Anxiety and Depression in Children And

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Anxiety and Depression in Children andAdolescents with Sickle Cell Disease

Tami D. Benton, MD, Judith A. Ifeagwu, MD,and Kim Smith-Whitley, MD

Corresponding authorTami D. Benton, MDDepartment of Child and Adolescent Psychiatry,Childrens Hospital of Philadelphia, 3440 Market Street,Suite 200, Philadelphia, PA 19104, USA.E-mail: bentont@ email.chop.edu

Current Psychiatry Reports 2007, 9:114121Current Medicine Group LLC ISSN 1523-3812Copyright 2007 by Current Medicine Group LLC

A growing body of evidence suggests that depres-

sive disorders and anxiety disorders are much more

prevalent among medically ill children and adoles-

cents when compared with the general population,

and that the presence of comorbidity may adversely

affect medical outcomes and quality of life. Whereas

the prevalence and impact of anxiety and depressive

disorders have been described in chronic conditions

such as asthma, diabetes, and epilepsy, much less is

known about sickle cell disease (SCD), a disorder thataffects more than 70,000 Americans, primarily those

of African and Mediterranean descent. A hallmark of

this disorder is recurrent, acute, and chronic pain that

often requires emergency management and hospitaliza-

tion. Medical advances in the treatment of this illness

have transformed SCD from a condition associated with

very early morbidity and mortality into a chronic con-

dition of adulthood. This article reviews the evidence

describing our knowledge of anxiety and depression in

children and adolescents with SCD, its clinical impact,

and effectiveness of interventions.

IntroductionA large body o evidence has demonstrated the negative

impact o depressive disorders on the outcomes o many

medical conditions, such as heart disease [13], cancer,

neurologic disorders, and HIV/AIDS, in adult populations

[4]. A growing body o evidence also points to a bidirec-

tional relationship between depression and medical illness,

suggesting that depression may be both a cause and a con-

sequence o some medical illnesses, such as cardiovascular

disease, HIV/AIDS, cancer, epilepsy, and stroke [4].

Relatively less is known about the prevalence and impact

o anxiety and depressive disorders, two highly comorbid

conditions, on children and adolescents with chronic ill-

nesses. Whereas the evidence suggests that adolescents

with chronic illness have rates o mental health disorders

three to our times higher than those o their healthy peers,

other studies suggest that the vast majority cope well withtheir illnesses [5]. Prevalence estimates o children and

adolescents with chronic illness vary, ranging rom 17% in

community samples to 33% in clinical samples [6,7,8].

The prevalence o anxiety and depressive disorders

has been described in some specifc diagnostic groups in

children and adolescents (Table 1), whereas much less is

known about other medical conditions that are prevalent

among children and adolescents.

Sickle cell disease (SCD), the most common genetic

hemoglobin disorder, aects more than 70,000 Ameri-

cans, primarily those o Arican and Mediterranean

descent. Characterized by chronic hemolytic anemia,

vasoocclusive complications, and an increased risk orinection, SCD is associated with a liespan shortened

by up to 30 years in aected individuals [9]. However,

medical advances in the last 3 decades have supported

the success o comprehensive care programs and have

provided a realistic expectation or increased survivability

and improved quality o lie or patients with SCD.

SCD, a group o hemoglobin syndromes in which

sickle hemoglobin predominates, results when a gene or

sickle hemoglobin is inherited in an autosomal recessive

pattern or in a compound heterozygous state with another

beta globin gene variant such as hemoglobin C or beta

thalassemia. One in 375 Arican-American newborns

has SCD, and one in 12 Arican-Americans has the sicklecell trait. The most common genotype, the SS type (SCD-

SS), occurs in approximately 65% o aected patients,

ollowed by SCD-SC (25%), SCD-Sb+thalassemia (8%),

SCD-Sb0thalassemia (2%), and a very small percentage o

patients with other genotypes. Classically, patients with

SCD-SS and SCD-Sb0thalassemia are at greater risk or

severe complications when compared with those with the

SCD-SC and SCD-Sb+thalassemia. However, the vari-

ability o complications within and between patients with

various types o SCD is high [10].


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Anxiety and Depression in Children and Adolescents with SCD Benton et al. 115

Historically, the pathophysiologic mechanisms

underlying SCD have included solely intracellular poly-

merization o sickle hemoglobin, increased endothelial

adhesion, and subsequent vascular occlusion. Chronic

inammation, erythrocyte hydration, and vasoactive

cytokines are prominent pathophysiologic eatures, and

pharmacologic therapies to address these mechanisms

directly are being developed. Recently, chronic hemolysis

and impaired nitric oxide metabolism have been shown

to contribute to the pathophysiology o pulmonary hyper-

tension, priapism, and leg ulcers.Nationwide newborn screening programs or SCD,

established in many states starting in 1992, have acili-

tated the identifcation o newborns with SCD and the

initiation o inection prophylaxis by age 2 months. His-

torically, many young children died rom overwhelming

bacterial inections, but presently, 93.6% o individuals

with SCD survive to age 18 years when only SCD-related

complications are considered [11], primarily due to inec-

tion prophylaxis and comprehensive care.

Pain, the hallmark eature o SCD, occurs in acute and

chronic orms. The more common acute pain syndromes

are largely unpredictable but may be associated with trig-

gers such as extreme temperatures, strenuous exercise,stress, inection, and dehydration. Although pain man-

agement is the most common reason or hospitalization,

many patients manage painul episodes at home with oral

analgesics and nonpharmacologic methods employing

heat and rest. Hydroxyurea therapy, as demonstrated in

a 1995 hallmark study, reduces the rate o acute painul

episodes in patients with SCD-SS [12]. This is the frst

eective pharmacologic intervention directed at improv-

ing SCD-related complications by altering known biologic

properties specifc to SCD. However, no disease-specifc

therapies have demonstrated signifcant eectiveness in

reducing acute pain or chronic pain in large populations

o patients with SCD.Neurologic complications, common in patients with

SCD-SS, are associated with cognitive and motor dys-

unction. Stroke, a potentially devastating complication,

occurs in 10% to 15% o patients with SCD-SS. Once a

stroke has occurred, chronic transusion therapy can lower

recurrent stroke risk. Recently, transcranial Doppler ultra-

sound screening has been shown to identiy children with

SCD-SS at high risk or stroke [13]. Chronic transusion

therapy using a goal hemoglobin S o less than 30% can

reduce stroke risk by 92% in this patient population [14].

Cerebral inarction aecting nonmotor areas o the brain

is classifed as silent inarction. However, neurocogni-

tive defcits are high in aected patients. Researchers are

currently investigating whether chronic transusions can

prevent progression o silent inarction and decrease

the progression o neurocognitive dysunction.

Pulmonary complications, requently observed in

patients with SCD, are the most common cause o death in

adults with SCD. Acute chest syndrome, a pneumonia-like

illness caused by inection; inarction; and bone marrow

emboli can be rapidly progressive and result in pulmonaryailure [15]. Acute management includes antibiotics and

supportive care, but the use o blood transusions early in

the course may improve associated morbidity and mortal-

ity. Pulmonary hypertension, occurring in 33% o adult

patients with SCD-SS, is associated with an increased

risk o death [16]. Present management includes sildenafl

and supportive care, although clinical research with other

interventions is underway [17].

Medical therapies such as chronic transusion pro-

grams and hydroxyurea therapy have decreased the rate

o acute painul events and acute chest syndrome. More

importantly, hydroxyurea reduces SCD-related mortality

in patients with SCD-SS overall [18]. However, the needor requent side eect monitoring and concern regarding

long-term complications are potential barriers to the wide-

spread use o these therapies. Although allogenic stem cell

transplantation oten results in a cure, availability o an

HLA-identical sibling without SCD; acute toxicities; and

long-term complications such as grat ailure, endocrine

abnormalities, and grat-versus-host disease limit its use.

As survivability continues to improve, research eorts will

be directed toward reducing the toxicity and complication

profle o present interventions, identiying new eective

therapies, preventing chronic organ damage, and improv-

ing the quality o lie o patients with SCD.

Although these medical advances have optimized out-comes or individuals with SCD, children and adolescents

with this illness continue to ace many challenges related to

their illness. Because adolescents with SCD may be smaller

than their healthy peers in the early phases o puberty, they

may experience heightened sel-consciousness and dissat-

isaction with their body images [19]. Fatigue may reduce

participation in sports, urther increasing social isola-

tion and decreasing sel-esteem. Cognitive defcits related

to neurologic complications o the illness may impact

academic perormance and perceived competence, and

Table 1. Prevalence of anxiety and depressive disorders in some specific diagnostic groupsin children and adolescents

Medical diagnosis

Asthma Epilepsy Diabetes

Prevalence of depression,% 2030 [ 48] 2030 [6] 26 [49,50]

Prevalence of anxiety,%

24.7 33 20


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116 Child and Adolescent Disorders

recurrent painul crisis with missed school days or hospi-

talizations can cause academic and social disruptions. An

adolescents experience o these limitations can contributeto pessimism, hopelessness, and social withdrawal [19,20].

Depression and anxiety in SCDCurrent evidence suggests that psychiatric difculties

are signifcant among adults with SCD (Table 2). One o

the frst studies examining depression and SCD, a case

series describing three patients with SCD and depres-

sion, suggested that depression occurs more requently

than expected. These individuals were treated with elavil,

150 mg, and both pain and depression were responsive to

antidepressant treatment [21]. Expanding upon this work,

Belgrave and Molock [22] used a convenience sample

to assess patients or coping with illness and depressionusing the Beck Depression Inventory (BDI). In this sample

o 46 adult patients with SCD, the investigators identifed

56.5% o the sample as being mildly to severely depressed

using the BDI.

In a larger study o 109 adults with SCD, Thompson

et al. [23] examined the presence o depression and other

psychological problems. A total o 56% o the sample

met criteria or poor psychological adjustment, with 40%

meeting criteria or depression.

Wilson Schaeer et al. [24] assessed 440 individuals

with SCD using the Centers or Epidemiologic Studies

Depression Scale during their yearly outpatient routine

clinic visits. The authors ound that 18% o the individu-als interviewed exhibited signifcant levels o depression

using stringent cuto scores. This study reported rates

much lower than prior studies but still signifcantly higher

than those o the general population

In a more recent study, Hasan et al. [25] assessed the

prevalence o depressive symptoms in a population o 27

men and 23 women with SCD. Using the BDI to assess

or depressive symptom severity in a convenience sample

o patients presenting to an outpatient SCD clinic, these

investigators ound that 44% o their sample scored within

the mild to severe range o depression on the BDI, again

suggesting that the prevalence o depressive symptoms in

individuals with SCD is higher than the prevalence o those

symptoms in the general Arican-American population.

Children and AdolescentsStudies o children and adolescents with SCD have

reported adjustment problems. These problems have

included poor sel concept; social adjustment problems;

behavior problems; and symptoms o depression, anxiety,

and pica. Those studies suggest that adjustment problems

seem to increase with age, and boys demonstrate more

problems than girls. The severity o illness appears to

have less impact than gender and age [26].

Most o the data regarding prevalence o anxiety

and depression in SCD have been derived rom psycho-

social studies examining these symptoms in the context

o broader psychosocial issues such as mediators o cop-

ing and adjustment to illness. Depression and anxiety aspredisposing, precipitating, or perpetuating actors in the

course o SCD have been investigated in a limited number

o studies and have not been well described in children

and adolescents.

Studies specifcally examining the prevalence o

anxiety and depressive disorders in children and adoles-

cents have been contradictory. In one o the frst studies

examining SCD in adolescent patients, Kumar et al. [27]

compared 29 adolescents with SCD with a school-based

sample o peers without SCD using standardized,

validated instruments. These investigators ound the ado-

lescents with SCD to be less anxious than the comparison

group, to exhibit more withdrawn behaviors, and to havea poorer sel concept, but not to exhibit any more adjust-

ment difculties than peers. In a ollow-up to this study,

Morgan and Jackson [19] studied 24 adolescents with

SCD and their mothers with a matched comparison group

o adolescents without SCD and their mothers to deter-

mine whether adolescents with SCD exhibited less body

satisaction, more symptoms o depression, and greater

social withdrawal than healthy peers. Using the Childrens

Depression Inventory (CDI) and subscales o the Child

Behavior Checklist (CBCL), these authors reported higher

scores on the CDI and subscales o the CBCL, suggesting

higher rates o depression and social withdrawal and less

body satisaction than healthy peers and supporting theearlier fndings.

Lemanek et al. [ 28], studying psychological adjust-

ment in children with SCD, compared 30 children with

SCD and 30 healthy controls matched or age, sex, socio-

economic status, and IQ. They ound that the children

with SCD did not have signifcantly greater psychological

maladjustment when compared with healthy peers. How-

ever, when the SCD group was compared with national

norms, they were noted to have more behavior problems

at home and in school. However, the behavior difculties

Table 2. Estimated prevalence rates of depressionamong adults and adolescents

StudyPrevalence rate,

%

Hasan et al. (adults) [25] 44 (mild-severe);26 (severe)

Wilson Schaeffer et al. (adults) [24] 43.4Hilton et al. (adults) [51] 29

Grant et al. [52] 25.6

Belgrave and Molock (adolescents) [22] 56.5(mild-severe)

Yang et al. (adolescents) [34] 29

Barbarin et al. (adolescents) [31] 25 (adjustmentproblems)


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in both groups were higher than norms, suggesting that

the psychological difculties were perhaps related to envi-

ronmental actors and not the SCD.

In a more recent cross-sectional study o 50 children

with SCD aged 7 to 12 years, 64% were ound to have

mother-reported behavior problems, and 50% met DSM

IIIcriteria or a psychiatric disorder. Internalizing behav-

ior problems by mother report and anxiety diagnosis by

child report were most common [29].

Lee et al. [30] compared 14 children with SCD with

14 nondiseased siblings using the Depression Sel Rating

Scale. In this study, children with SCD scored lower on

measures o perceived physical competence, whereas their

nondiseased siblings had higher depression scores. The

authors hypothesized that the shit in dynamics o the am-

ily, requiring more attention to be paid to the sick child,

might contribute to this fnding o elevated depression

scores in siblings. Although this small sample size might

limit generalizability, it highlights the importance o pro-

viding support to the amilies o children with SCD.Barbarin et al. [ 31] attempted to estimate the preva-

lence o psychosocial problems in children with SCD. In

a sample o 327 parents and children rom a comprehen-

sive sickle cell center, participants completed a structured

interview during their annual medical visit. Parents were

interviewed using a psychosocial interview covering illness,

social, academic, psychological, and amily adjustment

domains. Frequencies o difculties in each domain were

assessed or the child and amily. The authors also divided

the study groups by age: 4 to 7 years, 8 to 13 years, and 14

to 17 years. The authors were able to look at gender dier-

ences as well. Overall, they ound signifcant problems in

social relationships, isolation, and shyness and signifcantacademic problems, with school ailure rate or boys being

twice as high as that ound or a national sample o Ari-

can-American children matched or income. Adolescents

were more likely to ail classes than the younger children.

The younger children who reported more requent painul

episodes were more likely to be overprotected by parents

and older siblings and more prone to anger, hopelessness,

depression, and shame. The parents o children with more

requent pain also were more earul and worried than

the parents o children who were pain ree. Girls who

experienced more requent pain were ound to be more

overprotected, with siblings who were ound to be more

earul than the other group.Using an innovative approach, Trzepacz et al. [32]

examined psychosocial adjustment o children with SCD

and a group o demographically matched comparison

peers. They did so rom the perspectives o their parents/

caregivers using a measure with validated psychometric

properties in Arican-American children. Home visits were

used to complete evaluations to minimize the inuence o

the clinical setting and to optimize caregiver participation,

with a total sample size o 70 caregivers and 67 compari-

son peers. Using the CBCL to interview the caregivers, the

authors ound slightly elevated concerns or children with

SCD compared with comparison peers but no dierences

in internalizing symptoms between the groups. However,

the scores or both groups were elevated compared with

CBCL norms. Competence scores on the CBCL were sig-

nifcantly lower or children with SCD due to low social

competence and school perormance scores. Contrary to

expectations, the authors ound an increased requency o

externalizing problems with children with SCD; overall,

the authors suggested that caregivers o children with SCD

perceived their children as having slightly more problems

than their well counterparts. One weakness o this study

was that the children were not interviewed.

Seigel et al. [ 33], in a study assessing the association

between depression, sel-esteem, and lie events in ado-

lescents with asthma, SCD, and diabetes, examined 80

adolescents aged 12 to 18 years and a comparison group o

100 demographically matched peers. Both groups completed

the BDI, Rosenberg Scale o Sel Esteem, and the McCutch-

eon Lie Events Checklist. These authors ound that themean depression scores were signifcantly higher in the

chronic disease groups when compared with healthy peers,

and that the illness groups were more likely to have low sel-

esteem. However, they ound no dierences between the

illness groups in depression, sel-esteem, or lie events.

In one o the ew studies examining depression spe-

cifcally using psychiatric assessment, Yang et al. [34]

studied a convenience sample o 38 adolescents aged 16

to 18 years using the Childrens Depression Rating Scale-

Revised (CDRS-R) and a diagnostic assessment by a child

and adolescent psychiatrist. The study subjects included

38 children with SCD and a demographically matched

control group o adolescents without SCD. Detailedmedical histories, including requency o painul crisis

and complications o SCD, were obtained to assess the

severity o illness. Although 29% o the adolescents with

SCD obtained high scores on the CDRS-R, compared

with 12% o the controls, the authors concluded that

the dierences were related to elevated scores on somatic

complaints, especially atigue, worries about death, and

sel-esteem problems, suggesting that the dierences were

not signifcant between the two groups on other measures

o depression. However, the study did identiy a positive

correlation between the clinical severity o SCD and the

CDRS-R scores.

The diering methodologies used in these studiesmake reaching consensus on these issues very difcult.

Additionally, aws in the study designs limit the inter-

pretation o these data. Many o the studies suer rom

small sample sizes that limit generalizability, nonrandom

samples, absence o comparison groups, use o poorly

validated instruments or instruments that have not been

validated or this population, use o wide age ranges

obscuring developmental issues, and the use o vague

terms to defne anxiety and depression and psychological

and social unctioning [35]. Additionally, the potential


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inuences o ethnicity, economic inequality, and racial

discrimination on psychosocial outcomes have been

largely overlooked [32].

Despite the methodological issues raised, the preponder-

ance o the existing evidence supports an increased prevalence

o anxiety and depression among adults and adolescents

with SCD and increased anxiety and depressive symptoms

among children, adolescents, and adults with SCD. Some o

the relationships between the presence o these symptoms

and medical outcomes have been described.

Impact upon IllnessDepression and anxiety have been identifed as predictors

o admission to the emergency room or treatment and/or

hospitalization in older adolescents and adults [36,37].

Depressive symptoms, depression, recent loss, and social

and academic problems were common predictors. In a

retrospective study o 22 hospitalized patients examin-

ing actors contributing to painul crisis, pain crisis waspreceded by severe depression and responses to loss [37].

In another study examining hospital admissions or pain

episodes, 56% (n = 47) o patients reported eelings o

depression prior to hospitalization. The authors described

depression and younger age (adolescence) to be the best

predictors o both emergency room treatment and hospi-

talization [22].

Depression and anxiety also have been implicated as

important actors in the adjustment o children and adoles-

cents to SCD and their abilities to cope with its associated

pain. Some o the research has documented that psycho-

social actors explain substantially more variability in

adaptability than biomedical actors [38,39]. Most o theavailable studies to date have examined the eects o psy-

chological adjustment, specifcally interpersonal actors

(coping styles, competence) and amily actors (cohesion

and parental adaptation), on the adaptation to living with

SCD and management o pain.

Studies o interpersonal actors have ocused on stress

processing in children with SCD, suggesting that active

coping strategies and perceived control are associated

with higher levels o adjustment, including ewer physical

symptoms and psychological problems. Avoidance coping

has been associated with more anxiety symptoms, reduced

activity, and increased need or medical interventions;

disengaged coping styles have predicted more internaliz-ing behavioral problems [40]. Thompson et al. [23] have

demonstrated that pain coping strategies characterized by

passive adherence and negative thinking (catastrophizing

and sel-statements o ear and anger) were associated with

more requent emergency visits, less activity, and higher

levels o sel-reported distress. Active coping strategies such

as cognitive and behavioral strategies, including diverting

attention, calming sel-statements, and reinterpreting pain

sensations, were associated with ewer emergency visits

and more activity during painul episodes [23].

The importance o amily actors in child unctioning

has been well described as an important mediating actor

in SCD [20,41]. Greater amily cohesion has been associ-

ated with more adaptive coping, whereas greater amily

discord has been associated with less adaptive coping

[41]. In a study examining the psychological adjustment

o mothers to their children with SCD, Thompson et al.

[29] ound that maternal anxiety accounted or a signif-

cant proportion o the variance associated with the child

behavior problems identifed by mothers.

These studies support the fndings o Telair [36],

underscoring the importance o the amily in the process

o illness adjustment o children with SCD. Telair [36]

suggested that the presence o anxiety and depression in

parents/caregivers aected treatment outcomes, noting

that early detection and reduction o psychosocial stress-

ors should be part o a comprehensive continuity o care.

These early fndings have been supported by a large body

o literature describing the impact o all childhood chronic

illnesses upon amilies and the need to assess amilies orpathology, stress, and/or difculties coping, and to pro-

vide help and support when these are identifed. Telair

[36] also recommended that all care providers understand

the child/parent coping patterns when the child is not ill,

as that will lead to better understanding and identifca-

tion o an impending decompensation.

Diagnostic and treatment strategiesOur review did not reveal studies specifc to the treatments

or depression and anxiety disorders in individuals with

SCD. Most treatment studies have ocused on cognitive

and behavioral strategies as adjuncts to analgesics or SCD

pain. These strategies consist o behavioral interventionssuch as relaxation, deep breathing, bioeedback, behavioral

modifcation, or exercise, or psychological interventions

such as cognitive therapies, hypnotherapy, imagery, dis-

traction, or social support. Physical interventions might

include hydration, heat, massage, hydrotherapy, ultra-

sound, acupuncture, transcutaneous electrical nerve

stimulator, or physical therapy [42]. This ocus on pain

management is extremely important, as many studies

support a positive correlation between pain, anxiety, and

depression, fnding the prevalences o these disorders to

be much higher among those experiencing recurrent and

chronic pain in the adult population. Studies also suggest

higher rates o suicidal thinking and actions among adultswith chronic pain [43].

Diagnosing anxiety and depression in patients with

SCD can be difcult because the disease itsel can con-

ound symptoms o the disorders. Many o the symptoms

o anxiety or depression (atigue, low energy, poor

appetite and concentration, irritable mood, insomnia or

hypersomnia, and psychomotor agitation or retardation)

may result rom mood or anxiety symptoms or SCD or

medications related to its treatment. However, symptoms

o worthlessness, inappropriate guilt, suicidal thoughts,


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and inability to think or concentrate are much less com-

mon and should help to clariy the diagnosis [44].

There is also a defnite relationship between depres-

sive symptoms and pain. Depressive symptoms complicate

pain, may lower the threshold or tolerance o pain, and

may interere with a child or adolescents ability to cope

with pain [26]. Pain may precipitate depressive or anxi-

ety symptoms in individuals who are vulnerable. Patients

who are taking analgesics such as opiates, or who are

discontinuing those same medications, may experience

medication-induced depression and anxiety. The psychiat-

ric assessment o the child or adolescent with SCD should

include a thorough assessment or psychosocial disrup-

tion or psychiatric symptoms, especially those related to

anxiety or depression, or school or social problems that

could reect subtle neurocognitive problems, pica, and

problems with chronic pain [42].

When depression or anxiety has been identifed in a

child or adolescent with SCD, those disorders should be

treated aggressively using interventions that are currentlyvalidated or children and adolescents without SCD. Suc-

cessul treatment o anxiety symptoms can reduce pain

and pain-related distress. All patients with SCD should

be careully evaluated using a biopsychosocial approach

to determine the presence and severity o psychiatric ill-

ness that may decrease adherence to medical regimens

and complicate the course o their illness. I an anxiety

or depressive disorder is identifed, the patient and am-

ily should be educated about the illness and the impact

o comorbidity and provided with a treatment plan that

incorporates pharmacotherapy, psychotherapy, and

school- and home-based supports as appropriate, and

amily interventions, including education, support, andamily therapy i indicated [45].

Although there are no studies examining the use o

antidepressants or the treatment o anxiety or depres-

sion in children or adolescents with SCD, the current

antidepressant agents used or the treatment o depres-

sion and anxiety, specifcally the selective serotonin

reuptake inhibitors, have avorable side eect profles

and are not likely to interact with the medications com-

monly prescribed to individuals with SCD. Although

other psychotropics are not contraindicated in SCD,

it is important to be mindul o P450 interactions and

additive drug eects. Phenothiazines may antagonize

the analgesic eects o opiate agonists, and tricyclicantidepressants, monoamine oxidase inhibitors, and

other central nervous system depressants may potenti-

ate adverse eects o opioids [42]. There has been one

case report o an adolescent male aged 16 years who

developed priapism ater initiating venlaaxine, 37.5 mg,

or depression and attention-defcit disorder, although it

was unclear whether the priapism was related to the ven-

laaxine or concurrent alcohol and marijuana use. Given

the occurrence o priapism in adolescents with SCD, it is

important to monitor or this side eect [46].

ConclusionsWhereas studies suggest that anxiety and depressive

symptoms are more prevalent among patients with

SCD, the evidence o clinical anxiety and depression

in children remains unclear. Although the evidence has

demonstrated that multiple inuences, such as illness

severity, child coping, parent coping, social support,

adaptive unctioning, and treatment compliance, impact

outcomes and quality o lie or these individuals, the

presence o psychopathology will impact all o the above

considerably. The presence o symptoms o depression

and anxiety, or the presence o anxiety or depressive dis-

orders, could serve as a predisposing, precipitating, or

perpetuating actor or poor coping adaptation to illness

and adherence.

In act, some studies suggest that the presence o a

psychiatric disorder predicts a worse outcome or children

and adolescents than the presence o the chronic illness

itsel [47]. Chen et al. [47] assessed quality o lie or

a community sample o 705 adults 17 years ater an initialassessment or chronic physical conditions and Axis I and

II psychiatric disorders as teens. These authors ound that

mental disorders during adolescence were more strongly

associated with reduced quality o lie in adulthood than

adolescent physical illnesses, that individuals living with

physical illnesses were at increased risk o living in a more

adverse environmental context as adults, and that adoles-

cents with comorbid physical illness and mental disorder

tended to experience a particularly large reduction in

quality o lie by adulthood. This urther emphasized the

need or prevention, recognition, and treatment o comor-

bid mental health conditions.

AcknowledgmentsNone o the authors has a possible conict o interest,

fnancial or otherwise.

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mental disorders and physical illnesses on quality o lie 17years later. Arch Pediatr Adolesc Med2006, 160:9399.

This is an excellent study describing the quality-o-lie outcomeso a 17-year ollow-up study o adolescents with chronic medicalconditions compared with adolescents with medical and psychiatricconditions. The results suggest that the presence o a mental healthcondition independently predicts worse quality o lie than the pres-ence o a medical condition.


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48. Goodwin RD, Messineo K, Bregante A, et al.: Prevalence oprobable mental disorders among pediatric asthma patientsin an inner-city clinic.J Asthma 2005, 42:643647.

This is a nice study that examines the prevalence o psychiatriccomorbidity in an urban, minority population o asthmatics. Oneo the ew examining minority populations.

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