Cortisol is a “stress hormone” and has been used as an indicator in stress evaluation in various studies. There is good evidence of many studies where stress and anxiety are related to increase resting levels of cortisol. Anxiety and Depression are psychological behaviors associated with stress, as stress increases there is increase the anxiety and depression so increases the serum cortisol level. Hence the present study was aimed to assess and co-relate the anxiety, depression and serum cortisol levels in surgically treated and conservative treated patients compare with normal individuals. Total of 150 samples was included in the study that were divided into different groups, GROUP I (Surgical treated patients), GROUP II (conservative treated patients) and GROUP III (Control group). All the patients were assessed for serum cortisol level, severity of anxiety and depression by (HAM‑A) questionnaire and (HAM‑D) questionnaire respectively. A significant co-relation was seen between serum cortisol level, anxiety level and depression level in surgically treated patients, conservative treated patients and control group. Assessing anxiety and depression in patients with surgically and conservative treated patients, comparing with the serum cortisol level may reveal the level of stress. Proper psychological counseling should be given to patients so that they can cope with stress avoiding ill effects.
Stress is a feeling of emotional or physical tension which may manifests itself as somatic and/or psychological symptoms like lethargy, insomnia, anxiety and/or depression. Anxiety can be defined as “an emotional state, characterized by uneasiness, discomfort and fear about some defined or undefined threat” while depression is “a state of unhappiness or sadness” which is experienced from time to time.1 Stress utilizes two mechanisms to deteriorate our immune system to facilitate disease process. One is the biological mechanism which is mediated through the “hypothalamic- pituitary-adrenal (HPA) axis” and the production of “cortisol”. Second is the behavioral mechanism which promotes the poor health behaviors like smoking, alcoholism, consuming unhealthy diet, poor oral hygiene habits, Para functional habits etc that’s caused by anxiety sometimes. The Patient’s health deteriorates in response to these unhealthy habits, and causes variety of diseases as well as systemic organs involved.1 Stress is one of the main etiology and predisposing factor in many diseases. In course of time people fall in prey to deleterious a habit that’s caused by anxiety and depression, leading to harmful effects. Some diseases are considered as idiopathic, hence diagnosis and treatment plan of such diseases always becomes difficult2. Apart from this anxiety and depression are more responsible for late recovery of conservative as well as surgical treatments and poor prognosis.
Cortisol “stress hormone” has been used as an indicator in stress evaluation in various studies. Cortisol is the major gluco-corticoid in humans and has influences on metabolism, immune-regulation, vascular responsiveness, cognition, and behavior. In stressful situations, there is an activation of the HPA (hypothalamus–pituitary–adrenal) axis, causing the release of cortisol, a hormone which shows a complex action on the metabolism of carbohydrates, proteins and lipids, besides acting on inflammatory and immunological responses.2 In recent years, the important interrelationship between chronic physical illnesses and psychiatric disorders has been studied extensively. It is found that individuals with chronic somatic diseases are relatively at a higher risk of developing psychological distress than physically healthy people. 2 Psychological distress can manifest itself in many different ways, which causes more difficulty to cope with illnesses, through emotional symptoms such as grief or anxiety that can naturally accompany a fearful situation, to a clear cut psychiatric disorder.2
Many studies have shown association between psychiatric morbidity and chronic disorders such as cardiovascular diseases, diabetes mellitus, chronic obstructive pulmonary disease, diabetes mellitus and others related to psychosomatic autoimmune disorders3
AIM & OBJECTIVES
To assess the anxiety, depression and serum cortisol levels in surgically treated and conservative treated patients, compare with normal healthy individuals.
This study was conducted in Rajkiya Medical College, Orai (Jalaun), Uttar Pradesh with the associated Department of Physiology and Biochemistry. This observational study conducted on 150 patients who were reported in OPD of General Medicine and General surgery with the different chief complaints. As per study plan, Group I consist 50 patients whom going for surgical treatment taken from general surgery, Group II consist 50 whom admitted for conservative treatment under the department of general medicine and as Group III consist 50 healthy volunteers (control group) taken from college staff for the study. First taken consent from all 150 people whom the part of the observational study followed by clinical history after clearance from institutional ethical committee.
In this study age group 20-40 years both gender included followed by the inclusion criteria such as Patients willing for the study, no accidental cases. Assessment of anxiety and depression by Hamilton Anxiety Rating Scale (HAM‑A) questionnaire 8, Hamilton Depression Rating Scale (HAM‑D) questionnaire 9 respectively and for serum cortisol, blood sample was collected with pre-surgical routine test and perform test in the department of biochemistry.
Assessment for severity of anxiety and depression: All the patients were assessed for severity of anxiety and depression by the Hamilton Anxiety Rating Scale (HAM‑A) questionnaire 8 and the Hamilton Depression Rating Scale (HAM‑D) questionnaire 9 respectively. The HAM‑A scale comprised 14 items (anxious mood, tension, fears, insomnia, intellectual, depressed mood, somatic complaints muscular, somatic complaints sensory, cardiovascular symptoms, respiratory symptoms, gastrointestinal symptoms, genitourinary symptoms, autonomic symptoms, behavior at interview) and 5 responses (with scores 0, 1, 2, 3, and 4 indicating not present, mild, moderate, severe, very severe, respectively) to each item. A patient has to select one response (answer) for each item (question) and then the total score (range from 0 to 56) is calculated.
0 = Not present, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Very severe.
Normal range |
Mild |
Moderate |
Severe |
0-13 |
14-17 |
18-24 |
25 and over |
The HAM‑D scale comprised 17 items (depressed mood, feeling of guilt, suicide, insomnia early, insomnia middle, insomnia late, works and interests, retardation, agitation, anxiety psychic, anxiety somatic, somatic symptoms gastrointestinal, somatic symptoms general, genital symptoms, hypochondriasis, loss of weight, and insight) and 3–5 responses (with scores between 0 and 4) for each item. The interviewing clinician had to select one response (answer) for each item (question) and then the total score (range 0–52) was calculated.
NORMAL |
MILD |
MODERATE |
SEVERE |
VERY SEVERE |
0-7 |
8-13 |
14-18 |
19-22 |
>23 |
Comparison of variables between two groups with normal distribution was carried out using Independent samples t-test. Comparison of means of more than two groups were carried out using One-Way ANOVA with post hoc Tukey’s HSD for data meeting the assumption of homogeneity
Age group |
No. of patients |
Percentage |
Mean age |
21-25 |
25 |
16.66% |
33.56±6.45 |
26-30 |
35 |
23.33% |
|
31-35 |
25 |
16.66% |
|
36-40 |
35 |
23.33% |
|
Total |
150 |
100.00% |
Table 1: Age group distribution of total sample
Male (%) |
Female (%) |
Total (%) |
110 (73.33) |
40 (26.67) |
150 (100) |
Table 2: Gender distribution of total sample
Group |
No. of patients |
Percentage |
Group 1(Conservative treated) |
50 |
33.33% |
Group 2 ( Surgically Treated |
50 |
33.33% |
Group 3 (Control) |
50 |
33.33% |
Table 3: Distribution of study subjects
|
SURGICALLY TREATED PATIENTS |
|||||
|
Serum Cortisol |
Anxiety |
Depression |
Total Anxiety |
Total depression |
Total |
N |
50 |
50 |
50 |
50 |
50 |
250 |
∑X |
9302.98 |
17 |
9 |
430 |
215 |
9973.98 |
Mean |
186.0596 |
0.34 |
0.18 |
8.6 |
4.3 |
39.896 |
∑X2 |
1817584.4184 |
17 |
9 |
4844 |
1189 |
1823643.4184 |
Std.Dev. |
42.0582 |
0.4785 |
0.3881 |
4.8361 |
2.3234 |
75.669 |
P value |
<.00001 |
Table 4: Intra-group correlation among serum cortisol level, Anxiety, depression, total anxiety and total depression in surgically treated patients group.
|
CONSERVATIVE TREATED PATIENTS |
|||||
|
Serum Cortisol |
Anxiety |
Depression |
Total Anxiety |
Total depression |
Total |
N |
50 |
50 |
50 |
50 |
50 |
250 |
∑X |
18651.9314 |
62 |
72 |
850 |
590 |
20225.9314 |
Mean |
373.0386 |
1.24 |
1.44 |
17 |
11.8 |
80.904 |
∑X2 |
7385286.9718 |
86 |
152 |
14878 |
7634 |
7408036.9718 |
Std.Dev. |
93.3936 |
0.4314 |
0.993 |
2.9555 |
3.7033 |
152.248 |
P value |
<.00001 |
Table 5: Intra-group correlation among serum cortisol level, Anxiety, depression, total anxiety and total depression in Conservative treated patients group.
|
CONTROL GROUP |
|||||
|
Serum Cortisol |
Anxiety |
Depression |
Total Anxiety |
Total depression |
Total |
N |
50 |
50 |
50 |
50 |
50 |
250 |
∑X |
9302.98 |
17 |
9 |
430 |
215 |
9973.98 |
Mean |
186.0596 |
0.34 |
0.18 |
8.6 |
4.3 |
39.896 |
∑X2 |
1817584.4184 |
17 |
9 |
4844 |
1189 |
1823643.4184 |
Std.Dev. |
42.0582 |
0.4785 |
0.3881 |
4.8361 |
2.3234 |
75.669 |
P value |
<.00001 |
Table 6: Intra-group correlation among serum cortisol level, Anxiety, depression, total anxiety and total depression in control group
|
SERUM CORTISOL LEVEL |
|||
SURGICALLY |
CONSERVATIVE |
CONTROL |
Total |
|
N |
50 |
50 |
50 |
150 |
∑X |
23798.3447 |
18651.9314 |
9302.98 |
51753.2561 |
Mean |
475.9669 |
373.0386 |
186.0596 |
345.022 |
∑X2 |
11697854.4947 |
7385286.9718 |
1817584.4184 |
20900725.8849 |
Std.Dev. |
86.9706 |
93.3936 |
42.0582 |
142.949 |
P value |
<.00001 |
Table 7: Comparison among surgically treated patients group, Conservative treated patients group and control group on the bases of serum cortisol level.
|
TOTAL ANXIETY LEVEL |
|||
SURGICALLY |
CONSERVATIVE |
CONTROL |
Total |
|
N |
50 |
50 |
50 |
150 |
∑X |
894 |
850 |
430 |
2174 |
Mean |
17.88 |
17 |
8.6 |
14.493 |
∑X2 |
16582 |
14878 |
4844 |
36304 |
Std.Dev. |
3.4913 |
2.9555 |
4.8361 |
5.6731 |
P value |
<.00001 |
Table 8: Comparison among, surgically treated patients group, Conservative treated patients group and control group on the bases of total anxiety level
|
TOTAL DEPRESSION LEVEL |
|||
SURGICALLY |
CONSERVATIVE |
CONTROL |
Total |
|
N |
50 |
50 |
50 |
150 |
∑X |
628 |
590 |
215 |
1433 |
Mean |
12.56 |
11.8 |
4.3 |
9.553 |
∑X2 |
9054 |
7634 |
1189 |
17877 |
Std.Dev. |
4.8788 |
3.7033 |
2.3234 |
5.3011 |
P value |
<.00001 |
Table 9: Comparison among, surgically treated patients group, Conservative treated patients group and control group on the bases of total depression level
Cortisol is a vital catabolic hormone produced by the adrenal cortex of the kidney. It is released in a diurnal fashion, with blood levels peaking in the morning to facilitate arousal and steadily declining thereafter. Cortisol is a key player in the stress response. In the presence of a physical or psychological threat, cortisol levels surge to provide the energy and substrate necessary to cope with stress provoking stimuli or escape from danger. However, although a stress-induced increase in cortisol secretion is adaptive in the short term, excessive or prolonged cortisol secretion may have crippling effects, both physically and psychologically.10 Cortisol is used as an indicator in stress evaluation in various studies. In stressful situations, there is an activation of the HPA (hypothalamus–pituitary–adrenal) axis, causing the release of cortisol, a hormone which shows a complex action on the metabolism of carbohydrates, proteins and lipids, besides acting on inflammatory and immunological responses.11 Stress is one of the main etiology and predisposing factor in many diseases as well as depression and anxiety. In course of time people fall in prey to deleterious habits and problems associated with anxiety and depression related issues and conditions which are very common in hospitalized patients and attended .12 In many studies it was found that both physical and mental stress was related to increase in cortisol level (Schommer et al. 2003). There is good evidence of many studies where stress and anxiety are related to increase resting levels of cortisol (Schommer et al. 2003; Wirtz et al. 2007). The interrelationship between chronic physical illness and psychiatric morbidity is also well established.13 Hence the following study was conducted to determine the Anxiety, Depression and serum cortisol level in hospitalized patients for conventional or surgically treatments and their attended and co-relate the serum cortisol level with Anxiety and Depression.14
A total of 150 patients were studied. 25 (16.66%) patients were between age group of 21- 25yrs, 35 (23.33%) between 26-30 yrs, 25 (16.66%) between 31-35 yrs, 25 (16.66%) between 36-40 yrs, 35 (23.33%) and age group 41-45 has 30 (20.02%) yrs respectively. The mean age was 33.56±6.45 yrs.[Table1]. Among the patients 110 (73.33%) were males and 40 (26.67%) were females [Table2]. In this study total 150 samples divided into three groups, group 1 conservative treated patients, group 2 Surgically treated patients and group 3 control [Table 3].
Assessment of intra-group correlation among serum cortisol level, anxiety, depression, total anxiety and total depression level respectively mean value186.0596, 0.34, 0.18, 8.6 and 4.3 after analysis we found p value of correlation is significant (<.00001) [Table 4]. None of them had severe anxiety which is in accordance with the study conducted by Mallik S et al 200615 they had been done their study that’s similar to this study.
The mean serum cortisol level in surgically treated patient’s 475.96, conservative treated patients 373.03 and in control group 186.05 after comparison we found significant p value <.00001[Table 7]. Comparison among, surgically treated patients group, Conservative treated patients group and control group on the bases of total anxiety level by HAM-A scale(1959)31, we found as resultant mean value of surgically treated patients, conservative treated and control group respectively 17.88, 17, 8.6 and p value found (<.00001) that’s highly significant. [Table 8] Partially similar study has to be done in 2004 by Strik JJMH et al16 , In their study they had found nearly similar results as found in our study.
Shanmugasegaram S et al conducted comparative study in 2012 as present our study and found nearly similar significant results like Comparison among, surgically treated patients group, Conservative treated patients group and control group on the bases of total anxiety level by HAM-D scale (1960)17, we found as resultant mean value of surgically treated patients, conservative treated and control group respectively 12.56, 11.8, 4.3 and p value found (<.00001) that’s highly significant. [Table 9]
The present study was undertaken to assess and co-relate the anxiety, depression and serum cortisol levels in surgically treated, conservative and control patients. A significant increase in serum cortisol levels were seen in patients with anxiety and depression when compared to that of normal patients. Serum cortisol levels were also raised in patients with surgically treated followed by conservative patients and lower in control group. It can be concluded that there is strong positive co-relation between serum cortisol level, anxiety level and depression level in patients with surgically treated compare with conservative treatment highly significant. This is the first study were anxiety, depression and serum cortisol levels were assessed in admitted patients for surgically and conservative treatment. Further studies with larger sample size must be done to co-relate other neuro-endocrinal abnormalities among patients.
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