Depressive symptoms but not chronic pain have an impact on the survival of patients undergoing maintenance hemodialysis

INTRODUCTION

More than 1/3 of patients with end-stage renal disease who are in a chronic dialysis program suffer from chronic pain and depression/anxiety. The aim of the study was to determine the impacts of symptoms of depression/anxiety, chronic pain and quality of life (QoL) on 6-year patient survival.

MATERIAL AND METHODS

Observational study of end-stage renal disease patients on maintenance hemodialysis (n = 205) who met the inclusion criteria. Patients from three dialysis centers in Lower Silesia were asked to complete a battery of validated questionnaires: the Hospital Anxiety and Depression Scale (HADS), the 36-item Short Form Health Survey Questionnaire, the Verbal Rating Scale (VRS) and the Visual Analog Scale (VAS). Clinical and biochemical data (dialysis adequacy) were recorded.

RESULTS

One hundred thirty from 205 enrolled hemodialysis patients (63.4%) suffered from chronic pain. Patients with pain were on maintenance dialysis for longer times and had higher levels of parathyroid hormone, more depressive symptoms and a lower QoL than those without pain. In the 6-year period, 96 (46.8%) patients died. The most common cause of death was cardiovascular disease in 44 (45.8%) patients. Highly depressed patients (HADS depression score > 8) exhibited higher mortality (< 8 vs. > 8 points; p = 0.016) independent of age, diabetes, cardiovascular disease, C-reactive protein or albumin level.

CONCLUSIONS

Chronic pain, although common among hemodialysis patients, did not lower survival. Depressive symptoms are an important predictor for all-cause mortality in hemodialysis patients, with the relationship independent of nutritional or inflammatory status.

The role of tryptophan degradation in the association between inflammatory markers and depressive symptoms in chronic dialysis patients

Background

Among chronic dialysis patients, associations have been found between inflammatory markers and depressive symptoms. In this population, no studies have examined the mechanism linking the association between inflammatory markers and depressive symptoms. We examined whether the association between inflammatory markers and depressive symptoms is mediated by tryptophan (TRP) degradation along the kynurenine (KYN) pathway.

Methods

The data are part of an observational, prospective cohort study in five urban dialysis centres in The Netherlands. Depressive symptoms were determined with the Beck Depression Inventory. Peripheral blood was collected before dialysis to measure inflammatory markers [high sensitivity C-reactive protein (HsCRP), interleukin (IL)-1β, IL-6, IL-10 and tumour necrosis factor-α (TNF-α)], TRP, KYN and 3-hydroxykynurenine. The KYN/TRP ratio was used as a measure of TRP degradation. The association between inflammatory markers and depressive symptoms was determined using linear regression analysis and adjusted for the KYN/TRP ratio.

Results

In total, 490 chronic dialysis patients were included. HsCRP [ β = 3.8; confidence interval (CI): 1.0-6.6], IL-6 ( β = 9.1; CI: 4.0-14.1) and TNF-α ( β = 1.3; CI: 0.9-1.7) were associated with the KYN/TRP ratio. We found significant associations between HsCRP ( β = 0.8; CI: 0.3-1.3) and IL-6 ( β = 1.2; CI: 0.3-2.2) levels and depressive symptoms. However, this association was not attenuated after adjustment for the KYN/TRP ratio. Also, no significant associations were found between the KYN/TRP ratio and depressive symptoms.

Conclusion

The association between inflammatory markers and depressive symptoms in chronic dialysis patients was not mediated by TRP degradation along the KYN pathway.

Differences in the association of inflammation and tryptophan with depressive symptoms between white and non-white chronic dialysis patients

OBJECTIVE

Possibly, different biochemical parameters are involved in the development of depressive symptoms in white and non-white dialysis patients. We examined whether the association between inflammation and depressive symptoms and between tryptophan and depressive symptoms differs between white and non-white dialysis patients and whether the association between inflammation and depressive symptoms is mediated by tryptophan degradation along the kynurenine pathway in both groups.

METHOD

Depressive symptoms were measured with the BDI-II. HsCRP, IL-1β, IL-6, IL-10, and TNFα and tryptophan and its degradation products kynurenine and 3-hydroxykynurenine were measured in 270 white and 220 non-white patients.

RESULTS

The presence of depressive symptoms was significantly higher in non-white patients (51%) than in white patients (37%) (P<0.01). Among white patients, HsCRP was significantly associated with depressive symptoms (β=0.6 (95% CI: 0.1-1.2)). Among non-white patients, significant associations with depressive symptoms were found for both HsCRP (β=1.0 (95% CI: 0.1-2.0)) and IL-6 (β=2.6 (95% CI: 0.8-4.4)). Tryptophan levels were only significantly associated with depressive symptoms in non-white patients (β=-0.3 (95% CI: -0.4--0.1)). Tryptophan degradation along the kynurenine pathway did not mediate the association between inflammatory markers and depressive symptoms in either group.

CONCLUSION

Our results indicate that for white and non-white dialysis patients different biochemical parameters are associated with depressive symptoms.

A comparison of anxiety and depression between pre-dialysis chronic kidney disease patients and hemodialysis patients using hospital anxiety and depression scale

Objective:

Tocompare frequency of anxiety and depression between pre-dialysis chronic kidney disease (CKD) and hemodialysis patients (ESRD) in Pakistan.

Methods:

This study was conducted in an out-patient department and hemodialysis unit of Sharif Medical City Hospital. Inclusion criteria included age above 18 years and a diagnosis of CKD including both pre-dialysis CKD and ESRD patients. Patients were screened for anxiety and depression using hospital anxiety and depression scale (HADS).

Results:

A total of 156 patients were included in the study. Out of these patients, 81 (51.9%) had ESRD and 75 (48.1%) had pre-dialysis CKD. Mean age of all patient was 47.3±18.3 years, 96 (61.5%) were males and 60 (38.5%) were females. Median duration of renal disease was 16 months (IQR 8-36 months). Anxiety and depression were present in 111 (71.2%) and 113 (72.4%) of all patients respectively. Moderate to severe anxiety and depression were present in 54 (34.6%) and 60 (38.5%) patients respectively. In multiple logistic regression model, after adjusting for other variables, ESRD vs. pre-dialysis CKD was significantly associated with moderate to severe depression (AOR 2.26 (1.1-5.1).

Conclusion:

Both anxiety and depression are common in pre-dialysis CKD and ESRD patients. Patients with ESRD have higher frequency of depression compared to pre-dialysis CKD patients.

Brief cognitive behavioural intervention for depression and anxiety symptoms improves quality of life in chronic haemodialysis patients

OBJECTIVES

Psychological treatment of depression in end-stage renal disease (ESRD) has focused on severely depressed patients. We designed and tested a brief (5 weeks) cognitive behavioural intervention (CBI) to reduce mild and moderate depression and anxiety symptoms in patients with ESRD.

DESIGN

For the purpose of this study, a single-blind, randomized controlled design was used to compare patients with ESRD under haemodialysis treatment with and without the CBI.

METHODS

Depression and anxiety symptoms were screened in 152 subjects (18-60 years old, 84 male). Sixty participants (age 41.8 ± 14.7, 29 males) with mild or moderate scores of depression (Beck Depression Inventory) and anxiety (Beck Anxiety Inventory) were randomly assigned to CBI or the control group. CBI techniques consisted of positive self-reinforcement, deep breathing, muscle relaxation, and cognitive restructuring. Depression, anxiety, quality of life (QoL), and cognitive distortion scores were evaluated at baseline, after 5 weeks (end of treatment) and after 4-week follow-up. All scores were compared by ANOVA for repeated measures with post-hoc tests adjusted by Bonferroni's method (p < .05 was considered significant).

RESULTS

At follow-up, depression, anxiety, and cognitive distortions had decreased, and QoL had increased in the intervention group, and there were no changes in the control group. Clinical utility was 33% for depression and 43% for anxiety.

CONCLUSIONS

A brief CBI of 5 weeks is effective for decreasing mild or moderate depression and anxiety symptoms and improving QoL in ESRD haemodialysis patients.

PRACTITIONER POINTS

A brief, systematic and structured cognitive behavioural intervention (CBI) decreases anxiety and depression symptoms and improves quality of life in patients with end-stage renal disease (ESRD) who are being treated with haemodialysis. These benefits are not achieved when anxiety and depression symptoms are identified but not treated psychologically. This CBI consisted of cognitive restructuring of the distorted thoughts (perfectionism, catastrophic thinking, negative self-labelling, and dichotomous thinking) that are correlated with depression and anxiety symptoms and that can be assessed by a validated questionnaire designed for patients with ESRD. The handbooks that were developed for this study are structured and systematic. They could be valuable in supporting the efforts and participation of non-specialized health professionals in CBI such as nurses, physicians, social workers, and psychologists, raising the possibility of further application in a variety of clinical populations. Both the therapy and the client workbooks are available in Spanish upon request.

EFFECT OF PERCEIVED SOCIAL SUPPORT ON THE LEVELS OF ANXIETY AND DEPRESSION OF HEMODIALYSIS PATIENTS

Purpose:

of this study was to explore the effect of social support on the levels of anxiety and depression of hemodialysis patients.

Material and Methods:

258 patients undergoing hemodialysis were enrolled. A questionnaire developed for the purpose of the study was used to collect data through the interview process. Apart from socio-demographic, clinical and other characteristics, the questionnaire also included the Multidimensional Scale of Perceived Social Support (MSPSS) to assess social support from significant others, family and friends, and the questionnaire Hospital Anxiety and Depression Scale (HADs) to assess the levels of anxiety and depression of patients.

Results:

53,9% of the participants were male while 34,1% of the participants were >70 years old. 32,9% and 30,2% of the participants felt high levels of anxiety and depression, respectively. Analysis of data showed a statistically significant association between anxiety/depression and social support from significant others, family and friends (p=<0,001 for all associations). In particular, patients with high levels of anxiety and depression felt less support from their significant others, family and friends. The multinomial logistic regression, showed a statistically significant effect of social support from friends in anxiety levels (p=0,004). An one point increase of the support from friends seems to reduce by 57% the probability of having high levels of anxiety. In addition, statistically significant effect of social support from significant others, family and friends was observed on the levels of depression (p=<0,001, p=0,001 & p=0,003, respectively). Specifically, an one point increase of the support from significant others, family and friends it was found to reduce by 77%, 71% and 56% respectively the probability of experiencing high levels of depression.

Conclusions:

Phyco-social evaluation is essential when providing holistic care to hemodialysis patients.

Discriminant validity of the Hospital Anxiety and Depression Scale, Beck Depression Inventory (II) and Beck Anxiety Inventory to confirmed clinical diagnosis of depression and anxiety in patients with chronic obstructive pulmonary disease

The objective of this study was to investigate the discriminant validity of commonly used depression and anxiety screening tools in order to determine the most suitable tool for patients with chronic obstructive pulmonary disease (COPD). COPD patients (n = 56) completed the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI). These scores were compared to confirmed clinical diagnoses of depression and anxiety using the Mini Neuropsychiatric Interview. HADS depression subscale (HADS-D) sensitivity/specificity was 78/81%; BDI-II 89/77%; HADS anxiety subscale (HADS-A) 71/81%; and BAI 89/62%. HADS-D sensitivity/specificity was improved (100/83%) with the removal of Q4 'I feel as if I am slowed down' and adjusted cut-off (≥5). Removal of BDI-II Q21 'Loss of interest in sex' with adjusted cut-off ≥12 resulted in similar improvement (100/79%). No problematic items were identified for HADS-A or BAI. Previously reported low sensitivity/specificity of the HADS for COPD patients was not replicated. Furthermore, simple modifications of the HADS-D markedly improved sensitivity/specificity for depression.BDI-II, HADS-A and BAI produced acceptable sensitivity/specificity unmodified. Pending further research for COPD patients we recommend continued use of the HADS-A with standard cut-off (≥8) and removal of Q4 of the HADS-D with lower cut-off ≥5.

ASSOCIATION BETWEEN ANXIETY AND DEPRESSION AND QUALITY OF LIFE OF CHRONIC RENAL PATIENTS ON HEMODIALYSIS

ABSTRACT To analyze the relationship between anxiety and depression and quality of life in chronic renal failure patients on hemodialysis. This is a correlational study with a cross-sectional, quantitative approach, conducted with 100 kidney patients under treatment at a Renal Replacement Therapy Unit in the state of São Paulo. Data were collected using a sociodemographic questionnaire, Hospital Anxiety and Depression Scale and Kidney Disease and Quality of Life Short-Form. A negative correlation was found between anxiety and depression and the quality of life domains. In addition, the average scores on the Kidney Disease and Quality of Life Short-Form were significantly lower in patients with anxiety and depressive symptoms. In conclusion, there is a negative correlation between depression and anxiety and the health-related quality of life of chronic renal failure patients on hemodialysis.

The association of acculturation and depressive and anxiety symptoms in immigrant chronic dialysis patients

OBJECTIVE

Among immigrant chronic dialysis patients, depressive and anxiety symptoms are common. We aimed to examine the association of acculturation, i.e. the adaptation of immigrants to a new cultural context, and depressive and anxiety symptoms in immigrant chronic dialysis patients.

METHODS

The DIVERS study is a prospective cohort study in five urban dialysis centers in the Netherlands. The association of five aspects of acculturation ("Skills", "Social integration", "Traditions", "Values and norms" and "Loss") and the presence of depressive and anxiety symptoms was determined using linear regression analyses, both univariate and multivariate.

RESULTS

A total of 249 immigrant chronic dialysis patients were included in the study. The overall prevalence of depressive and anxiety symptoms was 51% and 47%, respectively. "Skills" and "Loss" were significantly associated with the presence of depressive and anxiety symptoms, respectively ("Skills" β=0.34, CI: 0.11-0.58, and "Loss" β=0.19, CI: 0.01-0.37; "Skills" β=0.49, CI: 0.25-0.73, and "Loss" β=0.33, CI: 0.13-0.53). The associations were comparable after adjustment. No significant associations were found between the other subscales and depressive and anxiety symptoms.

CONCLUSION

This study demonstrates that less skills for living in the Dutch society and more feelings of loss are associated with the presence of both depressive and anxiety symptoms in immigrant chronic dialysis patients.

Rationale and design of A Trial of Sertraline vs. Cognitive Behavioral Therapy for End-stage Renal Disease Patients with Depression (ASCEND)

Major Depressive Disorder (MDD) is highly prevalent in patients with End Stage Renal Disease (ESRD) treated with maintenance hemodialysis (HD). Despite the high prevalence and robust data demonstrating an independent association between depression and poor clinical and patient-reported outcomes, MDD is under-treated when identified in such patients. This may in part be due to the paucity of evidence confirming the safety and efficacy of treatments for depression in this population. It is also unclear whether HD patients are interested in receiving treatment for depression. ASCEND (Clinical Trials Identifier Number NCT02358343), A Trial of Sertraline vs. Cognitive Behavioral Therapy (CBT) for End-stage Renal Disease Patients with Depression, was designed as a multi-center, 12-week, open-label, randomized, controlled trial of prevalent HD patients with comorbid MDD or dysthymia. It will compare (1) a single Engagement Interview vs. a control visit for the probability of initiating treatment for comorbid depression in up to 400 patients; and (2) individual chair-side CBT vs. flexible-dose treatment with a selective serotonin reuptake inhibitor, sertraline, for improvement of depressive symptoms in 180 of the up to 400 patients. The evolution of depressive symptoms will also be examined in a prospective longitudinal cohort of 90 HD patients who choose not to be treated for depression. We discuss the rationale and design of ASCEND, the first large-scale randomized controlled trial evaluating efficacy of non-pharmacologic vs. pharmacologic treatment of depression in HD patients for patient-centered outcomes.

Accuracy of the Hospital Anxiety and Depression Scale for identifying depression in chronic obstructive pulmonary disease patients

Psychological morbidity is common in chronic respiratory diseases. The diagnostic accuracy of the Hospital Anxiety and Depression Scale (HADS) and risk factors for comorbid depression in chronic obstructive pulmonary disease (COPD) are addressed. Consecutive COPD patients (GOLD stage I–IV, 40–75 years old) were enrolled in a multicentre, cross-sectional cohort study. Diagnosis of depression was ascertained through clinical records. Lung function, HADS score, 6-minute walking test (6-MWT), MRC dyspnoea score, and COPD Assessment Test (CAT) were evaluated. Two hundred fifty-nine COPD patients (mean age 62.5 years; 32% female; mean FEV1 48% predicted) were included. Patients diagnosed with depression (29/259; 11.2%) had significantly higher HADS-D and HADS-Total scores than nondepressed patients (median (quartiles) HADS-D 6 [4; 9] versus 4 [2; 7], median HADS-Total 14 [10; 20] versus 8 [5; 14]). Receiver-operating characteristic plots showed moderate accuracy for HADS-D, AUC 0.662 (95%CI 0.601–0.719), and HADS-Total, AUC 0.681 (95%CI 0.620–0.737), with optimal cut-off scores of >5 and >9, respectively. Sensitivity and specificity were 62.1% and 62.6% for HADS-D compared to 75.9% and 55.2% for HADS-Total. Age, comorbidities, sex, and lower airflow limitation predicted depression. The HADS exhibits low diagnostic accuracy for depression in COPD patients. Younger men with comorbidities are at increased risk for depression.

Prescription of psychotropic drugs in patients with chronic renal failure on hemodialysis

OBJECTIVE

Patients on hemodialysis commonly have comorbid depression and require treatment with psychotropic drugs. This study aimed to investigate the prevalence of the use of psychotropic drugs among patients on hemodialysis and to elucidate the factors associated with use of each class of psychotropic medication.

METHODS

This cross-sectional study enrolled 195 hemodialysis patients with a mean age of 58.5 years. Patients were assessed using the Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale, Chalder Fatigue Scale and Short-form Health-related Quality of Life. We analyzed the frequency of psychiatric outpatient department visits within six months prior to interview and psychotropic drugs use within one month prior to interview, including antidepressants, antipsychotics, mood stabilizers, benzodiazepines (BZDs) and hypnotics.

RESULTS

Of the 195 patients, 47 (24.1%) fulfilled the DSM-IV criteria for major depressive disorder (MDD). Only 6.4% of patients diagnosed with MDD visited the psychiatry outpatient department within six months prior to interview. Of the total patients, the proportions with use of antidepressants, antipsychotics, mood stabilizers, BZDs and hypnotics were 5.6%, 1.0%, 3.1%, 42.6% and 20.0%, respectively. Having MDD was an independent factor associated with taking antidepressants (adjusted OR = 3.98, p = 0.036) and taking hypnotics (adjusted OR = 2.75, p = 0.011).

CONCLUSIONS

Depression is generally undetected or not well-managed among hemodialysis patients in the clinical setting. Only a small proportion of depressed patients received antidepressant treatment. BZDs and/or hypnotics might be exorbitantly prescribed. Clinicians should pay more attention to patients' emotional distress and provide appropriate treatment.

Validation of two depression screening instruments in a sleep disorders clinic

STUDY OBJECTIVES

Depression is a commonly diagnosed comorbidity in sleep disorder clinics. However, screening instruments for major depressive episode (MDE) have not been validated in this setting. We aimed to validate the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory - Fast Screen (BDI-FS) with the Mini International Neuropsychiatric Interview (MINI) in patients with suspected obstructive sleep apnea (OSA).

DESIGN

Cross-sectional study.

SETTING

Academic center.

PARTICIPANTS

One hundred one new patients with a clinical suspicion of OSA, as assessed by a sleep physician.

MEASUREMENTS

MDE, generalized anxiety disorder (GAD), and panic disorder (PD) were assessed by (1) a diagnostic interview utilizing the MINI and (2) by two self-report questionnaires: HADS and BDI-FS. A receiver operating characteristic (ROC) analysis was undertaken to assess which HADS and BDI-FS threshold yielded the highest correlation for a diagnosis of MDE and/or GAD/PD as assessed with an interview conducted using the MINI.

RESULTS

A HADS-Depression score ≥ 8 gave optimal sensitivity (83.1%) and specificity (83.3%) with an area under the ROC curve (AUC) 0.851 for predicting the diagnosis of MDE. A HADS-Anxiety score ≥ 11 gave an optimal sensitivity (93.1%) and specificity (84.7%) with an AUC 0.911 for predicting the diagnosis of GAD/PD. A BDI-FS threshold ≥ 6 gave optimal sensitivity (86.7%) and specificity (82.9%) with an AUC 0.897 for MDE.

CONCLUSION

The HADS and BDI-FS are accurate screening instruments with high concurrent validity for identifying the probability of a patient having MDE and-in the case of HADS-GAD and PD disorder in a sleep disorders clinic.

Psychological outcomes in critically ill patients receiving renal replacement therapy: a matched-pairs analysis

We conducted a single-centre observational study over five years to assess the impact of renal replacement therapy on the psychological health of survivors of critical illness. We hypothesised that the added burden of renal replacement would increase the prevalence and severity of anxiety, depression and stress reactions in these patients, compared with matched pairs (matched for age, sex and APACHE II score) who did not receive renal replacement. Participants completed postal questionnaires. A total of 342 patients with acute kidney injury received renal replacement. One hundred and seventy-nine (52.3%) survived to hospital discharge, and 161 (47.1%) were alive at 90 days. Seventy-seven (47.8% of survivors) completed questionnaires. We found 77 matches for the Hospital Anxiety and Depression Scale analysis and 72 for the Impact of Events Scale analysis. Clinically relevant symptoms of psychiatric morbidity were common, with anxiety and depression affecting 49 (63.6%) patients and stress reactions affecting 24 (33.3%) patients. Mean scores (95% CI) were 11.4 (9.6-13.2) and 20.1 (15.7-24.6), respectively. On multivariate analysis, we found no significant differences between renal replacement patients and controls, in either the frequency or severity of these symptoms.

Prevalence and patterns of depression and anxiety in hemodialysis patients: a 12-month prospective study on incident and prevalent populations

OBJECTIVE

Depression is common in dialysis patients and has been shown to be associated with higher morbidity and mortality, but little is known about the course of symptoms over time. The current study set up to explore group and individual patterns of change in symptoms of anxiety and depression within the hemodialysis population and to identify socio-demographic, clinical, and psychological factors that may be associated with different trajectories of emotional distress.

METHODS

A total of 159 hemodialysis patients (n = 42 incident and n = 117 prevalent) completed the Hospital Anxiety and Depression Scale and social support and symptoms subscales from the Kidney Disease Quality of Life (Short Form) on two occasions 12 months apart. Clinical cut-offs were used to identify individual patterns of change in anxiety and depression symptoms across time, and analysis of variance (ANOVA) procedures were employed to establish potential correlates of these trajectories.

RESULTS

Mean levels of anxiety and depression symptoms remained unchanged over 1 year with 44.7-54.1% of patients above cut-off at both baseline and follow-up. Individual-level analyses showed that the course of symptoms does not follow a single trajectory. While most patients had either persistent symptoms of distress (39.6% and 31.8% for depression and anxiety, respectively) or no/low symptoms of distress (32.1% and 36.9% for depression and anxiety, respectively), a total of 12.7-18.5% patients either had new-onset symptoms of depression/anxiety or symptoms diminishing over time. Patients with persisting or new-onset symptoms of depression or anxiety reported reduced perceived social support and quality of social interaction compared to the subgroups with low depressive/anxious symptoms.

CONCLUSION

Different patterns of symptoms reflect heterogeneity in patients' emotional reactions and adjustment. More research is needed to identify patients at risk for emotional distress and to explore social support in the context of dialysis. Statement of contribution What is already known on this subject? Depression and poor mental health are common in hemodialysis patients and are associated with higher risk of hospitalization and death. Course of depression in incident hemodialysis patients is variable, but evidence on prevalent patients and course of symptoms of anxiety is largely lacking. What does this study add? Anxiety and depression remain undifferentiated over time with most patients reporting persistently high or no symptoms of anxiety or depression. New-onset symptoms of anxiety or depression or recovery are less frequent. The lack of consistent associations between socio-demographic or clinical parameters with patterns of emotional distress makes early identification difficult. Regular screening as part of clinical care is hence essential. Persistently high or new-onset symptoms of anxiety and/or depression are associated with reduced perceived social support. More research is needed to explore the role of social resources in the context of dialysis.

Depression in hemodialysis patients: the role of dialysis shift

OBJECTIVE

Depression is the most important neuropsychiatric complication in chronic kidney disease because it reduces quality of life and increases mortality. Evidence demonstrating the association between dialysis shift and depression is lacking; thus, obtaining such evidence was the main objective of this study.

METHOD

This cross-sectional study included patients attending a hemodialysis program. Depression was diagnosed using Beck's Depression Inventory. Excessive daytime sleepiness was evaluated using the Epworth Sleepiness Scale.

RESULTS

A total of 96 patients were enrolled (55 males, age 48±14 years). Depression and excessive daytime sleepiness were observed in 42.7% and 49% of the patients, respectively. When comparing variables among the three dialysis shifts, there were no differences in age, dialysis vintage, employment status, excessive daytime sleepiness, hemoglobin, phosphorus levels, or albumin levels. Patients in the morning shift were more likely to live in rural areas (p<0.0001), although patients in rural areas did not have a higher prevalence of depression (p = 0.30). Patients with depression were more likely to be dialyzed during the morning shift (p = 0.008). Independent risk factors for depression were age (p<0.03), lower levels of hemoglobin (p<0.01) and phosphorus (p<0.01), and dialysis during the morning shift (p = 0.0009). The hospitalization risk of depressive patients was 4.5 times higher than that of nondepressive patients (p<0.008).

CONCLUSION

These data suggest that depression is associated with dialysis shift, higher levels of phosphorus, and lower levels of hemoglobin. The results highlight the need for randomized trials to determine whether this association occurs by chance or whether circadian rhythm disorders may play a role.

Understanding the Outcomes Measures used in Huntington Disease Pharmacological Trials: A Systematic Review

BACKGROUND

The identification of the gene mutation causing Huntington disease has raised hopes for new treatments to ease symptoms and slow functional decline. As such, there has been a push towards designing efficient pharmacological trials (i.e., drug trials), especially with regard to selecting outcomes measures that are both brief and sensitive to changes across the course of the disease, from subtle prodromal changes, to more severe end-stage changes.

OBJECTIVES

Recently, to aid in efficient development of new HD research studies, the National Institute of Neurological Disorders and Stroke (NINDS) published recommendations for measurement selection in HD. While these recommendations are helpful, many of the recommended measures have little published data in HD. As such, we conducted a systematic review of the literature to identify the most common outcomes measures used in HD clinical trials.

METHODS

Major medical databases, including PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, were used to identify peer-reviewed journal articles in English from 2001 through April 2013; 151 pharmacological trials were identified.

RESULTS

The majority of HD clinical trials employed clinician-reported outcomes measures (93%); patient reported outcome measures (11%) and observer reported outcome measures (3%) were used with much less frequency.

CONCLUSIONS

We provide a review of the most commonly used measures across these trials, compare these measures to the clinical recommendations made by the NINDS working groups, and provide recommendations for selecting measures for future clinical trials that meet the Food and Drug Administration standards.

Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease

AIM

Although depression and anxiety are the most common psychological problems among dialysis patients, little is known about the association between depression, anxiety and quality of life (QOL) in patients with predialysis chronic kidney disease (CKD). Therefore, we assessed the prevalence of depression and anxiety, and their association with QOL in patients with predialysis CKD.

METHODS

Two hundred and eight predialysis patients (male 61.1%) with a mean age of 55.7 ± 13.7 years and an estimated glomerular filtration rate < 60 ml/min/1.73 m(2) were enrolled. Depression and anxiety were assessed with the Hospital Anxiety and Depression Scale. Patients with anxiety and depression scores ≥ 8 were diagnosed with anxiety and depression disorders respectively. The WHOQOL-BREF questionnaire was used to assess patient QOL.

RESULTS

The prevalence of depression (47.1%) and anxiety (27.6%) did not differ across CKD stages. Depression correlated positively with age, employment, income, education, comorbidity index, haemoglobin level, albumin concentration and anxiety score, and negatively with all WHOQOL-BREF domain scores. Anxiety correlated significantly with QOL, but not with socioeconomic factors. In a multiple regression analysis, haemoglobin level, anxiety and QOL were independent factors associated with depression. In a linear regression analysis, depression and anxiety independently correlated with QOL after we adjusted for age, alcohol use, employment, income, education, haemoglobin level and albumin concentration.

CONCLUSIONS

Patients with predialysis CKD have a high prevalence of depression and anxiety, which are associated with reduced QOL. Early detection of depression and anxiety and active interventions should be considered to improve the QOL of these patients.

Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies

Prevalence estimates of depression in chronic kidney disease (CKD) vary widely in existing studies. We conducted a systematic review and meta-analysis of observational studies to summarize the point prevalence of depressive symptoms in adults with CKD. We searched MEDLINE and Embase (through January 2012). Random-effects meta-analysis was used to estimate the prevalence of depressive symptoms. We also limited the analyses to studies using clinical interview and prespecified criteria for diagnosis. We included 249 populations (55,982 participants). Estimated prevalence of depression varied by stage of CKD and the tools used for diagnosis. Prevalence of interview-based depression in CKD stage 5D was 22.8% (confidence interval (CI), 18.6-27.6), but estimates were somewhat less precise for CKD stages 1-5 (21.4% (CI, 11.1-37.2)) and for kidney transplant recipients (25.7% (12.8-44.9)). Using self- or clinician-administered rating scales, the prevalence of depressive symptoms for CKD stage 5D was higher (39.3% (CI, 36.8-42.0)) relative to CKD stages 1-5 (26.5% (CI, 18.5-36.5)) and transplant recipients (26.6% (CI, 20.9-33.1)) and suggested that self-report scales may overestimate the presence of depression, particularly in the dialysis setting. Thus, interview-defined depression affects approximately one-quarter of adults with CKD. Given the potential prevalence of depression in the setting of CKD, randomized trials to evaluate effects of interventions for depression on patient-centered outcomes are needed.

The relationship between psychological factors, inflammation, and nutrition in patients with chronic renal failure undergoing hemodialysis

OBJECTIVE

Hemodialysis has an adverse impact on the immunological, nutritional, and emotional status of patients. The biochemical markers of inflammation and nutrition were studied as well as the relationship of these factors to emotional symptoms.

METHOD

One hundred and ninety-five patients undergoing hemodialysis were enrolled. The mean age was 58.5 years. Emotional symptoms were assessed using the Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale, Chalder Fatigue Scale, and Short-form Health-related Quality of Life. Venus blood was collected for laboratory assessment of serum hemoglobin, albumin, ferritin, C-reactive protein, interleukin (IL) 1beta), IL-6, and tumor necrosis factor alpha.

RESULTS

Among the 195 subjects (92 men and 103 women), 47 (24.1%) fulfilled the criteria for a major depressive disorder (MDD). The IL-6 level in patients with a MDD was significantly higher than in the patients without a MDD. Significant correlation was observed among the following factors: IL-6, fatigue, and quality of life for both physical and mental components. The albumin levels showed a significant correlation with the IL-6 and depression scores.

CONCLUSIONS

These results show that the serum levels of albumin and IL-6 might be laboratory markers associated with the expression of emotional symptoms in patients undergoing hemodialysis. Prospective studies are needed to determine the causal relationships among these variables.

Association between uremic toxins and depression in patients with chronic kidney disease undergoing maintenance hemodialysis

OBJECTIVE

Patients with chronic kidney disease (CKD) who are undergoing maintenance hemodialysis have a higher prevalence of depression than the general population. The underlying cause of this association is unknown, but may be related to accumulation of uremic toxins. Little is known about the association of accumulation of uremic toxins and depression in hemodialysis patients.

METHOD

We conducted a cross-sectional study of 209 CKD patients from a single institution to evaluate the associations of a soluble small uremic toxin (urea), a soluble large uremic toxin (β2 microglobulin) and two protein-bound uremic toxins [total p-cresol sulfate (PCS) and indoxyl sulfate (IS)] with the presence of depression.

RESULTS

A total of 47 patients (22.4%) had depression. Depressive patients had lower body mass index, lower serum creatinine, lower serum albumin and lower total IS. Univariate and multivariate logistic regression analyses that adjusted for age, gender and other statistically significant variables indicated that depression was significantly and independently associated with lower serum albumin and lower total IS. The levels of urea, β2 microglobulin and PCS were not significantly associated with depression.

CONCLUSION

Our results indicate that depression in patients with CKD was significantly and independently associated with lower serum albumin and lower total IS. However, the pathological mechanisms underlying these associations are unknown.

Comparison of the SF-36 Five-item Mental Health Inventory and Beck Depression Inventory for the screening of depressive symptoms in chronic dialysis patients

BACKGROUND

The Beck Depression Inventory (BDI) is a standard and validated questionnaire to screen for depressive symptoms in chronic dialysis patients, but is relatively extensive to use repeatedly in clinical practice. We investigated whether the five-item Mental Health Inventory (MHI-5) of the 36-item Short-Form Health Survey Questionnaire (SF-36) could be applied to screen for depressive symptoms in dialysis patients. Moreover, we determined the optimal MHI-5 cut-off score to assess depressive symptoms.

METHODS

Chronic dialysis patients from three centres filled out the SF-36 and the BDI. A receiver operating characteristic (ROC) curve was constructed for the MHI-5 score with BDI ≥ 16 as reference standard to (i) calculate the area under the curve to determine whether the MHI-5 could be considered as a useful screening instrument for depressive symptoms and (ii) proxy the optimal cut-off score of the MHI-5 to assess depressive symptoms. The optimal cut-off score was determined by the value for which the sum of sensitivity and specificity had an optimum.

RESULTS

Of 133 included patients, 23% had depressive symptoms as determined with BDI ≥ 16. The correlation of the BDI with MHI-5 was -0.64. The area under the ROC curve was 0.82 (95% confidence interval 0.74-0.90). The optimal cut-off point of the MHI-5 was 70. MHI-5 ≤ 70 had 77 sensitivity, 72 specificity, 44 positive predicting value and 91% negative predicting value with the presence of depressive symptoms determined with BDI ≥ 16.

CONCLUSIONS

The MHI-5 may help clinicians to screen for depressive symptoms in dialysis patients without using an additional depression screening questionnaire once the SF-36 is completed. A cut-off value of 70 can be used safely for the purposes of screening applications.

Screening for anxiety and depression in dialysis patients: comparison of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory

OBJECTIVE

Although anxiety and depression are frequent comorbid disorders in dialysis patients, they remain underrecognized and often untreated. The aim of the study was to evaluate the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI) and a truncated version of the BDI, the Cognitive Depression Index (CDI), as screening tools for anxiety and depression in dialysis patients.

METHODS

A total of 109 participants (69.7% males), from four dialysis centers, completed the self-report symptom scales HADS and BDI. Depression and anxiety disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). The sensitivity, specificity, positive and negative predictive value, overall agreement, kappa and receiver operating characteristic (ROC) curves were assessed.

RESULTS

Depressive disorders were found in 22% of the patients based on the SCID-I, while anxiety disorders occurred in 17%. The optimal screening cut-off score for depression was ≥ 7 for the HADS depression subscale (HADS-D), ≥ 14 for the HADS-total, ≥ 11 for the CDI and ≥ 17 for the BDI. The optimal screening cut-off for anxiety was ≥ 6 for the HADS anxiety subscale (HADS-A) and ≥ 14 for the HADS-total. At cut-offs commonly used in clinical practice for depression screening (HADS-D: 8; BDI: 16), the BDI performed slightly better than HADS-D.

CONCLUSION

The BDI, CDI and HADS demonstrated acceptable performance as screening tools for depression, as did the HADS-A for anxiety, in our sample of dialysis patients. The recommended cut-off scores for each instrument were: ≥ 17 for BDI, ≥ 11 for CDI, ≥ 7 for HADS depression subscale, ≥ 6 for HADS anxiety subscale and ≥ 14 for HADS total. The CDI did not perform better than the BDI in our study. Lower cut-off for the HADS-A than recommended in medically ill patients may be considered when screening for anxiety in dialysis patients.

Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the Depression, Anxiety and Stress Scale (DASS) and the hospital, Anxiety and Depression Scale (HADS)

BACKGROUND

While it is recognised that depression is prevalent in Rheumatoid Arthritis (RA), recent studies have also highlighted significant levels of anxiety in RA patients. This study compared two commonly used scales, the Depression Anxiety and Stress Scale (DASS) and the Hospital Anxiety and Depression Scale (HADS), in relation to their measurement range and cut points to consider the relative prevalence of both constructs, and if prevalence rates may be due to scale-specific case definition.

METHODS

Patients meeting the criteria for RA were recruited in Leeds, UK and Sydney, Australia and asked to complete a survey that included both scales. The data was analysed using the Rasch measurement model.

RESULTS

A total of 169 RA patients were assessed, with a repeat subsample, resulting in 323 cases for analysis. Both scales met Rasch model expectations. Using the 'possible+probable' cut point from the HADS, 58.3% had neither anxiety nor depression; 13.5% had anxiety only; 6.4% depression only and 21.8% had both 'possible+probable' anxiety and depression. Cut points for depression were comparable across the two scales while a lower cut point for anxiety in the DASS was required to equate prevalence.

CONCLUSIONS

This study provides further support for high prevalence of depression and anxiety in RA. It also shows that while these two scales provide a good indication of possible depression and anxiety, the estimates of prevalence so derived could vary, particularly for anxiety. These findings are discussed in terms of comparisons across studies and selection of scales for clinical use.

The Clinical Global Impression Scale and the influence of patient or staff perspective on outcome

BACKGROUND

Since its first publication, the Clinical Global Impression Scale (CGI) has become one of the most widely used assessment instruments in psychiatry. Although some conflicting data has been presented, studies investigating the CGI's validity have only rarely been conducted so far. It is unclear whether the improvement index CGI-I or a difference score of the severity index CGI-S (dif) is more valid in depicting clinical change. The current study examined the validity of these two measures and investigated whether therapists' CGI ratings correspond to the view the patients themselves have on their condition.

METHODS

Thirty-one inpatients of a German psychotherapeutic hospital suffering from a major depressive disorder (age M = 45.3, SD = 17.2; 58.1% women) participated. Patients filled in the Beck Depression Inventory (BDI). CGI-S and CGI-I were rated from three perspectives: the treating therapist (THER), the team of therapists involved in the patient's treatment (TEAM), and the patient (PAT). BDI and CGI-S were filled in at admission and discharge, CGI-I at discharge only. Data was analysed using effect sizes, Spearman's ρ and intra-class correlations (ICC).

RESULTS

Effect sizes between CGI-I and CGI-S (dif) ratings were large for all three perspectives with substantially higher change scores on CGI-I than on CGI-S (dif). BDI (dif) correlated moderately with PAT ratings, but did not correlate significantly with TEAM or THER ratings. Congruence between CGI-ratings from the three perspectives was low for CGI-S (dif) (ICC = .37; Confidence Interval [CI] .15 to .59; F(30,60) = 2.77, p < .001; mean ρ = 0.36) and moderate for CGI-I (ICC = .65 (CI .47 to .80; F(30,60) = 6.61, p < .001; mean ρ = 0.59).

CONCLUSIONS

Results do not suggest a definite recommendation for whether CGI-I or CGI-S (dif) should be used since no strong evidence for the validity of neither of them could be found. As congruence between CGI ratings from patients' and staff's perspective was not convincing it cannot be assumed that CGI THER or TEAM ratings fully represent the view of the patient on the severity of his impairment. Thus, we advocate for the incorporation of multiple self- and clinician-reported scales into the design of clinical trials in addition to CGI in order to gain further insight into CGI's relation to the patients' perspective.