Journal of Applied Hematology

: 2020  |  Volume : 11  |  Issue : 4  |  Page : 212--213

Depression among patients with immune thrombocytopenia: Are we missing the elephant in the room?

Anwar A Sayed 
 Department of Medical Microbiology and Immunology, Taibah University, Madinah, Saudi Arabia; Department of Surgery and Cancer, Imperial College London, London, United Kingdom

Correspondence Address:
Dr. Anwar A Sayed
Department of Medical Microbiology and Immunology, College of Medicine, Taibah University, Madinah 42353

How to cite this article:
Sayed AA. Depression among patients with immune thrombocytopenia: Are we missing the elephant in the room?.J Appl Hematol 2020;11:212-213

How to cite this URL:
Sayed AA. Depression among patients with immune thrombocytopenia: Are we missing the elephant in the room?. J Appl Hematol [serial online] 2020 [cited 2021 Apr 20 ];11:212-213
Available from:

Full Text

Depression is increasingly becoming a public health concern with more resources and efforts devoted to promoting its awareness and fighting associated stigmas. It has become a major cause of disability in both developed and developing countries.[1] The financial burden of depression in the USA only, as demonstrated by either employee absenteeism or decreased performance, has been estimated to be $44 billion per year. However, the impact of depression goes far beyond being an economic burden, as it encompasses detrimental suffering on both personal and interpersonal levels, as well impacting societies.

Studies have highlighted the significant association between chronic diseases and the prevalence of depression, especially in the elderly with a predominance among females. The comorbidity of depression with chronic diseases is associated with a significantly higher rate of disability. This resulting disability leads to persistent depression, forming a vicious cycle of further disability and recurrent depressive episodes.

Hence, immune thrombocytopenia (ITP) is no exception, and patients who suffer from ITP are not immune from developing depression. Patients with ITP often share feelings of frustration and helplessness and, rightly so, about their chronic condition. A patient's journey with ITP usually starts with a series of hematological investigations, which, apart from the low platelet count, are negative because ITP is a disease of exclusion. The etiology of ITP is yet to be determined, and ITP remains without any diagnostic tests, with no cure nor a single treatment that fits all.[2] Hematologists do their best to choose the most appropriate treatment for their patients. However, these treatments are not guaranteed to improve the patient's condition nor induce remission, that is, disease-free period, and they are not without side effects. From one aspect, patients with ITP usually go through trials of treatment with different medications depending on their response. Patients could stop responding to treatment without any previous indication of treatment failure, and could also relapse after a period of remission for no clear reason. From another perspective, patients struggle with the bleeding manifestation as well as living a restricted lifestyle to avoid any serious events. This, in turn, impacts patients' social life as it restricts the activities in which patients could participate. Furthermore, patients suffer from the rather common side effects of the received therapies. All these factors contribute to the feelings of helplessness that affect patients' mentality and most probably predispose them to develop depression.

Despite the high prevalence of depression, especially among those with chronic conditions, it remains seriously underdiagnosed. It has been estimated that only <50% of patients, at best, were found to be clinically diagnosed, making depression “the missed elephant.” Therefore, the identification of depression among patients with chronic diseases is much needed to ensure the provision of proper care. Effective treatment strategies that increase the likelihood of successful treatment often involve a multidisciplinary approach, including active interventions by psychiatrists and other mental health specialists.

Studies that are attempting to establish a link between ITP and depression are severely lacking. So far, Terrell et al. were the first to evaluate current depression in adult patients with ITP. Their cross-sectional study included almost 180 patients, from the UK and the USA, in which the levels of depression were evaluated. The evaluation was self-administered using the standard screening instrument eight-item Patient Health Questionnaire (PHQ-8) depression scale. Similar to other chronic conditions, up to 25% of patients self-reported moderate depression. There were also significantly higher odds of depression with bleeding symptoms and co-morbidities.[3]

Efforts to address the impact of ITP on sufferers' health-related quality of life (HRQoL) have been made. Over 50% of patients – adults, adolescents, and children – reported fatigue, reduced energy levels, and restricted social engagement. The presence of these symptoms negatively affected the HRQoL scores and correlated with the disease activity, that is, in the presence of symptoms.[4],[5] The commonly reported symptoms, such as fatigue and reduced energy levels, are considered “red flags” for depression that require the physician's attention. In these studies, depression seems to be the missed “elephant in the room.” Physicians should not be fixated on their patients' symptoms with the sole goal of alleviating them. Instead, physicians should attempt to understand the underlying cause that led to the manifestation of these symptoms to better treat them. So, when a patient who is bleeding seeks medical aid, the physician looks for the cause of bleeding, which is the low platelet count in ITP, and corrects it. Similarly, fatigue, low energy levels, and reduced HRQoL scores could be manifestations of a bigger problem: depression, “the elephant,” which will require the physician's attention.

Hematologists should be aware that their chronic patients, especially those who are symptomatic, are at high risk of developing depression. Although hematologists do not treat depression, they have ethical and legal obligations, depending on their location of practice, to refer patients when needed. It is time for hematologists to adopt a holistic approach toward patients who might suffer from depression, along with their ITP. Hematologists should be able to recognize signs of depression among their patients, which could be reasonably achieved through self-administered surveys, such as the PHQ-8 questionnaire. Once depression is suspected, a multidisciplinary approach should be adopted to effectively manage depression. Treating depression that is associated with chronic diseases improves patients' adherence to treatment. Therefore, addressing and treating the possible depression associated with ITP will lead to patient's compliance and adherence to ITP treatments. On a larger scale, multi-center studies should be conducted to evaluate the various aspects of depression among patients with ITP. These aspects should include its prevalence, association with the disease activity/platelet count, and the influence of the active management of depression on the ITP course. In addition, clinical training and guidelines should be reviewed and updated to consider patients' mental health problems associated with ITP. These guidelines should also provide clear guidance on how to properly and actively deal with patients suspected of suffering from depression.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Richards D. Prevalence and clinical course of depression: A review. Clin Psychol Rev 2011;31:1117-25.
2Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2019;3:3829-66.
3Terrell DR, Reese J, Branesky D, Lu K, Watson SI, Thachil J, et al. Depression in adult patients with primary immune thrombocytopenia. Am J Hematol 2016;91:E462-3.
4Grace RF, Klaassen RJ, Shimano KA, Lambert MP, Grimes A, Bussel JB, et al. Fatigue in children and adolescents with immune thrombocytopenia. Br J Haematol 2020;191:98–106.
5Trotter P, Hill QA. Immune thrombocytopenia: Improving quality of life and patient outcomes. Patient Relat Outcome Meas 2018;9:369-84.