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Guest Editorial
Palliative Care: An Opportunity for Mental Health Professionals
Harvey Max Chochinov
(PDF)

In Review
Structured Interview Assessment of Symptoms and Concerns in Palliative Care
Keith G Wilson, Ian D Graham, Raymond A Viola, Susan Chater, Barbara J de Faye, Lynda A Weaver, Julie A Lachance
(PDF)

Palliative Care for Families: Remembering the Hidden Patients
Linda J Kristjanson, Samar Aoun
(PDF)

Psychotherapeutic Interventions at the End of Life: A Focus on Meaning and Spirituality
William Breitbart, Christopher Gibson, Shannon R Poppito, Amy Berg
(PDF)

Review Paper
Prevalence Studies of Substance-Related Disorders: A Systematic Review of the Literature
Julian M Somers, Elliot M Goldner, Paul Waraich, Lorena Hsu
(PDF)

Original Research
Stress and Psychological Impact on SARS Patients During the Outbreak
Siew E Chua, Vinci Cheung, Grainne M McAlonan, Charlton Cheung, Josephine WS Wong, Erik PT Cheung, Marco TY Chan, Teresa KW Wong, Khai M Choy, Chung M Chu, Peter WH Lee, Kenneth WT Tsang
(PDF)

Brief Communication
Psychological Effects of the SARS Outbreak in Hong Kong on High-Risk Health Care Workers
Siew E Chua, Vinci Cheung, Charlton Cheung, Grainne M McAlonan, Josephine WS Wong, Erik PT Cheung, Marco TY Chan, Michael MC Wong, Siu W Tang, Khai M Choy, Meng K Wong, Chung M Chu, Kenneth WT Tsang
(PDF)

Schizophrenia: The Quest for a Minimum Sense of Identity to Ward Off Delusional Disorder
Marie-Christine Noël-Jorand, Max Reinert, Sébastien Giudicelli, Daniel Dassa
(PDF)

Diabetes, Tardive Dyskinesia, Parkinsonism, and Akathisia in Schizophrenia: A Retrospective Study Applying 1998 Diabetes Health Care Guidelines to Antipsychotic Use
Emmanuelle Lévy, Howard C Margolese, Lawrence Annable, Guy Chouinard
(PDF)

The Psychosocial Effects of Being Quarantined Following Exposure to SARS: A Qualitative Study of Toronto Health Care Workers
Emma Robertson, Karen Hershenfield, Sherry Lynn Grace, Donna Eileen Stewart
(PDF)

Hard Times and Good Friends: Negative Life Events and Social Support in Patients With Seasonal and Nonseasonal Depression
Erin E Michalak, Edwin M Tam, Chinnapalli V Manjunath, Lakshmi N Yatham, Anthony J Levitt, Robert D Levitan, Raymond W Lam
(PDF)

Letters to the Editor
(PDF)

Combined Transcranial Magnetic Stimulation and Right Unilateral Electroconvulsive Therapy in Patients With Treatment-Refractory Depression

Re: Treatment Noncompliance With Orally Disintegrating Olanzapine Tablets

Reply: Treatment Noncompliance With Orally Disintegrating Olanzapine Tablets

Quetiapine in the Management of Psychosis Secondary to Huntington's Disease: A Case Report

Ziprasidone-Induced Lupus Erythematosus

Lorazepam-Induced Prolongation of the QT Interval in a Patient With Schizoaffective Disorder and Complete AV Block

Original Research

Stress and Psychological Impact on SARS Patients During the Outbreak

Siew E Chua, MRCPsych¹, Vinci Cheung, MPhil², Grainne M McAlonan, PhD¹, Charlton Cheung, BSc³, Josephine WS Wong, MRCPsych¹, Erik PT Cheung, MA², Marco TY Chan⁴, Teresa KW Wong, BSc⁵, Khai M Choy, BM, BCh⁶, Chung M Chu, FRCP⁷, Peter WH Lee, PhD⁸, Kenneth WT Tsang, FRCP⁹

Severe acute respiratory syndrome (SARS) is caused by a novel and highly transmissible coronavirus (1). It spread rapidly to 30 countries via air travel (2). Probable SARS cases (n = 8422) resulted in 916 deaths, or a mortality rate of 11%; one-quarter of all cases occurred in Hong Kong (3). Early SARS is clinically similar to influenza (4), so a terror-stricken public stayed home to avoid cross infection. Worldwide, health care workers (HCWs) accounted for up to 50% of infected cases (5) and constituted a uniquely high-risk population. In such circumstances, a range of psychological health problems can be anticipated but have yet to be formally evaluated. We therefore conducted a prospective study of SARS patients and healthy control subjects to quantify stress levels and characterize psychological problems attendant on SARS. We postulated that stress levels or psychological effects encountered would be related to perceptions about risk of infection. We offered follow-up on request, and with future outbreaks still possible (2,6), we believe this study forms a basis to plan intervention as necessary.

Methods

The study was approved by the institutional review boards of the participating hospitals. We developed a brief, confidential, self-administered questionnaire containing the Perceived Stress Scale-10 (PSS-10; 7), which is well validated in community norms to determine stress levels over 1 month. In addition, respondents could indicate any psychological effects they experienced on a list of items commonly raised in thorough group discussion and in consultation with clinicians caring for SARS patients. Items were determined to be positive (40%) or negative (60%) according to group consensus. At the end of the questionnaire, the subjects were given the option of leaving their contact details if they wished to be contacted in confidence for assistance from a mental health professional.

First, we pilot-tested the questionnaire (available on request) in 120 subjects (specifically, HCWs and patients from the Department of Psychiatry) and obtained an 88% successful return rate (8). Healthy control subjects were also recruited from the general community; these subjects were in apparent good health, lacked any health care education or experience, and had no contact with SARS patients or suspected SARS patients. After the pilot test, we invited patients diagnosed with SARS to complete the questionnaire. Patients were recruited from 2 major hospitals with SARS isolation wards. The first hospital was in the catchment area of Amoy Gardens, a residential complex that produced an outbreak of over 300 infected cases (9); the second was a teaching hospital that received any cases diverted from all other hospitals at full capacity.

The diagnosis of SARS was made if a person had fever equal to or greater than 38°C, with one or more symptoms of lower respiratory tract illness and radiographic evidence of lung infiltrates consistent with pneumonia or respiratory distress syndrome, providing that no alternative diagnosis could explain the illness (6). In the Hong Kong outbreak, the vast majority of patients initially presented with fever equal to or greater than 38°C for over 24 hours, with over one-half also complaining of nonproductive cough, dyspnea, malaise, and headache (10,11). Dyspnea usually occurred 3 to 7 days after fever began, with crackles and dullness on percussion. Daily chest radiograph showed progression of lower lobe pulmonary consolidation. Lymphopenia was common, along with slightly elevated aspartate aminotransferase (AST) or alanine aminotransferase (ALT) that was present in 40% to 60% of patients. If the patients did not respond to high-dosage, broad-spectrum anti- biotic therapy, combination treatment with steroids and ribavirin was administered (11). Stringent precautions were adopted when handling questionnaires from subjects on the SARS isolation wards, including scrutiny for contamination, hand-washing after use, and 72-hour quarantine of questionnaires before data entry. Data were collected from 11 April to 19 May 2003, during the peak of SARS hospital admissions in Hong Kong (12). Power analysis (Instat Graphpad; 13) for a sample size of 70 per group had 95% power to detect a 10% difference at a significance level of P < 0.01.

Statistical Analysis
Group comparisons on nominal variables were analyzed by chi-square test, ordinal variables by Mann–Whitney tests, and interval variables by t tests. Bonferroni correction was made for multiple comparisons. We used 2-way analysis of variance (ANOVA) to compare groups on their direction (that is, negative vs positive) regarding the outbreak’s psychological impact. Spearman’s rho was computed for correlation between stress and perceived risk of infection.

Results

A total of 280 questionnaires were returned, of which 224 yielded valid data, constituting an 80% return rate; 20% of the questionnaires were invalid for reasons such as failure to complete 40% or more of the questions or unclear group membership. Our final sample comprised 79 SARS patients and 145 healthy control subjects, all of whom were Hong Kong residents. The 2 groups were equally balanced for age, sex, educational level, and living circumstances (Table 1). Of the SARS patients, 39% (n = 30) were HCWs, mainly female nurses from internal medicine.

Stress Levels
Both groups reported increased stress, with SARS patients being significantly more affected (Perceived Stress Scale [PSS] score = 20) than healthy control subjects (PSS score = 18, Mann–Whitney U = 4604, P < 0.04, 2-tailed). These scores are higher than the established community norm of 12 (7). In the SARS patient group, stress levels for HCWs (n = 30) and non-HCWs (n = 49) were not statistically different (Mann–Whitney U = 685.5, P > 0.8).

Psychological Effects of the Outbreak
A range of psychological effects were reported, with 90% of respondents stating that these were attributable to the outbreak rather than to other major events. These effects were considered common if experienced by a majority (> 50%) of subjects. For completeness, we also report effects in a sizeable minority (> 20%). For the sake of brevity, we do not report experiences recorded by fewer than 20% of subjects.

Positive Psychological Effects. These were reported by most healthy control subjects (88%, n = 127) and patients (90%, n = 71). Most healthy control subjects and patients reported awareness of hygiene, focus on current affairs, and awareness of physical state. A sizeable minority (> 20%) of healthy control subjects and patients shared civic-mindedness, caring for others, being fortunate, and willing to help. Patients also reported being united, and healthy control subjects reported being aware of danger.

Negative Psychological Effects. These were fewer in healthy control subjects (68%, n = 99) than in patients (91%, n = 72). The single most common response among both healthy control subjects and patients was worry about health. In addition to this, most patients were fatigued. More than 20% of healthy control subjects and patients shared worry about finances or had fear of social contact. The patients also disclosed numerous additional problems, including poor sleep, weepiness, loneliness, boredom, poor concentration, depressed mood, nightmares, and impaired judgement.

Taken as a whole, total positive psychological effects significantly outnumbered total negative ones (F_1,220 = 63.8, P < 0.0005; for significant effect of direction of response, see Figure 1). Patients who were HCWs (39%, n = 30) had significantly more positive (t₇₅ = 3.6, P = 0.001, Bonferroni corrected), as well as negative (t₇₅ = 2.1, P < 0.04), psychological effects, compared with other patients (61%, n = 49). Increased stress significantly correlated with more negative psychological effects in both patients (ñ = 0.4, P < 0.005) and healthy control subjects (ñ = 0.3, P < 0.0005). Increased stress significantly correlated with increased age for healthy control subjects only (Spearman’s rho 0.33, P < 0.005, Bonferroni corrected) but not with educational level for either group.

Figure 1   The positive and negative psychological effects attributable to SARS

Perceptions of Risk
We asked subjects to evaluate what they perceived as their overall risk of SARS, that is, risk of infection by SARS, of dying from SARS, or of contracting SARS from a doctor or nurse. Both groups reported moderate-to-high perceived risk. In addition, subjects were asked to choose from 15 statements suggesting how infection was very likely transmitted. Most patients and healthy control subjects selected 8 routes (in decreasing order of frequency): droplets (97%), saliva (87%), phlegm (81%), nasal mucus (79%), kissing or hugging (70%), excreted waste (69%), public objects (58%), and sharing food (57%). Less frequently selected were shaking hands (45%), sharing clothes (38%), sharing home (38%), sharing bathroom (38%), sweat (32%), air (28%), and animals (22%).

Follow-Up of SARS Patients
At their request, 20 SARS patients were contacted by telephone by a senior clinical psychologist. In these cases, preliminary observations are worrying. They appear to fall into 2 main groups: those reporting no problem and those with residual problems. Individuals who report no problem are not, however, without symptoms. Rather, they need to be reminded of their residual symptoms and report being more easily tired and having various aches and pains only after being specifically asked. In response to an open-ended question such as “How have you been lately?” they say that they have been pretty well. Conversely, patients who report residual problems experience a multitude of deficits every day; these may be social, emotional, cognitive, physical, or occupational. Their problems are manifest, not so much in the form of obvious psychiatric disabilities as in the form of subclinical distress and an obviously reduced quality of life. It is still unclear what proportion of these patients suffer from undetected psychiatric disorder, and our follow-up continues so that formal assessment and treatment can be arranged, if required.

Discussion

Stress and Psychological Responses to SARS
Stress levels were high in both groups and greatly exceeded the normative community score of 12 on the PSS scale, which is well-validated for healthy as well as stressed populations (7). For SARS patients, several reasons could explain this, including their having contracted a new and highly infectious disorder; uncertainty about the efficacy of treatment; negative media reports; being in quarantine for at least 21 days in isolation wards and lacking the solace of visitors; physical deterioration; apprehension that they might have unknowingly transmitted the virus, especially to loved ones; and high mortality rate. Pulmonary salvage using high-dosage steroids is known to cause adverse reactions such as mood fluctuation and (or) cognitive distortion. Stress levels were not related to educational level, indicating that all sectors of the community were adversely affected. However, stress levels were significantly positively correlated with age in healthy control subjects, suggesting that older healthy subjects were cognisant of poorer prognosis if infected. We did not observe the effect of age in our sample of patients, and this may be because they enjoyed relatively good prognosis: their capacity to complete a research questionnaire attested to the fact that they were less severely ill or were responding to treatment.

Given the challenging circumstances, it was unsurprising that patients had a high number of negative psychological responses. This correlated with stress levels, which suggests that both were measuring the adverse impact of similar psychological dimensions on the individual. Worry, poor sleep, poor concentration, and nightmares implicate adjustment and acute stress disorders. Patients also complained of loneliness and boredom, likely related to prolonged quarantine. Over 20% of patients had depressed mood, weepiness, fear of social contact, and fatigue, which may indicate risk of depressive disorder or postviral fatigue syndrome. Thus, discharged patients require vigilance after they return to the community, in case they suffer psychiatric decompensation. Our findings can facilitate detection, assessment, and monitoring of psychological problems. An integral feature of our questionnaire was that it allowed respondents to specifically request psychological intervention.

Positive psychological responses were also reported by most subjects in terms of awareness about hygiene, physical state, and current affairs. In addition, at least 1 in 4 subjects expressed a sense of caring for others, being fortunate, and being civic-minded. SARS patients also reported feeling united, compared with healthy subjects, possibly because they had overcome a common grave threat. For both groups, total positive psychological responses significantly exceeded negative ones. This was counterintuitive, because our questionnaire contained an excess of negative psychological responses (60%), compared with positive ones (40%); therefore, our finding cannot be attributed to design artifact. We listed psychological responses randomly according to consensus reached after thorough discussion by all group members, including clinicians caring for SARS patients.

We were limited practically in the amount of data that we could collect, because we had to minimize the risk of cross- infection from patients to research personnel. For example, the questionnaire had to be brief and self-administered, because patients tired easily and were in isolation wards. We guaranteed confidentiality to yield as high a return rate as possible, and this helped to allay patients’ concerns about possible stigmatization. Our principal aim was to describe accurately the range of experiences encountered by those most proximate to the outbreak at the height of hospital admissions in Hong Kong. We did not formally evaluate the psychometric properties of psychological responses to the outbreak, because the questionnaire was brief and the outbreak was soon brought under control after emergency mass quarantine measures took effect.

Infected HCWs
This group comprised a substantial 39% of the SARS patients in our study and so merits closer examination. The high percentage of infected HCWs in our sample was nearly double the overall rate of 22% in Hong Kong (14). Compared with non-HCWs, they were exposed to an increased burden of stress as a result of working in a hospital environment and perhaps being deployed from other specialties. Further, many had looked after patients from the Amoy Gardens outbreak, which alone produced over 300 confirmed SARS cases leading to in excess of 40 deaths. It was not surprising that they had the most negative psychological responses of any group. However, it was salutary to note that, despite such adversity, HCW patients also reported significantly greater adaptive or positive psychological responses than did non-HCW patients, which may explain their similar stress scores. When 8 HCWs died, an image of stalwart heroism or sacrifice was conferred on HCWs by the media and community, who collected protective equipment, oranges, vitamins, and nourishing tonic drinks and consigned them into hospital battle zones. Lacking confidence in infection-control measures correlated with stress and negative psychological effects. Our data do not reveal whether such lack of confidence predated or postdated HCWs’ infected status, but this group may need further attention as they return to work and normal life. Recovered HCWs comprise 25% of the 20 patients requesting psychological assistance, and preliminary observations suggest that further support is needed in the postrecovery phase.

Future Directions
Public health education is needed to allay undue fears, which can be rapidly fuelled by the mass media. For example, even healthy subjects judged their risk from SARS to be moderately high, and most people listed more than 8 routes as very likely to transmit SARS. Further, perhaps infected HCWs who lacked confidence in infection control can be offered further infection-control training and stress management as they resume work. For recovered patients, functional recovery definitely lags behind recovery from SARS and raises the possibility of a range of major psychiatric sequelae such as adjustment or stress-related disorders and depression.

Conclusion

Our principal observation was of high stress levels with both positive and negative responses to the outbreak. The positive effects of stress are best exemplified by infected HCW patients. This group reported the most negative and positive responses, which shows their resilience in the face of high adversity. We also noted that public education about SARS could alleviate the concern reported by most subjects, who appeared to perceive the risk and transmissibility of SARS to be unduly high. There is also preliminary evidence suggesting that patients have difficulties in resuming normal daily living after discharge and that they may be at risk of psychiatric sequelae such as stress-related, depressive, and anxiety disorders. For HCWs, access to appropriate psychological assistance is important, because the risk of future global outbreaks remains real.

Acknowledgements

We warmly thank the staff of the Departments of Psychiatry and Medicine of Queen Mary Hospital and United Christian Hospital for their assistance. We are also grateful to Dr KF Chung for making the Chinese version of PSS-10 available to us.

References

1. Peiris JSM, Lai ST, Poon LLM, Guan Y, Yam LYC, Lim W, and others. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003;361:1319.

2. Wenzel RP, Edmond MB. Managing SARS amidst uncertainty. New Engl J Med 2003;348:1947–8.

3. World Health Organisation. Cumulative number of reported probable cases of severe acute respiratory syndrome (SARS). Communicable disease surveillance and response. Available: http://www.who.int/csr/sars/country/2003_08_15/en/ Accessed 2003 Aug 15.

4. Tsang KW, Ho PL, Ooi GC, Yee WK, Wang T, Chan-Yeung M, and others. A cluster of cases of severe acute respiratory syndrome in Hong Kong. New Engl J Med 2003;348:1977–85.

5. Zambon M, Nicholson KG. Sudden acute respiratory syndrome may be a rehearsal for the next influenza pandemic. BMJ 2003;326:669–70.

6. World Health Organisation. Alert, verification and public health management of SARS in the post-outbreak period. Clinical case definition of SARS. World Health Organisation. Available: http://www.who.int/csr/sars/postoutbreak/en/ Accessed 2003 Aug 14.

7. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385–96.

8. McAlonan G, Chua SE, Cheung V, Cheung C, Wong JGWS, Choy KM, and others. Psychological effects of SARS on health-care workers in Hong Kong. [e-letter]. BMJ 2003. Available: http://bmj.com/cgi/eletters/326/7398/1067 Accessed 2003 June 5.

9. Peiris JSM, Chu CM Cheng VCC, Chan KS, Hung IFN, Poon LLM, and others. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767.

10. Tsang KW, Lam W. Management of severe acute respiratory syndrome: the Hong Kong University experience. Am J Respir Crit Care Med 2003;168:417–24.

11. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt G, and others. A major outbreak of severe acute respiratory syndrome in Hong Kong. New Engl J Med 2003;348:1986–94.

12. Yip P. Hong Kong SARS update. April to May 2003. 2003. Clinical Trials Centre, The University of Hong Kong.

13. Motulsky H. Instat GraphPad. Version 2. San Diego (CA): Instat GraphPad; 1994. Available: http://www.graphpad.com/.

14. Department of Health, Government of Hong Kong, SAR. Latest figures on severe acute respiratory syndrome. Available: http://www.info.gov.hk/dh/ diseases/ap/eng/infected.htm. Accessed 2003 Aug 21.

Author(s)

Manuscript received October 2003 and accepted February 2004.

1. Assistant Professor, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

2. Research Assistant, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

3. MPhil Student, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

4. Medical Student, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

5. PhD Student, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

6. Executive Manager, Professional Services, Hospital Authority, Argyle Road, Kowloon, Hong Kong, SAR, China.

7. Consultant Physician, Department of Medicine, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong, SAR, China.

8. Professor of Psychology, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

9. Associate Professor and Honorary Consultant Physician, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China.

Address for correspondence: Dr SE Chua, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, SAR, China

e-mail: sechua@hkucc.hku.hk

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