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Anxiety and depression in hospitalized patients in resistant organism isolation. (Original Article).

Background: Previous studies have reported an increase in psychiatric symptoms in seriously ill patients who were placed in resistant organism isolation. We conducted this study to assess whether there is an increase in symptoms of anxiety and depression in patients who are not critically ill and are placed in isolation.

Methods: Patients hospitalized with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus species infections were evaluated with the Hamilton Anxiety Rating Scale and the Hamilton Depression Rating Scale at baseline and again during hospitalization. The results were then compared with the results of patients who were hospitalized for infectious diseases that did not require isolation.

Results: Patients in isolation had significantly higher scores on both the anxiety and depression scales at the time of follow-up than did patients who were not isolated. There was no significant difference between the scores of the two groups before isolation.

Conclusion: The results of this preliminary study suggest that placement in resistant organism isolation may increase hospitalized patients' levels of anxiety and depression.

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There are clinical situations in the general hospital in which contact isolation is necessary. The most common types of infectious disease isolation are source isolation and reverse barrier isolation. (1) Source isolation refers to a patient who is colonized or infected by an organism and requires isolation to protect other patients from possible infection. (1) Protective (ie, reverse barrier) isolation protects the patient from infections potentially carried by others. (1) Both types of isolation may adversely affect the delivery of medical care. For example, physical rehabilitation can be hampered by isolation protocols because of the patient's restricted access to the physical therapy areas. (2) Many community facilities are reluctant to accept patients who require that isolation precautions be taken. (2)

Another consideration is that patients dislike being placed in isolation. Patients in isolation often perceive that they are treated differently from other patients. (1) These concerns about different levels of care may not be far off the mark; in their study, Kirkland and Weinstein (3) found that health care workers were half as likely to enter the room of a patient in contact isolation as they were to enter the room of a nonisolated patient.

There is concern that isolation may negatively affect a patient's mental health. Peel et al (2) stated that the psychologic impact of spending weeks in isolation is "considerable." MacKellaig (1) reported that "extreme changes in human behavior" can occur in people who have been isolated, including delusions, hallucinations, and memory disturbances. Holland et al (4) noted that these patients felt isolated and that they thought that their "most significant" psychologic deprivation was the loss of human touch. Gammon (5) noted that isolated patients had significant feelings of "helplessness" and that "source isolation does have negative psychological effects."

Investigators who have examined this phenomenon have found varying results. Wilkins et al (6) examined patients in isolation cubicles. They thought that behavioral illness did not seem to be related directly to the experience of isolation. Another study followed 39 patients who were placed in isolation rooms with laminar air flow (LAF) while undergoing bone marrow transplantation (BMT). In that study, Sasaki et al (7) stated that variables that predicted the development of mental disturbance in this population included female sex and having an unrelated bone marrow donor. In a retrospective chart review by Zerbe et al, (8) BMT patients who were placed in reverse isolation were compared with those in LAF rooms. Patients who were isolated in LAF rooms had significantly higher anxiety levels. In another study, questionnaires were sent to facilities that used LAF units in their isolation settings. (9) Symptoms commonly reported in isolated patients included depression, hallucinations, anxiety, and irregular sleep patterns. (9) Another study followed patients who were scheduled to undergo BMT and spend significant time in a protected environment. (10) They found that patients' anxiety decreased during the course of the hospitalization, whereas depression was noted to increase throughout the isolation period. (10) Hollenbeck et al (11) monitored children who were treated for cancer in LAF rooms. The most frequently scored behavior was passivity. (11) Using the State-Trait Anxiety Inventory, Powazek et al (12) also examined isolation in children with cancer. Older children were found to be more anxious, possibly because of a "greater awareness of the seriousness of their medical condition and its consequences." (12)

Most researchers agree that isolation can affect a patient's emotional state. In the studies described above, the evaluated patients were seriously ill and required BMT with placement in a germ-free environment. We studied patients who were less seriously ill but who were still placed in infectious disease isolation. We sought to assess whether contact isolation is associated with an increase in the symptoms of anxiety and depression in patients in the acute hospital setting who are not critically ill.

Patients and Methods

Research Design

After obtaining approval from our hospital and university institutional review boards, 102 patients ages 18 years and older were entered into the study. Each patient received a complete description of the study, and written informed consent was obtained. We asked consecutive patients admitted to the isolation and infectious disease units to participate. Forty-one percent of those patients invited to take part in the study agreed to participate. The active patients were in resistant organism isolation because of colonization or infection with either methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus species. The control patients were admitted to the hospital for the treatment of infections that did not require contact isolation or respiratory isolation. None of the patients included in this study required treatment in an intensive care unit. Of these patients, 27 isolation patients and 24 control patients provided at least initial data and 1-week follow-up data, and 12 isolation p atients and 9 controls provided initial data as well as 1- and 2-week follow-up data. Patients who developed delirium because of worsening of their medical condition and isolation patients who had family members stay with them in their rooms were excluded from the study.

Control patients received their baseline evaluations within the first 48 hours after hospital admission. Isolation patients underwent baseline evaluations within the first 48 hours after admission if they were placed on isolation status at admission or within the first 48 hours after being placed in isolation. The 14-item Hamilton Anxiety Rating Scale (HAM-A) and the 21-item Hamilton Depression Rating Scale (HAM-D) were used at baseline and at weekly intervals. Staff who had been trained in the use of these scales administered them. Individual patients had all of their evaluations completed by the same staff member. Patients who were taking established doses of benzodiazepines when they were admitted to the hospital were allowed to remain in the study. Patients who used "as needed" doses of benzodiazepines or who were given new prescriptions for benzodiazepines were excluded. Patients who had been taking stable doses of antidepressants for more than 3 months were allowed to participate. Patients who were taki ng newly prescribed antidepressants were excluded.

Statistical Analysis

The characteristics of patients in the isolation group and the control sample were compared with the use of t tests for continuous variables and [chi square] analysis for categorical variables. Changes in HAM-D and HAM-A scores were examined by performing analysis of covariance (ANCOVA) with a single between-group factor (isolation or control group), a single within-group factor (baseline or follow-up), and age as a covariate.

Sample Characteristics at Baseline

Of the 102 patients who consented to participate in the study, 51 provided both baseline and 1-week follow-up data. Twenty-one patients (12 in the control group and 9 in isolation) provided baseline, 1-week follow-up, and 2-week follow-up data. The baseline characteristics of the group of patients who completed both the initial evaluation and the I-week follow-up evaluation are presented in Table 1. The groups were roughly equal in size. The mean ages of the patients in the two groups were not significantly different (P = 0.188), even though the difference in the mean was almost 7 years. We noted, however, that the statistical power of this analysis was only 0.42; therefore, subsequent analyses were conducted with age as a covariate. There was a significant difference in the proportion of men and women between the isolation group and the control group (P = 0.001). As noted in Table 1, men predominated in the control group, and women made up a majority of the isolation group. Although there was a difference be tween groups with regard to sex, there were no differences in test scores between the sexes within groups. Once again, although the isolation group did have a higher percentage of patients with a prior Axis I psychiatric diagnosis than the control group, this difference was found not to be significant (P = 0.173). Also, correlation analyses showed that there was no relationship between the presence of a prior Axis I psychiatric diagnosis and change in HAM-A or HAM-D score for either the isolation group or the control group (P > 0.05).

Results

The pattern of the HAM-D scores during the two test periods is shown in Figure 1. The control group's score decreased from 8.46 to 6.00 after 1 week of hospitalization, and the isolation group's score increased from 8.42 to 10.73. The ANCOVA showed this time-by-group interaction to be significant (P < 0.001). The HAM-D results obtained when only the patients who were available for the initial evaluation and two weekly follow-up visits were included are shown in Figure 2. The control group's scores began at 9.78, then dropped first to 5.44 and then to 4.22 at Weeks 1 and 2. The isolation group's scores began at 7.25, increased to 8.83 at Week 1, and then increased to 11.50 at Week 2. The ANCOVA of baseline and Week 2 follow-up scores again showed the time-by-group interaction to be significant (P = 0.001).

The pattern of the HAM-A scores during the two test periods is shown in Figure 3. The control group's score decreased from 8.37 to 4.71 after 1 week of hospitalization, and the isolation group's score increased from 8.00 to 11.11. The ANCOVA showed this time-by-group interaction to be significant (P < 0.001). The HAM-A results obtained when only the patients who were available for the initial evaluation and two weekly follow-up visits were included are shown in Figure 4. The control group's scores began at 11.00, then decreased first to 4.44 and then to 2.44 at Weeks 1 and 2. The isolation group's scores began at 5.83, increased to 8.67 at Week 1, and then decreased slightly to 8.33 at Week 2. The ANCOVA of baseline and Week 2 follow-up scores again showed the time-by-group interaction to be significant (P < 0.001).

Discussion

On the basis of our findings, it seems that resistant organism isolation does have negative effects on a patient's mood and also causes an increase in anxiety level. Although our nonisolated patients with infectious illness had a noticeable improvement in their HAM-A and HAM-D scores while in the hospital, this statement could not be made of patients in isolation. In fact, there were significant differences between the HAM-A and HAM-D scores of isolation patients and the control group after only 1 week of isolation. This difference continued to be significant during the second follow-up visit as well. Many of the earlier studies focused on the responses of seriously ill patients (eg, BMT patients) to strict isolation, such as LAF rooms. (4,7,8,10) Our study demonstrates that significant negative alterations in mood and anxiety level occur after only 1 week of isolation, even in those patients who were not as severely ill as those studied previously.

The goal of any isolation experience is likely to be to allow the patient's physical health to improve without worsening mental function. Future studies may show that some of the previously suggested isolation coping strategies are helpful in solving this problem. These strategies include the suggestion of Holland et a1 (4) that patients be prepared emotionally before being placed in isolation as a way to decrease their anxiety. Zerbe et a1 (8) recommended that each patient be given tours and educational materials to explain the isolation unit and its procedures as a way to decrease the psychologic stress of isolation. The physician who cares for isolation patients may wish to consider these recommendations.

This study has a number of limitations. First, the number of patients involved is small; with only 51 active patients, it is difficult to generalize the findings of this study to larger populations. Second, the study lasted for only three visits with the patients enrolled for the longest period. It would be helpful to continue the study for a longer period to better understand this phenomenon. Third, although the study focused on mood and anxiety disturbances, cognitive disturbances could have been assessed as well. Also, this study design did not permit a blind rating, so bias cannot be excluded. Another limitation is that it remains difficult to control for the severity of medical illness in this patient population.

On the basis of our findings, we conclude that resistant organism isolation seems to cause an increase in symptoms of anxiety and depression compared with those seen in patients who are hospitalized for treatment of an infectious process but are not isolated. Because patients who are placed in resistant organism isolation can experience worsening of anxiety and depression symptoms as early as 1 week after they are placed in isolation, strategies designed to diminish the negative impact of this setting should be developed and implemented.

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Table 1

Group characteristics at baseline

 Isolation Control
 group group
Characteristic (n = 27) (n = 24)

Mean age (yr) 52.2 [+ or -] 15.3 59.0 [+ or -] 19.7
Sex
 No. of men 10 20
 No. of women 16 4
Prior Axis I psychiatric 22.2% 8.3%
 diagnosis (%)


Acknowledgment

We thank John Schinka, PhD, for his review of the manuscript and his assistance with the statistical analysis.

Accepted June 24, 2002.

References

(1.) MacKellaig JM. A study of the psychological effects of intensive care with particular emphasis on patients in isolation. Intensive Care Nurs 1987;2:176-185.

(2.) Peel RK, Stolarek I, Elder AT. Is it time to stop searching for MRSA? Isolating patients with MRSA can have long term implications. BMJ 1997;315:58 (letter).

(3.) Kirkland KB, Weinstein JM. Adverse effects of contact isolation. Lancet 1999;354:l177-1178.

(4.) Holland J, Plumb M, Yates J, Harris S, Tuttolomondo A, Holmes J, et al. Psychological response of patients with acute leukemia to germ-free environments. Cancer 1997;40:871-879.

(5.) Gammon J. The psychological consequences of source isolation: A review of the literature. J Clin Nurs 1999,8:13-21.

(6.) Wilkins EG, Ellis ME, Dunbar EM, Gibbs A. Does isolation of patients with infections induce mental illness? J Infect 1988;17:43-47.

(7.) Sasaki T, Akaho R, Sakamaki H, Akiyama H, Yoshino M, Hagiya K, et al. Mental disturbances during isolation in bone marrow transplant patients with leukemia. Bone Marrow Transplant 2000;25:315-318.

(8.) Zerbe MB, Parkerson SG, Spitzer T. Laminar air now versus reverse isolation: Nurses' assessments of moods, behaviors, and activity levels in patients receiving bone marrow transplants. Oncol Nurs Forum 1994; 21:565-568.

(9.) Kellerman J, Rigler D, Siegel SE. The psychological effects of isolation in protected environments. Am J Psychiatry 1977;134:563-565.

(10.) Meyers CA, Weitzner M, Byrne K, Valentine A, Champlin RE, Przepiorka D. Evaluation of the neurobehavioral functioning of patients before, during, and after bone marrow transplantation. J Clin Oncol 1994;12:820-826.

(11.) Hollenbeck AR, Susman EJ, Nannis ED, Strope BE, Hersh SP, Levine AS, et al. Children with serious illness: Behavioral correlates of separation and isolation. Child Psychiatry Hum Dev 1980;11:3-11.

(12.) Powazek M, Goff JR, Schyving J, Paulson MA. Emotional reactions of children to isolation in a cancer hospital. J Pediatr 1978;92:834-837.

RELATED ARTICLE: Key Points

* Infectious disease isolation has been associated with many psychiatric symptoms, including anxiety, depression, hallucinations, and delusions.

* Previous studies have monitored only critically ill patients who were placed in isolation.

* This study suggests that, as compared with patients who are not isolated, even patients who are not critically ill show increased symptoms of anxiety and depression when placed in isolation.

From the Departments of Psychiatry and Behavioral Medicine and Internal Medicine, and the College of Medicine, University of South Florida, Tampa, FL; the Psychiatric Service, James A. Haley Veterans Hospital, Tampa, FL; and the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY.

Reprint requests to Glenn Catalano, MD, University of South Florida Psychiatry Center, 3515 E. Fletcher Avenue, Tampa, FL 33613. Email: gcatalan@hsc.usf.edu

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9602.0141
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:research indicates that placement in resistant organism isolation may increase hospitalized patients' anxiety and depression
Author:Laliotis, Georgia J.
Publication:Southern Medical Journal
Date:Feb 1, 2003
Words:2814
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