Anxiety, depression and post-traumatic stress disorder in patients on hemodialysis in the setting of the pandemic, inflation, and the Beirut blast: a cross-sectional study

Mediating effect of intolerance of uncertainty between feeling of unsafety and depression/well-being among a sample of Lebanese adults

BACKGROUND

Eastern Mediterranean countries, particularly Lebanon, have seen a significant rise in mental disorders, primarily driven by ongoing economic instability, political unrest, and regional conflicts. These conditions fuel feelings of unsafety, which are linked to lower psychological well-being and increased depressive symptoms. Unsafe circumstances inflate apprehension and uncertainty, leaving individuals unable to foresee a stable, secure tomorrow and often trapped in an anticipatory negative thinking state. Therefore, this study posits that in unsafe environments, Intolerance of Uncertainty (IU) may mediate the relationships between the feeling of unsafety and depression/well-being and aims to test this hypothesis among a sample of adults from Lebanon, a frequently crisis-ridden country.

METHODS

A one-time-point online survey was conducted among Lebanese adults from the general population (N = 905; mean age = 27.38 (SD: 9.28); 60% females), recruited anonymously via snowball sampling. The questionnaire included socio-demographic variables and the following Arabic validated scales: Feeling of Unsafety Scale- Arabic (FUSA), World Health Organization Well-Being Index (WHO-5), Patient Health Questionnaire-9 (PHQ-9), and Intolerance of Uncertainty Scale (IUS-12). Statistical analysis was performed using SPSS v.27 with mediation analysis via PROCESS MACRO v3.4 Model 4.

RESULTS

After adjusting for potential confounders, mediation analysis showed that both prospective and inhibitory anxiety fully mediated the association between the feeling of unsafety and depression and partially mediated the association between the feeling of unsafety and well-being. Higher feeling of unsafety was significantly associated with higher prospective and inhibitory anxiety (Beta = 0.32; p < 0.001; 95% CI 0.27; 0.37 and Beta = 0.19; p < 0.001; 95% CI 0.15; 0.23 respectively), which in turn were significantly associated with higher depression (Beta = 0.42; p < 0.001; 95% CI 0.35; 0.48 and Beta = 0.62; p < 0.001; 95% CI 0.54; 0.70 respectively) and lower well-being (Beta = - 0.39; p < 0.001; 95% CI -0.44; -0.33 and Beta = - 0.39; p < 0.001; 95% CI -0.47; -0.32 respectively). It is of note that while higher feeling of unsafety did not show a direct association with higher depression (Beta = - 0.03; p = 0.187; 95% CI -0.09; 0.02 and Beta = -0.02; p = 0.399; 95% CI -0.07; 0.03 respectively), it was significantly and directly associated with lower well-being (Beta = - 0.07; p < 0.01; 95% CI -0.12; -0.03 and Beta = - 0.12; p < 0.001; 95% CI -0.17; -0.07 respectively).

CONCLUSION

The hypothesis that IU mediates the relationships between the feeling of unsafety and depression/well-being is confirmed. This finding highlights a key target for interventions. Psychotherapeutic and public mental health initiatives could enhance psychological well-being by dedicating efforts to promoting uncertainty tolerance, particularly in vulnerable populations facing unstable settings.

Mediterranean-DASH Diet Intervention for Neurodegenerative Delay Diet and Psychological Problems in Maintenance Hemodialysis Patients by the Structural Equation Modeling Analysis of Malnutrition and Inflammation Markers Approach

OBJECTIVE

Although it is known that diet quality affects psychological problems in hemodialysis (HD) patients, there is need to explain the role of modifiable risk factors in this relationship. Therefore, the aim of this study was (1) to investigate the relationship between diet quality and modifiable risk factors to depression and anxiety in end-stage renal disease patients receiving maintenance HD; (2) to explore the mediating roles of modifiable factors in the relationship with diet quality to depression and anxiety.

METHODS

This cross-sectional study included 216 patients with end-stage renal disease receiving maintenance HD treatment. We assessed participants' dietary records for Mediterranean-DASH Diet Intervention for Neurodegenerative Delay (MIND) quality, Global Leadership Initiative on Malnutrition criteria for malnutrition and Hospital Anxiety and Depression Scale for psychological problems. Furthermore, biochemical findings and anthropometric measurements were performed to evaluate nutritional markers, metabolic risk factors and inflammation. We applied hierarchical regression analysis to estimate modifiable risk factors for depression and anxiety and structural-equation-modeling analysis to determine the mediating role of modifiable risk factors between diet quality and psychological problems.

RESULTS

Depression symptoms were observed in 59.2% (n = 128) of the participants, whilst the rate was 35.1% (n = 76) for anxiety. Depression and anxiety were found to be negatively correlated with MIND levels after covariate adjusting model, and the rates of explanation were found to be 16.2% and 12.2%, respectively. C-reactive protein (CRP), albumin levels and the presence of malnutrition were shown to be significant predictors of depression (ΔF = 14.761 and ΔR2: 0.071 for covariate-adjusted model). Albumin levels, CRP, HD duration, and malnutrition were found to be independent predictors of anxiety (ΔF = 16.174 and ΔR2: 0.077 for covariate-adjusted model). It was found that CRP and malnutrition partially mediated the association of MIND score with depression, and CRP mediated the association with anxiety.

CONCLUSION

It was concluded that adherence to the MIND diet is associated with a better nutritional profile and reduced inflammation, which in turn may be linked to fewer psychological problems.These further studies are needed to validate and expand upon our findings.

The aftermath of multiple trauma on a nation: unraveling Lebanon's unique mental health struggle

Objective

This study examines the national prevalence of mental health disorders and their associated factors in Lebanon, specifically in the aftermath of the 2020 events, including the catastrophic events of Beirut blast and the concurrent financial meltdown amid the global pandemic.

Methods

Conducted between July and September 2022, the study interviewed a nationally representative sample of 1,000 Lebanese via telephone, using the Computer Assisted Telephone Interview (CATI) system. Gender-specific bivariate and multivariate models were generated for probable posttraumatic stress disorder (PTSD), depression, and anxiety.

Results

High rates of mental health disorders emerged - 47.8% screened positive for probable depression, 45.3% for probable anxiety, and 43.5% met the probable diagnosis for PTSD. Multivariate gender-specific analyses revealed no significant associations with governorate, employment status, or marital status, while the financial composite score consistently influenced all disorders.

Conclusion

Lebanon faces a severe mental health crisis, evidenced by elevated rates of probable depression, anxiety, and PTSD. The universal impact of multiple traumas transcends typical determinants, emphasizing the need for nuanced interventions and targeted policy considerations.

Music therapy in hemodialysis patients: Systematic review and meta-analysis

BACKGROUND

Patients undergoing hemodialysis (HD) face significant challenges; however, non-pharmaceutical interventions hold potential for enhancing their quality of life. This paper evaluates the effects of music therapy on various mental and physiological outcomes in patients undergoing HD.

METHODS

This systematic review and meta-analysis followed the PRISMA 2020 guidelines. A comprehensive database search conducted up to May 21, 2024, identified studies for inclusion based on PICOS criteria. The methodological quality of these studies was assessed using the Cochrane risk-of-bias tool and Review Manager 5.4. For the meta-analysis, R and Stata/SE 15.1 were used, applying a random-effects model in cases of significant heterogeneity, and a fixed-effects model when heterogeneity was minimal.

RESULTS

Twenty-four studies involving 1703 participants were analyzed. Music therapy significantly decreased anxiety (SMD: -0.72, 95 % CI: -0.97 to -0.46, I²: 83 %), pain (SMD: -1.22, 95 % CI: -1.68 to -0.75, I²: 93 %), depression (SMD: -0.85, 95 % CI: -1.31 to -0.39, I²: 77 %), stress (SMD: -0.93, 95 % CI: -1.17 to -0.68, I²: 41 %), and adverse reactions associated with HD (SMD: -0.67, 95 % CI: -0.88 to -0.46, I²: 0 %), all showing strong effect sizes (p < 0.001 for all). However, no significant changes were observed in sleep quality, fatigue, satisfaction with HD, systolic or diastolic blood pressure, heart rate, or finger temperature. A slight reduction in respiration rate (p = 0.0072) and an increase in oxygen saturation (p = 0.0056) were noted. While music therapy showed promising results, the notable heterogeneity in pain and anxiety outcomes suggests careful interpretation, although no significant publication bias was detected.

CONCLUSION

Music therapy has demonstrated encouraging outcomes in improving the well-being of patients undergoing HD, particularly in reducing anxiety, pain, and stress. However, due to notable heterogeneity and methodological issues such as small sample sizes and inconsistent blinding, further high-quality research is needed to confirm these findings and establish more robust evidence.

Psychological Treatment Options for Patients with Mild to Moderate Depression Undergoing Hemodialysis: TCM-Related Emotion-Thought Therapy

Objective

To assess the effect of Chinese medicine affective therapy on psychotherapy for mild to moderate depression in hemodialysis patients, and to provide a reference basis for clinical practice.

Methods

Clinical data (January 2021-January 2023) from the Fourth Affiliated Hospital of Nanchang University were retrospectively analyzed. Patients were divided into control (routine care) and observation (routine care + Chinese medicine affective therapy) groups. The data of anxiety self-assessment scale (SAS), self-rating depression scale (SDS), pittsburgh sleep quality index (PSQI), general well-being scale (GWB) and Health Questionnaire (SF-36) were compared between the two groups.

Results

PSM matched 80 patients each in observation and control groups, showing no significant baseline differences. Pre-care scores (SAS, SDS, PSQI, GWB, SF-36) had no notable discrepancies (P > .05). Post-care, SAS, SDS, PSQI were lower in the observation group (P < .05), while GWB and SF-36 scores were higher (P < .001). The SAS, SDS, and PSQI scores were lower in the observation group relative to the control group after care (All P-values were < .05), whereas the GWB and SF-36 score scores of the observation group were higher than those of the control group (All P-values were < .05).

Conclusion

Traditional Chinese Medicine (TCM) affective therapy may be able to improve the quality of sleep, quality of life, and general well-being of hemodialysis patients with mild-to-moderate depression, as well as alleviate the patients' adverse emotions.

Neuronal damage and inflammatory biomarkers are associated with the affective and chronic fatigue-like symptoms due to end-stage renal disease

BACKGROUND

Many biochemical, immunological, and neuropsychiatric changes are associated with end-stage renal disease (ESRD). Neuronal damage biomarkers such as glial fibrillary acidic protein (GFAP), neurofilament light chain (NFL), S100 calcium-binding protein B (S100B), ionized calcium-binding adaptor molecule-1 (IBA1), and myelin basic protein (MBP) are among the less-studied biomarkers of ESRD.

AIM

We examined the associations between these neuro-axis biomarkers, inflammatory biomarkers, e.g., C-reactive protein (CRP), interleukin (IL-6), IL-10, and zinc, copper, and neuropsychiatric symptoms due to ERSD.

METHODS

ELISA techniques were used to measure serum levels of neuronal damage biomarkers in 70 ESRD patients, and 46 healthy controls.

RESULTS

ESRD patients have higher scores of depression, anxiety, fatigue, and physiosomatic symptoms than healthy controls. Aberrations in kidney function tests and the number of dialysis interventions are associated with the severity of depression, anxiety, fibro-fatigue and physiosomatic symptoms, peripheral inflammation, nestin, and NFL. Serum levels of neuronal damage biomarkers (NFL, MBP, and nestin), CRP, and interleukin (IL)-10 are elevated, and serum zinc is decreased in ESRD patients as compared with controls. The neuronal damage biomarkers NFL, nestin, S100B and MBP are associated with the severity of one or more neuropsychiatric symptom domains. Around 50 % of the variance in the neuropsychiatric symptoms is explained by NFL, nestin, S00B, copper, and an inflammatory index.

CONCLUSIONS

The severity of renal dysfunction and/or the number of dialysis interventions may induce peripheral inflammation and, consequently, neurotoxicity to intermediate filament proteins, astrocytes, and the blood-brain barrier, leading to the neuropsychiatric symptoms of ESRD.

The effects of exercise training interventions on depression in hemodialysis patients

Purpose

Depression considerably influences the clinical outcomes, treatment compliance, quality of life, and mortality of hemodialysis patients. Exercise plays a beneficial role in depressive patients, but its quantitative effects remain elusive. This study aimed to summarize the effects of exercise training on depression in patients with end-stage renal disease undergoing hemodialysis.

Methods

The PUBMED, EMBASE, and Cochrane Library databases were systematically searched from inception to April 2023 to identify published articles reporting the effect of exercise training on the depression level of patients with End-Stage Renal Disease undergoing hemodialysis. Data were extracted from the included studies using predefined data fields by two independent researchers. The Cochrane Handbook for Systematic Reviews of Interventions and Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies were employed for quality evaluation.

Results

A total of 22 studies enrolling 1,059 patients who participated in exercise interventions were included. Hemodialysis patients exhibited superior outcomes with intradialytic exercise (SMD = -0.80, 95% CI: -1.10 to -0.49) and lower levels of depression following aerobic exercise (SMD = -0.93, 95%CI: -1.32 to -0.55) compared to combined exercise (c - 0.85, 95% CI: -1.29 to -0.41) and resistance exercise (SMD = -0.40, 95%CI: -0.96 to 0.17). Regarding exercise duration, patients manifested lower depression levels when engaging in exercise activities for a duration exceeding 6 months (SMD = -0.92, 95% CI: -1.67 to -0.17). Concerning the duration of a single exercise session, the most significant improvement was noted when the exercise duration exceeded 60 min (SMD = -1.47, 95% CI: -1.87 to -1.06).

Conclusion

Our study determined that exercise can alleviate depression symptoms in hemodialysis patients. This study established the varying impacts of different exercise parameters on the reduction of depression levels in hemodialysis patients and is anticipated to lay a theoretical reference for clinicians and nurses to devise tailored exercise strategies for interventions in patients with depression.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, with registration number CRD42023434181.

Depression and death anxiety among patients undergoing hemodialysis during the COVID-19 pandemic in Palestine: a cross sectional study

Background

Hemodialysis patients are vulnerable to serious complications such as prolonged hospital stay and psychosocial issues like depression and death anxiety. Studies on psychosocial factors on end-stage renal disease patients' outcomes during COVID-19 pandemic are limited. We aimed to determine the prevalence of depression and death anxiety among Palestinian hemodialysis patients and the evaluate the relationship between their sociodemographic and clinical characteristics during COVID-19 Pandemic.

Methods

A cross-sectional study was conducted using a convenience sampling technique. We recruited 308 hemodialysis patients from five hemodialysis units located in government hospitals in Palestine. Beck Depression Inventory and the Templers Death Anxiety Scale were used to collect data, which were then analyzed using SPSS version 20. Descriptive statistics (frequencies and means), t-test, ANOVA and multiple linear regression models were used for data analysis.

Results

Nearly 66.2% of the sample had depression symptoms, 61.4% met the diagnostic threshold for depression, and 69.8% had death anxiety. Furthermore, the multivariate analysis revealed that having a female identity, residing in a city or refugee camp, and patients who reported not experiencing depression had a significant relationship with death anxiety, while having a higher educational level than 12 years, having one or more chronic co-morbidities, and patients who reported experiencing death anxiety had a significant correlation with depression.

Conclusion

Patients receiving hemodialysis frequently experience depression and death anxiety. These patients should receive a psychiatric evaluation in the early stages of their illness so that timely and appropriate psychological interventions can be given in hemodialysis facilities in Palestine during and after future pandemics.

Inflammatory Determinants and Associated Morbidity in Hemodialysis Patients

Hemodialysis deteriorates patients' physical, metabolic, and mental status. Clinical outcomes derived from inflammation determine a worse status but are less frequently identified. The objective of the study was to identify inflammatory determinants and the effect of SNP-related serum IL-6 and IL-10 levels on associated morbidity in hemodialysis. A sample of hemodialysis patients at IMSS Regional Hospital No.46 in Guadalajara (n = 85) were tested using the Malnutrition Inflammation Score (MIS) and Patient Health Questionnaire-9 (PHQ-9) to assess the associated morbidity. Serum cytokine levels were quantified by enzyme-linked immunosorbent assay (ELISA). The restriction fragment length polymorphism (RFLP) technique was used for analysis of IL-6-572C/G and IL-10-1082A/G. Using data visualization methods, we identified relevant determinants of inflammation. A simple regression model was constructed between predictors and targets with genotypes as covariates. Results showed malnutrition in 85.9% of patients and depressive symptoms in 50.6%. IL-10 was the most relevant inflammatory determinant, with regression coefficients (R2) between 0.05 and 0.11. The GG genotype of IL-10-1082 A/G evinced small effect on both clinical outcomes (δ of 0.35 and 0.37, respectively). Hemodialysis increases the associated morbidity, cytokines act as inflammatory determinants, and genetic variability contributes to the severity of clinical outcomes. Further studies need to refine the causal relationship between inflammation and CKD.

Quantification of Epistemic Capacity and Physical Frailty in Chronic Kidney Disease: Koch's Disease Co-infection

Background Chronic kidney disease (CKD) and tuberculosis (TB) co-infection devastates the affected individual physically and psychologically. Moreover, poor immune status and mental turmoil worsen cognition and quality of life. Hence, studying the cognitive function and quality of life among such patients is necessary. This study aimed to determine the changes in mini-mental state examination (MMSE) score and general health questionnaire (GHQ-12) score at six months from baseline. Methodology This prospective, observational study was conducted at Sriram Chandra Bhanja Medical College and Hospital, India, from February 2020 to December 2021. A total of 40 patients with stage 3-4 CKD and pulmonary TB were assessed with MMSE and GHQ-12 scales at baseline, two, and six months. The study population was grouped as ≤50 and >50 years of age. We used R software (version 4.1.1) for data analysis. Results In total, 40 (69%) of the 58 enrolled participants completed this study. The mean age of the study population was 50.93 ± 9.83 years. The baseline MMSE scores (≤50 years: 20.8 ± 2.1, >50 years: 20.1 ± 1.7, p = 0.17) were increased (≤50 years: 25.4 ± 1.8, >50 years: 22.4 ± 1.6, p = 0.08) at six months. The baseline GHQ-12 scores (≤50 years: 22.8 ± 2.6, >50 years: 23.1 ± 2.8, p = 0.56) were reduced (≤50 years: 17.9 ± 1.9, >50 years: 20.3 ± 2.3, p = 0.14) at six months. Conclusions The study participants' cognitive function and quality of life improved after six months of modified antitubercular drugs. Nevertheless, the intergroup differences were not statistically significant.