Psychosocial determinants of recovery

Contribution of individual psychological and psychosocial factors to symptom severity and time-to-recovery after naturally-occurring acute infective illness: The Dubbo Infection Outcomes Study (DIOS)

BACKGROUND

Substantial heterogeneity exists in both the severity of symptoms experienced as part of the sickness response to naturally-occurring infections, and the time taken for individuals to recover from these symptoms. Although contributing immunological and genetic factors have been previously been explored, less is known about the role of individual psychological and psychosocial factors, which may modulate the host immune response, or contribute independently, to symptom severity and duration.

METHODS

Longitudinally-collected data from 484 Caucasian participants (mean age: 33.5 years; 51% women) experiencing a naturally-occurring acute infective illness enrolled in the prospective Dubbo Infection Outcome Study (DIOS) were analysed. At intake and subsequent follow-up assessments, self-report questionnaires were used to ascertain individual psychological and psychosocial characteristics and symptom information. Principal component analysis was applied to symptom data to derive endophenotype severity scores representing discrete symptom domains (fatigue, mood, pain, neurocognitive difficulties) and an overall index of severity. The contribution of individual psychological (trait neuroticism, locus of control, and illness behaviours) and psychosocial factors (relative socioeconomic advantage) to endophenotype severity at baseline were examined using multivariable linear regression models; interval-censored flexible parametric proportional hazards survival models were used to explore time to recovery (defined using within-sample negative threshold values).

RESULTS

After controlling for time since symptom onset, greater levels of trait neuroticism consistently predicted greater symptom severity across all symptom domains (all p's < 0.015). Similarly, greater relative socioeconomic disadvantage was significantly associated with greater severity across all endophenotypes (p's < 0.025) except neurocognitive disturbance. Locus of control and illness behaviours contributed differentially across endophenotypes. Reduced likelihood of recovery was significantly predicted by greater initial symptom severity for all endophenotypes (all p's < 0.001), as well as higher levels of trait neuroticism.

CONCLUSIONS

Individual psychological and psychosocial factors contribute to the initial severity and to the prolonged course of symptoms after naturally-occurring infective illnesses. These factors may play an independent role, represent a bias in symptom reporting, or reflect increased stress responsivity and a heightened inflammatory response. Objective metrics for severity and recovery are required to further elucidate their roles.

Psychosocial Analysis of Cancer Deaths

In addition to biological activity and cancer treatment, psychosocial considerations may influence both the quality of survival and its length. The investigators used information from psychological autopsies of cancer deaths, and correlated observed survival (measured in months beyond expected survival) with psychosocial findings. Patients who lived significantly longer tended to maintain cooperative and mutually responsive relationships, especially towards the end of their lives. Patients with death wishes, depression, apathy, and long-standing mutually destructive relationships survived for shorter periods than expectable. Why longevity occurs in some patients, but not in others, may be related to different traits which create alienation in personal life and in caretaking staff as life draws to a close. More assertive patients ask for and get better attention and services, and as a result, may live longer and die better deaths.

The course of anxiety and depression in surgical and non-surgical patients

OBJECTIVE

The aim of this study was to compare the level of anxiety and depression in patients admitted to surgery or internal departments.

METHODS

The study was carried out on 359 hospitalized patients over the age of 18 years and designed as a cross sectional survey. Participants were recruited from internal medicine and surgery departments of Khatam Ol Anbia hospital, Tehran, Iran. Information was collected using the Hospital Anxiety and Depression Scale.

RESULTS

Ninety-four (26.18%) patients had no anxiety and depression, 96 (26.7%) were borderline cases of anxiety, 140 (39%) were very anxious, 89 (24.8%) were borderline cases of depression, and 106 (29.5%) had depressed mood. There was a significant correlation between anxious mood and sex and duration of background disease as well as between the level of depressive mood and age. Patients with anxiety are significantly more prone to depression. However there were no significant differences between the level of anxiety or depression between surgical or non-surgical patients.

CONCLUSIONS

The prevalence of anxious and depressive moods was high in both surgical and non-surgical patients. However, non-surgical treatments were as stressful as surgical procedures for patients admitted to hospital in the first 24 h.

Analysis of the stressful effects of hospitalisation and source isolation on coping and psychological constructs

This quantitative research has attempted to investigate the psychological effects of hospitalisation and source isolation, and assessed whether were they influential in affecting a patient's cognitive coping with these two stressors. The research evaluated whether isolating a person because of an infection was a more stressful event (causing negative effects on four measured psychological constructs) than routine hospital admission. The research was conducted in two large District General Hospitals and one elderly care hospital. Individuals admitted to one of the research sites, and who satisfied the sample criteria, were adopted. The total number of subjects was 40. The research design was quasi experimental (post test only control group design), using a quantitative approach. Following a period of hospitalisation or isolation subjects in the control group (Group 1, hospitalised subjects n = 20) and subjects in the experimental group (Group 2, isolated subjects, n = 20) were given the following to complete: the Hospital Anxiety and Depression Scale, the Health Illness (Powerlessness) Questionnaire, and the Self Esteem Scale. These measured four psychological constructs: anxiety, depression, self esteem and sense of control. The quantitative data generated were analysed using descriptive statistics and the Student's t-test. The findings confirmed and validated previous research that hospitalisation results in many negative feelings that have detrimental effects on psychological well being and coping. However, more significantly, infected subjects who were isolated demonstrated feelings of anxiety, and depression that were significantly higher, and feelings of self esteem and sense of control that were significantly lower than those demonstrated by hospitalised subjects. Thus it could be argued that isolation has an even greater negative effect on their coping. Further research therefore needs to examine how specific nurse interventions can ameliorate the identified negative effects of isolation and so facilitate effective coping and positive psychological well being.

Psychiatric management of patients who threaten to sign out against medical advice

Patients who are seriously ill are often unable to tolerate the stress of hospitalization and threaten to sign out against medical advice. Such a crisis often evolves because of inadequate or distorted communication with persons in the hospital environment such as physician and other patients. Physical illness, which stirs up issues of autonomy or loss of control, can compromise an individual's ability to cope. The patient, fearing loss of control, can utilize denial in his decision to leave the hospital prematurely. By exploring these factors, the psychiatric consultant can effectively evaluate and then manage this difficult situation, from his own position in the small group comprised of patient, staff and consultant. Case examples illustrate effective evaluation and management of the patient who threatens to sign out against medical advice.

Patient perception of involvement in medical care: relationship to illness attitudes and outcomes

OBJECTIVE

The purpose of this study was to explore the relationships among patients' perceptions about the roles they played during medical visits, their subsequent attitudes about their illnesses and treatments, and their self-rated improvement.

DESIGN

Questionnaires were completed by patients before, one day after, and one week after their medical visits, and by their physicians following the visits.

SETTING

The study was conducted in a general internal medicine faculty practice that provided adult primary care to a largely HMO population.

PARTICIPANTS

Adult patients with new or increased symptoms who were capable of reading and understanding the study questionnaire.

MAIN RESULTS

Fifty-five patients (47%) reported playing an active role; 62 patients (53%) reported playing a passive role. After adjusting for age, sex, baseline illness ratings, and physician-rated prognosis, "active" patients reported less discomfort (p = 0.04), greater alleviation of symptoms (p = 0.008), and more improvement in their general medical condition (p = 0.04) one week after the visits than did "passive" patients. These differences were not influenced by the roles patients desired to play. Active patients also reported less concern with their illnesses (p = 0.04), a greater sense of control of their illnesses (p = 0.04), and more satisfaction with their physicians (p = 0.02) one day after the visit. Post-visit dysfunction ratings were not related to patients' role perceptions.

CONCLUSIONS

Patients' perceptions about their involvement in care appeared to be related to their attitudes about their illnesses as well as to recovery. Further research is needed, however, to determine the factors that influence these role perceptions and to define the types of patients, illnesses, and settings in which the benefits of active-role perceptions are most likely to be realized.

Anxiety and depression among medical and surgical patients nearing hospital discharge

Ninety-eight medical and surgical inpatients were interviewed 24-72 hours prior to discharge. Thirty-five (36%) had clinical levels of anxiety and depression as defined by the SCL-90-R, a self-report symptom inventory. Compared with patients with normal SCL-90-R subtest scores, anxious and depressed patients more often had the following characteristics: older age, black race, lower socioeconomic class, a recent previous hospitalization, and impaired functional status prior to admission. Three to four weeks after discharge, 25 of the 35 anxious and depressed patients were again interviewed. Thirteen remained anxious and depressed, while 11 patients had returned to normative distress levels. Older, black, poor inpatients with a recent prior hospitalization and impaired functional status are at high risk for clinical anxiety and depression. Half of those with anxiety and depression may remain anxious and depressed after discharge. Intervention should be considered for these patients.

Breast cancer: varied perceptions of social support in the illness experience

Social support has been identified as an important factor in cancer. However, the stigma associated with cancer often leads to avoidance behavior and withdrawal of support. This investigation examines perceived social support in a population of 100 breast cancer patients, and anticipated social support among 100 disease-free individuals. Results demonstrate that healthy individuals report assignment of stigma and avoidance behavior directed towards cancer patients, yet they believe they themselves would have a dense network of support to call upon if stricken with cancer. Patients report nonmaterialization of expected support networks, and decreased adjustment due to this subjective experience. In addition, patients assert that the support extended to them is often inappropriate in nature, due to the mistaken assumption on the part of healthy individuals that the most salient concern of a mastectomized woman is the loss of her breast, rather than the fact that she has cancer.