Medical Safety & Global Health
Open Access

The aim of the study was to determine the effect of sociodemographic factors and the frequency of anxiety and depression in patients with chronic respiratory, heart and renal diseases.

Methodology Design and sample

A cross-sectional survey was established to evaluate and compare the prevalence of anxiety and depression in patients with COPD, asthma, chronic heart failure (CHF), and chronic renal failure (CRF). The consecutive 301 patients, who were diagnosed with chronic asthma (according to the Global Initiative for Asthma (GINA) criteria) and chronic COPD (according to the Global initiative for Chronic Obstructive Lung Disease (GOLD) criteria), chronic CHF (New York Heart Class II-IV, with ejection fraction of <40 % on transthoracic echocardiography) and CRF (individuals who have undergone hemodialysis for at least 6 months) in Sakarya University Hospital (Turkey) in March 2014-2016 period and who have not received an antidepressant and any anxiolytic drugs in last one year were included in the study. The patients who were receiving a therapy for the psychiatric disease or with another chronic disorder (i.e. diabetes, malignancy, rheumatologic and neurologic diseases) that could affect emotional states were excluded from the study. The patients who provided informed consent were included in the study, and the questionnaire form evaluating the demographic characteristics was filled out by all patients.

Main Outcome Measures

The emotional states were assessed by using the Hospital Anxiety and Depression (HAD) scale which was developed in 1983 by the Zigmond and Snaith (1983). Its validity and reliability were tested by the same researchers. It includes the subscales of anxiety and depression. This scale consisted of a total of 14 questions: 7 of them investigate the symptoms of depression, and another 7 investigate the symptoms of anxiety.

The answers were taken by a four-point Likert type scale. The scale consists of scores between 0 (best) and 3 (worst). The purpose of the scale is not to diagnose, but to identify the risk group by scanning anxiety and depression in patients in a short time. The scale can also be used in the follow up of changes in the patient’s emotional state. Although the scale uses the word “hospital”, it can also be used in every health establishment including outpatient polyclinics.

The aim was to minimize the impact of the existing somatic disease on the HAD scale results. Therefore, it does not contain any physical  signs. In the scale, the score of “0-1” was accepted as normal, “2” was accepted as at the borderline symptomatic, and “3” was accepted as having marked symptoms. This scale has been proven to be a useful evaluation tool and the score range provides results minimizing false-positive and false-negative data. Scores obtained from the scale were not affected by the presence of somatic disease. The HAD scale was compared to the other scales, it was found to be adequate to  detect anxiety and depression in patients with somatic diseases.

Turkish adaptation study of HAD scale was made by Aydemir et al. (1997). According to this study, for the anxiety sub-scale cut-off score was found as 10 and more, and the depression subscale cut-off score was found as 7 and more.

The results showed that the limit value for anxiety was 10 or higher while for depression was 7 or higher. It was reported that an anxiety score which is greater than 10 can be classified as HAD-A (+), under 10 as HAD-A (−), and patients having depression scores over 7 can be classified as HAD- D (+), while under 7 as HAD-D (−). HAD is preferred because it does not contain any issue related to the physical state.

In the scale reliability studies, Cronbach's alpha coefficient was found to be 0.732, and in our study, Cronbach's alpha coefficient was 0.637, which shows the reliability of the present study.

Data Analysis

The obtained data were evaluated through t-test, correlation test, chi-square and Mann Whitney u test, also frequency, mean, standard errors were calculated for both independent and dependent groups in SPSS program.

Ethical Considerations

The study was approved by the Ethics Committee. Informed consent was obtained from all participants, in addition, the study was approved by the Ethics Committee of the Faculty of Medicine, Sakarya University

Limitations of the Study

The study population consists of only the State Hospitals Association in the city centre of Sakarya. Therefore these study results cannot  be generalised.

Results

The study included 301 patients with CRD (n=97), CHD (n=116) and CRF (n=88).

It was found that anxiety score was 52.2% (n=157) and depression score was 81.7% (n=246). It was observed that the highest anxiety score was in the CRD patients (66.6%), then CHD (46.6%) and CRF (44.3%) patients, and there was the statistically significant difference between the groups (p=0,004). It was revealed that the highest depression score was in the CHD patients (%89.7), followed by CRD (%86.6) and CRF (65.9%) patients and a significant difference between disease groups was also found (p<0,001)(Table 2).

There was a positive correlation between age and depression, that is, depression score increased with age (r=0.173, p=0.003). The mean depression score for the age below 50 years was 8.6 and for over 50 years was 9.5, and the difference between the groups was significant. There was no significant difference between anxiety and depression scores in terms of gender, marital status, education level, working status and disease duration (Table3). There was no correlation between disease duration and mood disorders

Discussion

Physiological disorders such as pain, dyspnea, fatigue, insomnia, which may occur in chronic diseases, restrict the daily activities of an individual to a great extent, and their lives are adversely affected due to frequent hospitalizations. Degraded quality of life and limited physical activity cause loneliness and failure to meet their own needs or fulfill their family duties, resulting in mental problems such as anxiety and depression (Abu-Shakra 2016; Williams et al. 2009; Hacihasanoglu, et al. 2010).

In the present study, the anxiety and depression rates were 52.2% and 81.7%, in patients with chronic diseases, respectively. Anxiety and depression were reported in previous studies at very different rates depending on the used method, the differences in the patient population, and the severity of the diseases (Yohannes et al. 2006; Wang et al. 2006; Grau et al. 2003; Elbi Mete 2008; Dickens 2008). Patients with respiratory diseases may have a persistent or shortened breathing difficulty, a tendency on restricted effort capacity, a high incidence of sudden deaths (in cardiac patients) and an increased fear of death, anxiety and depression scores, while patients with regular dialysis are more likely to have contact with other patients during dialysis, which may have contributed to their reduced anxiety and depression scores.

It is known that the age-related chronic diseases also increase the susceptibility to anxiety and depression symptoms (Hacihasanoglu et al 2010;30). In our study, it was seen that depression was in relation to the mean age, resulting in a significant difference (p = 0.003), but it did not correlate with anxiety. Depression was significantly higher in the patients over 50 years of age. Yildiz et al. (2016) found a correlation between age and depression in their study of COPD patients, but they did not find an association between age and anxiety as in our study. The effect

of long disease duration on anxiety and depression scores was examined, no significant difference was found between the duration of illness and HAD scale scores. Although the length of the illness is thought to affect the emotional state even worse, there may be cases that the patients accept the illness over the years, learn to live with it and get used to it. In the initial stages of the illness, the feeling of future uncertainty and prejudice can negatively affect the psychological state. In individuals with a deteriorated disease, the obvious symptoms may cause a more negative effect. In contrast to our study, there were studies where the duration of diseases extended, and the signs of cohabitation, behavioral reactions, anxiety, and depression were observed (Ozkan 1993; Cam & Saka 2009; Ince et al.,2005).

The relationship between gender and anxiety as well as depression scores was examined in the present study and no significant difference was found. Janson et al., reported that the incidence of emotional disorders in women was higher (Jonsan et al.1998). Similarly, it was reported that the mean anxiety score of women was higher than that of males (Hacihasanoglu et al., 2010; Gilmour 2008; Grau et al. 2003). Biological structure, mental characteristics, personality structure, the way of coping with problems, social and cultural position make a woman susceptible to depression.

However, this tendency in the normal population can appear more in disease existence.

In our study, there was no relationship between education status, working status, marital status and mood disorders. Same results are also revealed in previous studies. Uskul et al. (2006) found no relationship between the anxiety, depression scores, and the gender, marital status, educational status, income level, occupation, duration of hospitalization and duration of illness of the patients in the chest diseases clinic. Anar et al. (2012) also found parallel results to our findings and found no difference in terms of gender, working status, marital status, anxiety and depression status. Similarly, in the study of Atacanli & Dilbaz (2001), there was no relationship between sociodemographic factors and depression. Sociodemographic features are associated with depression, the coexistence of chronic physical disease and coexisting depression in the normal population, which can be interpreted that socio-demographic differences play an important role.

Conclusion

Psychiatric comorbidities are quite common in patients with chronic somatic disorders. In the present study, depression, and anxiety were related to asthma, COPD, heart and kidney diseases, which can also significantly affect the treatment process of patients and may further alleviate their somatic disease. For this reason, it may be useful to provide psychosocial support besides the treatment of patients with this type of chronic illness, especially for the health workers who are in close relationship with patients. In the light of these results,  we would like to investigate the presence of depression in routine controls especially in the chronic heart and respiratory patients and evaluate the two patient groups together to improve their quality of life and to improve the effectiveness of treatment.

This work will be presented in 27th Global Nursing and Health Care Conferenc