Frequency and Correlates of Depression in Hemodialysis Patients versus Apparently Healthy Population in Egypt

Introduction

Depression is the most common mental health condition in the general population [1, 2], characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration [3]. In its most severe form, depression can lead to suicide [4, 5] and increased risk of mortality [6]. Depression frequently takes a chronic course and considerably weakens the possibility of an individual’s occupation [7] and quality of life [8, 9]. Depression could be dependably diagnosed and treated by primary health physicians [10, 11].

Depression is a common mental health problem worldwide in the past two decades during the era of the development of the Internet and online health information. Furthermore, depression is described to be one of the most common psychological conditions among hemodialysis patients [12]. The prevalence of depression was found to be dissimilar in the various communities, 34.5% in a tertiary hospital among hemodialysis patients in Nigeria [13] compared to a prevalence of 27% among African American hemodialysis patients [14]. However, it is 72% among end- stage renal disease (ESRD) patients in Sudan [15]. The risk factors for depression among ESRD patients include low compliance to medications, poor nutritional status, and marital problems [16], connections to the hemodialysis machine for three hours per session with a minimum of three sessions per week [17]. Socio-demographic variables such as age and family support have been reported to show a significant role in the psychological well-being of hemodialysis patients [18]. Patients with varying dialysis duration reported differences in the prevalence of depression [19]. In a previous study of our group; it was reported that depression determinants in Egyptian hemodialysis patients were female gender, diabetes mellitus, IHD, malnutrition, and lower serum albumin and blood hemoglobin [20]. The latter study stimulated us to compare the difference in the determinants and correlates of depression between hemodialysis patients and the apparently healthy control group in relation to socioeconomic status, education level, employment status, and other demographic and associated comorbidities of the studied group.

Material and Methods

The study was conducted in four renal dialysis units in Dakahalia governorate in Egypt where 234 hemodialysis patients and 242 apparently healthy controls were recruited for the study. The demographic data, socioeconomic status, education level, employment status, associated comorbidities, and depression scoring of all the cases and apparently healthy control groups were reported. The patients with known CKD or maintained on dialysis were not included in the control group.

Depression was measured using the Center for Epidemiologic Studies Depression Scale (CES-D), NIMH. Depression scoring design is clarified as the following, zero for answers in the first column, 1 for answers in the second column, 2 for answers in the third column, and 3 for answers in the fourth column. The scoring of positive items is reversed. The possible range of depression scores is zero to 60, with the higher scores indicating the presence of more symptomatology. The used depressive score scale put higher stress on related mood symptoms referred to as depressive mood rather than physical symptoms to avoid the possible overlap with the medical conditions.

Results

The total studied groups were 234(136 males, 98 females) patients on dialysis with a mean age of 55.6±13.6 years (range 21–79 years), and 242(157 males, 85 females) healthy individuals with a mean age of 33.6±13.3 years (range 18–70 years) (Table 1). Table 1 showed demographic data and depression scores in both studied groups where there was a nearly significant higher depressive score in hemodialysis patients. While, table 2 showed the distribution of gender, associated comorbidities, socioeconomic status, and education level in both studied groups: There were higher frequencies of associated comorbidities (diabetes, hypertension, and ischemic heart disease) in the dialysis group. Additionally, there were higher frequencies of poor socioeconomic status, and illiteracy (Table 2) as well as more number of unemployed personnel in HD patients (Table 3) Table 4 showed the distribution of depression scores in relation to employment status in both groups; there was higher depression score in mental employee in the control group. However, it was higher in unemployed persons in HD patients yet, the depression score was the least in mental employees on hemodialysis.

The severity of depression was significantly positively correlated with younger age, higher socioeconomic status, and a higher level of education in the control group (Tables 5 & 6) while Tables 7 & 8 showed associations of depression score with different variables in the cases group where Depression scores were positively correlated with older age, higher body mass index, lower socioeconomic status and lower level of education in HD patients. Females both in dialysis patients as well as in the controls had statistically significantly higher depression scores indicating more depressive symptoms, than their male counterparts. In HD patients, the severity of depressive symptoms was significantly related to the presence of diabetes mellitus and ischemic heart disease. Comparisons of the distribution of depression scores between control and cases were shown in Table 9. There was no statistically significant difference in the severity of depression distribution between both groups even, after the exclusion of associated comorbidities (Table 10).

Discussion

Depression is the most common mental health condition in the general population, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration. In a previous report of our group about depression determinants in Egyptian hemodialysis patients conveyed that depression in dialysis patients is associated with female gender, diabetes mellitus, IHD, malnutrition, and lower serum albumin and blood hemoglobin [20]. This report guided us to compare the severity and correlates of depression in hemodialysis patients versus a control group and to analyze the relationship between socioeconomic status, education level, employment status, and other demographic factors and associated comorbidities in the hemodialysis patients as well as the control group. In this research, we aimed to assess the severity and correlates of depression in HD patients and compare them to a group of apparently healthy individuals in Egypt.

In the present work, there were higher frequencies of poor socioeconomic status, illiteracy, and unemployment in the group of cases than in the control one. This could be clarified by less orientation of the risk factors, diagnosis, and management of chronic kidney disease in illiteracy and poor socioeconomic status. Additionally, dialysis could result in an increased frequency of unemployment status due to loss of job especially if the original work of the patient is physical work that could be greatly affected by the dialysis determining factors and individual physical health. There were higher frequencies of associated comorbidities (diabetes, hypertension, and ischemic heart disease) in the dialysis group than the frequencies in the control group in the present study. This is could be explained by the presence of diabetes, hypertension, and ischemic heart disease acting as risk factors for the development and progression of CKD.

In this study, the depressive scores were higher in HD patients than those of the apparently healthy group. This could be explained by the loss of jobs in dialysis, the low self- esteem of the patients, and due to the persistent needs of the patients for the dialysis machine. This observation is shared by Karamanidou, et al. [17] who explained that the connection of the patients to the hemodialysis machine for three hours per session with a minimum of three sessions per week could be related to increased depression in hemodialysis patients [17]. Additionally, Turkistani, et al. [18] clarified that socio- demographic variables such as age and family support could play a significant role in the psychological well-being of hemodialysis patients. The impact of the loss of a job and low level of income as well as the older age of the patients on the occurrence of depressive symptoms has been confirmed in many previous publications [18, 21, 22]. In this work, the average depression score was higher in mental workers, younger individuals, those coming from higher socioeconomic status, and those having a higher level of education in the control group. On the other hand, in dialysis patients, higher depression score is observed more with non –employment, older age, lower socioeconomic status, and lower level of education. Moreover, the least depression score was in mental employees in dialysis patients. It is easily conceivable that hemodialysis patients have less ability to do physical activity, thus, they are inclined toward mental jobs with less effort and more satisfaction. This concept is shared by many previous publications that reported a high prevalence of depressive symptoms in HD patients with unemployment, and lower socioeconomic status [21, 22]. In the same context, Park, et al. [23] found that depression in HD patients was more in old age (>60 years), with low hemoglobin level (<10 g/dl), and low economic status, and old age was the most important risk factor among them. In addition, female gender, presence of diabetes mellitus, and high CRP (>0.5 mg/dl) were common factors associated with decreased health-related quality of life and depression [23].

In our work, there is a higher depression score in the female gender in both the CKD patients and control groups. This is supported by Puri and his associates who reported that the prevalence of depressive symptoms in women is known to be twice as high as in men in the general population [24]. The same trend was also reported by Park HC [23]. Furthermore, there are gender differences in the prediction of lethality in suicide attempts among people suffering from severe depression, more in females [25].

.In this work, the frequency of depression was higher in patients with diabetes mellitus and ischemic heart disease. This finding is reinforced by many publications that found a strong association between depression and cardiovascular risk [26, 27]. Additionally, depression and metabolic syndrome are positively correlated and act as independent predictors of adverse cardiac outcomes [28, 29]. Moreover, depression frequency is higher among HD patients with diabetes, [23] and depression is correlated with poor glycemic control [28]. After controlling for the associated comorbidities, the frequency of depressive symptoms was comparable between the HD patients and the apparently healthy group in the present work.

Conclusion

The frequency of depressive symptoms was demographically higher in hemodialysis patients compared to the apparently healthy individuals and was more pronounced in patients with more advanced age, lower socioeconomic status, non-employment condition, and lower education level. This necessitates more consideration of the level of social and psychological care offered to these patients.