Saudi Journal of Kidney Diseases and Transplantation

: 2016  |  Volume : 27  |  Issue : 2  |  Page : 331--334

The effect of depression and anxiety on the performance status of end-stage renal disease patients undergoing hemodialysis

Emilda Juidth Ezhil Rajan, Somasundaram Subramanian 
 Department of Clinical Psychology, Sri Ramachandra Medical College, Bharathiar University, Porur, Chennai, Tamil Nadu, India

Correspondence Address:
Emilda Juidth Ezhil Rajan
Department of Clinical Psychology, Sri Ramachandra University, Porur, Chennai, Tamil Nadu


Individuals who are diagnosed with end-stage renal disease (ESRD) undergo major changes in lifestyle. The present cross-sectional study was conducted to identify the relationship between patients who undergo hemodialysis (HD) and their performance status, and how it is influenced by the presence of the level of depression and anxiety. A total of 50 patients were recruited from HD centers in and around Chennai. The patients were screened using the General Health Questionnaire to screen for co-morbid psychiatric conditions. The patients were assessed for depression and anxiety, and their performance status was assessed using Beck«SQ»s Depression Inventory, Beck«SQ»s Anxiety Inventory, and Karnofsky Performance Status. The study findings indicate that there is a positive correlation between anxiety and depression in ESRD patients. The findings also indicated that depression and anxiety are positively correlated with the performance status of ESRD patients. The duration on, as well as the frequency of dialysis, also correlated with the performance status of ESRD patients. It can be concluded that anxiety and depression are prevalent among ESRD patients and that they interfere with the performance status; additionally, duration on dialysis also interferes with performance status. Addressing depression and anxiety can help in enhancing the patient«SQ»s performance status.

How to cite this article:
Rajan EJ, Subramanian S. The effect of depression and anxiety on the performance status of end-stage renal disease patients undergoing hemodialysis.Saudi J Kidney Dis Transpl 2016;27:331-334

How to cite this URL:
Rajan EJ, Subramanian S. The effect of depression and anxiety on the performance status of end-stage renal disease patients undergoing hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Dec 5 ];27:331-334
Available from:

Full Text


Affective disorders of anxiety and depression are established to be the most commonly occurring disorders in medical illness. [1] It has been seen that compared to depression, anxiety has received little clinical attention, although it was noted to be prevalent in patients with end-stage renal dialysis (ESRD). [2]

Among ESRD patients, depression has been established as a primary mental health issue. [3] Several studies have shown that there is an association between depression and mortality. [4] Recent findings have shown that the use of pharmacotherapy, as well as non-drug therapy for depression and anxiety, is prevalent among ESRD patients. [5] It has also been noted that behavioral phenomena mediate the relationship between anxiety and depression and also other adverse outcomes. [6] Depression is also known to alter the outcome of medical treatment in ESRD patients starting with compliance to treatment, altered immune system, increased cytokine levels, and poor nutrition. [7]

One of the most common misconceptions among ESRD patients is that they are viewed as being too ill to perform any physical activity and also that they lack the motivation to do so, and more importantly perceived as a health risk. [8] Studies implementing the use of physical activity as part of the treatment regimen for ESRD patients have indicated that physical activity improves physical functioning and psychological status as well as their quality of life. [9] Physical exercise has greatly benefited ESRD patients by showing significant improvement in their level of depression, quality of life, physical and mental health and are also known to improve symptoms of anxiety. [10]

 Patients and Methods

This study is a cross-sectional study, and a purposive sampling method was used. A total of 50 patients on hemodialysis (HD), irrespective of gender, were recruited from hospitals in and around Chennai. The eligibility was based on individuals undergoing HD for at least one year or more and individuals falling in the age range of 30-60 years. Patients who were being prepared to receive a transplant and those who had a current history of substance abuse were excluded from the study. Individuals with a history of psychiatric disorder(s) were also excluded from the study.

Informed consent was obtained from all participants and also, their sociodemographic details were collected.


General Health Questionnaire (Goldberg; 1972) [11]

General Health Questionnaire-12 was used to screen our respondents with psychiatric disorders in the dialysis setting.

Beck's Depression Inventory-II (Aron. T. Beck, 1996) [12]

The Beck's Depression Inventory-II (BDI-II) is a 21-item self-report instrument for measuring the severity of depression in psychiatrically diagnosed adults and adolescent patients aged 13 years and older. The psychometric characteristics of BDI-II indicate reliability with an internal consistency; the coefficient alphas are 0.92 and 0.93. Test-retest stability was seen to be significant. Construct validity of BDI-II was performed in comparison with several other psychological tests used in clinics; BDI-II was noted to have good construct validity and factorial validity.

Beck's anxiety inventory (Aron. T. Beck, 1993) [13]

The Becks Anxiety Inventory (BAI) is a 21item scale that measures the severity of anxiety in adults and adolescents. The psychometric characteristic of BAI was determined using both clinical and nonclinical samples. Reliability was checked by calculating internal consistency for which BAI indicated a coefficient alpha of 0.94. Item analysis revealed an item-total correlation ranging from 0.003 to 0.71. Test-retest reliability of the inventory gave a correlational score of 0.75.

Karnofsky Performance Status (Karnofsky DA Burchenal JH. 1949) [14]

The Karnofsky Performance Status Scale (KPS) is widely used to quantify the functional status of cancer patients. The reliability of 47 National Health Service interviewers was found to be 0.97. The construct validity of the KPS was analyzed, and the KPS was found to be strongly related (P <0.001) to two other independent measures of functioning of patients. Finally, the relationship of the KPS to longevity (r = 0.30) in a population of terminal cancer patients documented its predictive validity. These findings indicated the utility of KPS as a valuable research tool when employed by trained observers.


The data were collected cross-sectionally. The patients were assessed in a single session and, the data were interviewer-based on both responses from the patient as well as family members. All the tests were administered and scored by a trained clinical psychologist.

 Statistical Analysis

Descriptive statistics using Spearman's rank order correlation was used. The analysis defined the relationship between depression, anxiety and performance status of HD patients. Statistical analysis was made using SPSS version 19.


A total of 50 HD patients were included in the study. The study population consisted of 32 males and 18 females with duration on dialysis ranging from 3.06 ± 1.26 years with a mean value of 1.36 ± 0.46 years. [Table 1] indicates the relationship between the socio-demographic variables among the study patients. The analysis indicated a significant positive correlation between age of the patients and the duration on dialysis ( P ≤0.01).{Table 1}

The correlation between anxiety and depression and performance status of HD patients is indicated in [Table 2]. There was a significant positive correlation between anxiety and depression in HD patients ( P ≤0.01). Furthermore, there was a significant negative correlation between performance status and depression ( P ≤0.01) and also a significant negative correlation between performance statues and anxiety ( P ≤0.01).{Table 2}


In general, anxiety and depression are wellestablished factors that are known to complicate the treatment of medical illnesses. [1] Furthermore, it has also been established that depression constitutes the primary concern in the treatment of ESRD patients undergoing HD. [3] The findings of the current study indicate a relationship between depression and anxiety among ESRD patients on HD; [7] this further expands to explain the findings that the presence of depression might indicate the presence of anxiety as well among ESRD patients undergoing HD. Thus, presence of depression increases the likelihood of developing symptoms of anxiety that may complicate the treatment regimen of ESRD patients on HD.

Individuals with ESRD are considered to be too delicate and always in a state of illness that may put them at risk if they try to move; i.e., a perceived threat of reduced health if individual chooses an active lifestyle. Hence, this leads to reduced physical activity. Physical exercises in ESRD patients have been noted to have a great impact on the individuals' quality of life, physical and mental health and more specifically, effective and beneficial in addressing symptoms of depression and anxiety. [10] The current study also indicates that depression and anxiety have a relationship with the individual's performance status. There is an inverse relationship between the extent of physical activity and presence of depression, and by improving the individuals' performance status one can reduce the level of depression and anxiety and more realistically, provide an effective coping process in enabling an individual to overcome depression. This finding further emphasizes that physical activity does influence the betterment of health in ESRD patients. [9]

 Conclusion and Implication

The importance of addressing depression and anxiety among ESRD patients undergoing HD has been long established, and if it is not tackled, it may complicate the medical care of the patients. The current study further concludes that anxiety and depression are comorbid entities that are prevalent among ESRD patients. The management of depression and anxiety can be made easy by introducing regular physical activity among HD patients, as the two are inter-related, as is indicated in this study. Further research is required to understand the level of physical activity required, in relation to the condition of the patients on HD.

Conflict of interest: None declared.


1Dimatteo MR, Lepper HS, Croghan TW. Depression is a health risk for non-compliance with medical care. Arc Intern Med 2000;160: 2101-7.
2Cukor D, Cohen SD, Peterson RA, Kimmel PL. Psychosocial aspects of chronic disease: ESRD as a paradigmatic illness. J Am Soc Nephrol 2007;18:3042-55.
3Kimmel PL, Peterson RA. Depression in patients with end-stage renal disease treated with dialysis: Has the time to treat arrived? Clin J Am Soc Nephrol 2006;1:349-52.
4Kimmel PL, Peterson RA, Weihs KL, et al. Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney Int 2000;57: 2093-8.
5Cukor D, Coplan J, Brown C, et al. Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol 2007;2:484-90.
6Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients' adherence to antidepressant therapy. Med Care 1995;33:67-74.
7Cohen SD, Norris L, Acquaviva K, Peterson RA, Kimmel PL. Screening, diagnosis, and treatment of depression in patients with end-stage renal disease. Clin J Am Soc Nephrol 2007;2:1332-42.
8Painter P, Carlson L, Carey S, Myll J, Paul S. Determinants of exercise encouragement practices in hemodialysis staff. Nephrol Nurs J 2004;31:67-74.
9Wong SW, Chan YM, Lim TS. Correlates of physical activity level among hemodialysis patients in Selangor, Malaysia. Malays J Nutr 2011;17:277-86.
10Kosmadakis GC, Bevington A, Smith AC, et al. Physical exercise in patients with severe kidney disease. Nephron Clin Pract 2010;115: c7-16.
11Goldberg DP. The Detection of Psychiatric Illness by Questionnaire. London: Oxford University Press; 1972.
12Beck AT, Steer RA, Brown GK. Becks Depression Inventory-II. San Antonio, USA: The Psychological Corporation, Harcourt Brace and Company; 1996.
13Beck AT, Steer RA. Becks Anxiety Inventory. San Antonio, USA: The Psychological Corporation, Harcourt Brace and Company; 1993.
14Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. J Clin Oncol 1984;2: 187-93.