|Year : 2021 | Volume
| Issue : 1 | Page : 57-62
Assessment of quality of life and psychiatric morbidity in patients undergoing hemodialysis at a tertiary care center
Ananda Reddy Endreddy1, Lakshmi Rajesh Chennareddy1, Subahani Shaik2
1 Associate Professor, Department of Psychiatry, Narayana Medical College, Nellore, Andhra Pradesh, India
2 Assistant Professor, Department of Psychiatry, ACSR Medical College, Nellore, Andhra Pradesh, India
|Date of Submission||02-Dec-2020|
|Date of Acceptance||11-Jan-2021|
|Date of Web Publication||09-Apr-2021|
Dr. Ananda Reddy Endreddy
Associate professor, Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Hemodialysis is a procedure performed in persons who suffer from acute/chronic renal failure or who have end-stage renal disease. Due to disabilities caused by renal disease and the continuous requirement of dialysis, it is frequently associated with comorbid psychiatric disorders, which in turn adversely affects the quality of life (QOL) of patients.
Aims and Objectives: Our study was conducted with the objectives of estimating the proportion of psychiatric comorbidities and the QOL among the patients who were on hemodialysis.
Materials and Methods: A cross-sectional study was done on a total of fifty consecutive patients undergoing dialysis in the hemodialysis unit, Department of Nephrology, Narayana Medical College and Hospital. A semi-structured questionnaire was used to obtain the sociodemographic details, history including details of illness, dialysis, and medical comorbidities. The presence of psychiatric comorbidities was assessed using Mini-International Neuropsychiatric Interview. The WHOQOL-BREF Scale was used to assess the QOL and the Modified Kuppuswamy Socioeconomic Scale was used to assess the socioeconomic status.
Results: Psychiatric comorbidities were observed in 80% of the patients undergoing hemodialysis. Among the psychiatric comorbidities, major depressive disorder was found in 54%, dysthymia in 14%, and generalized anxiety disorder in 12% of the patients. History of diabetes was found in 80% of the patients and history of hypertension was found in all the patients in the study. Among the patients, a significant association was observed between the psychiatric comorbidities and the score in all the four domains of the WHOQOL-BREF Scale.
Conclusions: Our study concludes that the majority of the patients were found to have psychiatric comorbidities. On the WHOQOL-BREF Scale, all the four domains in QOL were significantly associated with psychiatric morbidity.
Keywords: Dysthymia, hemodialysis, Mini-International Neuropsychiatric Interview Scale, major depression, WHO Quality of Life-BREF
|How to cite this article:|
Endreddy AR, Chennareddy LR, Shaik S. Assessment of quality of life and psychiatric morbidity in patients undergoing hemodialysis at a tertiary care center. Arch Ment Health 2021;22:57-62
|How to cite this URL:|
Endreddy AR, Chennareddy LR, Shaik S. Assessment of quality of life and psychiatric morbidity in patients undergoing hemodialysis at a tertiary care center. Arch Ment Health [serial online] 2021 [cited 2021 Nov 28];22:57-62. Available from: https://www.amhonline.org/text.asp?2021/22/1/57/313420
| Introduction|| |
The prevalence of chronic kidney disease (CKD) in India was estimated in the range of 0.79% to 1.4% of the population and the incidence of end-stage renal disease was estimated to be 181 per million of the population in India. Treatment of these patients aims to enhance survival, with options being hemodialysis, peritoneal dialysis, and renal transplantation. The level of improvement in the disease status has a profound effect on the patient's life, with serious physiological, psychological, socioeconomic implications for the individual, family, and community.
Hemodialysis is the mainstay of treatment for end-stage renal disease, usually lasts for 4 h, and is performed three times a week, most often in hospital-based units. Studies have shown that an increased frequency of dialysis may improve treatment efficiency and outcome., Even when these patients are compliant enough to these treatment procedures, they do not provide the patient with a meaningful quality of life (QOL).,
A myriad of potential mental health problems including depression, dementia, delirium, psychosis, anxiety, personality disorder, and substance abuse are seen in patients on maintenance hemodialysis. The prevalence of depression in CKD as high as 50% has been reported in some studies. Depression can lead to functional impairment, reduced health-related QOL, increased health-care utilization, and mortality.,, Depression affects the QOL in all patients, and it may result in less compliance toward treatment.
Studies have shown that the commonly associated comorbidity in hemodialysis patients is anxiety disorders, which in turn affects work productivity, function, and health-care costs., Symptoms of anxiety disorder were observed in 21% of the patients who were on dialysis, comorbid depression and anxiety were found in 15.5% of these patients, and comorbid anxiety was found in 44.3% of the depressed patients. Suicide was associated with old age, male gender, and lower educational status. Recent hospitalization for mental illness was found to be an independent predictor of suicide.
The QOL domains include physical, psychological, social, and environmental domains. Depression is strongly correlated with decreased health-related QOL, especially in psychological dimension. Caregiver's burden was significantly high in those caring for patients with comorbid psychiatric illness. The patient's QOL is negatively impacted by the dependence on treatment, and it may also exacerbate the feeling of a loss of control.
Many of the clinicians underestimate the importance of psychiatric comorbidities among hemodialysis patients, due to the overlap of symptoms of renal manifestations like uremia with psychiatric comorbidities. It is usually neglected, and although the negative impact of psychiatric morbidities in dialysis patients has been given importance to some extent, these conditions are still underdiagnosed and untreated. Therefore, this study has been conducted so that clinicians familiarize themselves with the prevalence and hazards posed by psychiatric disorders and their alterations of QOL in patients on dialysis. Hence, an attempt was made to study the psychiatric comorbidities and QOL of these patients.
| Materials and Methods|| |
This was a cross-sectional study, conducted in the dialysis unit of the Department of Nephrology, Narayana Medical College and Hospital. Our study was done with the aim of estimating the psychiatric comorbidities and assessing the QOL among the patients on hemodialysis. The study period was between March 2019 and December 2019. Approval was taken from the institutional ethical committee before the recruitment of participants into our study. The sample size was calculated using the formula n = 4pq/d2 where p = prevalence (from previous studies), q = 100−prevalence, and d = absolute precision (15%). Substituting the appropriate values in the above equation, we got n = 41. Hence, we consider the study sample as 50.
Inclusion and exclusion criteria
Individuals aged 18 years and above, of both the sexes, willing to give consent, with the history of hemodialysis of at least 2 months and a frequency of two times per week, were included in the study. Patients with prior history of psychiatric disorders, with bereavement in the past 6 months, and with serious cognitive dysfunction were excluded from the study.
Mini-International Neuropsychiatric Interview
The Mini-International Neuropsychiatric Interview (MINI) is a brief structured interview for the diagnosis of major Axis I psychiatric disorders in Diagnostic and Statistical Manual of Mental Disorders-IV and International Statistical Classification of Diseases and Related Health Problems-10. The MINI has acceptably, high validation, and reliability scores and can be administered in a much shorter period of time. MINI is designed with precise questions about psychiatric problems, which require “Yes or No” answer. Several studies were conducted using this scale around the world, to validate its reliability.
WHO Quality of Life-BREF
It was a four-domain rating scale. This scale consists of a total number of 26 items., Domain scores were scaled in a positive direction; higher scores denote a higher QOL on a five-point scale.
Modified Kuppuswamy Socioeconomic Status Scale
It was one of the established determinants of health. The Modified Kuppuswamy Socioeconomic Status Scale was an important tool in hospital- and community-based research in India, which was proposed in 1972. The main limitation of this scale was an overemphasis on income rather than on educational and occupational factors. Socioeconomic status was classified into five classes based on the score obtained on this scale.
Informed consent was taken from the study participants after explaining the design and nature of the study. Investigator used a specially designed semi-structured pro forma to collect details about sociodemographic details, history including illness details, details of dialysis, and medical comorbidities. Each participant was administered with MINI to confirm their psychiatric diagnosis. Participants were also evaluated using the WHOQOL-BREF Scale to assess their QOL and by the Modified Kuppuswamy Scale to assess socioeconomic status. Data were analyzed using SPSS 21.0 (Statistical package for the social sciences,(SPSS) Ibm SPSS statistics.USA), and the continuous variables were summarized as mean ± standard deviation. Categorical variables were summarized in terms of the frequency with percentages and were tested using Chi-square/Fisher's exact test. For all test parameters, P < 0.05 was considered statistically significant.
| Results|| |
The age of the participants in our study population ranged from 27 to 77 years, with an average of 59 ± 9.69 years. The average age of female participants was comparatively higher than that of male participants (61.87 ± 9.1 and 57.67 ± 9.8, respectively). The majority (92%) of the study participants were married, and there were no illiterates in our study participants. Twenty percent of the participants had primary education, 14% completed middle school, 16% completed high school, 20% were graduates, and 6% were professionals. The details of occupation and economic status of the participants are shown in [Table 1]. Major depressive disorder was the most common psychiatric morbidity (54%) observed among the study participants and dysthymia and generalized anxiety disorder were observed among 14% and 12%, respectively, in our study population [Table 2]. The distribution of scores with WHOQOL-BREF in all the domains of the study participants is shown in [Table 3]. The duration of dialysis was found to be almost similar in both the groups, and there was no significant difference [Table 4].
|Table 2: Distribution of psychiatric morbidity among the study participants|
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|Table 3: Distribution of WHO Quality of Life Assessment BREF domains of study participants|
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The score in the physical domain (30.94 ± 9.06) was less in the patients with psychiatric morbidity when compared to those who do not have psychiatric morbidity (57.44 ± 4.33). The median score (56) in the physical domain was higher in those who do not have any psychiatric morbidity. The difference in physical health scores was statistically significant (P < 0.001). The score in the psychological domain (26.33 ± 5.93) was less in the group having psychiatric morbidity when compared to those who do not have psychiatric morbidity (45.33 ± 9.86). The median score (44) was higher in those who do not have any psychiatric morbidity. There was a significant difference in physical health scores with P < 0.001. The score in the environmental domain was less in the patients having psychiatric morbidity when compared to those who do not have psychiatric morbidity [Table 5]. The score in the social relationship domain was less in the patients having psychiatric morbidity when compared to those who do not have psychiatric morbidity.
|Table 5: Association between WHO Quality of Life Assessment BREF domain scores and psychiatric morbidity|
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| Discussion|| |
Our study was aimed to estimate the prevalence, type of psychiatric morbidity, and the QOL in patients undergoing hemodialysis. It was also intended to study the various factors that contribute to these psychiatric morbidities. The prevalence of overall psychiatric comorbidities among the patients on hemodialysis according to the present study was 80%, where major depressive disorder was observed in 54% (n = 27) of the patients, dysthymia in 14% (n = 7), and generalized anxiety disorder in 12% (n = 6) of the patients.
Our study found that the prevalence of major depressive disorder was in 54% of the participants comparable to the studies done by Rai et al. (47.8%), Bossola et al. (52.5%), Kao et al. (60.5%), and Montinaro et al. (50%). In the present study, we found that the prevalence of generalized anxiety disorder was in 12% of the study participants, which was in accordance with the studies done by Reckert et al., who observed the prevalence of generalized anxiety disorder as 17% in their study population. In a study done by Cukor et al., anxiety disorder was found among 27% of the study population.
In our study, the duration of dialysis (in years) was not associated with psychiatric morbidities. A similar finding was observed in the studies done by Wolcott et al., Cukor et al., Taskapan et al., and Koo et al. QOL was an important parameter in patients with chronic illness; in our study, the QOL was associated with psychiatric morbidity. The QOL among the entire study participants was found to be poor in all the four domains. In our study, QOL was significantly associated with the psychiatric morbidities in the patients, which was similar to the findings observed in the study done by Ibrahim and El Salamony.
| Conclusions|| |
Our study concludes that the majority (80%) of the participants were found to have psychiatric comorbidities, out of which major depressive disorder was found in 54%, dysthymia in 14%, and generalized anxiety disorder in 12% of the patients. On the WHOQOL-BREF Scale, all the four domains in QOL were significantly associated with psychiatric morbidity among the patients undergoing hemodialysis at a tertiary care center.
Future studies can be aimed at assessing the relationship between sociodemographic profile, personality profile, stress coping skills, and psychiatric comorbidity in a larger sample of hemodialysis patients with an objective to compare with the native population.
The size of the sample was small (50). The study was limited to the patients attending the dialysis unit of tertiary care center; hence, the results cannot be generalized to entire dialysis population.
The authors would like to thank Dr. B. Madhavulu, Professor, Department of Pharmacology, Narayana Medical College and Hospital, for his support in manuscript review services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rajapurkar M, Dabhi M. Burden of disease – Prevalence and incidence of renal disease in India. Clin Nephrol 2010;74 Suppl 1:S9-12.
Deori R, Bhuyan B. Iron status in chronic kidney disease patients. Int J Res Med Sci 2016;4:3229-34.
Unruh ML, Larive B, Chertow GM, Eggers PW, Garg AX, Gassman J, et al
. Effects of 6-times-weekly versus 3-times-weekly hemodialysis on depressive symptoms and self-reported mental health: Frequent Hemodialysis Network (FHN) Trials. Am J Kidney Dis 2013;61:748-58.
Son YJ, Choi KS, Park YR, Bae JS, Lee JB. Severity of depression symptoms and the quality of life in the patients on the hemodialysis for end-stage renal disease. Am J Nephrol 2009;29:36-42.
FHN Trial Group, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, et al
. In-center hemodialysis six times per week versus three times per week. N Engl J Med 2010;363:2287-300.
Kontodimopoulos N, Niakas D. An estimate of lifelong costs and QALYs in renal replacement therapy based on patients' life expectancy. Health Policy 2008;86:85-96.
Araujo SM, de Bruin VM, Daher Ede F, Almeida GH, Medeiros CA, de Bruin PF. Risk factors for depressive symptoms in a large population on chronic hemodialysis. Int Urol Nephrol 2012;44:1229-35.
O'Donnell K, Chung JY. The diagnosis of the major depression in the ESRD. Psychother Psychosom 1997;66:38-43.
Levy NB, Cohen LM. The end-stage renal disease and its treatment: Role of dialysis and the transplantation. In: Stoudemire A, Fogel BS, Greenberg D, editors. Psychiatric Care of the Medical Patient. 2nd
ed. London: Oxford University Press; 2000. p. 791-800.
Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 2003;41:105-10.
Billington E, Simpson J, Unwin J, Bray D, Giles D. Does the hope predict adjustment to an end-stage renal failure and the consequent dialysis? Br J Health Psychol 2008;13:683-99.
Hedayati S, Bosworth H, Briley L, Sloane R, Pieper C. Death or the hospitalization of the patients on chronic hemodialysis is associated with a physician-based diagnosis of the depression. Kidney Int 2008;74:930-6.
Kimmel PL, Weihs KL, Peterson RA, Alleyne S, Veis JH, Simmens SJ, et al
. The multiple measurements of the depression will predict the mortality in longitudinal study of the chronic hemodialysis outpatients. Kidney Int 2000;57:2093-8.
Kroenke K, Spitzer RL, Williams JB, Löwe B. Patient health related questionnaire for somatic, anxiety, and the depressive symptom scales. Gen Hosp Psychiatry 2010;32:345-59.
Kuo HW, Tsai SS, Tiao MM, Yang CY. Epidemiological features of CKD in Taiwan. Am J Kidney Dis 2007;49:46-55.
Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317-25.
Chen CK, Tsai YC, Hsu HJ, Wu IW, Sun CY, Chou CC, et al
. Depression and suicide risk in hemodialysis patients with chronic renal failure. Psychosomatics 2010;51:528-32.
Keskin G, Engin E. The evaluation of depression, suicidal ideation and coping strategies in haemodialysis patients with renal failure. J Clin Nurs 2011;20:2721-32.
Kurella M, Kimmel PL, Young BS, Chertow GM. Suicide in the United States end-stage renal disease program. J Am Soc Nephrol 2005;16:774-81.
Tsay SL, Healstead M. Self-care self-efficacy, depression, and quality of life among patients receiving hemodialysis in Taiwan. Int J Nurs Stud 2002;39:245-51.
Chen HY, Cheng IC, Pan YJ, Chiu YL, Hsu SP, Pai MF, et al
. The role of cognitive-behavioral therapy for sleep disturbance decreases inflammatory cytokines and oxidative stress in the hemodialysis patients. Kidney Int 2011;80:415-22.
Jadhav BS, Dhavale HS, Deress SS. Dadarwala DD. Psychiatricmorbidity, quality of life and caregiver burden in patients undergoing haemodialysis. Med J DY Patil Univ 2014;7:722-7. [Full text]
Chilcot J, Wellsted D, Da Silva-Gane M, Farrington K. Depression on dialysis. Nephron Clin Pract 2008;108:c256-64.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al
. The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
The WHOQOL Group. The World Health Organization Quality of Life assessment (WHOQOL): Position paper from the World Health Organization. Soc Sci Med 1995;41:1403.
Lucas-Carrasco R, Skevington SM, Gómez-Benito J, Rejas J, March J. Using the WHOQOL-BREF in persons with dementia: A validation study. Alzheimer Dis Assoc Disord 2011;25:345-51.
Mishra D, Singh HP. Kuppuswamy's socioeconomic status scale – A revision. Indian J Pediatr 2003;70:273-4.
Rai M, Rustagi T, Rustagi S, Kohli R. Depression, insomnia and sleep apnoea in patients on maintainence hemodialysis. Indian J Nephrol 2011;21:223-9.
] [Full text]
Bossola M, Ciciarelli C, Di Stasio E, Conte GL, Vulpio C, Luciani G, et al
. Correlates of symptoms of depression and anxiety in chronic hemodialysis patients. Gen Hosp Psychiatry 2010;32:125-31.
Kao TW, Lai MS, Tsai TJ, Jan CF, Chie WC, Chen WY. Economic, social, and psychological factors associated with health-related quality of life of chronic hemodialysis patients in Northern Taiwan: A multicenter study. Artif Organs 2009;33:61-8.
Montinaro V, Iaffaldano GP, Granata S, Porcelli P, Todarello O, Schena FP, et al
. Emotional symptoms, quality of life and cytokine profile in hemodialysis patients. Clin Nephrol 2010;73:36-43.
Reckert A, Hinrichs J, Pavenstädt H, Frye B, Heuft G. Prevalence and correlates of anxiety and depression in patients with end-stage renal disease (ESRD). Z Psychosom Med Psychother 2013;59:170-88.
Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA, et al
. Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol 2007;2:484-90.
Wolcott DL, Nissenson AR, Landsverk J. Quality of life in chronic dialysis patients. Factors unrelated to dialysis modality. Gen Hosp Psychiatry 1988;10:267-77.
Cukor D, Coplan J, Brown C, Friedman S, Newville H, Safier M, et al
. Anxiety disorders in adults treated by hemodialysis: A single-center study. Am J Kidney Dis 2008;52:128-36.
Taskapan H, Ates F, Kaya B, Emul M, Kaya M, Taskapan C, et al
. Psychiatric disorders and large interdialytic weight gain in patients on chronic haemodialysis. Nephrology (Carlton) 2005;10:15-20.
Koo JR, Yoon JW, Kim SG, Lee YK, Oh KH, Kim GH, et al
. The association of the depression with malnutrition in the chronic hemodialysis patients. AJKD 2003;41:1037-42.
Ibrahim S, El Salamony O. Depression, quality of life and malnutrition-inflammation scores in hemodialysis patients. Am J Nephrol 2008;28:784-91.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]