An Assessment of Mental Health among Dialysis Patients in Gadag District, Karnataka

Introduction

Chronic kidney disease (CKD) is a global issue that imposes a heavy financial and healthcare burden on society. Approximately 850 million individuals worldwide suffer from various forms of kidney problems, and one in ten adults suffer with chronic kidney disease.¹ Renal and urinary tract diseases are considered to be the cause of about 0.7 million fatalities worldwide each year (World Health Organization, 2008). Out of 133 conditions listed by the Global Burden of Disease (GBD), CKD ranks as the 12^th most common cause of death. Globally, CKD caused more deaths in 2017 than either HIV or tuberculosis combined, and the number of CKD deaths was nearly equivalent to the number of deaths from traffic accidents.²

The World Health Organization (WHO) reported that depression ranked second among all illnesses in people aged 15 to 44 years in terms of disability-adjusted life years. By 2030, depression will account for more years of life lost to disability than all other illnesses combined in the general population.³ Depression is higher and more difficult to treat in people suffering from chronic illness.⁴ Among these chronic illnesses, chronic kidney disease (CKD) is common. Depression has been identified as the most prevalent form of mental health problem among the dialysis patients.³ Patients on dialysis, particularly those undergoing hemodialysis (HD) and peritoneal dialysis (PD), experience a wide range of somatic symptoms and participate in social, professional, and recreational activities far less frequently. Patients suffering from end stage renal disease (ESRD) are primarily observed to have depressive problems.⁵ But they can happen at any stage in the CKD process. Additionally, a higher percentage of individuals with depression are hemodialyzed patients.⁶ Early CKD diagnosis and treatment of depression is particularly crucial since it is linked to worsening quality of life and mental health, resulting in poor treatment adherence and impairing recovery.

Depression develops when depressing physical symptoms are combined with psychological sadness, resulting in a markedly lower quality of life (QoL) and with an estimated prevalence ranging from 23% to 39%.⁴ It is a serious public health issue that primarily affects adults in their older years and has a lifetime risk of 10-25% in women and 5–12% in men.⁷ Despite depression being second only to hypertension, it is not addressed in people receiving haemodialysis.⁵ According to World Health Organization predictions, depression will rank second among psychological abnormalities most commonly seen in patients with end-stage renal disease (ESRD) receiving hemodialysis within the next 20 years.⁶ The risk of suicide in people receiving chronic dialysis is f ifteen times higher than in the general population.⁸

Depression is three to four times more common in people with CKD and ESRD than in the general population, and two to three times more common in those with other chronic conditions. Depression in patients with chronic kidney disease (CKD) is associated with several factors, such as being younger, female, Black or Hispanic, having less education, having a lower family income, being unemployed, having high blood pressure, smoking, having diabetes, and having coronary artery disease than the general population. Depression may result from CKD and ESRD patients’ psychological burden of having a disease that affects their future morbidity and death.⁹ It may also result from the increased burden of self care associated with CKD and ESRD, which includes frequent clinic and hospital visits, food restrictions, an increased pill burden, and home glucose and weight monitoring.¹⁰

Depression can have a negative impact on nutritional status, immune system function, and compliance with medication and dialysis schedules, all of which can lead to poor clinical outcomes.¹¹

Materials and Methods

Study design

This was a cross-sectional study conducted at Government and Private hospitals in Gadag district, Karnataka between December 2023 to January 2024. The study participants were patients who were assigned to the respective dialysis units. All the dialysis patients visiting Government and Private hospitals in Gadag district during the time frame were included in the study. Dialysis patients who were not willing to participate in the study and those admitted in ICU and Emergency unit were excluded. Also, patients <18 years of age and those undergoing dialysis for a duration of less than three months were excluded.

Sampling design and sample size

The time period sample technique (for 06.12.2023 to 30.01.2024) was used. There were 110 patients registered in the dialysis unit overall, with 100 of them receiving haemodialysis. A sample size of 100 CKD patients was achieved and recruitment was based on their willingness to participate. Ethical approval was obtained from the IEC, KSRDPRU, Gadag. All patient data was anonymised and confidentiality and privacy were assured.

Study instrument

The data collection tool consisted of four parts:

1. Sociodemographic information (i.e., Age, Gender, Religion, Marital status, Type of family, Education, Occupation, Family income and Socio-economic status). 
2. Clinically related information (i.e., Diagnosis, Dialysis duration, Type of Access, Dialysis Schedule, Dialysis unit name).
3. The self-administered Beck Depression Inventory (BDI) Scale-2. BDI-2 questionnaire was the instrument employed to assess depression. A four point Likert-type scale (ranging from 0 to 3) was used to rate and measure the components of each category.
4. Extended questionnaire was used to assess reasons for depression.

Outcome measures

The primary aim of this investigation was to assess the prevalence of depression and causal factors contributing to depression among chronic kidney disease (CKD) patients undergoing hemodialysis. As outlined in the BDI-2 scale questionnaire, individuals scoring between 0-13 were classified as experiencing minimal depression, while those scoring between 14-19 were categorized as experiencing mild depression. Furthermore, individuals scoring between 20-28 were identified as experiencing moderate depression, and those scoring between 29-63 were classified as having severe depression. This research endeavored to determine the correlation between various independent variables, such as sociodemographic characteristics, clinical data, and factors contributing to depression among CKD patients.

Statistical analysis

In order to analyse the data, version 20.0. of the Statistical Package for Social Scientists (SPSS) program (SPSS Inc., Chicago, IL, USA) was employed. Frequencies and percentages were utilized to present descriptive statistics for categorical variables. Examination of the relationship between independent variables, such as socio-demographic variables, clinical information, reason for depression variables, and the outcome measure, was conducted employing the Chi-square test for categorical variables and the Pearson Chi-square test for continuous variables. For the analysis, a level of significance of P <0.05 was used.

Results

Table 1 summarizes the characteristics of 100 haemodialysis patients who responded to the depression inventory. In this study, all the dialysis patients were in Stage 5 renal disease, or ESRD. The socioeconomic and demographic characteristics of this sample are listed in Table 1. The majority of participants (n =75, 74%) were married (n = 94, 94%), had children (n =53, 53%), and were male (n=75, 75%). Although the levels of education varied, most of them had completed secondary or higher education. The majority of them had low family incomes (n =71, 71% earn ≤ 9307) and were from joint families (n=81, 81%). According to socioeconomic status, 87% of these respondents were below the poverty level.

Table 2 summarizes the clinical scenario of the study population. The majority of respondents (45%) were diagnosed with chronic kidney disease, hypertension, and diabetes, and in most of the study participants, the access was achieved through fistulas (n=93;93%), and 77 of them had been on dialysis for less than five years. More than half of these study participants were availing treatment at a government hospital (n=64; 64%).

BDI-Beck Depression Inventory Scale

According to the Beck Depression Inventory-II scale, depression can be classified as minimal, mild, moderate, or severe, as shown in Table 3. In our study, all of the haemodialysis patients were found to be suffering from depression. Most of the respondents (n = 62, 62%) suffered from severe depression.

Table 4 shows the top patient concerns, which primarily include fluid restrictions (95%), chronic pain (88%), financial issues (88%), and sleep disruptions (84%). Other significant concerns are related to children (69%), work-life balance (79%), and discomfort associated with dialysis (80%). Less frequent concerns include the fear of passing away (28%) and inability to get support from a pension scheme or salaried income (10%) to manage the chronic illness.

Table 5 summarizes Pearson’s Chi-square test, which was performed to determine the association between various sample characteristics and the severity of depression among participants. The table examines the impact of various characteristics on patient outcomes, showing significant associations (P <0.05). Higher severity of depression was noted among most of the subjects, unemployed individuals, and those with lower family income. Other severe effects reported by patients included chronic pain, financial difficulties, treatment costs, and sleep disruptions. Dietary constraints and aspirations also have a major impact on severity levels. These results underscore the complex issues associated with patient well-being management.

Table 6 explores the relationship between diagnosis, type of access, dialysis duration, and hospital type with patient outcomes. No significant differences were found across these variables (P >0.05). The severity of patient outcomes was similar regardless of the diagnosis, type of dialysis access, frequency, and whether the hospital was government or private.

Discussion

In today’s world, depression is becoming a major public health concern due to its effects and the sequalae it can cause. Patients with chronic conditions experience depression more frequently than patients with other ailments in general. Patients with chronic kidney disease (CKD) often experience depression due to the irreversible nature of the condition and poor prognosis. This study aimed to determine the prevalence of depression in chronic kidney disease patients in the Gadag district of Karnataka at both Government and private hospitals.

This study involved one hundred participants with chronic renal disease. The mean age of the participants was 49.94 (± 12.85) years. Regardless of the severity of condition, all the haemodialysis patients (100%) in our study had depression. The prevalence was found to be higher than that of other studies, which reveals depression prevalence varying from 9% to 60% and 40% to 55% among dialysis patients^12,5. This covers almost half of the results of our investigation. According to other reports, depression is highly prevalent in CKD.¹³ This variation could be explained by the population’s characteristics and several depression assessment tools used.

The investigation of the patients’ sociodemographic characteristics revealed similarities to a Dutch study of CKD patients, in which 57% of participants were men, 58% were married, and 84% were unemployed. The mean age recorded in our study is comparable with the two earlier Saudi Arabian investigations which reported the mean age of CKD patients with depression to be 43.6 (± 15.1) years and 46.55 (± 12.09) years, respectively.¹⁴ However, our results were not comparable to a Taiwanese study that reported the participants’ mean age to be 65.70 ± 12.37 years.¹⁵ The proportion of male participants was found to be 75% which is consistent with the findings of prior studies (69.6%, 61.9%, and 52%).¹⁶  Although Uzzal et al. reported that 72.2% of participants were unemployed, the current study findings are not quite comparable.¹⁷

No statistically significant variations in depression were observed between genders or age groups receiving hemodialysis in this study. Similarly, studies found that depression in patients on dialysis was not related to age and gender of the patients.^18,19 This was supported by findings of Salehi M which showed no discernible difference in the two patient groups depressed and non depressed with regard to gender, age, marital status, or the length of dialysis.²⁰

A 2018 Addis Ababa study revealed an association between depression and a medium income level. Patients receiving dialysis frequently struggle with inadequate income, which can be related to issues keeping a job, a decline in physical function and energy, and a reduction in cognitive abilities. Our study also found a similar relationship with family income.²¹ Similar to our f indings, literature also underscores that poverty-related factors play an important role in the development of depression in CKD patients in low income countries.²²

Depression among dialysis users is largely caused by f inancial burden.¹⁷ In this exploration, we also found that f inancial difficulties were the primary concern and have an impact on depression. This study reported depression among all the participants. Additionally, we identified patients with mild (11%), moderate (22%), severe (62%), and minimal (5%) depression in our study. These f indings are supported by a study which reported a high prevalence of severe depression in nearly half (43.7%) of hemodialysis patients.²³ Similar results were noted in other studies as well.²⁴ These findings are inconsistent with those of other studies, which showed that 50% of the patients had depression, with 33.3% experiencing mild depression, 15% moderate and 1.7% severe depression.²⁰ According to a 2017 Saudi Arabian study, the majority of kidney disease patients displayed various types of depression.²⁵ Research published in 2022 found that 74.58% of haemodialysis patients had depression, with the majority of renal disease patients classified into the categories of normal, mild, moderate, or severe depression based on the Zung self-rating depression scale. According to the Beck Depression Inventory-2, depression was classified as minimal, mild, moderate, or severe in our study. The prevalence of depression in haemodialysis patients was 100%.

Limitations

A relatively small sample size and data collected from only two private hospitals are some of the limitations of this study. More significant insights can be gained from a long-term study including patients from different sites. Furthermore, to fully comprehend the causes of depression in dialysis patients, qualitative research may be useful. In this study, there was no clinical diagnosis made. Instead, the evaluation of depression was based completely on self-reported responses.

Conclusion

Dialysis patients often have to balance the responsibilities of their jobs, families, and social obligations in addition to the numerous stressors caused by their condition. Anxiety and depression are the most prevalent psychological issues that dialysis patients deal with. CKD patients have an increased risk of severe depression. This study showed that CKD patients frequently experience severe depression compared to general population. According to our research, CKD patients experience significant depression. As a result, screening and diagnosing hemodialysis patients for depression is crucial for successful medication adherence. Research indicates that Stage V CKD dialysis patients had the highest rate of depression symptoms. Numerous sociodemographic factors and depression are substantially correlated. In our study, patients who were unemployed or with lower family incomes are more likely to experience depression. Patients experiencing financial difficulties, chronic discomfort, or sleep troubles are more severely affected. Due to the exorbitant expense of dialysis therapy in India, ESRD patients from poor socioeconomic background have a high prevalence of depression symptoms. Due to their inability to pay for their care, majority of patients stop their therapy. The growing amount of evidence linking depression to increased morbidity and death in CKD makes it clear that effective remedies are still a long way ahead in terms of research. Research into the efficacy and safety of antidepressant, as well as the efficacy of behavioural and psychological therapies, may prove beneficial. Both the management of chronic illness and the management of anxiety and depression are difficult. Solutions must be integrated due to the interplay of these two elements.

To enhance the patient’s wellbeing, depression should be evaluated on a regular basis and treated with psychological counselling. Our findings are consistent with the recommendation that patients undergoing dialysis undergo routine screenings for depression and that dialysis staff members be made aware of mental health disorders and their symptoms, as well as how they affect their religion, employment, family income, sleep patterns, chronic pain, dietary restrictions, ability to pursue hopes and dreams, and financial difficulties.

Funding

None

Conflict of interest

None