|Year : 2018 | Volume
| Issue : 2 | Page : 115-119
Depression and anxiety in patients with chronic kidney disease undergoing hemodialysis
Vinod Kumar1, Vikash Khandelia2, Ankita Garg1
1 Department of Psychiatry, Government Medical College and Hospital, Kota, Rajasthan, India
2 Department of Nephrology, Government Medical College and Hospital, Kota, Rajasthan, India
|Date of Web Publication||30-Nov-2018|
Department of Nephrology, Government Medical College and Hospital, Rangbari Rd, Sector - A, Rangbari, Kota - 324 010, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Chronic kidney disease (CKD) is a global health problem with a high economic burden on the health-care system. Considering the chronic nature of disease patients undergoing hemodialysis are at risk of developing psychiatric disorders. In this study, we aimed to evaluate the incidence of depression and anxiety in CKD patients undergoing hemodialysis. Methods: This was a prospective, cross-sectional, observational study conducted between June 2016 and September 2017. Patients of either sex having CKD and undergoing hemodialysis were included in the study. Sociodemographic and depression and anxiety related details were collected. Results: A total 150 patients were enrolled in this study, of which 92 (61.3%) patients had depression and 42 (28%) had anxiety. Overall, depression was higher in males, but the difference was not significant; similarly, the anxiety was higher in males, but the difference was statistically significant (P = 0.050). Majority of patients with depression were aged more than 80 years; however, anxiety was more common in patients aged between 40 and 60 years. A total of 59.4% of depressive patients were Hindus, and 27.3% of anxiety patients were Hindus. The correlation between depression and marriage was significant; however, the relationship was not significant between anxiety and marriage. Among patients with depression 55.9% of patients were illiterate, and among patients with anxiety, 25.4% were illiterate. Conclusions: This study provides extensive information on the relationship between depression or anxiety and sociodemographics features among patients with CKD undergoing hemodialysis.
Keywords: Anxiety, depression, hemodialysis, psychiatric morbidity
|How to cite this article:|
Kumar V, Khandelia V, Garg A. Depression and anxiety in patients with chronic kidney disease undergoing hemodialysis. Ann Indian Psychiatry 2018;2:115-9
|How to cite this URL:|
Kumar V, Khandelia V, Garg A. Depression and anxiety in patients with chronic kidney disease undergoing hemodialysis. Ann Indian Psychiatry [serial online] 2018 [cited 2019 Aug 20];2:115-9. Available from: http://www.anip.co.in/text.asp?2018/2/2/115/246526
| Introduction|| |
Chronic kidney disease (CKD) is progressive renal impairment or glomerular filtrate rate <60 ml/min/1.73 m2 for 3 months or more irrespective of the cause. It is one of the most common severe public health problems worldwide. In India, Screening and Early Evaluation of Kidney Disease (SEEK), a community-based voluntary health screening program which was started in 2006, showed the overall prevalence of CKD in the SEEK-India cohort to be 17.2%, with nearly 6% of patients having CKD stage 3–5.
In patients with end-stage renal disease (ESRD), renal transplant, or hemodialysis is necessary for survival. However, considering challenges with donor, hemodialysis remains the treatment of choice for majority of patients. It is also reported that the increasing duration of hemodialysis is associated with poorer quality of life. Hence, there is a potential for the emergence of various psychiatric disorders. Patients treated with hemodialysis are more likely to be affected with mental disorders compared to those treated with peritoneal dialysis., Psychiatric disorders in these patients has an association with poor prognosis and high mortality. The prevalence of anxiety, depression, and insomnia in India was found to be 71%, 69%, and 86.5%, respectively. These factors were found to be significantly correlated with unemployment, low income, low education, urban residence, and presence of comorbidities. Depression is the most common disorders in dialysis patients and is the independent risk factor in these patients.,,,,
The research findings in India regarding the mental health-related issues in CKD patients undergoing hemodialysis is limited. The aim of this study was to evaluate the incidence of depression and anxiety in CKD patients undergoing hemodialysis.
| Methods|| |
This was a prospective cross-sectional observational study conducted between June 2016 and September 2017. Institutional Review Board reviewed and approved the study protocol. The study was conducted in accordance with the International Conference on Harmonization Good Clinical Practice Guidelines and the ethical principles that have their origin in the Declaration of Helsinki. A written informed consent (assent where applicable along with consent from parents) was obtained from each study participant before enrollment.
The study included patients of either sex having CKD (Stage 5) and undergoing hemodialysis. Patients previously diagnosed with psychiatric illness before the onset of CKD, mental retardation, serious unstable comorbid medical illness other than renal disease, and those who were on antidepressant and antiepileptic drugs before the onset of renal disease were excluded from the study.
The selected patients underwent physical examination along with other relevant investigations. Patients diagnosed with depression and anxiety (using Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) were further evaluated for severity using Hamilton rating scale for depression (HAMD) and Hamilton rating scale for anxiety (HAMA). The HAMD scale consists of 17 or 21 items scored between 0 and 4 points., The first 17 measures the severity of depression and the extra four items measures nonsevere factors related to depression such as obsessional and compulsive symptoms. A 17-item scale shows 0–7 score as normal, 8–13 suggests mild depression, 14–18 suggests moderate depression, 19–22 severe depression, and 23 above score are indicative of very severe depression. We used 17-item scale for our study. The HAMA scale is most widely used to measure the severity of perceived anxiety symptoms. It consists of 14 symptom-defined elements mainly focused on psychologic and somatic symptoms with great belief on patient's subjective report. The score 0–13 indicates normal level of anxiety, 14–17 as mild anxiety, 18–24 as moderate, and 25 or more indicates severe anxiety. The subjects who were positive for both the scales counted as cases cases of depression. For patients aged more than 60 years, assessment for dementia or cognitive impairment was not done.
There was no formal sample size calculation employed for this study. A total of 150 patients were considered sufficient for the study based on the number of patients visiting our center for hemodialysis within the limited study period. The data obtained was tabulated, analyzed, and presented using descriptive statistics-means (standard deviations) or as number (percentages). To compare continuous variables, independent t-test was used, and for comparing categorical variables, Chi-square test has been used. Value of P < 0.05 was considered statistically significant.
| Results|| |
A total of 173 patients were screened and 150 patients were enrolled in this study. The mean age of patients was 49.3 years, around 70% of patients were males and around 61% of patients had received some formal education. The majority of patients were practicing Hinduism and were living in urban areas. Of the 150 patients, 92 (61.3%) patients undergoing hemodialysis had depression and 42 (28%) patients had anxiety and 16 (10.7%) were normal.
Overall, depressive disorder was higher in males, but the difference was not statistically significant; similarly, the anxiety was higher in males, and the difference was significant (P = 0.050) [Table 1]. Majority of patients with depression were aged more than 60 years; however, anxiety was more common in patients aged between 40 and 60 years. Overall, there was no relationship between age group and anxiety; but depression significantly increased with age. It was observed that among Hindu CKD patients, 59.4% patients had depressive disorder 27.3% had anxiety; however, among Muslim CKD patients, 72.7% had depressive disorder and 31.8% had anxiety. The difference was not statistically significant (P > 0.05) [Table 1].
|Table 1: Sociodemographic characteristics and psychiatric morbidity in patients with chronic kidney disease undergoing hemodialysis|
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Of the total 150 patients undergoing hemodialysis, 101 (67.3%) patients were living in urban areas. Among patients with depression 69.3% and among patients with anxiety 33.7% were living in urban areas, and this was not significantly different from patients living in rural areas [Table 1]. Of the total patients, 122 were married, and among these married patients 80 had depression, and 36 had anxiety. The correlation between depression and marriage was significant; however, the relationship was not significant between anxiety and marriage [Table 1].
It was found that 55.9% of patients with depression were illiterate, 78.9% were educated up to primary, and 61.1% were postgraduates. Among patients with anxiety, 25.4% were illiterate, 64.3% had primary education and 42.9% had secondary education. Overall there was no relationship between education and depression or anxiety. It was also observed that among patients with depression, 64.6% were housewives and 64.1% were self-employed; however, among patients with anxiety, 43.8% were housewives. Overall results show that occupation has no relationship with depression, but had a significant relationship with anxiety among patients undergoing hemodialysis. Similarly, income had no relationship with depression but had some relationship with anxiety. The family type has no relationship with depression and anxiety among patients undergoing hemodialysis [Table 1].
Overall, more number of patients with depression and anxiety had CKD diagnosed <3 years, however, 57.6% of patients with depression and 24.2% of patients with anxiety had CKD diagnosed for more than 5 years. More than 60% of patients with depression and more than 25% of patients with anxiety were undergoing hemodialysis for <3 years. When looked at the relationship between duration of CKD or hemodialysis and depression or anxiety, no relationship was found [Table 2].
|Table 2: Summary of duration of chronic kidney disease and hemodialysis and its relationship with depression and anxiety|
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The overall severity of depression and anxiety are presented in [Table 3]. Around 38.7% of patients undergoing hemodialysis had normal HAMD score. Around 22% had mild depression, 20% had moderate, 10.7% had severe, and 8.7% had very severe depression. Around 72% of patients undergoing hemodialysis had normal HAMA score. Around 20.7% had mild anxiety, 6.0% had moderate, and 1.3% had severe anxiety.
| Discussion|| |
This cross-sectional observational study was conducted to evaluate the various sociodemographic features and depression and anxiety in patients with CKD undergoing hemodialysis. The overall, psychiatric morbidity among CKD patients in our study was consistent with several previous studies.
There was a preponderance of male patients (70.0% vs. 30.0%) among CKD patients undergoing hemodialysis. In the present study, around 89.3% of patients were aged <60 years, the mean age was 49.3 years, more than half patients were practicing Hinduism (85.3%) and more than two-thirds (81.3%) of patients were married. In the present study, the prevalence of depression and anxiety were 61.3% and 28.0%, respectively. These findings were consistent with previous reports.,, A study by Hou et al. investigated anxiety, depression, and related factors in Chinese patients with ESRD receiving maintenance hemodialysis found that around 69% of patients had a depressive disorder and around 37% patients had anxiety symptoms. In another study from Iran, the prevalence of depression among the hemodialysis patients was 80% and Cukor et al. found that 27% of patients from the USA had current major anxiety.
In the present study, the relationship between depression and age was significant, but there was no relationship between age and anxiety. In a previous study, 19.23% of patients were diagnosed to have a psychiatric illness belonged to the age group of 40–60 years. It was reported that younger patients are more likely to be hospitalized with a mental disorder. On the contrary, few studies have shown no relationship between age and psychiatric illness., In our study, there was a significant relationship between anxiety and gender; but there was no relationship between depression and gender. In a previous study, it was reported that moderate depression was commonly reported in male patients (62.1%). Another study found that depression was more frequent in women; however, a study by Sheayria et al., found to have no relationship between depression and gender.
In our study, we did not find a significant relationship between depression or anxiety and religion, domicile, or education. It was observed that 65.6% depressive patients were married and 42.9% unmarried, which was statistically significant; however, the relationship with anxiety was not significant. This finding was supported by the study of Saeed et al., who found that marriage was correlated with increased depression grade. In our study, it was also observed that 64.6% depressive patients and 43.8% of patients were housewives. Overall, there was no significant relationship between occupation and depression or anxiety. The study was in line with the study of Sheayria et al. who found that depression was not related to employment and Khaira et al. found that depression in patients and spouses was not associated with employment.
In the present study, anxiety was found to be significantly related with financial status; however, it was not related to depression. These results were consistent with previous reports which showed that depression and anxiety were more prevalent in low-income group., In addition, depression and anxiety had no significant relationship with duration of CKD and duration of hemodialysis. Our results were consistent with the previous study, where 30.2% of patients had mild mood disturbance, 17.6% borderline clinical depression, 23.9% moderate depression and 14.5% severe depression. In another study, authors found that 38.7% of patients had mild depression, 5.5% had moderate depression, and 0.6% had severe depression.
Authors acknowledge following limitations of the study. This was a single center study conducted in a teaching hospital in Kota, India. Kota is located in the southeast of the northern Indian state of Rajasthan and has several hospitals providing hemodialysis services for CKD patients in and around the city. Our results may not be generalized considering our study population was limited to a single center. In addition, the study population was relatively small.
| Conclusions|| |
Overall, results from this study provide extensive information on the relationship between depression or anxiety and sociodemographics features among patients with CKD undergoing hemodialysis. These results add data to the literature and contribute to study the trend of psychiatric disorders in Indian patients with CKD undergoing hemodialysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh AK, Farag YM, Mittal BV, Subramanian KK, Reddy SR, Acharya VN, et al.
Epidemiology and risk factors of chronic kidney disease in India – Results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol 2013;14:114.
Gerasimoula K, Lefkothea L, Maria L, Victoria A, Paraskevi T, Maria P, et al.
Quality of life in hemodialysis patients. Mater Sociomed 2015;27:305-9.
Reichsman F, Levy NB. Problems in adaptation to maintenance hemodialysis. A four-year study of 25 patients. Arch Intern Med 1972;130:859-65.
Kimmel PL, Thamer M, Richard CM, Ray NF. Psychiatric illness in patients with end-stage renal disease. Am J Med 1998;105:214-21.
White SL, Cass A, Atkins RC, Chadban SJ. Chronic kidney disease in the general population. Adv Chronic Kidney Dis 2005;12:5-13.
Finkelstein FO, Finkelstein SH. Depression in chronic dialysis patients: Assessment and treatment. Nephrol Dial Transplant 2000;15:1911-3.
Aggarwal HK, Jain D, Dabas G, Yadav RK. Prevalence of depression, anxiety and insomnia in chronic kidney disease patients and their co-relation with the demographic variables. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2017;38:35-44.
Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes. An epidemiological evaluation. Diabetes Care 1993;16:1167-78.
Kimmel PL, Weihs K, Peterson RA. Survival in hemodialysis patients: The role of depression. J Am Soc Nephrol 1993;4:12-27.
Burton HJ, Kline SA, Lindsay RM, Heidenheim AP. The relationship of depression to survival in chronic renal failure. Psychosom Med 1986;48:261-9.
Shulman R, Price JD, Spinelli J. Biopsychosocial aspects of long-term survival on end-stage renal failure therapy. Psychol Med 1989;19:945-54.
Peterson RA, Kimmel PL, Sacks CR, Mesquita ML, Simmens SJ, Reiss D, et al.
Depression, perception of illness and mortality in patients with end-stage renal disease. Int J Psychiatry Med 1991;21:343-54.
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.
Bagby RM, Ryder AG, Schuller DR, Marshall MB. The Hamilton Depression Rating Scale: Has the gold standard become a lead weight? Am J Psychiatry 2004;161:2163-77.
Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50-5.
Hou Y, Li X, Yang L, Liu C, Wu H, Xu Y, et al.
Factors associated with depression and anxiety in patients with end-stage renal disease receiving maintenance hemodialysis. Int Urol Nephrol 2014;46:1645-9.
Hamody AR, Kareem AK, Al-Yasri AR, Sh Ali AA. Depression in Iraq hemodialysis patients. Arab J Nephrol Transplant 2013;6:169-72.
Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA, et al.
Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol 2007;2:484-90.
Ramasubramanian V, Ponnudurai R, Soundararajan P, Balakrishnan K, Srinivasan B. Psychiatric morbidity in patients with chronic kidney disease undergoing hemodialysis. Asian J Pharm Clin Res 2015;8:312-16.
Sheayria F, Karkar AM, Almenawi LA, Alreemawi R, Awn N, Alzenim MM, et al.
Stroke-free status and depression scores among Saudi dialysis patients. Ren Fail 2015;37:392-7.
Gemeay E, Gaber S, Kanona A, Alshebel AA. Impact of hemodialysis on the psychosocial state of patients with end-stage renal disease. Life Sci J 2012;9:5867-71.
Sqalli-Houssaini T, Ramouz I, Fahi Z, Tahiri A, Sekkat FZ, Ouzeddoun N, et al.
Effects of anxiety and depression on haemodialysis adequacy. Nephrol Ther 2005;1:31-7.
Saeed Z, Ahmad AM, Shakoor A, Ghafoor F, Kanwal S. Depression in patients on hemodialysis and their caregivers. Saudi J Kidney Dis Transpl 2012;23:946-52. [Full text]
Khaira A, Mahajan S, Khatri P, Bhowmik D, Gupta S, Agarwal SK, et al.
Depression and marital dissatisfaction among Indian hemodialysis patients and their spouses: A cross-sectional study. Ren Fail 2012;34:316-22.
Wang SY, Zang XY, Liu JD, Cheng M, Shi YX, Zhao Y, et al.
Indicators and correlates of psychological disturbance in Chinese patients receiving maintenance hemodialysis: A cross-sectional study. Int Urol Nephrol 2015;47:679-89.
Rai M, Rustagi T, Rustagi S, Kohli R. Depression, insomnia and sleep apnea in patients on maintenance hemodialysis. Indian J Nephrol 2011;21:223-9.
] [Full text]
Alanazi O, Al-mansour M, Sami M. Depression and quality of life in patients with chronic kidney disease on haemodialysis in central province in Saudi Arabia. Hamdan Med J 2015;8:223-4.
Firoz MN, Shafipour V, Jafari H, Hosseini SH, Charati JY. Sleep quality and depression and their association with other factors in hemodialysis patients. Glob J Health Sci 2016;8:53485.
[Table 1], [Table 2], [Table 3]