Effects of visiting restrictions on anxiety and depression in patients hospitalized for surgery: A cross-sectional study

Abstract

Surgical patients frequently experience anxiety and depression, associated with postoperative complications. In cases of infective diseases pandemic, patients who have undergone surgery are subjected to strict visiting restrictions (VR) during their hospitalization, which could lead to a new/unique stressful situation. The purpose in this study is to assess the effects of VR on anxiety and depression in patients who underwent surgery. This cross-sectional study included patients who underwent surgery. The questionnaire includes the presence of VR during hospitalization, clinical characteristics (e.g., age at admission, sex, and underlying diseases). The Hospital Anxiety and Depression Scale was used to evaluate anxiety and depression with cutoff values of 8/9 points. Of the 100 patients who underwent surgery, the mean ± standard deviation of age was 50.4 ± 13.0 years (male: 46%). The most frequent underlying reason for surgery was orthopaedic disease (27.0%). Anxiety and depression were observed in 30.0% and 74.0% in the included patients, respectively. Severity of anxiety and depression in patients without VR significantly decreased after surgery. In patients with VR, although severity of anxiety significantly decreased after surgery, severity of depression did not. Multivariate analysis showed improvement of depression in patients with VR was significantly lower than that in patients without VR. Careful attention to presence and/or severity of depression would be mandatory especially in patients with depression before surgery under VR situations. Recognizing that VR affect the mental distress would be important to manage patients who underwent surgery under VR situation.

INTRODUCTION

Surgery is an effective intervention for many diseases, such as cancer, cerebrovascular diseases, and orthopaedic disorders. Although surgery is necessary in current medicine, patients who undergo surgery frequently experience emotional distress related to the surgery. Approximately 11–34% and 6–56% of patients undergoing surgery experienced anxiety and depression before the surgery, respectively^2,8,17,25). The rates of anxiety and depression in such patients decreased after surgery but remained high at 9–19% and 8–15%, respectively^17,18,25). Patient characteristics such as sex, cognitive impairment, pain, infection, and limited mobility are known as associated factors for mental distress^6,8). The presence of mental distress in these patients preoperatively is attributed to issues such as prolonged hospital stays, postoperative mortality, and postoperative complications. Thus, early recognition of and intervention for mental distress in patients undergoing surgery are needed even after surgery.

In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, some cities were locked down in an effort to curb transmission, during which many people experienced loneliness, and the prevalence of depressive symptoms has been higher than before the pandemic^5,19,31). Although messenger ribonucleic acid (mRNA) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines have been developed and their efficacy and safety have been demonstrated, some patients undergoing surgery were forced to remain under visiting restrictions (VR) (i.e., restrictions on meeting family and friends) in hospitals, to prevent the spread of infections even in the endemic phase²²⁾. Patients undergoing surgery frequently experience mental distress both before and after surgery even without any VR. However, the changes in mental distress from before to after the surgery under VR remain unclear.

A previous study reported that VR due to COVID-19 lead to loneliness¹²⁾. Moreover, residents living in nursing homes experienced mood disorders, psychological stress (e.g., fear, sadness, and agitation), and low quality of life under VR conditions^26,29). Another study reported that insufficient communication between surgery patients and members of their families leads to hopelessness¹⁰⁾. These studies suggest that VR-induced limitations in the communication of surgical patients with their friends or family members might be an additional mental burden to these patients even in the postoperative phase. Thus, this study sought to elucidate the effects of VR on the anxiety and depression of patients both preoperatively and postoperatively.

METHODS

Participants

This cross-sectional study included patients who had been admitted to any hospital in Japan for surgery between 2019 and 2022. The exclusion criteria were as follows: 1) patients aged < 18 years at the time of the surgery and 2) patients who underwent non-elective surgery. The participants were registered as interviewees in the database of a web research company and were invited to participate in our study through an e-mail from the company. The participants answered a questionnaire on a webpage after accepting the invitation.

This study was conducted after obtaining the informed consent of each participant through a web page and was approved by the Ethical Committee for Epidemiology of Hiroshima University (#E2022-0094). The authors declare no conflict of interest in relation to this work.

Data collection

The questionnaires were answered by the participants via a webpage in August 2022. The questionnaires included their age at admission, sex, and presence of cohabitation with another person. In addition to questions on the basic characteristics of the patients, the questionnaires also included the presence of VR in the hospital, length of hospital stay, year of admission, underlying diseases requiring the surgery, and type of anaesthesia used during the surgery. The severity of anxiety and depression before and after surgery was evaluated using the Japanese version of the Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire³¹⁾. The HADS comprises 14 items (7 for anxiety and 7 for depression), and each item is scored on a scale from 0 to 3 points. Higher scores indicate more severe anxiety (HADS-A) and depression (HADS-D), with possible total scores ranging from 0 to 21 points. We considered patients to have anxiety and depression when the HADS-A and HADS-D scores were ≥ 8 points. We also evaluated the changes in the severity of anxiety and depression after surgery by subtracting the postoperative HADS-A and HADS-D scores from the preoperative HADS-A and HADS-D scores, respectively. For the changes in HADS-A and HADS-D scores, higher scores indicated that anxiety and depression had improved after surgery.

Statistical analysis

Data are shown as mean ± standardized deviation (SD), number (%), standardized β, or odds ratio (OR) with 95% confidence interval (CI). We estimated that a 100 patients were needed to detect a difference between people with VR and those without VR for the main outcomes (i.e., anxiety and depression) following a previous study (statical power: 80%)²⁷⁾. Patients were stratified by the presence of VR in the hospital to evaluate the effects of these restrictions on anxiety and depression. The Shapiro–Wilk W test was used to evaluate the Gaussian distribution. The t-test or the Mann–Whitney U test was used to compare continuous variables, and the chi-square test was used to compare binary data between patients with and without VR. A regression analysis was used to evaluate the factors associated with anxiety and depression after surgery. Univariate regression analysis and stepwise analysis (i.e., multiple regression analysis or logistic regression analysis) (forward-stepwise selection, removing terms with P ≥ 0.20) were used for seeking associated factors for anxiety or depression. When the two-sided P-value was < 0.05, the null hypothesis was rejected. All statistical analyses were performed using Stata version 15.1 (Stata-Corp, College Station, TX, USA).

RESULTS

Of the included 100 patients, the mean ± SD age and length of hospital stay were 50.4 ± 13.0 years and 11.6 ± 14.0 days, respectively (Table 1). Fifty-six of these patients were men, and all lived with another person. The most common underlying diseases that necessitated surgery were orthopaedic diseases (27.0%), followed by gastroenterological (24.0%), gynaecological (16.0%), and cardiac (8.0%) diseases. Furthermore, 63% of the patients were treated under general anaesthesia. Moreover, 30% and 74% of the patients had anxiety and depression before surgery, respectively (HADS-A: 5.4 ± 4.7 points, HADS-D: 9.8 ± 4.2 points). As shown in Table 1, 75.0% of the patients underwent surgery under VR. No significant differences were noted between patients with and without VR in terms of age, sex, and cohabitation with another person. The proportions of underlying diseases and the type of anaesthesia also did not significantly differ between the groups. Regarding the preoperative HADS score, the degree and presence of anxiety and depression did not differ between patients with and without VR.

Table 1

Clinical characteristics

	All	w/o VR	VR	p-value
Number, N (%)	100 (100.0)	25 (25.0)	75 (75.0)	—
Age, y.o.	50.4 ± 13.0	51.2 ± 14.2	50.2 ± 12.6	0.52
Male, N (%)	56 (56.0)	18 (72.0)	38 (50.7)	0.06
Person who lived together, N (%)	100 (100.0)	25 (100.0)	75 (100.0)	1.00
Length of hospital stay, days	11.6 ± 14.0	12.2 ± 15.6	11.4 ± 13.5	0.81
Underlying diseases, N (%)
Orthopedics	27 (27.0)	9 (36.0)	18 (24.0)
Gastroenterology	24 (24.0)	4 (16.0)	20 (26.7)
Gynecology	16 (16.0)	2 (8.0)	14 (18.7)
Cardiology	8 (8.0)	3 (12.0)	5 (6.7)
Oral	5 (5.0)	2 (8.0)	3 (4.0)
Urology	4 (4.0)	2 (8.0)	2 (2.7)
Otolaryngology	3 (3.0)	1 (4.0)	2 (2.7)
Neurology	3 (3.0)	0 (0.0)	3 (4.0)
Hematology	2 (2.0)	0 (0.0)	2 (2.7)
Pulmonology	2 (2.0)	1 (0.0)	1 (1.3)
Endocrinology	2 (2.0)	0 (0.0)	2 (2.7)
Dermatology	2 (2.0)	0 (0.0)	2 (2.7)
Ophthalmology	1 (1.0)	0 (0.0)	1 (1.3)
Proctology	1 (1.0)	1 (4.0)	0 (0.0)	0.45
Anesthesia, N (%)
General anesthesia	63 (63.0)	13 (52.0)	50 (66.7)
Local anesthesia	37 (37.0)	12 (48.0)	25 (33.3)	0.19
Admitted years, N (%)
2022	18 (18.0)	3 (12.0)	15 (20.0)
2021	42 (42.0)	6 (24.0)	36 (48.0)
2020	25 (25.0)	6 (24.0)	19 (25.3)
2019	15 (15.0)	10 (40.0)	5 (6.7)	0.001
HADS before surgery, points
HADS-A, points	5.4 ± 4.7	4.7 ± 5.7	5.5 ± 4.8	0.81
Anxiety, N (%)	30 (30.0)	7 (28.0)	23 (30.7)	0.80
HADS-D, points	9.8 ± 4.2	10.3 ± 4.6	9.7 ± 4.1	0.55
Depression, N (%)	74 (74.0)	20 (80.0)	54 (72.0)	0.43

VR: Visiting restrictions, N: Number, HAD: Hospital Anxiety and Depression Scale

Among the patients with VR, the severity of anxiety significantly decreased after surgery (5.5 ± 4.8 vs. 4.2 ± 4.5 points, P = 0.002), but that of depression did not (9.7 ± 4.1 vs. 9.2 ± 4.5 points, P = 0.23) (Fig. 1A). Among the patients without VR, the severity of both anxiety and depression significantly decreased after surgery (HADS-A: 5.7 ± 4.7 vs. 4.7 ± 4.3 points, P = 0.02; HADS-D: 10.3 ± 4.6 vs. 8.1 ± 4.9 points, P = 0.0003) (Fig. 1B). No significant differences were noted between patients with and without VR regarding the change in the severity of anxiety after surgery (1.0 ± 1.8 vs. 1.4 ± 3.5 points, P = 1.00; Fig. 2). However, the change in the severity of depression in patients without VR was significantly greater than that in patients with VR (2.2 ± 2.6 vs. 0.5 ± 3.3 points, P = 0.02; Fig. 2).

Figure 1

Comparison of anxiety and depression scores before and after surgery.

(A) Patients with visiting restrictions.

(B) Patients without visiting restrictions.

The cross symbol and error bar represent mean value and standard deviation, respectively. Violin plot means distribution of anxiety or depression score.

Figure 1

Comparison of anxiety and depression scores before and after surgery.

(A) Patients with visiting restrictions.

(B) Patients without visiting restrictions.

The cross symbol and error bar represent mean value and standard deviation, respectively. Violin plot means distribution of anxiety or depression score.

Figure 2

Comparison of changes in anxiety and depression between patients with visiting restrictions and those without visiting restrictions.

VR: visiting restrictions.

The cross symbol and error bar represent mean value and standard deviation, respectively. Violin plot means distribution of changes in anxiety or depression score.

Among patients without VR who did not have anxiety or depression before surgery, none developed anxiety or depression newly after surgery (Table 2A and B). Conversely, among patients under VR but without anxiety or depression, 9.6% and 28.6% patients newly developed anxiety or depression after surgery, respectively (Table 2A and B). Regarding patients with anxiety or depression before surgery, the trends in the presence of anxiety or depression after surgery were not different between patients with VR and those without VR (Table 2C and D).

Next, univariate regression analysis showed that VR during admission was not significantly associated with the changes in the HADS-A score after surgery (Table 3A) or with the presence of anxiety after surgery; while young age was significantly associated with presence of anxiety in stepwise analysis (OR [95%CI]: 0.95 [0.92–0.99], P = 0.01) (Table 3B). Regarding depression, in stepwise analysis the severity of depression after surgery in patients without VR decreased significantly more than that in patients with VR (β = −0.23, P = 0.02; Table 4A) while the presence of depression after surgery did not differ significantly between patients with VR and those without VR (Table 4B).

Table 2

Detailed trends of changes of presence of anxiety and depression after surgery

(A) Anxiety in the patients without anxiety before surgery

	w/o VR	VR	p-value
Presence (Before → After), N (%)
Absent → Exist	0 (0.0)	5 (9.6)
Absent → Absent	18 (100.0)	47 (90.4)	0.17

(B) Depression in the patients without depression before surgery

	w/o VR	VR	p-value
Presence (Before→ After), N (%)
Absent → Exist	0 (0.0)	6 (28.6)
Absent → Absent	5 (100.0)	15 (71.4)	0.17

(C) Anxiety in the patients with anxiety before surgery

	w/o VR	VR	p-value
Presence (Before → After), N (%)
Exist → Exist	6 (85.7)	13 (56.5)
Exist → Absent	1 (14.3)	10 (43.5)	0.16

(D) Depression in the patients with depression before surgery

	w/o VR	VR	p-value
Presence (Before → After), N (%)
Exist → Exist	14 (70.0)	46 (85.2)
Exist → Absent	6 (30.0)	8 (14.8)	0.14

VR: Visiting restrictions, N: Number

Table 3

Associated factors for changes of anxiety after surgery

(A) Changes of HADS-A

	Univariate			Stepwise
	β	p-value		β	p-value
Visiting restrictions	0.06	0.59		Removed
Age	−0.06	0.57		Removed
Male	−0.003	0.98		Removed
Length of hospital stay	0.05	0.59		Removed
Anesthesia
Local Anesthesia	(ref.)	—		(ref.)	—
General anesthesia	0.16	0.12		0.15	0.14
Admitted years
2022	(ref.)	—		(ref)	—
2021	−0.11	0.45		0.08	0.58
2020	−0.20	0.14		0.19	0.21
2019	−0.25	0.051		0.26	0.052

(B) Presence of anxiety

	Univariate			Stepwise
	OR (95%CI)	p-value		OR (95%CI)	p-value
Visiting restrictions	1.00 (0.35–2.89)	1.00		Removed
Age	0.96 (0.92–0.99)	0.02		0.95 (0.92–0.99)	0.01
Male	0.73 (0.29–1.83)	0.50		Removed
Length of hospital stay	1.03 (1.00–1.06)	0.09		1.03 (1.00–1.06)	0.06
Anesthesia
Local Anesthesia	(ref.)	—		Removed
General anesthesia	1.23 (0.47–3.24)	0.67
Admitted years
2022	(ref.)	—		Removed
2021	1.57 (0.43–5.70)	0.49
2020	0.48 (0.09–2.46)	0.38
2019	1.27 (0.26–6.27)	0.77

HADS: Hospital Anxiety and Depression Scale, OR: Odds ratio, CI: Confidence interval

Table 4

Associated factors for changes of depression after surgery

(A) Changes of HADS-D

	Univariate			Stepwise
	β	p-value		β	p-value
Visiting restrictions	−0.23	0.02		−0.23	0.02
Age	−0.01	0.90		Removed
Male	0.14	0.15		Removed
Length of hospital stay	0.005	0.96		Removed
Anesthesia
Local Anesthesia	(ref.)	—		Removed
General anesthesia	−0.04	0.70
Admitted years
2022	(ref.)	—		Removed
2021	0.12	0.33
2020	−0.08	0.57
2019	−0.11	0.43

(B) Presence of depression

	Univariate			Stepwise
	OR (95%CI)	p-value		OR (95%CI)	p-value
Visiting restrictions	1.78 (0.70–4.50)	0.23		Removed
Age	0.97 (0.94–1.01)	0.12		0.97 (0.94–1.01)	0.12
Male	1.01 (0.44–2.30)	0.99		Removed
Length of hospital stay	1.00 (0.97–1.03)	0.99		Removed
Anesthesia
Local Anesthesia	(ref.)	—		Removed
General anesthesia	1.31 (0.56–3.06)	0.54
Admitted years
2022	(ref.)	—		Removed
2021	0.69 (0.21–2.32)	0.55
2020	0.99 (0.26–3.82)	0.99
2019	0.44 (0.10–1.88)	0.27

HADS: Hospital Anxiety and Depression Scale, OR: Odds ratio, CI: Confidence interval

DISCUSSION

This study showed that depressive states in patients with VR did not improve after surgery. Furthermore, decrease in severity of depression in patients with VR after surgery was significantly less than that in patients without VR. Conversely, the anxious state in patients with VR improved after surgery, though decrease in severity of anxiety after surgery was not different between patients with VR and those without VR. This study indicates that the presence of VR could be an obstacle to improvement of depression after surgery.

Our findings revealed that 74% of the patients had depression before surgery; this was higher than that the prevalence reported in previous studies which indicated that focused management of depression in patients undergoing surgery under VR might be needed^3,8,17). Furthermore, this study showed that severity of depression after surgery in patients with VR did not improve and, the improvement of depression in patients with VR was less than that in patients without VR. Although the exact reason for the differences in trends of depression between patients with VR and without VR are unknown, several possible reasons can be considered. Patients in this study may have experienced loneliness due to the restrictions. Some previous studies have reported that VR stations can lead to feelings of isolation, reduced communication, and sadness after surgery, speculating that these psychological burdens contribute to anxiety or depression^16,17). Moreover, the association between depression and loneliness might also explain the unchanged severity of depression in these patients after surgery, as feelings of loneliness due to VR remained unchanged even after surgery⁴⁾. Furthermore, a previous study reported that welcoming family members into the patient’s room improved communication between patients and medical staff as well as the family member²⁸⁾. Since some studies indicated that less information was associated with high depression levels during the perioperative period, it is possible that the patients being under VR would be a factor for insufficient giving of information, and they might feel more depressive state even after the operation^9,30). Moreover, a systematic review which was based on randomized control trials has shown that family focused interventions for improving communication significantly reduced depression among young patients¹³⁾. Under VR circumstances the patients, regardless of their age, might be forced to be in depression due to less communication which might be associated with VR.

The prevalence/incidence of anxiety before surgery in this study was not higher than that estimated in a previous meta-analysis¹⁾. A previous study revealed that half of the patients who underwent surgery were preoperatively worried about complications and pain due to surgery¹⁶⁾. These factors may not interact with anxiety in patients with VR. Preoperative education about surgery-related complications and pain could be a helpful intervention for reducing anxiety before surgery^11,15,20,24). Moreover, the present study showed that the severity of anxiety decreased after surgery, regardless of the presence of VR. One of the interpretations of this result is as follows: the factors associated with anxiety in patients undergoing surgery have been reported to be “Results of operation,” “Harm from medical doctor/nurse mistakes,” “Waiting for operation,” “Awareness during surgery/Injection of anaesthesia,” and “Feeling pain during operation”; these may be eliminated from the patients’ minds after surgery, regardless of the presence of VR^16,23). For the anxiety after surgery, we speculated the situation which relates with anxiety might be eliminated after surgery, but not for depression.

To the best of our knowledge, this study is the first to show the presence and severity of mental distress including its trends before and after surgery in patients with VR. The patients with surgery would be forced to be under VR situation during the pandemic. In the long view of the human history, many types of pandemics or disease outbreaks, COVID-19 as well as black death, Spanish influenza, severe acute respiratory syndrome, and Middle East respiratory syndrome, have occurred²¹⁾, and thus, it is highly speculated other types of pandemics will occur in the future. The World Health Organization has reported more than 30 types of pathogens that can potentially trigger the next pandemic. Of these, influenza A virus, dengue virus, and monkeypox virus are considered high-risk for future pandemics¹⁴⁾. These pandemics would likely increase the demand of VR in the future. The findings of this study might be useful for the management of mental health in patients undergoing surgery during future pandemic. Although no studies have specifically reported on effective VR-based intervention or management strategies to prevent anxiety or depression among patients undergoing surgery, we suggest that providing video or audio massage from family members whether pre- or post-operation could help alleviate patients’ mental distress⁷⁾. Furthermore, some diseases (such as leukaemia) require VR due to postoperative cares. The results of this study might be applicable in these situations; our findings suggest that patients with VR, regardless of the reasons for these restrictions, might be at a high risk for prolonged depression. Despite the strengths of this study, we recognize the following limitations. The recall method was applied when participants answered the questionnaire. Because of the nature of the recall method, we cannot deny any recall bias in this study. Regarding anxiety and depression, it was highly speculated that using smart phone or tablet terminals to connect with family members and friends would reduce anxiety and depression. We cannot exclude the confounding effect of this factor (even if slight) on the prevalence of anxiety and depression in our study participants since they had free access to these terminals in the hospital. Moreover, it was highly possible that post-operative complications could impact the development of anxiety or depression after surgery. However, we did not examine the presence of complications among participants, as they participants were mainly non-medical specialists who would not be able to answer the question about post-operative complications. Furthermore, the participants could have been suffering from anxiety and depression before the need for surgery arose; thus, the questionnaire should account for previous mental health issues. Finally, we could not include the types of underlying diseases that necessitated surgery as a variable for regression analysis because the number of underlying diseases was insufficient for the analysis. Further studies are required to resolve these limitations.

In conclusion, the severity of anxiety and depression decreased after surgery in patients without VR while the severity of depression did not decrease after surgery in patients with VR, and some patients with VR who did not have anxiety or depression before surgery developed anxiety or depression after surgery. We should keep in mind the characteristics of patients undergoing surgery under VR and the need for early recognition of and intervention for depression in such patients even after surgery.

Disclosure

The authors declare no conflict of interest in relation to this work.

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