Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.56 no.2 Campinas Mar/Apr. 2006
Impact of preanesthetic evaluation on anxiety and depression in cancer patients undergoing surgery*
Impacto de la evaluación pre-anestésica sobre la ansiedad y la depresión de los pacientes quirúrgicos con cáncer
Lidiomar Lemos de Magalhães Filho, M.D.I; Arthur Segurado, TSA, M.D. II; José Alvaro Marques Marcolino, M.D.III; Lígia Andrade da Silva Telles Mathias, TSA, M.D.IV
Assistente, Hospital Central da ISCMSP
IIMédico Assistente, Hospital Sírio-Libanês; Pós-Graduando da Faculdade de Ciências Médicas da ISCMSP; Co-Responsável do CET/SBA da ISCMSP
IIIMédico Assistente, Hospital Central da ISCMSP; Professor Adjunto de Psiquiatria da Faculdade de Ciências Médicas da ISCMSP
IVDiretora do Serviço e Disciplina de Anestesiologia da ISCMSP e Faculdade de Ciências Médicas da ISCMSP; Responsável pelo CET/SBA da ISCMSP
AND OBJECTIVES: In the course of a cancer disease, anxiety (ANX) and depression
(DEPR) manifest during the several moments of diagnosis and continue during and
after treatment. The surgical treatment may bring severe physical and psychological
consequences to the cancer patient. However, the present studies do not discuss
the cancer patients' emotional status when they are close to be hospitalized to
undergo an anesthetic-surgical procedure. Also, there is no analysis of the impact
of the ambulatory preanesthetic evaluation on these patients' anxiety and/or depression.
The prospective study aimed at checking the impact of the preanesthetic evaluation
on the anxiety and depression levels and prevalence of surgical cancer patients.
METHODS: Upon approval by the Hospital Ethics Committee on Research, 63 adult patients bearing cancer and undergoing a di-sease-related surgery were selected and assigned to two groups, their end points being the before (AAPA) or after (DAPA) scale as regards the preanesthetic visit. For this purpose the Hospital Anxiety and Depression (HAD) scales were applied. The variables analyzed included age, age range, gender, skin color, marital status, education level and present working status, number and percentage of patients experiencing Anxiety / with Depression (HAD > 8) and the HAD-ANX and HAD-DEPR scales scores. In the statistical analysis, a p < 0.05 was regarded as a significant value.
RESULTS: Both groups were homogeneous, as regards socio demographic data. When comparing these groups, a significant difference was noted in the Anxiety prevalence levels (HAD-ANX) between them, whereas the difference in the Depression (HAD-DEPR) levels and prevalence was not noted. The mean of the before and after preanesthetic analysis in both groups was under the cut point, however a significant reduction of the Anxiety scores was noted between the groups. As regards the risk factors analysis, there was a significant difference only in the age range variable (more prevalence of anxiety in patients aged d" 60 years old).
CONCLUSIONS: The preanesthetic evaluation reduced the patients' anxiety levels and prevalence in this study, but did not impact on the depression levels and its prevalence. The variable 60-year or below age was identified as a risk factor for anxiety.
Key words: COMPLICATIONS: anxiety, depression; PREANESTHETIC EVALUATION: psychological status; SURGERY, Oncologic.
Y OBJETIVOS: En la trayectoria del cáncer, la ansiedad (Ans) y la depresión
(Dep) se manifiestan durante los diversos momentos del diagnóstico y continúan
durante y después del tratamiento. El tratamiento quirúrgico puede
presentar graves consecuencias físicas y psicológicas para el paciente
con cáncer. Los estudios no discuten la situación emocional de los
pacientes con cáncer enfrente a la proximidad de la internación
para el acto anestésico-quirúrgico. Tampoco se analiza la influencia
de la evaluación pre-anestésica ambulatoria sobre la Ans y/o la
Dep de estos pacientes. Esta pesquisa prospectiva buscó verificar el impacto
de la evaluación pre-anestésica sobre los niveles y predominio de
la ansiedad y la depresión de los pacientes quirúrgicos con cáncer.
MÉTODO: Después de la aprobación del Comité de Ética del Hospital, se seleccionaron 63 pacientes adultos, con cáncer que serian sometidos a una intervención quirúrgica relacionada con la enfermedad. Los pacientes fueron separados en dos grupos con aplicación da escala antes o al final de la consulta pre-anestésica. Fueron utilizadas las escalas de Ansiedad y Depresión Hospitalaria (HAD). Las variables analizadas fueron: edad, faja de edad, sexo, color de la piel, estado civil, grado de escolaridad y situación ocupacional actual, número y porcentaje de pacientes con Ans / con Dep (HAD > 8); escores de las escalas HAD-Ans y HAD-Dep. En el análisis estadístico p < 0,05 fue considerado significativo.
RESULTADOS: Los grupos fueron homogéneos con relación a los datos socio-demográficos. Comparando los dos grupos, se observó una diferencia significativa de los niveles y predominio de Ans entre los dos grupos y no se verificó ninguna diferencia significativa en los niveles y predominio de la Dep (HAD-depresión). El promedio de los valores de AAPA y DAPA en los dos grupos se quedó abajo del punto de corte, pero hubo una reducción significativa en los escores de Ans entre los grupos. Con relación al análisis de los factores de riesgo, hubo una diferencia significativa apenas en el ítem faja de edad (mayor predominio de Ans en pacientes < 60 años).
CONCLUSIONES: La evaluación pre-anestésica redujo el predominio y los niveles de ansiedad de los pacientes de este estudio, pero no hubo ningún efecto sobre el predominio ni sobre los niveles de la depresión. La variable "edad" presentó un valor menor o igual a 60 años y fue identificada como factor de riesgo para la ansiedad.
Anxiety and depression are the psychiatric disorders most commonly associated with clinical diseases1-3.
Anxiety may be regarded as normal or pathologic. The pathologic disorder may be present in conditions such as physical diseases, use of medicaments or drugs, lack of depressors of the central nervous system or even, basically, are so called anxious disorders4.
The depression psychological and somatic symptoms are frequently present in clinical patients, even in the absence of the depressive syndrome5-7.
The global frequency of anxiety and humor disorders affecting in-patients has ranged between 15% and 60%. The most common symptom standard is that of non differentiated nature, involving a mixing of much worries, anxiety, depression and insomnia4,8.
Many instruments to evaluate anxiety and depression (questionnaires, inventories and scales) are described in a literature9-11.
The majority of these instruments was designed to be applied to psychiatric patients by a interviewer. They usually contain items to evaluate psychic and somatic symptoms, which may be confounded with signs and symptoms resulting from the baseline disease or its treatment, thus leading to a false-positive result 9-11.
The hospital anxiety and depression (HAD) scale was developed to detect anxiety and depression conditions in physically sick patients and able to respond to it by themselves. The HAD differs from other tools used to measure anxiety and depression because it does not have somatic items such as weight loss, anorexia, insomnia, fatigue, pessimism about the future, headache, dizziness etc. HAD has been used both for diagnosis and to measure severity of anxious and depressive disorders7,9,12.
Cancer is a devastating disease. The awareness of the disease has a significant impact on patients' lives, triggering physical and psychological changes. Anxiety and depression are consequences experienced by some cancer patients as of the diagnostic and which remain during and after treatment is concluded13-20.
One of the measures for cancer control is the surgical removal of the tumor. However, although this is often possible, certain surgical practices may lead to severe physical consequences (such as those involving mutilation of part of the body). The psychological changes are significant as well. The majority of the patients is afraid of anesthesia, of filling pain, of dying or experiencing mutilations. The surgical procedure fear is such that causes pathologic anxiety and disturbed thinking, thus leading to refusal of treatment in more than 5% of the cases21,22.
From the investigation of all the literature about anxiety and depression in cancer patients, particularly in those undergoing a surgical procedure, it was noted that the studies do not discuss the emotional condition of involved subjects facing the hospitalization for the anesthetic-surgical act, and at the moment of the preanesthetic evaluation. Also, the impact of this evaluation on the patient's anxiety and depression is not regarded, and this led to the design of the present study, to check the impact of the preanesthetic evaluation on anxiety and depression of cancer patients undergoing a surgical procedure.
Upon approval by the Ethics Committee on Research of the Santa Casa de Misericórdia de São Paulo, it were included in this prospective and open study the ambulatory patients of the Preanesthetic Evaluation bearing any kind of cancer and undergoing the correspondent surgical procedure, during a 6-months period.
Patients included were both men and women, regarded physical status ASA II and ASA III, and aged 18 years old or over. The exclusion criteria involved patients experiencing hearing loss, phonation loss or mental impairment and those under psychoactive drugs therapy.
At the preanesthetic visit, the informed consent was also obtained from the subjects to allow them to participate in the trial. Then, the involved subjects answered to the sociodemographic data questionnaire. All study procedures were carried out by the responsible anesthesiologist only.
The subjects were randomized into two groups, according to the preanesthetic visit phase in which scales were applied.
The patients assigned to the group before the preanesthetic evaluation undergone the anxiety and depression scales as soon as they entered the preanesthetic evaluation room, before starting the visit. Those assigned to the group after the preanesthetic evaluation undergone the evaluation first, followed by the application of the anxiety and depression scales.
In both environments, subjects were asked to reply to the HAD-anxiety and HAD-depression scales by themselves.
The analyzed variables included sociodemographic variables: age, gender, skin color, marital status, education grade, present working situation and scores of the scales applied.
The scores regarded as "cut points" to classify patients with/without anxiety and with/without depression were:
HAD-anxiety: without anxiety: 0 to 8; with anxiety: > 9 11;
HAD-depression: without depression: 0 to 8; without depression: > 9 11.
A descriptive analysis of the results was also carried out. The non paired Student t test was used to compare age-related results. The anxiety and depression scales scores were evaluated by their means. The Fisher Exact and the Mann-Whitney tests were applied to compare the results of the other variables. A p < 0.05 value was regarded as a statistically significant difference. The tests used comprise the software SPSS (Statistical Package for the Social Sciences) for Windows 10.
The total sample was comprised of 63 patients, 32 assigned to before the preanesthetic evaluation (AAPA) group and 31 to after the preanesthetic evaluation (DAPA) group.
Means, standard deviation, minimum and maximum age va-lues for the two groups were: AAPA group = 52.1 ± 10.4 years (22 72); DAPA group = 58.6 ± 11.4 years (17 70) (non paired Student t test - p = 0.143). Table I shows sociodemographic data and results of statistical tests applied.
Table II shows total number and percentage results for patients with/without anxiety and with/without depression in both groups studied, respectively, as per the HAD scale. The Mann-Whitney test showed a significant statistical difference (p = 0.048) as regards prevalence of anxiety in AAPA and DAPA groups, however it did not show significant difference (p = 1.000) in the prevalence of depression in these groups.
Table III shows means and percentages 25 and 75 of the anxiety and depression scales for both AAPA and DAPA groups. A statistically significant difference was noted in the comparison of anxiety scale between AAPA and DAPA groups, as per the Mann-Whitney test (p = 0.045), whereas no significant difference was found in the depression scale.
Figure 1 shows the anxiety and depression scores evaluated by HAD-anxiety and HAD-depression for both studied groups.
An individual analysis of each sociodemographic variable was carried out to check the presence of anxiety as a risk factor (Table IV), and a significant difference was found in the age range variable (patients aged > 60 years old and d" 60 years) (p = 0.049), higher in the d" 60 years old patients. No significant difference was found in the analysis conducted for checking the existence of depression as a risk factor (Table IV).
The reasons for the adoption of HAD anxiety and depression scale for this study involved its easy handling and rapid implementation, which is very important in preanesthetic evaluation ward environment, when patients have been waiting for, or just have been submitted to a 45 min minimum visit and have wanted go home. Evaluation may be performed also by the patient (which is the case of the present study) or by the interviewer (when patients are illiterate or bear visual or motor impairment). Most of all, this scale has been chosen for not containing, as already mentioned, evaluation items for somatic symptoms, which prevent that symptoms normally associated with cancer (weight loss and anorexia) may impact the depression scores. Furthermore, many studies have been shown the validity and reliability of this scale for cancer patients 14,23-30.
The anxiety prevalence noted in the AAPA group was similar to that found in cancer patients when using the same HAD scale14. However, it was higher among non-hospitalized cancer patients, although different evaluation tools having been applied for this scenario 31,32.
The preoperative period is another variable regarded as a contributory factor for the high prevalence of anxiety in the AAPA group.
Maranets and Kain 33 mention that the preoperative anxiety incidence in adult patients ranges from 11% to 80% (mean 45.5%), depending on the measuring method.
Caumo et al. 34 performed a cross study with 592 adult patients hospitalized for elective surgery and found significantly high levels of preoperative anxiety in cancer patients.
The prevalence of depression noted in this study (18.7%) in within the limits described in the literature regarding patients studing several types of cancers, evaluated by various evaluation tools (17% to 50%) 14,35-42. It is worth to mention that the population selected for the present study experienced diverse kinds of cancer.
When comparing AAPA and DAPA groups, it was noted a significant reduction in both level and prevalence of anxiety (level: 7.5 / 5.0 - prevalence: 40.6% / 16.1%).
This result corroborates the proposal submitted by several authors who described the reduction of the surgical patient anxiety as one of the principal functions of the preanesthetic evaluation 43-46.
Mackenzie 47 analyzed the anxiety level in 200 adult patients undergoing general anesthesia. They were evaluated at the moment of the surgical procedure date appointment and on the surgery date. The nature of the preanesthetic experience was the first determinant of the anxiety level at the appointment of the surgical procedure date. The appointment day anxiety measure was the main determinant of the anxiety level existing on the surgical day, the previous experience and type of procedure representing independent secondary factors. Ninety percent of the patients enjoyed to having been submitted to a preanesthetic evaluation to reduce their anxiety level.
In the Brazilian environment, an early study suggests that patients able to express their understanding about the surgical proposal, present lower values in the anxiety scale. Furthermore, the surgical procedure was apparently understood by 73% of cases studied, down to 37% when the subject was the anesthesia itself 48.
Shuldham 49 carried out a review in which he noted that the psycho-educational interventions (clarification on each step of the hospitalization process till the time of the surgical procedure) performed with adults hospitalized for elective procedure lead to shorter postoperative hospital stay, lower anxiety and pain level and more satisfaction.
As regards level and prevalence of depression, no difference was noted in the results for AAPA and DAPA groups (level: 4.5 / 4.0 - prevalence: 18.7% / 16.1%).
Some authors mention a relationship between anxiety and depression 34,50. However, this relationship was not noted in the present study.
It is possible to consider cancer as such important disease in affecting the patient, that probably a 45-minute clinical visit could not modify a depressing state.
No studies were found in the literature that evaluated the anxiety and depression variation, regardless of the measuring scale used, between two samples of surgical patients, the single differentiation factor applied being the preanesthetic evaluation parameter.
In the analysis of anxiety risk factors, a significant difference was found in the age range variable. Similar results in comparing young adults and elderly patients are referred to in the literature 38,51-53.
Several authors mentioned the importance to note the association between the cancer patient's age and gender when analyzing his/her anxiety level and that higher anxiety scores were observed among women and in younger subjects 53-55.
In the present study, no risk factor(s) were identifiable for depression, due to the low number of patients with depression (n = 6).
The literature reports more prevalence of depression among young and female cancer patients 36,38,41,51,53 this fact was also noted in the present study, however with no statistical value).
Results of higher prevalence of anxiety and depression in low education, higher income and not married patients (also non significant) matched the literature 34,53,56-58.
Several authors propose the application of basic communication techniques and standard and structured diagnostic methods to differentiate cancer patients requiring depression therapy from those needing a very specific psychological/psychiatric treatment 37-40,59-63.
As regards cancer patients hospitalized for surgical treatment, Rispoli et al.64 highlighted the importance to design an appropriate and continuous psychological support system to help them in the pre and postoperative period, thus trying to avoid the rise of other psychological disorders.
As these disorders affect a substantial portion of the cancer patients' population, the application of anxiety/depression evaluation questionnaires to the whole population of cancer patients undergoing surgery or the introduction of a diffe-rentiated treatment for these subjects during their stay in the preanesthetic evaluation ward environment, even without a definite diagnosis, is highly justifiable 65,66.
This study highlights the importance of the patient's psychological profile evaluation. As important as it is to know about all details of the patient's medical history, former anesthetic accidents, allergies and other items comprising the classic preanesthetic analysis, is the understanding that the cancer patient, on the eve of undergoing a surgical procedure with possible crucial impact on his/her future, is probably anxious and depressive. The present study has evidenced still further the definition dimension of this patient as a bio-psycho-social human being, and as a subject experiencing a unique life course, which cannot be put apart from his/her health or disease natural history.
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Dra. Lígia Andrade da Silva Telles Mathias
Alameda Campinas, 139/41
01404-000 São Paulo, SP
for publication 20 de junho de 2005
Accepted for publication 09 de janeiro de 2006
* Received from CET/SBA, Serviço de Anestesiologia da Irmandade Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP.