|Year : 2020 | Volume
| Issue : 3 | Page : 173-178
Prevalence and correlates of depression among patients with chronic kidney disease
Olufisayo K Adesokun, Chukwuma U Okeafor, Princewill C Stanley
Department of Mental Health/Neuropsychiatry, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
|Date of Submission||20-Nov-2019|
|Date of Acceptance||08-Apr-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Chukwuma U Okeafor
Department of Mental Health/Neuropsychiatry, University of Port Harcourt Teaching Hospital, Port Harcourt
Source of Support: None, Conflict of Interest: None
Background This study sought to determine the prevalence and correlates of depression among patients with chronic kidney disease (CKD).
Patients and methods This is a comparative cross-sectional study of 69 patients with CKD, who were selected by systematic random sampling and matched (by age and sex) with a control group of 69 hospital workers. Eligible and consenting participants completed a sociodemographic questionnaire and were interviewed with the Mini International Neuropsychiatry Interview. Data were analyzed with the Statistical Package for Social Sciences, version 21. P value less than 0.05 was considered significant.
Results The mean age of the patients was 44.7 years (SD ±10.14 years). The patients included 53% females. The prevalence of depression among patients with CKD was 34.8% compared with 2.9% in the control group (P=0.0001). A significant relationship was found between the average monthly income and presence of depression in patients with CKD (P=0.015). There was no association found between the prevalence of depression and the stage of CKD.
Conclusion Depression is very common in patients with CKD. Assessment for depression should be integrated into the care plan for patients with CKD, so as to ensure early detection and prompt intervention.
Keywords: chronic kidney disease, depression, mental health
|How to cite this article:|
Adesokun OK, Okeafor CU, Stanley PC. Prevalence and correlates of depression among patients with chronic kidney disease. J Egypt Soc Nephrol Transplant 2020;20:173-8
|How to cite this URL:|
Adesokun OK, Okeafor CU, Stanley PC. Prevalence and correlates of depression among patients with chronic kidney disease. J Egypt Soc Nephrol Transplant [serial online] 2020 [cited 2020 Aug 13];20:173-8. Available from: http://www.jesnt.eg.net/text.asp?2020/20/3/173/290013
| Introduction|| |
Chronic kidney disease (CKD) is increasingly being recognized as a disease of significant public health importance across the globe, with elevated risks of adverse clinical outcomes ,. It is defined as reduced glomerular filtration rate and/or increased excretion of urinary albumin occurring for at least 3 months . In addition to the physical and laboratory parameters, psychiatric comorbidities like depression have been shown to significantly influence the clinical course and outcome in patients with CKD ,,,.
Depression is an affective disorder of public health importance, which is characterized by low mood and loss of interest in previously enjoyable activities . It is often associated with chronic stress and a sense of loss, which are common experiences of people with CKD . Moreover, the lifestyle restrictions and changes in role imposed by CKD and its treatment are associated with significant distress, which also heightens the risk of developing depression .
CKD, being a chronic disease, exerts a heavy and disproportionate human, economic, and social burden on societies and health care systems around the world. It accounts for ∼5–8% of the noncommunicable disease burden globally , with a worldwide prevalence of 10–16% ,. More than a million people undergo renal replacement therapy each year . Some scholars have asserted that the burden of CKD may even be more pronounced in the developing countries compared with the developed ones owing to the presence of adverse environmental factors, and the extra burden of infectious diseases ,.
The grave projection and enormous burden of CKD underscores the need for research into all aspects of the disease that may affect clinical outcomes. Psychological distress and depression are part of the everyday experiences of patients with CKD, which have been shown to affect them ,. Unfortunately, renal physicians are most often unaware of the burden of the psychiatric morbidity in their patients with CKD because the mental health of these patients are frequently not assessed . As a result, most of the psychological burden is unrecognized, and thus not given adequate attention. Ultimately, depression is underdiagnosed and undertreated in patients with CKD. Therefore, this study sought to assess the prevalence and factors associated with depression among patients with CKD.
| Patients and methods|| |
The study was done in Port Harcourt, which is the center of socioeconomic activity of the Niger Delta region of Nigeria. Port Harcourt is the capital of Rivers state in the South–South region of Nigeria. The study location was the University of Port Harcourt Teaching Hospital (UPTH). UPTH is an 850-bed tertiary health institution with 16 clinical departments, which provides specialties in-patient, out-patient, and emergency clinical services, as well as training and research.
Study design and study population
This was a comparative cross-sectional study with a control group. The study population was selected from among the two groups as follows:
Case group: adult patients attending the nephrology clinic in UPTH, Port Harcourt, who have been diagnosed as having CKD by a consultant nephrologist.
Control group: apparently healthy administrative staff of UPTH, who were matched with the cases in the ratio 1 : 1 for age (±3 years) and sex.
Patients aged 18 years and above who were attending the renal clinic and have been diagnosed with CKD using the US National Kidney Foundation guidelines, Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for CKD: Evaluation, Classification and Stratification, were included in the study. Exclusion criteria were dialysis within 3 months of commencement of study (as increased prevalence of depression noted within this period); presence of dementia, delirium, or other severe medical condition which preclude their being interviewed; and presence of hearing and/or visual impairment, which preclude their being interviewed.
Sample size determination
Sample size formula for comparative studies was employed in the research . Using alpha of 0.05, beta of 0.20, prevalence of depression of 22.1% among patients with CKD in a previous study , prevalence of depression in the general population of 5.2% , and nonresponse of 10%, a sample size of 69 patients and 69 controls was attained.
The sampling was done using the systematic random sampling technique.
The control group was selected from the administrative staff of UPTH who met the selection criteria and matched with the patients with CKD.
The sociodemographic/clinical questionnaire comprised age, sex, ethnicity, marital status, employment status, highest level of education, average monthly income, and stage of CKD.
The Mini International Neuropsychiatry Interview − Clinician rated (MINI), version 5.0.0, is a standardized diagnostic instrument that was developed in 1990 by psychiatrists from America and Europe. It is a clinician-rated short structured diagnostic interview that covers all the major diagnoses of Axis 1 in the Diagnostic and Statistical Manual of Mental Disorders-IV and International Classification of Diseases, version 10 . It employs different time frames to assess for current, lifetime, or past episodes of various disorders. The MINI depressive module was used in this study. The first two questions, A1 and A2, assess for depressed mood and loss of interest, respectively. If neither A1 nor A2 is positive, depression is not present. A3 has seven questions that address other features of depression. Patients’ responses are graded ‘yes’ or ‘no.’ Total positive responses must be at least five to diagnose major depression. MINI too has been validated and found to have high validity and reliability ,,,,. The MINI questionnaire was applied to both patients with CKD and controls to determine the presence of depression.
Ethical approval and consent to participate
The ethical approval to conduct this study was obtained from the Research and Ethics Committee of UPTH. Every eligible participant was informed of the nature, purpose, method, extent, and benefits of the research, and their consent was sought and obtained thereafter. In addition, those who did not wish to partake in the study were informed that their refusal to consent will not in any way affect their treatment or overall care. Patients who gave informed consent were recruited into the study after signing the consent form. Serial numbers were used to identify participants to ensure anonymity. Study participants identified as having depression were informed, counseled, and referred to the mental health clinic for further evaluation. All information obtained during the course of the study was handled with utmost consideration for confidentiality.
The data was analyzed using the Statistical Package for Social Sciences, version 21 (IBM, Chicago, Illinois, USA). Quantitative variables were presented as means, SD, and ranges where appropriate. Age of respondents was categorized as young adults (adults <35 years), middle-aged adults (36–55 years), and old adults (>55 years). Depression was calculated as a proportion and categorized as present or absent based on a MINI diagnosis. c2 test or the Fisher’s exact test was used, as appropriate, to compare the differences in proportions. Bivariate analyses, with depression as a dependent variable, was carried out to determine the sociodemographic factors associated with depression. Odds ratio with confidence intervals set at 95% was computed to determine the measure of association. A P value of less than 0.05 was considered statistically significant.
| Results|| |
Characteristics of patients and controls
Mean age of cases and controls was 44.64±10.34 and 44.71±10.10 years, respectively (t=0.042; P=0.967). In both groups, males and females were 32 (46.4%) and 37 (53.6%), respectively (c2=0.000; P=1.000). The highest frequency of patients with CKD was in stage 4 (27.5%), whereas the least frequent was in stage 1 (10.2%), as shown in [Figure 1].
|Figure 1 CKD staging among patients with CKD. CKD, chronic kidney disease.|
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Prevalence of depression
Prevalence of depression was higher among patients with CKD (34.8%) in comparison with controls (2.9%). Patients with CKD were ∼18 times more likely to de depressed than the controls (odds ratio=17.87; 95% confidence interval: 4.02–79.36; P=0.0001) ([Table 1]).
|Table 1 Prevalence of depression among patients with chronic kidney disease and controls|
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Correlates of depression
Sociodemographic characteristics and depression among patients with CKD are presented in [Table 2]. Patients with CKD in the youngest age category of 19–28 years had the highest prevalence of depression (50.0%), whereas those patients aged 49 years and above had the lowest prevalence (14.3%). There was no significant relationship between age of the patient and occurrence of depression (P=0.102). Although not statistically significant at 0.05 level, depression occurred more commonly among patients with CKD who were males (50.6%), belonged to separated marital status (57.1%), who had secondary level of education (50.0%), and who were unemployed (35.7%). Monthly income was the only variable that showed significant relationship with depression. Patients with CKD earning less than 50 000 Nigerian Naira which is equivalent to 140 United States Dollars had the highest prevalence of depression (48.4%) (P=0.012). There was no significant relationship between CKD staging and depression (P=0.956) ([Table 3]).
|Table 2 Sociodemographic characteristics and depression among patients with chronic kidney disease|
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|Table 3 Relationship between chronic kidney disease staging and depression among patients with chronic kidney disease|
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| Discussion|| |
This study examined the prevalence of depression between patients with CKD and an age-matched and sex-matched control group. The study also examined the sociodemographic characteristics related to depression among the patients with CKD. In the current study, the mean age of the population was 44.67±10.19 years, with a range of 19–64 years, and slightly more than half (53.6%) were females. The mean age was similar to that of the study by Amira , though the sex proportions and the age ranges were dissimilar, where there were more males and the age range was 16–87 years. The difference in age range could be attributed to the fact that in this study, the controls were selected from among the working population with a statutory age limit. The most represented age range in the current study was 39–48 years. This is in keeping with the majority of population-based CKD surveys in Nigeria. However, the prevalence of CKD ordinarily increases with age in the developed world, with the highest prevalence in elderly people. In Nigeria, the prevalence is highest among 20–50 year olds with peak incidence occurring between 30 and 50 years ,. This higher prevalence in younger ages in developing countries like Nigeria has been attributed to the increased exposure to infectious agents and increasing prevalence of diabetic nephropathy . Thus, the morbidity associated with CKD could also be a contributor to the relatively lower life expectancy in Nigeria in comparison to other developed countries .
In this study, the prevalence of depression was found to be 34.8% compared with 2.9% in the control group. The proportion of depressed patients in the CKD group being much higher than the proportion of depressed patients found among the controls is similar to the finding in the study by Amira , where a group of patients with CKD were compared with a control group of apparently normal individuals.
The prevalence of depression found among patients with CKD in this study was similar to the 30% prevalence reported by Balogun et al.  in a study among US veterans, and comparable with that reported by Sumanathissa et al.  in Sri Lanka. The prevalence found in the current study is also within the range reported in the review by Palmer et al. .
However, some other studies, which also used diagnostic interview instruments, have reported lower prevalence rates. For instance, Hedayati et al.  reported a prevalence of 21% when the MINI was used for assessment in a group of mostly male US veterans with CKD stages 2–5. Moreover, Ayanda et al.  in Ilorin reported a prevalence of 22.1%. The difference in prevalence rates between these studies and the current one may be explained by differences in population characteristics and the use of different assessment instruments. Noteworthy, studies in the literature have similarly demonstrated increased rate of depression among patients with chronic medical diseases, including CKD, compared with general populations ,. The current study confirms this trend.The present study found that among the sociodemographic variables, only the average monthly income was significantly lower in the depressed patients with CKD compared with those without depression. This is similar to the reports of Lee et al.  and Dunstan and Scott  The lack of a viable health insurance scheme in the country means that treatment cost is borne by the patient and/or his family. Paying out of pocket for the treatment of a chronic disease like CKD could be financially demanding for the patient and his/her caregivers. This financial burden is an additional stressor that can predispose the patient to depression. The strain on financial resources may also impair the interpersonal relationship between the patient and his/her caregivers, resulting in decreased social support and thus further increasing the likelihood of being depressed .
The use of a validated Diagnostic and Statistical Manual of Mental Disorders-IV-based structured interview schedule (MINI) for ascertainment of depression as well as the inclusion of a sex-matched and age-matched control group in the index study are the strengths of the study. Furthermore, the study was conducted in a region where previous studies on the patient were nonexistent. The findings of the index study reveal the need for clinicians to routinely screen for depression among patients with CKD. Nonetheless, the study is not without limitations, which includes the cross-sectional design. This limits the assumptions of a causal relationship between the variables. Longitudinal studies to determine the effect of depression and its treatment on clinical outcomes in our CKD populations should be encouraged.
| Conclusion|| |
The prevalence of depression found in patients with CKD was significantly higher than that of the control group. Among the sociodemographic variables assessed in this study, the average monthly income was found to be significantly associated with depression in patients with CKD. The need for depression screening among patients with CKD is highlighted in this study. The collaboration between nephrologists and mental health specialists in the care of these patients is also recommended.
Olufisayo K. Adesokun contributed to the concepts of the study, data collection, and draft preparation. Chukwuma U. Okeafor conceptualized the study design, analyzed the data, and edited the draft. Princewill C. Stanley contributed to the concepts and reviewed the final draft.
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]