Posttraumatic stress after SARS.Posttraumatic stress disorder Posttraumatic stress disorder An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life. (PTSD PTSD posttraumatic stress disorder. PTSD abbr. posttraumatic stress disorder Post-traumatic stress disorder (PTSD) ) can arise in patients with medical illness. We used 2 Chinese self-report measures to examine features of PTSD, anxiety, and depression in 131 survivors of severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. at 1 month and 3 months after discharge from the hospital. Risk factors associated with psychological distress psychological distress The end result of factors–eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others'. See Humanistic psychology. were identified. ********** In the outbreak of severe acute respiratory syndrome (SARS) in Hong Kong Hong Kong (hŏng kŏng), Mandarin Xianggang, special administrative region of China, formerly a British crown colony (2005 est. pop. 6,899,000), land area 422 sq mi (1,092 sq km), adjacent to Guangdong prov. in 2003, a total of 1,755 people were infected, and 299 died. Among the infected, 386 were healthcare workers (1). According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the literature, a life-threatening physical illness can lead to symptoms associated with posttraumatic stress disorder (PTSD) after recovery. The prevalence rates of PTSD are 1%-5% for childbirth and 14%-59% for a life-threatening situation in an intensive care unit (ICU ICU intensive care unit. ICU abbr. intensive care unit ICU see intensive care unit. ICU ) (2). Predictors of PTSD identified in previous studies included aspects of the trauma itself, emotional support, and invasiveness of the medical intervention. Severity of illness was not correlated with the development of PTSD (2). Previous studies showed that 10%-35% of SARS survivors reported having features of anxiety, depression, or both at 1 month after discharge (3-6). Repeated measures of the effect at different time points beyond 1 month after discharge are needed to understand the psychological sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention related to SARS and enrich the understanding of the long-term psychological functioning of survivors of life-threatening infectious disease Infectious disease A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. . The Study This study examined the psychological sequelae related to SARS at 1 month and 3 months after discharge from hospital. According to previous studies on posttraumatic posttraumatic /posttrau·mat·ic/ (post?traw-mat´ik) occurring as a result of or after injury. post·trau·mat·ic adj. Following or resulting from injury or trauma. stress, 3 categories of risk factors were postulated pos·tu·late tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates 1. To make claim for; demand. 2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument. 3. . The first category included pre-SARS variables: sex, age, education level, family income, availability of emotional support as indicated by the number of persons with whom one could talk and share worries, and whether one was a healthcare worker. The second category included parameters for severity of disease and treatment regimen: lowest level of blood oxygen saturation oxygen saturation sO2 The O2 concentration of blood expressed as a ratio of its total O2-carrying capacity; the OS is a measure of the utilization of O2 transport capacity; sO2 (Sa[O.sub.2]) during hospitalization, duration of hospitalization for SARS treatment, whether treatment in ICU was required, and total steroid dosage used during hospitalization. The third category was SARS-related psychological and social variables: whether the participant knew anyone who was suspected or confirmed to have SARS, whether the participant knew anyone who died of SARS, and rating for subjective sense of threat. The assessment materials printed in Chinese were mailed to 476 SARS patients 1 month and 3 months after they were discharged from the hospital. Of the 476 SARS survivors contacted, 25 were healthcare workers. One hundred ninety-five (41%) respondents returned the completed questionnaires at 1 month after discharge; characteristics and survey results for the psychological adjustment of these respondents were previously documented (5). A total of 131 (28%) respondents responded at both 1 month and 3 months alter discharge. Our study was based on the data for these 131 respondents. No significant difference was seen between the 3-month respondents and nonrespondents for all the variables examined at 1 month. Among the 131 participants, ages were 18-84 years (mean 41.82, standard deviation In statistics, the average amount a number varies from the average number in a series of numbers. (statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. [SD] 14.01); 57 (44%) were men, 74 (56%) were women. Fourteen (11%) were healthcare workers, 4 (3%) had a history of psychiatric consultation, 12 (9%) had other chronic diseases, and 15 (11%) required treatment in the ICU. The lowest level of Sa[O.sub.2] during hospitalization was 79% 96% (mean 91.59%, SD 3.29). The total steroid dosage used for treatment ranged from 0 to 86,900 mg (mean 14,120.28 mg, SD 12,254.95). Fifty-seven participants (44%) personally knew someone who was suspected or confirmed to have SARS. Fourteen (11%) knew someone who died of SARS. Regarding the number of persons with whom they could talk and share their worries, 6 participants (5%) indicated no one, 68 (52%) indicated 1-2, 41 (31%) indicated 3-4, and 16 (12%) indicated >5. For the rating on subjective sense of threat caused by the disease, 11 participants (8%) reported "not at all," 37 (28%) reported "a little," 43 (33%) reported "moderate," 28 (21%) reported "quite serious," and 12 (9%) reported "extremely serious." The measures used in the study include the Chinese versions of the Impact of Event Scale Revised (IES-R) (7,8) and the Hospital Anxiety and Depression Scale (HADS HADS Hospital Anxiety and Depression Scale HADS Helicopter Air Data System HADS Hellenic American Dental Society, Inc. HADS Humans Against Dragon Stereotypes HADS High Altitude Defense System HADS Hawaiian Air Defense System ) (8-10). Based on research on PTSD and the Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective , Fourth Edition (DSM-IV DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States. ) (11), intrusion, avoidance, and hyperarousal were identified as the primary domains of measurement on the IES-R. Scoring was based on previous studies that indicated a mean subscale score of 2, representing a moderate level of distress, is the appropriate cutoff point Cutoff point The lowest rate of return acceptable on investments. (7,8). The Chinese HADS (8-10) is a sell-report instrument designed to detect symptoms related to anxiety and depression. As in previous studies, the marker for a moderate level of distress (i.e., the subscale score of 11) was used as the cutoff point for HADS subscale scores (8-10). Repeated measures analysis of variance (ANOVA anova see analysis of variance. ANOVA Analysis of variance, see there ), with time (1 month vs. 3 months after discharge) as the within-subject factor, was used to examine the change of symptom severity. The 1-month scores for IES-R intrusion (mean 1.12, SD 0.73), hyperarousal (mean 1.05, SD 0.79), and HADS anxiety (mean 5.87, SD 3.89) were significantly higher than the 3-month scores for IES-R intrusion (mean 0.91, SD 0.73), [F.sub.1, 130] = 18.52, p<0.001), hyperarousal (mean 0.85, SD = .74), [F.sub.1, 130] = 13.96, p<0.001, and HADS anxiety (mean 5.19, SD 4.48), [F.sub.1, 130] = 5.23, p<0.05). At 1 month after discharge, the number of participants who surpassed the subscale cutoff was 16 (12%) for intrusion, 12 (9%) for avoidance, 19 (15%) for hyperarousal, 17 (13%) for anxiety, and 23 (18%) for depression. At 3 months alter discharge, 13 participants (10%) surpassed the subscale cut-off cut-off Anesthesiology The point at which elongation of the carbon chain of the 1-alkanol family of anesthetics results in a precipitous drop in the anesthetic potential of these agents–eg, at > 12 carbons in length, there is little anesthetic activity, for intrusion, 11 (8%) for avoidance, 12 (9%) for hyperarousal, 18 (14%) for anxiety, and 17 (13%) for depression. As PTSD is characterized by the presence of all 3 symptom clusters (i.e., intrusion, avoidance, and hyperarousal), the percentage of participants who passed the cutoff for all IES-R subscales was examined. Among the 131 participants, 6 (4%)at 1 month and 7 (5%) at 3 months postdischarge had all 3 IES-R subscale scores above the cutoffs. Results of multivariate analysis multivariate analysis, n a statistical approach used to evaluate multiple variables. multivariate analysis, n a set of techniques used when variation in several variables has to be studied simultaneously. of variance indicated significant difference in the combined dependent variables between participants with and without a history of psychiatric consultation (Wilks = 0.83, F [tests.sub.5, 125] = 5.18, p<0.001, effect size 0.17). Results in univariate F tests suggested that having a history of psychiatric consultation, being a healthcare worker, and knowing someone who had SARS were associated with various IES-R and HADS scores (Table 1). Results of Pearson correlations (Table 2) showed that the level of Sa[O.sub.2], the number of persons with whom one could talk and share worries, and the rating on perceived threat were significantly related to various IES-R and HADS subscale scores. To determine which variables had the greatest effect on symptom severity at 3 months after discharge, standard multiple regressions were conducted with IES-R and HADS subscale scores as the criterion variables. The lowest level of Sa[O.sub.2] during hospitalization, the rating for subjective sense of threat, and the number of persons with whom one could talk and share worries were entered into the regression model as predictor variables. Overall, the amount of total variance accounted for in individual IES-R and HADS subscale scores by these variables was significant. The lowest level of Sa[O.sub.2] during hospitalization was the most significant predictor for intrusion and avoidance scores. High level of perceived threat was the most significant predictor for hyperarousal and the HADS anxiety scores. The number of persons with whom one could talk was the most important predictor for the HADS depression score. Conclusions The occurrence rate of PTSD features for SARS survivors is in the middle of the range reported in previous samples of other medical diseases (2). For most SARS survivors, a significant decrease in symptom severity from 1 month to 3 months after discharge was identified. The significant predictive value pre·dic·tive value n. The likelihood that a positive test result indicates disease or that a negative test result excludes disease. predictive value a measure used by clinicians to interpret diagnostic test results. of Sa[O.sub.2] as an index of disease severity in this study suggests that direct physiologic measures may be more sensitive as indexes of disease severity than other indexes, which could be confounded by other factors (e.g., treatment regimen). Our findings imply that mobilization of resources for emotional support may enhance resilience of SARS survivors. SARS survivors who were healthcare workers, knew someone who had SARS, or had a history of psychiatric consultation had a higher risk for psychological distress and may warrant early and focused support services support services Psychology Non-health care-related ancillary services–eg, transportation, financial aid, support groups, homemaker services, respite services, and other services . Our study was limited by the low response rate and small sample size of certain groups of participants (e.g., healthcare workers and patients with history of psychiatric consultation). As criterion A in DSM-IV for PTSD, which focuses on the nature and personal response involved in the traumatic experience, was not specifically assessed, the occurrence rate of PTSD could not be taken as a prevalence estimate for PTSD in a straightforward manner. Such findings could better be substantiated by clinical interviews. The study is limited by the availability of a comparison group. Since SARS is a new disease, the psychological effect of some possible long-term physical outcomes related to the disease and treatment regimen (e.g., avascular necrosis Avascular necrosis is a disease resulting from the temporary or permanent loss of the blood supply to the bones. Without blood, the bone tissue dies and causes the bone to collapse. If the process involves the bones near a joint, it often leads to collapse of the joint surface. ) that were not discovered until recently were not captured.
Table 1. Results obtained for predictors with significant group
difference in IES-R and HADS subscales (N = 131) *
IES-R intrusion IES-R avoidance
M (SD) F M (SD) F
History of psychiatric consultation
Yes (n = 4) 2.31 17.24 ([section]) 1.71 5.73 ([double
(0.80) (0.084) dagger])
No (n = 127) 0.86 0.84
(0.68) (0.70)
Healthcare worker
Yes (n = 4) 1.28 4.26 ([dagger]) 1.16 2.43
(0.89) (0.73)
No (n = 127) 0.86 0.84
(0.69) (0.72)
Know someone to have SARS
Yes (n = 4) 1.01 2.09 1.00 2.98
(0.66) (0.75)
No (n = 127) 0.83 0.77
(0.76) (0.70)
IES-R hyperarousal
M (SD) F
History of psychiatric consultation
Yes (n = 4) 2.33 18.70 ([section])
(0.80)
No (n = 127) 0.80
(0.68)
Healthcare worker
Yes (n = 4) 1.35 7.61 ([double dagger])
(0.77)
No (n = 127) 0.79
(0.71)
Know someone to have SARS
Yes (n = 4) 0.96 2.42
(0.75)
No (n = 127) 0.76
(0.72)
HADS anxiety HADS depression
M (SD) F M (SD) F
History of psychiatric consultation
Yes (n = 4) 11.50 8.61 ([double 9.50 4.21 ([dagger])
(4.12) dagger]) (5.25)
No (n = 127) 5.00 5.03
(4.36) (4.25)
Healthcare worker
Yes (n = 4) 7.14 2.99 6.85 2.39
(4.94) (4.12)
No (n = 127) 4.96 4.97
(4.39) (4.33)
Know someone to have SARS
Yes (n = 4) 6.07 3.89 6.12 4.96 ([dagger])
(3.93) (4.24)
No (n = 127) 4.52 4.44
(4.78) (4.78)
* IES-R, Impact of Event Scale--Revised; HADS, Hospital Anxiety
and Depression Scale.
([dagger]) p<0.05.
([double dagger]) p<0.01.
([section]) p<0.001.
Table 2. Summary of multiple regression analyses of
IES-R and HADS subscales (N = 131) *
Predictor variables B [beta] s[r.sup.2]
Regression analysis to predict IES-R intrusion score
Subjective threat 0.12 0.18 0.03 ([dagger])
Emotional support -0.17 -0.18 0.03 ([dagger])
Sa[O.sub.2] -0.04 -0.22 0.04 ([dagger])
Regression analysis to predict IES-R hyperarousal score
Subjective threat 0.13 0.19 0.04 ([dagger])
Emotional support -0.14 -0.15 0.02
Sa[O.sub.2] -0.02 -0.13 0.02
Regression analysis to predict IES-R avoidance score
Subjective threat 0.15 0.22 0.05 ([double dagger])
Emotional support -0.17 -0.19 0.03 ([dagger])
Sa[O.sub.2] -0.05 -0.24 0.06 ([double dagger])
Regression analysis to predict HADS anxiety score
Subjective threat 0.73 0.18 0.03 ([dagger])
Emotional support -0.77 -0.13 0.02
Sa[O.sub.2] -0.16 -0.12 0.01
Regression analysis to predict HADS depression score
Subjective threat 0.24 0.06 0.00
Emotional support -10.03 -0.18 0.03 ([dagger])
Sa[O.sub.2] -0.18 -0.14 0.02
Predictor variables R [R.sup.2]
Regression analysis to predict IES-R intrusion score
Subjective threat 0.22 ([double dagger])
Emotional support -0.21 ([double dagger])
Sa[O.sub.2] -0.26 ([double dagger]) 0.13
Regression analysis to predict IES-R hyperarousal score
Subjective threat 0.22 ([double dagger])
Emotional support -0.17 ([dagger])
Sa[O.sub.2] -0.16 ([dagger]) 0.09
Regression analysis to predict IES-R avoidance score
Subjective threat 0.26 ([double dagger])
Emotional support -0.22 ([double dagger])
Sa[O.sub.2] -0.29 ([section]) 0.17
Regression analysis to predict HADS anxiety score
Subjective threat 0.20 ([double dagger])
Emotional support -0.15 ([dagger])
Sa[O.sub.2] -0.15 ([dagger]) 0.07
Regression analysis to predict HADS depression score
Subjective threat 0.09
Emotional support -0.20 ([dagger])
Sa[O.sub.2] -0.16 ([dagger]) 0.06
Predictor variables Overall F
Regression analysis to predict IES-R intrusion score
Subjective threat
Emotional support
Sa[O.sub.2] [F.sub.3, 127] = 6.57 ([section])
Regression analysis to predict IES-R hyperarousal score
Subjective threat
Emotional support
Sa[O.sub.2] [F.sub.3, 127] = 4.15 ([dagger])
Regression analysis to predict IES-R avoidance score
Subjective threat
Emotional support
Sa[O.sub.2]
Regression analysis to predict HADS anxiety score
Subjective threat
Emotional support
Sa[O.sub.2] [F.sub.3, 127] = 3.43 *
Regression analysis to predict HADS depression score
Subjective threat
Emotional support
Sa[O.sub.2] [F.sub.3, 127] = 20.91 ([dagger])
* IES-R, Impact of Event Scale--Revised; HADS, Hospital Anxiety and
Depression Scale, Subjective threat, subjective sense of threat;
emotional support, number of persons one could talk to and share
worries with; Sa[O.sub.2], lowest level of blood oxygen saturation
during hospitalization.
([dagger]) p<0.05.
([double dagger]) p<0.01.
([section]) P<0.001.
Acknowledgments We thank M.W. Tse, S.P. Lam, H.P. So, and K.M. Wong for their dedication in patient care; W.M. Tsang, T. Cheung, and C. Ng for their assistance in data collection and analysis; the Hospital Authority SARS Collaborative Group for data sharing The ability to share the same data resource with multiple applications or users. It implies that the data are stored in one or more servers in the network and that there is some software locking mechanism that prevents the same set of data from being changed by two people at the same time. ; and the patients who participated in the study. The study was supported by the Caritas Medical Centre, Kwong Wah Hospital Kwong Wah Hospital (Traditional Chinese: 廣華醫院) is a major hospital in South Kowloon of Hong Kong. It is located at Waterloo Road in Yau Ma Tei. , and Wong Tai Sin
Wong Tai Sin (Chinese: 黃大仙; Pinyin: Huáng Dàxian) is a Chinese deity popular in Hong Kong with the power of healing. Hospital. References (1.) World Health Organization. Data on SARS, 2003. [cited 2003 Aug 15]. Available from http://www.who.int/csr/sars/country/en/country2003 _08_15.pdf (2.) Tedstone JE, Tarrier tar·ry 1 v. tar·ried, tar·ry·ing, tar·ries v.intr. 1. To delay or be late in going, coming, or doing. See Synonyms at stay1. 2. To wait. 3. N. Posttraumatic stress disorder following medical illness and treatment. Clin Psychol Rev. 2003;23:4094-8. (3.) Au A, Chan I, Li P. Chan J, Chan YH, Ng F. Correlates of psychological distress in discharged patients recovering from acute respiratory syndrome 'respiratory syndrome' A relatively specific immune response to high-dose rifampin therapy, characterized by a flu-like complex, dyspnea and wheezing, leukopenia, thrombocytopenia; other hypersensitivity reactions caused by rifampin include flushing, fever, in Hong Kong. The International Journal of Psychosocial Rehabilitation. 2004;8:41-51. (4.) Cheng SKW SKW Schweizerischer Kosmetik- und Waschmittelverband (Swiss union of cosmetics and detergents) SKW Strike Warfare , Wong CW, Tsang CW, Wong KC. Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS). Psychol Med. 2004;34:1187-95. (5.) Wu KK, Chan KS, Ma MT. Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS). J Traum Stress. 2005;18:39-42. (6.) Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S galea /ga·lea/ (ga´le-ah) [L.] a helmet-shaped structure. galea aponeuro´tica the aponeurosis connecting the two bellies of the occipitofrontalis muscle. , Styra R. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis. 2004;10:1206-12. (7.) Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to Post Traumatic Stress Disorder, damage can be measured in physical changes inside the brain and to brain chemistry, which affect the person's and PTSD. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Guilford Press; 1997. p. 3994-11. (8.) Wu KK, Chan KS. The development of the Chinese version of Impact of Event Scale-Revised (CIES-R). Social Psychiatry social psychiatry n. The branch of psychiatry that deals with the relationship between social environment and mental illness. Psychiatr Epidemiol. 2003;38:94-8. (9.) Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361-70. (10.) Leung CM, Ho S, Kan CS, Hung CH, Chen CN. Evaluation of the Chinese version of the Hospital Anxiety and Depression Scale. international Journal of Psychosomatics. 1993;40:29-34. (11.) American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. . Diagnostic and statistical manual of mental disorders. 4th ed. Washington: The Association; 1994. Kitty K. Wu, * Sumee K. Chan, ([dagger]) and Tracy M. Ma ([double dagger double dagger n. A reference mark (  ) used in printing and writing. Also called diesis.Noun 1. ]) * Caritas Medical Centre, Hong Kong; ([dagger]) Princess Margaret Hospital, Hong Kong Princess Margaret Hospital (Chinese: 瑪嘉烈醫院) or PMH is a hospital in south Kwai Chung, near Lai Chi Kok, Hong Kong. It is a major hospital mostly serving Kwai Tsing District and managed by Hospital Authority. ; and ([double dagger]) Kwong Wah
Kwong Wah and Wong Tai Sin Hospitals, Hong Kong Dr. Wu is the clinical psychologist in charge of the Caritas Medical Centre in Hong Kong. She is an adjunct assistant professor and an honorary assistant professor in the Departments of Psychology of the Chinese University of Hong Kong The motto of the university is "博文約禮" in Chinese, meaning "to broaden one's intellectual horizon and keep within the bounds of propriety". and the University of Hong Kong The University of Hong Kong (commonly abbreviated as HKU, pronounced as "Hong Kong U") is the oldest tertiary institution in Hong Kong. Its motto is "Sapientia et Virtus" in Latin, and " , respectively. Her research interests include traumatic stress Traumatic stress is recognized by the Diagnostic and Statistical Manual of Mental Disorders [1] as an acute emotional condition associated with reactive anxiety. and developmental neuropsychology neuropsychology Science concerned with the integration of psychological observations on behaviour with neurological observations on the central nervous system (CNS), including the brain. . Address for correspondence: Kitty Wu, Department of Clinical Psychology, Caritas Medical Centre, 111 Wing Hong St, Shamshuipo, Kowloon Hong Kong; fax: 852-2307-5894; email: wukyk@ha.org.hk |
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