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Received June 17, 2010; revised July 15, 2010; accepted July 16, 2010.
From the Dept. of Psychiatry and Nephrology, Chang Gung Memorial
Hospital at Keelung, Taiwan; Chang Gung University School of Medicine, Taiwan; Division of Mental Health and Drug Abuse Research,
National Health Research Institute, Miaoli, Taiwan; and the Master of
Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan. Send correspondence and reprint requests to Liang-Jen Wang, M.D., Dept. of Psychiatry, Chang Gung
Memorial Hospital at Keelung. No. 200 Ave 208 Chi-Chin-Yi Rd.,
Keelung, Taiwan. e-mail: WangLiangJen@gmail.com
2010 The Academy of Psychosomatic Medicine
528
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Chen et al.
1.1%15% for men and 1.8%23% for women.6 However,
the prevalence of major depression among ESRD patients
is approximately 20%30%,3 and it may be as high as
47%.7 Furthermore, a strong correlation exists between
depression and mortality for long-term hemodialysis patients.1,8,9 The incidence of anxiety, also a disorder common to hemodialysis patients, is 27% 46%.10,11 The comorbidities of depression and anxiety increased over time
in subjects who were on hemodialysis in a 16-month follow-up study.11
Fatigue is a subjective symptom characterized by
tiredness, weakness, and lack of energy.12 Roughly 60%
97% of patients on hemodialysis experience some fatigue.13 Fatigue is also one of the most debilitating symptoms reported by hemodialysis patients, and it is
negatively correlated with quality of life.14 Health-related
quality of life is an important measure of how a disease
affects the lives of patients. The quality of life domains
include physical, psychological, and social functioning
and general satisfaction with life.15 Numerous studies
have demonstrated that hemodialysis patients had a lower
quality of life than that of a healthy population.16 18
Suicide may be the gravest result of depression. Corroborative evidence has identified a high incidence of suicide threats and attempts among hemodialysis patients;
however, suicide risk differed among studies.19,20 Suicidal
ideation and attempt are associated with depression and
anxiety in the general population.21 A high suicide rate is
also related to poor quality of life.22 Identification of the
relationships between psychological issues and suicide
risk for dialysis patients is crucial.
Currently, the relationships between suicide, depression, anxiety, fatigue, and life quality remain
poorly understood. The objective of this study is to
identify the demographic and psychological factors associated with depression in hemodialysis patients. This
study also elucidates the relationships among depression, anxiety, fatigue, health-related quality of life, and
suicide risk.
METHOD
Study Population
This study enrolled 200 patients, age 18 years, on
hemodialysis at Chang Gung Memorial Hospital, Keelung,
between 2007 and 2009. Written informed consent was
obtained from each patient before participation. This study
Psychosomatics 51:6, November-December 2010
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Statistical Analysis
Data were analyzed with SPSS Version 16 statistical
software. Variables are presented as mean standard
deviation (SD) or frequency. An HADS score 8 is the
dichotomous cutoff for significant depression or anxiety
symptoms. Descriptive statistics were analyzed by independent t-test and paired t-test; metric variables were analyzed by one-way analysis of variance (ANOVA); and 2
test and Fishers exact test were used for categorical variables. The Mann-Whitney test and Wilcoxon signed-ranks
test were also applied to metric variables when the data
distribution violated parametric assumptions. Partial correlation was used to analyze the relationships among suicide risk, and HADS, SF36, and CFS scores, while controlling for body mass index (BMI) and number of
comorbid physical illnesses. Structural-equation modeling, using maximum-likelihood estimation, was further
utilized to analyze the strength of variable relationships
among depression, anxiety, fatigue, quality of life, and
suicide risk. All tests were two-tailed, and the level of
significance was p 0.05.
RESULTS
Mean age of the 200 patients on hemodialysis in this study
was 58.6 (13.9) years. Of all patients, 94 (47.0%) were
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Chen et al.
DISCUSSION
Study results demonstrate that depression was correlated
with low BMI and a high number of comorbid physical
illnesses. Depressed patients had a significantly higher
incidence of anxiety and fatigue, more common suicidal
ideation, and significantly lower quality of life than nondepressed patients. The intercorrelations between fatigue,
depression, anxiety, and quality of life were significant.
Suicidal ideation was strongly related to depression and
anxiety, but not to fatigue or quality of life.
A high BMI is associated with increased survival rate
and reduced risk of hospitalization for hemodialysis patients.30,31 Poor nutrition and inflammation have been sug-
TABLE 1.
Characteristic
Gender (men/women), N (%)
Smoking, N (%)
Alcohol use, N (%)
Age, years a
Education, years a
Body mass index (BMI; kg/m2) a
Comorbidity, physical illnesses, N
Hemodialysis duration, months a
Total (N200)
Non-Depressed (N130)
Depressed (N70)
94/106 (47.0/53.0)
36 (18.8)
22 (11.5)
58.6 (13.9)
7.1 (4.6)
23.3 (4.0)
2.0 (1.6)
68.1 (65.8)
56/74 (43.1/56.9)
19 (15.3)
10 (8.1)
58.5 (13.3)
7.3 (4.4)
24.0 (4.7)
1.8 (1.4)
67.1 (64.1)
38/32 (54.3/45.7)
17 (25.0)
12 (17.6)
58.8 (15.0)
6.6 (4.8)
20.3 (2.8)
2.4 (1.8)
69.7 (69.5)
NS
NS
0.058
NS
NS
0.001
0.018
NS
Depression was defined as a Hospital Anxiety and Depression Rating Scale (HADSD) score 8.
a
Mean (standard deviation).
TABLE 2.
Characteristic
Non-Depressed (N130)
Depressed (N70)
8 (6.2)
1 (0.8)
2 (1.5)
3.0 (2.9)
2.9 (2.2)
17.0 (4.2)
35 (50.0)
6 (8.6)
5 (7.1)
7.7 (4.3)
13.2 (3.5)
24.7 (5.5)
0.001
0.008
0.052
0.001
0.001
0.001
67.2 (23.2)
71.9 (40.0)
87.1 (31.0)
60.8 (18.3)
79.8 (13.7)
81.9 (22.9)
76.2 (22.5)
52.0 (24.0)
57.9 (25.1)
44.1 (34.0)
34.6 (43.3)
36.2 (42.8)
29.1 (14.9)
42.4 (17.1)
59.3 (24.8)
59.3 (24.8)
23.2 (16.0)
39.6 (27.0)
0.001
0.001
0.001
0.001
0.001
0.001
0.001
0.001
0.001
81.9 (18.4)
36.8 (22.7)
0.001
Suicidality, N (%)
Suicidal ideation, past month
Suicide plan, past month
Suicide attempt, lifetime
HADSAnxiety score
HADSDepression score
Fatigue score
Health-Related Quality of Life
Physical Functioning
Physical Role Functioning
Emotional Role Functioning
Vitality
Mental Health
Social Functioning
Bodily Pain
General Health
Physical Component
Summary
Mental Component Summary
Depression was defined as the Hospital Anxiety and Depression Rating Scale (HADSD) 8.
Values are mean (standard deviation), unless otherwise indicated.
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TABLE 3.
Suicide risk
Depression
Anxiety
Fatigue
PCS
MCS
Correlation of Suicide Risk, Depression, Anxiety, Fatigue, and Health-Related Quality of Life, Controlling for Body Mass
Index (BMI) and Number of Comorbid Physical Illnesses
Suicide Risk
Depression
Anxiety
Fatigue
PCS
MCS
0.46***
0.46***
0.37***
0.19**
0.39***
0.59***
0.68***
0.35***
0.77***
0.58***
0.39***
0.62***
0.54***
0.63***
0.21**
PCS: Physical Component Summary of Health-Related Quality of Life; MCS: Mental Component Summary of Health-Related Quality of Life.
*
p0.05; ** p0.01; *** p0.001.
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Chen et al.
may be a primary response when a patient begins hemodialysis; nevertheless, suicide is undoubtedly an adverse
consequence.22 The suicide rate of ESRD patients was
approximately 15 times greater than that for the general
United States population. Suicide was associated with several demographic characteristics.20 A preexisting anxiety
disorder was identified as an independent risk factor for
subsequent onset of suicidal ideation and attempts.43 Depression is also a prominent predictor for suicide for many
chronic illnesses.20,44 Results of this study revealed a significant direct effect for depression and anxiety on suicidal
ideation.
Several limitations of this study must be considered.
First, this is an observational, cross-sectional study. The
causal inferences of fatigue, anxiety, depression, and reduced quality of life remain unclear. Second, the Charlson
Comorbidity Index,45 which been shown to be an effective
measure of comorbidity severity, was not computed for
patients in this study. Third, diagnosing depressive disorders or anxiety disorders is difficult for hemodialysis patients when we apply DSMIV criteria. To meet the diagnostic DSMIV criteria for major depressive disorder or
anxiety disorders, the subjects need to fulfill the exclusion
criterion The symptoms are not due to the direct physiological effects of a medication or a general medical condition. It is difficult to judge arbitrarily whether the depressive symptoms are due to the direct physiological
effects of a medication or a general medical condition in
hemodialysis patients. The DSMIV criteria may have a
higher specificity but a lower sensitivity than the HADS.
Therefore, the authors used the HADS to define caseness
of depressive disorders and anxiety disorders. Last, subjects in this study were from a single site. Hence, the
external validity may be limited. Ethnic differences in
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