The course of depression and anxiety in

patients undergoing disc surgery: A

longitudinal observational study

Abstract

Objective
This study examines longitudinal depression and anxiety rates in disc
surgery patients in comparison to the general population, the change and
associated determinants of depression and anxiety over time.

Methods
The longitudinal observational study refers to 305 consecutive disc surgery
patients (age range: 18–55 years). Depression and anxiety was assessed with
the Hospital Anxiety and Depression Scale. Random effects regression
models for unbalanced panel data were used.

Results
Depression and anxiety decreases significantly during nine months after
surgery. Depression rates vary between 23.6% (T0), 9.6% (T1) and 13.1%
(T2). Only at T0 the depression rate differs significantly from the general
population. Anxiety rates range between 23.7% (T0), 10.9% (T1) and 11.1%
(T2). Compared to the general population anxiety rates are significantly
higher at all three assessment points. Risk factors for anxiety or depression
at the time of the surgery are psychiatric comorbidity before surgery, higher
age, female gender, lower educational level, lower physical health status and
higher pain intensity. Regarding depression and anxiety in the course of time
significant time interactions were found for the existence of other chronic
diseases, higher pain intensity and vocational dissatisfaction.

Conclusions
Compared to the general population patients undergoing herniated
disc surgery are often affected by depression and anxiety during
hospital treatment and also in the course of time. Multimodal diagnostics
regarding psychological well-being, pain and physical health status may help
to identify this risk group. The assistance by mental health professionals
during hospital and rehabilitation treatment may reduce poor postoperative
outcome.
Introduction

There are numerous causes for back pain reaching from muscular back strain
to more serious conditions such as a herniated disc. Disc-related diseases
represent a large contributor to the incidences of back pain in the general
population [1]. While most patients will recover by using conservative
treatment methods such as physiotherapy and analgesia medication, in
about 15% of the cases persistent pains and deficits in sensory and motor
function make herniated disc surgery necessary [2]. In Germany the
incidence for degenerative intervertebral disc surgery is about 87 operations
per 100,000 inhabitants and per year [3]. This leads to an annual number of
about 71,000 disc surgeries in Germany, showing a light preponderance of
males (1,17:1) [3].
Even though outcome studies of disc surgery document high proportions of
successful outcome rates [4], [5], there is still a considerable number of
patients who will experience persistent or recurrent pain and who will not
benefit substantially from surgery treatment [6], [7], [8], [9]. Identifying and
possibly treating factors leading to poor outcome may therefore be of great
importance for the treatment of patients undergoing surgery for a herniated
disc [5].
Although it is well-known that added morbidity of depression and anxiety in
patients suffering from chronic musculoskeletal pain is strongly associated
with more severe pain, greater disability and anxiety [10], [11], [12], data
regarding psychiatric comorbidity in disc surgery patients are rare. A recent
review [13] revealed that only a small number of studies investigated
depression and anxiety rates in patients undergoing herniated disc surgery.
Only five studies could be identified using a longitudinal study design to
present the change of depression in the course of time [13]. Merely one study
used a longitudinal design to investigate anxiety rates in disc surgery
patients in the course of time [13]. None of the reviewed studies made
comparisons between depression and anxiety rates in the disc surgery
sample and the general population.
The few studies referring to depression and anxiety in disc surgery patients
show that a large number of individuals suffer from relevant psychological
symptoms [13]. These findings underline the importance of investigating the
course of depression and anxiety over time. Gaining knowledge about risk
factors for depression and anxiety in the course of time might have major
implications for diagnosis and treatment in the rehabilitation process in
order to prevent poor surgery outcome. This study aims to investigate
depression and anxiety rates in a longitudinal study design and to compare
those rates with representative data from the German general population.
Further, it is intended to examine the impact of socio-demographic, illness-
related, vocational and rehabilitation-related characteristics on depression
and anxiety in the course of time.
Therefore the following questions will be addressed within this paper:
• 1.
How do the rates of depression and anxiety in patients undergoing
herniated disc surgery change over time?
• 2.
How are the rates of depression and anxiety in patients undergoing
herniated disc surgery at the time of the surgical treatment (T0), three
months (T1) and nine months (T2) later in comparison to the general
population?
• 3.
Which socio-demographic, illness-related, vocational and
rehabilitation-related characteristics are associated with the change of
depression and anxiety over time?

Section snippets

Study design

The present study follows a longitudinal observational study design with

three assessment points.
The baseline assessment (T0) was conducted in the form of face-to-face
interviews and took place during hospital stay, approximately 3.45 days (SD
3.170) after disc surgery. The first follow-up interview (T1) was carried out
three months, the second follow-up (T2) 9 months after disc surgery by
telephone.
The head nurses in the participating hospitals informed the study staff which
patients fulfilled
Patient sample

Table 1 presents an overview of the socio-demographic, illness-related,

vocational and rehabilitation-related variables of the disc surgery sample at
the time of the baseline interview (T0) , three (T1) and nine months later
(T2). At the time of the baseline interview the disc surgery sample has a
mean age of 42.3 years (SD 7.7) and includes 58.7% males and 41.3%
females. 41.6% of the patients declared to have at least one other chronic
disease besides the disc related illness at baseline. Among
Discussion

The present study refers to disc surgery patients who have never been
investigated for the course of the depression and anxiety over time in
comparison to the general population. Our findings make clear that about
30% of the patients have been affected by depression or anxiety for at least
one time during the period of nine months after undergoing disc surgery.
The highest rates of depression and anxiety were found to be during hospital
stay after disc surgery. Here the depression and anxiety
Conclusions

Patients undergoing herniated disc surgery are strongly affected by

depression and anxiety during hospital stay. Though depression and anxiety
decreases in the course of nine months after disc surgery, anxiety remains
significantly above the anxiety level in the general population. Our findings
outline that there is a special risk group for depression and anxiety in the
course of time after disc surgery, which might have a negative impact on a
successful surgery outcome [10], [12]. At the time
Conflict of interest

None
Funding and ethics approval

This publication was funded by the Deutsche Rentenversicherung Bund

(Project: Psychiatric comorbidity and early retirement in patients with
somatic diseases. Reference Number: 8011-106-31/31.81) and has received
ethics committee approval.

Acknowledgement
This publication has been supported by the Department of Neurosurgery of
the Klinikum St. Georg gGmbH Leipzig, by the Department of Neurosurgery
of the University of Leipzig and by the Department of Neurosurgery of the
Berufsgenossenschaftliche Kliniken Bergmannstrost Halle (Saale).
References (45)
• J.H. van Dieën et al.
Fractures of the Lumbar Vertebral Endplate in the Etiology of Low Back
Pain: a Hypothesis on the Causative Role of Spinal Compression in Aspecific
Low Back Pain
Med Hypotheses
(1999)
• A. Manca et al.
 Relationship Between Health-Related Quality of Life, Pain, and Functional
Disability in Neuropathic Pain Patients With Failed Back Surgery Syndrome
Value Health
(2010)
• M. Härter et al.
A Descriptive Study of Psychiatric Disorders and Psychosocial Burden in
Rehabilitation Patients With Musculoskeletal Diseases
Arch Phys Med Rehabil
(2002)
• V. Graver et al.
Can Psychological Traits Predict the Outcome of Lumbar Disc Surgery When
Anamnestic and Psychological Risk Factors Are Controlled for? Results of a
Prospective Cohort Study
J Psychosom Res
(1995)
• P.M. Averill et al.
Correlates of Depression in Chronic Pain Patients: a Comprehensive
Examination
Pain
(1996)
• H.D. Basler et al.
Does Disphoric Mood Really Predict the Outcome of Lumbar Spine Surgery?
Methodological Pitfalls in Psychological Research
Eur J Pain
(1997)
• J. Ylinen et al.
Decreased Strength and Mobility in Patients After Anterior Cervical
Diskectomy Compared With Healthy Subjects
Arch Phys Med Rehabil
(2003)
• R.H. Dworkin et al.
Unraveling the Effects of Compensation, Litigation, and Employment on
Treatment Response in Chronic Pain
Pain
(1985)
• A.L. Weickgenant et al.
Coping Activities in Chronic Low Back Pain: Relationship With Depression
Pain
(1993)
• J. Krämer
Bandscheibenbedingte Erkrankungen
(1994)