Introduction: Postoperative delayed paradoxical depression (PDPD) is a psychiatric condition described in patients who despite no prior history of mood disorders, become clinically depressed during recovery from an uncomplicated, major surgical intervention with a favorable outcome. PDPD has been recognized in other common major surgical interventions such as thoracotomy for coronary artery bypass grafting and vascular surgery.
Methods: The cohort of 105 patients was derived from a prospective observational data set of 3788 consecutive cases of intracranial aneurysms accrued from 1991 to 2015. 792 cases treated by the senior neurosurgeon were identified. Starting in 2010, patients with PDPD were identified and their psychiatric treatment and outcomes documented. After exclusions such as a prior history of mood disorders, a cohort of 105 patients was identified. The incidence of PDPD in patients without a pre-operative history of depression was analyzed. A descriptive comparison of baseline characteristics was performed. Multivariate logistic regression was performed to analyze associations of variables with paradoxical depression. Patients with pre-operative depression or bipolar illness were excluded.
Results: Of the 105 patients included, 11.4% (n=12) were found to have newly-diagnosed clinical depression after surgical treatment of intracranial aneurysms. By univariate analysis, significant differences were noted in their extended Glasgow Outcome Scale (GOSE) (p=0.021) at discharge, GOSE at last followup (p=0.006), discharge to home (p=0.005), last visit modified Rankin scale (mRS) (p=0.016), and return to daily activities (p<0.001). By multivariate logistic regression analysis, however, only discharge to home was significant (p=0.004,OR=9.85,CI=[1.98, 49.41]). All 12 patients with PDPD recovered fully, 9 after psychotherapy and/or pharmacotherapy and 3 without intervention.
Conclusions: PDPD after uncomplicated, mostly uneventful aneurysm surgery can be surprising to both the neurosurgeon and the patient, but should be promptly identified and addressed to accomplish the patient’s full recovery. PDPD has been identified as a variant of post-traumatic disorder. When it was identified and treated promptly, PDPD was treated successfully in all cases in this series.
Patient Care: By identifying patients risk for developing postoperative delayed paradoxical depression we will be able to enhance the recovery of aneurysm patients after surgery.
Learning Objectives: Determine the incidence and potential factors associated with PDPD after craniotomy for clipping of an intracranial aneurysm.