Self-reported depression symptoms in haemodialysis patients: Bi-factor structures of two common measures and their association with clinical factors

Approaches to the identification and management of depression in people living with chronic kidney disease: A scoping review of 860 papers

BACKGROUND

Depression is prevalent across the spectrum of Chronic Kidney Disease and associated with poorer outcomes. There is limited evidence regarding the most effective interventions and care pathways for depression in Chronic Kidney Disease.

OBJECTIVES

To investigate how depression is identified and managed in adults with Chronic Kidney Disease.

DESIGN

Scoping review.

METHODS

Systematic search of eight databases with pre-defined inclusion criteria. Data relevant to the identification and/or management of depression in adults with Chronic Kidney Disease were extracted.

RESULTS

Of 2147 articles identified, 860 were included. Depression was most identified using self-report screening tools (n = 716 studies, 85.3%), with versions of the Beck Depression Inventory (n = 283, 33.7%) being the most common. A total of 123 studies included data on the management of depression, with nonpharmacological interventions being more frequently studied (n = 55, 45%). Cognitive Behavioural Therapy (n = 15) was the most common nonpharmacological intervention, which was found to have a significant effect on depressive symptoms compared to controls (n = 10). However, how such approaches could be implemented as part of routine care was not clear. There was limited evidence for antidepressants use in people with Chronic Kidney Disease albeit in a limited number of studies.

CONCLUSIONS

Depression is commonly identified using validated screening tools albeit differences exist in reporting practices. Evidence regarding the management of depression is mixed and requires better-quality trials of both pharmacological and nonpharmacological approaches. Understanding which clinical care pathways are used and their evidence, may help facilitate the development of kidney care specific guidelines for the identification and management of depression.

The identification and management of depression in UK Kidney Care: Results from the Mood Maps Study

BACKGROUND

Depression is common in people with chronic kidney disease, yet little is known about how depression is identified and managed as part of routine kidney care.

OBJECTIVES

The primary objective was to survey all UK adult kidney centres to understand how depression is identified and managed. A secondary objective was to broadly describe the variability in psychosocial care.

DESIGN

Online survey.

METHODS

The survey comprised of three sections: (1) general kidney care, (2) psychological provision and (3) social work provision.

RESULTS

48/68 (71%) of centres responded to the general survey with 20 and 13 responses from psychological and social work module respectively. Only 31.4% reported having both in centre psychological and social work practitioners. Three centres reported no access to psychosocial provision. Of the 25 centres who reported on pathways, 36.0% reported having internal pathways for the identification and management of depression. Within services with psychological provision, screening for depression varied across modality/group (e.g., 7.1% in mild/moderate chronic kidney disease vs. 62.5% in kidney donors). Cognitive Behavioural Therapy and Acceptance and Commitment Therapy were the most common interventions offered. Most psychosocial services were aware of the National Institute for Health and Care Excellence guidelines for managing depression in long-term conditions (n = 18, 94.7%) yet few fully utilised (n = 6, 33.3%). Limited workforce capacity was evident.

CONCLUSIONS

There is considerable variability in approaches taken to identify and treat depression across UK kidney services, with few services having specific pathways designed to detect and manage depression. Workforce capacity remains a significant issue.

Do patients dialysing with higher ultrafiltration rates report more intradialytic symptoms and longer postdialysis recovery times?

BACKGROUND

Many hemodialysis (HD) patients report intradialytic symptoms, and take time to recover postdialysis. To improve quality of life, patient groups have highlighted the need to reduce postdialysis fatigue and other peridialytic symptoms. As compartmental shifts of fluid during dialysis have been proposed to cause peridialytic symptoms we investigated whether patients dialysing with higher ultrafiltration rates (UFR) reported more intradialytic symptoms and recovery times.

METHODS

We reviewed the hospital records of HD patients who completed a self-reported intradialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous midweek pre- and postdialysis segmental bioimpedance measurements.

RESULTS

Six hundred and five patients returned the peridialytic symptom questionnaire with pre- and postdialysis bioimpedance measurements. The majority were male (64.8%), mean age 64.2 ± 15.6 years, duration of dialysis treatment 26.8 (10.7-59.2) months, 85% treated by hemodiafiltration and mean dialysate temperature 35.4 ± 0.4°C. We divided patients into terciles according to UFR adjusted for weight, and there was a greater fall in the ratio of extracellular water (ECW) to total body water (TBW) postdialysis in the nonfistula arm from the lower to middle to higher tercile (0.8 (0-1.54) vs. 1.28 (0.52-1.85) vs. 1.54 (0.78-2.52)), trunk (1.5 (0.74-2.27) vs. 1.53 (0.99-2.2) vs. 1.98 (1.18-2.66)), left leg (1.56 (0.49-2.25) vs. 1.77 (1.24-2.43) vs. 2.08 (1.18-2.95)), lower versus higher tercile p < 0.05. However, no differences in intradialytic symptoms or postdialysis recovery times between the UFR terciles were observed.

CONCLUSION

There were no differences in self-reported intradialytic symptoms or postdialysis recovery times with differing UFRs, despite changes in intracompartmental fluid shifts as measured by changes in ECW/TBW.

Interventions for fatigue in people with kidney failure requiring dialysis

BACKGROUND

Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD).

OBJECTIVES

We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported.

AUTHORS' CONCLUSIONS

Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.

Comparison of two self-report scales to assess anxiety and depressive symptoms in hemodialysis patients

INTRODUCTION

Psychiatric illness is prevalent among hemodialysis (HD) patients. This study compared the assessment of anxiety and depressive symptoms among HD patients using two self-administered scales; hospital anxiety and depression scale (HADS) and brief symptom inventory (BSI).

METHODS

A cross-sectional study was conducted among a convenience sample of HD patients (n = 352) from different dialysis centers in Jordan. Patients were interviewed in dialysis units, and demographics, clinical status, disease, and dialysis history data were collected. Symptoms of anxiety (HADS-A ≥ 8 and BSI-A ≥ 0.82) and depression (HADS-D ≥ 8 and BSI-D ≥ 0.82) were also measured.

RESULTS

The mean age of participants was 52.2 ± 15.6 years. The majority had been receiving HD three times daily and for >2 years. A significant moderate-strong correlation was observed between HADS-A and BSI-A (r = 0.753, p < 0.0001) as well as HADS-D and BSI-D (r = 0.588, p < 0.0001). Anxiety prevalence was 43.7 % using HADS-A ≥ 8 and 80.7 % using BSI-A ≥ 0.82, while depression prevalence was 53.1 % using HADS-D ≥ 8 and 51.7 % using BSI-D ≥ 0.82. When HADS was used as a standard, the operating characteristics reveal that a higher cut-off for BSI-A is recommended (≥1.58) for better anxiety screening.

DISCUSSION

Specific and suitable cut-off points need to be further explored and validated for HADS and BSI scales among patients undergoing dialysis.

Longitudinal assessment of depression during the first year after stroke: Dimensionality and measurement invariance

OBJECTIVE

Repeated measurement of depression using summative scores of commonly used depression scales assumes that the construct is unidimensional and invariant across time, but little is known about the validity of these assumptions in stroke patients. The study examined the assumptions during the first year after mild to moderate stroke using the 8-item Patient Health Questionnaire (PHQ-8).

METHODS

Data were obtained from the 2014-2016 Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study with longitudinal follow-up in Texas, United States. Depressive symptoms were assessed with the PHQ-8 at 3, 6, and 12 months post-stroke (n = 648, 542, 533, respectively). Dimensionality of the PHQ-8 was examined using exploratory bifactor analysis and confirmatory factor analysis (CFA). Based on a one-factor CFA model, longitudinal measurement invariance was examined by fitting configural, weak, strong and strict invariance models sequentially.

RESULTS

Mean age was 65.6 (SD = 11.2), half were women, and 56.7% were Mexican American. Reliability measures suggested a generally unidimensional construct (Omega Hierarchical: 0.79-0.86), good internal consistency (Cronbach's alpha: 0.84-0.88) and good temporal stability (intraclass correlation coefficient: 0.838). Configural invariance for equality of item-factor structure (RMSEA = 0.038, CFI = 0.982, WRMR = 0.970) was supported. Partial weak invariance for equality of factor loadings (p = 0.11) was supported by chi-square difference tests, whereas full longitudinal invariance was supported by changes in comparative fit index and root mean square error of approximation.

CONCLUSIONS

The findings suggest the PHQ-8 may be a reasonable tool for repeated measurement of depression in stroke patients, and more research on its longitudinal psychometric properties is needed.

The effect of gratitude and self-encouragement on depression in psychiatric inpatients in Korea

This study aimed to investigate the effect of gratitude and self-encouragement on depression in psychiatric inpatients in South Korea. A cross-sectional and correlational research design was used. The participants were 112 psychiatric inpatients recruited from the psychiatric units of four general hospitals in South Korea. Data were collected using the Korean version of the Gratitude Questionnaire-6, the Self-Encouragement Inventory, and the Korean version of Beck's Depression Inventory II. Data were analyzed using two-stage hierarchical regression analysis. The results showed that emotional self-encouragement (β = -0.43, p = .004) and gratitude (β = -0.22, p = .029) were factors significantly influencing depression. The regression model explained 28.0% of depression. Therefore, it is recommended that mental health nurses provide intervention to psychiatric inpatients to help them foster gratitude and emotional self-encouragement so that they can decrease depression.

Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis

Background

Quality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms.

Methods

We reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW).

Results

We studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times.

We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times.

Conclusion

We found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.

Falls in systolic blood pressure during dialysis which require no nursing intervention are associated with increased patient intra-dialytic symptom self-reporting and prolonged post-dialysis recovery times

Background

Haemodialysis (HD) patients may suffer symptoms during dialysis and take time to recover post HD. We wished to determine whether patients with symptomatic intra-dialytic hypotension (IDH), requiring nursing interventions, or an asymptomatic fall in systolic blood pressure (SBP) reported more symptoms during dialysis.

Methods

Six hundred three HD patients completed self-reported intra-dialytic symptom questionnaires and recovery using a visual analogue scale, which were compared with their dialysis session records.

Results

Twenty-nine (4.8%) of patients suffered symptomatic IDH, and 187 (31.0%) had a fall in SBP of > 20 mmHg. Symptomatic patients had greater total symptom scores (30 (23–44) vs 23 (10–38), p < 0.05, versus asymptomatic patients, with increased low blood pressure, dizziness, cramps, palpitations and feeling cold reported (all p < 0.05). Patients with a SBP fall of > 20 mmHg had greater total scores compared with those with a SBP increase of > 10 mmHg (26 (13–38) vs 17 (7–34), p < 0.05), with more dizziness, cramps, backache, shortness of breath and headache reported (all p < 0.05). Although ultrafiltration rates were similar, HD weight loss was greater for patients with a SBP fall of > 20 mmHg (2.5 ± 1.1 vs 2.0 ± 1.3%, p < 0.05). Patients with highest symptoms scores (highest vs lowest quartile) had longer recovery times (40.3 vs 7.6% > 4 h), p < 0.001.

Multivariable analysis showed that patients reporting more intradialytic symptoms had higher psychological distress thermometer scores (odds ratio (OR) 1.34 (95% confidence limits 1.26–1.44)), systolic blood pressure < 100 mmHg (OR 2.53 (1.04–6.1)), whereas symptom scores were lower for male gender (OR 0.34 (0.22–0.51)), and with increasing age (OR 0.99 (0.97–0.99)).

Conclusion

Patients with both symptomatic and asymptomatic IDH, self-reported more symptoms during dialysis, and those patients reporting more symptoms had longer recovery times. We found that younger, female patients, those with greater psychological distress, and lower systolic blood pressure self-reported more intra-dialytic symptoms. More attention is required to prevent falls in intra-dialytic blood pressure to improve the patient experience of HD and shorten post-dialysis recovery times.

Dimensions of Depressive Symptoms and Their Association With Mortality, Hospitalization, and Quality of Life in Dialysis Patients: A Cohort Study

OBJECTIVE

Unraveling specific dimensions of depressive symptoms may help to improve screening and treatment in dialysis patients. We aimed to identify the best-fitting factorial structure for the Beck Depression Inventory-II (BDI) in dialysis patients and to assess the relation of these structure dimensions with quality of life (QoL), hospitalization, and mortality.

METHODS

This prospective study included chronic dialysis patients from 10 dialysis centers in five hospitals between 2012 and 2017. Dimensions of depressive symptoms within the BDI were analyzed using confirmatory factor analysis. To investigate the clinical impact of these dimensions, the associations between symptom dimensions and QoL, hospitalization rate, and mortality were investigated using logistic, Poisson, and Cox proportional hazard regression models. Multivariable regression models included demographic, social, and clinical variables.

RESULTS

In total, 687 dialysis patients were included. The factor model that included a general and a somatic factor provided the best-fitting structure of the BDI-II. Only the somatic dimension scores were associated with all-cause mortality (hazard ratio of 1.7 [1.2-2.5], p < .007) in the multivariable model. All dimensions were associated with increased hospitalization rate and reduced QoL.

CONCLUSIONS

The somatic dimension of the BDI-II in dialysis patients was associated with all-cause mortality, increased hospitalization rate, and reduced QoL. Other dimensions were associated with hospitalization rate and decreased QoL. These findings show that symptom dimensions of depression have differential association with adverse clinical outcomes. Future studies should take symptom dimensions into account when investigating depression-related pathways, screening, and treatment effects in dialysis patients.