health issue, Dr. Graham said.

She offered several possible reasons for this finding:

  • Mental health may affect other preoperative risk factors of postsurgical readmissions such as smoking, alcohol use, and obesity.
  • Mental health could affect stress hormones such as cortisol or adrenaline, which in turn could cause issues with wound healing and immune function.1
  • Depression may lower a patient’s threshold for pain, a common reason for postsurgical readmission.

The study confirms earlier research showing that adults with mental health disorders experience worse surgical outcomes, Dr. Graham said. Last year, Dr. Graham participated in an analysis of the same cohort that showed patients with depression were twice as likely to develop a postoperative infection following knee arthroscopy and were 14 percent more likely to experience an unplanned readmission in the 30 days following surgery.2 Another study found that depression was associated with increased lengths of stay in patients undergoing major abdominal surgery.3

Although the two new studies were not designed to identify explanations for their findings, both lead authors speculated that poor communications could be a contributing factor and that improving communications before the procedure could help reduce the need for postsurgical care.

In children, a developmental disorder may hinder individuals from communicating their condition early on, resulting in delayed diagnosis that allows the condition to progress, Dr. Kvasnovsky said.

In adults, a mental disorder may contribute to postsurgical complications in a number of ways, Dr. Graham said. But better care coordination before surgery, including mental health screening, could help improve outcomes, she noted. For instance, less than 20 percent of patients with a documented mental health diagnosis had evidence of a mental health clinic visit in the 30 days after their surgical procedure.

To improve patient outcomes after surgery, there is increasing interest in special programs such as Prehabilitation (PREHAB), the concept that recovery should begin before surgery through preoperative physical conditioning4, and Enhanced Recovery After Surgery (ERAS). “Mental health screening questions and referrals to treatment could be easily incorporated into these existing programs,” Dr. Graham said.


  1. Morris M, et al. Postoperative 30-day Readmission. Ann Surg (2016); 264:621-631.
  2. Cancienne JM, et al. Patient-related risk factors for infection following knee arthroscopy: An analysis of over 700,000 patients from two large databases. Knee (2017); 24(3):594-600.
  3. Orri M, et. al. Influence of Depression on Recovery After Major Noncardiac Surgery. Ann Surg (2015); 262(5):882-890.
  4. Jankowski CJ. Preparing the Patient for Enhanced Recovery After Surgery. International Anesthesiology Clinics (2017); 55(4): 12–20. https://journals.lww.com/anesthesiaclinics/fulltext/2017/05540/Preparing_the_Patient_for_Enhanced_Recovery_After.2.aspx