A comparative study of psychosocial determinants and mental well-being in chronic kidney disease patients: A closer look.

BACKGROUND: Depressive illness in chronic kidney disease (CKD) is an independent risk factor for morbidity and mortality. The relation between depressive illness and quality of life (QoL) in this vulnerable group is complex. We attempted to study the burden of depressive illness, the QoL in patients of CKD on hemodialysis (HD), and peritoneal dialysis (PD) as well as those who were not on any dialysis but on conservative medical management only.
MATERIALS AND METHODS: Observational study with cross-sectional analytical controlled design. STATISTICAL METHODS USED: Chi-square statistic or Fisher's exact test for categorical variables and t-test and ANOVA for continuous variables. Correlational analysis was done using Spearman's correlation coefficient. P <0.05 was considered as statistically significant.
RESULTS: Depressive symptoms were present significantly across all 3 groups of CKD patients. Depressive disorder was significantly higher in the HD group. Mean QoL was significantly better in patients of CKD on PD. DISCUSSION: There is huge hidden burden of depressive symptoms and depressive illness in patients of CKD whether on dialysis or on conservative medical management. The study found significantly higher burden of depressive illness and lower QoL among the HD vis a vis PD patients, even though the majority of our CKD who require dialysis are on HD.
CONCLUSION: Depressive burden is the hidden factor behind poor QoL, poor overall satisfaction as well as treatment outcome in patients of CKD whether or not on dialysis. To address this hidden depressive burden comprehensively, close cooperation between nephrologist and psychiatrist is called for. Copyright:

According to the World Health Organization (WHO), depression is the second most common cause of disability-adjusted life years in the age 15–44 years, and by the year 2030, depression will result in more years of life lost to disability than any other illness in general population.[1] In people suffering from chronic illnesses, depression is not only higher,[2] but also more severe and difficult to treat.[3] Among these chronic illnesses, chronic kidney disease (CKD) is common and ever increasing, even though data from India is limited on its prevalence. Of the few studies available, a prevalence of CKD have been found to be 15%–17%.[45] In the United States (US), there has been a 30% increase in prevalence of CKD over last 10 years.[6] Actual Indian figures are likely to be similar and continuously increasing due to lifestyle diseases and increased longevity.[7] End-stage renal disease (ESRD) represents the final stage of CKD. While, CKD is present in as many as 20 million in the US, and ever increasing, ESRD affects approximately 500,000 patients in the US.[6] A rough estimate of the magnitude of the our problem can be had from the results of an Indian study which found incidence of ESRD to be 229/million population.[8]

There are 3 major modalities of treatment for ESRD patients – conservative management as per standard guidelines (involves management of hypertension (HTN) and diabetes mellitus (DM) as indicated, nutritional and other supportive therapies, hemodialysis [HD] and peritoneal dialysis [PD]). Among the ESRD patients on dialysis, majority (up to 90%) are on HD and the rest on PD.[9] As per US Centers for Disease Control and Prevention control data, by 2013, 63.7% of all prevalent ESRD cases were receiving HD therapy and 6.8% were being treated with PD.[10] Patients with ESRD whether or not on maintenance dialysis experience significant impairments in quality of life (QoL).[11]

The question arises as to what causes this deterioration in the QoL. The obvious sources appear to be problems with physical health, psychological state, level of independence, social support, personal beliefs and their relationship to salient features of their environment.[12] We set out to study these parameters with special emphasis on psychological health in patients of ESRD on dialysis as well as those on conservative medical management.

A literature search into the prevalence of depression in ESRD, the focus of our study, revealed a figure of up to 21.4%.[13] Apart from its own independent morbidity, depression is also a risk factor for premature death in CKD.[5]

Having underlined the huge disease burden of depression in CKD, especially ESRD patients, it appears that the relation between depression and CKD is complex and perhaps bidirectional, each worsening the other.[14151617] This high burden of depressive symptoms may be one of the major, though not the only contributors, to the marked impairments in QoL in this population[18] which is an important aspect in management of any chronic illness. QoL instruments measure individual's own views of his wellbeing. The core components of QoL are physical, functional, psychological/emotional, and work/occupational.[19] The WHO definition of QoL is a broad ranging concept affected by the person's complex physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment.[20]

We undertook the current study, unique and one of its kind, to compare 3 domains (symptom burden, depression, and QoL) in 2 group of samples (patients with ESRD receiving chronic dialysis (HD as well as PD)[21] using a control arm of patients of ESRD who are not on dialysis but only on conservative medical management, using well validated screening tools, stringent exclusion criteria and structured clinical interview (SCID) by a qualified trained psychiatrist to diagnose depression. Our search revealed no such studies on Indian population.

MATERIALS AND METHODS

Between January and June 2018, all patients reporting to the nephrology outpatient department of a tertiary care hospital of Eastern India, who were diagnosed as ESRD, were offered to be included in the study. Of these, 56 patients on HD, 50 pts on continuous ambulatory PD, and 32 pts not on any dialysis (on conservative medical management only) were included. Exclusion criteria included age above 18 year and <70 year, active infection (pneumonia), active coronary artery disease (e.g., unstable angina, myocardial infarction) within the last 6 months, bed bound patients, advanced cirrhosis, advanced dementia, substance use disorder including alcohol abuse, the presence of schizophrenia, bipolar mood disorder, past history for treatment for psychiatric illness, past h/o head injury, and stroke in the last 6 months. A specially designed pro forma was administered to elicit sociodemographic characteristics and biochemical and hematological variables from the medical record. Diagnosis of ESRD was based on CKD-epidemiology collaboration formula, and a glomerular filtration rate (GFR) of <15 ml/min/1.78 m2 body surface area was diagnosed as ESRD. The Beck's depression inventory (BDI)[22] was used to quantify depression followed by a SCID by a qualified trained psychiatrist. For recording other symptoms, general health questionnaire -12 was given. We used the brief version of the WHO's QoL scale ((World health organization Quality of Life Instrument – Short Form))[23] in our study. Data obtained from the above were then analyzed and compared been groups. Institutional ethical committee clearance was taken, and all participants provided informed consent.

Statistical analysis

For our analyses, differences between the groups in demographic characteristics, clinical variables, depression, and QoL scores were assessed using ANOVA for continuous variables and the Chi-square statistic for categorical variables. Standard t-test was used to compare group means. We assessed correlations in each patient group using Spearman's correlation coefficient and evaluated the internal consistency reliability using Cronbach's coefficient alpha. P <0.05 was considered to represent statistical significance in all analysis. All data handling and in-depth analyses were done by one of the authors who is a qualified statistician too, using the SPSS version 20 IBM, Armonk USA.

RESULTS

Among the samples, there are 3 subgroups – HD, PD, and controls (CKD patients not on dialysis but on conservative medical management only). We compared the following parameters between these 3 major groups:

Sociodemographic variables

Common physical and mental symptoms

The presence or absence of depressive disorder

QoL of the patients.

Sociodemographic variables

HD group was significantly younger than other 2 groups; there was no difference in gender though. The number of cases with HTN and DM were significantly higher in PD patients (P = 0.000 and 0.010, respectively, for DM and HTN, respectively). Only one patient was on antidepressants. Six patients were on prescription sedatives (4 on tablet alprazolam and 2 on tablet zolpidem). Mean duration of dialysis in HD group was 38.18 months. For PD, this average was 27.5 months (P < 0.05). The mean difference in hemoglobin levels in the 3 groups was not significant (P > 0.05).

The most common symptoms across the sample were sleep disturbance (27.01%) followed by forgetfulness (22.9%) and fatigue (27.04%). These symptoms were evenly distributed among all the 3 groups.

Depression

The mean BDI scores were not significantly different between the 3 major groups [Table 1a and b]. However, when the BDI scores were converted into categories of depressed (BDI > 12) and not depressed (BDI < 12), the depressive disorder was significantly higher in the HD group than the PD group (P = 0.038) [Table 2]. There was significant difference in all QoL domains between those depressed and those not depressed among the total 122 samples (P < 0.05) [Table 3]. This correlation was also confirmed from the finding that BDI scores were significantly correlated with all the domains of QoL in a negative direction (higher the BDI score, lower the QoL).

Table 1a

Comparison of quality of life and Beck’s depression inventory parameters between the 3 groups - control, hemodialysis, and peritoneal dialysis

Parameter	Mean (SD)
	Control (19)	HD (50)	PD (53)
QOL score (Q1)	3.32 (1.003)	2.90 (0.931)	3.85 (1.199)
Satisfaction score (Q2)	3.89 (0.809)	3.16 (0.866)	3.81 (0.982)
DOM 1 (physical health)	3.34 (0.676)	3.72 (0.648)	3.48 (0.840)
DOM 2 (psychological health)	3.39 (0.838)	3.22 (0.777)	3.33 (0.776)
DOM 3 (social health)	3.47 (0.630)	3.65 (0.622)	3.73 (0.735)
DOM 4 (environment health)	3.66 (0.661)	3.63 (0.814)	3.67 (0.835)
BDI score	8.89 (5.483)	9.28 (5.115)	9.68 (5.734)

QOL – Quality of life; BDI – Beck’s depression inventory; SD – Standard deviation; HD – Hemodialysis dialysis; PD – Peritoneal dialysis; DOM –domain

Table 1b

Comparison of quality of life domains and Beck’s depression inventory between the 3 groups - control, hemodialysis, and peritoneal dialysis

Parameters	P for the comparison between
	Control and HD	Control and PD	HD and PD
QOL score (Q1)	0.321 (NS)	0.152	0.000 (S)
Satisfaction score (Q2)	0.009 (S)	0.937	0.001 (S)
DOM 1 (physical health)	0.140 (NS)	0.757	0.235 (NS)
DOM 2 (psychological health)	0.693 (NS)	0.962	0.732 (NS)
DOM 3 (social health)	0.568 (NS)	0.317	0.829 (NS)
DOM 4 (environment health)	0.991 (NS)	0.997	0.963 (NS)
BDI score	0.999 (NS)	0.929	0.842 (NS)

QOL – Quality of life; BDI – Beck’s depression inventory; HD – Hemodialysis dialysis; PD – Peritoneal dialysis; S – Significant; NS – Not significant; DOM –domain

Table 2

Comparison of prevalence of depression between the 3 groups

Group	Depressed	P	Significance
HD (n=50)	20	0.366 (HD vs. control)	NS
PD (n=53)	12	0.041 (PD vs. HD)	S
Control (n=19)	5	0.748 (PD vs. control)	NS

HD – Hemodialysis dialysis; PD – Peritoneal dialysis; S – Significant; NS – Not significant

Table 3

The Quality of life domains compared between depressed and nondepressed group - result of t-test

Parameter	Mean (SD)		P
	Depression group	No depression group
QOL score (Q1)	2.56 (0.97)	3.72 (1.04)	<0.05 (S)
Satisfaction score (Q2)	2.89 (0.78)	3.84 (0.89)	<0.05 (S)
DOM 1 (physical health)	3.35 (0.71)	3.64 (0.75)	<0.05 (S)
DOM 2 (psychological health)	2.74 (0.80)	3.53 (0.65)	<0.05 (S)
DOM 3 (social health)	3.34 (0.63)	3.80 (0.65)	<0.05 (S)
DOM 4 (environment health)	3.13 (0.76)	3.89 (0.70)	<0.05 (S)

S – Significant; QOL – Quality of life; SD – Standard deviation; DOM –domain

Quality of life score

There was significant difference in mean scores of HD and PD group with respect to QoL score [Table 1a and b]. QoL score is significantly higher for PD (P < 0.05). There was significant difference in mean scores of satisfaction scores between HD and PD group as well as between control, and HD-HD has significantly lower mean values of satisfaction compared to control and PD. All the 4 domains of QoL were significantly correlated (P < 0.05).

DISCUSSION

The results of this study throw much wanted light in the Indian context on the depressive burden on patients of CKD in ESRD with or without renal replacement therapy (dialysis). As can be seen from the results, we found that depression was quite common across the samples in all 3 group with an overall prevalence of 31.15% which is a little more than what has been described in previous studies.[13] Between the 3 groups, depressive syndrome was highest in those on HD. The reason for this high prevalence of depression in this population have been discussed in previous studies and apart from psychosocial and illness/drugs related interactions, also include immune dysfunction seen both in depression as well as CKD independently.[24] The relationship appears to be bidirectional. A large study in this context has brought out the role of depressive symptoms in CKD as independent predictors of adverse clinical outcomes, including faster GFR decrease, dialysis therapy initiation, or hospitalization concluding that depression should be evaluated early and treated in patients with CKD promptly.[25] Furthermore, noteworthy is the finding from our study that all the 3 groups have widespread depressive symptoms, even though diagnosable depressive disorder was significantly higher in the HD group. These subsyndromal depressive symptoms need to be picked up and addressed through counseling, psychotherapy, or antidepressants. The overall outcome (morbidity and mortality) in ESRD patients, especially those on HD can be improved significantly by detecting and treating concomitant depression.

It can also be clearly seen that the overall QoL and satisfaction is much favorable in those ESRD patients who are on PD. Does it have anything to do with the fact that PD patients stay home and are in more control of their illness/treatment as compared to HD patients who have to come 2–3 times a week for HD to the hospital. Apart from any inherent effect of the HD process itself, in Indian and rural/semiurban context, we also need to consider psychosocial factors such as travel, poor modes of communication, stay, need for an attendant/caregiver to accompany, financial burden as well as mental and physical labor involved.

QoL – previous studies have found poorer QoL in CKD patients in general and poorer QoL in dialysis patients in particular vis a vis those who are on conservative medical management (controls).[26] Our results corroborate this finding in Indian population as the QoL in the control group (not on dialysis) was poor but better than the 2 dialysis group. More importantly, there was a significant difference in QoL between peritoneal (PD) and HD group in favor of PD. In fact all parameters-depression as well as QoL was worse in HD group. This assumes importance given that only 10% of ESRD are on PD and the majority is on HD.

Our correlational analysis revealed a positive significant correlation among the domains of satisfaction score, physical health, psychological health, social health, and environmental support which means that these parameters are significantly related in a positive direction indicating a higher value of one parameter influenced other parameter to have higher values. Expectedly, that is quite understandable and logical inference and validates our findings – a patient who has poor social support, is low on confidence and money and is far away from the dialysis center/hospital is likely to have less subjective satisfaction and is likely to rate his QoL as poor. The impact of depressive symptoms was clearly seen in our correlational analysis which found a negative significant correlation between BDI score with all 4 domains of QoL. This implies that a patient who is more depressed will have a poorer physical health, poorer psychological health, poor social and environmental health as well as poor overall satisfaction from treatment.

We also found that there are memory related issues, fatigue and sleep related issues which are going unrecognized. Those who are on HD have significantly higher fatigue and sleep disturbance. This needs to be taken note of as it is quite possible that this contributes to the overall distress and QoL in our patients. It is important to note that these symptoms are also a part of the depressive syndrome, and hence, an intragroup analysis revealed that these symptoms were not restricted to the depressed only, meaning that people who were not having depressive disorder, also reported these distressing symptoms in significant numbers. Clinicians need to make a note of this and ask specifically about the presence or absence of these symptoms even in those who do not “look' depressed, and when found, address it adequately. It may go a long way in overall improvement in our patients.[27]

CONCLUSIONS

There is a huge hidden burden of depressive symptoms and depressive disorder in ESRD patients irrespective of their dialysis status. Those on HD had more psychopathology. Depressive burden is responsible for poor QoL in these patients. PD patients seem to be having better QoL overall as compared to HD patients. From our study there is evidence that in CKD patients in India, depressive disorder, overall well-being and overall QoL is un unfinished task calling for wider attention. This should alert our specialty of the nuances of mental health on our pts and call for greater collaboration between mental health specialists and nephrology for better outcome in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.