Interrelationship between depression, anxiety, pain, and treatment adherence in hemophilia: results from a US cross-sectional survey

Michelle L Witkop,¹ Angela Lambing,² Cynthia D Nichols,³ James E Munn,⁴ Terry L Anderson,⁵ Bartholomew J Tortella<sup>5

1</sup>Nursing Department, Northern Regional Bleeding Disorders Center, Munson Medical Center, Traverse City, MI, USA; ²Nursing Department, Henry Ford Hemophilia and Thrombosis Treatment Center, Detroit, MI, USA; ³Nursing Department, Munson Medical Center, Traverse City, MI, USA; ⁴Hemophilia & Coagulation Disorders Program, University of Michigan Hemophilia Treatment Center, Ann Arbor, MI, USA; ⁵Medical Affairs, Pfizer Inc, Collegeville, PA, USA

Correspondence: Michelle L Witkop
National Hemophilia Foundation, 7 Penn Plaza, Suite 1204, New York, NY 10001, USA
Tel +1 347 541 2963
Fax +1 212 328 3777
Email mwitkop@hemophilia.org

Purpose: Depression, anxiety, pain, and treatment adherence have reciprocal effects not characterized extensively in hemophilia. This study explored the relationships between depression, anxiety, chronic pain, and treatment adherence in adults with hemophilia.
Patients and methods: Adults with self-reported hemophilia A or B completed the cross-sectional IMPACT QoL II survey. Depression (9-item Patient Health Questionnaire [PHQ-9]), anxiety (7-item Generalized Anxiety Disorder scale [GAD-7]), chronic pain (Faces Pain Scale–Revised [FPS-R]), social support (Duke UNC Functional Social Support questionnaire), level of pain control, clotting factor treatment adherence (VERITAS-Pro or -PRN), and previous depression/anxiety were analyzed.
Results: Among 200 participants (male, 77.3%; female, 22.8%), 54% had PHQ-9 and 52% had GAD-7 scores indicating moderate to severe depression or anxiety without diagnosis of either disorder. Participants with PHQ-9 scores ≥10 (moderate to severe depression) were more likely to have lower treatment adherence than those with PHQ-9 scores <10 (P<0.05). Participants with PHQ-9 or GAD-7 scores ≥10 were more likely to report uncontrolled pain and less social support versus PHQ-9 or GAD-7 scores <10 (χ² P<0.05). Significant correlations were found between PHQ-9 and GAD-7 (P<0.0001), PHQ-9 and FPS-R (P=0.0004), PHQ-9 and VERITAS (P=0.01), GAD-7 and FPS-R (P=0.02), and GAD-7 and VERITAS (P=0.001).
Conclusion: Depression and anxiety are underdiagnosed in hemophilia. Depression is associated with anxiety, pain, and lower treatment adherence. While treatment providers play an important role in diagnosis, social workers may play a pivotal role in depression and anxiety screening. This study highlights the importance of regular screening and treatment for these disorders.

Keywords: blood coagulation disorders, depressive disorder, mental disorders, comorbidity, patient compliance, social support