Depression is a widespread and life-threatening condition that affects how people feel, think and behave. It could appear after a recent surgery, such as an ostomy. “An estimated 1 million people in the United States and Canada have ostomies, with this number increasing by an annual rate of 100,000. Ostomies result in loss of control of intestinal contents, both stool, and gas. Previous studies have demonstrated that patients with ostomies have decreased health-related quality of life (HRQOL). Specifically, ostomates have been shown to have significant difficulty with sexual relationships, stomal care, physical appearance, and travel.”1
Facing lifestyle changes is complicated for a new ostomate, especially the first weeks after surgery. As a result, fears and insecurities appear, and patients start to feel dissatisfied with themselves.
The Negative Psychological States after Ostomy
As new ostomates, patients must learn to care for the stoma, which can cause frustration and stress if they do not have proper guidance. “Patients have to face the challenge of acquiring skills to live with the altered body and experience a psychosocial transition. The use of collecting equipment is associated with negative feelings, such as fear, anguish, sadness, and helplessness, which can prompt self-deprecating experiences, linked to feelings of mutilation, loss of health and self-esteem, and reduced self-efficacy and a sense of chronic uselessness and incapacitation, among other emotions. Stoma patients experience changes in their lives especially related to their social network (work and leisure) and to sexuality, aggravating their feelings of insecurity and fear of rejection.”2
Having a stoma bag causes several insecurities related to leakage, odors, and gas. Stressful situations also occur at night, as the patient is uncertain if a leakage accident may occur, or what side they should sleep on to avoid bag pressure. All these new situations might cause depression and isolation.
“Patients with stomas face many problems, both physical and psychological. Leakage caused by failure of adhesive or bag welds, ballooning of bags, poor siting, and difficulty in keeping bags in place are some of the daily problems. Anxiety and embarrassment over a stoma may lead to an alteration in lifestyle, including the ability to find work, desire to travel, and overall self-image. The way patients feel about the changes in their bodies can affect their behavior toward family and friends; problems with sex life also occur. Some patients have initial problems with diet and clothing, but most are thought to adapt with time. The inconvenience and distress caused by this need to adapt and by other changes in lifestyle and body image related to stomas are poorly documented.”3
“An estimated 18% to 26% of patients with colostomies experience psychological symptoms within the first 3 months of surgery. The most common symptoms are adjustment disorder with anxious or depressed mood, major depressive disorder, panic disorder, social phobia, and generalized anxiety disorder. In a population of 500 cancer patients, 50% reported feeling depressed following colostomy creation, and 10% considered or attempted suicide. The validity of early study findings has been questioned because of a lack of standardized methods and instruments.”4
How to Overcome Depression and Stress as an Ostomate?
Getting professional mental health guidance and education is vital for the new ostomates, who could have difficulties coping with this new stage in their lives.
“Coping mechanisms include adaptive, behavioral, and cognitive mechanisms through which people change how they think or behave. Some people act aggressively or avoid potentially difficult situations. Examples of the latter can include avoiding going out to dinner or visiting new places, due to lack of toilets.”5 Listening to other ostomates’ experiences and how they can cope with their individual situation is crucial to confront it and reach a comfortable everyday routine and adaptation process.
“Problems can occur in the adaptation process following ostomy surgery secondary to its negative physical and mental impacts. New ostomy pouches developed with advances in technology can decrease the problems of leakage, odor, and ballooning that interfered with the activities of daily living that ostomy patients endured in the past.”6
Find Guidance and Counseling regarding the Ostomy
Psychological help is valuable for any stoma patient every few months, as they face new challenges and daily situations that might affect them on different levels. Activities like going to the beach, visiting an amusement park or playing sports require different preparation after having a colostomy, ileostomy or urostomy; not knowing how to perform or prepare for these activities with a stoma can make patients depressed. Receiving professional and experienced help, education, and guidance will help prevent extended depression periods that, in some cases, could turn suicidal.
“It is essential to ensure that patients are discharged home from the hospital with an adequate understanding of the care of their stoma as this has a positive effect on their quality of life. Therefore, it is essential that during the hospital stay, the stoma specialist nurse teaches the ostomate the practical care of the stoma appliance. The basic appliance change technique will include the collection of all the necessary equipment, gentle removal of the old appliance, thorough cleaning and drying of the skin around the stoma, and then, application of the new, correctly sized and placed stoma appliance, with appropriate disposal of the rubbish. It is also essential to ensure that the ostomate knows what is normal and who to seek help from if a problem occurs. The postoperative care provided by the multidisciplinary team enables the ostomate to feel supported, aiding the ostomate in the path to accepting the stoma and new body image.”7
Professional education from the nurses at hospital sites and psychological help are vital for any ostomate. Guiding patients through and after the process gives them confidence and assures them that they will feel free, and get used to their new lifestyle.
The Positive Impact of Postoperative Education
“Because most patients are first-time ostomates, many do not have prior experience of a stoma. Before discharge, the priority of postoperative education is to prepare patients for stoma self-care. The need to acquire all practical skills for stoma care within the short period of hospitalization may lead to psychological distress among patients. Practical skills include learning that the pouch change requires intricate skills such as cutting the pouch to fit the stoma, aligning the pouch properly with the stoma, and applying the pouch to avoid creases and leakages. In addition to the pouch change, patients also were expected to learn to clean their stoma, identify stoma complications, and understand lifestyle changes such as adopting a low-residue diet and avoiding lifting heavy objects. The uncertainty of whether they could manage their stoma independently caused fear, insecurity, and anxiety among these patients. Therefore, preparation for discharge was considered a stressful event for many patients, and psychological support should be provided alongside postoperative education.”8
Support groups serve to listen to other ostomates who had the surgery and have used the ostomy bag for a long time. They can share significant life experiences and tips on how to deal with similar daily situations.
The Role of Health Organizations in Ostomy Counseling
“There is also a need for reflection on the organization of the health system to include adequate care for patients with stoma in order to integrate them into society as citizens and to include new demands for care. For this to occur, it is not enough to recognize only the changes related to the physical and corporal dimension; it is necessary that the health professionals offer support for the inclusion of these patients in society. Adaptation after hospital discharge may be favored by effective coping with embarrassment situations, with the understanding of their anguish, fears and doubts during the surgical treatment, since the physical and psychoemotional preparation until the adaptation to the changes caused by the stoma in their life. The care from health professionals should go much further than providing kits, booklets and self-care guidance regarding the colostomy and the collection bag. Expanding the possibilities of active social life despite the need for adaptations is also important. In addition, spaces for discussion of social prejudice and stigmas can be disseminated in society for the implementation of integral care.”9
Regardless if they had recent surgery or have been ostomates for years, psychological and mental support from a specialist, family or ostomates groups is always beneficial and necessary.
“The possible negative psychological outcomes and emotional issues arising from the stoma make essential the provision of comprehensive patient care, with an interdisciplinary and specialized approach to the needs of patients and their families, with a view to full physical, emotional and social recovery towards rehabilitation. It is necessary to prepare patients, mainly during the perioperative period, when they experience anxiety and distress before the unknown – the “stoma”. This preparation must include pre-operative education, demarcation of the stoma and guidance on self-care for patients and their families, in the postoperative period.”10
Several mechanisms should be available for ostomates to find help and advice when needed. “The provision of long-term ongoing counseling and support, such as regular appointments with stoma nurses and a 24-hour helpline to help patients with stomas cope with any stoma-related challenges faced during daily living, could be helpful. Nurses also could help to create social platforms such as stoma support groups and organize outings for patients. In addition, a home visitation program for stoma care also could ensure the continuity of stoma care and enhance the patient’s long-term adjustment in the community.”11
New ostomates can overcome their depression only if they are willing to take the first step and be receptive. “Learning to live with a stoma needs adjustment to the changed body image and the new way in which the ostomy now eliminates waste products. There is evidence to show that a good support system can aid the adaptation process, whereas complications, either preoperatively or with the stoma, can result in delays in the ostomate adjusting to their new stoma.”12 Seek a specialist if you have feelings of isolation, anger, hopelessness after an ostomy procedure.
(1, 4) Overcoming challenges: life with an ostomy. Popek, S., Grant, M., Gemmill, R., Christopher S. Wendel, M.S., M. Jane Mohler, Ph.D., Susan M. Rawl, Ph.D., Carol M. Baldwin, Ph.D., Clifford Y. Ko, M.D., C. Max Schmidt, M.D., Robert S. Krouse. https://www.americanjournalofsurgery.com/article/S0002-9610(10)00452-6/fulltext
(2, 9, 10) Psychological aspects of patients with intestinal stoma: integrative review. Michelato Silva, N., Antônio dos Santos, M., Rodrigues Rosado, S., Galvão, C.M. & Megumi Sonobe, H. 2017. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692017000100608&lng=en&tlng=en
(3) Quality of Life in Stoma Patients. Karen P. Nugent, M.S., Phyll Daniels, Beverley Stewart, Roy Patankar, Colin D. Johnson, M. Dis Colon Rectum. 1999. https://link.springer.com/article/10.1007/BF02236209
(5, 7, 12) Optimal support systems for patients with stomas – an opinion piece. Jennie Burch. Dove Medical Press Limited. 2014. https://www.dovepress.com/optimal-support-systems-for-patients-with-stomas-ndash-an-opinion-piec-peer-reviewed-fulltext-article-NRR
(6) The Effect of Permanent Ostomy on Body Image, Self-Esteem, Marital Adjustment, and Sexual Functioning. Kilic, E., Taycan, O., Korkut Belli, A. & Özmen, M. Turkish Journal of Psychiatry. 2007. https://es.scribd.com/document/218910003/The-Effect-of-Permanent-Ostomy-on-Body-Image-Self-Esteem-Marital-Adjustment-And-Sexual-Functioning
(8, 11) Stressors Relating to Patient Psychological Health Following Stoma Surgery: An Integrated Literature Review. Giap Marcus, S., Chen, H-C., Chiew Siah, R-J., He, H-G. and Klainin-Yobas, P. Oncology Nursing Forum. 2013. https://pdfs.semanticscholar.org/d25b/fefa8f964795f1571043d3e69430f213f8d7.pdf