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Mood and anxiety disorders among inpatients of a university hospital in Turkey
General Hospital Psychiatry 35 (2013) 417–422
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Mood and anxiety disorders among inpatients of a university hospital in Turkey Fatih Kayhan, M.D. a,⁎, Erdinc Cıcek, M.D. b, Faruk Uguz, M.D. c, İbrahim Fatih Karababa, M.D. d, Rahim Kucur, M.D. c a
Department of Psychiatry, Beysehir State Hospital, Konya, Turkey Department of Psychiatry, Research and Training Hospital, Urfa, Turkey c Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey d Department of Psychiatry, University of Harran Faculty of Medicine, Sanliurfa, Turkey b
a r t i c l e
i n f o
Article history: Received 1 December 2012 Revised 18 February 2013 Accepted 6 March 2013 Keywords: Depression Anxiety Inpatients
a b s t r a c t Objective: The aim of the study was to assess the prevalence of mood and anxiety disorders among inpatients and the relationship between sociodemographic factors, medical illnesses and treatments. Methods: In the present study, we selected 650 inpatients from all clinics except psychiatry and pediatrics in a general hospital by a simple random sampling method. Based on the exclusion criteria, 57 patients were excluded. Mood and anxiety disorders were determined by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Results: Of the participants, 226 (37.5%) had a psychiatric disorder, 87 (14.4) had a mood disorder and 146 (24.2%) had an anxiety disorder. The most common specific diagnoses were not otherwise specified as anxiety disorder (9.5%), major depression (8.6%) and generalized anxiety disorder (7.6%). While the overall prevalence was highest in the hematology clinic (60.0%), it was lowest in the clinic of infectious diseases (22.7%). Logistic regression analysis indicated that the independent factors associated with psychiatric disorders were being of the female gender and a personal history of psychiatric disorders. Conclusions: In conclusion, results of the present study suggest that mood and anxiety disorders were frequently observed among inpatients, particularly in female patients and those with an individual history of psychiatric disorder. Successful treatment of these disorders may positively contribute to the course of the disease in inpatients. However, this assumption should be confirmed by further studies. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Mood and anxiety disorders are important public health issues leading to chronic disability, decrease in quality of life, as well as loss in family, social and occupational functions [1,2]. Epidemiological studies have suggested that these disorders constitute the majority of the psychiatric disorders observed in the community. While mood disorders affect 2.8–6.5% of people, anxiety disorders are seen in 6.5– 7.3% of the general population [3–5]. Compared to the general population, it has been reported that subjects with medical illness are under a higher risk of occurrence of a psychiatric disorder [6]. Various studies have suggested that the prevalence rate of psychiatric disorders is between 30% and 60% among inpatients with a medical illness [7,8]. Concurrent psychiatric disorders appear to be associated with an impairment in response to the medical treatment, the patient's compliance to the treatment, longer hospital stay and higher morbidity rate [9,10]. Therefore, awareness and successful treatment of the comorbid psychiatric disorders may be important to alleviate this medical problem.
⁎ Corresponding author. Konya Beyşehir Devlet Hastanesi Psikiyatri Anabilim Dalı, 42000 Beyşehir/Konya, Turkey. Tel.: + 90 332 512 49 49. E-mail address: [email protected] (F. Kayhan). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.03.004
Psychiatric disturbances among subjects with a general medical condition have been widely examined. However, most of these studies include a unique medical illness. The number of studies representing all categories of inpatients in a hospital is inadequate. Moreover, to our knowledge, no published studies have examined this topic in Turkey, a developing country. In this study, we aimed to investigate the current prevalence rate of mood and anxiety disorders and associated factors among inpatients of a university hospital. 2. Methods 2.1. Sample The study was conducted at inpatient clinics for adult subjects of Meram Faculty of Medicine of Necmettin Erbakan University in Konya, Turkey, between May 2010 and December 2010. The inpatient clinics included hospitalized patients for their medical illnesses. The hospital is one of two tertiary hospitals in Konya City. To determine the sample size, we used hospital data including the year 2009. According to the statistics of the hospital, a total of 35,156 patients were hospitalized in the year 2009. In order to assess the prevalence of mood and anxiety disorders in the range of 20.0%±4% (with 95% confidence interval), the required sample size was calculated to be at
418
F. Kayhan et al. / General Hospital Psychiatry 35 (2013) 417–422
least 380. To provide more comprehensive data about the prevalence rate of the disorders in each specific inpatient clinic, we evaluated 650 inpatients. Inclusion criteria for this study were as follows: (a) current age of at least 18 years; (b) voluntary participation in the study; (c) absence of mental retardation; (d) general medical condition of the patients appropriate for psychiatric interviews and (e) the duration of hospitalization of 2 days or more. Exclusion criteria included (a) patients who were hospitalized in intensive care units; (b) patients with a history of schizophrenia or related psychotic disorders; (c) patients currently in the perinatal period and (d) patients with a psychiatric diagnosis of delirium. Based on these criteria, 57 subjects were excluded from the present study; thereby, the final sample included 603 patients. The study was approved by the ethics committee of Meram Faculty of Medicine of Necmettin Erbakan University. 2.2. Procedures Initially, the study procedures were explained to all participants, and written informed consent forms were obtained. The distribution of participants to each department was determined on the basis of the ratio of the number hospitalizations in the specific inpatient clinic to the total number of all inpatient hospitalizations for the year 2009. The participants were selected via a simple randomization method. After the sociodemographic characteristics and medical data of the patients were recorded, psychiatric interviews were carried out. Medical diagnoses were obtained from the medical record by electronic record. Mood and anxiety disorders were diagnosed with The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-I) [11]. Psychiatric interviews with SCID-I were conducted by a psychiatrist with 4 years of experience about psychiatric disorders and the diagnostic instruments. Family history of psychiatric disorders was based on patients' reports about their first-degree relatives. Information on the study participants' current medical condition and hospital stays were obtained from the hospital records. The number of hospitalization was obtained by self-report of the subjects. 2.3. Statistical analyses The study data were analyzed with Statistical Package for the Social Sciences (SPSS) 13.0 for Windows (SPSS, Chicago, IL, USA). Categorical variables between the groups including patients with and without psychiatric diagnosis were compared with the chi-square test and Fisher's Exact Test, as necessary. To analyze continuous variables between the same patient groups, t test was used. Independent variables associated with the existence of mood or anxiety disorders were determined with logistic regression analysis. 3. Results 3.1. Sample characteristics Table 1 shows demographic characteristics of the study sample. The mean±S.D. of the age of the participants (n=603) was 51.07±15.72 years. The proportion of women in the total sample was 49.6%. Approximately 75% of the participants were illiterate or primary school graduates, and mostly were currently married and unemployed. The sample size for each inpatient clinic and prevalence rate of chronic medical disorders is presented in Table 2. Inpatient clinics that contributed the largest number of participants to this study were cardiology, general surgery and gynecology. Of all the subjects, 475 (78.8%) had at least one chronic medical illness. One hundred and seventy-one patients (28.4%) were in the postoperative period. The prevalence rate of a history of surgery in the past years was 48.1%. The mean±S.D. for the number of hospitalizations was 2.59±
Table 1 Demographic characteristics of the study sample Age (year) ±
Gender Male Female Marital status Single Married Divorced–Widowed Educational status İlliterate Primary education High school University Economic situation Good Medium Poor Occuption Yes No Smoking Yes No
51.07±15.72 n
%
304 299
50.4 49.6
59 489 55
9.8 9.1 81.1
125 340 97 41
20.7 56.4 16.1 6.8
210 358 35
34.8 59.4 5.8
142 461
23.5 76.5
189 414
31.3 68.7
1.78, the mean±S.D. for the duration of hospitalization during the evaluation was 6.16±6.02 days and the mean±S.D. for the length of hospital stay was 11.70±9.49 days. While 186 subjects (30.8%) had been hospitalized for the first time, the others had at least one previous history of hospitalization. The current length of hospital stay was significantly longer in subjects with psychiatric diagnosis compared to those patients without a psychiatric diagnosis (14.31± 11.81 vs. 10.14±7.38 days, P=.000). Of the subjects, 177 (29.4%) had a history of psychiatric disorder. The frequencies of a previous history of mood and anxiety disorder were 11.4% and 12.9%, respectively. The rate of subjects receiving psychiatric medication was 7.13% (n= 43). This rate was 17.70% (n= 40) and 0.79% (n=3) in the subjects with and without any psychiatric diagnosis, respectively. A total of 37 (6.13%) subjects were taking antidepressants. Antipsychotics and benzodiazepine were received by Table 2 The sample size for each inpatient clinics and prevalence rate of chronic medical disorders Clinics
n
%
Medical clinics Endocrinology Nephrology Hematology Gastroenterology Rheumatology Oncology Cardiology Chest diseases Infectious diseases clinic Dermatology Physical medicine and rehabilitation Neurology Surgical clinics General surgery Chest surgery Cardiovascular surgery Plastic and reconstructive surgery Urology Orthopedia Otorhinolaryngology Neurosurgery Gynecology and obstetrics clinic Total
336 10 21 11 22 9 20 62 42 23 37 35 44 267 50 10 21 9 38 47 22 21 49 603
55.7 1.7 3.5 1.8 3.6 1.5 3.3 10.3 7.0 3.8 6.1 5.8 7.3 44.3 8.3 1.7 3.5 1.5 6.3 7.8 3.6 3.5 8.1 100
F. Kayhan et al. / General Hospital Psychiatry 35 (2013) 417–422
clinics where psychiatric disorders were most commonly determined were hematology (60.0%), gastroenterology (52.3%), cardiovascular surgery (52.3%) and endocrinology (50.0%). The overall prevalence was lowest in the clinics of infectious diseases (22.7%), general surgery (28.0%) and urology (28.9%). The psychiatric diagnoses were most frequent among subjects with chronic liver disease (61.1%), diabetes mellitus (DM) (52.1%) and chronic kidney deficiency (51.7%).
Table 3 Current prevalance rate of mood and anxiety disorders in sample
Any mood or anxiety disorder, n (%) Any mood disorder, n (%) Any anxiety disorder, n (%) MD, n (%) Otherwise specified depression, n (%) Dysthymia, n (%) Genaralized anxiety disorder, n (%) PD, n (%) OCD, n (%) SAD, n (%) SP, n (%) PTSD, n (%) AD-NOS, n (%)
Medical clinics
Surgical clinics
General hospital
125 (37.2) 52 (15.5) 79 (23.5) 33(9.8) 14 (4.2) 5 (1.5) 26 (7.7) 11 (3.3) 13 (3.9) 2 (0.6) 2 (0.6) 0 (0) 30 (8.9)
101(37.8) 35 (13.1) 67(25.1) 19 (7.1) 6 (2.2) 10(3.7) 20 (7.5) 5 (1.9) 9 (3.4) 6 (2.2) 1 (0.4) 2 (0.7) 27 (10.1)
226 (37.5) 87 (14.4) 146 (24.2) 52 (8.6) 20 (3.3) 15 (2.5) 46 (7.6) 16 (2.7) 22 (3.6) 8 (1.3) 3 (0.5) 2 (0.3) 57 (9.5)
419
3.3. Factors associated with any mood or anxiety disorder
AD-NOS: anxiety disorder not otherwise specified; OCD: obsessive compulsive disorder; SAD: social anxiety disorder; SP: social phobia.
only 3 (0.5%) subjects. The proportion of subjects who reported a family history of psychiatric disorder was 14.8%. 3.2. Prevalence of mood and anxiety disorders SCID-I indicated that 226 (37.5%) subjects met the criteria for any current mood or anxiety disorder. Anxiety disorders (23.2%) were more prevalent compared to mood disorders (14.3%). The most common specific diagnoses were not otherwise specified anxiety disorder (9.5%), major depression (MD) (8.6%) and generalized anxiety disorder (GAD) (7.6%) (Table 3). Tables 4 and 5 list the prevalence rate of mood and anxiety disorders in each clinic and chronic medical illnesses highly correlated with a psychiatric diagnosis, respectively. The inpatient
As summarized in Table 6, psychiatric disorders were more prevalent in women compared to men. The number of hospitalizations in subjects with a psychiatric diagnosis was significantly higher than those without the diagnosis (P= .000). Compared to the group that were not diagnosed with a psychiatric disorder, patients with mood or anxiety disorders had significantly higher frequencies of medical diagnoses of Type II DM (P=.000), chronic liver disease (P= .047) and hyperlipidemia (P= .049). The difference was not significant between patients with and without mood or anxiety disorder with respect to other specific chronic medical disease. Other variables established as significantly different between the groups were a history of surgery (P= .000), a history of individual psychiatric disorder (P= .000), a family history of psychiatric disorder (P= .000) and economic status (P= .000). The variables found significantly different between the groups when compared with the χ 2 test or t test were analyzed by binary logistic regression analysis to determine independent factors for the existence of any mood or anxiety disorder. The regression analysis indicated that female gender (B=0.49, Wald χ 2= 6.28, df=1, P= .012) and an individual history of psychiatric disorder (B=1.96, Wald χ 2= 80.74, df= 1, P= .000) were independent factors associated with the existence of mood or anxiety disorders. In contrast, economic
Table 4 The prevalence of mood and anxiety disorders in each chronic medical illness
DM n=121 Thyroid diseases n=26 Other endocrine diseases n=8 Hypertension n=280 Coronary artery disease n=89 Hyperlipedimia n=126 Cerebrovascular disease n=32 Carcinoma n=88 Hematologic diseases n=12 Choronic obstructive pulmonary disease n=51 Asthma n=23 Choronic kidney deficiency n=29 Chronic liver diseases n=18 Rheumatismal diseasesn=46 Benign tumors n=33 Others chronic diseases n=9
MD n (%)
DD-NOS n (%)
18 (14.9)
4 (3.3)
Dysthmia n (%)
GAD n (%)
PD n (%)
OCD n (%)
SAD n (%)
SP n (%)
PTSD n (%)
AD-NOS n (%)
Total N (%)
4 (3.3)
19 (15.7)
8 (6.6)
10 (8.3)
0 (0)
0 (0)
0 (0)
11 (9.1)
63 (52.1)
6 (23.1)
0 (0)
0 (0)
3 (11.5)
3 (11.5)
2 (7.7)
0 (0)
0 (0)
0 (0)
2 (7.7)
13 (50.0)
1 (12.5)
0 (0)
0 (0)
1 (12.5)
1 (12.5)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
3 (37.5)
7 (2.5)
11 (3.9)
1 (0.4)
1 (0.4)
0 (0)
24 (8.6)
27 (9.6)
9 (3.2)
11 (3.9)
8 (9.0)
3 (3.4)
3 (3.4)
9 (10.1)
2 (2.2)
5 (5.6)
1 (1.1)
0 (0)
0 (0)
9 (10.1)
35 (39.3)
14 (11.1)
6 (4.8)
4 (3.2)
14 (11.1)
2 (1.6)
6 (4.8)
1 (0.8)
0 (0)
0 (0)
15 (11.9)
57 (45.2)
5 (15.6)
2 (6.2)
0 (0)
3 (9.4)
0 (0)
4 (12.5)
0 (0)
0 (0)
0 (0)
2 (6.2)
13 (40.6)
13 (14.8)
3 (3.4)
2 (2.3)
7 (8.0)
2 (2.3)
0 (0)
3 (3.4)
0 (0)
0 (0)
14 (15.9)
37 (42.0)
1 (8.3)
2 (16.7)
0 (0)
2 (16.7)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
1 (8.3)
6 (50.0)
2 (3.9)
2 (3.9)
3 (5.9)
5 (9.8)
2 (3.9)
2 (3.9)
0 (0)
1 (2.0)
0 (0)
5 (9.8)
19 (37.3)
3 (13.0)
0 (0)
1 (4.3)
2 (8.7)
2 (8.7)
1 (4.3)
0 (0)
0 (0)
0 (0)
2 (8.7)
10 (43.5)
4 (13.8)
2 (6.9)
2 (6.9)
2 (6.9)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
6 (20.7)
15 (51.7)
7 (38.9)
0 (0)
0 (0)
1 (5.6)
0 (0)
1 (5.6)
0 (0)
0 (0)
0 (0)
2 (11.2)
11 (61.1)
1 (2.2) 4 (12.1)
1 (2.2) 0 (0)
1 (2.2) 1 (3.0)
11 (23.9) 2 (6.1)
1 (2.2) 1 (3.0)
2 (4.3) 2 (6.1)
0 (0) 0 (0)
0 (0) 0 (0)
0 (0) 0 (0)
4 (8.7) 2 (6.1)
20 (43.5) 12 (36.4)
7 (5.7)
8 (6.6)
7 (5.7)
13 (10.7)
1 (0.8)
4 (3.3)
0 (0)
0 (0)
0 (0)
16 (13.1)
52 (42.6)
DD-NOS: depressive disorder not otherwise specified.
24 (8.6)
107 (38.2)
420
F. Kayhan et al. / General Hospital Psychiatry 35 (2013) 417–422
Table 5 Prevalence of mood and anxiety disorders in each clinics
Endocrinology n=10 Nephrology n=21 Haematology n=11 Gastroenterology n=22 Rheumatology n=9 Oncology n=20 Cardiology n=62 Chest diseases n=42 Infectious diseases n=23 Dermatology n=37 Physical medicine and rehabilitation n=35 Neurology n=44 General surgery n=50 Chest surgery n=10 Cardiovascular surgery n=21 Plastic and reconstructive surgery n=9 Urology n=38 Orthopedia n=47 Otorhinolaryngology n=22 Neurosurgery n=21 Gynecology and obstetrics clinic n=49
MD n (%)
DD-NOS n (%)
Dysthmia n (%)
GAD n (%)
PD n (%)
OCD n (%)
SAD n (%)
SP n (%)
PTSD n (%)
AD-NOS n (%)
Total n (%)
3 (30) 3 (14.3) 1 (9.1) 4 (18.2) 0 (0) 4 (20) 4 (6.5) 2 (4.8) 2 (8.7) 0 (0) 4 (11.4) 6 (13.6) 5 (10) 1 (10) 1 (4.8) 1 (11.1) 2 (5.3) 2 (4.3) 2 (9.1) 0 (0) 5 (10.2)
0 (0) 1 (4.8) 2 (18.2) 2 (9.1) 1 (11.1) 0 (0) 1 (1.6) 1 (2.4) 0 (0) 0 (0) 3 (8.6) 3 (6.8) 0 (0) 0 (0) 2 (9.5) 1 (11.1) 1 (2.6) 2 (4.3) 0 (0) 0 (0) 0 (0)
0 (0) 1 (4.8) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1.6) 1 (2.4) 0 (0) 2 (5.4) 0 (0) 0 (0) 1 (2) 0 (0) 2 (9.5) 0 (0) 3 (7.9) 1 (2.1) 1 (4.5) 0 (0) 2 (4.1)
1 (10) 0 (0) 2 (18.2) 2 (9.1) 1 (11.1) 1 (5) 5 (8.1) 1 (2.4) 1 (4.3) 4 (10.8) 5 (14.3) 3 (6.8) 4 (8) 0 (0) 1 (4.8) 1 (11.1) 1 (2.6) 3 (6.4) 1 (4.5) 4 (19) 5 (10.2)
0 (0) 0 (0) 0 (0) 1 (4.5) 0 (0) 1 (5) 3 (4.8) 4 (9.5) 0 (0) 0 (0) 1 (2.9) 1 (2.3) 0 (0) 1 (10) 0 (0) 0 (0) 1 (2.6) 1 (2.1) 0 (0) 1 (4.8) 1 (2)
1 (10) 0 (0) 0 (0) 1 (4.5) 2 (22.2) 0 (0) 2 (3.2) 1 (2.4) 0 (0) 0 (0) 0 (0) 6 (13.6) 1 (2) 0 (0) 2 (9.5) 0 (0) 0 (0) 0 (0) 1 (4.5) 1 (4.8) 4 (8.2)
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (5) 1 (1.6) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2.6) 1 (2.1) 0 (0) 3 (14.3) 1 (2)
0 (0) 0 (0) 0 (0) 1 (4.5) 0 (0) 0 (0) 1 (1.6) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4.3) 0 (0) 0 (0) 0 (0)
0 (0) 4 (19) 1 (9.1) 2 (9.1) 0 (0) 4 (20) 3 (4.8) 5 (11.9) 1 (4.3) 4 (10.8) 2 (5.7) 4 (9.1) 5 (10) 1 (10) 3 (14.3) 0 (0) 3 (7.9) 4 (8.5) 1 (4.5) 2 (9.5) 8 (16.3)
5 (50) 9 (42.9) 5 (54.5) 11 (52.4) 3 (30) 8 (40.0) 21 (33.9) 14 (33.3) 5 (22.7) 10 (26.3) 15 (42.9) 18 (40.9) 14 (28.0) 4 (40.0) 11 (52.4) 2 (25.0) 11 (28.9) 18 (40.0) 7 (31.8) 10 (47.6) 22 (45.8)
status (P=.467), family (P= .413), history of surgery (P= .298), family history of psychiatric disorder (P= .063), Type II DM (P= .065), chronic liver disease (P= .172), hyperlipidemia (P= .461) and number of hospitalizations (P= .045) were not significant predictors.
4. Discussion In the present study, the prevalence rate of any mood or anxiety disorder was 37.3%. This rate is higher than the current prevalence rates of psychiatric disorders estimated in the general population [4,12,13]. The number of published studies conducted on patients in inpatient clinics is inadequate. Silverstone et al. [14] reported that 27% of inpatients had any current psychiatric disorder. Two other studies found the prevalence rate to be 23.4–56.0% [15,16], which are consistent with our results. Large-scale epidemiological studies have reported that the current prevalence rate of MD in the community was 2.2–4.9% [3,4,17–20]. In our sample, this rate was 8.6%. When other specific disorders were compared, the study data on MD among inpatients with a general medical condition are more prevalent. However, the available studies are mostly based on self-report scales. Other authors using interview instruments similar to those used in the current study reported this rate to be 8.3–9.4%, which are in line with our findings [21–23].
Anxiety disorders have been assessed less frequently among inpatients compared to depression. The prevalence rate of any anxiety disorder determined in this study (23.2%) was in agreement with that reported by Fava et al. (23.5%) [24]. While the frequency of GAD (7.6%) was found similar to the results (10.3–10.8%) of previous studies [24,25], panic disorder (PD) had lower prevalence rate (2.7%) compared to previous studies (10–50%) [26–28]. The previous studies investigating PDs mostly included cardiac disorders, myocardial infarction, arrhythmia and mitral valve diseases. In contrast, the proportion of subjects with these diagnoses in our sample was very low. We found no other studies on the prevalence of other anxiety disorders among inpatients of general hospitals. The prevalence rates of posttraumatic stress disorder (PTSD) found in this study are exceedingly low than seen in the general population [4,29]. The difference could be due to differences between the study samples. For example, the mean age of subjects in the present study is relatively high. We examined only the prevalence rate of current but not lifetime psychiatric disorders. In addition, our study was carried out in the inpatient clinics of a general hospital. Turkish patients usually exhibits tendency to concealing psychological traumatic events during psychiatric interviews performed in the inpatient clinics of a general hospital. To our knowledge, there is no published study on the prevalence rate of specific mood and anxiety disorders relevant to specific
F. Kayhan et al. / General Hospital Psychiatry 35 (2013) 417–422
421
Table 6 Sociodemographic and clinical characteristic in subjects with and without any diagnosis mood or anxiety disorders
Age, mean±S.D. Gender, n (%) Marital status, n (%)
Educational status, n (%)
Occuption, n (%) Economic situation, n (%)
Number of hospitalizations, mean±S.D. Smoking, n (%) Chronic disease, n (%) DM, n (%) Tyroid diseases, n (%) Other endocrine diseases, n (%) Hypertension, n (%) Coronary artery diseases, n (%) Cerebrovascular diseases, n (%) Hyperlipidemia, n (%) Chronic obtructive pulmonary disease, n (%) Asthma, n (%) Carcinoma, n (%) Hematologic diseases, n (%) Rhematologic diseases, n (%) Chronic liver diseases, n (%) Chronic kideny deficiency, n (%) Bengin tumors, n (%) Undergo an operation, n (%) New operation, n (%) Personal history of psychiatric disorders, n (%) Familiy history of psychiatric disorders, n (%)
Female Male Single Married Divorced–Widowed İlliterate Primary education High school University Yes No Good Medium Poor Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Patients with mood and anxiety disorders
Patients without mood and anxiety disorders
50.81±15.61 129 (57.1) 97 (42.9) 19 (8.4) 182 (80.5) 25 (11.1) 50 (22.1) 127 (56.2) 38 (16.8) 11 (4.9) 46 (20.4) 180 (79.6) 22 (9.7) 137 (60.6) 67 (29.6) 2.93±1.94 66 (29.2) 160 (70.8) 187 (82.7) 39 (17.3) 63 (27.9) 163 (72.1) 13 (5.8) 213 (94.2) 3 (1.3) 223 (98.7) 107 (47.3) 119 (52.7) 35 (15.5) 191 (84.5) 13 (5.8) 213 (94.2) 57 (25.2) 169 (74.8) 19 (8.4) 207 (91.6) 10 (4.4) 216 (95.6) 37 (16.4) 189 (83.6) 6 (97.3) 220 (2.7) 20 (8.8) 206 (91.2) 11 (4.9) 215 (95.1) 15 (6.6) 211 (93.4) 12 (5.3) 214 (94.7) 132 (58.4) 94 (41.6) 71 (31.4) 155 (68.6) 129 (57.1) 97 (42.9) 53 (23.5) 173 (76.5)
51.23±15.81 170 (45.1) 207 (54.9) 40 (10.6) 307 (81.4) 30 (8) 75 (19.9) 213 (56.5) 59 (15.6) 30 (8.0) 96 (25.5) 281 (74.5) 13 (3.4) 221 (58.6) 143 (37.9) 2.38±1.64 123 (32.6) 254 (67.4) 288 (76.4) 89 (23.6) 58 (15.4) 319 (84.6) 13 (3.4) 364 (96.6) 5 (1.3) 372 (98.7) 173 (45.9) 204 (54.1) 54 (14.3) 323 (85.7) 19 (5) 358 (95) 69 (18.3) 308 (81.7) 32 (8.5) 345 (91.5) 13 (3.4) 364 (96.6) 51 (13.5) 326 (86.5) 6 (1.6) 371 (98.4) 26 (6.9) 351 (93.1) 7 (1.9) 370 (98.1) 14 (3.7) 363 (96.3) 21 (5.6) 356 (94.4) 158 (41.9) 219 (58.1) 100 (36.5) 277 (73.5) 48 (12.7) 329 (87.3) 36 (9.5) 341 (90.5)
P value .748⁎ .005⁎⁎ .332⁎⁎⁎
.485⁎⁎⁎
.166⁎⁎ .002⁎⁎⁎
.000⁎⁎ .415⁎⁎⁎ .80⁎⁎ .000⁎⁎ .214⁎⁎ 1.000⁎⁎ .737⁎⁎ .723⁎⁎ .711⁎⁎ .049⁎⁎ 1.000⁎⁎ .661⁎⁎ .343⁎⁎ .380⁎⁎ .429⁎⁎ .047⁎⁎ .117⁎⁎ 1.000⁎⁎ .000⁎⁎ .225⁎⁎ .000⁎⁎ .000⁎⁎
⁎ t test. ⁎⁎ Fisher's exact test. ⁎⁎⁎ chi-square test.
departments and medical diagnoses among a representative sample of inpatients of a general hospital. In our sample, compared to the epidemiological data reported in the general population, the prevalence of any mood or anxiety disorder appeared to be similar in the departments of infectious diseases, dermatology, general surgery, plastic and reconstructive surgery, urology and otorhinolaryngology. The rate appears to be slightly higher in the departments of rheumatology, chest surgery, chest diseases and cardiology and is markedly higher in other departments.
At 61.1%, chronic liver disease was a specific medical diagnosis for which psychiatric disorders were most commonly observed. The prevalence rate of MD was 38.9% in these patients. This is lower than the results (15.8–18.9%) of previous studies that were carried out in patients with chronic liver deficiency due to hepatitis B or hepatitis C virus infections [29,30]. However, the current study included chronic liver deficiency due to other etiologies except these infections. Patients taking interferon-alpha treatments were also excluded from the study. Association between interferon treatment and depression
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has been well documented [31]. This may explain the differences between the results of our study and the previous studies. Type II DM was another disease for which psychiatric diagnoses frequently existed in our sample. Previous studies have also suggested that compared to the general population, lifetime prevalence of depression in this patient group is approximately three to fourfold higher. Most of the inpatients with DM had unregulated blood glucose levels or complications due to DM, which may be related to high prevalence rates of mood or anxiety disorders. Female gender was one of the two independent factors related to the existence of a mood or anxiety disorder in this study. It is known that psychiatric disorders are more prevalent in women than men in the community [32–34]. In addition, some authors reported a connection between female gender and depression among inpatients [35–37]. It is an expected finding that individual history of psychiatric disorder was associated with a current mood or anxiety disorder because psychiatric disorders mostly have a chronic and relapsing course. The main strengths of this study are the assessment of mood and anxiety disorders by means of a structured psychiatric interview method in a representative sample of a general hospital. Moreover, we have also presented descriptive data on the prevalence rate of mood and anxiety disorders for each medical condition and inpatient clinic. However, the cross-sectional design of the present study is a restrictive factor in the interpretation of the results, particularly about associated factors with mood or anxiety disorders. This study was carried out among inpatients of a university hospital; therefore, it may not be representative of all inpatients. In addition, we did not examine the rates of mood and anxiety disorders diagnosed by the treating clinicians and compare them to the SCID diagnosed obtained. In conclusion, the present study suggests that mood and anxiety disorders were frequently observed among inpatients. The most important risk factors seem to be being of the female gender and an individual history of psychiatric disorders. Successful treatment of these disorders may positively contribute towards the recovery of these patients. However, this assumption should be confirmed by further studies. References [1] Kessler RC, Angermeyer M, Anthony JC, Graaf R, Demyttenaere K, Gasquet I, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the WHO world mental health surveys. World Psychiatry 2007;6:168–76. [2] Huppert JD, Simpson HB, Nissenson KJ, Liebowitz MR, Foa EB. Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls. Depress Anxiety 2009;26:39–45. [3] Regier DA, Farmer ME, Rae DS, Myers JK, Kramer M, Robins LN, et al. One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the epidemiologic catchment area study. Acta Psychiatr Scand 1993;88:35–47. [4] Vicente B, Kohn R, Rioseco P, Saldivia S, Baker C, Torres S. Population prevalence of psychiatric disorders in Chile: 6-month and 1-month rates. Br J Psychiatry 2004;84:299–305. [5] Canino GJ, Bird HR, Shrout PE, Rubio-Stipec M, Bravo M, Martinez R, et al. The prevalence of spesific psychiatric disorders in Puerto Rico. Arch Gen Psychiatry 1987;44:727–35. [6] Gagnon LM, Patten SB. Major depression and its association with long-term medical conditions. Can J Psychiatry 2002;47:149–52. [7] Özmen E, Aydemir Ö, İçelli İ. Bedensel hastalığı olanlarda psikiyatrik tanı dağılımı (Türkiye'de yapılan çalışmlaraın gözden geçirilmesi). Ege Psikiyatrisi Sürekli Yayınları Konsültasyon Liyezon Psikiyatrisi- II 1997;2:285–98. [8] Yıldız M, Tural Ü, Kesepara C, Aydın M, Etuş H. Fiziksel hastalıklara eşlik eden ruhsal bozukluklar: Bir üniversite hastanesinde psikiyatri konsültasyonu sonuçlarının değerlendirilmesi. Düşünen Adam 2002;15:21–4. [9] Özkan S. Konsültasyon liyezon psikiyatrisi; kavramlar, kurumsallaşma, uygulama. Türkiye Klinikleri J Int Med Sci 2006;2:1–13.
[10] Özkan S. Psikiyatrik tıp: Konsültasyon liyezon psikiyatrisi tanımı, kavramları, hizmet alanı, eğitim ve araştırma objektifleri ile dünyada gelişimi ve bir bilim dalı ve uzmanlık alanı olarak kurumsallaştırılması. İstanbul: Konsültasyon Liyezon Psikiyatrisi Kongre Kitabı; 1994. [11] First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Clinical Version (SCID-I/CV). Washington DC: American Psychiatric Press; 1997. [12] Regier DA, Myers JK, Kramer M, Robins LN, Blazer DG, Hough RL, Eaton WW, Locke BZ. The NIMH epidemiologic catchment area program arch gen psychiatry. Arch Gen Psychiatry 1984;41:934–41. [13] Bijl RV, Ravelli A, Zessen VG. Prevalence of psychiatric disorder in the general population: results of the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Soc Psychiatry Psychiatr Epidemiol 1998;33:587–95. [14] Silverstone PH. Prevalence of psychiatric disorders in medical inpatients. J Nerv Ment Dis 1996;184:43–51. [15] Strain JJ. Needs for psychiatry in the general hospital. Hosp Community Psychiatry 1982;33:996–1002. [16] Ateşci FÇ, Oğuzhanoğlu NK, Baltalarlı B, Karadağ F, Özdel O, Karagöz N. Kanser hastalarında psikiyatrik bozukluklar ve ilişkili etmenler. Turk Psikiyatri Derg 2003;14:145–52. [17] Wilhelm K, Mitchell P, Slade T, Brownhill S, Andrews G. Prevalence and correlates of DSM-IV major depression in an Australian national survey. J Affect Disord 2003;75:155–62. [18] Ohayon MM, Priest RG, Guilleminault C, Caulet M. The prevalence of depressive disorders in the United Kingdom. Biol Psychiatry 1999;45:300–7. [19] Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey. Am J Psychiatry 1994;51:979–86. [20] Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA 1996;276:293–9. [21] Hansen MS, Fink P, Frydenberg M, Oxhoj M, Sondergaard L, Munk-Jorgensen P. Mental disorders among internal medical inpatients: prevalence, detection, and treatment status. J Psychosom Res 2001;50:199–204. [22] Booth BM, Blow FC, Cook CA. Functional impairment and co-occurring psychiatric disorders in medically hospitalized men. Arch Intern Med 1998;158:1551–9. [23] Zhong B, Chen H, Zhang J, Xu H, Zhou C, Yang F, et al. Prevalence, correlates and recognition of depression among inpatients of general hospitals in Wuhan, China. Gen Hosp Psychiatry 2010;32:268–75. [24] Fava GA, Porcelli P, Rafanelli C, Mangelli L, Grandi S. The spectrum fo anxiety disorders in the medically ill. J Clin Psychiatry 2010;71:910–4. [25] Martucci M, Balestrieri M, Bisoffi G, Bonizzato P, Covre MG, Cunico L, et al. Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey. Psychol Med 1999;29:823–32. [26] Moser DK. The rust of life: impact of anxiety on cardiac patients. Am J Crit Care 2007;16:361–9. [27] Rothenbacher D, Hahmann H, Wüsten B, et al. Symptoms of anxiety and depression in patients with stable coronary heart disease: prognostic value and consideration of pathogenetic links. Eur J Cardiovasc Prev Rehabil 2007;14: 547–54. [28] Moran MG. Solunum sistemi bozuklukları. In: Sadock BJ, Sadock VA, editors. Comprehensive Text Book of Psychiatry. Güneş Kitabevi: Sekizinci Baskı. 3.Cilt; 2007. p. 2148–52. [29] Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62: 593–602. [30] Özkan M, Corapcioglu A, Balcioglu I, Ertekin E, Khan S, Özdemir S, et al. Psychiatric morbidity and its effect on the quality of life of patients with chronic hepatitis B and hepatitis C. Int J Psychiatry Med 2006;36:283–97. [31] Golden J, O' Dwyer AM, Conroy RM. Depression and anxiety in patients with hepatitis C: prevalence, detection rates and risk factors. Gen Hosp Psychiatry 2005;27:431–8. [32] Çiçek Eİ. İnterferon tedavisi sonucu gelişen depresyon ile oksidatif stres ve nörotrofik faktörlerin ilişkisi. Danışman: Nazmiye Kaya. (Uzmanlık Tezi) Konya: Selçuk Üniversitesi Meram Tıp Fakülesi; 2010. p. 13–4. [33] Lipowski ZJ, Wolston EJ. Liasion psychiatry: referral patterns, and their stability over time. Am J Psychiatry 1981;138:1608–11. [34] Sağduyu A, Ögel K, Özmen E, Boratav C. Birinci basamak saglık hizmetlerinde depresyon. Turk Psikiyatri Derg 2000;11:3–16. [35] Rezaki M. Bir saglık ocağına basvuran hastalarda depresyon. Turk Psikiyatri Derg 1995;6:13–20. [36] Martucci M, Balestrieri M, Bisoffi G, Bonizzato P, Covre M, Cunico L, et al. Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey. Psychol Med 1999;29:823–32. [37] Pakriev S, Kovalev J, Mozhaev M. Prevalence of depression in a general hospital in Izhevsk, Russia. Nord J Psychiatry 2009;63:469–74.
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Mood and anxiety disorders among inpatients of a university hospital in Turkey Fatih Kayhan, M.D. a,⁎, Erdinc Cıcek, M.D. b, Faruk Uguz, M.D. c, İbrahim Fatih Karababa, M.D. d, Rahim Kucur, M.D. c a
Department of Psychiatry, Beysehir State Hospital, Konya, Turkey Department of Psychiatry, Research and Training Hospital, Urfa, Turkey c Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey d Department of Psychiatry, University of Harran Faculty of Medicine, Sanliurfa, Turkey b
a r t i c l e
i n f o
Article history: Received 1 December 2012 Revised 18 February 2013 Accepted 6 March 2013 Keywords: Depression Anxiety Inpatients
a b s t r a c t Objective: The aim of the study was to assess the prevalence of mood and anxiety disorders among inpatients and the relationship between sociodemographic factors, medical illnesses and treatments. Methods: In the present study, we selected 650 inpatients from all clinics except psychiatry and pediatrics in a general hospital by a simple random sampling method. Based on the exclusion criteria, 57 patients were excluded. Mood and anxiety disorders were determined by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Results: Of the participants, 226 (37.5%) had a psychiatric disorder, 87 (14.4) had a mood disorder and 146 (24.2%) had an anxiety disorder. The most common specific diagnoses were not otherwise specified as anxiety disorder (9.5%), major depression (8.6%) and generalized anxiety disorder (7.6%). While the overall prevalence was highest in the hematology clinic (60.0%), it was lowest in the clinic of infectious diseases (22.7%). Logistic regression analysis indicated that the independent factors associated with psychiatric disorders were being of the female gender and a personal history of psychiatric disorders. Conclusions: In conclusion, results of the present study suggest that mood and anxiety disorders were frequently observed among inpatients, particularly in female patients and those with an individual history of psychiatric disorder. Successful treatment of these disorders may positively contribute to the course of the disease in inpatients. However, this assumption should be confirmed by further studies. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Mood and anxiety disorders are important public health issues leading to chronic disability, decrease in quality of life, as well as loss in family, social and occupational functions [1,2]. Epidemiological studies have suggested that these disorders constitute the majority of the psychiatric disorders observed in the community. While mood disorders affect 2.8–6.5% of people, anxiety disorders are seen in 6.5– 7.3% of the general population [3–5]. Compared to the general population, it has been reported that subjects with medical illness are under a higher risk of occurrence of a psychiatric disorder [6]. Various studies have suggested that the prevalence rate of psychiatric disorders is between 30% and 60% among inpatients with a medical illness [7,8]. Concurrent psychiatric disorders appear to be associated with an impairment in response to the medical treatment, the patient's compliance to the treatment, longer hospital stay and higher morbidity rate [9,10]. Therefore, awareness and successful treatment of the comorbid psychiatric disorders may be important to alleviate this medical problem.
⁎ Corresponding author. Konya Beyşehir Devlet Hastanesi Psikiyatri Anabilim Dalı, 42000 Beyşehir/Konya, Turkey. Tel.: + 90 332 512 49 49. E-mail address: [email protected] (F. Kayhan). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.03.004
Psychiatric disturbances among subjects with a general medical condition have been widely examined. However, most of these studies include a unique medical illness. The number of studies representing all categories of inpatients in a hospital is inadequate. Moreover, to our knowledge, no published studies have examined this topic in Turkey, a developing country. In this study, we aimed to investigate the current prevalence rate of mood and anxiety disorders and associated factors among inpatients of a university hospital. 2. Methods 2.1. Sample The study was conducted at inpatient clinics for adult subjects of Meram Faculty of Medicine of Necmettin Erbakan University in Konya, Turkey, between May 2010 and December 2010. The inpatient clinics included hospitalized patients for their medical illnesses. The hospital is one of two tertiary hospitals in Konya City. To determine the sample size, we used hospital data including the year 2009. According to the statistics of the hospital, a total of 35,156 patients were hospitalized in the year 2009. In order to assess the prevalence of mood and anxiety disorders in the range of 20.0%±4% (with 95% confidence interval), the required sample size was calculated to be at
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least 380. To provide more comprehensive data about the prevalence rate of the disorders in each specific inpatient clinic, we evaluated 650 inpatients. Inclusion criteria for this study were as follows: (a) current age of at least 18 years; (b) voluntary participation in the study; (c) absence of mental retardation; (d) general medical condition of the patients appropriate for psychiatric interviews and (e) the duration of hospitalization of 2 days or more. Exclusion criteria included (a) patients who were hospitalized in intensive care units; (b) patients with a history of schizophrenia or related psychotic disorders; (c) patients currently in the perinatal period and (d) patients with a psychiatric diagnosis of delirium. Based on these criteria, 57 subjects were excluded from the present study; thereby, the final sample included 603 patients. The study was approved by the ethics committee of Meram Faculty of Medicine of Necmettin Erbakan University. 2.2. Procedures Initially, the study procedures were explained to all participants, and written informed consent forms were obtained. The distribution of participants to each department was determined on the basis of the ratio of the number hospitalizations in the specific inpatient clinic to the total number of all inpatient hospitalizations for the year 2009. The participants were selected via a simple randomization method. After the sociodemographic characteristics and medical data of the patients were recorded, psychiatric interviews were carried out. Medical diagnoses were obtained from the medical record by electronic record. Mood and anxiety disorders were diagnosed with The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-I) [11]. Psychiatric interviews with SCID-I were conducted by a psychiatrist with 4 years of experience about psychiatric disorders and the diagnostic instruments. Family history of psychiatric disorders was based on patients' reports about their first-degree relatives. Information on the study participants' current medical condition and hospital stays were obtained from the hospital records. The number of hospitalization was obtained by self-report of the subjects. 2.3. Statistical analyses The study data were analyzed with Statistical Package for the Social Sciences (SPSS) 13.0 for Windows (SPSS, Chicago, IL, USA). Categorical variables between the groups including patients with and without psychiatric diagnosis were compared with the chi-square test and Fisher's Exact Test, as necessary. To analyze continuous variables between the same patient groups, t test was used. Independent variables associated with the existence of mood or anxiety disorders were determined with logistic regression analysis. 3. Results 3.1. Sample characteristics Table 1 shows demographic characteristics of the study sample. The mean±S.D. of the age of the participants (n=603) was 51.07±15.72 years. The proportion of women in the total sample was 49.6%. Approximately 75% of the participants were illiterate or primary school graduates, and mostly were currently married and unemployed. The sample size for each inpatient clinic and prevalence rate of chronic medical disorders is presented in Table 2. Inpatient clinics that contributed the largest number of participants to this study were cardiology, general surgery and gynecology. Of all the subjects, 475 (78.8%) had at least one chronic medical illness. One hundred and seventy-one patients (28.4%) were in the postoperative period. The prevalence rate of a history of surgery in the past years was 48.1%. The mean±S.D. for the number of hospitalizations was 2.59±
Table 1 Demographic characteristics of the study sample Age (year) ±
Gender Male Female Marital status Single Married Divorced–Widowed Educational status İlliterate Primary education High school University Economic situation Good Medium Poor Occuption Yes No Smoking Yes No
51.07±15.72 n
%
304 299
50.4 49.6
59 489 55
9.8 9.1 81.1
125 340 97 41
20.7 56.4 16.1 6.8
210 358 35
34.8 59.4 5.8
142 461
23.5 76.5
189 414
31.3 68.7
1.78, the mean±S.D. for the duration of hospitalization during the evaluation was 6.16±6.02 days and the mean±S.D. for the length of hospital stay was 11.70±9.49 days. While 186 subjects (30.8%) had been hospitalized for the first time, the others had at least one previous history of hospitalization. The current length of hospital stay was significantly longer in subjects with psychiatric diagnosis compared to those patients without a psychiatric diagnosis (14.31± 11.81 vs. 10.14±7.38 days, P=.000). Of the subjects, 177 (29.4%) had a history of psychiatric disorder. The frequencies of a previous history of mood and anxiety disorder were 11.4% and 12.9%, respectively. The rate of subjects receiving psychiatric medication was 7.13% (n= 43). This rate was 17.70% (n= 40) and 0.79% (n=3) in the subjects with and without any psychiatric diagnosis, respectively. A total of 37 (6.13%) subjects were taking antidepressants. Antipsychotics and benzodiazepine were received by Table 2 The sample size for each inpatient clinics and prevalence rate of chronic medical disorders Clinics
n
%
Medical clinics Endocrinology Nephrology Hematology Gastroenterology Rheumatology Oncology Cardiology Chest diseases Infectious diseases clinic Dermatology Physical medicine and rehabilitation Neurology Surgical clinics General surgery Chest surgery Cardiovascular surgery Plastic and reconstructive surgery Urology Orthopedia Otorhinolaryngology Neurosurgery Gynecology and obstetrics clinic Total
336 10 21 11 22 9 20 62 42 23 37 35 44 267 50 10 21 9 38 47 22 21 49 603
55.7 1.7 3.5 1.8 3.6 1.5 3.3 10.3 7.0 3.8 6.1 5.8 7.3 44.3 8.3 1.7 3.5 1.5 6.3 7.8 3.6 3.5 8.1 100
F. Kayhan et al. / General Hospital Psychiatry 35 (2013) 417–422
clinics where psychiatric disorders were most commonly determined were hematology (60.0%), gastroenterology (52.3%), cardiovascular surgery (52.3%) and endocrinology (50.0%). The overall prevalence was lowest in the clinics of infectious diseases (22.7%), general surgery (28.0%) and urology (28.9%). The psychiatric diagnoses were most frequent among subjects with chronic liver disease (61.1%), diabetes mellitus (DM) (52.1%) and chronic kidney deficiency (51.7%).
Table 3 Current prevalance rate of mood and anxiety disorders in sample
Any mood or anxiety disorder, n (%) Any mood disorder, n (%) Any anxiety disorder, n (%) MD, n (%) Otherwise specified depression, n (%) Dysthymia, n (%) Genaralized anxiety disorder, n (%) PD, n (%) OCD, n (%) SAD, n (%) SP, n (%) PTSD, n (%) AD-NOS, n (%)
Medical clinics
Surgical clinics
General hospital
125 (37.2) 52 (15.5) 79 (23.5) 33(9.8) 14 (4.2) 5 (1.5) 26 (7.7) 11 (3.3) 13 (3.9) 2 (0.6) 2 (0.6) 0 (0) 30 (8.9)
101(37.8) 35 (13.1) 67(25.1) 19 (7.1) 6 (2.2) 10(3.7) 20 (7.5) 5 (1.9) 9 (3.4) 6 (2.2) 1 (0.4) 2 (0.7) 27 (10.1)
226 (37.5) 87 (14.4) 146 (24.2) 52 (8.6) 20 (3.3) 15 (2.5) 46 (7.6) 16 (2.7) 22 (3.6) 8 (1.3) 3 (0.5) 2 (0.3) 57 (9.5)
419
3.3. Factors associated with any mood or anxiety disorder
AD-NOS: anxiety disorder not otherwise specified; OCD: obsessive compulsive disorder; SAD: social anxiety disorder; SP: social phobia.
only 3 (0.5%) subjects. The proportion of subjects who reported a family history of psychiatric disorder was 14.8%. 3.2. Prevalence of mood and anxiety disorders SCID-I indicated that 226 (37.5%) subjects met the criteria for any current mood or anxiety disorder. Anxiety disorders (23.2%) were more prevalent compared to mood disorders (14.3%). The most common specific diagnoses were not otherwise specified anxiety disorder (9.5%), major depression (MD) (8.6%) and generalized anxiety disorder (GAD) (7.6%) (Table 3). Tables 4 and 5 list the prevalence rate of mood and anxiety disorders in each clinic and chronic medical illnesses highly correlated with a psychiatric diagnosis, respectively. The inpatient
As summarized in Table 6, psychiatric disorders were more prevalent in women compared to men. The number of hospitalizations in subjects with a psychiatric diagnosis was significantly higher than those without the diagnosis (P= .000). Compared to the group that were not diagnosed with a psychiatric disorder, patients with mood or anxiety disorders had significantly higher frequencies of medical diagnoses of Type II DM (P=.000), chronic liver disease (P= .047) and hyperlipidemia (P= .049). The difference was not significant between patients with and without mood or anxiety disorder with respect to other specific chronic medical disease. Other variables established as significantly different between the groups were a history of surgery (P= .000), a history of individual psychiatric disorder (P= .000), a family history of psychiatric disorder (P= .000) and economic status (P= .000). The variables found significantly different between the groups when compared with the χ 2 test or t test were analyzed by binary logistic regression analysis to determine independent factors for the existence of any mood or anxiety disorder. The regression analysis indicated that female gender (B=0.49, Wald χ 2= 6.28, df=1, P= .012) and an individual history of psychiatric disorder (B=1.96, Wald χ 2= 80.74, df= 1, P= .000) were independent factors associated with the existence of mood or anxiety disorders. In contrast, economic
Table 4 The prevalence of mood and anxiety disorders in each chronic medical illness
DM n=121 Thyroid diseases n=26 Other endocrine diseases n=8 Hypertension n=280 Coronary artery disease n=89 Hyperlipedimia n=126 Cerebrovascular disease n=32 Carcinoma n=88 Hematologic diseases n=12 Choronic obstructive pulmonary disease n=51 Asthma n=23 Choronic kidney deficiency n=29 Chronic liver diseases n=18 Rheumatismal diseasesn=46 Benign tumors n=33 Others chronic diseases n=9
MD n (%)
DD-NOS n (%)
18 (14.9)
4 (3.3)
Dysthmia n (%)
GAD n (%)
PD n (%)
OCD n (%)
SAD n (%)
SP n (%)
PTSD n (%)
AD-NOS n (%)
Total N (%)
4 (3.3)
19 (15.7)
8 (6.6)
10 (8.3)
0 (0)
0 (0)
0 (0)
11 (9.1)
63 (52.1)
6 (23.1)
0 (0)
0 (0)
3 (11.5)
3 (11.5)
2 (7.7)
0 (0)
0 (0)
0 (0)
2 (7.7)
13 (50.0)
1 (12.5)
0 (0)
0 (0)
1 (12.5)
1 (12.5)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
3 (37.5)
7 (2.5)
11 (3.9)
1 (0.4)
1 (0.4)
0 (0)
24 (8.6)
27 (9.6)
9 (3.2)
11 (3.9)
8 (9.0)
3 (3.4)
3 (3.4)
9 (10.1)
2 (2.2)
5 (5.6)
1 (1.1)
0 (0)
0 (0)
9 (10.1)
35 (39.3)
14 (11.1)
6 (4.8)
4 (3.2)
14 (11.1)
2 (1.6)
6 (4.8)
1 (0.8)
0 (0)
0 (0)
15 (11.9)
57 (45.2)
5 (15.6)
2 (6.2)
0 (0)
3 (9.4)
0 (0)
4 (12.5)
0 (0)
0 (0)
0 (0)
2 (6.2)
13 (40.6)
13 (14.8)
3 (3.4)
2 (2.3)
7 (8.0)
2 (2.3)
0 (0)
3 (3.4)
0 (0)
0 (0)
14 (15.9)
37 (42.0)
1 (8.3)
2 (16.7)
0 (0)
2 (16.7)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
1 (8.3)
6 (50.0)
2 (3.9)
2 (3.9)
3 (5.9)
5 (9.8)
2 (3.9)
2 (3.9)
0 (0)
1 (2.0)
0 (0)
5 (9.8)
19 (37.3)
3 (13.0)
0 (0)
1 (4.3)
2 (8.7)
2 (8.7)
1 (4.3)
0 (0)
0 (0)
0 (0)
2 (8.7)
10 (43.5)
4 (13.8)
2 (6.9)
2 (6.9)
2 (6.9)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
6 (20.7)
15 (51.7)
7 (38.9)
0 (0)
0 (0)
1 (5.6)
0 (0)
1 (5.6)
0 (0)
0 (0)
0 (0)
2 (11.2)
11 (61.1)
1 (2.2) 4 (12.1)
1 (2.2) 0 (0)
1 (2.2) 1 (3.0)
11 (23.9) 2 (6.1)
1 (2.2) 1 (3.0)
2 (4.3) 2 (6.1)
0 (0) 0 (0)
0 (0) 0 (0)
0 (0) 0 (0)
4 (8.7) 2 (6.1)
20 (43.5) 12 (36.4)
7 (5.7)
8 (6.6)
7 (5.7)
13 (10.7)
1 (0.8)
4 (3.3)
0 (0)
0 (0)
0 (0)
16 (13.1)
52 (42.6)
DD-NOS: depressive disorder not otherwise specified.
24 (8.6)
107 (38.2)
420
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Table 5 Prevalence of mood and anxiety disorders in each clinics
Endocrinology n=10 Nephrology n=21 Haematology n=11 Gastroenterology n=22 Rheumatology n=9 Oncology n=20 Cardiology n=62 Chest diseases n=42 Infectious diseases n=23 Dermatology n=37 Physical medicine and rehabilitation n=35 Neurology n=44 General surgery n=50 Chest surgery n=10 Cardiovascular surgery n=21 Plastic and reconstructive surgery n=9 Urology n=38 Orthopedia n=47 Otorhinolaryngology n=22 Neurosurgery n=21 Gynecology and obstetrics clinic n=49
MD n (%)
DD-NOS n (%)
Dysthmia n (%)
GAD n (%)
PD n (%)
OCD n (%)
SAD n (%)
SP n (%)
PTSD n (%)
AD-NOS n (%)
Total n (%)
3 (30) 3 (14.3) 1 (9.1) 4 (18.2) 0 (0) 4 (20) 4 (6.5) 2 (4.8) 2 (8.7) 0 (0) 4 (11.4) 6 (13.6) 5 (10) 1 (10) 1 (4.8) 1 (11.1) 2 (5.3) 2 (4.3) 2 (9.1) 0 (0) 5 (10.2)
0 (0) 1 (4.8) 2 (18.2) 2 (9.1) 1 (11.1) 0 (0) 1 (1.6) 1 (2.4) 0 (0) 0 (0) 3 (8.6) 3 (6.8) 0 (0) 0 (0) 2 (9.5) 1 (11.1) 1 (2.6) 2 (4.3) 0 (0) 0 (0) 0 (0)
0 (0) 1 (4.8) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1.6) 1 (2.4) 0 (0) 2 (5.4) 0 (0) 0 (0) 1 (2) 0 (0) 2 (9.5) 0 (0) 3 (7.9) 1 (2.1) 1 (4.5) 0 (0) 2 (4.1)
1 (10) 0 (0) 2 (18.2) 2 (9.1) 1 (11.1) 1 (5) 5 (8.1) 1 (2.4) 1 (4.3) 4 (10.8) 5 (14.3) 3 (6.8) 4 (8) 0 (0) 1 (4.8) 1 (11.1) 1 (2.6) 3 (6.4) 1 (4.5) 4 (19) 5 (10.2)
0 (0) 0 (0) 0 (0) 1 (4.5) 0 (0) 1 (5) 3 (4.8) 4 (9.5) 0 (0) 0 (0) 1 (2.9) 1 (2.3) 0 (0) 1 (10) 0 (0) 0 (0) 1 (2.6) 1 (2.1) 0 (0) 1 (4.8) 1 (2)
1 (10) 0 (0) 0 (0) 1 (4.5) 2 (22.2) 0 (0) 2 (3.2) 1 (2.4) 0 (0) 0 (0) 0 (0) 6 (13.6) 1 (2) 0 (0) 2 (9.5) 0 (0) 0 (0) 0 (0) 1 (4.5) 1 (4.8) 4 (8.2)
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (5) 1 (1.6) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2.6) 1 (2.1) 0 (0) 3 (14.3) 1 (2)
0 (0) 0 (0) 0 (0) 1 (4.5) 0 (0) 0 (0) 1 (1.6) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4.3) 0 (0) 0 (0) 0 (0)
0 (0) 4 (19) 1 (9.1) 2 (9.1) 0 (0) 4 (20) 3 (4.8) 5 (11.9) 1 (4.3) 4 (10.8) 2 (5.7) 4 (9.1) 5 (10) 1 (10) 3 (14.3) 0 (0) 3 (7.9) 4 (8.5) 1 (4.5) 2 (9.5) 8 (16.3)
5 (50) 9 (42.9) 5 (54.5) 11 (52.4) 3 (30) 8 (40.0) 21 (33.9) 14 (33.3) 5 (22.7) 10 (26.3) 15 (42.9) 18 (40.9) 14 (28.0) 4 (40.0) 11 (52.4) 2 (25.0) 11 (28.9) 18 (40.0) 7 (31.8) 10 (47.6) 22 (45.8)
status (P=.467), family (P= .413), history of surgery (P= .298), family history of psychiatric disorder (P= .063), Type II DM (P= .065), chronic liver disease (P= .172), hyperlipidemia (P= .461) and number of hospitalizations (P= .045) were not significant predictors.
4. Discussion In the present study, the prevalence rate of any mood or anxiety disorder was 37.3%. This rate is higher than the current prevalence rates of psychiatric disorders estimated in the general population [4,12,13]. The number of published studies conducted on patients in inpatient clinics is inadequate. Silverstone et al. [14] reported that 27% of inpatients had any current psychiatric disorder. Two other studies found the prevalence rate to be 23.4–56.0% [15,16], which are consistent with our results. Large-scale epidemiological studies have reported that the current prevalence rate of MD in the community was 2.2–4.9% [3,4,17–20]. In our sample, this rate was 8.6%. When other specific disorders were compared, the study data on MD among inpatients with a general medical condition are more prevalent. However, the available studies are mostly based on self-report scales. Other authors using interview instruments similar to those used in the current study reported this rate to be 8.3–9.4%, which are in line with our findings [21–23].
Anxiety disorders have been assessed less frequently among inpatients compared to depression. The prevalence rate of any anxiety disorder determined in this study (23.2%) was in agreement with that reported by Fava et al. (23.5%) [24]. While the frequency of GAD (7.6%) was found similar to the results (10.3–10.8%) of previous studies [24,25], panic disorder (PD) had lower prevalence rate (2.7%) compared to previous studies (10–50%) [26–28]. The previous studies investigating PDs mostly included cardiac disorders, myocardial infarction, arrhythmia and mitral valve diseases. In contrast, the proportion of subjects with these diagnoses in our sample was very low. We found no other studies on the prevalence of other anxiety disorders among inpatients of general hospitals. The prevalence rates of posttraumatic stress disorder (PTSD) found in this study are exceedingly low than seen in the general population [4,29]. The difference could be due to differences between the study samples. For example, the mean age of subjects in the present study is relatively high. We examined only the prevalence rate of current but not lifetime psychiatric disorders. In addition, our study was carried out in the inpatient clinics of a general hospital. Turkish patients usually exhibits tendency to concealing psychological traumatic events during psychiatric interviews performed in the inpatient clinics of a general hospital. To our knowledge, there is no published study on the prevalence rate of specific mood and anxiety disorders relevant to specific
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421
Table 6 Sociodemographic and clinical characteristic in subjects with and without any diagnosis mood or anxiety disorders
Age, mean±S.D. Gender, n (%) Marital status, n (%)
Educational status, n (%)
Occuption, n (%) Economic situation, n (%)
Number of hospitalizations, mean±S.D. Smoking, n (%) Chronic disease, n (%) DM, n (%) Tyroid diseases, n (%) Other endocrine diseases, n (%) Hypertension, n (%) Coronary artery diseases, n (%) Cerebrovascular diseases, n (%) Hyperlipidemia, n (%) Chronic obtructive pulmonary disease, n (%) Asthma, n (%) Carcinoma, n (%) Hematologic diseases, n (%) Rhematologic diseases, n (%) Chronic liver diseases, n (%) Chronic kideny deficiency, n (%) Bengin tumors, n (%) Undergo an operation, n (%) New operation, n (%) Personal history of psychiatric disorders, n (%) Familiy history of psychiatric disorders, n (%)
Female Male Single Married Divorced–Widowed İlliterate Primary education High school University Yes No Good Medium Poor Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Patients with mood and anxiety disorders
Patients without mood and anxiety disorders
50.81±15.61 129 (57.1) 97 (42.9) 19 (8.4) 182 (80.5) 25 (11.1) 50 (22.1) 127 (56.2) 38 (16.8) 11 (4.9) 46 (20.4) 180 (79.6) 22 (9.7) 137 (60.6) 67 (29.6) 2.93±1.94 66 (29.2) 160 (70.8) 187 (82.7) 39 (17.3) 63 (27.9) 163 (72.1) 13 (5.8) 213 (94.2) 3 (1.3) 223 (98.7) 107 (47.3) 119 (52.7) 35 (15.5) 191 (84.5) 13 (5.8) 213 (94.2) 57 (25.2) 169 (74.8) 19 (8.4) 207 (91.6) 10 (4.4) 216 (95.6) 37 (16.4) 189 (83.6) 6 (97.3) 220 (2.7) 20 (8.8) 206 (91.2) 11 (4.9) 215 (95.1) 15 (6.6) 211 (93.4) 12 (5.3) 214 (94.7) 132 (58.4) 94 (41.6) 71 (31.4) 155 (68.6) 129 (57.1) 97 (42.9) 53 (23.5) 173 (76.5)
51.23±15.81 170 (45.1) 207 (54.9) 40 (10.6) 307 (81.4) 30 (8) 75 (19.9) 213 (56.5) 59 (15.6) 30 (8.0) 96 (25.5) 281 (74.5) 13 (3.4) 221 (58.6) 143 (37.9) 2.38±1.64 123 (32.6) 254 (67.4) 288 (76.4) 89 (23.6) 58 (15.4) 319 (84.6) 13 (3.4) 364 (96.6) 5 (1.3) 372 (98.7) 173 (45.9) 204 (54.1) 54 (14.3) 323 (85.7) 19 (5) 358 (95) 69 (18.3) 308 (81.7) 32 (8.5) 345 (91.5) 13 (3.4) 364 (96.6) 51 (13.5) 326 (86.5) 6 (1.6) 371 (98.4) 26 (6.9) 351 (93.1) 7 (1.9) 370 (98.1) 14 (3.7) 363 (96.3) 21 (5.6) 356 (94.4) 158 (41.9) 219 (58.1) 100 (36.5) 277 (73.5) 48 (12.7) 329 (87.3) 36 (9.5) 341 (90.5)
P value .748⁎ .005⁎⁎ .332⁎⁎⁎
.485⁎⁎⁎
.166⁎⁎ .002⁎⁎⁎
.000⁎⁎ .415⁎⁎⁎ .80⁎⁎ .000⁎⁎ .214⁎⁎ 1.000⁎⁎ .737⁎⁎ .723⁎⁎ .711⁎⁎ .049⁎⁎ 1.000⁎⁎ .661⁎⁎ .343⁎⁎ .380⁎⁎ .429⁎⁎ .047⁎⁎ .117⁎⁎ 1.000⁎⁎ .000⁎⁎ .225⁎⁎ .000⁎⁎ .000⁎⁎
⁎ t test. ⁎⁎ Fisher's exact test. ⁎⁎⁎ chi-square test.
departments and medical diagnoses among a representative sample of inpatients of a general hospital. In our sample, compared to the epidemiological data reported in the general population, the prevalence of any mood or anxiety disorder appeared to be similar in the departments of infectious diseases, dermatology, general surgery, plastic and reconstructive surgery, urology and otorhinolaryngology. The rate appears to be slightly higher in the departments of rheumatology, chest surgery, chest diseases and cardiology and is markedly higher in other departments.
At 61.1%, chronic liver disease was a specific medical diagnosis for which psychiatric disorders were most commonly observed. The prevalence rate of MD was 38.9% in these patients. This is lower than the results (15.8–18.9%) of previous studies that were carried out in patients with chronic liver deficiency due to hepatitis B or hepatitis C virus infections [29,30]. However, the current study included chronic liver deficiency due to other etiologies except these infections. Patients taking interferon-alpha treatments were also excluded from the study. Association between interferon treatment and depression
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has been well documented [31]. This may explain the differences between the results of our study and the previous studies. Type II DM was another disease for which psychiatric diagnoses frequently existed in our sample. Previous studies have also suggested that compared to the general population, lifetime prevalence of depression in this patient group is approximately three to fourfold higher. Most of the inpatients with DM had unregulated blood glucose levels or complications due to DM, which may be related to high prevalence rates of mood or anxiety disorders. Female gender was one of the two independent factors related to the existence of a mood or anxiety disorder in this study. It is known that psychiatric disorders are more prevalent in women than men in the community [32–34]. In addition, some authors reported a connection between female gender and depression among inpatients [35–37]. It is an expected finding that individual history of psychiatric disorder was associated with a current mood or anxiety disorder because psychiatric disorders mostly have a chronic and relapsing course. The main strengths of this study are the assessment of mood and anxiety disorders by means of a structured psychiatric interview method in a representative sample of a general hospital. Moreover, we have also presented descriptive data on the prevalence rate of mood and anxiety disorders for each medical condition and inpatient clinic. However, the cross-sectional design of the present study is a restrictive factor in the interpretation of the results, particularly about associated factors with mood or anxiety disorders. This study was carried out among inpatients of a university hospital; therefore, it may not be representative of all inpatients. In addition, we did not examine the rates of mood and anxiety disorders diagnosed by the treating clinicians and compare them to the SCID diagnosed obtained. In conclusion, the present study suggests that mood and anxiety disorders were frequently observed among inpatients. The most important risk factors seem to be being of the female gender and an individual history of psychiatric disorders. Successful treatment of these disorders may positively contribute towards the recovery of these patients. However, this assumption should be confirmed by further studies. References [1] Kessler RC, Angermeyer M, Anthony JC, Graaf R, Demyttenaere K, Gasquet I, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the WHO world mental health surveys. World Psychiatry 2007;6:168–76. [2] Huppert JD, Simpson HB, Nissenson KJ, Liebowitz MR, Foa EB. Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls. Depress Anxiety 2009;26:39–45. [3] Regier DA, Farmer ME, Rae DS, Myers JK, Kramer M, Robins LN, et al. One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the epidemiologic catchment area study. Acta Psychiatr Scand 1993;88:35–47. [4] Vicente B, Kohn R, Rioseco P, Saldivia S, Baker C, Torres S. Population prevalence of psychiatric disorders in Chile: 6-month and 1-month rates. Br J Psychiatry 2004;84:299–305. [5] Canino GJ, Bird HR, Shrout PE, Rubio-Stipec M, Bravo M, Martinez R, et al. The prevalence of spesific psychiatric disorders in Puerto Rico. Arch Gen Psychiatry 1987;44:727–35. [6] Gagnon LM, Patten SB. Major depression and its association with long-term medical conditions. Can J Psychiatry 2002;47:149–52. [7] Özmen E, Aydemir Ö, İçelli İ. Bedensel hastalığı olanlarda psikiyatrik tanı dağılımı (Türkiye'de yapılan çalışmlaraın gözden geçirilmesi). Ege Psikiyatrisi Sürekli Yayınları Konsültasyon Liyezon Psikiyatrisi- II 1997;2:285–98. [8] Yıldız M, Tural Ü, Kesepara C, Aydın M, Etuş H. Fiziksel hastalıklara eşlik eden ruhsal bozukluklar: Bir üniversite hastanesinde psikiyatri konsültasyonu sonuçlarının değerlendirilmesi. Düşünen Adam 2002;15:21–4. [9] Özkan S. Konsültasyon liyezon psikiyatrisi; kavramlar, kurumsallaşma, uygulama. Türkiye Klinikleri J Int Med Sci 2006;2:1–13.
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