Mental health aspect of sickle cell disorder: Anxiety, depression and drug addiction

About one in four adults suffer from mental illness at some point in their lives, and nearly that many children are affected as well. It is a very common-and treatable -health problem that has a major impact on the quality of life for both individuals and their families. In sickle cell disorder (SCD) the prevalence of mental illness, e.g. anxiety and depression, is much higher than in normal population, that is, people without any chronic medical condition.

Higher prevalence of anxiety and depression in patients with SCD may result from the impact of pain,the constant demands of the illness, intrusive treatments and symptoms on their daily lives, and society’s attitudes towards them. The other psychological problems encountered include social withdrawal, aggression, poor relationships and addiction, especially to opiates. High levels of parental anxiety, overprotection, excessive feelings of responsibility and guilt, could also negatively impact on their coping strategies. Apart from their chronic excruciating pains and other symptoms of their health condition, which could be triggers for developing anxiety and depression, they are also amenable to other causative factors of mental illness in the general population which, among other things, include genetic factors (hereditary), poor socioeconomic status, psycho-social factors (high level of parent-child conflict, poor communication, weak family bonds, early separation from parents, abused as a child (sexually, physically or emotionally, interpersonal childhood adversities), environmental factors (insecurity, exposure to violence).

Many of the symptoms of depression include depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad, empty, hopeless) or observation made by others (e.g. appears tearful); markedly diminished interest or pleasure in all, or almost all, activities most of the day. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite, insomnia or hypersomnia nearly every day, fatigue or loss of energy nearly every day feelings of worthlessness or inappropriate guilt, diminished ability to think or concentrate, or indecisiveness, recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide.

In case of anxiety, an individual may exhibit excessive worry (apprehensive expectation) about a number of events or activities, finds it difficult to control the worry, restlessness or  feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension and sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying  sleep). Anxiety and depression cause significant distress or impairment in social, occupational, or other important areas of functioning and overall quality of life of an affected individual. In addition, they worsen the clinical outcome of SCD.  Clinical studies have shown that patients with SCD and depression/anxiety, experience less favourable medical outcomes than patients without depression/anxiety. Depression and anxiety were found to be associated with frequent hospitalization for pain crisis, more emergency room visits and recurrent blood transfusion.

As noted above, SCD is characterized by recurrent acute painful crisis, the prevention and treatment of which, is central to the management of the disorder. Opioids (pentazocine, pethidine, tramadol, morphine, etc.) are often used in the management of these painful episodes; the extent of its use in the management of pain in this disorder is an issue of debate. Sub-optimal treatment of painful episodes could be an important contributory factor to the development of drug abuse through self-medication. Apart from their analgesic property, they also have euphoriant effects – ability to induce a state of mental detachment and extreme well-being and sedative property. Patients with anxiety or depression could resort to using these Opioid drugs to manage their psychological distress even when they are not really having any pain crisis and thus, get addicted.

Cause of drug addiction, generally, include genetic factors (family history of addiction is a strong predictor of risk regardless of socioeconomic status), familial factors (high level of parent-child conflict, poor communication, weak family bonds, early separation from parents), abused as a child (sexually, physically or emotionally), psychological factors(Interpersonal childhood adversities), attempt to medicate pre-existing emotional problems, behavioral disorders as well as to cope with personality disorders, ways of coping with situational stress and trauma, efforts to compensate for feelings of inferiority or powerlessness, and environmental and sociocultural factors (increasing availability of various substances within the community), exposure opportunities, influence of peer group and social media.

Common drugs of addiction in general can be roughly classified as follows:

1. a) Brain Depressants (little doses of cannabis, alcohol,sedatives like valium and rohypnol, nitrous oxide,volatile solvents e.g. sniffing of gum,petrol). These drugs slow down the excitable brain tissues. Such sedation affects the brain centers that control speech,vision, coordination and social judgment. The individual also experiences agitation and excitability when coming off these drugs – a withdrawal effect known as a hangover. High doses can slow down respiratory and heart rate leading to stupor,coma or death.
2. b) Brain Stimulants (Caffeine, nicotine, Amphetamines, Metamphetamine (a.k.a. speed,Ice,crank,fire,glass),cocaine,etc. These drugs speed up the functions of excitable brain tissues leading to energized muscles, increased respiratory rate, heart rate, blood pressure and decreased appetite. It may also cause depression,psychosis or suicidal behaviours.
3. c) Narcotics/Opiates(Codeine, Tramadol, Heroin, etc. The users are more likely to experience a state of stuporousinactivity and dwell in daydreaming fantasies.
4. d) Hallucinogens (LSD (lysergig acid diethylamide), PCP (phencyclidine, a.k.a Angel dust),large doses of cannabinoids (Indian Hemp),etc. These drugs produce gross distortion of thinking and sensory processes thereby inducing a psychotic state e.g. visual hallucination, high anxiety, misperception of reality,depersonalization,depression and hostility.

An individual is suffering from a drug addiction if he or she has a strong desire to take the drug,has difficulties in controlling its use,persisting in its use despite harmful consequences,gives a higher priority to drug use than to other activities and obligations, increased tolerance and sometimes a physical withdrawal state. Drug addiction and mental health are related. Drug addiction may be an attempt to escape the symptoms of mental illness;drug addiction may also cause mental illness. Drug addiction and mental illness maintain each other and the two may share a common cause(brain).

WHAT DO WE DO?

Prevention is key in the management of drug addiction. Government,society,non-governmental organisations,religious organisations,schools,parents and individuals have significant roles to play. Early identification and treatment is very crucial. Full recovery is a challenge but it is possible. Multiple treatments may be required for success, and remaining in treatment for an adequate period of time is critical for effectiveness.

In people with SCD,adequate assessment of each vaso-occlusive episode including physical and psychosocial approach,adequate education on opioids and pain management is essential. Always differentiate between addiction and pseudo-addiction (when patient keeps asking for painkillers because of sub-optimal pain control) and include non-pharmacological approach in pain management.

Mental health promotion, early diagnosis and prompt treatment of anxiety, depression and drug addiction in SCD patients will go a long way to improving their clinical outcomes, their quality of life and the quality of life of their parents or primary care givers. This can be best achieved by including mental health as a component of their health care.

Dr. Obembe [MB,BS; FWACP] is Consultant Psychiatrist,

Federal Neuro-Psychiatric Hospital, Yaba, Lagos.

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