Pa ge 1 Pa ge 50 American Journal of Human Psychology (AJHP) Depression in Adolescent Sickle Cell Patients: A 2021 Sudan Study Fatima Hassan Salman1, Ziryab Elmahdi1, Sahar Moawia Balla Elnour2* Volume 1 Issue 1, Year 2023 ISSN: 2994-8878 (Online) DOI: https://doi.org/10.54536/ajhp.v1i1.2144 https://journals.e-palli.com/home/index.php/ajhp Article Information ABSTRACT Received: September 25, 2023 Accepted: October 28, 2023 Published: November 03, 2023 The global mental health crisis, particularly depression, is escalating due to genetic mutations affecting the sixth amino acid, glutamic acid. This cross-sectional study aimed to investigate depression among adolescents with SCA using the Beck Depression Inventory (BDI) between February 2021 and August 2021. This hospital-based cross-sectional study was conducted in Khartoum, Sudan. The study involved 102 SCA patients aged 10-19, with a majority (63.7%) aged 13-16. Depression severity was diagnosed using the Beck Depression Inventory (BDI), and statistical analysis involved chi-square tests to compare proportions between groups, with a significance level of p<0.05 and 95% confidence level. The study found that most males (38.5%) had none-mild depression, while most females (42.0%) had mild-moderate depression with a p-value of 0.310. Age groups showed the highest prevalence of mild-to-moderate depression (46.2%) in 10-12-year-olds and the most mild depression (33.3%) in 17-19-year-olds. Crisis frequency was infrequent among participants (p=0.933). A significant association was observed between crisis frequency and depression severity, with severe depression primarily seen in crisis-prone individuals (27.8%) (p=0.001). The study highlights the global mental illness burden and challenges faced by individuals with SCA, particularly females, emphasizing the need for early psychological support and intervention to improve their well-being. Keywords Adolescent, Depression, Sickle Cell Anaemia, Sickle Cell Disease, Sudan 1 Sheikh Khalifa Medical City, Al Karamah St. Al Manhal, Al Tibbiya, Abu Dhabi, United Arab Emirates 2 Sudan Medical Specialization Board, Al Khurtum, Sudan * Corresponding author’s e-mail: dr.saharmoawia@gmail.com INTRODUCTION The worldwide prevalence of mental health issues is increasing, with depression emerging as a significant global public health concern. According to Alatab et al., 2020, approximately 264 million individuals are affected by depression, and its prevalence and incidence continue to escalate (Alatab et al., 2020; Ferrari et al., 2013; Fu et al., 2013). The disorder is considered a financial liability and affects the struggling healthcare systems (Murray et al., 2012). Additionally, vascular blockage and anaemia are characteristics of Sickle cell anaemia (SCA), an inherited disorder caused by mutations that cause the sixth amino acid to be replaced by valine instead of glutamic acid (Zorca et al., 2010). Haemoglobin S and haemoglobin C are the predominant haemoglobin variants found in Africa (Chakravorty & Williams, 2015). A decade ago, approximately 80% of infants in sub-Suharan Africa had SCA, but according to Oppong et al. 2020 projections, this percentage is expected to rise by 10% by the year 2050 (Oppong et al., 2020). The sickle-shaped red blood cells are responsible for obstructing small capillaries and pathways when exposed to low oxygen levels, as demonstrated by Makani et al. in 2013 and Ngwengi et al. in 2020 (Makani et al., 2013; Ngwengi et al., 2020). Conversely, Osteomyelitis and acute chest syndrome are the complications that SCA patients encounter every day (Chakravorty & Williams, 2015). Those with a genetic tendency have a shorter life expectancy as a result of morbidities such as respiratory, renal, and cardiac failure and stroke. There are several contributing factors to this reduced life expectancy (Chakravorty & Williams, 2015; Lanzkron et al., 2013). In developed countries, the life expectancy of individuals with SCA typically ranges from 40 to 60 years. However, in economically disadvantaged nations like Sudan, the life expectancy for SCA patients is significantly lower (Hamideh & Alvarez, 2013; Piel et al., 2013). Additionally, around 30% of individuals with SCA experience persistent chronic pain, which is defined as enduring for more than three months (Smith et al., 2008). Numerous studies have shown a strong correlation between chronic pain and mental health issues, including depression (Arnow et al., 2006; Currie & Wang, 2004; Ohayon & Schatzberg, 2003). Notably, depression was more prevalent among SCA patients compared to the general population (Comer, 2004; Jenerette et al., 2005). Furthermore, there is a notable association between depression in SCA patients and increased hospitalizations for vaso-occlusive pain, frequent emergency room visits, and the need for blood transfusions (Hasan et al., 2003). Additionally, depression may contribute to the development of further medical complications (Leavell & Ford, 1983). Therefore, the objective of this study was to investigate the prevalence and impact of depression among adolescents with sickle cell anemia in Sudan. The study on depression among adolescents with Sickle Cell Anemia offers unique insights into the mental health of this population. It focuses on the adolescent population, revealing varying depression severity across age groups, gender differences, and a significant association between vaso-occlusive crises and depression severity. The research recommends routine screenings, a holistic approach, and stigma reduction to improve the quality of life for SCA patients. Pa ge 51 https://journals.e-palli.com/home/index.php/ajhp Am. J. Hum. Psychol. 1(1) 50-55, 2023 MATERIALS AND METHODS A cross-sectional survey was conducted in hospitals located within the state of Khartoum, Sudan, from February 2021 to August 2021. This survey focused on individuals diagnosed with SCA who fell within the age range of 10 to 19 and attended referral clinics along with a parent or guardian. The selection of participants was based on a modified version of the Cochran Formula, specifically adapted for small populations. In total, 102 patients diagnosed with SCA were included in the study. Data collection involved patients completing a pre-coded questionnaire through direct interviews conducted in an outpatient clinic. The questionnaire encompassed various aspects, including socio-demographic information, an assessment of depression severity, and an evaluation of the frequency of crises. Diagnosing Depression with the Black Depression Inventory (BDI) For the diagnosis of depression among participants, the BDI was employed. The BDI assigns scores that indicate different levels of depression severity, as follows (Beck et al., 1961). • Scores from 0 to 9: Minimal depression • Scores from 10 to 18: Mild to moderate depression • Scores from 19 to 29: Moderate to severe depression • Scores from 30 to 63: Severe depression Data Analysis In this study, data collection, validation, and analysis were conducted using the statistical software tool (SPSS version 25). The study involved the generation of frequency distributions for both independent and dependent variables that were pertinent to the study objectives. The chi-square test compared the proportions between the two groups. Moreover, a confidence level of 95% was utilized, and a P-value of 0.05 was considered statistically significant. RESULTS The study included 102 participants who were diagnosed with SCA and ranged in age from 10 to 19 years. Among the participants, males were 51%, and females were 49%. The age distribution was 10 to 12 years (12.7%), 13 to 16 years (63.7%), and 17 to 19 years (23.5%). Additionally, the majority of the participants experienced mild to moderate depression (38.2%). Specifically (37.3%) demonstrated no to mild symptoms of depression. Subsequently, an additional (17.6%) of participants exhibited moderate to severe depression. In contrast, (6.9%) of participants showed symptoms of severe depression, as shown in Figure 1. Figure 1: Severity of depression Furthermore, an examination of the relationship between depression severity and gender revealed that there was no statistically significant association (p = 0.310). Among males, the majority experienced none to mild depression (38.5%), followed closely by those with mild to moderate depression (34.6%), while (23.1%) exhibited moderate to severe depression, and only (3.8%) had severe depression. A similar distribution was observed among females, with the highest percentage experiencing mild to moderate depression (42.0%), followed by none to mild depression (36.0%), (13.8%) experiencing moderate to severe depression, and (10%) exhibiting severe depression, as shown in Table 1. However, analysing the connection between depression severity and age groups indicated no statistically significant association (p =0.583). Among the 10-12 years age group, mild to moderate depression was the most prevalent, Table 1: Demographic distribution vs. Severity of depression Gender Severity of depression None-mild Mild-moderate Moderate- severe Severe p. Value Male 38.5% 34.6% 23.1% 3.8% 0.310 Female 36.0% 42.0% 12.0% 10.0% Age groups 10-12 yo 30.8% 46.2% 23.1% 0 0.583 13-16 yo 40.0% 40.0% 13.8% 6.2% 17-19 yo 33.3% 29.2% 25.0% 12.5% affecting (46.2%0 of participants. In the 13-16 years age group, none to mild and mild to moderate depression were (40.0%) equally prevalent. Moreover, among the 17- 19 years age group, mild to no depression was the most frequently observed, affecting (3.3%) of the participants. The frequency of crisis was distributed as follows: rarely (41.2%), sometimes (20.6%), often (18.6%), always (17.6%) and never (2%), as shown in Figure 2. Pa ge 52 https://journals.e-palli.com/home/index.php/ajhp Am. J. Hum. Psychol. 1(1) 50-55, 2023 experiencing crises, with percentages of (53.8%) for the 10-12 years age group, (40.0%) for the 13-16 years, and (37.5%) for the 17-19 years as shown in Table 2. Consequently, there was a statistically significant association observed between the frequency of crises and depression severity (p = 0.001). The following breakdown describes the distribution of depression severity among participants based on the frequency of crises: Among participants who never experienced a crisis, 50% had none to mild depression, while the other half had mild to moderate depression. Those who rarely experienced crises predominantly had none to mild depression (42.9%), followed by mild to moderate depression (47.6%), with a smaller percentage experiencing moderate to severe depression (9.5%). Among participants who sometimes experienced crises, the majority had mild to moderate depression (61.9%0, while the remaining had none to mild depression (38.1%). Approximately half of the participants who often had crises experienced mild to moderate depression (52.6%0, followed by moderate to severe depression (31.6%), and some experienced none to mild depression (15.8%). For participants who always had crises, the distribution of depression severity was as follows: none to mild depression (11.1%), mild to moderate depression (16.7%), moderate to severe depression (44.4%), and severe depression (27.8%), as shown in Figure 3. Figure 2: Frequency of crisis Table 2: Demographic distribution vs. Frequency of crisis Gender Frequency of crisis Never Rarely Sometimes Often Always p. Value Male 1.9% 38.5% 21.2% 17.3% 21.2% 0.903 Female 2.0% 44.0% 20.0% 20.0% 14.0% Age 10-12 yo 0 53.8% 15.4% 15.4% 15.4% 0.933 13-16 yo 1.5% 40.0% 21.5% 16.9% 20.0% 17-19 yo 4.2% 37.5% 20.8% 25.5% 12.5% In addition, the analysis of the relationship between the frequency of crises and gender revealed that there was no statistically significant association (p = 0.903). A significant proportion of males and females reported rarely experiencing crises, with percentages of (38.5%) and (44.0%), respectively. Similarly, the association between the frequency of crises and age groups showed no statistical significance (p = 0.933). The majority of participants among all age groups reported rarely Figure 3: Frequency of crisis vs. Depression severity DISCUSSION Patients with SCA are challenged with substantial stress due to their disease and its management. Although many environmental stressors could cause depressive symptoms not related to SCA. However, this study aimed to investigate depression among patients between the ages Pa ge 53 https://journals.e-palli.com/home/index.php/ajhp Am. J. Hum. Psychol. 1(1) 50-55, 2023 of 10 and 19 with sickle cell anaemia patients in Sudan. Most participants in the current study had mild-moderate depression (38.2%), followed closely by those who had no-mild depression (37.3%). Almost half the participants rarely had a crisis (41.2%). In this study, the severity of depression in association with gender (p=0.310) and age (p=0.583) showed a significant statistical association. While males and females were mostly on the lower scale of BDI, more females had severe depression in comparison to males. These findings are in line with a previous study where (44.4%) of the females had depression, and (20.3%) of males had depression (P = .0038) (Adam et al., 2017). In this study, by observing the incidence of severe depression, it was evaluated that depression increases as age increases, and it was not present in the age group 10-12 years. Previous studies on adolescents report more depressive symptoms than younger children because of the stressors they experience (Barakat et al., 2006; Jiya et al.). However, other studies have stated that there is no association between age and the prevalence of depression in SCA patients (Alhomoud et al., 2018; Ali et al., 2017; Graves et al., 2016; Sehlo & Kamfar, 2015). Furthermore, in this study frequency of crisis in association with gender (p=0.903) and age (p=0.933) showed a significant statistical association where the majority of participants had rarely experienced a crisis. Patients with SCD who also suffered from depression were shown to have a likelihood that was 2.8 times higher of being hospitalized due to a crisis than patients who did not suffer from the disease (Jonassaint et al., 2016). As a result of this observation, it was examined that there exists an inverse relationship between the two variables. Consequently, there was a statistically significant correlation between the number of crises experienced and the degree of depression (p = 0.001). The severity of depression was mild to moderate, with the exception of patients who occasionally experienced a crisis. Numerous studies have indicated that psychosocial factors play a significant role in contributing to negative medical outcomes. These outcomes encompass an elevated occurrence, longer duration, and increased intensity of painful episodes, along with adverse psychosocial consequences among individuals diagnosed with SCA (Belgrave & Molock, 1991; Gil et al., 1989; Molock & Belgrave, 1994). Individuals who experienced a greater number of traumatic experiences exhibited an elevated susceptibility to acquiring depression. Moreover, those who encountered traumatic events with higher frequency displayed an increased vulnerability to developing severe depression in comparison to individuals who experienced less traumatic events. According to (Asnani et al., 2010; Hasan et al., 2003; Levenson et al., 2008), vaso-occlusive crises are the major cause of pain, substantial morbidity, and frequent hospitalization in SCA patients. This observation suggests a deterioration of the illness and an escalation of its associated burden. Failure to address physical discomfort and other important conditions might result in severe morbidity and perhaps fatal outcomes (Novelli & Gladwin, 2016; Simon et al., 2016). CONCLUSION In conclusion, this study found a significant difference in depression prevalence between males and females, with females exhibiting a greater susceptibility to this mental health condition. Furthermore, the study findings indicated a tendency for the severity of depression to increase in patients diagnosed with sickle cell anemia as both their age and the number of crisis episodes increased. The study on depression among adolescents with Sickle Cell Anemia in Sudan provides valuable insights into the mental health challenges faced by this population. It highlights the importance of early detection, comprehensive assessments, and psychosocial support programs. The findings have implications for healthcare policies and public health awareness, contributing to a broader effort to destigmatize mental health issues. LIMITATIONS AND STRENGTHS • The sample size of 102 participants may limit the generalizability of the findings. • However, the study focuses on adolescents with SCA, a demographic with unique mental health challenges. The Beck Depression Inventory (BDI) is used for diagnosing depression, enhancing its reliability and validity. RECOMMENDATIONS • Healthcare providers should include routine depression screenings in their standard care protocol for individuals with Sickle Cell Anemia (SCA) to ensure timely intervention and support. • Comprehensive mental health assessments, including anxiety and stress, should be conducted to identify co- occurring mental health conditions. • Future research should focus on longitudinal studies to explore additional risk factors. Quality-of-life assessments should identify areas needing targeted interventions. • Psychosocial support programs, patient education, multidisciplinary care teams, crisis management strategies, and public health campaigns should be launched to reduce the stigma surrounding mental health issues in SCA patients. Future Research Directions Future research should address gaps and build upon current findings. Future research directions include longitudinal studies, qualitative research, treatment effects, health-related quality of life, cultural and societal factors, intervention studies, comparison studies, diverse samples, telehealth integration, family and caregiver perspectives, and resilience and coping strategies. These efforts can contribute to a more comprehensive understanding of depression in SCA patients and develop targeted interventions for improved mental health. REFERENCES Adam, S. S., Flahiff, C. M., Kamble, S., Telen, M. J., Reed, S. D., & De Castro, L. M. (2017). 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