SARS Took Long-Term Psychological Toll

TORONTO, June 25 -- A year after recovering from severe acute respiratory syndrome (SARS), most people were physically well but still suffering psychological distress, researchers here said.

On a standard quality-of-life assessment, they were about one standard deviation below the normal range on such elements as general health, vitality, and social functioning, according to Margaret Herridge, M.D., of the University of Toronto, and colleagues reported in the June 25 issue of Archives of Internal Medicine.

By one year, they had normal pulmonary function and exercise capacity, although many continued to report shortness of breath and fatigue and 35% rated their physical health worse than it had been before SARS, they noted.

Because of the dramatic nature of the outbreak -- an unknown cause, widespread fear, and quarantine and isolation -- patients "were subjected to extraordinary stressors during and after the outbreak and experienced significant emotional consequences as a result," the researchers said.

Among troubling aspects, they said, were:

• Feelings of social stigmatization.
• Quarantine and isolation.
• Inability to be present at the death of close family and co-workers or attend funeral services.

• "Overwhelming" fear for physical health.
• Worry about transmitting the disease to family or loved ones.

The researchers enrolled 117 SARS survivors in a prospective observational study, which involved clinic visits and testing at three, six, nine, and 12 months after hospital discharge.

At each visit, they were given a physical exam, a six-minute walk test, a lung function test, and a chest X-ray. They also answered quality-of-life questions and reported how often and for what reason they saw a physician.

A year after discharge:

• Pulmonary function measures were in the normal range, but 18% of patients still had a reduction in the six-minute walk test.
• On the Medical Outcomes Study 36-Item Short Form Health Survey, a standard instrument, results remained 0.3 to 1.0 standard deviations below normal.
• While most were back on the job - 23 were able to return to full-time work almost immediately -- 17% had not returned to work.
• Just over 40% (51) made 668 visits to mental health practitioners. The next largest number of doctor visits -- 468 -- was to family doctors.

SARS survivors used health care services frequently, but "psychiatric evaluation accounted for the greatest number of visits," the researchers said.

The data may be useful for those planning for pandemics, Dr. Herridge and colleagues said.

Among other things, they suggested, use of Internet technology, such as video conferencing with friends and relatives, might alleviate some of the psychological stress of isolation and quarantine.

They noted several limitations of the study. For one thing, only 38% of the Toronto population of adult SARS survivors was enrolled; many survivors did not wish to be seen or discuss their experiences.

The study may also have limited generalizability because the sample contained an excess of health care workers, had a high level of education, and a large percentage of women in both the patient and caregiver groups.

The premorbid health status of patients and their caregivers and the health care utilization of patients were not documented.

The retrospective nature of the caregiver survey makes the caregiver information subject to recall bias.

No control group was included in the study.