Anxiety, depression, and coping styles among patients with chronic pancreatitis in East China

Chronic pancreatitis (CP) is a progressive inflammatory disease characterized by irreversible pancreatic fibrosis [1]. Current studies suggested that the development of CP is associated with the interaction between environmental (tobacco, alcohol, etc.) and genetic factors [2‐4]. Globally, the incidence of CP ranges from 4.4 to 14 per 100,000 people, the prevalence ranges from 36.9 to 52.4 per 100,000 people, and the mortality rate is about 0.09 per 100,000 persons [5, 6]. The incidence of CP is significantly different in different regions. In the United States [7], the UK [8], China [9], Denmark [10], and Japan [11], the annual incidence of CP was about 5 to 8, 5.9 to 12.8, 3.1 to 13.5, 12.6, and 14.0 per 100,000 persons, respectively. Although there is still a lack of large-scale epidemiological studies on the incidence and prevalence of CP currently, the available data have shown that, with the increases of alcohol consumption and the application of more sensitive imaging technologies in recent years, the incidence of CP is increasing [10, 12].

Pain is the most common symptom of CP and the main reason for patients to seek medical attention, and more than 80% patients with CP will experience varying degrees of upper abdominal pain during the course of the disease [13]. Due to the atrophy of pancreatic acinar cells and pancreatic fibrosis, patients with CP also often experience obvious symptoms of pancreatic insufficiency such as elevated blood sugar, weight loss, sarcopenia, and complications including pancreatic duct stones, pancreatic duct stenosis, pancreatic pseudocysts and pancreatic cancer, which affect the quality of life seriously [7]. Pain, decline in quality of life, and concerns about the prognosis of the disease can bring enormous psychological stress for CP patients and undermine their confidence in coping with disease, ultimately leading to the occurrence of psychiatric comorbidities [14].

As the most common psychological complications in hospitalized patients, anxiety and depression among CP population have received increasing attention from researchers in recent years. A recent multicenter study conducted in the United States and Denmark showed that the incidence of anxiety and depression among CP patients was 46.8% and 38.6%, respectively, and there were significant differences in pain patterns, pain severity, and quality of life between CP patients with and without psychological comorbidities [14]. Furthermore, in India, a study reported that 34.85% of CP patients had anxiety symptoms and 29.23% had depression symptoms [15]. However, at present, there are no studies related to the incidence and influencing factors of anxiety and depression symptoms in Chinese CP patients. Therefore, the aims of this study were (1) to investigate the incidence and level of anxiety and depression symptoms among East Chinese patients with CP; (2) to analyze the factors associated with anxiety and depression, and to explore the relationship between anxiety, depression, and coping styles.

CP is a clinically rare disease of the digestive system. Currently, most of the studies have focused on the pathogenesis, clinical symptoms and treatment of CP, but less on the mental health of CP patients and its influencing factors. To the best of our knowledge, this study is the first to investigate the incidence of anxiety and depression in East Chinese CP patients and to analyze their relationship with patient demographic characteristics, clinical characteristics of CP, and coping styles. Our findings suggested that a relatively high proportion of Chinese CP patients have obvious symptoms of anxiety and depression, and that anxiety and depression are significantly associated with patients’ previous health status, frequency of abdominal pain episodes, pain severity, and level of disease coping.

In our study, more than one-fifth (22.64%) of CP patients reported symptoms of anxiety and nearly 40% (38.61%) of patients had depressive symptoms. However, this result is significantly lower than the results of a previous five-year population-based cohort study, in which the prevalence of anxiety and depression among CP patients in the United States was 36.8% and 46.8%, respectively[23]. The differences in results may arise from the following aspects. First, although the study was based on a longer and larger study cohort, it did not explicitly disclose the assessment instruments for anxiety and depression due to its retrospective nature. Differences in morbidity may stem from the differences in assessment performance between different measurement tools. In addition, since the data in their study was sourced from public database, the consistency of records between different institutions could not be guaranteed [24]. Second, in terms of the epidemiology of CP, unlike Western countries, alcoholism only accounts for about 20% of the causes of CP in Chinese patients [25]. Since alcohol abuse is considered to be one of the important risk factors for increased pain and increased stone formation in CP patients [26, 27], the differences in the etiology of CP between East and West and the different severity of the disease caused by it may contribute to the differences in the incidence of anxiety and depression. In addition, Shah et al. found that the prevalence of opioid dependence among CP patients in the United States was 48.87%, and opioid dependence was associated with a higher incidence of anxiety and depression [28]. However, the use of opioids in China is quite conservative due to medical regulations [29]. Since patients cannot easily buy opioid analgesics, most of them tend to go to the hospital soon after the onset of symptoms. In this study, patients with constant pain only accounted for 2.50% of the total participants, significantly lower than the 45.25% incidence of constant pain in a previous study [30]. Therefore, differences in pain types, analgesic medication use, and health care habits between Eastern and Western CP patients may explain the lower incidence of anxiety and depression in this study. In addition, the incidence of depression among CP patients in our study is also lower than that in a study from India, in which the incidence of depression in Indian CP patients is 46.77% [31]. In their study, researchers used the Beck depression inventory (BDI) to measure the depression level of patients, while in our study, we used the SDS. Through literature search, we found that existing research evidence have showed that compared with other self-reported depression assessment tools, when measured with BDI scale, the incidence of depression was significantly higher [32, 33]. Therefore, we believe that the use of different measuring tools of depression may be the reason for the different incidence of depression in the two studies. Our study provided preliminary evidence for the epidemiology of anxiety and depression in Chinese CP patients. It is expected that future studies can recruit more patients, incorporate more demographic and clinical characteristics, and use a variety of other anxiety and depression measurement tools to further explore the prevalence and risk factors of anxiety and depression in Chinese CP patients on the basis of this study.

Patients with CP often experience recurrent abdominal pain, weight loss, steatorrhea, and other comorbidities such as diabetes, pancreatic duct stones, pancreatic duct stenosis, and a higher risk of pancreatic cancer. These physical and psychological stressors and stressful events may jointly lead to the development of anxiety and depression [34]. Pain and psychological comorbidities play an important role in the progression of the disease course among CP patients. In this study, we found that higher VAS-P scores (7-10points) and more frequent abdominal pain episodes in the past 12 months (constant pain) were significantly associated with the occurrence of anxiety and depression in CP patients. Existing studies have reported that the existence of psychological comorbidities in CP patients may aggravate their pain symptoms and affect their pain experience [35, 36], and pain was considered to be closely related to adverse outcomes such as weakness, decreased quality of life, and increased disability [14, 37]. Furthermore, Kroenke et al. found that pain and depression had a bidirectional effect, with changes in the severity of one symptom likely to have the same effect on the other [38]. Therefore, the interventions for pain and prevention for psychological disorders are particularly important. However, so far, there is still a lack of observational and interventional studies on psychological disorders such as anxiety and depression in CP populations. We recommended that, for patients with mild pain, screening for psychological disorders can be carried out early to prevent anxiety or depression symptoms from aggravating the pain experience of patients, and for CP patients with severe pain, it is very meaningful to conduct psychological counseling for patients while carrying out pain intervention, which can relieve their anxiety and depression symptoms, and then assist in pain relief.

Coping style is considered a habitual tendency of individuals to solve problems and a common strategy for coping with stressful events [39]. Studies have shown that coping styles were significantly related to anxiety and depression [40]. This result was also validated in our study. In our study, low levels of subjective disease coping were found to be independent risk factors for anxiety and depression in CP patients. Subsequent further correlation analysis of coping styles with anxiety and depression scores showed that mature coping styles (Problem solving, Seeking for help) had a positive impact on anxiety and depression scores, while immature coping styles (Self-blame, Fantasy, Repression, Rationalization) had negative effects on anxiety and depression scores. Therefore, for medical service providers, it is necessary and important to strengthen health education for CP patients, guide them to adopt mature coping methods, establish the concept of “Solving Rather than Escaping” when facing the difficulties and pressures brought by the disease, and instruct them to actively try to seek others’ help.

This study had some limitations. First, the number of relevant factors included in this study was limited and measured in a crude manner. Some variables in our study, such as health status and social support, were not measured using specific assessment scales. Based on the results of this study, future researches can select these professional scales to further explore the specific relationships between the above variables and anxiety and depression in CP patients. Second, we only recruited CP patients admitted to our hospital for treatment. On the one hand, since our center is the largest CP diagnosis and treatment center in China, the patients in this study were more seriously ill compared to patients from other medical institutions and patients who were not hospitalized, and thus may lead to an overestimation of the incidence of anxiety and depression. On the other hand, the patients in our center mainly come from Shanghai, Jiangsu, Zhejiang, Anhui and Jiangxi proviences in eastern China[41]. Due to the better economic level and educational resources in eastern China compared with the central and westernChina, as well as the important impact of patients’ educational level and disease knowledge on the patients’ psychological comorbidities, the epidemiological evidence of anxiety and depression in patients with CP in our study may still be biased from the overall status of anxiety and depression in patients with CP in China. It is suggested that future studies should not be limited to a single-center clinical setting, but could conduct multicenter and even community-based epidemiological investigations on the prevalence of anxiety and depression in Chinese CP patients. Although this study has the above limitations, it is undeniable that it is still the first and largest study on the epidemiological status of anxiety and depression in patients with CP in China, filling the gap in the study of psychological comorbidities in Chinese CP patients.

Anxiety and depression are common in East Chinese CP patients. Our study found that CP patients with anxiety and depression had worse previous health status and subjective disease coping levels, higher frequency of abdominal pain episodes, and greater pain severity. Anxious patients were more likely to be female, and depressed patients had lower levels of social support. In addition, mature coping styles were found to have a positive impact on anxiety and depression. Our findings provide preliminary evidence for the investigation of the epidemiology and influencing factors of anxiety and depression in Chinese CP patients, and provide a reference for the management of anxiety and depression. It is hoped that the screening and early intervention of psychological comorbidities in CP patients can be strengthened in future clinical practice to reduce the level of anxiety and depression in Chinese CP patients.