Emotional state and coping style among gynecologic patients undergoing surgery
Toshiko Matsushita, PhD, Graduate School of International University of Health and Welfare, Amity Nogizaka, 1-24-1 Minamiaoyama, Minato-Ku, Tokyo 107-0062, Japan. Email: firstname.lastname@example.org
Abstract The aim of the present study was to investigate changes in emotional state and the relationship between emotional state and demographic/clinical factors and coping style among gynecologic patients undergoing surgery. Using the Japanese version of the Profile of Mood States (POMS), 90 patients (benign disease: 32, malignancy: 58) were examined on three occasions: before surgery, before discharge, and 3 months after discharge. They were also examined using the Coping Inventory for Stressful Situations (CISS) on one occasion before discharge. The scores for the subscales depression, anger, and confusion were the highest after discharge while those for anxiety were the highest before surgery. The average scores of the POMS subscales for all subjects were within the normal range. With regard to the relationship between these emotional states and other factors, multiple regressions showed that the principal determinants of anxiety before surgery were religious belief, psychological symptoms during hospitalization and emotion-oriented (E) coping style; further, it was found that depression after discharge could be explained by chemotherapy, duration of hospitalization, and E coping style. The principal determinants of anger after discharge and vigor before surgery were length of education and E coping style, and severity of disease, chemotherapy, E coping style and task-oriented coping style, respectively. Those of post-discharge fatigue and confusion were length of education, psychological symptoms, and E coping style. In summary it is suggested that the following should be taken into account in patients undergoing gynecologic surgery: anxiety before surgery, depression, anger, and confusion after surgery, including coping styles.
Since the 1980s, many studies in the field of psycho-oncology have investigated the relationship between coping style and psychological distress, such as depression, among cancer patients.1–5 Results have suggested that focusing on the coping style of patients and attempting to influence coping style might reduce deterioration in the quality of life (QOL). The effects and usefulness of such interventions have therefore been investigated.6–8 In particular, in addition to psychiatric outcome, the effect of these interventions on prognosis has been reported.9,10 However, the majority of such studies have focused on patients with breast cancer, and few have investigated the relationship between psychological distress and the coping style of patients with gynecologic cancer.
Patients with gynecologic disease, including cancer, who are undergoing surgery, can be particularly vulnerable to distress associated with damage to self-image, altered sexual function, and loss of fertility,11–19 in addition to general preoperative stress. Furthermore, approximately 30% of cancer patients are reported to be diagnosed with depression or adjustment disorders.20,21 We must therefore take into account psychiatric complications among gynecologic cancer patients. Compared to studies conducted in Europe and America, in Japan fewer studies have investigated the perioperative emotional state among gynecologic patients, including those with cancer.
In the present study on gynecologic patients, the aim was to investigate the emotional state in the perioperative period and to ascertain the relationship between emotional state and other factors, including coping style, using self-administered questionnaires. We used the Profile of Mood States (POMS)22 as a scale for estimating emotional state, and the Coping Inventory for Stressful Situations (CISS)23 as a scale for coping style. We selected POMS and CISS because these scales are used internationally, and the subjects using these scales are not limited to the members of a particular group such as cancer patients.
We hypothesized that gynecologic patients undergoing surgery are likely to perioperatively exhibit particular psychological symptoms, irrespective of whether or not the patient has cancer. In addition, we hypothesized that the emotional state of the patient is related to their coping style, in particular, the emotion-oriented (E) coping style that has been reported as a maladaptive coping style by many researchers.24–28 We predicted that there should be timely intervention in gynecologic patients undergoing surgery who exhibit psychological symptoms; further, patient characteristics, including coping styles, should be focused on perioperatively.
The subjects consisted of 98 patients who were admitted to the Department of Obstetrics and Gynecology, Tokyo Medical and Dental University Hospital between June 2002 and March 2004 for the surgical treatment of gynecologic disease, including cancer. Patients with cognitive impairment and those undergoing psychiatric treatment were excluded. Two patients did not consent to participate in the study; a further four subsequently withdrew consent or dropped out due to deterioration in physical condition and two patients died before discharge. Consequently, 90 patients (mean age ± SD, 46.9 ± 13.1 years) participated in the present study. Of these, 32 were diagnosed with benign disease (mean age, 41.0 ± 11.3 years) and 58 with malignancy (mean age, 50.2 ± 13.0 years). Patients who dropped out from the study after the first examination day were all cancer patients. There was no difference in the other clinical/demographic factors.
The following diagnoses were made in the benign group: ovarian tumor (n = 16), tubo-ovarian abscess (n = 10), and other tumors including cervical adenoma (n = 6). The diagnoses in the malignant group were as follows: cervical cancer (n = 28), cancer of the uterine body (n = 12), and ovarian cancer (n = 18). The following surgical procedures were performed: laparotomy (n = 55), conization (n = 19), and adnexectomy (n = 16). In the malignant group, tumor extension was classified according to the general classification rules for gynecologic cancer.29,30 Patients at disease stage 0, I, or II were classified as the early stage group (n = 47) and those at stages III or IV as the advanced-stage group (n = 11). Table 1 shows the average age, length of education, duration of hospitalization, habitation status, employment status, location of tumor, progress, surgical treatment, and chemotherapy administration in the benign and malignant groups. No cancer patient received chemotherapy and/or radiotherapy after discharge. The two groups exhibited no significant difference in demographic/clinical factors, such as length of education, habitation status, employment status, or surgical treatment. In contrast, significant differences were observed in age, duration of hospitalization, and location of tumor. All patients were informed of their diagnoses before admission, and when the diagnosis was not confirmed preoperatively, the cancer patients were told that the findings were ‘suspicious of cancer’. There were five such patients. There was no patient with benign disease in whom cancer was suspected.
Table 1. Sociodemographic subject characteristics
|Age (years)||41.0||11.3||50.2||13.0||d.f. = 88/t = 3.372||0.0011|
|Length of education (years)||14.0||1.8||13.0||2.3||d.f. = 88/t = −1.939||0.0566|
|Duration of hospitalization (days)||14.0||5.3||28.2||25.4||d.f. = 88/t = 3.109||0.0025|
| Single||6||18.8||12||20.7||d.f. = 2/χ2 = 0.438||0.8032|
| Spouse only||7||21.9||17||29.3|| || |
| Others||19||59.4||29||50.0|| || |
| Employed||13||40.6||24||41.4||d.f. = 1/χ2 = 1.78E-30||>0.999|
| Unemployed||19||59.4||34||58.6|| || |
|Location of tumor|
| Uterine cervix||2||6.3||28||48.3||d.f. = 2/χ2 = 29.354||<0.0001|
| Uterine body||1||3.1||12||20.7|| || |
| Ovary||29||90.6||18||31.0|| || |
| Advanced||NA||NA||11||19.0|| || |
| Laparotomy||17||53.1||38||65.5||d.f. = 1/χ2 = 1.161||0.2812|
| Conization/others||15||46.9||20||34.5|| || |
Following routine admission and stabilization, informed consent was obtained from each patient. Two self-administered questionnaires were used. The patients’ emotional state was evaluated using the Japanese version of POMS,31–33 and coping style was measured using the Japanese version of CISS.34,35 The POMS questionnaire was administered on three occasions: before surgery, before discharge, and 3 months after discharge. In contrast, CISS was administered only before discharge.
POMS assesses six emotional states: tension–anxiety, depression, anger–hostility, vigor, fatigue, and confusion; a higher score (in the case of vigor, a lower score) indicates a more severe emotional state. These subscales were standardized according to the consecutive studies of Yokoyama and Araki33: scores lower than average + SD (scores are based on data collected from these studies) indicate ‘no emotional problem’, scores between average + SD and average + 2.4 SD indicate that ‘medical attention is advised in the event of symptoms’, and scores of average + 2.5 SD or more indicate that ‘medical attention is necessary’. In the present study we used standardized scores that were converted from raw scores.
CISS was used to determine the typical coping style of the subjects during the most stressful situations. CISS assesses the following three coping styles: task-oriented (T) coping style, emotion-oriented (E) coping style, and avoidance-oriented (A) coping style, and includes a total of 48 items (16 items for each coping style); a higher score indicates that the coping style is often used. Coping style is defined as the typical cognitive/behavioral pattern adopted most often during stressful situations.23,34,35 We assumed that although this style might vary depending on the occasion, an individual’s coping style is a type of character trait. We therefore assumed that coping style would be more likely to affect emotional state than vice versa. CISS was selected as a measurement of coping style because it is often used as an international scale, thereby enabling us to compare our findings with those of other studies. Further, the reliability and validity of the Japanese version of CISS have been confirmed, and this scale can be used for both patients with benign disease and cancer patients.
For statistical analysis, the demographic/clinical data between the benign and malignant groups was compared using Student’s t-test and the χ2 test. The change in each POMS subscale score over the three test administration days was analyzed using repeated measures analysis of variance (anova) with post-hoc comparisons (Scheffe’s F-test; 95% significance). Multiple regressions were subsequently performed by treating the factors (including the CISS scores) significantly related to the POMS scores as independent variables and the POMS scores as dependent variables. This was done in order to assess determinants of the POMS subscale scores exhibiting the greatest deterioration. P < 0.05 was considered significant.
Emotional states over the three test administration days
On all occasions, the POMS scores for all subjects were within normal range. Significant differences in the tension–anxiety, depression, anger–hostility, and confusion scores were evident across the three test administration days (tension-anxiety: F = 9.356, P = 0.0001; depression: F = 6.819, P = 0.0015; anger–hostility: F = 15.101, P < 0.0001; confusion: F = 3.956, P = 0.0211). For vigor and fatigue, no significant difference was apparent in the values of the scores over the study period. In summary, the tension–anxiety score was the highest before surgery, and the depression, anger–hostility, and confusion scores were the highest after discharge (Table 2).
Table 2. POMS subscale scores (±SD) in the three groups (benign, early stage, and advanced-stage) over the three examination days
| All subjects||47.7 ± 10.6||42.0 ± 9.2||43.9 ± 10.3†‡|
| Benign group||49.7 ± 11.8||42.6 ± 10.8||45.6 ± 11.0|
| Early stage group||46.4 ± 11.1||42.1 ± 9.7||44.2 ± 10.8|
| Advanced-stage group||48.4 ± 5.6||39.8 ± 5.3||38.7 ± 3.0|
| All subjects||46.3 ± 9.0||44.0 ± 6.6||47.8 ± 10.8§|
| Benign group||47.2 ± 8.6||44.8 ± 7.7||48.2 ± 10.0|
| Early stage group||45.4 ± 8.7||43.8 ± 6.9||49.0 ± 12.1|
| Advanced-stage group||45.8 ± 5.7||42.5 ± 3.5||41.7 ± 2.4|
| All subjects||42.3 ± 5.7||40.2 ± 4.3||44.4 ± 8.5†‡§|
| Benign group||44.8 ± 5.6||40.2 ± 3.5||46.4 ± 8.0|
| Early stage group||41.3 ± 5.3||40.1 ± 4.9||44.5 ± 9.2|
| Advanced-stage group||39.1 ± 1.1||39.0 ± 1.8||39.2 ± 2.2|
| All subjects||48.5 ± 9.6||51.4 ± 11.1||51.0 ± 11.2|
| Benign group||45.0 ± 10.5||50.0 ± 12.5||50.8 ± 11.6|
| Early stage group||52.6 ± 7.7||53.2 ± 11.2||51.1 ± 12.1|
| Advanced-stage group||42.3 ± 8.1||48.9 ± 10.9||51.5 ± 5.3|
| All subjects||43.3 ± 9.1||43.0 ± 9.6||44.7 ± 9.7|
| Benign group||46.1 ± 9.8||44.0 ± 11.0||46.8 ± 10.3|
| Early stage group||41.0 ± 7.8||41.4 ± 8.9||44.6 ± 9.8|
| Advanced-stage group||47.9 ± 9.6||43.3 ± 9.6||40.5 ± 6.0|
| All subjects||44.4 ± 10.5||42.1 ± 8.8||45.3 ± 11.5§|
| Benign group||46.8 ± 10.8||42.9 ± 10.1||46.6 ± 11.0|
| Early stage group||42.0 ± 10.5||40.8 ± 8.8||46.2 ± 12.3|
| Advanced-stage group||45.2 ± 8.2||43.2 ± 7.5||37.9 ± 5.8|
Furthermore, with the exception of anger–hostility, no significant difference was apparent in the POMS subscales between the three groups (benign, early stage, advanced-stage groups) across the three test administration days. The anger–hostility score was the lowest in the advanced-stage group and the highest in the benign group (F = 4.016, P = 0.0220); post-hoc tests showed that there was a significant difference between these two groups with regard to this score.
Clinically, three patients demonstrated psychological symptoms such as depressed mood from before surgery to before discharge (during hospitalization). One patient was diagnosed with depression before discharge (her gynecologic diagnosis was benign), and the other two patients were diagnosed with adjustment disorder (all had benign disease).
Relationship between POMS and demographic/clinical parameters
We selected the presurgery tension–anxiety and vigor scores and the post-discharge depression, anger–hostility, fatigue, and confusion scores as dependent variables because these were the highest scores (in the case of vigor, the lowest scores) over the study period.
Next, we performed the following process for selecting the dependent variables for each regression model. First, we analyzed the relationship between POMS and other demographic/clinical factors (continuous variables) including the coping style by using Pearson’s correlation test. Second, we analyzed the relationship between POMS and other demographic/clinical factors (nominal variables) by using two-way anova with repeated measures. Third, we confirmed the multicollinearity by analyzing the relationship between the significant demographic/clinical factors (continuous variables) other than POMS by using the Pearson’s correlation test. The following results were obtained.
With regard to the relationship between POMS and clinical parameters, Pearson’s correlation test results showed that variables such as CISS scores, age, length of education, and duration of hospitalization were related to the POMS subscale scores (Table 3). The results of two-way anovas with repeated measures showed that variables such as benign/malignant group, religion, chemotherapy, administered during hospitalization, and psychological symptoms during hospitalization were significantly related to the POMS subscales. With regard to the relationship between the significant clinical parameters, including the CISS scores, Pearson’s correlation test results indicated significant relationships between the age and duration of hospitalization (r = 0.369, P = 0.0013), age and length of education (r = −0.532, P < 0.0001), age and E coping style scores (r = −0.313, P = 0.0071), duration of hospitalization and length of education (r = −0.410, P = 0.0003), and E coping style scores and A coping style scores (r = 0.320, P = 0.0058).
Table 3. Variables significantly related to the POMS subscale scores (Pearson’s correlation tset)
| Task-oriented coping style||T-A before discharge||−0.267||0.0249|
|V before discharge||0.388||0.0008|
|C before discharge||−0.253||0.0344|
| Emotion-oriented coping style||All POMS scores except for V before discharge||0.263–0.612||<0.0001–0.0278|
| Avoidance-oriented coping style||T-A after discharge||0.332||0.0048|
|D after discharge||0.317||0.0073|
|A-H after discharge||0.292||0.0137|
|F after discharge||0.267||0.025|
|C after discharge||0.315||0.0076|
|Age||D before surgery||−0.270||0.0236|
|A-H before surgery||−0.270||0.0234|
|C before surgery||−0.251||0.0357|
|D before discharge||−0.300||0.0112|
|F after discharge||−0.238||0.0469|
|Length of education||V before surgery||0.242||0.0434|
|C after discharge||0.263||0.0278|
|Duration of hospitalization||F before discharge||0.259||0.0301|
Taking these results into account, we attempted multiregression analyses with some combinations of independent variables, and we were able to achieve the most adaptive model (the best combination of the independent variables) for each dependent variable. Table 4 shows the results of those multiple regression analyses. Presurgery tension–anxiety scores for non-religious patients were higher than those for religious patients. Presurgery tension–anxiety scores and fatigue/confusion scores after discharge were higher in patients with psychological symptoms than patients without them. Depression scores after discharge and vigor scores before surgery for patients who underwent chemotherapy were lower than those for patients who did not receive chemotherapy. The longer the duration of hospitalization, the higher were the patients’ depression scores. The longer the length of education, the higher were the patients’ anger–hostility, fatigue, and confusion scores after discharge. Presurgery vigor scores were higher in cancer patients and patients with high T coping style scores than in other patients. Furthermore, presurgery tension–anxiety and vigor, and post-discharge depression, anger–hostility, fatigue, and confusion scores were higher (in the case of vigor, lower) for patients with high E coping style scores than for those with low E coping style scores.
Table 4. Final multiple regression model for predicting POMS scores
|Tension–Anxiety before surgery||Age||0.099||0.124||0.2699||0.270||3.198/0.0024|
|Religious beliefs||8.196||0.210||0.0411|| || |
|Severity of disease||−1.794||−0.082||0.4468|| || |
|Chemotherapy||−8.098||−0.289||0.1845|| || |
|Psychiatric symptom||−10.236||−0.263||0.0118|| || |
|Duration of hospitalization||−0.149||−0.306||0.1558|| || |
|Task-oriented coping style||−0.093||−0.121||0.2290|| || |
|Emotion-oriented coping style||0.331||0.332||0.0035|| || |
|Avoidance-oriented coping style||0.051||0.058||0.5706|| || |
|Vigor before surgery||Age||0.033||0.045||0.6759||0.324||4.736/<0.0001|
|Religious beliefs||−0.567||−0.016||0.8691|| || |
|Severity of disease||5.181||0.260||0.0130|| || |
|Chemotherapy||15.236||0.598||0.0046|| || |
|Psychiatric symptom||0.664||0.019||0.8478|| || |
|Duration of hospitalization||0.105||0.239||0.2437|| || |
|Task-oriented coping style||0.207||0.297||0.0023|| || |
|Emotion-oriented coping style||−0.218||−0.241||0.0206|| || |
|Depression after discharge||Age||0.063||0.075||0.5758||0.464||5.019/<0.0001|
|Length of education||1.006||0.197||0.1376|| || |
|Religious beliefs||3.370||0.093||0.3751|| || |
|Severity of disease||2.224||0.097||0.3802|| || |
|Chemotherapy||14.300||0.525||0.0178|| || |
|Psychiatric symptom||−6.655||−0.171||0.0997|| || |
|Duration of hospitalization||0.265||0.565||0.0092|| || |
|Task-oriented coping style||−0.089||−0.113||0.2815|| || |
|Emotion-oriented coping style||0.475||0.479||0.0001|| || |
|Avoidance-oriented coping style||0.146||0.155||0.1409|| || |
|Anger-Hostility after discharge||Age||0.128||0.194||0.1841||0.377||3.517/0.0011|
|Length of education||1.160||0.287||0.0459|| || |
|Religious beliefs||1.157||0.040||0.7197|| || |
|Severity of disease||−1.128||−0.062||0.6001|| || |
|Chemotherapy||6.664||0.310||0.1869|| || |
|Psychiatric symptom||−0.547||−0.018||0.8721|| || |
|Duration of hospitalization||0.116||0.314||0.1696|| || |
|Task-oriented coping style||−0.058||−0.093||0.4123|| || |
|Emotion-oriented coping style||0.390||0.498||0.0002|| || |
|Avoidance-oriented coping style||0.107||0.144||0.2036|| || |
|Fatigue after discharge||Age||0.057||0.075||0.6070||0.366||3.347/0.0017|
|Length of education||1.694||0.366||0.0100|| || |
|Religious beliefs||0.245||0.007||0.9477|| || |
|Severity of disease||−0.731||−0.035||0.7689|| || |
|Chemotherapy||6.743||0.273||0.2474|| || |
|Psychiatric symptom||−9.091||−0.258||0.0238|| || |
|Duration of hospitalization||0.179||0.422||0.0690|| || |
|Task-oriented coping style||−0.013||−0.018||0.8737|| || |
|Emotion-oriented coping style||0.301||0.336||0.0100|| || |
|Avoidance-oriented coping style||0.111||0.130||0.2535|| || |
|Confusion after discharge||Age||0.145||0.160||0.2511||0.429||4.349/0.0001|
|Length of education||2.144||0.388||0.0056|| || |
|Religious beliefs||3.322||0.085||0.4327|| || |
|Severity of disease||1.372||0.055||0.6265|| || |
|Chemotherapy||9.375||0.319||0.1570|| || |
|Psychiatric symptom||−10.775||−0.256||0.0183|| || |
|Duration of hospitalization||0.159||0.315||0.1512|| || |
|Task-oriented coping style||−0.090||−0.106||0.3289|| || |
|Emotion-oriented coping style||0.430||0.403||0.0014|| || |
|Avoidance-oriented coping style||0.179||0.175||0.1078|| || |
Change in emotional state over the study period
With regard to changes in emotional state, the present results showed that over the study period, depression and anger changed in a different manner as compared to anxiety. While anxiety was the highest before surgery, depression and anger were maximal 3 months after discharge. High anxiety before surgery might be due to general concerns regarding the surgery itself. In contrast, high depression and anger after discharge might be attributed to psychological distress associated with damage to self-image, altered sexual function, and loss of fertility.11–19 Such distress appears to be overt after discharge when the patient’s physical condition has improved.
Previously, we investigated the psychological state of gastrointestinal patients (including cancer patients) undergoing surgery. We found that depression increased from before surgery to before discharge and had not recovered to presurgery levels 6 months after discharge; but the scores for anxiety did not change over the study period.36 Although it is evident that patients with gastrointestinal disease differ from those with gynecologic disease in terms of parameters such as gender and physical status, the two studies showed similar results with regard to the following two points: (i) depression changed significantly over the study period; and (ii) the changing pattern of anxiety was different from that of depression. In conclusion, we should focus on the timely initiation of treatment or care to gynecologic patients. For example, we should communicate to patients with gynecologic disease taking into account their anxiety, and offer preoperative orientation and explanation about surgery. Furthermore, follow-up psychological examinations should be carried out by skilled experts to evaluate patient deteriorated emotional states such as depression, anger, and confusion. The routine psychological screening test carried out during follow up after discharge might be useful.
Incidence of psychiatric disease and the level of emotional state over the study period
All the POMS average scores for all subjects were within the standard range for each subscale on all test administration days. Furthermore, only three of 90 subjects had psychological symptoms warranting psychiatric diagnosis. Hence, the morbidity rate was relatively low at 3.3% when compared with findings from previous studies that investigated psychiatric morbidity rates among cancer patients.
Using the Center for Epidemiologic Studies Depression Scale (CES-D) and the State–Trait Anxiety Inventory (STAI) as depression/anxiety evaluation scales, Bodurka-Bevers et al. investigated depression and anxiety among patients with ovarian cancer (26% of subjects had early stage cancer, 74% had advanced-stage cancer, and 49% were undergoing active treatment).37 They reported that scores exceeded the threshold for depression in 21% of all subjects and scores for anxiety exceeded 75% of the average scores in 29% of all subjects. In the present study, the fact that the POMS average scores were all within the normal range might be explained by differences in the measurements used and the inclusion of subjects with benign tumors and the fact that patients with early stage disease outnumbered those with advanced-stage disease in the present study. In contrast, our study showed that the emotional status of advanced-stage patients was not different from that of benign and early stage patients. This contradiction might be because there were only a few advanced-stage patients in the present study and their physical condition was not severe.
Next, Tanaka et al. reported that 29.2% of gynecologic cancer patients who had been informed of their diagnosis were diagnosed with psychiatric diseases within 1 week of being given the diagnosis.38 In the present study, preoperative tests were administered some weeks after the patients were informed of their diagnosis; this might contribute to differences between the Tanaka et al. findings and those of the present study.
We now discuss our findings that there was no difference in most POMS subscale scores between the benign, early stage, and advanced-stage groups and the finding that the anger–hostility score was higher in the benign group than in the advanced-stage group. As for the former observation, the physical condition of the advanced-stage patients in the present study was not severe. Additionally, Lutgendorf et al. investigated QOL and mood in women with gynecologic cancer at an initial clinic visit and after 1 year by using FACT (measuring QOL) and POMS.39 They reported that QOL and mood improved among the early stage and regionally advanced oncology patients and that there was no significant difference between the two patient groups in the level of and change in mood over time. Their finding is consistent with the present findings. Irrespective of whether the patients have cancer or whether their cancer is at an early or at an advanced stage, most distress common to all gynecologic patients undergoing surgery might be associated with concerns other than surgery, cancer, and the disease itself. Furthermore, as for the second finding (that the anger–hostility score was found to be higher in the benign group than in the advanced-stage group), we did not obtain the same results in proceeding studies in gynecologic patients. However, because gynecologic patients with benign diseases have no fear of cancer, that is, they are not severely anxious, feelings such as anger and hostility might be exhibited to a greater extent by these patients than by cancer patients. In fact, through clinical experience in gynecologic wards we confirmed that strong negative emotions such as fear and anxiety often prevail over anger and hostility.
Relationship between emotional state and demographic/clinical parameters
Anxiety before surgery was related to religious beliefs and to the E coping style. In crisis situations, patients with religious beliefs might experience less stress than non-religious patients. Jarvis et al. examined the relationship between religious practice and psychological distress in a culturally diverse urban population, and confirmed that attendance at religious services was related to lower levels of distress.40 Salsman et al. investigated the relationship between religiousness and adjustment (distress and life satisfaction) and between spirituality and adjustment; they reported that intrinsic religiousness and prayer fulfillment are related to life satisfaction, and that life satisfaction is mediated by optimism and social support.41
Moreover, it appears plausible that patients exhibiting psychological symptoms during hospitalization are more likely to feel anxiety, fatigue, and confusion after discharge than those who do not exhibit psychological symptoms. It also appears plausible that patients who underwent long hospitalization stays were more depressed after discharge than those who underwent a short hospitalization. With regard to the finding that scores for anger, fatigue, and confusion after discharge were lower among patients with short-term education, many previous studies showed that gynecologic patients are more likely to suffer from distress associated with loss of female identity and self-image than that resulting from the disease itself.11–19 The cognitive scheme against such distress might be related to the length of education. However, this scheme is assumed to be different from coping styles because the length of education affected patient mood after discharge independently of coping styles. In contrast, it is unclear why vigor scores before surgery were higher for cancer patients than for patients with benign diseases, and why depression scores after discharge were lower for patients who underwent chemotherapy than for those who did not.
Corney et al. investigated psychological and sexual distress among patients with uterine and vulval cancer undergoing surgery by using interview methods incorporating HADS.42 They reported that anxiety was not related to age or surgical methods and sexual problems were significantly related to the anxiety level. In addition Greimel and Freidl investigated daily living and psychological well-being among gynecologic cancer patients perioperatively; they reported that the scores were not significantly related to age, tumor location, or disease progression.43 Therefore, although we cannot make a simple comparison, their findings regarding age, tumor location, surgical methods, and disease progression appear to be consistent with the present findings.
Relationship between emotional status and coping style
After the multicollinearity in the regression model was considered, the present findings suggested that anxiety and vigor before surgery and depression, anger, fatigue, and confusion after discharge depend on the individual’s coping style. In particular, the E coping style had a great influence on all emotional states. Previous studies using CISS have reported that among the various population, the E coping style is related to negative psychological states, personality, or psychiatric pathology.24–28 Some studies have also reported that the T coping style is related to positive personality traits.27,28 These findings are similar to those of the present study. From the standpoint of optimizing mental health and promoting comprehensive patient care, concrete strategies should focus on the coping style of gynecologic patients, particularly the E coping style. Patients who cope emotionally should be enrolled in a psychoeducational program focusing on adjusting coping style.
The present study clarified perioperative changes in the emotional state in gynecologic patients undergoing surgery, and the relationship between these and multiple related factors. In particular, the findings showed that there are not many differences between the mood of patients with benign disease and those with cancer. Additionally, the findings elucidated the characteristics of subjects who should receive more clinical attention. However, although we were able to identify these characteristics, it is difficult to extrapolate these findings into concrete methods for care or intervention for characteristics such as the physical condition of patients, types of treatments, and patient background such as educational length. In contrast, with regard to coping style, it is not impossible to prompt patients to alter their cognitive style and to urge them to use a more adaptive style through therapy such as psychoeducational group therapy. Furthermore, considering that almost all the psychological variables studied changed over the perioperative period, it can be concluded that timely intervention taking into account individual treatment conditions and situations is important.