Depression and coping in candidates for kidney transplantation: Racial and ethnic differences

Psychosocial Distress in Patients With Advanced CKD by Racial Group and Immigrant Status: A Canadian Cross-sectional Study

RATIONALE & OBJECTIVE

Patients with advanced chronic kidney disease (CKD) have been reported to experience profound psychosocial distress. Other work has established that patients with CKD from marginalized populations (including individuals who on the basis of race often face racism and related discrimination, termed "racialization") experience health care inequities. Given limited information on the intersection of these 2 phenomena, we assessed the association of psychosocial distress with racialized status and immigrant status in Canadians with advanced CKD.

STUDY DESIGN

Secondary analysis of cross-sectional data.

SETTING & PARTICIPANTS

536 patients with advanced CKD (estimated glomerular filtration rate<30mL/min/1.73m², with or without kidney replacement therapy) from multiple clinical centers in Toronto.

EXPOSURE

Racialized status (individuals who identify as Asian or as African, Caribbean, or Black Canadian), immigrant status, and combined immigrant-racialized status.

OUTCOME

Psychosocial distress, defined as the presence of depression, anxiety, or social difficulties (ie, a score of≥10 points on the Patient Health Questionnaire 9, Generalized Anxiety Disorder 7, or Social Distress 16 scales, respectively).

ANALYTICAL APPROACH

The independent associations of racialized status and immigrant status with psychosocial distress, depression, anxiety, and social difficulties were examined using univariable- and multivariable-adjusted logistic regression.

RESULTS

Mean age of the 536 participants was 57±16 (SD) years, 62% were male, and 45% were immigrants. Of the sample, 58% were White, 22% were African, Caribbean, or Black Canadian, and 20% were Asian. Psychosocial distress was present in 36% of participants (depression in 19%, anxiety in 12%, and social difficulties in 31%). To assess the combined impact of racialized and immigrant status, we created a variable with mutually exclusive categories: White nonimmigrant, racialized nonimmigrant, White immigrant, and racialized immigrant participants. In our final multivariable-adjusted model, compared with White nonimmigrant participants, racialized immigrant participants were more likely to have psychosocial distress (OR, 2.96 [95% CI, 1.81-4.81]), depression (OR, 1.87 [95% CI, 1.05-3.34]), and social difficulties (OR, 3.36 [95% CI, 2.03-5.57]). Overall similar associations were seen for racialized nonimmigrants and for White immigrants.

LIMITATIONS

Convenience sample; small subgroups; combined exposure variable grouping Asian and African, Caribbean, and Black participants together; lack of data about mechanisms.

CONCLUSIONS

Both racialized and immigrant status based on self-report of demographic characteristics were associated with psychosocial distress among patients with advanced CKD. These patients may benefit from culturally competent psychosocial support.

PLAIN-LANGUAGE SUMMARY

Psychosocial distress is frequent in patients with advanced chronic kidney disease and impacts quality of life and clinical outcomes. Psychosocial distress may be especially scarring in people who are racialized (marginalized on account of their membership in a particular racial group) and/or who are immigrants. We assessed the association of psychosocial distress with racialized and immigrant status in Canadians with advanced chronic kidney disease. Among 536 participants from multiple medical centers in Toronto, we found that racialized and immigrant participants were more likely to have psychosocial distress, depression, and social difficulties compared with White nonimmigrant participants. This is likely related to the multiple intersectional challenges, including experience with racism and discrimination that racialized immigrant patients may face. Further studies are needed to elucidate the specific factors that contribute to more distress. The potential impact of culturally competent and safe support for these patients will also need to be studied.

Inequalities and outcomes: end stage kidney disease in ethnic minorities

Background

The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers.

Methods

Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature.

Results

Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity.

Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning.

Conclusions

Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Comparison of Helplessness and Hopelessness as Sources of Cognitive Vulnerability Among Black and White College Students

The Cognitive Style Questionnaire (CSQ), an expansion of the Attributional Style Questionnaire (ASQ), was created as an enhanced measure of cognitive vulnerability to depression using a hopelessness theory framework. However, the CSQ’s development emphasized facets of cognitive vulnerability consistent with a Eurocentric worldview. Consequently, the CSQ may inadvertently degrade rather than enhance assessment of cognitive vulnerability to depression for Black participants whose vulnerability may be shaped by a different sociopolitical context. Participants were 259 White and 180 Black college students. As predicted, cognitive vulnerability to depression assessed via the reformulated learned helplessness (ASQ) but not hopelessness theory (CSQ) was associated with increased symptoms of depression for Black participants. The opposite pattern of results was found for White participants for whom hopelessness (CSQ), but not helplessness (ASQ) was associated with higher levels of depression symptoms. The current findings support the need for more extensive examination of social context and race in assessing cognitive vulnerability to depression.

A Comparison Of Depressive Symptons In African Americans And Caucasian Americans

The study examined group differences in depressive symptomatology on the Beck Depression Inventory in 278 African Americans and 278 Caucasian Americans seeking psychotherapy. Relative to Caucasian Americans, African Americans reported less pessimism, dissatisfaction, self-blame, and suicidal ideation and more sense of punishment and weight change, but for reasons unrelated to depression. Self-dislike was a stronger manifestation of depression in Caucasian Americans, and sleep disturbance, loss of appetite, and loss of libido were stronger manifestations of depression in African Americans. Group differences were not accounted for by gender, marital status, age, or education. The study contributes to the understanding of sociocultural variants of self reported depression by distinguishing different ways in which symptomatology may differ.

Reliability and Validity of the Beck Depression and Anxiety Inventories in Caucasian Americans and Latinos

Although the Beck Depression Inventory and Beck Anxiety Inventory are two of the most widely used instruments for assessing depressive and anxious symptoms in both clinical and nonclinical populations, their cross-cultural reliability and validity have yet to be fully established. In this study, 2,703 Caucasian American and 1,110 Latino college students completed both measures. For each measure, exploratory factor analysis with promax rotation, conducted separately by ethnic group, revealed similar factor structures across groups. For both groups, and both instruments, factor analysis yielded highly similar two-factor solutions. Reliability, as evidenced by internal consistency coefficients, was good; all alphas exceeded .82. On both measures, Latino students scored significantly higher than Caucasian American students on total scores and women scored significantly higher than men. These results support the reliability, validity, and cultural equivalence of these measures of depressive and anxious symptomatology for use with Caucasian American and acculturated Latino younger college students.

Racial Differences in Hopelessness as a Risk Factor for a Nearly Lethal Suicide Attempt

Hopelessness is associated with suicide. Hopelessness has been associated with life experiences, social-environmental, and biological factors. Racial differences exist in these factors and in coping behaviors. Better understanding racial differences in hopelessness and suicide may result in more effective interventions to slow the increasing Black American suicide rate. Data from a case-control study of nearly lethal suicide attempters were analyzed. Interaction results from logistic regression suggest that the effect of hopelessness on a nearly lethal suicide attempt may differ for Black and White Americans. Hopelessness was strongly associated with a nearly lethal suicide attempt for Blacks and Whites, but the odds were greater for Blacks than Whites. Interventions may need to be adjusted to address the difference.

The psychological assessment of candidates for reconstructive hand transplantation

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at-risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the 'Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT-PSP)' which utilizes a semi-structured interview and standardized psychological screening procedures and continuous follow-up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT-PSP. Psychological impairments including social withdrawal, embarrassment, reduced self-esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi- or unilateral impairment, native or accidental loss of hand, and social integration.

Psychological assessment and care of organ transplant patients

Organ transplant has been developed in animal models over the past 100 years. The major limiting factor in transplant medicine is the shortage of donor organs. This shortage creates pressure for fair and efficient allocation of organs, with expectations that those involved in transplantation will strive to achieve optimal outcomes and ensure just access. This article reviews the major types of transplants and the illnesses and behavioral comorbidities that lead to these procedures, the psychological assessment of transplant candidates, the adaptive tasks required of the transplant recipient at various stages of the transplant process, and relevant psychological interventions. Liaison with others on the transplant team and ethical issues of concern to psychologists who work with transplant patients, including living organ donors, are also discussed. Finally, new developments in transplant and suggestions for future psychological research in organ transplant are presented.

Psychosocial challenges in transplantation

The authors review the psychosocial aspects of transplantation. They first review psychosocial risk factors that place transplant patients at higher risk for noncompliance and negative outcomes. They then discuss what assessments should be included in a pretransplantation psychosocial evaluation. Goals of the psychosocial evaluation include selection of candidates most likely to benefit from transplantation and identification of areas for psychosocial intervention, both before and after transplantation. The assessment should address the patient's premorbid psychiatric state, past adaptation to stressors, history of compliance with treatment, substance abuse history, and level of social support, including community and faith-based support systems. Results of psychometric assessments may be helpful when considered in conjunction with a clinical interview and other sources of information about the patient. It may also be helpful to use a screening tool developed specifically to evaluate psychosocial factors relevant to transplantation, such as the Psychological Assessment of Candidates for Transplantation (PACT) scale and the Transplantation Evaluation Rating Scale (TERS). The authors then review issues related to psychopharmacologic interventions in transplant patients, including the use of antidepressant medication pre- and post-transplant, strategies for avoiding delirium associated with immunosuppressive medications immediately post-transplantation, neuropsychiatric symptoms associated with interferon alpha therapy for hepatitis C, and interactions between over-the-counter and herbal agents (e.g., St. John's Wort) and immunosuppressive agents. Although limited research has been done on nonpharmacologic interventions, such as transplant support groups, it appears that certain types of group therapy, in particular, cognitive-behavioral groups that target specific risk factors such as depression, distress, and compliance, may also offer promising approaches for dealing with the problems of transplant patients. The authors then focus on two special situations that create particular problems for transplantation teams: liver transplantation in patients with alcoholic liver disease (ALD) and obesity in transplant patients. The authors conclude that the prognosis for patients with ALD who receive liver transplantation is similar to that of non-alcoholics and that alcoholism is not a contraindication for liver transplantation. However, careful preliminary psychosocial assessment is essential to review candidates for factors that are predictive of relapse, while close follow-up post-transplantation can help improve outcomes. It appears that obesity can increase the risk of negative outcomes in transplant patients, although there is currently no consensus on the use of obesity as an exclusion criteria. Interventions that take into account the special psychological and medical needs of transplant patients need to be developed for treating obesity both pre- and post-transplantation. Improved strategies for identifying high-risk patients and finding ways to intervene both pre- and post-transplantation can not only help lengthen transplant recipients' life spans, but also improve their adaptation to transplantation and lead to improved quality of life.

A psychometric normative database for pre-liver transplantation evaluations. The Florida cohort 1991-1996

In this study, the authors describe the psychological characteristics of a large sample (N = 407) of adult patients evaluated for liver transplantation, and provide normative data on commonly used measures of cognitive functioning, affective status, psychosocial adjustment, coping, quality of life, and life satisfaction. The normative data suggest that the study's liver transplant candidates have poorer cognitive functioning and health-related quality of life when compared with available normative comparison groups, yet the former group is more comparable to medically ill peers on measures of anxiety, depression, psychosocial adjustment, and coping. Data also suggest a high rate of affective disturbance in liver transplant candidates. Results indicate the utility of normative data, such as the authors', for providing an appropriate comparison group for liver pretransplant candidates.