HEMODIALYSIS AND DEPRESSION: SOCIAL REPRESENTATION OF PATIENTS¹

Abstracts

This study aimed to analyze the different semantic fields associated with inducing stimuli: Chronic Renal Failure (CRF) treatment, hemodialysis and depression, elaborated by patients with Chronic Kidney Disease (CKD) on hemodialysis with and without symptoms of depression. Fifteen patients on hemodialysis participated in this study, their aged were between 20 and 73 years (M= 46.05; SD = 13.4), who answered to a sociodemographic questionnaire, the Hospital Anxiety and Depression Scale (HADS) and the Free Word Association Test. The data were analyzed using descriptive statistics and factorial correspondence analysis. The results indicated that 20% of patients had depressive symptoms. The knowledge of common sense about the CRF was focused on the ignorance of the causes which lead to kidney disease and related to the treatment and its associated difficulties, which was considered a nightmare. The treatment was based on the therapeutic triad: hemodialysis sessions, diet and medication, as well as in the emotional support from care and hope. The semantic field about the hemodialysis stimulus was represented by the symbolic representation of the machine and by the death eminence. The symptom of depression has been objectified in the elements: agony, sadness, crying, and lack of desire and support. The results highlighted the importance of emotional, family and social support to kidney patients once it was observed that support was mentioned as one of the key factors in helping both the Chronic Renal Failure and the depression.

Social representation; hemodialysis; depression

Este estudo objetivou analisar os diferentes campos semânticos associados aos estímulos indutores insuficiência renal crônica (IRC), tratamento, hemodiálise e depressão, elaborados por pacientes com doença renal crônica em hemodiálise com e sem sintomas de depressão. Participaram do estudo 50 pacientes em tratamento de hemodiálise, com idades entre 20 e 73 anos (M= 46,05; DP= 13,4), que responderam a um questionário sociodemográfico, à Escala Hospitalar de Ansiedade e Depressão e à Técnica de Associação Livre de Palavras. Os dados foram analisados por meio da estatística descritiva e análise fatorial de correspondência. Os resultados indicaram que 20% dos pacientes apresentaram sintomas depressivos. O conhecimento do senso comum acerca da IRC esteve focado no desconhecimento das causas que ocasionam a doença renal, bem como no tratamento e suas dificuldades, sendo a IRC considerada um pesadelo. O tratamento foi calcado na tríade terapêutica sessões de hemodiálise, dieta e medicação, assim como, no suporte emocional proveniente do apoio, cuidados e esperança. O campo semântico do estímulo hemodiálise esteve voltado para a representação simbólica da máquina e para a iminência da morte. A sintomatologia da depressão foi objetivada nos elementos agonia, tristeza, choro, não ter vontade e apoio. Os resultados evidenciaram a importância do suporte emocional, familiar e social aos pacientes renais, tendo sido observado que o apoio foi mencionado como um dos fatores fundamentais para o auxílio tanto na doença renal crônica quanto na depressão.

Representação social; hemodiálise; depressão

Este estudio tuvo como objetivo analizar los diferentes campos semánticos asociados con los estímulos inductores: Insuficiencia Renal Crónica (IRC), tratamiento, hemodiálisis y depresión, elaborados por los pacientes con Enfermedad Renal Crónica en hemodiálisis con y sin síntomas de depresión. Participaron 50 pacientes en tratamiento de hemodiálisis, con edades entre 20 y 73 años (M= 46,05, DP= 13,4), que contestaron a un cuestionario sociodemográfico, la Escala Hospitalaria de Ansiedad y Depresión y la Técnica de Asociación Libre de Palabras. Los datos fueron analizados mediante la estadística descriptiva y el análisis factorial de correspondencia. Se observó que un 20% de los pacientes presentó síntomas depresivos. El conocimiento del sentido común acerca de la IRC se ha centrado en la ignorancia de las causas que conducen a la enfermedad renal, asociada al tratamiento y sus dificultades, que se consideró una pesadilla. El tratamiento se basó en la tríada terapéutica: sesiones de hemodiálisis, dieta y medicamentos, así como, en el soporte emocional proveniente del apoyo, los cuidados y de la esperanza. El campo semántico del estímulo hemodiálisis estuvo dirigido para la representación simbólica de la máquina y en la inminencia de la muerte. Los síntomas de la depresión se objetivó en los elementos: agonía, tristeza, llanto, no tener deseo y apoyo. Los resultados destacaron la importancia del apoyo emocional, familiar y social a los pacientes renales, ya que se observó que el apoyo fue mencionado como uno de los factores fundamentales en la ayuda tanto en la Enfermedad Renal Crónica, como en la depresión.

Representación social; hemodiálisis; depresión

The hemodialysis is one of the greatest advances in medicine, considering that the kidneys are the only major organs which may be substituted, even though not perfectly, by a machine. In this case, the hemodialysis is considered the most commonly used treatment for renal function replacement today. It is a mechanical and extracorporeal process which consists of toxic substances removal from the blood. In general, this treatment is performed in a hospital unit, three weekly sessions in average, for a period of three to five hours per session, depending on the individual needs of each patient (Andreoli & Nadaletto, 2011).

According to the data provided by the census of the Sociedade Brasileira de Nefrologia- SBN (Brazilian Society of Nephrology), in 2012, the prevalence of patients on chronic dialysis program more than doubled over the past eight years, reaching an average of 97,000 referrals, in Brazil. This fact has positioned the country as the third in the world in hemodialysis treatments. In face of this reality, the Chronic Kidney Disease (CKD) has received increasing attention from the international scientific community because of its high prevalence has been demonstrated in recent studies, which constitutes a public health problem in Brazil and the worldwide nowadays (Bastos & Kirsztajn, 2011).

The CKD corresponds to a syndrome characterized by the progressive, irreversible and multifactorial loss of renal function, which generates changes in different organ systems; this contributes to the failure of the body's ability to maintain metabolic and hydroelectrolytic balance, resulting in the retention of urea and other nitrogenous wastes in the blood. As it is asymptomatic, the individuals are unaware of its existence until its clinical condition present fairly advanced, requiring urgent treatment to replace the kidney function (Smeltzer & Bare, 2009).

Pilger, Rampari, Waidman and Carreira (2010); Kimmel, Cohen and Peterson (2008), show that hemodialysis leads to changes in the lifestyle of the individuals and their families, resulting in limitations regarding the emotional, economic, social, labor, and other issues aspects. It is also observed that the constant exposure to adverse factors inherent to kidney disease, such as the time spent on hemodialysis, the constant doctor visits, the lab tests, the diets, the expectation of transplantation, associated with frequent stay in hospital environments have contributed to the emergence of psychoaffective diseases, among them, the depression symptoms (Ferreira & Anes, 2010).

The etiology of depressive symptoms, in general, is bound to losses. For patients with kidney disease, the most prominent are: the loss of kidney function, the loss of the sense of well-being, the loss of the role in the family and at work, the loss of physical and cognitive abilities and also the sexual function, among others (Kimmel, et al., 2008; Dalgalarrondo, 2008).

The literature points that the symptoms of depression is common in patients suffering from CKD who are on hemodialysis treatment and that its prevalence may reach a rate of up to 100%, depending on the instruments used (Kimmel, et al., 2008; Smith, Hong, & Robson, 1985). More recent studies have shown less comprehensive prevalence as Garcia, Veiga and Motta (2010) and Costa, Coutinho, Melo and Oliveira (2014), which indicate an oscillation among 56.3% to 68%. Other studies show a smaller variation among 10% and 30% (Kimmel et al., 2008; Almeida 2003).

Despite this change in mood be prevalent routinely, it often lies underdiagnosed. Some criteria relate to screening tools, which are generally self-reports, requiring that the patient taxes the frequency or the severity of symptoms, or when applied to people with chronic illnesses, both the screening tools and the diagnosis are sensitive to the contamination criterion, as it includes investigation and somatic symptoms, which overlap the symptoms of physical disease (Chilcot, Wellsted, Silva-Gane, & Farrington, 2008). As Cukor, Coplan, Brown, Peterson and Kimmel (2008), the aspects that also contribute to the underdiagnosis of depression symptoms in the context of hemodialysis are the diversity of populations, medical team with different training and experiences, heterogeneous diagnostic criteria of depression and different measurement instruments factors.

Accordingly, besides to quantify the symptoms of depression in these patients, it is important to give voice to those social actors, allowing them to expose their thoughts and interpretations of everyday life through their thoughts, images, beliefs, values and experiences. These elements are present in the discourse on CRF, treatment and depression, which are structured according to their socio-cultural organizers, attitudes and cognitive schemas (Coutinho, 2005).

There are several meanings that pass through the imagination of people affected by CKD, ranging from the impact of the diagnosis, related to the recognition of the disease severity and the treatment until its consequences, such as drug effects and the limitations in the eating habits and in the social life. In general, these situations provoke doubt, insecurity, fear, anguish and suffering related to the healing and the possibility of living (Ramos et al. 2008).

In light of this context, a question has been arisen: how patients with and without depression represent the CRF, the treatment and the depression in the hemodialysis context? The kidney patients contribute to direct the behavior, the communications and the daily practices due to the way they build the social representations. In this direction, it is expected that the results of this study can be used by the scientific community to support the development of public policy and treatment plans that take into account both the psychosocial aspects (affective, cognitive), and physical (hemodialysis and food diet), resulting from the kidney disease (Coutinho, 2005).

As theoretical basis for this article we used the input of social representations (SR). According to Moscovici (2011), the SR are the result of a process of transformation from what is unfamiliar and unknown to something familiar and particular. Therefore, a basic function of the SR is the integration of the new, what is obtained by means of two interconnected processes: the anchoring and the objectification. The anchoring transfers the unknown to the frame of reference, by means of the comparison and interpretation; in turn, the process of objectification plays the unknown, between what is visible and tangible. Thus, an SR arises in front of a new object, through the materialization of an abstract entity, which was anchored by the classification and by the appointment (Moscovici, 2011).

In the literature it is observed that there are anchored searches in the psychosocial approach, in the context of hemodialysis, as seen in Quintana and Muller (2006); Campos and Turato (2010) and Pilger et al. (2010). However, the studies conducted by these authors were more frequent in nursing, with little emphasis on psychology. Besides, it was not visible samples of patients with depressive symptoms as well as to understand the SR of depressive symptoms in these studies.

Given the possible lack of information on this topic, this article aims to analyze the SR through the different semantic fields associated with the inducing stimuli: Chronic Kidney Disease, treatment, hemodialysis, depression and myself (the patient himself), produced by patients with CKD on hemodialysis with and without symptoms of depression. The identification of these elements allows understanding how these individuals interpret this new reality of life, permeated by the kidney disease and its treatment (Coutinho, 2005).

METHOD

Type of study

It was a field and descriptive survey, subsidized on a multimethod approach, highlighting a psycsociological perspective on the studied phenomena.

Participants and Location

The survey had 50 CKD patients, aged between 20 and 73 years (M= 46.05; SD = 13.4), the most of them were female (52%) and 66% married. The sample was of no-probabilistic type and of convenience. It was adopted, as inclusion criteria, to be more than 18 years and being on hemodialysis treatment.

The research was conducted in three hospitals that provide the hemodialysis treatment for adults, and maintain agreement with the Sistema Único de Saúde - SUS (Unified Health System), located in the city of João Pessoa/PB-Brasil.

Instruments

To obtain the data, it was used a sociodemographic questionnaire, the Free Word Association Test (FWAT) and the Hospital Anxiety and Depression Scale (HADS). The first instrument was used in order to obtain information about the participants, such as; age, sex and marital status, thus understanding the characteristic profile of the sample as well as the establishment of fixed variables that comprised the database which was processed by Trideux-Mots computer program.

The FWAT was used with the inducing stimulus: CRF, hemodialysis treatment, depression and myself (the pacient himself). This instrument allows the update of implicit or latent elements that would be lost or masked in the discursive productions. It is a projective technique widely used in the context of social psychology, especially when working with the theoretical contribution of the SR, which allows evidencing semantic universes that reflect the ordinary universes of words facing the different stimuli and subjects or groups (Nobrega & Coutinho, 2011).

It was also used the HADS, which is an instrument that Botega, Bio, Zomignani, Garcia and Pereira (1995) suited for the Brazilian population. This scale has 14 items, seven aimed to assess the anxiety (HADS-A) and seven for the depression (HADS-D), which have the respective coefficients of Cronbach alpha, 0.68 and 0.77. Each item can be scored from zero to three, composing a score of 0 ± 21, being recommended an 8 as the cutoff point. (Marcolino, Mathias, Piccinini Filho, Guaratini, Suzuki, & Alli, 2007; Botega et al., 1995 ).

In a study by Marcolino et al. (2007) in order to assess the criterion validity and reliability with preoperative patients, compared with the Beck scales of anxiety and depression, it was found that the correlation of HADS, ranged from 0.6 to 0.7, and it was considered a medium to strong correlation, showing internal consistency rates recommended for screening tools. In this study, we used the sub-scale referred to depression (HADS-D), as a means of screening.

Ethical procedures and data collection

This study was conducted considering the ethical conditions established by the Conselho Nacional de Saúde - Committee of the National Health Council- appropriate to research involving human subjects, in accordance with the Resolution 466/2012, and with an establishment designated by the Resolution 246/97, being approved by the Comitê de Ética em Pesquisa do Centro de Ciências da Saúde (Ethics Committee in Research of the Health Sciences Center), from the Federal University of Paraíba, under the protocol 392/11.

Regarding the data collection procedure, patients were addressed both in the waiting room and in the machine, when they were dialyzing. Initially, each patient signed a consent form, followed by the administration of the instruments, according to the following order: first, the FWAT; then the sociodemographic questionnaire and, finally, the HADS-D. The instruments were administered individually and orally (being read by researchers), due to the inability of some participants to respond in writing. The average time of application of the instruments was 25 minutes.

Data Analysis

The data from the sociodemographic questionnaire and THE HADS-D were analyzed using the Statistical Package for the Social Sciences (SPSS - 19.0), being used the descriptive statistics (mean, standard deviation and frequency) in order to describe the study sample and to assess the depression prevalence.

The data collected from the FWAT were processed by the Trideux-Mots software (2.2 version) and analyzed by the Factorial Correspondence Analysis (FCA). The FCA highlights the axes that explain the modalities of answers, showing structures that are consisted of elements of the representational field, which provides a graphic display of both the fixed variables (gender, marital status and depression) and the opinion variables, that correspond to the words evoked by the participants (Nobrega & Coutinho, 2011).

RESULTS AND DISCUSSION

The results arising, from the HADS-D, reported that 20% of participants had symptoms of depression, with a score ranging from 8 to 18 points, with an average of 5.36 (SD = 3.4). This prevalence is in line with the literature, which rates are between 10 to 100% (Smith et al., 1985 Almeida, 2003; Kimmel et al., 2008; Garcia et al., 2010; Costa et al., 2014).

Given this prevalence, it is possible to conclude that patients with CKD, who are undergoing hemodialysis treatment, are more likely to be affected by the symptoms of depression, once the literature reports that this syndrome is common to this population. In these patients, the depressive symptomatology seems to be related to the changes in the quality of life, the immunity and the functional capacity decreased, the personal care relaxation and the treatments and the diets adherence. Consequently, these problems cause an increase in the number of outpatient consultations, hospitalizations, and even death (Chilcot et al, 2008; Cukor et al., 2008).

The social representations, which arise from the FAWT, shown in the Figure 1, provide a representational reading of semantic variations associated with the inducing stimuli: CRF, treatment, hemodialysis, depression and myself, developed by CKD patients on hemodialysis with and without symptoms of depression, revealing the approaches and the gaps from the construction methods of the axes or factors (F1 and F2). The sum of these two factors highlighted a 80.6% explanatory power of the total variance of the answers, in which the F1 showed 63.2%, and the F2, 17.4%, thus, demonstrating statistical parameters with internal consistency and reliability, taking surveys conducted within the SR view (Nobrega & Coutinho, 2011).

Figure1: Correspondence
factor plan of social representations elaborated by renal patients

Legend:

Factor 1 (F1), black, is located on the horizontal axis to the right and left.

Factor 2 (F2), in gray, is located in the lower and upper vertical axis.

Inducing stimuli: CRF = 1; treatment = 2; hemodialysis = 3; depression = 4 and myself =5.

In factor 1 (F1) it was observed the buildings of renal patients who are undergoing hemodialysis treatment regardless of whether they are affected by the depressive symptoms, compared to the inducing stimulus CRF which was objectified as: "Paralized Kidney". The renal female patients, who were presented with depressive symptoms, prepared the same semantic field for this inducer stimulus representing it as "difficult treatment" disease.

Still in F1, the semantic field produced by participants was found when comparing to the second stimulus inducing treatment. This was represented by the elements: "medicine", "to filter the blood", "health" and "injection hole". The female patients with symptoms of depression, represented that the treatment included: "Support", "hope", "care", "diet" and the availability of "time" to accomplish it.

As to the stimulus hemodialysis, this was represented consensually by the patients regardless of sex and symptoms of depression, as a way of "treatment". On the other hand, the female and depressive participants reported that "if they stop the hemodialysis, they can die".

The inducing stimulus depression was consensually objectified by the patients in the elements, "support" and "agony". For the last inducing stimulus, "myself", these same patients reported themselves as: "sick", "normal", "glad " and "good". As the female patients with depressive symptoms showed no evoking for the stimulus depression, although these same participants represented themselves as "calm" and "sad" persons.

The second factor (F2) reflects the collective thinking of the nephrology patients in relation to marital status. Thus, the married participants objectified the CRF in the elements: "nightmare" and "do not know the reason." It is also observed that the inducing stimulus treatment was represented by the married patients, by the elements: "Can not drink liquid" and "healing." For the other group, this stimulus was objectified in: "God". Regarding the stimulus 3 hemodialysis, the married participants did not emerge evocations. On the other hand, the unmarried patients objectified the "hemodialysis" using the words: "machine" and "paralyzed kidney".

As referred to the stimulus depression, married patients had no objectivations, and they defined themselves as persons who are "always at home", "limited" and that "like to help people." On the other hand, unmarried participants represented a depression through the evocations: "sad," "cry" and "unwillingness" and they described themselves as "glad", "good" and "good health" persons.

Given the results presented, it can be verified that in general the patients represented the CRF linked to the ignorance of the causes of kidney disease, so the CRF disease is directly related to the difficulties encountered during the treatment, giving the feeling that they are living in a "nightmare".

Indeed, as medical knowledge, the renal disease in its last stage is considered progressive, irreversible and responsible, in a multifactorial way, by the loss of renal function (Smeltzer & Bare, 2009). The kidney disease can be caused by several factors, including genetic, environmental, occupational, and dietary. In fact, there is not the specificity of only one factor (Bastos & Kirsztajn, 2011; Ribeiro et al., 2008). Accordingly, it was observed that the patients are unaware of the reasons of CRF; consequently they realize it only when the symptoms are already advanced, since its development and chronicity occur in a silent way. For Santos and Valadares (2011) this ignorance associated with the disease and its treatment leaves room for arising ideas sometimes more perverse than the reality itself, overwhelming the subject and leaving him unsafe, so the event was mythologized causing frightening and desperate figures.

In general, the CRF was anchored by the participants in the erudite knowledge when the CRF was attributed as a synonym for paralyzed kidney as well as in the emotional category when they objective the disease as a "nightmare". For Moscovici (2011), these are the categories or labels that give meaning to the studied object.

The SR treatment was linked to "injection hole" to filter the blood as an opportunity to obtain health, since he also ingests drugs and do not drink; these patients also associated God with the successful treatment, it may be inferred that such representation was related mostly to specific concrete factors, which involve the progression of therapy. Conversely, the patients with depressive symptoms attributed that the treatment requires support, hope, care, diet, and time to accomplish it; accordingly, for this group, the treatment was also associated with their emotional character, suggesting the need for support, care and hope.

According to Balaga (2012), the renal treatment includes a therapeutic triad: frequent hemodialysis sessions and indicated time, medication and adherence to the diet plan and to the liquid control. In this study, it was observed that the social representations of the participants are in line with what is established by the scientific knowledge.

When relating the treatment to "injection hole" to filter the blood, the participants referred to the process of hemodialysis, and especially the change in the body image resulting from this process. As Tijerina (2009), the hemodialysis may cause changes in the body appearance due to: the catheter presence to vascular access or to the arteriovenous fistula, the discoloration of the skin, the weight loss, or the scars from the surgical creation; contributing to the loss of identity of this population.

It might also notice that the treatment was anchored in the spiritual realm, through the objectification: God. As Quintana and Muller (2006), the faith in a higher being is seen as a source of hope, strength and comfort, giving to the patient the necessary support to face the changes resulting from the illness. The religion and the spirituality are enablers for the meaning of life, favoring that the individual is at peace with himself, so he can adapt himself not only to the disease and its treatment, but also to the multiple physiological and psychosocial problems resulting from the chronic disease (Greenstreet, 2006).

To Tanyi and Werner (2008), the spirituality, especially in the last stage of CKD refers to four main themes: the diagnosis, treatment and themselves acceptance; fortification, as the individuals seek strength in God, they are able to fight their illness; Understanding, the spirituality allows that the patients have different perceptions of the disease, allowing them to question, to understand and to learn from their disease, in this sense, more knowledge about the disease can help them in their self-care; and emotions modulation, the spirituality is also essential to reduce fear, providing peace and helping the individuals to maintain a positive outlook towards the disease.

The inducing stimulus hemodialysis was objectified as a mandatory treatment mode which treats the paralyzed kidney through a machine; the patients with depressive symptoms have emphasized that if they stop the hemodialysis they may die. Possibly, these patients affected with the depressive symptomatology realized that the hemodialysis has greater value in their lives than the other patients; in this case, the presence of these symptoms can further enhance the negative aspects of the treatment. Dalgalarrondo (2008) explains that in the depressive mood the disturbance in attention, cognition and memory occur; this way, the individual tends to maximize the experienced aspects negatively.

Broadly, the representative elements of the hemodialysis are anchored in the psycho-affective spectrum and structural of the kidney disease. The results of this study is in accordance with those by Pereira and Guedes (2009), when the authors state that hemodialysis is the main factor for survival of patients with advanced stage of the renal disease. The hemodialysis is necessary to maintain the welfare of these people, despite bringing a suffering reality for the patient and based on the consequences related to the process, which was also considered as difficult, arduous and full of restrictions (Pereira & Guedes, 2009). For Campos and Turato (2010), the hemodialysis was associated with the survival and the obligation. The survival emerged as major significance for the treatment, considered a possibility of maintaining its existence and conflict with an eminent death situation; as the obligation was marked by a lack of other treatment options for kidney disease.

In this study, the hemodialysis was marked by the symbolism of the machine, because it gives them the continuity of life; however, it is through this device that the limitations imposed by the disease are realized with greater intensity. Some of the restrictions experienced by renal patients are: the employment loss, restrictions on the time to study or travel, changes in eating habits, including essentially a ban on drinking water, in addition to having the body scarred generated by fistulas, catheters, exams and surgeries, as well as the yellowing of the skin which gradually becomes pale, dry and stained.

Regarding the depression inducing stimulus, patients without the depression symptoms built their semantic field structured in their objectivations: agony, sadness, crying and unwillingness. Moreover, these participants reported that the depression was also linked to the support. Possibly it can be inferred that this representation is around a preventive character, or in an aspect related to the depressive syndrome treatment.

The depression was mainly anchored to psychosocial and psychoemotional aspects. These results correspond with those found by Fonseca, Coutinho and Azevedo (2008), when investigating the youths with and without depressive symptoms. To Tremblay (2005), it is important to recognize the different representations related to the depression, as these are likely to have an impact on the disease progression and on the treatment efficacy. It is noteworthy that the representations around the organization, social and psychological depression insertions provide a means to identify with greater precision and better understanding of the different positions of patients and of interested ones in dealing with the depression.

By consensus, the patients defined themselves as: sick, normal, glad and good people while the patients with depressive symptoms, although they did not elaborate any evoking for the depression stimulus, they represented themselves as quiet and sad people. The married patients see themselves as people who are always at home, limited and who enjoy helping others. On the other hand, the unmarried described themselves as glad, good and good health people.

These representations are anchored both in positive and negative self-perception. It is noteworthy that the negative self-perception (sad) was prominently represented by the participants with symptoms of depression; this aspect was seen by Fonseca et al. (2008). It was also possible to see that despite the kidney disease, some patients consider themselves normal people and with good health. In this respect, Guedes and Pereira (2009) say that in the hemodialysis scenario the patients feel as a sick person, although the trend is to deny that feeling for not discouraging and having strength to continue living with all the restrictions that this disease imposes.

FINAL THOUGHTS

The results of this research, which were obtained by means of free associations, allowed analyzing the different semantic fields associated with inducing stimuli: CRF, treatment, hemodialysis, depression and myself, from the perspective of dimensional approach of the SR. In the factorial plan, in the Factor 1 was found that the patients SR without depressive symptoms, which are distinct, and, on the other hand, the patients' naive knowledge related to the depressive symptomatology. In the same sense, in the Factor 2, the representations that remained in dispute about the marital status of the participants were observed.

Concerning the evoked words in the free association, the CRF has been realized as a disease of unknown reason, which paralyzes the kidneys, being associated with the treatment and the inherent difficulties of this process. It might be inferred that such representation may increase the vulnerability to the onset of depressive symptoms in renal patients, since renal disease was also realized as a nightmare. Thus, there is a need for further clarification on the causes and symptoms of kidney disease to the population as a whole, once some of these causes could be prevented, which would contribute to the emersion backwardness on the symptoms of this disease.

The SR hemodialysis prepared by depressed patients also corroborated with the need for emotional support, since this representation was based on the imminence of death. This support also emerged in the depression representation, raising the preventive character or one of the aspects concerning this syndrome. Broadly, the results observed in this study raised the need for greater attention to promote psychological care services to these patients at the moment of the diagnosis as well as during the treatment in order to make it the least impactful moment in their lives.

Other aspects highlighted in this study were issues, such as: the life finiteness, since these people are living between life and the death eminence; factors such as the lack of knowledge about the reasons of CKD as well as its main form of treatment, the hemodialysis; it was even realized that the participants SR can modulate their behavior in relation to adhere or not to the diets proposed for this disease (in this case, issues related to the nutritional restrictions are of extremely importance to be treated). Furthermore, we suggest the development of resilience strategies among these patients, in order to contribute to a better quality of life for them. Finally, we emphasize the importance of emotional supports (family, social and religious) to kidney patients, since it was observed that the support was mentioned as one of the key factors in helping both the CKD and the depression, demonstrating consensuality between the representations of these two constructs.

The use of a non-probability sample reveals itself as an important limitation regarding the possibility of generalization of the results. Thus, we suggest caution when comparing these results to the other authors. It is also noteworthy that the prevalence of the found depression is not a diagnosis, once it was used only one instrument for depression screening and a battery of instruments to diagnose this phenomenon would be required.

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• 1
  Support: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

Publication Dates

• Publication in this collection
  Oct-Dec 2014

History

• Received
  07 May 2014
• Accepted
  28 Oct 2014