Abstract
Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.
Approximately 40-50 million surgeries are performed annually in the United States. 1 Several psychosocial factors including operative stress, pain, sleep, anxiety, depression, and eating behaviors can impact surgical outcomes in the short- and long-term. The use of modern surgical techniques, enhanced recovery protocols, and improvements in patient education can reduce surgical trauma, stress response to the surgical process, and enhance recovery from surgery. 2 However, there remain several psychosocial and physiological factors impacting surgical outcomes and postoperative quality of life (QoL) that are not fully addressed through surgical or pharmacological means, 3 suggesting the need for adjunctive interventions such as mindfulness. The main aims of this article are to (a) provide a brief overview of psychosocial surgical outcomes and mindfulness-based interventions (MBI) and (b) provide a review of the literature evaluating the use of MBIs in surgical patient populations to target psychosocial outcomes of surgery and enhance QoL following surgery.
Surgery and Anxiety
Up to 93% of individuals preparing for various surgical procedures endorse symptoms of anxiety associated with their upcoming surgery. 4 This preoperative anxiety is associated with an increased need for anesthesia, increased mortality risk, higher levels of and risk of postoperative pain, and longer hospital stays. Additionally, the literature indicates links between preoperative anxiety and depressive symptoms, increased disability, lower patient satisfaction, difficulty engaging in self-care activities, poorer recovery following surgery, and poorer overall surgical outcomes.5-10
Surgery and Depression
Depression prior to surgery is associated with increased need for analgesics. Several studies, including a systematic review, found depression to be a predictor of chronic postsurgical pain (CPSP). Depression is also related to postoperative delirium, infection, wound healing, impaired QoL, and poorer recovery after surgery.11-13 Depression is additionally associated with mortality in older surgical patients admitted to the ICU and poorer weight loss outcomes in bariatric surgery populations.11,14
Surgery and Sleep
Sleep disturbances, including changes in sleep continuity, sleep architecture, and perceived sleep quality, are common following surgery and can negatively impact surgical outcomes. These disturbances can persist for up to 6 months following surgery. 15 Across surgical patient populations, poor sleep can exacerbate postsurgical pain, which in turn negatively impacts sleep, suggesting a bidirectional relationship. 16 Similar relationships are seen between sleep and depression, and anxiety in surgical patients. 15
Surgery and Eating Behaviors
A subset of individuals who undergo bariatric surgery to address obesity develop disordered eating behaviors or experience a recurrence of disordered eating behaviors that were present prior to surgery. Postsurgical problematic patterns of eating and symptoms of disordered eating have been linked to poorer weight loss outcomes and higher levels of psychopathology symptoms following bariatric surgery.17-19
Surgery and Pain
Poorly managed surgical pain can affect wound healing, have negative psychological effects, and lead to higher health care costs and increased opioid use.20,21 Perioperative pain is also predictive of CPSP, 21 which develops in approximately 10% of surgical patients. 22 Depression and anxiety have been identified as risk factors for CPSP and CPSP is associated with functional impairment, lower mood, and poorer QoL.23,24
Surgery and Quality of Life
Many patients experience an improvement in QoL following surgical procedures. While some surgical treatments decrease risk of mortality, they may also lead to impairment in health-related QoL; additionally, some patients continue to experience a QoL postoperatively that is lower than the general population.25-27 Factors that impact postoperative QoL include anxiety, coping style, depression, surgical complications, and pain.12,27,29,30
Mindfulness
A 2004 consensus statement describes mindfulness as self-regulated attentional focus to the immediate moment and adoption of a curious, open, and accepting perspective. 30 Mindfulness-based interventions incorporate meditation practices to bring awareness to internal (thoughts and emotions) or external (things one can see, taste, touch, smell, or hear) cues in a non-judgmental manner. Mindfulness-based interventions can be provided in individual-, group-, or self-help-based formats.
Research evaluating MBIs demonstrates the applicability of mindfulness-based practices to address stress in both clinical and non-clinical samples.31,32 Although the mechanisms of MBI efficacy are still being elucidated, available literature indicates that a combination of neurological, endocrinological, immunological, cognitive, and behavioral mechanisms are at play and both top-down (alteration of cognitive processes) and bottom-up (stimulation of somatic, visceral, and chemosensory receptors) processes work together bidirectionally to impact physical health. 32
The most commonly studied MBIs include Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), and Acceptance and Commitment Therapy (ACT). These interventions have shown promise in addressing medical and psychiatric symptoms. In clinical samples, MBIs have been associated with a reduction in symptoms of chronic medical illnesses, including diabetes, hypertension, psoriasis, HIV, irritable bowel syndrome, pain conditions, cancer, and insomnia. These interventions have also been linked to reductions in psychological distress related to chronic medical illnesses, reduction in risk of relapse for depression, decreases in symptoms of depression, anxiety, and PTSD,32-35 and improvements in suicidality, overall QoL, and wellbeing. 36
Evidence indicating improvement of symptoms commonly experienced by patients presenting for surgery—including anxiety, depression, sleep, stress, and pain—supports the potential application of these interventions to surgical practice. In addition, mindfulness is considered a low-risk intervention, and some mindfulness interventions can be effectively administered by health professionals from a variety of disciplines, including occupational therapists, physical therapists, nurses, and behavioral health providers. 37
eHealth Interventions
Mindfulness-based interventions have traditionally been evaluated using in-person synchronous formats and the extant literature suggests the efficacy of this modality. However, given the need for social distancing during the COVID-19 pandemic, there has been a shift to telemedicine-based programs and medical services. Even as pandemic restrictions ease, virtual options are continually being made available due to cost-effectiveness, convenience, travel limitations, and efficacy. Interventions delivered using computer technology, known as eHealth interventions, have been shown to be feasible and acceptable for use in surgical patient populations38,39 and have been linked to improvements in surgery-related health behaviors.40,41 Additionally, results of a systematic review suggest that eHealth mindfulness and relaxation interventions can positively affect general health (physical functioning, disability, and QoL) and self-efficacy and reduce symptoms of depression and anxiety in patients with medical illness. 42
Literature Search
To evaluate the evidence for the use of mindfulness in surgical patient populations, the literature was searched using the following electronic databases PubMed, MEDLINE, EMBASE, PsycINFO, Web of Science, and Google Scholar using the following search terms: “mindfulness,” “ACT,” “DBT,” and “surgery.” Only English language studies were included.
Mindfulness and Postsurgical Psychological Wellbeing
Out of the 24 studies identified, 13 studies looked at aspects of mental health, particularly depression, anxiety, sleep, eating disorders, and QoL.
Depression and Anxiety
Mindfulness-based interventions are found to be effective in lowering depression and anxiety in organ transplant recipients43-45 and in breast cancer populations who have undergone surgical treatment, though the effect sizes in the 2 studies evaluating breast cancer populations ranged from low46,47 to moderate for both outcomes. Additionally, it is unclear to what extent improvements in depressive symptoms last. For patients who underwent surgery to treat breast cancer and organ transplant recipients initial reductions in symptoms of depression were not sustained 3 months following mindfulness intervention.44,46,48 Reductions in depression were also found in patients post-bariatric surgery who underwent cognitive behavioral mindfulness group therapy intervention, though long-term outcomes were not evaluated. 49
Sleep Outcomes
Sleep outcomes were improved in kidney, lung, and pancreas transplant recipients following an 8-week MBSR intervention.44,45 Unlike depressive symptoms, the improvement in sleep quality persisted at 3 months 44 and 6 months post-intervention. 45 A randomized controlled trial (RCT) found that 8 weeks of MBSR resulted in a clinically and statistically significant improvement in sleep quality in patients with failed back surgery syndrome (FBSS). 50
Eating Disorders
An RCT for patients post-bariatric surgery found significant improvement in body dissatisfaction and eating disordered behaviors, and greater acceptance of weight-related thoughts and feelings in those who had received ACT with moderate-to-large effect sizes. 51 Cognitive behavioral mindfulness-based group therapy was also shown to reduce binge eating and emotional eating in bariatric surgery patients. 52 Mindfulness-Based Eating Awareness Training (MB-EAT), an intervention targeting symptoms of binge eating disorder, led to reductions in emotional eating in response to anger in bariatric surgery patients. 52
Quality of Life
Quality of Life is a frequently evaluated outcome in the context of MBIs. In an RCT of women who developed moderate-to-severe menopausal symptoms after undergoing risk-reducing salpingo-oophorectomy, 8 weeks of MBSR training resulted in statistically significant improvements in QoL 3 and 12 months from baseline. 53 Weineland51,54 also found improvements in health-related QoL via ACT-based intervention in a bariatric patient population following initial intervention and at 6-month follow-up. Esmer 50 found that QoL significantly improved in spinal surgery patients who had undergone MBSR.
Mindfulness, Pain, and Physical Functioning
Mindfulness has also been studied in the context of pain management and physical functioning amongst surgical patients. In a study examining patients who underwent lumbar spine surgery to address lumbar spine degenerative disc, MBSR resulted in a significant improvement in physical functioning and reductions in back pain and pain interference; improvements in pain interference were sustained for at least 12 months. 56 Similarly, participation in an MBSR program was associated with a reduction in functional limitation and pain level in patients with FBSS. 50 Individuals with breast cancer who had undergone surgery reported higher levels of physical functioning after participating in a 6-weeks MBSR program. 48 A mindfulness of breath intervention reduced preoperative pain scores and a mindfulness of pain intervention reduced postoperative pain intensity in patients undergoing total joint arthroplasty (TJA). 56
Mindfulness and Patient Satisfaction
Thus far, only one study has assessed the impact of a mindfulness intervention on surgical patient satisfaction. This pilot study provides preliminary evidence that cardiothoracic surgery patients provided with a mindfulness intervention perioperatively report high levels of satisfaction postoperatively. 57
Time Point of Intervention Administration
Preoperative Interventions
There is evidence supporting the efficacy of preoperative mindfulness interventions in improving some postoperative outcomes. In a systematic review of 20 studies, Nelson 58 found that 7 out of 8 studies using preoperative MBIs with a guided imagery component saw reductions in postoperative pain and improvements in psychological comorbidities, especially anxiety. 58 Mindfulness-Based Stress Reduction administered preoperatively predicted improvements in postoperative psychological outcomes such as tension, anger, state anxiety, and pain.50,55,56,59 In patients undergoing lumbar spine surgery, preoperative MBSR was shown to enhance physical functioning and improve QoL, anxiety, depression, and sleep. However, MBSR did not significantly reduce duration of hospital stay or analgesic intake following surgery. 55 A preoperative mindfulness of pain intervention for patients undergoing TJA resulted in reduced postoperative pain intensity. 56 Lastly, a single session of a preoperative ACT intervention led to small positive effects on postoperative pain and anxiety among women presenting for breast cancer-related surgery. 46
Postoperative Interventions
In an RCT for bariatric surgery patients, ACT resulted in significant improvements in postoperative disordered eating behaviors and acceptance of weight-related thoughts and feelings with large effect sizes, and improvements in body dissatisfaction and QoL with medium effect sizes compared to treatment as usual. 51 Similarly, targeted MB-EAT for weight maintenance and psychological symptoms administered to post-bariatric patients resulted in a significant reduction in depression and improvements in binge eating and emotional eating. 52 A small pilot study evaluating the mindfulness-based Stress Management and Resiliency Training program indicated trends toward improvement in sleep, anxiety, and depression in patients who had undergone mastectomy or lumpectomy surgeries for breast cancer. 47 Organ transplant recipients who received MBSR experienced improvements in sleep quality and duration and improvements in anxiety and depression. 45
eHealth Delivered Interventions
Few studies have specifically evaluated MBIs delivered via eHealth platforms in surgical patient populations. An online MBSR intervention for adults undergoing lumbar spine surgery resulted in significantly higher physical functioning and lower pain interference at 3 and 12 months following intervention. 55 An RCT among bariatric surgery patients evaluated an ACT intervention that utilized in-person sessions and internet-based applications and found improvements in disordered eating behaviors, body dissatisfaction, and QoL in patients provided with the intervention compared to controls. 54 Treatment gains were maintained at 6 months follow-up. 51
Clinical Implications and Future Research
The documented benefits of MBIs, including reductions in stress, anxiety, depressive symptoms, and acute and chronic pain, and improvements in emotion regulation and overall satisfaction, suggest the likely benefit of incorporating these into surgical care procedures.
Among psychological outcomes, MBIs appear to be effective in decreasing depressive symptoms in the short-term and anxiety and sleep in the long-term in organ transplant recipients and patients with breast cancer who have undergone surgical treatment. In bariatric surgery populations, there is support for MBI efficacy in reducing eating disordered behavior. Preoperative mindfulness interventions appear to be helpful in ameliorating postoperative outcomes such as pain, psychological distress, physical limitations, sleep impairment, and the frequency of harmful behaviors, but the extent of efficacy appears to be limited in reducing analgesic intake and duration of hospital stay. While postoperative follow-up remains standard of care across many procedures, a patient’s engagement and attendance at postoperative appointments may vary, further supporting the potential benefits of intervening preoperatively.
The expansion of telehealth services through the COVID-19 pandemic may provide a feasible mechanism of providing MBIs, without relying on in-person follow-up visits. Research evaluating telemedicine-based MBIs in surgical patient populations is preliminary but promising, and further research is needed in this area. A currently recruiting pilot RCT 59 seeks to examine the effectiveness of web-based MBCT on prevention of chronic postsurgical pain following cardiac surgery. Additionally, there is well-documented benefit to providing postoperative web-based MBIs among patients who have undergone bariatric surgery. Garland 60 found that single session MBIs delivered in-person by hospital social workers contributed to clinically significant improvements in pain and anxiety. While promising, shortages in the health care workforce, particularly among behavioral health providers, may make in-person service delivery less feasible or sustainable. Thus, future research evaluating the efficacy of single session MBIs delivered over telehealth should be considered.
Both pre-existing conditions, such as psychiatric comorbidities and chronic pain, and postoperative factors, including surgical complications, predict psychosocial outcomes following surgery, highlighting the importance of effectively addressing patients’ psychosocial needs both before and after surgery. 61 Further research may expand our understanding of which surgical patients are likely to benefit from MBIs and offer a possible rationale for screening patients for pre-existing risk factors that may suggest greater postoperative difficulty. Additional areas of needed research are the effect of type of provider (e.g. behavioral health provider, nurse, physician, and advanced practice provider), and the amount of time elapsed between the surgery, on the efficacy and effectiveness of MBIs in surgical patient populations.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.