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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 946-952
Depression in patients on hemodialysis and their caregivers

Department of Nephrology and Psychiatry, Federal Shaikh Zayed Postgraduate Medical Institute, Lahore, National Health Research Complex, Federal Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan

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Date of Web Publication13-Sep-2012


Depression is recognized as the most common psychiatric problem in patients with end-stage renal disease. Stress negatively affects the quality of life of not only the patients on hemodialysis but also their caregivers. The objective of this study was to measure and compare the frequency of depression in these patients and their attendants, and to assess the associated risk factors in both groups. A cross-sectional study was conducted at our hemodialysis unit from June to September 2009. A total of 180 patients and 180 caregivers were enrolled and the Beck's Depression Inventory (BDI-II) questionnaire was administered. Of the 360 respondents, 201 (55.8%) were males and 264 (73.3) were married. According to the BDI scoring, 135 (75%) of the patients and 60 (33.4%) of the attendants were found to be moderately to severely depressed. Marriage (OR 1.817), low income status (OR 1.757) and unemployment (OR 4.176) correlated with increased depression grade, while gender and education level did not. Anemia was the only co-morbidity showing positive association with depression scores in the patients' group (P = 0.023). We conclude that the majority of the patients undergoing dialysis were depressed and were twice more likely to be depressed than their caregivers. In both groups, marriage and unemployment were associated with increased depressive symptoms, while household income showed negative association with depression. Gender and education level were not related to the depression scores.

How to cite this article:
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

How to cite this URL:
Saeed Z, Ahmad AM, Shakoor A, Ghafoor F, Kanwal S. Depression in patients on hemodialysis and their caregivers. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2022 Jul 4];23:946-52. Available from: https://www.sjkdt.org/text.asp?2012/23/5/946/100869

   Introduction Top

End-stage renal disease (ESRD) has a significant impact on not only the physical but also the psychological aspects of the patient's life. [1],[2] Medications' detrimental side-effects, immobility and associated fatigue, inability to work, sexual dysfunction, fear of death and dependency on a machine for life adversely affect the quality of life of patients undergoing dialysis. [3],[4] Depression is now widely recognized as the most common psychiatric problem in patients with ESRD and is considered second only to hypertension in its occurrence as a comorbid diagnosis in this patient group. [5],[6] A great variability is observed in the studies reporting the prevalence rates of depression in patients undergoing dialysis from 10% to as high as 60% depending on the demographics of the study population and the assessment tools employed. [7],[8],[9],[10] 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. [1] This is important as depression in chronic medical illnesses has been associated with lack of adherence to the treatment regimens, suicidal tendencies and poor survival rates. [11],[12],[13],[14] A holistic approach thus needs to be sought in treating dialysis patients involving both psychiatrists and nephrologists as part of a multi-disciplinary team to effectively improve the quality of life in these patients alongside with addressing to the underlying medical problems. [15],[16],[17]

The stress of treatment and disease burden due to life-long dialysis is inevitable on the patients and the entire family; [18],[19] especially when the patient is the head of the household. Only a few studies in the literature have looked into any symptoms of depression in the care-givers of these patients [20],[21] or compared those with the ones found in the latter group.

The aim of our study was to determine the frequency of depression in patients undergoing hemodialysis and their caregivers in the hospital settings of a developing country in order to delineate potential associated risk factors for depression in both groups.

   Patients and Methods Top

We conducted a cross-sectional study in the hemodialysis unit of Shaikh Zayed Hospital, Lahore, from June to September 2009. A total of 180 patients and 180 attendants were enrolled with a refusal rate of 4% of all those requested to take part. The Beck Depression Inventory (BDI-II) questionnaire consisting of 21 items, adapted in Urdu, was administered as a diagnostic tool. Every respondent was explained thoroughly about the performa and a verbal consent was obtained before filling out the forms. Patients who were mentally disoriented, unconscious or unwilling to participate were excluded from the study. Although the questionnaire was largely self-administered, the questionnaire was read out to illiterate individuals and their responses recorded to allow for their participation in the study. Relevant demographic data including education level, marital status, occupation and household income was also obtained from every respondent. According to the BDI-II, grading of depression was done based on the score levels: minimal depression (0-13), mild (depression scale 14-19), moderate (depression scale 20- 28) and severe (depression scale 29-63). Ethical acceptance was obtained from the Ethics Review Board of the institution before conducting the study.

All the patients who fulfilled the inclusion criteria were approached and a total of 180 patients and 180 attendants participated in the study. All the patients were dialyzed for a minimum time period of three months. A statistically significant difference was observed in the age distribution (P = 0.027), marital status (P <0.001), education (P = 0.037) and employment status (P < 0.001), with the attendants being relatively younger, more educated and employed than the patients. This was expected as most of the patients were physically fatigued and incapable of working and hence unemployed. Similarly, many of the attendants were children of the patients and so younger and better educated. There were no attendants in the category of widowed/divorced. The summary of the characteristics of the two study groups is given in [Table 1].
Table 1: Demographic characteristic of the two groups.

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The most frequent cause of ESRD was diabetic nephropathy in 77 patients (42.8%), followed by hypertensive nephropathy in 63 patients (35%). Other causes included chronic glomerulonephritis, renal calculi, systemic lupus erythematosus (SLE) and polycystic kidney disease. More than half (56.7%) of the patients were sero-positive for hepatitis C. Hypertension was prevalent among 85% of those under dialysis, while 43.3% and 18.3% had diabetes mellitus and anemia, respectively.

   Statistical Analysis Top

The data collected was entered in Epidata and analyzed through SPSS (ver 16.00). Frequencies for the demographic data of the two study groups were obtained and compared. The chi-square test was used to determine whether the difference in the prevalence of moderately to severely depressed individuals between the patients and attendants groups was statistically significant. The mean depression score was associated with its potential risk factors using the student T-test in both the groups collectively. The association of the depression mean score was also determined with the different co-morbidities in the patients group using the student "t" test. For both groups, an over-all multiple logistic regression model was then used to determine the predictive strength of moderate to severe depression with the nominal variables of sex, marital status, employment status and level of income (below or above Rs. 5000/month). This model was then tested via the Chi-square statistic to evaluate the level of significance of our predicted model. To highlight the predictors for moderate to severe depression in the patient population separately, a binary logistic regression was applied to evaluate the combined effect of age (40 years and above), sex, marital status, level of education, employment status and level of income, and was tested through the Chi-square statistic.

   Results Top

The prevalence of moderate and severe depression was 75% among patients undergoing hemodialysis and 33.4% among attendants of these patients (P < 0.001). There was a highly significant difference in the mean scores of depression, 25.4 ± 11.4 and 14.1 ± 9.1, between the patients and the caregivers groups (P < 0.001). The frequency of the depression grades in the two groups is shown in [Table 2].
Table 2: Frequency of depression grades in the two groups.

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The risk factors of marital status (mean score of 20.1 in married and 17.0 in unmarried with P-value of 0.007), employment status (mean score of 22.6 in unemployed and 11.6 in employed at P-value < 0.001) and low income level (with those with a monthly income less than Rs. 5000 having a mean depression score of 21.1 compared with 15.1 in those with higher household incomes at P-value <0.001) had a significant association with depression. This was also demonstrated in the overall logistic model as shown in [Table 3].
Table 3: Logistic regression output for patients and caregivers (n = 360).

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Married patients who were unemployed and had a household monthly income less than Rs. 5000 were most vulnerable and at risk to be moderate to severely depressed.

Within the patients group, marital status (P <0.001), employment status (P = 0.01), low income level (P-value = 0.061), female gender (P-value = 0.002) and education below grade 10 (P = 0.045) were positively associated with moderate to severe depression in patients. This is shown in [Table 4]. Married females, those who were less educated, those who were unemployed and those with an income less than Rs. 5000/month were most likely to be depressed. Moreover, in our patient population, there was no statistically significant association between hepatitis C (P = 0.947), hypertension (P = 0.443), diabetes mellitus (P = 0.073) or ischemic heart disease (P = 0.609) with the mean depression score. However, anemia was associated with more symptoms of depression (P = 0.023).
Table 4: Logistic regression output for patients only (n = 180).

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   Discussion Top

Despite the high level of prevalence, depression is usually under diagnosed and not treated in dialysis patients, which may be due to the overlapping of somatic symptoms of depression such as sleep disturbance, anorexia, fatigue, sexual dysfunction and gastrointestinal upsets with those of uremia. [22]

Different methods have been used in the literature to assess depression in patients with ESRD leading to a great variability in results. [23],[24],[25],[26] In our study, we used the BDI-II questionnaire, which has been tested and validated in many studies. [27] The prevalence of moderately to severely depressed individuals among our patients was found to be 75%. This value is slightly higher than the frequencies observed in other similar studies conducted in different dialysis centers of Pakistan [28],[29] and considerably higher than the prevalence of depression observed in the Pakistani population at large (mean point prevalence = 33%). [30] When compared with the caregivers, more than twice as many patients (75% as opposed to 33.4%) were observed to be clinically depressed in our study.

Many risk factors have been established in literature to have a positive relationship with increased symptoms of depression. In our study, low income status, marital status and unemployment were identified as positive associative factors, while gender and education level were not in both study groups. Nearly two-thirds of the study population had a monthly income of less than Rs. 5000, which was associated with increased depression both among the patients and their attendants. Independent of the household income, employment status of an individual was associated with high depression. Studies have reported prolonged unemployment to be associated with increased stress in individuals. [31],[32] In our study, 81% of the patients and 61% of the attendants were unemployed, and this was associated with an increase in the mean depression scores. The greater proportion of patients reflects increased fatigue and debility that renders most patients incapable of working effectively.

Married individuals were more prone to depression in our study. Sustaining a family is a huge responsibility in terms of providing economical and social support to all its members. Although most studies report increased depression among singles, [32],[33],[34] one study conducted previously in Pakistan reported results similar to ours. [29]

Most studies performed worldwide and in Pakistan report increased depressive symptoms in females as opposed to men, with the difference usually being large. Our study too showed an increased prevalence of depression among women, but the difference was statistically significant only in the patients' subgroup. One hypothesis could be due to low testosterone levels in male patients, an effect of uremia, which is associated with increased depression. [35] However, this does not explain increased scores among male attendants too. Similarly, it is a general consideration that increased education and awareness about a disease condition may make it more tolerable for patients and their families. Most studies report on these lines, with improved quality of life associated with increased education. [34] In our study, most of the study patients were moderately educated, with the great majority of the study subjects being above grade 10 but not graduated. Although education did not show a statistically significant association with increased depression scores in our entire population, patients who received education beyond grade 10 were less likely to be moderately to severely depressed (odds ratio 0.45). Badema Cengic et al has showed similar trends between education and depression in patients undergoing hemodialysis. [36]

Within the patients group, different physical co-morbidities were sought for association with the depression scores. Only anemia was found to be statistically significant. Anemia has been associated with increased fatigue, lethargy and weakness in individuals and also with sleep disorders in hemodialysis patients. [37] Our study showed a statistically significant (P = 0.023) difference between the mean depression scores observed in anemic versus non-anemic patients. Other diseases, especially hepatitis C and hypertension, have been identified in the literature to be strongly associated with depression. [38],[39],[40],[41] However, this was not found in our study population.

The limitations in our study include the fact that 82 participants (52 patients and 30 attendants) were illiterate and so were interviewed, which may have lead to a form of information bias. Expanding and converting the study into a longitudinal one, by establishing baseline mental status to rule out any psychiatric illness and doing periodic administration of the BDI-II, can increase the strength of our study and can be conducted in the future.

Another limitation of our study is that it is a single-center study; expanding it further to include other dialysis centers catering to different population subgroups would increase the impact of our study in terms of depicting the overall prevalence of depression in this patient group and their families in our part of the world.

In conclusion, this study highlights the need to recognize and address the inevitable stress and depression dialysis patients and their families are exposed to and to design intervention programs aimed to improve the quality of life in this population, which is also associated with better patient outcome and survival.

   References Top

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Correspondence Address:
Aizaz M Ahmad
Department of Nephrology, Federal Shaikh Zayed Postgraduate Medical Institute, National Institute of Kidney Diseases, Lahore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.100869

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