Introduction

Hemodialysis patients are known to face numerous psychosocial stressors. These include physical symptoms, specific dietary regimens, time constraints and changes in their body image. Therefore, psychological and social problems are common in such population [1].

Depression is likely to be the most common psychopathology in hemodialysis patients. It might affect their adherence to treatment and is associated with increased morbidity and mortality [2]. Some investigators have estimated that depression occurs in as many as 39–62 % of hemodialysis patients. However, the prevalence of depression in hemodialysis patients has not been definitively determined, and it is generally underdiagnosed and undertreated [3, 4].

Of importance, physical, psychosocial, and lifestyle disturbances, along with physical and emotional symptoms, have been shown to impact health-related quality of life (HRQOL) of those dependent on renal replacement therapy [5, 6]. The World Health Organization defines QOL as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” The core components of QOL are physical, functional, psychological/emotional and work/occupational; all of them are affected by kidney disease [7]. Moreover, patients on hemodialysis might have worse QOL than those on peritoneal dialysis [8].

Until recently, despite being an important concern in the overall health of hemodialysis patients, psychosocial issues were understudied even in some developed countries [9, 10]. Similar reports among Egyptian patients are scarce [11]. This might be due to cultural and social concerns that generally hinder expression and diagnosis of depression [12]. Hereby, we assess depression and its relation to other clinical aspects as well as to HRQOL among a group of Egyptian hemodialysis patients.

Subjects and methods

This cross-sectional study was conducted at the dialysis unit of the Urology and Nephrology Center, Mansoura University, Egypt. It enrolled 76 chronic hemodialysis patients with the following inclusion criteria: (1) hemodialysis for more than 6 months, (2) age more than 18 years, (3) the absence of cognitive or other deficits that may interfere with full communication and (4) an informed patient consent to participate in the study.

Updated history and clinical examination as well as current investigations of the participating patients were retrieved from the unit database system. Psychiatric interview was carried out for the studied patients with stress upon the psychiatric diagnosis and the social background. A structured clinical interview for DSM-IV (SCID) was adopted. In addition, psychometric assessment of depression and HRQOL was performed using an Arabic-adapted Beck Depression Inventory II (BDI-II) [13, 14] and Short Form scale (SF-36), respectively [15]. BDI-II included 21 questions for which each answer is being scored on a scale value of 0–3. The cutoffs used were: 0–13: no or minimal depression, 14–19: mild depression, 20–28: moderate depression and 29–63: severe depression [16]. SF-36 is a measure of health status that consists of eight scaled scores, which are the weighted sums of the questions in their section. Each scale is directly transformed into a 0–100 scale on the assumption that each question carries equal weight. The lower the score the more the disability, while the higher the score the less the disability. Therefore, a score of zero is equivalent to maximum disability, and a score of 100 is equivalent to no disability [15]. The SF-36 is a disease-unspecific questionnaire. The extended version questionnaire KDQOL (Kidney Disease Quality Of Life) may be more precise way to capture the health-related quality of life in kidney patients [17]. Up to our knowledge, at the time of commencement of our work, a validated Arabic-adapted KDQOL version was unfortunately not available. Therefore, we used a validated Arabic-adapted SF-36.

Patients who were diagnosed as having depression received special attention as well as antidepressant medications as a duty health service, but the drug–response curve is not part of this study.

Continuous data were expressed as mean ± standard deviation (M ± SD) or, if skewed, as median, while nominal data were expressed as number (percentage). Statistical analysis was conducted using SPSS program (version 17.0). Student’s t test was used to compare two groups relative to their continuous data, while ANOVA test was used for comparison of more than two groups. For comparison of nominal data, Chi-square test was performed. A p value <0.05 was considered significant.

The study was approved by the Ethical Committee of the Urology and Nephrology Center, Mansoura University, Egypt.

Results

The study included 76 out of 100 hemodialysis patients after exclusion of those who opted not to participate in the study (12 patients) and those who did not fit to other inclusion criteria. The patients’ mean age was 43.2 ± 14.96 years, and of them, 54 (71.1 %) were males and 22 (29.9 %) were females. Patients were undergoing three-time weekly hemodialysis. Demographic and laboratory characteristics of the included group of patients are shown in Tables 1 and 2, respectively. Before the current study, none of our patients has been seen by a psychiatrist (except for a brief exclusion of psychiatric contraindication for transplant candidates), has been diagnosed as having psychiatric illness or has received antipsychotic treatment.

Table 1 Demographics and clinical characteristics of all patients and of groups with different degrees of depression
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Table 2 Laboratory data of all patients and of groups with different degrees of depression
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Depression was diagnosed in 58 patients (76.3 %). Of them, 18 (23.7 %), 15 (19.7 %) and 25 patients (32.9 %) were suffering from mild, moderate and severe depression, respectively.

The nephrologist who has the longest and the closest contact with the patients was asked to expect the presence of depression and its degree for every patient based on his personal opinion while blind of psychiatric and psychometric assessment results. Of patients diagnosed as having severe depression (25 patients), he expected severe, moderate, mild and no depression in four (16 %), eight (32 %), nine (36 %) and four (16 %) patients, respectively.

Tables 1 and 2 show that patient groups with mild, moderate and severe degrees of depression were comparable to each other and to the non-depressed patient group regarding demographic, clinical and laboratory data except for the prevalence of iron therapy, post-dialysis blood urea nitrogen (BUN), pre-dialysis potassium and total protein (p = 0.049, 0.012, 0.049 and 0.027, respectively). The whole group of depressed patients was also comparable to the non-depressed group except for peripheral neuropathy (46.7 vs. 11.5 %; p = 0.034) and iron therapy (52.7 vs. 86.7 %; p = 0.017).

Table 3 shows scores of different HRQOL aspects among patient groups with different degrees of depression as well as among the whole group of depressed patients. Except for role limitation due to physical problems, all HRQOL aspects were significantly worse among the whole group of depressed patients compared to the non-depressed group. As almost one-third of patients are being prepared for transplantation, their HRQOL was compared to those who are not candidates for transplantation. Four HRQOL aspects (pain, energy/fatigue, emotional well-being and social functioning) were significantly better in the group undergoing transplant preparation (p = 0.006, >0.001, 0.002 and 0.04, respectively).

Table 3 HRQOL scores among patient groups with different degrees of depression as well as among the whole group of depressed patients
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Discussion

In a recent systematic review and meta-analysis of 249 populations (55,982 participants) on the prevalence of depression in chronic kidney disease including dialysis [18], only two studies were from Africa. In most of the included studies, depression was reported using rating instruments (commonly the Beck Depression Inventory) either administered by clinicians or self-administered by patients. In only 16 populations, patients were interviewed by a psychiatrist or the diagnosis was confirmed by a psychiatrist. In our study which included 76 Egyptian hemodialysis patients, both psychiatric interview and the Beck Depression Inventory administered by the psychiatrist were performed. Although BDI is primarily a self-report questionnaire, psychiatric interview was conducted to support the results of BDI and ensure that all Diagnostic and Statistical Manual of Mental Disorders, Forth Edition (DSM-IV) [19] symptom domains of major depressive disorder were actually there in patients who have a score of clinical interest.

In their meta-analysis, Palmer et al. [18] reported a wide variation in the prevalence of depressive symptoms (1.4–94.9 %) among studies that involved dialysis patients (198 populations). They concluded that prevalence of depression is highly dependent on the diagnostic methods used. In our study, we reported a 52.6 % prevalence of moderate-to-severe depression (BDI score >20). In a similar study [20] that involved 62 patients (hemodialysis >6 months; mean age 48.8 years) assessed with both BDI and psychiatrist interview, 56.5 % had BDI score >21 while 54.8 % had both BDI score >18 and psychiatrist-confirmed criteria for major depressive symptoms. On the other hand, despite apparently adequate dialysis (mean Kt/V = 1.33), uremic symptoms might still have an effect on the prevalence of depression among our patients. This is especially of importance as post-dialysis blood urea nitrogen was highest among patients with severe depression.

Twelve percent of our hemodialysis patients were excluded before starting our work because they refused to be enrolled in the study. The Egyptian community, like many eastern ones, is conservative toward the idea of psychiatric illness. There is an emphasis on social integration rather than autonomy. Therefore, shame is a major driving force. Physical illness and somatic manifestations of psychological distress are more acceptable and likely to evoke a caring response than vague complaints of psychological symptoms, which can be either disregarded, believed to be cured by extra-praying, considered a stigma of being “soft”—or, even worse, insane. Egyptians who are depressed either resort to their primary health-care physician, who is likely to request unneeded and costly investigations, or ask traditional healers to alleviate their suffering. A considerable number do not ask for help at all, especially in rural populations, among which the absence from work or inability to face day-to-day affairs is largely tolerated by the community [12].

Despite the relatively high prevalence of depression, 71.1 % of our patients were actively practicing their work/job compared to only 25 % reported by van Manem et al. [21] from the Netherlands. This apparent contradiction may be explained by the difference in socioeconomic standards and insurance services.

In our study, peripheral neuropathy was significantly more common among the depressed group of patients. Peripheral neuropathy may contribute, in part, to the occurrence of depression. As stated by Biyik et al. [22], painful peripheral neuropathy is common in patients receiving maintenance hemodialysis. This may be due to comorbid conditions such as diabetes mellitus or a result of uremia per se. Chronic pain, sleep disturbance and affective disorders (mainly depression) often occur simultaneously. Of interest, a potential common pathophysiology has been recently discovered. The endogenous nitric oxide synthase inhibitor, which is markedly elevated in dialysis patients [23], can induce both increased heat pain threshold [24] and depressive behavior [25] at least in the preclinical setting. Although our findings relate “peripheral neuropathy” rather than “increased pain threshold” to depression, yet a relation between both neurologic abnormalities is possible. On the other hand, among our patients, the prevalence of iron therapy had statistically significant difference between the depressed and non-depressed groups. This difference might be related to the influence of iron on mood. Iron deficiency can cause psychological issues like depression. However, unfortunately, there is no control in our study of possible effects of iron therapy on mood.

Depression was reported in kidney transplant patients with graft failure [26]. As our center is dedicated for kidney transplantation, graft failure is common among our hemodialysis patients (43.4 %). Nevertheless, graft failure did not seem to be a contributing factor for depression among our patients as its prevalence was comparable among different groups. Eleven (33.3 %) out of 33 graft failure patients are being prepared for re-transplantation. This might partially ameliorate the negative psychological impact of graft failure among our patients. Although that different groups of depression were comparable relative to the frequency of those who are in preparation for transplantation, yet four HRQOL aspects were significantly better among patients in preparation compared to those who are not in preparation for transplantation. This might reflect the positive psychological effect of transplant preparation and/or might be due to better general health of transplant candidates.

Except for physical functioning and role limitation due to physical problems, all HRQOL aspects were significantly worse among the depressed group of our patients. Our data concur with those of Soni et al. [27] who reported more fatigue, cognitive difficulties, pain and sleep disturbances among their end-stage renal disease patients with depression. It was stated that HRQOL is significantly compromised in patients with end-stage renal disease. Furthermore, low HRQOL has been associated with increased morbidity and mortality. Depression has been found to have a profound negative impact through a number of ways on HRQOL in chronic kidney disease patients [28].

In our study, the nephrologist who has the longest and the closest contact with the patients failed to anticipate—based on his personal judgment—the prevalence and degree of depression among his patients. Although these data need further confirmation, yet they emphasize the importance of adopting systematic approach and of nephrology/psychiatry collaboration in order to accurately diagnose and treat depression among hemodialysis patients.

In conclusion, depression is common among our hemodialysis patients. Although important, it is likely for depression to be overlooked in this group of patients even with meticulous nephrology care. It seems to adversely affect almost all aspects of HRQOL. Therefore, a regular combined nephrology/psychiatry approach should be central to the medical care of hemodialysis patients in order to accurately assess for depression among them. Moreover, large national studies to delineate the prevalence and impact of depression among Egyptian hemodialysis patients are needed.