Prevalence of psychiatric disorders, depression, and suicidal behavior in child and adolescent with thalassemia major

Quality of life, mood disorders, and cognitive impairment in adults with β-thalassemia

Advances in understanding the disease process in β-thalassemia supported development of various treatment strategies that resulted in improved survival. Improved survival, however, allowed multiple morbidities to manifest and cemented the need for frequent, lifelong treatment. This has directly impacted patients' health-related quality of life and opened the door for various psychiatric and cognitive disorders to potentially develop. In this review, we summarize available evidence on quality of life, depression and anxiety, suicidality, and cognitive impairment in adult patients with β-thalassemia while sharing our personal insights from experience in treating patients with both transfusion-dependent and non-transfusion-dependent forms.

Prevalence of Depression among Iranian Patients with Beta-Thalassemia Major: A Systematic Review and Meta-analysis

BACKGROUND

Patients with beta-thalassemia (BT) are susceptible to psychological disorders such as depression. The present study was conducted to estimate the pooled prevalence of depression among patients with BT in Iran.

METHODS

Domestic and international databases were searched for relevant articles published from 1991 until June 2019. We searched international databases such as Scopus, ISI, and Embase; Iranian databases such as SID, Magiran, and IranDoc; and Google Scholar and PubMed search engines. The MeSH keywords used were "depression", "mental health", "depressive disorder", "thalassemia", "beta-thalassemia major", "prevalence", "epidemiology", and "Iran". Relevant cross-sectional or cohort studies were included in the analysis. Cochran's Q test and the I² index were used to assess heterogeneity. The pooled prevalence and its 95% confidence interval (CI) were calculated using "metaprop" commands in Stata 14. In cases, where the I² statistic was greater than 50%, the random-effects model was used.

RESULTS

Eighteen eligible studies were included. The pooled prevalence of depression was 42% (95% CI: 33% to 52%), whereas the pooled prevalence of mild, moderate, severe, and extremely severe depression was 16% (95% CI: 11% to 22%), 13% (95% CI: 9% to 18%), 13% (95% CI: 9% to 17%), and 3% (95% CI: 0% to 8%), respectively. The pooled prevalence of depression in moderate- and high-quality studies was 45% (95% CI: 29% to 61%), and 39% (95% CI: 27% to 51%), respectively.

CONCLUSION

The high prevalence of depression highlights the urgent need for the establishment of interventions for the prevention, early detection, and treatment of depression among Iranian patients with BT.

Cognitive Function in Adults with Beta-Thalassemia Major in Oman: A Pilot Study

Objectives

Neurocognitive dysfunction has been established in several studies in children with beta-thalassemia major (TM). However, despite its wide occurrence in populations across the Arabian Peninsula, scant attention has been paid to shedding light on neuropsychological functioning among adults with TM. This study aimed to examine the level of neuropsychological functioning among Omani adults with TM regularly followed-up at a tertiary care hospital in Oman. A related aim was to examine the factors associated with neuropsychological performance.

Methods

Standard neuropsychological tests were used to measure attention and concentration, learning and remembering, verbal fluency, and executive functioning. Participants were also gauged on indices of intellectual ability and affective range. As normative data for neuropsychological functioning in Oman is scarce, healthy age- and sex-matched controls underwent the same testing procedure. The log-linear model was used to identify factors associated with TM patients on demographic and neuropsychological performance.

Results

This study recruited 28 adult patients with TM (age 30.0±6.5) and 39 healthy controls (age 29.2±6.1). Findings suggested that having a diagnosis of TM was significantly associated with symptoms of depression (p < 0.001) and anxiety (p < 0.001), indices of executive functioning (verbal fluency) (p =0.003), working memory (digit span) (p < 0.001), and verbal and auditory attention scores (California Verbal Learning, p = 0.002).

Conclusions

The data appears to suggest that short-term memory capacity, verbal fluency, and verbal and auditory attention may be impaired in TM compared to controls. Studies on a larger cohort are therefore warranted.

Uncertain crisis time affects psychosocial dimensions in beta-thalassemia patients during Covid-19 pandemic: A cross-sectional study

Psychosocial variables are key factors influencing the delicate equilibrium of chronic patients during crisis time. In this study, we explored distress, anxiety, depression, loneliness, coping strategies, and changes in life habits in 43 beta-thalassemia patients and 86 controls during Covid-19 pandemic. Patients showed higher anxiety levels and a predominant transcendent coping profile compared to controls. Patients significantly differed from controls in outdoor habits. Social isolation and habits changes in uncertain life-threaten situations as Covid-19 pandemic are particularly detrimental in fragile beta-thalassemia patients. Structured support interventions are needed to promote well-being in the Covid-19 era.

Determinant factors of depression in beta major thalassemia children

Thalassemia is a chronic disease with long-term treatment that increases the potential for impact on physical, cognitive, and psychological conditions. About 80% of patients with major thalassemia have at least one psychiatric disorder, depression is one of the most frequently reported, especially in prepubertal and puberty periods. The aim of this study is to evaluate determinant factors of depression in beta mayor thalassemia children. This was a cross-sectional study on patients aged 9 to 17 years at hematology outpatient clinic in Dr. Soetomo General Hospital from September to Desember 2018. Level of depression determinded by Children Depression Inventory (CDI) questionnaire. The data were collected and analyzed using using the IBM SPSS Statistics version 21. It is statistically significant with p<0.05. Forty-five participants were included in this study, 15 participants with mild depression and 30 participants without depression. Gender (p=0.462), age of diagnosis (p=0.385), frequency of tranfussion (p=0.065), family history of depression (p=0,350), physical change (p=0.711), duration of illness (p=0.674) have no significant value as a determinant factor while complication (p=0.049) and serum cortisol level (p=0.037) had significant value as determinant factors of depression in Beta Major Thalassemia children. Mild depression is more common in thalassemia patients who experience complications and had high serum cortisol levels

Construction of an exposure-pathway-phenotype in children with depression due to transfusion-dependent thalassemia: Results of (un)supervised machine learning

BACKGROUND

Transfusion dependent thalassemia (TDT) patients are treated with continued blood transfusions and show a higher prevalence of depression. TDT with consequent iron overload and inflammation is associated with increased severity of depressive symptoms in TDT children.

AIM OF THE STUDY

To construct a pathway-phenotype which combines iron overload and neuro-immune biomarkers with depressive symptom subdomains in TDT children.

METHODS

We measured iron status parameters (iron, ferritin, transferrin saturation percentage) and inflammatory (interleukin-1β and tumour necrosis factor-α) biomarkers in TDT (n=111) and healthy (n=53) children and analyzed the results using machine learning.

RESULTS

Cluster analysis separated TDT children with depression from those without depression and revealed two depressive subgroups one with low self-esteem and another with increased social-irritability scores. Exploratory factor analysis validated four depressive symptom dimensions as reliable constructs, namely key depressive, physiosomatic, lowered self-esteem and social-irritability dimensions. Partial Least Squares showed that 73.0% of the variance in a latent vector extracted from those four clinical subdomains, immune-inflammatory and iron overload biomarkers was explained by exposure variables including the number of blood transfusions and hospitalizations and use of deferoxamine. The exposure data, iron and immune biomarkers, and symptom subdomains are reflective manifestations of a single latent trait, which shows internal consistency reliability and predictive relevance.

CONCLUSIONS

The nomological network combining exposure, pathways and behavioral phenome manifestations provides an index of overall severity and disease risk and, therefore, constitutes a new drug target, indicating that iron overload and immune activation should be targeted to treat depression due to TDT.

Depression, Anxiety, and Stress Symptoms in Patients With Beta Thalassemia Major in Almadinah Almunawwarah, Saudi Arabia

Introduction

Beta thalassemia major (BTM) is a chronic hereditary blood disorder. Patients are dependent on blood transfusion and are prone to multiple comorbidities. Depression, anxiety, and stress (DAS) can complicate their condition. No reports from Saudi Arabia to measure DAS in BTM patients. We report the prevalence of DAS symptoms in our BTM patients using the DASS-21 (Depression, Anxiety, and Stress Scale - 21 Items) test.

Methods

A cross-sectional study including adolescents and adults aged 14 years and above with BTM treated in Almadinah Almunawwarah and excluding patients who had bone marrow transplant or with central nervous system insults were performed.

Results

A total of 31 male and 31 female patients were enrolled, with a mean age of 24.32 ± 7.05 years. Depression symptoms were detected in 60 % of patients, anxiety symptoms were detected in half of the studied group, and stress symptoms were detected in 38.7% of patients. We found a significant positive correlation between DAS and DASS total score. Age below or above 18, parent’s employment, patient’s educational level, and status of satisfaction about medical care were statistically significant in having positive effects on scores of DAS symptoms.

 Conclusions

BTM patients are prone to develop psychological disorders, which can affect the course of the disease. Our results are comparable to international and Arab population studies, which have the highest reported prevalence. It is important to not ignore the psychological evaluation of patients with BTM and to refer them for proper evaluation and management.

Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation

BACKGROUND

Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear.

METHODS

We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO.

RESULTS

A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons.

CONCLUSIONS

Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.

The burden of psychiatric illnesses in adult patients with beta-thalassemia: a 5-year nationwide inpatient evaluation in the United States

Beta-thalassemia (ß-thalassemia) is a frequently inherited monogenic disorder worldwide with severe physical and mental health comorbidities. The aim of this study is to evaluate the burden of psychiatric disorders in adult patients hospitalized with ß-thalassemia in the United States (US). We utilized the discharge data from the National Inpatient Sample (NIS) from 2010 through 2014 to identify hospitalized ß-thalassemia patients who are 18 years and older. We assessed categorical and continuous variables using chi-square test and Student's t test respectively. The burden of psychiatric disorders was assessed using descriptive statistics and represented in terms of frequency (n) and percentage (%). A p value threshold of < 0.05 was considered clinically significant. All statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Of the 10,046 ß-thalassemia patients studied, 24.4% (n = 2448) reported psychiatric disorders. Mood disorders (15.2%; inclusive of 10.3% depression), followed by anxiety (9.4%), and substance abuse disorder (6.5%; 4.3% drug abuse, 2.2% alcohol abuse) were most prevalent. Comorbid mental illnesses increased the length of stay by 44.6% and total costs by 23.4%. All-cause mortality rate was reported at 1.9% in overall ß-thalassemia patients. This study highlights higher rates of psychiatric disorders such as depression and anxiety and correlated increases in length of stay and cost in hospitalized ß-thalassemia patients. To improve medical outcomes and curtail unnecessary health-care costs, implementation of an integrated care model can be considered.

Role of Inflammation in Suicide: From Mechanisms to Treatment

Suicidal behavior is complex and manifests because of a confluence of diverse factors. One such factor involves dysregulation of the immune system, which has been linked to the pathophysiology of suicidal behavior. This review will provide a brief description of suicidality and discuss the contribution of upstream and downstream factors in the etiology of suicidal behavior, within the contextual framework of inflammation. The contribution of inflammatory conditions such as traumatic brain injury, autoimmune disorders, and infections to neuropsychiatric symptoms and suicidality is only beginning to be explored. We will summarize studies of inflammation in the etiology of suicide, and provide a neurobiological basis for different mechanisms by which inflammation might contribute to the pathophysiology. Finally, we will review treatments that affect upstream and downstream pathways related to inflammation in suicidality.

Psychological Aspects in Children and Adolescents With Major Thalassemia: A Case-Control Study

BACKGROUND

Thalassemia is an inherited blood disease. It is a serious public health problem throughout the Mediterranean region, the Middle East and the Indian subcontinent, as well as in Southeast Asia.

OBJECTIVES

Thalassemia is an inherited blood disease. It is a serious public health problem. In this study we assessed psychological aspects in Iranian children and adolescents with thalassemia major.

PATIENTS AND METHODS

In this case-control study sixty healthy subjects aged 7-18 years and Sixty Patients with confirmed diagnosis of major thalassemia were enrolled. After obtaining informed consent from parents of all participating thalassemia patients and healthycontrols, we assessed psychological aspects and quality of life by Pediatric Quality of LifeTM (PedsQL™), Strengths and Difficulties Questionnaires (SDQ), State and Trait Anxiety, Children's Depression Inventory (CDI).

RESULTS

The results of this study indicate that there are significant changes in depression, anxiety, QOL and behavioral screening between children with thalassemia major compared with healthy subjects by means of both parents and children reports. According to the results, children with thalassemia major have more psychological problems than healthy ones. Patients with thalassemia have a lower QOL than their peers (P = 0.001), the rate of depression is higher in this group (P = 0.015), Also behavioral problems in these children are more than healthy subjects (P = 0.009).

CONCLUSIONS

We recommend appropriate treatment and counseling procedures in addition to specific treatment of thalassemia. According to the results we suggest to establish pediatric psychiatric clinics beside thalassemic clinics to cure psychological aspects of the disease.

Conduct behaviors and oppositional defiant behaviors in children and adolescents with ADHD

There is controversy about the association among attention deficit hyperactivity disorder (ADHD), conduct disorder behaviors, and oppositional defiant behaviors. This study examines whether different subcategories of conduct behaviors co-occur in children with ADHD, and investigates the association of conduct behaviors with ADHD symptoms and oppositional defiant behavior, considering the covariant factors of parental age and educational level. A total of 441 children and adolescents with ADHD participated in this study - 342 (77.6%) boys and 99 girls (22.4%). Their mean age was 9.1 (standard deviation = 2.2) years. They came from families with 1 to 8 children. There were statistically significant correlations among different subcategories of conduct disorder (p < 0.001 for all the correlations). Oppositional behavior scores were associated with all 4 subcategories of conduct behaviors. The severity of hyperactivity/impulsivity was associated with the subcategory of "destruction of property." The inattentiveness score was associated with "aggression to people and animals." The current results do not suggest that conduct behaviors exclude oppositional defiant behaviors. The subcategories of conduct behaviors occur in a cluster rather than as a solitary behavior. Larger family size and lower educational level of the father increase the risk of aggression to people and animals in children with ADHD.

The perception of biological experience in patients with major Thalassemia: a qualitative research

BACKGROUND

Thalassemia Major Disease is not only assumed as a health disorder, but also a social- economic problem in many countries. The costs of transport and preparation of drugs is considered as the greatest problems for more than 63.8% of the patients' families. This study was conducted by aiming at describing biological experience among parents of patients with Thalassemia Major.

METHOD

The current qualitative investigation was carried out on 32 parents of patients with Thalassemia Major and by means of unstructured interview in- depth through snowball sampling technique in 2013. The data were analyzed by conventional content analytical method.

FINDINGS

The perception of biological experience of parents of patients with Thalassemia Major were classified based on participants' experiences into three main themes including psychological experiences, physical experiences, and social experiences. 1) Psychological (mental) experiences comprise of two subclasses of the reduced self-confidence, deficient emotions and negative emotions; 2) Physical experiences consist of three subclasses of sleeping disorders, pains in various parts of body, and limited physical activity; and 3) Social experiences includes 3 subcategories of interpersonal relations, reduced income, job, and limitation in doing tasks. 4) Treatment experiences comprise of five sub-themes including 1- Shortage of drugs, blood, and filter etc; 2- Less experienced personnel; 3- Lack of training the patients' parents by personnel in thalassemia ward; 4- Lack of visiting patients by physician in thalassemia ward; and 5- Inappropriate behavior of personnel toward patients and their parents.

CONCLUSION

Thalassemia Major has affected negatively on several fields of health for these patients and their parents including physical, mental, economic, and social areas. Reducing these problems requires constant interventions and surveying health and medical status of these patients.

Hematopoietic stem cell transplantation for thalassemia

Thalassemia is an autosomal recessive disorder associated with defective synthesis of the α- or β-chain of hemoglobin. For β-thalassemia major patients, therapeutic options are either monthly red cell transfusions and chelation therapy or allogeneic stem cell transplant. Patients undergoing transfusion therapy remain at risk for transmitted infections and iron overload with associated tissue damage. Stem cell transplant is the only curative approach and success is inversely correlated with the degree of iron overload and hepatic damage. Overall outcomes following stem cell transplant with a matched sibling donor are excellent with over 90% of low-risk children becoming transfusion free. Hypertransfusion therapy and aggressive chelation in addition to hydroxyurea, azathioprine and fludarabine is a new approach for high-risk patients to decrease graft rejection by suppressing endogenous erythropoiesis pretransplant. The use of unrelated donors and novel approaches such as gene therapy are under current investigation.

Psychometric analysis of the new ADHD DSM-V derived symptoms

BACKGROUND

Following the agreements on the reformulating and revising of ADHD diagnostic criteria, recently, the proposed revision for ADHD added 4 new symptoms to the hyperactivity and Impulsivity aspect in DSM-V. This study investigates the psychometric properties of the proposed ADHD diagnostic criteria.

METHOD

ADHD diagnosis was made according to DSM-IV. The parents completed the screening test of ADHD checklist of Child Symptom Inventory-4 and the 4 items describing the new proposed symptoms in DSM-V.

RESULTS

The confirmatory factor analysis of the ADHD DSM-V derived items supports the loading of two factors including inattentiveness and hyperactivity/impulsivity. There is a sufficient reliability for the items. However, confirmatory factor analysis showed that the three-factor model is better fitted than the two-factor one. Moreover, the results of the exploratory analysis raised some concerns about the factor loading of the four new items.

CONCLUSIONS

The current results support the two-factor model of the DSM-V ADHD diagnostic criteria including inattentiveness and hyperactivity/impulsivity. However, the four new items can be considered as a third factor.

Plasma lipids and lipoproteins in children and young adults with major β-thalassemia from western Iran: influence of genotype

To determine the plasma lipid and lipoprotein profiles and their possible association with the type of β-thalassemia mutation we studied 103 major β-thalassemia patients including 71 children and 32 young adults compared to 102 healthy subjects consisted of 90 children and 12 young healthy adults. The plasma lipid and lipoprotein levels were measured by conventional methods. Considering all of the patients the levels of total cholesterol (TC), LDL-cholesterol (LDL-C), and HDL-cholesterol (HDL-C) were significantly lower compared to controls. However, the level of TG was significantly higher in cases than controls. Comparing thalassemic patients homozygous for a β0 type of mutation with those homozygous for a β+ type of mutation (IVSI.110 G:A) indicated that the levels of LDL-C, TC were significantly increased and TG concentration tended to be higher in the latter patients. In conclusion, our study indicates that hemolytic stress results in hypocholesterolemia in major β-thalassemia patients and the presence of more severe genotype in patients is correlated with more reduction in TG, TC, and LDL-C levels.

Symptoms of depression and anxiety in patients with thalassemia: prevalence and correlates in the thalassemia longitudinal cohort

Thalassemia is an inherited blood disorder that requires lifelong adherence to a complicated and burdensome medical regimen which could potentially impact emotional functioning of patients. The importance of understanding and promoting healthy emotional functioning is crucial not only to psychological well-being, but also to physical health as it has been shown to impact adherence to medical regimens [1-4]. The current study aimed to [1] determine the prevalence of depressive and anxiety symptoms in adolescent and adult patients with thalassemia; and [2] explore possible demographic, medical, and psychosocial correlates of these symptoms in 276 patients (14-58 years old, M age = 27.83; 52% female). Overall, most patients did not report experiencing significant symptoms of anxiety and depression (33% of participants indicated experiencing symptoms of anxiety and 11% symptoms of depression). Females and older patients were more likely to experience these symptoms than males and younger patients. Symptoms of anxiety and depression were positively associated with self-report of difficulty with adherence and negatively associated with quality of life. Given these findings, regular screening for anxiety and depression symptoms could help to identify at-risk individuals to provide them with appropriate psychological support with the goal of improving both emotional and physical health.

Cultural structures of the Persian parents' ratings of ADHD

OBJECTIVE

The objective was to study the cultural structure of Farsi-speaking parents' ratings with diagnostic definitions of ADHD.

METHOD

The children with ADHD and their parents were interviewed. The parents rated their children on the Farsi-speaking parents' ADHD rating questionnaire.

RESULTS

The principal components analysis extracted the two factors of inattention and hyperactivity- impulsivity. The items "often has trouble playing or enjoying leisure activities quietly," "Is often 'on the go' or often acts as if 'driven by a motor,'" and "Often talks excessively" were loaded on the impulsivity, not the hyperactivity factor.

CONCLUSION

The Farsi version of the items of the DSM-IV ADHD criteria consisted of two separate factors of hyperactivity-impulsivity and inattentiveness. In addition, the factor of hyperactivity-impulsivity consisted of two separate factors of hyperactivity and impulsivity. There are some differences in the items loading from previous studies in other cultures.

Psychiatric disorders and family functioning in children and adolescents with functional abdominal pain syndrome

BACKGROUND AND AIM

Functional abdominal pain syndrome (FAPS) is a functional gastrointestinal disorder. There is a heightened risk when conducting potentially dangerous and unnecessary medical investigations and procedures in children with FAPS. The aim of this study was to survey the rate of the psychiatric disorders and family functioning in children and adolescents with FAPS.

METHODS

The subjects were a consecutive new sample of 45 children and adolescents with FAPS, 45 with an organic abdominal pain, and 45 pain-free comparison subjects aged 5-18 years that were interviewed using the Farsi version of K-SADS. Family functioning and the severity of pain were also studied.

RESULTS

About 51.1% of patients with FAPS suffered from at least one psychiatric disorder. Psychiatric disorders in the FAPS patients studied included general anxiety disorder (8.9%), obsessive-compulsive disorder (11.1%), attention deficit hyperactivity disorder (15.6%), separation anxiety disorder (24.4%), and major depressive disorder (15.6%). Except for generalized anxiety disorder and tic disorder, the other disorders were significantly more common in the FAPS group than in the two other control groups. Family functioning scores were not significantly different between groups.

DISCUSSION

There is a high rate of psychiatric disorders in children and adolescents with FAPS in Iran, but our study found fewer incidences of disorders than previous reports have indicated. Family dysfunction difficulties in FAPS children are not more common than those in the control groups.

Association of nail biting and psychiatric disorders in children and their parents in a psychiatrically referred sample of children

BACKGROUND

Nail biting (NB) is a very common unwanted behavior. The majority of children are motivated to stop NB and have already tried to stop it, but are generally unsuccessful in doing so. It is a difficult behavior to modify or treat. The objective of this study was to investigate the prevalence of co-morbid psychiatric disorders in a clinical sample of children with NB who present at a child and adolescent mental healthcare outpatient clinic and the prevalence of psychiatric disorders in their parents.

METHOD

A consecutive sample of 450 referred children was examined for NB and 63 (14%) were found to have NB. The children and adolescents with nail biting and their parents were interviewed according to DSM-IV diagnostic criteria. They were also asked about lip biting, head banging, skin biting, and hair pulling behaviors.

RESULTS

Nail biting is common amongst children and adolescents referred to a child and adolescent mental health clinic. The most common co-morbid psychiatric disorders in these children were attention deficit hyperactivity disorder (74.6%), oppositional defiant disorder (36%), separation anxiety disorder (20.6%), enuresis (15.6%), tic disorder (12.7%) and obsessive compulsive disorder (11.1%). The rates of major depressive disorder, mental retardation, and pervasive developmental disorder were 6.7%, 9.5%, 3.2%, respectively. There was no association between the age of onset of nail biting and the co-morbid psychiatric disorder. Severity and frequency of NB were not associated with any co-morbid psychiatric disorder. About 56.8% of the mothers and 45.9% of the fathers were suffering from at least one psychiatric disorder. The most common psychiatric disorder found in these parents was major depression.

CONCLUSION

Nail biting presents in a significant proportion of referrals to a mental healthcare clinic setting. Nail biting should be routinely looked for and asked for in the child and adolescent mental healthcare setting because it is common in a clinical population, easily visible in consultation and relatively unintrusive to ask about. If present, its detection can then be followed by looking for other more subtle stereotypic or self-mutilating behaviors.

Zinc in thalassemic patients and its relation with depression

Studies have shown that there is a relationship between zinc levels and depression. Thalassemic patients are at risk of zinc deficiency due to various causes including Desferal injection. The aim of this study, therefore, is to investigate hair zinc levels in thalassemic patients and their association with depression. For the purposes of this survey, 50 patients with major thalassemia between 10-20 years old were selected randomly. The patients' hair zinc concentration was compared with a control group of similarly aged healthy individuals. Simultaneously, their psychological status was evaluated with either the "Beck" or "Marya Kovacs" test (according to age) so that the relation between depression and zinc concentration could be assessed. The mean hair zinc concentration in patients was more than the controls (193.96 +/- 92.4 ppm vs 149.6 +/- 72.21 ppm). Zinc deficiency was present in 10% of the patients, and 52% had some degree of depression. There was a reverse correlation between zinc deficiency and blood transfusion rate (p < 0.05). Also, while there were more incidences of depression among the zinc deficient patients, the difference was not significant. Regarding the high prevalence of depression and insignificant relation to the zinc deficiency in these thalassemic patients, this research suggests the need for further consideration concerning patients' psychological status, the risk factors of zinc deficiency, as well as extended assessment into other causes of depression.