Sex-Differences in Distress, Quality of Life, and Depression Among People with Hemophilia

Introduction: A recently validated hemophilia-distress questionnaire (HRDq) was developed to evaluate patients’ hemophilia-specific concerns. Distress is a multi-factorial and unpleasant experience that is associated with adverse health outcomes, and it can be independent of depression. Potential sex-differences in hemophilia-related distress as well as other aspects of mental and physical well-being have not been well described.

Objective: To examine self-reported hemophilia-related distress, general distress, depression, quality of life, pain, and overall health according to sex.

Methods: This cross-sectional study was a planned secondary analysis of HRDq validation study data. Adults aged ≥18 years with Hemophilia A or B who were recruited from one of two hemophilia treatment centers between July 2017 and December 2019 and agreed to participate. Those who did not complete HRDq were excluded (n=6) from the study. We used a validated hemophilia-related distress questionnaire (HRDq) that asks participants to rate their level of concern across four domains 1) hemophilia management; 2) financial concerns; 3) perceived self-efficacy; and 4) daily functioning. We also examined hemophilia-related quality of life (Haem-A-QoL) and general measures of QoL (EQ-5D-5L), distress (Kessler 6+; NCCN distress thermometer), mental health (PROMIS-29 and depression with PHQ9), physical health (PROMIS-29), and overall health (EQ-5D-5L VAS). Average scores according to sex were compared with independent T-tests. Unadjusted and multivariable linear regression models were used to examine potential mediators of sex and HRDq and other scores.

Results: Among 149 participants enrolled in the study, 143 completed the HRDq and were included in analyses. Approximately 82.0% were male and 18.0% were female. Most participants had Hemophilia A (89.2%), and the average age was 35.1 years [standard deviation (SD)=14.7 years]. A higher proportion of men had Hemophilia A, severe disease, an inhibitor, target joint bleeds, HIV or HCV infection, and were treated with prophylaxis compared to women (Table 1). Self-reported education, household income, health insurance, financial rating, and age were similar.

Total HRDq scores and domain specific scores were similar in men and women (Table 2). Haem-A-QoL scores were significantly lower (indicating better QoL), in females than males (B=-6.57, SE=3.28; p-value=.048), but after accounting for severity, these differences were no longer statistically significant. NCCN distress thermometer, PHQ-9 depression, PROMIS-29 anxiety, and fatigue scores were significantly higher in women than men. Approximately 32.0% of woman reported moderate or severe depression compared to 15.2% of men (p-value<.001). After accounting for severity and treatment, the elevated NCCN distress, PHQ-9 depression, PROMIS-29 anxiety, and fatigue scores among females remained. There were no differences between groups in general QoL, self-reported pain intensity, nor overall health.

Conclusions: Hemophilia-related distress scores were similar in men and women, despite men having more severe disease and unfavorable clinical characteristics. Men had poorer Haem-A-QoL scores, which was accounted for by disease severity. However, general measures of distress and depression were higher among women with hemophilia compared to men, which is consistent with what is observed in the general population and among people with other chronic diseases. This study highlights the need for mental health services to be integrated into the care of women with hemophilia as well as the need for future research to better understand the impact of mental health on traditional bleeding outcomes.

Buckner:Pfizer: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Spark: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees; Tremeau Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; BioMarin: Consultancy, Membership on an entity's Board of Directors or advisory committees; uniQure, Inc: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Cafuir:BioMarin: Membership on an entity's Board of Directors or advisory committees. Kempton:Genentech: Consultancy; Novo Nordisk: Consultancy, Research Funding; Grifols: Honoraria.