Blood Advances in a Different Vein
High Rates of Depression Resulting in Higher Health-Care Costs in Patients With Sickle Cell Disease
Depression is approximately five times more prevalent in patients with sickle cell disease ( SCD ) than in the general population , and it is significantly associated with worse mental and physical health-related quality-of-life ( HRQoL ) outcomes , according to a study published in Blood Advances . Health-care use and inpatient costs were also higher in SCD patients with depression than in SCD patients without depression , leading to higher overall health-care expenditures , reported Soheir S . Adam , MD , of the Department of Medicine at Duke University in Durham , North Carolina , and co-authors .
The researchers conducted a prospective study evaluating the relationship between depression and clinical variables , HRQoL outcomes , and use of medical resources among adult patients with SCD receiving regular clinical care at the Duke Adult Comprehensive Sickle Cell Center between February and November 2009 .
Patients were excluded from the analysis if they had experienced vaso-occlusive crises ( VOC ) within the previous 30 days ; had an independent current diagnosis of psychosis , depression with psychosis , or a comorbid disorder with psychosis as a primary symptom ; were actively abusing alcohol or illegal drugs ; or had concurrent chronic systemic disease .
A total of 142 eligible patients ( mean age at enrollment = 34.2 ± 12.6 years ) completed all study-related testing , including the Beck Depression Inventory ( BDI ), the self-reported 36-Item Short Form Survey of QoL measures , and a computerized neurocognitive test . Study protocol also asked patients to keep a pain diary recording the time , location , severity , and types of management of painful episodes for one consecutive week each month . Information about use of medical resources and costs was collected for one year prior to study inclusion and during six months of follow-up .
SCD severity was assessed using a modified version of a previously validated chronic disease severity score , where 1 point is given for pulmonary dysfunction , avascular necrosis of the hip or shoulder , central nervous system abnormality , kidney dysfunction , or a history of leg ulcers , with 5 being the highest possible score and representing the most severe disease . Patients had the following disease severity :
• score 0 : 34 ( 24 %)
• score 1 : 54 ( 38 %)
• score 2 : 31 ( 21.8 %)
• score 3 : 16 ( 11.2 %)
• score 4 : 7 ( 5 %)
More than one-third of patients in the study ( n = 50 ; 35 %) had some degree of depression , including 37 ( 26 %) with clinical depression ( defined as a BDI score ≥14 ). The remaining 13 patients ( 9 %) had a BDI score < 14 but were actively receiving therapy for depression . Women were more likely to be depressed than men ( n = 26 / 81 and n = 12 / 59 , or 44.4 % and 20.3 %, respectively ; p = 0.004 ). Body mass index , age , and SCD genotype did not appear to be related to depression .
Most patients ( 87 %) reported an annual household income between $ 2,500 and $ 25,000 ; reported income did not differ between those with and without depression . Most patients ( 60 %) received disability benefits , and 25 percent reported being employed .
Hemoglobin ( p = 0.009 ) and male sex ( p = 0.004 ) were significantly associated with disease severity , but severity scores did not significantly differ between patients with and without depression ( 1.29 ± 1.08 vs . 1.46 ± 1.16 ; p = 0.72 ).
Female sex ( p < 0.001 ) and receipt of disability benefits ( p = 0.03 ) were significantly related to worse physical QoL outcomes , and female sex was also significantly associated with poorer mental QoL outcomes ( p < 0.001 ).
The researchers did not observe significant differences in neurocognitive function ( including memory , psychomotor speed , reaction time , complex attention , and cognitive flexibility ) among those with and without depression .
When looking at use of medical resources , the authors found that the mean number of hospitalizations was not statistically different between patients with and without depression , in either the 12-month period prior to enrollment ( 1.2 with depression vs . 0.6 without ; p = 0.06 ) or the six-month period following enrollment ( 0.6 vs . 0.4 ; p = 0.35 ).
However , overall health-care costs were significantly higher in patients with depression during both time periods :
• $ 30,665 for patients with depression vs . $ 13,016 for those without in the 12 months prior to depression assessment ( p = 0.01 )
• $ 13,766 vs . $ 8,670 in the six months after assessment ( p = 0.04 )
Both the total inpatient and overall costs were significantly higher for patients with depression , and the adjusted total average costs were 1.9 times higher for patients with than without depression ( 95 % CI 1.2-3.2 ; p = 0.01 ), the authors reported .
Inpatient costs were a substantial driver of costs , comprising 84 percent of total costs in the year prior to assessment and 74 percent in the six months after assessment in patients with depression ; in patients without depression , however , inpatient costs stayed the same , at 58 percent during both time periods .
“ Mental health is an integral part of the comprehensive management of this patient population . Our results highlight an important but inadequately studied aspect of SCD ,” the authors concluded . “ Additional efforts should be exerted for prevention , early diagnosis , and therapeutic intervention to reduce the impact of depression on [ patients with ] SCD and improve HRQoL outcomes .”
The study is limited by its single-center design . Also , because the researchers enrolled only patients from the clinic , this patient population was more likely to be compliant with clinic visits and have less severe disease , compared with patients who are admitted through the emergency department or day hospital . The trial excluded patients with VOC , which may decrease the generalizability of these outcomes . In addition , the study was unable to ascertain the time of depression , precluding distinction between hospitalizations and events associated with preexisting depression . ●
The authors report no financial conflicts .
REFERENCE
Adam SS , Flahiff CM , Kamble S , et al . Depression , quality of life , and medical resource utilization in sickle cell disease . Blood Advances . 2017 October 24 .
64 ASH Clinical News December 2017