Depression among patients with end-stage renal disease in hemodialysis

Geraldo B. Silva Juniora,b,c*, Elizabeth F. Daherb, Ana Paula A. Buosid, Rafael S.A. Limac, Mikaelly M. Limac, Eveline C. Silvac, Aline M. Sampaiob, João Moisés L. Santanac, Francisco Emmanuel C. Monteiroc and Sônia M.H.A. Araújoa

aSchool of Medicine, University of Fortaleza, Fortaleza, Brazil; bDepartment of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil; cCentro de Nefrologia de Caucaia, Caucaia, Brazil; dSchool of Psychology, State University of Ceara, Fortaleza, Brazil

(Received 28 May 2013; accepted 12 September 2013)

Depression is frequent in end-stage renal disease (ESRD) and predicts mortality in dialysis patients. The aim of this study was to investigate the occurrence of depression among patients on hemodialysis. We conducted an observational cross- sectional study at two hemodialysis centres in the metropolitan area of Fortaleza, Ceará, Brazil, between September and October 2010. The occurrence of depression was evaluated according to Beck Depression Inventory II. Among 148 patients interviewed, the mean age was 46 ± 13 years and 54% were male. The average time on dialysis was 5.3 ± 5.2 years. Depression was found in 101 (68.2%) cases. Depression was classified as mild (49.5%), moderate (41.5%) and severe (9%). Only 15.5% had prior depression diagnosis. Follow-up with Psychologist was being done in only 32.4% of cases. Patients with depression had a higher frequency of antidepressant use (20.7% vs. 4.2%, p = .01) and benzodiazepines (33.6% vs. 8.5%, p = .001). Among patients using antidepressant, improvement of symptoms was reported by 81.6%. Depression is one potentially modifiable risk factor in ESRD. The investigation and multidisciplinary approach of depression should be part of routine evaluation of patients on dialysis.

Keywords: depression; chronic kidney disease; end-stage renal disease; hemodialysis

Introduction

Chronic kidney disease (CKD) and its treatment represent a major stress for the affected individuals and, frequently, require considerable social adaptation. There are many factors reported to be associated with health-related quality of life including age, gender, education, income, comorbid conditions, hemoglobin level, personality characteristics, depression, anxiety and others (Franke, Reimer, Philipp, & Heemann, 2003; Matas et al., 2002; Prihodova et al., 2009).

The prevalence of depression is higher in end-stage renal disease (ESRD) patients than in the general populations (Chilcot, Wellsted, Da Silva-Gane, & Farrington, 2008) and predicts mortality in dialysis patients (Riezebos, Nauta, Honig, Dekker, & Siegert, 2010). The aim of this study is to investigate the occurrence of depression among patients with CKD on hemodialysis.

*Corresponding author. Email: ef.daher@uol.com.br

© 2013 Taylor & Francis

Psychology, Health & Medicine, 2014 Vol. 19, No. 5, 547–551, http://dx.doi.org/10.1080/13548506.2013.845303

Methods

This was an observational cross-sectional study conducted at two hemodialysis centres in the metropolitan area of Fortaleza, Ceará, Brazil, between September and October 2010. The Beck Depression Inventory II (BDI-II) questionnaire consisting of 21 items was administered as a diagnostic tool (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). A signed consent was obtained before filling out the forms. Depression was classified as mild (score 10–18), moderate (score 19–29) and severe (score >30). The study protocol was reviewed and approved by the Ethics Committee of the University of Fortaleza. Statistical analysis was performed using Epi Info, version 6.04b. The comparison between two groups of patients (depression vs. non-depression) was done using Student’s t-test, Fischer exact test, Mann–Whitney test and Chi-square test when appropriate. “p values” below 5% ( p < .05) were considered statistically significant.

Results

A total of 180 patients were interviewed, of which 148 accepted in answer the question- naire. The mean age was 46 ± 13 years and 54% were male. The average time on dialy- sis was 5.3 ± 5.2 years. Depression was found in 101 (68.2%) cases. The intensity of depression was classified as mild in 50 (49.5%), moderate in 42 (41.5%) and severe in 9 (9%) patients. Only 23 patients (15.5%) had prior depressive diagnosis. Follow-up with Psychologist was being done in only 48 cases (32.4%). Comparison between patients with and without depression showed similar age (45.2 ± 14 years vs. 48.2 ± 12.9 years, p = .21), gender (male 53.4% vs. female 55.3%, p = .86) and time on dialysis (5.5 ± 5.2 vs. 4.9 ± 5.1 years, p = .51) (Table 1). Patients with depression had a higher frequency of antidepressant use (20.7% vs. 4.2%, p = .01) and benzodiazepines (33.6% vs. 8.5%, p = .001). Among 46 (86.9%) patients who were using antidepressant, improvement of symptoms was reported by 40 (81.6%) patients. A comparison between

Table 1. Comparison of depression and non-depression in patients with ESRD in hemodialysis.

Parameter Depression (n = 101) Non-depression (n = 47) p

Age (years) 45.2 ± 14.0 48.2 ± 12.9 .21 Gender Male 54 (53.4%) 26 (55.3%) .86 Female 47 (46.6%) 21 (44.7%) .10

Employment 33 (32.6%) 22 (46.8%) .10 Time on dialysis (years) 5.5 ± 5.2 4.9 ± 5.1 .51 Previous kidney transplantation 7 (6.9%) 6 (12.7%) .34 Preparing to kidney transplantation 40 (39.6%) 23 (48.9%) .29 BDI-II score 19.4 ± 7.8 5.5 ± 2.6 .0001 Use of antidepressant 21 (20.7%) 2 (4.2%) .01 Use of benzodiazepines 34 (33.6%) 4 (8.5%) .001 Improvement with medication 40 (39.6%) 6 (12.7%) .001 Psychologist follow-up 36 (35.6%) 12 (25.5%) .26 Family history of depression 28 (27.7%) 10 (21.2%) .54 Low income 79 (78.2%) 41 (87.2%) .26 Family support 76 (75.2%) 41 (87.2%) .12 Smoking 8 (7.9%) 2 (4.2%) .50 Alcoholism 7 (6.9%) 4 (8.5%) .74 Physical activity 27 (26.7%) 15 (31.9%) .55

Notes: BDI-II = Beck Depression Inventory II. Values expressed as mean ± SD. Student’s t-test and Fisher exact test. Significant p < .05.

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patients with moderate to severe depression and patients without depression is shown in Table 2.

Discussion

Depression is widely recognized as the most common psychiatric problem in patients with ESRD and is considered the second most common medical problem in this popula- tion after hypertension (Chilcot et al., 2008). Depression has been associated with lack of adherence to treatment, suicidal tendencies and poor survival rates (Diefenthaeler, Wagner, Poli-de-Figueiredo, Zimmermann, & Saitovitch, 2008). It is important to consider that complaints of malaise, anorexia and sleep disturbances can be mistaken for depressive symptoms (Murtagh, Addington-Hall, & Higginson, 2007). Chilcot, Davenport, Wellsted, Firth, and Farrington (2011) found significant depressive symptoms (BDI-II score ≥ 16) in 25% of hemodialysis patients. In the present study, depression was found in 68% of cases, which is impressive high.

Most studies performed worldwide report increased depressive symptoms in females (Araújo et al., 2012; Saeed, Ahmad, Shakoor, Ghafoor, & Kanwal, 2012). In the present study, the majority of depressed patients (54%) were male. According to another study (Chilcot et al., 2011), only 15% of depressed patients had prior depressive diagnosis.

Despite the high incidence of depression in dialysis patients, the diagnosis is often missed and not addressed, focusing only on the physical aspects of the disease (Cukor, Cohen, Peterson, & Kimmel, 2007). Saeed et al. (2012) found moderate and severe depression in 75% of studied cases. In the present study, only 15% had prior depressive diagnosis. The intensity of depression was classified as mild in 50%, moderate in 41% and severe in 9% of patients.

Employment status of an individual was associated with higher frequency of depres- sion (Saeed et al., 2012). In our patients with depression, 67% were unemployed and 78% had low income level, but there were no statistical difference between depressive

Table 2. Comparison of moderate-severe depression and non depression in patients with ESRD in hemodialysis.

Moderate-severe depression (n = 55)

Non-depression (n = 47) p

Age (years) 45.5 ± 14.1 48.2 ± 12.9 .26 Gender Male 29 (52.7%) 26 (55.3%) .83 Female 26 (47.3%) 21 (44.7%) Employment 33 (60%) 22 (46.8%) .52 BDI-II score 22 ± 6.8 5.5 ± 2.6 .0001 Time on dialysis (years) 6.2 ± 6.0 4.9 ± 5.1 .40 Previous transplantation 5 (9.0%) 6 (12.7%) 1.0 In preparation for transplantation 22 (40%) 23 (48.9%) .40 Family support 42 (76.3%) 41 (87.2%) .19 Use of medication 28 (51%) 6 (12.7%) .0001 Use of antidepressant 11 (20%) 2 (4.2%) .06 Use of benzodiazepine 21 (38%) 4 (8.5%) .0001 Psychologic follow-up 23 (41.8%) 12 (25.5%) .28 Improvement with medication 22 (78.5%) 6 (12.7%) .005

Notes: Values expressed as mean ± SD. Student’s t-test and Fisher exact test. Significant p < .05.

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and non-depressive group, maybe due to the high prevalence of unemployment and low income.

There is mixed evidence that treating depression has a positive impact on survival outcomes in other physical illnesses (Detweiler-Bedell, Friedman, Leventhal, Miller, & Leventhal, 2008). The use of antidepressants is reported to be as low as 10% (Chilcot et al., 2011). In the present study, only 20% of patients with depression were using antidepressant and 33% benzodiazepines. Among patients using antidepressant, 82% reported improvement of symptoms.

In summary, depression is one potentially modifiable risk factor that is associated with high mortality and non-adherence among patients in dialysis. Depression is a frequent and underdiagnosed disease in these patients. Follow-up with a Psychologist is also uncommon, as well as the specific drug treatment. The investigation of depression should be part of routine monitoring of patients on dialysis. Multidisciplinary approach needs to be sought in treating dialysis patients involving Psychologists, Psychiatrists and Nephrologists to improve the quality of life in these patients.

Study limitations

There are some limitations in this study. The number of patients could be higher, but it is difficult to convince all patients of our centre to enrol the study. The cut-off values used in the questionnaire may overestimate the prevalence of depression. There are also other approach methods to assess depression in these patients.

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