Temporal Changes in Quality of Life and Psychological Burden of Patients with Thalassemia: A Comparative Data Analysis from 2018 to 2025

Abstract

Background/Objectives: Thalassemia significantly affects the mental well-being and lifestyle of patients and their families. This study evaluated the temporal changes in quality of life (QoL) and psychological burden among thalassemia patients in 2025 and in relation to 2018. Methods: Two cross-sectional samples of patients (n = 236) were recruited during 2025 (n₁ = 117) and 2018 (n₂ = 119) at the Thalassemia Units on Crete/Greece. The EQ-5D-3L Quality of Life Scale, the EQ VAS Index, and the Hospital Anxiety and Depression Scale (HADS) were used through multiple logistic regression analysis to assess relative parameters. Results: High mean Health Status (EQ VAS Index) and QoL scores remained consistent from 2018 to 2025, anxiety mean levels were low and remained consistent from 2018 to 2025, depression levels were low but higher in 2025 in relation to 2018 (p = 0.041), anxiety significantly exceeded depression in both 2018 and 2025, better QoL was associated with improved health status and reduced anxiety and depression, and individuals with children exhibited significantly lower odds of experiencing low or moderate QoL. Conversely, each unit increase in the Anxiety score significantly increased the odds of low or moderate QoL (OR = 1.26, p = 0.002). Similarly, each unit improvement in health status significantly reduced the odds of low or moderate QoL (OR = 0.97, p = 0.009). Conclusions: Health status and QoL remained consistent from 2018 to 2025, while depression levels increased. Anxiety significantly exceeded depression, and better QoL was associated with improved health status and reduced anxiety and depression.

1. Introduction

The term “thalassemias” encompasses a group of hereditary blood disorders characterized by the diminished synthesis of one of the two polypeptide chains (α or β) that constitute normal adult hemoglobin (HbA, α2β2). Consequently, hemoglobin deficiency ensues, ultimately leading to anemia [1].

Syndromes are categorized into α-thalassemia and β-thalassemia based on the genes affected and their impact on globulin chain production. Rarer forms include γ-, δ-, and δβ-thalassemias. β-thalassemia, or Mediterranean anemia, is more prevalent and severe, manifesting as heterozygous or homozygous β-thalassemia major [1]. The predominant types observed in Greece and neighboring countries include complete deactivation of CD39 gene (19%), IVS1-1 (13%), mRNA\FSC6 (T → U), (-A) (4%), IVS2-1 (2%), and partial ablation of IVS1-110 (42%). IVS1-6 exhibits a T → C (8%), and -87 exhibits a C → G (2%) [2].

Thalassemia, a significant public health concern globally, affects over 1.3 million people annually, causing about 11,000 deaths. South Asia, the Middle East, and Southeast Asia bear a disproportionate burden. While the global burden has declined since 1990, cases among the elderly and gender disparities in mortality persist, especially in South Asia. Thalassemia causes chronic anemia, iron overload, organ damage, high healthcare costs, and a reduced quality of life (QoL). These impacts are more severe in low- and middle-income countries due to limited screening and treatment access [3]. Notably, Mediterranean populations, particularly in Greece and Cyprus, exhibit exceptionally high rates of β-thalassemia. These rates commence at 7.5% and can reach up to 10–12% in certain regions [4].

Similar to other chronic illnesses, thalassemia significantly impacts the mental well-being and lifestyle of both the afflicted individual and their family. It has been consistently observed that, beyond the disease itself, various factors can influence mood, ranging from positive to negative, such as the individual’s acceptance of the condition and adherence to treatment. Consequently, patients with thalassemia often experience a diminished QoL due to the difficulties inherent in the disease, including employment challenges, relationship difficulties, family planning, and limited social support. Patients with thalassemia frequently experience mental health challenges such as anxiety and depression due to various factors. These factors include the chronic nature of the illness, treatment complications, financial difficulties, social and personal stressors, the absence of familial and social support, evolving body image, and impaired self-esteem. Anxiety and depression symptoms can significantly impact the disease’s progression, including reduced treatment adherence, increased morbidity, and diminished QoL [5,6].

During the COVID-19 pandemic, patients with thalassemia face a critical predicament. Prolonged isolation and delayed blood transfusions or chelators pose a significant risk of severe anemia and iron overload. Furthermore, hospital visits for screenings can exacerbate the risk of infection by COVID-19, in addition to the psychological and emotional challenges associated with prolonged home confinement [7]. These patients stand out in the pandemic context due to their frequent healthcare visits for blood transfusions. Their conditions necessitate the implementation of protective measures, as hospital environments may be considered potential hotspots for viral transmission. This situation is particularly concerning for patients residing in developing or low-income countries, where access to disease-specific treatment is limited [8].

The present study is predicated on the hypothesis that there is a negative correlation between these factors and QoL, and examines its fluctuations over time (temporal trends/changes), in comparison to previous research conducted in 2018, prior to the pandemic [9]. The purpose of this study was to evaluate the QoL and psychological burden, specifically anxiety and depression, among thalassemia patients in Crete in order to change in the pre- and post-pandemic periods.

2. Materials and Methods

2.1. Study Design, Sample and Participants

The present cross-sectional study employed a questionnaire and was conducted from January to March 2025. Convenience sampling was the chosen sampling method. The final study sample comprised n = 236 patients, all of whom had thalassemia. Of these, n₁ = 117 were from the 2025 survey and n₂ = 119 were from a previous study in 2018 [9]. Since the data collection was conducted anonymously, there was no possibility of identifying participants surveyed in both periods.

The study was conducted in the Thalassemia Units of the Heraklion and Chania hospitals, which specialize in the care of individuals with thalassemia. Inclusion criteria included a diagnosis of thalassemia, an age of over 18 years, and the ability to comprehend and complete the questionnaire. Patients with severe mental disorders and those who declined to participate were excluded from the study. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

2.2. Research Tools

Data collection was conducted through structured questionnaires, which participants completed in person, thereby ensuring their anonymity. The following psychometric scales were utilized:

The Hospital Anxiety and Depression Scale (HADS) evaluates anxiety and depression levels [10]. This classification categorizes levels into normal, mild (ranging from 8 to 10), moderate (ranging from 11 to 14), and severe (ranging from 15 to 21).

The EQ-5D-3L (EuroQoL-5 Dimensions-3 Levels) was employed to evaluate the participants’ quality of life. The total EQ-5D-3L index ranges from 0 to 1.000, with higher values indicating superior quality of life [11].

The EQ VAS (Visual Analogue Scale) evaluated the subjective perception of health in patients, employing a scale ranging from 0 to 100. Higher values correspond to improved self-reported health status [9].

The scores were derived from international standards [9,12,13]. To assess the reliability of the instruments, the Cronbach’s α coefficient was employed, demonstrating high internal consistency across most scales (HADS α = 0.912; HADS-Anxiety α = 0.865; HADS-Depression α = 0.866; EQ-5D-3L α = 0.671). The EQ-5D-3L Quality of Life Index was set at a score of 1.000 based on the distribution of study participants [9].

2.3. Data Collection

Data collection was conducted at the Thalassemia Units on the island of Crete from January to March 2025. The researchers engaged with participants within the Thalassemia Units of the hospitals of Heraklion and Chania, which specialize in the care of individuals with thalassemia. For the study’s purposes, participating patients were required to provide responses to questions pertaining to their medical history and QoL. Additionally, a set of demographic questions, including age and gender, was administered. Participants were accorded the right to decline any question that might cause embarrassment or was deemed irrelevant to their circumstances. Personal information, such as the patient’s name, was not requested, and all responses were kept completely confidential.

2.4. Ethical Considerations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Committee of the Hellenic Mediterranean University and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Ethical approval was obtained from the Research and Bioethics Committee of the Venizeleio General Hospital of Heraklion, Crete/48991-25/11/2024 and the Research and Bioethics Committee of St. George Chania General Hospital/44789-29/10/2024. The study participants were informed about the study objectives, expected outcomes, and associated benefits and risks. Written consent was obtained from the participants prior to their completion of the questionnaire. The authors also obtained permission to use the hospital facilities before data collection.

2.5. Statistical Analysis

Data analysis was conducted using SPSS software (IBM Corp. Released 2020, IBM SPSS Statistics for Windows, v.25.0, Armonk, NY, USA: IBM Corp.). The frequency distributions of the characteristics of the 236 participating patients were estimated, along with their comparison frequencies across the study years (2018 and 2025). The χ² method was employed for this comparison. Following the distribution verification of the EQ-5D-3L QoL Scales, the EQ VAS Index (“Health Status” or “thermometer”), and the Hospital Anxiety and Depression Scale (HADS) using Blom’s method (QQ plot) to check normality, which revealed strong asymmetry, and a comparison was conducted using the Mann–Whitney and Wilcoxon tests. The non-parametric Spearman method was employed to assess the univariate correlation between the scales and the characteristics of the participants. Finally, hierarchical multiple logistic regression analysis was applied (nested models) to correlate the patients’ low/moderate QoL (<1.00) with their characteristics, anxiety and depressive symptomatology, and health status levels. The acceptable significance level was set at 0.05.

3. Results

Of the 236 patients with thalassemias in the study (

Table 1. Descriptive characteristics of 236 patients with thalassemia participating in the study in 2018 and 2025.

		Total (n = 236)		Study Year
				2018 (n = 119)	2025 (n = 117)
		n	%	%		p-Value
Gender	male	102	43.2	47.1	39.3	0.230
	female	134	56.8	52.9	60.7
Age, years	mean (stand. dev.)	43.3 (8.7)		39.7 (8.5)	46.9 (7.9)	<0.001
Family status	married	184	78.0	47.1	59.8	<0.001
	unmarried, divorced	52	22.0	52.9	40.2
Children	no	77	32.6	11.8	53.8	<0.001
	yes	159	67.4	88.2	46.2
Education level	minimum/no education	21	8.9	8.4	9.4
	secondary	93	39.4	41.2	37.6	0.847
	higher	122	51.7	50.4	53.0
Occupation	employed	96	40.7	47.1	34.2	0.044
	unemployed (retired, student, etc.)	140	59.3	52.9	65.8
Body Mass Index	underweight	9	3.8	2.5	5.1
	normal	165	69.9	73.1	66.7	0.421
	overweight, obese	62	26.3	24.4	28.2
Family income, €	<1000	3	1.3	1.7	0.9
	1000–5000	50	21.2	21.0	21.4
	5001–10,000	63	26.7	29.4	23.9	0.832
	10,001–20,000	96	40.7	37.8	43.6
	>20,000	24	10.2	10.1	10.3
Thalassemia	α	11	4.7	4.2	5.1	0.137
	β	202	85.6	87.4	83.8
	microdrepanocytic anemia	15	6.4	3.4	9.4
	other	8	3.4	5.0	1.7

χ² and Student t tests.

), the majority were female (56.8%) and the average age of all was 43.3 years (±8.7). 78.0% were married, 67.4% reported having children, while 51.7% reported having a higher education. A total of 40.7% were employed, 69.9% had a normal body weight, and 22.5% had an annual income of up to 5000 euros. Furthermore, in terms of the type of thalassemia disease, 4.7% had α-thalassemia, 85.6% β-thalassemia, 6.4% sickle cell disease, and 3.4% other types (“other”).

Regarding the differentiation between the two study years, the patients who participated in 2018 (n = 119) and those in 2025 (n = 117) differ in some of their characteristics. Among other things, they had a significantly higher mean age in 2025 compared to 2018 (46.9 vs. 39.7 years, p < 0.001) and were more likely to be single/divorced/widowed (40.2% vs. 4.2%, p < 0.001), childless (53.8% vs. 11.8%, p < 0.001), or unemployed (65.8% vs. 52.9%, p = 0.044).

In the context of the EQ-5D-3L QoL Scale (Figure 1), a significant disparity is observed in the frequency distributions for the question “Compared to my health status in the last 12 months, my current situation is:”. In 2025, a substantially higher proportion of individuals (8.5%) reported experiencing a decline in their health status over the past 12 months compared to 2018, when only 0.8% reported such a decline (p = 0.016). Figure 2 further illustrates the EQ VAS Index (Health Status or “thermometer”) ranging from 0 to 100 on the EQ-5D-3L scale. Generally, a consistently high average Health Status score is observed, with no significant variation observed between 2025 and 2018 (75.4 vs. 76.9, p > 0.05).

Table 2. Levels of quality of life (European Quality of Life scale, EQ-5D-3L), anxiety & depression (Hospital Anxiety and Depression Scale, HADS) of 236 patients with thalassemia between the years 2018 and 2025.

	Study Year
	2018 (n = 119)	2025 (n = 117)
Scale	Mean ± Stand. Dev.		p-Value
EQ-5D-3L Quality of Life (higher score ⇨ better QoL)	0.85 ± 0.16	0.84 ± 0.15	0.791
lower (score < 1.00)	66.1%	67.5%	0.817
excellent (score = 1.00)	33.9%	32.5%
HADS, anxiety (higher score ⇨ high symptomatology)	4.94 ± 4.13	5.07 ± 3.99	0.640
normal (<8)	75.6%	74.4%	0.961
mild (8–10)	13.4%	15.4%
moderate (10–14)	7.6%	7.7%
severe (15–21)	3.4%	2.6%
HADS, depression (higher score ⇨ high symptomatology)	3.28 ± 3.54	4.14 ± 4.06	0.041
normal (<8)	87.4%	83.8%	0.491
mild (8–10)	8.4%	7.7%
moderate (10–14)	3.4%	5.1%
severe (15–21)	0.8%	3.4%
HADS, total (higher scale ⇨ high symptomatology)	8.22 ± 7.16	9.21 ± 7.30	0.194
normal (up to 16)	85.7%	86.3%	0.892
mild, moderate, severe (16+)	14.3%	13.7%

Mann–Whitney & χ² tests. Wilcoxon test between anxiety & depression scales in 2018 (p < 0.001) & 2025 (p = 0.002).

presents the QoL & Hospital Anxiety and Depression Scale (HADS) scores of the 236 patients who participated in the study, categorized by study year (2018 and 2025). The total score of the EQ-5D-3L QoL Scale, where a higher score (→1.000) indicates a superior QoL (as shown in Table 2), exhibits a high average QoL score, with no significant difference between 2018 and 2025 (0.84 vs. 0.85, p > 0.05). Consequently, patients with an excellent QoL (score 1.000) demonstrate no significant difference in their QoL between 2018 and 2025 (32.5% vs. 33.9%, p > 0.05). A low average score for Anxiety is also observed, with no significant difference between 2018 and 2025 (5.07 vs. 4.94, p > 0.05). Conversely, a low average score for Depression is observed, with significantly higher levels in 2025 compared to 2018 (4.14 vs. 3.28, p = 0.041). Overall, a low average score for Anxiety and Depression is observed, with no significant difference between 2018 and 2025 (9.21 vs. 8.22, p > 0.05). Regarding the assessment of levels, a high percentage of patients in both 2018 and 2018 were found to have normal levels of Anxiety (74.4% vs. 75.6%, p > 0.05), Depression (83.8% vs. 87.4%, p > 0.05), and total score (86.3% vs. 85.7%, p > 0.05). Comparatively, significantly higher levels of Anxiety compared to Depression are observed in both 2018 (4.94 vs. 3.28, p < 0.001) and 2025 (5.07 vs. 4.14, p = 0.002).

From the correlation of the EQ-5D-3L QoL Scale and the Anxiety & Depression Scale in all patients (

Table 3. Correlations of health status, quality of life (European Quality of Life scale, EQ-5D-3L) and anxiety & depression (Hospital Anxiety and Depression Scale, HADS) of 236 patients with thalassemia.

	EQ-VAS Score (Health Status) (Higher Score ⇨ Better Health Status)	EQ-5D-3L Quality of Life (Higher Score ⇨ Better QoL)	HADS, Anxiety (Higher Score ⇨ High Symptomatology)
	rho-Spearman
EQ-5D-3L Quality of Life (higher score ⇨ better QoL)	0.520 *
HADS, anxiety (higher score ⇨ high symptomatology)	−0.497 *	−0.567 *
HADS, depression (higher score ⇨ high symptomatology)	−0.474 *	−0.556 *	0.668 *
HADS, total (higher scale ⇨ high symptomatology)	−0.538 *	−0.616 *	-

* p < 0.05.

), significant correlations emerge. Specifically, better QoL is associated with improved health status (rho = 0.520, p < 0.05), reduced anxiety (rho = −0.567, p < 0.05), and depression (rho = −0.556, p < 0.05). Additionally, better health status is associated with reduced anxiety (rho = −0.497, p < 0.05) and depression (rho = −0.474, p < 0.05). Based on their characteristics (data not presented in Table), younger patients are associated with improved health status (rho = −0.134, p < 0.05). Better QoL is associated with employed individuals (rho = −0.159, p < 0.05) and those with higher annual incomes (rho = 0.134, p < 0.05). Higher levels of depressive symptomatology are associated with older individuals (rho = −0.377, p < 0.05), single/divorced or widowed individuals (rho = 0.170, p < 0.05), individuals with lower educational levels (rho = −0.146, p < 0.05), and the unemployed (rho = 0.161, p < 0.05).

Table 4. Hierarchical multiple logistic regression analysis in 236 patients with thalassemia and with lower quality of life score (<1.00), in relation to their characteristics and the levels of anxiety/depression and health status scales.

	Patients with Lower QoL (Score < 1.00) Compared to Excellent QoL (Score = 1.00)
	1st Model		2nd Model
	Odds Ratio (95% CIs)	p-Value	Odds Ratio (95% CIs)	p-Value
Gender (females vs. males)	1.22 (0.69–2.18)	0.497	1.36 (0.68–2.74)	0.387
Age (by decade)	1.15 (0.80–1.66)	0.454	1.19 (0.76–1.87)	0.457
Family status (unmarried and divorced vs. married)	0.92 (0.40–2.12)	0.835	1.00 (0.38–2.65)	0.995
Children (yes vs. no)	0.51 (0.24–1.06)	0.071	0.40 (0.17–0.96)	0.040
Education level (by education level: minimum/no education, secondary, higher)	0.96 (0.60–1.56)	0.877	0.99 (0.57–1.72)	0.970
Occupation (unemployed vs. employed)	1.86 (1.01–3.43)	0.048	1.94 (0.94–3.98)	0.072
Body Mass Index (by category: underweight, normal, overweight/obese)	1.16 (0.65–2.07)	0.621	1.11 (0.57–2.18)	0.753
Family income (by level)	0.80 (0.58–1.11)	0.182	0.92 (0.64–1.33)	0.656
Years of study (2025 vs. 2018)			0.90 (0.80–1.02)	0.108
HADS, anxiety score (by unit)			1.26 (1.09–1.45)	0.002
HADS, depression score (by unit)			1.11 (0.95–1.31)	0.199
EQ-5D-3L Quality of Life (by unit)			0.97 (0.94–0.99)	0.009
Pseudo R2Nagelkerke	0.082		0.392

95% CIs, 95% confidence intervals.

presents the multiple logistic regression analysis of the correlation between low/moderate QoL (defined as a score of less than 1.00) and various patient characteristics, anxiety and depressive symptomatology levels, and health status levels. Model 1, which incorporates characteristics, indicates that individuals who are unemployed or retired exhibit significantly higher odds (OR = 1.86, p = 0.048) of having low/moderate QoL. Conversely, model 2, which considers the year of study, reveals that individuals with children have significantly lower odds (OR = 0.40, p = 0.040) of experiencing low/moderate QoL. Furthermore, for each unit increase in the Anxiety score, the odds of having low/moderate QoL increase significantly (OR = 1.26, p = 0.002). Conversely, for each unit improvement in health status, the odds of having low/moderate QoL decrease significantly (OR = 0.97, p = 0.009).

4. Discussion

The objective of this research study was to assess the QoL and psychological burden experienced by individuals with thalassemia in Greece, particularly in comparison to previous research conducted prior to the pandemic [9]. Key findings included: (a) high mean Health Status (EQ VAS Index) & QoL scores remained consistent from 2018 to 2025, without significant change (p > 0.05), (b) anxiety mean levels were low and remained consistent from 2018 to 2025 (p > 0.05), (c) depression levels were low but higher in 2025 in relation to 2018 (p = 0.041), (d) anxiety significantly exceeded depression in both 2018 (p < 0.001) and 2025 (p = 0.002), (e) better QoL was associated with improved health status and reduced anxiety and depression (p < 0.05), and (f) individuals with children exhibited significantly lower odds of experiencing low or moderate QoL (p = 0.040). Conversely, each unit increase in the Anxiety score significantly increased the odds of low or moderate QoL (OR = 1.26, p = 0.002). Similarly, each unit improvement in health status significantly reduced the odds of low or moderate QoL (OR = 0.97, p = 0.009).

Analyzing the results of the present study in comparison to the previous study conducted by Rikos et al. (2021) [9] yields several noteworthy conclusions. The present study, conducted with a sample of 236 adult patients with thalassemia in Greece, presents one of the few comparative quantitative approaches over time, comparing data from 2018 to 2025. The study focuses on both quality-of-life indicators and mental health symptoms, utilizing the EQ-5D-3L and the HADS as primary tools.

The longitudinal comparison reveals several critical points of research importance. Firstly, the socio-demographic profile undergoes a significant shift between the two time points. In 2025, an increased number of patients aged 51 and above is observed. This aging population and social isolation may portend a future increase in mental burden. This hypothesis is partially supported by the increased mean depression score in 2025 (4.14) compared to 2018 (3.28), with a p-value of 0.041.

Secondly, despite the observed social changes and aging population, there is no significant variation in either the general Health Status Index (VAS) or the overall QoL EQ-5D-3L. This finding suggests a stability in perceived health and QoL, even in the face of changing social and psychological contexts.

Similarly, anxiety levels remain stable and low, while the overall psychological burden (HADS) does not exhibit significant changes. However, analyzing the differences within the same year, the study reveals that patients consistently experience higher levels of anxiety compared to depression. This may be attributed to ongoing uncertainty surrounding the management of their chronic disease.

Of paramount importance is the multivariate analysis of factors influencing low or moderate QoL. As evidenced, unemployment (OR = 1.86, p = 0.048) and elevated anxiety levels (OR = 1.26, p = 0.002) substantially increase the likelihood of diminished QoL, while having children (OR = 0.40, p = 0.040) and improved health status (VAS) (OR = 0.97, p = 0.009) mitigate it. This finding presents a valuable clinical tool: stress emerges as a pivotal, manageable predictor of QoL, even surpassing factors such as age or marital status. The correlation between the EQ-5D-3L and the HADS further supports this interpretation. Enhanced perceived health (VAS) and overall QoL exhibit negative correlations with stress (rho = −0.567 and −0.497, respectively) and depression (rho = −0.556 and −0.474, respectively), while employment and higher income are positively correlated with QoL. In summary, the intra-study comparison indicates that despite the anticipated increase in age and social decline among patients in 2025, the overall QoL remains stable. Mental burden slightly shifts towards depression, without reaching clinical pathology levels. Notably, the QoL in patients with thalassemia is influenced more by experienced stress and employment status than by biological or demographic factors.

In an attempt to compare the results of this study with other studies, it was observed that QoL in Greece is significantly lower compared to other countries. A 2017 study recorded low QoL in Greece. Conversely, during the same period, moderate values were observed in the USA, the United Kingdom, France, Italy, and Germany, where QoL fluctuates around 54% [4]. In contrast, a study conducted in Oman in 2024 reported high QoL [14]. Low QoL was also observed in countries such as China in 2024, Gaza in 2015, Italy in 2021, Iran in 2016, and the USA in both 2023 and 2024 [15,16,17,18,19,20]. In a cross-sectional study conducted in Malaysia in 2022, the mean World Health Organization QoL-BREF (WHOQOL-BREF) score was as follows: physical health (62.6), psychological health (64.7), social relationships (64), and environmental health (60.8). Notably, mental health issues, financial status, education level, ethnicity, and marital status were significant determinants of QoL scores [21].

Analyzing anxiety levels, it was observed that they consistently remain low. A similar study conducted in Turkey revealed 19.3% of patients with β-thalassemia had low anxiety, while 58.7% exhibited no to minimal anxiety [22]. Another study conducted in Iran in 2016 also indicated low anxiety levels, at 23.7% [23]. In Iran, anxiety levels ranged from mild to severe, with a value of 4.8 ± 3.9 in 2014 [24]. A systematic review conducted in 2024 categorized anxiety levels as normal. In contrast, moderate to high rates of anxiety were identified in Iran in 2018 and in Italy, where anxiety is included in the spectrum of mental disorders [18,25]. A systematic review conducted in 2025 revealed that anxiety rates range from very high values of 84% to 42% [26].

In the present study, the prevalence of depression remains low. Depression rates in Iran ranged from mild to severe among individuals aged 12 and above in 2015 [24], while mild depression was observed in 2014 [18]. In Turkey, a 20.5% prevalence of depression was identified among adult patients in 2014 [22], similar to the prevalence of 19.8% in Iran in 2018 [23]. A systematic review conducted in 2024 revealed a range of depression rates from 35% to 10.3% [25].

In both 2018 and 2025, anxiety levels were significantly higher than depression levels among the study participants. On an international scale, similar studies indicate that depression affects 20.5% of the population, while anxiety affects 19.3%. Notably, depression slightly exceeds anxiety in these studies [22].

Mild to severe depression has a score of 6.4 ± 5, while anxiety has a score of 4.8 ± 3.9. In this case, depression again exceeds anxiety [24]. Another study suggests that depression has a value of 6.64 ± 5.07, while anxiety has a lower value of 5.03 ± 3.95 [18]. A study conducted in Korea indicates that depression levels are lower at 19.8% compared to anxiety levels at 23.7% [23].

A notable finding of the present study is the positive correlation between improved QoL and enhanced health status or a reduction in anxiety and depression. A 2017 study conducted in Greece elucidates this relationship without delving into the specific nature of their association [4].

A comprehensive analysis of the correlation between QoL and health status is presented in the 2021 Greek study, which demonstrates a direct link between high QoL and improved health outcomes. Furthermore, the study underscores the connection between QoL and mental well-being, indicating that for each unit increase in anxiety, the likelihood of experiencing lower QoL increases significantly [9]. At the same time, a 2022 study underscores the association between a history of mental health challenges and diminished QoL [14].

A 2023 study further emphasizes the connection between anxiety and depression, highlighting their detrimental impact on QoL [16]. This negative correlation between anxiety and depression and QoL is corroborated by numerous other studies, reinforcing the findings presented in the present study [18,24,25].

In this study, it was discovered that individuals with children exhibit a significantly reduced likelihood of experiencing low or moderate QoL. Conversely, each unit increase in the stress score corresponds to a substantially higher probability of low or moderate QoL, while each unit increase in health status leads to a corresponding reduction in the probability of low or moderate QoL.

Regarding the direct association between children and QoL, the literature does not establish such a connection. However, a correlation was identified between marital status and QoL [14].

The relationship between stress and QoL, as previously reported, is corroborated by numerous studies [14,16,18,24,25]. These studies collectively demonstrate a correlation between the two variables.

There is a growing body of literature indicating a decline in QoL associated with health status [4,14,15,19,20,27,28,29], and it is vital to acknowledge the potential connection between these factors. However, the literature primarily focuses on QoL as a comprehensive construct, neglecting the interactions between QoL and health status. This oversight warrants further investigation in order to elucidate the nuanced relationship between these variables.

Limitations of the Study

The data collection for this study encountered certain limitations. Individuals declined to complete the questionnaires due to personal reasons, leading to data loss. While cross-sectional studies can elucidate associations between variables, they do not establish causation. Furthermore, the sample consisted solely of patients seen at a single location (Crete), thereby restricting the generalizability of the findings. Furthermore, restrictions such as the non-normal distribution of the used relevant parameters do not allow the use of multivariate parametric methods. Future research endeavors should prioritize conducting a multi-centric study to address concerns regarding data representativeness when assessing patients with thalassemia.

5. Conclusions

The longitudinal comparison unveils several critical study points of significance. First, the socio-demographic profile undergoes a substantial shift between the two time points. In 2025, a larger proportion of patients aged 51 and above were observed. Second, despite the observed societal changes and the aging population, there is no notable variation in either general health status or overall QoL. Anxiety levels remain stable and low, and the overall psychological burden does not exhibit significant fluctuations. However, analyzing the differences within the same year, the study indicates that patients consistently experience higher levels of anxiety compared to depression. This may be attributed to ongoing uncertainty surrounding the management of their chronic disease. Having children and improved health status mitigates this effect. This finding presents a valuable clinical tool: anxiety emerges as a pivotal, manageable predictor of QoL, even surpassing factors such as age or marital status. In summary, the intra-study comparison suggests that despite the anticipated increase in age and social decline among patients in 2025, the overall QoL remains stable.