Determining the anxiety and depression levels of pre-dialysis patients in eastern Turkey

Abstract

Background: This study aimed to characterize the onset of psychopathological manifestations before dialysis in patients with chronic renal disease, thus contributing to the nursing care of these patients. Subjects and methods: A total of 120 patients registered at the Atatürk University Medical School who fulfilled the eligibility criteria and provided informed consent were included in this study. Results: The majority of the participants, 63.4% were female, 50.0% were 39 years of age or older, 70.0% were married, 80.0% had no current occupation, 56.7% were high school graduates, and 48.3% did not know the cause of their disease. As indicated, 35.0% of the subjects had a depression score over the threshold level, with an average score of 8.53 ± 2.45, while patients with scores over the threshold for anxiety made up 53.4%, with an average score of 11.45 ± 3.56. Conclusion: This study shows the presence of psychopathological problems before patients are started on dialysis. Therefore, nurses may alleviate pre-dialysis patients’ fears and provide the necessary support to cope with anxiety and depression, thereby raising the patients’ quality of life.

• Pre-dialysis
• depression
• anxiety
• nursing

Introduction

Chronic renal failure (CRF) is defined as a chronic and progressive failure of the kidneys to achieve fluid and electrolyte balance and regulation of metabolic and endocrine function.1,2 There were 8514 patients in pre-dialysis in Turkey according to data from 2011. The majority of these patients had received education relative to dialysis treatment, while 3311 had not prior to beginning dialysis therapy.3

Although it is well known that depression constitutes the most frequent psychiatric condition among patients with terminal kidney failure, it is not assessed for or treated in most patients with chronic somatic disease.4

Hospitalization caused by increasingly more frequent psychiatric conditions, especially depression and anxiety, has been reported to increase by a factor of 1.5–3 in patients undergoing dialysis for end-stage renal disease.5

While it is imaginable that patients in the pre-dialysis phase experience depression due to the need for monthly outpatient follow-up visits and the probability of becoming connected to a dialysis unit, very few studies on quality of life and levels of anxiety and depression have been conducted on pre-dialyses patient. Anxiety has been classified with nursing diagnoses and associated with a functional health pattern assessment which is approved by NANDA International, Inc. Whereas, depression is classified as a medical diagnosis. In many studies, however, depression and anxiety have been considered to be associated with each other and have been evaluated together.2,6,7 Considering the irreversible character of chronic kidney failure, and assuming that the perception of the concepts of “disease” and “failure” are present before the start of dialysis, this study aimed to characterize the onset of potential associated psychopathological manifestations before dialysis in patients with chronic renal disease, thus contributing to the nursing care of these patients prior to and during dialysis therapy.

Materials and methods

Data for this descriptive study was acquired from July to September 2012. A total of 120 patients from 200 patients, registered at the Atatürk University Medical School among patients admitted to the nephrology service that fulfilled the eligibility criteria and provided informed consent were included in this study. These patients, 30 of them for agreeing to participate in research, 50 of them of chronic kidney disease not in phase, be age under 18, have got hearing trouble as reasons did not participate in research. The questionnaires were filled out by the investigator in a 20-min one-on-one interview in clinic.

Eligibility criteria

1. Age over 18

2. Absence of hearing trouble

3. Consent to participate in the study

4. Stage 3 CRF and a glomerular filtration rate of less than 60 mL/min/1.73 m²

5. Dialysis not started yet

Criteria for CRF were formulated in accordance with the national renal function definitions.8

Data collection tools

A Patient Introduction Form with the patients’ personal characteristics (age, sex, marital status, employment status, educational status, and presence or absence of other chronic disease) and the Hospital Anxiety and Depression Scale (HADS) were used for data acquisition.

Hospital Anxiety and Depression Scale: The HADS, developed by Zigmond and Snaith, has been tested for validity and reliability.9 The scale has 14 items, seven of which relate to anxiety and seven to depression. Its validity and reliability for our area was tested by Aydemir et al.10 Scoring is not uniform for each of the 14 items. Items 1, 3, 5, 6, 8, 10, 11, and 13 are scored in a negative direction, from 3 to 0, while items 2, 7, 9, 12, and 14 are scored in a positive direction, from 0 to 3.

Items 1, 3, 5, 7, 9, 11, and 13 are added together to make up the anxiety subscale, and 2, 4, 6, 8, 10, 12, and 14 for the depression subscale. The cut-off score in the study performed in Turkey was indicated as 10/11 for the anxiety score and 7/8 for the depression score; subjects with higher scores are evaluated as being at risk. Cronbach’s alpha coefficient was found to be 0.85 for the anxiety subscale and 0.77 for the depression subscale in the reliability study.10 Cronbach’s alpha coefficient was found to be 0.70 for the anxiety subscale and 0.75 for the depression subscale in the present study.

Data analyses

Coding and statistical treatment of the data was performed using the SPSS 15.0 (Statistical Package for the Social Sciences, SPSS Inc., Chicago, IL) software package. Percentage calculations were performed and the Kruskal–Wallis test, the Mann–Whitney U-test, and the t-test were used. The significance limit for was set as p < 0.05.

Review board approval

Only patients who voluntarily consented to participate were included in the study. Assurance was given that confidential personal information would not be disclosed. Permission to conduct the study was obtained from the Health Sciences Institute Ethics Committee.

Results

Table 1, 63.4% of patients were female, 50.0% were 39 years of age or older, 70.0% were married, 80.0% had no current occupation, 56.7% were high school graduates, and 48.3% did not know the cause of their disease.

Table 1. Relationship of the socio-demographic characteristics of pre-dialysis patients with their anxiety and depression levels.

Socio-demographic characteristic	Number of patients	Percentage	Depression mean ± SD	p	Anxiety mean ± SD	p
Gender
Female	76	63.4	7.34 ± 3.44		12.42 ± 4.21
Male	44	56.6	5.76 ± 2.60	p < 0.05	10.54 ± 3.44	p < 0.05
Age (years)
18–28	24	20.0	4.20 ± 3.23		10.31 ± 2.54
29–39	36	30.0	6.92 ± 3.61	p < 0.05	10.56 ± 3.71	p < 0.05
39 or higher	60	50.0	8.23 ± 2.90		12.35 ± 3.67
Marital status
Married	84	70.0	7.14 ± 5.12		12.54 ± 3.25
Single	36	30.0	8.56 ± 2.16	p > 0.05	10.81 ± 3.12	p > 0.05
					U:171.000
Occupational status
Occupied	24	20.0	8.25 ± 3.15		11.48 ± 3.45
Not occupied	96	80.0	6.17 ± 2.65	p > 0.05	9.78 ± 3.24	p > 0.05
Educational status
Primary school	42	35.0	5.69 ± 2.36		10.45 ± 3.46
High school	68	56.7	3.67 ± 2.02	p > 0.05	10.58 ± 3.23	p > 0.05
Higher education	10	8.3	8.65 ± 3.12		11.34 ± 2.78
Disease other than CRF
Hypertension	26	21.1	5.61 ± 3.21	p > 0.05	10.44 ± 3.54	p > 0.05
Diabetes mellitus	38	31.6	4.86 ± 2.13		10.79 ± 3.89
None found	58	48.3	7.21 ± 3.16		11.42 ± 3.68

Levels of anxiety and depression in patients with significant correlation was found between age and gender (p < 0.05). Female patients had higher depression scores than men, as high as 7.34 ± 3.44, anxiety scores at 12.42 ± 4.21. The mean depression score in patients over the age of 39 were as high as that of other age groups, at 8.23 ± 2.90, and the mean anxiety score, 12.35 ± 3.67 was as high as that of other age groups.

Table 2, 35.0% of the patients had a depression score above the threshold level, with an average score of 8.53 ± 2.45, and 53.4% of the patients had an anxiety score above the threshold level, with an average score of 11.45 ± 3.56.

Table 2. Anxiety and depression levels of pre-dialysis patients.

	Scores higher than threshold values
Hospital anxiety and depression scale (HADS)	Number	Percentage	Mean ± SD
Depression	42	35%	8.53 ± 2.45
Anxiety	64	53.4%	11.45 ± 3.56

Discussion

Depending on individuality, social environment, age, perception of disease, and difficulties caused by the affliction, chronic disease disrupts the patient’s balance and adjustment, defeating his or her coping skills.11 As a result, problems such as anxiety and depression can occur in individuals. Anxiety has been classified with nursing diagnoses, and associated with functional health pattern assessment, which is approved by NANDA International, Inc. Depression is classified as a medical diagnosis. However, because depression is often associated with anxiety and depression, the two disorders are examined together in many studies.2,6,7,12

This study showed that the majority of the patients were women, and that sex distribution was correlated with anxiety and depression levels. In addition, patients aged 39 or over were the majority, and age was similarly correlated with anxiety and depression levels. Studies performed in pre-dialysis patients have indicated that quality of life decreases and psychological problems become more frequent with age.13,14

When examining the etiopathology of end-stage renal disease (ESRD) in our patients, it was found that the primary disease remained unknown in 48.3%, while diabetes mellitus was the leading cause in patients with a known cause of ESRD, followed by arterial hypertension. Bulantekin et al.2 reported that the causal factor of ESRD remained unknown in a majority (57.1%) of cases. Reports by Neto et al.15 and Taşcı16 similarly support our findings.

In our study, 35% of the patients had scores above the threshold for depression, and 53.4% had scores above the threshold for anxiety. Most authors are of the opinion that mental disease is widespread among CRF patients due to severe physical and psychosocial limitations, which supports our study results.17

House et al.,18 reported a 30% rate of mental disorder according to DSM-III. Adjustment disorders were the most frequent, with 14% followed by major depressive attack, agoraphobic panic disorder (2%), and diffuse anxiety disorder (1.5%).

Kimmel et al.,19 pointing to the etiological relationship between loss and depression, have indicated that as patients experience various irreversible losses, such as those of kidney function, health condition, position in the family and the workplace, time, financial means, and sexual function, the high incidence of depression reported in numerous studies should not be a surprise. The onset of depression in chronic disease patients, as with other patient populations, is a result of complex multifactorial interactions. These factors include the patient’s personality, coping mechanisms, the presence or absence of social support, and genetic or biological propensity.20

Numerous studies on pre-dialysis patients in other countries have reported depression in 7–40%.21–23 Lee et al.,24 in a study on pre-dialysis patients, reported that they had the same ratio of anxiety as patients who had started dialysis. The high incidence of depression and anxiety in pre-dialysis patients might be explained by the patient’s role in the family, workplace factors, loss of physical activity, visits to the hospital, psychological stress, sexual dysfunction, and imminent dialysis treatment.25,26

When nurses consider the psychological problems of dialysis patients and include them in their patient care plans, the patients can have better quality of life. In this study, the patients experienced psychological problems even before dialysis started.

Limitations of the study

The scope of the study was limited by including only patients who received dialysis at the Atatürk University Research Hospital. Therefore, results can only be generalized to these patients.

Conclusion

Patients are experiencing a number of problems before dialysis. In pre-dialysis patients by giving them training to the reduction of anxiety and depression cases can be helped. Relatives of patients should be educated on this issue. Therefore, when treating pre-dialysis patients, nurses should be trained to relieve their fears, depression, and anxiety and raise their quality of life by providing adequate support.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.