Reducing preoperative anxiety in patients of different ethnic origin undergoing open heart surgery at the National Heart Institute, Kuala Lumpur, Malaysia

Abstract

Facing major surgery is stressful. How patients cope with this stress can have an important influence on recovery from surgery and more generally on the outcome of illness (Cohen, 1987). Psychological interventions have been shown to reduce the levels of preoperative and post-operative anxiety and to promote recovery after surgery (Ridgeway & Mathews, 1982; Wallace, 1984; Anderson, 1987; Aiken & Henrichs, 1971, Johnston & Carpenter, 1980; Manyande & Salmon, 1992). The purpose of this study was to (1) investigate coping strategies employed by patients of different ethnic backgrounds facing cardiac surgery, (2) provide preparatory packages to patients before surgery, emphasizing different coping strategies (relaxation; coping skills; praying); (3) compare the outcome across these interventions four to five days after surgery and at two to three months after surgery; (4) compare the effectiveness of the coping skills and relaxation information packages on post-surgical outcome among the three ethnic groups, and finally (5) to study the effect of prayer as a means of reducing anxiety among Malay patients. The sample consisted of 143 Malay, Chinese and Indian patients who had been admitted to the National Heart Institute in Kuala Lumpur for open heart surgery. Patients were seen three times before the operation and once after the operation, and then follow-up was done by mail and/or phone two to four months after discharge. After the first visit, patients were allocated to four experimental conditions: control, relaxation, coping skills, or praying. The control group received the routine hospital procedure. The Prayer group was given a list of Quranic verses to be read and meditated. All the experimental groups also received the routine hospital procedure. Psychological interventions were conducted during the second and third visits. The fourth visit was to collect post-operative data. Pre-operative measures in this study included the Beck Depression Inventory (BDI), the Coping Strategies Questionnaire (CSQ), the State-Trait Anxiety Inventory (STAI) and the General Health Questionnaire (GHQ). During the post-operative visit, state anxiety was assessed and the post-operative schedule was completed. The follow-up data by mail (two months after discharge) consisted of BDI, STAI, GHQ and the follow-up schedule. The findings of the study include: (1) pre-operatively, a small minority of patients were depressed as measured by the BDI whereas the majority of patients regardless of ethnicity were anxious as measured by the STAI. (2) As measured by the CSQ, Malays, Chinese and Indian patients used praying and hoping, and coping self-statements more frequently than other coping strategies. In addition, there were inter-ethnic differences in the use of coping strategies; Malays tended to reinterpret pain sensations more frequently than Chinese patients, while Indians used Catastrophizing more than the Chinese and Malay patients as a mode of controlling pain. (3) Among the psychological packages used, relaxation and coping interventions were equally helpful in reducing anxiety, anxiety dysphoria and suicidal depression in all three races. (4) However among the Malay patients, the prayer intervention had no effect in reducing anxiety when compared to the relaxation and coping interventions. Finally (5) the study also indicated that preference for a particular coping strategy did not influence the treatment outcome in any of the three experimental groups. In conclusion, brief psychological interventions appear to be of value in reducing the distress experienced after major cardiac surgery. With further refinement, these psychological techniques could be incorporated into routine hospital preparation for surgical patients