Original Article: Clinical Investigation
Psychological profile of Taiwanese interstitial cystitis patients
Alex TL Lin md, Division of Urology, Department of Surgery, Taipei Veterans General Hospital no. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan. Email: email@example.com
Objectives: The correlation between anxiety and interstitial cystitis has, as best we know, not yet been reported on. The present study investigated the psychological profile, including anxiety and depression, of patients suffering from interstitial cystitis (IC).
Methods: A total of 47 IC patients, all of whom met National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases (NIDDK) criteria, plus a group of 31 age-matched, asymptomatic women received a structured interview on depression (Hamilton Rating Scale for Depression) and also on anxiety symptoms (Hamilton Rating Scale for Anxiety). IC patients also completed questionnaires relating to IC symptom severity, including urgency and frequency (visual analog scale) and O'Leary Sant index.
Results: A total of 85% of our IC patients featured significant affective symptoms. The average depression scores were 16.6. Fifteen patients (31.9%) featured mild depressive symptoms, five (10.6%) had mild to moderate and 20 (42.6%) had moderate to severe depression symptoms. The mean anxiety score was 21.0, with 21 (44.7%), nine (19.1%) and 17 (36.2%) patients revealing mild, mild to moderate, and moderate to severe anxiety symptoms, respectively. Further, IC patients reported a significantly greater extent of depression and anxiety than was the case for controls. Pain scale and O'Leary Sant index were significantly correlated to anxiety and depression score.
Conclusions: Most of our IC patients feature significant depression and anxiety. The extent of affective symptoms would appear to correlate well with IC symptom severity.
Interstitial cystitis (IC) is a chronic, relapsing syndrome of bladder pain associated with urinary urgency and frequency, and nocturia. Previous research has demonstrated that patients with IC experience depression symptoms;1 however, to the best of our knowledge, the correlation between anxiety and interstitial cystitis has not yet been evaluated in the past. Moreover, IC is typically reported based on patients from Western countries, with only very few papers focused on Asian IC patients. In the present study, we investigate the extent of depression and anxiety symptoms among Taiwanese patients with IC.
We recruited a total of 47 patients aged from 23 to 79 years (mean 50.2 ± 12.9) with a diagnosis of IC in accordance with the 1987 National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases guidelines (NIDDK).2 Of these 47 patients, nine (19.1%) were male. All of these patients were newly diagnosed cases of IC, and none had received any definitive treatment, such as hydrodistention, for IC. Four (8.5%) patients had previously visited psychiatrists and received some medication to relieve their anxiety or depression. All of our patients didn't take any antidepressant during the period of clinical and psychological evaluation. The mean duration of the symptoms was 10.3 ± 8.4 years (range 1 to 36).
All patients completed the questionnaires relating to symptom severity including urgency and frequency (visual analog scale 1–10) and O'Leary Sant index.3 O'Leary symptom and bother index both included four questions that targeted the degree of urgency, frequency of urination, nocturia and level of bladder pain in the previous 4 weeks. Each of the questions was rated on a severity scale of 0–5. The summed scores for symptom and bother score were then calculated.
All participants underwent cystoscopy and hydrodistention (maximum distention at 80 cm water pressure for 15 min) under general anesthesia. Bladder capacity was measured. The degree of mucosal hemorrhage was graded from 0 to 5 as defined by Nordling et al.4
A total of 31 asymptomatic women 25–61 years of age (mean age 43.5 ± 9.1) without any history of chronic inflammatory or pain conditions, chronic urinary disorder including IC symptoms, anxiety, depression or anti-inflammatory medication were used to serve as controls.
All patients and controls completed a structured interview relating to depression symptoms (Hamilton Rating Scale for Depression [HRSD]) and anxiety symptoms (Hamilton Rating Scale for Anxiety [HAM-A]) by the same one interviewer.
The HRSD is a 17-item structured interview of depression symptoms.5 Items are cued to the week immediately preceding testing and rated on a severity scale of 0–2 or 0–4. Asummed score of between 10 and 13 are defined as a mild symptoms score, whereas a score between 14 and 17 is defined as mild to moderate symptoms. A cutoff score of 17 serves as a marker for moderate to severe depression symptoms. The HRSD has been used extensively in chronically ill populations and it has demonstrated validity.
The HAM-A, is a 14-item structured interview of anxiety symptoms.6 Items are cued to the week immediately preceding testing and are rated on a severity scale of 0–4. A score of <17 is considered mild, 18–24 is mild to moderate and a score of 25–30 is considered to display moderate to severe anxiety.
Descriptive statistics were carried out for severity distribution of affective symptoms. Nonparametric correlations with Spearman's rho were used to test the relationships among affective symptoms ratings and the relative severity of (subjective) IC symptoms. In addition, the correlations between the symptomatic duration prior to the diagnosis and affective symptoms ratings and IC-symptoms severity, were also made by Spearman's rho. The correlation between affective symptoms and objective IC severity including bladder capacity, analyzed as a categorical variable, and hemorrhage grading, was made by the Kruskal–Wallis test. Mann–Whitney U-test was carried out so as to compare affective symptoms ratings and IC-symptoms severity for both male and female patients. In order to adjust for the age effect, multiple linear regression testing with anova, was carried out so as to compare affective symptoms in both IC and healthy patients.
A total of 85% of our patients revealed significant affective symptoms. The average depression scores were 16.6 ± 8.06 (range: 5–38) with a mild degree of depression in 15 patients (31.9%), mild to moderate degree in five (10.6%) and moderate to severe degree in 20 (42.6%). The average anxiety scores was 21.0 ± 8.9 (range: 8–45) for the study population, including 21 patients (44.7%) who revealed a mild level of anxiety symptoms, nine (19.1%) who featured a mild to moderate score, and 17 (36.2%) who demonstrated a moderate to severe anxiety symptoms (Table 1).
Table 1. Findings in 47 patients with interstitial cystitis
| Male||9 (19.1)|
| Female||38 (80.9)|
| Mild||15 (31.9)|
| Mild to moderate||5 (10.6)|
| Moderate to severe||20 (42.6)|
| Mild||21 (44.7)|
| Mild to moderate||9 (19.1)|
| Moderate to severe||17 (36.2)|
| Grade I||22 (46.8)|
| Grade II||10 (21.3)|
| Grade III||10 (21.3)|
| Grade IV||5 (10.6)|
|Bladder capacity (c.c.)|
| 800 and greater||6 (12.8)|
| 600–799||18 (38.3)|
| 400–599||19 (40.4)|
| 200–399||4 (8.5)|
| 0–199||0 (0)|
Interstitial cystitis patients reported a greater degree of depression and anxiety than controls (P = 0.0001 and 0.0001, respectively), after age adjustment. For controls, the average HRSD score was 4.3 ± 4.3 (range: 0–15) and the average HAM-A score was 4.8 ± 3.6 (range 0–14). For the control group, four (12.9%) revealed mild depression symptoms, whereas others were basically normal, and all exhibited mild anxiety.
The severity of bladder pain, and O'Leary symptom index correlated significantly with anxiety scores (P = 0.004 and 0.006 individually); however, urgency scale and O'Leary bother index were not significantly correlated with anxiety scores.
The severity of bladder pain and O'Leary Sant index, including symptom and bother score, appeared to feature significant correlation with depression scores (P = 0.042, 0.015 and 0.023). Urgency scale did not appear to be significantly correlated with depression score (Table 2).
Table 2. Correlation between affective symptoms and interstitial cystitis symptoms
| Pain scale||0.042||0.301|
| Urgency scale||0.468||0.109|
| O'Leary symptom index||0.015||0.36|
| O'Leary bother index||0.023||0.347|
| Pain scale||0.004||0.414|
| Urgency scale||0.116||0.232|
| O'Leary symptom index||0.006||0.406|
| O'Leary bother index||0.273||0.171|
Bladder capacity and hemorrhage grading were not significantly correlated either with anxiety or depressive symptom score. Symptomatic duration prior to diagnosis was significantly correlated to O'Leary symptom index (r = −0.302, P = 0.049). Other variables, however, did not prove to be correlated with the duration that patients were symptomatic prior to diagnosis. No sex difference was noted among affective and IC symptoms severity apart from the exception of anxiety symptoms (P = 0.006).
A total of 85% of our patients with IC reported symptoms of depression, and more than 40% of IC patients appeared to have moderate to severe symptoms. In 2002, Rothrock et al. noted that although IC patients reported significantly greater depressive symptoms than healthy controls, less than 20% of these experienced moderate or severe depression symptoms. It is interesting to note that our patients described herein, would appear to experience more-severe depression symptoms and also a higher-prevalence of depression. This may be explained by the differences in IC disease severity between our patients and the cases in published reports. In addition, our patients were all newly diagnosed without having experienced any previous definitive treatment, whereas those patients in the earlier study by Rothrock et al. were currently receiving treatment, or had received treatment in the relevant clinic, for the previous 2 years. The mean duration that our patients were symptomatic prior to diagnosis was 10.3 years, clearly a long time. In 2007, Takaaki et al. reported that the interval before diagnosis of IC was 36.5 months on average with a range of 1–360 months.7 Certainly longstanding untreated pain would produce a depression symptom, and longstanding untreated IC patients typically feature chronic sleep deprivation, thus leading to depression symptoms. Other factors might also play a role here. For example, patients featuring rheumatoid arthritis (RA), has suggested that high daily stress, and a somewhat low self-efficacy in managing illness by themselves and overall helplessness were predictive of depression.8,9 We adduced RA because it is also characterized by chronic pain. Additionally, in a survey of 222 patients with interstitial cystitis, RA was the common IC-associated disease, occurring in more than 13% of IC patients.10 However, it remains to be determined whether stress or other personality variables may modulate the relationship between IC symptoms and psychological status.
Depression scores have significant correlation with the severity of IC, which included pain, O'Leary symptom and bother index. Consistent with our findings, in 2005, Novi et al. noted that subjects with severe IC had significantly higher depression symptom scores.11 By contrast to our findings, however, Rothrock et al. did not find a relationship between the severity of IC and the relative severity of depression symptoms. Both our study and the study of Novi et al. included only newly diagnosed patients with IC, whereas patients in the study of Rothrock et al. received some form of therapy for IC. The lower rates of depression noted in Rothrock et al.′s study may be indicative of a certain level of accommodation to the disease process and/or the effect of medical interventions. Having said this, however, our urgency scale was not correlated to depression scores. Clearly thus, because of the small number of our sample size, future studies involving larger numbers of patients would appear to be necessary to more fully evaluate the relationships between IC symptoms and depression.
The HAM-A is a 14-item structured interview of anxiety symptoms. A score of <17 is considered mild, 18–24 is mild to moderate and a score of 25–30 is considered to display moderate to severe anxiety. No cutoff score serves as a marker to discriminate anxiety from normal psychological status. Accordingly, 100% of our IC patients would appear to feature some level of anxiety, but 36.2% would appear to feature moderate to severe anxiety symptoms. Unlike depression, the relationship between anxiety and IC, or chronic pain, would appear to be less ‘talked about’. The prevalence of anxiety in RA has received ever more increased attention over recent years. For example, in 2005, Zyrianova et al. found that 44.4% of patients suffering from RA featured some evidence of anxiety, and that 17.8% had moderate to severe anxiety.12 Similarly, patients with severe IC symptoms measured with an appropriate pain scale and O'Leary symptom index, appeared to demonstrate greater anxiety symptoms than those who did not. Since this is only a cross-sectional study, whether affective symptoms are reactions to, occur concurrently with or predate IC can not be inferred from our data.
The actual disease severity of IC evaluated through cystoscopy did not appear to be correlated with the relative severity of symptoms in our study. The correlation between cystoscopic finding and the severity of IC symptoms is inconsistent as reported in the literature. In 2001, Tomaszewski et al. reported that the presence and severity of glomerulations did not have a significant correlation with IC symptom severity.13 In contrast to our findings, in 1997, Simon et al. reported a positive correlation of symptom severity scores with increasingly severe physiological markers, such as the severity of glomerulations, scar tissue, Hunner's patches and/or decreased bladder capacity.14 One factor for such inconsistent observations might be dissimilar classification system of cystoscopic findings among studies. For future studies it is necessary to use a standardized system to score symptoms and cystoscopic findings.
Based on the findings obtained from the present study, we propose that psychological assessment and support are vital in promoting a holistic approach to the management of IC patients. Research with RA patients has found a significant (negative) association between self-efficacy for coping with pain, and both anxiety and depression.15 Patients who were less efficacious about their ability to deal with pain and symptoms of depression, were more likely to be depressed.16 Another potential predictor of emotional distress is self-stigmatization. For example, in 2000, Rabin et al. claimed that internal feelings of stigmatization would be prevalent among IC patients, and would appear to correlate significantly with psychological depression.17 These associations would, thus, appear to have important therapeutic implications. For example, IC patients who have been unable to obtain adequate relief from medical remedies, would greatly value a psychotherapeutic intervention that could be applied in order to diminish some level of their suffering. Psychological support, which may be provided by psychiatrists, social workers, consultation phone lines or even patient supportive groups, are clearly important, and would appear to provide an overall optimal care for IC patients.
Most of our IC patients have significant depression and anxiety. The extent of depression and anxiety increases along with the increased IC-symptoms severity. Identifying, and then treating accordingly the affective symptoms of IC may significantly improve the overall results of IC management.