| Abstract|| |
The goals of chronic dialysis treatment for end-stage renal disease (ESRD) patients include restoration of the highest achievable state of personal physical health and preservation as well as restoration and development of the highest level of psychological and social functions. We conducted this study to evaluate factors influencing the process of adaptation such as religious faith, economic status and extended family-tribal system. It was hoped that studying these factors might provide further dimension to our understanding of the psychopathology of ESRD patients, and to help offer new ideas to improve the quality of their lives. A sample comprising 54 patients with ESRD was studied in Abha hemodialysis centre in Southern Saudi Arabia. The socio-demographic characteristics, clinical and laboratory data were collected. The psychiatric status of the patients was evaluated using a structured "The Comprehensive Psychiatric Rating Scale" (CPRS) clinical interview. The result indicated that the major co-morbidity (in 60% of these patients) was a depressive illness due to renal failure diagnosable according to DSM-IV criteria. Our study suggests the need for specific anti-depressant treatment in order to ameliorate many distressing symptoms, which may affect the quality of these patients' life. Concomitant social problems of poverty, absence of spouse and illiteracy, dictate a more prompt attitude in initiating support systems and attention to providing leisure activities.
Keywords: Depressive illness, Hemodialysis, Saudi Arabia, Abha.
|How to cite this article:|
AL-Homrany MA, Bilal AM. Psycho-social Features of Chronic Dialysis Patients in Saudi Arabia: Experience of one Centre. Saudi J Kidney Dis Transpl 2001;12:164-71
|How to cite this URL:|
AL-Homrany MA, Bilal AM. Psycho-social Features of Chronic Dialysis Patients in Saudi Arabia: Experience of one Centre. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2019 Jun 27];12:164-71. Available from: http://www.sjkdt.org/text.asp?2001/12/2/164/33806
| Introduction|| |
Terminal renal failure is probably one of the most devastating illness experiences that human beings endure. The picture has reportedly changed since the introduction of hemodialysis (HD) which has offered a new lease of life to these patients and, as consequence of further technological advances over the last 15 years, these patients are now being kept alive for considerable periods of time.  Global interest has grown in the study of psycho-social adaptation of these once terminally ill patients, and the quality of life they lead. Various contributing variables i.e., medical, psychological, social and dynamic influences have been reported that can effect the quality of these patients' life. In the Department of Internal Medicine of Assir Central Hospital in the Southern Region of the Kingdom of Saudi Arabia, we have become increasingly aware that our patients with renal failure seemed to face many psychological problems. This is despite the impressive health-care resources and social support systems offered by official as well as voluntary organizations in the Kingdom. Developing ideas to improve the quality of life of these patients requires better understanding of factors that may influence their psychopathology, such as cross-cultural support systems contributing to the process of adaptation. These include the influences of religious faith and those of the extended family-tribal systems.
The Assir region (its name literally means rugged in Arabic), is the mountainous area of south-west Saudi Arabia. It is characterized by pleasant year-round atmospheric conditions on the high lands but a rather dry, hot and dusty climate on the plains that separate the mountains from the Red Sea coast. The capital town of the region is Abha, a beautiful urban centre housing the Government offices, a medical school and other colleges, which are affiliated to two major Saudi universities. It is widely reputed as the Kingdom's cultural resort. As with other parts of Saudi Arabia, the region shares a rapid and massive development in health-care system, which is provided free of cost for all, particularly emergency and life-saving care including HD. The population is mixed, especially in bigger towns, but in most other areas indigenous Saudi nationals predominate. The inhabitants of the high lands are comparatively urbanized, more educated and enjoy more material affluence than the dwellers of the low lands. The Islamic faith is the only religion adopted by the indigenous Saudi population.
| Material and Methods|| |
The study was carried out at the main HD centre of the Assir Region in Abha town. All the 54 patients with terminal renal failure who attended HD sessions between April 1998 and May 1999 were included. Socio-demographic characteristics were recorded. Medical data used in the study were: duration on HD (in years), frequency (per week) of dialysis, and record of symptoms of note such as itching and muscle cramps. Dietary and fluid restrictions and, whether these bothered the patient, as well as the use of erythropoietin and whether it made any difference to the patient's well-being, were noted. Adequacy of dialysis was assessed by the urea reduction ratio (URR). The values of serum potassium, calcium, inorganic phosphorous and hemoglobin were measured using a random sample during the patient's clinical evaluation.
The subjective report of psychosocial stress as judged by the patient i.e., financial dependence, social dependence, self-esteem, life satisfaction and the degree of participation in community work, sports, home and school social activities was rated between zero for negative response and 3 for extreme degrees. Coping behavior was measured by how much (range 0-3) the patient was realistically aware of the gravity of his illness (denial) and whether he/she thought others were responsible for his/her illness (projection). Psychological tests are being used increasingly in dialysis populations, both for psychosomatic research and for clinical evaluations but we preferred to use a full length structured clinical interview. We felt that a clinically oriented scale which offered thorough and comprehensive scrutiny of the patient's mental state was offered by "A Comprehensive Psychopathological Scale", (CPRS).  The main advantage of using the CPRS is that it contains many items that are rarely included in similar rating scales (e.g. hostility) and that it evaluates subjective symptom-reports as well as observed mental status, separately. 2 The scale covers psychopathological variables which are scored by the rater in operationally defined steps, i.e., 0, 1, 2, 3. The Arabic language version of CPRS (professional translation) was tested and back translated to English and yielded satisfactory results before it was applied on our patients. As many of our patients were illiterate or were too ill to comprehend, or may rush to answer questions without due thought, the scale items were first read out, patiently explained and their answers were gauged and recorded by the psychiatrist.
Statistical analysis was done by using the "Advanced SPSS for windows" package on a personal computer. We used two identical data files for the sake of the analysis, i.e., in one file, we entered numerical data from parametric variables and string values for non-parametric variables. In the second file, we converted all string values into weighted numerical variables in order to facilitate wide scale inter-correlations (data screening) using Pearson's two-tailed t-test. Frequency distributions of variables were done. This was followed by inter-correlations and then further analysis was done on the original file using chi-square test on cross-tabulated data.
| Results|| |
The socio-demographic characteristics of the study sample are shown in [Table - 1]. These were inter-correlated with other variables using Pearson's 2-tailed t-test. Significant associations were further analysed by chi square on X by X contingency tables. The results shown in [Table - 2](a,b,c) demonstrated significant (p<0.05) associations of gender, age and education with other variables respectively. In [Table - 2](a), males were shown to be significantly unlikely to be financially or socially dependent.
Females were significantly less likely to have social participation and were noted to have significantly high expressed hostility. Examination of the sample according to age-group distribution revealed that the young were least likely to be socially dependent and to project their problems to others. Evaluation of the sample on education showed that literate patients were more likely to be socially and financially independent, while illiterates had less social participation. Erythropoietin was prescribed for 34 patients (65% of the sample). Since the supply of the drug was not steady and the dose could not therefore, be standardized, we decided to drop any further analysis of these variables.
Biochemical data (hemoglobin, urea clearance, calcium, phosphorous, potassium levels) showed no significant association with the symptoms of itching, lassitude, sexual dysfunction or muscle tension.
Somatic and psychological variables were inter-correlated using Pearson's two-tailed t-test. [Table - 3] shows that itch was the most distressing physical symptom and correlated significantly with reported sadness, loss of feelings towards others, lassitude, fatiguability, poor concentration, observed sadness and expressed hostility. Expressed sad mood was significantly related to hostility, lack of feelings towards others, pessimism, lassitude, poor concentration, poor appetite, insomnia, autonomic instability, aches and pains, objective sadness and expressed feelings of hostility. Sexual weakness as a common symptom in this sample did not correlate with either itch or depressed mood.
Sadness was reported by 32 patients (59.5% of the sample) while 22 patients (40.7%) were observed to be clinically depressed. [Table - 4] depicts the association of clinical depressed mood by crosstabulation with other variables using chisquare test. This showed that the lack of clinically observed sad mood was significantly related to the absence of expressed sadness. Also, the group who had the least duration on dialysis did not show depressed mood. Clinically depressed patients thought that their life was meaningless while clinically non-depressed patients participated socially more than their clinically depressed counterparts.
| Discussion|| |
The socio-demographic characteristics of our sample [Table - 1] is possibly fully representative of the general population in terms of age distribution, gender, nationality and education since there was no selectivity involved in the admission criteria to the HD centre. Non-Saudi patients (11.1%) enjoy the same facilities that are offered to their Saudi counterparts and at no cost. The high representation of divorced/widowed group (27.8%) may reflect an unfortunate trend of divorcing the wife once she became ill. Almost all the females were housewives while the males were evenly distributed between manual work, clerical work and a non-earning group (retired, unemployed or student). Females are traditionally supported by their husbands or relatives in this region. Well over half of our patients (57%) were classifiable as poor (by any standard) but they managed to carry on with the help of society-support groups, mainly non-official, Muslim religious groups. Most of the sample patients (70.4%) resided in the vicinity of the centre for convenience. Patients who lived on the low lands of Tihama (29.6%) had to make the journey to the centre unassisted.
Evaluation of patients' gender, age and education [Table - 2]a, b and c revealed that male patients were financially and socially less dependent than females and also were more socially participating. This reflected an expected cultural pattern of male dominance and probably explains why females expressed more hostility. Our data do not support that of Livesley, , who reported that psychiatric symptoms were more frequent in women than in men and that they were more frequently personally disturbed and personally ill.
Young patients were less socially dependent and tended to use more projection defense mechanisms than the older patients. We found that projection correlated strongly with hostility, lending support to published reports that younger patients were more hostile and could be overtly aggressive.  Analysis of the sample according to educational status reflected some socially expected patterns; the literate were less likely to be socially and financially dependent and enjoyed higher incomes than their illiterate counterparts. The illiterates participated less socially, and the literates were more likely to be critical as they used projection. It seemed that the young and the literate as well as females employed these mechanisms more than the others suggesting that these groups were more intensely conscious of the limitations that the illness and its treatment had exerted on their lives.
The fact that only nine (16.7%) of our patients expressed denial and that no correlation was found between denial and other variables is worth discussion. The role of denial in emotional adjustment and rehabilitation in dialysis patients  has been documented as an important defense mechanism and is used a great deal in dialysis patients to help them cope with their disease and with more adaptive attitudes toward illness.  Our clinical impression indicated that older patients tended to admit their illness with pleasure as this meant to them submissiveness to the will of God rewarded by forgiveness in the after life.
The small number of our patients who were prescribed erythropoietin, may explain why our results failed to support other reports that erythropoietin, through its effectiveness in the treatment of renal anemia, significantly decreases fatigue, vertigo, dyspnea, muscular weakness, leading to a marked improvement in the quality of life. ,
We did not find any correlation between tested biochemical parameters and many of the distressing somatic symptoms of dialysis patients namely itching, poor appetite, lassitude, muscle tension, muscle cramps, fatiguability, and sexual dysfunction.
The significant correlation between somatic and psychological symptoms [Table - 3] is remarkable as it provides strong evidence that we are dealing with depressive illnesses. This lends support to similar reports concluding that the strongest correlate of common somatic symptoms in dialysis patients is affect disturbance. We concur with Barret et al  and feel that such conditions met the criteria for, and should be diagnosed as, "Mood disorder due to renal failure, code 293.83" of the DSM-IV. There seems to be adequate basis for such a diagnosis since the depressed mood could be attributable to renal failure although there are no infallible guidelines for determining an etiological link between the two. Treatment with adequate dosage of appropriate anti-depressants or even electroconvulsive therapy (ECT),  may improve both depression and the somatic symptoms. Sexual weakness, a common symptom reported by these patients,  did not correlate with symptoms suggesting depressive illness or any of the biochemical indices. This may be due to the fact that sexual dysfunction was global in this sample so that it failed to figure statistically with any subgroup of variables. Weizman et al,  suggested that there was a relationship between sexual dysfunction and serum prolactin levels which may be explained by hyper-prolactinemia in uremic patients. Duration on dialysis was significantly associated with depression, both reported and observed. This is different from the observation of Wolcott et al,  that duration on dialysis was not related to quality of life. Patients treated with HD often developed psychotic episodes and neuropsychiatric manifestations. , The reason we did not encounter such patients in our sample was due to the fact that such patients are generally hospitalized and were most unlikely to figure as out-patients.
| Conclusion|| |
Our study suggests that the most evident co-morbidity suffered by our sample patients was depression. The significant association between somatic and psychological symptoms suggests that these symptom-constellations represented the same clinical disorder and may thus benefit from specific anti-depressant treatments. Ameliorating these symptoms would invariably lead to improving these patients' quality of life and would improve their compliance with prescribed treatments. Concomitant social problems such as poverty, absence of spouse and illiteracy, dictate a more prompt attitude in initiating support systems and attention to providing leisure activities. 
Further research into trans-cultural aspects concerning concepts about kidney function and kidney disease, the role of the extended family and the influence of traditional healers on the pattern of management of patients with chronic renal failure are needed. Also, it is important to elucidate if there are any great cross-cultural differences in the reactions and adaptation to maintenance HD of such diversely different groups like South African Blacks and Western societies. 
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Mohammed A AL-Homrany
Department of Internal Medicine, King Khalid University, P.O. Box 641, Abha
[Table - 1], [Table - 2], [Table - 3], [Table - 4]