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Author's personal copy Journal of Psychosomatic Research 72 (2012) 249–250
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Journal of Psychosomatic Research
Letter to the Editor Why do colonoscopy patients reject research?
Dear Editor, Colonoscopy is frequently used to investigate gastrointestinal symptoms. Although colonoscopy is not a therapy in itself, it is postulated that it may provide clinical benefit through reassuring and reducing anxiety [1]. Since colonoscopy is costly and invasive, its role in reducing patients' experience of anxiety (where there is a low likelihood of an important organic finding) is worth exploring. Two studies that examined anxiety in patients with functional symptoms before and after colonoscopy produced opposing results [2,3]. Spiegel et al. [3] retrospectively surveyed 458 participants with functional bowel disorders aged between 18 and 49 years. No decrease in anxiety related to negative colonoscopy was found. In fact, anxiety increased after a time period, suggesting the procedure had the inverse effect. In a separate study, Esfandyari and Harewood [2] prospectively examined 18–49 year old outpatients with non-specific gastrointestinal symptoms who were undergoing a colonoscopy. Here, anxiety decreased immediately post-procedure, and remained significantly reduced throughout the 6 months, which suggests that colonoscopy does provide reassurance and reduce experienced anxiety. In response to these conflicting results we designed a prospective observational study of patients aged 18–65 years (M = 50.78, SD = 7.27). Post colonoscopy, six patients were given organic (43%) and eight functional diagnoses (57%). We measured anxiety at four times: preprocedure, 1 week, 2 weeks and 12 months post-procedure using the Hospital Anxiety and Depression Scale (HADS) [4] and the State Trait Anxiety Inventory (STAI) [5]. On both measures, anxiety decreased significantly over the 12 months (p b .001) (see Table 1). The present study supported the findings of Esfandyari and Harewood [2], showing
Table 1 Colonoscopy-related anxiety at 4 time intervals during 12 months of observation as reported on the HADS and STAI. Variable
Time
n
Mean
SD
HADS anxiety (Possible scores 0–21, with normal (0–7), mild (8–10), moderate (11–14) and severe (15–21))
Pre-procedure
13
10.46
3.43
1 week post-procedure 2 weeks post-procedure 12 months post-procedure Pre-procedure
13 13 8 13
7.69 7.62 6.91 46.46
4.46 4.63 3.66 12.05
1 week post-procedure 2 weeks post-procedure 12 months post-procedure
13 13 8
36.23 32.53 32.13
9.18 8.46 7.56
STAI state anxiety (possible scores 20–80, with higher scores meaning higher anxiety)
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the psychological benefits of colonoscopies in terms of anxiety reduction. It should be acknowledged, though, that the sample in the present study comprised mixed organic and functional diagnoses and this may have impacted on the findings. However, the most surprising finding of the current study was the overwhelming reticence of patients to participate in the research. Of 99 patients approached, only 13 (13%) agreed to participate and of the latter, only 8 (8%) remained within the study for the whole duration, resulting in the lowest response rate we have ever experienced in research at this clinic. Most patients did not want to provide a reason for declining; however, those who did said that “stress”, “too much to deal with”, “invasion of privacy” and “too sensitive a topic” were reasons for not participating, indicating the perceived stigma attached to the procedure. This response was completely unanticipated and came as a real surprise to staff who work regularly in clinical gastroenterology. This striking finding has significant implications for future patient care, and may suggest that better community education regarding colonoscopy is desirable to increase its uptake when appropriate. The result may also indicate that medical staff need to be more aware of the extreme level of embarrassment many patients experience when undergoing colonoscopy. Competing interest statement This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. All authors have completed the Unified Competing Interest form at http://www.icmje.org/ coi_disclosure.pdf and declare that they have no competing interests to report. References [1] Brenner H, Chang-Claude J, Seiler CM, Sturmer T, Hoffmeister M. Does a negative screening colonoscopy ever need to be repeated? Gut Aug 2006;55(8): 1145–50. [2] Esfandyari T, Harewood GC. Value of a negative colonoscopy in patients with nonspecific gastrointestinal symptoms. Journal of Gastroenterology and Hepatology Oct 2007;22(10):1609–14. [3] Spiegel BM, Gralnek IM, Bolus R, Chang L, Dulai GS, Naliboff B, et al. Is a negative colonoscopy associated with reassurance or improved health-related quality of life in irritable bowel syndrome? Gastrointestinal Endoscopy Dec 2005;62(6):892–9. [4] Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica Jun 1983;67(6):361–70. [5] Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
Antonina A. Mikocka-Walus School of Psychology, University of Adelaide, Adelaide, Australia School of Nursing and Midwifery, University of South Australia, Adelaide, Australia Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
Author's personal copy 250
Letter to the Editor
Corresponding author at: School of Nursing and Midwifery, University of South Australia, Australia. Tel.: +61 8 83022468; fax: +61 8 83022168. E-mail address:
[email protected].
Jane M. Andrews Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
Lauren G. Moulds Nicole Rollbusch School of Psychology, University of Adelaide, Adelaide, Australia
6 January 2012
