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Prevalence and Incidence of Anxiety and Depression Among Children, Adolescents, and Young Adults With Life-Limiting ConditionsA Systematic Review and Meta-analysis

Educational Objective
To conduct a systematic review and meta-analysis to estimate the prevalence and/or incidence of anxiety and depression in children, adolescents, and young adults with life-limiting conditions.
1 Credit CME
Key Points

Question  What is the prevalence and/or incidence of anxiety and depression in children, adolescents, and young adults with life-limiting conditions?

Findings  In this systematic review and meta-analysis, the pooled prevalence of anxiety in 19 studies was 19.1%, with significant differences in prevalence according to the type of assessment tool used; in a meta-analysis of 36 studies, depression prevalence was 14.3% and was associated with increasing age. No studies included information on incidence of anxiety or depression.

Meaning  The high prevalence of anxiety and depression in children, adolescents, and young adults with life-limiting conditions highlights the need for improved services to address their psychological needs.

Abstract

Importance  Children, adolescents, and young adults with life-limiting conditions experience various challenges that may make them more vulnerable to mental health problems, such as anxiety and depression. However, the prevalence and incidence of anxiety and depression among this population appears to be unknown.

Objective  To conduct a systematic review and meta-analysis to estimate the prevalence and/or incidence of anxiety and depression in children, adolescents, and young adults with life-limiting conditions.

Data Sources  Searches of MEDLINE (PubMed), PsycInfo, and Embase were conducted to identify studies published between January 2000 and January 2018.

Study Selection  Studies were eligible for this review if they provided primary data of anxiety or depression prevalence and/or incidence, included participants aged 5 to 25 years with a life-limiting condition, were conducted in an Organisation for Economic Co-operation and Development country, and were available in English.

Data Extraction and Synthesis  Random-effects meta-analyses were generated to provide anxiety and depression prevalence estimates. Meta-regression was conducted to analyze associations between study characteristics and each prevalence estimate.

Main Outcomes and Measures  Prevalence of anxiety and depression.

Results  A total of 14 866 nonduplicate articles were screened, of which 37 were included in the review. Of these, 19 studies reported anxiety prevalence, and 36 studies reported depression prevalence. The mean (range) age of participants was 15.4 (6-25) years. The meta-analysis of anxiety prevalence (n = 4547 participants) generated a pooled prevalence estimate of 19.1% (95% CI, 14.1%-24.6%). Meta-regression analysis found statistically significant differences in anxiety prevalence by assessment tool; diagnostic interviews were associated with higher anxiety prevalence (28.5% [95% CI, 13.2%-46.8%]) than self-reported or parent-reported measures (14.9% [95% CI, 10.9%-19.4%]). The depression meta-analysis (n = 5934 participants) found a pooled prevalence estimate of 14.3% (95% CI, 10.5%-18.6%). Meta-regression analysis revealed statistically significant differences in depression prevalence by the mean age of the sample (β = 0.02 [95% CI, 0.01-0.03]; P = .001).

Conclusions and Relevance  In this systematic review and meta-analysis, the prevalence of anxiety and depression among children, adolescents, and young adults with life-limiting conditions was high, highlighting the need for increased psychological assessment and monitoring. Further research is required to determine the prevalence and incidence of anxiety and depression in a larger sample of children, adolescents, and young adults with a broader range of life-limiting conditions.

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Article Information

Accepted for Publication: March 20, 2019.

Corresponding Author: Mary M. Barker, MPH, Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York YO10 5DD, United Kingdom (mmb529@york.ac.uk).

Published Online: July 8, 2019. doi:10.1001/jamapediatrics.2019.1712

Author Contributions: Dr Barker had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Barker, Beresford, Fraser.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Barker, Beresford, Fraser.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Barker, Bland, Fraser.

Obtained funding: Beresford, Fraser.

Supervision: Beresford, Fraser.

Conflict of Interest Disclosures: Dr Fraser reported grants from Martin House Children’s Hospice during the conduct of the study. No other disclosures were reported.

Funding/Support: This article was undertaken as part of the Martin House Research Centre, which is supported by Martin House Hospice Care for Children and Young People and the University of York.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Liam Robson, BSc, MPH, University of York, conducted a portion of the abstract screening and full text review. Tom Ainscough, PhD, University of York, reviewed sections of the manuscript. They were not compensated for their contributions.

References
1.
Kieling  C, Baker-Henningham  H, Belfer  M,  et al.  Child and adolescent mental health worldwide: evidence for action.  Lancet. 2011;378(9801):1515-1525. doi:10.1016/S0140-6736(11)60827-1PubMedGoogle ScholarCrossref
2.
Perou  R, Bitsko  RH, Blumberg  SJ,  et al; Centers for Disease Control and Prevention (CDC).  Mental health surveillance among children—United States, 2005-2011.  MMWR Suppl. 2013;62(2):1-35.PubMedGoogle Scholar
3.
Kessler  RC, Berglund  P, Demler  O, Jin  R, Merikangas  KR, Walters  EE.  Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication  [published correction appears in Arch Gen Psychiatry. 2005;62(7):768].  Arch Gen Psychiatry. 2005;62(6):593-602. doi:10.1001/archpsyc.62.6.593PubMedGoogle ScholarCrossref
4.
Pinquart  M, Shen  Y.  Behavior problems in children and adolescents with chronic physical illness: a meta-analysis.  J Pediatr Psychol. 2011;36(9):1003-1016. doi:10.1093/jpepsy/jsr042PubMedGoogle ScholarCrossref
5.
Pinquart  M, Shen  Y.  Anxiety in children and adolescents with chronic physical illnesses: a meta-analysis.  Acta Paediatr. 2011;100(8):1069-1076. doi:10.1111/j.1651-2227.2011.02223.xPubMedGoogle ScholarCrossref
6.
Pinquart  M, Shen  Y.  Depressive symptoms in children and adolescents with chronic physical illness: an updated meta-analysis.  J Pediatr Psychol. 2011;36(4):375-384. doi:10.1093/jpepsy/jsq104PubMedGoogle ScholarCrossref
7.
Together for Short Lives. Children’s palliative care definitions. https://www.togetherforshortlives.org.uk/get-support/supporting-you/family-resources/childrens-palliative-care-definitions/. Published 2017. Accessed December 30, 2017.
8.
Barlow  JH, Ellard  DR.  The psychosocial well-being of children with chronic disease, their parents and siblings: an overview of the research evidence base.  Child Care Health Dev. 2006;32(1):19-31. doi:10.1111/j.1365-2214.2006.00591.xPubMedGoogle ScholarCrossref
9.
Christie  D, Viner  R.  Adolescent development.  BMJ. 2005;330(7486):301-304. doi:10.1136/bmj.330.7486.301PubMedGoogle ScholarCrossref
10.
Nadeau  L, Tessier  R.  Social adjustment of children with cerebral palsy in mainstream classes: peer perception.  Dev Med Child Neurol. 2006;48(5):331-336. doi:10.1017/S0012162206000739PubMedGoogle ScholarCrossref
11.
Hedström  M, Ljungman  G, von Essen  L.  Perceptions of distress among adolescents recently diagnosed with cancer.  J Pediatr Hematol Oncol. 2005;27(1):15-22. doi:10.1097/01.mph.0000151803.72219.ecPubMedGoogle ScholarCrossref
12.
Celano  CM, Freudenreich  O, Fernandez-Robles  C, Stern  TA, Caro  MA, Huffman  JC.  Depressogenic effects of medications: a review.  Dialogues Clin Neurosci. 2011;13(1):109-125.PubMedGoogle Scholar
13.
Higham  L, Ahmed  S, Ahmed  M.  Hoping to live a “normal” life whilst living with unpredictable health and fear of death: impact of cystic fibrosis on young adults.  J Genet Couns. 2013;22(3):374-383. doi:10.1007/s10897-012-9555-1PubMedGoogle ScholarCrossref
14.
Fraser  LK, Miller  M, Hain  R,  et al.  Rising national prevalence of life-limiting conditions in children in England.  Pediatrics. 2012;129(4):e923-e929. doi:10.1542/peds.2011-2846PubMedGoogle ScholarCrossref
15.
National Institute for Health and Care Excellence (NICE). End of life care for infants, children and young people with life-limiting conditions: planning and management. https://www.nice.org.uk/guidance/ng61/chapter/recommendations. Published 2016. Accessed December 11, 2017.
16.
Fraser  LK, Jarvis  SW, Moran  NE, Aldridge  J, Parslow  RC, Beresford  BA. Children in Scotland requiring palliative care: identifying numbers and needs (the CHISP study). https://www.york.ac.uk/media/spru/projectfiles/ProjectOutput_ChispReport.pdf. Published 2015. Accessed May 28, 2019.
17.
Hoy  D, Brooks  P, Woolf  A,  et al.  Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement.  J Clin Epidemiol. 2012;65(9):934-939. doi:10.1016/j.jclinepi.2011.11.014PubMedGoogle ScholarCrossref
18.
Barendregt  JJ, Doi  SA, Lee  YY, Norman  RE, Vos  T.  Meta-analysis of prevalence.  J Epidemiol Community Health. 2013;67(11):974-978. doi:10.1136/jech-2013-203104PubMedGoogle ScholarCrossref
19.
Laufersweiler-Plass  C, Rudnik-Schöneborn  S, Zerres  K, Backes  M, Lehmkuhl  G, von Gontard  A.  Behavioural problems in children and adolescents with spinal muscular atrophy and their siblings.  Dev Med Child Neurol. 2003;45(1):44-49. doi:10.1111/j.1469-8749.2003.tb00858.xPubMedGoogle ScholarCrossref
20.
Till  C, Udler  E, Ghassemi  R, Narayanan  S, Arnold  DL, Banwell  BL.  Factors associated with emotional and behavioral outcomes in adolescents with multiple sclerosis.  Mult Scler. 2012;18(8):1170-1180. doi:10.1177/1352458511433918PubMedGoogle ScholarCrossref
21.
Matziou  V, Perdikaris  P, Galanis  P, Dousis  E, Tzoumakas  K.  Evaluating depression in a sample of children and adolescents with cancer in Greece.  Int Nurs Rev. 2008;55(3):314-319. doi:10.1111/j.1466-7657.2008.00606.xPubMedGoogle ScholarCrossref
22.
Kersun  LS, Rourke  MT, Mickley  M, Kazak  AE.  Screening for depression and anxiety in adolescent cancer patients.  J Pediatr Hematol Oncol. 2009;31(11):835-839. doi:10.1097/MPH.0b013e3181b8704cPubMedGoogle ScholarCrossref
23.
Durualp  E, Altay  N.  A comparison of emotional indicators and depressive symptom levels of school-age children with and without cancer.  J Pediatr Oncol Nurs. 2012;29(4):232-239. doi:10.1177/1043454212446616PubMedGoogle ScholarCrossref
24.
Bemis  H, Yarboi  J, Gerhardt  CA,  et al.  Childhood cancer in context: sociodemographic factors, stress, and psychological distress among mothers and children.  J Pediatr Psychol. 2015;40(8):733-743. doi:10.1093/jpepsy/jsv024PubMedGoogle ScholarCrossref
25.
Rivas-Molina  NS, Mireles-Pérez  EO, Soto-Padilla  JM, González-Reyes  NA, Barajas-Serrano  TL, Barrera de León  JC.  Depresión en escolares y adolescentes portadores de leucemia aguda en fase de tratamiento.  Gac Med Mex. 2015;151(2):186-191.PubMedGoogle Scholar
26.
Casier  A, Goubert  L, Huse  D,  et al.  The role of acceptance in psychological functioning in adolescents with cystic fibrosis: a preliminary study.  Psychol Health. 2008;23(5):629-638. doi:10.1080/08870440802040269PubMedGoogle ScholarCrossref
27.
White  T, Miller  J, Smith  GL, McMahon  WM.  Adherence and psychopathology in children and adolescents with cystic fibrosis.  Eur Child Adolesc Psychiatry. 2009;18(2):96-104. doi:10.1007/s00787-008-0709-5PubMedGoogle ScholarCrossref
28.
Smith  BA, Modi  AC, Quittner  AL, Wood  BL.  Depressive symptoms in children with cystic fibrosis and parents and its effects on adherence to airway clearance.  Pediatr Pulmonol. 2010;45(8):756-763. doi:10.1002/ppul.21238PubMedGoogle ScholarCrossref
29.
Casier  A, Goubert  L, Theunis  M,  et al.  Acceptance and well-being in adolescents and young adults with cystic fibrosis: a prospective study.  J Pediatr Psychol. 2011;36(4):476-487. doi:10.1093/jpepsy/jsq111PubMedGoogle ScholarCrossref
30.
Modi  AC, Driscoll  KA, Montag-Leifling  K, Acton  JD.  Screening for symptoms of depression and anxiety in adolescents and young adults with cystic fibrosis.  Pediatr Pulmonol. 2011;46(2):153-159. doi:10.1002/ppul.21334PubMedGoogle ScholarCrossref
31.
Oliver  KN, Free  ML, Bok  C, McCoy  KS, Lemanek  KL, Emery  CF.  Stigma and optimism in adolescents and young adults with cystic fibrosis.  J Cyst Fibros. 2014;13(6):737-744. doi:10.1016/j.jcf.2014.04.005PubMedGoogle ScholarCrossref
32.
Quittner  AL, Goldbeck  L, Abbott  J,  et al.  Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of the International Depression Epidemiological Study across nine countries.  Thorax. 2014;69(12):1090-1097. doi:10.1136/thoraxjnl-2014-205983PubMedGoogle ScholarCrossref
33.
Askew  K, Bamford  J, Hudson  N,  et al.  Current characteristics, challenges and coping strategies of young people with cystic fibrosis as they transition to adulthood.  Clin Med (Lond). 2017;17(2):121-125. doi:10.7861/clinmedicine.17-2-121PubMedGoogle ScholarCrossref
34.
Pao  M, Lyon  M, D’Angelo  LJ, Schuman  WB, Tipnis  T, Mrazek  DA.  Psychiatric diagnoses in adolescents seropositive for the human immunodeficiency virus.  Arch Pediatr Adolesc Med. 2000;154(3):240-244. doi:10.1001/archpedi.154.3.240PubMedGoogle ScholarCrossref
35.
Murphy  DA, Durako  SJ, Moscicki  AB,  et al; Adolescent Medicine HIV/AIDS Research Network.  No change in health risk behaviors over time among HIV infected adolescents in care: role of psychological distress.  J Adolesc Health. 2001;29(3)(Suppl):57-63. doi:10.1016/S1054-139X(01)00287-7PubMedGoogle ScholarCrossref
36.
Elliott-DeSorbo  DK, Martin  S, Wolters  PL.  Stressful life events and their relationship to psychological and medical functioning in children and adolescents with HIV infection.  J Acquir Immune Defic Syndr. 2009;52(3):364-370. doi:10.1097/QAI.0b013e3181b73568PubMedGoogle ScholarCrossref
37.
Andrinopoulos  K, Clum  G, Murphy  DA,  et al; Adolescent Medicine Trials Network for HIV/AIDS Interventions.  Health related quality of life and psychosocial correlates among HIV-infected adolescent and young adult women in the US.  AIDS Educ Prev. 2011;23(4):367-381. doi:10.1521/aeap.2011.23.4.367PubMedGoogle ScholarCrossref
38.
Martinez  J, Harper  G, Carleton  RA,  et al; Adolescent Medicine Trials Network.  The impact of stigma on medication adherence among HIV-positive adolescent and young adult females and the moderating effects of coping and satisfaction with health care  [published correction appears in AIDS Patient Care STDS. 2014;28(10):565].  AIDS Patient Care STDS. 2012;26(2):108-115. doi:10.1089/apc.2011.0178PubMedGoogle ScholarCrossref
39.
Nachman  S, Chernoff  M, Williams  P, Hodge  J, Heston  J, Gadow  KD.  Human immunodeficiency virus disease severity, psychiatric symptoms, and functional outcomes in perinatally infected youth.  Arch Pediatr Adolesc Med. 2012;166(6):528-535. doi:10.1001/archpediatrics.2011.1785PubMedGoogle ScholarCrossref
40.
Salama  C, Morris  M, Armistead  L,  et al.  Depressive and conduct disorder symptoms in youth living with HIV: the independent and interactive roles of coping and neuropsychological functioning.  AIDS Care. 2013;25(2):160-168. doi:10.1080/09540121.2012.687815PubMedGoogle ScholarCrossref
41.
Brown  LK, Whiteley  L, Harper  GW, Nichols  S, Nieves  A; ATN 086 Protocol Team for The Adolescent Medicine Trials Network for HIV/AIDS Interventions.  Psychological symptoms among 2032 youth living with HIV: a multisite study.  AIDS Patient Care STDS. 2015;29(4):212-219. doi:10.1089/apc.2014.0113PubMedGoogle ScholarCrossref
42.
Clemente  C, Tsiantis  J, Sadowski  H,  et al.  Psychopathology in children from families with blood disorders: a cross-national study.  Eur Child Adolesc Psychiatry. 2002;11(4):151-161. doi:10.1007/s00787-002-0257-3PubMedGoogle ScholarCrossref
43.
Aydinok  Y, Erermis  S, Bukusoglu  N, Yilmaz  D, Solak  U.  Psychosocial implications of thalassemia major.  Pediatr Int. 2005;47(1):84-89. doi:10.1111/j.1442-200x.2004.02009.xPubMedGoogle ScholarCrossref
44.
Cakaloz  B, Cakaloz  I, Polat  A, Inan  M, Oguzhanoglu  NK.  Psychopathology in thalassemia major.  Pediatr Int. 2009;51(6):825-828. doi:10.1111/j.1442-200X.2009.02865.xPubMedGoogle ScholarCrossref
45.
Adanır  AS, Taskıran  G, Fettahoglu  EC, Ozatalay  E.  Psychopathology and family functioning in adolescents with beta thalassemia.  Adolesc Psychiatry. 2017;7(1):4-12. doi:10.2174/2210676606666161115143217Google ScholarCrossref
46.
Bäckman  ML, Santavuori  PR, Aberg  LE, Aronen  ET.  Psychiatric symptoms of children and adolescents with juvenile neuronal ceroid lipofuscinosis.  J Intellect Disabil Res. 2005;49(pt 1):25-32. doi:10.1111/j.1365-2788.2005.00659.xPubMedGoogle ScholarCrossref
47.
Amato  MP, Goretti  B, Ghezzi  A,  et al; Multiple Sclerosis Study Group of the Italian Neurological Society.  Cognitive and psychosocial features of childhood and juvenile MS.  Neurology. 2008;70(20):1891-1897. doi:10.1212/01.wnl.0000312276.23177.faPubMedGoogle ScholarCrossref
48.
Amato  MP, Goretti  B, Ghezzi  A,  et al; Multiple Sclerosis Study Group of the Italian Neurological Society.  Cognitive and psychosocial features in childhood and juvenile MS: two-year follow-up.  Neurology. 2010;75(13):1134-1140. doi:10.1212/WNL.0b013e3181f4d821PubMedGoogle ScholarCrossref
49.
Elsenbruch  S, Schmid  J, Lutz  S, Geers  B, Schara  U.  Self-reported quality of life and depressive symptoms in children, adolescents, and adults with Duchenne muscular dystrophy: a cross-sectional survey study.  Neuropediatrics. 2013;44(5):257-264. doi:10.1055/s-0033-1347935PubMedGoogle ScholarCrossref
50.
Parrish  JB, Weinstock-Guttman  B, Smerbeck  A, Benedict  RH, Yeh  EA.  Fatigue and depression in children with demyelinating disorders.  J Child Neurol. 2013;28(6):713-718. doi:10.1177/0883073812450750PubMedGoogle ScholarCrossref
51.
Kogon  AJ, Vander Stoep  A, Weiss  NS, Smith  J, Flynn  JT, McCauley  E.  Depression and its associated factors in pediatric chronic kidney disease.  Pediatr Nephrol. 2013;28(9):1855-1861. doi:10.1007/s00467-013-2497-5PubMedGoogle ScholarCrossref
52.
Kogon  AJ, Matheson  MB, Flynn  JT,  et al; Chronic Kidney Disease in Children (CKiD) Study Group; Chronic Kidney Disease in Children CKiD Study Group.  Depressive symptoms in children with chronic kidney disease.  J Pediatr. 2016;168:164-170. doi:10.1016/j.jpeds.2015.09.040PubMedGoogle ScholarCrossref
53.
Kilicoglu  AG, Bahali  K, Canpolat  N,  et al.  Impact of end-stage renal disease on psychological status and quality of life.  Pediatr Int. 2016;58(12):1316-1321. doi:10.1111/ped.13026PubMedGoogle ScholarCrossref
54.
Mellins  CA, Brackis-Cott  E, Leu  C-S,  et al.  Rates and types of psychiatric disorders in perinatally human immunodeficiency virus-infected youth and seroreverters.  J Child Psychol Psychiatry. 2009;50(9):1131-1138. doi:10.1111/j.1469-7610.2009.02069.xPubMedGoogle ScholarCrossref
55.
Vizard  T, Pearce  N, Davis  J,  et al. Mental health of children and young people in England, 2017: emotional disorders. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017. Published 2018. Accessed March 8, 2019.
56.
Ferro  MA, Boyle  MH.  The impact of chronic physical illness, maternal depressive symptoms, family functioning, and self-esteem on symptoms of anxiety and depression in children.  J Abnorm Child Psychol. 2015;43(1):177-187. doi:10.1007/s10802-014-9893-6PubMedGoogle ScholarCrossref
57.
van Steensel  FJA, Bögels  SM, Perrin  S.  Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis.  Clin Child Fam Psychol Rev. 2011;14(3):302-317. doi:10.1007/s10567-011-0097-0PubMedGoogle ScholarCrossref
58.
Palmer  S, Vecchio  M, Craig  JC,  et al.  Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies.  Kidney Int. 2013;84(1):179-191. doi:10.1038/ki.2013.77PubMedGoogle ScholarCrossref
59.
Einfeld  SL, Ellis  LA, Emerson  E.  Comorbidity of intellectual disability and mental disorder in children and adolescents: a systematic review.  J Intellect Dev Disabil. 2011;36(2):137-143. doi:10.1080/13668250.2011.572548PubMedGoogle ScholarCrossref
60.
Vos  P, De Cock  P, Munde  V, Petry  K, Van Den Noortgate  W, Maes  B.  The tell-tale: what do heart rate; skin temperature and skin conductance reveal about emotions of people with severe and profound intellectual disabilities?  Res Dev Disabil. 2012;33(4):1117-1127. doi:10.1016/j.ridd.2012.02.006PubMedGoogle ScholarCrossref
61.
Wiener  L, Kazak  AE, Noll  RB, Patenaude  AF, Kupst  MJ.  Standards for the psychosocial care of children with cancer and their families: an introduction to the special issue.  Pediatr Blood Cancer. 2015;62(suppl 5):S419-S424. doi:10.1002/pbc.25675PubMedGoogle ScholarCrossref
62.
Kerem  E, Conway  S, Elborn  S, Heijerman  H; Consensus Committee.  Standards of care for patients with cystic fibrosis: a European consensus.  J Cyst Fibros. 2005;4(1):7-26. doi:10.1016/j.jcf.2004.12.002PubMedGoogle ScholarCrossref
63.
Thabrew  H, McDowell  H, Given  K, Murrell  K.  Systematic review of screening instruments for psychosocial problems in children and adolescents with long-term physical conditions.  Glob Pediatr Health. 2017;4:X17690314. doi:10.1177/2333794X17690314PubMedGoogle Scholar
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