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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 22-25

Assessment of level of depression and anxiety in pre- and postoperative stages: A prospective cross-sectional study in SCB Medical College, Cuttack


1 Department of Surgery, SCB Medical College and Hospital, Cuttack, Odisha, India
2 Department of Clinical Psychology, Mental Health Institute (Centre of Excellence), SCB Medical College and Hospital, Cuttack, Odisha, India
3 Department of Microbiology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
4 Dnadvent Life Sciences Pvt. Ltd., KIIT Technology Business Incubator, KIIT, Bhubaneswar, Odisha, India
5 Department of Biotechnology, BJB Autonomous College, Bhubaneswar, Odisha, India

Date of Web Publication11-Mar-2019

Correspondence Address:
Anshuman Sarangi
Dnadvent Lab, Life Sciences Pvt. Ltd., KIIT-Technology Business Incubator, Campus-11, KIIT, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_94_18

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  Abstract 


Objectives: Mood disorders are considered to be prevalent in hospitalized patients. Our study aimed to investigate the prevalence of depression and anxiety symptoms in pre- and postoperative stage in surgical patients. Methods: We included 60 surgical patients in this cross-sectional study which includes 43 male and 17 female patients and average age of 38.8 years. Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were used to screen for symptoms of depression and anxiety at 12 h after admission for electively scheduled surgeries and 12–24 h after the surgery for patients undergoing emergency surgery. Results: In presurgery stage, anxiety was found to be prevalent in 43.3% of patients while depression is 38%. In postsurgery stage, anxiety and depression were found in 18.3% and 35% of patients, respectively. Conclusions: Both anxiety and depression are highly prevalent in pre- and postoperative stage of surgery. Such symptoms should be attended with more seriousness, otherwise would lead to higher morbidity and mortality.

Keywords: Anxiety, depression, stress, surgery


How to cite this article:
Panda S, Samantaray N, Patanaik M, Sahoo D, Sarangi A, Jena S. Assessment of level of depression and anxiety in pre- and postoperative stages: A prospective cross-sectional study in SCB Medical College, Cuttack. Apollo Med 2019;16:22-5

How to cite this URL:
Panda S, Samantaray N, Patanaik M, Sahoo D, Sarangi A, Jena S. Assessment of level of depression and anxiety in pre- and postoperative stages: A prospective cross-sectional study in SCB Medical College, Cuttack. Apollo Med [serial online] 2019 [cited 2019 Mar 22];16:22-5. Available from: http://www.apollomedicine.org/text.asp?2019/16/1/22/253880




  Introduction Top


Anxiety, depression, and stress are common in patients during hospitalization and considered to be indisputable. The effects of these emotional states are consistent in nature and impact on people's physical and psychological well-being. They are influenced by each person's individual differences, personality traits, and surgical process.[1],[2]

Various studies have documented the variation in the degree of these emotional studies in different stages of surgery. In many studies, anxiety during preoperative stage was significantly higher than their postoperative stage.[3] Major depressive disorder has been a frequent complication of surgery. Depression is a frequent cause of morbidity in surgery patients suffering from a wide range of conditions.[4]

A study by Marcolino et al.[5] on surgical cases showed the presence of anxiety and depression in 44.3% and 26.6% of patients, respectively, in the preoperative period of general surgery. In a study carried out during the preoperative period of myocardial revascularization surgery, the anxiety and depression were seen in 34.4% and 28.1% of patients,[6] respectively, reinforcing high occurrence of these emotional states among hospitalized patients and, in particular, in those with cardiologic alterations with surgical indication and the importance of the early detection of these symptoms.

Review of studies has mentioned various factors associated with these psychological symptoms which are not only related to a poor adjustment to hospitalization distress,[7] but also associated with adverse events and unsatisfactory outcomes.[8] Although factors and process associated with psychological disorders and its relation to adverse outcomes in hospitalized patients have been explained to some extent,[9],[10] screening strategies to identify patients at higher risk for hospitality-related mood disorders are not robust. Various studies need to focus on risk factors for depressive and anxiety disorders in inpatient settings which have not been exclusively determined.[11],[12]

Advantage of identifying anxiety and depressive symptoms awaiting for surgery allows the planning of appropriate interventions to improve such symptoms, individually, on one's needs, or even on health education groups, preparing patients for a surgical procedure.[13]

Risk stratification in hospitalized patients for mood disorders could also help in identifying those with a higher probability to develop poor outcomes.[14] This is of particular importance when considering that depression and anxiety disorders have been associated with readmission, higher morbidity and mortality, and even postdischarge psychiatric diagnosis.[15]


  Methods Top


Sixty patients admitted to the surgery ward of SCB Medical College, Cuttack, were enrolled consecutively in this prospective observational cross-sectional study, of whom 43 were male and 17 were female. The average age was 38.8 years. The majority of our study population had lower-middle socioeconomic status, supportive familial relationships, and religious belief. The Institutional Ethics Committee of SCB Medical College approved the study protocol.

Patients aged ≥18 years who were conscious and cooperative and gave their informed consent were enrolled in the study. Patients with a diagnosis of current psychiatric disorder, who were taking antidepressive, anxiolytic, or antipsychotic medications, or had an altered mental status were excluded from the study.

A clinical psychologist used the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) to evaluate patients' mood symptoms at 12 h after admission for electively scheduled surgeries and 12–24 h after the surgery for patients undergoing emergency surgery. Demographics and other clinical and surgical characteristics of patients were also recorded.

HAM-D was developed by Max Hamilton to evaluate the severity of symptoms of depression. Test–retest reliability and inter-rater reliability of HAM-D is 0.81, and validity of HAM-D ranges from 0.65 to 0.90. It consists of 21 items; however, only 17 items are scored about symptoms of depression experienced over the past week. Eight items are scored on a 5-point scale ranging from 0 (not present) to 4 (severe). Nine items are scored from 0 to 2. A score of 0–7 is accepted to be within normal range. A score of 8–13 indicates mild severity, 14–18 indicates moderate severity, 19–22 indicates severe depression, and score more than 23 indicates very severe level of depression.

HAM-A was developed by Max Hamilton to evaluate the severity of symptoms of anxiety. It consists of 14 items scored on a 5-point scale ranging from 0 to 4. A score of <17 is accepted to be within mild range. A score of 18–24 indicates mild-to-moderate level of anxiety and 25–30 indicates severe level of anxiety.


  Results Top


The sociodemographic features of the study population are described in [Table 1]. Our study included 60 patients of which 43 were males and 17 were female.48 of them were married with 41 from rural background and 19 urban. In the parameter of education 44 patients were matriculate and above.
Table 1: Sociodemographic Features of the Study Population (N=60)

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Hamilton Depression rating (HAMD) and Hamilton anxiety rating (HAMA) scores are represented in [Table 2] showing preoperative and postoperative stages. In preoperative stage anxiety was prevalent in 43.3 % patients while depression in 38% patients. Whereas in postoperative stage anxiety was 18.3% and depression 35% patients.
Table 2: Pre- and postscores of Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale scores

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  Discussion Top


Our study was carried out in an inpatient setting to screen patients admitted to the surgical ward for symptoms of depression and anxiety at pre- and postsurgery stages. Our findings suggest that both these emotional states are highly prevalent in both stages of surgery. In presurgery stage, anxiety was found to be prevalent in 43.3% while depression is 38%. In postsurgery stage, anxiety and depression were found in 18.3% and 35%, respectively.

Similarly, high prevalence is also seen in other studies; anxiety and depression in the preoperative period of general surgery are 44.3% and 26.6%, respectively,[5] and 34.4% and 28.1% in a study by Carneiro et al.[6]

However, in a large administrative study by Daratha et al.,[8] in a hospital setting, only 2.3% of adult patients who had been hospitalized for any medical conditions were diagnosed with co-occurred mood disorders. In contrast, a study by Rentsch et al.,[16] looking at hospitalized patients in an internal medicine department, identified 26.9% of patients with depressive disorders and 11.3% with major depression based on the Diagnostic and Statistical Manual of Mental Disorders criteria and 34.9% with depressive disorder and 18.4% with major depression according to the Patient Health Questionnaire criteria.

A national survey showed anxiety to be high in 19.7% of the 106 preoperative patients evaluated, with anxiety being significantly higher in women than men.[17]

In various studies, depression at the time of admission was significantly associated with longer hospital stay, a previous history of mood disorders, the need for surgery or reoperation, underlying diseases, surgical complication, and lack of familial support. Indeed, these predictors are either a stressor to newly admitted patients or a supporting factor that if present would help the patients to adopt their conditions.

However, on admission, anxiety symptoms were significantly associated with female gender, lower educational level, and previous history of mood disorders in univariate analysis in literature. Anxiety in the second week was also related to the need for a surgical procedure for the admission-related condition. Later, depression also correlated with lack of familial support and being under the poverty line. Liberzon et al.[18] identified risk factors for posttraumatic stress disorders or depressive symptoms in patients with an aortic aneurysm or occlusive diseases as younger age, having increased preoperative blood pressure, and being incubated at the end of the surgery.

Another study using HADS investigated factors associated with suicidal thoughts among hospitalized patients. The study revealed that admission to the infectious disease department and oncology and hematology units presents a higher probability of suicidal ideation.[19] Their results also revealed that suicidal ideation was associated with depression at younger age, alcohol abuse, and smoking. Many other studies concluded that female gender, retired or in a disabled job condition, low income and bad family relationships, and presence of chronic somatic illness were risk factors for depression among hospitalized patients. Depression had a high comorbidity with organic mental and anxiety disorders.[20]

Various researches have suggested that factors including a poor familial support, type of diseases, need for reoperation, postoperative complications, previous history of mood disorders and other psychiatric disorders, and unsatisfactory outcomes may play an important role in the development of mood symptoms among surgical in patients with varying significance.

Several authors emphasized[19],[21],[22] that it is necessary to acknowledge more and more importance to the influence of adequate preoperative information on the postoperative course: in other words the patients psychological reality is a key determinant in anxiety and depression. Furthermore, the precise role of the psychologist within the hospital structure is to be recognized and confirmed on the basis of the above considerations, especially in view of a correct program of prevention of anxiety and depression linked to surgery both in the patients and in those concerned with them.

However, most of the studies have emphasized that such behavioral and emotional symptoms in nonpsychiatric units should be attended with more seriousness.[8],[10],[12] These mood disorders in their severe form can predispose the admitted patients to higher morbidity and mortality more than three times than general population.


  Conclusions Top


Our findings suggest that both anxiety and depression are highly prevalent in pre- and postoperative stage of surgery. In presurgery stage, anxiety was found to be prevalent in 43.3% while depression is 38%. In postsurgery stage, anxiety and depression were found in 18.3% and 35%, respectively. Various analyses of literature suggest that such behavioral and emotional symptoms in nonpsychiatric units should be attended with more seriousness and these in their severe form can predispose the admitted patients to higher morbidity and mortality.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hibbert A. Stress in surgical patients: A Physiological Prespective. In: Manley K, Bellman L, editors. Surgical Nursing –Advanced practice Loures, Portugal:Luso-science; 2003. p. 159-73.  Back to cited text no. 1
    
2.
Barbosa VC, Radomile M. Pre-operative anxiety in the general Hospital. Revista de Virtual de Psicologia Hospitalar e da saude, 2006;2:45-50.  Back to cited text no. 2
    
3.
Akinsulore A, Owojuyigbe AM, Faponle AF, Fatoye FO. Assessment of preoperative and postoperative anxiety among elective major surgery patients in a tertiary hospital in Nigeria. Middle East J Anaesthesiol 2015;23:235-40.  Back to cited text no. 3
    
4.
Ghoneim MM, O'Hara MW. Depression and postoperative complications: An overview. BMC Surg 2016;16:5.  Back to cited text no. 4
    
5.
Marcolino JA, Mathias LA, Piccinini Filho L, Guaratini AA, Suzuki FM, Alli LA, et al. Hospital anxiety and depression scale: A study on the validation of the criteria and reliability on preoperative patients. Rev Bras Anestesiol 2007;57:52-62.  Back to cited text no. 5
    
6.
Carneiro AF, Mathias LA, Rassi Júnior A, Morais NS, Gozzani JL, Miranda AP, et al. Evaluation of preoperative anxiety and depression in patients undergoing invasive cardiac procedures. Rev Bras Anestesiol 2009;59:431-8.  Back to cited text no. 6
    
7.
Tully PJ, Baker RA. Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: A contemporary and practical review. J Geriatr Cardiol 2012;9:197-208.  Back to cited text no. 7
    
8.
Daratha KB, Barbosa-Leiker C, Burley HM, Short R, Layton ME, McPherson S, et al. Co-occurring mood disorders among hospitalized patients and risk for subsequent medical hospitalization. Gen Hosp Psychiatry 2012;34:500-5.  Back to cited text no. 8
    
9.
Shapira-Lichter I, Beilin B, Ofek K, Bessler H, Gruberger M, Shavit Y, et al. Cytokines and cholinergic signals co-modulate surgical stress-induced changes in mood and memory. Brain Behav Immun 2008;22:388-98.  Back to cited text no. 9
    
10.
Capo-Ramos DE, Gao Y, Lubin JH, Check DP, Goldin LR, Pesatori AC, et al. Mood disorders and risk of lung cancer in the EAGLE case-control study and in the U.S. Veterans affairs inpatient cohort. PLoS One 2012;7:e42945.  Back to cited text no. 10
    
11.
Koivula M, Tarkka MT, Tarkka M, Laippala P, Paunonen-Ilmonen M. Fear and anxiety in patients at different time-points in the coronary artery bypass process. Int J Nurs Stud 2002;39:811-22.  Back to cited text no. 11
    
12.
Stundner O, Kirksey M, Chiu YL, Mazumdar M, Poultsides L, Gerner P, et al. Demographics and perioperative outcome in patients with depression and anxiety undergoing total joint arthroplasty: A population-based study. Psychosomatics 2013;54:149-57.  Back to cited text no. 12
    
13.
World Health Organization. World Health Organization Disability Assessment Schedule II. World Health Organization; 2006.  Back to cited text no. 13
    
14.
Székely A, Balog P, Benkö E, Breuer T, Székely J, Kertai MD, et al. Anxiety predicts mortality and morbidity after coronary artery and valve surgery – A 4-year follow-up study. Psychosom Med 2007;69:625-31.  Back to cited text no. 14
    
15.
Gerson S, Mistry R, Bastani R, Blow F, Gould R, Llorente M, et al. Symptoms of depression and anxiety (MHI) following acute medical/surgical hospitalization and post-discharge psychiatric diagnoses (DSM) in 839 geriatric US veterans. Int J Geriatr Psychiatry 2004;19:1155-67.  Back to cited text no. 15
    
16.
Rentsch D, Dumont P, Borgacci S, Carballeira Y, deTonnac N, Archinard M, et al. Prevalence and treatment of depression in a hospital department of internal medicine. Gen Hosp Psychiatry 2007;29:25-31.  Back to cited text no. 16
    
17.
Gonçalves KK, Silva JI, Gomes ET, Pinheiro LL, Figueiredo TR, Bezerra SM, et al. Anxiety in the preoperative period of heart surgery. Rev Bras Enferm 2016;69:397-403.  Back to cited text no. 17
    
18.
Liberzon I, Abelson JL, Amdur RL, King AP, Cardneau JD, Henke P, et al. Increased psychiatric morbidity after abdominal aortic surgery: Risk factors for stress-related disorders. J Vasc Surg 2006;43:929-34.  Back to cited text no. 18
    
19.
Botega NJ, de Azevedo RC, Mauro ML, Mitsuushi GN, Fanger PC, Lima DD, et al. Factors associated with suicide ideation among medically and surgically hospitalized patients. Gen Hosp Psychiatry 2010;32:396-400.  Back to cited text no. 19
    
20.
Pakriev S, Kovalev J, Mozhaev M. Prevalence of depression in a general hospital in Izhevsk, Russia. Nord J Psychiatry 2009;63:469-74.  Back to cited text no. 20
    
21.
Elliott PC, Murphy BM, Oster KA, Le Grande MR, Higgins RO, Worcester MU, et al. Changes in mood states after coronary artery bypass graft surgery. Eur J Cardiovasc Nurs 2010;9:188-94.  Back to cited text no. 21
    
22.
Burg MM, Benedetto MC, Rosenberg R, Soufer R. Presurgical depression predicts medical morbidity 6 months after coronary artery bypass graft surgery. Psychosom Med 2003;65:111-8.  Back to cited text no. 22
    



 
 
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