2026; 9(2): 7-19
DOI: 10.32114/CCI.2026.9.2.7.19
Published online: 2026-06-30 (first online 2026-05-25)
Postoperative psychological distress beyond pain: a narrative review of psychosocial determinants across global surgical settings.
Nirosha Rathnakumari [1]
.
[1] Department of Nursing, Faculty of Nursing, KIU, Sri Lanka.
Abstract:
Abstract [EN] -
INTRODUCTION: Postoperative recovery is traditionally managed via a biomedical framework prioritizing pain control. However, psychological distress, including anxiety and depression, is highly prevalent and often exists independently of physical symptoms. This narrative review synthesizes recent global evidence (2021–2026) to examine the psychosocial determinants of postoperative distress, specifically emotional regulation, coping mechanisms, and social support across diverse healthcare contexts. MATERIALS AND METHODS: A systematic search was conducted across PubMed, Google Scholar and the Web of Science. Study selection followed PRISMA principles, focusing on peer-reviewed primary research and systematic reviews involving adult surgical populations. Data were extracted regarding psychological outcomes and psychosocial predictors, then synthesized using a narrative thematic approach. RESULTS: Findings reveal a significant discordance between pain intensity and psychological morbidity; high distress levels persist even with well-controlled pain. Emotional dysregulation and maladaptive coping are core drivers of postoperative anxiety. While perceived social support is a consistent protective buffer, its efficacy is mediated by socioeconomic factors. In LMICs, distress is amplified by financial toxicity and systemic barriers, whereas HICs struggle to integrate psychological care into standardized biomedical pathways. CONCLUSIONS: Postoperative psychological distress is a multifactorial phenomenon that pain scores alone cannot adequately predict. Optimizing global surgical outcomes requires a transition toward a biopsychosocial model that incorporates routine psychological screening, targeted emotional regulation interventions, and context-sensitive social support strategies.
Streszczenie [PL] -
WSTĘP: Tradycyjnie rekonwalescencja pooperacyjna jest zarządzana w oparciu o ramy biomedyczne, w których priorytetem jest kontrola bólu. Jednak stres psychologiczny, w tym lęk i depresja, jest bardzo powszechny i często występuje niezależnie od objawów fizycznych. Niniejszy przegląd narracyjny syntetyzuje najnowsze globalne dane (2021–2026) w celu zbadania psychospołecznych uwarunkowań stresu pooperacyjnego, w szczególności regulacji emocjonalnej, mechanizmów radzenia sobie i wsparcia społecznego w różnych kontekstach opieki zdrowotnej. MATERIAŁY I METODY: Przeprowadzono systematyczne przeszukiwanie baz PubMed, Google Scholar i Web of Science. Dobór badań przeprowadzono zgodnie z zasadami PRISMA, koncentrując się na recenzowanych badaniach podstawowych i przeglądach systematycznych obejmujących populacje dorosłych pacjentów chirurgicznych. Dane dotyczące wyników psychologicznych i predyktorów psychospołecznych zostały wyekstrahowane, a następnie zsyntetyzowane za pomocą tematycznego podejścia narracyjnego. WYNIKI: Wyniki wskazują na istotną rozbieżność między intensywnością bólu a zachorowalnością psychologiczną; wysoki poziom stresu utrzymuje się nawet przy dobrze kontrolowanym bólu. Dysregulacja emocjonalna i dezadaptacyjne radzenie sobie są głównymi czynnikami wywołującymi lęk pooperacyjny. Chociaż postrzegane wsparcie społeczne stanowi stały bufor ochronny, jego skuteczność jest mediowana przez czynniki społeczno-ekonomiczne. W krajach o niskich i średnich dochodach (LMIC) stres jest wzmacniany przez toksyczność finansową i bariery systemowe, podczas gdy kraje o wysokich dochodach (HIC) mają trudności z integracją opieki psychologicznej ze standardowymi ścieżkami biomedycznymi. WNIOSKI: Pooperacyjny stres psychologiczny jest zjawiskiem wieloczynnikowym, którego same skale bólu nie są w stanie odpowiednio przewidzieć. Optymalizacja globalnych wyników chirurgicznych wymaga przejścia do modelu biopsychospołecznego, który uwzględnia rutynowe badania psychologiczne, ukierunkowane interwencje w zakresie regulacji emocji oraz strategie wsparcia społecznego uwzględniające kontekst.
Citation:
VANCOUVER FORMAT
Rathnakumari N. Postoperative psychological distress beyond pain: a narrative review of psychosocial determinants across global surgical settings.
Crit Care Innov. 2026; 9(2): 7-19.
DOI: 10.32114/CCI.2026.9.2.7.19
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References:
| [1] |
National American Society of Anesthesiologists. Practice guidelines for acute pain management in the perioperative
setting: An updated report. 2023.
| (WWW) | |
| [2] |
National Institute for Health and Care Excellence. Perioperative care in adults (NICE Guideline NG180). 2022.
| (WWW) | |
| [3] |
Nigussie S, Belachew T, Wolancho W. Predictors of preoperative anxiety among surgical patients in Jimma
University Specialized Teaching Hospital, South Western Ethiopia. BMC Surg. 2014; 14(1): 67.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [4] |
Powell R, Scott NW, Manyande A, Bruce J, Vögele C, Byrne-Davis LM, et al. Psychological preparation and
postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev.
2016; 2016(5): CD008646.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [5] |
Rosenberger PH, Jokl P, Ickovics J. Psychosocial Factors and Surgical Outcomes: An Evidence-Based Literature
Review. J Am Acad Orthop Surg. 2006; 14(7): 397-405.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [6] |
Hinrichs-Rocker A, Schulz K, Järvinen I, Lefering R, Simanski C, Neugebauer EA. Psychosocial predictors and
correlates for chronic post-surgical pain (CPSP) – A systematic review. Eur J Pain. 2009; 13(7): 719-730.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [7] |
Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a
qualitative systematic review. Anesthesiology. 2009; 111(3): 657-677.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [8] |
Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic
review. Clin Psychol Rev. 2010; 30(2): 217-237.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [9] |
Schäfer JÖ, Naumann E, Holmes EA, Tuschen-Caffier B, Samson AC. Emotion Regulation Strategies in Depressive
and Anxiety Symptoms in Youth: A Meta-Analytic Review. J Youth Adolesc. 2017; 46(2): 261-276.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [10] |
Uchino BN. Social Support and Health: A review of physiological processes potentially underlying links to disease
outcomes. J Behav Med. 2006; 29(4): 377-387.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [11] |
Taylor SE. Social support: A review. In: Friedman HS, editor. The Oxford handbook of health psychology. 2nd ed.
Oxford: Oxford University Press; 2021.
| Scholar Google | |
| [12] |
Dare AJ, Grimes CE, Gillies R, Greenberg SLM, Hagander L, Meara JG, et al. Global surgery: defining an emerging
global health field. Lancet. 2014; 384(9961): 2245-2247.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [13] |
World Health Organization. Mental health and well-being: Global report. 2022.
| (WWW) | |
| [14] |
World Bank. World Bank country and lending groups. 2023.
| (WWW) | |
| [15] |
Rekik M, Maaloul K, Kammoun S, Jerbi S, Amor M, Trigui A. Preoperative anxiety and postoperative pain
associated with cataract surgery under local anesthesia. La Tunisie Médicale. 2024; 102(3): 176-180.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [16] |
Oswald A, McBride K, Seif S, Koh C, Ansari N, Steffens D. Depression, anxiety, stress and distress following
cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: results of a prospective cohort study. J Clin
Psychol Med Settings. 2023; 30(3): 490-500.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [17] |
Stoop JM, Geensen R, Adam SC, Van Dam KAM, Van Dessel E, Dolmans-Zwartjes A, et al. Prevalence and
severity of pain, anxiety, stress, and sleep disturbances among surgical patients: a nationwide single-day
multicentre flash mob study. Br J Surg. 2025; 112(7): znaf124.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [18] |
Ma F, Zhu Y, Liu Y. The relationship between psychological distress and the nursing humanistic care demands in
postoperative cancer inpatients: a cross-sectional study. BMC Nurs. 2024; 23(1): 26.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [19] |
Mony N, Shimul MMH, Pantho SA, Probal MSI, Khandker S. Proportion and predictors of postoperative depression
among elderly urology patients in Bangladesh. Discov Ment Health. 2025; 5(1): 175.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [20] |
Periañez CAH, Castillo-Díaz MA. Preoperative psychological distress and acute postoperative pain among
abdominal surgery patients. J Psychosom Res. 2025; 190: 112055.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [21] |
McCann WD, Hou X, Stolic S, Ireland MJ. Predictors of Psychological Distress among Post-Operative Cardiac
Patients: A Narrative Review. Healthcare. 2023; 11(20): 2721.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [22] |
Zhou D, Wang L, Wu H, Gao L, Yang X. Early-stage postoperative depression and anxiety following orthognathic
surgery: a cross-sectional study. BMC Anesthesiol. 2024; 24(1): 338.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [23] |
Majumdar JR, Barton-Burke M, Gilliland JL, Jairath NN. Coping strategies and psychological distress in
postoperative recovery: A repeated-measures study in women undergoing breast-conserving surgery. Asia-Pac J
Oncol Nurs. 2025; 12: 100674.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [24] |
Naeyaert A, Fournier V, Caton L, Gandolphe M, Duprez C, Laroussi‐Libeault L, et al. Emotion Regulation
Interventions for Cancer Patients and Their Relatives: A Systematic Review. Cancer Med. 2026; 15(2): e71514.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [25] |
Cheng W, Sun S, Fang J, Zhang N, Zhang Y, Zhang B, et al. Identifying psychosocial distress phenotypes in
postoperative patients with breast cancer: A latent profile analysis. Asia-Pac J Oncol Nurs. 2025; 12: 100792.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [26] |
Tegegne SS, Alle YF. Magnitude and factors associated with postoperative depression among adult orthopedics
patients during COVID-19 pandemics: A multi-center cross-sectional study. Front Psychiatry. 2022; 13: 965035.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [27] |
Zou J, Jia H, Wang J, Li Y. Social isolation as a significant risk factor for depression in colorectal cancer patients
post-colostomy: a cross-sectional study. Front Psychiatry. 2025; 16: 1588314.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [28] |
Adamakidou T, Menti K, Charalambous A, Tsiou C, Vlachou E, Govina O. Changes in unmet care needs, social
support and distress from initial diagnosis to post-surgery in patients with gynecological cancer: A longitudinal study.
Eur J Oncol Nurs. 2023; 66: 102358.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [29] |
O’Gara B, Leon JPE, Robinson K, Schaefer M, Talmor D, Fischer M. New onset postoperative depression after
major surgery: an analysis from a national claims database. BJA Open. 2023; 8: 100223.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [30] |
Kovoor JG, Jacobsen JHW, Stretton B, Bacchi S, Gupta AK, Claridge B, et al. Depression after stoma surgery: a
systematic review and meta-analysis. BMC Psychiatry. 2023; 23(1): 352.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [31] |
Rowe DG, O’Callaghan E, Yoo S, Dalton JC, Woo J, Owolo E, et al. Perioperative Trends in Distress among Cancer
Patients: A Systematic Review and Meta‐Analysis. Cancer Med. 2025; 14(6): e70456.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [32] |
ElBarazi A. Stress, anxiety, and depression before and twelve months after bariatric surgery: Repeated crosssectional
study. Indian J Psychol Med. 2024; 46(2): 159-164.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [33] |
Maroof H, Van Chi Mai D, El‐Kafsi J, De’Ath HD. The impact of depression in patients undergoing emergency
abdominal surgery: an exploratory study. World J Surg. 2023; 47(4): 835-842.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [34] |
Zheng C, Hou Z, Wang T, Yi L, Chen Y. Impact of multimodal analgesia on postoperative anxiety and depression
following total knee arthroplasty. J Orthop Surg Res. 2023; 18(1): 712.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [35] |
Ripoll-Romero E, Agüera Z, Puig-Llobet M, Galimany-Masclans J. The impact of nursing-led emotional preparation
on mental health after total hip arthroplasty. Front Psychol. 2025; 16: 1693111.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [36] |
Kehlet H. Enhanced Recovery After Surgery (ERAS): good for now, but what about the future? Can J Anaesth.
2014; 62(2): 99-104.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [37] |
Grocott M, Pearse R. Perioperative medicine: the future of anaesthesia? Br J Anaesth. 2012; 108(5): 723-726.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [38] |
Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-Avoidance model of chronic pain. Clin J Pain.
2012; 28(6): 475-483
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [39] |
Gross JJ. Emotion Regulation: Current status and future Prospects. Psychol Inq. 2015; 26(1): 1-26.
| Digital Object Identifier (DOI) | Scholar Google | |
| [40] |
Sloan E, Hall K, Moulding R, Bryce S, Mildred H, Staiger PK. Emotion regulation as a transdiagnostic treatment
construct across anxiety, depression, substance, eating and borderline personality disorders: A systematic review.
Clin Psychol Rev. 2017; 57: 141-163.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [41] |
Bushnell MC, Čeko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev
Neurosci. 2013; 14(7): 502-511.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [42] |
Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985; 98(2): 310-357.
| PubMed (NCBI) | Scholar Google | |
| [43] |
Carli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M, et al. Effect of Multimodal Prehabilitation
vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of
Colorectal Cancer. JAMA Surg. 2020; 155(3): 233-242.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [44] |
Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and
solutions for achieving health, welfare, and economic development. Lancet. 2015; 386(9993): 569-624.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [45] |
Ng-Kamstra JS, Greenberg SLM, Abdullah F, Amado V, Anderson GA, Cossa M, et al. Global Surgery 2030: a
roadmap for high income country actors. BMJ Glob Health. 2016; 1(1): e000011.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |
| [46] |
Tong J, Wan K, Liu Y, Liu L. Mindfulness-based interventions to reduce anxiety among Chinese college students: A
systematic review and meta-analysis. Front Psychol. 2022; 13: 1031398.
| Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google | |