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
Citation:
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
Email: auml@ha.org.hk
ACKNOWLEDGEMENTS
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.
Abstract
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.
INTRODUCTION
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.
METHOD
Participants
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.
Measures
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.
RESULTS
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)
Sex
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)
Employment
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)
SSQR
Availability of social
support
3.04
(2.21)
Satisfaction with
social support
2.73 (0.58)
HADS
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
HADS
Anxiety
Depression
Adjusted
Depression
Age
0.60**
0.64**
0.62**
Number
of disruption areas
0.62**
0.69**
0.70**
SSQR
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)
|
|
|
Standardized
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)
|
|
|
Standardized
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)
|
|
|
Standardized
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.
DISCUSSION
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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