Prevalence of depression and anxiety in adult patients with β-thalassemia major and intermedia

Quality of life, mood disorders, and cognitive impairment in adults with β-thalassemia

Advances in understanding the disease process in β-thalassemia supported development of various treatment strategies that resulted in improved survival. Improved survival, however, allowed multiple morbidities to manifest and cemented the need for frequent, lifelong treatment. This has directly impacted patients' health-related quality of life and opened the door for various psychiatric and cognitive disorders to potentially develop. In this review, we summarize available evidence on quality of life, depression and anxiety, suicidality, and cognitive impairment in adult patients with β-thalassemia while sharing our personal insights from experience in treating patients with both transfusion-dependent and non-transfusion-dependent forms.

Gender Disparities in Psychological Disturbances and Quality of Life Among Adolescent and Adult Patients with Thalassemia: A Review

Thalassemia is a chronic disease caused by impaired globin chain synthesis, leading to ineffective erythropoiesis, hemolysis, and chronic anemia. The treatment of patients with thalassemia, including blood transfusion combined with chelation therapy has progressed and improved their survival and prognosis. However, thalassemia-related psychological problems and impaired health-related quality of life (QoL) challenges still exist. Gender is one of the factors that has been suggested, to contribute to the disparities in psychological outcomes. This review article examined the evidence for gender differences in psychological disturbances and QoL in adolescent and adult patients with thalassemia. A non-systematic search of the literature was conducted in PubMed and Google Scholar for English full-text available from 2013 to 2023. We identified 23 studies with a sample size ≥ 100 that examined gender disparities in anxiety, depression, and QoL in adolescent and adult patients with thalassemia (mean prevalence of female = 53.1%; mean age = 28 years). Our review shows that there are gender disparities in psychological distress and QoL in adolescent and adult patients with thalassemia. Statistically significant gender differences were demonstrated in 62% of the psychological and QoL outcomes from 16 studies. Female patients had a higher prevalence of anxiety, depression, and poorer QoL in some studies. However, further studies with sufficient power and design are necessary to confirm the existence of gender disparities in psychological disturbances and QoL outcomes.

Management of transfusion-dependent β-thalassemia (TDT): Expert insights and practical overview from the Middle East

β-Thalassemia is one of the most common monogenetic diseases worldwide, with a particularly high prevalence in the Middle East region. As such, we have developed long-standing experience with disease management and devising solutions to address challenges attributed to resource limitations. The region has also participated in the majority of clinical trials and development programs of iron chelators and more novel ineffective erythropoiesis-targeted therapy. In this review, we provide a practical overview of management for patients with transfusion-dependent β-thalassemia, primarily driven by such experiences, with the aim of transferring knowledge to colleagues in other regions facing similar challenges.

Psychometric evaluation of the NTDT-PRO questionnaire for assessing symptoms in patients with non-transfusion-dependent beta-thalassaemia

OBJECTIVES

The non-transfusion-dependent beta-thalassaemia-patient-reported outcome (NTDT-PRO) questionnaire was developed for assessing anaemia-related tiredness/weakness (T/W) and shortness of breath (SoB) among patients with NTDT. Psychometric properties were evaluated using blinded data from the BEYOND trial (NCT03342404).

DESIGN

Analysis of a phase 2, double-blind, randomised, placebo-controlled trial.

SETTING

USA, Greece, Italy, Lebanon, Thailand and the UK.

PARTICIPANTS

Adults (≥18 years) (N=145) with NTDT who had not received a red blood cell transfusion within 8 weeks prior to randomisation, with mean baseline haemoglobin level ≤100 g/L.

MEASURES

NTDT-PRO daily scores from baseline until week 24, and scores at select time points for the 36-Item Short Form Health Survey version 2 (SF-36v2), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and Patient Global Impression of Severity (PGI-S).

RESULTS

Cronbach's alpha at weeks 13-24 was 0.95 and 0.84 for the T/W and SoB domains, respectively, indicating acceptable internal consistency reliability. Among participants self-reporting no change in thalassaemia symptoms via the PGI-S between baseline and week 1, intraclass correlation coefficients were 0.94 and 0.92 for the T/W and SoB domains, respectively, indicating excellent test-retest reliability. In a known-groups validity analysis, least-squares mean T/W and SoB scores at weeks 13-24 were worse in participants with worse scores for the FACIT-F Fatigue Subscale (FS), SF-36v2 vitality or PGI-S. Indicating responsiveness, changes in T/W and SoB domain scores were moderately correlated with changes in haemoglobin levels, and strongly correlated with changes in SF-36v2 vitality, FACIT-F FS, select FACIT-F items and the PGI-S. Improvements in least-squares mean T/W and SoB scores were higher in participants with greater improvements in scores on other PROs measuring similar constructs.

CONCLUSIONS

The NTDT-PRO demonstrated adequate psychometric properties to assess anaemia-related symptoms in adults with NTDT and can be used to evaluate treatment efficacy in clinical trials.

Behavioral Modification of an Uncooperative Preschool Child with Sickle Beta Thalassemia Disease in a Dental Clinic: A Case Report

Background:

Treating medically compromised pediatric patients with dental anxiety can be challenging, especially when general anesthesia and sedation are not an option. This paper reported a case of an uncooperative preschool child who was medically compromised and presented in the dental clinic with Severe-Early-Childhood-Caries (S-ECC). The dental behavior management of such a case was not previously discussed in the literature.

Case Presentation:

This paper explains the dental management and behavior modification carried out for a 5-year-old male child who was diagnosed with sickle beta thalassemia disease (Sβ-thalassemia), S-ECC, had a negative dental behavior, and was successfully and efficiently treated under a dental setting. The patient presented with his mother, who was concerned about her child’s decayed teeth and sought dental treatment as soon as possible to avoid any risk of infection. Dental examination revealed multiple dental caries and high caries risk. The patient’s behavior can be classified as definitely negative with high level of anxiety. The mother showed permissive parenting and the father exerted an authoritative parenting style. Dental management focused mainly on child behavioral modification via utilizing the difference between the parenting styles. Middle way of treatment, the child showed behavioral improvement, which was progressing toward the end of the treatment. Teeth were successfully restored with composite and metal crowns.

Conclusion:

With several behavior management techniques and understanding the parenting styles, the patient's behavior improved, and the treatment plan was successfully used on a dental chair without the need for more advanced management under general anesthesia.

Prevalence of Depression among Iranian Patients with Beta-Thalassemia Major: A Systematic Review and Meta-analysis

BACKGROUND

Patients with beta-thalassemia (BT) are susceptible to psychological disorders such as depression. The present study was conducted to estimate the pooled prevalence of depression among patients with BT in Iran.

METHODS

Domestic and international databases were searched for relevant articles published from 1991 until June 2019. We searched international databases such as Scopus, ISI, and Embase; Iranian databases such as SID, Magiran, and IranDoc; and Google Scholar and PubMed search engines. The MeSH keywords used were "depression", "mental health", "depressive disorder", "thalassemia", "beta-thalassemia major", "prevalence", "epidemiology", and "Iran". Relevant cross-sectional or cohort studies were included in the analysis. Cochran's Q test and the I² index were used to assess heterogeneity. The pooled prevalence and its 95% confidence interval (CI) were calculated using "metaprop" commands in Stata 14. In cases, where the I² statistic was greater than 50%, the random-effects model was used.

RESULTS

Eighteen eligible studies were included. The pooled prevalence of depression was 42% (95% CI: 33% to 52%), whereas the pooled prevalence of mild, moderate, severe, and extremely severe depression was 16% (95% CI: 11% to 22%), 13% (95% CI: 9% to 18%), 13% (95% CI: 9% to 17%), and 3% (95% CI: 0% to 8%), respectively. The pooled prevalence of depression in moderate- and high-quality studies was 45% (95% CI: 29% to 61%), and 39% (95% CI: 27% to 51%), respectively.

CONCLUSION

The high prevalence of depression highlights the urgent need for the establishment of interventions for the prevention, early detection, and treatment of depression among Iranian patients with BT.

Beta Thalassemia Minor: Patients Are Not Tired but Depressed and Anxious

OBJECTIVE

We aimed to investigate whether the severity of fatigue and the incidences of depression and anxiety of patients with beta thalassemia minor (BTm) are different from healthy individuals using the Fatigue Severity Scale (FSS) and Hospital Anxiety and Depression Scale (HADS).

SUBJECTS AND METHODS

BTm patients who were followed at the University of Health Sciences Istanbul Training and Research Hospital Hematology Clinic between 2016 and 2017 and who had normal biochemical parameters, thyroid function tests and C-reactive protein levels, and did not use any medications, consume alcohol or tobacco, have any chronic diseases or sleep disturbances were included in the study. Healthy control subjects who were matched with age, sex, marital status, educational status, and body mass index (BMI) were also included for comparison.

RESULTS

Thirty-nine BTm patients and 25 healthy controls were included in the study. The BTm and the control groups were comparable in terms of gender, age, BMI, educational status and marital status (p = 0.368, 0.755, 0.851, 0.785, and 0.709, respectively). FSS score was ≥4 in 23 (59.0%) BTm subjects and in 15 (60%) control subjects (p = 1.0). HADS anxiety score was ≥10 in 20 (51.3%) BTm subjects and in 5 (20.0%) control subjects (p = 0.018), and HADS depression score was ≥7 in 20 (51.3%) BTm subjects and in 6 (24.0%) healthy control subjects (p = 0.039).There was no correlation of hemoglobin with FSS score (p = 0.526, r = -0.105), HADS anxiety score (p = 0.703, r = -0.063), or HADS depression score (p = 0.718, r = -0.06) in the BTm group.

CONCLUSION

We found that both depression and anxiety were higher in BTm patients than in healthy individuals, but this difference was not feasible for fatigue.

Depression, Anxiety, and Stress Symptoms in Patients With Beta Thalassemia Major in Almadinah Almunawwarah, Saudi Arabia

Introduction

Beta thalassemia major (BTM) is a chronic hereditary blood disorder. Patients are dependent on blood transfusion and are prone to multiple comorbidities. Depression, anxiety, and stress (DAS) can complicate their condition. No reports from Saudi Arabia to measure DAS in BTM patients. We report the prevalence of DAS symptoms in our BTM patients using the DASS-21 (Depression, Anxiety, and Stress Scale - 21 Items) test.

Methods

A cross-sectional study including adolescents and adults aged 14 years and above with BTM treated in Almadinah Almunawwarah and excluding patients who had bone marrow transplant or with central nervous system insults were performed.

Results

A total of 31 male and 31 female patients were enrolled, with a mean age of 24.32 ± 7.05 years. Depression symptoms were detected in 60 % of patients, anxiety symptoms were detected in half of the studied group, and stress symptoms were detected in 38.7% of patients. We found a significant positive correlation between DAS and DASS total score. Age below or above 18, parent’s employment, patient’s educational level, and status of satisfaction about medical care were statistically significant in having positive effects on scores of DAS symptoms.

 Conclusions

BTM patients are prone to develop psychological disorders, which can affect the course of the disease. Our results are comparable to international and Arab population studies, which have the highest reported prevalence. It is important to not ignore the psychological evaluation of patients with BTM and to refer them for proper evaluation and management.

Brain functional impairment in beta-thalassaemia: the cognitive profile in Italian neurologically asymptomatic adult patients in comparison to the reported literature

Cognitive involvement in beta-thalassaemia is strikingly controversial and poorly studied in adulthood. This multicentre prospective study investigated 74 adult neurologically-asymptomatic beta-thalassaemia patients (mean-age 34·5 ± 10·3 years; 53 transfusion-dependent [TDT], 21 non-transfusion dependent [NTDT]) and 45 healthy volunteers (mean-age 33·9 ± 10·7 years). Participants underwent testing with Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV), Brief Psychiatric Rating Scale (BPRS) and multiparametric brain 3T-magnetic resonance imaging (MRI) for parenchymal, vascular and iron content evaluation. Patients had lower Full-Scale Intelligence Quotient (FSIQ) than controls (75·5 ± 17·9 vs. 97·4 ± 18·1, P < 0·0001) even after correction for education level. Compared to TDT, NTDT showed a trend of higher FSIQ (P = 0·08) but a similar cognitive profile at WAIS-subtests. FSIQ correlated with total and indirect bilirubin (P < 0·0001 and P = 0·002, respectively); no correlation was found with splenectomy, intracranial MRI/magnetic resonance-angiography findings, brain tissue iron content or other disease-related clinical/laboratory/treatment data. FSIQ did not correlate with BPRS scores, although the latter were higher among patients (28·74 ± 3·1 vs. 27·29 ± 4·8, P = 0·01) mainly because of increased depression and anxiety levels. Occupation rate was higher among controls (84·4% vs. 64·9%, P = 0·004) and correlated with higher FSIQ (P = 0·001) and education level (P = 0·001). In conclusion, Italian adult beta-thalassaemia patients seem to present a characteristic cognitive profile impairment and an increased rate of psychological disorders with possible profound long-term socio-economic consequences.

The Effects of Cognitive Behavioral Therapy on Depression and Anxiety among Patients with Thalassemia: a Randomized Controlled Trial

Introduction: Thalassemia is a chronic hereditary anemia which can be associated with different psychological, emotional, and behavioral problems such as depression and anxiety. This study aimed to evaluate the effects of cognitive behavioral therapy on depression and anxiety of patients with thalassemia.

Methods: This was a randomized controlled trial study. A total of 76 patients were randomly allocated to an experimental (n=38) and a control group (n=38). Patients in the experimental group were provided with cognitive behavioral therapy while their counterparts in the control group received routine care services. Depression and anxiety assessments were performed four weeks before the intervention as well as four and six weeks after that. Between-group and within-group comparisons were performed through the independent-sample t-tests and the paired sample t-test, respectively

Results: The post-test mean score of anxiety in the experimental group was significantly lower than that for the control group, while there was no significant difference between the groups regarding the post-test mean score of depression. The mean score of depression in both study groups decreased significantly. The rate of decrease in the experimental group was significantly greater than that in the control group.

Conclusion: Cognitive behavioral therapy can be used to prevent or alleviate depression and anxiety among patients.

The burden of psychiatric illnesses in adult patients with beta-thalassemia: a 5-year nationwide inpatient evaluation in the United States

Beta-thalassemia (ß-thalassemia) is a frequently inherited monogenic disorder worldwide with severe physical and mental health comorbidities. The aim of this study is to evaluate the burden of psychiatric disorders in adult patients hospitalized with ß-thalassemia in the United States (US). We utilized the discharge data from the National Inpatient Sample (NIS) from 2010 through 2014 to identify hospitalized ß-thalassemia patients who are 18 years and older. We assessed categorical and continuous variables using chi-square test and Student's t test respectively. The burden of psychiatric disorders was assessed using descriptive statistics and represented in terms of frequency (n) and percentage (%). A p value threshold of < 0.05 was considered clinically significant. All statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Of the 10,046 ß-thalassemia patients studied, 24.4% (n = 2448) reported psychiatric disorders. Mood disorders (15.2%; inclusive of 10.3% depression), followed by anxiety (9.4%), and substance abuse disorder (6.5%; 4.3% drug abuse, 2.2% alcohol abuse) were most prevalent. Comorbid mental illnesses increased the length of stay by 44.6% and total costs by 23.4%. All-cause mortality rate was reported at 1.9% in overall ß-thalassemia patients. This study highlights higher rates of psychiatric disorders such as depression and anxiety and correlated increases in length of stay and cost in hospitalized ß-thalassemia patients. To improve medical outcomes and curtail unnecessary health-care costs, implementation of an integrated care model can be considered.

Management of Children With β-Thalassemia Intermedia: Overview, Recent Advances, and Treatment Challenges

Our knowledge of the various clinical morbidities that thalassemia intermedia (TI) patients endure has substantially increased over the past decade. It is mandatory to grasp a solid understanding of disease-specific complications in order to tailor management. The optimal course of management for TI patients has been hard to identify, and several controversies remain with regard to the best treatment plan. Although advances in TI are moving at a fast pace, many complications remain with no treatment guidelines. Studies that expand our understanding of the mechanisms and risk factors, as well as clinical trials evaluating the roles of available treatments, will help establish management guidelines that improve patient care. Novel therapeutic modalities are now emerging. This article focuses on the management of children with β-TI. We present various clinical morbidities and their association with the underlying disease pathophysiology and risk factors. All therapeutic options, recent advances, and treatment challenges were reviewed.

β-Thalassemia intermedia: a comprehensive overview and novel approaches

β-Thalassemia intermedia is a clinical condition of intermediate gravity between β-thalassemia minor, the asymptomatic carrier, and β-thalassemia major, the transfusion-dependent severe anemia. It is characterized by a significant clinical polymorphism, which is attributable to its genetic heterogeneity. Ineffective erythropoiesis, chronic anemia, and iron overload contribute to the clinical complications of thalassemia intermedia through stepwise pathophysiological mechanisms. These complications, including splenomegaly, extramedullary erythropoiesis, iron accumulation, leg ulcers, thrombophilia, and bone abnormalities can be managed via fetal hemoglobin induction, occasional transfusions, chelation, and in some cases, stem cell transplantation. Given its clinical diversity, thalassemia intermedia patients require tailored approaches to therapy. Here we present an overview and novel approaches to the genetic basis, pathophysiological mechanisms, clinical complications, and optimal management of thalassemia intermedia.

The Effect of Partnership Care Model on Mental Health of Patients with Thalassemia Major

BACKGROUND

Thalassemia major has become a public health problem worldwide, particularly in developing and poor countries, while the role of educating the family and community has not been considered enough in patients' care.

OBJECTIVES

This study examines the impact of partnership care model on mental health of patients with beta-thalassemia major.

MATERIALS AND METHODS

This experimental study, with pretest and posttest design, was performed on patients with beta-thalassemia major in Jiroft city. 82 patients with beta-thalassemia major were allocated randomly into two groups of intervention (41 patients) and control (n = 41) groups. Mental health of the participants was measured using the standard questionnaire GHQ-28 before and after intervention in both groups. The intervention was applied to the intervention group for 6 months, based on the partnership care model.

RESULTS

There were significant differences between the scores of mental health and its subscales between two groups after the intervention (P < 0.05).

CONCLUSIONS

The findings of the study revealed the efficacy and usefulness of partnership care model on mental health of patients with beta-thalassemia major; thus, implementation of this model is suggested for the improvement of mental health of patients with beta-thalassemia major.

Evidence for multidimensional resilience in adult patients with transfusion-dependent thalassemias: Is it more common than we think?

BACKGROUND

Life expectancy of patients with transfusion-dependent thalassemias has increased with the development of improved treatment over the last few decades. However, β-thalassemia disorder still has considerable lifetime treatment demands and heightened risk of frequent complications due to transfusion-transmitted infections and iron overload, which may affect thalassemic patients' functioning in different domains.

OBJECTIVES

The vast majority of published studies on thalassemic patients have focused on children and adolescent functioning, and little research has examined adults. Hence, the current study was planned to examine the functioning and resilience of adult thalassemic patients in a comprehensive way.

METHODS

We examined multidimensional resilience and functioning across different domains (psychological adjustment, treatment adherence, social functioning and occupational functioning). We also examined demographic and medical variables that may relate to resilience and functioning. Participants were adult patients [n = 38; age M = 31·63, standard deviation (SD) = 7·72; 72% female] with transfusion-dependent thalassemia in treatment in a hospital in the northeastern United States.

RESULTS

The results suggest that most adult thalassemic patients tend to be resilient, demonstrating good functioning in four main domains: psychological adjustment, treatment adherence, social functioning and occupational functioning.

CONCLUSION

Despite the considerable demands of their illness, adult thalassemic patients appeared to be adapting well, demonstrating evidence of multidimensional resilience.

Thalassaemia in children: from quality of care to quality of life

Over the past few decades, there has been a remarkable improvement in the survival of patients with thalassaemia in developed countries. Availability of safe blood transfusions, effective and accessible iron chelating medications, the introduction of new and non-invasive methods of tissue iron assessment and other advances in multidisciplinary care of thalassaemia patients have all contributed to better outcomes. This, however, may not be true for patients who are born in countries where the resources are limited. Unfortunately, transfusion-transmitted infections are still major concerns in these countries where paradoxically thalassaemia is most common. Moreover, oral iron chelators and MRI for monitoring of iron status may not be widely accessible or affordable, which may result in poor compliance and suboptimal iron chelation. All of these limitations will lead to reduced survival and increased thalassaemia-related complications and subsequently will affect the patient's quality of life. In countries with limited resources, together with improvement of clinical care, strategies to control the disease burden, such as public education, screening programmes and appropriate counselling, should be put in place. Much can be done to improve the situation by developing partnerships between developed countries and those with limited resources. Future research should also particularly focus on patient's quality of life as an important outcome of care.