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

The impact of severe depression on the survival of older patients with end-stage kidney disease

BACKGROUND

Incidence of depression increases in patients with end-stage kidney disease (ESKD). We evaluated the association between depression and mortality among older patients with ESKD, which has not been studied previously.

METHODS

This nationwide prospective cohort study included 487 patients with ESKD aged >65 years, who were categorized into minimal, mild-to-moderate, and severe depression groups based on their Beck Depression Inventory-II (BDI-II) scores. Predisposing factors for high BDI-II scores and the association between the scores and survival were analyzed.

RESULTS

The severe depression group showed a higher modified Charlson comorbidity index value and lower serum albumin, phosphate, and uric acid levels than the other depression groups. The Kaplan-Meier curve revealed a significantly lower survival in the severe depression group than in the minimal and mild-to-moderate depression groups (p = 0.011). Multivariate Cox regression analysis confirmed that severe depression was an independent risk factor for mortality in the study cohort (hazard ratio, 1.39; 95% confidence interval, 1.01-1.91; p = 0.041). Additionally, BDI-II scores were associated with modified Charlson comorbidity index (p = 0.009) and serum albumin level (p = 0.004) in multivariate linear regression. Among the three depressive symptoms, higher somatic symptom scores were associated with increased mortality.

CONCLUSION

Severe depression among older patients with ESKD increases mortality compared with minimal or mild-to-moderate depression, and patients with concomitant somatic symptoms require careful management of their comorbidities and nutritional status.

The efficacy and safety of sertraline in maintenance hemodialysis patients with depression: A randomized controlled study

OBJECTIVE

To determine the efficacy and safety of sertraline in maintenance hemodialysis (MHD) patients with depression.

METHODS

A randomized controlled trial was conducted involving 125 MHD patients with depression. The treatment group received sertraline, while the control group did not receive any antidepressant treatment. After 12 weeks, we compared the changes in the Hamilton Depression Rating Scale (HAMD), the Medication Adherence Report Scale-5 (MARS-5), the Mini Nutritional Assessment short-form (MNA-SF), the Kidney Disease Quality of Life-36 (KDQOL-36) scores, selected clinical and laboratory indicators, and the incidence of drug-related adverse reactions between the two groups.

RESULTS

After 12 weeks of treatment, the HAMD scores of patients in the treatment group significantly decreased compared to before treatment and were lower than those in the control group. The KDQOL-36, MARS-5, and MNA-SF scores in the treatment group also significantly improved compared to before treatment and were superior to those in the control group. Albumin and hemoglobin levels in the treatment group significantly increased, while C-reactive protein significantly decreased. The incidence of nausea was slightly higher in the treatment group, and was mostly relieved after reducing the dosage of sertraline.

LIMITATIONS

This study is a single-center, small-sample study with a relatively short duration of treatment and follow-up.

CONCLUSIONS

Sertraline can alleviate depressive symptoms, and improve the quality of life and treatment compliance of MHD patients, while improving chronic inflammation, malnutrition, and anemia. However, starting with a low dose and reducing the maintenance dose is recommended when administering sertraline.

Consumer values, perspectives and experiences of psychological health when living with dialysis at home: An in-depth interview study

BACKGROUND

People treated with home dialysis report social and emotional isolation, fear of catastrophic events and concern about being a burden. There is a paucity of research exploring psychological well-being among consumers dialysing at home. We aimed to explore the psychological health issues related to home dialysis, and how these issues may impact on sustaining home-based treatment.

METHODS

We conducted a qualitative interview study with 36 consumers. We included patients with experience of home dialysis and caregivers. Thirteen participants had experienced peritoneal dialysis, seven home haemodialysis, seven had experienced both and nine caregivers. Data were analysed inductively to generate themes and a conceptual framework.

RESULTS

We identified four themes and subthemes: overwhelming isolation and disconnection (devastating isolation of home dialysis; abandoned from support; escalating anxiety; compounding impact of feeling like a burden); importance of support systems (impact on relationships; need for emotional support; reassurance through shared experiences; valuing trustworthy and committed clinicians); burden of distress (individualised feelings of low mood; grappling with stigma surrounding diagnosis; contemplating treatment withdrawal and suicide); seeking mental health support (normalising mental health support as a distinct entity in dialysis care; overcoming barriers to seeking mental health support; additional tools for mental health support and connection).

CONCLUSION

Consumers may experience intense psychological distress during home-based dialysis care. Increasing clinician and health services literacy about the management of psychological impacts of home-based dialysis may improve consumer safety, quality of life and sustainability of home treatment.

Psychological resilience and quality of life among middle-aged and older adults hospitalized with chronic diseases: multiple mediating effects through sleep quality and depression

BACKGROUND

The present study is intended to examine the multiple mediating roles of sleep quality and depression in the relationship between psychological resilience and quality of life in middle-aged and older adults hospitalized with chronic diseases.

METHODS

From October 2, 2021, to February 27, 2022, a questionnaire survey was conducted using a multistage stratified sampling method among 339 middle-aged and older adults (45 years and over) hospitalized with chronic diseases. These participants were recruited from a hospital in Zhejiang Province, China. The questionnaire included the Aged Cumulative Disease Rating Scale, the Psychological Resilience Scale, the Pittsburgh Sleep Quality Index Scale, the Depression Scale, and the Quality-of-Life Scale. A descriptive analysis was performed to characterize the sample. Linear regression was utilized to evaluate the relationship between psychological resilience and quality of life. Amos 24.0 was used to analyze the multiple mediated effects of sleep quality and depression.

RESULTS

Psychological resilience exerted a remarkable direct effect on the quality of life in middle-aged and older adults hospitalized with chronic diseases (β = 0.239, 95% CI = 0.125-0.354), which represented 52.98% of the total effect. Through three significantly mediated pathways indirectly affect the quality of life: (1) through the sleep quality pathway (β = 0.115, 95% CI = 0.056-0.201), which represented 25.39% of the total effect; (2) through the depression pathway (β = 0. 060, 95% CI = 0.023-0.114), which represented 13.24% of the total effect; and (3) through both the sleep quality and depression pathway (β = 0. 038, 95% CI = 0.019-0.074), which represented 8.39% of the total effect. The total mediating effect was 47.02%.

CONCLUSIONS

Sleep quality and depression mediate the relationship between psychological resilience and quality of life in middle-aged and older adults hospitalized with chronic diseases. Therefore, healthcare professionals and stakeholders should be concerned about the sleep status and mental health of middle-aged and older adults hospitalized with chronic diseases, strengthen their attention to psychological resilience, and provide interventions and treatment measures for hospitalized patients who have sleep problems and depressive tendencies.

Depression Symptoms and Physical Activity in Veterans With COPD: Insights From a Web-Based, Pedometer-Mediated Physical Activity Intervention

BACKGROUND

Depression is known to limit physical activity (PA) among individuals with chronic obstructive pulmonary disease (COPD). However, whether and how depression influences the effectiveness of PA interventions is unknown.

PURPOSE

The study examined the association between baseline depression symptoms and change in daily step count and whether group assignment to a web-based, pedometer-mediated PA intervention moderated the association between baseline depression symptoms and change in daily step count.

METHODS

Secondary analysis included two cohorts of U.S. Veterans with COPD (n = 212; 97% male; mean age 69 ± 8 years) assessed at baseline and 3 months. Cohorts 1 and 2 were randomly assigned to the same PA intervention (n = 111) or a control group (n = 101). Multivariate regressions tested the main effects of baseline depression symptoms (BDI-II total and cognitive-affective and somatic subscales) on change in daily steps, as well as the interaction between baseline BDI-II and subscales and group assignment on change in daily steps.

RESULTS

Greater BDI-II total score (B = -31.8, SE = 14.48, p = .030) and somatic subscale scores (B = -99.82, SE = 35.76, p = .006) were associated with less improvement in daily step count. There was a significant interaction between baseline cognitive-affective subscale and the intervention predicting change in daily step count (B = -88.56, SE = 42.31, p = .038). When cognitive-affective subscale scores were ≥1 SD above the mean, the intervention was no longer associated with an increase in daily step count (p = .585).

CONCLUSIONS

Depression should be routinely assessed and targeted as part of PA promotion efforts.

Somatic Symptoms of Depression Lose Association with Mortality upon Adjustment for Frailty: Analysis from the Fitness Haemodialysis Cohort

Introduction

The somatic symptom component of depression is associated with increased hospitalisation and mortality and poorer health-related quality of life (HRQOL). However, the relationship of subsets of depression symptoms with frailty and outcomes is not known. This study aimed to (1) explore the relationship between the Clinical Frailty Scale (CFS) and components of depression and (2) their association with mortality, hospitalisation, and HRQOL in haemodialysis recipients.

Methods

We conducted a prospective cohort study of prevalent haemodialysis recipients, with deep bio-clinical phenotyping including CFS and PHQ-9 somatic (fatigue, poor appetite, and poor sleep) and cognitive component scores. EuroQol EQ-5D summary index assessed HRQOL at the baseline. Electronic linkage to English national administration datasets ensured robust follow-up data for hospitalisation and mortality events. Findings. Somatic (β = 0.067; 95% C.I. 0.029 to 0.104; P < 0.001) and cognitive (β = 0.062; 95% C.I. 0.034 to 0.089; P<0.001) components were associated with increased CFS scores. Both somatic (β = -0.062; 95% C.I. -0.104 to -0.021; P<0.001) and cognitive (β = 0.052; 95% C.I. -0.081 to -0.024; P < 0.001) scores were associated with lower HRQOL. Somatic scores lost mortality association on addition of CFS to the multivariable model (HR1.06; 95% C.I. 0.977 to 1.14; P=0.173). Cognitive symptoms were not associated with mortality. Neither the component score was associated with hospitalisation on multivariable analyses.

Conclusions

Both somatic and cognitive depression symptoms are associated with frailty and poorer HRQOL in haemodialysis recipients but were not associated with mortality or hospitalisation when adjusted for frailty. The risk profile of depression somatic scores may be related to overlap with symptoms of frailty.

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.

Quality of Life before and after the Start of Dialysis in Older Patients

BACKGROUND AND OBJECTIVES

In older people with kidney failure, improving health-related quality of life is often more important than solely prolonging life. However, little is known about the effect of dialysis initiation on health-related quality of life in older patients. Therefore, we investigated the evolution of health-related quality of life before and after starting dialysis in older patients with kidney failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality study is an ongoing prospective, multicenter study in patients aged ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m². Between April 2012 and December 2021, health-related quality of life was assessed every 3-6 months using the 36-item Short-Form Health Survey (SF-36), providing a mental component summary (MCS) and a physical component summary (PCS). Scores range from zero to 100, with higher scores indicating better health-related quality of life. With linear mixed models, we explored the course of health-related quality of life during the year preceding and following dialysis initiation.

RESULTS

In total, 457 patients starting dialysis were included who filled out at least one SF-36 during follow-up. At dialysis initiation, mean ± SD age was 76±6 years, eGFR was 8±3 ml/min per 1.73 m², 75% were men, 9% smoked, 45% had diabetes, and 46% had cardiovascular disease. Median (interquartile range) MCS was 53 (38-73), and median PCS was 39 (27-58). During the year preceding dialysis, estimated mean change in MCS was -13 (95% confidence interval, -17 to -9), and in PCS, it was -11 (95% confidence interval, -15 to -7). In the year following dialysis, estimated mean change in MCS was +2 (95% confidence interval, -7 to +11), and in PCS, it was -2 (95% confidence interval, -11 to +7). Health-related quality-of-life patterns were similar for most mental (mental health, role emotional, social functioning, vitality) and physical domains (physical functioning, bodily pain, role physical).

CONCLUSIONS

Patients experienced a clinically relevant decline of both mental and physical health-related quality of life before dialysis initiation, which stabilized thereafter. These results may help inform older patients with kidney failure who decided to start dialysis.

A Cross-sectional Study of Depression among Non-dialysis Stage 3-5 Chronic Kidney Disease Patients

Depression is common among patients undergoing dialysis. However, there is a dearth of data on depression and its predictors among patients at different stages of chronic kidney disease (CKD). This study assessed the prevalence of depression and the relationships between depression and sociodemographic and clinical factors among non-dialysis CKD patients. A convenience sample of 88 CKD patients was recruited using a cross-sectional study design. The Beck Depression Inventory-II (BDI-II) was used to assess the levels of depression among CKD patients, with a cutoff score of ≥11. Data on the sociodemographic factors and clinical factors were also collected. Inferential statistics were used to determine the characteristics of the sample and assess the prevalence and severity of depression. Multiple regression analysis was used to assess the associations between the characteristics of the sample and depression. The overall mean BDI-II score was 6.23 ± 6.13. With a cutoff score of ≥11, patients with major depressive episodes constituted 18.2% of the sample. Stages of the disease, comorbidities, and sex were independently associated with a high depression score. The model explained 39% of the variation in the depression score. Depression is common among non-dialysis CKD patients. Screening for depression with brief validated tools should be integrated into routine clinical practice at renal clinics because patients in the advanced stages of CKD and those with multiple comorbidities require close attention. Furthermore, large studies assessing the prevalence and predictors of depression among different stages of CKD are required.

Validation of Two Screening Tools for Anxiety in Hemodialysis Patients

Background: Symptoms of anxiety are often unrecognized and untreated in dialysis patients. We investigated the diagnostic accuracy of two widely used screening tools for anxiety in hemodialysis patients. Methods: For this cross-sectional validation study, chronic hemodialysis patients from eight dialysis centers in the Netherlands were included. The Beck Anxiety Inventory (BAI) and Hospital Anxiety and Depression Scale—Anxiety subscale (HADS-A) were validated by the Mini International Neuropsychiatric Inventory (MINI) diagnostic interview. Receiver operating characteristic curves were used to determine the optimal cut-off values. Results: Of 65 participants, 13 (20%) were diagnosed with one or more anxiety disorders on the MINI, of which 5 were included in the analysis. ROC curves showed a good diagnostic accuracy of the BAI and HADS-A. The optimal cut-off value for the BAI was ≥13 (sensitivity 100%, specificity 85%) and for the HADS-A was ≥10 (sensitivity 80%, specificity 100%). Conclusions: Based on our limited data, both the BAI and the HADS-A seem to be valid screening instruments for anxiety in hemodialysis patients that can be used in routine dialysis care. The HADS-A consists of fewer items and showed fewer false-positive results than the BAI, which might make it more useful in clinical practice.

Symptom dimensions of anxiety and depression in patients receiving peritoneal dialysis compared to haemodialysis

BACKGROUND

Differences in symptom burden, treatment satisfaction and autonomy between patients receiving peritoneal dialysis and haemodialysis could be reflected by a difference in symptom dimensions of anxiety and depression. The aim of this study is to assess differences in prevalence and symptom dimensions of anxiety and depression between patients receiving peritoneal dialysis and haemodialysis.

METHODS

Baseline data from the Depression Related Factors and Outcomes in Dialysis Patients With Various Ethnicities and Races Study were used. Symptoms of anxiety and depression were measured with the Beck Anxiety Inventory and Beck Depression Inventory- second edition. Linear and logistic regression models were used to compare anxiety and depression total scores and somatic and subjective/cognitive symptom dimension scores between patients receiving peritoneal dialysis and haemodialysis, adjusted for potential confounders.

RESULTS

In total, 84 patients receiving peritoneal dialysis and 601 patients receiving haemodialysis were included. Clinically significant symptoms of anxiety and depression were present in respectively 22% and 43% of the patients, with no differences between dialysis modality. Both modalities scored high on the somatic symptom dimensions and on individual somatic items. Almost all patients reported symptoms related to loss of energy and sleep.

CONCLUSION

No differences in symptom dimensions of anxiety and depression were found between patients receiving peritoneal dialysis and haemodialysis. The high prevalence of somatic symptom dimensions in both groups underscores the possible interaction between somatic and psychiatric symptoms in dialysis patients and the need for early recognition and treatment of symptoms of anxiety and depression regardless of treatment modalities.

Relevant functioning aspects and environmental factors for adults and seniors undergoing hemodialysis: A qualitative study

OBJECTIVE

To identify which functioning, personal and environmental factors are more relevant to adults in hemodialysis treatment.

MATERIALS AND METHODS

Data was collected by semi-structured interview, recorded, transcribed in full, verified and produced by Bardin Thematic content analysis. Two independent researchers identified the relevant themes and named the thematic categories found according to the coding of the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Six men and three women aged between 32-65 years were interviewed, with per capita family income between 1-2.9 minimum salaries and hemodialysis treatment time between 5 to 26 years. Fifty-seven ICF categories were listed: 17 Body Functions, 9 Body Structures, 21 Activities and Participation, and 10 Environmental Factors. Health, transportation and general social support services, systems and policies; doing housework; recreation and leisure; emotional functions, temperament and personality functions; energy and drive functions; sensation of pain; and structures of the cardiovascular system, lower extremity and musculoskeletal structures related to movement were the most reported aspects by the participants.

CONCLUSION

Patients' need for physical/emotional support from their partners, friends and health professionals, including emotional and social support, with health policies, transportation and job maintenance, in order to increase their survival and quality of life.

The impact of somatic and cognitive depressive symptoms on medical prognosis in patients with end-stage renal disease

PURPOSE

To determine whether somatic or cognitive depressive symptoms affect hospitalization and death in patients with end-stage renal disease.

DESIGN AND METHOD

In an observational retrospective design, the patients (n = 190) completed the Beck Depression Inventory-II at baseline and were followed for 5 years to collect data all-cause mortality and hospitalization.

FINDINGS

High somatic (53.7%, n = 102) and cognitive (52.1%, n = 99) depressive symptoms scores significantly associated with mortality (38% vs. 19%; hazard ratio [HR] = 2; 95% CI, 1.1-3.7; p = 0.02) and hospitalization (62.5% vs. 49.4%; HR = 1.6; 95% CI, 1.0-2.6; p = 0.03), respectively.

PRACTICE IMPLICATIONS

In the context of diagnosing and intervening, awareness of depressive symptoms dimensionality is crucial.

Association Between Lipophilic Beta-Blockers and Depression in Diabetic Patients on Chronic Dialysis

Background:

Depression is associated with lower quality of life and increased risk of mortality. The prevalence of depression in chronic dialysis patients, as well as in patients with diabetes, is more than 20%. It is debated whether use of beta-blockers increases the risk of depression. Therefore, we examined in chronic dialysis patients with and without diabetes, the association between beta-blockers and depressive symptoms.

Methods:

Data were collected from the DIVERS-I study, a multicentre prospective cohort among chronic dialysis patients in the Netherlands. Depressive symptoms were assessed with the Beck Depression Inventory (BDI-II). We defined depressive symptoms as a BDI-II score ⩾16. The cross-sectional association at baseline between depressive symptoms and beta-blocker use in chronic dialysis patients, was studied by multivariable logistic regression adjusted for potential confounders.

Results:

We included 684 chronic dialysis patients, of whom 43% had diabetes mellitus, and 57% used a beta-blocker of which 97% were lipophilic. After multivariable adjustment, the OR (95% CI) for depressive symptoms in patients with compared to without diabetes was 1.41 (1.00-1.98), and in beta-blocker users compared to non-users 1.12 (0.80-1.56), respectively. Dialysis patients with diabetes and beta-blocker use compared to those without diabetes and not using beta-blockers had an OR of 1.73 (1.12-2.69) for depressive symptoms. The association was stronger in dialysis patients with diabetes and lipophilic beta-blocker use with an OR of 1.77 (1.14-2.74).

Conclusions:

We found a possible association between lipophilic beta-blocker use and depressive symptoms in chronic dialysis patients with diabetes.

Be Fit, Be Sharp, Be Well: The Case for Exercise as a Treatment for Cognitive Impairment in Late-life Depression

OBJECTIVE

To lay out the argument that exercise impacts neurobiological targets common to both mood and cognitive functioning, and thus more research should be conducted on its use as an alternative or adjunctive treatment for cognitive impairment in late-life depression (LLD).

METHOD

This narrative review summarizes the literature on cognitive impairment in LLD, describes the structural and functional brain changes and neurochemical changes that are linked to both cognitive impairment and mood disruption, and explains how exercise targets these same neurobiological changes and can thus provide an alternative or adjunctive treatment for cognitive impairment in LLD.

RESULTS

Cognitive impairment is common in LLD and predicts recurrence of depression, poor response to antidepressant treatment, and overall disability. Traditional depression treatment with medication, psychotherapy, or both, is not effective in fully reversing cognitive impairment for most depressed older adults. Physical exercise is an ideal treatment candidate based on evidence that it 1) is an effective treatment for depression, 2) enhances cognitive functioning in normal aging and in other patient populations, and 3) targets many of the neurobiological mechanisms that underlie mood and cognitive functioning. Results of the limited existing clinical trials of exercise for cognitive impairment in depression are mixed but overall support this contention.

CONCLUSIONS

Although limited, existing evidence suggests exercise may be a viable alternative or adjunctive treatment to address cognitive impairment in LLD, and thus more research in this area is warranted. Moving forward, additional research is needed in large, diverse samples to translate the growing research findings into clinical practice.

The cross-lagged association between depressive symptoms and health-related quality of life in patients receiving maintenance hemodialysis: a three-wave longitudinal study

PURPOSE

To examine the cross-lagged relationship between depressive symptoms and health-related quality of life (HRQoL) in patients receiving maintenance hemodialysis.

METHODS

A longitudinal, observational study was conducted in two public hospitals in Shanghai, China. The sample consisted of 204 patients at baseline (T1). Of these, 144 completed the 12-month follow-up survey (T2), and 135 completed the 24-month follow-up survey (T3). Depressive symptoms were assessed using the depression subscale of the Hospital Anxiety and Depression Scale, and HRQoL was assessed using the Kidney Disease Quality of Life 36 short form. Cross-lagged path analysis was used to examine the temporal relationship between depressive symptoms and domains of health-related quality of life.

RESULTS

Lower levels of three out of five domains of HRQoL (physical functioning, burden of kidney disease, and symptoms of kidney disease) at T1 were associated with increases in depressive symptoms at T2. Moreover, higher depressive symptoms at T2 were associated with decreases in four domains of HRQoL (mental functioning, burden of kidney disease, symptoms of kidney disease, and effects of kidney disease) at T3.

CONCLUSIONS

Patients who had poor HRQoL were more likely to report more subsequent depressive symptoms, which in turn predict lower HRQoL over time. It indicates a need to break this cycle in patients receiving maintenance hemodialysis.

Treatment of current depressive symptoms in dialysis patients: A systematic review and meta-analysis

OBJECTIVE

Symptoms of depression are highly prevalent and undertreated in dialysis patients. To aid clinicians in offering treatment to patients with depression, we conducted a systematic review and meta-analysis on the treatment of current depressive symptoms in dialysis patients.

METHODS

Nine databases were searched on January 8th 2020 for randomized controlled trials on the treatment of depressive symptoms in dialysis patients. In contradiction to previous reviews, we only included studies who selected patients with a score above a defined cut-off for depressive symptoms and used an inactive control group, to investigate the effectiveness of treatments in currently depressed patients. All interventions aimed to treat depressive symptoms were accepted for inclusion. Standardized mean differences were calculated in a random effect meta-analysis.

RESULTS

Seventeen studies were included in the systematic review (1640 patients). Nine studies could be included in the meta-analysis. A pooled analysis of 7 studies on psychotherapy showed a standardized mean difference of -0.48 [-0.87; -0.08], with a moderate heterogeneity (I² = 52%, X² = 12.56, p = .05). All studies on psychotherapy performed a per protocol analysis and scored high on potential bias. A pooled analysis of two studies on SSRI's showed no statistically significant improvement of depressive symptoms (SMD -0.57 [-6.17; 5.02], I² = 71%, X² = 0.2474, p = .06).

CONCLUSIONS

Psychotherapy is a promising treatment for currently depressed dialysis patients, although quality of evidence is low. More evidence is needed regarding the efficacy of SSRI's, exercise therapy and dietary supplements in this population.

PROSPERO

CRD42018073969.

General distress and symptoms of anxiety and depression: A factor analysis in two cohorts of dialysis patients

OBJECTIVE

Depression and anxiety often coexist in patients with end-stage-kidney disease. Recently, studies showed that a composite 'general distress score' which combines depression and anxiety symptoms provides a good fit in dialysis and oncology patients. We aim to investigate if the three most frequently used self-report questionnaires to measure depression and anxiety in dialysis patients are sufficiently unidimensional to warrant the use of such a general distress score in two cohorts of dialysis patients.

METHODS

This study includes two prospective observational cohorts of dialysis patients (total n = 749) which measured depression and anxiety using Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Hospital Anxiety and Depression Scale (HADS). Confirmatory factor analyses was used to investigate both a strictly unidimensional model and a multidimensional bifactor model that includes a general distress, depression and anxiety factor. The comparative fit index (CFI) and The Root Mean Square Error of Approximation (RMSEA) were used as model fit indices.

RESULTS

Factor analysis did not show a good fit for a strictly unidimensional general distress factor for both the BDI/BAI and HADS (CFI 0.690 and 0.699, RMSEA 0.079 and 0.125 respectively). The multidimensional model performed better with a moderate fit for the BDI/BAI and HADS (CFI 0.873 and 0.839, RMSEA 0.052 and 0.102).

CONCLUSIONS

This data shows that the BDI/BAI and HADS are insufficiently unidimensional to warrant the use of a general distress score in dialysis patients without also investigating anxiety and depression separately. Future research is needed whether the use of a general distress score might be beneficial to identify patients in need of additional (psychological) support.

Symptom dimensions of anxiety and their association with mortality, hospitalization and quality of life in dialysis patients

OBJECTIVE

Symptoms of anxiety are highly prevalent in dialysis patients and are associated with adverse clinical outcomes. Identifying symptom dimensions may help to understand the pathophysiology, improve screening and guide treatment. Currently, there are no data on symptom dimensions of anxiety in dialysis patients. This study aimed to identify the best fitting dimensional model for anxiety in dialysis patients and assess the association between symptom dimensions of anxiety and adverse clinical outcomes.

METHODS

This study is a prospective observational cohort study including patients from 10 urban dialysis centers between 2012 and 2017. Anxiety symptoms were measured using the self-reported questionnaire Beck Anxiety Inventory. Confirmatory factor analysis was used to identify symptom dimensions. The association between dimensions and mortality, hospitalization and quality of life was investigated using stepwise cox, poisson and lineair regression models. Multivariable models included demographic, social, laboratory and clinical variables to adjust for possible confounding.

RESULTS

In total 687 chronic dialysis patients were included. A Somatic and Subjective anxiety dimension were identified. Only Somatic anxiety symptoms showed an association with increased risk of hospitalization and mortality (Rate Ratio 1.73 (1.45-2.06) p = .007 and Hazard Ratio 1.65 (1.15-2.37) p = .007 respectively). These associations were independent from somatic comorbidity. All symptom dimensions of anxiety showed an association with Quality of Life.

CONCLUSION

This study shows that anxiety is common in chronic dialysis patients and comprises of a somatic, subjective, and a total score. The discrimination between anxiety dimensions can be useful for clinical practice, as they are related to different clinical outcomes.