1
Prevalence of Depression in Beta-Thalassemic Teenagers as assessed by the
Beck’s depression inventory
Running title: Depression in beta-thalassemic teenagers
Authors:,; Shiva Nazari, MD1; Akbar Shafiee MD, MSc2; Mohammad Taghi Sadeghi Koupaei
PhD3
1- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti
University of Medical Sciences, Tehran, Iran Tehran
2- Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
3- Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences,
Tehran, Iran.
Correspondence to:
Shiva Nazari MD; Assistant Professor, Pediatric Congenital Hematologic Disorders Research
Center, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Shariati Ave,
Tehran, 1983963113, Iran. Tel: +98 21 22227021-9; Fax: +98 21 22220254.
Email: Shnazari2000@Gmail.com
Abstract word count: 1491; Article’s word count: 1110; Table: 1; Figure: 0
1
2
ABSTRACT
Objectives: Beta-thalassemia is a frequent hereditary chronic disease, and a plausible cause for
psychological disorders. In this cross sectional study we aimed to identify the rate and severity of
depression among teenagers with beta- thalassemia using the Beck’s depression inventory.
Methods: Beta-thalassemic patients aged 13-20 years who presented to Mofid Children Hospital
for blood transfusion within a one-year period were asked to complete the Beck’s depression
inventory, after signing an informed consent. The collected data were then described.
Results: A total of 56 subjects (mean age=17.2 ± 2.59 years; male=27 [48.21%]) completed the
BDI form. Mean score for BDI was 14.27 ± 12.79. Various degrees of depression existed in
almost 50% of the study population. Age and gender did not have a significant effect on the BDI.
Conclusion: High rate of depressive disorder in thalassemic patients signifies the necessity for
improving psychosocial care in this specific group of patients.
KEYWORDS:
Thalassemia; depression; Beck’s depression inventory; epidemiology, Iran
2
3
INTRODUCTION
Beta thalassemia, one of the most common genetic disorders worldwide, results from aberrant
beta-globin chain production (1). It has a high frequency among the people of Mediterranean,
African, or Asian race (2-5). Beta-Thalassemia is considered as the most prevalent single gene
disorder in Iran which is estimated to affect over 25,000 individuals. Its prevalence in Iran ranges
from 4% to 10%, especially in the northern part of the country (6). This chronic hereditary
disease can predispose its young patients to psychological complications (7, 8).
Depression, a common psychiatric complication in the course of any chronic disease, is widely
seen among thalassemic patients (9). However, the natural history of the disease, associated
complications and treatment modalities and adverse effects, particularly iron overload, can all
engage in triggering the depressive disorder. A higher rate of depression among thalassemic
patients compared to other chronic diseases emphasizes the importance of this condition,
especially in early stages (10).
Beck’s depression inventory (BDI) is a standard self-administered questionnaire which is
commonly used to screen patients for depression in the clinical setting (11). This easy-to-use tool
covers all clinical criteria necessary for diagnosing various degrees of depression and has been
used with success in many studies to evaluate depressive symptoms.
Due to the high frequency of beta-thalassemia in the Middle East and the importance of
depression in these patients, we aimed to identify the prevalence and degree of depression among
beta-thalassemic teenagers, using the Beck’s depression inventory as a simple standard
questionnaire in a referral university hospital.
METHODS
In this cross-sectional study, we consecutively enrolled beta-thalassemic teenagers who admitted
to Mofid Children Hospital, Tehran, Iran, for monthly blood transfusion from January 2011 to
December 2011. Participants have received blood transfusion therapy for at least 5 years and did
not have any serious clinical complication within the past 12 months. We used the standardized
Persian version of Beck's Depression Inventory second edition (BDI-II) in this study (12). BDI-II
is a 21-item standard self report questionnaire that evaluates sad mood, pessimistic outlook,
feelings of guilt and loss of appetite and is interpreted as follows: symptom-free (0–15), mild
depression (16–30), moderate depression (31–46) and severe depression (47–63) (11).
Questionnaires were filled out by the patients within 20 minutes and supervised by their
physician.
Patients signed an informed consent and agreed to participate in the study. As far as many
patients were below the age of 16, their parents also signed the consent form. They were assured
of the confidentiality of the study. The proposal of this study was approved by the research board
of Shahid Beheshti University of Medical Sciences and the study was supported financially by
Mofid Children Hospital.
Descriptive statistics were used to show frequency rate of variables. Numerical variables with
normal distribution were expressed as mean ± standard deviation. Chi-aquare test was used for
3
4
comparing non-parametric variables. We used the Pearson correlation to assess the correlation of
depressive symptoms and age. Effect of gender on the means of the BDI score was tested by
student’s t-test. Statistical analysis was performed using PASW-18 statistics (SPSS Inc.,
Chicago, Illinois, USA). P-value below 0.05 was considered as significant.
RESULTS
Within the study period, 68 thalassemic subjects referred to Mofid Children Hospital of which 8
subjects refused to take part, four subjects gave incomplete form and finally, 56 subjects
participated in this study and completed the BDI form. Mean age of the participants was 17.2 ±
2.59 years, and 27(48.21%) of them were male. Mean score for BDI was 14.27 ± 12.79 [Min: 0,
Max: 44] (Table-1). Of all patients, 35 (62.5%) had a BDI score below 15 and therefore not
classified as depressed. Based on the BDI results, 4 (6.2%) patients had moderate depression
while 7 (12.5%) patients had severe depression. Details of the BDI score and results of the study
group are described in table 1.
There were no significant correlations between age and the BDI score (p=0.52). Although the
mean BDI score was a bit higher in males, gender did not have a significant effect on the BDI
score (p=0.49).
DISCUSSION
Depression is a common psychiatric disorder in many chronic diseases and beta-thalassemia is of
no exception. The present study showed that various degrees of depression existed in almost
50% of teenagers with beta-thalassemia. However, age and gender did not have any significant
effect on the BDI score as an indicator of depression.
The pathophysiology of depression in thalassemic patients is also still vague. Iron overload is
known as the culprit for a number of complications in thalassemia as well as depression (13).
Nonetheless, many studies have reported a high rate of psychological disorders in thalassemic
patients that can be attributable to several factors, from physiological changes to socio-economic
conditions (14-16)(17).
The rate of depression in our study is much higher compared to the rate of healthy subjects in
Iranian studies (18, 19). In a recent study, the rate of depression in the normal control group of
children was reported to be 21.1% (20). Moreover, the rate of psychological disorders and
depression was reported to be 50.8% and 11.6% in a cross sectional study on 164 thalassemic
patients. These differences may stem from different diagnostic tools used in various studies.
Nonetheless, the rate of depression in the present study population was comparable to other
studies that discussed depression in thalassemic patients affected, those affected by other chronic
diseases or those who were posed to specific social conditions (9, 20-22). Likewise, the rate of
depression in our study similar to the prisoners of war’s children, with a rate of 48.4% (23).
From the preventive and supportive point of view, this finding can be disappointing as the
steadiness of the rate of depression in thalassemic patients conveys the reality that no robust
4
5
intervention has been performed to reduce the rate of psychosocial disorders in this group of
patients, at least in Iran.
As a limitation to this study, we did not perform a psychiatric interview to evaluate depression
symptoms and signs, and presence of suicidal thoughts. Also, this was a cross sectional study and
a control group was not a part of study. We also did not test the relationship of hematologic
features with the presence and severity of depression in the study population. However, it is
important to acknowledge that this study can provide a basic understanding of the rate of
depression among thalassemic patients.
In conclusion, high rate of depressive disorder in the beta-thalassemic teenagers emphasizes the
necessity for improving social support and psychological care in this group of patients. The next
steps would be finding out the risk factors of depression and also selecting the appropriate
psychosocial interventions in the beta-thalassemic patients.
ACKNOWLEDGEMENTS
The present study was supported by Shahid Beheshti University of Medical Sciences.
CONFLICT OF INTEREST
The authors have no conflict of interest to declare
REFERENCES
1.
Knott M, Ramadan KM, Savage G, Jones FG, El-Agnaf M, McMullin MF, et al. Novel and
Mediterranean beta thalassemia mutations in the indigenous Northern Ireland population. Blood Cells
Mol Dis. 2006 Mar-Apr;36(2):265-8.
2.
Bolaman Z, Enli Y, Köseoğlu M, Koyuncu H, Aslan D. Prevalence of beta thalassemia trait in
Denizli. Turk J Haematology. 2001;18:85-8.
3.
Zahed L, Demont J, Bouhass R, Trabuchet G, Hanni C, Zalloua P, et al. Origin and history of the
IVS-I-110 and codon 39 beta-thalassemia mutations in the Lebanese population. Hum Biol. 2002
Dec;74(6):837-47.
4.
Mehrabani D, Pasalar M, Afrasiabi A, Mehravar Z, Reyhani I, Hamidi R, et al. Frequency of
Thalassemia, iron and glucose-6phosphate dehydrogenase deficiency among Turkish migrating nomad
children in Southern Iran. Acta Medica Iranica. 2009;47(1):20-4.
5.
Canatan D, Kose M, Ustundag M, Haznedaroglu D, Ozbas S. Hemoglobinopathy control program
in Turkey. Community genetics. 2006;9(2):124.
6.
Rahimi Z, Muniz A, Akramipour R, Tofieghzadeh F, Mozafari H, Vaisi-Raygani A, et al.
Haplotype analysis of beta thalassemia patients in Western Iran. Blood Cells Mol Dis. 2009 MarApr;42(2):140-3.
7.
Aydinok Y, Erermis S, Bukusoglu N, Yilmaz D, Solak U. Psychosocial implications of
Thalassemia Major. Pediatr Int. 2005 Feb;47(1):84-9.
5
6
8.
Ratip S, Skuse D, Porter J, Wonke B, Yardumian A, Modell B. Psychosocial and clinical burden
of thalassaemia intermedia and its implications for prenatal diagnosis. Archives of disease in childhood.
1995;72(5):408-12.
9.
Ghanizadeh A, Khajavian S, Ashkani H. Prevalence of psychiatric disorders, depression, and
suicidal behavior in child and adolescent with thalassemia major. J Pediatr Hematol Oncol. 2006
Dec;28(12):781-4.
10.
Mikelli A, Tsiantis J. Brief report: Depressive symptoms and quality of life in adolescents with bthalassaemia. J Adolesc. 2004 Apr;27(2):213-6.
11.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression.
Arch Gen Psychiatry. 1961 Jun;4:561-71.
12.
Kavian H, Mossavi AS, Mohit A: Principal reliance in psychological interviews and tests. 1st
edition. Tehran: Sena; 2000:179-180.
13.
Abetz L, Baladi JF, Jones P, Rofail D. The impact of iron overload and its treatment on quality of
life: results from a literature review. Health Qual Life Outcomes. 2006;4:73.
14.
AYDIN B, YAPRAK I, AKARSU D, ÖKTEN N, üLGEN M. Psychosocial aspects and
psychiatric disorders in children with thalassemia major. Pediatrics International. 1997;39(3):354-7.
15.
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. Internal and emergency medicine.
2008;3(4):339-43.
16.
Naderi M, reza Hormozi M, Ashrafi M, Emamdadi A. Evaluation of Mental Health and Related
Factors among Patients with Beta-thalassemia Major in South East of Iran. Iranian Journal of Psychiatry.
2012;7(1).
17.
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]. Zahedan
Med Scienc Univers J 2007; 8: 35-41.
18.
Ahmadi J, Toobaee S, Alishahi M. Depression in nursing students. J Clin Nurs. 2004
Jan;13(1):124.
19.
Modabber-Nia MJ, Shodjai-Tehrani H, Moosavi SR, Jahanbakhsh-Asli N, Fallahi M. The
prevalence of depression among high school and preuniversity adolescents: Rasht, northern Iran. Arch
Iran Med. 2007 Apr;10(2):141-6.
20.
Razavi SH, Ratki R, Kazem S, Molavi Nojomi M, Namiranian N. Depression and general anxiety
in the prisoner of war’s children: a cross sectional study. Medical Journal of the Islamic Republic of Iran
(MJIRI). 2012;26(4):179-84.
21.
Finkelstein FO, Finkelstein SH. Depression in chronic dialysis patients: assessment and
treatment. Nephrol Dial Transplant. 2000 Dec;15(12):1911-3.
22.
Ghanizadeh A, Baligh-Jahromi P. Depression, anxiety and suicidal behaviour in children and
adolescents with Haemophilia. Haemophilia. 2009 Mar;15(2):528-32.
23.
Razavi SH, Razavi-Ratki SK, Nojomi MM, Namiranian N. Depression and general anxiety in the
prisoner of war's children: a cross sectional study. Medical Journal of the Islamic Republic of Iran.
2012;26(4):179.
6
7
Table-1: Scores obtained to the BDI from the 56 beta-thalassemic teenagers
Male, n (%)
Female, n (%)
Diagnosis
BDI Score
17 (30.35)
18 (32.14)
Normal
0-15
4 (7.14)
6 (10.71)
Mild depression
16-39
2
(3.57)
2 (3.57)
Moderate depression
31-46
4 (7.14)
3 (5.35)
Severe depression
47-63
14.76
13.81
Mean BDI
* P-value <0.05 was considered as a level of significance.
7
Total, n (%)
35 (62.5)
10 (17.9)
4 (6.2)
7 (12.5)
14.27
p-value*
0.44
0.41
0.91
0.32
0.67