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Year : 2011  |  Volume : 14  |  Issue : 4  |  Page : 460-463

Prevalence of symptoms of depression among patients with chronic kidney disease

Department of Medicine, College of Medicine, University of Lagos, Idi-Araba, Laos

Date of Acceptance15-Sep-2011
Date of Web Publication12-Jan-2012

Correspondence Address:
O Amira
Department of Medicine, College of Medicine, University of Lagos, Idi-Araba
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.91756

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Objective: Depression is the most common psychiatric illness in patients with chronic kidney disease (CKD). Depression has been shown to affect mortality in end-stage renal disease patients. The objective of this study was to determine prevalence of depressive symptoms among CKD patients.
Materials and Methods: A cross-sectional study of patients with CKD (Stages 3-5) attending the renal clinic of a tertiary hospital was conducted. Demographic and clinical data were documented. A self-administered Zung depression questionnaire was administered. The Zung depression questionnaire has 20 weighted questions. Individuals with a total score of 50 are considered to be depressed, while a score of 70 and above is indicative of severe depression.
Results: One hundred and eighteen patients and fifty controls were interviewed. There were 73 (61.9%) males and 45 (38.1%) female patients. The mean age did not differ: males 43.8 ± 15.4 years, females 43.2 ± 14.7 yrs, P = 0.83. The prevalence of depression among the CKD patients was 23.7%, while for the control group was 2%; χ2 = 10.14, P < 0.001. Further analysis showed that CKD patients on dialysis were more likely to be depressed than the pre-dialysis patients with frequency of depressive symptoms of 34.5% for dialysis patients versus 13.3% in pre-dialysis patients; χ2 = 6.17, P = 0.01. No difference was observed in the mean Zung score among males, and female patients mean Zung score was 40.1 in females and 40.7 in male patients; P > 0.05.
Conclusion: Depression is highly prevalent among our patients with CKD and treatment modality was the major predictor of depression among our patients.

Keywords: Chronic kidney disease, depression, Zung depression scale

How to cite this article:
Amira O. Prevalence of symptoms of depression among patients with chronic kidney disease. Niger J Clin Pract 2011;14:460-3

How to cite this URL:
Amira O. Prevalence of symptoms of depression among patients with chronic kidney disease. Niger J Clin Pract [serial online] 2011 [cited 2022 Oct 7];14:460-3. Available from:

   Introduction Top

Psychiatric disorders are common among patients with chronic kidney disease (CKD) and these include depression, dementia, delirium, psychosis, anxiety, personality disorders, and substance abuse. [1] Depression is the most common psychiatric problem in patients with end-stage renal disease ESRD. [1],[2],[3] The prevalence of depression in CKD patients has varied widely in different studies, in different populations, using different assessment tools. [1],[2],[3] Prevalence rates as high as 30% have been reported in some studies. [2],[3],[4]

Depression is characterized by both cognitive and somatic features. The somatic characteristics of depression are very similar to the symptoms of uraemia, such as anorexia, sleep disturbances, fatigue, gastrointestinal disorders. [1],[2],[3] These similarities make the recognition of a depressive disorder difficult. Symptoms suggestive of depression include: depressed mood most of the time, loss of interest or pleasure in most activities for most of the time. [1]

Some studies have demonstrated a clear relationship between depression and mortality in patients treated with haemodialysis. [5],[6],[7],[8],[9],[10] Depression among peritoneal dialysis patients has been associated with higher incidence of peritonitis. [11] It has also been associated with increased rate of hospitalization. [12] Co-morbid depression impacts negatively on quality of life in CKD [13],[14] and improved detection and intervention (pharmacological and non-pharmacological) will improve outcomes. In this study we evaluated the frequency of symptoms of depression in Nigerians with CKD and also determined the relationship between treatment category (pre-dialysis and haemodialysis) and frequency of depressive symptoms.

   Materials and Methods Top

This was a cross-sectional study of patients with CKD attending the renal out-patients clinic of the Lagos University Teaching Hospital, Lagos State, South West Nigeria. Approval was given by the Health Research and Ethics Committee of the institution. Consecutive CKD patients who agreed to participate in the study were recruited. The control group consisted of apparently healthy age-matched individuals from among staff and students. Demographic and clinical data were documented. The glomerular filtration rate (GFR) among patients was estimated using the using the 4-variable Modification of Diet in Renal Disease Study equation. [15]

Major depressive disorder (MDD) diagnoses are made according to a set of symptoms that are present for 2 weeks, involving both somatic and cognitive symptoms, including suicidal ideation. [1],[2],[3] A diagnosis of major depressive disorder should be made if during a period of at least 2 weeks, a patient experiences depressed mood most of the time or loss of interest or pleasure in usual activities and at least five of the following symptoms: loss of weight, change in sleep pattern, e.g., insomnia or hypersomnia, psychomotor retardation, fatigue or loss of energy most days, feelings of worthlessness or guilt, decreased ability to think or concentrate, suicidal ideation, and thoughts of death. [1]

We used the Zung Self-rating Depression Scale (ZSDS), which is a widely validated 20-weighted item questionnaire including questions to identify the presence of affective, psychological and somatic symptoms associated with depression. [16] The cut-off for defining depression using the ZSDS is 50. A score of 60-69 is indicative of moderate depression while ≥ 70 is severe depression. The ZSDS questionnaire was also translated into Yoruba and local English (pidgin English) for patients who could not speak English. The patients with end-stage renal disease (ESRD) on dialysis were compared with those with pre-dialysis CKD (stages 3 to 5 but not on dialysis) and CKD patients with controls.

Data analysis

Data were analysed using Epi Info ® 2002. Continuous variables are presented as mean ± standard deviation (SD) and compared using students T test. Categorical variables are presented as proportions and compared using Yates corrected X 2 test. Multivariate analysis was used to determine risk factors associated with depression. P value <0.05 is regarded as being statistically significant.

   Results Top

A total of 118 CKD patients and 50 control subjects were interviewed. There were 73 (61.9%) male and 45 female (38.1%) patients; 26 (52%) male and 24 (48%) female control subjects. The mean age for the CKD patients and controls were similar (43.6 ± 15.1 for CKD patients and 40.3 ± 12.1 years, P = 0.17), age range was 16-87 years. [Table 1] shows the clinical data of the patients and controls. The duration of CKD ranged from 3 months to 36 months. The etiology of CKD was hypertension in 50.8% of the patients, glomerulonephritis in 17.8%, diabetes in 11%, unknown in 5.9% and other causes like obstructive nephropathy, human immunodeficiency virus associated nephropathy, sickle cell nephropathy and lupus nephritis accounted for 14.5%.

Thirty-eight patients (30.6%) were in CKD stage III, 23 (18.5%) CKD stage IV and 63 (50.8%) CKD stage V. The mean GFR for patients in stage III was 46.8 ± 8.58 ml/minute/1.73m 2 , stage IV 19.8 ± 4.18 ml/minute/1.73m 2 and 8.13 ± 3.11 ml/minute/1.73m 2 .
Table 1: Comparison of demographic characteristics and ZSDS parameters in CKD patients and controls

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Prevalence of depression

CKD patients were much more likely to be depressed compared with controls; the prevalence of symptoms of depression among the CKD patients was 23.7%, while for the control group was 2% X 2 = 10.14, P < 0.001. Further analysis showed that 10.5% of patients in CKD stage 3 had depression , 13% in CKD stage 4 and 33.3% in CKD stage 5 X 2 8.52, df 2 P= 0.014; 3.4% of CKD patients had moderate depression no case of severe depression was recorded in the study population. No difference was observed in the mean Zung score among the male and female patients mean Zung score was 40.1 in females and 40.7 in male patients, P > 0.05.

When we compared the pre-dialysis CKD patients on conservative treatment with CKD patients on dialysis, the dialysis patients were more likely to be depressed with frequency of depressive symptoms of 34.5% in dialysis patients versus 13.3% in pre-dialysis patients X (2) = 6.17, P = 0.01 (OR 0.29, 95% CI 0.10-0.80). [Table 2] shows comparison of clinico-demographic data in pre-dialysis and HD patients. Multivariate analysis showed that treatment modality was the only risk factor associated with depression. Duration of CKD, gender and age were not associated with CKD [Table 3].
Table 2: Comparison of demographic characteristics and ZSDS parameters in pre-dialysis and ESRD patients

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Table 3: Logistic regression analysis showing the risk factors associated with depression

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   Discussion Top

Depression is frequently seen in CKD patients both as a reaction to the diagnosis and treatment as well as the losses experienced in terms of health, life style, finances, and status. [1] In this study the frequency of depressive symptoms among patients with CKD was high. This is consistent with reports in the literature. [5],[17],[18],[19] Aghanwa et al., using the Diagnostic and Statistical Manual of Mental Disorders revised third edition (DSM III), reported a prevalence of major depressive episode of 25% among patients undergoing haemodialysis in Ile-Ife compared with 0% among their controls. [17] Hedayati reported prevalence of major depressive episode of 21% among a cohort of male veterans with CKD using the DSM IV instrument. [18] Watnick et al., also found a high prevalence of depressive disorder in a small population of ESRD patients treated with both hemodialysis and peritoneal dialysis using the Beck Depression Inventory (BDI), the Patient Health Questionnaire 9 (PHQ-9), and a structured, clinical psychiatric interview. [19]

We noted a rising prevalence of depressive symptoms with increasing severity of CKD from 10.5% in CKD stage III to 33.3% in CKD stage V. This is similar to findings from the study by Hedayati et al., that reported an association of increased prevalence of depression and severe CKD using the BD) as a screening instrument and the National Institute of Mental Health Diagnostic Interview Schedule (DIS) for diagnosis of major depression. In their study patients with severe CKD, defined as GFR of <30 ml/minute were more likely to have depressive symptoms (54.5%) and major depression (21.6%) compared with those without severe CKD (32.8% and 13%, respectively). [5]

In our study, patients with ESRD on dialysis were more likely to be depressed compared with the predialysis CKD patients. This differs from some reports in the literature which showed no difference in the prevalence of depression among pre-dialysis and ESRD patients. [18],[20],[21] Abdel-kaber et al., compared prevalence of depressive disorder among ESRD patients on haemodialysis and patients with CKD stages 4 and 5 not on dialysis using Patient Health Questionnaire - 9 (PHQ-9), they found no difference in prevalence of major depression among both groups. [20] The different instruments used for the assessment of depression in our study and other studies may account for these differences. Other possible reasons for the observed higher prevalence of depressive symptoms among our dialysis patients are: the huge financial burden of haemodialysis therapy in Nigeria and the fact that cost of treatment is borne entirely by patients and their relatives thus putting a strain on the family finances. In addition there are uncertainties about outcomes of treatment coupled with the fear of death and the severity of disease with its attendant numerous complications all of these could contribute to higher frequency of depression among these patients. There may also be marital conflicts, strained inter-personal relationships with family and medical personnel, and risk of job losses as a result of frequent absenteeism from work.

The effect of depression on survival is controversial, while a few studies involving small numbers have not shown any association between baseline depression scores and outcomes, [22],[23] majority of studies showed that presence of depression impacts negatively on survival. [3],[5],[10] Depression has also been shown to impact negatively on the quality of life (QOL). [14] The mechanism whereby depression impacts on QOL and survival include non-compliance with medications and dialysis prescription, poor nutrition and possible increased inflammation from dysregulation of cytokine metabolism. [2],[3]

Despite the high prevalence of depression in ESRD, few patients diagnosed with depression are on treatment. [3] Reasons for this are lack of carefully planned randomised controlled trials evaluating the efficacy and safety of antidepressants in this population of patients. It is important to treat depression among CKD patients given its negative impact on survival and QOL. Cognitive behavioural therapy (CBT) has been recognised as an effective psychological treatment for mild to moderate depression.­ [14] A combination of antidepressants medications such as selective serotonin uptake inhibitors and psychotherapy may be the optimal form of therapy. [2],[3]

Our limitation is the use of self -reported measurement of depressive symptoms; we did not use the DSM IV instrument which is the gold standard for diagnosis of major depressive disorder (MDD). Further research using this instrument as well as carrying out a comparative study of prevalence of depression among patients with different chronic illnesses is desirable so as to assess the impact of the chronic medical illness on depression as well as on outcomes.

   Conclusions Top

In conclusion, depressive symptoms are common among patients with CKD and treatment modality was the major predictor of depression among our patients. Patients with CKD should be screened routinely for depression.

   References Top

1.Kimmel PL, Levy NB. Psychology and rehabilitation. In: Daugirdas JT, Blake PG, Ing TS, editors. Handbook of Dialysis, 3 rd ed. Philadelphia: Lippincott Williams and Wilkins 2001; 413-419.   Back to cited text no. 1
2.Hedayati SS, Finkelstein FO. Epidemiology, diagnosis, and management of depression in patients with CKD. Am J Kidney Dis 2009;54:741-52.   Back to cited text no. 2
3.Kimmel PL, Peterson RA. Depression in patients with end-stage renal disease treated with dialysis: Has the time to treat arrived? Clin J Am Soc Nephrol 2006;1:349-52.   Back to cited text no. 3
4.Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 2003;41:105-10.  Back to cited text no. 4
5.Hedayati SS, Jiang W, O'Connor CM, Kuchibhatla M, Krishnan KR, Cuffe MS, et al. The association between depression and chronic kidney disease and mortality among patients hospitalized with congestive heart failure. Am J Kidney Dis 2004;44:207-15.  Back to cited text no. 5
6.Kimmel PL, Cohen SD, Peterson RA. Depression in patients with chronic renal disease: Where are we going? J Ren Nutr 2008;18:99-103.  Back to cited text no. 6
7.Hedayati SS, Bosworth HB, Briley LP, Sloane RJ, Pieper CF, Kimmel PL, et al. Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression. Kidney Int 2008;74:930-6.   Back to cited text no. 7
8.Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe C, et al. Dialysis Outcomes and Practice Patterns Study: Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 2002;62:199-207.   Back to cited text no. 8
9.Riezebos RK, Nauta KJ, Honig A, Dekker FW, Siegert CE. The association of depressive symptoms with survival in a Dutch cohort of patients with end-stage renal disease. Nephrol Dial Transplant. 2010;25:231-6.  Back to cited text no. 9
10.Boulware LE, Liu Y, Fink NE, Coresh J, Ford DE, Klag MJ, et al. Temporal relation among depression symptoms, cardiovascular disease events, and mortality in end-stage renal disease: Contribution of reverse causality. Clin J Am Soc Nephrol 2006;1:496-504.  Back to cited text no. 10
11.Troidle L, Watnick S, Wuerth DB, Gorban-Brennan N, Kliger AS, Finkelstein FO. Depression and its association with peritonitis in long-term peritoneal dialysis patients. Am J Kidney Dis 2003;42:350-354.   Back to cited text no. 11
12.Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Alan AS, Bosworth HB. Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis. Am J Kidney Dis 2005;46:642-9.   Back to cited text no. 12
13.Walters BA, Hays RD, Spritzer KL, Fridman M, Carter WB. Health-related quality of life, depressive symptoms, anemia, and malnutrition at hemodialysis initiation. Am J Kidney Dis 2002;40:1185-94.   Back to cited text no. 13
14.Cruz LN, de Almeida Fleck MP, Polanczyk CA. Depression as a determinant of quality of life in patients with chronic disease: Data from Brazil. Soc Psychiatry Psychiatr Epidemiol 2010;45:953-61.  Back to cited text no. 14
15.Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461-70.  Back to cited text no. 15
16.Zung WW. A self-rating depression scale in an outpatient clinic. Arch Gen Psychiatry 1965;13:508-15.  Back to cited text no. 16
17.Aghanwa HS, Morakinyo O. Psychiatric complications of haemodialysis at a kidney centre in Nigeria. J Psychosom Res 1997;42:445-51.  Back to cited text no. 17
18.Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Prevalence of major depressive episode in CKD. Am J Kidney Dis 2009;54:424-32.   Back to cited text no. 18
19.Watnick S, Wang PL, Demadura T, Ganzini L. Validation of 2 depression screening tools in dialysis patients. Am J Kidney Dis 2005;46:919-24.  Back to cited text no. 19
20.Abdel-Kader K, Unruh ML, Weisbord SD. Symptom burden, depression, and quality of life in chronic and end-stage kidney disease. Clin J Am Soc Nephrol 2009;4:1057-64.  Back to cited text no. 20
21.Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Validation of depression screening scales in patients with CKD. Am J Kidney Dis 2009;54:433-9.   Back to cited text no. 21
22.Devins GM, Mann J, Mandin H. Psychosocial predictors of survival in end-stage renal disease. J Nerv Ment Dis 1990;178:127-33.  Back to cited text no. 22
23.Christensen AJ, Wiebe JS, Smith TW, Turner CW. Predictors of survival among hemodialysis patients: Effects of perceived family support. Health Psychol 1994;13:521-5.  Back to cited text no. 23


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