In brief
In a randomized trial of 100 adults undergoing sinus surgery, a five-session computer-assisted CBT program lowered preoperative anxiety, stabilized cortisol and vital signs, reduced postoperative insomnia, shortened anesthesia/PACU recovery time, and improved satisfaction, though it did not change depression scores.
What this article is about
Quick Answer
In a randomized trial of 100 adults undergoing sinus surgery, a five-session computer-assisted CBT program lowered preoperative anxiety, stabilized cortisol and vital signs, reduced postoperative insomnia, shortened anesthesia/PACU recovery time, and improved satisfaction, though it did not change depression scores.
Student takeaways
Key Takeaways
- Preoperative state anxiety (SAI) was significantly lower in the cCBT group than usual care at T2 (39.76 vs 44.80, p<0.01), and fewer cCBT patients had moderate-to-severe anxiety (72% vs 88%, p=0.04).
- Serum cortisol stayed essentially stable in the cCBT group from baseline to just before surgery (307.07 to 306.22 nmol/L), while it rose significantly in the usual-care group (295.43 to 349.57 nmol/L, p=0.001), with a significant between-group difference at T2 (p=0.02).
- Postoperative insomnia (Athens Insomnia Scale) was significantly lower in the cCBT group at both 48 hours (4.90 vs 6.16, p=0.002) and 96 hours (1.92 vs 3.18, p=0.003) after surgery.
- Preoperative systolic blood pressure, diastolic blood pressure, and heart rate were all significantly lower and more stable in the cCBT group than usual care (all p<0.01).
- The cCBT group had shorter anesthesia duration (199.24 vs 214.68 minutes, p=0.001) and shorter PACU stay (22.98 vs 32.20 minutes, p<0.01), plus higher satisfaction with psychological and overall care, although PHQ-9 depression scores and total surgical time did not differ between groups.
Student summary
Why This Research Matters
Surgery is stressful, and few procedures show that more clearly than functional endoscopic sinus surgery (FESS). Because bleeding in the nasal cavity can obscure the surgeon's view, patients need calm nerves and stable blood pressure before they ever reach the operating room. This 2021 randomized controlled trial, published in Perioperative Medicine by Yang and colleagues, tested whether a newly built computer-assisted cognitive behavioral therapy (cCBT) program could reduce that stress and improve recovery, compared with usual perioperative care alone.
The researchers randomly assigned 100 adults having FESS to either the cCBT group (n = 50) or a usual-care (UC) group (n = 50) using a random number table. The cCBT program was not an internet app but a structured, computer-delivered course of five 20-minute sessions, timed at two days before surgery, one day before surgery, and two, three, and four days after surgery. Each session combined short videos teaching cognitive reframing of surgery-related fears with guided relaxation exercises such as progressive muscle relaxation, breathing techniques, and mindfulness, plus take-home practice. Later sessions also covered practical topics like managing postoperative pain and insomnia, preventing blood clots, exercise and diet, and discharge planning. The usual-care group received standard perioperative teaching without this structured psychological program.
Both groups were measured at four time points: T1 (baseline, the day after admission), T2 (one hour before surgery), T3 (48 hours after surgery), and T4 (96 hours after surgery, once the cCBT program was finished). Researchers tracked anxiety (State Anxiety Inventory, SAI), depressive symptoms (PHQ-9), insomnia (Athens Insomnia Scale, AIS), the stress hormone cortisol, blood pressure, heart rate, how long anesthesia and post-anesthesia care unit (PACU) recovery took, and how satisfied patients were with their nursing care.
The results favored the cCBT group on almost every psychobiological measure. Right before surgery (T2), cCBT patients had noticeably lower anxiety scores than the usual-care group, and fewer of them fell into the moderate-to-severe anxiety range (72% versus 88%). Their cortisol levels stayed roughly flat from baseline to just before surgery, while the usual-care group's cortisol rose significantly, a sign of unmanaged stress response. Blood pressure and heart rate just before surgery were also lower and more stable in the cCBT group. After surgery, insomnia scores at 48 and 96 hours were significantly better in the cCBT group, and far fewer of these patients still met criteria for clinical insomnia. Anesthesia time and PACU recovery time were both shorter for the cCBT group, though total surgery time itself did not differ between groups. Patients who received cCBT also reported higher satisfaction with their psychological and psychosomatic care, and with their overall care, though satisfaction with routine disease-related care was similar in both groups. One outcome did not improve: depressive symptoms measured by the PHQ-9 were similar across groups at every time point, suggesting depression was not strongly affected by short-term surgical stress in this sample, or that the intervention window was too brief to shift it.
For nursing students, this study is a useful example of how a low-cost, standardized psychoeducational and relaxation program, delivered without extra staff time at the bedside, might meaningfully reduce measurable physiological stress markers and speed early recovery milestones. It also illustrates the value of combining subjective scales (anxiety, insomnia) with objective biomarkers (cortisol, blood pressure, heart rate) when evaluating a nursing intervention. At the same time, the trial was conducted at a single center with a modest sample, blood samples were collected from only a subset of participants, and there was no long-term follow-up, so students should treat these findings as promising rather than definitive, and consider how such a program might need adaptation for use in Canadian perioperative settings.
Source abstract
Study Overview
Abstract Background Functional endoscopic sinus surgery (FESS) is required to minimize bleeding to maintain a clear operative field during surgery, so it is important to preoperative anti-anxiety and stable hemodynamics. Initial evidence suggests cognitive behavioral therapy (CBT) is effective to minimize surgery-related stress and to speed up recovery. The study aimed to evaluate the efficacy of a newly developed computer-assisted CBT (cCBT) program on surgery-related psychobiological responses in patients undergoing FESS. Methods Participants were allocated to a CCBT group (cCBT; n = 50) or a UC group (usual care; n = 50) by random number table. The State Anxiety Inventory (SAI), Patients Health Questionnaire-9 (PHQ-9), Athens Insomnia Scale (AIS), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were assessed before intervention (T1), at 1 h before operation (T2), at postoperative 48 h (T3), and 96 h (T4: after intervention completed) respectively. The stress hormone was assayed at T1 and T2. The duration of surgery, anesthesia, and post-anesthesia care unit (PACU) were recorded. A satisfaction survey about nursing services was completed by participants before discharge. Results Compared to the UC group, the SAI scores at T2 and the AIS scores at T3 were lower in the CCBT group (p < 0.01 and p = 0.002). The positive rate of participants who were moderate and severe anxiety (SAI score > 37) at T2 were lower (72% vs. 88%, p = 0.04); the cortisol levels, SBP, DBP, and HR at T2 in the CCBT group were lower (p = 0.019 and all p < 0.01); the duration of anesthesia and PACU was shorter (p = 0.001 and p < 0.01); the CCBT group showed higher satisfaction scores. Conclusion The newly developed cCBT program was an effective non-pharmacological adjunctive treatment for improving the surgery-related psychosomatic responses and perioperative outcomes. Trial registration The study was registered with the Chinese Clinical Trial Registry ( ChiCTR1900025994 ) on 17 September 2019.
Evidence appraisal
Main Findings
- Preoperative state anxiety (SAI) was significantly lower in the cCBT group than usual care at T2 (39.76 vs 44.80, p<0.01), and fewer cCBT patients had moderate-to-severe anxiety (72% vs 88%, p=0.04).
- Serum cortisol stayed essentially stable in the cCBT group from baseline to just before surgery (307.07 to 306.22 nmol/L), while it rose significantly in the usual-care group (295.43 to 349.57 nmol/L, p=0.001), with a significant between-group difference at T2 (p=0.02).
- Postoperative insomnia (Athens Insomnia Scale) was significantly lower in the cCBT group at both 48 hours (4.90 vs 6.16, p=0.002) and 96 hours (1.92 vs 3.18, p=0.003) after surgery.
- Preoperative systolic blood pressure, diastolic blood pressure, and heart rate were all significantly lower and more stable in the cCBT group than usual care (all p<0.01).
- The cCBT group had shorter anesthesia duration (199.24 vs 214.68 minutes, p=0.001) and shorter PACU stay (22.98 vs 32.20 minutes, p<0.01), plus higher satisfaction with psychological and overall care, although PHQ-9 depression scores and total surgical time did not differ between groups.
Practice transfer
Clinical Relevance
- A structured, computer-delivered psychoeducation and relaxation program timed around the perioperative period may help reduce measurable preoperative anxiety and stabilize hemodynamics without requiring extra one-on-one nursing time at each session.
- Because untreated preoperative stress was linked with a rise in cortisol and higher blood pressure and heart rate, perioperative nurses could consider structured relaxation and cognitive-reframing content as a low-risk adjunct alongside standard anxiety screening and reassurance.
- The intervention's association with shorter anesthesia time and PACU stay suggests psychological preparation may have downstream effects on recovery efficiency, which could be relevant to perioperative flow and discharge planning discussions.
- Because postoperative insomnia was meaningfully reduced in the cCBT group, nurses might consider incorporating structured sleep-focused education and relaxation techniques into post-surgical care plans, particularly after procedures with known disrupted sleep.
- Since depressive symptoms were not improved by this short intervention, nurses should not assume a brief perioperative psychoeducation program addresses mood symptoms; patients with depressive symptoms may need separate assessment and referral pathways.
Faculty notes
Educational Relevance
This single-site, randomized, single-blind controlled trial (Yang et al., 2021, Perioperative Medicine) evaluated a novel computer-assisted cognitive behavioral therapy (cCBT) program as an adjunct to usual perioperative care in 100 adults undergoing functional endoscopic sinus surgery (FESS), a procedure in which preoperative anxiety and hemodynamic instability can directly compromise surgical field visibility and safety. Participants (ASA I-II, ages 18-60, without psychiatric history or PHQ-9 ≥ 20) were allocated 1:1 by random number table to cCBT (n = 50) plus usual care, or usual care alone (n = 50).
The intervention itself is worth highlighting for curricular use: it was a non-internet, computer-delivered program of five 20-minute modules scheduled at 2 and 1 days preoperatively and 2, 3, and 4 days postoperatively, combining video-based cognitive restructuring with behavioral relaxation techniques (progressive muscle relaxation, breathing exercises, mindfulness) and structured homework, alongside practical modules on pain, insomnia, thromboprophylaxis, activity/diet, and discharge teaching. This is a clear example of a structured, replicable, low-intensity psychoeducational nursing intervention rather than formal psychotherapy.
Outcomes were assessed at four time points (T1 baseline, T2 one hour preoperative, T3 48h postoperative, T4 96h postoperative) using the State Anxiety Inventory, PHQ-9, Athens Insomnia Scale, serum cortisol and ACTH (subsample, n = 60), vital signs, anesthesia/PACU duration, and a discharge satisfaction survey. Repeated-measures ANOVA, chi-square, Student's t-test, and Wilcoxon rank-sum tests were used, with Bonferroni correction.
Key findings for classroom discussion: the cCBT group showed significantly lower preoperative SAI scores (39.76 vs 44.80) and a smaller proportion with moderate-to-severe anxiety (72% vs 88%) at T2; cortisol remained stable in the cCBT group while rising significantly in usual care between T1 and T2; systolic/diastolic blood pressure and heart rate were all significantly lower preoperatively in the cCBT group; postoperative insomnia (AIS) was significantly lower at both T3 and T4; anesthesia duration and PACU stay were shorter in the cCBT group, though total surgical time did not differ; and satisfaction with psychological/psychosomatic care and overall care was higher in the cCBT group. Notably, PHQ-9 depression scores did not differ between groups at any time point, a useful teaching point about the specificity of intervention effects and the limits of a brief perioperative program for affective symptoms with a different time course than acute anxiety.
This paper supports classroom discussion of dose and timing of psychoeducational interventions, the use of biomarkers (cortisol) alongside self-report scales to triangulate stress response, and the distinction between patient-reported outcomes and hard perioperative endpoints (anesthesia/PACU time). Authors themselves note important limitations: single-site design with a modest sample, partial (not full-cohort) blood sampling raising type II error risk for hormonal outcomes, no long-term follow-up, no measurement of intraoperative blood loss or surgeon-rated field visibility (the clinically pertinent surgical outcome implied in the introduction), and involvement of two surgical teams introducing possible heterogeneity. A further caveat is that although the trial was described as single-blind, patients completing extra structured sessions could not realistically be blinded to their group, so attention effects cannot be excluded for self-reported outcomes. Faculty might use this study to discuss how nurse-led, technology-delivered psychoeducation could be piloted and evaluated locally, while cautioning students against over-generalizing single-center RCT findings, especially across different health systems, populations, and languages.
Critical appraisal
Limitations
- The trial was conducted at a single center with a relatively small sample size (50 per group), which limits statistical power and generalizability to other populations or settings.
- Cortisol and ACTH were measured in only a subset of participants (60 of 100), raising the risk of a type II error (missing a true effect) for hormonal outcomes.
- The study did not include long-term follow-up, so it is unknown whether the anxiety, insomnia, and satisfaction benefits persist beyond the 96-hour post-intervention assessment window.
Classroom use
Discussion Questions
- Why might reducing preoperative anxiety and stabilizing hemodynamics be especially important in a procedure like FESS, where the surgical field must remain visibly clear of bleeding?
- The cCBT group's cortisol stayed flat while the usual-care group's rose significantly before surgery. What does this pattern suggest about the biological pathway linking anxiety and the stress response?
- The study found no difference in PHQ-9 depression scores between groups at any time point. What does this tell you about the specificity of a brief perioperative intervention, and what might explain why anxiety improved but depression did not?
- The cCBT program combined cognitive reframing videos with behavioral relaxation techniques (progressive muscle relaxation, breathing, mindfulness) and homework. How might a nurse decide which of these components to prioritize if time or resources were limited?
- Anesthesia duration and PACU stay were shorter in the cCBT group even though total surgery time was not different. What perioperative mechanisms might explain a difference in anesthesia recovery time without a difference in surgical time itself?
- Only 60 of the 100 participants had cortisol drawn. How does partial biomarker sampling affect your confidence in the hormonal findings, and what would you want to see in a follow-up study?
- Although the trial was labelled single-blind, patients receiving cCBT necessarily knew they were completing extra structured sessions. How might that awareness influence self-reported outcomes like anxiety and satisfaction, independent of the program's actual content?
- This intervention was delivered by computer rather than by a nurse in person. What are the potential advantages and disadvantages of computer-delivered psychoeducation compared with nurse-led, in-person sessions in a busy perioperative unit?
- If you were adapting this cCBT program for a Canadian hospital, what practical, cultural, or resource considerations would you need to address before piloting it?
- Given the single-site design and modest sample size, what would a well-designed follow-up multi-site trial need to include to more confidently support widespread adoption of this intervention?
Knowledge check
Quiz
1. What was the primary goal of this randomized controlled trial?
- To compare two anesthesia techniques for FESS
- To evaluate whether a computer-assisted CBT program improves psychobiological responses and perioperative outcomes in FESS patients
- To test a new surgical technique for reducing bleeding during FESS
- To assess long-term quality of life five years after FESS
Rationale: The abstract states the study 'aimed to evaluate the efficacy of a newly developed computer-assisted CBT (cCBT) program on surgery-related psychobiological responses in patients undergoing FESS.'
2. How were the 100 participants allocated to study groups?
- By patient preference
- By surgeon assignment
- By random number table into a cCBT group (n=50) and a usual care group (n=50)
- By date of hospital admission
Rationale: The abstract states: 'Participants were allocated to a cCBT group (n = 50) or a UC group (usual care; n = 50) by random number table.'
3. What happened to preoperative State Anxiety Inventory (SAI) scores at T2 in the cCBT group compared with usual care?
- SAI scores were higher in the cCBT group
- SAI scores were significantly lower in the cCBT group (39.76 vs 44.80)
- There was no difference between groups
- SAI was not measured at T2
Rationale: Full-text results show the SAI scores at T2 were lower in the cCBT group (39.76) than the usual-care group (44.80), p<0.01, consistent with the abstract's statement that 'the SAI scores at T2...were lower in the CCBT group.'
4. What pattern was observed in cortisol levels from T1 to T2 in the usual-care group compared with the cCBT group?
- Cortisol dropped sharply in usual care but rose in cCBT
- Cortisol was unmeasured in both groups
- Cortisol rose significantly in usual care while remaining essentially stable in the cCBT group
- Cortisol was identical between groups at all time points
Rationale: Full-text results show usual-care cortisol rose from 295.43 to 349.57 nmol/L (p=0.001) while the cCBT group's cortisol stayed nearly flat (307.07 to 306.22 nmol/L), matching the abstract statement that 'cortisol levels...at T2 in the CCBT group were lower.'
5. Which outcome showed NO significant difference between the cCBT and usual care groups at any time point?
- Athens Insomnia Scale (AIS) scores
- PHQ-9 depression scores
- Systolic blood pressure at T2
- Patient satisfaction with psychosomatic care
Rationale: The full text reports 'no significant between-group differences at T1, T3, or T4' for the PHQ-9, unlike anxiety, insomnia, hemodynamics, and satisfaction, which did differ significantly.
6. How was the cCBT program structured and delivered?
- A single 2-hour in-person counseling session with a psychologist
- An internet-based mobile app used only after discharge
- Five 20-minute computer-delivered sessions spanning 2 days before to 4 days after surgery, combining cognitive video content with relaxation techniques and homework
- A weekly telephone hotline available for one month post-surgery
Rationale: Full-text description confirms a non-internet, computer-delivered program of five 20-minute sessions timed at 2 and 1 days preoperatively and 2, 3, 4 days postoperatively, combining cognitive restructuring videos, relaxation techniques (progressive muscle relaxation, breathing, mindfulness), and homework.
7. What was the effect of cCBT on anesthesia duration and PACU stay compared with usual care?
- Both were significantly longer in the cCBT group
- Neither differed between groups
- Anesthesia duration and PACU stay were both significantly shorter in the cCBT group
- Only PACU stay differed, with no effect on anesthesia duration
Rationale: The abstract states 'the duration of anesthesia and PACU was shorter (p = 0.001 and p < 0.01)' in the cCBT group, consistent with full-text values of 199.24 vs 214.68 minutes for anesthesia and 22.98 vs 32.20 minutes for PACU.
8. Which of the following is a limitation the study authors themselves identified?
- The study enrolled patients from ten different countries
- Blood samples for cortisol/ACTH were collected from only a subset of participants, raising type II error risk
- The cCBT program had no relaxation component at all
- Patients were followed for ten years after surgery
Rationale: The full text lists author-identified limitations including 'only partial blood collection participation (potential type II error)' along with single-site design, no long-term follow-up, and lack of blinding.
9. What did the satisfaction survey show about the cCBT group compared with usual care?
- The cCBT group reported lower total satisfaction
- There was no difference in any satisfaction domain
- The cCBT group reported higher satisfaction with psychological and psychosomatic care and higher total satisfaction, though not for routine disease-related care
- Satisfaction was not assessed in this study
Rationale: Full-text results show cCBT scored higher on psychological care, psychosomatic management, and total satisfaction (all p<0.01), while disease care satisfaction did not differ (p=0.12), matching the abstract's statement that 'the CCBT group showed higher satisfaction scores.'
10. What overall conclusion did the study authors draw about the cCBT program?
- It was ineffective and should not be used clinically
- It was an effective non-pharmacological adjunctive treatment for improving surgery-related psychosomatic responses and perioperative outcomes
- It only improved depression scores, not anxiety
- It eliminated the need for any anesthesia during FESS
Rationale: The abstract's conclusion states: 'The newly developed cCBT program was an effective non-pharmacological adjunctive treatment for improving the surgery-related psychosomatic responses and perioperative outcomes.'
Study cards
Flashcards
What surgery was studied in this trial?
Functional endoscopic sinus surgery (FESS), a procedure requiring a clear operative field with minimal bleeding.
What does 'cCBT' stand for in this study?
Computer-assisted cognitive behavioral therapy, a structured, computer-delivered psychoeducation and relaxation program.
How many participants were in each study group?
50 participants in the cCBT group and 50 in the usual-care (UC) group, for a total of 100.
How were participants assigned to groups?
By random number table, making this a randomized controlled trial.
What were the four assessment time points in the study?
T1 (baseline), T2 (1 hour before surgery), T3 (postoperative 48 hours), and T4 (postoperative 96 hours, after the intervention was complete).
What scale was used to measure preoperative anxiety?
The State Anxiety Inventory (SAI).
What scale was used to measure depressive symptoms?
The Patient Health Questionnaire-9 (PHQ-9).
What scale was used to measure insomnia?
The Athens Insomnia Scale (AIS).
What stress hormone was assayed in this study?
Cortisol (along with ACTH in a subsample).
How many sessions made up the cCBT program, and how long was each?
Five sessions, each about 20 minutes long.
When were the cCBT sessions delivered relative to surgery?
At 2 days before surgery, 1 day before surgery, and 2, 3, and 4 days after surgery.
What relaxation techniques were included in the cCBT program?
Progressive muscle relaxation, breathing exercises, and mindfulness meditation, alongside video-based cognitive restructuring and homework.
What happened to SAI scores at T2 in the cCBT group versus usual care?
SAI scores were significantly lower in the cCBT group (39.76) than usual care (44.80), p<0.01.
What percentage of each group had moderate-to-severe anxiety at T2?
72% in the cCBT group versus 88% in the usual-care group (p=0.04).
How did cortisol change from T1 to T2 in the usual-care group?
It rose significantly, from 295.43 to 349.57 nmol/L (p=0.001).
How did cortisol change from T1 to T2 in the cCBT group?
It stayed essentially stable, from 307.07 to 306.22 nmol/L.
Did depression scores (PHQ-9) differ between groups?
No; PHQ-9 scores showed no significant between-group difference at any time point.
What happened to insomnia scores (AIS) postoperatively?
AIS scores were significantly lower in the cCBT group at both 48 hours and 96 hours after surgery.
How did anesthesia duration and PACU stay differ between groups?
Both were significantly shorter in the cCBT group (anesthesia: 199.24 vs 214.68 minutes; PACU: 22.98 vs 32.20 minutes).
What overall conclusion did the authors reach about the cCBT program?
It was an effective non-pharmacological adjunctive treatment for improving surgery-related psychosomatic responses and perioperative outcomes, though it did not improve depression scores.
Search-ready answers
Frequently asked questions
What is computer-assisted cognitive behavioral therapy (cCBT) in this study?
It is a structured, computer-delivered program of five 20-minute sessions combining video-based cognitive restructuring with relaxation techniques (progressive muscle relaxation, breathing exercises, mindfulness) and homework, timed around the perioperative period for patients having sinus surgery.
Does cCBT reduce anxiety before sinus surgery?
Yes, according to this trial, patients who received cCBT had significantly lower State Anxiety Inventory scores one hour before surgery than patients receiving usual care, and fewer of them fell into the moderate-to-severe anxiety range.
Does cCBT lower stress hormone (cortisol) levels before surgery?
The cCBT group's cortisol stayed essentially flat from baseline to just before surgery, while the usual-care group's cortisol rose significantly, suggesting cCBT helped blunt the physiological stress response.
Does this cCBT program improve depression symptoms?
No. The study found no significant difference in PHQ-9 depression scores between the cCBT and usual-care groups at any time point, suggesting this brief perioperative intervention was not effective for mood symptoms in this sample.
Does cCBT help with sleep after sinus surgery?
Yes, the cCBT group had significantly lower Athens Insomnia Scale scores at 48 and 96 hours after surgery, and far fewer patients still met criteria for clinical insomnia compared with usual care.
How does cCBT affect anesthesia recovery time?
Patients who received cCBT had shorter anesthesia duration and a shorter post-anesthesia care unit (PACU) stay than those receiving usual care, although total surgery time itself did not differ between groups.
How many patients were in this study?
100 adults undergoing functional endoscopic sinus surgery were randomized, 50 to the cCBT group and 50 to usual care.
Were patients more satisfied with their care after cCBT?
Yes, the cCBT group reported higher satisfaction with psychological care, psychosomatic management, and overall care, though satisfaction with routine disease-related care did not differ significantly between groups.
What are the main limitations of this cCBT study?
The trial was single-site with a modest sample size, collected cortisol from only a subset of participants, lacked long-term follow-up, did not measure intraoperative blood loss or surgical field visibility, and had no blinding of patients to their group assignment.
Is cCBT ready for routine clinical use in perioperative nursing care?
This single trial suggests promise as a non-pharmacological adjunct to usual perioperative care, but the authors themselves note it needs replication in larger, multi-site studies with longer follow-up before being considered standard practice.