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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 26-30

Psychiatric morbidity in end-stage renal disease patients’ on dialysis

1 Department of Psychiatry, Rajendra Hospital, Patiala, Punjab, India
2 Department of Psychiatry, MGM Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Submission17-Apr-2020
Date of Acceptance01-May-2020
Date of Web Publication06-Jun-2020

Correspondence Address:
Dr. Arun V Marwale
Department of Psychiatry, MGM Medical College and Hospital, N-6, Cidco, Aurangabad 431003, Maharashtra.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.MGMJ_28_20

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Background: In India, millions of people are suffering from chronic kidney disease (CKD). Hemodialysis imposes a variety of physical and psychosocial stressors that challenge not only the patients but also the caregivers. Psychiatric illness in patients with end-stage renal disease (ESRD) has persistently intrigued health-care workers due to its effect on morbidity and health-care costs in ESRD. Objective: The objective of this study was to assess psychiatric morbidity among ESRD patients on hemodialysis. Materials and Methods: The study enrolled 170 patients with ESRD undergoing hemodialysis. Psychiatric morbidity was assessed using Mini International Neuropsychiatric Interview. Results and Discussion: Of the 170 patients studied, 70.6% were males and 29.4% were females. The mean age of the patients was 40.8 (SD = 14.8). Psychiatric morbidity was present in 42(24.7%) patients. The common diagnosis was major depressive episode (n = 37) followed by generalized anxiety disorder (n = 3), dysthymia (n = 1), and alcohol dependence syndrome (n = 1). No significant association was seen between gender and marital status in psychiatric morbidity. Duration of renal illness had a significant association with psychiatric illness (P < 0.0001). A similar duration of dialysis also had an association with psychiatric illness (P < 0.0001) with a majority of patients having psychiatric complaints within 6 months of onset of dialysis. The presence of nonrenal comorbidities also had a significant association with psychiatric illness (P < 0.005). Conclusion: This study has shown psychiatric illness among patients with ESRD on hemodialysis and its association with various factors such as duration of renal illness, duration of dialysis, and the presence of comorbidities.

Keywords: Chronic kidney disease, end-stage renal disease, hemodialysis, psychiatric morbidity

How to cite this article:
Vermani A, Marwale AV, Gokani NS. Psychiatric morbidity in end-stage renal disease patients’ on dialysis. MGM J Med Sci 2020;7:26-30

How to cite this URL:
Vermani A, Marwale AV, Gokani NS. Psychiatric morbidity in end-stage renal disease patients’ on dialysis. MGM J Med Sci [serial online] 2020 [cited 2022 Sep 28];7:26-30. Available from: http://www.mgmjms.com/text.asp?2020/7/1/26/286104

  Introduction Top

Hemodialysis is the most common method used to treat end-stage renal disease (ESRD). Hemodialysis imposes a variety of physical and psychosocial stressors that challenge not only the patients but also the caregivers.[1] A patient on dialysis is in a situation of abject dependence on a machine, the procedure, and a group of qualified medical professionals for the rest of his/her life. No other medical condition has such a degree of dependence for the maintenance treatment of a chronic illness. Psychiatric illness in patients with ESRD has persistently intrigued health-care workers due to its effect on morbidity and health-care costs in ESRD.[2]

Psychiatric morbidity is commonly associated with chronic kidney disease (CKD) patients on dialysis with the prevalence rate reported being as low as 8.9% to as high as 65.2%[3],[4] Kalman et al.[5] assessed psychiatric morbidity in patients undergoing dialysis and reported that 44 of the 89 patients (48%) were psychiatrically impaired either by their scores on general health questionnaire or by a history of prior psychiatric treatment. A study conducted by Chandra et al.[6] evaluated 60 patients of CKD on dialysis and compared them to patients with CKD not receiving dialysis using the Mini International Neuropsychiatric Interview (MINI) questionnaire to evaluate for psychiatric disorders. Psychiatric morbidity was found in 50% of the study group as compared to 20% in the control group. There are only a few studies about the prevalence of psychiatric morbidity in patients with CKD on hemodialysis in the Indian population and the previous studies conducted had a small sample size.

  Materials and methods Top

The study was conducted at the Department of Psychiatry and Department of Nephrology at the Hemodialysis Center of tertiary care hospital. Prior Ethics Committee approval was obtained.

Inclusion criteria

The inclusion criteria of the study included the following:

  1. Age 18 years and above of both sexes, from all communities and all socioeconomic class.

  2. Patients diagnosed with ESRD and undergoing hemodialysis.

  3. Patients willing to participate in the study after written informed consent regarding participation in the study.

Exclusion criteria

The exclusion criteria of the study included the following:

  1. Patients with preexisting psychiatric illness.

  2. Patients not willing to give written informed consent.

  3. Patients currently admitted to the intensive care unit for decompensated ESRD.

  4. Patients with altered sensorium/delirium/uremic encephalopathy.

  5. Patients who could not communicate verbally.

A total of 220 patients with ESRD on dialysis were approached for participation in the study. Of those 36 patients who had a diagnosis of acute kidney injury on dialysis, six had the prior psychiatric illness and eight patients did not give their consent to participate in the study, so they were excluded from the study. Thus, a total of 170 patients were evaluated for 1 year. Demographic variables such as age, sex, the religion of the patient along with the duration of renal disease, duration of hemodialysis, presence of comorbidities, and recent urea levels were also noted.

Patients were screened for psychiatric morbidity using MINI questionnaire (English version 5.0.0), which is based on Diagnostic and Statistical Manual, 4th edition, text revision (DSM-IV-TR).[6] The MINI includes 23 disorders and is organized in diagnostic sections with branching tree logic and two to four screening questions with yes or no responses for each disorder. Additional symptom questions are asked only when a screening question is endorsed. The collected data were compiled from Microsoft Excel sheet 2007. For analysis of the data, the Statistical Package for the Social Sciences (SPSS) software program, version 20.0 for Windows 7 was used. The qualitative data were represented in the form of frequency and percentiles, which included all demographic data. The quantitative data were represented in the form of mean and standard deviation (SD). For qualitative data, univariate analysis such as t test and analysis of variance (ANOVA) were applied. To check the association between two categorical variables, the chi-square test was applied. Both the quantitative and qualitative data were represented in the form of visual impressions such as bar and pie diagrams. The level of significance was determined by a P value of less than 0.05.

  Results Top

The patients attending hemodialysis were as follows: males 120 (70.6%) and females 50 (29.4%). The mean age of the patients undergoing hemodialysis was 40.8 (SD = 14.8). Fifty-three (31.2%) of the patients were to the age group of fewer than 30 years, 41 (24.12%) were to the age group of 31–40 years, 32 (18.8%) were between 41 and 50 years, 25 (14.7%) were between 51 and 60 years, and 19 were more than 60 years. One hundred thirty-four (78.8%) patients were married, 30(17.6%) were single, and 6 (3.5%) were widowed.

Duration of renal illness was studied which showed that 29 (17.6%) were diagnosed less than 6 months back, 58 (34.11%) were diagnosed between 6 months to 1 year back, 55 (32.35%) were diagnosed 3 years back, and 28 (16.48%) had a diagnosis of CKD for more than 3 years. Duration since when patients were receiving hemodialysis was studied, 20 (15.38%) were receiving dialysis for less than 1 month, 69 (40.59%) were receiving dialysis for less than 6 months, 17 (10%) were on dialysis for less than 1 year, and 64 (37.64%) were on dialysis for more than 1 year. Psychiatric morbidity was seen in 42 (24.70%) of the patients. The most common diagnosis was major depressive episode 37(88.09%) followed by generalized anxiety disorder 3(7.14%). One patient had a diagnosis of dysthymia (2.38%) and one had alcohol dependence syndrome (2.38%). No significant association was found between psychiatric morbidity and gender of the patients (P = 0.52), marital status (P = 0.452), and religion of the patients (P = 0.765). A significant association was found between the age group and psychiatric morbidity (P < 0.001). Psychiatric morbidity was highest in the age group at 51–60 years. The duration of illness and psychiatric morbidity had a significant association (P < 0.0001). Patients with a total duration of illness of more than 36 months were found to have more psychiatric morbidity, followed by patients having just been diagnosed with CKD (duration less than 6 months).

Nonrenal medical comorbidity was seen in 126 (74.1%) of the patients. This was significantly associated with psychiatric morbidity. A number of medical comorbidities have been assessed and found that higher numbers of comorbidity were significantly associated with psychiatric illness. Of the 126 patients, 90 patients had a single comorbidity (71.43%) and the rest had more than one comorbidity. The most common nonrenal comorbidity seen was hypertension, which was present in 124 (98.4%) patients. There was a significant association between the duration of dialysis and psychiatric morbidity (P < 0.0001). Maximum morbidity was seen in the group who had started receiving dialysis between 1 and 6 months.

  Discussion Top

CKD is emerging to be an important chronic condition and it is associated with many psychiatric problems. The age of patients ranged from 18 to 72 years with a mean age of 40.8 years (SD = 14.8). This is similar to the findings of Chandra et al.[7] whose study population’s mean age was 38.38 (SD = 12.94). However, Ramasubramanian et al.[8] reported the mean age of patients receiving hemodialysis as 53 years (SD = 13.9). The reason for the much lower age of onset in our study may be because in India there is a delay in detecting renal disease and the failure to institute controlling and preventive measures in patients with progressive renal failure, both of which result in faster deterioration of renal function and progression to ESRD. Late referrals lead to faster progression of comorbid conditions and worsen overall patient’s survival. Also in developing countries, higher pesticide exposure might also be a factor for the earlier age of onset of kidney disease.

When considering gender, there were significantly fewer females as compared to males receiving hemodialysis. Similar results were obtained by Makkar et al.[9] and among Indian studies, Agarwal et al.[10] (community-based) showed a male prevalence of 48% among patients, whereas other hospital-based studies found males constituting 60%–78% of the CKD population. The Indian CKD Registry, a voluntary reporting body of CKD patient data initiated in June 2005, has 199 contributing centers. The database has 63,538 patients enrolled and 70% of them are men.[11] 78.8% of patients were married, 17.6% were single and 3.5% were widowed. This is similar to the results obtained in other studies.[6],[8] This is explained by the fact that in India people get married earlier. Hindu patients constituted the bulk of the study group, which is explained by their religious distribution over other communities in India, which is similar to other Indian studies.[6],[8]

Overall 42 (24.70%) patients had diagnosable psychiatric illness. Most of the patients diagnosed with psychiatric illness had a diagnosis of major depression 21.76% (n = 37) followed by generalized anxiety disorder 1.7% (n = 3), dysthymia 0.58% (n = 1), and alcohol dependence syndrome 0.58% (n = 1). This is similar to the results obtained by Hedayati et al.,[12] who found the prevalence of psychiatric morbidity using SCID as 26.7%. Of the 26 patients diagnosed to be depressed on SCID, 65% had major depression, 27% dysthymia, and 8% minor depression. There were no patients who had suicidal ideation. Various studies report the incidence of depression in dialysis patients, reportedly ranging from 10% to 66%.[3],[13],[14] Drayer et al.[15] found the prevalence of depression in 28% of the patients using PRIME-MD, which is similar to the prevalence of depression found in our study. Similarly, Son et al.[16] reported that 25.3% of the patients had depression when Becks Depression inventory was applied to his study population.

In a study carried out in 2008 with hemodialysis patients, Göker[17] reported that 65.2% of patients had a psychiatric disorder, which is much higher compared to our study. However, this difference can be attributed to different assessment tools they used (SCID) and they evaluated only a small population of patients receiving dialysis (n = 42). The variation in prevalence rates of psychiatric morbidity might be accounted for, by differences in sample sizes and assessment tools. Despite such variations, depression is unquestionably one of the most important mental illnesses among dialysis patients.

There was a significant association between age group and psychiatric morbidity in our study (P < 0.001). 56% of the patients with psychiatric morbidity belonged to the age group of 51–60 years. This is similar to results obtained by Ramasubramanian et al.[8] PHS 19008 who reported that most of the patients belonged to the age group of 40–60 years. This can be explained due to increased liabilities with physical, social, and economic stresses and strains of life being highest in this age group. In this study, we did not find any correlation between marital status and psychiatric morbidity (P = 0.45) which goes with the findings of Preljevic et al.[18] and Chandra et al.[7] who found no significant relationship between these two variables. This might be explained because in India most people live in either joint families or extended nuclear families so these families provide social support even if the patients are single or divorced.

According to our study, a significant association was found between the duration of illness and psychiatric morbidity (P < 0.0001). Similar results were obtained by Ramasubramanian et al.[8] who found that patients with a duration of renal dysfunction of 3.14 years (SD = 3.83) had significantly higher psychiatric morbidity whereas Dogan et al.[19] found no relationship between psychiatric morbidity and duration of renal illness. There was a significant association between the number of nonrenal medical comorbidities and psychiatric illness (P < 0.05). This is similar to the results obtained by Lopes et al.[20] The World Health Organization found that nonrenal medical comorbidities were associated more with physician-diagnosed depression as well as self-reported depression.

DeNour and Czaczkes[21] cautioned that the first 3–6 months of ESRD therapy constitute an unstable period for the patient, during which medical conditions and relationships with family, spouses, and staff can change. Similar to the above observations we found an association between the duration since the start of hemodialysis and psychiatric morbidity (P < 0.0001). Patients who started recently (within 6 months of inclusion in the study) had higher rates of psychiatric illness compared to those on dialysis for a longer duration. The findings of this study should be interpreted in light of the following limitations. This study was conducted at one center due to which the findings of this study cannot be generalized. A relatively small study population was studied. The adequacy and frequency of dialysis were not measured, which could have a confounding effect on the study.

  Conclusion Top

Hemodialysis is a life-sustaining procedure for patients with ESRD; however, it is associated with a high prevalence of psychiatric morbidity, particularly depression. The duration of renal illness, duration of dialysis, and the presence of nonrenal medical comorbidities all had a significant association with psychiatric morbidity. Hence, it is of high importance that psychological support is given to the patient. Psychosocial interventions would be better to begin at diagnosis, should be adapted to the progress of the disease and focus on the physical, psychological, and social functioning of the people. The role of the health professional is to encourage patients to accept treatment limitations, take self-care, enable patients to take responsibility for their health and fulfill their obligations toward family and society.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Yeh SC, Huang CH, Chou HC. Relationships among coping, comorbidity and stress in patients having haemodialysis. J Adv Nurs 2008;63:166-74.  Back to cited text no. 1
Reichsman F, Levy NB. Problems in adaptation to maintenance hemodialysis: a four-year study of 25 patients. Arch. Intern. Med. 1972;130:859-65.  Back to cited text no. 2
Kimmel PL, Thamer M, Richard CM, Ray NF. Psychiatric illness in patients with end-stage renal disease. Am J Med 1998;105:214-21.  Back to cited text no. 3
Baykan H, Yargic I. Depression, anxiety disorders, quality of life and stress coping strategies in hemodialysis and continuous ambulatory peritoneal dialysis patients. Bull Clin Psychopharmacol 2012;22:167-76.  Back to cited text no. 4
Kalman TP, Wilson PG, Kalman CM. Psychiatric morbidity in long-term renal transplant recipients and patients undergoing hemodialysis: A comparative study. JAMA 1983;250:55-8.  Back to cited text no. 5
American psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Text revised 4th ed. Washington, DC: American Psychiatric Association; 2000.  Back to cited text no. 6
Chandra P, Deo RM, Singh BK. A study of psychiatric co-morbidity in cases of renal failure undergoing hemodialysis. Indian J Public Health Res Develop 2011;2:68-70.  Back to cited text no. 7
Ramasubramanian V, Ponndurai R, Soundararajan P, Balakrishnan K, Srinivasan B. Psychiatric morbidity in patients with chronic kidney disease undergoing hemodialysis. Asian J Pharm Clin Res 2015;8:312-6.  Back to cited text no. 8
Makkar V, Kumar M, Mahajan R, Khaira NS. Comparison of outcomes and quality of life between hemodialysis and peritoneal dialysis patients in Indian ESRD population. J Clin Diagn Res 2015;9:OC28-31.  Back to cited text no. 9
Agarwal SK, Dash SC, Irshad M, Raju S, Singh R, Pandey RM. Prevalence of chronic renal failure in adults in Delhi, India. Nephrol Dial Transplant 2005;20:1638-42.  Back to cited text no. 10
Veerappan I, Abraham G. Chronic kidney disease: current status, challenges and management in India. Ch. 2013;130:593-7.  Back to cited text no. 11
Hedayati SS, Bosworth HB, Kuchibhatla M, Kimmel PL, Szczech LA. The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients. Kidney Int 2006;69:1662-8.  Back to cited text no. 12
Kimmel PL. Depression in patients with chronic renal disease: What we know and what we need to know. J Psychosom Res 2002;53:951-6.  Back to cited text no. 13
Kimmel PL, Weihs K, Peterson RA. Survival in hemodialysis patients: The role of depression. J Am Soc Nephrol 1993;4:12-27.  Back to cited text no. 14
Drayer RA, Piraino B, Reynolds CF 3rd, Houck PR, Mazumdar S, Bernardini J, et al. Characteristics of depression in hemodialysis patients: Symptoms, quality of life and mortality risk. Gen Hosp Psychiatry 2006;28:306-12.  Back to cited text no. 15
Son YJ, Choi KS, Park YR, Bae JS, Lee JB. Depression, symptoms and the quality of life in patients on hemodialysis for end-stage renal disease. Am J Nephrol 2009;29:36-42.  Back to cited text no. 16
Goker C. Psychiatric morbidity and quality of life in hemodialysis patients and their partners. Specialization Thesis, Ankara University School of Medicine, Department of Psychiatry, Ankara, 2008.  Back to cited text no. 17
Preljevic VT, Østhus TB, Os I, Sandvik L, Opjordsmoen S, Nordhus IH, et al. Anxiety and depressive disorders in dialysis patients: Association to health-related quality of life and mortality. Gen Hosp Psychiatry 2013;35:619-24.  Back to cited text no. 18
Dogan E, Erkoc R, Eryonucu B, Sayarlioglu H, Agargun MY. Relation between depression, some laboratory parameters, and quality of life in hemodialysis patients. Ren Fail 2005;27:695-9.  Back to cited text no. 19
Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe C, et al; Dialysis Outcomes and Practice Patterns Study (DOPPS). Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 2002;62: 199-207.  Back to cited text no. 20
De-Nour AK, Czaczkes JW. The influence of patient’s personality on adjustment to chronic dialysis. J Nerv Ment Dis 1976;162:323-33.  Back to cited text no. 21


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