|Ahead of print publication
Common mental disorders and its associated factors among thalassemic patients
Department of Public Health, College of Public health, Imamm Abdul Rahman Bin Faisal University, Damamm, KSA
|Date of Submission||15-Mar-2022|
|Date of Decision||17-Apr-2022|
|Date of Acceptance||22-May-2022|
|Date of Web Publication||18-Oct-2022|
Department of Public Health, College of Public Health, Imam Abdul Rehman Bin Faisal University, Dammam
Source of Support: None, Conflict of Interest: None
Background: Thalassemia is a common genetic disorder among Asian population. The objective of this study is to determine the common mental disorders among thalassemic patients. Methods: A cross-sectional study conducted in different thalassemic centers across Pakistan. A total 250 study participants were selected through multistage stratified sampling technique. A structured and validated questionnaires was used. Chi-square test used to determine the relationship between sociodemographic characteristics with mental disorders. Results: Among study participants, 16%, 20%, and 5% suffered from severe anxiety, depression, and psychosis disorder, respectively. Those patients living without parents had more likely associated with depression, anxiety and psychosis disorders. these patients also had more frequent need to blood transfusion. Conclusion: Prevalence of common mental disorders highest among thalassemic patients. There is need to screening of mental disorders among the thalassmic patients and they referred to psychiatry clinic for early management.
Keywords: Blood, disorder, mental, thalassemia, transfusion
| Introduction|| |
Among blood disorders, thalassemia is a high burden chronic disease in the world. In the Asia continent, it is a public health problem. Every year, 6000 children born with this disease. This disease is caused by reduced filling of oxygen in red blood cells and transmitted by genes. The prevalence of Thalassemia in north American region from 1% to 3%, European region from 2% to 20%, African region from 5% to 15%, South American region from 7% to 25% and in Asian region from 3% tp 15%.
Different studies' results found that this disease has severe implications such as adverse effects on mental health of patients and their families and leads to social and economic impacts. The mental disorders among thalassemia patients are 14%–25%. Different studies found that there are different mental disorders such as depression, anxiety, and obsessive–compulsive disorders present among these patients.,
The previous study found that the depression prevalence among male and female patients was 9%–13% and 22%–27%, respectively. These findings are higher compared to general populations. Other common symptoms are emotional distress and low self-esteem throughout the child's life, which lead to mental disorders in later life.
Other study found that physical symptoms associated with mental disorders were high hospitalization rate, delayed puberty, and risk of heart failure. Another study found that depression and anxiety among thalassemic patients were 20.8% and 24.7%, respectively. A study conducted in Iran found that depression among thalassemic patients was 11%, which is higher than other chronic diseases.
In Pakistan, a total of 500,000 patients with different blood disorders were registered in different centers in all countries. Approximately, 100,000 thalassemic children were registered in these centers, and the prevalence rate was 6%–8%. Thalassemia is a chronic disease and is important to know the social and psychological impacts on the patient and their family. In Pakistan, prevention services are very limited due to poor resources in the country. Early diagnosis of this disease prevent the complication but in developing countries it diagnosed late which lead to mental disorders among patients. After the diagnosis, family stress started due to regular and long-term treatment of this disease.
There is no previous study to determine the common mental disorder among thalassemic patients in Pakistan. This study is to determine the common mental disorders among thalassemic patients. The result of this study will help to identify the factors that contribute to mental disorders and counter these factors to reduce the burden of mental disorders among thalassemic patients.
| Methods|| |
Study setting and study design
It is a cross-sectional survey conducted in a multicenter. Study participants were selected from different blood transfusion centres across the country. We selected five centers from different major cities in Pakistan. The validated and structured questionnaire was used, which consists of questions related to demographic information and a mental disorder information section.
Sample size and sampling technique
The Epi Info is statistical software for epidemiology developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US) online sample size calculator was used to calculate the sample size. Approximately 100,000 patients registered in different centers, and we selected five centers from different major cities in Pakistan. The following parameters were used to calculate sample size: prevalence of mental disorder, 50% (as it was unknown from previous studies); 95% confidence interval; and 5% margin of error. The sample size for this study was 250. The sampling technique for the selection of participants used was multi-stage proportionate stratified sampling. At each center, 50 patients were selected through simple random sampling.
Inclusion and exclusion criteria
Patients aged from 6 to 15 years were included in the study and patients who have any comorbidity with mental disorders were excluded from the study.
Data collection procedure
Assent form was filled before start the data collection; after that, data collection was started. All details regarding the objective of the study, risk and benefit of research, and details of the questionnaire were included in the assent form.
A questionnaire consists of three sections. Demographic parameters included age and gender. The mental disorders determined through Beck Depression Scale indicate the sensitivity of this instrument as 61% and specificity as 94%. The Beck Anxiety Inventory Scale used for anxiety treatment found a sensitivity of 92% and a specificity of 76% for the diagnosis of anxiety. The Psychotic Symptom Rating Scale was used to assess the presence of psychosis disorder. This is the validated scale to determine the psychosis.
The Beck Depression Scale score ranges from 1 to 40. A score of 1–10 indicates normal, 11–16 mild, 17–30 moderate, 31–40 severe, and over 40 very severe. A Beck Anxiety Inventory Scale score ranges from 0 to 60. A score of 0–21 indicates mild, 22–35 moderate, and over 36 severe anxiety. Psychotic Symptom Rating Scales range from 0 to 40. A score of 0–13 indicates mild psychosis, 14–25 indicates moderate psychosis, 26–34 indicates severe psychosis, and 35–40 indicates very severe psychosis.
Data analysis was done by the SPSS Statistics is a statistical software suite developed by IBM, USA. Mean and standard deviation were calculated for continuous variables, and frequencies and percentages were calculated for categorical variables. The normality of the data was determined through the Kolmogorov–Smirnov test. P < 5% was considered statistically significant. The Chi-square test was used to test the relationship between categorical variables.
| Results|| |
The average age of these students was 10.41 years, 75% of the patients were 7–10 years, 65% were female, 73% of the patients were living with parents, and 70% received blood transfusion once per month [Table 1].
Those patients living without parents were more likely to have mental disorders (anxiety, depression, and psychosis) compared to those living with parents (P ≤ 0.005). Those patients who had received blood transfusion more than once per month have more mental disorders (anxiety, depression, and psychosis) compared to those who have only one time transfusion per month (P ≤ 0.005) [Table 2].
|Table 2: Relationship between base line characteristics with psychological disorder among study participants|
Click here to view
Most of the patients had moderate levels of anxiety, depression, and psychosis disorders [Figure 1].
Most (16%, 20%, and 5%) of the patients were suffering from severe anxiety, depression, and psychosis disorder, respectively [Figure 2].
| Discussion|| |
Thalassemia is the major predictor of mental disorders among study participants. The study found that some of the study participants were suffering from severe anxiety, depression, and psychosis (16%, 20%, and 5%, respectively).
The study found that all patients of thalassemia were suffering from different levels of mental disorders. The patient's social contacts are commonly reduced due to disease, which leads to mental disorders due to isolation and exclusion fear from the society. The main part of life is full of despair and pain. These results were consistent with other study results. Mental health also affects the physical health of patients; most of the patient's dependents and their role in the family and society were severely affected.
The study results found that those patients with more than one transfusion of blood had more likely associated with severe mental disorders. These results are consistent with other study results, which reveal that 30% of the patients had severe mental disorders with more than one time blood transfusion. The reason for these events has anxiety because of fear of a needle piercing into the body. Another study found an association between pain and increased anxiety in with patients having thalassemia. This disease also caused negative self-esteem due to mental disorders. Another study found that 39% of patients with thalassemia have negative self-esteem due to mental disorders.
The results of this study found that those patients living without parents were more likely to have mental disorders. This is due to lack of sympathy from natural parents, which is required during treatment of this disease. These results are consistent with other studies' results, which found that patients living with foster parents had various mental disorders.,, Many predictors for mental disorders affect the education of thalassemic patients such as negative self-esteem, expressive and social issues, school absenteeism, lack of protective nature from parents, negative relationship with friends, and family finance problem.,,,
A previous study found that higher level of mental disorders among thalassemic patients. Some behavioral problems are also found to exist along with mental disorders. There remains a need to improve the management of thalassemia in terms of psychological aspects to improve the mental health of this family.,,
There are several limitations of this study; first, it is a cross-sectional study that lacks temporality between cause and effects. Second, the scale we used is the self-report scale which is used for screening and which affects the generalization of results. There is a need for clinical examination of patients for definitive diagnosis of mental disorders in future studies.
| Conclusion|| |
The study found that mental disorders among thalassemic patients are very high. The major factors that contribute to this burden are multiple transfusions and living with foster parents. It is recommended that clinicians should involve in the study to examine not only the physical but also the psychological state of the child and that an integrated management approach would be appropriate to enable the necessary assistance.
We thank all teachers and students who help in this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Aydin B, Yaprak I, Akarsu D, Okten N, Ulgen M. Psychosocial aspects and psychiatric disorders in children with thalassemia major. Acta Paediatr Jpn 1997;39:354-7.
Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: An increasing global health problem. Bull World Health Organ 2001;79:704-12.
Waheed U, Saba N, Wazeer A, Ahmed S. A systematic review and meta-analysis on the epidemiology of hepatitis B and hepatitis C virus among beta-thalassemia major patients in Pakistan. J Lab Physicians 2021;13:270-6.
Messina G, Colombo E, Cassinerio E, Ferri F, Curti R, Altamura C, et al.
Psychosocial aspects and psychiatric disorders in young adult with thalassemia major. Intern Emerg Med 2008;3:339-43.
Tarım HŞ, Öz F. Thalassemia major and associated psychosocial problems: A narrative review. Iran J Public Health 2022;51:12-8.
Mehr MA, Kalhorpour H, Shirani V, Seyed-Nezhad A, Kord A, Zainivand M. Study of quality of life from the perspective of parents and children with thalassemia major. Med Sci 2019;23:333-8.
Jaafari Z, Sadidi N, Abdolahinia Z, Shahesmaeili A. Prevalence of Depression among Iranian Patients with Beta-Thalassemia Major: A Systematic Review and Meta-analysis. Iranian Journal of Medical Sciences. 2022;47:15.
Hoseini SH, Khani H, Khalilian A, Vahid Shahi K. Comparison mental health of patients with beta thalassemia major that referred to Bou-Ali Sina Hospital of Sari, Iran between 2003-2005 with control group. Mazandaran Med Sci Univ J Iran 2007;17:51-60.
Hongally C, Benakappa AD, Reena S. Study of behavioral problems in multi-transfused thalassemic children. Indian J Psychiatry 2012;54:333-6.
] [Full text]
Arian M, Vaismoradi M, Badiee Z, Soleimani M. Understanding the impact of COVID-19 pandemic on health-related quality of life amongst Iranian patients with beta thalassemia major: A grounded theory. Prim Health Care Res Dev 2021;22:e67.
Bibi A, Hassan M, Khan SU, Naeem MO, Asnath L. Assessment of the quality of life of children with beta thalassemia in Peshawar district: A cross sectional study. Pak J Med Res 2021;60:121-5.
Amoudi AS, Balkhoyor AH, Abulaban AA, Azab AM, Radi SA, Ayoub MD, et al.
Quality of life among adults with beta-thalassemia major in western Saudi Arabia. Saudi Med J 2014;35:882-5.
Musallam KM, Vitrano A, Meloni A, Pollina SA, Karimi M, El-Beshlawy A, et al
. Survival and causes of death in 2,033 patients with non-transfusion-dependent β-thalassemia. Haematologica 2021;106:2489.
Noorbala AA, Bagheri Yazdi SA, Yasamy MT, Mohammad K. Mental health survey of the adult population in Iran. Br J Psychiatry 2004;184:70-3.
Mednick L, Yu S, Trachtenberg F, Xu Y, Kleinert DA, Giardina PJ, et al.
Symptoms of depression and anxiety in patients with thalassemia: prevalence and correlates in the thalassemia longitudinal cohort. Am J Hematol 2010;85:802-5.
Khairkhah F, Mahmoodi Nesheli H, Yahyaei AR, Khodabakhsh E, Husseini SR. Evaluation of mental health and quality of life among β-thalassemia major patients. CJP 2015;1:54-9.
Khodaie S, Karbakhsh M, Asasi N. Evaluation psycho-social state of juvenile with Thalassemia major based on their self-report and GHQ-12 test results. Zahedan Med Sci Univ J Iran 2005;6:18-23.
Taher AT, Musallam KM, Cappellini MD, Weatherall DJ. Optimal management of β thalassaemia intermedia. Br J Haematol 2011;152:512-23.
Noorbala AA, Bagheri Yazdi SA, Mohammad K. The validation of general health questionnaire-28 as a psychiatric screening tool. Hakim Res J 2009;11:47-53.
Shaligram D, Girimaji SC, Chaturvedi SK. Psychological problems and quality of life in children with thalassemia. Indian J Pediatr 2007;74:727-30.
Chengappa KN, Kupfer DJ, Frank E, Houck PR, Grochocinski VJ, Cluss PA, et al.
Relationship of birth cohort and early age at onset of illness in a bipolar disorder case registry. Am J Psychiatry 2003;160:1636-42.
Canatan D, Ratip S, Kaptan S, Cosan R. Psychosocial burden of beta-thalassaemia major in Antalya, south Turkey. Soc Sci Med 2003;56:815-9.
Maheri A, Sadeghi R, Shojaeizadeh D, Tol A, Yaseri M, Rohban A. Depression, anxiety, and perceived social support among adults with beta-thalassemia major: Cross-sectional study. Korean J Fam Med 2018;39:101-7.
Naderi M, Hormozi MR, Ashrafi M, Emamdadi A. Evaluation of mental health and related factors among patients with beta-thalassemia major in south east of Iran. Iran J Psychiatry 2012;7:47-51.
Alavi A, Parvin N, Kheyri S, Hamidizade S, Tahmasebi S. Comparison attitude children with thalassaemia major and their parents about life quality of these children in Shahr-e Kord, Iran. Journal of Shahrekord University of Medical Sciences 2007;8:35-41.
[Figure 1], [Figure 2]
[Table 1], [Table 2]