|Year : 2020 | Volume
| Issue : 2 | Page : 219-225
Correlates of hopelessness in clinically stable nigerian adults with sickle cell disease
O Aloba1, D Eyiolawi2
1 Department of Mental Health, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria
2 Department of Clinical Psychology, Obafemi Awolowo University, Ile-Ife,Osun State, Nigeria
|Date of Submission||24-Feb-2019|
|Date of Acceptance||22-Oct-2019|
|Date of Web Publication||7-Feb-2020|
Dr. O Aloba
Department of Mental Health, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Hopelessness is the most significant predictor of suicide among the clinical and nonclinical populations. The aim of this study is to examine the correlates and predictors of hopelessness among Nigerian adults with sickle cell disease (SCD). Subjects and Methods: Adopting a convenience sampling technique, 123 clinically stable SCD adult patients were selected from three hematological centers in Southwestern Nigeria. They completed a sociodemographic and illness-related questionnaire in addition to the Beck Hopelessness Scale (BHS), the Hospital Anxiety and Depression Scale (HADS), the 10-item Connor-Davidson Resilience Scale (CDRISC-10), and the Sickle Cell Self-Efficacy Scale (SCSES). The relationship between hopelessness and the other study variables was examined using correlational analysis (Spearman's rho). The extent of the variance these measures contributed to the score on the BHS was evaluated applying hierarchical regression analysis. The level of statistical significance was set at P value less than 0.05. Results: The mean age (years) of the participants was 25.38 ± 6.73 years. There were 68 (55.3%) females. The mean BHS score was 2.89 ± 3.30. Hopelessness had modest negative correlations with hemoglobin concentration (r = −0.366, P < 0.001), resilience (r = −0.483, P < 0.001), and self-efficacy (r = −0.318, P < 0.001), while modest positive correlations were observed with the HADS-Anxiety (r = 0.351, P < 0.001) and Depression (r = 0.530, P < 0.001) subscales. The hemoglobin concentration, resilience, and depression were the main predictors of hopelessness. Conclusion: Hopelessness among clinically stable Nigerian adults with SCD is significantly influenced by hemoglobin concentration and psychological variables (resilience and depression). These variables can serve as templates for the development of health promotion strategies (medical and psychological) aimed specifically at the amelioration of the severity of hopelessness within this population.
Keywords: Anxiety, depression, hopelessness, Nigerian adults, resilience, sickle cell disease
|How to cite this article:|
Aloba O, Eyiolawi D. Correlates of hopelessness in clinically stable nigerian adults with sickle cell disease. Niger J Clin Pract 2020;23:219-25
| Introduction|| |
Sickle cell disease (SCD) is a genetically based disease which is due to the inheritance of two abnormally structured hemoglobin genes from each parent. In SCD, the alteration in the hemoglobin gene precipitates the output of red blood cells (RBCs) that are sickle-shaped, with the tendency to stick together and subsequently obstruct blood vessels. In comparison to normal RBCs, the abnormally shaped ones in SCD have shorter life spans which makes them break down prematurely. Individuals with SCD can be categorized fundamentally into those who are homozygous for the aberrant sickle cell hemoglobin (otherwise referred to as sickle cell anemia) and individuals with a sickle cell hemoglobin gene in combination with another unusual hemoglobin type. The World Health Organization (WHO) has acknowledged the public health importance of SCD. Globally, Nigeria has the highest absolute population of individuals who have SCD, and approximately 150,000 affected newborns are delivered annually. SCD has a prevalence that ranges from 2% to 3% within the Nigerian population.
Hopelessness has been frequently identified as the most reliable risk factor for either attempted suicide or death by suicide. The importance of hopelessness is further reflected by the fact that it is the only variable that has been consistently incorporated into the measures developed for the assessment of suicide and suicide-related behaviors. Studies involving both clinical and nonclinical respondents have insinuated that the assessment of hopelessness may be beneficial in the early identification of high suicide risk individuals. A prospective community survey conducted over more than a decade reported that those who died through suicide, those with suicidal ideation, and those who attempted suicide were all statistically predicted by hopelessness. Statistically significant relationship has been reported between hopelessness and the presence of a long-term medical disorder. The correlation between chronic physical diseases and suicide has been reported. Individuals with chronic physical diseases such as central nervous system pathologies, cardiovascular, and oncological diseases are at an increased risk for suicide attempt and death through suicide. Pain, a common and recurrent phenomenon in SCD, has also been related to an elevated risk of suicide.
An electronic literature search revealed that there are no studies regarding the correlates of hopelessness or suicide-related behaviors among Nigerian adults with SCD, despite the strong relationship between hopelessness and suicide-related behaviors among other patient populations in developed countries and in Nigeria. Due to the central role of hopelessness in relation to suicide and suicide attempts,, we are of the opinion that the first step toward the amelioration of hopelessness severity among Nigerian SCD adult patients will be the identification of the illness-related and psychological variables that significantly correlate with hopelessness. This study aims to examine the correlates and predictors of hopelessness in a sample of clinically stable Nigerian adults with SCD. We hypothesized that hopelessness would have statistically significant correlations with illness-related characteristics [hemoglobin concentration (Hb conc g/dL)] and the number of vaso-occlusive episodes in the previous 12 months] and psychological variables; anxiety and depressive symptoms, resilience, and illness-related self-efficacy.
| Subjects and Methods|| |
Sample size calculation
The participants were selected from the following three hematological centers in South-western Nigeria: 1) Sickle cell outpatient clinic, Department of Hematology of the Obafemi Awolowo University Teaching Hospital (OAUTH), Ile-Ife, Osun State, 2) Hematology outpatient clinic of the Ladoke Akintola University of Technology Teaching Hospital (LAUTECH), Osogbo, Osun State, and 3) Outpatient clinic service unit of the Sickle Cell Foundation Nigeria (SCFN), Idi Araba, Lagos State.
Evaluation of the records in the Health Information Departments in the three study centers showed that obtaining a relatively large sample size will not be possible, due to some reasons. First, a significant proportion of the outpatients in the centers were less than 18 years (mainly children and adolescents). Second, most of those who were older than 18 years of age had to be excluded due to the presence of SCD-related complications.
We calculated the sample size based on the formula by Araoye for a construct (which in this study is hopelessness) without a known prevalence.
where n = sample size, Z = standard normal distribution for 95% confidence interval (Z = 1.96), P = prevalence, a value of 50% will be applied in determining the sample size, and d = degree of accuracy = 10%.
n = 96.
A degree of accuracy (d) of 10% (0.1) instead of 5% (0.05) was adopted due to the likelihood that we will not be able to obtain a large sample size. We added a nonresponse rate of 25% (n = 24) based on the assumption that many potential participants will decline to participate. This yielded a sample size of 120.
The participants were recruited from these centers over a period of 4 months when they presented for their outpatient follow-up evaluations. The criteria for eligibility include age 18 years and above, diagnosed and receiving treatment for SCD, the ability to communicate in English language, they must not be in any form of distress (i.e. painful vaso-occlusive episode), no previous or current history of having a mental disorder, absence of physical complications of SCD (i.e. ulcers) or sickle cell-related medical conditions, and must provide written consent for participation. During the recruitment period, a total of 51 adults presented at the OAUTH, while 54 and 66 adults presented at the LAUTECH and SCFN, respectively, making a total of 171. We excluded 16 individuals in the OAUTH, while 18 of the adult patients were excluded in LAUTECH. In the SCFN, 14 were excluded. The reason for exclusion in these centers was the presence of physical complications of SCD (i.e. chronic leg ulcers and orthopedic complications). Consent was obtained from those who fulfilled the inclusion criteria after the aim of the study was explained to them. Thus, a total of 123 adults receiving treatment for SCD were recruited cumulatively from the three centers. The clinically stable patients usually present on a monthly basis in these centers for their outpatient evaluation and monitoring, during which their hemoglobin concentration values will be checked. Approval for the research protocol was granted by the Ethics and Research Committees of the hematological centers.
A research packet consisting of the following measures was completed by the respondents:
A sociodemographic and illness-related questionnaire
This was specifically designed for this study. The sociodemographic variables include age (years), gender, marital status, and the level of education. The illness-related variables include the hemoglobin concentration (Hb conc g/dL) and the number of vaso-occlusive episodes experienced in the preceding 12 months. These parameters were corroborated from the patients' medical records. The hemoglobin concentration was included as an illness-related variable because clinically stable SCD patients usually have it within a range, except during periods of acute complications such as vaso-occlusive crises or infections. We reviewed the medical records of each participant to obtain their hemoglobin concentration values over the preceding 3 months. These values were then used to compute the mean steady-state hemoglobin concentration for each participant.
Beck Hopelessness Scale
Hopelessness was quantified with the Beck Hopelessness Scale (BHS). It consists of 20 items which are either negatively or positively phrased. A negatively worded item is scored 1 point if the respondent assented to it, while a positively worded item is scored the same point if the respondent indicated his or her response as “no.” The total score ranges from 0 to 20, with higher scores reflecting a greater level of hopelessness. Globally, the BHS has been statistically demonstrated to be the most reliable measure in the prediction of suicide. The BHS has been used in the evaluation of hopelessness among diverse nonclinical and clinical, populations in Nigeria.
Sickle Cell Self-Efficacy Scale
The respondents also completed the nine-item Sickle Cell Self-Efficacy Scale (SCSES), whose validity and reliability were originally examined in a sample of adults (18–73 years) with SCD. The items of the SCSES evaluate the subjective ability of the individuals with SCD to effectively cope with the ailment, in addition to their ability to function on a daily basis. Each item is rated on a 5-point Likert scale from 1 (not at all sure) to 5 (very sure). The respondent's rating on each item is summed to yield a cumulative score, which ranges from 9 to 45. Higher self-efficacy is indicated by higher scores on the SCSES.
Connor-Davidson Resilience Scale-10
The level of resilience was evaluated with the 10-item Connor-Davidson Resilience Scale (CDRISC). The items are rated according to a 5-point Likert format (0 = never to 4 = almost always). The scale is completed based on the extent to which each of the 10 items applied to the respondent in the previous 1 month. An aggregate of the responses indicated on each item produces a score that ranges from 0 (minimum) to 40 (maximum). The higher the respondent's level of resilience, the higher the total scores on the CDRISC-10. The scale has been demonstrated to be a satisfactorily valid and reliable measure of resilience among the Nigerian adolescent and adult populations.
Hospital Anxiety and Depression Scale
This 14-item Hospital Anxiety and Depression Scale (HADS) was used to evaluate the level of anxiety and depressive symptoms. The Anxiety and Depression subscales of the HADS each consists of seven items, which are rated on a 4-point Likert scale (0 to 3). The cumulative score on each subscale ranges between 0 and 21. Higher scores on the subscales are indicative of greater severity of anxiety and depressive symptoms. Adequacy of reliability and validity of the HADS in terms of its screening characteristics for anxiety and depressive symptoms has been described among the Nigerian clinical and nonclinical populations.
Data analyses were conducted with the IBM Statistical Package for Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY, USA). The categorical sociodemographic characteristics of the participants were depicted applying descriptive statistics specifically frequencies (percentages). The distributions of continuous variables were assessed using the Shapiro–Wilk test. The continuous variables which included the illness-related characteristics and the scores on the study measures were summarized using means (standard deviations) and range. The relationship between hopelessness and illness-related variables and other study measures (resilience, self-efficacy, anxiety, and depression) were examined applying correlation analysis; adopting the parametric (Pearson's product moment) or nonparametric (Spearman's rho) method. The variables that were significantly associated with hopelessness at the correlation level were subsequently subjected to multiple linear regressions, adopting the hierarchical approach. The aim of the regression analysis was to identify the illness-related variables and study measures that significantly predicted hopelessness scores among the participants. All hypotheses were two-tailed and the level of statistical significance was set at P value less than 0.05.
| Results|| |
Sociodemographic and illness-related characteristics
[Table 1] shows that 55.3% of the respondents were females and most (87.8%) were single. The mean steady-state Hb conc and the number of vaso-occlusive episodes in the preceding 12 months were 8.22 ± 1.35 g/dL and 3.37 ± 3.47, respectively. The mean hopelessness score is 2.89 ± 3.30, with a range of 0–13. The mean scores on the HADS-Anxiety, HADS-Depression, CDRISC-10, and SCSEC were 7.04 ± 3.12, 4.15 ± 3.12, 26.76 ± 7.17, and 32.62 ± 6.88 respectively.
|Table 1: Sociodemographic, illness-related, and study measure characteristics of the respondents (n=123)|
Click here to view
Correlations between BHS and the illness-related variables and other study measures
Data distribution for the illness-related characteristics and other study measures was non-normal. Thus, Spearman's rho correlation analysis was used to examine the relationships between hopelessness and other variables. As depicted in [Table 2], hopelessness had statistically significant modest negative correlations with the steady-state Hb conc (r = −0.366, P < 0.001), resilience (r = −0.483, P < 0.001), and self-efficacy (r = −0.318, P < 0.001). Statistically significant modest positive correlations were observed between hopelessness and anxiety (r = 0.351, P < 0.001) and depressive (r = 0.530, P < 0.001) symptoms.
|Table 2: Correlations (Spearman's rho) between BHS and the sociodemographic, illness-related, and other study|
Click here to view
Regression analysis showing the variables that significantly predicted hopelessness scores among the respondents
In [Table 3], the first model in the hierarchical linear regression analyses included the only illness-related variable that significantly correlated with hopelessness: the steady-state Hb conc. This illness-related variable explained 14.1% (adjusted R2 = 0.141) of the total variance in the hopelessness scores. The other study measures (CDRISC-10, SCSES, and the HADS-Anxiety and Depression Subscales) were included in the second model. Only the resilience and depression scores significantly predicted the hopelessness scores. Resilience and depressive symptoms in combination with the steady-state Hb conc values cumulatively explained 39.7% (adjusted R2 = 0.397) of the total variance in the hopelessness scores. The regression model predicting hopelessness score is −0.629 × Hb conc value + (−0.145) × CDRISC-10 score + 0.237 × HADS-Depression score + 12.166. The F-statistics, degrees of freedom (df), and the P values for each of the two models in the hierarchical regression analyses are also depicted in [Table 3].
|Table 3: Linear regression (hierarchical) showing the variables that significantly predicted hopelessness among the respondents|
Click here to view
| Discussion|| |
This primary aim of this study is to identify the illness-related and psychological correlates of hopelessness in a sample of Nigerian adults with SCD who were not in any form of clinical distress. We were able to confirm our hypotheses regarding the psychological variables and one of the illness-related characteristics. The direction and to a modest extent the strength of the relationships between hopelessness and the illness-related characteristic and the psychological variables were all as expected. To the knowledge of the authors, an extensive electronic literature search revealed that no study either in developed or developing countries has specifically explored the correlates of hopelessness among adults with SCD. Therefore, a comparison of our findings with previous studies that have the same specific aim and participants was not feasible.
Regarding the relationship, we noted between hopelessness and hemoglobin concentration values in our sample, a study that involved a sample of American adults reported a significant relationship between hopelessness and the presence of a biological marker for endothelial dysfunction in arteriosclerosis. We are of the opinion that further studies are needed to replicate our observation and to explore how the establishment of the cut-off values for hemoglobin concentration will be useful in the identification of adults with SCD at risk of suicide on account of severe levels of hopelessness. The positive relationship between hopelessness and anxiety among our respondents has been reported among patients with other physical and psychological disorders. Our observation of a positive correlation between hopelessness and depression is consistent with previous literature on adults with chronic medical disorders such as hemato-oncological and long-term psychological disorders.
Resilience, which is the capability to satisfactorily withstand and adapt to extremely discomforting circumstances through the application of various resources, has been reported in previous studies that involved patients with chronic disorders to have a negative correlation with hopelessness, as observed in our study. In a meta-analytic review, the mean scores on the measures of resilience among patients with chronic physical diseases were significantly lower than those of healthy controls.
Self-efficacy, which is reduced in individuals with SCD, refers to a cognitive attitude regarding an individual's ability to engage on a daily basis in the activities that will beneficially influence his or her ability to control the symptoms of their illnesses. To the knowledge of the authors, the relationship between hopelessness and self-efficacy has not been examined specifically among adults with SCD. Our observation of a negative correlation between these two psychological variables has been reported in previous studies of adults with other types of chronic medical disorders.
From a clinical perspective, it thus appears that to address high levels of hopelessness among the Nigerian adults with SCD, managing physicians may need to ensure that there is an optimization of the patients' hemoglobin concentration levels. The adoption of some specific physical treatment methods for SCD patients has been reported to significantly reduce anemia. In addition, mental health specialists and hematologists may need to liaise in the screening and identification of adults SCD patients with significant depressive symptoms and low levels of resilience. Due to the observation that depressive symptoms are common in adults with SCD, the identification of those harboring high levels of depressive symptoms through screening and prompt treatment may ameliorate the severity of hopelessness among Nigerian adults with SCD. Thus, indirectly an overall improvement in the SCD patients' clinical state may reduce the level of hopelessness. The negative association we noted between hopelessness and resilience lends credence to what has been previously suggested that there is the need to institute psychological interventions that will increase resilience among patients with chronic physical diseases.
The importance of identifying Nigerian adult SCD patients with elevated levels of hopelessness is buttressed by both longitudinal and cross-sectional studies reporting that the risk of suicide can be predicted precisely on the basis of hopelessness. It has been demonstrated that cognitive behavioral therapy can effectively reduce the severity of hopelessness in those at increased risk of suicide.
The limitation of our study is that it is cross-sectional in nature, involving adults with SCD recruited from hematological centers in South-western Nigeria; therefore, caution needs to be taken in generalizing our observations to adults with SCD in the other geopolitical regions of the country. The strength of this study is that it is the first to the knowledge of the authors to examine the illness-related and psychological factors that are associated with hopelessness among Nigerian adults' patients with SCD. Our opinion is that there is a need for additional studies to explore other variables that may contribute to elevated hopelessness among Nigerian adult patients with SCD. Approximately 40% of the variance in hopelessness score was accounted for by the combination of three of our study variables. The implication of this is that additional studies are needed among the Nigerian adults with SCD to further identify other illness-related and psychological variables (i.e. quality of life, psychological distress, etc.) that may significantly influence hopelessness among this population. The identification of such variables may facilitate the development of clinical and psychotherapeutic interventions specifically targeted at Nigerian adults with SCD.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Serjeant GR. The natural history of sickle cell disease. Cold Spring Harb Perspect Med 2013;3:a011783.
Kato GJ. Anemia, age, desaturation, and impaired neurocognition in sickle cell anemia. Pediatr Blood Cancer 2012;59:773-4.
Stuart MJ, Nagel RL. Sickle-cell disease. Lancet 2004;364:1343-60.
Yawn BP, John-Sowah J. Management of sickle cell disease: Recommendations from the 2014 expert panel report. Am Fam Physician 2015;92:1069-76.
Anie KA, Egunjobi FE, Akinyanju OO. Psychosocial impact of sickle cell disorder: Perspectives from a Nigerian setting. Global Health 2010;6:2.
Odunvbun ME, Okolo AA, Rahimy CM. Newborn screening for sickle cell disease in a Nigerian hospital. Public Health 2008;122:1111-6.
Hendin H, Phillips MR, Vijayakumar L, Pirkis J, Wang H, Yip P, et al
., editors. Suicide and Suicide Prevention in Asia. World Health Organization, Department of Mental Health and Substance Abuse. Geneva. Switzerland: WHO Press; 2008.
Milnes D, Owens D, Blenkiron P. Problems reported by self-harm patients: Perception, hopelessness, and suicidal intent. J Psychosom Res 2002;53:819-22.
Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients. A 20-year prospective study. J Consult Clin Psychol 2000;68:371-7.
Kuo WH, Gallo JJ, Eaton WW. Hopelessness, depression, substance disorder, and suicidality: A 13-year community-based study. Soc Psychiatr Psychiatric Epidemiol 2004;39:497-501.
Bener A, Alsulaiman R, Doodson L, Agathangelou T. Depression, hopelessness and social support among breast cancer patients: In highly endogamous population. Asian Pac J Cancer Prev 2017;18:1889-96.
Webb RT, Kontopantelis E, Doran T, Qin P, Creed F, Kapur N. Suicide risk in primary care patients with major physical diseases: A case-control study. Arch Gen Psychiatry 2012;69:256-64.
Jones JE, Hermann BP, Barry JJ, Gilliam FG, Kanner AM, Meador KJ. Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy. Epilepsy Behav 2003;4:S31-8.
Hooley JM, Franklin JC, Nock MK. Chronic pain and suicide: Understanding the association. Curr Pain Headache Rep 2014;18:435.
Bourgeois M, Swendsen J, Young F, Amador X, Pini S, Cassano GB, et al
. Awareness of disorder and suicide risk in the treatment of schizophrenia: Results of the international suicide prevention trial. Am J Psychiatry 2004;161:1494-6.
Aloba O, Akinsulore A, Mapayi B, Oloniniyi I, Mosaku K, Alimi T, et al
. The Yoruba version of the Beck Hopelessness Scale: Psychometric characteristics and correlates of hopelessness in a sample of Nigerian psychiatric outpatients. Compr Psychiatry 2015;56:258-71.
Araoye MO. Research Methodology with Statistics for Health and Social Sciences. 1st
ed. Ilorin: Nathadex Publishers; 2003.
Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The hopelessness scale. J Consult Clin Psychol 1974;42:861-5.
Sidley GL, Calam R, Wells A, Hughes T, Whitaker K. The prediction of parasuicide repetition in a high-risk group. Br J Clin Psychol 1999;38:375-86.
Aloba O, Ajao O, Alimi T, Esan O. Psychometric properties and correlates of the beck hopelessness scale in family caregivers of Nigerian patients with psychiatric disorders in Southwestern Nigeria. J Neurosci Rural Pract 2016;7:S18-25.
Aloba O, Esan O, Alimi T. Adaptation of the Beck Hopelessness Scale as a suicide risk screening tool among Nigerian patients with schizophrenia. Int J Psychiatry Clin Pract 2018;22:19-24.
Edwards R, Telfair J, Cecil H, Lenoci J. Reliability and validity of a self-efficacy instrument specific to sickle cell disease. Behav Res Ther 2000;38:951-63.
Campbell-Sills L, Stein MB. Psychometric Analysis and Refinement of the Connor-Davidson Resilience Scale (CD-RISC): Validation of a 10-item Measure of Resilience. J Trauma Stress 2007;20:1019-28.
Aloba O, Olabisi O, Aloba T. The 10-item Connor–Davidson Resilience Scale: Factorial structure, reliability, validity, and correlates among student nurses in Southwestern Nigeria. J Am Psychiatr Nurses Assoc 2016;22:43-51.
Aloba O, Ajao O, Akinsulore A, Mapayi B, Alimi T, Esan O. Exploration of the psychometric properties and correlates of the 10-item Connor-Davidson Resilience Scale among family caregivers of Nigerian patients with psychiatric disorders. Int J Mental Health Psychiatr 2016;2:10-8.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.
Abiodun OA. A validity study of the Hospital Anxiety and Depression Scale in general hospital units and a community sample in Nigeria. Br J Psychiatry 1994;165:669-72.
Do DP, Dowd JB, Ranjit N, House JS, Kaplan GA. Hopelessness, depression, and early markers of endothelial dysfunction in U.S. adults. Psychosom Med 2010;72:613-19.
Peres MFP, Mercante JPP, Tobo PR, Kamei H, Bigal ME. Anxiety and depression symptoms and migraine: A symptom-based approach research. J Headache Pain 2017;18:37.
Paiva CB, Ferreira IB, Bosa VL, Narvaez JC. Depression, anxiety, hopelessness, and quality of life in users of cocaine/crack in outpatient treatment. Trends Psychiatry Psychother 2017;39:34-42.
Gheihman G, Zimmermann C, Deckert A, Fitzgerald P, Mischitelle A, Rydall A, et al
. Depression and hopelessness in patients with acute leukemia: The psychological impact of an acute and life-threatening disorder. Psychooncology 2016;25:979-89.
Windle G. What is resilience? A review and concept analysis. Rev Clin Gerontol 2011;21:152-69.
Hofer A, Mizuno Y, Frajo-Apor B, Kemmler G, Suzuki T, Pardeller S, et al
. Resilience, internalized stigma, self-esteem, and hopelessness among people with schizophrenia: Cultural comparison in Austria and Japan. Schizophr Res 2016;171:86-91.
Ghanei Gheshlagh R, Sayehmiri K, Ebadi A, Dalvandi A, Dalvand S, Nourozi Tabrizi K. Resilience of patients with chronic physical diseases: A systematic review and meta-analysis. Iran Red Crescent Med J 2016;18:e38562.
Sinnakaruppan I, Macdonald K, McCafferty A, Mattison P. An exploration of the relationship between perception of control, physical disability, optimism, self-efficacy and hopelessness in multiple sclerosis. Int J Rehabil Res 2010;33:26-33.
Jonassaint CR, Jones VL, Leong S, Frierson GM. A systematic review of the association between depression and health care utilization in children and adults with sickle cell disease. Br J Haematol 2016;174:136-47.
Kuyken W. Cognitive therapy outcome: The effects of hopelessness in a naturalistic outcome study. Behav Res Ther 2004;42:631-46.
Alavi A, Sharifi B, Ghanizadeh A, Dehbozorgi G. Effectiveness of cognitive-behavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts. Iran J Pediatr 2013;23:467-72.
[Table 1], [Table 2], [Table 3]