Understanding Depression Following Cardiac Surgery
Thursday, January 17, 2019
Las Vegas, Nevada
Understanding Depression Following Cardiac Surgery
Freshly recovering from my second aortic valve replacement surgery in eleven years, I feel uniquely qualified to reflect on the the “depression” typically following open heart procedures.
In 2008, after suffering with increasingly severe back pain, an infectious disease specialist identified the underlying cause as a systemic infection of the blood. Bacteria had entered two inter-vertebral discs, causing the back pain. Meanwhile, it also silently eroded the aortic valve of my heart.
Fearing a bacterial-vegetation causing a heart attack or a stroke, she immediately admitted me to Huntington Memorial Hospital, in Pasadena, for a total of 20 days. First, she ordered intravenous antibiotics to kill the bacteria. Second, she prescribed, also intravenously, an array of narcotics to reduce the then-excruciating back pain. Third and last, once the bacteria cleared my system, a thoracic surgeon sawed open my sternum, dissected away the tissues surrounding the heart, and removed the diseased aortic valve. He replaced it with one from a pig.
While recovering from that initial surgery, hospital staff provided me with a set of materials describing the “depression” I might experience.
Those materials were idiotic.
They made the depression sound like a virus, like influenza; they suggested I be “on the lookout” for “depressive symptoms” like you’d be looking for muscle aches, sore throat, or fatigue.
Those documents completely mis-stated the type of emotional distress often experienced by open-heart surgery patients.
Fast forward nearly 11 years, and it’s now late 2018. I contracted endocarditis again—that’s the technical name for a bacterial infection of the heart. Once you have endocarditis, you are at a greater risk of catching it again. The bacteria infected the prosthetic valve, which was nearing the end of its lifespan. On December 17, 2018, I had a “re-do,” namely yet another open heart procedure in which the valve was replaced with a newer, crisper one.
One more quick point before more accurately describing post-open-heart-surgery emotional funk. I firmly believe the mind and body are one. Like Baruch Spinoza, who coined the phrase “aspect dualism,” I consider our subjective experience but one aspect of our worlds. Neurophysiology is another, cultural anthropology still another.
Our subjective world relates to the brain, of course, but it does not only connect to the brain in a singularly reductionist manner. It also exists immersed in other, immensely complex contexts.
What are these other contextual factors?
They include other, internal physiological phenomena like hormones, underlying chronic diseases like hypertension or diabetes, general state of health, degree of fitness, etc.; they also include a multitude of external processes like culture, language, degree of education, socioeconomic status, geography, air quality, nutrition, and so on.
Therefore, when looking at emotional reactions, I privilege neither mind nor body.
I see them as linked, together, a heart-mind.
Having noted my personal background and explained the unified mind-body concept, I turn now to explaining some of the factors leading patients undergoing open heart procedures prone to emotional upset:
First, the surgery itself proves as significant a trauma to your body as any major automobile accident or other serious injury. As I noted, a team of surgeons has sawed your sternum, cut through muscle, fat, and viscera, stopped your heart, run your blood through a bypass machine, made incisions to replace coronary arteries or valves, sutured back together the bits of anatomy torn asunder, and re-started your heart.
In my most recent, December 2018 experience, I entered the hospital for this gruesome procedure in excellent condition. I felt good, had been going to the gym daily, and felt mentally prepared for going through open heart gig number 2.
Go ahead and try to prepare yourself; you’ll fail miserably, as I did.
I entered USC/Keck hospital at 530am on that Monday morning. When I awoke around 4pm that evening, I was a wreck. Dazed by the lingering anesthesia and pain medication, I nonetheless felt severe pain in my sternum. I struggled to breathe. I felt frightened. I could barely move, even lying prone in the bed.
Nursing staff starts you walking the actual day of the surgery. They then encourage you to walk each subsequent day. Walking perhaps 50 feet to the end of hall left me winded and weak.
The aftermath of the surgery was an absolute shock, especially the stark contrast between how I felt the days and weeks before and how I felt the first day post-surgery, and the second, and the third, and so on.
Just getting this list started, the surgical attack on the body/mind is mind-blowing. It is absolutely unbelievable how much you are traumatized by it.
Second, the experience reminds you, also throughout your body-mind, of your incredible vulnerability. Some think any surgery of the heart, because the organ is stopped and your blood runs through a bypass machine, or perhaps because of the nearby nerve connections to the brain, elicits a greater sense of vulnerability.
In any event, the normal “denial of death,” described so brilliantly in Ernest Becker’s book by the same title (see reference list), breaks down after an open heart surgery. You become instantaneously aware of the miracle of your human existence, of life. You can’t believe the fragility of it. Separate and distinct from the trauma of the surgery, then, is the immediate and intense experience of your personal vulnerability.
Third, the experience adversely affects self-image.
Am I a flawed person now?
Am I permanently damaged, impaired, inadequate, impotent?
Still having neurophysiological correlates, this reaction feels more purely psychological. The post-surgical experience often leaves you feeling damaged, less adequate.
Closely related to the self-image attack, post-open-heart surgery patients are left with a legitimate fear of a recurrence. Valves only last so long, and so do stents or arterial bypasses. If you’re young enough, you will likely be visiting your thoracic surgeon again. That elicits persistent fear, conscious or unconscious, a fourth impact of open-heart surgery.
Fifth, the experience heightens your sense of existential aloneness. No matter how immersed you may be in the love of others, you pass through the surgical experience intensely alone. It reminds you of the cliche saying about coming into, and exiting the world, alone. After the hugs and kisses from those that love you, hospital staff wheels you into the operating room while you lie there on the gurney entirely alone.
Existential aloneness offers a transition into the sixth point, namely the effect of open-heart surgery on those around you. You go into the experience with fear and loathing; those who love you have parallel experiences. I propose that, while you are the one undergoing this traumatic surgical experience, those comprising your social network are having a parallel traumatic experience. They wonder:
Will you die?
Will you end up with a stroke or other permanent impairment?
Will they be ok if they depend on you emotionally, financially, or in other ways?
Unless you lack any sense of conscience, this impact on loved ones additionally affects you. You may feel guilt or shame. You may feel concern for their reactions. This, then, adds to the overall emotional reaction. Assuming you survive the surgery, the impact on those around you persists. They too fear a recurrence, a complication, or similar negative reactions. They also see you as more vulnerable.
On yet another level, your own serious encounter with death reminds those around you of their own vulnerability. I have particularly seen this in people I view more as acquaintances than friends. They don’t really want to hear the details because they don’t want to even think of the possibility of it happening to them or someone they love.
These six points immediately come to my mind—impact of trauma, heightened sense of vulnerability, fear of recurrence, effects on self-image, increased feelings of existential aloneness, and the shock wave passing through your interpersonal world.
I could extend the list indefinitely.
Suffice to say that, even given this limited list of reactions, the array of emotions experienced by post-open-heart surgery patients exceeds the number of words available to describe them. I experienced, and imagine most post-cardiac surgical patients do too, feelings including terror, dread, loss, sadness, rage, irritation, revulsion, and envy.
Still only four weeks since the latest surgery, I have not yet enjoyed yet another and much more positive emotion—pure, unadulterated joy. I mean, the miracle, the amazing grace of physicians and medical technology being capable of performing such a procedure and extending your life.
Hooray for them, and for me, but my sternum still hurts like hell, I feel short of breath, and become tired by mid-day. I look forward to the immersion in joy, and wait patiently (kind of) for it to arrive.
In conclusion then, ignore those nonsensical brochures about “post-cardiac surgery depression.”
Depression is a garbage word, a generalization minimizing a much more complex reaction to a serious life event. Consider, instead, the complexity of our subjective worlds and how, should you have the experience of an open heart surgery, better to ready yourself for a complicated wave of emotions, allow these to pass through you, and keep you eye on love and the beauty of the present moment.
Becker, E. (1973). The denial of death. New York: Free Press.
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