Is depression associated with increased health care utilization in SCD? A brief systematic review

It is well-known that persons with sickle cell disease (SCD) experience a disproportionately high incidence of emergency department (ED) visits and hospitalizations, a consequence of the unpredictable and severe vaso-occlusive pain crises and disease-related complications so common in this population. It is less well-known that SCD is associated with a higher prevalence of depression compared to that of the general population. The true prevalence of depression in SCD is not known but some study estimates would suggest that 26 to 57% of persons with SCD are clinically depressed [1-5]. Given the strong relationship between depression and increased pain symptoms reported in non-SCD populations [9], it is important to take a closer look at depression in SCD and how it impacts the lives of these patients. Indeed, depression in SCD is associated with more severe pain symptoms, greater opioid use with less relief, and poorer quality of life [2, 3, 6-8]. Patients with SCD who present with depression may have a more severe disease course and have greater need for medical care over their life course. It is not yet clear, however, from the current literature if depressive symptoms are associated with greater utilization; some studies have found an association [1, 10] while others have not [2].

Therefore, we conducted a systematic review of the literature to help determine the true association between depression, or depressive symptoms, and health care utilization. We limited our population to adult patients and included studies that both measured depression and/or depressive symptoms and emergency department visits and/or hospitalizations. We found eight different studies total that met this criteria; only five reported depression for patients with low and high health care utilization (i.e. >3 ED visits or hospitalizations/year)[1, 11-14]. Figure 1 shows the relative risk (RR) for each of these five studies and the overall RR across all studies. Of 2442 patients analyzed, 610 (29%) had been diagnosed with depression or reported symptoms meeting depression criteria. As shown at the bottom of Figure 1, pooled results of these studies suggest depression is associated with a two-fold increased risk of high health care use (pooled relative risk = 2.3; 95% CI, 1.9 to 2.8) among adults with SCD.

Figure 1. Forest plot summarizing studies showing depression associated with increased risk of high health care utilization in SCD

Figure 1. Forest plot summarizing studies showing depression associated with increased risk of high health care utilization in SCD

The studies examining depression and health care utilization are limited and the methods differ significantly between studies. Further, the studies included in this review generally have small samples sizes (e.g. 46 participants) and only the Carroll et al. studies include longitudinal data. Therefore, the direction of this association is not clear. Overall, however, it does seem that depression is related to health care utilization in some way, whether depression is a contributor to health care use or a result of being in the hospital. Large scale, longitudinal studies will be needed to better understand the nature of the depression-utilization association. However, even without knowing depression impacts or is affected by health care use, we know that depression in SCD is high and depression is a detriment to the quality of life of its suffers. Therefore, the WISSH community should likely be directing efforts to treating depression in SCD more so than simply trying to understand it.

REFERENCES:

1.Belgrave, F.Z. and S.D. Molock, The role of depression in hospital admissions and emergency treatment of patients with sickle cell disease. J. Natl. Med. Assoc., 1991. 83(9): p. 777-781.
2.Levenson, J.L., et al., Depression and anxiety in adults with sickle cell disease: The PiSCES project. Psychosomatic Medicine, 2008. 70(2): p. 192-196.
3.Wilson Schaeffer, J.J., et al., Depression, disease severity, and sickle cell disease. Journal of Behavioral Medicine, 1999. 22(2): p. 115-126.
4.Molock, S.D. and F.Z. Belgrave, Depression and anxiety in patients with sickle cell disease: conceptual and methodological considerations. Journal of Health and Social Policy, 1994. 5(3-4): p. 39-53.
5.Sogutlu, A., et al., Somatic symptom burden in adults with sickle cell disease predicts pain, depression, anxiety, health care utilization, and quality of life: the PiSCES project. Psychosomatics, 2011. 52(3): p. 272-9.
6.Barakat, L., et al., Quality of life among adolescents with sickle cell disease: Mediation of pain by internalizing symptoms and parenting stress. 2008. p. 60.
7.McClish, D.K., et al., Pain site frequency and location in sickle cell disease: the PiSCES project. Pain, 2009. 145(1-2): p. 246-51.
8.Smith, W.R., et al., Understanding pain and improving management of sickle cell disease: the PiSCES study. Journal of the National Medical Association, 2005. 97(2): p. 183-93.
9.Lepine, J.P. and M. Briley, The epidemiology of pain in depression. Hum Psychopharmacol, 2004. 19 Suppl 1: p. S3-7.
10.Hasan, S.P., et al., Depression in sickle cell disease. J Natl Med Assoc, 2003. 95(7): p. 533-7.
11.Aisiku, I.P., et al., Comparisons of high versus low emergency department utilizers in sickle cell disease. Annals of Emergency Medicine, 2009. 53(5): p. 587-593.
12.Carroll, C.P., C. Haywood, Jr., and S. Lanzkron, Prediction of onset and course of high hospital utilization in sickle cell disease. J Hosp Med, 2011. 6(5): p. 248-55.
13.Sandoval, E., et al., A Comparison of Frequent and Infrequent Visitors to an Urban Emergency Department. J. Emerg. Med., 2010. 38(2): p. 115-121.
14.Carroll, C.P., et al., The course and correlates of high hospital utilization in sickle cell disease: Evidence from a large, urban Medicaid managed care organization. American Journal of Hematology, 2009. 84(10): p. 666-670.

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