Doi:10.1016/j.apnu.2007.04.007

Available online at www.sciencedirect.com Jingping Zhang, Man Ye, Haishan Huang, Lezhi Li, and Aiyun Yang Odds of major depression have significantly increased among adults withchronic diseases. However, the diagnosis of depression is often unrecognizedin China.To know the prevalence of depression in medical inpatients with differ-ent chronic diseases and to assess the level of unrecognized depression amonghospitalized patients, we assessed depression in patients with cardiovasculardisease, diabetes, and chronic pulmonary heart disease. In this study, it hasbeen shown that 78.9% of patients with pulmonary heart disease, diabetes, hy-pertension, or coronary heart disease have different levels of depression. Therewere no significant differences in incidence of depression among different gen-der, age, education levels, marital status, or course of disease. There were nosignificant differences in total incidence rate of depression and in incidencerate of different levels of depression among the three groups of patients. It isvery important to help patients with chronic diseases to reduce their depressionby psychological nursing after evaluating their mental status.
D 2008 Elsevier Inc. All rights reserved.
CHRONIC ILLNESS IS the largest cause of as any illness of 3 or more months' duration death in the world, with cardiovascular disease in the lead, followed by cancer, chronic lung diseases, more than 160 million people are chronically ill hypertension was 18.8% among adults and became the number one cause of death; diabetes, on the other major depression has significantly increased among hand, will pose a great threat to the Chinese people if adults with chronic diseases. However, the diagnosis of depression is often unrecognized. Currently, areas, the morbidity of chronic obstructive pulmon- studies on depression of chronic medical patients ary disease is 18.24% among adults older than are still not adequate in China. To know the prevalence of depression in medical inpatients with leading causes of mortality were cardiovascular different chronic diseases and to assess the level ofunrecognized depression among hospitalized From the Nursing School of the Central South patients, we chose to survey inpatients with cardio- University, Changsha, Hunan, China; and The vascular disease, diabetes, or chronic pulmonary Sencond Hospital of the Central South University, heart disease, as these diseases are characteristic Address reprint requests to Jingping Zhang, RN, PhD, chronic diseases in China, and we intend to supply Associate Professor, Nursing School of the Central South advice on psychological nursing for those patients.
University, No. 172. Tongzipo Road, Changsha, Hunan,China.
n 2008 Elsevier Inc. All rights reserved.
Chronic illness is defined, in keeping with the U.S. National Center for Health Statistics definition, Archives of Psychiatric Nursing, Vol. 22, No. 1 (February), 2008: pp 39–49 disease, chronic pulmonary heart disease, and cancer only 20% had depressive symptoms documented in their case notes by junior medical staff, and even influence patients' physical condition seriously, and after the junior doctors had been informed that major the coexistence rate of emotional diseases is depression was a possible diagnosis in these patients, only 27% of the patients eventually received psychiatric consultation and only 13% disorders in the world, and the World Health were given antidepressant medication. In Shanghai, Organization has predicted that by 2020, depres- a large city in China, only 21% of the patients who sion will be the second leading contributor world- had depressive symptoms were recognized by wide to burdens of disease, measured as disability- discriminating rate was much lower. Many Chinese Prevalence of major depression is significantly physicians pay more attention to physical problems increasing among adults with chronic diseases.
than to psychological problems, and some are Coexistence of chronic diseases such as coronary unfamiliar with depressive symptoms and treat- artery disease, chronic arthritis, or strokes in ments, in particular that the severity of medical particular, is associated with increased odds of problems can lead physicians to underestimate the presence of affective disorders in patients.
We designed a cross-sectional study using sion among patients with diabetes mellitus has our conceptual framework. We wanted to (a) investigate the prevalence and discriminating rate frequency of patients with myocardial infarction of depression among inpatients with chronic who had a score of 40 or higher on the Self-Rating diseases in Changsha, China; (b) find out how to Depression Scale (SDS) score was 46% (18/39) take care of them in nursing practice; and finally, (c) and that of patients who scored higher than 50 was improve the quality of nursing. As the medical model shifted from the biomedical model to the biopsychosocial model in the past decade, we have reported that 60% of inpatients with coronary heart underscored the importance of psychological and disease had depression accompanied by anxiety.
and the nursing philosophy also has changed patients with type 2 diabetes had psychological from patient-centered nursing to person-centered disorders and that 34.78% of them had depression nursing. Person centeredness is defined by accompanied by anxiety. Depression is common as a standing or status that is bestowed upon one human being by others in the context of However, the diagnosis of depression is often relationship and social being. It implies recognition, respect, and trust. Based on such a definition, diagnosed symptomatic depression in 67 of 155 from it as the heart of person-centered nursing: (a) patients (43%), whereas the geriatrician identified being in relation, (b) being in a social world, (c) symptomatic depression in 29 (19%) of the 155 being in place, (d) and being with self. The concept patients, one of whom was not diagnosed with makes the nurses not only focus on technical depression by the psychogeriatrician. Thus, the competence but also engage in authentic humanistic geriatrician failed to identify 39 patients who were caring practices that embrace all forms of knowing diagnosed by the psychogeriatrician as having and acting to promote choice and partnership in , only 8.7% of inpatients with depressionwere correctly identified as depressed by junior This study was designed as a cross-sectional reported that, among 15 patients identified as having major depression by Diagnostic and Statistical involving four steps. First, we selected Changsha (a Manual of Mental Disorders, Third Edition, criteria, city the in Hunan Province of China) as the study DEPRESSION OF CHRONIC MEDICAL INPATIENTS IN CHINA site, a moderate city in respect to its local economic, demographic, and geographical features. Second,we identified four top hospitals by convenient sampling. Third, we chose all of the cardiovascular,respiratory, and endocrine medical wards in these hospitals by means of cluster sampling. Finally, we clinical practice setting. Patients were asked to interviewed and distributed the questionnaires to report the frequency of specific characteristics of each resident (if he or she was willing to participate depression in the previous 2-week period. The in it) whose first diagnosis was hypertension, scoring provides an indication of the degree of coronary heart disease, chronic pulmonary heart depression as reported by the patient. The ques- disease, or diabetes individually in these wards. The tionnaire includes 20 items of self-evaluation questionnaires of SDS and a self-designed ques- measurements. The items are coded from 1 to 4, tionnaire for collecting demographic data were used so the scores range from 20 to 80; higher scores indicate higher levels of depression. A participant isconsidered to be not depressive if the SDS score is less than 50, minimal to mild depressive if the SDS Four hundred thirty patients were selected from 14 score is between 50 and 59, moderate to marked wards of the medical departments of four hospitals in depressive if SDS score is between 60 and 69, and Hunan Province (three affiliated hospitals of Central severe to extreme depressive if the SDS score is South University and the People's Hospital of Hunan more than 70. The SDS is well constructed and Province) between July 2002 and January 2003.
consistently reliable in its evaluation of depression These 14 wards included cardiovascular medical in Chinese patients with chronic medical diseases; a wards (n = 5), endocrine medical wards (n = 5), and cutoff point of 55 had a sensitivity of 66.7% and a respiratory medical wards (n = 4). Patients were eligible if they were 18 years or older, spoke Chinese, had no discernible cognitive impairment as deter-mined by study personnel, and were willing to The demographic data collection was obtained with a questionnaire designed by the study team.
Characteristics of the sample included gender, age, marriage, educational level, occupation, income, First, we obtained the approval for the study from assets, medical expense in recent 2 years, diseases the institutional review board (IRB) of the four suffered, course of diseases, and complications hospitals and the patients' agreements to join in the survey. One trained research assistant then conductedthe survey at all hospitals to ensure consistency and reliability. The trained research assistant distributed Approval for the study was obtained from the the questionnaires to each participant and provided IRB of the four chosen hospitals in Hunan directions on how to complete the instruments. When Province. A cover letter that explained the purpose the patients finished, the research assistant collected of this study was attached to each questionnaire; the the questionnaires immediately and recorded at the participants were told that they could withdraw end of the questionnaires whether the patient had a from the study at any time. Participants were diagnosis of depression by the assessment of the advised that they had the option to omit questions physician. There were 10 illiterate patients who could they did not want to answer. Participants were also not read but could understand the items when read to assured that their participation was voluntary and them. The research assistant read all the items of the anonymous and that whatever they did would not questionnaires to these 10 patients and recorded their affect the care provided to them. All participants responses. A total of 430 patients agreed to gave written consent prior to the start of the study.
participate; 61 respondents withdrew for various There were 10 patients who could not read. The reasons, and 48 respondents omitted 20% or more consent form was read to them to ensure a good questions. In all, 322 patients' questionnaires were understanding of the study's implications, after completed, and the effective response rate is 75%.
Table 2. Zung Scores of 322 Cases of Chronic Patients Descriptive analysis was used for demographic data. One-way classification of analysis of variance (ANOVA) was used to analyze the mean of total scores of depression. Comparisons of the qualita- tive data were analyzed by chi-square test. All statistical procedures were performed with SPSSversion 11.0 for Windows.
Most (85.09%, n = 274) of the patients were married. Most respondents (78.26%, n = 252) havecompleted at least a junior middle school education.
Duration of diseases in 94 (29.19%) inpatients is Three hundred twenty-two patients were divided short (less than 3 years); in 148 (45.96%), moderate into three groups according to the disease category: (3–10 years); and in 80 (24.85%), long (over 10 pulmonary heart disease (29.8%, n = 96), diabetes years). There were no significant differences among (38.5%, n = 124), and hypertension and coronary the general data of these three groups according to atherosclerotic heart disease (31.6%, n = 102). Of chi-square test. The demographic distribution of the 322 patients, 184 (58.4%) were men and 138 (41.6%) were women. The median age for allparticipants is 60.32 years, with a range of 18 to 90.
Zung Scores of 322 Cases ofChronic Patients The minimum, maximum, and mean SDS scores of self-assessment depression in 322 patients were 39, 80, and 54, respectively. There were 255 patients (78.9%) who had depression, including 194 (60.3%) patients with mild depression, 58 (17.7%) with moderate or marked depression, and 3 (0.9%) with severe or extreme depression There were no significant differences in incidence of depression among gender, age, education level, marital status, and the course of disease in multiple The mean SDS score of three groups of diseases differences in the mean SDS score among the three groups of diseases using one-way classification of ANOVA (F = 0.075, P = .928). The incidence of depression including the mild, the moderate to marked, and the severe to extreme depression is Table 3. Comparison of Zung Scores of Patients With Different DEPRESSION OF CHRONIC MEDICAL INPATIENTS IN CHINA Table 4. Comparison of Varying Degrees of Depression in Three 46% among patients with myocardial infarction depressive symptoms in the study might be a result of the Chinese economic status and the overall low educational level of participants. Firstly, China is a developing country and the income per capita is very low (about 1,000 dollars every year), whereas the fee of hospitalization is several hundred to one thousand dollars generally and chronic illnesses are prone to relapse. It is reported that there were133.41 million people who had medical insurance by September 2005 in China. However, there are differences among the three groups according to still a lot of people who do not have medical chi-square test (χ2 = 4.309, P = .366).
insurance. The patients often have to pay the entirecost of outpatient service and 5% to 15% of inpatient hospital fees. The financial burden is quite heavy, especially for those who must pay for the entire medical care. Secondly, one fifth of our assessment and psychiatric assessment are shown participants had less than 6 years of education. Low educational level might limit their awareness or clinically significant levels of depression. However, ability to search for related resources to cope with only 39 patients were diagnosed by physicians as their depression. Chronic illnesses such as pulmon- having clinical depression. The ability of medical ary heart disease, diabetes, hypertension, or cor- physicians to discriminate depression in medically onary heart disease are associated with chronic ill patients ranged from 14% to 16% compared with pain, one or more medicines to take regularly to prevent the illness from becoming more serious, Results also showed that depression rates, as financial burden to pay for medication and medical diagnosed by medical physicians, were higher in fees, and so forth. In addition, these chronic China (e.g., pulmonary heart disease [11.45%], illnesses interfere with daily activities and add to diabetes [12.90%], hypertension, and coronary patients' overall levels of stress. On the basis of these factors, depressive symptoms of inpatients inour study might be expected to be higher than those The frequency of depression was also noticeably higher than that of general medical inpatients due to Of patients with pulmonary heart disease, different choices of participants. Inpatients of all diabetes, hypertension or coronary heart disease, medical diseases were studied in the research by 78.9% had varying degrees of depression, which confirms that chronic disease seriously affects the three diseases. There were no significant differ- mental health of patients. The incidence of major ences in incidence of depression among gender, depression significantly increased among patientswith pulmonary heart disease, diabetes, hyperten- Table 5. Comparison of Medical Assessment and Assessment of sion, or coronary heart disease. This finding is It is striking that the rate of depression (78.9%) among these chronic inpatients in our study was much higher than those of similar populations in Western countries: 11% to 15% among patients age, education level, marital status, or the course of often overlooked. In our study, symptomatic disease using multiple regression analysis. There depression was recognized by medical physicians were also no significant differences in total in 16% or less of patients who have depression incidence rate of depression in the incidence rate diagnosed using the SDS. In our study, the rate of of different levels of depression among three groups underrecognition of depression was higher than the of patients, which has not been reported before.
The high prevalence of depression among patients with pulmonary heart disease, diabetes, hypertension, we asked the physicians or nurses whether they or coronary heart disease requires attention and noticed patients' depressive symptoms and paid interventions. Studies have shown that the high attention to each patient's differences, the physi- frequency of emotional diseases among chronic cians said that they were not specialists in medical inpatients has led to poor self-care, wrong psychological areas; hence, they may not detect diagnosis of diseases, low quality of life, and high and treat these symptoms, and they therefore believed that the psychological symptoms were natural among inpatients. They argued that the most that baseline depression leads to an increased risk of important thing to do was to cure the patients' physical diseases, and that if the physical diseases A cross-sectional study suggested that 35% of the were cured, the psychological symptoms would patients with pulmonary hypertension (PH) had mental disorders, the most common being major The other possible reasons for underrecognition depressive disorder (15.9%), and that the prevalence of depression are as follows: Firstly, the coexistence of mental disorders in patients with PH increased of depression and physical illness may be coin- significantly with functional impairment, from 17.7% cidental. Depression may lead to physical illness, or (New York Heart Association [NYHA] Class I) to physical illness may lead to depression; thus, depressive symptoms may be understandable in . A significant and consistent association was the context of physical illness, and physicians may found between depression and complications of sometimes overlook those symptoms of depression.
Secondly, uncontrolled comorbidity and medication treatment are factors that may be misleading in associated with inadequate treatment of several diagnosing depression. For example, the geriatri- chronic diseases including diabetes mellitus ( cian may fail to recognize depression among patients with osteoarticular diseases who complain about bone and joint pain, although the pain associated with this common degenerative disorder may be increased by depression. Moreover, physi- cians are probably not sufficiently aware of the fact pharmacy data. Patients with depression who do not that older patients with depression often present take their medication for psychological disorders are hospitalized more frequently and have higher overall that they think somatic symptoms may be the result health care costs than the average person of the physical illness itself. Furthermore, depres- sive symptoms may be present covertly, in particular substantially increases the costs of care to patients with with psychosomatic symptoms or with hypochon- dria, which may lead to confusion with the their stress burden. Therefore, we must attach greater coexisting illness. Finally, many Chinese physicians importance to the emotional problems of patients and are unfamiliar with depressive symptoms and treatments, in particular that the severity of medicalproblems can lead physicians to underestimate the presence of affective disorders in patients. This could result in patients who showed depressive When depression occurs in comorbidity with symptoms requiring psychiatric intervention but other diseases, especially chronic diseases, it is were not referred to the appropriate services.
DEPRESSION OF CHRONIC MEDICAL INPATIENTS IN CHINA one may apply to care for inpatients with chronic Person-centered nursing is regarded as the diseases. In pursuing these, it is important to optimum way of delivering health care and is communicate with the patient, both verbally and defined as valuing people as individuals. Early nonverbally. Genuine interest and concern, eye proponents of person centeredness theories began to contact, attentive listening, and an unhurried recognize the importance of ethical and legal rights manner provide the basis for a successfully of people and the importance of holistic care in therapeutic nurse–patient relationship.
that nurses need to acknowledge the singularity of their patients and identify their specific needs,establish a health care professional–patient relation, and understand the implications of this relation. It is routine part of every examination. There is a high therefore important to tailor treatments to each prevalence of depression in patients with chronic patient's specific needs. Based on the four core diseases. Assessments should include patient report of somatic symptoms, mood changes or irritability, ) and on what we did in our clinical nursing profound sadness, and anxiety. Every level should practice and our findings in our research, we suggest be explored, and patients should be asked about that we pay more attention to psychological aspects their ability to function at home or work, level of of chronic medical inpatients; learn how to assess fatigue experienced, appetite, and interest in social the symptoms of the patients physically, psycholo- activities. The next step in the process is to validate gically, and socially; treat the patients' depression initial impressions of each patient. It is important to by pharmacology and psychology; and make use of tell the patient what has been observed and to ask their own ability and the social or family support to him or her to describe his or her mood. This allows the patients to communicate what they are feeling intheir own words. If the interpretation of initial data is incorrect and the patient's responses do not indicate depression, then other causes for the The high degree of morbidity and the low level symptoms need to be explored. If the patient of recognition and treatment of depression sug- describes a depressed mood, a useful follow-up is gested that current health care providers focus only to have the patient quantify the severity of what he on physical symptoms. A great need exists for or she is feeling using one or more rating scales.
research to guide the assessment and treatment of There are many formal screening tools available psychological problems, especially depression in such as SDS, Beck Depression Inventory, General primary care settings and among older populations Health Questionnaire, and Center for Epidemiolo- with chronic illnesses. In this study, nurses and gic Study Depression Scale. These tools have physicians admitted that they had limited knowl- relatively good sensitivity (80%–90%) but only edge on the psychological needs of their patients.
They lacked sensitivity to recognize depressive symptoms and also felt pressured to provide one screening scale over another; therefore, clin- efficient medical care, impairing their relation icians can choose the method that best fits their with the patient. Providers acknowledged their personal preference, the patient population served, focus on addressing the primary illness without and the practice setting. The SDS is well con- consideration or exploration of psychological structed and consistently reliable in its evaluation of impact on the patient's life. Therefore, many depression in Chinese patients with chronic medical opportunities to treat these symptoms are missed.
The philosophy of person-centered nursing empha- questions that are easy to understand. The advan- sizes establishing a relationship with the patient and tage of the SDS is that only can it identify focusing on the patient as an individual. On the symptoms of depression but it can also quantify basis of our study in China, the psychological the severity of the depressive state. Depression aspects of care require greater emphasis. There are screening allows the patient to be an active specific assessment and intervention strategies that participant in the process of identifying his or her conditions. It also provides insight into likely to be successful in recognizing or managing trials, in which 10 trials measured the effect of dence and self-efficacy for each patient. Patient screening and feedback on depression outcomes education and input in treatment decisions are from 1 month to 2 years after the intervention. Of critical for quality outcome. Nurses should provide these 10 studies, 5 showed significant improve- information such as effects and side effects of the ments in the clinical outcomes of patients with medication in both written and verbal forms and depression, and 3 others reported improvements but closely monitor the patient's reactions. TCAs have did not reach statistical significance.
many undesirable effects––their anticholinergicproperties may cause cognitive disorders, dry mouth, delirium, constipation, blurred vision, and If the patient has depression, treatment should be increased intraocular pressure; anti-alpha1-adre- offered to reduce symptoms, to restore functioning, nergic properties are responsible for orthostatic and to prevent recurrence. Medications that are hypotension phenomena that could lead to falls proven effective in treatment of depression include tricyclic antidepressants (TCAs), selective seroto- tell the patients about the undesirable effects, nin reuptake inhibitors, and other antidepressants, monitor patients for such symptoms, and teach the such as mianserin, mirtazapine, moclobemide, and patients what they should do when such symptoms nefazodone. Psychotherapy modalities include happen. Furthermore, nurses can ask the patients cognitive–behavioral therapy (CBT), peer support, to tell their stories and talk with them about the and family therapy. For major depression, a positive aspects of their former lives to give them combination of psychotherapy and pharmacology hope. They can ask patients about their ambitions, is advised because it is the most effective way to discuss their goals, and help them revise their improve the medical health status and quality of life objectives when necessary. There are still other of the patient, enhancing functional capacity, ways nurses can empower patients to acknowledge increasing longevity, and lowering health care their ability to resolve problems and find new meaning and importance in life. In our facility, we In China, doctors use CBT to provide insight to hold a party in which every patient will give a patients that their depression is a consequence of performance, we teach the patients to make self-defeating thought patterns. Behavior changes handicraft themselves, or we encourage the are influenced by modeling, practice and reinforce- patients to exercise appropriately by continuing ment of correct behavior, group visits, and family the activities that they previously enjoyed or by interactions to help patients learn more about their taking up new ones that they have always wanted diseases and get more social and family support to try such as walking and doing yoga. Nurses can help patients to establish their new goals and skills and effective communication with others support them in reaching these goals by identify- including families, relatives, doctors, and nurses are ing and obtaining necessary resources and making being developed in China. This is called inter- appropriate referrals. In doing so, most patients will have a feeling of self-accomplishment. Praise Relaxation training, listening to music, or tai ji and recognition by staff increase the patient's exercises are interventions used to release stress.
We also help patients to identify critical issues anddevise and implement appropriate solutions (pro- Maintaining interpersonal connections with others is an important intervention to reduce depression. In our study, nurses encourage tele- In this study, most patients were eager to obtain phone calls, correspondence, and visits. Nurses information about their health, methods of treat- build emotional support networks by involving ment, and the routines of ward care. Patients who patients in support groups. The group process are knowledgeable about their illness are more includes patients telling their stories involving DEPRESSION OF CHRONIC MEDICAL INPATIENTS IN CHINA their disease, the underlying cause of disease, chronic illness and on preventing or minimizing and difficulties experienced in their life. All associated limitations. This contravened the philo- members of the group provide input and offer sophy of person-centered nursing, which empha- suggestions and encouragement. The nurses utilize sizes the individual's value and humanistic caring this group time to emphasize healthy lifestyle and practices. In clinical care, nurses should practice treatment recommendations. Nurses also can form person-centered nursing. This includes paying a course with patients with the same disease to attention to the emotional problems of patients, discuss how to improve their quality of life or psychosocial assessment, identification of depres- utilize peer support to share their recovery sion, and the extent of depression among patients experience. Family support is also very important by using depression-screening tools. Interventions should include appropriate health education, psy- members are involved in the care and are also chotherapy such as CBT, and aerobic exercise educated about depression and how to cope with interventions should be conducted to help patientsrestore confidence, overcome psychological bar- riers, and improve both their mental health and There were several limitations to this study.
physical health. Additional research is needed to First, there may be sampling bias because the explore how to put person-centered nursing into results were obtained from only four institutions, which are all teaching hospitals and ranked asfirst-class hospitals in Hunan. Inpatients were numerous, and the categories of diseases were This study was supported by the Health Department comprehensive; thus, it was easier to carry out this of Hunan Province (series ZD02-01) and the Nursing survey. Second, the intensity and acuity of the School of the Central South University in China. We chronic condition were higher. Therefore, depres- are grateful to all the participants. We also thank Dr.
sion in patients in our study was greater than the Shuqiao Yao for his suggestions, and we acknowledge depression of inpatients in other common hospi- the resources and support available from the Psycho- tals. A sampling bias may have been caused by the logical Research Center in the second teaching categories of diseases that we selected, although hospital of the Central South University.
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Source: http://netclass.csu.edu.cn/jpkc2010/CSU/nkhlx/wenjian/chengguo/keyan/7/SCI/Depression%20of%20Chronic%20Medical__%20Inpatients%20in%20China.pdf