Services on Demand
On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.2 Campinas Mar./Apr. 2007
Measurement of anxiety and depression in preoperative patients. Comparative study*
Medida de la ansiedad y de la depresión en pacientes en el preoperatorio
José Álvaro Marques MarcolinoI; Fernando Mikio SuzukiII; Luís Augusto Cunha AlliII; Judymara Lauzi Gozzani, TSAIII; Ligia Andrade da Silva Telles Mathias, TSAIV
Adjunto do Departamento de Psiquiatria e Psicologia Médica da Faculdade
de Ciências Médicas da Santa Casa de São Paulo
IIGraduando do 6° Ano da Faculdade de Ciências Médicas da Santa Casa de São Paulo
IIIMestre em Biologia Molecular; Doutora em Medicina; Responsável pelo Grupo de Dor da ISCMSP
IVDiretora do Serviço e Disciplina de Anestesiologia, ISCMSP e Faculdade de Ciências Médicas da Santa Casa de São Paulo; Responsável pelo CET/SBA, ISCMSP
OBJECTIVES: Patients scheduled for surgeries experience anxiety. Anxiety
and depression are the disorders most commonly associated with organic diseases.
The Hospital Anxiety and Depression Scale (HADS) does not include items that
could be present in organic diseases and in anxiety and depression. The objective
of this study was to measure the frequency and the level of anxiety and depression
in preoperative patients and in a control group.
METHODS: Seventy-nine patients admitted to the Surgical Department of Santa Casa de São Paulo and 56 caretakers answered a questionnaire on socio-demographic data and the HADS.
RESULTS: The evaluation of the symptoms showed that 35 (44.3%) patients and 36 (64.3%) caretakers had anxiety (Fisher Exact test p = 0.03) and 21 (26.6%) patients and 23 (41.1%) caretakers had depression (p = 0.09). Regarding the impact of the socio-demographic data on the measurement of anxiety and depression, it was only observed that patients that were unemployed had higher anxiety levels.
CONCLUSIONS: This study confirmed that the HADS could be used in hospitalized surgical patients. It also showed that patients should be evaluated preoperatively for anxiety and depression, regardless of the presence of severe clinical and/or surgical disorders, because the frequency of patients with anxiety is relevant and they deserve a differentiated approach at least the administration of tranquilizers before surgery. Caretakers presented significantly higher levels of anxiety. Those people, evaluated in the absence of concomitant clinical problems, probably demonstrated to be exposed to a considerable level of stress, resulting in a higher anxiety state than the patients scheduled for surgeries.
Key Words: PREANESTHETIC EVALUATION: psychological status.
JUSTIFICATIVA Y OBJETIVOS:
Los pacientes que serán sometidos a un procedimiento quirúrgico
tuvieron ansiedad. La ansiedad y la depresión son los disturbios más
asociados a las enfermedades físicas. En la Escala Hospitalaria de Ansiedad
y Depresión (HADS) no figuran ítems que podrían estar presentes
en enfermedades físicas y en la ansiedad y en la depresión. El
objetivo de este estudio fue medir la frecuencia y el nivel de la ansiedad y
de la depresión en pacientes en el preoperatorio y en un grupo control.
MÉTODO: Setenta y nueve pacientes internados en el Departamento de Cirugía de la Santa Casa de São Paulo y 56 acompañantes respondieron a un cuestionario de datos socio demográficos y la HADS.
RESULTADOS: La evaluación de los síntomas mostró que 35 (44,3%) pacientes y 36 (64,3%) acompañantes fueron considerados con ansiedad (teste exacto de Fisher - p = 0,03) y 21 (26,6%) pacientes y 23 (41,1%) acompañantes fueron considerados con depresión (p = 0,09). En relación al impacto de las variables socio demográficas sobre la medida de la ansiedad y de la depresión, se observó apenas que los pacientes sin empleo presentaron un nivel más elevado de ansiedad.
CONCLUSIONES: Este estudio confirmó la posibilidad del uso de la escala HADS de ansiedad y depresión en pacientes quirúrgicos internados. También nos mostró que la evaluación de la ansiedad en el período preoperatorio debe ser realizada, independientemente de que el paciente presente o no enfermedad clínica y/o quirúrgica grave, pues la frecuencia de pacientes con ansiedad es relevante y ellos merecen algún tipo de cuidado diferenciado, como mínimo el uso de medicación ansiolítica antes de la intervención quirúrgica. Fueron encontrados niveles significativamente mayores de ansiedad entre los acompañantes de los pacientes. Esas personas, evaluadas sin que existiese un concomitante problema clínico, posiblemente demostraron estar expuestas a un nivel ostensible de estrés, lo que conllevó a un estado de ansiedad mayor que el que tendrían los pacientes que serían sometidos a procedimiento quirúrgico.
Anxiety and depression are the most common psychiatric disorders associated with organic diseases 1,2. Ideally, preoperative patients should not have greater worries than those related with their own disease. However, the anticipation of pain, being away from the family, the loss of independence, and fear of becoming disabled, of the surgical procedure, and of death frequently lead to anxiety symptoms in this period (11% to 80% of adult patients) 3.
Regarding mood disorders (polarized humor, both for depression and elation), the measure of the global frequency in hospitalized patients has also varied from 20% to 60% 4-7. This wide variation is related to the socio-demographic characteristics of the study population, the type of disease, its severity, and also with the definition of the methods used in each study, as well as the inclusion criteria, the study tools, the cutting point, and case definition 4-7.
At least one third of patients with mood disorders are not identified as such by their physicians 8-10. This difficulty can be explained by the fact that some symptoms, such as fatigue, insomnia, tachycardia, dyspnea, anorexia, decreased sex drive, and others, can be caused both by physical and psychological disorders, misleading the diagnosis.
There are reports in the literature describing several tools to evaluate anxiety and depression, such as the Hamilton Anxiety Scale 11, the Anxiety Inventory STAI I and II 11, Beck Anxiety and Depression Inventories 11, and the Hospital Anxiety and Depression Scale (HADS) 12-24. Most of them were created to be applied by the researcher to patients with psychiatric disorders. The HADS 12 was developed initially to identify anxiety and depression symptoms in patients admitted to clinical, not psychiatric, hospitals 13-20,25,26, outpatients basis 14-16, and healthy people 27-29.
The Hospital Anxiety and Depression Scale was limited to 14 items, divided in anxiety and depression subscales. Zigmond and Snaith 12 recommended two cutting points to be used in both subscales: possible cases receive a score greater than 8 and probable cases receive a score greater than 11. They also proposed a third cutting point: severe disturbances receive a score greater than 15. The HADS was translated to several languages. Botega et al. 30 undertook a study to validate the HADS in Portuguese.
The HADS differs from other scales in that, in order to prevent the interference of somatic disorders, every anxiety and depression symptom related to physical disorders were excluded. Items such as weight loss, anorexia, insomnia, fatigue, grim outlook about the future, headache, dizziness, and etc., could also be symptoms of somatic diseases. In case of comorbidities, the psychological symptoms, more than the somatic symptoms, determine the diagnosis of mood disorders and other clinical diseases. In the case of a study with patients admitted for surgical procedures, the presence of somatic symptoms of anxiety and depression could be mistaken with signs and symptoms of the patient's condition or its treatment.
The objective of this study was to measure the frequency and the level of anxiety and depression in patients admitted for surgical procedures and in a control group composed by the caretakers of the patients.
This study was approved by the Ethics Committee of the Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP). The Statistics Department indicated that the study population should be composed of 160 individuals, 80 in each group. Eighty patients admitted to the Surgical Ward of the ISCMSP, older than 16 years, ASA physical status I and II, scheduled to undergo elective small- and medium-sized surgeries, were included in this study. Patients with cancer; psychiatric disorders; hearing, visual, and speech disorders; and taking psychoactive drugs were excluded. Eighty caretakers were invited to take part in the study, composing the control group.
The informed consent was presented to the patients always by the same researchers (two 3rd-year medical students). Those who agreed to participate were required to answer the following tools the day before the surgery, prior to the preanesthetic evaluation:
a) Socio-demographic questionnaire: including the following data: gender, age, marital status, level of education, occupation, and prior surgeries.
b) Hospital Anxiety and Depression scale (HADS) 12: 14 items, seven evaluating anxiety (HADS-A) and seven, depression (HADS-D). Each of the items receives scores that vary from 0 to 3, with a total of up to 21 points for each scale (Chart I).
The two medical students were trained, before the beginning of the study, on how to use the HADS.
The answers to the HADS were used to evaluate the frequency of anxiety and depression. The cutting points recommended by Zigmond and Snaith 12 for both subscales were used:
- HAD-anxiety: without anxiety: 0 to 8; with anxiety: > 9;
- HAD-depression: without depression: 0 to 8; with depression: > 9.
A descriptive analysis of the results was done. Non-paired test t Student was used to compare the results regarding age. The scores of the anxiety and depression scales were evaluated through their median. The Fisher Exact test, Chi-square test, and Mann-Whitney test were used to compare the other variables. A p < 0.05 was considered statistically significant. The tests used are part of the Statistical Package for the Social Sciences for Windows 10 31.
The final sample was composed of 79 patients and 56 caretakers, due to the refusal of one patient and fourteen caretakers to participate in the study. The greater number of refusal by caretakers was probably due to the restricted visiting hours, which would be further reduced if they had agreed to answer the questionnaires. Table I shows the socio-demographic data.
Following the cutting points recommended by Zigmond and Snaith 12, the evaluation of the symptoms showed (table II) that 35 (44.3%) patients and 36 (64.3%) caretakers had anxiety (Fisher Exact test p = 0.03), and 21 (26.6%) patients and 23 (41.1%) caretakers had depression (p = 0.09).
Comparing the levels of anxiety and depression showed no statistically significant differences (Mann-Whitney test p > 0.05) regarding age, marital status, and schooling of patients and caretakers.
The same is true for the gender of the patients, which showed no statistically significant difference (Mann-Whitney test p > 0.05). As for the caretakers, women were more anxious than men (Mann-Whitney test p = 0.034). There were no differences regarding the evaluation of depression.
Unemployed patients were significantly more anxious (Mann-Whitney test p = 0.041). There were no differences regarding the caretakers.
Preoperative patients frequently present symptoms of anxiety and depression that can be mistaken for symptoms of the disease that originated the surgical intervention. Thus, it is difficult to differentiate the "cases" from the "non-cases" of anxiety and depression, especially when they present, besides the physical disorder, psychological distress and social problems. Many researchers have suggested that elevated preoperative anxiety levels are associated with poor results, both clinical and psychological. Despite causing considerable suffering and clinical implications, they are not recognized as such by their physicians 8-10.
The HADS was chosen for this study since it is easy to apply, it can be done fairly quickly, and it can be done by the patient or the researcher (in case of illiterate patients or those with visual or motor deficits).
In this study, we found 35 (44.3%) cases of anxiety and 21 (26.6%) cases of depression among the patients. This frequency of anxiety, 44.3%, showed that a reasonable number of patients present these symptoms and, therefore, deserve a more detailed evaluation of their mental status before surgery.
On planning this study, a control group composed of the caretakers of the patients was envisioned. However, anxiety was much more frequent in the control group. In a revision by Herrmann 25 of healthy people used as control group, 7% had anxiety and 5% had depression.
Despite this result having invalidated this group as control, it was clear that those people demonstrated to be under considerable stress, maybe due to family worries about the patient, which resulted in a higher level of anxiety than that suffered by the patients who were going to be operated.
Among the causes of this result, we should mention the fact that 75% of the caretakers were females, and a review of the literature showed that women, even when they are healthy, have anxiety more often than men 32,33. Besides, sometimes the caretakers waited over one hour for visiting hours, which probably generates some anxiety, as well as other variables, such as missing the patient, and financial worries.
The severity of the patient's disease or surgery could be one of the factors that would increase the anxiety level of the caretakers, but since patients with uncontrolled associated disorders and/or cancer, or those scheduled for large-size surgeries were excluded, this item does not seem important.
This study confirmed that the HADS anxiety and depression scale could be used in hospitalized surgical patients. It also showed that patients should be submitted to preoperative anxiety evaluation, regardless of the presence or not of severe clinical and/or surgical disorder 34, because the frequency of patients with anxiety is relevant and they deserve some type of differentiated care, at least the administration of tranquilizers before the surgery. Besides, their caretakers also presented significant levels of anxiety and, therefore, this information should be given to the social service and psychology department of those institutions for careful consideration on how to humanize visiting hours and decrease the suffering of those people.
This study was part of the Programa Institucional de Bolsas de Iniciação Científica do Conselho Nacional de Pesquisas (PIBIC CNPq) granted by the Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo for the 2003/2004 biennium.
01. Moffic HS, Paykel ES Depression in medical-in-patients. Br J Psychiatry, 1975;126:346-353. [ Links ]
02. Maguire P, Faulkner A, Regnard C Managing the anxious patient with advancing disease a flow diagram. Palliat Med, 1993:7:239-244. [ Links ]
03. Maranets I, Kain ZN Preoperative anxiety and intraoperative anesthetic requirements. Anesth Analg, 1999;89:1346-1351. [ Links ]
04. Mayou R, Hawton K Psychiatric disorder in the general hospital. Br J Psychiatry, 1986;149:172-190. [ Links ]
05. Clarke DM, Minas IH, Stuart GW The prevalence of psychiatric morbidity in general hospital in patients. Aust N Z J Psychiatry, 1991;25:322-329. [ Links ]
06. Arolt V, Driessen M, Bangert-Verleger A et al. Psychiatric disorders in hospitalized internal medicine and surgical patients. Prevalence and need for treatment. Nervenarzt, 1995; 66:670-677. [ Links ]
07. Saravay SM Psychiatric interventions in the medically ill. Outcome and effectiveness research. Psychiatr Clin North Am, 1996;19:467-480. [ Links ]
08. Querido A Forecast and follow-up an investigation into the clinical, social, and mental factors determining the results of hospital treatment. Br J Prev Soc Med, 1959;13:33-49. [ Links ]
09. Saravay SM, Steinberg MD, Weinschel B et al. Psychological comorbidity and length of stay in the general hospital. Am J Psychiatry, 1991;148:324-329. [ Links ]
10. Knights E, Folstein MF Unsuspected emotional and cognitive disturbance in medical patients. Ann Intern Med, 1977;87:723-734. [ Links ]
11. Andrade L, Gorenstein C Escalas de Avaliação Clínica em Psiquiatria e Psicofarmacologia. São Paulo: Lemos Editorial, 2000;139. [ Links ]
12. Zigmond AS, Snaith RP The hospital anxiety and depression scale. Acta Psychiatr Scand, 1983;67:361-370. [ Links ]
13. Kabak S, Halici M, Tuncel M et al. Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases. J Orthop Trauma, 2003;17:555-562. [ Links ]
14. Vage V, Solhaug JH, Viste A Anxiety, depression and health-related quality of life after jejunoileal bypass: a 25-year follow-up study of 20 female patients. Obes Surg. 2003;13:706-713. [ Links ]
15. Al-Ruzzeh S, Mazrani W, Wray J et al. The clinical outcome and quality of life following minimally invasive direct coronary artery bypass surgery. J Card Surg, 2004;19:12-16. [ Links ]
16. Brandberg Y, Arver B, Lindblom A Preoperative psychological reactions and quality of life among women with an increased risk of breast cancer who are considering a prophylactic mastectomy. Eur J Cancer, 2004;40:365-374. [ Links ]
17. Brilstra EH, Rinkel GJ, van der Graaf Y et al. Quality of life after treatment of unruptured intracranial aneurysms by neurosurgical clipping or by embolisation with coils. A prospective, observational study. Cerebrovasc Dis, 2004;17:44-52. [ Links ]
18. Christensen FB Lumbar spinal fusion. Outcome in relation to surgical methods, choice of implant and postoperative rehabilitation. Acta Orthop Scand, 2004;75(s313):2-43. [ Links ]
19. Keller M, Sommerfeldt S, Fischer C et al. Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach. Ann Oncol, 2004;15:1243-1249. [ Links ]
20. Brady S, Thomas S, Nolan R et al. Pre-coronary artery bypass graft measures and enrollment in cardiac rehabilitation. J Cardiopulm Rehabil, 2005;25:343-349. [ Links ]
21. Hobby JL, Venkatesh R, Motkur P The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome. J Bone Joint Surg Br, 2005; 87:196-200. [ Links ]
22. Gustafsson M, Ahlstrom G Emotional distress and coping in the early stage of recovery following acute traumatic hand injury: A questionnaire survey. Int J Nurs Stud, 2006;43:557-565. [ Links ]
23. Johansson M, Thune A, Nelvin L et al. Randomized clinical trial of day-care versus overnight-stay laparoscopic cholecystectomy. Br J Surg, 2006;93:40-45. [ Links ]
24. Muszbek K, Szekely A, Balogh EM et al. Validation of the Hungarian translation of Hospital Anxiety and Depression Scale. Qual Life Res, 2006;15:761-766. [ Links ]
25. Herrmann C International experiences with the Hospital Anxiety and Depression Scale a review of validation data and clinical results. J Psychosom Res, 1997;42:17-42. [ Links ]
26. Bjelland I, Dahl AA, Haug TT et al. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res, 2002;52:69-77. [ Links ]
27. Kliszcz J, Nowicka-Sauer K, Trzeciak B et al. The level of anxiety, depression and aggression in nurses and their life and job satisfaction. Med Pr, 2004;55:461-468. [ Links ]
28. Weigl V, Rudolph M, Eysholdt U et al. Anxiety, depression, and quality of life in mothers of children with cleft lip/palate. Folia Phoniatr Logop, 2005;57:20-27. [ Links ]
29. Andrews B, Hejdenberg J, Wilding J Student anxiety and depression: Comparison of questionnaire and interview assessments. J Affect Disord. 2006;95:29-34. [ Links ]
30. Botega NJ, Bio MR, Zomignani MA et al. Transtornos de humor em enfermarias de clínica médica e validação de escala de medida (HAD) de ansiedade e depressão. Rev Saúde Publ, 1995;29:355-363. [ Links ]
31. Norusis MJ SPSS for windows. Professional statistics. Release 6.0. Chicago, 1993. [ Links ]
32. Westbrook MT, Viney LL Age and sex differences in patients reactions to illness. J Health Soc Behav, 1983;24:313-324. [ Links ]
33. Gentil VF, Lotufo FN Transtornos de Ansiedade, em: Almeida O, Dartiu L, Laranjeira R Manual de Psiquiatria. Rio de Janeiro, Guanabara Koogan, 1996;168-179. [ Links ]
34. Magalhães Filho LL, Segurado A, Marcolino JAM et al. Impacto da avaliação pré-anestésica sobre a ansiedade e a depressão dos pacientes cirúrgicos com câncer. Rev Bras Anestesiol, 2006;56:126-136. [ Links ]
Dr. José Álvaro Marques Marcolino
Rua Monte Alegre, 428 Conjunto 53
05040-000 São Paulo, SP
Submitted em 05
de janeiro de 2006
Accepted para publicação em 27 de novembro de 2006
* Received from Hospital Central da Irmandade Santa Casa de Misericórdia de São Paulo (HC ISCMSP), São Paulo, SP