Muhammad Nafees

Original Article Depressive disorder in the mothers of Thalassemia patients in Punjab, Pakistan Nazia Malik, Farhana Nosheen, Muhammad Nafees, Rizwan Ashraf, Manahil Jabbar Department of Sociology, Institute of Home Economics and Food Sciences, Government College University Faisalabad, Pakistan Objective: To investigate the depressive disorder in the mothers of Thalassemia Patients using Hamilton Depression Rating Scale (HDRS), and to suggest apposite policy initiatives. Methodology: This cross sectional correlational study was carried out in Thalassemia centers in the Punjab, Pakistan during November 2019 and 120 mothers were conveniently interviewed. The socio-economic status of the respondents was studied using a self-designed interview schedule and the depressive disorder was measured by using HDRS. The influence of various variables on the depressive disorder was analyzed through multiple liner regression analysis. Results: High scores of the respondents on HDRS were observed. Among 20.8% respondents, the depression was at very severe level, in 22.5% at severe level, in 28.3% at moderate level, and in the 25.0% it was mild. Only 3.3% respondents were normal. There was inability to concentrate on routine activities, impact of disease on economic status, poor behavior of the relatives, inability to attend social gatherings and the poor relationship with the husband were the outcomes of caregiving. Multiple linear regression analysis showed these were the major causes of depression among the respondents. Conclusion: There is high prevalence of depression among the mothers of thalassemia patients. There is need to initiate an effective policy to address the incidence of depression among this segment. (Rawal Med J 202;45:882885). Keywords: Depressive disorder, thalassemia, depression. INTRODUCTION Mothers of children with disabilities have significant part in support and care that such children require, hence at increased risks of 1 depression. Thalassemia is the most common form of inherited anemia globally.2 They need lifelong management that comprises of regular blood transfusion, use of several medicines and iron 3 chelation. Every year, more than 5,000 patients are born with thalassemia in Pakistan and thalassemia carrier rate is about 5-7%, with 9.8 million carriers 4,5 in the whole population. In Pakistan, around 2.7 million blood donations are gathered per annum, and about a fourth of them are consumed on thalassemia patients.6 Thalassemia patients in the developing countries are unable to avail standardized treatments.7 This chronic disease is associated with many difficulties not only for the patients but also for their families.8 The process of availing medical treatments of a family member, especially children results a significant psychological effect on the family.9 It creates problems for the caregivers to maintain their routine activities and going to the hospitals 10 with their children. Some researchers also found prevalence of psychiatric disorders among the parents, and specifically in mothers of children having chronic diseases.11 The identified factors of depression were frequent hospital visits, low life expectancy, expected complication due to disease and economic burden.12 A study reported that 60.6% caregivers of Thalassemia patients were depressed and there was no distinction in depression among 13 school and college educated caregivers. This study aimed to investigate the incidence of depressive disorder among the mothers of thalassemia Patients in Punjab, Pakistan. 882 METHODOLOGY This cross-sectional study was conducted on the Rawal Medical Journal: Vol. 45. No. 4, Oct.-Dec. 2020 Depressive disorder in the mothers of Thalassemia patients mothers of thalassemia patients in Punjab Pakistan in November 2019. Multistage sampling technique was used in this study. At first step, one thalassemia center in Punjab Province and registered with Thalassemia Federation of Pakistan was selected randomly. Then respondents were purposively taken from Ali Zaib Foundation, Faisalabad. Ethical approval for the study was obtained from the management of thalassemia centers. One hundred and twenty mothers of Thalassemia Major patients receiving blood transfusion and medical treatments for minimum of two years, were interviewed and the respondents were selected using non -probability purposive sampling technique. Three experts (one senior medical officer, the coordinator of thalassemia center and one sociologist) having broad experience of dealing with patients of Thalassemia, and research were consulted to assure the validity of interview schedule. The interview schedule was further modified in view of subsequent pilot study conducted on ten respondents. The degree of depression in the respondents was measured through Hamilton Depression Rating 14 Scale (HDRS). This is considered as one of the most frequently used measures of the severity of 15 depression in clinical practice and research. Socioeconomic status was measured through combining the occupation, income, and education to help expose discriminations about access to capitals, and issues regarding Power, privilege, and control.16 Statistical Analysis: Statistical analysis was performed using SPSS version 24. Data analysis was done by applying descriptive (Frequency Distribution) and inferential statistics (Gamma and Multiple linear regressions). 25.0 percent was mild. Only 3.3 percent respondents were normal. Table 1. Socio-economic characteristics of the respondents (N=120). Table 2. Scores on Hamilton Depression Rating Scale. RESULTS Table 1 shows the demographic characteristics of study populationThe depression was measured through HDRC which has been used in many key 17 studies of depression and its treatment. Table 2 illustrates that although the degree of depression is varying but the depression exists in most of the respondents. Depression among 28.3 percent respondents was moderate, in 22.5 percent was severe, among 20.8 percent was very severe, and in 883 Rawal Medical Journal: Vol. 45. No. 4, Oct.-Dec. 2020 Depressive disorder in the mothers of Thalassemia patients Table 3. Multiple Linear Regression Analysis. Analysis shows the standardized coefficient beta score of inability of the respondents to concentrate in routine activities (X1) is 0.216 which means that the depression of the 0.216 units of the respondents' nd depression is increased due to this variable. The 2 variable in the above table has 0.203 standardized coefficient beta score which narrates that the impact on economic status of the respondents due to the disease of their children enhances 0.203 units of their depression. Most of the respondents were downgraded by their relative due to the disease of their children. -0.244 score on X3explains the impact of 0.244 units of this behavior on the incidence of depression among the patients. The respondents more downgraded by their relative had high scores on HDRC. The variable (X 4 ) have 0.212 standardized coefficients beta as to table number 3 that shows that 0.212 units of depression in the respondents were increasing due to the inability to attend their social gatherings (Table 3). DISCUSSION Socio-economic characteristics shows that majority of the respondents were middle-aged housewives with least level of education and belonged to lower class. Some researchers suggest overcoming the prevalence of thalassemia there is dire need to launch educational and awareness programs especially the education of mothers is more 18 important than of fathers. The results obtained through HDRC shows that 71.6 percent respondents were the victims of "moderate depression" to "very severe level of depression" with minor differences of frequency in each 884 category and more importantly 20.8 percent respondents were the victim of "very severe depression". The results from previous studies also explored high rates of depression among parents especially mothers of such patients.19,20 These issues, during multiple linear regression analysis, were found to the significant factors of depression among the mothers of thalassemia major patients. Likewise, findings from a previous study that explored that the problems created due to the disease and hospitalization of children cause adverse impression on the whole family, while another study concluded that thalassemia had adverse impact on financial status of the families of the patients.21,22 Also due to the repetitive nature of the disease management, the mothers (respondents) are usually unable to attend social gatherings and parents of such patients face stress, depression, anxiety, low confidence and, they have poor relationships with the people around them.23,24 CONCLUSION The present study found high prevalence of depression among the mothers of thalassemia patients. Management of thalassemia need multifaceted attention which causes many problems to their caregivers (mothers) and hinder them to live a normal life. Author Contributions: Conception and Design: Muhammad Nafees Collection and Assembly of data: Manahil Jabbar Analysis and interpretation of data: Nazia Malik Drafting of the article: Muhammad Nafees Critical revision of the article for important intellectual content: Farhana Statistical Expertise: Nazia Malik, Rizwan Ashraf Final approval and guarantor of the article: Nazia Malik Corresponding author email: Nazia Malik:-Conflict of Interest: None declared Rec. Date: Mar 19, 2020 Revision Rec. Date: Jul 20, 2020 Accept Date: Nov 13, 2020 REFERENCES 1. 2. Sharghi A, Karbakhsh M, Nabaei B, Meysamie A, Farrokhi A. Depression in mothers of children with thalassemia or blood malignancies: a study from Iran. Epidemiol Ment Health. 2006;2:27-9. Habibzadeh F, Yadollahie M, Roshanipoor M, Haghshenas M. Reproductive behaviour of mothers of children with beta-thalassaemia major. East Mediterr Rawal Medical Journal: Vol. 45. No. 4, Oct.-Dec. 2020 Depressive disorder in the mothers of Thalassemia patients Health J. 2012;18:246-49. Zaman Q, Salahuddin M. Association between the Education and Thalassaemia: A Statistical Study. Pakistan J Stat Oper Res. 2006;2:103-7. 4. Ishaq F, Abid H, Kokab F, Akhtar A, Mahmood S. Awareness among parents of β-thalassemia major patients, regarding prenatal diagnosis and premarital screening. J Coll Physicians Surg Pak. 2012;22:218-21. 5. Ansari SH, Shamsi TS, Ashraf M, et al. Molecular epidemiology of β-thalassemia in Pakistan: far reaching implications. Int J Mol Epidemiol Genet. 2011;2:403-8. 6. Safe Blood Transfusion Programme. Annual Data C o l l e c t i o n R e p o r t 2 0 1 8 . Av a i l a b l e f r o m : https://www.sbtp.gov.pk/wp-content/uploads/2019/10/ National-Data-Collection-Report-2018.pdf. 7. Caocci G, Efficace F, Ciotti F, Roncarolo MG, Vacca A, Piras E, et al. Health related quality of life in Middle Eastern children with beta-thalassemia. BMC Blood Disord. 2012;12:6. 8. Loukopoulos D. Thalassemia: a dreadful disease turned to a chronic condition. Thalassemia Rep. 2013 Mar 26:e2-. 9. Ammad SA, Mubeen SM, Shah SF, Mansoor S. Parents' opinion of quality of life (QOL) in Pakistani thalassemia children. J Pak Med Assoc. 2011;61:470-3. 10. Barlow JH, Ellard DR. The psychosocial well-being of children with chronic disease, their parents and siblings: an overview of the research evidence base. Child Care Health Dev. 2006;32:19-31. 11. Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: an increasing global health problem. Bull World Health Organ. 2001;79:-. Hisam A, Khan NUS, Tariq NA, Irfan H, Arif B, Noor M. Perceived stress and monetary burden among thalassemia patients and their caregivers. Pak J Med Sci. 2018;34:901-6. 13. Inamdar S, Inamdar M, Gangrade A. Stress Level among Caregivers of Thalassemia Patients. Ntl J Community Med. 2015;6:579-82. 3. 885 14. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62. 15. Rohan KJ, Rough JN, Evans M, Ho SY, Meyerhoff J, Roberts LM, et al. A protocol for the Hamilton Rating Scale for Depression: item scoring rules, rater training, and outcome accuracy with data on its application in a clinical trial. J Affect Disord. 2016 ;200:111-8. 16. Socioeconomic Status [Internet]. https://www.apa.org. 2020. Available from: https://www.apa.org/topics/ socioeconomic-status/. 17. Wong LP, George E, Tan JA. A holistic approach to education programs in thalassemia for a multi-ethnic population: consideration of perspectives, attitudes, and perceived needs. J Community Genet. 2011;2:71-9. 18. Ghazanfari Z, Arab M, Forouzi M, Pouraboli B. Knowledge level and education needs of thalassemic children's parents of Kerman city. JCCN. 2010;3:3-4. 19. Ashrafizadeh H, Adineh M, Baraz Sh, Darvishi M. Depression and Anxiety among Parents of Children with Blood disease in Ahvaz, South West of Iran. Int J Pediatr. 2016;4:-. Shahraki ZE, Efffatpanah M, Gray S, Radfar M, Radfar S. A Comparative Study of Psychiatric Disorders among Mothers of Children with Chronic Diseases and Mothers of Healthy Children. J App Pharm Sci. 2017;7:-. Hockenberry MJ, Wilson D, Wong DL. Wong's essentials of pediatric nursing: Mosby Incorporated; 2012. 22. Sattari M, Sheykhi D, Nikanfar A, Pourfeizi A, Nazari M, Dolatkhah R, et al. The Financial and Social Impact of Thalassemia and Its Treatment in Iran. Phar Sci. 2012;18:171-6. 23. Telfer P, Constantinidou G, Andreou P, Christou S, Modell B, Angastiniotis M. Quality of life in thalassemia. Ann N Y Acad Sci. 2005;1054:-. Adineh M , Toulabi T, Pournia Y, Baraz Sh. The Effect of Family Presence during Pediatric Intensive Care Unit Bedside on Family General Health: Clinical Trial Study. Int J Pediatr. 2016;4:1809-17. Rawal Medical Journal: Vol. 45. No. 4, Oct.-Dec. 2020