Anxiety, Depression a Problem for School-aged Patients in China
School-age children and adolescents with spinal muscular atrophy (SMA) in China experience a high rate of anxiety and depression, a questionnaire-based study suggests.
“Professional psychological care [may be] included in the standard of care,” the researchers wrote, noting that a higher prevalence of depression was seen among students with SMA who have respiratory and digestive problems, and skeletal deformities.
“These results also call for possible targets for intervention such as reducing complications, improving drug accessibility, retaining normal schooling, strengthening school support, and enhancing the ability of the caregivers of SMA patients to assist in the diagnosis and treatment of the disease, so improving the mental health of SMA patients,” the investigators wrote.
The study, “Anxiety and depression in school-age patients with spinal muscular atrophy: a cross-sectional study,” was published in the Orphanet Journal of Rare Diseases.
Muscle weakness and atrophy (shrinkage) are hallmarks of SMA, but patients also can experience digestive, respiratory, cardiovascular, and motor problems, which may seriously reduce their quality of life.
Anxiety, depression, and other psychological disorders often accompany chronic physical disorders and can substantially impact disease progression. Such psychological symptoms also can complicate symptoms and increase the difficulty of diagnosis and treatment.
Research shows that depression and anxiety may lower interest in social activities, limit motivation, and impair cognitive function, further reducing social functioning and quality of life.
In adults with SMA, studies have found that patients’ levels of anxiety and depression were significantly affected by the disease. However, the psychological health of school-age children and adolescents with SMA has not been fully explored.
“The purpose of the current study was to describe the prevalence of anxiety and depression and to investigate the risk factors for these in school-age SMA patients,” according to the researchers, from the Zhejiang University School of Medicine, in China. All but one researcher is affiliated with the National Clinical Research Center for Child Health at the university, based in Hangzhou.
Two questionnaires, the Screen for Child Anxiety-Related Emotional Disorders (SCARED) and the Depression Self-Rating Scale for Children (DSRSC), were used to assess anxiety and depression. In both, higher scores indicate worse anxiety and depression. Questionnaires were completed by telephone, or in face-to-face interviews, or via an online platform with patients and their caregivers.
The study involved 155 respondents, diagnosed with SMA, who ranged in age from 8 to 18 (mean 10.28); most of the students (78.7%) were between 8 and 12 years old. Among the students, 71 (45.8%) were male, and 84 (54.2%) were female.
Infantile-onset SMA type 1 had been diagnosed in 12 of the participants (7.7%), while SMA type 3, also referred to as juvenile SMA, was confirmed in 42 (27.1%). The majority of the students — 101 or 65.2% — had intermediate SMA type 2, which usually develops between 7 and 18 months of age.
Eight participants were treated with Spinraza (nusinersen), and three were diagnosed with anxiety or depression.
A total of 48 patients attended personalized school, where children can obtain special academic, emotional, or physical support from the school or teachers. The remaining were in traditional, mainstream schools with no supporting programs for SMA patients, and lacking personalized support and equipment. For more than half of the respondents, there were reported academic delays.
Overall, 60 respondents (40.0%) generated a SCARED score of 25 or more, which met the definition of anxiety, while 39 (25.2%) had a DSRSC score of 15 or higher, meeting the criteria for depression.
Notably, depression and anxiety also were high among most of the children’s caregivers. When asked about themselves, most caregivers responded “Yes” to questions on their subjective anxiety (83.9%) and depression (80.0%).
The presence of anxiety among the children significantly correlated with respiratory and digestive problems as well as with skeletal deformities, but did not differ significantly in terms of gender, age, or disease type.
“Patients with type  and type  SMA had the highest and the lowest prevalence rates of anxiety, respectively, although this difference did not attain statistical significance,” the team wrote.
“A possible explanation for these observations is that type  patients retain more mobility than type  patients and can therefore maintain normal contacts, but that type  patients cannot enjoy the same activity levels as their normal peers, which leads to anxiety,” they wrote.
There was a significantly lower prevalence of severe anxiety among those who engaged in exercise compared with those not doing any exercise.
Additionally, children with academic delays were more likely to be anxious than those without delays. There also was a significant correlation between depression and academic delay as well as higher rates among those who attended traditional, mainstream schools.
Patients who resided in households with a high annual income reported a significantly lower prevalence of depression versus those from low-income families. There also was a significant inverse correlation between higher anxiety and lower household income level, meaning that those with less family income were much more likely to have greater anxiety.
Higher anxiety in school-aged SMA children also positively correlated with their caregivers’ subjective anxiety, and the caregivers’ subjective depression was significantly associated with the children’s anxiety, “such that the patients’ anxiety increased as their caregivers’ subjective depression increased,” the researchers wrote.
Additionally, patients’ anxiety was significantly lower when caregivers had high expectations for their diagnosis and treatment than when caregivers had low expectations.
As seen with anxiety, a higher prevalence of depression also was found in patients with respiratory and digestive problems and skeletal deformities than those without these issues. In contrast, there were no observed differences regarding gender and SMA type. Depression in patients with rehabilitation exercise was significantly lower than in those without.
“The lack of a significant difference in the prevalence of anxiety and depression between genders in our study might be explained by the fact that SMA morbidity is unrelated to gender,” the scientists wrote.
Finally, depression in patients was positively correlated with the caregivers’ subjective anxiety, but depression in patients was not different from the caregivers’ subjective depression. Also, the expectation of caregivers significantly affected depression in patients.
“In this study sample of SMA patients in China, depression and anxiety were prevalent, respectively affecting over one-quarter and one-third of the study population,” the researchers wrote.
“Professional psychological care for SMA patients is essential,” they added. “Scaling-up of mental health services—including personalized schooling, enhancing the mental health and expectations of caregivers, and precise management of multisystem disorders—is also crucial for the prevention of anxiety and depression in patients with SMA.”
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