The International Journal of Psychosocial Rehabilitation
Correlates of Psychological Distress in
 Discharged Patients Recovering from Severe Acute Respiratory Syndrome in Hong Kong


Alma Au
 Iris Chan
Clinical Psychology Service, Queen Elizabeth Hospital, Hong Kong, China

Patrick Li
Johnny Chan
Y. H. Chan  
Fiona Ng
Department of Medicine, Queen Elizabeth Hospital, Hong Kong, China


Au A., Chan I., Li P., Chan J.,  Chan Y.H.,  & Ng F., (2004)  Discharged patients recovering from acute
respiratory symdrome in  Hong Kong
? International Journal of Psychosocial Rehabilitation. 8, 41-51.

Reprint requests and correspondence should be sent to:
Alma Au. Ph.D.
Department of Clinical Psychology
Queen Elizabeth Hospital
30 Gascoigne Road
Hong Kong, China

Phone: 852-2958-6308 Fax: 852-2958-6665

The authors would like to express gratitude to Ms Polly Lau and Mr David Yu of the Kowloon Central Cluster Physiotherapy Department for granting access to the results and categorization of the Six-minute Walk Test. The authors would like to thank Mr John Wong and the nursing staff of the Department of Medicine of the Queen Elizabeth Hospital for their support in data collection for the study.
Objective: To study the correlates of psychological distress of discharged patients recovering from severe acute respiratory syndrome (SARS)
Design: Cross section and correlational
Setting: Queen Elizabeth Hospital, Hong Kong, China
Patients: Forty-one SARS adult patients aged between 20-71 followed up at Queen Elizabeth Hospital
Main outcome measures: Measures of disruption areas, social support, anxiety and depression.
Results: After controlling for age, the number of disruption areas and the lack of satisfaction with social support were found to be significant correlates of psychological distress. High scorers on the anxiety and depression scales were found to report disruption felt in physical functioning extending to other areas of their lives. Furthermore, these high scorers also reported a relative lack of satisfaction with the available social support.
Conclusions:  The findings of the present study can be useful in the following three areas: understanding the nature of events contributing to the distress in discharged SARS patients, developing appropriate psychological intervention and assisting staff to effectively identify the need for psychosocial support for these patients.

Severe Acute Respiratory Syndrome (SARS) is an acute atypical pneumonia believed to be caused by a previously unknown coronavirus 1. The situation presented by sudden onset of acute illness is often characterized by uncertainties that elicit significant emotional distress. Diagnostic uncertainties threaten the sense of security and future predictability. Such ambiguities can be especially stressful when established treatments do not yet exist for the condition under investigation. Even in cases where treatment appears effective, concern over side effects and other longer-term consequences can introduce further stress 2.  In the case of SARS, some individuals are faced with the threat of death not only for themselves but also for their relatives. Some actually experienced the loss of significant others while struggling with their own survival. The recovery phase of those who managed to be discharged may continue to be punctuated with fears of possible recurrence of illness and the elusiveness of a complete recovery.

 Maintaining psychological equilibrium while living with the aftermath of the sudden onset of a severe illness poses major challenges to individuals’ adaptive capabilities 3. Folkman 4 has described stress in a deficit model in which demands made upon an individual exceed the resources available at any given time. Stress can include physical, psychological or environmental factors that can cause distress. SARS patients are faced with multiple stressful experiences that tend to fluctuate over the course of time. After recovering initially in the physical sense, other challenges begin to surface. These include uncertainties about the ability to return to the previous occupation and handle interpersonal relationships. A severe illness like SARS can cause major disruptions to valued and essential activities. The subjective sense of physical frailty and fatigue can also lower the perception of personal control to return to their previous lifestyle and functioning level. 
SARS patients are also possibly challenged with social prejudice and negative stereotypes.  The stigmatizing nature of SARS can be particularly severe as evidence indicates that the virus is primarily spread by close contact with an infected person although there is still a great deal of uncertainty about other possible modes of transmission. Moreover, there is no universally established treatment regime and the disease may reappear again 5. The fears of contracting the SARS virus could potentially fuel the shunning of persons with SARS and anyone associated to them. Such negative attitudes can exist even in the patients’ significant others. Thus, SARS can cause difficulties for the infected individuals in getting the support they need. Social support has been argued to be important buffer to the negative psychological consequences of stressful experiences by enhancing self-efficacy and promoting recovery 6-8. Social prejudice can be significant barriers to social and vocational rehabilitation.
Thus, the psychological distress caused by SARS is not only limited to the debilitating impact of the physical symptoms. Discharged SARS patients have a long way to go to cope with the intrusion of the illness causing disruption to various aspects of their daily functioning.  Furthermore, public fears of the illness and social prejudice can cause difficulties in these patients in getting the help when it is most needed. Understanding the processes that shape psychological adjustment in this population can be an important guide for conceptualizing intervention. For routine screening purpose, the HADS has been administered with the assistance of nursing staff about one week prior to the present study. About 90 questionnaires were distributed to SARS patients at their regular follow up the QEH clinic. A total of 75 completed questionnaires were collected from 47 female patients and 28 male patients seen on average of 54.61 (SD= 17.33) days after discharge from hospital. About 6.7% reported moderate to severe anxiety symptoms and 6.7 % reported depressive symptoms 9. The purpose of the present study was to explore the psychosocial correlates of psychological distress in discharged SARS patients who agreed to take part in a follow-up interview.  
41 participants were recruited from 90 outpatients attending the SARS Clinic of Queen Elizabeth Hospital. At the time of their regularly scheduled appointments at the clinic, patients were invited to an interview with the clinical psychologist. After briefly outlining the purpose of the assessment and obtaining written consent, participants were invited to complete self-administered questionnaires.
Demographic and illness related factors: Demographic characteristics were collected through the questionnaire. These included age, gender, education, work status and marital status. They were also asked if they had witnessed any family member contracting SARS and whether they experienced bereavement due to relatives who died of SARS. In addition, the following information about the patients was obtained from the medical records: the length of hospital stay, admission into the Intensive Care Unit and results of the Six Minute Walk Test 10 performed at about the same period. The classification system of the Six Minute Walk Test was adopted from Yu (unpublished data) with category 2 covering the range from the 30th to 70th percentile and category 3 covering the range below the 30th percentile. 

Disruption Scale (DS)
Scales have often been used to identify areas of stress-causing disruption experienced by patients with acute onset of severe illness. Adopting from existing stress scales for severe chronic illness 2,11, 6 possible areas of disruption were identified for the present SARS patients: physical functioning, work/job functioning, interpersonal functioning, finance and social discrimination. There is one final item for participants to list any additional disruption areas they experienced that are not covered. The number of areas of stress is aggregated into a total stress count score with a minimum of zero and a maximum of six.
Revised Social Support Questionnaire (SSQR)
The SSQR 12 comprises 6 items tapping on the number of available others and degree of satisfaction for the particular kind of support stated in the question. The 4-point Likert scale ranged from “not satisfied” to “very satisfied”. The internal consistency of both dimensions was reported to be 0.90 and 0.93 respectively.
Hospital Anxiety and Depression Scale (HADS)
The HADS was chosen to provide a relatively comprehensive and sensitive measure of psychological distress. The HADS 13 consists of fourteen items from which two independent scores are calculated for anxiety and depression. Ranging from 0 to 21 for each of the 2 scales, low scores reflect absence of anxiety and/or depression. The scale was partially validated in Hong Kong and the Chinese version demonstrated good agreement with the original English version 14,15. Research with cancer patients in Hong Kong indicated that the internal consistency was high for both anxiety and depression scales (Cronbach’s alpha = 0.90 and 0.79, respectively), suggesting that the HADS could be a valid measure of psychological distress for the local population 15. Preliminary normative data had been obtained from a group of medical students 14. 
Statistical Analysis
Firstly, the following data was explored on a descriptive basis: demographic characteristics, illness-related factors, BSS, SSQR and HADS. Secondly, Pearson product-moment correlation coefficients were computed to explore the relationships between HADS on one hand and demographic characteristics, the illness-related and psychosocial variables on the other. Hierarchical regression was used to identify the most relevant correlates of HADS measures. Finally, an attempt was made to identify the characteristics of high scorers on the HADS.
Demographic characteristics and illness-related variables
Patients were seen on average 55.81 days (SD = 15.77) after their discharge from the hospital. Results obtained are summarized in Table 1.

Table 1.
Results obtained for demographic characteristics and illness-related factors (N=41)
Variables                                                                       Frequency (Percentage)                        Mean (SD)
            Males                                                               19 (46.34)
            Females                                                            22 (53.66)
Age                                                                                                                                                      35.85 (11.15)
            20-29                                                                                                12 (29.27)
            30-39                                                                                                16 (39.02)
            40-49                                                                                                    8 (19.51)
            50-71                                                                                                    5 (12.20)
Education                                                                                                                                              13.19 (5.10)
Employed                                                                      22 (53.55)
Unemployed                                                                  19 (46.34)
Marital Status
            Married                                                             19 (46.34)
            Single                                                                18 (43.90)
            Divorced/ Widowed                                              4 ( 9.76)
Witnessing a significant other contracting SARS              12 (29.27)
Bereaved of significant other who died of SARS                6 (14.63)
Bereaved of spouse who died of  SARS                                ( 4.87)
Length of hospitalization                                                                                                                       28.17 (19.09)
ICU admission                                                                14 (34.15)
Six Minute Walk Test
            Category 2                                                          25 (60.98)
            Category 3                                                          16 (39.02)
Disruption areas and SSQR availability and satisfaction scores
Details are listed in Table 2. The number of disruption areas endorsed ranged from 0 to 6 with a mean of 1.70 (SD = 1.75). Of the 6 areas, physical functioning was the most frequently endorsed. Qualitative responses from patients suggested worries over the recurrence of SARS, the ability to recover completely and the side effects of medication. Over 20% of the patients indicated disruption in finance, work/job and interpersonal functioning. For the SSQR, the mean satisfaction with social support across 6 items was found to lie between “quite satisfied” and  “only a little satisfied”.
HADS scores

The means and standard deviation are listed in Table 2. Using the cut-off score of 11 suggested in the manual 14, 12.1 % were classified as moderately to severely anxious while 12.1% were classified as moderately to severely depressed. In terms of the specific items, about 73.2% of the patients reported at least occasionally feeling “tense or wound up” and “getting a sort of frightened feeling as if something awful is about to happen”. About 85.4% of the patients reported feeling at least sometimes “slowed down”. As these patients have undergone severe illness and intensive medical treatment, it is possible that the item on slowing down may be reflective of physical condition rather than actual depression. In other words, physical symptoms can mimic depressive symptoms 16. Taking into account that slowing down may be reflective of physical condition rather than psychological distress, an adjusted HADS Depression score was calculated leaving out Item 8 and prorating the score on the remaining 6 items. Using the adjusted Depression score (Mean = 4.64, SD = 4.52), 9.8% of the patients were still found to have moderately to severely depressed symptoms.

Table 2
Results obtained for the Disruption scale, SSQR and HADS (N=41)
Variables                                                         Frequency (Percentage)                        Mean (SD)
Disruption Scale
Number of disruption areas                                                                                           1.71 (1.75)
            0 area                                                               8 (19.51)
1 areas                                                                        22 (53.66)
            2 areas                                                               0 ( 0.00)
            3 areas                                                               3 ( 7.32)
            4 areas                                                               2 ( 4.87)
            5 areas                                                               5 (12.20)
         6 areas                                                                  1 ( 2.44)
Nature of disruption areas
            Physical functioning                                           26 (63.41)
            Work/Job functioning                                         10 (24.39)
Interpersonal functioning                                                10 (24.39)
Emotional functioning                                                      8  (19.51)       
Finance                                                                         11 (26.83)
Discrimination/ Prejudice                                                 5 (12.20)
Availability of social support                                                                                        3.04 (2.21)
            Satisfaction with social support                                                                        2.73 (0.58)
            Anxiety                                                                                                          6.00 (3.74)
            Depression                                                                                                     5.24 (4.39)
            Adjusted Depression                                                                                       4.64 (4.52)

Relationships of psychological distress to demographic variables, illness-related factors, disruption areas and social support
In terms of demographic variables, only age was found to show significant correlation with the HADS scores. No significant correlations were found between the HADS scores and illness factors including the length of hospital stay, ICU admission and the Six Minute Walk Test. On the other hand, the HADS scores were found to correlate significantly with the number of disruption areas and the SSQR social satisfaction score. However, the HADS score did not correlate with the social availability score (Table 3). In other words, higher anxiety and depression scores were associated with the number of disruption areas reported. On the other hand, lower anxiety and depression scores were associated with a greater level of satisfaction with social support. 

Table 3
Results of bivariate correlation of age, number of disruption areas, social availability and satisfaction with HADS scores
Anxiety          Depression        Adjusted
Age                                                                   0.60**              0.64**             0.62**
Number of disruption areas                                 0.62**              0.69**              0.70**
Availability of social support                               -0.07                 -0.15               -0.12
Satisfaction with social support                           -0.59**             -0.68**            -0.67**       
**p < 0.01

Hierarchical regression
To reduce the number of predictors, only variables that showed significant bivariate correlation with the HADS scores were included in the regression analysis. The 3 independent variables included age, disruption areas and satisfaction with social support. The 3 variables were grouped into two blocks: age and psychosocial variables. The psychosocial block included both the number of disruption areas and social satisfaction. Sequential regression was employed to examine the contribution of psychosocial variables to the HADS scores after controlling for age. Thus, age is entered as the first block and the psychosocial variables as the second block. The dependent variables were the HADS Anxiety and Depression scores. To bypass the possible content overlap between mental health and physical condition, regression analysis was also carried out for the adjusted Depression score that was prorated from the remaining 6 items after leaving out the “fatigue” item. After controlling for age, the psychosocial variables was found to contribute significantly to the HADS scores, accounting for 17.0% of the variance for the HADS Anxiety score, 24.4% of the variance for the HADS Depression score and 26.0% of the Adjusted Depression score. An examination of the standard beta coefficients suggested that both the number of disruption areas and social satisfaction demonstrated significant association with all the 3 HADS scores (Table 4).

Table 4
Summary of regression analysis for predicting HADS scores (N=41)
Regression analysis for predicting HADS Anxiety Score (N=41)
Step 1
β coefficients
Step 2
R R2 R2 change F change
Block 1 Age 0.60 0.24 0.60 0.36 0.36 21.62**
Block 2 Psychosocial variables     0.72 0.52 0.17  6.52**
      Number of disruption areas    0.35*        
      Social satisfaction   -0.28*        
Regression analysis for predicting HADS Depression Score (N=41)
Step 1
β coefficients
Step 2
R R2 R2 change F change
Block 1 Age 0.64 0.21 0.64 0.41 0.41 27.32**
Block 2 Psychosocial variables     0.81 0.65 0.24 13.09**
      Number of disruption areas     0.39**        
      Social satisfaction    -0.37**        
Regression analysis for predicting HADS Adjusted Depression Score (N=41)
Step 1
β coefficients
Step 2
R R2 R2 change F change
Block 1 Age 0.62 0.17 0.62 0.38 0.38 24.23**
Block 2 Psychosocial variables     0.80 0.64 0.26 13.35**
      Number of disruption areas     0.42**        
      Social satisfaction    -0.36**        
* p < 0.05   ** p < 0.01

Characteristics of high scorers on the HADS
Those who scored at or above the cut-off of 11 on either the HADS Anxiety scale or HADS Depression scale were classified to be high scorers, suggesting moderate to severe levels of psychological distress. Five patients of the present sample scored above the cutoff for the Anxiety scale. Out of these Anxiety high scorers, three also scored above the cut-off for the Depression scale. Two patients scored above the cutoff for Depression but not for the Anxiety scale. All five (100%) Anxiety scorers and 80% of Depression high scorers are over 40 in age and are unemployed. One of them has recently lost her spouse in SARS. Three out of the four others reported that they had lost their jobs because of SARS.
In terms of the disruption areas, 80% of the Anxiety high scorers and 80% of the Depression high scorers reported as having more than one disruption areas. All the high scorers indicated having disruption in the physical area. In addition, 60% of the Anxiety high scorers and 80% of the Depression high scorers indicated disruption in the financial area.  In terms of social support, 80% of the Anxiety high scorers and 80% of the Depression high scorers reported an average in the category of being “only a little satisfied with the available social support”. The pattern holds for the adjusted Depression score as 75% of the adjusted score high scorers who reported having more than one disruption area and being only a little satisfied with the available social support.
The present exploratory study documented in local SARS patients the association between anxiety and depression on one hand, and the number of disruption areas and satisfaction with social support on the other hand. The findings can be useful for at least three reasons. Firstly, it is important to understand the nature of the stressful events contributing to psychological distress in discharged SARS patients. Results suggested the most reported disruption included physical functioning, finance, work and interpersonal issues. All the patients scoring above the cutoff for HADS reported disruption in physical functioning. Most of them also reported an additional disruption such as finance or job issues together with the lack of satisfaction with social support. Thus, psychological distress could be caused by the “spilling over” of disruption in physical functioning to difficulties in finance, work or interpersonal issues.  
Secondly, the correct understanding of the nature of the stressful events is essential in designing and tailoring appropriate psychological intervention for the distressed individuals. As patients reported many potential concerns related to tangible areas like physical, financial and interpersonal issues, individual psychological intervention should be provided in the context of a multidisciplinary team. Apart from dealing with the more traditional psychotherapeutic issues such as reducing negative thinking and instilling hope, patients should be empowered with the knowledge of where and how to get support with the tangible and practical issues.
Finally, the psychosocial correlates of distress among SARS patients can help frontline medical and nursing staff to effectively identify the need for further intervention. Patients may find it easier to talk about the disruption and social support rather than directly reporting anxiety and depressive symptoms. This can be a particularly important point as the suggestion of psychological and psychiatric disturbance may aggravate the sense of stigmatization and prejudice already experienced by many SARS patients. Thus, as part of the holistic screening procedure during follow-up, medical and nursing staff can ask patients about the disruption/ changes experienced in the daily lives as the result of SARS. Starting with the more familiar physical aspects, patients can then be asked about the concerns/worries in other aspects of theirs lives including finance, work and relationship with family members and colleagues. Finally, it is important to ask patients to indicate how satisfied they are with the available support. Following the results of the present study, the following can be indicators for referral of further psychosocial intervention. The first indication is the disruption extending from physical problems to other areas of their lives. The second indication is the suggestion of lack of satisfaction with the available social support.
It may be interesting to compare the present data on SARS patients with available data of other local patient groups. In general, the level of psychological distress was substantially lower than those found for the local Chinese patients with advanced cancer and pain of which over 50% had been found to be moderately to severely anxious and depressed 16. Comparing with other pateint groups in Hong Kong, the level of emotional distress of the present SARS patients also appeared lower than that of the newly diagnosed patients with human immunodeficiency virus (HIV) cases of which over 10% had reported anxiety or depressive symptoms above the cutoff on the
HADS 17. In comparison with established epilepsy patients who have been diagnosed for over 10 years, although the anxiety level of the SARS patients appeared relatively mild, the depression levels were similar 18.
 Like SARS, both HIV and epilepsy can involve a rather sudden and traumatic diagnosis for the patient.  Furthermore, patients with HIV and epilepsy may also have constant worries over physical deterioration or an imminent seizure attack. However, the chance of a complete recovery appeared higher for SARS patients than for cancer, HIV and epilepsy patients. Thus, it is perhaps not surprising to find that the level of psychological distress of SARS patients were lower than that for cancer, HIV and epilepsy patients. On the other hand, the infectious nature of SARS could be more complicated than that for cancer, epilepsy and HIV. The limited knowledge of the mode of transmission of SARS may contribute to the social prejudice and negative stereotypes. It is not surprising than the satisfaction with social support of the present SARS patients were found to be significantly lower than that for the epilepsy cases 17. 
The present study had certain limitations. The sample size was rather small and had come from one hospital. Basically, a cross-sectional design was used and no cause-effect inferences can be made. Futhermore, a longitudinal study is really needed to monitor long-term changes in stress and distress. However, the present study did document in a group of local SARS patients the relationship of psychological distress with disruption areas and the satisfaction of social support. Comparison of the present data has also made with available data on other patient groups. In particular, the relative lack of satisfaction with social support of the present group of SARS patients has been highlighted.  The clinical implications of the findings are discussed in the context of developing appropriate intervention as well as assisting frontline staff in identifying the need for psychosocial support in SARS patients.   



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