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.