Depression and coping in adults undergoing dialysis for end-stage renal disease

Transcription

1 bs_bs_banner Offi cial journal of the Pacifi c Rim College of Psychiatrists Asia Pacific Psychiatry ISSN ORIGINAL ARTICLE Depression and coping in adults undergoing dialysis for end-stage renal disease Norhayati Ibrahim 1 PhD, Norella Kong Chiew-Thong 2 MD, Asmawati Desa 3 PhD & Rosdinom Razali 4 MMed(Psych) 1 Health Psychology Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2 Nephrology and SLE Unit, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 3 School of Psychology and Human Development, Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia 4 Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Keywords continuous ambulatory peritoneal dialysis, coping skill, depression, end-stage renal disease, hemodialysis Correspondence Norhayati Ibrahim PhD, Health Psychology Program, School of Health Care Management, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia. Tel : Fax : norhayati70@gmail.com DOI: /appy Abstract Introduction: Research on depression in local patients with end-stage renal disease (ESRD) is sparse. Thus, this study aims to examine the frequency and severity of depression among ESRD patients and relate depression with their coping skills. Methods: A cross-sectional study using universal sampling method was conducted at several dialysis centers in Kuala Lumpur, Selangor and Johor, Malaysia. The Beck Depression Inventory II (BDI-II) and the Brief COPE scale were used to measure depression and coping skill, respectively. Results: The study involved 274 ESRD patients, comprising of 183 hemodialysis and 91 continuous ambulatory peritoneal dialysis patients. The result showed that 21.1% of the patients experienced moderate to severe depression. Several components of coping skill were associated with depression. However, only two components in the Brief COPE (behavioral disengagement and self-blame) were identified as predictors. Discussion: This study showed that depression is common in ESRD patients and is related to the types of coping skills adopted by patients. Hence, this study provides some insight into ESRD patients with depression. Appropriate counseling should be given to these patients to empower them to cope with the illness so as to enhance their quality of life. Introduction End-stage renal disease (ESRD) occurs when an individual s kidneys fail to function and the kidney failure is complete and irreversible. The kidneys are no longer able to filter waste products and fluids from the blood circulation. According to the National Kidney Foundation (2005), ESRD is defined as the point when kidney function is at 10% of normal. Kidney disease at this stage often cannot be cured except by kidney transplantation. Unfortunately, not every chronic patient is lucky enough to receive a new kidney. They will need to queue on the transplant program s waiting list to receive kidneys from a limited donor pool, and the kidney received must be of almost perfect match. Even then, some patients could suffer from several post-transplantation complications. Nonetheless, kidney transplantation is the best option for a normal life whilst dialysis is a holding option in developed countries. Having kidney disease is stressful and could lead to a range of emotional reactions, especially depression. Severe depression was noted by Gonzalez et al. (1963) in half of their patients. Smith et al. (1985) found that the proportion of depressed patients was 47% as measured by the Beck Depression Inventory (BDI). Meanwhile, Watnick et al. (2005) found a 19% prevalence of major depression in a cohort of 62 dialysis patients from Oregon, USA. However, Craven et al. (1988) found that only 8.1% met Diagnostic and Statistical Manual, Third Edition, criteria for major depression. Kimmel and colleagues reported that Asia Pacific Psychiatry 5 (2013)

2 Depression and coping in adults undergoing dialysis for end-stage renal disease N. Ibrahim et al. among outpatients who were treated with HD, approximately 25% of them were depressed, with mean BDI scores that corresponded to mild levels of depression in the general population (Cohen et al., 2007). Although depression and dialysis are relatively common among individuals with ESRD, there have been few systematic studies of suicide in this population. Studies by Kurella et al. (2005) shows that from 465,563 patients, 44,465 (9.6%) withdrew from dialysis before death and 264 (0.0005%) died from suicide in the USA. Other researchers have shown that withdrawal from dialysis occurred in 9 20% of ESRD patients and was more likely to occur in the older, white, female patients (Leggat et al., 1997; Port et al., 1989). Coping mechanisms for each renal disease patient are different, and may be influenced by the differences of personality, religion, culture, and moral and socioeconomic support. The association of a particular type of coping with patient adherence was predicted to depend on the specific type of stressful conditions (Christensen et al., 1995). These include how such individuals could cope with the stress that was influencing their psychological well-being, social functioning and somatic health (Folkman & Lazarus, 1988). Choice of coping strategies is an important behavioral aspect of personality that has been examined in studies of depression and chronic illness. The use of less active and more passive coping strategies has been associated with increasing symptoms of depression in patients living with chronic illness, including illnesses that have a substantial fatigue component (Bardwell et al., 2001). Studies have found that patients with ESRD experience varying levels of life quality and use wide ranges of coping mechanisms to manage their illness and daily lives (Gudex, 1995; Valderrabano et al., 2001). Thus, the objective of this study is to examine the frequency and severity of depression among ESRD patients and to determine which coping skills are predictors for depression The HD sample comprised patients attending the dialysis centers in Universiti Kebangsaan Malaysia (UKM) Medical Center, Pusat Perubatan Primer Universiti Kebangsaan Malaysia (PPPUKM) in Bandar Tasik Selatan and UKM Health Center in Bangi, Malaysia. Patients receiving HD treatment at dialysis centers patronized by the Charity Dialysis Center MAA-Medicare, under the MAA-Medicare Kidney Charity Fund, in Jalan Ipoh, Cheras and Kajang, were also enrolled into this study. The CAPD sample comprised patients at the dialysis centers in UKM Medical Center and Putra Specialist Hospital, Batu Pahat, Johor. The inclusion criteria for this study were: ESRD patients aged above 18 years who had undergone dialysis treatment for at least 3 months. Patients who were unable to speak and write in Bahasa Malaysia or English, with stroke or having history of impaired cognitive functions were excluded. Study procedure Subjects who met the inclusion and exclusion criteria and gave consent for the study were interviewed individually at the bedside while they were undergoing their 4 hours of treatment. CAPD patients were interviewed while they were waiting in the clinic for review by their doctors or nurse trainees. Privacy and comfort of patients were ensured throughout the interview sessions. Patients were assessed using the BDI-II and the Brief COPE. Patients who had moderate and severe depression were offered a further assessment by a psychiatrist. Instruments Questionnaire on sociodemographic data Information gathered included age, sex, ethnicity, religion, marital status, working status, type of dialysis and duration of treatment. Methods Setting This was a cross-sectional study conducted on patients who were undergoing chronic dialysis treatment (hemodialysis [HD] and continuous ambulatory peritoneal dialysis [CAPD]) for their ESRD using the universal sampling method. It was conducted over a period of 8 months, from November 2008 to July BDI-II The BDI-II is a self-reporting instrument with 21 items intended to assess the existence and severity of symptoms of depression. This is a 4-point scale with each item ranging 0 3. The BDI-II has high internal consistency with a coefficient a for students showing a good value of 0.93 comparable to the coefficient a for 277 psychiatric patients, which also showed a high value of 0.92 (Beck et al. 1996). The BDI-II showed good convergent and discriminant validity when correlated 36 Asia Pacific Psychiatry 5 (2013) 35 40

3 N. Ibrahim et al. Depression and coping in adults undergoing dialysis for end-stage renal disease against other validated measures of depression (e.g. Revised Hamilton Psychiatric Rating Scale for Depression) (Hamilton, 1960). In Malaysia, it has been translated into Malay and tested for validity and reliability on post-partum women in Kedah, Malaysia. The value of the internal consistency of this Malay version of the BDI-II is high at The correlations with the BDI-II Edinburgh Postnatal Depression Scale (EPDS) and Hamilton Rating Scale for depression were 0.72 and 0.75, respectively (Wan Mahmod et al., 2004). Brief COPE Coping skills of the study sample were measured using the Brief COPE which has 28 items rated by a 4-point Likert scale. The higher score represents greater coping strategies used by the respondents. In total, 14 dimensions were covered by this scale: (i) selfdistraction; (ii) active coping; (iii) denial; (iv) substance abuse; (v) use of emotional support; (vi) use of instrumental support; (vii) behavioral disengagement; (viii) venting; (ix) positive reframing; (x) planning; (xi) humor; (xii) acceptance; (xiii) religion; and (xiv) self-blame. Every dimension has two items. Carver (1997) reported that the internal consistency coefficient of the subscale is between 0.50 and The Malay version of Brief COPE was validated by Yusoff et al. (2010) on cancer patients with internal consistency ranging Data analysis Data were analyzed with SPSS for Windows ver Pearson s correlation was used to analyze the relationship between coping skill and depression. A stepwise multiple regression procedure was conducted to predict coping skills for depression. Approval This study was approved by the university s research and ethics committee. Results A total of 274 ESRD patients on chronic dialysis were recruited. Their sociodemographic profile is summarized in Table 1. The majority of patients were aged years (37.6%), male (51.5%), Malay (49.3%), married (75.9%) and Muslim by religion (52.2%). Most of the patients were unemployed and were living without pension (56.2%). Of the 274 patients, 66.8% Table 1. Sociodemographic and clinical profiles of the end-stage renal disease patients Variable Frequency Percentage Sex Male Female Ethnicity Malay Chinese Indian Others Religion Islam Buddhism Hinduism Christianity Others Age <40 years years years >60 years Marital status Married Single Divorced/widowed Working status Employed Unemployed without pension Unemployed with pension Type of dialysis Hemodialysis Continuous ambulatory peritoneal dialysis Duration of treatment <36 months months >120 months Percentage (%) Normal Mild Moderate Severe Figure 1. Level of depression in end-stage renal disease patients. were on HD treatment and the remaining 33.2% were on CAPD treatment. The majority of the patients (50.7%) had been on dialysis for less than 36 months. As shown in Figure 1, 6.9% of patients had severe depression, 14.2% moderate and 15.3% mild. Table 2 shows the correlations between several domains of coping skills and depression. Active Asia Pacific Psychiatry 5 (2013)

4 Depression and coping in adults undergoing dialysis for end-stage renal disease N. Ibrahim et al. Table 2. Correlation between coping skills and depression in end-stage renal disease patients Variable r Active coping -0.23** Self-distraction 0.03 Denial 0.18** Substance abuse 0.15 Use of emotional support -0.13* Use of instrumental support -0.14* Behavioral disengagement -0.41** Venting 0.04 Positive reframing -0.17** Planning -0.22** Humor 0.06 Acceptance Religion Self-blame 0.47** *P < 0.05; **P < Table 3. Multiple regression analysis between coping skills with depression in end-stage renal disease patients Model B SE Beta t Constant ** Active Denial Emotional support Instrumental support Behavioral disengagement ** Positive reframing Planning Self-blame ** R 2 = 31.6%. *P < 0.05; **P < SE, standard error. coping, emotional support, instrumental support, positive reframing and planning were significantly negatively correlated with depression. In other words, high usage of active coping, higher level of support from others on emotional and instrumental aspects, and greater positive reframing and planning were related to less depression in these ESRD patients. However, the correlation of denial and behavioral disengagement were in the positive direction, which means that the usage of denial and behavioral disengagement as coping skills were related to high rates of depression. Further multiple regression analysis shows that the predictors of depression in this study population included behavioral disengagement and self-blame (Table 3). These factors contributed 31.6% of the variance in depression (R 2 = 0.316, t = 3.11, P < 0.01). Other subscales, namely, instrumental support, religion, humor, emotional support, acceptance, substance abuse, active coping, positive reframing, self-distraction, planning, venting, and denial, were not significant predictors of depression. Discussion Living with chronic kidney disease and regular dialysis can be stressful as it affects nearly every aspect of the patient s life. This study showed that many dialysis patients suffer from depression, consistent with findings from studies by Hinrichsen et al. (1989) and Craven et al. (1988). This study found that despite depression being a common psychological problem among the ESRD patients in Malaysia, the percentage of patients experiencing severe depression was small. This finding may be due to several factors. One of the contributing factors was social support received by patients. An earlier report by Ibrahim et al. (2011a,b) on the same study population has shown that support from family and friends played an important role in determining the patients quality of life, whereby patients who had high depression scores tended to have low quality of life. The patients own perception towards their illness may be an important determinant of behavior leading to depression. The way a patient feels about and thinks of one s self, the disease and also the treatment will affect his/her quality of life. Less depression was noted among patients who had good interpersonal and treatment control, and greater understanding of their illness (Ibrahim et al., 2011c). The routine of dialysis treatment and varying levels of physical health may also have impact on feelings of hopelessness, which may induce episodes of depression (Chilcot et al., 2008). Depression is common in patients with ESRD, but it is often underdiagnosed and understudied. Even though the rate of severe depression in this study was only 6.9%, all patients deserve proper treatment and support to help them cope with the disease and changes in their lives. All patients with ESRD should be monitored for depression and given adequate treatment in the form of psychotherapy or pharmacotherapy. Health-care providers such as nurses, psychologists and psychiatrists should play a greater role in helping patients with depression in terms of controlling their emotions, and providing mobility and treatment schedules. Eight out of 14 dimensions of coping skills in this study are weakly correlated with depression and only two dimensions, namely, behavior disengagement and self-blame, were identified as predictors for depres- 38 Asia Pacific Psychiatry 5 (2013) 35 40

5 N. Ibrahim et al. Depression and coping in adults undergoing dialysis for end-stage renal disease sion, with the latter being a better one. Thus, this study supports the findings by Phelan et al. (2011) who reported high prevalence of stigma, self-blame and perceived blame from men with colorectal cancer (CRC), which were associated with depressive symptoms. Shaver and Drown (1986) also suggested that the affective connotations inherent in self-blame may lead to depression. This study also found that behavior disengagement is correlated and becomes a second predictor of depression. This finding is supported by that reported by Gülseren Keskin and Esra Engin (2011), who also found that behavior disengagement and depression were positively correlated in renal failure patients undergoing HD treatment. Using self-blame or behavioral disengagement as coping strategies leads patients into depression more readily than other coping skills. For example, patients often blame themselves for causing inconvenience and burden to others for their dependence on transportation to the dialysis centers and for other activities of daily living. Their sense of helplessness and guilt ultimately result in depression. Thus, support from family members and counseling is indicated to reduce the level of depression and self-blame, and enhance their quality of life. Limitations of study There were several limitations in this study. Being a cross-sectional study, it could not detect changes in depression at different time points. Other factors possibly related to depression such as ethnicity, socioeconomic status, social interactions between patients, physicians and dialysis staff, and patient compliance, should be investigated in future studies. Probably, future longitudinal, interventional studies would be more useful because this method is more comprehensive, provides more statistical power and allows the assessment of the contributions of change. Conclusion End-stage renal disease is an emotionally and physically depriving condition which can lead to depression. This study shows the importance of how coping skill determines depression in ESRD patients. All doctors and psychologists should be aware of the importance of detecting depression in this high-risk group and be able to offer appropriate physical and psychological treatment. Advice on proper coping strategies may help patients to cope with their illness better and improve their quality of life. Acknowledgments The authors would like to thank all ESRD patients, nurses and doctors who cooperated and supported this study. Conflict of interest The authors declare no conflict of interest. References Bardwell W.A., Ancoli-Israel S., Dimsdale J.E. (2001) Types of coping strategies are associated with increased depressive symptoms in patients with obstructive sleep apnea. Sleep. 24, Beck A., Steer R., Brown G. (1996) BDI-II The Beck Depression Inventory. The Psychological Corporation, San Antonio, TX. Carver C.S. (1997) You want to measure coping but your protocol s too long: consider the Brief COPE. Int J Behav Med. 4, Christensen A.J., Benotsch E.G., Wiebe J.S., Lawton W.J. (1995) Coping with treatment-related stress: effects on patient adherence in hemodialysis. J Consult Clin Psychol. 63, Chilcot J., Wellsted D., Da Silva-Gane M., Farrington K. (2008) Depression on dialysis. Nephron Clin Pract. 108, 256 c264. Cohen S.D., Norris L., Acquaviva K., Peterson R.A., Kimmel P.L. (2007) Screening, diagnosis, and treatment of depression in patients with end-stage renal disease. CJASN. 2, Craven J.L., Raden G.M., Litlefield C. (1988) The beck depression inventory as a screening device for major depression in renal dialysis patients. Int J Psychiatry Med. 18, Folkman S., Lazarus R. (1988) Ways of Coping Revised Questionnaire. Consulting Psychologists Press, Palo Alto, CA. Gonzalez F.M., Pabico R.C., Brown H.W., Maher J.F., Schreiner G.E. (1963) Further experience with the use of routine intermittent hemodialysis in chronic renal failure. Trans Am Soc Artif Intern Organs. 9, 11. Gudex C.M. (1995) Health-related quality of life in end-stage renal failure. Qual Life Res. 4, Hamilton M. (1960) A rating scale of depression. J Neurol Neurosurg Res. 29, Hinrichsen G.A., Lieberman J.A., Pollack S., Steinberg H. (1989) Depression in hemodialysis patients. Psychosomatics. 30, Asia Pacific Psychiatry 5 (2013)

6 Depression and coping in adults undergoing dialysis for end-stage renal disease N. Ibrahim et al. Ibrahim N., Desa A., Kong N. (2011a) Social support and religious coping strategies in health-related quality of life of end-stage renal disease patients. Pertanika J Soc Sci & Hum. 19, Ibrahim N., Desa A., Kong N. (2011b) Depresi dan kualiti hidup kesihatan pesakit buah pinggang tahap akhir. e-bangi. 6, Ibrahim N., Desa A., Kong N. (2011c) Illness perception and depression in patients with end-stage renal disease on chronic haemodialysis. Soc Sci J. 6, Keskin G., Engin E. (2011) The evaluation of depression, suicidal ideation and coping strategies in haemodialysis patients with renal failure. J Clin Nurs. 20, Kurella M., Kimmel P.L., Young B.S., Chertow G.M. (2005) Suicide in the United State end stage renal disease program. J Am Soc Nephrol. 16, Leggat J.E. Jr, Bloembergen W.E., Levine G., Hulbert-Shedron T.E., Port F.K. (1997) An analysis of risk factors for withdrawal from dialysis before death. J Am Soc Nephrol. 8, National Kidney Foundation (2005) NewYork. [Cited 2 November 2012.] Available from URL: index.cfm Phelan S.M., Griffin J.M., Zafar S.J., et al. (2011) Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer. Psychooncology. 22, doi: /pon Port F.K., Wolfe R.A., Hawthorne V.M., Ferguson C.W. (1989) Discontinuation of dialysis therapy as a cause of death. Am J Nephrol. 9, Shaver K.G., Drown D. (1986) On causality, responsibility, and self-blame: a theoretical note. J Pers Soc Psychol. 50, Smith M., Hong B.A., Robson A.M. (1985) Diagnosis of depression in patients with end stage renal disease. Comparative analysis. Am J Med. 79, Valderrabano F., Jofre R., Lopez-Gomez J. (2001) Quality of life in end stage renal disease patients. Am J Kidney Dis. 38, Wan Mahmod W.M., Awang A., Herman I., Mohamed M.N. (2004) Analysis of the psychometric properties of the Malay version of Beck Depression Inventory 11 (BDI 11) among postpartum women in Kedah, Nort West of Peninsular Malaysia. Malays J Med Sci. 11, Watnick S., Wang P.L., Demadura T., Ginzini L. (2005) Validation of 2 depression screening tools in dialysis patients. Am J Kidney Dis. 46, Yusoff N., Low W.Y., Yip C.H. (2010) Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy: a Malaysian study. Med J Malaysia. 65, Asia Pacific Psychiatry 5 (2013) 35 40