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DEPRESSION IN DIALYSIS

DEPRESSION IN DIALYSIS (END STAGE RENAL DISEASE) PATIENTS: A CASE CONTROL STUDY

1.Ravi Rana, 2Dr.D.K.Sharma,  3 C.S.Sushil 4 D.K. Vijayvergia ,5 Ratandeep Lamba

Senior Resident1, Professor & Head2, Professor3,, Associate Professor4, Resident5      Department of psychiatry, S.N. Medical College, Agra, U.P., Maharao Bhim Singh Hospital attached to Government Medical College, Kota

 

Abstract

Background: Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are emerging public health problems in developing countries, and need changes in health-care policy. ESRD incidence data are not available from large parts of the developing world including India.

Aims: Our study was aimed to find out depressive illness in End stage renal disease (dialysis) patients.

Methodology:  A case control study was conducted in Dialysis unit of M.B.S Hospital, Govt. Medical College Kota. The study included 50 consecutive dialysis patients attending Dialysis unit. Another age and sex matched 50 persons preferably relatives of the patients constituted the control group.

Results & Conclusion: 40% of the patients had depression. Depression was more common in males, urban & those were belonged to lower socioeconomic class. Severity of depression increased with increase in number of dialysis. 

Background: Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are emerging public health problems in developing countries, and need changes in health-care policy. ESRD incidence data are not available from large parts of the developing world including India.

Aims: Our study was aimed to find out depressive illness in End stage renal disease (dialysis) patients.

Methodology:  A case control study was conducted in Dialysis unit of M.B.S Hospital, Govt. Medical College Kota. The study included 50 consecutive dialysis patients attending Dialysis unit.

Key words: ESRD (end stage renal disease)

 

Introduction


The impact of psychosocial factors on the outcome of patients with end‐stage renal disease (ESRD) has been receiving more attention recently.  Depression and anxiety are the primary psychiatric problems of end-stage renal disease (ESRD) patients. [1, 2, 3] Depression has been identified as the most common psychiatric illness in patients with end-stage renal disease (ESRD), but its prevalence has varied widely in different studies, in different populations, using different assessment tools. [4, 5, 6, 7, 8]

Depression is characterized by both cognitive and somatic features. The somatic characteristics of depression have an uncanny similarity to the symptoms of uremia, such as anorexia, sleep disturbances, fatigue, gastrointestinal disorders, aspects of volume overload, and pain. These similarities make the determination of the role of an association between depression and mortality potentially problematic.[6,8,9]We used a tool, the Cognitive Depression Index (CDI), a subset of the well-validated Beck Depression Inventory (BDI), to separate the somatic from the cognitive features of depression.[6,10]

Depression has been suggested to affect medical outcomes in ESRD patients through modification of immunologic and stress responses, impact on nutritional status, and/or reduction of compliance with prescribed dialysis and medical regimens. [1,3,6] Recent biologic studies suggest that proinflammatory  cytokines may mediate the behavioral and neurochemical features of depression.[11,12] Many of the same inflammatory biomarkers are known to be dysregulated in ESRD patients, so perhaps there is a direct biologic link between increased levels of depression and renal disease.[13,14,15]

Material & Methods 

The aim of the study was to find out the magnitude and severity of depressive illness in dialysis (ESRD) patients and to find out the relation between number of dialysis & depression in ESRD patients.

Study Design & Methodology

To fulfill the above aims a case control study was conducted in the Dialysis unit of M.B.S. Hospital, attached to Govt. Medical College Kota. 50 cases of ESRD patients coming for dialysis as indoor or outdoor patients & well enough to complete the assessment constituted the sample of the study. 50 subjects preferably relatives of the patients matched on age & sex constituted the control group.

All subjects were evaluated in detail by using especially designed semi structured proforma design for this study. A brief mental state examination was carried out in all subjects. After administration of screening measures, those who were found to have a probable psychiatric morbidity were subjected to detail mental status examination.

 A. Specially Designed Semi structured Proforma Having personal identification and socio-demographic data : Like name, age, sex, cast, religion, education,  occupation, marital status, economic status, domicile, type of family , family size, birth order  etc. Historical data:   including complaints, details of ESRD like creatinine level, no of dialysis, duration, associated physical illness, drug abuse, h/o psychiatric illness. Mental Status Examination.

B. Beck’ Depression Inventory (B.D.I.) (A.T.BECK, 1994) [16]


Observations

      Table 1

Distribution of patients of ESRD & controls according to severity of Depression on Beck’s Depression Inventory

Score on BDI

Study group

N=50

Control group

N=50

        Depression

20 (40%), n=20

9(18%), n=9

        Mild(10-18)

5 (25%)

6 (66.6%)

        Moderate (19-29)

8 (40%)

3 (33.3%)

Severe (>29)

7 (35%)

-

(x2=6.656 , df= 2, p<.05)  Significant

                                                                              Table 2

                            Relationship b/w no of dialysis & depression in dialysis patients

No of dialysis

Depressive patients

Severity of depression

 

<5

 

8(40%)

Mild          4 (50%)

Mod          3 (37.5%)

Severe       1 (12.5%)

≥5

 

12(60%)

Mild          3 (25%)

Mod          5 (41.6%)

Severe       4 (33.3%)

                                                                       

 Results & Discussion

Mean age of ESRD patients was 57 years, 61% of the patients were males. Depression was found in 40% of the dialysis patients, while 18% of the control group had depression. Out of 20 Depressive patients in study group, 35% had mild depression, 40% had moderate while 25% had severe depression while in controls respective figures were 55.5%, 33.3% & 11%, and this is found highly significant, statistically. In the study of Danial Cukor et al (2007), twenty-nine percent patients had a current depressive disorder: 20% had major depression, and 9% had a diagnosis of dysthymia or depression not otherwise specified. Twenty-seven percent had a current major anxiety disorder. [17]

Patients who had more than 5 Dialysis comprised 60 %( 12) of the Depressive patients as compared to 40% (8) who had less than 5 dialysis. 33.3% of the depressive patients suffered from severe depression had, five or more dialysis while only 12.5% of the patients suffered from severe depression that had less than five dialysis.

Conclusion

Depression was found in 40% of the dialysis patients. Dialysis patients had significantly more severe depressive disorders as compared to controls. Severity of depression increased with increasing no. of Dialysis. The need for aggressive targeted treatment of depression and anxiety at the hemodialysis center is clear. As there is mounting evidence that both pharmacologic [18] and cognitive behavioral strategies [19] are effective choices for depression treatment for hemodialysis patients, every center should routinely screen their patients for depression and treat it & other psychiatric illnesses.

References

1.       Kimmel PL, Peterson RA: Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs. Semin Dialysis18:91 –97, 2005.

2.       Cukor D, Peterson RA, Cohen SD, Kimmel PL: Depression in end-stage renal disease hemodialysis patients. Nature Clin Pract Nephrol2:678 –687, 2006.

3.       Cukor D, Cohen SD, Peterson RA, and Kimmel PL: Psychosocial aspects of chronic disease: ESRD as a paradigmatic illness. J Am Soc Nephrol18:3042 –3055, 2007.

4.       Ustun TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray CJ: Global burden of depressive disorders in the year 2000. Br J Psychiatry184:386 –392, 2004.

5.       Kimmel PL: Psychosocial factors in dialysis patients. Kidney Int59:1599 –1613, 2001

6.       Kimmel PL, Weihs KL, and Peterson RA: Survival in hemodialysis patients: The role of depression. J Am Soc Nephrol4:12 –27, 1993

7.       Keiner GI, Ryan CE Keitner GI, Ryan CE, Miller IW, Kohn R, Epstein NB: 12-month outcome of patients with major depression and comorbid psychiatric or medical illness. Am J Psychiatry148:345 –350, 1991

8.       Iosifescu DV, Nierenberg AA, Alpert JE, Smith M, Bitran S, Dording C, Fava M: The impact of medical comorbidity on acute treatment in major depressive disorder. Am J Psychiatry160:2122 –2127, 2003

9.       Smith MD, Hong BA, Robson AM: Diagnosis of depression in patients with end-stage renal disease. Comparative analysis. Am J Med79:160 –166, 1985

10.    Kimmel PL, Peterson RA: Depression in end stage renal disease patients: Tools, correlates, outcomes and needs. Semin Dial18:91 –97, 2005

11.    Segerstrom SC, Miller GE: Psychological stress and the human immune system: meta-analytic study years of inquiry. Psychol Bull130:601 –630, 2004

12.    Miller GE, Cohen S, and Ritchey AK: Chronic psychological stress and the regulation of pro-inflammatory cytokines: a glucocorticoid-resistance model. Health Psychol21:531 –541, 2002

13.    Kimmel PL, Phillips TM, Simmens SJ, Peterson RA, Weihs KL, Alleyne S, Cruz I, Yanovski JA, Veis JH: Immunologic function and survival in hemodialysis patients. Kidney Int54:236 –244, 1998

14.    14.Koo JR, Yoon JW, Kim SG, Lee YK, Oh KH, Kim GH, Kim HJ, Chae DW, Noh JW, Lee SK, Son BK: Association of depression with malnutrition in chronic hemodialysis patients. Am J Kidney Dis41:1037 –1042, 2003

15.    Vazquez I, Valderrabano F, Jofre R, Fort J, Lopez-Gomez JM, Moreno F, Sanz-Guajardo D: Spanish Cooperative Renal Patients Quality of Life Study Group: psychosocial factors and quality of life in young hemodialysis patients with low comorbidity. J Nephrol16:886 –894, 2003

16.    Beck AT, Steer R: Manual for the Beck Depression Inventory, San Antonio, TX, Psychological Corporation, 1987

17.    Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA, Kimmel PL: Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol2:484 –490, 2007.

18.    Finkelstein F, Watnick S, Finkelstein S, Wuerth D: The treatment of depression in patients maintained on dialysis. J Psychosom Res53:957 –960, 2002

19.    Cukor D: The hemodialysis center: a model for psychosocial intervention. Psych Services58 :711 –712,2007