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A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine
General Hospital Psychiatry 26 (2004) 470 – 474
Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address all those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine Krishnamachari Srinivasan*, Willie Joseph Department of Psychiatry, St. John’s Medical College Hospital, Sarjapur Road, Bangalore 560034, Karnataka, India Received 16 February 2004; accepted 9 June 2004
Abstract We studied the prevalence of anxiety and depressive disorders in patients with chest pain presenting to an emergency department. Majority of the patients had coronary artery disease (CAD). Twenty-three percent of patients with chest pain had a diagnosable psychiatric disorder according to ICD-10 research criteria. Anxiety and depressive disorders were equally distributed among patients with concomitant psychiatric syndrome. The level of psychological distress as measured on hospital anxiety and depression scale in patients of CAD with comorbid psychiatric syndrome was significantly more than patients with CAD alone and similar to non-CAD patients with psychiatric disorder. This finding is in agreement with an earlier study suggesting that the psychological distress seen in patients with CAD is related to the comorbid psychiatric condition and not to CAD. D 2004 Elsevier Inc. All rights reserved. Keywords: Anxiety disorders; Depression; Chest pain; Coronary artery disease; Emergency medicine
1. Introduction Chest pain is one of the most common complaints among patients seeking help from emergency departments [1]. Studies show that in over 50% of such patients the chest pain is of noncardiac origin [2,3]. There is considerable evidence that noncardiac chest pain is associated with psychiatric disorders, especially panic disorder [4–6]. Prevalence of panic disorder in patients with noncardiac chest pain seen in an emergency setting ranges from 16% to 25% [7,8], whereas in cardiology departments the prevalence is even greater (31–56%) [5,6,9]. While most studies have focused on patients with noncardiac chest pain, others suggest that panic disorder may also occur in patients with established coronary artery disease (CAD) [9–12]. Fleet et al. [13] reported that 34% of CAD patients who consulted
* Corresponding author. Tel.: +91 080 5505858; fax: +91 080 5521798. E-mail address: [email protected] (K. Srinivasan). 0163-8343/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2004.06.001
the emergency department of a cardiology hospital for chest pain and were found to have noncardiac chest pain diagnosis, had panic disorder. Thus, the prevalence of panic disorder in patients with CAD is similar to those observed in patients without CAD [13]. In the majority of patients with chest pain the treating physicians did not recognize the presence of panic disorder [7,8,14]. A poor outcome has consistently been reported for emergency room attendees with chest pain [15], with significant psychosocial impairment lasting many years [16]. They also undergo unnecessary cardiac invasive investigations, such as coronary angiogram and cardiac catherization, resulting in considerable costs to the community [5]. In addition, some studies suggest that patients with anxiety disorders are at higher risk of mortality from cardiovascular disease [17–19]. Depression has been reported to be an independent risk factor for progression of cardiovascular disease [20] and in patients after myocardial infarction, depression is associated with increased mortality rate [21].
K. Srinivasan, W. Joseph / General Hospital Psychiatry 26 (2004) 470 – 474
Studies that have examined the etiopathogenesis of noncardiac chest pain have emphasized the role of cognitive appraisal and conditioning in the origin of noncardiac chest pain [15,22]. Central to cognitive appraisal theory is the role of attribution, whereby minor physiological symptoms are misinterpreted as evidence of serious illness [15]. Others have suggested that illness experience, especially prior exposure to cardiac events in self or others, plays a crucial role in development of noncardiac chest pain [22,23]. Moreover this health-related anxiety is specific with patients with noncardiac chest pain reporting more cardiopulmonary fears relative to other bodily fears [24] and accompanying behavioral changes, such as repeated reassurances, greater awareness of cardiac events, and life-style measures linked to protecting the heart [25]. Most studies that have looked at the association between chest pain and anxiety and depressive disorders have been on patient populations from the West. In addition, the majority of the studies have been done on the patient population attending cardiology clinics or emergency departments of a cardiology hospital. The aim of the present report was to study the prevalence of anxiety and depressive disorders among patients presenting with chest pain to an emergency department in a teaching general hospital in India. We hypothesized that the severity of psychological distress seen in patients with both CAD and psychiatric disorder (PD) is specifically attributable to the concomitant psychiatric disorder. 2. Method 2.1. Subjects This study was conducted in a tertiary care teaching general hospital. The emergency department located in the hospital caters to patients from both the urban metropolis and the surrounding rural areas. A consecutive series of adult patients presenting with a primary complaint of chest pain to the emergency department over a 1-year period between 1999 and 2000 were evaluated for the purpose of the study. A written informed consent was obtained from the patient. The institutional ethics review board approved this study. Patients were either interviewed in the emergency department if the clinical condition allowed or in the inpatient unit after the medical condition had stabilized. Only those patients who spoke English or a local language (Kannada) and were competent to provide informed consent were included in the study. Patients who had psychosis, cognitive dysfunction, or substance abuse were excluded from the study. Of the 381 patients who presented with chest pain to the emergency department during the study period, 337 patients met the study criteria and were interviewed. 2.2. Clinical assessments Patients were initially screened for presence of anxiety or depressive syndromes using the Hospital Anxiety and
471
Depression Scale (HADS) [26]. This instrument was chosen because it was specially designed to detect states of depression and anxiety in a medically ill population. HADS is subdivided into an anxiety subscale (HADS-A) and a depression subscale (HADS-D). In most studies that have used HADS, a score of 8 or above on both the HADS-A and HADS-D defined psychiatric caseness [27]. In the present study, patients scoring 8 or more on the HADS were further interviewed using a structured psychiatric interview schedule, Schedule for Clinical Assessment in Neuropsychiatry (SCAN) [28]. The SCAN was used to generate a lifetime psychiatric diagnosis according to the ICD-10 diagnostic criteria for research diagnosis. SCAN is a structured interview schedule for use by trained professionals and the psychiatric diagnosis was arrived at using a computer-generated algorithm. Version 2.0 of the SCAN was used in the present study. One of the authors (W.J.) obtained training in its administration. SCAN has been used in previous research in India and a standardized version in a local language (Kannada) is available [29]. Cardiac diagnosis was obtained from the patient’s medical charts at the time of discharge. A diagnosis of CAD was based on either a documented myocardial infarction, coronary bypass surgery, angioplasty, and a coronary angiogram indicative of stenosis in major coronary artery or an abnormality on treadmill test. For the purpose of this study four groups of patients were compared on demographic and clinical variables: (a) Patients with both CAD and PD; (b) patients with PD only; (c) patients with CAD but without PD; and (d) patients with neither CAD nor PD. 2.3. Statistics Differences among the diagnostic groups on categorical variables were analyzed using the v 2 test. One-way analysis of variance was done for comparing various clinical variables across the diagnostic groups. Significant effects on one-way analysis of variance were followed up by posthoc tests using least significant difference with Bonferroni correction for multiple comparisons. We used a probability value of .05 as significant for the analyses. 3. Results The sample comprised a consecutive series of 337 adult patients, of whom 69% were males (n = 231). The majority of study participants were married (82%) and literate (61%). Of the 337 patients, 208 patients (62%) were discharged with a diagnosis of CAD. Twenty-two patients had medical conditions other than CAD and PD. Seventynine patients (23%) met with ICD-10 research diagnostic criteria for a psychiatric syndrome. Among patients with a psychiatric diagnosis, 43 had anxiety disorders and 35 had a diagnosis of depression, while 1 patient had somatization disorder. Among patients with anxiety disorders, 28 (8.3%)
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K. Srinivasan, W. Joseph / General Hospital Psychiatry 26 (2004) 470 – 474
Table 1 Comparison of demographic variables across diagnostic groups Variable Age (yr) MeanFSD Gender, n(%) Male Female Marital status, n(%) Married Single/widowed Occupation, n(%) Employed Unemployed Education, n(%) Elementary High school College Income (Rs.), n(%) b4000 N4000 Residence, n(%) Urban Rural Religion, n(%) Christian Hindu Muslim
Group 4 (n = 81)
F/m2
41.3 F16.3
43.5*
142(80) 35(20)
46(57) 35(43)
21.1**
24(86) 4(14)
151(85) 26(15)
60(74) 21(26)
.16
13(45) 16(55)
14(50) 14(50)
111(63) 66(37)
43(53) 38(47)
.16
16(55) 8(28) 5(17)
8(29) 11(39) 9(32)
68(38) 57(32) 52(30)
29(36) 35(43) 17(21)
13(45) 16(55)
12(43) 16(57)
72(41) 105(59)
46(57) 35(43)
.12
23(79) 6(21)
24(86) 4(14)
118(67) 59(33)
60(74) 21(26)
.12
5(17) 18(62) 6(21)
3(11) 21(75) 4(14)
43(24) 108(61) 26(15)
25(31) 51(63) 5(6)
.14
Group 1 (n = 29)
Group 2 (n = 28)
55 F12.5
35 F11.4
20(69) 9(31)
14(50) 14(50)
23(79) 6(21)
Group 3 (n = 177) 56.8 F10.9
.22
Group 1 = PD & CAD, Group 2 = PD only, Group 3 = CAD only, Group 4 = neither CAD nor PD. * P b.01, df = 3, 311. ** P b.01, df = 3.
had a primary diagnosis of panic disorder and 15 (4.9%) had generalized anxiety disorder. We excluded one patient who had a diagnosis of somatization disorder from further analysis. Three-hundred and fifteen patients formed the sample for final analysis and were categorized into the following groups. Nine percent (n = 29) had both CAD and PD (group 1); 8% (n = 28) had PD only (group 2); 53% (n = 177) had CAD with no PD (group 3); and 24% (n = 81) had neither CAD nor PD (group 4). In the CAD-PD group, anxiety disorders were present in 12 patients while 17 patients were diagnosed with depressive disorders. In the PD-only group, 14 patients had anxiety disorders and depressive disorders were present in 14 patients. 3.1. Demographic characteristics There were more male subjects among patients with CAD and CAD-PD diagnostic groups. CAD and CAD-PD patients were significantly older than patients belonging to other diagnostic groups. Patients in the four groups were not Table 2 Scores on hospital anxiety and depression scales across diagnostic groups Variable
Group 1 (n = 29)
Group 2 (n = 28)
Group 3 (n = 177)
Group 4 (n = 81)
F value
HAD-A HAD-D
8.2 F 3.7 7.4 F 3.8
14.3 F 3 9.6 F 3.6
3.5 F 2.3 2.2 F 2.2
3.3 F 2.8 2.2 F 2.7
63.3* 54.5*
* P b.001, df = 3, 311.
significantly different in terms of marital status, income, education, residence, religion, and occupation. Demographic characteristics are presented in Table 1. 3.2. Psychological morbidity One-way analysis of variance revealed a significant difference across diagnostic groups on both the subscale of HADS. Because patients in certain groups differed in age and gender, we conducted analyses of covariance with psychological test scores on HAD-A and HAD-D as dependent variables adjusting for these factors. Adjusted means and levels of significance are presented in Table 2. Post-hoc tests showed that on both HAD-A and HAD-D subscales, CAD with PD (Group I) and PD without CAD (Group II) differed significantly from the other two groups, namely CAD without PD (Group III) and the group neither CAD nor PD (Group IV) ( P b.001). Among patients with psychiatric syndrome, those belonging to Group II had a significantly higher score on HAD-A and HAD-D compared to Group I ( P b.001). 4. Discussion Results of this study show that 23% (79 of 337) of patients with chest pain who consulted the emergency department of a teaching general hospital had a diagnosable psychiatric syndrome according to ICD-10 research diagnostic criteria.
K. Srinivasan, W. Joseph / General Hospital Psychiatry 26 (2004) 470 – 474
Among those with psychiatric diagnosis, anxiety and depressive disorders were equally distributed. Our finding of 23% of patients with chest pain having a concomitant psychiatric syndrome is lower than the figures reported in some earlier studies [9]. This lower prevalence figure could be related to both the diagnostic composition of the patient sample and the hospital setting in which the study was conducted. The majority of patients with chest pain in the present study had a discharge diagnosis of CAD (62%). Most studies that have examined prevalence of panic in chest pain patients have been done on patients without CAD or on patients who had chest pain that was atypical for angina [9]. In other studies, patient selection was not on a consecutive basis [9,30]. In addition, earlier studies have included patients attending specialized treatment facilities, such as cardiology outpatient clinics [9,30] or emergency facilities attached to a cardiology hospital [13]. Yet another reason for lower prevalence of psychiatric syndrome in the present study may be related to use of HADS as a screening instrument in identifying patients with psychiatric illness. HADS has items pertaining mainly to mood and cognitive symptoms and excludes somatic symptoms such as headaches, insomnia, anergia, and fatigue. Many studies done in India have shown that patients with depression and anxiety present initially to physicians with multiple physical symptoms, a phenomenon observed across diverse clinical settings [31–33]. Thus, it is likely that some patients with chest pain may not have been obtained a score of 8 or above on HADS and the concomitant psychological distress may have been missed. The finding that the level of psychological distress in patients with CAD and PD is significantly different from patients of CAD but without CAD is in agreement with the observation made by Fleet et al. in their study on panic disorder in patients with CAD [13]. This suggests that the psychological distress seen in patients with CAD is primarily attributable to the comorbid psychiatric condition. The extent of psychological distress between CAD with PD and bpure PDQ groups of patients tended to be similar. This finding also suggests that the nature of psychiatric syndrome seen in patients with CAD is similar to bpureQ psychiatric syndrome, although this requires further validation [13]. Thus, the poor long-term outcome reported in many studies in patients with chest pain seeking help from emergency room [15,16] can be improved with better screening and management of the concomitant psychiatric syndrome. However, recognizing anxiety disorder, especially panic disorder among patients with myocardial infarction, is not easy due to commonality of symptoms [34], especially in developing countries where somatization of psychological distress is common [32]. This study has certain limitations, the fact that it is based on a population seeking help from an emergency department attached to a tertiary referral hospital may limit generalizability. Some cases of panic disorder, especially the nonfearful variety of panic attacks that are reported to be common among patients with cardiovascular symptoms [35]
473
may have been missed. The psychiatric interviewer (W.J.) was not blind to the patient’s medical condition or to the specific hypothesis of the study, resulting in a possible expectancy effect. In conclusion, a significant proportion of patients presenting with chest pain to an emergency department had a diagnosable psychiatric illness. The level of psychological distress seen in patients of CAD with comorbid anxiety and depressive disorders was similar to those with pure psychiatric conditions. Thus, it is important for emergency room physicians and cardiologists to identify psychiatric syndromes in patients with chest pain and be able to offer appropriate treatment. References [1] Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med 1989; 86:262 – 6. [2] Karlson BW, Herlitz J, Petterson P, Ekvall HE, Hjalmarson A. Patients admitted to the emergency room with symptoms indicative of acute myocardial infarction. J Intern Med 1991;230:251 – 8. [3] Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985;145:65 – 9. [4] Cormier LE, Katon W, Russo J, Hollifield M, Hall ML, Vitaliano PP. Chest pain with negative cardiac diagnostic studies. Relationship to psychiatric illness. J Nerv Ment Dis 1988;176:351 – 8. [5] Carter C, Maddock R, Amsterdam E, McCormick S, Waters C, Billet J. Panic disorder and chest pain in the coronary care unit. Psychosomatics 1992;33:302 – 9. [6] Beitman BD, Mukerji V, Lamberti JW, et al. Panic disorder in patients with chest pain and angiography normal coronary arteries. Am J Cardiol 1989;63:1399 – 403. [7] Yingling KW, Wuslin LR, Amold LM, Rouan GW. Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain. J Gen Intern Med 1993;8:231 – 5. [8] Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation and physician recognition. Am J Med 1996;101:371 – 80. [9] Beitman BD, Basha I, Flaker G, et al. Atypical or nonanginal chest pain. Panic disorder or coronary artery disease? Arch Intern Med 1987;147:1548 – 52. [10] Basha I, Mukerji V, Langevin P, et al. Atypical angina in patients with coronary artery disease suggests panic disorder. Int J Psychiatry Med 1989;19:341 – 6. [11] Katon WJ. Chest pain, cardiac disease, and panic disorder. J Clin Psychiatry 1990;51:S27–S30 [Suppl.]. [12] Zaubler TS, Katon W. Panic disorder and medical comorbidity: a review of the medical and psychiatric literature. J Clin Psychiatry 1990;51:27 – 30. [13] Fleet RP, Dupuis G, Marchand A, et al. Panic disorder in coronary artery disease patients with noncardiac chest pain. J Psychosom Res 1998;44:81 – 90. [14] Wulsin LR, Hillard JR, Geier P, Hissa D, Rouan GW. Screening emergency room patients with atypical chest pain for depression and panic disorder. Int J Psychiatry Med 1998;18:315 – 23. [15] Mayou R. Chest pain, palpitations and panic. J Psychosom Res 1998;44:53 – 70. [16] Potts SG, Bass CM. Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long term followup study. Psychol Med 1995;25:339 – 47.
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[17] Coryell W, Noyes R, Clancy J. Excess mortality in panic disorder. A comparison with primary unipolar deppression. Arch Gen Psychiatry 1982;39:701 – 3. [18] Haines AP, Imeson JD, Meade TW. Phobic anxiety and ischaemic heart disease. BMJ 1987;295:297 – 9. [19] Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The normative aging study. Circulation 1994;90:2225 – 9. [20] Barefoot JC, Schroll M. Symptoms of depression, acute myocardial infarction, and total mortality in a community sample. Circulation 1996;93:1976 – 80. [21] Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation 1995;91:999 – 1005. [22] Aikens JE, Michael E, Levin T, Myers TC, Lowry E, McCracken LM. Cardiac exposure history as a determinant of symptoms and emergency department utilization in non-cardiac chest pain patients. J Behav Med 1999;22:605 – 17. [23] Eifert GH. Cardiophobia: a paradigmatic behavioral model of heart focused anxiety and non-anginal chest pain. Behav Res Ther 1992;30:329 – 45. [24] Aikens JE, Zvolensky MJ, Eifert GH. Differential fear of cardiopulmonary sensations in emergency room non cardiac chest pain patients. J Behav Med 2001;24:155 – 67. [25] Eifert GH, Hodson SE, Tracey DR, Seville JL, Gunawardene K. Heart focused anxiety, illness beliefs, and behavioral impairment: comparing
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Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address all those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine Krishnamachari Srinivasan*, Willie Joseph Department of Psychiatry, St. John’s Medical College Hospital, Sarjapur Road, Bangalore 560034, Karnataka, India Received 16 February 2004; accepted 9 June 2004
Abstract We studied the prevalence of anxiety and depressive disorders in patients with chest pain presenting to an emergency department. Majority of the patients had coronary artery disease (CAD). Twenty-three percent of patients with chest pain had a diagnosable psychiatric disorder according to ICD-10 research criteria. Anxiety and depressive disorders were equally distributed among patients with concomitant psychiatric syndrome. The level of psychological distress as measured on hospital anxiety and depression scale in patients of CAD with comorbid psychiatric syndrome was significantly more than patients with CAD alone and similar to non-CAD patients with psychiatric disorder. This finding is in agreement with an earlier study suggesting that the psychological distress seen in patients with CAD is related to the comorbid psychiatric condition and not to CAD. D 2004 Elsevier Inc. All rights reserved. Keywords: Anxiety disorders; Depression; Chest pain; Coronary artery disease; Emergency medicine
1. Introduction Chest pain is one of the most common complaints among patients seeking help from emergency departments [1]. Studies show that in over 50% of such patients the chest pain is of noncardiac origin [2,3]. There is considerable evidence that noncardiac chest pain is associated with psychiatric disorders, especially panic disorder [4–6]. Prevalence of panic disorder in patients with noncardiac chest pain seen in an emergency setting ranges from 16% to 25% [7,8], whereas in cardiology departments the prevalence is even greater (31–56%) [5,6,9]. While most studies have focused on patients with noncardiac chest pain, others suggest that panic disorder may also occur in patients with established coronary artery disease (CAD) [9–12]. Fleet et al. [13] reported that 34% of CAD patients who consulted
* Corresponding author. Tel.: +91 080 5505858; fax: +91 080 5521798. E-mail address: [email protected] (K. Srinivasan). 0163-8343/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2004.06.001
the emergency department of a cardiology hospital for chest pain and were found to have noncardiac chest pain diagnosis, had panic disorder. Thus, the prevalence of panic disorder in patients with CAD is similar to those observed in patients without CAD [13]. In the majority of patients with chest pain the treating physicians did not recognize the presence of panic disorder [7,8,14]. A poor outcome has consistently been reported for emergency room attendees with chest pain [15], with significant psychosocial impairment lasting many years [16]. They also undergo unnecessary cardiac invasive investigations, such as coronary angiogram and cardiac catherization, resulting in considerable costs to the community [5]. In addition, some studies suggest that patients with anxiety disorders are at higher risk of mortality from cardiovascular disease [17–19]. Depression has been reported to be an independent risk factor for progression of cardiovascular disease [20] and in patients after myocardial infarction, depression is associated with increased mortality rate [21].
K. Srinivasan, W. Joseph / General Hospital Psychiatry 26 (2004) 470 – 474
Studies that have examined the etiopathogenesis of noncardiac chest pain have emphasized the role of cognitive appraisal and conditioning in the origin of noncardiac chest pain [15,22]. Central to cognitive appraisal theory is the role of attribution, whereby minor physiological symptoms are misinterpreted as evidence of serious illness [15]. Others have suggested that illness experience, especially prior exposure to cardiac events in self or others, plays a crucial role in development of noncardiac chest pain [22,23]. Moreover this health-related anxiety is specific with patients with noncardiac chest pain reporting more cardiopulmonary fears relative to other bodily fears [24] and accompanying behavioral changes, such as repeated reassurances, greater awareness of cardiac events, and life-style measures linked to protecting the heart [25]. Most studies that have looked at the association between chest pain and anxiety and depressive disorders have been on patient populations from the West. In addition, the majority of the studies have been done on the patient population attending cardiology clinics or emergency departments of a cardiology hospital. The aim of the present report was to study the prevalence of anxiety and depressive disorders among patients presenting with chest pain to an emergency department in a teaching general hospital in India. We hypothesized that the severity of psychological distress seen in patients with both CAD and psychiatric disorder (PD) is specifically attributable to the concomitant psychiatric disorder. 2. Method 2.1. Subjects This study was conducted in a tertiary care teaching general hospital. The emergency department located in the hospital caters to patients from both the urban metropolis and the surrounding rural areas. A consecutive series of adult patients presenting with a primary complaint of chest pain to the emergency department over a 1-year period between 1999 and 2000 were evaluated for the purpose of the study. A written informed consent was obtained from the patient. The institutional ethics review board approved this study. Patients were either interviewed in the emergency department if the clinical condition allowed or in the inpatient unit after the medical condition had stabilized. Only those patients who spoke English or a local language (Kannada) and were competent to provide informed consent were included in the study. Patients who had psychosis, cognitive dysfunction, or substance abuse were excluded from the study. Of the 381 patients who presented with chest pain to the emergency department during the study period, 337 patients met the study criteria and were interviewed. 2.2. Clinical assessments Patients were initially screened for presence of anxiety or depressive syndromes using the Hospital Anxiety and
471
Depression Scale (HADS) [26]. This instrument was chosen because it was specially designed to detect states of depression and anxiety in a medically ill population. HADS is subdivided into an anxiety subscale (HADS-A) and a depression subscale (HADS-D). In most studies that have used HADS, a score of 8 or above on both the HADS-A and HADS-D defined psychiatric caseness [27]. In the present study, patients scoring 8 or more on the HADS were further interviewed using a structured psychiatric interview schedule, Schedule for Clinical Assessment in Neuropsychiatry (SCAN) [28]. The SCAN was used to generate a lifetime psychiatric diagnosis according to the ICD-10 diagnostic criteria for research diagnosis. SCAN is a structured interview schedule for use by trained professionals and the psychiatric diagnosis was arrived at using a computer-generated algorithm. Version 2.0 of the SCAN was used in the present study. One of the authors (W.J.) obtained training in its administration. SCAN has been used in previous research in India and a standardized version in a local language (Kannada) is available [29]. Cardiac diagnosis was obtained from the patient’s medical charts at the time of discharge. A diagnosis of CAD was based on either a documented myocardial infarction, coronary bypass surgery, angioplasty, and a coronary angiogram indicative of stenosis in major coronary artery or an abnormality on treadmill test. For the purpose of this study four groups of patients were compared on demographic and clinical variables: (a) Patients with both CAD and PD; (b) patients with PD only; (c) patients with CAD but without PD; and (d) patients with neither CAD nor PD. 2.3. Statistics Differences among the diagnostic groups on categorical variables were analyzed using the v 2 test. One-way analysis of variance was done for comparing various clinical variables across the diagnostic groups. Significant effects on one-way analysis of variance were followed up by posthoc tests using least significant difference with Bonferroni correction for multiple comparisons. We used a probability value of .05 as significant for the analyses. 3. Results The sample comprised a consecutive series of 337 adult patients, of whom 69% were males (n = 231). The majority of study participants were married (82%) and literate (61%). Of the 337 patients, 208 patients (62%) were discharged with a diagnosis of CAD. Twenty-two patients had medical conditions other than CAD and PD. Seventynine patients (23%) met with ICD-10 research diagnostic criteria for a psychiatric syndrome. Among patients with a psychiatric diagnosis, 43 had anxiety disorders and 35 had a diagnosis of depression, while 1 patient had somatization disorder. Among patients with anxiety disorders, 28 (8.3%)
472
K. Srinivasan, W. Joseph / General Hospital Psychiatry 26 (2004) 470 – 474
Table 1 Comparison of demographic variables across diagnostic groups Variable Age (yr) MeanFSD Gender, n(%) Male Female Marital status, n(%) Married Single/widowed Occupation, n(%) Employed Unemployed Education, n(%) Elementary High school College Income (Rs.), n(%) b4000 N4000 Residence, n(%) Urban Rural Religion, n(%) Christian Hindu Muslim
Group 4 (n = 81)
F/m2
41.3 F16.3
43.5*
142(80) 35(20)
46(57) 35(43)
21.1**
24(86) 4(14)
151(85) 26(15)
60(74) 21(26)
.16
13(45) 16(55)
14(50) 14(50)
111(63) 66(37)
43(53) 38(47)
.16
16(55) 8(28) 5(17)
8(29) 11(39) 9(32)
68(38) 57(32) 52(30)
29(36) 35(43) 17(21)
13(45) 16(55)
12(43) 16(57)
72(41) 105(59)
46(57) 35(43)
.12
23(79) 6(21)
24(86) 4(14)
118(67) 59(33)
60(74) 21(26)
.12
5(17) 18(62) 6(21)
3(11) 21(75) 4(14)
43(24) 108(61) 26(15)
25(31) 51(63) 5(6)
.14
Group 1 (n = 29)
Group 2 (n = 28)
55 F12.5
35 F11.4
20(69) 9(31)
14(50) 14(50)
23(79) 6(21)
Group 3 (n = 177) 56.8 F10.9
.22
Group 1 = PD & CAD, Group 2 = PD only, Group 3 = CAD only, Group 4 = neither CAD nor PD. * P b.01, df = 3, 311. ** P b.01, df = 3.
had a primary diagnosis of panic disorder and 15 (4.9%) had generalized anxiety disorder. We excluded one patient who had a diagnosis of somatization disorder from further analysis. Three-hundred and fifteen patients formed the sample for final analysis and were categorized into the following groups. Nine percent (n = 29) had both CAD and PD (group 1); 8% (n = 28) had PD only (group 2); 53% (n = 177) had CAD with no PD (group 3); and 24% (n = 81) had neither CAD nor PD (group 4). In the CAD-PD group, anxiety disorders were present in 12 patients while 17 patients were diagnosed with depressive disorders. In the PD-only group, 14 patients had anxiety disorders and depressive disorders were present in 14 patients. 3.1. Demographic characteristics There were more male subjects among patients with CAD and CAD-PD diagnostic groups. CAD and CAD-PD patients were significantly older than patients belonging to other diagnostic groups. Patients in the four groups were not Table 2 Scores on hospital anxiety and depression scales across diagnostic groups Variable
Group 1 (n = 29)
Group 2 (n = 28)
Group 3 (n = 177)
Group 4 (n = 81)
F value
HAD-A HAD-D
8.2 F 3.7 7.4 F 3.8
14.3 F 3 9.6 F 3.6
3.5 F 2.3 2.2 F 2.2
3.3 F 2.8 2.2 F 2.7
63.3* 54.5*
* P b.001, df = 3, 311.
significantly different in terms of marital status, income, education, residence, religion, and occupation. Demographic characteristics are presented in Table 1. 3.2. Psychological morbidity One-way analysis of variance revealed a significant difference across diagnostic groups on both the subscale of HADS. Because patients in certain groups differed in age and gender, we conducted analyses of covariance with psychological test scores on HAD-A and HAD-D as dependent variables adjusting for these factors. Adjusted means and levels of significance are presented in Table 2. Post-hoc tests showed that on both HAD-A and HAD-D subscales, CAD with PD (Group I) and PD without CAD (Group II) differed significantly from the other two groups, namely CAD without PD (Group III) and the group neither CAD nor PD (Group IV) ( P b.001). Among patients with psychiatric syndrome, those belonging to Group II had a significantly higher score on HAD-A and HAD-D compared to Group I ( P b.001). 4. Discussion Results of this study show that 23% (79 of 337) of patients with chest pain who consulted the emergency department of a teaching general hospital had a diagnosable psychiatric syndrome according to ICD-10 research diagnostic criteria.
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Among those with psychiatric diagnosis, anxiety and depressive disorders were equally distributed. Our finding of 23% of patients with chest pain having a concomitant psychiatric syndrome is lower than the figures reported in some earlier studies [9]. This lower prevalence figure could be related to both the diagnostic composition of the patient sample and the hospital setting in which the study was conducted. The majority of patients with chest pain in the present study had a discharge diagnosis of CAD (62%). Most studies that have examined prevalence of panic in chest pain patients have been done on patients without CAD or on patients who had chest pain that was atypical for angina [9]. In other studies, patient selection was not on a consecutive basis [9,30]. In addition, earlier studies have included patients attending specialized treatment facilities, such as cardiology outpatient clinics [9,30] or emergency facilities attached to a cardiology hospital [13]. Yet another reason for lower prevalence of psychiatric syndrome in the present study may be related to use of HADS as a screening instrument in identifying patients with psychiatric illness. HADS has items pertaining mainly to mood and cognitive symptoms and excludes somatic symptoms such as headaches, insomnia, anergia, and fatigue. Many studies done in India have shown that patients with depression and anxiety present initially to physicians with multiple physical symptoms, a phenomenon observed across diverse clinical settings [31–33]. Thus, it is likely that some patients with chest pain may not have been obtained a score of 8 or above on HADS and the concomitant psychological distress may have been missed. The finding that the level of psychological distress in patients with CAD and PD is significantly different from patients of CAD but without CAD is in agreement with the observation made by Fleet et al. in their study on panic disorder in patients with CAD [13]. This suggests that the psychological distress seen in patients with CAD is primarily attributable to the comorbid psychiatric condition. The extent of psychological distress between CAD with PD and bpure PDQ groups of patients tended to be similar. This finding also suggests that the nature of psychiatric syndrome seen in patients with CAD is similar to bpureQ psychiatric syndrome, although this requires further validation [13]. Thus, the poor long-term outcome reported in many studies in patients with chest pain seeking help from emergency room [15,16] can be improved with better screening and management of the concomitant psychiatric syndrome. However, recognizing anxiety disorder, especially panic disorder among patients with myocardial infarction, is not easy due to commonality of symptoms [34], especially in developing countries where somatization of psychological distress is common [32]. This study has certain limitations, the fact that it is based on a population seeking help from an emergency department attached to a tertiary referral hospital may limit generalizability. Some cases of panic disorder, especially the nonfearful variety of panic attacks that are reported to be common among patients with cardiovascular symptoms [35]
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may have been missed. The psychiatric interviewer (W.J.) was not blind to the patient’s medical condition or to the specific hypothesis of the study, resulting in a possible expectancy effect. In conclusion, a significant proportion of patients presenting with chest pain to an emergency department had a diagnosable psychiatric illness. The level of psychological distress seen in patients of CAD with comorbid anxiety and depressive disorders was similar to those with pure psychiatric conditions. Thus, it is important for emergency room physicians and cardiologists to identify psychiatric syndromes in patients with chest pain and be able to offer appropriate treatment. References [1] Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med 1989; 86:262 – 6. [2] Karlson BW, Herlitz J, Petterson P, Ekvall HE, Hjalmarson A. Patients admitted to the emergency room with symptoms indicative of acute myocardial infarction. J Intern Med 1991;230:251 – 8. [3] Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985;145:65 – 9. [4] Cormier LE, Katon W, Russo J, Hollifield M, Hall ML, Vitaliano PP. Chest pain with negative cardiac diagnostic studies. Relationship to psychiatric illness. J Nerv Ment Dis 1988;176:351 – 8. [5] Carter C, Maddock R, Amsterdam E, McCormick S, Waters C, Billet J. Panic disorder and chest pain in the coronary care unit. Psychosomatics 1992;33:302 – 9. [6] Beitman BD, Mukerji V, Lamberti JW, et al. Panic disorder in patients with chest pain and angiography normal coronary arteries. Am J Cardiol 1989;63:1399 – 403. [7] Yingling KW, Wuslin LR, Amold LM, Rouan GW. Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain. J Gen Intern Med 1993;8:231 – 5. [8] Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation and physician recognition. Am J Med 1996;101:371 – 80. [9] Beitman BD, Basha I, Flaker G, et al. Atypical or nonanginal chest pain. Panic disorder or coronary artery disease? Arch Intern Med 1987;147:1548 – 52. [10] Basha I, Mukerji V, Langevin P, et al. Atypical angina in patients with coronary artery disease suggests panic disorder. Int J Psychiatry Med 1989;19:341 – 6. [11] Katon WJ. Chest pain, cardiac disease, and panic disorder. J Clin Psychiatry 1990;51:S27–S30 [Suppl.]. [12] Zaubler TS, Katon W. Panic disorder and medical comorbidity: a review of the medical and psychiatric literature. J Clin Psychiatry 1990;51:27 – 30. [13] Fleet RP, Dupuis G, Marchand A, et al. Panic disorder in coronary artery disease patients with noncardiac chest pain. J Psychosom Res 1998;44:81 – 90. [14] Wulsin LR, Hillard JR, Geier P, Hissa D, Rouan GW. Screening emergency room patients with atypical chest pain for depression and panic disorder. Int J Psychiatry Med 1998;18:315 – 23. [15] Mayou R. Chest pain, palpitations and panic. J Psychosom Res 1998;44:53 – 70. [16] Potts SG, Bass CM. Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long term followup study. Psychol Med 1995;25:339 – 47.
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