Depression, suicidal ideation, and attempts in black patients with sickle cell disease

1090 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 101, NO. 11, NOVEMBER 2009

o r i g i n a l c o m m u n i c a t i o n

IntroductIon

Rates of successful suicides are relatively high among blacks who are chronically ill as com-pared to other populations, hypothesized by

many as a function of disproportional social stressors.1-3 There is a known and intimate relationship between sui-cidal thoughts, gestures, attempts, and successful sui-cides, and major depressive episode.4 Major depression is very common among patients with chronic obstruc-tive pulmonary disease (COPD),5 coronary heart disease (CHD),6-8 and diabetes mellitus.9-13 The prevalence rates of depression in these populations vary between 6% and 42%, and depression contributes to functional impair-ments and high rates of rehospitalization among these populations.14-16

Depression and coping also account for a substantial amount of the variance in disability among chronic med-ically ill populations.17,18 Strong correlates of depression that likely influence disability include but are not limited to obesity, increased rates of cancer, arthritis, asthma, cardiovascular disease and poor cardiovascular health, and poor diabetic control.19

Depression in blacks can be particularly complex and associated with a range of factors that affect etiol-ogy, progression, and resolution of symptoms associated with other diseases. Blacks have been found to have a lower overall lifetime prevalence of major depressive disorder (10.4%) as compared to their Caucasian coun-terparts (17.9%), but greater symptom severity and increased functional impairments.20 There is further evi-

Author Affiliations: Department of Psychiatry, Division of Medical Psychol-ogy (Drs Edwards, Wellington, Feliu, McDougald, and Hubbard; Mss Green, Wood, and Edwards; Mr Muhammad), Department of Medicine, Division of Hematology (Drs Edwards and DeCastro, Ms Abrams), and Pain and Palliative Care Center (Dr Edwards), Duke University Medical Center, Dur-ham, North Carolina; Department of Psychology, The Ohio State University (Dr Sollers, Ms Green, Mr Hill), Columbus, Ohio; Department of Psychology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Barksdale); Department of Psychology, North Carolina Central University, Durham, North Carolina (Dr Robinson); Department of Psychology, East

Carolina University, Greenville, North Carolina (Dr McDougald); Depart-ment of Psychology, Duke University, Durham, North Carolina (Dr Whitfield); Department of Biology, North Carolina A&T State University, Greensboro, North Carolina (Dr Byrd); Department of Psychiatry and Neurology, Tulane University, New Orleans, Louisiana (Dr Cola); School of Nursing, University of North Carolina–Greensboro, Greensboro, North Carolina (Dr McNeil).corresponding Author: Christopher L. Edwards, PhD, BCIAC, IABMCP, Medical Director, Biofeedback Laboratory and Pediatric Neuropsy-chology Service, Director, Chronic Pain Management Program, Duke University Medical Center, 932 Morreene Rd, Rm 170, Durham, NC 27705 ([email protected]).

Funding/Support: Several members of the current research team were funded by grant 1U101-AA016473-03 from National Heart, Lung, and Blood Institute.

There is a strong relationship between suicidal ideation, sui-cide attempts, and depression. Rates of successful suicides are relatively high among the chronically ill compared to other populations but are reduced with treatment. Depres-sion and suicide rates also often differ among blacks as com-pared to other populations. Using survey methods, we evalu-ated self-reported rates of depression, suicidal ideation, and suicide attempts in 30 male and 37 female black patients with sickle cell disease (SCD). SCD is a condition characterized by chronic, unpredictable pains and psychosocial distress. Thirty-six percent of the sample self-reported depression in the past 30 days, while 22 percent of the sample exhibited scores on the Beck Depression Inventory indicative of mild or greater depression (mean BDI, 8.31 ± 7.79). Twenty-nine percent of patients indicated an episode of suicidal ideation and 8%, a suicidal attempt in their lifetime. Thirty-three percent reported treatment by a mental health professional.

We conclude that there is a continuing need for mental health services in the management of depressed affect and risk for suicide among patients with SCD. Standards of clini-cal care must remain flexible to accommodate the mental health needs of this population of patients.

Keywords: depression n sickle cell anemia n African Americans

J Natl Med Assoc. 2009;101:1090-1095

Depression, Suicidal Ideation, and Attempts in Black Patients With Sickle Cell DiseaseChristopher L. Edwards, PhD; Marquisha Green, PhD; Chanté C. Wellington, PhD; Malik Muhammad, PhD; Mary Wood, MA; Miriam Feliu, PsyD; Lekisha Edwards, PhD; LaBarron Hill, MA; John J. Sollers III, PhD; Crystal Barksdale, PhD; Elwood L. Robinson, PhD; Camela S. McDougald, PhD; Mary Abrams, MPH; Keith E. Whitfield, PhD; Goldie Byrd, PhD; Bob Hubbard, PhD; Monique Cola, PhD; Laura DeCastro, MD; Janice McNeil, PhD

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 101, NO. 11, NOVEMBER 2009 1091

DEPRESSION, SUICIDAL IDEATION, AND SICKLE CELL DISEASE

dence that blacks with chronic illnesses in lower socio-economic strata or who have limited social resources may be particularly at increased risk for negative effects of depression.21

While black women appear to be at significant risk for depression, black men may have a higher overall risk for suicide attempts, ideation, and successes. In an anal-ysis of a sample of 153 death records representing com-pleted suicides by blacks, Willis, Coombs, Drentea, and Cockerham22 reported inconsistent prototypical precur-sors of suicidality and severe depression (ie, withdrawal from friends and family, verbal declaration of intent), making the prediction of their depressive status difficult. Demographically, blacks who successfully committed suicide were also more likely to be male, aged less than 35 years, and come from urban or metropolitan areas. Generally, black males that are affected by depression appear less likely than their depressed black female counterparts to seek mental health services.23

Despite the vast research on the prevalence of depres-sion among patients with chronic medical illness and its association with multiple aspects of the health experi-ence, little is known about the influence of depression among black adult patients with sickle cell disease (SCD).24-26 Some researchers estimate that as many as 40% of patients with SCD will experience at least 1 clin-ically relevant episode of depression in their lifetime,27

while others have estimated the lifetime prevalence as exceeding 50%.28 Depression in patients with SCD is important to understand because it is associated with increased emergency room treatments, hospital admis-sions, chronic pain flares, SCD crises, and higher levels of related psychopathologies.24,28-32

Although SCD is the most common genetic disease of the blood,33 and it is evident that almost half of black patients with SCD will experience at least 1 lifetime epi-sode of depression, few studies provide evidence for the more common symptoms associated with depression in this population. Unfortunately, those studies that are available often appear in conflict. For example, Hasan and colleagues27 found that patients with SCD experi-ence depressive symptoms at higher rates than the gen-eral black population, while in contrast Laurence et al34 found that the prevalence of depression in blacks with SCD is similar to that of the general black population.

Independent of ongoing debates about the incidence and prevalence of depression, for black adults with SCD, depression clearly appears potentially associated with SCD crises. Jenerette, Funk, and Murdaugh24 reported a small but significant relationship between frequencies of SCD crises and self-reported depressive symptoms in a sample of black patients with SCD. Patients with the most clinically severe SCD pain also exhibited the greatest prevalence of depression. Of the symptoms associated with depression, suicidality presents as the most lethal.34

Whereas researchers have examined the causes of

mortality in children with SCD, limited research exists to elucidate the causes of death in adults with this disease. Perronne and colleagues35 published 1 of 3 existing stud-ies examining causes of death among adults with SCD receiving tertiary care in Europe. Approximately 1000 patients were followed throughout a 16-year period. Dur-ing the course of the study, 61 patients with SCD, 9 patients with HbSC, and 3 with HBSß died with the pri-mary cause of death documented as acute sickle-related vaso-occlusion (51% of the 53 available patients) evi-denced by acute multiorgan failure (n = 13), acute chest syndrome (n = 9) and stroke (n = 5). Further, 10 partici-pants (19%) died of infections such as human immuno-deficiency virus, streptococcus pneumoniae meningitis, infection with Gram-negatives rods, and varicellae penu-monitis. An additional 10 participants died from chronic terminal visceral involvement associated with their SCD. Two participants (4%) actively committed suicide, whereas an additional 2 participants (4%) passively com-mitted suicide by refusing necessary medical treatment (ie, transfusions for severe SCD with multivisceral com-plications). Of note and when extrapolated to the general population, these results related to the rates of suicide are commensurate with the incidence of suicidality among other severely, chronically ill populations.35

Given that blacks may manifest their depressive symptoms, including suicidality, in a manner that is dif-ficult to detect and recognize, and given that the preva-lence of depression is increased among blacks with chronic illness, we explored symptoms of depression in black patients with SCD in the current study. Patients with SCD are estimated to have a lifetime depression prevalence at 50% and appear an ideal population in which to conduct such an evaluation. Further, evidence that sickle cell pain may be related to depression and psychosocial factors in some patients further empha-sizes the need to better understand depression and sui-cide in a prospective manner in patients with SCD.36-38

MethodS

Study designThe current study represents a cross-sectional survey

evaluation of first-year data collected as part of a longi-tudinal evaluation of the interplay among physiological, psychosocial factors, and pain in black patients with SCD. We sought to explore the effects of suicide on clin-ical indices associated with clinical outcomes in patients with SCD.

SubjectsOf the 178 patients who were approached about par-

ticipation, 143 were consented for the current study. Individuals who refused participation generally indi-cated (1) time constraints, (2) already participating in a research study, or (3) lack of interest in participating in



scientific research as their primary reasons for refusal. Of the patients who consented, 67 completed testing, 40 partially completed testing, and 36 had not begun testing by the time of analysis more than 12 months after sign-ing consent. Only subjects with complete assessments were used in the current analysis. All subjects were given and signed informed consent, and the study was approved by the Duke University (Durham, North Caro-lina) institutional review board.

Sixty-seven consecutive patients (mean age 36.82 ± 11.47; range, 18-70) were recruited from the Duke Com-prehensive Sickle Cell Center during routine clinic appointments. Subjects were excluded from participa-tion in the study if they were actively in an acute episode of pain or other urgent medical crisis at the time of clinic visit, had been diagnosed with an eating disorder, or if they were unable to read and comprehend the written instructions for testing. Patients were also excluded from analysis if they had a significant diagnosis other than SCD (mental retardation, etc).

MAterIAlS

Sickle cellLongitudinal Exploration of Medical and Psycho-

social Factors in Sickle Cell Disease (LEMPFSCD). The LEMPFSCD is a multidimensional paper and pen-cil instrument designed specifically for examining this population. The LEMPFSCD is a 700-question tool con-sisting of pain, demographics, and 8 validated (Symp-toms Checklist-90 Items-Revised, Beck Depression Inventory, Multidimensional Pain Inventory, Short-Form McGill Pain Questionnaire, Menstrual Symptoms Questionnaire, Marlowe Crowne Scale of Social Desir-ability, Duke Religiosity Scale, John Henryism Scale [Appendix A]), content-driven instruments for the assessment of psychiatric, behavioral, and social func-tioning. As such, it does not yet have its own psychomet-ric properties (validity and reliability) beyond that asso-ciated with each individual scale. For the purpose of the current study the following content areas were exam-ined: demographics, pain, psychopathology, negative affect, and socially desirable responding.

Pain. The Short-Form McGill Pain Questionnaire (SF-MPQ) and a visual analogue scale (VAS) were used to measure pain severity. The SF-MPQ is structured to assess qualitative and quantitative aspects of pain, includ-ing location, intensity, quality, and temporal dimensions. Subjects were asked to rate the current intensity of each pain-related adjective by circling “none, mild, moderate, or severe.” Participants also rated the items on a 10-point scale. The VAS consists of a 100-mm line with “no pain” written at one end and “worst imaginable pain” written at the opposite end, and was used to assess spontaneous pain. The distance in millimeters from the “no pain” end to the location of the mark gave a measurement of the

pain. In the current report, we present the results for all 4 composite items from the SF-MPQ. Two of the variables were subscales (sensory and affective) of the SF-MPQ. One variable was the VAS. The final variable, the present pain index (PPI), is a single-question summarizing the patient’s pain experience. The measure has demonstrated validity and reliability with multiple pain populations. Intraclass correlations, as estimates of reliability, for the sensory, affective, and average pain scores, are 0.96, 0.95, 0.88, and 0.89, respectively.34 There is a very high correlation between scales of the long and short forms of the McGill Pain Questionnaire.

Psychopathology. The Symptoms Checklist-90 Items-Revised (SCL-90-R)39 was used to evaluate the magnitude of common psychopathologies, including somatization, obsessive-compulsive, interpersonal sen-sitivity, depression, anxiety, phobic anxiety, hostility, paranoia, psychosis, General Severity Index (GSI), Posi-tive Symptom Distress Index (PSDI), and the Positive Symptom Total (PST). Response options range from 0 (not at all) to 4 (extremely). Internal consistency for the subscales ranges from .77 to .90. Cronbach a’s for the GSI are exceptionally high and between .96 and .97 (Derogatis, Rickels, and Rock; 1976).

Social desirability. The Marlow-Crowne Social Desirability Scale (MCSD)40 is often incorporated into studies to account for a study subject’s tendency to respond to questions in a culturally desirable manner. The scale presents culturally approved behaviors with a low probability of occurrence. Higher scores represent an increased tendency to answer questions according to what the subject believes would likely please the proc-tor. Kuder-Richardson coefficient of internal consis-tency is .88 with a 1-month test-retest correlation of .89.

Procedures. Study procedures are described in more detail in several previous and recent studies.30,31 All patients were consented and enrolled individually in the current study during routine visits to the hematology clinic. Patients were identified by the study hematologist as suitable for participation based upon the patient’s ability to read, and their characteristics matched against inclusion and exclusion criteria. They were then approached by study personnel about participation. All patients were given a brief verbal overview of the study, which included conducting a review of their historical patterns of health care utilization from their medical records, and then allowed to read the consent forms. Each subject was allowed to ask questions and gain clar-ification before signing consent.

Subjects were then provided a copy of the survey, moved to a relatively quiet or isolated portion of the waiting room when possible, and given instructions for completion of the survey by a member of the study team. Additional clarification or instructions were given to patients as requested. Once complete, the survey was collected and an informal debriefing was provided.



Statistical AnalysisDescriptive statistics were used to describe the sam-

ple characteristics. Analysis of variance was used to evaluate the differential effects of suicide on pain and clinical outcomes in patients with SCD. c2 Was used to evaluate the frequency of nominal level data such as depression and anxiety.

reSultSThirty-two percent of patients were married, 48%

were single, 2% were separated, 15% were divorced, and 3% were living with a significant other. Of those patients who reported that they were involved in a relationship, the mean relationship duration in months was 89.92 ± 107.70 months. On a 0-to-10 scale, where 0 represents poor quality and 10 represents highest quality, patients in relationships rated their mean relationship quality 7.57 ± 2.35. Sixty-four percent of patients were employed at the time of assessment. Seventy-four per-cent of reporting patients (57) indicated 12 or more years of formal education (mean education, 13.28 ± 1.84). Forty-five percent of patients used in the current analyses were male (30).

depressionTwenty-nine percent (19) of patients reported that

they had experienced anxiety, c2 = 11.88, p < .0001, while 36% (24) indicated that they had experienced depression in the 30 days prior to assessment, c2 = 4.91, p < .03. Patients who endorsed these psychological symptoms did not differ in their gender, age, education, tendency to report in a socially desirable manner, or reports of pain from patients who did not endorse the presence of these symptoms, p nonsignificant.

On a more formal and psychometrically reliable measure of depression, the Beck Depression Inventory (BDI), 22% of patients (7) self-reported scores indica-tive of mild or greater depression (BDI >14). Mean BDI score was found to be in the asymptomatic range (8.31 ± 7.79; mode = 1) with scores ranging from 0, asymptom-atic to 39, severe depression. Thirty-three percent of patients (22) reported treatment by a mental health pro-fessional for their depression, c2 = 7.33, p = .007.

Only fourteen percent of patients (9) reported hope-lessness, with only 6% (4) reporting anhedonia. One percent of patients (1) reported apathy, 3% reported aggression or violence (2), while 17% (11) reported cry-ing spells. Forty-eight percent of patients (32) reported fatigue; 42% (28), appetite disturbance; and 29% (19), irritability.

SuicideIn response to the question “Have you ever thought

about committing suicide?” 29% of patients (18) indicated an episode of suicidal ideation (c2 = 11.57, p < .0007), while 8% of patients responded affirmatively to the ques-

tion “Have you ever attempted to commit suicide?”Patients who reported previous suicidal ideation

(13.50 ± 2.48) reported greater mean levels of depres-sion as compared to patients who did not report such ideation (6.04 ± 1.47), t (29) = 6.69, p = .02. Previous suicidal ideation(s) accounted for 18.7% of the variance in the total BDI score. Similarly, patients who reported previous suicidal attempts (24.50 ± 4.69) reported greater mean levels of depression as compared to patients who did not report such attempts (7.23 ± 1.21), t (30) = 12.71, p = .001. Previous suicidal attempt(s) accounted for 30.0% of the variance in total BDI score.

Suicidal ideation or attempts did not affect daily pain ratings, average weekly and monthly pain ratings, pain frequency, duration, or severity. Further, suicidal ide-ation or attempts did not affect the sensory, affective, or summary indices of the pain experiences.

health care utilizationThe average number of hospitalizations per year for

patients with SCD was 6.33 ± 10.19. The average num-ber of days per hospitalization was 1.32 ± 2.03, and the average number of emergency room visits per year was 3.94 ± 6.99. There was no effect of suicidal ideation or attempts on the number of hospitalizations per year, the number of days hospitalized per visit, and the number of emergency room visits per year.

SuMMAryWe conducted the current study to begin to inform

about the lack of empirical evidence of the prevalence of depression and suicidality in patients with SCD and how commonly the associated symptoms present in an adult sample. Previous studies provided evidence that a sig-nificant number of blacks with chronic illness may not present as symptomatic prior to a successful suicide. This implies that they either suffer in silence, maintain-ing an asymptomatic social presentation, or that they do not experience those symptoms.

Consistent with the literature, we found that of the approximately one-third of patients with SCD who self-reported depression over the past 30 days, only approxi-mately one-fifth of the patients exceeded the commonly held clinical threshold for depression per the BDI. Further, several common symptoms of depression in majority pop-ulations such as apathy, hopelessness, and crying spells tended to underestimate the prevalence rate of depression in our sample. Symptoms such as fatigue and appetite dis-turbance that are shared between SCD and depression appeared to significantly overestimate the rates of per-ceived and psychometrically supported rates of depression. Symptoms such as irritability appeared to most closely mimic the self-reported and psychometrically supported rates of depression in this sample of patients with SCD.

Somewhat lower than what has been previously reported in the literature, we estimated our prevalence of



depression in the current sample as ranging from 22% to 36%, depending on whether we rely on patient’s percep-tion or psychometric testing such as the BDI. Our sam-ple appeared to be more educated, high functioning (60% employed), and more supported (most in long-term, high-quality relationships) than many of the sam-ples reviewed. This, in part, could account for the differ-ences in rates of depression.

The number of patients who reported at least 1 epi-sode of suicidality in the past year better matched patient’s self-perception of their depression (29/36) as compared to the psychometrically supported rate (29/ 22) and in a manner consistent with data on the relation-ship of suicidality to depression. Traditional conceptual-izations have a smaller percentage of patients who are depressed experiencing suicidality. There are few con-ceptualizations until recent (suicide bombers, etc) that have suicide as a symptom in the absence of depression. Surprisingly, suicidal ideation or attempts did not impact patients’ ratings of daily, weekly, and monthly pain intensity. Suicidality was also not related to reported pain severity, duration, or frequency.

We interpret these data in a manner consistent with a growing segment of the literature indicating that blacks may, for whatever reasons, present with nontraditional symptoms of depression, and as such, may be more sus-ceptible to underdiagnosis and undertreatment. Further, there is a significant need to begin to understand models of depression in diverse populations within the United States and to aggressively move beyond the “one size fits all” mentality or depression conceptualization, evalua-tion, and treatment.41,42 Future studies, for example, must begin to evaluate whether unique presentations of depres-sion in blacks alter evaluation, diagnosis, and treatment of patients pursuing substance abuse and related treat-ments. We estimate from the current results that such prospective studies are important and necessary to move to a science that serves all patients in a fashion that is ecologically valid in consideration of their history and context, as well as reduces health disparities.

concluSIonSWe conclude that there is a continuing need to under-

stand the unique variance exhibited by blacks when they present for the treatment of depression43 and to provide effective mental health services in the management of risk associated with suicide and other psychopatholo-gies among clinical patients.44,45 Standards of medical care must remain flexible to potentially accommodate the mental health needs of blacks, given that many of the signs and symptoms of depression documented in majority populations are less prevalent in our sample of black patients with SCD. Notably, both groups appear at equal risk for suicide. We must begin to understand for what other black clinical populations such diverse pre-sentations exist and have influence on care.46

AcKnowledgMentSWe would like to give a special thanks to Richard

Robinson for his assistance in reviewing, editing, and assisting to align research efforts to the lives of patients with SCD.

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Appendix A. Additional Suicide Evaluation Questions

Have you ever thought about committing suicide? (1) Yes (0) No

Have you ever attempted to commit suicide? (1) Yes (0) No

Have you ever been treated by a mental health professional before (counselor, psychologist, psychiatrist, social worker, etc)? (1) Yes (0) No



2000;41:465-471.17. McDougald C, Edwards CL, Wood M, et al. Coping as Predictors of Psy-chiatric Morbidity and Pain in Patients with Sickle Cell Disease (SCD). J Afri-can American Stud. (in press).18. Simon GE, Von Korff M, Lin E. Clinical and functional outcomes of depression treatment in patients with and without chronic medical illness. Psychol Med. 2005;35:271-279.19. Siegal JM, Yancey AK, McCarthy WJ. Overweight and Depressive Symptoms among Black Women. Prev Med. 2000;31:232-240.20. Williams DR, Gonzalez HM, Neighbors H, et al. Prevalence and Distribu-tion of Major Depressive Disorder in Blacks, Carribean Blacks, and Non-His-panic Whites: Results for the National Survey of American Life. Arch Gen Psychiatry. 2007;64:305-315.21. de Groot M, Auslander W, Williams JH, et al. Depression and Pov-erty Among Black Women at Risk for Type 2 Diabetes. Anns Beh Med. 2003;25:172-181.22. Willis LA, Coombs DW, Drentea P, et al. Uncovering the Mystery: Factors of Black Suicide. Suicide Life Threat Behav. 2003;33:412- 429.23. Neighbors HW, Caldwell C, Williams DW, et al. Race, Ethnicity, and the Use of Services for Mental Disorders: Results for the National Survey of American Life. Arch Gen Psychiatry. 2007;64:485-494.24. Jenerette C, Funk M, Murdaugh C. Sickle Cell Disease: A Stigmatiz-ing Condition that May Lead to Depression. Issues Ment Health Nurs. 2005;26:1081-1101. 25. Harrison MO, Edwards CL, Koenig HG, et al. Religiosity/ Spirituality and Pain in Patients With Sickle Cell Disease. J Nerv Ment Dis. 2005;193:250-257.26. Keefe F, Lumley MA, Buffington A, et al. The Changing Face of Pain: The Evolution of Pain Research. Psychosom Med. 2002;64:921-938.27. Hasan SP, Hashmi S, Alhassen M, et al. Depression in sickle cell disease. J Natl Med Assoc. 2003;95:533-537.28. Belgrave FZ, Molock SD. The role of depression in hospital admissions and emergency treatment of patients with sickle cell disease. JAMA. 1991;83:771-781.29. Edwards CL, Killough A, Wood M, et al. Prediction of Mental Health Symptoms From Negative Emotional Reactions to Pain in Adult Patients with Sickle Cell Disease (SCD). Clin J Pain. (in press).30. Pells J, Edwards CL, McDougald C, et al. Gender Differences in Fear of Movement (Kinesiophobia) and Pain-Related Outcomes in Patients With Sickle Cell Disease (SCD). Clin J Pain. 2007;23:707-713. 31. Pells J, Presnell K, Edwards CL, et al. Moderate Chronic Pain, Weight, And Dietary Intake In African American Adult Patients With Sickle Cell Dis-

ease (SCD). J Natl Med Assoc. 2005;97:1622-1629.32. Schaeffer JJ, Gill KM, Burchinal M, et al. Depression, Disease Severity, and Sickle Cell Disease. J Behav Med. 1998;22:115-126.33. Mankad V, Moore R. Sickle cell disease: Pathophysiology, Diagnosis and Management. Westport, CT: Praeger Publishers; 1992.34. Laurence B, George D, Woods D. Association between elevated depressive symptoms and clinical disease severity in Black adults with sick-le cell disease. J Natl Med Assoc. 2006;98:365-369.35. Perronne V, Roberts-Harewood M, Bachir D, et al. Patterns of mortality in sickle cell disease in adults in France and England. Hematol J. 2002;3:56-60.36. Edwards CL, Whitfield K, Sudhakar S, et al. Parental Substance Abuse, Reports of Chronic Pain, and Coping in Adult Patients with Sickle Cell Dis-ease (SCD). J Natl Med Assoc. 2006;98:420-428.37. Edwards CL, Scales M, Loughlin C, et al. A Brief Review of the Patho-physiology, Associated Pain, and Psychosocial Issues Associated With Sick-le Cell Disease (SCD). Int J Behav Med. 2005;12:171-179.38. Edwards CL, Fillingim RB, Keefe F. Race, Ethnicity, and Pain. Pain. 2001;94:133-137.39. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol Bull. 1973;9:13-28.40. Shrauger JS. Performance on the Marlowe-Crowne Scale and its per-ceived purpose. J Pers Assess. 1972;36:287-290.41. Edwards CL, Primm A, Johnson S, et al. Reconsideration of the Training of Psychiatrists and Mental Health Professionals: Helping to Make Soup. J Natl Med Assoc. 2006;98:1498-1500.42. Phan A, Edwards CL, Robinson E. The Assessment of Pain and Discom-fort in Individuals With Mental Retardation. Res Dev Disabil. 2005;26:433-438.43. Whitfield KE, Allaire JC, Belue R, Edwards CL. Are comparisons the answer to understanding behavioral aspects of aging in racial and ethnic groups? J Gerontol Psychol Sci. 2008;63b.44. Alao AO, Cooley E. Depression and Sickle Cell Disease. Harv Rev Psy-chiatry. 2001;9:169-177.45. Whitfield KE, Edwards CL, Brandon D, et al. The genetic and environ-mental influences on depressive symptoms by age and gender in Black twins. J Aging Ment Health. 2008;12:1-7.46. Edwards CL, Feliu M, Johnson S, et al. Beyond Sepsis, Pain, and Disfigure-ment: The Case of Psychological Reactions to Chemical Burn in a Patient with Extensive Psychiatric History. J African American Stud. 2008;12:243-265. n

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Depression, suicidal ideation, and attempts in black patients with sickle cell disease