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A (1) Eu me sinto tenso ou contraído: D (8) Eu estou lento para pensar e fazer as coisas:
3 ( ) A maior parte do tempo 3 ( ) Quase sempre
2 ( ) Boa parte do tempo 2 ( ) Muitas vezes
1 ( ) De vez em quando 1 ( ) De vez em quando
0 ( ) Nunca 0 ( ) Nunca
D (2) Eu ainda sinto gosto pelas mesmas coisas de antes: A (9) Eu tenho uma sensação ruim de medo, como um frio na
0 ( ) Sim, do mesmo jeito que antes barriga ou um aperto no estômago:
1 ( ) Não tanto quanto antes 0 ( ) Nunca
2 ( ) Só um pouco 1 ( ) De vez em quando
3 ( ) Já não sinto mais prazer em nada 2 ( ) Muitas vezes
3 ( ) Quase sempre
A (3) Eu sinto uma espécie de medo, como se alguma coisa ruim
fosse acontecer: D (10) Eu perdi o interesse em cuidar da minha aparência:
3 ( ) Sim, e de um jeito muito forte 3( ) Completamente
2 ( ) Sim, mas não tão forte 2( ) Não estou mais me cuidando como deveria
1 ( ) Um pouco, mas isso não me preocupa 1( ) Talvez não tanto quanto antes
0 ( ) Não sinto nada disso 0( ) Me cuido do mesmo jeito que antes
D (4) Dou risada e me divirto quando vejo coisas engraçadas: A (11) Eu me sinto inquieto, como se eu não pudesse ficar parado
0 ( ) Do mesmo jeito que antes em lugar nenhum:
1 ( ) Atualmente um pouco menos 3 ( ) Sim, demais
2 ( ) Atualmente bem menos 2 ( ) Bastante
3 ( ) Não consigo mais 1 ( ) Um pouco
0 ( ) Não me sinto assim
A (5) Estou com a cabeça cheia de preocupações:
3 ( ) A maior parte do tempo D (12) Fico esperando animado as coisas boas que estão por vir:
2 ( ) Boa parte do tempo 0( ) Do mesmo jeito que antes
1 ( ) De vez em quando 1( ) Um pouco menos do que antes
0 ( ) Raramente 2( ) Bem menos do que antes
3( ) Quase nunca
D (6) Eu me sinto alegre:
0 ( ) A maior parte do tempo A (13) De repente, tenho a sensação de entrar em pânico:
1 ( ) Muitas vezes 3( ) A quase todo momento
2 ( ) Poucas vezes 2( ) Várias vezes
3 ( ) Nunca 1( ) De vez em quando
0( ) Não sinto isso
A (7) Consigo ficar sentado a vontade e me sentir relaxado:
0 ( ) Sim, quase sempre D (14) Consigo sentir prazer quando assisto a um bom programa
1 ( ) Muitas vezes de televisão, de rádio ou quando leio alguma coisa:
2 ( ) Poucas vezes 0 ( ) Quase sempre
3 ( ) Nunca 1 ( ) Várias vezes
2 ( ) Poucas vezes
3 ( ) Quase nunca
Seguindo os pontos de corte adotados no estudo realizado por O mesmo foi encontrado com relação ao sexo dos pacientes
Zigmond e Snaith 12, a avaliação dos sintomas mostrou (Ta- quando não se observou diferença estatística significativa
bela II) que 35 (44,3%) pacientes e 36 (64,3%) acompanhan- (teste de Mann-Whitney — p > 0,05). Já para os acompa-
tes foram considerados com ansiedade (teste Exato de Fisher nhantes, as mulheres se mostraram mais ansiosas do que
— p = 0,03) e 21 (26,6%) pacientes e 23 (41,1%) acompa- os homens (teste de Mann-Whitney — p = 0,034). Não hou-
nhantes foram considerados com depressão (p = 0,09). ve diferença com relação à avaliação da depressão.
A comparação dos níveis de ansiedade e de depressão não Os pacientes que se declararam desempregados estavam
mostrou diferença estatística significativa (teste de Mann- muito mais ansiosos que os assalariados (teste de Mann-
Whitney — p > 0,05) com relação à idade, ao estado civil e Whitney — p = 0,041). Não foi encontrada diferença entre os
à escolaridade dos pacientes e dos acompanhantes. acompanhantes.
Sexo 0,015*
Feminino 43 (54,4%) 42 (75%)
Masculino 36 (45,6%) 14 (25%)
Idade 17 — 83 19 — 68
41,19 ±15,34 40,75 ± 11,49 0,85**
Estado civil 0,36***
Casado/amasiado 40 (50,6%) 34 (60,8%)
Solteiro 22 (27,8%) 11 (19,6%)
Divorciado 12 (15,2%) 9 (16,1%)
Viúvo 5 (6,3%) 2 (3,6%)
Escolaridade 0,34***
Até o superior 8 (10,1%) 6 (10,7%)
Até o 2° grau 33 (41,8%) 31 (55,4%)
Até o 1° grau 35 (44,3%) 19 (33,9%)
Analfabeto 3 (3,8%) —
Situação ocupacional 0,88***
Remunerados 46 (58,2%) 34 (60,7%)
Desempregados 17 (21,5%) 4 (7,2%)
Atividades domésticas 9 (11,4%) 16 (28,6%)
Estudantes 6 (7,6%) 1 (1,8%)
Aposentados 1 (1,3%) 1 (1,8%)
HADS-A
Com ansiedade 35 44,3 36 64,3 0,03
Sem ansiedade 44 55,7 20 35,7
HADS-D
Com depressão 21 26,6 23 41,1 0,09
Sem depressão 58 73,4 33 58,9
At least one third of patients with mood disorders are not visual, and speech disorders; and taking psychoactive drugs
identified as such by their physicians 8-10. This difficulty can were excluded. Eighty caretakers were invited to take part in
be explained by the fact that some symptoms, such as fati- the study, composing the control group.
gue, insomnia, tachycardia, dyspnea, anorexia, decreased The informed consent was presented to the patients always
sex drive, and others, can be caused both by physical and by the same researchers (two 3rd-year medical students).
psychological disorders, misleading the diagnosis. Those who agreed to participate were required to answer
There are reports in the literature describing several tools to the following tools the day before the surgery, prior to the
evaluate anxiety and depression, such as the Hamilton preanesthetic evaluation:
Anxiety Scale 11, the Anxiety Inventory STAI I and II 11, Beck a) Socio-demographic questionnaire: including the following
Anxiety and Depression Inventories 11, and the Hospital data: gender, age, marital status, level of education,
Anxiety and Depression Scale (HADS) 12-24. Most of them occupation, and prior surgeries.
were created to be applied by the researcher to patients with b) Hospital Anxiety and Depression scale (HADS) 12: 14
psychiatric disorders. The HADS 12 was developed initially to items, seven evaluating anxiety (HADS-A) and seven,
identify anxiety and depression symptoms in patients ad- depression (HADS-D). Each of the items receives scores
mitted to clinical, not psychiatric, hospitals 13-20,25,26, outpa- that vary from 0 to 3, with a total of up to 21 points for each
tients basis 14-16, and healthy people 27-29. scale (Chart I).
The Hospital Anxiety and Depression Scale was limited to 14 The two medical students were trained, before the beginning
items, divided in anxiety and depression subscales. Zig- of the study, on how to use the HADS.
mond and Snaith 12 recommended two cutting points to be The answers to the HADS were used to evaluate the fre-
used in both subscales: possible cases receive a score quency of anxiety and depression. The cutting points recom-
greater than 8 and probable cases receive a score greater mended by Zigmond and Snaith 12 for both subscales were
than 11. They also proposed a third cutting point: severe used:
disturbances receive a score greater than 15. The HADS • HAD-anxiety: without anxiety: 0 to 8; with anxiety: ≥ 9;
was translated to several languages. Botega et al. 30 un- • HAD-depression: without depression: 0 to 8; with depres-
dertook a study to validate the HADS in Portuguese. sion: ≥ 9.
The HADS differs from other scales in that, in order to pre- A descriptive analysis of the results was done. Non-paired
vent the interference of somatic disorders, every anxiety and test t Student was used to compare the results regarding
depression symptom related to physical disorders were age. The scores of the anxiety and depression scales were
excluded. Items such as weight loss, anorexia, insomnia, evaluated through their median. The Fisher Exact test, Chi-
fatigue, grim outlook about the future, headache, dizziness, square test, and Mann-Whitney test were used to compare
and etc., could also be symptoms of somatic diseases. In the other variables. A p < 0.05 was considered statistically
case of comorbidities, the psychological symptoms, more significant. The tests used are part of the Statistical Package
than the somatic symptoms, determine the diagnosis of for the Social Sciences for Windows 10 31.
mood disorders and other clinical diseases. In the case of
a study with patients admitted for surgical procedures, the RESULTS
presence of somatic symptoms of anxiety and depression
could be mistaken with signs and symptoms of the patient’s The final sample was composed of 79 patients and 56 care-
condition or its treatment. takers, due to the refusal of one patient and fourteen ca-
The objective of this study was to measure the frequency retakers to participate in the study. The greater number of
and the level of anxiety and depression in patients admitted refusal by caretakers was probably due to the restricted
for surgical procedures and in a control group composed by visiting hours, which would be further reduced if they had
the caretakers of the patients. agreed to answer the questionnaires. Table I shows the socio-
demographic data.
METHODS Following the cutting points recommended by Zigmond and
Snaith 12, the evaluation of the symptoms showed (table II)
This study was approved by the Ethics Committee of the that 35 (44.3%) patients and 36 (64.3%) caretakers had
Hospital Central da Irmandade da Santa Casa de Misericór- anxiety (Fisher Exact test — p = 0.03), and 21 (26.6%) pa-
dia de São Paulo (ISCMSP). The Statistics Department tients and 23 (41.1%) caretakers had depression (p = 0.09).
indicated that the study population should be composed of Comparing the levels of anxiety and depression showed no
160 individuals, 80 in each group. Eighty patients admitted statistically significant differences (Mann-Whitney test — p >
to the Surgical Ward of the ISCMSP, older than 16 years, 0.05) regarding age, marital status, and schooling of patients
ASA physical status I and II, scheduled to undergo elective and caretakers.
small- and medium-sized surgeries, were included in this The same is true for the gender of the patients, which sho-
study. Patients with cancer; psychiatric disorders; hearing, wed no statistically significant difference (Mann-Whitney
D (2) I still enjoy the things I used to: A (9) I get a sort of frightened feeling like butterflies in the
0 ( ) Definitely as much stomach:
1 ( ) Not quite so much 0 ( ) Not at all
2 ( ) Only a little 1 ( ) From time to time
3 ( ) Hardly at all 2 ( ) Quite often
3 ( ) Very often
A (3) I get a sort of frightened feeling as if something awful is
about to happen: D (10) I have lost interest in my appearance:
3 ( ) Very definitely and quite badly 3 ( ) Definitely
2 ( ) Yes, but not too badly 2 ( ) I don’t take so much care as I should
1 ( ) A little, but it doesn’t worry me 1 ( ) I may not take quite as much care
0 ( ) Not at all 0 ( ) I take just as much care as ever
D (4) I can laugh and see the funny side of things: A (11) I feel restless, as if I had to be on the move:
0 ( ) As much as I always could 3 ( ) Very much indeed
1 ( ) Not quite as much now 2 ( ) Quite a lot
2 ( ) Definitely not so much now 1 ( ) Not very much
3 ( ) Not at all 0 ( ) Not at all
A (5) Worrying thoughts go through my mind: D (12) I look forward with enjoyment to things:
3 ( ) Most of the time 0 ( ) As much as I ever did
2 ( ) A lot of times 1 ( ) A little less than I used to
1 ( ) From time to time 2 ( ) Definitely less than I used to
0 ( ) Only occasionally 3 ( ) Hardly at all
A (7) I can seat at ease and feel relaxed: D (14) I can enjoy a good TV or radio program or book:
0 ( ) Definitely 0 ( ) Often
1 ( ) Usually 1 ( ) Sometimes
2 ( ) Not often 2 ( ) Not often
3 ( ) Not at all 3 ( ) Hardly at all
test — p > 0.05). As for the caretakers, women were more an- Unemployed patients were significantly more anxious (Mann-
xious than men (Mann-Whitney test — p = 0.034). There were Whitney test — p = 0.041). There were no differences regar-
no differences regarding the evaluation of depression. ding the caretakers.
Gender 0.015*
Female 43 (54.4%) 42 (75%)
Male 36 (45.6%) 14 (25%)
Age 17 — 83 19 — 68
41.19 ± 15.34 40.75 ± 11.49 0.85***
Marital status 0.36***
Married/living together 40 (50.6%) 34 (60.8%)
Single 22 (27.8%) 11 (19.6%)
Divorced 12 (15.2%) 9 (16.1%)
Widow 5 (6.3%) 2 (3.6%)
Level of education 0.34***
College 8 (10.1%) 6 (10.7%)
High School 33 (41.8%) 31 (55.4%)
Junior High 35 (44.3%) 19 (33.9%)
Illiterate 3 (3.8%) —
Occupation 0.88***
Employed 46 (58.2%) 34 (60.7%)
Unemployed 17 (21.5%) 4 (7.2%)
Housework 9 (11.4%) 16 (28.6%)
Student 6 (7.6%) 1 (1.8%)
Retired 1 (1.3%) 1 (1.8%)
HADS-A
With anxiety 35 44.3 36 64.3 0.03
Without anxiety 44 55.7 20 35.7
HADS-D
With depression 21 26.6 23 41.1 0.09
Without depression 58 73.4 33 58.9
of patients present these symptoms and, therefore, deserve a 04. Mayou R, Hawton K — Psychiatric disorder in the general hos-
more detailed evaluation of their mental status before surgery. pital. Br J Psychiatry, 1986;149:172-190.
05. Clarke DM, Minas IH, Stuart GW — The prevalence of psychiatric
On planning this study, a control group composed of the ca-
morbidity in general hospital in patients. Aust N Z J Psychiatry,
retakers of the patients was envisioned. However, anxiety 1991;25:322-329.
was much more frequent in the control group. In a revision 06. Arolt V, Driessen M, Bangert-Verleger A et al. — Psychiatric
by Herrmann 25 of healthy people used as control group, 7% disorders in hospitalized internal medicine and surgical pa-
had anxiety and 5% had depression. tients. Prevalence and need for treatment. Nervenarzt, 1995;
66:670-677.
Despite this result having invalidated this group as control,
07. Saravay SM — Psychiatric interventions in the medically ill.
it was clear that those people demonstrated to be under Outcome and effectiveness research. Psychiatr Clin North Am,
considerable stress, maybe due to family worries about the 1996;19:467-480.
patient, which resulted in a higher level of anxiety than that 08. Querido A — Forecast and follow-up an investigation into the
suffered by the patients who were going to be operated. clinical, social, and mental factors determining the results of
hospital treatment. Br J Prev Soc Med, 1959;13:33-49.
Among the causes of this result, we should mention the fact
09. Saravay SM, Steinberg MD, Weinschel B et al. — Psychological
that 75% of the caretakers were females, and a review of the comorbidity and length of stay in the general hospital. Am J
literature showed that women, even when they are healthy, Psychiatry, 1991;148:324-329.
have anxiety more often than men 32,33. Besides, sometimes 10. Knights E, Folstein MF — Unsuspected emotional and cognitive
the caretakers waited over one hour for visiting hours, which disturbance in medical patients. Ann Intern Med, 1977;87:723-
734.
probably generates some anxiety, as well as other variables,
11. Andrade L, Gorenstein C — Escalas de Avaliação Clínica em
such as missing the patient, and financial worries. Psiquiatria e Psicofarmacologia. São Paulo: Lemos Editorial,
The severity of the patient’s disease or surgery could be one 2000;139.
of the factors that would increase the anxiety level of the 12. Zigmond AS, Snaith RP — The hospital anxiety and depression
caretakers, but since patients with uncontrolled associated scale. Acta Psychiatr Scand, 1983;67:361-370.
13. Kabak S, Halici M, Tuncel M et al. — Functional outcome of open
disorders and/or cancer, or those scheduled for large-size
reduction and internal fixation for completely unstable pelvic
surgeries were excluded, this item does not seem important. ring fractures (type C): a report of 40 cases. J Orthop Trauma,
This study confirmed that the HADS anxiety and depression 2003;17:555-562.
scale could be used in hospitalized surgical patients. It also 14. Vage V, Solhaug JH, Viste A — Anxiety, depression and health-
showed that patients should be submitted to preoperative related quality of life after jejunoileal bypass: a 25-year follow-
up study of 20 female patients. Obes Surg. 2003;13:706-713.
anxiety evaluation, regardless of the presence or not of
15. Al-Ruzzeh S, Mazrani W, Wray J et al. — The clinical outcome
severe clinical and/or surgical disorder 34, because the fre- and quality of life following minimally invasive direct coronary
quency of patients with anxiety is relevant and they deserve artery bypass surgery. J Card Surg, 2004;19:12-16.
some type of differentiated care, at least the administration 16. Brandberg Y, Arver B, Lindblom A — Preoperative psychological
of tranquilizers before the surgery. Besides, their caretakers reactions and quality of life among women with an increased
risk of breast cancer who are considering a prophylactic mas-
also presented significant levels of anxiety and, therefore,
tectomy. Eur J Cancer, 2004;40:365-374.
this information should be given to the social service and 17. Brilstra EH, Rinkel GJ, van der Graaf Y et al. — Quality of life
psychology department of those institutions for careful con- after treatment of unruptured intracranial aneurysms by neu-
sideration on how to humanize visiting hours and decrease rosurgical clipping or by embolisation with coils. A prospective,
the suffering of those people. observational study. Cerebrovasc Dis, 2004;17:44-52.
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surgical methods, choice of implant and postoperative reha-
ACKNOWLEDGMENTS bilitation. Acta Orthop Scand, 2004;75(s313):2-43.
19. Keller M, Sommerfeldt S, Fischer C et al. — Recognition of
This study was part of the Programa Institucional de Bolsas distress and psychiatric morbidity in cancer patients: a multi-
de Iniciação Científica do Conselho Nacional de Pesquisas method approach. Ann Oncol, 2004;15:1243-1249.
20. Brady S, Thomas S, Nolan R et al. — Pre-coronary artery by-
(PIBIC — CNPq) granted by the Faculdade de Ciências Mé- pass graft measures and enrollment in cardiac rehabilitation. J
dicas da Santa Casa de Misericórdia de São Paulo for the Cardiopulm Rehabil, 2005;25:343-349.
2003/2004 biennium. 21. Hobby JL, Venkatesh R, Motkur P — The effect of psychological
disturbance on symptoms, self-reported disability and surgical
outcome in carpal tunnel syndrome. J Bone Joint Surg Br, 2005;
87:196-200.
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