Depression in Dialysis Patients - An Insight

Introduction

Depression is considered one of the mental health disorders. It can have serious ill effects on dialysis patients' lives. According to studies, depression is observed as one of the most prevalent psychiatric conditions among dialysis patients. Its prevalence rate among dialysis patients ranges from 20 percent to 47 percent.

A patient undergoing dialysis for end-stage renal disease becomes entirely dependent on a machine and medical personnel. In addition, the patient must adhere to dietary restrictions and take many medications. They have to follow a schedule for the dialysis process, and they become dependent on others. The patient is placed under a great deal of financial strain. This may be due to the high cost of therapy and lost workdays. All these may contribute to the development and high risk of depression among dialysis patients when compared to the general population.

What Is Depression in Dialysis Patients?

Depression is a mental health disorder. This condition affects those with dialysis for kidney failure. Depression is characterized by continuous feelings like sadness, hopelessness, loss of interest in daily activities, weakness, and other physical and emotional symptoms.

Depression is more common among dialysis patients than in the general population. It can affect the quality of life and prognosis of dialysis patients. Depression may affect their sleep, diet, treatment, and other aspects, too.

Chronic kidney disease is considered to be a silent disease. This condition is increasing throughout the world. This condition is often diagnosed at the end stage when it is advanced. The treatment options left for such conditions are dialysis and renal transplantation.

The most common issue faced among those on hemodialysis is depression. This issue may influence the treatment's success. Depression is usually undetected or undertreated. Depression is responsible for decreased quality of life, increased hospitalization of patients, and death among those who are on dialysis.

How Common Is Depression in Dialysis Patients?

It was observed that around the world, kidney and urinary tract diseases are found to be responsible for 0.7 million deaths each year. In the coming decades, the estimation provides information that end-stage renal disease (ESRD) is going to be higher.

The exact number of people needing dialysis is not known. The prevalence of chronic kidney disease in India is estimated to be 0.7 to 1.4 percent.

Depression is very commonly seen among dialysis patients. It was estimated that around 20 to 90 percent of dialysis patients suffer from depression. The rate of depression among dialysis patients is higher than among the general population, where the rate of depression is found to be seven percent.

According to a few studies, it was observed that depression usually begins before or at the commencement of dialysis among 40 to 45 percent of patients. In India, 2 lakh people are being diagnosed every year.

Why Does Dialysis Increase Depression?

Dialysis is a process that helps a patient by saving their life. Despite saving lives, it may have some disadvantages, like physical, emotional, and social challenges. These challenges may lead to depression.

The following factors are responsible for depression among dialysis patients. These include:

• Chronic diseases like kidney failure require frequent dialysis. This may affect the daily life of a patient. Dialysis is usually done three times a week. This may limit their work, social life, and family time. This may cause reduced life satisfaction among them.

• The symptoms, like fatigue, muscle pain, sleep disturbances, headaches, fluctuating blood pressure, and other complications, may lead to stress. This stress may manifest as depression.

• Lifestyle changes like a restricted diet, fluid restrictions, and reduced independence may lead to frustration and low self-esteem. These may lead to depression among dialysis patients.

• The high cost of treatment, the loss of a job, or reduced ability to work may be responsible for precipitating anxiety and depression. The financial burden of dialysis and medication costs acts as a constant source of stress.

• Biological factors like alterations in the brain chemicals and inflammation of kidney disease may contribute to mood disorders like depression.

• Feeling about the uncertainties about the future makes these patients fear for their health. Kidney failure, the need for a transplant, or complications from dialysis precipitate depression.

• Dialysis patients may feel like a burden to their families. This may lead to guilt and emotional distress in them. Patients’ perception about their condition and their ability to cope may influence their emotional state.

• Changes in the physical appearance due to fluid retention, weight gain or loss, and other factors related to dialysis can affect body image and self-esteem.

• The body and brain need certain vitamins, minerals, and other compounds to stay healthy. When certain nutrients are missing, this may cause changes in mood, focus, and emotional well-being.

All the above factors contribute to depression in dialysis patients. The mental health issue is generally overlooked among dialysis patients. The healthcare providers usually give importance to blood sugar, blood pressure, nutrition, and vascular access. There is a limited time available to address mental health issues during the process of dialysis. This also contributes to the high risk of depression.

What Are the Symptoms of Depression in Dialysis Patients?

Depression can exhibit various symptoms among dialysis patients. Some of the symptoms may overlap with kidney disease symptoms. This may be the reason for undetected depression among dialysis patients, and most of them may not realize that they have depression. Many people hesitate to take treatment for depression.

The symptoms of depression among dialysis patients include:

• Sadness, loneliness, hopelessness, or emptiness. These emotions may always be observed among dialysis patients.

• Irritability may be high, and frustration may also be seen.

• They lose interest in activities that they used to enjoy before.

• They may experience guilt, feel worthless, and feel helpless.

• They may exhibit anxiety or excessive worry.

• They may find it difficult to make decisions and concentrate.

• Their memory decreases, and they have problems remembering things.

• They may have more negative thoughts.

• Affected individuals exhibit pain, weakness, and low energy.

• These may experience decreased sleep or excessive sleep.

• They feel an altered appetite. Appetite may be decreased or increased.

• They experience body pain and headaches.

• They may exhibit restlessness or slow movement.

• They may get isolated from society and experience social withdrawal.

• They may not stick to dialysis or medications.

• They may get addicted to substances like alcohol or drugs.

Severe symptoms include:

• Suicidal tendencies and self-harming may be observed. In such cases. Immediate help should be taken.

Some of the symptoms are similar to those caused by dialysis side effects. Hence, it is the responsibility of a treating doctor to carefully screen for the symptoms of depression. They can use standardized screening tools.

How to Diagnose Depression in Dialysis Patients?

Diagnosing depression in dialysis patients is not easy. This may be due to the overlapping of symptoms. The symptoms of depression overlap with the physical effects of kidney disease and dialysis treatment. Diagnosis of depression among these patients is very important. This may help improve the quality of life of an affected individual and help them stick to the treatment.

Diagnosis Can Be Done Through the Following Approaches:

Recognizing the Symptoms of Depression Among Dialysis Patients: Symptoms of depression include:

1. Emotional symptoms include sadness, hopelessness, irritability, and anxiety.

2. Cognitive symptoms include difficulty in making decisions and loss of memory.

3. Behavioral symptoms include isolation from society, a loss of interest in activities, and decreased motivation.

4. Physical symptoms include fatigue, sleep disturbances, loss of appetite, and fluctuation in weight.

Screening Tools:

• Patient Health Questionnaire-9 (PHQ-9): This tool is used to assess symptoms occurring in the past two months. These are self-assessment questionnaires used to determine symptoms.

• Beck Depression Inventory (BDI-II): This is a screening test that helps determine the severity of depression. The disadvantage is that it is influenced by the physical symptoms of kidney disease. The BDI-II contains 21 items with different scores.

• Hospital Anxiety and Depression Scale (HADS): This tool is used to differentiate between anxiety and depression. It focuses less on somatic symptoms. It is an indicative measurement of anxiety and depression. This has 14 items with different scores.

Differentiating Depression From Uremia-Related Symptoms:

It is difficult to differentiate between symptoms of depression and symptoms of uremia. Symptoms like fatigue, sleep disturbances, and lack of concentration may be due to either depression or kidney disease (ESRD). The key differences include:

• Symptoms related to depression tend to persist even after dialysis adequacy.

• Patients with depression may have symptoms such as worthlessness, sadness, and suicidal thoughts. These symptoms are less common in uremia (when waste products build up in the blood because of kidney damage).

Clinical Interview:

An interview by a psychiatrist or nephrologist must examine for

• Any history of depression or psychiatric disorders.

• Psychosocial factors like financial burden and loss of independence.

• Side effects of medications being used may give rise to depressive symptoms.

Family Members and Caregivers:

• Asking for the help of family members and caregivers to help to know about the changes in mood and behavior may help in diagnosing.

Consulting a Mental Health Specialist:

• If depression is suspected, help can be obtained from a mental health specialist.

What Are the Treatment Options for Depression in Dialysis Patients?

The treatment options for depression in dialysis patients should consider the following. These include:

Psychological Interventions:

1. Cognitive Behavioral Therapy (CBT): This therapy is a psychotherapy that helps to recognize negative thoughts and change them. It helps to develop coping strategies.

2. Support Groups and Counseling: Support groups help patients to know about people facing the same problem. They try to interact and get to know each other. Patients interacting with psychologists and social workers may get the emotional support they need.

3. Mindfulness and Relaxation Techniques: Relaxation techniques like meditation, breathing exercises, and progressive muscle relaxation can help reduce stress. This can further improve the mood of the affected individuals.

Pharmacological Treatments:

Antidepressants can help reduce depression, but these should be used carefully, considering drug metabolism in kidney disease. These include:

1. Selective Serotonin Reuptake Inhibitors (SSRIs): Drugs such as Sertraline, Escitalopram, and Citalopram are considered as they have low renal clearance.

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Vanlafaxine is required due to kidney function.

3. Mirtazapine: This drug can be used to correct appetite and sleep disturbances. It is usually used in dialysis patients.

4. Avoiding Particular Medications: Some medications, such as Tricyclic antidepressants (TCAs) and Monoamine oxidase inhibitors (MAOIs), should be used very cautiously. The reason is their side effects, such as fluctuation of blood pressure.

Lifestyle Modifications:

1. Exercise: Physical exercises help to improve mood and overall well-being.

2. Nutrition: Dialysis patients generally face malnutrition. Giving them the proper nutrition may help elevate their mood and energy levels.

3. Sleep: Any sleep disorders should be addressed so that depressive symptoms are reduced.

Dialysis-Related Changes:

• If dialysis duration is longer and done frequently, it can improve depression along with overall well-being.

• Treating dialysis-related pain and fatigue can improve depression.

Social Support and Spiritual Care:

• Family members and loved ones can improve depression symptoms.

• Religious and spiritual support, like faith, can help deal with depressive symptoms.

Integrated Approach:

• Combined efforts from nephrologists, psychiatrists, psychologists, social workers, and dieticians can give better outcomes for dialysis patients.

How to Live With Dialysis and Depression?

It is a very challenging task to live with dialysis and depression. There are certain ways to reduce these challenges.

• Taking care of mental health by seeking help from psychiatrists and psychologists.

• Accepting emotions is important.

• Family, friends, and support groups may help.

• Properly taking the medications can help.

• Keeping track of dialysis and medications.

• Not getting isolated from society, and lifestyle modifications.

These can help improve the quality of life of affected individuals.

Conclusion:

Depression is a mental health disorder. Dialysis treatment exhibits many challenges to the affected individual. It may create depression among them. Dealing with depression is very important. Sometimes, depression may not be recognized and may be misdiagnosed. This causes many problems. Hence, it becomes important to identify depression among dialysis patients early.

Key Takeaways from iCliniq

Depression among those undergoing dialysis is found to be common. Often, it is not noticed. Understanding it helps in managing it effectively.