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© 2002 American Society for Clinical Oncology Psychiatric Morbidity and Impact on Hospital Length of Stay Among Hematologic Cancer Patients Receiving Stem-Cell TransplantationByFrom the Department of Psychiatry, Clinical Institute of Psychiatry and Psychology and Stem-Cell Transplantation Unit, Department of Hematology, Institute of Hematology and Oncology, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain. Address reprint requests to Jesús M. Prieto, MD, Centre de Salut Mental, Sta Llogaia 67, 17600 Figueres, Spain; email: jmprieto{at}comg.es
PURPOSE: To determine the prevalence of psychiatric disorders during hospitalization for hematopoietic stem-cell transplantation (SCT) and to estimate their impact on hospital length of stay (LOS). PATIENTS AND METHODS: In a prospective inpatient study conducted from July 1994 to August 1997, 220 patients aged 16 to 65 years received SCT for hematologic cancer at a single institution. Patients received a psychiatric assessment at hospital admission and weekly during hospitalization until discharge or death, yielding a total of 1,062 psychiatric interviews performed. Psychiatric disorders were determined on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Univariate and multivariate linear regression analyses were used to identify variables associated with LOS. RESULTS: Overall psychiatric disorder prevalence was 44.1%; an adjustment disorder was diagnosed in 22.7% of patients, a mood disorder in 14.1%, an anxiety disorder in 8.2%, and delirium in 7.3%. After adjusting for admission and in-hospital risk factors, diagnosis of any mood, anxiety, or adjustment disorder (P = .022), chronic myelogenous leukemia (P = .003), Karnofsky performance score less than 90 at hospital admission (P = .025), and higher regimen-related toxicity (P < .001) were associated with a longer LOS. Acute lymphoblastic leukemia (P = .009), non-Hodgkin’s lymphoma (P = .04), use of peripheral-blood stem cells (P < .001), second year of study (P < .001), and third year of study (P < .001) were associated with a shorter LOS. CONCLUSION: Our data indicate high psychiatric morbidity and an association with longer LOS, underscoring the need for early recognition and effective treatment.
HEMATOPOIETIC stem-cell transplantation (SCT) is rapidly becoming a part of conventional cancer treatment. Today, over 350 centers in Europe perform more than 18,000 stem-cell transplants a year.1 Although SCT is able to cure a variety of malignant and nonmalignant diseases, the procedure is still associated with significant morbidity and mortality.1,2 Research investigating the impact of this highly aggressive procedure on quality of life and psychosocial issues has increased in recent years. Many studies have been performed 1 to 10 years after SCT2 and have examined the problems associated with long-term adjustment, but have not investigated the impact during hospitalization for SCT. A few longitudinal studies that include hospitalization and post-SCT assessments indicate that it is during the hospitalization period when individuals often experience greater psychological distress.3-5 In the only published study of psychiatric morbidity using standardized diagnostic criteria during hospitalization for SCT, a psychiatric disorder was diagnosed in 41% of 39 allogeneic SCT patients.6 Reviews of depression7,8 or anxiety9 among different cancer populations indicate that prevalence rates of these disorders remain uncertain because of limitations in research methodology: depression ranged from 1% to 53% and anxiety ranged from 1% to 44%. Methodologic inadequacies included the use of self-report questionnaire scores at a level suggestive of a clinical diagnosis without using standardized diagnostic criteria, the use of retrospective chart reviews, biased samples, or small sample sizes.7-9 Although self-report scales do not measure prevalence of disorders, ratings of depressive and anxiety symptoms from the patient’s perspective are considered very valuable because these are subjectively experienced symptoms. Because of the limitations of different methods for psychiatric evaluation, the most accurate assessment would include self-report, psychiatric interview, and chart review taken together. Psychiatric morbidity can adversely affect patients in many ways: it can impair quality of life,10 functional status,11 and energy level12; increase symptom burden and pain intensity13-15; interfere with medical treatment16-18; and possibly reduce overall survival time.19-21 Furthermore, in diverse medical populations and after adjusting for potential confounders, psychiatric morbidity has been associated with higher health care costs22,23 and increased hospital length of stay (LOS).24 Previous studies of the impact of psychiatric morbidity on LOS present methodologic limitations such as lack of use of standardized psychiatric diagnostic criteria, retrospective or cross-sectional designs, lack of controlling for potential confounding variables such as disease or treatment-related factors, or small sample size. To our knowledge, no studies adjusting for potential confounding variables have evaluated whether psychiatric morbidity has an impact on LOS in the SCT setting. These above-mentioned complications associated with psychiatric disorders, coupled with the substantial emotional suffering, and the fact that psychiatric disorders tend to be underecognized,8,9,25 highlight the critical importance of identifying and treating these disorders in transplant patients. Knowledge of psychiatric morbidity in the SCT setting may contribute to early identification of those disorders and to the design of appropriate prevention and treatment strategies. In this 3-year prospective inpatient study, we evaluated the psychiatric morbidity as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition26 (DSM-IV) during hospitalization for SCT. We tested the hypothesis that, compared with individuals without psychiatric disorders, patients with psychiatric disorders would have a longer LOS, even after adjusting for other disease- or treatment-related variables.
Study Population Patients were consecutively recruited from the SCT Unit, Hospital Clínic, Barcelona, between July 21, 1994, and August 8, 1997. Inclusion criteria were hematologic malignancy, at least 16 years of age, patient’s first SCT, and verbal informed consent. Of 253 patients that received an SCT, 235 met the eligibility criteria. Because of scheduling difficulties, 15 patients could not be interviewed. All patients who were approached agreed to be interviewed. Thus, the final study cohort included 93.6% of the eligible population (220 of 235).
Conditioning Regimens, Graft-Versus-Host Disease Prophylaxis, and Patient Care All patients were assisted in laminar airflow rooms and received Pneumocystis carinii, viral, bacterial, and fungal prophylaxis according to institutional protocols. Discharge criteria, which did not change over the course of the study, included engraftment, adequate oral intake, and control of medical problems.
Study Procedures Three interviewers participated in the study; the main investigator was a psychiatrist (J.M.P), the two others were a fourth-year psychiatric resident (J.A) who participated in the study for the first 11 months and a psychiatrist (J.B) who participated in the rest of the study. Psychiatric information from the patient interviews was complemented with information from the family and medical and nursing staff. Psychiatric diagnoses were assigned at a diagnosis meeting held every 2 months, at which a consensus diagnosis was reached on each patient. No interrater reliability assessment was carried out. The study was naturalistic by design. Psychiatric care consisted of psychopharmacologic treatment and/or brief psychotherapeutic sessions provided by the corresponding research psychiatrist. Psychiatric intervention could be prompted by referral by the hematologist or by decision of the research psychiatrist in accordance with the hematologist. No attempt was made to influence the amount or type of psychiatric therapy given to patients. The clinical research protocol was reviewed and approved by the Department of Psychiatry’s Committee on Clinical Research.
Psychiatric Assessment Current psychiatric status. In a checklist format, the DSM-IV criterion items required for the diagnosis of a major depressive episode and adjustment disorder were rated during the interview by the clinician as absent, subthreshold, or present during the past week. As for anxiety disorders, we used screening questions relevant to panic disorder, generalized anxiety disorder, phobia, and obsessive-compulsive disorder, and in case of positive findings, full criteria were ascertained. Although alcohol and smoking histories were also obtained, we did not include specific questioning for abuse or dependence criteria. The DSM-IV requires a symptom to be counted toward the diagnosis of major depressive episode only if it is thought not to be attributable to cancer itself or to the conditioning treatment. Because five out of a list of nine criteria are required for diagnosis, the DSM-IV presents a risk of underdiagnosis. In the current report, we used the model of the Sloan-Kettering group to diagnose a major depressive episode, which is recommended for research purposes.33 This modified DSM-IV approach eliminates anorexia and fatigue from the list of nine criteria, and requires only four of the remaining seven symptoms for diagnosis. This approach ensures the most homogeneous depressed group possible, with the fewest confounding variables, thereby increasing the clinical and statistical significance of the research data.33 Psychiatric rates by time of diagnosis and overall prevalence rates. Depending on the time of psychiatric diagnosis, we distinguish admission prevalence from postadmission incidence. Admission prevalence is the rate at which existing disorders are diagnosed at hospital admission (first interview). Postadmission incidence is the rate at which new disorders occur during in-hospital follow-up (from the second interview until discharge or death). Overall prevalence is the rate at which existing disorders are diagnosed during the hospitalization period (from hospital admission until discharge or death). Postadmission prevalence at any specific weekly interview is the rate that will include those psychiatric disorders that currently meet diagnostic criteria (whenever first diagnosed at this interview or not).
Instruments Functional status. The Karnofsky Performance Scale27 is a widely accepted index of physical disability developed for the evaluation of oncology patients. Patients are rated in deciles from 0 to 100, with lower scores reflecting greater impairment in normal activity, work, and self-care. Regimen-related toxicity. The Bearman Toxicity Scale31 is used to rate the complications caused by chemotherapy or chemoradiotherapy. When toxicity can be attributed to infection, graft-versus-host disease, bleeding, or side effects of noncytotoxic treatment, that toxicity is excluded. Cardiac, bladder, renal, pulmonary, hepatic, CNS, gastrointestinal, and stomatitis toxicities are assigned a grade of 0 to 4 in increasing severity according to specific guidelines for each organ. The regimen-related toxicity score assigned to each patient is the sum of the highest toxicity observed in each organ at any time.
Other Study Variables Sociodemographics. Characteristics assessed were age, sex, ethnicity, marital status, and educational attainment. Disease- and treatment-related data. Variables included hematologic cancer diagnosis, time since cancer diagnosis, conditioning regimen, source of stem cells, and type of SCT. One potential time-related influence affecting LOS over a 3-year period was practice variations. We included in our analyses a variable encoding the year of study as an adjustment for practice variations. On the basis of prior research,34 patients were divided according to their disease risk status. Low-risk patients had myelofibrosis, chronic myelogenous leukemia in chronic phase, or were in first complete remission from any disease. High-risk patients were partially responsive, had refractory disease, or were in relapse at the time of transplantation. Patients with myelodysplastic syndromes were defined as high risk, in case of life-threatening hemorrhage or infection and/or refractoriness to platelet transfusions. Intermediate-risk patients were having at least second completed responses or chronic myelogenous leukemia in accelerated phase. In-hospital complications included acute graft-versus-host disease,35 veno-occlusive disease,36 and presence of documented bacterial, fungal, or viral infections.
Statistical Analysis
To examine the impact of psychiatric disorders on LOS for those patients surviving until hospital discharge, we used univariate and multivariate linear regression analysis. By using Admission and in-hospital risk factors used to study its association with LOS were chosen a priori, on the basis of past work in the field and because of clinical relevance.24,34 Admission risk factors included age (continuous variable), sex, Karnofsky score (90-100 v < 90), hematologic cancer diagnosis (acute myelogenous leukemia, acute lymphoblastic leukemia, chronic myelogenous leukemia, non-Hodgkin’s lymphoma, Hodgkin’s disease, multiple myeloma, and other), disease risk status (low, intermediate, and high), conditioning regimen (chemotherapy v chemoradiotherapy), type of SCT (autologous or syngeneic v allogeneic), source of stem cells (peripheral blood only or combined with bone marrow v bone marrow), period of study (July 1994 to June 1995, July 1995 to June 1996, and July 1996 to August 1997), and occurrence of any admission mood, anxiety, or adjustment disorder. In-hospital risk factors included the regimen-related toxicity (continuous variable), graft-versus-host disease (grades 0 to 1 v 2 to 4), occurrence of documented infection, veno-occlusive disease, or delirium, and occurrence of any overall mood, anxiety, or adjustment disorder. Those variables with a marginal association (P < .10) or significant association (P < .05) with LOS in univariate linear regression analysis were entered as candidate risk factors in multivariate linear regression models. For the multivariate models, a stepwise selection method was used to select significant variables. A baseline model included as independent variables admission risk factors, and a full model evaluated the additional contribution of in-hospital risk factors to the baseline model. As higher regimen-related toxicity or presence of in-hospital complications can be associated with presence of delirium24 or any mood, anxiety, or adjustment disorder,7-9,24 all possible interaction terms between these variables were tested. All models were adjusted for sex and age. To meet the assumption of normality of the linear regression model, we performed a log transformation on LOS. We obtained the estimated mean percentage increase in LOS by taking the antilog of the linear regression coefficient for each independent variable. Collinearity was assessed using variance inflation factors with standard residuals-based diagnostic procedures being used to assess model assumptions and adequacy of the model fit. Performance of the model was assessed by the adjusted explained variance (R2). All reported P values are two-tailed. P values were considered significant if they were less than .05. No adjustment of the alpha level for multiple tests was made. Data were analyzed using SPSS version 10.0 software (SPSS, Inc, Chicago, IL).
Patient Characteristics Selected sociodemographic and medical characteristics are listed in Table 1. There were no differences in age, sex, ethnicity, hematologic diagnosis, or disease status risk between the 220 patients who participated in the study and the 15 patients not evaluated because of scheduling difficulties (P > .20).
DSM-IV Psychiatric Disorders A total of 1,062 psychiatric assessments were performed throughout the transplant process. Rates of DSM-IV psychiatric disorders by time of diagnosis and overall prevalence rates for the total sample (n = 220) are listed in Table 2. Overall prevalence rates were as follows: 22.7% (95% confidence interval [CI], 28.2% to 17.2%) for any adjustment disorder, 14.1% (95% CI, 18.7% to 9.5%) for any mood disorder, 8.2% (95% CI, 11.8% to 4.6%) for any anxiety disorder, and 7.3% (95% CI, 10.7% to 3.9%) for delirium. Overall prevalence rate for any mood, anxiety, or adjustment disorder was 42.3% (95% CI, 48.8% to 35.8%) and for any psychiatric disorder 44.1% (95% CI, 50.7% to 37.5%). Twenty patients (9.1%) met criteria for comorbid psychiatric diagnoses, with delirium the most common second diagnosis (12 of 20).
By using serial psychiatric assessments, we were able to observe a number of changes in diagnosis. Regarding adjustment disorders, we found that 11 (18.0%) of 61 patients initially receiving this diagnosis (four at hospital admission and seven during in-hospital follow-up) evolved into a major depressive episode (n = 9) or a panic disorder (n = 2) after longitudinal assessment. Comparing autologous and allogeneic SCT, we found no significant differences in prevalence rates of delirium (6.2% v 8.8%, P = .64), any overall mood, anxiety, or adjustment disorder (38.8% v 47.3%, P = .26), or any overall psychiatric disorder (41.1% v 48.4%, P = .35). When we compared modified and unmodified DSM-IV approaches to diagnose a major depressive episode, we found that seven patients that met modified DSM-IV criteria for a major depressive episode were diagnosed as having an adjustment disorder when applying unmodified DSM-IV criteria and that one patient that met unmodified DSM-IV criteria for a major depressive episode was diagnosed as having an adjustment disorder when applying modified DSM-IV. No other differences in psychiatric disorder rates were observed. Therefore, the overall rate of any mood, anxiety, or adjustment disorder was the same for both approaches (42.3%), with the unmodified DSM-IV approach producing a lower rate of a major depressive episode (9.5%) compared with the modified DSM-IV approach (12.3%).
Predictors of LOS for Survivors Univariate predictors of LOS are listed in Table 3. A baseline model including admission risk factors and a full model including the additional contribution of in-hospital risk factors are displayed in Table 4. The comparisons between different categories of a particular independent variable (eg, women compared with men) are adjusted for all independent variables in the multivariate model. In the baseline model, any mood, anxiety, or adjustment disorder diagnosed at hospital admission did not reach statistical significance (P = .69). As LOS was defined by the number of overnight stays from day of transplantation (day 0) until hospital discharge, instead of using as an admission risk factor any admission mood, anxiety, or adjustment disorder we used any mood, anxiety, or adjustment disorder diagnosed by day 0, and we obtained the same significant predictors as shown in the baseline model of Table 4, but in this analysis having any mood, anxiety, or adjustment disorder diagnosed by day 0 showed a trend for significance in its association with increased LOS (mean LOS increase, 8%; P = .12). In the full model, having any overall mood, anxiety, or adjustment disorder was significantly associated with increased LOS (mean LOS increase, 8%; 95% CI, 1% to 15%; P = .022) and having delirium showed a close to significant association with increased LOS (mean LOS increase, 10%; P = .05). Interaction terms of delirium by any overall mood, anxiety, or adjustment disorder, or any of these two psychiatric variables by regimen-related toxicity or any in-hospital risk factor did not reach statistical significance. Adjusted explained variance for the baseline and full models were 54% and 61%, respectively. When we studied the impact of mood, anxiety, and adjustment disorders as separate variables on LOS, none reached statistical significance in the multivariate models (data not shown).
Year of study entry was a multivariate significant factor predicting LOS (Table 4). Median LOS was 25, 20, and 17 days, for first, second, and third years of study, respectively. Year of study was not associated with regimen-related toxicity (P = .86), whereas percentage of patients receiving peripheral-blood stem cells significantly increased from the first to the third year of the study (60.0%, 72.7%, and 90.3%; P < .001).
To our knowledge, this is the largest in-hospital study with an unselected cohort using standardized diagnostic criteria and longitudinal assessments to estimate the prevalence of psychiatric disorders in any cancer sample. In this 3-year prospective study, we found that 44.1% of patients met DSM-IV criteria for a psychiatric diagnosis; an adjustment disorder was diagnosed in 22.7%, a mood disorder in 14.1%, an anxiety disorder in 8.2%, and delirium in 7.3%. Comparison with other studies reporting psychiatric morbidity in cancer patients is difficult because of differences in research methodology.7-9 Our overall prevalence of psychiatric morbidity is very similar to other reports.6,32 Outside the SCT setting, Derogatis et al32 carried out the largest study to date that used a nonbiased sample investigating psychiatric morbidity prevalence with standardized diagnostic criteria (DSM-III). In this cross-sectional multicenter study with a sample of 215 hospitalized and ambulatory patients receiving active treatment for a variety of cancer diagnoses, 47% of patients met criteria for a psychiatric disorder; compared with our prevalence rates, they reported a higher rate of adjustment disorders (32%) and lower rates of mood (6%) and anxiety disorders (2%). These differences may be because our patients were receiving a more intensive anticancer treatment, or because our prospective inpatient design allowed us to observe a development of a depressive or an anxiety disorder from an initial adjustment disorder. Because fluctuations in severity and course of depressive and anxiety symptoms are common, studies using repeated measures at multiple points in time may be an accurate reflection of the total psychiatric morbidity. In the SCT setting, Sasaki et al6 reported that a psychiatric disorder was diagnosed in 41% of 39 allogeneic SCT patients, with adjustment disorder (23%) and mood disorder (8%) being the two most frequent diagnoses. For those studies that only describe self-report scale scores suggestive of a clinical diagnosis during hospitalization for SCT, depression estimates ranged from 20% to 43%,4,5,37,38 and anxiety from 20% to 33%.4,5,39 The limiting factors in these studies were restriction of psychiatric morbidity assessment to depressive and/or anxiety symptoms, only one preadmission or admission assessment plus one5,37-39 or two in-hospital evaluations,4 or a small sample size (n = 44 to 744,37-39 and n = 1205). There were no differences in rates of psychiatric disorder variables by type of SCT. As regards studies that compared autologous and allogeneic SCT patients in terms of depressive and/or anxiety symptoms during hospitalization for SCT, one study found a poorer outcome for autologous SCT patients4 and other studies did not find significant differences.3,5,37 In a multivariate full model that controlled for the effects of admission and in-hospital risk factors, having any overall mood, anxiety, or adjustment disorder was associated with an 8% LOS increase (P = .022). In a multivariate baseline model that controlled for the effects of admission risk factors, any mood, anxiety, or adjustment disorder diagnosed by day 0 showed a trend for significance (mean LOS increase, 8%; P = .12). When we considered mood, anxiety, and adjustment disorders as separate diagnoses, they did not reach statistical significance in a multivariate model. However, it is possible that a significant difference was not revealed because of the small size of the groups. As regards the studies in medical or surgical populations that adjusted for potential confounding variables, we found that psychiatric measures such as depression,40-43 anxiety,40,41 stress disorders (including adjustment disorders),42 delirium,42-46 cognitive impairment,40,41 or any psychiatric disorder47 significantly increased LOS. Methodologic limitations of these studies include nonuse of standardized psychiatric diagnostic criteria,40,41 retrospective reviews from hospital discharge databases with its high risk of underdiagnosis,42,47 restriction to an elderly sample,43-46 and a highly biased sample.46 Several mechanisms underlying the association between any mood, anxiety, or adjustment disorder and increased LOS may be proposed. There is a tendency of depressive or anxiety disorders to present with multiple or unexplained physical complaints,13,14,48,49 or to be frequently associated with pain symptoms.15,50 This increased symptom burden can increase LOS by itself or indirectly, by leading to more extensive and time-consuming tests. It is also likely that behavioral phenomena such as noncompliance with treatment recommendation may affect the relation between depression and longer LOS.16 Nonadherence can be manifested as a difficulty in accepting medication, nursing services, or diagnostic tests; poorly performing daily self-care behaviors needed to prevent the high risk of infection; or as a low discharge disposition. Although research on psychoneuroimmunology is still in its infancy,8,51 accumulating evidence supports the view that psychological stress has an adverse effect on immunologic function, resulting in reduced ability to resist cancer progression52 or difficulties in resolution of infectious episodes.51 Another possible explanation is that a longer LOS induces psychiatric morbidity. However, most patients were diagnosed at hospital admission or initial hospitalization. Finally, it is possible that psychiatric morbidity may be an indirect indication of severity of complications or treatment-related toxicity. Nonetheless, psychiatric disorder variables remained significant after adjusting for potential confounding variables. In the multivariate analysis, having delirium showed a close to significant association with increased LOS (P = .05). However, it is possible that a significant difference was not revealed because of the small number of survivor patients who had delirium (n = 10). Delirium is often difficult to diagnose and treat. Its symptoms are diverse, sometimes mistaken for mood or anxiety disorders, and the clinical findings may vary or fluctuate. The difficulty in providing good medical care, the delay in diagnosis, and the fact that delirium is often a proxy for increased medical morbidity or complications could explain the close to significant association of delirium with LOS.24 The findings of this study are strengthened by its prospective design, good recruitment rates, large population, use of standardized psychiatric diagnostic criteria, and a comprehensive set of clinical risk variables considered for risk adjustment. Most studies analyzing LOS or costs of SCT (considered as a proxy for LOS) have usually focused on specific treatment protocols without examining the patient characteristics and medical complications associated with these outcomes.53-56 We have found only one prospective study in which costs of SCT were analyzed by using admission and in-hospital risk factors (not including psychiatric measures).34 Our finding that cancer type,34 use of peripheral-blood stem cells,53-56 in-hospital complications or toxicity from treatment,34,54,56 and year of study34,54 are significantly associated with LOS confirms the reports of others on factors associated with LOS or costs of SCT. Bennet et al54 suggested that LOS and cost in autologous SCT decreased over time in relation to improvement in supportive care technologies, better patient selection, and experience of the transplant team. Lee et al34 found that costs and LOS for autologous SCT decreased with time whereas costs for allogeneic SCT increased and LOS did not significantly change. However, in their study34 only 3% of allogeneic SCT patients received peripheral-blood stem cells. In our sample, the increasing proportion of patients receiving peripheral-blood stem cells over the course of the study could in part explain the shortening in LOS. This study has several limitations. First, we only focused on a limited range of psychiatric conditions known to be common in cancer patients,6-9,32 so as not to impose an undue burden on our patients. Second, although we did not measure interrater reliability, we sought to maximize the reliability of our psychiatric diagnoses by using standardized diagnostic criteria, serial observations, multiple sources of information, and discussion in regular meetings between investigators. Third, the data abstractor was not formally blinded to LOS. Although this may have influenced the results, strict guidelines were followed to rate the Bearman Toxicity Scale and clear definitions of in-hospital complications were applied. Fourth, in order to reduce the possibility of a type II error, mood, anxiety, and adjustment disorders were combined into one group. However, this composite variable was justified by the consistently higher median LOS for patients with those disorders, and by the frequent coexistence of depressive and anxiety symptoms.7,9 Fifth, as in any single-institution study, some conclusions are specific to our center and reflect our patient characteristics and practice patterns. However, the multivariate analysis controlled for a wide range of confounding variables, and our results supported relatively robust inferences about the association of LOS with admission and in-hospital risk factors. Sixth, possible benefits from psychiatric treatment on LOS cannot be evaluated under the available design. In such a naturalistic observational sample, comparisons of outcomes on the basis of treatment received are subject to substantial bias. Seventh, we did not measure costs of care during hospitalization. In a previous study, LOS was significantly correlated with hospitalization costs for autologous and allogeneic SCT (partial r2 = .76 and .77, respectively).34 Another study reported an association between decreased LOS and lower costs.54 Although LOS can be considered a proxy for costs, adding economic measures can give a more complete view than merely assessing hospital LOS. Finally, the cross-sectional data indicating an association between any overall mood, anxiety, or adjustment disorder and longer LOS precludes definitive causal inferences. However, when we used as a predictor variable any mood, anxiety, or adjustment disorder diagnosed by day 0, we found a trend for significance (P = .12), suggesting that psychiatric morbidity may have a role in predicting LOS. In cancer populations, the effect of psychopharmacologic and psychological interventions has been reviewed and shown to be beneficial.7-9,57 Research must focus on the development of models directed to early detection and effective treatment of psychiatric disorders. Because of our relatively high prevalence of psychiatric disorders at hospital admission, it would be better to conduct a first comprehensive assessment after the patient agrees to undergo SCT. The high prevalence of a psychiatric disorder enhances the practical utility of a screening program by increasing the positive predictive value. Furthermore, the homogeneity of the psychiatric disorders studied permits the application of specific, replicable, targeted intervention studies.24 Adding measures of costs to the intervention studies is likely to be of more relevance to health policy than merely assessing hospital LOS. Although it remains to be determined whether early recognition and effective treatment of psychiatric disorders will result in shorter LOS or lower costs, it has the potential to improve medical practice, reduce patient suffering, enhance patient quality of life, and improve health care outcomes. Among other outcomes, the course and predictors of psychiatric disorders and their impact on quality of life and survival will be presented in future articles.
Supported by research grant no. FIJC 98/QV-JMP from the Josep Carreras International Leukemia Foundation. We thank the patients who participated in this study and the medical and nursing staff for providing medical information. We also thank Llorenç Badiella, Statistical and Consulting Service, Universitat Autònoma de Barcelona, for his assistance with the data analysis.
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ABSTRACT
INTRODUCTION
2 test with Yates correction or Fisher’s exact test; continuous variables were compared by parametric (t test and analysis of variance) or nonparametric (Mann-Whitney U and Kruskal-Wallis tests) statistics, as appropriate. 
