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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 2  |  Page : 341-348
Depression and anxiety disorders in chronic hemodialysis patients and their quality of life: A cross-sectional study about 106 cases in the northeast of morocco

1 Department of Psychiatry, Faculty of Medicine, CHU Mohammed VI, University Mohammed I, Oujda, Morocco
2 Department of Nephrology, Faculty of Medicine, CHU Mohammed VI, University Mohammed I, Oujda, Morocco
3 Department of Community Health and Epidemiology, Faculty of Medicine, CHU Mohammed VI, University Mohammed I, Oujda, Morocco

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Date of Web Publication23-Mar-2017


Hemodialysis (HD) has a severe impact on the life of HD patients. The aim of this work was to assess the prevalence of depression and anxiety disorders, suicidal ideation, and the quality of life among HD patients. Associated factors were also studied. A cross-sectional study was carried out among 103 HD patients treated at the HD Center of Al Farabi Hospital of Oujda during a period of six months in 2015. The Mini-International Neuropsychiatric Interview and European Quality of Life-5 Dimensions (EQ-5D) were used for the assessment. Major depressive episode (MDE) was found in 34% of our patients, whereas anxiety disorder was observed in 25.2%. Suicidal ideation was found in 16.5% and 1.9% of our patients planned their suicide. The EQ-5D index was 0.41 ± 0.36 and the EQ-Visual Analog Scale score was 45.73 ± 14. Multivariate analysis showed that MDEs were associated with three factors: marital status, pain, and anxiety disorder. There was also an association between anxiety disorder and age and EQ-Visual Analog Scale score. Suicidal ideation was associated with marital status and anxiety disorders. Together, these results underline the importance of the collaboration between nephrologists and psychiatrists for a better care of HD patients.

How to cite this article:
El Filali A, Bentata Y, Ada N, Oneib B. Depression and anxiety disorders in chronic hemodialysis patients and their quality of life: A cross-sectional study about 106 cases in the northeast of morocco. Saudi J Kidney Dis Transpl 2017;28:341-8

How to cite this URL:
El Filali A, Bentata Y, Ada N, Oneib B. Depression and anxiety disorders in chronic hemodialysis patients and their quality of life: A cross-sectional study about 106 cases in the northeast of morocco. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2021 May 9];28:341-8. Available from: https://www.sjkdt.org/text.asp?2017/28/2/341/202785

   Introduction Top

End-stage renal failure (ESRD) is a major public health issue in both developed and developing countries.[1],[2]

In the United States, there are 615,899 patients on renal replacement therapy.[3] In France, the prevalence of the ESRD is 1127 cases per million population.[4] In North Africa, the prevalence of ESRD treated by dialysis ranged between 47 and 680 cases per million population.[5] In Morocco, it was estimated at 267.1 to be cases per million population in four regions according to the first annual report of the Magredial register.[6]

Patients on hemodialysis (HD) many psychological disturbances due to psychological distress[7] including depression and anxiety,[8],[9],[10] with increased symptom load and a poor quality of life (QoL).[11]

There are few studies on psychological disorders and QoL have been reported from Morocco.

The aim of this study was to assess the prevalence of depressive and anxiety disorders, suicidal ideation, and the QoL among HD patients and their associations with socio-demographic characteristics.

   Materials and Methods Top

This is a cross-sectional study carried out at the Center of hemodialysis of Al Farabi Hospital of Oujda, Morocco, during a period of six months between July and December 2015, among 103 HD patients.

All recruited patients were over 18-year-old, who had been on HD for at least one month and who have no known psychiatric disorder. They were all informed by their physicians about the purpose of the study, and they gave their verbal consent. We excluded from the study, all patients with an intellectual disability or do not speak Moroccan dialect or those who have a sensory deficit which prevents them from having the psychiatric interview.

For each patient, the data were collected by a psychiatric resident from medical records and dialysis notebook, as well as by an inquiry conducted by nurses and physicians, and also through a confidential personal, 30 min interview which takes place during the dialysis session.

The following are the four parts of the survey questionnaire.

The first one related to demographic characteristics including age, gender, profession, marital status, socioeconomic level, and education level.

To determine the socioeconomic level of the participants, we used the problems meeting basic needs scale which is composed of five items specifying, if in the last 30 days, the participants met serious problems concerning food, transportation, finance, housing, and clothing.

The second part was about the clinical and dialytic data for each patient. We determined comorbidities such as diabetes, hypertension, heart disease, glomerular disease, and family history of psychiatric disorders.

The third part of the survey concerned the assessment of anxiety and depressive disorders using a semi-structured interview based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) which is the Mini-International Neuropsychiatric Interview (MINI) translated and validated into Moroccan dialect.[12] It allows identifying a current major depressive episode (MDE), a previous depressive episode, melancholic features, a current panic disorder, agoraphobia, social phobia, generalized anxiety disorder (GAD), suicidal ideations during the last month, and suicide risk.

The MINI sensitivity varied between 45% and 96%, specificity of 86%–100%, and the correlation coefficient (kappa) between 0.43 and 0.90. It is particularly good for the diagnosis of depressive disorders, panic disorders, and agoraphobia.[13]

The validity study demonstrated a satisfactory quantitative assessment. The data suggest that the Moroccan version of the MINI has managed to raise the validity of the symptoms of criteria used in the DSM-IV diagnoses.

The last part included the assessment of the QoL of patients using an interview based on the five dimensions of Morocco of the European Quality of Life-5 Dimensions (EQ-5D) and the Visual Analog Scale (EQ-VAS), translated and validated in Moroccan dialect.[14] This scale is relatively short and therefore more simple and fast to complete, and the information obtained could be converted into a single index. As it is frequently used in patients with ESRD.[15],[16],[17] This scale was collected by the investigator.

   Statistical Analysis Top

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software version 21.0 for Windows (SPSS Inc, Chicago, IL, USA). All variables were summarized using descriptive statistics. Qualitative variables were described in terms of proportions, and the quantitative variables were described in terms of means and standard deviations. Multivariate analysis was conducted by step-down logistic regression. Variables significantly associated to the 20% threshold in the univariate analysis were selected to be introduced into an initial model. P <0.05 was considered statistically significant, and the results have been expressed by the odds ratio and its 95% confidence interval.

   Results Top

One hundred and sixteen chronic HD patients were recruited, 13 of them were excluded for these reasons: death in one case, mental retardation in five cases, and deafness in six cases, whereas the last case was a non-Moroccan dialect speaker [Table 1]. Nearly 10.7% of HD patients had a member of the family with a psychiatric disorder.
Table 1: Socio-demographic characteristics of the sample.

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Among 103 participants, 35 patients had a current MDE, of whom 65.7% had melancholic features, whereas 25.7% had a recurrent depressive disorder while the prevalence of anxiety disorders was 26% [Table 2].
Table 2: Prevalence of depressive and anxiety disorders.

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During the last month before the study, 16.5% of patients had thoughts about suicide, 1.9% planned their suicide, and none attempted suicide.

The mean of EQ-5D index value was 0.41 ± 0.36 [Table 3].
Table 3: EQ-5D descriptive system in chronic hemodialysis patients.

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The median of EQ-5D index value was 0.52 (0.20; 0.68). It was lower for patients with current MDE, anxious patients, and in those with suicidal ideation, whereas it was higher in patients with no anxious-depressive disorder [Figure 1].
Figure 1: Median of EQ-5D index.

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The EQ-VAS score for these patients was 45.73 ± 14.

Multivariate analysis showed that the current MDE was associated with three factors: living alone, the presence of pain, and anxiety disorder. Suicidal ideations were correlated with patients living alone and having anxiety disorders. While anxiety disorders were combined with age and pain [Table 4].
Table 4: Associated factors of the current MDE, anxiety disorder, and suicidal ideation: uni- and multi-variate analysis.

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   Discussion Top

To the best of our knowledge, this is the first study in Morocco that has studied the psychopathology of depressive and anxiety disorders in chronic HD patients and assessed the suicidal risk in these patients.

The prevalence of the current MDE in the general population is about 1.1%–15% among men and 1.8%–23% among women.[13] In our study, these rates were significantly higher in the HD patients (34%), which is similar to the rate reported in a systematic review.[18] However, this rate is distinctly lower than two previous studies, one from Morocco and the other from Tunisia (67%[19] and 46.2%,[20] respectively). It should be noted that both studies used the Hospital Anxiety and Depression Scale to explore depression in HD patients; however, another study using the Beck Depression Inventory and Beck Anxiety Inventory found a lower rate (25.7%).[21] This variation can be explained by the use of different methodologies.[22] A diagnostic interview provides better information about having psychiatric disorders compared to a self-reported questionnaire. Moreover, the assessment of somatic symptoms of depression is particularly difficult in chronic renal failure patients because they can be caused by uremic symptoms.[20]

Anxiety disorders were also found to be common (25.2%), social phobia at 9.7%, panic disorder at 7.8%, agoraphobia at 5.8%, and GAD at 18.4%. A similar study using the same scale (MINI) found similar prevalence for social phobia and panic disorder, a higher rate for agoraphobia and a lower rate for the GAD.[23] This difference in rates can be linked to the small sample size of the study referred to.

Regarding the suicidal risk, our study showed that suicidal ideations were greater among HD patients, with a rate estimated at 16.5%. This result was also shown a systematic review.[18] In a study from Lebanon carried out among 51 HD patients using the same instrument (MINI) reported a rate of 37%.[24] This difference in rates can be due to the small sample size of the study mentioned.

For QoL, the majority of our patients has reported moderate-to-extreme problems in usual activities, mobility, anxiety/depression, and pain/discomfort (76.7% and 71.8%, 66%, and 59.2%, respectively). However, only 31.1% reported the same degree of problems in self-care. This result differs from a study from Malaysia in 654 patients, which showed that the majority of patients reported no problems in terms of the five dimensions of the EQ-5D system.[25] This variation can be explained by ethnic difference, the delay in diagnosis, at delay of treatment, and poor adequacy of dialysis.

As regards of EQ-5D index, the mean score was 0.41 ± 0.36 which is similar to that reported by Lee et al,[15] whereas it was lower than those found by Wasserfallen et al,[26] Roderick et al,[27] and Yang et al.[28]

The EQ-VAS score among our patients was 45.73 ± 14. This is lower than rates reported from England and Ireland (58.3± 23.9).[11]

Many other researchers using different tools reported reduced QoL in HD patients.[29],[30] We have shown that patients with a current MDE had a lower QoL score than the nondepressed patients (P = 0.04). On the other hand, there was no association between anxiety on QoL (P = 0.8). Vazquez et al[31] have previously shown that depression affects the physical components of QoL, whereas the anxiety affects the emotional and social components of QoL which are not assessed by the EQ-5D. Untas et al have demonstrated, using Kidney Disease Quality of Life (KDQoL), that patients with high depressive and/or anxious symptomatology had a low physical and mental QoL, but with a low correlation between physical QoL and anxiety.[32]

It should be mentioned that our suicidal patients had a low QoL compared with other patients (P = 0.008).

Multivariate analysis in our study has shown that the MDE was associated with three factors living alone, presence of pain, and anxiety disorders. Evans et al[33] and Mingardi[34] also found that married HD patients have a better QoL than those living alone.

A previous study from our center showed that depression was more prevalent in patients with pain.[35] Similar results have been reported.[36]

Association of depressive disorder to anxiety disorder was described both in our study and in literature data.[19]

We also found an association between adulthood and low EQ-VAS score and anxiety disorder. For this age group, we can explain this by the fact that adults are still building their future in fear of death and living thus in painful and permanent psychological suffering.

Multivariate analysis has also shown, as in the depression case, that suicidal ideation was associated with living and anxiety disorder.

It behooves health-care staff looking after chronic HD patients to remember that they constitute a population at risk of having depressive and anxiety disorders as well as suicidal ideation and that taking care of the HD patients must include psychiatric assessment and treatment if required.

   Conclusion Top

Our study confirms the high prevalence of depressive and anxiety disorders and suicidal ideations among chronic HD patients and their association with an altered QoL.

Conflict of interest:

None declared.

   References Top

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Correspondence Address:
Bouchra Oneib
Department of Psychiatry, Faculty of Medicine, CHU Mohammed VI, University Mohammed I, Oujda
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DOI: 10.4103/1319-2442.202785

PMID: 28352018

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  [Table 1], [Table 2], [Table 3], [Table 4]


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