|ORIGINAL RESEARCH REPORT
|Year : 2018 | Volume
| Issue : 1 | Page : 41-47
A study of anxiety and depression among patients undergoing radiological investigations in a Nigerian Tertiary Hospital
Raphael Emeka Ogbolu1, Olubukola Abeni Titilayo Omidiji2
1 Department of Psychiatry, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Radiation Biology, Radiotherapy, Radiodiagnosis and Radiography, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
|Date of Web Publication||23-Feb-2018|
Dr. Olubukola Abeni Titilayo Omidiji
Department of Radiodiagnosis, Lagos University Teaching Hospital, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: Patients who come for radiological investigations often have anxiety due to a number of factors – the fear of hospitals, injections, diagnosis, or being in an enclosed space. Such anxiety needs to be allayed to prevent delays, incomplete tests, or cancellations. The study aims to assess the prevalence of anxiety and depression among patients undergoing radiological investigations in a tertiary hospital. Materials and Methods: Two hundred and three literate, consenting adults who presented to the Radiology Department of a Teaching Hospital, from May 2015 to April 2016, were recruited consecutively. Children and adults who could not read/write were excluded from the study. Instruments used were a sociodemographic questionnaire, the State-Trait Anxiety Inventory (STAI) for state anxiety, and Hospital Anxiety and Depression Scale (HADS). Data were analyzed using IBM SPSS for Windows version 22. Results: The mean HADS score for anxiety was 5.0 + 4.4 (Range 0–12), and for depression, the mean score was 5.2 + 4.3 (Range 0–19). Twenty-nine (14.3%) respondents screened positive for depression, while 27 (13.3%) had suspected borderline depression. Thirty (14.8%) screened positive for anxiety, with 27 (13.3%) being borderline anxiety as well. Anxiety and depression were the most common among those with an unknown diagnosis (4.4% and 6.4%, respectively). The mean STAI score was 46.48 + 7.2 (Range 25–67). Thirty (14.8%) respondents had anxiety, while 27 (13.3%) were borderline. Ninety-three (45.8%) had state anxiety, the most common among those with unknown diagnoses (15.3%). Depression was mostly seen among those undergoing magnetic resonance imaging (6.9%) P < 0.05. Conclusion: State anxiety, probable anxiety disorder, and probable depressive disorder were quite common with a prevalence of 45.8%, 14.8%, and 14.3%, respectively; these should be addressed among participants going for radiological investigations, especially those with an unknown diagnosis. A pretest counseling session is a good recommendation for such participants to allay anxiety.
Keywords: Adults, anxiety, depression, investigations, radiology
|How to cite this article:|
Ogbolu RE, Omidiji OA. A study of anxiety and depression among patients undergoing radiological investigations in a Nigerian Tertiary Hospital. J Clin Sci 2018;15:41-7
|How to cite this URL:|
Ogbolu RE, Omidiji OA. A study of anxiety and depression among patients undergoing radiological investigations in a Nigerian Tertiary Hospital. J Clin Sci [serial online] 2018 [cited 2022 Aug 18];15:41-7. Available from: https://www.jcsjournal.org/text.asp?2018/15/1/41/226041
| Introduction|| |
Anxiety as a feeling or state can be a normal part of life, in which case, it can be defined as, “an abnormal and overwhelming sense of apprehension and fear often marked by physical signs (such as tension, sweating, and increased pulse rate), by doubt concerning the reality and nature of threat, and self-doubt about one's capacity to cope with it.” Certain and different things can bring about a state of anxiety to varying degrees in different people. When such an anxiety state becomes more sustained, with associated impairment of functioning it amounts to an anxiety disorder, which includes “separation anxiety disorders, selective mutism, specific phobia, social anxiety, disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety disorder, and anxiety disorder due to another medical condition.”
Similarly, it is a normal part of life to feel sad in relationship to events of everyday life; however, sadness is usually transient and does not affect functioning significantly. Sustained low mood as seen in a clinical depression, on the other hand, is a disabling condition.
Anxiety and depression are termed the common mental disorders, and both are becoming increasingly common. Between the years 1990 and 2013, both increased globally by about 50%, affecting close to 10% of the world population. Depression affects about 322 million people worldwide (4.4% of the world population), while anxiety disorders affect about 264 million (3.6% of world population). They both contribute to global disability; 3.4% Years lived with disability (YLDs) in the case of anxiety and 7.5% of YLDs in the case of depression, making it the single largest contributor to global disability, according to the WHO.
Anxiety and depression are also strongly associated with general medical conditions, especially chronic medical conditions in the case of depression. Depression has been found to be highly comorbid with anxiety, ulcer, musculoskeletal disorders, and chronic pain. Among Nigerians, the lifetime prevalence of a major depressive disorder among Nigerians has been put at 3.1%, while for anxiety disorders, it is 5.7%. Specific phobia was the most common of the anxiety disorders. Of the two, anxiety is more common at primary care level, in the community with a 4.1% 12-month prevalence.
The experience of anxiety feelings or the occurrence of anxiety disorders may be associated with different aspects of illness such as from the experience of symptoms of illnesses, to diagnosis, and even treatment. The phobia for hospitals (nosocomephobia) or for hospital personnel may occur prior to hospital admission and may date back to early childhood. Certain aspects of visiting the hospital may elicit anxiety more than others, such as going for surgery, being given an injection and waiting for laboratory or other investigation results.
Claustrophobia, a specific phobia in which individuals experience fear in relation to being in enclosed places, comes to mind when considering anxiety in association with radiological examinations because magnetic resonance imaging (MRI) and computerized tomography (CT) scans require the individual to remain in an enclosed space, alone, for a duration of time. Some studies have explored this relationship. The possibility of such a relationship constitutes an additional reason why patients undergoing radiological investigations may experience anxiety, aside from the mild-to-moderate apprehension of not knowing the outcome of the tests.
The usefulness in exploring this relationship between anxiety among those undergoing radiological procedures arises because the possibility of a connection between one's level of anxiety during tests and the outcome of these tests exists. Some researchers, for instance, found an association between preprocedure anxiety and postprocedure pain among those undergoing hysterosalpingography.
An anxious patient may not be able to hold still long enough to complete the study, thereby resulting in a test outcome, that is, unacceptable, or leading to cancellations or undue delays, which in turn can affect the patient turnover, and undue delays may even spook other susceptible waiting patients. These states of anxiety can inadvertently, indirectly, or directly affect the efficiency of radiological investigations. Yıldızer Keriş examined anxiety among patients undergoing cone beam CT scan and found a mean State-Trait Anxiety Inventory (STAI)-S score of 37.2 and also reported that patients showing motion artifacts had higher STAI scores than those not showing artifacts, although not significantly so. The diagnosis or the indication for investigation may itself be a source of anxiety and may compound the anxiety already associated with the radiological investigations. Indeed many studies have identified anxiety among patients with such radiologically investigated conditions such as cancer , and dental treatment. Andersen et al. noted anxiety among cancer patients undergoing radiotherapy.
There has been interest in ways that this anxiety associated with radiological investigations can be addressed, and communication has been suggested as being helpful., Tamburrini et al. had suggested the need for more interaction between the patient and radiologist based on their findings that all their studied participants undergoing diagnostic imaging had anticipatory anxiety, which was of psychopathological levels in >50% of them. Acuff et al. found that a calling device used to maintain communication between the patient and technologist reduced anxiety in positron emission tomography/CT imaging.
There is a general dearth of studies on depression among those undergoing diagnostic investigations. It is, however, possible that repeated investigations associated with an unknown diagnosis may make a patient more likely to develop depression, and it may be similar to depression among those undergoing elective procedures.
A number of instruments have been used to study anxiety and depression in the hospital setting most notably Spielberger's STAI-, as well as the Hospital Anxiety and Depression Scale (HADS).,,,,,,
This study aimed to determine the prevalence of state anxiety, probable anxiety disorder, and probable depressive disorder among patients undergoing radiological investigations in a tertiary hospital. We believe that the findings from this study provide evidence for the need for interventions that will allay patients' anxiety and worries before such tests and therefore make the experience a better one for them.
| Materials and Methods|| |
This was a cross-sectional study with a consecutive sampling of all participants drawn at a University Teaching hospital from among those presenting at the radiology department over a 1-year period (from May 2015 to April 2016). The general population of people consists of those from different ethnic groups and nationalities, as the study was conducted in a cosmopolitan city.
All literate, adult cases who presented at the Radiology Department for ultrasound scan (USS), X-rays, MRI, and CT scans and agreed to participate in the study were included while those below 18 years old and who cannot read/write English were excluded from the study.
Patient's consent was sought and obtained after ethical approval was obtained from the institution. The study did not interfere with the participants' investigations.
A pretest was conducted using twenty participants at another center, and some questions were modified for better understanding. The study was explained to the participant, and following acceptance to participate the study, questionnaires were self-administered before the investigation was carried out. The administration took <15 min.
The STAI for adults developed by Spielberger was one of the instruments utilized, with questions on sociodemography., State Anxiety scale was used to ascertain the anxiety at the time of administration (i.e., in that state). It consists of two separate self-report scales, one for detecting state anxiety and the other for detecting trait anxiety. State anxiety is a transitory state characterized by a subjective feeling of tension and apprehension with associated autonomic arousal that is consciously perceived, or as “a transient momentary emotional status that results from situational stress.” The focus of this study is the detection of state anxiety, and for the purpose of this study, the State-Anxiety scale cutoff score of ≥40 was used.
The second instrument was the HADS formulated by Zigmond and Snaith,, used to identify probable anxiety and depression among patients in this nonpsychiatric clinical setting. It has seven anxiety and depression subscales each, rated from 0 to 3 and a maximum score of 21 for each. A cutoff score of ≥11 was used. Those found to have probable anxiety and depressive disorders were referred to the counseling unit of the hospital, while those with state anxiety were given reassurances about the intended procedure to allay their fears.
Data were analyzed using the IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY, USA: IBM Corp. The study yielded continuous and categorical data to which descriptive statistics, including frequencies, means, and tests of significance such as Chi-square, were applied, with a statistical significance set at 0.05.
A repeat assessment of the participants after the study and cost of investigation as a confounder was not conducted. Preexisting conditions or background mental disorders were also not addressed as the focus was on state anxiety.
| Results|| |
A total of 203 participants were seen, of which 105 (51.7%) were female, the majority were aged 30–39 years (47, 23.2%), married (n = 135, 66.5%), highly skilled professionals (n = 88, 43.3%), had tertiary education (n = 135, 66.5%), and Christians (n = 162, 79.8%) [Table 1].
The most common investigation was the USS (54.2%), followed by MRI (26.6%), CT scan (13.8%), and X-ray (5.4%); P > 0.05. Of those sent for radiological investigations, the diagnostic category was unknown in majority of the cases, i.e., 29.6% of all participants. This was followed by inflammatory/painful conditions (20.2%), neoplasm (11.8%), cerebrovascular/neurological conditions (6.4%), pregnancy related (5.4%), infertility (3.4%), and infections (2.5%). Other less common conditions such as blurred vision and postoperative routine accounted for 20.7% [Table 2].
|Table 2: Investigation and diagnostic category among gender in the study|
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The mean HADS score for anxiety was 5.0 and standard deviation (SD) was 4.4 (Range 0–12), and for depression, the mean score was 5.2 and SD was 4.3 (Range 0–19). Twenty-nine respondents (14.3%) screened positive for depression using the HADS, while 27 (13.3%) had suspected borderline depression. Thirty respondents (14.8%) had anxiety, while 27 (13.3%) were borderline, and 146 (71.9%) were normal using HADS [Table 3].
Using STAI to assess state anxiety, 93 participants (45.8%) had state anxiety, while 110 (54.2%) were normal. The mean STAI score was 46.48 and SD was 7.2 (Range 25–67) [Table 3].
Using investigations, depression was most often seen among those undergoing MRI (6.9%), followed by CT scan (3.9%) and ultrasound (3.4%); F = 30.0, df = 6, P < 0.05. Probable anxiety was the most common among those undergoing CT scan and ultrasonography (4.9% each), followed by MRI (3.9%); F = 18.946, df = 6, P < 0.05. State anxiety was the most common among those undergoing USS (20.7%), MRI (14.3%), and CT scan (7.9%). P > 0.05, df = 3, χ2 = 5.721 [Table 4].
When assessing by diagnosis using HADS, depression was the most common among those with an unknown diagnosis, (4.4%) followed by those with inflammatory/painful conditions (3.9%), and neoplasms and cerebrovascular/neurological disorder conditions (2.0%) each. Anxiety was the most common among those with an unknown diagnosis, (6.4%) followed by those with inflammatory/painful conditions (4.4%), cerebrovascular/neurological disorders conditions (1.4%), and neoplasms (0.9%). State anxiety was the most common among those with an unknown diagnosis (15.3%), followed by inflammatory/painful conditions (10.3%), other diagnoses (8.4%), neoplasms (6.4%), infertility (1.4%), among others [Table 5].
One hundred and thirty-six participants (67.0%) reported doing the investigation for the first time. Majority of the first-timers had no state anxiety (54.4%) compared with those repeating the investigations (45.6%) [Table 6].
|Table 6: Prevalence of state anxiety among first-timers and non first-timers|
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Twenty-six (86.7%) of those identified as probable cases of anxiety disorder using HADS showed state anxiety using STAI, while 67.1% of those without an anxiety disorder showed no state anxiety. On the other hand, 48 (51.6%) of those with state anxiety had no anxiety using HADS. Nearly 53.8% of those with state anxiety did not have a depressive disorder (P< 0.005) [Table 7].
|Table 7: Comparison of Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory scores in diagnosing anxiety Hospital Anxiety and Depression Scale versus State-Trait Anxiety Inventory|
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| Discussion|| |
The studied participants were spread across a wide age range, predominantly young adults. They were also mostly married, across a wide range of occupational skills and educational levels, and were mostly either Christian or Moslem. This pattern has also been noted in some studies in Southwest Nigeria.
The majority of participants came in for USS (54.2%). This may be due to the ubiquitous application of ultrasound as an investigative tool; or it may be a cost-dependent finding, as it tends to be cheaper than the other investigations. A similar finding is noted in a United Kingdom study of junior doctors and their radiological requests.
The prevalence of anxiety and depression using HADS was 14.8% and 14.3%, respectively. This HADS prevalence of anxiety was much lower than the state anxiety found in 45.8% of the participants. This suggests that while most of the participants may not have had a sustained state of anxiety in the form of an anxiety disorder, close to half of them had features of anxiety associated with their state of mind before or in association with the radiological investigation. The mean STAI score found is similar to that by Flory and Lang in their study on distress in the radiology waiting room at a medical school in Boston Massachusetts. Their study was similar to ours in they studied patients waiting for radiological procedures immediately before the procedures being conducted and they also used instruments for assessing anxiety in the radiology department. They also found that anxiety was higher among patients unsure of their diagnosis. The mean STAI score (46.48) was higher than that by Yıldızer Keriş (37.2) in his study of anxiety among those undergoing cone beam CT scan with motion artifacts. This difference may be related to the fact that this study also examined patients undergoing interventional radiological procedures.
Patients undergoing radiologic investigations for nonspecific symptoms or unknown diagnosis often experience anxiety, as seen in a study of patients suspected to have cancer (before the diagnosis being made). This was seen in this study as participants with unknown diagnoses had the higher percentages of anxiety and depression using the HADS scale.
MRI is one of the imaging modalities associated with anxiety, as seen in this study, in which a higher percentage of participants who had MRI done had anxiety. It came second to ultrasound, which had the highest percentage of anxiety in the study. Antwi et al., studying pre- and postprocedural anxiety among patients undergoing an USS, found that a lack of preprocedural information and fear of the examination outcomes were the major causes of anxiety.
Katz et al. also noted that 37% of patients undergoing MRI had moderate-severe anxiety, due to multifaceted reasons, including but not limited to fear of the unknown and pain. Harris et al. studied prediction of anxiety in 118 patients undergoing MRI scans using the MRI fear survey. The survey significantly predicted the number of panic attack symptoms and state anxiety experienced during MRI examinations. They also found that noise and being confined were the most unpleasant features identified by 48.3% of the participants. Chapman et al. also studied MRI-related anxiety in healthy male volunteers and found that anxiety was highest during the first MRI scan but dropped to control levels or below during the second scan.
The finding that most of the participants undergoing investigations for the first time did not experience state anxiety suggests that being a first timer did not seem to make them more likely to experience state anxiety. There are likely to be other factors contributory.
From the findings, it can be seen that while STAI tended to follow the same direction as HADS in terms of anxiety, having state anxiety did not translate to having a probable anxiety disorder using HADS. This supports the purpose for which the instruments were designed as having a probable anxiety disorder is a more enduring feature whereas state anxiety may be situational or circumstance related and so it implies that other factors are contributory to state anxiety. Having a depressive disorder did not seem to be a contributory factor to having state anxiety as the results showed that most of the participants with state anxiety did not have probable depression.
| Conclusion|| |
State anxiety (as identified by a useful instrument as STAI), probable anxiety, and probable clinical depression are quite common with a prevalence of 45.8%, 14.8%, and 14.3%, respectively, and should be addressed among participants going for radiological investigations, especially those with an unknown diagnosis. Caregivers should be made aware of this so they can be more empathetic in managing patients.
A pretest counseling session is a good recommendation for participants before undergoing radiological investigations. Those found to have state anxiety should be monitored during the remainder of their management. Possible ways to mitigate anxiety should be looked into, such as playing music in the waiting room and/or during the procedure.
We would like to thank the members of the Radiodiagnosis Department, Lagos University Teaching Hospital and Miss Suliat Adeleke for their support during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]