Depression, Anxiety Risk High in Adults With Cerebral Palsy

Damian McNamara

January 07, 2019

Adults with cerebral palsy (CP) are more likely to experience symptoms of depression and/or anxiety compared with adults without the motor disorder, new research suggests.

In a longitudinal study conducted in the UK, unadjusted analyses showed that the risk for depression among 1705 adults with CP was 43% higher compared with a group of 5115 adults without CP. Those with CP also had a 40% increased risk for anxiety.

In addition, those with CP but without intellectual disability (ID) were at greater risk for depression and/or anxiety.

"Our main take home message for physicians who treat adults living with cerebral palsy is that they should also be aware of worsening mental health alongside worsening physical health," principal investigator Kimberley J. Smith, PhD, Department of Psychological Sciences, Faculty of Health and Medical Sciences, University of Surrey, United Kingdom, told Medscape Medical News.

"However, more broadly than this [is that] we want to promote awareness among clinicians that cerebral palsy is a lifelong condition, not just something that affects people in childhood — as historically, cerebral palsy has been thought of as a pediatric condition," Smith added.

The findings were published online December 28 in JAMA Neurology.

Lifelong Condition

CP is usually diagnosed in early childhood and so many consider it to be a pediatric condition.

"However, CP is a lifelong condition with the majority of children living into adulthood, depending on the severity of the condition and associated physical comorbidities," the researchers write.

An estimated 20% to 25% of adults with CP experience clinically significant levels of depressive symptoms, previous research suggests. Another study, conducted in the US, found 31% of 501 adults with CP met diagnostic criteria for major depression, and 39% met criteria for anxiety disorder.

The current study addresses a paucity of research on mental health and CP in adults. Most studies assess children with CP and "cannot be generalized to adult populations," the researchers write. The current study is longitudinal, which allowed them to evaluate risk of developing depression or anxiety over time.

The investigators assessed the Clinical Practice Research Datalink primary care database, which covers more than 4 million people in the UK.

The large amount of data allowed them to compare each adult with CP with three others without CP matched for age, sex, and medical practice. They included patients from the same practice to approximate socioeconomic level.

People with CP had a higher frequency of primary care visits, epilepsy, and pain conditions compared with the matched controls group. The mean age was 33 years and 47% of the study population were women.

The researchers relied on clinical codes to identify cases of depression and anxiety. When codes only suggested depression or anxiety (for example, "mood disorder" or "worrying"), they looked for prescription of an antidepressant or anxiolytic medication.

Depression, Anxiety Data

The investigators identified 1179 new depression events during follow-up. This included 18.3% of patients with CP and 17% of the control cohort. Median follow-up was 5.7 years in the patient cohort and 9.1 years in the reference group.

Risk for depression was greater in the patient group (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.24 - 1.64) in an unadjusted Cox model.

The association remained statistically significant after controlling for potential confounders that could contribute to depression or anxiety (HR, 1.28; 95% CI, 1.09 - 1.51).

These factors included heart disease, lung disease, pain conditions (defined as four or more prescriptions of pain medication), epilepsy, diabetes, and the mean number of primary care visits.

The researchers had proposed that presence or absence of ID could affect the results.

They found that 19.6% of the group with CP but without ID developed depression compared with 13.3% of the CP group with ID. Compared with the control group, those with CP but no ID had higher risks for incident depression in an adjusted Cox regression analysis (HR, 1.44; 95% CI, 1.20 - 1.72).

In terms of anxiety, 15.3% of the full CP group experienced a new event, as did 13.6% of the control group. Median follow-up was 6 years in the CP group and 9.5 years among the controls.

Those with CP had a higher risk for anxiety compared with those acting as controls in an unadjusted analysis (HR, 1.40; 95% CI, 1.21 - 1.63). The risk remained essentially unchanged after researchers adjusted for chronic conditions and frequency of primary care visits (HR, 1.38; 95% CI, 1.15 - 1.64).

Intellectual disability also emerged as a factor affecting the relationship between CP and anxiety. A greater proportion of CP patients without ID experienced incident anxiety (16.2%) compared with the control group (12.2%). The median follow-up was at 5.6 years and 7.7 years, respectively.

Need for Mental Health Monitoring

"People living with any chronic physical health condition are two to three times more likely to have poorer mental health," Smith said. This population should also have their mental health monitored, she added.

However, CP is an "umbrella term for a heterogeneous collection of symptoms," which can make screening more challenging for clinicians, Smith acknowledged.

"These findings support the need to consider cerebral palsy as a lifelong condition and to identify and address mental health problems among people with cerebral palsy alongside physical health problems," said coauthor Jennifer M. Ryan, PhD, Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin.

"We hope that the findings of the study will help accelerate a response to adults with cerebral palsy who report inadequate provision of coordinated health services worldwide," Ryan added.

Based on the current study establishing an association between CP in adulthood and greater risk for depression and anxiety, a next step could be to elucidate possible mechanisms.

The researchers report that studies are underway to assess how aging with CP influences the risk for developing and dying from noncommunicable diseases. In addition, they plan to investigate the risk for arthropathies in this population.

Treatable Conditions

Asked by Medscape Medical News to comment on the findings, Robert Fortuna, MD, associate professor of internal medicine, pediatrics, and community health at the University of Rochester Medical Center, New York, said that the study "offers valuable insight into the increased risk of developing depression and anxiety in adults with CP compared to the general population. These findings are in line with other studies."

The current study is also important because patients with CP are increasingly surviving into later adulthood, said Fortuna, who was not involved with the study. In addition, health conditions in adults with CP, especially mental health conditions, frequently go undetected.

"Depression and anxiety are potentially treatable conditions, highlighting the importance of recognizing these conditions in adults with CP," he added.

"If anxiety and depression disorders are identified, initiating treatment may lead to improved quality of life, health, and physical functioning," Fortuna said.

The study was funded by a Research Catalyst Award from Brunel University London. Dr Smith, Dr Ryan, and Dr Fortuna have disclosed no relevant financial relationships.

JAMA Neurology. Published online December 28, 2019. Abstract

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