Depression as a determinant of quality of life in patients with chronic disease: data from Brazil

Global prevalence of depression in chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is commonly associated with psychosocial problems, especially depression, contributing to poor overall outcomes. Depression has not been given adequate priority in the management of CKD patients despite its significant adverse impact on all major outcomes. This systematic review and meta-analysis determined the pooled prevalence of clinical depression in the global CKD population and sub-populations.

METHODS

PubMed, African Journals Online (AJOL), and EMBASE were systematically searched to identify published articles with relevant data. The pooled prevalence of clinical depression in the global CKD population was determined using random effects meta-analytic techniques. The study protocol was registered with PROSPERO (CRD42022382708).

RESULTS

Sixty-five articles were included in this review, comprising 80,932 individuals with CKD from 27 countries. The participants' mean age ranged from 11.0 to 76.3 years. Most (70.4%) of the studies had medium methodological quality. The overall pooled prevalence of depression was 26.5% (95% CI 23.1-30.1%). Studies using the Diagnostic Statistical Manual for Mental Diseases (DSM) and International Classification of Disease (ICD) returned a pooled prevalence of 25.5% and 39.6%, respectively, p = 0.03. There was a significant difference in the pooled prevalence across regions; p = 0.002.The prevalence of depression was higher among individuals on chronic hemodialysis compared to pre-dialysis patients (29.9% versus 18.5%; p = 0.01) and among those on hemodialysis compared to peritoneal dialysis (30.6% versus 20.4%; p = 0.04). There was no significant difference between adults and children (26.8% versus 15.9%, p = 0.21). There was an increasing temporal trend in depression prevalence, though this did not achieve statistical significance (p = 0.16).

CONCLUSION

Depression is common in patients with CKD. The findings of this study highlight the need for clinicians to make efforts to evaluate individuals with CKD for depression, especially those with advanced stages of the disease.

Group Psychological Treatment Preferences of Individuals Living With Chronic Disease: Brief Report of a Saskatchewan-Based Cross-Sectional Survey

Given that individuals with chronic diseases comorbid with psychological distress experience worse clinical outcomes than those without psychological distress, treatment of the psychological sequalae that accompanies chronic diseases is of utmost importance. Thus, the present study aimed to examine group treatment preferences among adults living with chronic disease in Saskatchewan, Canada. An online survey regarding group treatment preferences was administered to 207 participants living with chronic disease comorbid with psychological distress. The most often reported treatment scenario was virtual sessions (45%) lasting 1 h (51%) and occurring every other week (45%) in the evening (63%) for 3 to4 months (40%). Preferences included a medium group (48%), a relatively closed group nature (ie, only occasional new members; 44%), and group leadership including at least 1 professional living with chronic disease (54%). Future-oriented (81%), supportive (83%), skill-based (95%), and group discussions (78%) were desired treatment characteristics among participants. Survey results showed clear preferences on treatment content and session logistics. Slight variations exist by gender and age, but a consensus can be identified and act as a preliminary treatment plan. This study contributes to the body of literature on psychological treatment preferences for individuals living with chronic disease by outlining the preferred format and composition of groups according to those with lived experience. Group-based psychological treatment for chronic disease patients should account for these preferences to improve its acceptability and usefulness among patients.

Quality of life and functional capacity in depressive patients on hemodialysis: a systematic review and meta-analysis

Depression is a common disorder in patients with chronic kidney disease (CKD), and some data support its relationship with functional capacity and quality of life. However, to date, this has not been evaluated systematically or through meta-analysis. We sought to investigate the relationship of quality of life and functional capacity with depressive disorder in patients with CKD on hemodialysis. This systematic review considered studies published up to 2021 and included cross-sectional and cohort studies. PubMed, Embase, SPORTDiscus, Web of Science, and Cochrane (CENTRAL) databases were used to search for studies. The New Castle-Ottawa Quality Assessment scale was used to measure the quality of the studies. A total of 4,626 studies were found and, after applying the selection criteria, 16 studies (2,175 patients) remained for qualitative analysis and 10 for meta-analysis (1,484 patients). The physical component summary (MD=-6.563; 95%CI: -9.702 to -3.424) and mental component summary (MD=-18.760; 95%CI: -28.641 to -8.879) were lower in depressive patients, as in all Short Form Health Survey 36 (SF-36) domains. Only one study provided data regarding functional capacity, but it was not evaluated by the defined outcome measure. Twelve studies were classified as "moderate quality" (5 to 6 stars) and four were classified as "low-quality" (0 to 4 stars). This meta-analysis with CKD patients on hemodialysis showed a negative relationship between depression and quality of life, with worsening in all physical and mental domains of the SF-36 in depressed patients.

Quality of life of pediatric and adult individuals with osteogenesis imperfecta: a meta-analysis

BACKGROUND

Osteogenesis imperfecta (OI) is a group of rare inheritable disorders of connective tissue. The cardinal manifestations of OI are low bone mass and reduced bone mineral strength, leading to increased bone fragility and deformity that may lead to significant impairment in daily life. The phenotypic manifestations show a broad range of severity, ranging from mild or moderate to severe and lethal. The here presented meta-analysis aimed to analyze existing findings on quality of life (QoL) in children and adults with OI.

METHODS

Nine databases were searched with predefined key words. The selection process was executed by two independent reviewers and was based on predetermined exclusion and inclusion criteria. The quality of each study was assessed using a risk of bias tool. Effect sizes were calculated as standardized mean differences. Between-study heterogeneity was calculated with the I² statistic.

RESULTS

Among the studies included two featured children and adolescents (N = 189), and four adults (N = 760). Children with OI had significantly lower QoL on the Pediatric quality of life inventory (PedsQL) with regards to the total score, emotional, school, and social functioning compared to controls and norms. The data was not sufficient to calculate differences regarding OI-subtypes. In the adult sample assessed with Short Form Health Survey Questionnaire, 12 (SF-12) and 36 items (SF-36), all OI types showed significantly lower QoL levels across all physical component subscales compared to norms. The same pattern was found for the mental component subscales namely vitality, social functioning, and emotional role functioning. The mental health subscale was significantly lower for OI type I, but not for type III and IV. All of the included studies exhibited a low risk of bias.

CONCLUSIONS

QoL was significantly lower in children and adults with OI compared to norms and controls. Studies in adults comparing OI subtypes showed that the clinical severity of the phenotype is not related to worse mental health QoL. Future research is needed to examine QoL in children and adolescents in more sophisticated ways and to better understand the association between clinical severity of an OI-phenotype/severity and mental health in adults.

The prevalence and correlates of depression among patients with chronic diseases in the United Arab Emirates

BACKGROUND

Chronic diseases constitute a major public health problem in the United Arab Emirates (UAE) and are the leading cause of mortality and morbidity. Chronic diseases have been found to be associated with an increased prevalence of depression and depressive symptoms. Depression can have detrimental effect on the prognosis of the disease and quality of life in patients.

AIMS AND OBJECTIVES

This study aimed to estimate the prevalence and correlates of depression in a sample of patients suffering from chronic disease in Al-Ain city, UAE.

MATERIALS AND METHODS

A cross-sectional survey based study was conducted with 417 participants recruited from seven primary health care centers of Al-Ain city. Men and women aged 18 years and above suffering from chronic disease filled the Patient Health Questionnaire (PHQ-9). Univariate and multivariable logistic regressions were performed on the collected data to investigate correlates of different factors with depression. Data was analyzed using SPSS (version 26). The study was approved by Ambulatory Healthcare Services (AHS) Human Ethics Research Committee.

RESULTS

The majority 62.41% (n = 254) of the sample were females, 57.97% (n = 240) aged above 55 years and with a median (Q25, Q75) duration of chronic disease of 8 (4, 15) years. The prevalence of depression was 21.1% (95% CI: 17.5%-25.3%). With severe depression was in 1.7% and mild-moderate in 34.7% of the participants. Depression severity was statistically significantly associated with increasing age (p = 0.006), low level of education (p<0.001), presence of asthma (p = 0.007) and heart disease (p = 0.013). Unadjusted logistic regression reported that presence of depression was significantly associated with female gender (cOR = 1.8, [95% CI; 1.1-3.1], p = 0.025), and presence of chronic kidney disease (cOR = 4.9, [95% CI; 1.3-20.2], p = 0.020) and heart disease (cOR = 2.9, [95% CI; 1.6-5.4], p = 0.001) longer duration of disease in years (cOR = 1.04, [95% CI; 1.01-1.07], p = 0.003). However, in the adjusted logistic regression analysis, participants with heart disease (aOR = 2.8, [95% CI; 1.4-5.5], p = 0.004), and with longer duration of disease (aOR = 1.04, [1.01-1.07], p = 0.014) remained significantly associated statistically with higher chance of having depression.

CONCLUSION

The prevalence of depression was quite high and the study highlights for health care professionals and policy makers, the importance of mental health support as part of a comprehensive management plan for patients with chronic diseases. A multidisciplinary comprehensive program will improve the long-term outcomes of these patients. Patients with chronic diseases may need more support and counseling at primary health care levels.

Affective and anxiety disorders in patients with different rare chronic diseases: a systematic review and meta-analysis

We aimed to identify the prevalence of affective and anxiety disorders across different rare disease and identify correlates of psychopathology. We performed a systematic review and meta-analysis. We systematically searched Medline, PSYNDEX, PsycINFO for observational studies examining clinically diagnosed affective and/or anxiety disorders in adults with rare chronic diseases. Two researchers reviewed titles and abstracts independently and, for eligible studies, independently extracted data. The prevalence rates were pooled using a random intercept logistic regression model. We published a review protocol (http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018106614CRD42018106614). We identified and screened 34 402 records for eligibility and considered 39 studies in the qualitative and 37 studies in the quantitative analysis, including N = 5951 patients with 24 different rare diseases. Heterogeneity between studies was large. Prevalence rates ranged widely between studies, with pooled prevalence estimates of 13.1% (95% CI 9.6-17.7%; I2 = 87%, p < 0.001) for current and 39.3% (95% CI 31.7-47.4%; I2 = 84%, p < 0.001) for lifetime major depressive disorder, 21.2% (95% CI 15.4-28.6%; I2 = 90%, p < 0.001) for current and 46.1% (95% CI 35.8-56.8%; I2 = 90%, p < 0.001) for lifetime affective disorders, and 39.6% (95% CI 25.5-55.6%; I2 = 96%, p < 0.001) for current and 44.2% (95% CI 27.0-62.9%; I2 = 94%, p < 0.001) for lifetime anxiety disorders. Sensitivity analyses excluding studies of low quality revealed nearly the same results. We conducted the first systematic review examining affective and anxiety disorders in adults with different rare diseases and found high prevalence rates. Supporting patients in disease adjustment can be crucial for their overall health and well-being.

Individual and organizational health literacies: moderating psychological distress for individuals with chronic conditions

BACKGROUND

People with chronic conditions experience high psychological distress.

METHODS

Using the National Health Survey in Australia during 2017-18, the study assessed whether and which health literacies moderated the relationship between chronic conditions and psychological distress for diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), arthritis, other musculoskeletal conditions, asthma, other chronic lower respiratory diseases and cancer. Psychological distress was regressed on chronic diseases, health literacy domains and their interactions, controlling for demographic, socioeconomic and health factors.

RESULTS

Of 5790 adults, 4212 (72.75%) aged 18-64; 846 (14.6%) had high or very high psychological distress, 1819 (31.4%) had diabetes, CKD or CVD, 2645 (45.7%) musculoskeletal conditions, and 910 (15.7%) lower respiratory conditions. Having sufficient information from healthcare providers was associated with the lowest level of psychological distress for CKD and cancer. Social support was associated with significantly lower levels of psychological distress for cardiovascular, musculoskeletal and lower respiratory conditions. Understanding health information was associated with the largest improvement in psychological distress for diabetes.

CONCLUSIONS

Higher health literacies were associated with reduced risks of psychological distress among individuals managing chronic conditions. Interventions for improving self-management and health inequalities should incorporate disease-specific health literacy enhancement strategies at individual and organizational levels.

Quality of life among patients with cardiac disease: the impact of comorbid depression

BACKGROUND

Patients with cardiac disease with or without depression may also have major physical and mental problems. This study assesses and compares the quality of life (QOL) of patients with cardiac disease with and without depression and accompanying comorbidities.

METHODS

A cross-sectional study was conducted with a convenience sample of 388 patients with cardiac disease. The 12-item Short-Form (SF-12)-patient was used to measure physical component scale (PCS) and mental component scale (MCS) QOL, and the Patient Health Questionnaire (PHQ-9) was used to measure depression. The Charlson Comorbidity Index was used to estimate 10-year survival probability. Descriptive statistics, analysis of covariance (ANCOVA), chi-square tests, and binary logistic regression were used for analysis.

RESULTS

The prevalence of minimal to mild depression was 65.7% [(95% CI (60.8, 70.4)] and that of moderate to severe depression was 34.3% [95% CI (29.6, 39.2)]. There was no significant association between the level of PHQ-categorised depression and age (p = 0.171), sex (p = 0.079), or ethnicity (p = 0.407). The overall mean PCS and MCS QOL was 32.5 [95% CI (24.4, 40.64)] and 45.4 [95% CI (44.4, 46.4)], respectively, with no significant correlation between PCS and MCS [r (Pearson's) = 0.011; p = 0.830)]. There were QOL differences among the five PHQ categories (PCS: p = 0.028; MCS: p ≤ 0.001) with both MCS and PCS decreasing with increasing depression. ANCOVA (with number of comorbidities as the covariate) showed a significant age × ethnicity interaction for PCS (p = 0.044) and MCS (p = 0.039), respectively. Young Indo-Trinidadians had significantly lower PCS than did Afro-Trinidadians, while the converse was true for MCS. Depression, age, and number of comorbidities were predictors of PCS, while depression, age, and sex were predictors of MCS.

CONCLUSIONS

Increasing severity of depression worsened both PCS and MCS QOL. Age and level of clinical depression predicted QOL, with number of comorbidities predicting only PCS and sex predicting only MCS. Efforts must be made to treat depression in all age groups of patients with cardiac disease.

Quality of life may be a more valuable prognostic factor than depression in older hemodialysis patients

PURPOSE

Depression and impairment of quality of life (QoL) reduce the survival of individual on hemodialysis (HD). However, few studies evaluated the impact of these conditions on the survival of older patients undergoing HD.

METHODS

A retrospective cohort study was performed including patients aged ≥ 60 years on HD in Recife, Brazil, assessed in 2013 and monitored until 2017. Depression was evaluated with the Mini-International Neuropsychiatric Interview and QoL with the Control, Autonomy, Self-realization, and Pleasure Questionnaire (CASP-16). Survival differences according to the depression and QoL status were measured by Kaplan-Meier analysis and Cox regression. Death Certificates were analyzed to assess the cause of death.

RESULTS

A total of 171 patients were included (mean age 68.7 ± 6.9 years). The mean follow-up time was 3 years (maximum 4.5 years) and there were 98 deaths (57.3% of the sample). In a multivariate model that included depression and QoL, only QoL impairment was associated with a higher risk of death (HR 1.62, p = 0.035). Among CASP domains, only "Control" was associated with survival (HR 0.90, p = 0.014). Depression was unrelated to the cause of death, but there was a trend for death by endocrine diseases if QoL was impaired (p = 0.057).

CONCLUSION

QoL impairment is a key predictor of prognosis in older patients on HD and may be more important than depression. It is important that teams dealing with this population include in protocols an assessment of QoL, in order to offer a range of care according to the needs of these patients.

Relationships between illness representations, physical activity and depression in chronic kidney disease

BACKGROUND

Chronic Kidney Disease (CKD) is exacerbated by depression and confers significant healthcare costs. Whilst adverse impacts may be mitigated by physical activity, many patients with CKD remain physically inactive, with this physical inactivity potentially influenced by how CKD is appraised.

OBJECTIVES

The study aims to explore the relationship between physical activity, depression and illness representations in CKD.

METHODS

Patients with CKD but not requiring dialysis completed the Revised Illness Perception Questionnaire (IPQ-R), Beck Depression Inventory (BDI-II) and Short-Form International Physical Activity Questionnaire (IPAQ-SF). Demographic information was obtained via medical records. Correlation and regression analyses were conducted to determine the relationship of illness representations with levels of physical activity. Moderation and mediation analyses were performed to investigate the role of depression in any relationship between illness representations and physical activity levels.

RESULTS

Seventy respondents, 60 % male, with a mean age of 60 ± 16 years, took part in the study. Of illness representation dimensions, personal control was positively associated with levels of physical activity whilst timeline cyclical (a subscale of the IPQ-R relating to patient beliefs about the nature of their illness) was a significant predictor. Severity of depression was neither a moderator nor a mediator of illness representations and levels of physical activity.

CONCLUSION

Facets of illness representations had significant relationships with levels of physical activity. Future research concerning the development and validation of psychological interventions based on an illness representations framework for patients with CKD not requiring dialysis is proposed. The efficacy of such interventions could be then evaluated using a randomised controlled method.

Depression and quality of life in patients on long term hemodialysis at a nationalhospital in Ghana: a cross-sectional study

The study examined quality of life and prevalence of depressive symptoms in patients on long term hemodialysis. Further, it explored the impact of socio-demographic characteristics on depression and quality of life.

DESIGN

Study design was cross-sectional.

SETTING

Study was conducted in the two renal dialysis units of the Korle-Bu Teaching hospital in Accra, Ghana.

PARTICIPANTS AND STUDY TOOLS

One hundred and six participants on haemodialysis were recruited for the study. The Patient Health Questionnaire and the World Health Organization Quality of Life instrument were used to assess depression and quality of life.

RESULTS

Forty five percent of participants screened positive for symptoms of depression. Approximately 19% obtained low scores on overall quality of life. There were significant negative correlations between the following: Depression and overall QoL, Depression and duration of dialysis treatment and Depression and income level. There was positive correlation between overall QoL and duration of dialysis, treatment and income.

CONCLUSION

Depressive symptoms were common amongst patients on long term hemodialysis. Haemodialysis patients who obtained low scores on quality of life measures were more likely to screen positive for depressive symptoms. Screening for depressive symptoms among these patients is critical as early treatment may improve their general wellbeing.

FUNDING

Not indicayed.

Pesticide exposure, tobacco use, poor self-perceived health and presence of chronic disease are determinants of depressive symptoms among coffee growers from Southeast Brazil

The lifestyle and other factors associated with the appearance of several health conditions that affect quality of life in rural zone is an issue that has been increasingly explored. Brazil is the largest coffee-producing nation in the world and has been a considerable consumer of pesticides since 2008. The aim of the present study was to investigate factors that could be contributing to the appearance of depressive symptoms in rural workers. Two hundred twenty male volunteers from nine cities in Southeast Brazil completed the Beck Depression Inventory-II (BDI-II) questionnaire about depressive symptoms and provided other information about socio-demographic characteristics and additional confounding factors. The adjusted multivariate logistic analysis demonstrated that pesticide exposure, tobacco use, poor self-perceived health and the presence of chronic disease contribute as risk factors for the appearance of depressive symptoms at a level above ups and downs considered normal in the BDI-II. This survey contributes to the search for solutions to improve quality of life and mental health in the rural living to the extent that social determinants of depression are being investigated.

The Relationship Between Fatigue and Depression in Adults With End-Stage Renal Disease on Chronic In-Hospital Hemodialysis: A Scoping Review

CONTEXT

Fatigue and depression are two prominent concerns in patients on in-hospital hemodialysis (IHHD) that have recently been identified as research priorities in the nephrology community. Although they are often reported to co-exist, no synthesis of the literature examining their relationship is available.

OBJECTIVE

The aim of this study was to characterize the literature on the relationship between fatigue and depression in IHHD patients.

METHODS

A scoping review as described by Arksey and O'Malley was conducted. Seven electronic databases were searched for relevant literature using search terms pertaining to fatigue, depression, and IHHD. Key journals and article reference lists were also hand searched to identify relevant literature. Articles were examined for relevance, and data were extracted to describe the nature and scope of the literature and to characterize the relationship between fatigue and depression. Findings were grouped thematically and summarized descriptively.

RESULTS AND CONCLUSIONS

Current literature on this topic is dominated by cross-sectional studies, which support the existence of an association between fatigue and depression in IHHD patients in various practice settings and subpopulations. Numerous multivariable analyses have been performed which suggest the association remains after adjustment for confounding factors. However, there is generally a dearth of longitudinal or interventional literature to clarify the nature of the relationship over time. Current literature is sufficient to justify routine screening for depression in IHHD patients who present with fatigue. Future research should aim to clarify the nature of the relationship over time in IHHD patients, explore mediators and modifiers of the relationship, and investigate the effects of interventions.

A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies

BACKGROUND

Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints.

OBJECTIVE

The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates.

METHODS

Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers.

RESULTS

Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal.

CONCLUSIONS

This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.

Acceptance of Antidepressant Treatment by Patients on Hemodialysis and Their Renal Providers

BACKGROUND AND OBJECTIVES

Depression is common in patients receiving chronic hemodialysis but seems to be ineffectively treated. We investigated the acceptance of antidepressant treatment by patients on chronic hemodialysis and their renal providers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

As part of a clinical trial of symptom management in patients on chronic hemodialysis conducted from 2009 to 2011, we assessed depression monthly using the Patient Health Questionnaire 9. For depressed patients (Patient Health Questionnaire 9 score ≥10), trained nurses generated treatment recommendations and helped implement therapy if patients and providers accepted the recommendations. We assessed patients' acceptance of recommendations, reasons for refusal, and provider willingness to implement antidepressant therapy. We analyzed data at the level of the monthly assessment.

RESULTS

Of 101 patients followed for ≤12 months, 39 met criteria for depression (Patient Health Questionnaire 9 score ≥10 on one or more assessments). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 (70%) assessments, patients were receiving antidepressant therapy, and at 51 of 70 (70%) assessments, patients did not accept nurses' recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving antidepressant therapy, and in 40 (91%) instances, they did not accept recommendations to start treatment. The primary reason that patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 (61%) instances in which patients accepted the recommendation, renal providers were unwilling to provide treatment.

CONCLUSIONS

Patients on chronic hemodialysis with depression are frequently not interested in modifying or initiating antidepressant treatment, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Renal providers are often unwilling to modify or initiate antidepressant therapy. Future efforts to improve depression management will need to address these patient- and provider-level obstacles to providing such care.

Long-term Cost-Effectiveness of Diagnostic Tests for Assessing Stable Chest Pain: Modeled Analysis of Anatomical and Functional Strategies

Several tests exist for diagnosing coronary artery disease, with varying accuracy and cost. We sought to provide cost-effectiveness information to aid physicians and decision-makers in selecting the most appropriate testing strategy. We used the state-transitions (Markov) model from the Brazilian public health system perspective with a lifetime horizon. Diagnostic strategies were based on exercise electrocardiography (Ex-ECG), stress echocardiography (ECHO), single-photon emission computed tomography (SPECT), computed tomography coronary angiography (CTA), or stress cardiac magnetic resonance imaging (C-MRI) as the initial test. Systematic review provided input data for test accuracy and long-term prognosis. Cost data were derived from the Brazilian public health system. Diagnostic test strategy had a small but measurable impact in quality-adjusted life-years gained. Switching from Ex-ECG to CTA-based strategies improved outcomes at an incremental cost-effectiveness ratio of 3100 international dollars per quality-adjusted life-year. ECHO-based strategies resulted in cost and effectiveness almost identical to CTA, and SPECT-based strategies were dominated because of their much higher cost. Strategies based on stress C-MRI were most effective, but the incremental cost-effectiveness ratio vs CTA was higher than the proposed willingness-to-pay threshold. Invasive strategies were dominant in the high pretest probability setting. Sensitivity analysis showed that results were sensitive to costs of CTA, ECHO, and C-MRI. Coronary CT is cost-effective for the diagnosis of coronary artery disease and should be included in the Brazilian public health system. Stress ECHO has a similar performance and is an acceptable alternative for most patients, but invasive strategies should be reserved for patients at high risk.

Health status and mental health in patients after percutaneous coronary intervention

OBJECTIVE

to assess the association between perceived health status and the mental health of patients submitted to percutaneous coronary intervention after hospital discharge.

METHOD

a quantitative and cross-sectional study involving 101 participants. The following instruments were used: a sociodemographic and clinical characterization instrument, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Hospital Anxiety and Depression Scale (HADS). Participants were divided into three groups: no anxiety and no depression (G1); anxiety or depression (G2); and both (G3). The ANOVA test was used for the intergroup comparison of means on the SF-36 domains.

RESULTS

There was an association between perceived health status and mental health. The participants in G1 presented higher scores in all SF-36 domains in comparison with participants in G2 and G3.

CONCLUSION

Participants with no anxiety and depression presented better-perceived health status in comparison with those with anxiety or depression, or both.

The Impact of Anxiety and Depression on the Quality of Life of Hemodialysis Patients

Material and Methods:

The sample studied consisted of 395 hemodialysis patients. Data was collected by the completion of a specially designed questionnaire for the needs of the present study which apart from socio-demographic and clinical, it also included HAD_S scale to assess the level of anxiety and depression as well as the scale Missoula-VITAS Quality of Life Index (MVQOLI) to assess patients’ quality of life.

Results:

The results of this study showed that 47.8% had high anxiety levels and 38.2% had high levels of depression. The average total score of quality of life was found to be 17.14. It was also shown that the total score of quality of life presented statistically significant association with family status (p=0.007), educational level (p<0.001), the number of children (p=0.001), patients’ adherence to doctors’ orders (p=0.003) and proposed diet (p=0.002) and the relations of patients with healthcare professionals and the other patients (p<0.001). The multiple linear regression showed that the overall quality of life score was statistically associated with the levels of depression after adjusted for possible confounders. More specifically, it was found that total score of quality of life was 2.5 and 4.4 points lower for patients with moderate and high levels of depression, respectively, compared to patients with low levels of depression (p<0.001).

Conclusions:

Evaluation of anxiety and depression in conjunction with quality of life in hemodialysis patients should be an integral part of the therapeutic regimen.

Factors determining social function of patients after renal transplantation in Taiwan

BACKGROUND

Patients who are no longer in need of dialysis as a consequence save time and reduce stress every day. Social function was an important issue in patients with successful renal transplantation. According Bandura's social cognitive theory, ones' behavior is affected by social context and affective factors continuously. The quality of social function needs further investigation.

PURPOSE

The aims of this study were to describe the degree of social function after renal transplantation and to explore its predictive factors.

METHOD

A cross-sectional and descriptive study design was conducted in the outpatient department of a medical center in northern Taiwan from July to October 2010. The recipients were a convenience sample of 101 participants who had undergone renal transplantation. Hierarchical multivariate regression analysis was used to explore the predictive factors related to social function.

RESULTS

The results showed that renal transplant recipients have moderate to high social function. Regression analyses showed that psychological factors (perceived stress, stress after renal transplantation, and depressive symptoms) and social participation (paid-work and leisure activity) explained 37.1% of the total variance for social function. Depressive symptoms explained most of the total variance.

CONCLUSION

After renal transplantation, patients experienced higher levels of social function. Perceived stress, stress after renal transplantation, depressive symptoms, paid-work, and leisure activity were the predictive factors of social function. Managing levels of depressive symptoms is highly recommended to elevate the patient's social function.

Cost-effectiveness of high, moderate and low-dose statins in the prevention of vascular events in the Brazilian public health system

Background

Statins have proven efficacy in the reduction of cardiovascular events, but the financial impact of its widespread use can be substantial.

Objective

To conduct a cost-effectiveness analysis of three statin dosing schemes in the Brazilian Unified National Health System (SUS) perspective.

Methods

We developed a Markov model to evaluate the incremental cost-effectiveness ratios (ICERs) of low, intermediate and high intensity dose regimens in secondary and four primary scenarios (5%, 10%, 15% and 20% ten-year risk) of prevention of cardiovascular events. Regimens with expected low-density lipoprotein cholesterol reduction below 30% (e.g. simvastatin 10mg) were considered as low dose; between 30-40%, (atorvastatin 10mg, simvastatin 40mg), intermediate dose; and above 40% (atorvastatin 20-80mg, rosuvastatin 20mg), high-dose statins. Effectiveness data were obtained from a systematic review with 136,000 patients. National data were used to estimate utilities and costs (expressed as International Dollars - Int$). A willingness-to-pay (WTP) threshold equal to the Brazilian gross domestic product per capita (circa Int$11,770) was applied.

Results

Low dose was dominated by extension in the primary prevention scenarios. In the five scenarios, the ICER of intermediate dose was below Int$10,000 per QALY. The ICER of the high versus intermediate dose comparison was above Int$27,000 per QALY in all scenarios. In the cost-effectiveness acceptability curves, intermediate dose had a probability above 50% of being cost-effective with ICERs between Int$ 9,000-20,000 per QALY in all scenarios.

Conclusions

Considering a reasonable WTP threshold, intermediate dose statin therapy is economically attractive, and should be a priority intervention in prevention of cardiovascular events in Brazil.

Longitudinal associations of depressive symptoms and pain with quality of life in patients receiving chronic hemodialysis

Depressive symptoms and pain are common in patients on chronic hemodialysis (HD), yet their associations with quality of life (QOL) are not fully understood. We sought to characterize the longitudinal associations of these symptoms with QOL. As part of a trial comparing two symptom management strategies in patients receiving chronic HD, we assessed depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9), and pain using the Short Form McGill Pain Questionnaire (SF-MPQ) monthly over 24 months. We assessed health-related QOL (HR-QOL) quarterly using the Short Form 12 (SF-12) and global QOL (G-QOL) using a single-item survey. We used random effects linear regression to analyze the independent associations of depressive symptoms and pain, scaled based on 5-point increments in symptom scores, with HR-QOL and G-QOL. Overall, 286 patients completed 1417 PHQ-9 and SF-MPQ symptom assessments, 1361 SF-12 assessments, and 1416 G-QOL assessments. Depressive symptoms were independently and inversely associated with SF-12 physical HR-QOL scores (β = -1.09; 95% confidence interval [CI]: -1.69, -0.50, P < 0.001); SF-12 mental HR-QOL scores (β = -4.52; 95% CI: -5.15, -3.89, P < 0.001); and G-QOL scores (β = -0.64; 95%CI: -0.79, -0.49, P < 0.001). Pain was independently and inversely associated with SF-12 physical HR-QOL scores (β = -0.99; 95% CI: -1.30, -0.68, P < 0.001) and G-QOL scores (β = -0.12; 95%CI: -0.20, -0.05, P = 0.002); but not with SF-12 mental HR-QOL scores (β = -0.16; 95%CI: -0.050, 0.17, P = 0.34). In patients receiving chronic HD, depressive symptoms and to a lesser extent pain, are independently associated with reduced HR-QOL and G-QOL. Interventions to alleviate these symptoms could potentially improve patients' HR-QOL and G-QOL.

Depression and its correlates in South Africa and Ghana among people aged 50 and above: Findings from the WHO Study on global AGEing and adult health

OBJECTIVE

The growth of the older adult population in Africa demands more knowledge about their chronic health problems, such as depression. The aim of this paper is to estimate depression prevalence and identify correlates of depression among older adults in Ghana and South Africa.

METHOD

The WHO Study on global AGEing and adult health (SAGE study) was conducted in Ghana and South Africa from 2007 to 2009 by the World Health Organization, using a standardized questionnaire among an adult population. Our analyses included 4289 adults aged 50 and above in Ghana and 3668 in South Africa. Depression was measured using self-reported symptoms over the last 12 months according to ICD-10 criteria.

RESULTS

The prevalence of mild depression was 6.7% and 2.7% in Ghana and South Africa, respectively (p<.001), with a gender difference only in Ghana. Factors independently associated with depression among women in Ghana were migration and lack of current work.. Similarly, higher age, lack of current work and lower quality of life were independently associated with depression among women in South Africa, whereas higher age and lower quality of life were associated with depression among men in South Africa.

CONCLUSIONS

Ghana had a higher depression rate than South Africa and we identified different factors associated with depression among men and women in these two countries. Our finding underscores the need for culture- and gender-sensitive approaches for the prevention and management of depression among the older adult population in Ghana and South Africa.

Quality of life profile and correlated factors in chronic leg ulcer patients in the mid-west of São Paulo State, Brazil

BACKGROUND

Chronic leg ulcer may have an impact on patients' quality of life.

OBJECTIVES

This study aimed to identify the impact of leg ulcers on patient's quality of life using the Dermatology Life Quality Index and to define the main factors correlated with this perception.

METHOD

Cross-sectional, non-probabilistic sampling study. We included patients with chronic leg ulcers being treated for at least 3 months. A sociodemographic and clinical survey was conducted to assess the profile of the ulcers. We administered a screening for depressive symptoms and the Dermatology Life Quality Index. We performed a descriptive statistical analysis, chi-square test and Mann-Whitney test for categorical data, Pearson for numeric variables, and multiple regression for categorical data.

RESULTS

Forty-one patients were assessed. Their mean age was 61.78 years. Venous ulcers (48.8%) were the most prevalent. Seventy-three percent of the sample perceived no impact/low impact on quality of life in the past week, and 26.8% perceived moderate/high impact. A multiple regression analysis identified the causes of lesion, pain related to the ulcers, time of onset, and severity of the depressive symptoms as the variables that had an influence on quality of life.

CONCLUSIONS

The majority of the sample perceived low or no impact of the condition on the quality of the life. The variables etiology of the lesion (p<0.001), pain related to the ulcers (p=0.001), time of onset (p=0.006), and severity of the depressive symptoms (p<0.001) had an influence on the quality of life, suggesting the need for further studies with more robust designs to confirm the causal relationship between these characteristics and quality of life.

Risk factors of depression after prolonged low-dose rate environmental radiation exposure

PURPOSE

More than 10,000 Taiwanese people were exposed to excessive protracted low-dose rate radiation from contaminated reinforcement bars, which were installed in buildings before 1992. This study was conducted to assess the prevalence of depression amongst the exposed and identify related determinants now that more than two decades have passed since this population was informed of their exposure to radiation.

MATERIALS AND METHODS

We used the Beck depression inventory (BDI)-1A questionnaire to survey 2143 eligible people during their annual physical examinations between March 2009 and December 2009. In total, 1621 people participated in the survey. We employed multivariate logistic regression models with generalized estimating equations method to identify the determinants of depression.

RESULTS

The prevalence of depression (BDI-IA score ≥ 12) was 18.7%. Those who exhibited higher cumulative exposure [adjusted odds ratio (OR): 1.46, 95% confidence interval (CI): 1.02-2.07] and a previous history of depression (adjusted OR: 2.49, 95% CI: 1.36-4.58) were significantly associated with the risk of depression, whereas education level was inversely related to depression (adjusted OR: 0.71, 95% CI: 0.50-0.99).

CONCLUSION

Long-term, low-dose rate radiation exposure early in life might cause subsequent psychological stress and an increased risk of depression decades later.

The effect of self-efficacy, depression and symptom distress on employment status and leisure activities of liver transplant recipients

AIM

To examine the effect of self-efficacy, subjective work ability, depression and symptom distress on and to provide a description of, the employment and leisure activities of liver transplant recipients.

BACKGROUND

Return to work and leisure activities have become an important aspect of life for liver transplant recipients worldwide. An investigation of the factors that influence the employment status and leisure activities has been recommended as a means to help transplant recipients restore their productivity.

DESIGN

This was a cross-sectional, descriptive and correlational study in 2010.

METHODS

A convenience sampling method was used. Data were collected using a set of questionnaires that were administered retrospectively. A total of 106 liver transplant patients were included in this study.

RESULTS

The post-transplantation employment rate was 45.2%. The positive predictors of employment were higher subjective work ability and higher symptom distress. Gender (female), monthly family income (<US $2,000), depression and unemployment pre-transplantation were negatively associated with employment status. Of the 106 patients, 62 (58.5%) were in the low-diversity group (score of less than 3) of leisure activities. Monthly family income of <US $2,000 was associated with a low diversity of participation in leisure activities.

CONCLUSION

Subjective work ability and symptom distress were positive predictors of employment, while depression was a negative predictor. Nurses in the transplant team should focus on increasing a sense of confidence, decreasing depressive symptoms and monitoring the severity of symptoms to improve the employment status of liver transplant recipients.

Depression and sexual dysfunction in chronic kidney disease: a narrative review of the evidence in areas of significant unmet need

People with chronic kidney disease (CKD) have a high symptom burden and experience poorer quality of life than the general population. People with CKD frequently report fatigue, anorexia, pain, sleep disturbance, itching and restless legs. Depression and sexual dysfunction may also be common in CKD, although questions about optimal diagnosis and treatment remain unanswered. People with kidney disease identify lifestyle and the impact of CKD on family and psychosocial supports as key priorities and rate symptoms such as sexual dysfunction and psychological distress as severe. Here, we outline the current state of research underlying depression and sexual dysfunction in this population focusing on prevalence, diagnosis, screening, outcomes and interventions and suggest areas requiring additional specific research.

Relationship between psychiatric disorders and quality of life in nondialysis patients with chronic kidney disease

BACKGROUND

The aim of this study was to investigate the relationship between psychiatric disorders (anxiety and depression) and quality of life (QOL) in nondialysis patients with chronic kidney disease (CKD).

METHODS

QOL was evaluated in a sample of 57 nondialysis patients with CKD using the 36-item Short Form Health Survey questionnaire comprising 8 scales, including the physical component summary and mental component summary measures. Depression and anxiety were estimated using the Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale, respectively.

RESULTS

Depression and anxiety scores were negatively correlated with 7 of the 8 scales of the Short Form 36 questionnaire, and with the physical component summary and mental component summary scores, despite 38.6% patients with depression and 54.4% with anxiety, whereas QOL in the depression group, the anxiety group, and the anxiety and depression comorbid group was lower than that for those without the corresponding psychiatric disorders (P < 0.05).

CONCLUSIONS

This study demonstrates that depression and anxiety, commonly encountered in patients with CKD, could be a risk factor for QOL in 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.

Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review

Objectives

To systematically review evidence on depression screening in coronary heart disease (CHD) by assessing the (1) accuracy of screening tools; (2) effectiveness of treatment; and (3) effect of screening on depression outcomes.

Background

A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening in CHD.

Methods

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases searched through December 2, 2011; manual journal searches; reference lists; citation tracking; trial registries. Included articles (1) compared a depression screening instrument to a depression diagnosis; (2) compared depression treatment to placebo or usual care in a randomized controlled trial (RCT); or (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were few examples of screening tools with good sensitivity and specificity using a priori-defined cutoffs in more than one patient sample among 15 screening accuracy studies. Depression treatment with antidepressants or psychotherapy generated modest symptom reductions among post-myocardial infarction (post-MI) and stable CHD patients (N = 6; effect size = 0.20–0.38), but antidepressants did not improve symptoms more than placebo in 2 heart failure (HF) trials. Depression treatment did not improve cardiac outcomes. No RCTs investigated the effects of screening on depression outcomes.

Conclusions

There is evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. There is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence.

Clinical differences between melancholic and nonmelancholic depression as defined by the CORE system

BACKGROUND

The definition and delineation of melancholia have remained elusive for an extended period. A longstanding signal of psychomotor disturbance has been operationalized via the observer-rated CORE measure and with CORE-assigned melancholic and nonmelancholic compared in several Australian studies. Replication studies in other regions have not previously been reported. This study compares Brazilian patients with melancholic and nonmelancholic depression according to the CORE measure of psychomotor disturbance in terms of clinical characteristics, suicide ideation, stressful life events, quality of life, parental care, and personality styles.

METHODS

A total of 181 patients with unipolar major depression attending a tertiary care outpatient service in Brazil were evaluated in relation to melancholic status and study variables.

RESULTS

The CORE-assigned melancholic patients presented higher symptom severity, greater prevalence of suicide ideation, and Axis I comorbidities than nonmelancholics. Scores of dysfunctional personality styles and dysfunctional parental care measures were also higher among melancholics. Quality-of-life scores were low in both groups.

LIMITATIONS

The absence of a criterion standard for the diagnosis of melancholia and the use of medication can be potential limitations of the study.

CONCLUSION

Differences suggest that CORE-assigned melancholia defines a distinct group of patients and probably a disorder distinct from nonmelancholic depression not only in quantitative but also in qualitative aspects.

Prevalence, Awareness, Treatment, and Burden of Major Depressive Disorder: Estimates from the National Health and Wellness Survey in Brazil

OBJECTIVE

Major depressive disorder (MDD) is often underdiagnosed, undertreated, and associated with negative health outcomes. The current study examined the prevalence of MDD signs and symptoms in Brazil, including awareness, diagnosis, treatment, and the association of MDD with health outcomes.

METHODS

Data were collected from the 2011 National Health and Wellness Survey in Brazil (N = 12,000). Excluding those with bipolar disorder, respondents who met Patient Health Questionnaire-9 criteria for MDD (n = 1105) were compared with those not qualifying as having MDD or any depressive symptoms (n = 8684), analyzing separately those currently taking (n = 184) or not taking (n = 155) prescription medication for depression. Sociodemographics and health status, symptoms, experience of depression, diagnosis, MDD severity, pharmacotherapy, productivity impairment (Work Productivity and Activity Impairment questionnaire), health status (Short-Form 12, version 2), and health care resource use were measured. Results were weighted and projected to the Brazil adult population. Differences were measured with column proportion and mean tests for categorical and continuous outcomes, respectively.

RESULTS

MDD prevalence was 10.2%, with only 28.1% of the individuals with MDD diagnosed and 15.6% currently using prescription medication for depression. Males were especially likely to be unaware of MDD. Compared with non-MDD controls, patients with MDD (treated or untreated) reported significantly greater overall work impairment, worse mental and physical health status, and greater health care resource utilization (all P<0.05). There was a trend for worsening health outcomes with increasing MDD severity.

CONCLUSIONS

These findings suggest that Brazilians may be underdiagnosed and undertreated for MDD. Individuals with MDD reported substantially poorer health outcomes, suggesting the need to increase MDD awareness, especially among males, and provide better access to treatment.

Chronic Ischemic Heart Disease Affects Health Related Quality of Life

Background

Chronic diseases endanger not only physical health but also psychological and social health of patient. Thus, evaluation of such patients for psychological treatment decisions is very important.

Method

This is a descriptive study that was performed with 50 chronic patients (ischemic heart disease) selected from Valiasr and Mousavi at cardiac wards in Zanjan Province. They were given three types of questionnaire: demographic, WHOQOL, and Zung depression and anxiety index. The information was statically analyzed by frequency chart, central indexes, dispersion, Chi-Square and t tests, Pearson’s correlation index (P < 0.05).

Results

The average of quality of life in all patients were calculated as was respectively 12.19, 11.98, 12.08, and 12.4 in physical, psychological, social and environmental domains respectively, 68 percent of total number of the patients had various degrees of anxiety and 78 percent of them had various degrees of depression. There was a significant relationship between the life quality average in all domains and anxiety intensity and depression intensity (P < 0.05) and there was a significant relationship between life quality average in all domains and income (P < 0.05).

Conclusion

As the level of depression and anxiety goes up, quality of life decreases pointing out that they have a reverse relationship. Depression and anxiety are one of the most significant factors of quality of life among other variables. Regarding specific conditions of the treatment, it is necessary to pay special attention to psychological aspects.

Depression and quality of life of hemodialysis patients living in a poor region of Brazil

OBJECTIVE: To determine the correlation between depression and quality of life (QOL) of patients in hemodialysis (HD). METHOD: One hundred and sixty six patients over 18 years of age who had been in HD for at least three months and had no history of transplant. QOL was assessed using the SF-36. To categorize depression, a score > 10 was used on the 10-item version of the Center for Epidemiologic Studies Depression Scale (CES-D). Comparisons between depressed and nondepressed patients were performed using the chi-square test, Student's t-test, and Mann-Whitney test. Multiple regression was performed to assess the predictive variables of patients' QOL. RESULTS: Symptoms of depression were found in 13 (7.8%) patients. The only variable that differed among depressed patients was QOL. Depressed patients presented lower scores in vitality (40.7 vs. 57.3; p = 0.010), role-emotional (25.6 vs. 62.5; p = 0.006), and mental health (50.1 vs. 65.4; p = 0.023). Regression analysis demonstrated that depression was a predictor of role-emotional (OR = 0.981, CI = 0.967-0.996; p = 0.010) and mental health (OR = 0.970, CI = 0.946-0.996; p = 0.022). CONCLUSION: Depressed patients experience a poor QOL because, in addition to their chronically affected physical aspects, they also feel limited in the mental dimensions, which usually have the highest score among non-depressed HD patients.

Risk factors for depressive symptoms in a large population on chronic hemodialysis

Despite their significant influence on the quality of life, depressive symptoms are not usually included as a clinical parameter in the evaluation of hemodialysis patients. We aimed to identify depressive symptoms and associated risk factors in a large group of individuals with end-stage renal disease (ESRD) on chronic hemodialysis. This was a cross-sectional study of 400 consecutive patients. Cases were analyzed according to the presence/absence of depressive symptoms. All individuals were investigated by interview, and all variables were measured concurrently. Depressive symptoms were evaluated by the Beck Depression Inventory (BDI-II ≥16) and sleep quality by the Pittsburgh Sleep Quality Index (PSQI > 5). Among the 400 patients (59% male), depressive symptoms were present in 77 (19.3%). Depressive symptoms were more common in women and were independently associated with poor sleep quality (P = <0.005), unemployment (P = 0.001), diabetes (P = 0.02), hypoalbuminemia (P = 0.01), low education (P = 0.03), and pruritus (P = 0.04). Women with ESRD on chronic hemodialysis are at increased risk of depression. Furthermore, unemployment and the presence of diabetes, hypoalbuminemia, low education, and pruritus are significantly associated with depressive symptoms. Depressive symptoms are also independently associated with poor quality sleep and studies about the effects of sleep hygiene therapy on depressive symptoms are warranted.