Discussion
In recent years, the psychological state of children with strabismus and their families has been followed with interest increasingly. According to a series of studies, parents of children who have intermittent exotropia (IXT) show a clear predisposition toward psychological suffering based on their anxiety and depressive symptoms. Since more than 90% of IXT patients exhibit a decline in their mental health, the parents are genuinely worried about their children[20]. Successful strabismus surgery has a positive impact on children’s and their families’ psycho-social functioning, particularly anxiety, and quality of life.
In clinical practice, clinical evaluation by psychologist is still the standard method for diagnosing anxiety and depression; however, self-report tests like the HADS and SAS/SDS are commonly used for screening and measuring anxiety and depression as well. The HADS scale is a self-report questionnaire that is used to investigate how mood disorders, particularly anxiety and depression, contribute to suffering within the context of medicine practice. The scale was originally developed for use in a hospital setting, though it is now widely used across all settings, including screening in families of patients with diseases [29]. Another technique for determining a patient’s anxiety or depression levels when they exhibit symptoms connected to either condition is SAS/SDS. The 20-item of SAS and SDS scales evaluate how severe a patient’s depression symptoms have been over the past week.
According to a prior study,based on HADS criteria, anxiety and depression are diagnosed in 24% and 11% of adult strabismus patients, respectively [30]. This coincidentally aligns with our findings regarding parents of strabismus-affected children (positive rates of anxiety and depression were 21.82% and 16.82%, respectively), who in this study reported clinical levels of anxiety and depression—roughly ten times higher than those in the general population[31]. The anxiety rate by HADS-A was higher than that by SAS, and the depression detection rate by HADS-D was lower than that of SDS in our study, based on the HADS and SAS/SDS criteria. Compared with SAS, which aims to assess the psychological status of patients in the recent week, the higher detection rate of anxiety by HADS-A might be related to the fact that HADS-A is immediately affected by children’s hospitalization. We reasoned that the increased number of questions in the SDS from different perspectives and the tendency for the SDS scores to produce more depression patients could be the cause of the increasing risk of depression.
Although there were significant differences in detection rates between HADS-A and SAS and between HADS-D and SDS, there was no difference in anxiety/depression severity detected by the two scales. In addition, correlation analysis revealed that HADS-A and SAS were of good consistency in anxiety detection and HADS-D was consistent with SDS in detecting depression. Meanwhile, both clinical anxiety and depression detected by HADS-A and SAS, HADS-D and SDS in our study were experienced by 5.91% (13/220), and 10.91%(24/220) of patients, respectively. If these individuals had been examined by a mental health professional, they would likely they would have been diagnosed with an identifiable psychiatric disorder. We suggested that HADS and SAS/SDS were of value in assessing anxiety and depression in parents of children with patients, because both scales assessed depressive symptoms including emotional, cognitive, and behavioral symptoms, and were reliable measurements clinically in consensus.
Despite the fact that there were notable variations in the detection rates between HADS-A and SAS and between HADS-D and SDS, the two measures did not differ in the severity of anxiety or depression they detected. Furthermore, correlation analysis demonstrated strong consistency between HADS-A and SAS in recognising anxiety and consistency between HADS-D and SDS in detecting depression. In the meantime, 5.91% (13/220) and 10.91% (24/220) of patients in our study, respectively, reported having clinical anxiety and depression as determined by HADS-A and SAS, HADS-D and SDS. These people probably would have received a diagnosis of a recognised psychiatric condition if they had undergone a mental health examination. Since both scales assessed depressed symptoms, including emotional, cognitive, and behavioral symptoms, and were widely agreed to be accurate clinical measurements, we proposed that they were useful in evaluating anxiety and depression in parents of patients.
Further, HADS showed a stronger correlation with patients’ clinical data compared to SAS/SDS. Our research revealed a positive correlation between HADS-D and strabismus deviation in patients, parental education, and place of residence (urban vs. rural). With the increasing deviation angles, the status of ocular misalignment aggravates and the patient’s appearance becomes more obvious. Consequently, parents’ concerns and psychological distress symptoms will worsen as depression progresses. Prior research has also shown comparable results [32, 33]. Additionally, the parents of children with strabismus with depression have low educational levels and live in rural areas in our study. We consider the low level of education and the lack of rich medical resources in rural areas in China contribute to people’s perceptions of their condition’s visibility as well as their lack of social support and comprehension of strabismus.
Additionally, the HADS assessment took less time than the SAS/SDS assessment, which was in line with the earlier data[34]. This was a result of the questionnaire’s length, topic, and scoring methodology. An example of a chronic condition is strabismus, which may require both pre- and post-operative follow-up visits. The HADS’s quicker assessment time reduced the amount of time needed for each follow-up, which would encourage family members to cooperate more. In light of this, we propose that HADS is more appropriate and acceptable in clinics. However, more research is required to determine whether HADS is superior to SAS/SDS for assessing anxiety and depression.
The current study had some limitations: (1) it was a single-center clinical study, which could have a selection bias due to the region restriction; and (2) it was a cross-sectional study without follow-up, so we were unable to assess the long-term utility of using these two types of scales to assess anxiety and depression.
To sum up, in order to enhance the results of strabismus surgery, it is critical to identify the parents of strabismus-affected children who are enduring severe psychosocial suffering and to evaluate their expectations following surgery. For the assessment of anxiety and depression in parents of children with strabismus, HADS may be a practical and effective choice.