Journal of Psychosomatic Research 66 (2009) 249 – 253
Evaluation of psychiatric illness in Iranian stoma patients☆ Bahar Mahjoubi⁎, Homa Mohammadsadeghi, Mastoureh Mohammadipour, Rezvan Mirzaei, Reyhaneh Moini Iran University of Medical Sciences and Health Care Services, Tehran, Iran Received 6 November 2007; received in revised form 27 June 2008; accepted 23 October 2008
Abstract Introduction: The objective of this study was to assess the nonpsychotic psychiatric disorders of stoma patients in Iran. Method: In this cross-sectional study, patients referred to the Iranian Ostomy Association from 2005 to 2006 filled the 28-item General Health Questionnaire (GHQ) in Farsi as a screening instrument to identify cases of nonpsychotic psychiatric morbidity. Results: A total of 155 patients participated in the study, of whom 79 (51%) were female and 76 (49%) were male. Fifty-five percent of the patients (n=86) had psychiatric problems. The females' mean GHQ score was significantly higher than that of males
(P=.001). Psychiatric disorder was significantly more frequent among patients with the following specifications: educational level of high school or lower (P=.001), mucosal hemorrhage of the ostomy (P=.03), stomal stenosis (P=.012), and history of psychiatric drug consumption (P=.000). GHQ score decreased as stoma age increased (P=.032; r=−.177). Discussion: Similar to other complications, psychiatric problems are prevalent in Iranian stoma patients. Our findings highlight the need for special support. © 2009 Elsevier Inc. All rights reserved.
Keywords: Stoma; Ostomy; Mental health; Psychiatric illness; General Health Questionnaire, GHQ-28
Introduction Advances in sphincter-saving surgery have not eliminated the need for permanent ostomy. Stoma surgery is a radical treatment with permanent physical damage, loss of an important bodily function, and change in personal hygiene. About 80% of stoma patients experience some change in their lifestyle, and more than 40% encounter problems with their sex life [1]. These physical consequences have serious effects on emotional welfare, social relations, and activities.
☆ The abstract of this research was accepted for an oral presentation at the International University of Colon and Rectal Surgeons of June 2006 and the Istanbul 17th European Students' Conference of October 2006. ⁎ Corresponding author. Department of Surgery, Hazrate Rasoule Akram Hospital, Sattarkhan Street, Tehran, Iran 1445613131. Tel.: +98 912 118 1114; fax: +98 21 222 9113. E-mail address:
[email protected] (B. Mahjoubi).
0022-3999/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2008.10.015
Stoma patients face permanent changes to their accepted body image and lifestyle [2–4]. Investigations of studies confirm the existence of a variety of psychosocial problems, especially in the emotional, sexual, and social areas [2,5–7]. Around one quarter of stoma patients experience clinically significant psychosocial symptoms postoperatively [8], and living with a permanent ostomy significantly diminishes a patient's quality of life [9]. According to the Iranian Ostomy Association, there are about 30,000 stoma patients in Iran. Due to some limitations of access to the suitable instruments for stoma care and trained staff in Iran, there might be different aspects of postoperative complications. The only study [6] that evaluated stoma patients in Iran indicated that postoperative problems, especially psychosocial ones, have a rather high frequency in comparison with other reports, but since no standardized questionnaire was applied for the evaluation of psychosocial problems and their severity, further studies were needed. Therefore, the main objective of this study was to
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Table 1 Frequency of demographic and clinical characteristics of the patients Characteristic Sex Male Female Marital status Married Single Divorced Type of intestinal ostomy Colostomy Ileostomy Others Underlying diseases Rectal cancer Colon cancer Inflammatory bowel disease Bladder cancer Trauma Congenital problems Others History of psychiatric drug consumption No Yes Educational level High school or lower Higher than high school Psychiatric disorder Other stoma complications Dermal irritation Noise Odor Leakage Peristomal hernia Mucosal hemorrhage Stomal stenosis
Frequency [n (%)] (N=155) 76 (49) 79 (51) 119 (77.3) 31 (20.1) 4 (2.6) 117 (81.3) 10 (6.9) 17 (11.8) 54 (34.8) 40 (25.8) 17 (10.9) 15 (9.6) 3 (1.9) 3 (1.9) 11 (7.07) 123 (80.9) 29 (19.1) 122 (78.7) 33 (21.3) 86 (55.5) 72 (46.5) 63 (40.6) 62 (40) 44 (28.4) 15 (9.7) 13 (8.4) 11 (7.1)
assess the nonpsychotic psychiatric disorders of stoma patients in Iran. Method This cross-sectional study was performed on all patients with permanent stomas who were referred to the Iranian Ostomy Association from 2005 to 2006. The sample was collected by a nonprobability convenience sampling method. The sample size calculated for the estimation of type І error (α) (5%), predicted probability of psychiatric disorders among stoma patients (40%), and clinical difference (8%) was equal to 150 patients. In order to evaluate the psychiatric condition of the patients, we explained the objectives of the study to them and accordingly asked them to fill the 28-item General Health Questionnaire (GHQ-28) in Farsi; they all agreed to do so. The GHQ is a self-report questionnaire measuring current mental health, which is used to detect psychiatric disorder in the general population and within community or nonpsychiatric clinical samples, such as primary care and general medical outpatients.
Since the first performance of the GHQ by Goldberg in the 1970s, it has been extensively used by different researchers [2,7,10–15]. The GHQ-28 version has better performance compared with the 30- and 12-item versions [16,17]. For the GHQ-28, Likert-type scoring (0, 1, 2, and 3) is used to identify cases of nonpsychotic psychiatric morbidity [18]. According to the translation and validation study of the Farsi version, a cutoff score of 21 for women and Table 2 Comparison of GHQ scores of patients with different demographic and clinical characteristics Characteristic
GHQ score of patients [mean (SD)]
Sex Male 20.05 (1.9) Female 28.04 (1.7) Marital status Married 23.93 (1.8) Single 23.67 (1.8) Divorced 28.43 (1.5) Type of intestinal ostomy Colostomy 23.44 (1.9) Ileostomy 30.08 (2.0) Others 21.72 (1.6) Underlying diseases Rectal cancer 25.60 (1.9) Colon cancer 23.64 (1.8) Inflammatory bowel disease 21.76 (20.0) Bladder cancer 24.41 (1.5) Trauma 18.33 (1.2) Congenital problems 11.78 (1.6) Others 21.53 (2.1) History of psychiatric drug consumption No 21.37 (1.8) Yes 36.78 (1.7) Educational level High school or lower 26.06 (1.8) Higher than high school 17.15 (1.8) Dermal irritation No 25.40 (1.7) Yes 22.59 (1.9) Noise No 26.33 (1.8) Yes 22.31 (1.8) Odor No 23.28 (1.8) Yes 24.74 (1.8) Leakage No 22.54 (1.9) Yes 27.59 (1.7) Peristomal hernia No 24.04 (1.8) Yes 22.18 (1.7) Mucosal hemorrhage No 23.08 (1.8) Yes 34.16 (1.7) Stomal stenosis No 23.04 (1.8) Yes 37.53 (1.9) a
Pa .001 b
.858
.423
.492
.000 b
.001 b
.250
.109
.558
.072
.647
.030 b
.012 b
P values are based on one-sample t test or analyses of variance, whichever is appropriate, to compare the mean GHQ scores of the patients according to their different characteristics. b Statistically significant difference exists.
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that of 22 for men were recommended by Palahang [19], and higher scores are considered to indicate psychiatric morbidity. It has been demonstrated to have a sensitivity of 88%, a specificity of 79% for women and that of 78% for men, and an overall misclassification rate of 16% for women and that of 19% for men [19]. Patients also answered some additional questions concerning age, sex, marital status, education, indications for stoma surgery (malignancies or benign conditions), type of intestinal ostomy (colostomy, ileostomy, or others), duration of having a stoma, duration of the underlying disease before stoma surgery, history of psychiatric illness defined as previous psychiatric drug consumption, and complications of stoma (leakage, peristomal hernia, dermal irritation, noise, odor, mucosal hemorrhage, and peristomal stenosis). Dermal irritation was defined as the presence of any skin irritation around the stoma. Mucosal hemorrhage was considered as the presence of persistent bleeding from the stoma. Leakage was identified as any leak around the stoma bag. Statistical analysis Underlying variables were assessed as to whether they have any significant relationship with the GHQ score or not to evaluate factors associating psychiatric illness. χ 2 Analysis for testing the significance of the difference of proportions and two-tailed independent-samples t test and one-way analysis of variance for testing the significance of the difference of means were used. Correlations of the GHQ score with age, duration of having an ostomy, and duration of the underlying disease were calculated using Pearson's correlation equations. Since GHQ scores were not normally distributed, all statistical procedures were performed on the logarithm of
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GHQ scores that had a normal distribution in order to be able to use parametric tests. Statistical significance was accepted at Pb.05. Statistical analysis was done by SPSS for Windows version 13.
Results Among the 155 stoma patients who participated in the survey, 79 (51%) were female and 76 (49%) were male. The mean ages of the male and female subjects were 51.51 (SD=18.66) years and 50.89 (SD=13.96) years, respectively. Table 1 demonstrates the frequency of demographic and clinical characteristics of the patients, and Table 2 compares the GHQ scores of patients with different demographic and clinical characteristics. Generally, the GHQ score of the patients seemed to be higher in the females, in the group of patients with an educational level of high school or lower, and the patients with a history of psychiatric drug consumption. As shown in Table 2, among the ostomy complications, mucosal hemorrhage (23.08±2.10 vs. 34.16±2.35; P=.03) and stomal stenosis (23.04±2.10 vs. 37.53±2.44; P=.012) were the only ones that significantly increased the GHQ score of the patients. Implementing a GHQ-28 threshold of 21 for females and that of 22 for males, 86 patients (55.5%) had scores high enough to suggest the existence of psychiatric problems. Thirty-three men (43.4%) and 53 women (67.1%) were classified as probable cases with a psychiatric disorder, and the mean GHQ scores differed significantly between male and female patients (20.05±2.16 vs. 28.04±2.12; P=.001). Table 3 shows that dermal irritation with a ϕ value of 0.21 (P=.007) and noise were the only complications that were significantly associated to sex and were more prevalent among women.
Table 3 Comparison of different complications of ostomy in male and female patients Characteristic Psychiatric illness Yes No History of psychiatric drug consumption No Yes Educational level High school or lower Higher than high school Stoma complications Dermal irritation Noise Odor Leakage Peristomal hernia Mucosal hemorrhage Stomal stenosis a b
Pa
Female patients [n (%)] (n=74)
Male patients [n (%)] (n=76)
53 (67.1) 26 (32.9)
33 (43.4) 43 (65.6)
61 (77.2) 15 (19.0)
62 (81.6) 14 (18.4)
1.000
66 (83.5) 13 (16.5)
56 (73.7) 20 (26.3)
.170
45 (57) 40 (50.6) 37 (46.8) 21 (26.6) 10 (12.7) 7 (8.7) 7 (8.9)
27 (35.5) 23 (30.3) 25 (32.9) 23 (30.3) 5 (6.6) 6 (7.9) 4 (5.3)
.010 b .014 b .101 .722 .278 1.000 .535
P values are based on two-tailed Fisher's exact test between the male and female groups. Statistically significant difference exists.
.004 b
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GHQ score did not have any significant correlation with patient age (P=.77) and duration of the disease before construction of the ostomy (P=.61) but had a significant correlation with duration of having a stoma (P=.032; r=−.177).
Discussion In spite of the advances of modern surgery, complication rates for stomas remain high. Patients undergoing stoma surgery experience a profound threat to their sense of physical integrity and self-concept with the change to their body image in relation to bodily functions. This study was designed to give preliminary information about the mental health status of Iranian stoma patients. In comparison with the reported rates of psychiatric problems in the Iranian population, 10.81% in one study [20] and 12.5% to 16.7% in another [13], the rate of psychiatric problems in stoma patients in this study seems to be very high (about four times more). Furthermore, in comparison with similar studies performed in other countries [5,7,21], psychiatric problems, like other complications of this surgery (i.e., dermal irritation and mucosal hemorrhage), seem to be more prevalent in Iranian stoma patients [6]. Bekkers et al. [7] evaluated the prevalence of mental disturbances reported in studies done between 1982 and 1992 and stated frequencies of about 23% emotional problems, 45% decreased social contacts, and 57% decreased libido in stoma patients. Thomas et al. [5] reported that among stoma patients, 17% of males and 19% of females had moderate to severe psychiatric disturbance. In another study, 7% anxious, 9% depressed, and 9% severely depressed patients were seen [21]. Becker et al. [7] showed 29% motional, 35% social, and 23% sexual problems among their samples. On the whole, we conclude that the prevalence of psychiatric problems is high in Iranian stoma patients and that this high frequency of complications in Iranian stoma patients might be related mainly to technical problems in surgical methods and stoma care, which should be taken into consideration. Patients undergoing stoma surgery will more readily adapt to their new body image and way of life if they receive professional and voluntary input from ostomy agencies from the preoperative stages through to rehabilitation and their return to the community. These patients need psychological support, preoperative and postoperative consults, and regular visits with stoma nurses; studies in settings that employ stoma care nurses demonstrated that patients had better psychological adjustment [21] and quality of life [22]. According to the Iranian Ostomy Association, most stoma patients in Iran do not have access to optimal and standard ostomy bags because of high costs and shortage of available standard ostomy equipment. On the other hand, the absence of stoma nurses complicates the process of stoma care. The
high prevalence of psychiatric problems in these patients may be related to the shortage of stoma nurses and lack of standard equipment for stoma care. Our findings highlight the need for special support and attention to prepare standard equipment and educate patients for stoma care. The fact that patients with a history of psychiatric problems or lower educational level were shown to be at higher risk of developing psychiatric complications should be considered in stoma care programs and emphasizes the importance of preventive activities, which might include screening for history of psychiatric problems or more attention to patients with lower education and those with a history of psychiatric disorders. According to our findings about higher rates of psychiatric morbidity among females, there is also a need for special programs to help women who have to deal with stomas. Also, we found the higher prevalence of some stoma complications, such as dermal irritation and noise, in female patients, which should be studied and taken into attention. However, the high rate of psychiatric illness in Iranian stoma patients, especially females, could be the subject of further investigations to find the risk factors and predictors of psychiatric disorder and interventions to reduce this kind of complication. In addition, the retrospective design of our study and lack of a control group result in some methodological limitations in the interpretation of the findings. Further prospective studies considering control groups consisting of surgical patients without stoma would help us become sure of whether the results are related to the stoma or the major surgery the patients passed.
Acknowledgments We extend our special thanks to Dr. Ali Moghimi for his helpful advice and to Dr. Pedram Golnari and Alireza Mohammad Sadeghi for editorial consults.
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