Depression, anxiety, stress and cognition in females with Iron deficiency anemia

Vanishri A1, Kumar A2, R.S.A. Kiran Singh3

1Dr. Vanishri Ashok, Lab Registrar, Department of Pathology, King Fahad Hospital, Saudi Arabia, 2Dr. Ashok Kumar, ENT Specialist, King Fahad Hospital, Saudi Arabia, 3Dr. R.S.A. Kiran Singh, Department of Pathology, Katuri Medical College, Guntur, India

Address for Correspondence: Vanishri Ashok, Lab Registrar, Department of Pathology, King Fahad Hospital, Saudi Arabia

Abstract

Introduction: Iron deficiency anemia (IDA) is characterized by defect in the synthesis of hemoglobin leading to the poor delivery of oxygen to the cells and tissues expressing the clinical symptoms like lethargy, dizziness, shortness of breath and pale conjunctiva. Objectives: The present study is taken up to learn the levels of depression, anxiety, stress with IDA in females. The effect of IDA on cognitive skills was also studied. Methods: The present cross sectional study included thirty female participants with diagnosed iron deficiency anemia and thirty age matched controls, after obtaining voluntary, written informed consent. DASS-42 was used to assess depression, anxiety and stress. Spatial and verbal memory test was used to assess spatial and verbal memory test. Results: We have observed higher levels of depression, anxiety and stress and decreased spatial memory scores in females with iron deficiency anemia. Conclusion: We recommend further detailed studies in this area to explore the association of iron status with stress and cognition for planning better treatment options for the benefit of the patients.

Key words: Cognition, Iron deficiency anemia, spatial memory, Verbal memory

Manuscript received: 6th May 2017, Reviewed: 16th May 2017
Author Corrected: 24th May 2017, Accepted for Publication: 31st May 2017

Introduction

The concentration of hemoglobin (Hb) below 12 g/dl in non-pregnant women over 15 years of age and below 11 g/dl in pregnant women is defined as anemia given by the World Health Organization [1]. Iron deficiency anemia (IDA) is characterized by defect in the synthesis of hemoglobin leading to the poor delivery of oxygen to the cells and tissues expressing the clinical symptoms like lethargy, dizziness, shortness of breath and pale conjunctiva [2-5]. The adverse consequences of IDA are decreased academic performance, decreased cognitive skills, low reproductivity, neural dysfunction, immune system disorders [6] and also express the signs and symptoms of depression, stress and anxiety. Certain studies reported that the prevalence of depression in females of reproductive ages is twice when compare to men [7,8]. Nutition plays a key role in correcting and preventing depression. Studies stated that supplementation of iron alone can resolve most of the sign and symptoms of depression in subjects with IDA [9]. As many studies stated that IDA in females leads to many abnormalities effecting the normal life of the individual and increasing the complications during pregnancy too. Female being the most versatile person of the society contributing to the growth and development of the family and society is vulnerable for the IDA and its effects due to increased requirements, poor intake & absorption, menstrual loss & adolescent pregnancies. The present study is taken up to learn the levels of depression, anxiety, stress with IDA in females. The effect of IDA on cognitive skills was also studied.

Materials and Methods

Study design: The present cross sectional study.

Participants: The present study included thirty female participants with diagnosed iron deficiency anemia and thirty age matched controls, after obtaining voluntary, written informed consent. The following criteria were used in the selection of cases.

Inclusion criteria
1.  Willing participants with in age group of 30-50 years
2.  Hemoglobin levels less than 12 mg/dL
3.  Not having any other complications.

Exclusion criteria
1.  Participants with systematic diseases such as diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease.
2.  Participants using any medication
3.  Pregnant women

After collection of socio-demographic data of the participants, they were requested to fill the questionnaire for depression, anxiety and stress and conducted spatial and verbal memory test.

Assessment of depression, anxiety and stress: DASS-42 was used to assess depression, anxiety and stress [10]

Assessment of spatial and verbal memory: Spatial and verbal memory test was used to assess spatial and verbal memory test [11].

Statistical analysis: Data was analyzed by SPSS 16.0. Student t test was applied to observe significance of difference between the groups. P<0.05 was considered as significant.

Setting: The study was conducted at Department of Pathology, Katuri Medical College, Guntur, India.

Results

Results are presented in table no 1 and 2. Demographic data was presented in table no 1. Significantly higher level of depression, anxiety and stress was observed in cases when compared with controls. Significantly lower scores of spatial memory were observed in cases when compared with controls. No significant difference was observed in verbal memory scores.

Table-1: Demographic data of the participants

Parameter

Cases

Controls

P value

Age

35±8

34±10

0.6705

Height

144±13.66

141±16.92

0.4529

Weight

62±15.42

66±12.71

0.2774

Data was presented as Mean ± SD. P<0.05 is significant, **P<0.01 is significant, ***P<0.001 is significant.

Table- 2: Depression, anxiety, stress and memory scores of the participants

Parameter

Cases

Controls

P value

Depression

21±7

12±9

<0.0001***

Anxiety

17±5.4

12±3.56

<0.0001***

Stress

26±8.2

15±6.88

<0.0001***

Spatial memory

7±1

4±2

<0.0001***

Verbal memory

4±3

3±2

0.1342

Data was presented as Mean ± SD. P<0.05 is significant, **P<0.01 is significant, ***P<0.001 is significant.

Discussion

Iron deficiency, defined by two or more unusual measurements (serum ferritin, erythrocyte protoporphyrin, transferrin saturation), is dangerous and uneasily revealed by patients themselves and may not establish definite clinical symptoms. IDA is represented by a defect in hemoglobin synthesis owing to significant ID, arising in the declined ability of the red blood cells to deliver oxygen to body cells and tissues, and many clinical symptoms, such as pale conjunctiva, shortness of breath, dizziness, and lethargy. The main hazards for IDA and ID include a low intake of iron, poor absorption of iron from diets, chronic loss of iron (i.e., ulcer, metrorrhagia), adolescent girls and pregnancy [12,13,14,15] .

Iron is a basic element of hemoglobin, myoglobin, and many enzymes in cellular metabolism and DNA replication and repair. It also plays a main part in the development of the central neurological system [16,17,18,19], autoimmune system [20,21,22], endocrine system [23,24,25,26], and cardiovascular system[27,28].

In both developed and developing countries anemia is known to be the most common nutritional disorder in the world. In the development of the brain, iron accounted for the myelination of white matter [29]. Many researchers had shown their interest to learn the deficiency of iron and its relationship with brain function, cognition, and behavior (including emotional behavior) [30]. Patients with depression had being noticed with the changes in iron metabolism and suggested it as a potential pathological marker. In the present study we noticed a significantly higher level of depression, anxiety and stress in cases when compared with healthy individuals. Significantly lower scores of spatial memory were observed in cases when compared with controls further we noticed no significant difference in verbal memory scores. Certain studies reported that supplementation of iron alone had resolved the levels of depression and reduced the levels of stress and anxiety prior to the improvement in RBC counts. They assumed that this effect may be due to the improvement in the levels of neurotransmitters and iron dependent enzymes that are not related to the concentration of hemoglobin (hb) [31]. In contrast, other studies reported that there was no significant association between symptoms of depression and serum ferritin levels [32]. John L Beard et al., reported strong correlation between depression, anxiety and stress, cognitive functions with iron status. In the present study, we have observed significantly higher levels of depression, anxiety and stress and lower spatial memory in females with iron deficiency anemia when compared with controls.

Limitations: The major limitation of our study was lower sample size.

Conclusion

We have observed higher levels of depression, anxiety and stress and decreased spatial memory scores in females with iron deficiency anemia. We recommend further detailed studies in this area to explore the association of iron status with stress and cognition for planning better treatment options for the benefit of the patients.

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

References

1. McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005. Public Health Nutr. 2009 Apr;12(4):444-54. doi: 10.1017/S1368980008002401. Epub 2008 May 23. [PubMed]

2. DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the world. World Health Stat Q. 1985;38(3):302-16. [PubMed]

3. Joint World Health Organization/Centers for Disease Control and Prevention Technical Consultation on the Assessment of Iron Status at the Population Level (2004: Geneva Switzerland), World Health Organization. Assessing the iron status of populations: report of a joint world health organization/centers for disease control and prevention technical consultation on the assessment of iron status at the population level. Geneva, Switzerland: Geneva: World Health Organization; 2005.

4. World Health Organization. Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. Geneva: World Health Organization; 2008.

5. World Health Organization. Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. Geneva: World Health Organization; 2001.

6. Cook JD, Lynch SR. The liabilities of iron deficiency. Blood. 1986 Oct;68(4):803-9.

7. Mackler B, Person R, Miller LR, Finch CA. Iron deficiency in the rat: effects on phenylalanine metabolism. Pediatr Res. 1979 Sep;13(9):1010-1.

8. Kaplan HI. Kaplan & Sadock's Synopsis of Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2003. Doi: 10.1345/aph.1P356.

9. de Maeyer E, Adiels-Tegman M. The prevalence of anemia in the world. La prevalence de l'anemie dans le monde [Online]. [cited 1985]; Available from: URL: http://www.popline.org/node/417436.

10. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd Ed Psychology Foundation Sydney 1995.

11. Naveen KV, Nagarathna R, Nagendra HR, Telles S. Yoga breathing through a particular nostril increases spatial memory scores without lateralized effects. Psychol Rep. 1997 Oct;81(2):555-61. [PubMed]

12. DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the world. World Health Stat Q. 1985;38(3):302-16. [PubMed]

13. Joint World Health Organization/Centers for Disease Control and Prevention Technical Consultation on the Assessment of Iron Status at the Population Level (2004: Geneva Switzerland), World Health Organization: Assessing the iron status of populations: report of a joint world health organization/centers for disease control and prevention technical consultation on the assessment of iron status at the population level. 2005, Geneva, Switzerland: Geneva: World Health Organization.

14. World Health Organization: Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. 2008, Geneva: World Health Organization.

15. World Health Organization: Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. 2001, Geneva: World Health Organization.

16. Pollitt E: Effects of a diet deficient in iron on the growth and development of preschool and school-age children. Food Nutr Bull. 1991, 13: 110-118. doi: 10.1186/1471-244X-13-161.

17. Krebs NF. Dietary zinc and iron sources, physical growth and cognitive development of breastfed infants. J Nutr. 2000 Feb;130(2S Suppl):358S-360S.

18. Lind T, Lönnerdal B, Stenlund H, Gamayanti IL, Ismail D, Seswandhana R, Persson LA. A community-based randomized controlled trial of iron and zinc supplementation in Indonesian infants: effects on growth and development. Am J Clin Nutr. 2004 Sep;80(3):729-36.

19. Webb TE, Oski FA. Iron deficiency anemia and scholastic achievement in young adolescents. J Pediatr. 1973 May;82(5):827-30.

20. Gershwin ME, Keen CL, Mareschi JP, Fletcher MP. Trace metal nutrition and the immune response. Compr Ther. 1991 Mar;17(3):27-34.

21. Joynson DH, Walker DM, Jacobs A, Dolby AE. Defect of cell-mediated immunity in patients with iron-deficiency anaemia. Lancet. 1972 Nov 18;2(7786):1058-9.

22. Srikantia SG, Prasad JS, Bhaskaram C, Krishnamachari KA. Anaemia and immune response. Lancet. 1976 Jun 19;1(7973):1307-9. [PubMed]

23. Beard JL, Borel MJ, Derr J. Impaired thermoregulation and thyroid function in iron-deficiency anemia. Am J Clin Nutr. 1990 Nov;52(5):813-9.

24. Eftekhari MH, Eshraghian MR, Mozaffari-Khosravi H, Saadat N, Shidfar F. Effect of iron repletion and correction of iron deficiency on thyroid function in iron-deficient Iranian adolescent girls. Pak J Biol Sci. 2007 Jan 15;10(2):255-60.

25. Isguven P, Arslanoglu I, Erol M, Yildiz M, Adal E, Erguven M. Serum levels of ghrelin, leptin, IGF-I, IGFBP-3, insulin, thyroid hormones and cortisol in prepubertal children with iron deficiency. Endocr J. 2007 Dec;54(6):985-90. Epub 2007 Nov 12. [PubMed]

26. Zimmermann MB. The influence of iron status on iodine utilization and thyroid function. Annu Rev Nutr. 2006;26:367-89. [PubMed]

27. Andersen HS, Gambling L, Holtrop G, McArdle HJ: Maternal iron deficiency identifies critical windows for growth and cardiovascular development in the rat postimplantation embryo. J Nutr. 2006, 136 (5): 1171-1177.

28. Toxqui L, De Piero A, Courtois V, Bastida S, Sánchez-Muniz FJ, Vaquero MP. [Iron deficiency and overload. Implications in oxidative stress and cardiovascular health]. Nutr Hosp. 2010 May-Jun;25(3):350-65. [PubMed]

29. Beard JL: Why iron deficiency is important in infant development. J Nutr. 2008, 138 (12): 2534-2536.Beard JL, Wiesinger JA, Connor JR: Pre- and postweaning iron deficiency alters myelination in Sprague–Dawley rats. Dev Neurosci. 2003, 25 (5): 308-315. 10.1159/000073507.

30. Beard JL, Connor JR, Jones BC. Iron in the brain. Nutr Rev. 1993 Jun;51(6):157-70.

31. Mahan LK, Escott-Stump S. Krause's food, nutrition, & diet therapy. Philadelphia, PA: Saunders; 2008. Doi: 10.1002/food.19970410330 17.

32. Vahdat Shariatpanaahi M, Vahdat Shariatpanaahi Z, Moshtaaghi M, Shahbaazi SH, Abadi A. The relationship between depression and serum ferritin level. Eur J Clin Nutr. 2007 Apr;61(4):532-5. Epub 2006 Oct 25. [PubMed]

33. Seyyed Gholamreza Noorazar, Fatemeh Ranjbar, Negin Nemati, Neda Yesamineh, Parinaz Kalejahi. Relationship between severity of depression symptoms and iron deficiency anemia in women with major depressive disorder. J Anal Res Clin Med, 2015, 3(4): 219-24. doi: 10.15171/jarcm.2015.034.

34. John L. Beard, Michael K. Hendricks, Eva M. Perez, Laura E. Murray-Kolb, Astrid Berg, Lynne Vernon-Feagans, James Irlam, Washiefa Isaacs, Alan Sive, and Mark Tomlinson. Maternal Iron Deficiency Anemia Affects Postpartum Emotions and Cognition. J. Nutr. 2005;135: 267–272.

How to cite this article?

Vanishri A, Kumar A, R.S.A. Kiran Singh. Depression, anxiety, stress and cognition in females with Iron deficiency anemia. Trop J Path Micro 2017;3(2):201-205.doi: 10.17511/jopm.2017.i2.22.