Prevalence and clinical correlates of depression in chronic kidney disease patients in a tertiary care hospital.

BACKGROUND: Prognosis and associated complications of chronic kidney disease (CKD) may result in psychological distress and mood disorders especially depression. Prevalence and clinical correlates of depression in CKD patients in the Indian context are not well studied and established.
MATERIALS AND METHODS: This cross-sectional study included 84 CKD patients. The diagnosis was made based on the diagnostic and statistical manual, 4th edition criteria; psychiatric disorders were ruled out through the mini-neuropsychiatric interview. Montgomery-Asberg Depression Rating Scale was used to assess the severity of depression. Suicidal ideations were evaluated by using a modified scale of suicidal ideations. Data were analyzed using Epi Info 7 software.
RESULTS: The prevalence of major depression was 44.05%, while the prevalence of depressive symptoms was 82.14%. Age of the patients (P = 0.0065), patients on dialysis (P < 0.0001), and serum creatinine levels >5 (P = 0.0180) showed a statistically significant association with depression. The prevalence of depression was significantly associated with dialysis (P < 0.0001). The severity of depression and the severity of suicidal ideations were well correlated with each other (P < 0.0001).
CONCLUSION: The increased prevalence of depression and suicidal ideations was observed in CKD patients. We strongly recommend initiating screening of depression in CKD patients for appropriate rehabilitation and improved the quality of life.

INTRODUCTION

Chronic kidney disease (CKD) is an increasing public health issue with a global prevalence of 8%–16%.[12] In patients with CKD, poor health, high economic burden due to treatments, and complications associated with the disease adversely influence the quality of life, and psychosocial factors such as low social support and mood disorders – depression and anxiety.[34]

The assessment of depression is important as it is an independent factor for nonadherence in patients on maintenance dialysis[5] and is linked with increased suicidal risk.[6] Depression also doubles the mortality in patients suffering from end-stage renal disease as compared to others in earlier stages of CKD.[7] Therefore, it is important to screen, to diagnose, and to treat depression in patients with CKD.

Prevalence and associated factors of depression may vary in the Indian population due to variability in the ethnicity and socioeconomic factors. The assessment of prevalence and clinical correlates may aid in implementing modalities to improve the treatment outcome and quality of life in patients with CKD. Therefore, the present study aimed to evaluate the prevalence and clinical correlates of depression in patients with CKD in the Indian population.

MATERIALS AND METHODS

Data collection

This present 1-year cross-sectional study (January 2015–December 2015) was conducted at the Department of Psychiatry. A total of 84 patients diagnosed with CKD recruited from the Department of Nephrology were included in the study. Patients with a history of psychiatric illness including depressive disorder (3 months’ asymptomatic period was taken to be regarded as a past episode of a depressive disorder) were excluded from the study. Furthermore, the patients with chronic medical illness and uncooperative for the interview, except diabetes mellitus, and hypertension were exempted. Ethical clearance was obtained from the Institutional Ethical Committee. Informed consent was also obtained from all the participants after explaining the purpose of the study. Serum creatinine levels were estimated in all the patients.

Tools

Major depressive disorder was diagnosed using the Diagnostic and Statistical Manual (DSM), 5th Edition criteria. Other psychiatric disorders were ruled out through mini-neuropsychiatric interview conducted using DSM, 4th edition, and the International classification of diseases-10.[89]

Montgomery–Asberg Depression Rating Scale (MADRS) was used to rate the severity of depressive symptoms. MADRS is a 10-item rating scale with each item being scored from 0 to 6, ranging from 0 to 60.[10] Suicidal ideations were assessed using the modified scale for suicidal ideation. This is an 18-item scale, where each item is rated from 0 to 3, yielding to a total score ranging from 0 to 54.[11]

Data analysis

Epi Info-7 (Altanta, Georgia, USA) was used to analyze the data. Chi-square test was used to evaluate the effect of various parameters on depression in CKD patients. The effect of serum creatinine on the severity of depression was evaluated using the Kruskal–Wallis H-test. The Spearman's correlation coefficient was used for the correlation between various parameters. P < 0.05 was considered statistically significant.

RESULTS

The mean age of the CKD patients was 54 ± 12.56 years with male predominance (80.95%). Most of the patients (59.52%) had a 1–5 years’ history of CKD, and the predominant mode of treatment was dialysis (58.33%). Most of the CKD patients had hypertension along with diabetes mellitus (52.38%).

According to DSM, 5th edition criteria, 44.05% of patients had major depressive disorder; whereas, MADRS showed severe depression in 34.52% of patients. Most of the patients (46.43%) had a low suicidal ideation. There was an equal distribution (16.67%) of severe and mild-moderate suicidal ideations in the patients [Table 1].

Table 1

Distribution of patients with depression and suicidal ideations based on different criteria

The prevalence of depression was more in the 40–60 years age group, and there was a significant difference in the presence of depression among all the age groups (P = 0.0065). High prevalence of depression (63.27%) was observed among patients undergoing dialysis compared to patients with different mode of treatment (P < 0.0001). The effect of comorbidities (P = 0.13), duration of CKD (P = 0.29), and serum creatinine levels (P = 0.07) were not associated significantly with depression status [Table 2]. However, a significant association was observed between the serum creatinine levels and the severity of depression in the CKD patients (P = 0.0180).

Table 2

Effect of various parameters on depression in chronic kidney disease patients

A significant correlation was observed between suicidal ideation and the severity of depressive symptoms (r = 0.8472, P < 0.0001). Whereas, age (r = 0.10, P = 0.32) and serum creatinine (r = 0.19, P = 0.32) were not significantly correlated with suicidal ideation. Furthermore, there was no significant correlation found in between the severity of depressive symptoms and serum creatinine (r = 0.15, P < 0.17).

DISCUSSION

The present study was aimed to study the clinical correlates of depression in CKD patients in India. A high prevalence of depression and suicidal ideations were observed in CKD patients in our study.

The mean age in our study was in accordance with the study by Rai et al.[12] Wherein, the mean age observed was 53.82 ± 8.61 years. The highest proportion of depressed patients in this age group might be due to financial instability and disruption in daily life. Higher prevalence of men in our study was similar to various related studies.[1213] The duration of illness in our study was similar to a study by Chiang et al.[13] Wherein, the mean duration of CKD was 3.53 ± 2.85 years. We could not find an association between the duration of illness and depression; however, Craven et al.[14] reported that the mean dialysis duration of ≤24 months was associated with depression. In contrast, Rai et al.[12] reported the mean duration of >1 year of dialysis was significantly associated with depression (P = 0.001). In fact, both these studies[1012] focused only on the role of dialysis in CKD patients and its association with depression.

Indian registry states that diabetes and hypertension are the leading causes of CKD, which is reflected in our study too.[15] Renal diseases are common in patients with diabetes, among which almost half of the patients present with renal damage in their lifetime.[16] Similar to Sumanathissa et al.[17] study, diabetes mellitus and hypertension had not influenced the depression in CKD patients in our study.

A significant association was found between the dialysis and depression in our study. Increased financial cost, regular follow-ups, and disease-related psychosocial factors may be the reasons for such an association. A study by Kimmel.[18] also reported an increased risk of psychiatric disorders, particularly depression, in CKD patients undergoing dialysis. Usually, dialysis is implemented in Stage V CKD. Hence, the severity of CKD could also be the probable reason for the high incidence of major depression in these patients.

In this study, the mean depression scores were different in patients with serum creatinine levels <5 mg/dL and 5-10 mg/dL; however, they were similar in patients with serum creatinine levels >10 mg/dL. This may be attributed to the fact that usually patients with creatinine levels >10 mg/dL may have a chronic illness without sustained or long-term uremic symptoms such as insomnia and loss of appetite. The prevalence of major depressive disorder in CKD patients in our study was similar to a study by Rai et al.[12] This might be due to sample selection, methodology, or the higher susceptibility of the Indian population to major depressive episode.[19] Suicidal ideations in our study were consistent with the findings of Macaron et al.,[20] (37%), however, it differs from the study by Chen et al. (21.5%).[21] The probable reason might be due to difference in the population and methodology, as they did not employ a separate scale for computing suicidal ideations.

The significant correlation found in our study between suicidal ideations and severity of depression was similar to a study by Keskin and Engin.[6] A significant correlation found in our study between the treatment modality, and suicidal ideation was similar to a study by Liu et al.[22] This revealed that the patients undergoing dialysis had increased severity of suicidal ideations when compared to the patients undergoing other treatment modalities, mainly conservative. It can be further explained due to the increased severity of depressive symptoms in patients undergoing dialysis, and therefore, a correlation between the depressive symptoms and suicidal ideations in patients with CKD.

Our study has few limitations as follows: the study samples were obtained from a tertiary care hospital, hence, the findings cannot be generalized to the general population; sample size was comparatively smaller as compared to other studies, and the effect of stage of the disease could not be studied as all the patients in the study were in Stage III or more. This was a cross-sectional study; a prospective longitudinal study of cohorts would result in better comprehensive findings. More studies are required in the Indian population to evaluate the difference in the depressive symptoms in the patients and their response to treatment with antidepressants and psychotherapy.

CONCLUSION

In our population, almost half of the patients with CKD had major depressive disorder, and almost 1/6th of these patients expressed severe suicidal ideations along with other physical complaints, which need special care. Altogether, our findings suggest that the patients undergoing treatment for CKD should be evaluated for depression so that appropriate rehabilitation measures are incorporated to improve the quality of their lives.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.