Year : 2021 Month : June Volume : 8 Issue : 23 Page : 1982-1987.
Shameena Abdullah1, P.G. Saji2, Ganga Gangadhara Kaimal3
1 Department of Psychiatry, Directorate of Health Services, Kerala, India.
2, 3 Department of Psychiatry, Government Medical College, Kottayam, Kerala, India.
Dr. P.G. Saji,
Additional Professor of Psychiatry,
Government Medical College,
Kottayam, Kerala, India.
Email : firstname.lastname@example.org
Chronic kidney disease is a major health issue to be discussed in this current era due to its increasing prevalence. It is also known as end-stage renal disease (ESRD). This is a chronic condition which affect both the physical and psychological status of patients. Haemodialysis is the most common method used to treat ESRD. World health organisation (WHO) bulletin in 2018 pointed out the that low and middle income countries suffer very high burden due to chronic kidney disease.1 As per the report of the chronic kidney disease registry of India, 63538 cases of chronic kidney disease were registered in India in the year 2011. The disease was more in men and mean age of the patients was 50.7 in males and 48.1 in females. 17.38 % of patients were undergoing haemodialysis and 2.19 % of patients were on peritoneal dialysis. Among the patients 20.1 % were found to have tobacco use and 7.1 % were found to have alcohol use. The primary disease was diabetic nephropathy in 30.9 % of patients, chronic glomeruli nephritis in 13.3 % of patients, tubulointerstitial disease in 6.8 %, autosomal dominant polycystic kidney disease (ADPKD) in 2.2 % and graft dysfunction in 0.3 % of patients.2 A review on the adaptation to dialysis pointed out that, during the initial stages, patients accept dialysis, but later there occur increase anxiety, depression and confusion. The long-term effects of dialysis include regression, depression and denial.3 A study comparing patients between renal failure on dialysis with comorbid psychiatric illness and renal failure on dialysis with other comorbid medical conditions reported that psychiatric morbidity accounted for hospitalisation in 9 % of all dialysis patients. The hospitalisation rate was 1.5 to 3.0 times higher compared to other comorbid medical illness. Patients in younger age group and male patients were hospitalised more with a psychiatric illness. Compared to peritoneal dialysis, hospitalisation with mental illness was more in haemodialysis patients.4 A review article regarding the psychiatric issues in renal failure and dialysis patients discussed that the common mental disorders that occur in such patients were depression, substance use disorders, delirium, anxiety disorders and suicide. They also noted that the pharmacological treatments used for renal disease might increase the risk of behavioural manifestations such as agitation and confusion.5
A study on medication adherence among haemodialysis patients demonstrated moderate depression in 80 % of the patients with end stage renal disease undergoing haemodialysis. The study demonstrated an association between depression and lack of adherence to haemodialysis treatment regimens.6 A study comparing patients on haemodialysis and not on haemodialysis reported depression and anxiety in both groups but the prevalence of depression was high among patients undergoing haemodialysis. They also reported higher rates of depression among patients using steroids and/or immunosuppressant drugs.7 Another study from China reported severe depressive symptoms in 69.2 % of patients undergoing haemodialysis. They reported that patients with lower levels of blood urea nitrogen and shorter duration of HD were more likely to depressive disorder.8
A study from Nigeria demonstrated psychiatric disorders in 55 % of patients undergoing haemodialysis. Among the psychiatric disorders, 35 % had major depressive disorder and 20 % had generalized anxiety disorder.9 A 4 - year long-term follow-up study among end-stage renal failure patients on haemodialysis reported high frequency of dementia, delirium, and major depression. Management by psychiatrist was needed for these conditions especially for dementia in aged patients who were on long-term haemodialysis therapy.10
Depression may be also present at the start of dialysis. This was suggested by the finding that 44 percent among the one hundred and twenty-three incident dialysis patients scored above the validated cut-off on the beck depression inventory.11 In a cross-sectional study conducted in Kerala among haemodialysis patients by Vinod V. S et al. reported that 46 percentage of patients were found to have depression.12
Depression is found to be associated with an increased risk of hospitalization in dialysis patients and a greater number of hospital days.13 Depression was associated with increased morbidity and mortality. Prognosis was poor in patients with depressive disorder which was found to be independent of the severity of the primary renal disease even in patient who were not on dialysis.14
A study on mental illness and mortality among patients with end stage renal disease undergoing dialysis reported depression as the most common mental illness in children and young adults and organic disorders/dementia as the most common mental illness in elderly adults. Among young adults, depression and affective disorders were found in 3 % of the sample and alcohol use disorders were found in 1 % of the sample. Among elderly adults, 3 % of the sample were having organic disorder/dementia and 1 % of the sample were having depression/affective disorder. Among children 4 % of the sample were found to have depression/affective disorders.15
An Indian study reported 44.1 % prevalence of depression in patients with chronic kidney disease. 28.4 % had mild depression, 15.6 % had moderate depression and 0.8 % had severe depression. 53 % of the study sample was constituted by males and the mean age of the sample was 54.3 years. Depression was found to be more in male patients and in patients under the age of 60 years. The financial situation of the patient, duration of the chronic kidney disease, haemodialysis and presence of comorbidities were found to have significant effect on depression.16
A study from Sudan reported 68 % prevalence of depression in patients undergoing haemodialysis. Depressive symptoms were more in patients who were on dialysis for less than 1 year. Sixty percentage of the study participants were males. One third of the sample were above the age of 50 years. Comorbidities were common and the most common comorbidity was hypertension which was found in 53.3 % of the participants. The dialysis duration was less than one year in 48 % and more than 3 years in 22.7 % of the participants. Depression was found to be 1.4 times more in males compared to females.17
Anxiety disorders were found in 45.7 % of subjects undergoing haemodialysis and the perceived quality of life was lower in dialysis patients with comorbid anxiety disorders.18
A study among urban dialysis patients reported a twenty nine percent prevalence of depressive disorder and twenty seven percent prevalence of anxiety disorder. The mean age of the study sample was 53.2 years and females constituted fifty-three percentage of the sample. The average duration of dialysis was 61 months. 20 % of the sample had major depressive disorder and 9 % had dysthymia or depressive disorder not otherwise specified. Substance use disorder was found in 19 % of the sample and psychotic disorder was found in 10 % of the participants. The diagnosis of depression was independent of the medical health status of the patient. The study also found a special advantage for cognitive behavioural therapy in patients treated with many medications.19
Suicide is more common among chronic kidney disease patients than the general population. Independent predictors for suicide include male gender, white or Asian race, recent hospitalization, and alcohol or drug-dependence.20 Alcoholism appears to be particularly common among patients with end stage renal disease. In one study of 163 patients undergoing dialysis in an urban centre in the United States, 28 percent scored positive according to the Michigan Alcoholism Screening Test.21 Such patients were more likely to be young, HIV-positive, and male.
Various psychological factors affect patient's long-term physical outcome. Various co-morbid disorders are likely to reduce adherence with the complex dietary and medication regimens prescribed. Long-term dialysis therapy itself often results in loss of freedom, dependence on caregivers, disruption of marital, family, and social life, and reduced financial income. Due to these reasons, the physical, psychological, socioeconomic, and environmental aspects of life are negatively affected, leading to compromised quality of life.22
Patients with end-stage renal ailment need to attempt to adjust to a ceaseless physical disorder and the need much of the time of adjusting to dependence on a dialysis machine to stay alive. Modification in cognitive, behavioural and emotional terms is needed by patient their families.23-25
A study regarding stressors and coping among patients undergoing haemodialysis demonstrated that both psychosocial stressors and physiological stressors have equal impact. Maximum stress was reported in patients on dialysis for one to three years.26 A study regarding the coping strategies and quality of life among patients on haemodialysis and continuous ambulatory peritoneal dialysis reported that men were having better coping strategies with the physical aspects of the illness.27
Descriptive research design is used for the study. The sample of the study consisted of 180 patients with chronic kidney disease undergoing maintenance haemodialysis in a tertiary care institute. The dialysis was sponsored by government. Patients of both gender above 18 years with chronic kidney disease undergoing maintenance haemodialysis are included. Patients younger than 18 years, undergoing dialysis for acute kidney injury, patients with hearing, or speech deficits and patients with psychiatric illness prior to the diagnosis of CKD are excluded from the study. Specially designed Pro-forma, ICD 10 Symptoms Check list, and ICD 10 Diagnostic criteria for research are the tools used for the study. The ethical clearance was obtained from the institutional review board of Government Medical College, Kottayam. The study period was from June 1st 2017 to May 31st 2018. The participants were interviewed prior to the medical visits or after the haemodialysis session in a separate room. A written informed consent was obtained. The specially designed pro-forma was completed to collect the relevant socio demographic profile and clinical details of the patients. ICD 10 symptom checklist for mental health disorders-version 1.15 was used as a screening tool for all the patients. The patients who have mental disorders during screening were further evaluated by using the tool ICD 10 diagnostic criteria for research. Data was coded and entered in Microsoft Excel and analysed using IBM SPSS software V 16.0. Descriptive statistics were used in the analysis.
The mean age of the study population was 47.43 with a standard deviation of 13.87. Median age was 49. Minimum age was 19 and maximum age was 86. Among the total 180 patients, 46 (25.6 %) were females and 134 (74.4 %) were males. Diabetes mellitus was present in 101 (56.1 %) of patients and hypertension was present in 23 (12.8 %) of the patients. Of the study population, 59 (32.8 %) had diabetic nephropathy, 17 (9.4 %) had ischemic renal failure. Chronic glomerulonephritis was present in 61 patients (33.9 %) and IgA nephropathy was present in 21 patients. (11.7 %).17 (9.4 %) had chronic tubulointerstitial nephritis and 4 (2.2 %) had rapidly progressive glomerulonephritis (RPGN). Autosomal dominant polycystic kidney disease (ADPKD) was present in one patient. (0.6 %). 82 (45.6 %) patients had plan for renal transplant and 98 (54.4 %) had no plan for transplant. Among the patients, two were (1.1 %) on once weekly maintenance haemodialysis, one hundred and twelve (62.25 %) were on twice weekly maintenance haemodialysis and sixty-six were (36.7 %) on thrice weekly dialysis schedule.
Coming to the duration of disease and dialysis, the mean duration of disease was 9.01 years with a standard deviation of 5.63 years. Median duration of disease was 7.5 years. Mean duration on HD was 2.25 years with a standard deviation of 1.77 and median of 2.00 years. Mean dialysis free disease duration was 6.74 years with a standard deviation of 5.71 and a median of 5.00 years. Maximum duration of disease was 22.00 years, maximum duration on HD was 9.00 years and dialysis free disease duration was 20.00 years.
Regarding the psychiatric morbidity in patients, 27 patients (15.0 %) had depressive illness, 11 patients (6.1 %) had adjustment disorder, one patient (0.6 %) had psychosis and four patients (2.2 %) had anxiety disorder. 137 patients (76.1 %) had no psychiatric disorders. Thus, psychiatric morbidity was identified in 23.9 % of study population. Of the 46 female patients included in the study, 21 (11.7 % of total) had psychiatric illness and 25 were euthymic (13.9 % of total). The male subjects were predominantly euthymic (N = 112, 62.2 % of total) and 22 had psychiatric morbidity (12.2 % of total).
The mean duration of disease among patients with psychiatric illness was 9.63 years and those without psychiatric illness was 8.82 years. The mean duration of haemodialysis among patients with psychiatric illness was 2 years and those without psychiatric illness were 2.32 years.
Of the 59 patients with diabetic nephropathy (32.8 % of total) 19 (10.6 % of total) had psychiatric morbidity and 40 (22.2 % of total) were euthymic. In 17 ischemic renal failure patients (9.4 % of total), 2 (1.1 % of total) had psychiatric morbidity and 15 (8.3 % of total) were euthymic. Chronic glomerulonephritis subgroup had 47 patients (26.1 % of total) with no psychiatric comorbidity and 14 patients (7.8 % of total) had psychiatric illness. In patients with IgA nephropathy, 16 (8.9 % of total) were euthymic and 5 (2.8 % of total) had psychiatric diseases. In patients with chronic tubulo interstitial nephritis, 15 (8.3 % of total) had no psychiatric illnesses while 2 (1.1 % of total) had psychiatric comorbidity. Among the four patients who were on maintenance haemodialysis for the indication of RPGN non recovery, three (1.7 % of total) had no psychiatric diagnoses and 1 (.6 % of total) was found to have psychiatric illness. Only one ADPKD patient participated in the study was euthymic.
The present study reported a male preponderance among patients undergoing haemodialysis. 74.4 % of the study population was constituted by males. This finding is consistent with the 2011 report of the chronic kidney disease registry of India which states that males are affected more with chronic kidney disease.2 An Indian study and a study from Sudan also reported male preponderance.16-17 Chronic glomerulonephritis and diabetic nephropathy were the most common primary kidney disease found in the present study. This is also consistent with the report of the chronic kidney disease registry of India.2 Most of the patients in the present study was undergoing twice weekly dialysis and the mean duration of dialysis was 2 years in patients with psychiatric illness. A Sudanian study reported increased rate of psychiatric morbidity in patients with a dialysis duration of less than one year.17
Studies have reported high prevalence of psychiatric diagnosis in haemodialysis patients. The prevalence of psychiatric morbidity is found to be 23.9 % in the present study. This is inconsistent with the findings of other studies.6,8-9,17 The low prevalence of psychiatric morbidity found in the present study can be as a result of using confirmatory diagnostic tools after screening, which was lacking in the other studies. Among the psychiatric illness, depressive disorders were found to be the most prevalent one. 15.0 % of the study population was found to have depressive disorder and 6.1 % were found to have adjustment disorder with depressed mood. This is consistent with other studies which stated that the depression in the most common psychiatric illness in patients undergoing hemodialysis.6,7,9
The high prevalence of depression in patients with end stage renal disease undergoing haemodialysis can be explained by biological and psychological factors. The biological factors responsible for the development of depression can be hormonal factors such as cortisol, inflammatory activities and altered autonomic activities. The psychological factors that contribute to depression can be the increase burden caused by the disease.28
A major medical crisis can be a contributing factor in the onset or exacerbation of an anxiety disorder. Uncertainty about treatment options, outcome, worries about health, finances, schedule of treatment and change in appearance etc., along with medical conditions like uraemia, anaemia etc., can contribute to the development of anxiety. In our study, 2.2 % of the patients were diagnosed with anxiety disorder.
In this study the prevalence of psychiatric morbidity in patients undergoing maintenance haemodialysis was 23.9 %. The most common psychiatric diagnosis was depression seen in 15.0 %, and 6.1 % of the patients had adjustment disorder with depressed mood. 2.2 % of the patients were diagnosed with anxiety disorder
Depression affects medical outcomes in patients with ESRD through multiple mechanisms, making the assessment and treatment of depression a must. Depression in dialysis patients is associated with increased morbidity and mortality. It affects the quality of life of patients and it increases the risk of suicide. Depression is associated with an increased risk of hospitalization in dialysis patients. This appears to be independent of comorbid illnesses and demographic variables.
Since psychiatric disorders have a negative impact on this chronic condition, provisions should be made for early diagnosis and treatment of the condition before the condition deteriorates.
Small sample size was a limitation. Comparison between males and females with the variables like type of kidney disease, presence of diabetes mellitus, presence of hypertension, duration of disease, duration of haemodialysis and schedule of haemodialysis was not done.
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Financial or other competing interests: None.
Disclosure forms provided by the authors are available with the full text of this article at jebmh.com.
Disclosure forms provided by the authors are available with the full text of this article at jebmh.com
Financial or other competing interests: None.
Copyright © 2021 Shameena Abdullah et al. This is an open access article distributed under Creative Commons Attribution License [Attribution 4.0 International (CC BY 4.0)]
Abdullah S, Saji PG, Kaimal GG. Psychiatric morbidity among patients undergoing hemodialysis - a cross- sectional study at Government Medical College, Kottayam. J Evid Based Med Healthc 2021;8(23):1982-1987. DOI: 10.18410/jebmh/2021/372