ORIGINAL ARTICLE
Depression and essential health risk factors in surgical
patients in the preoperative anaesthesiological
assessment clinic
Heidi LinnenM, Henning KrampeM, Tim Neumann, Edith Weiß-Gerlach, Andreas Heinz,
Klaus-Dieter Wernecke and Claudia D. Spies
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Background and objective Depression is common in patients
with medical illness. However, little is known about frequency
and clinical relevance of preoperative depression in surgical
patients. The objective of this study was to investigate the
frequency of depression, essential health risk factors and
hospital length of stay (LOS) of patients in preoperative
anaesthesiological assessment.
Methods Patients were consecutively screened in the
preoperative anaesthesiological assessment clinics. In total,
5429 patients gave written informed consent to perform a
computerised self-assessment of lifestyle factors, including
alcohol use, tobacco smoking, weight, physical status, physical
exercise, sleeping disturbance, subjective health and sense of
coherence (SOC). Depression was defined by a WHO-5
well-being score of 13 or less. LOS was obtained from the
electronic patient management system.
Results A clinically relevant depressive state was found in
29.7% of the patients. Patients with depression had a
median LOS of 6.0 days as compared to patients with positive
Introduction
Depression is a common psychiatric condition in patients
with medical illnesses. Prevalence rates of clinically
significant depressive states are up to four times higher
in people with diverse medical conditions than in general
population samples, and, depending on severity and
chronicity of the medical disease, frequency of depres-
sion ranges between 15 and 50%.1–5 Recent studies
found that depression worsens the prognosis of medical
illness and has an impact on outcomes in surgical
patients.2,4,6–9 However, little is known about the
relationship between preoperative depression and other
health risk factors that have proven clinically relevant in
From the Department of Anaesthesiology and Intensive Care Medicine, Campus
Virchow Klinikum and Campus Charité Mitte, Charité – Universitätsmedizin Berlin
(HL, HK, TN, EW-G, CDS), Institute of Medical Biometry, Campus Charité Mitte,
Charité – Universitätsmedizin Berlin and SOSTANA GmbH (K-DW) and
Department of Psychiatry and Psychotherapy, Campus Charite Mitte, Charité –
Universitätsmedizin Berlin (AH), Berlin, Germany
Correspondence to Claudia D. Spies, MD, Professor of Anaesthesiology and
Intensive Care Medicine, Head of the Department, Department of Anaesthesiol-
ogy and Intensive Care Medicine, Campus Virchow Klinikum and Campus Charité
Mitte, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353
Berlin, Germany
Tel: +49 30 450 551 001; fax: +49 30 450 551 909;
e-mail: claudia.spies@charite.de

Heidi Linnen and Henning Krampe have contributed equally to the writing of this
article.
0265-0215 ß 2011 Copyright European Society of Anaesthesiology
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
well-being who had a LOS of 4.8 days (P < 0.001). Worse
subjective health, less physical exercise and experience of SOC,
as well as more severe sleeping disturbances were
independently and significantly associated with depression
(P < 0.001).
Conclusion Clinically significant depressive states are frequent
conditions in surgical patients of preoperative
anaesthesiological assessment and are associated with an
increased LOS. Different clinical pathways delivering adequate
preoperative information according to the needs, considering
subjective health and SOC of the patient as well as avoiding
immobilisation and sleep disturbances during hospital stay
should be considered. Long-term treatment programmes
including brief intervention in the hospital and an outpatient
concept should be offered.
Eur J Anaesthesiol 2011;28:733–741
Published online 14 September 2011
Keywords: clinical outcome, depression, health risk factors, preoperative
anaesthesiological assessment, psychosocial factors
anaesthesiology. In order to provide effective treatment
options for depression, both anaesthesiologists and psy-
chotherapists need to gather more detailed information
about how depression is associated with essential anaes-
thesiological health risk factors, above all hazardous alco-
hol consumption and tobacco smoking,10–12 as well as
indicators of preoperative physical health status such as
obesity,13 physical exercise14 and the ASA (American
Society of Anesthesiologists) physical status classification
system as an overall indicator for physical health.15 An
examination of preoperative depressive states in surgical
patients needs also to clarify the role of both risk factors
and protective factors that have shown to be associated
with depression in the general population. These factors
include sex,16 age,17 specific sociodemographic charac-
teristics (e.g. partnership status, education, employment
status),18 sleep disturbances,19 subjective experience
of health as one component of health-related quality of
life,20,21 as well as the personality disposition ‘sense of
coherence’. This construct was repeatedly found to be
highly correlated with depression and describes the
extent to which people experience that they are capable
of understanding, managing and finding a meaning in
what happens around them.22,23 Finally, in order to make
an estimate of the relationship of depression and surgical
recovery and healthcare use, it is important to examine to
DOI:10.1097/EJA.0b013e3283478361
 734 Linnen et al.
which extent preoperative depressive states have an
influence on outcomes in surgical patients.8
This study investigated the frequency of depression, its
association with essential health risk factors and its
clinical relevance in preoperative anaesthesiological
assessment by using a computerised self-assessment of
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patients’ lifestyle risks.
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The primary objectives of the study were to investigate
the frequency of depressive states by using the short
depression screening tool WHO-5 (World Health Organ-
ization 5-item Well-Being Index24) in preoperative
anaesthesiological assessment and to show its clinical
impact with regard to hospital length of stay (LOS).
The secondary objectives were to examine whether
patients scoring high vs. low on the WHO-5 differ with
regard to sex, age, partnership, education, employment
status, alcohol use disorders, tobacco smoking, BMI,
physical exercise, ASA classification, surgical field, sever-
ity of sleeping disturbance, the patients’ experience of
subjective health, and sense of coherence and to deter-
mine which of these risk or protective factors show
a statistically significant, independent impact for the
prediction of depression when entered simultaneously
into a logistic regression model of depression.
Patients and methods
Setting
The study was conducted in the preoperative assessment
clinics of the Charité – University Medicine Berlin,
Fig. 1
Assessed for eligibility n = 16687
Enrolled = 5708
Analysis
Analysed n = 5429
• Men n = 2749
Flowchart of phases of the clinical trial.
European Journal of Anaesthesiology 2011, Vol 28 No 10
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Campus Charité Mitte and Campus Virchow Klinikum,
Berlin, Germany, between February 2006 and December
2007. The Charité – University Medicine is one of the
largest hospitals in Europe performing approximately
65 000 general anaesthesias per year. Each patient under-
going elective surgery is examined by an anaesthetist
implying two principal goals: clarification of anaesthesia-
related risks of the intended surgery and the evaluation of
the patient’s individual level of risk. A total of 43 604
patients were seen in the preoperative assessment clinic
during the study period.
Patients and study design
The present study was designed as a prospective obser-
vational study. After the approval of the institutional
review board (application number EA1/23/2004) and after
having given written informed consent, 5429 consecutive
patients were enrolled in the study (Fig. 1).
During the study period, a total of 16 687 patients were
assessed for eligibility, with 3912 refusing to participate
and 7067 not being eligible according to inclusion/exclu-
sion criteria. Inclusion criteria are as follows: age at least
18 years, written informed consent, sufficient knowledge
of the German language and willing/capable of using a
computer. Exclusion criteria are as follows: participation
in another clinical trial, members of the hospital staff,
admitted in police custody, relatives of the study team,
surgery with an emergency or urgent indication. Patients
who had not been seen in the preoperative assessment
Excluded n = 7067
• Age <18 years n = 5181
• Not fluent in German n = 803
• Not willing/able to use computer n = 546
• Hospital staff n = 47
• Participant of other clinical study n = 456
• Not competent n = 34
• Declined to participate n = 3912
Incomplete questionnaire n = 279
Analysed n = 5429
• Women n = 2680
 Depression and essential health risk factors 735

clinic but had been seen and examined by an anaesthetist management system of the Charité Universitätsmedizin
on the ward were not recruited. Data were excluded from Berlin. LOS was measured in days and calculated by
analyses (n ¼ 279) in cases where patients had not com- subtracting the date of admission to hospital from the
pleted the electronic questionnaire or had provided date of discharge from hospital.
insufficient data. Complete data were available for
5429 participants from all surgical fields (see Fig. 1 for
Statistical analysis
details of the inclusion process).
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After testing the distribution of the observations for

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normality, results were expressed as mean  standard

Measurements
deviation (SD) or median with interquartile range for
Upon receipt of written informed consent, the patients
metric data, as well as relative frequencies in percentage
completed a computer-based self-assessment of lifestyle
for qualitative data. Because distributions were skewed,
risks as reported previously.25–28 All items were multiple
group differences regarding metric data were tested with
choice questions that could be answered by mouse only
the non-parametric Mann–Whitney test. Frequencies
technique, so that keyboard typing was not required. The
were tested with the (exact) x2 test in contingency tables.
assessment covered the following domains.
The primary objectives of this study were to determine
Sociodemographic information includes sex, age, partner-
how many patients score low (13) versus high (>13) on
ship status, level of education and current status of employ-
the WHO-5 and to examine whether these two groups
ment. Physical characteristics include body weight, height
with or without a clinically significant depressive state
and taking regular physical exercise. Substance use
differ with regard to the outcome parameter hospital
includes tobacco smoking, computerised version of the
LOS. Therefore, patients were divided into two groups
AUDIT, a standardised screening instrument for excessive
according to the WHO-5 cut-off: group 1 scoring 13 or less
alcohol consumption (Alcohol Use Disorder Identification
(‘patients with a clinically significant depressive state’)
Test29). Depression-related factors include sleeping
and group 2 scoring more than 13 (‘patients without a
disturbances, current subjective health status (visual
clinically significant depressive state’). In the next step,
analogue scale of the European Quality of Life Question-
patients with a clinically significant depressive state and
naire (EuroQOL30) and computerised version of the
patients without a clinically significant depressive state
BASOC (Brief Assessment of Sense of Coherence31).
were compared with regard to LOS using the Mann–
Depression includes computerised version of the WHO-
Whitney test. Finally, we analysed whether group differ-
5.24,32 This short depression screening instrument has
ences were dependant on age, sex, physical status and/or
shown high reliability and validity in several recent stu-
surgical field. This analysis was performed by logistic
dies.32–34 The five items of the WHO-5 measure self-
regression because distribution of LOS was skewed.
report of psychological well-being during the past 2 weeks
Patients were divided into two groups showing LOS
and cover mood, interests, energy, sleep and psychomotor
above versus below or equal to the median LOS of the
functioning. Responses are rated on a 6-point Likert scale
total sample. A multivariate logistic regression model
from 0 to 5 with sum scores ranging from 0 to 25, and higher
tested whether depression had a significant influence
scores indicating better well-being. A sum score of 13 or
on the defined binary LOS variable when simultaneously
less indicates poor well-being24 and can be interpreted as a
including age, sex, ASA classification and surgical field
clinically relevant depressive state including the whole
as covariates.
spectrum of depressive affect ranging from transient mood
disturbance to full-blown depressive disorders. A detailed The secondary objectives were to compare patients with
description of the computer-based self-assessment includ- or without a clinically significant depressive state regard-
ing all standardised measurements used in this study can ing selected health risk factors and other baseline patient
be found in Supplemental Digital Content 1, measure- characteristics. Univariate analyses of health risk factors
ments, http://links.lww.com/EJA/A21. and baseline patient characteristics with respect to
the mentioned groups were carried out using Mann–
The evaluation of patients’ perioperative risk according
Whitney tests and (exact) x2 tests, respectively. All vari-
to the ASA physical status classification system was
ables with a P value less than 0.10 in the univariate analyses
performed by the anaesthesiologists who did the preo-
were included in a multivariate logistic regression model in
perative assessment. Information on the surgical field was
order to determine the significant (independent) influen-
obtained from the electronic patient management system
cing factors of depression. Regression coefficients (B) with
of the Charité Universitätsmedizin Berlin and consisted
standard errors (SE) and odds ratios (ORs) with 95%
of the categories abdominothoracic surgery, peripheral
confidence intervals (CIs) were given.
surgery and neuro, head and neck surgery.
All significance tests were accomplished with a equal to
Outcome 5%, two-tailed, and, due to the exploratory nature of the
As an indicator of physical recovery and healthcare use, study, P values were not adjusted for the number of tests
hospital LOS was obtained from the electronic patient that were performed. For all statistical analyses, the

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Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 736 Linnen et al.
software SPSS Statistics, version 18, was used (SPSS
2010).
Results
Out of the included 5429 patients, 1610 (29.7%; 95% CI
28.5–30.9%) showed WHO-5 scores of less than or equal
to 13 indicating a clinically relevant depressive state, and
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3819 patients (70.3%; 95% CI 69.1–71.5%) had WHO-5
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scores above 13 indicating positive well-being.
Hospital LOS of patients with depression (n ¼ 1238,
median LOS 6.0 days, interquartile range 3.1–12.0 days)
was statistically significantly longer than hospital LOS
of patients without depression (n ¼ 3069, median LOS
4.8 days, interquartile range 2.3–8.1 days; P < 0.001,
Fig. 2). A multivariate logistic regression model with
the dependent variable ‘above versus below or equal
to the median LOS’ revealed that the influence of
depression on LOS persisted [OR ¼ 1.52 (95% CI
1.32–1.75), P < 0.001] when simultaneously including
the covariates sex [OR ¼ 0.95 (95% CI 0.84–1.08),
P ¼ 0.435], age [OR ¼ 1.019 (95% CI 1.015–1.023),
P < 0.001], ASA classification – ASA I, II versus III, IV
[OR ¼ 2.49 (95% CI 2.09–2.97), P < 0.001] and surgical
field [P < 0.001; abdominothoracic surgery versus rest:
OR ¼ 0.88 (95% CI 0.75–1.03), P ¼ 0.118; peripheral
surgery versus rest: OR ¼ 1.32 (95% CI 1.12–1.56),
P ¼ 0.001].
Univariate analyses showed that patients with clinically
relevant depressive states differed statistically signifi-
cantly from patients without depression with regard to
Fig. 2
25
Hospital length of stay (days)
20
15
10
5 first one to report a longer LOS in depressed patients in
0
Clinically relevant No clinically relevant
depressive state
Patients with clinically relevant depressive state (n ¼ 1238) show
longer hospital length of stay (LOS) than patients without clinically
relevant depressive state (n ¼ 3069; P < 0.001). Box plots depict
median LOS with 25%-quartile (QL) and 75%-quartile (QU): 6 days
(3.1–12.0 days) versus 4.8 days (2.3–8.1 days). Whiskers show inner
border: QL  1.5 IQR and QU þ 1.5 IQR (IQR: interquartile range) or
lowest values, respectively. Outliers above or below inner border are
not shown.
European Journal of Anaesthesiology 2011, Vol 28 No 10
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all analysed sociodemographic and clinical characteristics
except for BMI and surgical field (Table 1). Differences
in indicators of preoperative health and surgical field are
shown in Fig. 3. Interestingly, patients with depression
had considerably worse subjective health and a smaller
percentage taking physical exercise; however, differ-
ences were less strong with regard to physical health as
estimated by the ASA classification, as well as the
categories of surgical field (Fig. 3).
All sociodemographic and clinical characteristics with a
P less than 0.10 in the univariate analysis were entered
simultaneously in a multivariate logistic regression model.
As shown in Table 2, six factors continued to be statistically
significantly and independently associated with depres-
sion: less subjective health (P < 0.001), taking less physical
exercise (P < 0.001), less sense of coherence (P < 0.001),
more severe sleeping disturbances (P < 0.001), surgical
field (P ¼ 0.001) and younger age (P ¼ 0.007).
Discussion
The present study found that clinically significant
depressive states are frequent conditions in surgical
patients of preoperative anaesthesiological assessment
and are associated with an increased LOS. The preva-
lence of 29.7% lies in the middle range of the depression
rates between 15 and 50% that were reported for patients
with different medical conditions in previous studies.1–5
This prevalence rate is moderately higher than the
prevalence found in a recent study that also used the
cut-off of 13 or less of the WHO-5 for depression screen-
ing: Aujla et al.35 report depression rates of 21.3, 26.0 and
25.1% in people with type 2 diabetes mellitus, impaired
glucose regulation and normal glucose tolerance, respect-
ively. Correspondingly, the median WHO-5 score of 17 in
this sample of surgical patients is lower than the median
of 19 of a large German population sample (N ¼ 2473).36
Hospital LOS represents an indicator of physical recov-
ery, the related healthcare use and associated costs.
Because it is multiply determined, the influence of
specific factors on LOS was found to be significant but
small in previous studies on patients with cardiovascular
surgery.37–39 To our knowledge, the current study is the
the preoperative anaesthesiological assessment clinic
who came from diverse surgical specialties. The risk of
having a LOS above the median was 52% higher in
patients with depression than in patients without depres-
depressive state
sion even when factors were taken into account that have
proven to have an influence on surgical outcomes such as
age,8 sex,8 surgical field40 and ASA classification.15,41
The finding that depression was associated with a worse
socioeconomic, psychological and physical state confirms
that it is a serious condition.1,3,5 Independent factors
known to be correlates of depression in general
population were also identified in our study: sleep
 Depression and essential health risk factors 737

Table 1 Sociodemographic and clinical characteristics of patient sample (n U 5429) and comparison of patient groups scoring below and
above the WHO-5 cut-off for clinically relevant depressive states
Patients showing Patients showing
clinically relevant no clinically relevant
All patients depressive state depressive state
n U 5429 (WHO-5 cut-off < — 13) (WHO-5 cut-off >13)
Parameter (100%) n U 1610 (29.7%) n U 3819 (70.3%) PR
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Sex [n, (%)]

Male 2749 (50.6) 717 (44.5) 2032 (53.2) <0.001
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Female 2680 (49.4) 893 (55.5) 1787 (46.8)

Age in years [median (25–75th percentiles)] 48 (35–62) 48 (34–60) 48 (35–63) 0.034
Partnership status [n, (%)]
In partnership 4117 (75.8) 1140 (70.8) 2977 (78.0) <0.001
Without partner 1312 (24.2) 470 (29.2) 842 (22.0)
School education [n, (%)]
University entrance qualification 2134 (39.3) 568 (35.3) 1566 (41.0) <0.001
No university entrance qualification 3295 (60.7) 1042 (64.7) 2253 (59.0)
Current occupation [n, (%)]a
Employed 2649 (48.8) 684 (42.5) 1965 (51.5) <0.001
Not employed 2780 (51.2) 926 (57.5) 1854 (48.6)
Tobacco smoking [n, (%)]
No 3773 (69.5) 1033 (64.2) 2740 (71.7) <0.001
Yes 1656 (30.5) 577 (35.8) 1079 (28.3)
Hazardous alcohol consumption [n, (%)]b
No 4663 (85.9) 1340 (83.2) 3323 (87.0) <0.001
Yes 766 (14.1) 270 (16.8) 496 (13.0)
BMI, kg mS2 [median (25–75th percentiles)] 25.16 (22.35–28.65) 25.08 (22.04–29.01) 25.18 (22.49–28.41) 0.502
ASA classification [n, (%)]c
ASA I, II 4247 (81.4) 1156 (75.2) 3091 (84.0) <0.001
ASA III, IV 971 (18.6) 382 (24.8) 589 (16.0)
Surgical field [n, (%)]d
Abdominothoracic surgery 2204 (42.8) 685 (45.1) 1519 (41.8) 0.094
Peripheral surgery 1546 (30.0) 436 (28.7) 1110 (30.6)
Neuro, head and neck surgery 1402 (27.2) 398 (26.2) 1004 (27.6)
Taking physical exercise [n, (%)]
No 1593 (29.3) 639 (39.7) 954 (25.0) <0.001
Yes 3836 (70.7) 971 (60.3) 2865 (75.0)
Severity of sleeping disturbancese 1 (0–2) 2 (0–3) 0 (0–1) <0.001
[median (25–75th percentiles)]
Self-rating of subjective health 72 (51–85) 52 (38–71) 79 (60 –89) <0.001
[median (25–75th percentiles)]f
Sense of coherence [median (25–75th percentiles)]g 14 (12–15) 12 (9–13) 14 (13–15) <0.001

þ 2 a
Comparison of patient groups with a WHO-5 sum score 13 versus >13 with Mann–Whitney tests for metric data and x tests for categorical data. Currently not
employed: unemployed, in school/university/working at home, retired; currently employed: fully or partially employed, in training. b Alcohol Use Disorder Identification Test
(AUDIT), cut off for men: 8 points; cut-off for women 5 points. c n ¼ 5218 because of missing data; American Society of Anesthesiologists (ASA) I, II: healthy patients
(ASA I, n ¼ 1448) and patients with mild systemic disease presenting no functional limitations (ASA II, n ¼ 2799); ASA III, IV: patients with severe systemic disease
presenting definite functional limitation (ASA III, n ¼ 944) and patients presenting a constant threat to life (ASA IV, n ¼ 27). d n ¼ 5152 because of missing data. e Sum
score (0–5) of five self-report items concerning sleeping problems with higher scores indicating stronger sleeping disturbance. f Visual analogue scale, 0–100 with higher
scores indicating better subjective health. g Sum score (3–15) of the Brief Assessment of Sense of Coherence (BASOC) with higher scores indicating stronger sense of
coherence.

disturbances,19 sense of coherence,23 subjective experi-
ence of health20,21 as well as regular physical exercise.42
The influence of age was relatively small and not clini-
cally relevant. In contrast to subjective experience of
health and regular physical exercise, surgical field and
physical health as estimated by the ASA classification
were only weakly associated with depression, even
though these two factors had an impact on outcomes
in this study and previous research.15,40,41 However, the
influence of ASA classification and surgery might have
been greater in a sample with a higher percentage of
patients in the ASA categories III and IV, and when
analysing the effects of specific surgical procedures and
diagnoses instead of surgical field. Low preoperative
subjective well-being may, for example, be influenced
by the worries of patients concerning the reason for the
planned surgery.
Interestingly, also tobacco smoking and alcohol use dis-
orders did not show any independent association with
depression, even though there is evidence from previous
studies that depression is frequent in people with sub-
stance use disorders (for overview see 43,44). These results
suggest that depressive affect, smoking, problem drink-
ing and general physical health as estimated by the ASA
classification are factors that have independently of each
other an impact on outcomes in surgical patients.
Methodological limitations
Preoperative assessment clinics are a busy setting with
limited resources of time and personnel, so that it is not
possible to make comprehensive psychiatric examin-
ations in large patient samples. Brief computer-based
self-assessment represents a feasible instrument to
measure lifestyle and health risk factors in this special

European Journal of Anaesthesiology 2011, Vol 28 No 10

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 738 Linnen et al.

Fig. 3

(a) Subjective health (b) Physical (c) ASA (d) Surgical field
exercise classification
25 80 100 50
Self-rating (1-100)

80 80 40
60
60 60 30
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(%)

(%)

(%)
40
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40 40 20

20 20
20 10

0 0 0 0
Clinically relevant No clinically relevant I, II III, IV Abdomino Peripheral Neuro, head
depressive state depressive state thoracic and neck

Clinically relevant depressive state No clinically relevant depressive state

Patients with clinically relevant depressive state (n ¼ 1610, grey boxes or bars, respectively) differ from patients without clinically relevant depressive
state (n ¼ 3819, white boxes or bars, respectively) with regard to indicators of preoperative health and surgical field. (a) Patients with depression
show worse subjective health than patients without depression. Box plots depict median self-rating of subjective health with 25 and 75% quartile: 52
(38–71) versus 79 (60–89); P < 0.001. Whiskers show inner border or lowest/highest values, respectively. Outliers above or below inner border
are not shown. (b) A smaller percentage of patients with depression take regularly physical exercise: 60.3 versus 75% of patients without
depression; P < 0.001. (c) Patients with and without depression differ with regard to classification in the American Society of Anesthesiologists
(ASA) categories I and II (75.2 versus 84.0%) or III and IV (24.8 versus 16.0%); P < 0.001; n ¼ 5218. (d) There is a trend for different percentages of
patients with depression versus without depression in abdominothoracic surgery (45.1 versus 41.8%), peripheral surgery (28.7 versus 30.6), as well
as neuro, head and neck surgery (26.2 versus 27.6; P < 0.094; n ¼ 5152).

setting. The WHO-5, a brief screening instrument, can sleep quality and psychomotor functioning. Patients who
easily be integrated in this assessment and gives infor- show a relevant depressive state during the past 2 weeks
mation about the current depressive state of patients. according to their answers in the WHO-5 may show either
However, with this measurement, clinicians cannot make subthreshold depressive syndromes, transient elevated
diagnoses of mood disorder according to International depressive symptoms or a specific depressive disorder for
Classification of Diseases-10 or Diagnostic and Statistical more than 2 weeks.33,34 However, a WHO-5 sum score of
Manual of Mental Disorders, 4th Edition, Text Revi- 13 or less does not specify these states in terms of specific
sion.24,32 In this study, a clinically relevant depressive psychiatric disorders. Therefore, this screening will not
state was defined by a WHO-5 sum score of 13 or less allow including the diagnosis depression in the patient’s
indicating a considerable loss of positive mood, energy chart. This is very important to consider for the patients
and interest in activities, as well as substantial decrease of and the physicians.

Table 2 Multivariate analysis of sociodemographic characteristics and health risk factors associated with depression (n U 5010R)
Regression (per unit) odds ratio,
Parameter coefficient SE P OR (95% CI)

Sex (male U 0; female U 1) 0.110 0.078 0.156 1.117 (0.959–1.301)

Age in years 0.008 0.003 0.007 0.992 (0.987–0.998)
Partnership status (in partnership U 0; without partner U 1) 0.028 0.088 0.752 1.028 (0.865–1.223)
School education (University entrance qualification U 0; 0.132 0.081 0.100 0.876 (0.748–1.026)
no university entrance qualification U 1)
Current occupation (employed U 0; not employed U 1;a 0.007 0.084 0.935 0.993 (0.843–1.171)
Tobacco smoking (no U 0, yes U 1) 0.106 0.087 0.227 1.111 (0.936–1.319)
Hazardous alcohol consumption (no U 0, yes U 1)b 0.002 0.109 0.985 1.002 (0.809–1.241)
ASA classification (ASA I, II U 0, ASA III, IV U 1)c 0.118 0.103 0.254 1.125 (0.919–1.377)
Surgical field [n, (%)] 0.001
Abdominothoracic surgery versus rest 0.192 0.095 0.044 1.212 (1.005–1.460)
Peripheral surgery versus rest 0.155 0.103 0.132 0.857 (0.700–1.048)
Taking physical exercise (yes U 0, no U 1) 0.416 0.082 <0.001 1.515 (1.290–1.779)
Severity of sleeping disturbances (0–5)d 0.296 0.028 <0.001 1.344 (1.273–1.419)
Self-rating of subjective health (0–100)e 0.032 0.002 <0.001 0.968 (0.964–0.972)
Sense of coherence (3–15)f 0.369 0.019 <0.001 0.692 (0.667–0.717)

þ
n ¼ 5010 because of missing data (n ¼ 1468 patients with WHO-5 cut-off  13 versus n ¼ 3542 patients with WHO-5 cut-off > 13). a Currently not employed:
unemployed, in school/university/working at home, retired; currently employed: fully or partially employed, in training. b Alcohol Use Disorder Identification Test (AUDIT),
cut-off for men: 8 points; cut-off for women 5 points. c American Society of Anesthesiologists (ASA) I, II: healthy patients (ASA I) and patients with mild systemic disease
presenting no functional limitations (ASA II); ASA III, IV: patients with severe systemic disease presenting definite functional limitation (ASA III) and patients presenting a
constant threat to life (ASA IV). d Sum score (0–5) of five self-report items concerning sleeping problems with higher scores indicating stronger sleeping disturbance.
e
Visual analogue scale, 0–100 with higher scores indicating better subjective health. f Sum score (3–15) of the Brief Assessment of Sense of Coherence (BASOC) with
higher scores indicating stronger sense of coherence.

European Journal of Anaesthesiology 2011, Vol 28 No 10

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 Depression and essential health risk factors 739

The inclusion tree of this study requires further con-
sideration. Out of all patients assessed for eligibility, a
considerable portion was not included due to obvious
reasons such as age below 18 years or insufficient know-
ledge of German language. Only a minor portion (3%)
was not able or willing to use a computer, and less than
25% refused participation. One might speculate whether
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ing in this study constitute a large and clinically relevant
sample.
Clinical implications
There are three major clinical implications of this study.
First, clinically significant depressive states are common
in surgical patients of preoperative anaesthesiological

these patients had more or less symptoms of depression assessment; depression is associated with worse physical
XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 03/05/2024

than the included patients. Patients who feel less depres-
sed might, for example, be less interested in participating
in a self-assessment of lifestyle factors leading to a higher
rate of depression in the included patients. However, the
computerised questionnaire was not introduced as a
psychiatric depression screening, but as a lifestyle assess-
ment to give feedback on general factors of health
behaviour. One should also keep in mind that it is known
from clinical practice that patients with depression show
difficulties in motivation, interest and activity and might,
therefore, rather decline than agree to participate in
filling out questionnaires of lifestyle assessment. Finally,
as shown for a subsample of the present study, there were
other major reasons to refuse participation, most of all
lack of interest, complaints and time constraints.28 Hav-
ing these limitations in mind, it can be concluded that the
5429 patients undergoing computerised lifestyle screen-
and mental health factors and has an impact on hospital
LOS. Therefore, patients should routinely undergo brief
depression screening during preoperative anaesthesiolo-
gical assessment in order to implement depression treat-
ment if wished by the patient and required by evaluation
by a psychiatric specialist. Second, by gaining more
knowledge about preoperative depression and its associ-
ated factors, clinicians may be more successful in detect-
ing depression in surgical patients and addressing the
most important current problems of these patients such as
sleeping disturbance, lack of physical exercise, low sub-
jective health and low sense of coherence. Third, during
hospital stay, patients with depressive states require
a different pathway (Fig. 4). Preoperative information
tailored to these patient needs should be considered
including the subjective health status and the sense
of coherence. Also, all relevant steps to decrease the

Fig. 4

Preoperative depression screening

WHO-5 well-being index

Positive (WHO-5 ≤13) Negative (WHO-5 > 13)

Perioperative intervention
• Preoperative information tailored to patient's need
• Early mobilization
• Maintaining sleep and circadian rhythm

Postoperative diagnostics No mood disorder

Clinical psychiatric examination No psychiatric intervention

Mood Disorder according to ICD-10, DSM-IV

• Psychotherapeutic treatment:
- Cognitive behavior psychotherapy:
short term, long term, computerized
- Specialized programs for people with medical
conditions and depression
• Antidepressant medication
• Physical exercise and activity scheduling

An algorithm for detecting and treating clinically relevant depressive states in preoperative patients. ICD, International Classification of Diseases;
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text revision.

European Journal of Anaesthesiology 2011, Vol 28 No 10

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 740 Linnen et al.
perioperative risk should be named in this information
and multimodal strategies given, for example, early
mobilisation and maintaining sleep by avoiding
additional noise. Risk reduction should be one of the
goals to decrease LOS. According to a given patient’s
needs, depression therapy may be started during or after
the hospital stay. The results of this study suggest both
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pharmacological and psychotherapeutic1,3 treatment
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options for the different factors associated with depres-
sion. Contemporary depression therapy offers a wealth of
treatment possibilities including specialised programmes
for depression in people with medical conditions addres-
sing sleeping disturbances, physical exercise, as well as
subjective health and SOC.1,3,4,19
Conclusion
Clinically significant depressive states are frequent and
serious conditions in surgical patients of preoperative
anaesthesiological assessment. The problems of depres-
sed patients include a lack of physical exercise, sleeping
disturbances, decreased subjective health and low sense
of coherence. In order to detect and treat depression and
these associated impairments in surgical patients, therapy
programmes are needed that call for a close collaboration
of anaesthesiologists, surgeons and clinical psychologists.
Acknowledgements
The authors wish to thank the team of the preoperative anaesthe-
siological assessment clinic, Department of Anaesthesiology and
Intensive Care Medicine, Campus Virchow Klinikum and Campus
Charité Mitte, Charité – Universitätsmedizin Berlin, for their
excellent help with patient recruitment. They also would like to
thank Saskia Otto, MA, and Dr Bartosz Adamcio for their assistance
with preparing figures.
The present work was supported by Deutsche Krebshilfe, Bonn,
Germany, and by inner university grants, Charité – Universitäts-
medizin Berlin, Germany.
The authors have no conflicts of interest to declare.
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