Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study

doi:10.21203/rs.3.rs-4693535/v1

Download PDF

Research Article

Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-4693535/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Depression commonly arises among adolescents who have experienced long-standing psychosocial difficulties especially those facing chronic illnesses like Sickle Cell Anemia (SCA). SCA is a global health concern, and Tanzania is one of the countries with a high incidence, estimated at 8,000 to 11,000 births per year. This study aims to assess the magnitude and factors associated with depression among adolescents with SCA.

Methodology: A cross-sectional analytical study conducted on adolescents aged 11-19 years attending sickle cell clinics in referral hospitals in Dar-es-salaam Tanzania, from October 2023-March 2024. A validated Patient Health Questionnaire (PHQ-9) tool was used to screen for depression. Univarite and multivariate regression model was used to determine factors associated with clinical depression.A P value of less than 0.05 was considered statistically significant.

Results: Among 326 adolescents enrolled, the majority (64.7%) were 10-14 years of age. A total of 216 (54 %) had depression; when categorized into severity, 167 (38.7 %) had mild, 48 (14.7 %) had moderate and 1 (0.3%) had severe depression. Clinical depression, encompassing moderate to severe depression, was prevalent in 49 (15%) adolescents. Painful episodes were significantly associated with depression (aOR = 2.49) (95% CI: 1.17 - 5.29, p = 0.01).

Conclusion: Depression is common among adolescents with SCA in our setting. Painful episodes experienced by these adolescents were significantly associated with depression. This study highlights the need for screening adolescents with SCA for depression and integration of mental health services in sickle cell clinics.

Depression

adolescents

sickle cell anemia

clinical depression

Depression also known as major depressive disorder or clinical depression; is a mood disorder that affects how a person feels, thinks, and conducts daily activities. Globally, it has been estimated that 1 in every 7 (14%) 10-19-year-olds experience mental health conditions, majority being; depression, anxiety, and behavioral disorders. Depression occurs among 1.1% of adolescents with the age 10–14 years, and 2.8% of 15-19-year-olds. ¹ It is predicted that, by 2030 depression alone is likely to be the 3rd leading cause of disease burden in low-income countries and 2nd highest in middle-income countries. ²

Sickle cell disease (SCD) is a global disease which occurs as a result of a genetic mutation that leads to abnormal hemoglobin molecules which polymerize when deoxidized.^3,4 Sickle cell Anemia (SCA), is an autosomal recessive hemoglobin S mutation (HbSS) which has been linked to significant mortality and morbidity in African and Mediterranean ancestry.⁵ Tanzania is among the top 5 countries in Sub-Saharan Africa and the top leading in East Africa with the highest prevalence of SCD estimated at 8000-11,000 births per year.

Almost half of SCA patients (47.4%) in Tanzania were in the age group of 5–17 years ⁶. With improved care and advanced treatment modalities, there has been reduced mortality and thus increasing survival and transforming SCA into a chronic illness, accompanied with psychosocial and mental health burden. The occurrence of acute and chronic painful episodes, delayed puberty, recurrent hospital admissions and blood transfusion among others have been greatly linked to development of depressive symptoms in adolescents. Depression rates are found to be high in adolescents with SCA as compared to the general population of adolescence. ⁷

Despite the huge burden of SCA in Sub-Saharan Africa very few studies have been done to explore the burden of depression among adolescents with SCA. Depression magnitude among adolescents in Tanzania is unknown however we noted high prevalence 84% in some African countries like Congo ⁸ Studies done in Nigeria and other resource limited settings identified factors that may explain the presence of depression. These include; painful episodes, age, gender, level of education and socio-economic status.^8–9 Similar studies have been conducted for adult patients with SCA. ¹⁰ Data from this study provides the magnitude and severity of depression in adolescents with SCA. It further enlightens on factors associated with depression among adolescents with SCA.

Study design and setting:

A cross-sectional analytical study conducted among adolescents attending sickle cell clinics found in Dar es Salaam form October 2023 to March 2024. Dar es Salaam is one among the largest and fastest growing cities in Tanzania with estimated population of 7.4 million residents as per 2022 census and experience a rapid growth rate of about 5.6% per year. It comprises of 4 referral hospitals including a national referral hospital and three Regional Referral Hospitals (RRH) Mwananyamala RRH, Amana RRH and Temeke RRH.

Study participants:

Adolescents aged 11–19 years, confirmed with SCA by Hb electrophoresis or HPLC were included. Among these; adolescents who declined assent and consent, those with painful crisis at that time and those with additional comorbid illness which could further contribute to depression were excluded.

Sample size and selection

The sample size (N) was calculated using the formula for proportion. Where; N = minimum sample size required, P = 86% - mean prevalence of depression in adolescence with SCA in Congo.(19); E = Maximum allowable error of the study, which is 5%; Z = Standard normal distribution that corresponds to 95% level of confidence, which is 2.85. Therefore, the minimum sample size required was 320 participants. Convenience sampling was used to obtain participants and a total of 326 participants were recruited.

Data collection methods

Data was collected by the principal investigator with the help of 3 research assistants (medical personnel’s). The research assistants were pre-trained on the entire data collection process and had good understanding of the study. The study was conducted using pre-structured and pre-tested questionnaire to assess the prevalence, severity and factors associated with depression. The questionnaire had three sections including socio-demographic data, severity of SCA and Patient Health Questionnaire (PHQ-9) tools.

The interviews took place during the time at which clients waited to see the attending doctor or after they were done with their visit. This did not affect their access to necessary services during their clinic visit. The researcher administered the questionnaire due to the sensitivity of data and ease of obtaining data from participants who can’t read or write.

Data collection tools:

Structured questionnaire was used to obtain socio-demographic data and clinical profile of study participants. Sickle cell disease severity scores adapted from a study by ezenwosu et al was analyzed as follows. Items in the previous 12 months (number of hospitalizations, number of blood transfusions, and number of painful crises) were scored according to the frequency of their occurrence (0–3). Items in present state- splenic and liver enlargement were scored by severity (0 = < 5cm, 1 = 5-10cm, 2 > 10cm) while lifetime complications of SCA; leg ulcers, stroke, priapism, respiratory complications, arthritis, osteomyelitis, sickle cell nephropathy and gallstones (0 = absent, 1 = present). Total score was 21, whereby; a score ≤ 6 (mild), score 7–12 (moderate), and score > 12 (severe).⁹

Patient Health Questionnaire (PHQ-9) tool was used to screen for depression.¹¹ The severity of depression was obtained from the PHQ-9 tool scores whereas the total score from the 9 items ranged from 0 to 27. Clinical depression or major depressive disorder was suggested if PHQ-9 score ≥ 10 or if of the 9 items, 5 or more are checked as, “at least more than half the days” or each item 1 or 2 was checked as, “at least more than half the days”. A score of 0–4 (none-minimal depression), 5–9 (mild depression), 10–14 (moderate depression), 15–19 (moderately severe depression), 20–27 (severe depression).

Data analysis:

Data was entered in SPSS V23 and data cleaning was done. For numerical variables, mean and standard deviation were used. Categorical variables were described using frequencies and proportions with difference in proportions analyzed using the chi squared or Fishers exact test, as appropriate. Univariate and multivariate analysis were used for the associated factors. A P value of less than 0.05 was considered statistically significant.

Participant’s socio-demographic characteristics

Participant’s socio-demographic characteristics as elaborated on Table 1 revealed that the majority (64.7%) of participants were 10–14 years of age, with the mean age of 13.9 ± 2.4 SD. There was equal gender distribution. Most participants attended were from the tertiary referral clinic MNH clinic at (49.1%) followed by the regional hospital clinics, Temeke (23.6%) and almost equal proportion were from Mwananyamala (10.1%) and Amana (10.4%). Majority of participants had either primary level education (48.2%) or secondary level education (46.9%), with a small proportion (4.9%) having no formal education at all. Majority of participants were from Dar es salaam (urban and rural) (87.7%) and few (12.3%) were from Up-country (other regions in Tanzania). Sixty five (65%) of participants had health insurance coverage.

Participant’s Clinical profile

Three quarters of adolescents (74.5%) with SCA were on hydroxyurea (Table 2). Sickle cell disease Severity Score (SSS) was used to determine severity of SCA among participants classifying them as mild, moderate and severe disease category. It was observed that (96.3%) had mild disease severity, (3.7%) had moderate disease severity and none of them had severe disease. When looking at painful episodes, 39.6% of the adolescents reported to be pain-free in the past 12 months while the remaining had either 1 (26.4%), 2–3 (22.7%) or more than 3 (11.3%) painful episodes. The majority of the participants in the study did not receive blood transfusions (85.0%) or require hospital admission (66.3%) in the past 12 months and most of them had no current symptoms of hepatomegaly or splenomegaly represented by (97.9%) and (91.1%) of participants respectively.

Majority of adolescents in this study had no complications of SCA (Table 3). Of the few that reported complications, the most commonly observed complication was respiratory complications (pneumonia or acute chest syndrome) (Fig. 3).

Table 1

Socio-demographic characteristics of adolescents with SCA
		No of participants-326	Percentage (%)
Age(years)	10–14	211	64.7
Age(years)	15–19	115	35.3
Sex	Male	160	49.1
Sex	Female	166	50.9
Clinic	MNH	182	55.8
	Temeke	77	23.6
	Mwananyamala	33	10.1
	Amana	34	10.4
Education	No formal education	16	4.9
	Primary	157	48.2
	Secondary	153	46.9
Address	Dar es salaam	286	87.7
Address	Up-country	40	12.3
Health insurance	absent	212	65
Health insurance	present	114	35

Table 2

Participant’s Clinical profile
		No of participants-326	Percentage (%)
Hydroxyurea use	No	80	24.5
Hydroxyurea use	yes	246	75.5
Painful Episodes	none	129	39.6
	once	89	26.4
	2–3	74	22.7
	> 3	37	11.3
Hospital admission	none	216	66.3
	once	69	21.2
	2–3	32	9.8
	> 3	9	2.8
Blood transfusion	none	277	85.0
	once	34	10.4
	2–3	13	4.0
	> 3	2	0.6
Spleen enlargement	< 5cm	319	97.9
	5–10 cm	6	1.8
	> 10cm	1	0.3
Liver enlargement	< 5cm	323	99.1
Liver enlargement	5-10cm	3	0.9

Table 3

Participant’s Clinical profile; - Complications of SCA among participants
		No of participants	Percentage (%)
Stroke	No	320	98.8
Stroke	Yes	4	1.2
Osteomyelitis	No	324	99.4
Osteomyelitis	Yes	2	0.6
Arthritis	No	324	99.3
Arthritis	Yes	2	0.6
Chronic leg ulcer	No	323	99.1
Chronic leg ulcer	Yes	3	0.9
Sickle cell nephropathy	No	324	99.4
Sickle cell nephropathy	Yes	2	0.6
Respiratory complications	No	313	96.0
Respiratory complications	Yes	13	4.0
Priapism	No	320	96.0
Priapism	Yes	6	1.8
Gallstones	No	325	99.7
Gallstones	Yes	1	0.3
SCA disease severity	Mild	341	96.3
SCA disease severity	Moderate	12	3.7

Magnitude of depression among adolescents with SCA

Out of the 326 adolescents screened, 216 had depression, resulting in an overall prevalence rate of 54%. (Fig. 4). Depression was categorized as mild in 167 (38.7%) adolescents, moderate (moderate and moderately-severe) in 48 (14.7%) adolescents, and severe in 1(0.3%) adolescent (Fig. 5). Moreover, the study identified 49 adolescents (15%) with clinical depression, encompassing those in moderate, moderately-severe, and severe depression category.

3.4 Factors associated with clinical depression.

In the univariate and multivariable analysis, various factors including age, gender, education level, health insurance, use of hydroxyurea, hospital admission and blood transfusion showed no significant association with depression, p > 0.05. Those the multivariate analysis, those who experienced pwho experienced painful episodes in the previous 12 months had a significantly higher odds of depression compared to those who had no painful episodes, with a crude OR of 2.56(95% CI: 1.25–5.23, p = 0.01). After adjusting for other variables in the multivariate analysis, those who experienced painful episodes still exhibited higher odds of depression (adjusted OR = 2.49, 95% CI: 1.17–5.29, p = 0.01).

Table 5

Logistic regression factors associated with clinical depression
		Univariate analysis			Multivariable analysis
		cOR	95% CI	P-value	aOR	95% CI	P-value
Age(years)	10–14	ref
Age(years)	15–19	1.46	0.79–2.71	0.23	1.29	0.56–2.97	0.54
Gender	Male	ref
Gender	Female	1.34	0.73–2.48	0.34	1.35	0.70–2.58	0.37
Education level	No formal education	ref
	Primary	0.59	0.16–2.29	0.45	0.60	0.14–2.50	0.48
	Secondary	0.93	0.25–3.48	0.91	0.74	0.19–2.90	0.69
Health insurance	Non insured
Health insurance	Insured	1.41	0.73–2.75	0.31	1.47	0.72–3.02	0.29
SCA disease severity	Mild	ref
SCA disease severity	Moderate	0.58	0.07–4.44	0.56	0.35	0.04–3.39	0.36
Painful episodes	No	ref
Painful episodes	Yes	2.56	1.25–5.23	0.01	2.49	1.17–5.29	0.01
Hospital admission	No	ref
Hospital admission	Yes	1.30	0.69–2.42	0.42	1.14	0.53–2.43	0.73
Blood transfusion	No	ref
Blood transfusion	Yes	0.76	0.30–1.89	0.555	0.79	0.26–2.39	0.69
Use of hydroxyurea	No use
Use of hydroxyurea	Use	1.80	0.80–4.02	0.15	1.65	0.70–3.87	0.25

This study aimed to determine the magnitude and associated factors of depression; and to explore lived experiences among adolescents with SCA and depression. The overall prevalence of depression was seen to be quite high in our settings, more than half of the adolescents experienced depression mostly mild symptoms and only 15% were found to have clinical depression (moderate and severe depression).

This was similar to studies done in various continents which also demonstrated higher prevalence of depression among adolescents with SCA. Results revealed that 46% of adolescents with SCA had depression in America, 48% of adolescents attending sickle cell clinics also had depression in Saudi Arabia and in Congo 86% of adolescents were found to have depression.^8,12–13 Variations of prevalence estimates across different studies and between different countries could be attributed to differences in awareness of mental health and mental health seeking behavior which not so common in low income settings. Advancement in psychosocial care in high income settings lessens the burden of depression. Other minor variations could be due different diagnostic tools (PHQ-9, BDI, and DSM-V etc.), adopted classifications, and study methods used.

Mild depression was more common compared to moderate and severe depression this could mean that most adolescents suffer mild symptoms of depression which resolve however few progress to moderate and severe symptoms. This was similarly observed and reported by Aljumah et al (2016) in Saudi Arabia were the prevalence of mild, moderate and severe depression were 23.2%, 20.6%, and 6.8% respectfully; and another study by Sahril et al in Malaysia (2019) where prevalence of mild, moderate, and severe depression was found to be 16.6%, 12.8%, and 3.8% respectively. However, Lukoo et al (2015) reported mild, moderate and severe depression with prevalence of 14.3%, 77.1%, 8.6% respectively.^8,12,14 Depression severity has implications when it comes to choice of treatment and prognosis.

Socio-demographic factors like age, sex, level of education and health insurance, had no significant association with depression in this study. Contrary, studies by Alhamoud et al (2018) in Saudi Arabia and Mallicka et al (2021) in India reported that gender, low level of education and low socio-economic status were significantly associated with depression. ^15,16 Furthermore Asnani et al (2010), revealed that higher level of education was associated with higher odds of depression. The difference observed could be attributed to different cultural backgrounds and environmental settings of participants.¹⁷

Owing to SCA disease severity, participants in this study had mild to moderate disease severity; this could be attributed to the fact that participants were outpatients attending clinic and had no severe symptoms requiring admission. Mild to moderate disease severity had no significant association with depression. These findings were comparatively similar to a study done in Nigeria by Ezenwosu et al (2021), where disease severity in children and adolescents with SCA had no significant association with depression. A similar tool for assessing disease severity was used in this study.⁹

Painful episodes in the previous 12 month had 2.4 higher odds of depression with P value of 0.01. Similarly, a study by Asnani et al (2010), in Jamaica, showed that participants with frequent painful crises had 2.5 times higher odds of developing depression with a p-value of 0.003. ¹⁷ Another study by Ballah et al (2023), showed that among adolescent who had experienced crisis, more than half had mild to moderate depression. ¹⁸ Chronic or frequent painful episodes if not well controlled are associated with unusually high levels of stress hormone production which disrupts sleep patterns and affects mood, hence associated with development of anxiety and mood disorders.

Depression is common among adolescents with SCA in our setting with prevalence of 54%; where by mild, moderate and severe symptoms were found to be 38.7%, 14.7% and 0.3% respectively. Painful episodes experienced by these adolescents were significantly associated with depression. This study highlights the need for screening adolescents with SCA for depression as part of comprehensive care. Furthermore mental health services should be integrated in sickle cell clinics with the availability of a psychologist or counselor. Clinicians must prioritize effective prevention and comprehensive management of chronic pain or frequent painful episodes.

cOR - Crude Odds Ratio

aOR - Adjusted Odds Ratio

Hb - Hemoglobin

HbS - Sickled hemoglobin

HbAS - Heterozygous sickled hemoglobin

HbSS - Homozygous sickled hemoglobin

HPLC - High-Performance Liquid Chromatography

IDI - In Depth Interview

MUHAS- Muhimbili University of Health and Allied Sciences

MNH - Muhimbili National Hospital

RBC - Red Blood Cells

PHQ - Patient Health Questionnaire

RRH - Regional Referral Hospital

SCA - Sickle Cell Anemia

SCD - Sickle Cell Disease

SPSS - Statistical Package for Social Sciences.

SSS - Sickle cell anemia Severity Score

ACKNOWLEDGMENTS

Authors would like to appreciate parents/guardians and adolescents for their participation and members of staff-Sickle cell clinics at Muhimbili National Hospital, Temeke, and Amana Regional Referral Hospitals for their support during data collection.

ETHICAL APPROVAL

Ethical approval obtained from the Muhimbili University of Health and Allied sciences Ethical Board Committee MUHAS-REC-06-2023-1770. Permission letter for data collection were also obtained from each health facility. The data collected did not interfere with the routine care provided at the clinic. A clear informed consent and assent were sought and participants found to have moderate to severe depressive symptoms, were contacted and channeled to a clinical psychologists for further evaluation and therapy.

FUNDING

Research reported in this publication was supported by the National Heart, Lung, and Blood Institute (NHLBI) of the US National Institutes of Health (NIH) under Award Number U01 HL156853 (Sickle Pan-African Research Consortium—SPARCO Tanzania). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

DISCLOSURE

The authors report no conflicts of interest in this work.

WHO Fact Sheet.pdf. Accessed December 30, 2022. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health
Rathod S, Pinninti N, Irfan M, et al. Mental Health Service Provision in Low- and Middle-Income Countries. Heal Serv Insights. 2017;10. doi:10.1177/1178632917694350
Sedrak A, Kondamudi NP. Sickle Cell Disease. 2022 Aug 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan – . PMID: 29494006. Published online 2023:29494006.
Inusa BPD, Hsu LL, Kohli N, et al. Sickle cell disease—genetics, pathophysiology, clinical presentation and treatment. Int J Neonatal Screen. 2019;5(2). doi:10.3390/ijns5020020
Mangla A, Ehsan M, Agarwal N, et al. Sickle Cell Anemia. [Updated 2022 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482164/. Published online 2022:482164.
Makani J, Tluway F, Makubi A, et al. A ten year review of the sickle cell program in Muhimbili National Hospital, Tanzania. BMC Hematol. 2018;18(1):1-13. doi:10.1186/s12878-018-0125-0
Benton TD, Boyd R, Ifeagwu J, Feldtmose E, Smith-Whitley K. Psychiatric diagnosis in adolescents with sickle cell disease: A preliminary report. Curr Psychiatry Rep. 2011;13(2):111-115. doi:10.1007/s11920-011-0177-3
Lukoo RN, Ngiyulu RM, Mananga GL, et al. Depression in children suffering from sickle cell anemia. J Pediatr Hematol Oncol. 2015;37(1):20-24. doi:10.1097/MPH.0000000000000276
Ezenwosu O, Chukwu B, Ezenwosu I, et al. Clinical depression in children and adolescents with sickle cell anaemia: influencing factors in a resource-limited setting. BMC Pediatr. 2021;21(1):1-8. doi:10.1186/s12887-021-03015-1
Oudin Doglioni D, Chabasseur V, Barbot F, Galactéros F, Gay MC. Depression in adults with sickle cell disease: a systematic review of the methodological issues in assessing prevalence of depression. BMC Psychol. 2021;9(1):1-14. doi:10.1186/s40359-021-00543-4
Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): A diagnostic meta-analysis. J Gen Intern Med. 2007;22(11):1596-1602. doi:10.1007/s11606-007-0333-y
Aljumah Z, Ibrahim Ali S, Al-Saleem M, Almogarab K, Alghadeer F, AlEssa F. Depression in Sickle-Cell Disease patients in the Eastern Province. Int J Healthc Sci. 2015;3(February 2016):300-302. www.researchpublish.com
Jerrell JM, Tripathi A, McIntyre RS. Prevalence and treatment of depression in children and adolescents with sickle cell disease: A retrospective cohort study. Prim Care Companion J Clin Psychiatry. 2011;13(2):21977359. doi:10.4088/PCC.10m01063
Sahril NB, Yaacob NM, Ahmad NA, Abdullah S, Mahadir Naidu B, Aris T. Depression Severity and its Associated Factors among School-Going Adolescents in Malaysia. J Depress Anxiety. 2019;08(04):1-8. doi:10.35248/2167-1044.19.8.350
Alhomoud A, Gosadi IM, Wahbi HA. Depression among sickle cell anemia patients in the eastern province of Saudi Arabia. Saudi J Med Med Sci. 2018;(6):8-12. doi:10.5144/0256-4947.2018.130
Mallicka SC Das, Sahoe P, Priyadarshini P, Manasa R. Prevalence of Severe Depression among Adolescents in Rural Area of Odisha, India. Indian J Community Med. 2021;46(3):438–441. doi:https://doi.org/10.4103%2Fijcm.IJCM_570_20
Asnani MR, Fraser R, Lewis NA, Reid ME. Depression and loneliness in Jamaicans with sickle cell disease. BMC Psychiatry. 2010;10(1997). doi:10.1186/1471-244X-10-40
Balla Elnour SM, Hassan Salman F, Elmahdi Z. Depression in Adolescent Sickle Cell Patients - A 2021 Sudan Study. Am J Hum Psychol. 2023;1(1):50-55. doi:10.54536/ajhp.v1i1.2144

No competing interests reported.

Download PDF

Editorial decision: Revision requested
16 Jul, 2024
Editor assigned by journal
16 Jul, 2024
Submission checks completed at journal
12 Jul, 2024
First submitted to journal
05 Jul, 2024

You are reading this latest preprint version

Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study

Status:

Version 1

Abstract

Figures

BACKGROUND

METHODOLOGY

Study design and setting:

Study participants:

Sample size and selection

Data collection methods

Data collection tools:

Data analysis:

RESULTS

Participant’s socio-demographic characteristics

Participant’s Clinical profile

Magnitude of depression among adolescents with SCA

DISCUSSION

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1