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Depression in hemodialysis patients: the role of dialysis shift

Abstract

OBJECTIVE:

Depression is the most important neuropsychiatric complication in chronic kidney disease because it reduces quality of life and increases mortality. Evidence demonstrating the association between dialysis shift and depression is lacking; thus, obtaining such evidence was the main objective of this study.

METHOD:

This cross-sectional study included patients attending a hemodialysis program. Depression was diagnosed using Beck's Depression Inventory. Excessive daytime sleepiness was evaluated using the Epworth Sleepiness Scale.

RESULTS:

A total of 96 patients were enrolled (55 males, age 48±14 years). Depression and excessive daytime sleepiness were observed in 42.7% and 49% of the patients, respectively. When comparing variables among the three dialysis shifts, there were no differences in age, dialysis vintage, employment status, excessive daytime sleepiness, hemoglobin, phosphorus levels, or albumin levels. Patients in the morning shift were more likely to live in rural areas (p<0.0001), although patients in rural areas did not have a higher prevalence of depression (p= 0.30). Patients with depression were more likely to be dialyzed during the morning shift (p= 0.008). Independent risk factors for depression were age (p<0.03), lower levels of hemoglobin (p<0.01) and phosphorus (p<0.01), and dialysis during the morning shift (p= 0.0009). The hospitalization risk of depressive patients was 4.5 times higher than that of nondepressive patients (p<0.008).

CONCLUSION:

These data suggest that depression is associated with dialysis shift, higher levels of phosphorus, and lower levels of hemoglobin. The results highlight the need for randomized trials to determine whether this association occurs by chance or whether circadian rhythm disorders may play a role.

Depression; Dialysis Shift; Hemodialysis


INTRODUCTION

Chronic Kidney Disease (CKD) is a silent disease that is frequently diagnosed in the advanced stages when dialysis and renal transplantation are the only options. The beginning of dialysis treatment causes subtle changes in the life of CKD patients, mainly in the physical and social spheres. For this reason, individuals diagnosed with CKD usually develop neuropsychiatric complications. Depression is the most important of them, due to its high prevalence, reduction in quality of life, and potential to increase mortality (11. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095-105.,22. Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161(15):1849-56.). The prevalence of depression in CKD patients, even those in the predialysis stages, is higher than that reported for the general population and for individuals with other chronic diseases (11. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095-105.,22. Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161(15):1849-56.). Depressive patients with CKD on hemodialysis have a higher risk of death and hospitalizations compared with those without depressive symptoms (33. Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Allen AS, Bosworth HB. Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis. Am J Kidney Dis. 2005;46(4):642-9.). Despite the high prevalence (60% in some series) and damaging consequences, depression is still a misdiagnosed disorder because of the superposed symptoms related to uremia (anorexia, fatigue, sleep disorders) and the absence of a systematic psychiatric evaluation (44. Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis. 2003;41(1):105-10.). Beck's Depression Inventory (BDI) is one of the most widely used tests for assessing the severity of depression in this population and was recently modified for dialysis patients due to the high prevalence of symptoms that can mimic the clinical presentation of depression in this population (55. Grant D, Almond MK, Newnham A, Roberts P, Hutchings A. The Beck Depression Inventory requires modification in scoring before use in a haemodialysis population in the UK. Nephron Clin Pract. 2008;110(1):c33-8.). Unemployment, white race, dialysis vintage, and female sex are recognized factors associated with depression in dialysis patients (66. Son YJ, Choi KS, Park YR, Bae JS, Lee JB. Depression, symptoms and the quality of life in patients on haemodialysis for end stage renal disease. Am J Nephrol. 2009;29(1):36-42.,77. Lopes AA, Albert JM, Young EW, Satayathun S, Pisoni RL, Andreucci VE, et al. Screening for depression in haemodialysis patients: Associations with diagnosis, treatment and outcomes in the DOPPS. Kidney Int. 2004;66(5):2047-53.). Usually, dialysis units have morning, afternoon, and evening shifts, and patients are distributed depending on their own preference. Recent studies have suggested that dialysis shift may have an impact on sleep disorders, quality of life, and mortality (88. Merlino G, Piani A, Dolso P, Adorati M, Cancelli I, Valente M, et al. Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy. Nephrol Dial Transplant. 2006;21(1):184-90.

9. Cengić B, Resić H, Spasovski G, Avdić E, Alajbegović A. Quality of sleep in patients undergoing hemodialysis. Int Urol Nephrol. 2012;44(2):557-67.
-1010. Abbott KC, Reynolds JC, Trespalacios FC, Cruess D, Agodoa LY. United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Survival by time of day of hemodialysis: analysis of United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Am J Kidney Dis. 2003;41(4):796-806.). However, evidence regarding the influence of dialysis shift on the prevalence of depression is scarce (1111. Cengic B, Resic H. Depression in hemodialysis patients. Bosn J Basic Med Sci. 2010;10 Suppl 1:S73-8.).

Therefore, we aimed to evaluate the influence of the dialysis shift on depression frequency in a population of patients undergoing hemodialysis. In addition, we assessed the main outcomes related to depression symptoms and management and identified possible biochemical markers of depression in this specific population.

MATERIALS AND METHODS

This cross-sectional study included patients 18 years of age or older who were attending a hemodialysis program at a tertiary hospital. Patients who had undergone less than six months of dialysis, those with advanced malignancy, and those who were intellectually unable to answer the questionnaires or who refused to participate were excluded. The prevalence of depression symptoms was assessed using Beck's Depression Inventory (BDI), which is a questionnaire that includes 21 queries with graduated answers from 0 to 3 that addresses issues such as sadness, guilt, tiredness, concern with personal appearance, being able to work, sexual interest, and other issues (1212. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71.). Recently, BDI was validated for CKD patients through a comparison with a structured psychiatric interview using ICD-10 criteria and applied by a trained psychiatrist. Based on this study, the BDI cut-off of 10, which was validated for the general population, was raised to sixteen or higher for CKD patients (55. Grant D, Almond MK, Newnham A, Roberts P, Hutchings A. The Beck Depression Inventory requires modification in scoring before use in a haemodialysis population in the UK. Nephron Clin Pract. 2008;110(1):c33-8.). BDI was also validated in dialysis patients against the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID), and an identical cut-off was found (1313. Watnick S, Wang PL, Demadura T, Ganzini L. Validation of 2 depression screening tools in dialysis patients. Am J Kidney Dis. 2005;46(5):919-24.). BDI has already been translated, adapted, and validated in Brazilian Portuguese, showing good reliability and validity (1414. Gorenstein C, Andrade L. Validation of a Portuguese version of the Beck Depression Inventory and the State-Trait Anxiety Inventory in Brazilian subjects. Braz J Med Biol Res. 1996;29(4):453-7.). Excessive daytime sleepiness (EDS) was also evaluated using the Epworth Sleepiness Scale (ESS), and patients with values higher than 9 were considered to have EDS, as described previously (1515. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14(6):540-5.).

An additional questionnaire was applied to assess general data (age, gender, scholarship level, marital state, address in urban or rural area, occupation, cause of CKD, comorbidities, antidepressant drugs, number of hospitalizations in the last year) and data related to the dialysis session (time on dialysis, interdialytic weight gain, and single pool Kt/V [which measures dialysis dose]). Laboratory parameters were analyzed, such as hemoglobin, calcium, phosphorus, and albumin. The statistical analysis was performed based on the median values of the last three months. The patients were evaluated according to their dialysis shift: morning, afternoon, or evening.

Ethics

The study was submitted and approved by a local ethics committee (protocol number 1325), and all subjects provided written informed consent. This study was performed in accordance with the Helsinki Declaration of 1975.

Statistical analysis

The data are expressed as the mean±standard deviation (SD). For the statistical analysis and data description, patients were stratified according to dialysis shift (morning, afternoon, and evening). Numerical variables were submitted to the Kolmogorov-Smirnov test and compared using ANOVA with a Bonferroni post-test. The Mann-Whitney test was performed to analyze variables that were not normally distributed. Categorical variables were examined by a Chi-square test. The association between the laboratory data, demographic data, and the presence of depression was evaluated by logistic regression (Enter method). The variables used in the logistic regression model were gender, age, dialysis vintage, unemployment, dialysis shift, hospitalization, rural area, hemoglobin, and phosphorus. The significance level adopted was p<0.05 with a 95% confidence interval. All statistical analyses were performed using SPSS software (SPSS Inc., Chicago, IL).

RESULTS

After application of the exclusion criteria, 96 patients were enrolled during the four months of data collection (December 2009 to March 2010). Among these patients, 55 were male, and the mean age was 48±14 years. The main clinical, demographic, and laboratory characteristics are summarized in Table 1. Most of the patients were married (63.5%) and not employed (88.5%). Depression symptoms and EDS were observed in 41 (42.7%) and 47 (49%) patients, respectively. The dose of dialysis, expressed as Kt/V, was adequate for all patients.

Table 1
- Demographic and clinical data (N = 96).

There were no differences between individuals in the three dialysis shifts with respect to age, dialysis vintage, employment status, hemoglobin, phosphorus, albumin levels, or EDS (Table 2). Patients in the morning shift lived farther from the dialysis unit (p<0.0001), in a rural area. The prevalence of depression was higher among patients in the morning shift (Table 2).

Table 2
- Variables among dialysis shifts.

When comparing patients with and without depression, we found no difference in gender, dialysis vintage, employment status, or address in a rural area. The most important difference in depression prevalence was between individuals in the morning and evening dialysis shifts (Pearson Chi-Square = 6.20; CI 0.06-0.75; p= 0.015). There was no difference between morning and afternoon dialysis shifts (Pearson Chi-Square = 0.85; CI 0.26-1.61; p= 0.37). The difference between afternoon and evening shifts was marginally significant (Pearson Chi-Square = 3.07; CI 0.09-1.17; p= 0.09).

Using the logistic regression model, elderly patients had a higher risk of depression, as shown in Table 3. Lower levels of hemoglobin and phosphorus were significantly associated with depression symptoms. Depressive patients had a hospitalization risk that was 4.5 times higher than that of nondepressive patients (IC 1.48-14.01; p<0.008). Other variables used in the logistic regression (gender, dialysis vintage, unemployment, and address in a rural area) were not associated with depression. Only 19 (19.8%) patients were being administered the appropriate drug treatment for depression.

Table 3
- Independent risk factors for depression (logistic regression).

DISCUSSION

Based on our data, we have shown that the prevalence of depression symptoms was 42.7%. We found that depression was associated with dialysis during the morning shift, older age, lower hemoglobin and phosphate, and a high risk of hospitalization. The significance of the observed high frequency of depression becomes more evident if we compare it with the prevalence of 5% in the general adult population (1616. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095-105.).

In a recent analysis, it was demonstrated that CKD patients on dialysis had a higher risk of depression than predialysis patients, with a frequency of depressive symptoms of 34.5% for the dialysis group vs. 13.3% for the predialysis group (1717. Ibrahim S, El Salamony O. Depression, quality of life and malnutrition-inflammation scores in hemodialysis patients. Am J Nephrol. 2008;28(5):784-91.). Previous studies have demonstrated a high variability (from 20 to 65%) in the prevalence of depression in dialysis patients (11. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095-105.,44. Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis. 2003;41(1):105-10.,66. Son YJ, Choi KS, Park YR, Bae JS, Lee JB. Depression, symptoms and the quality of life in patients on haemodialysis for end stage renal disease. Am J Nephrol. 2009;29(1):36-42.,1717. Ibrahim S, El Salamony O. Depression, quality of life and malnutrition-inflammation scores in hemodialysis patients. Am J Nephrol. 2008;28(5):784-91.,1818. Oliveira CM, Costa SP, Costa LC, Pinheiro SM, Lacerda GA, Kubrusly M. Depression in dialysis patients and its association with nutritional markers and quality of life. J Nephrol. 2012;25(6):954-61.). This disparity could be the result of different diagnostic tools or a distinct BDI cut-off. The BDI is one of the most widely used tests for assessing the severity of depression. In the general population, the diagnosis of depression is based on receiving 10 points on the BDI. In patients with CKD, due to the presence of symptoms that can mimic the clinical presentation of depression (fatigue, anorexia, sleep disorders), the cut-off is higher; patients who score 16 or more points are considered to be depressed, with a sensitivity and specificity of 92 and 80%, respectively (55. Grant D, Almond MK, Newnham A, Roberts P, Hutchings A. The Beck Depression Inventory requires modification in scoring before use in a haemodialysis population in the UK. Nephron Clin Pract. 2008;110(1):c33-8.). In our study, we adopted the criteria mentioned above; hence, our prevalence was similar to the previous analysis with the same methodology (1717. Ibrahim S, El Salamony O. Depression, quality of life and malnutrition-inflammation scores in hemodialysis patients. Am J Nephrol. 2008;28(5):784-91.,1919. Armaly Z, Farah J, Jabbour A, Bisharat B, Qader AA, Saba S, et al. Major depressive disorders in chronic hemodialysis patients in Nazareth: identification and assessment. Neuropsychiatr Dis Treat. 2012;(8):329-38.). Recently, Lossman et al. compared BDI and the Hospital Anxiety and Depression Scale (HADS) in patients with CKD and depressive symptoms diagnosed by the Mini International Neuropsychiatric Interview (MINI) (2020. Loosman WL, Siegert CE, Korzec A, Honig A. Validity of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory for use in end-stage renal disease patients. Br J Clin Psychol. 2010;49(4):507-16.). Both the HADS and BDI were considered valid screening instruments for the diagnosis of depression in dialysis patients, with no significant difference between the scales. Therefore, in the last several years, BDI has been utilized by several authors for the measurement of depressive symptoms in CKD patients (2121. Feroze U, Martin D, Kalantar-Zadeh K, Kim JC, Reina-Patton A, Kopple JD. Anxiety and depression in maintenance dialysis patients: preliminary data of a cross-sectional study and brief literature review. J Ren Nutr. 2012;22(1):207-10.

22. Araujo SM, de Bruin VM, Daher Ede F, Almeida GH, Medeiros CA, de Bruin PF. Risk factors for depressive symptoms in a large population on chronic hemodialysis. Int Urol Nephrol. 2012;44(4):1229-35.
-2323. Kalender B, Ozdemir AC, Koroglu G. Association of depression with markers of nutrition and inflammation in chronic kidney disease and end-stage renal disease. Nephron Clin Pract. 2006;102(3-4):c115-21.).

Consistent with previous findings, depressed patients had lower levels of hemoglobin (2323. Kalender B, Ozdemir AC, Koroglu G. Association of depression with markers of nutrition and inflammation in chronic kidney disease and end-stage renal disease. Nephron Clin Pract. 2006;102(3-4):c115-21.,2424. Bornivelli C, Aperis G, Giannikouris I, Paliouras C, Alivanis P. Relationship between depression, clinical and biochemical parameters in patients undergoing haemodialysis. J Ren Care. 2012;38(2):93-7.). Due to the similarity between anemia and depressive symptoms, this is likely to be only a random association.

In our study, we found a strong correlation between low levels of phosphorus and depression. In fact, low phosphorus was an independent factor associated with depression. Moreover, depressive patients also presented a tendency to have lower albumin levels, which was associated with an increased risk of depression. These findings suggest that, at least in the present study, low levels of phosphorus might be the result of the poor nutritional status of depressed patients, as previously demonstrated by others (2525. Lee SK, Lee HS, Lee TB, Kim DH, Koo JR, Kim YK, et al. The effects of antidepressant treatment on serum cytokines and nutritional status in hemodialysis patients. J Korean Med Sci. 2004;19(3):384-9.,2626. Friend R, Hatchett L, Wadhwa NK, Suh H. Serum albumin and depression in end-stage renal disease. Adv Perit Dial. 1997;13:155-7.). However, it must be stressed that this relationship was not clarified in the present study because an additional assessment of nutritional status was not performed.

The association between depression and dialysis shift has not been fully explored in CKD patients. Recently, it has been determined that patients in the morning dialysis shift present a higher incidence of depressive symptoms (1111. Cengic B, Resic H. Depression in hemodialysis patients. Bosn J Basic Med Sci. 2010;10 Suppl 1:S73-8.). In the present study, we observed that the risk of depression was strikingly increased in patients who attended the morning dialysis shift compared with those who attended the evening shift. This noticeable advantage of the evening shift has already been demonstrated for EDS and mortality (99. Cengić B, Resić H, Spasovski G, Avdić E, Alajbegović A. Quality of sleep in patients undergoing hemodialysis. Int Urol Nephrol. 2012;44(2):557-67.,1010. Abbott KC, Reynolds JC, Trespalacios FC, Cruess D, Agodoa LY. United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Survival by time of day of hemodialysis: analysis of United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Am J Kidney Dis. 2003;41(4):796-806.). Taken together, our findings are similar and show a lower risk of depression among individuals attending the evening shift; notably, there was no difference in age, time on dialysis, or employment status among the three dialysis shifts. It must be noted that in our dialysis unit, patients who received treatment during the morning shift needed to wake up rather early because most of them lived far from the hospital (rural area); thus, it took them a long time to arrive at the dialysis center. Furthermore, if these patients waited too long for their dialysis session, they would not arrive at their houses until the end of the day. In contrast, most of the patients attending the evening shift lived nearby and usually did not spend much time traveling home from the dialysis clinic. Based on this information, is tempting to speculate that sleep deprivation may influence the higher incidence of depression observed in those attending the morning shift. However, we found no differences in EDS between dialysis shifts. It is noteworthy that the subjective sleep measurement using the Epworth Scale did not rule out the presence of sleep disturbances (2727. Roumelioti ME, Buysse DJ, Sanders MH, Strollo P, Newman AB, Unruh ML. Sleep-disordered breathing and excessive daytime sleepiness in chronic kidney disease and hemodialysis. Clin J Am Soc Nephrol. 2011;6(5):986-94.). Relatedly, Unruh et al. demonstrated that the polysomnography sleep time did not correlate with the self-reported sleep time in dialysis patients (2828. Unruh ML, Sanders MH, Redline S, Piraino BM, Umans JG, Chami H, et al. Subjective and objective sleep quality in patients on conventional thrice-weekly hemodialysis: comparison with matched controls from the sleep heart health study. Am J Kidney Dis. 2008;52(2):305-313.). This result can explain the lack of association between sleepiness assessed by the Epworth Scale and the morning shift in our data.

It can be argued that living in a rural area, rather than the morning shift itself, could be associated with depression. However, in multiple regression analysis, rural area was not an independent risk factor for depression. Moreover, the influence of the distance to the dialysis center on variables such as quality of life and depression has been recently studied, and distance was not found to have an effect (2929. Santos PR, Arcanjo FP. Distance between residence and the dialysis unit does not impact self-perceived outcomes in hemodialysis patients. BMC Res Notes. 2012;27;5:458.).

Despite the high prevalence of depression observed in our study, less than 20% of depressive patients were receiving appropriate treatment with antidepressants or alternative therapies, and most of them were not undergoing periodic psychiatric monitoring or psychotherapy. Alternative treatments, such as cognitive-behavioral therapy and exercise programs, have recently been demonstrated to have a positive impact on the management of depression (3030. Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral group therapy is an effective treatment for major depression in hemodialysis patients. Kidney Int. 2009;76(4):414-21.,3131. Ouzouni S, Kouidi E, Sioulis A, Grekas D, Deligiannis A. Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients. Clin Rehabil. 2009;23(1):53-63.); however, these treatments were not prescribed. Only a minority of CKD patients with depression are appropriately treated, especially those who require pharmacologic therapy (3232. Nagler EV, Webster AC, Vanholder R, Zoccali C. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2012;27(10):3736-45.,3333. Fischer MJ, Kimmel PL, Greene T, Gassman JJ, Wang X, Brooks DH, et al. Socioeconomic factors contribute to the depressive affect among African Americans with chronic kidney disease. Kidney Int. 2010;77(11):1010-9.). The main reason for this lack of treatment may be the absence of controlled trials studying the safety of antidepressants in this particular population (3232. Nagler EV, Webster AC, Vanholder R, Zoccali C. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2012;27(10):3736-45.,3434. Hedayati SS, Yalamanchili V, Finkelstein FO. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney Int. 2012;81(3):247-55.). However, serotonin selective reuptake inhibitors have been used in ESRD patients without any adverse effects requiring cessation (3535. Atalay H, Solak Y, Biyik M, Biyik Z, Yeksan M, Guney I, et al. Sertraline treatment is associated with an improvement in depression and health related quality of life in chronic peritoneal dialysis patients. Int Urol Nephrol. 2010;42(2):527-36.).

This study has several strengths. First, to our knowledge, this is the first study assessing the influence of dialysis shift on depression as the main objective. Second, we used a well-validated tool—the BDI—to assess the depression symptoms. Third, all patients were examined by the same observer, diminishing the bias in collecting data. This study also has several limitations. The design of the study did not allow us make conclusions based on follow-up or cause-effect. We could not clarify the association between low phosphorus and depression, and we were only able to make an assumption that depression is influenced by nutritional parameters. The patients were not examined by a psychiatrist to confirm the clinical diagnosis of depression. Finally, despite making adjustments to account for differences among the three dialysis shifts with respect to the address of the patients (rural or urban area), we could not guarantee that the beta error was completely eliminated.

In summary, depression is highly prevalent and most likely misdiagnosed among many CKD patients requiring dialysis. Despite the high prevalence rates, only a few patients were being properly treated for depression. The hospitalization risk in CKD patients increases markedly with the presence of depression. The most important factors associated with depression were dialysis shift and lower levels of phosphorus and hemoglobin. The association between depression and dialysis in the morning shift highlights the need for further studies to clarify this relationship. Sleep deprivation is thus far the most plausible explanation for our findings.

REFERENCES

  • 1
    Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095-105.
  • 2
    Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161(15):1849-56.
  • 3
    Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Allen AS, Bosworth HB. Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis. Am J Kidney Dis. 2005;46(4):642-9.
  • 4
    Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis. 2003;41(1):105-10.
  • 5
    Grant D, Almond MK, Newnham A, Roberts P, Hutchings A. The Beck Depression Inventory requires modification in scoring before use in a haemodialysis population in the UK. Nephron Clin Pract. 2008;110(1):c33-8.
  • 6
    Son YJ, Choi KS, Park YR, Bae JS, Lee JB. Depression, symptoms and the quality of life in patients on haemodialysis for end stage renal disease. Am J Nephrol. 2009;29(1):36-42.
  • 7
    Lopes AA, Albert JM, Young EW, Satayathun S, Pisoni RL, Andreucci VE, et al. Screening for depression in haemodialysis patients: Associations with diagnosis, treatment and outcomes in the DOPPS. Kidney Int. 2004;66(5):2047-53.
  • 8
    Merlino G, Piani A, Dolso P, Adorati M, Cancelli I, Valente M, et al. Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy. Nephrol Dial Transplant. 2006;21(1):184-90.
  • 9
    Cengić B, Resić H, Spasovski G, Avdić E, Alajbegović A. Quality of sleep in patients undergoing hemodialysis. Int Urol Nephrol. 2012;44(2):557-67.
  • 10
    Abbott KC, Reynolds JC, Trespalacios FC, Cruess D, Agodoa LY. United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Survival by time of day of hemodialysis: analysis of United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV. Am J Kidney Dis. 2003;41(4):796-806.
  • 11
    Cengic B, Resic H. Depression in hemodialysis patients. Bosn J Basic Med Sci. 2010;10 Suppl 1:S73-8.
  • 12
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71.
  • 13
    Watnick S, Wang PL, Demadura T, Ganzini L. Validation of 2 depression screening tools in dialysis patients. Am J Kidney Dis. 2005;46(5):919-24.
  • 14
    Gorenstein C, Andrade L. Validation of a Portuguese version of the Beck Depression Inventory and the State-Trait Anxiety Inventory in Brazilian subjects. Braz J Med Biol Res. 1996;29(4):453-7.
  • 15
    Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14(6):540-5.
  • 16
    Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095-105.
  • 17
    Ibrahim S, El Salamony O. Depression, quality of life and malnutrition-inflammation scores in hemodialysis patients. Am J Nephrol. 2008;28(5):784-91.
  • 18
    Oliveira CM, Costa SP, Costa LC, Pinheiro SM, Lacerda GA, Kubrusly M. Depression in dialysis patients and its association with nutritional markers and quality of life. J Nephrol. 2012;25(6):954-61.
  • 19
    Armaly Z, Farah J, Jabbour A, Bisharat B, Qader AA, Saba S, et al. Major depressive disorders in chronic hemodialysis patients in Nazareth: identification and assessment. Neuropsychiatr Dis Treat. 2012;(8):329-38.
  • 20
    Loosman WL, Siegert CE, Korzec A, Honig A. Validity of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory for use in end-stage renal disease patients. Br J Clin Psychol. 2010;49(4):507-16.
  • 21
    Feroze U, Martin D, Kalantar-Zadeh K, Kim JC, Reina-Patton A, Kopple JD. Anxiety and depression in maintenance dialysis patients: preliminary data of a cross-sectional study and brief literature review. J Ren Nutr. 2012;22(1):207-10.
  • 22
    Araujo SM, de Bruin VM, Daher Ede F, Almeida GH, Medeiros CA, de Bruin PF. Risk factors for depressive symptoms in a large population on chronic hemodialysis. Int Urol Nephrol. 2012;44(4):1229-35.
  • 23
    Kalender B, Ozdemir AC, Koroglu G. Association of depression with markers of nutrition and inflammation in chronic kidney disease and end-stage renal disease. Nephron Clin Pract. 2006;102(3-4):c115-21.
  • 24
    Bornivelli C, Aperis G, Giannikouris I, Paliouras C, Alivanis P. Relationship between depression, clinical and biochemical parameters in patients undergoing haemodialysis. J Ren Care. 2012;38(2):93-7.
  • 25
    Lee SK, Lee HS, Lee TB, Kim DH, Koo JR, Kim YK, et al. The effects of antidepressant treatment on serum cytokines and nutritional status in hemodialysis patients. J Korean Med Sci. 2004;19(3):384-9.
  • 26
    Friend R, Hatchett L, Wadhwa NK, Suh H. Serum albumin and depression in end-stage renal disease. Adv Perit Dial. 1997;13:155-7.
  • 27
    Roumelioti ME, Buysse DJ, Sanders MH, Strollo P, Newman AB, Unruh ML. Sleep-disordered breathing and excessive daytime sleepiness in chronic kidney disease and hemodialysis. Clin J Am Soc Nephrol. 2011;6(5):986-94.
  • 28
    Unruh ML, Sanders MH, Redline S, Piraino BM, Umans JG, Chami H, et al. Subjective and objective sleep quality in patients on conventional thrice-weekly hemodialysis: comparison with matched controls from the sleep heart health study. Am J Kidney Dis. 2008;52(2):305-313.
  • 29
    Santos PR, Arcanjo FP. Distance between residence and the dialysis unit does not impact self-perceived outcomes in hemodialysis patients. BMC Res Notes. 2012;27;5:458.
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  • No potential conflict of interest was reported.

Publication Dates

  • Publication in this collection
    Mar 2014

History

  • Received
    20 May 2013
  • Reviewed
    17 June 2013
  • Accepted
    23 Aug 2013
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