Pain, sleep disturbance and survival in hemodialysis patients.

BACKGROUND: Patients' perception of pain during hemodialysis (HD) and at times between HD treatment and its association with survival have not been well studied in end-stage renal disease (ESRD). We evaluated the experience of pain during HD and at times when the patient was not receiving HD, and assessed possible associations of the perception of pain and sleep disturbance with patient survival. METHODS: A total of 128 ESRD patients treated with HD completed questionnaires on psychosocial status, quality of life and sleep disorders. A modified McGill Pain questionnaire was used to assess the nature, location, frequency, intensity and duration of pain both during and at times between HD sessions. The Pittsburgh Sleep Quality Index was used to screen for sleep disturbances over a 30-day period. RESULTS: Controlling for age, diabetes mellitus, serum albumin concentration and human immunodeficiency virus infection, there was a significant association between mortality and both frequency and intensity of pain while patients were not on HD. There was no association between survival and duration of pain while off HD or any of the pain parameters while patients were on HD. There was no association between survival and the presence of a sleep disorder. CONCLUSIONS: Pain perception while off HD may be of more importance to patients than pain during HD. The mechanisms underlying the association are unknown but may involve linkage of pain with severity of medical illness or the generation of a maladaptive cytokine response. Multicenter prospective studies of pain interventions using well-validated pain perception tools are needed to establish causal relationships. Interventions directed toward treating pain on non-HD days may improve ESRD patient survival.

Anxiety disorders in adults treated by hemodialysis: a single-center study.

BACKGROUND: Anxiety is a complicating comorbid diagnosis in many patients with medical illnesses. In patients with end-stage renal disease (ESRD), anxiety disorders often are perceived to represent symptoms of depression rather than independent conditions and therefore have been relatively understudied in this medical population. STUDY DESIGN: To evaluate the psychosocial impact of anxiety disorders on patients with ESRD, we sought to identify the rates of these disorders in a sample of patients receiving hemodialysis at a single center by using a structured clinical interview. We also compared a commonly used screening measure, the Hospital Anxiety and Depression Scale (HADS), with these clinical diagnoses to determine the measure's criterion validity or ability to predict a psychiatric diagnosis in ESRD populations. Finally, we examined the relationship between anxiety diagnosis and perceptions of quality of life (QOL) and health status. SETTING & PARTICIPANTS: A sample of 70 randomly selected hemodialysis patients from an urban metropolitan center. PREDICTOR: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Diagnosis (SCID-I). OUTCOMES: HADS and Kidney Disease Quality of Life Short Form. RESULTS: Using the SCID, 71% of the sample received a DSM-IV Axis I diagnosis, with 45.7% of subjects meeting criteria for an anxiety disorder and 40% meeting criteria for a mood disorder. The concordance between DSM-IV anxiety disorders and anxiety scores acquired by using the HADS was not significant. Thus, although the HADS may provide an acceptable measure of overall "psychic distress" compared against the SCID-I, it has poor predictive power for anxiety diagnoses in patients with ESRD. Additionally, the presence of an anxiety disorder was associated with an overall perceived lower QOL (t = 2.4; P < 0.05). LIMITATIONS: Single-center study and a population not representative of US demographics. CONCLUSIONS: A substantial proportion of participating patients met criteria for an anxiety disorder. The utility of the HADS as a screening tool for anxiety in patients with ESRD should be questioned. The finding that anxiety disorders negatively impact on QOL and are not merely manifestations of depression in patients with ESRD emphasizes the importance of accurate diagnosis and effective treatment. Strategic options are necessary to improve the diagnosis of anxiety disorders, potentially enhancing QOL and medical outcome in patients with ESRD.

Depression in patients with chronic renal disease: where are we going?

Depression is quite prevalent in the end-stage renal disease (ESRD) population, with rates as high as 30% in some dialysis centers. There are fewer data on the epidemiology of depression in patients with earlier stages of chronic kidney disease (CKD), but the disease burden may be just as high. Depression may be associated with worse medical outcomes, including increased mortality. Close attention to screening and treating depression in all patients may be necessary. Several instruments have been used to screen for depression. The most common validated depression screening measure in ESRD patients is the Beck Depression Inventory. There are limited data on the appropriate therapy for depression in CKD patients. Psychotherapy combined with antidepressant medications, such as selective serotonin reuptake inhibitors, may be the optimal form of therapy (always in close consultation with mental health professionals). Adverse effects of antidepressant medications should be considered before prescribing these agents, particularly in patients with reduced glomerular filtration rate. Additional studies are necessary to further evaluate the optimal methods to screen for and treat depression in patients with CKD.

Psychosocial aspects of chronic disease: ESRD as a paradigmatic illness.

Psychosocial issues are an understudied yet important concern in the overall health of hemodialysis (HD) patients. Stress is a concomitant of chronic illness and its treatment, and may have meaningful influences on psychological and medical outcomes. This article reviews the influences of psychopathology, social support, family issues, dialysis unit culture, and socioeconomic status on patients treated with center HD. Depressive affect and decreased perception of social support have been linked with mortality in several studies of ESRD patients. Decreased marital satisfaction, disturbances in family dynamics, and lower socioeconomic status (SES) have been associated with poorer health outcomes and can affect patients' perception of social support and depressive affect. Chronically ill ESRD patients who undergo treatment with constant interaction and observation by medical staff are potentially an ideal group for evaluation of the effects of stress and psychosocial factors on outcomes in those with chronic disease, as well as an excellent patient population for intervention to reduce morbidity and mortality. These interactions between potentially modifiable psychosocial risk factors for disease and medical aspects of illness form a paradigm for the study of interventions related to adjustment to chronic illness in the ESRD population.

Depression in end-stage renal disease hemodialysis patients.

Depression has been identified as a complicating comorbid diagnosis in a variety of medical conditions, including end-stage renal disease (ESRD). Despite this, the psychological health of hemodialysis patients is understudied. The purpose of this paper is to review the research and issues involved in the assessment of depression and its sequelae in ESRD. Accurate estimation of the prevalence of depression in the ESRD population has been difficult due to the use of different definitions of depression and varied assessment techniques, the overlap of depressive symptomatology with symptoms of uremia, and the confounding effects of medications. We suggest that depressive affect is a more important construct to study than diagnosis of depression syndromes per se in patients with chronic kidney disease. The Beck Depression Inventory is a reasonable measure of depressive affect in the ESRD population, if a higher than usual cutoff score is used or if its somatic components are omitted. Several pathways link depression and ESRD, and are probably bidirectional. As such, treatment of depressive affect could impact medical as well as psychological outcomes. The need for treatment intervention trials is great. Limited evidence regarding the safety and efficacy of treatment of hemodialysis patients with selective serotonin reuptake inhibitors is available, and cognitive behavioral therapy holds promise as an intervention for depression in this complex medical population.

Psychosocial variables, quality of life, and religious beliefs in ESRD patients treated with hemodialysis.

BACKGROUND: Religious and spiritual aspects of quality of life (QOL) have not been fully assessed in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD), but psychosocial factors are associated with patient survival. METHODS: To investigate interrelationships between religious beliefs and psychosocial and medical factors, we studied 53 HD patients. Psychosocial and medical variables included perception of importance of faith (spirituality), attendance at religious services (religious involvement), the Beck Depression Inventory, Illness Effects Questionnaire, Multidimensional Scale of Perceived Social Support, McGill QOL Questionnaire scores, Karnofsky scores, dialysis dose, and predialysis hemoglobin and albumin levels. RESULTS: Eighty-seven percent of participants were African-American. Men had higher depression scores, perceived lower social support, and had higher religious involvement scores than women. No other parameters differed between sexes. Perception of spirituality and religiosity did not correlate with age, Karnofsky score, dialysis dose, or hemoglobin or albumin level. Greater perception of spirituality and religiosity correlated with increased perception of social support and QOL and less negative perception of illness effects and depression. A one-question global QOL measure correlated with depression, life satisfaction, perception of burden of illness, social support, and satisfaction with nephrologist scores, but not with age or Karnofsky score. CONCLUSION: Religious beliefs are related to perception of depression, illness effects, social support, and QOL independently of medical aspects of illness. Religious beliefs may act as coping mechanisms for patients with ESRD. The relationship between religious beliefs and clinical outcomes should be investigated further in patients with ESRD.

Patient satisfaction with care and behavioral compliance in end-stage renal disease patients treated with hemodialysis.

Compliance with the hemodialysis (HD) prescription is an important predictor of patient outcome. Although there is interest in the concept of patient satisfaction with medical care and caregivers, relatively few such data exist regarding HD patients. We examined whether associations exist between patient satisfaction with medical personnel and depressive affect and social support levels and behavioral compliance with prescribed HD treatment. Seventy-nine HD patients were interviewed, assessing depression, social support, and perception of satisfaction with dialysis staff. Medical and treatment data, Karnofsky functioning and severity of illness scores, and behavioral and laboratory compliance measures were determined. There was no association between patient satisfaction with care and level of depressive affect. A relationship was found between patient satisfaction with care with their nephrologist and attendance at dialysis sessions. Patients who had a poor perception of satisfaction with their nephrologist had poorer attendance at dialysis sessions. There was no relationship between behavioral compliance and patient perception of ancillary HD staff. In addition, patient perception of satisfaction with staff was related to perception of social support, protein catabolic rate, and serum albumin concentration, all of which have been linked to survival. We conclude that a nephrologist has a crucial role in patient compliance. These results suggest interventions that improve patient perception of physician support may improve patient adjustment and possibly survival.

Anxiety sensitivity as a predictor of the development of panic symptoms, panic attacks, and panic disorder: a prospective study.

The purpose of the study was to examine how anxiety sensitivity (AS) acts as a dispositional factor in the development of panic symptoms, panic attacks, and panic disorder. Between 1986 and 1988, data were collected from 505 undergraduates at an urban university. At Time 1, measures used were the ASI to assess AS, the trait scale of the State-Trait Anxiety Inventory (STAI-T) to measure trait anxiety, and self-report questionnaires to measure personal and family history of panic and anxiety symptoms. During the Spring of 1999, 178 of these subjects were re-contacted, and information was gathered on subjects' subsequent development of panic symptoms, panic attacks, panic disorder, and trait anxiety (STAI-T). The ASI was the strongest predictor of the development of panic symptoms and panic attacks. After controlling for trait anxiety, the ASI was not predictive of the development of panic disorder.

Depression in African-American patients with kidney disease.

There are few data on the epidemiology, consequences and treatment of depression in African-American patients with kidney disease in the US, even though such patients disproportionately bear the burden of this illness. This paper reviews data on the diagnosis and pathogenesis of depression and its consequences in patients with and without kidney disease, in addition to work on the epidemiology of depression in the African-American population and in the US End-stage Renal Disease (ESRD) program. African Americans are thought to have similar susceptibility to the development of depression as other populations in the US, but diminished access to care for this group of patients may be associated with differential outcomes. Data are presented from longitudinal studies of psychosocial outcomes in a population comprising primarily African-American patients with ESRD, and is reviewed the treatment of depression in patients with and without kidney disease. There are few studies of the management of depression that focus on minority populations. The authors agree with recommendations that treatment trials should include minority patients, patients with medical comorbidities, and the elderly, and assess function and quality of life as outcomes. The relationships between age, marital status and satisfaction, ethnicity, and perception of quality of life and depressive affect level and diagnosis of depression, and medical outcomes have not been determined in ESRD patients, or in African-American patients with ESRD. There are few studies of drugs for the treatment of depression in ESRD patients, and only one small randomized controlled trial. These have shown that therapy with selective serotonin reuptake inhibitors appears to be a safe treatment option for patients with ESRD. The long-term effectiveness of therapy, and its association with clinically important outcomes such as perception of quality of life, compliance, and survival have not been evaluated in ESRD patients. Also, therapeutic effectiveness and outcomes have not been assessed in minority populations with ESRD. These issues need to be addressed to optimize the management of depression in African Americans with kidney disease.

Psychological resilience: the impact of affectivity and coping on state anxiety and positive emotions during and after the Washington, DC sniper killings.

This research examined the impact of affectivity and coping on state anxiety and positive emotions among young adults living in the Washington, DC metro area both during and after the Washington, DC sniper killings. Participants completed questionnaires during three waves of data collection: (1) during the sniper attacks (n=92); (2) within two weeks after the snipers were captured (n=45); and (3) six months later (n=43). Affectivity (measured by neuroticism) was significantly associated with state anxiety and positive emotions during all three time periods. Coping (measured by constructive thinking) predicted state anxiety and positive emotions during the shootings, but was unrelated to either outcome immediately after the attacks, and marginally related to them six months later. Consistent with the Dynamic Model of Affect, state anxiety and positive emotions were more strongly (and negatively) correlated with each other during the killings than they were after the snipers were apprehended. Taken together, these results support transactional models of stress that emphasize the interaction between dispositional and situational influences, and they suggest that affectivity reflects a fundamental set of reactions to one's environment, while coping dispositions result in more stress-specific responses. Additional theoretical and practical implications of these findings are also discussed.

What makes people anxious about pain? How personality and perception combine to determine pain anxiety responses in clinical and non-clinical populations.

Although anxiety has both dispositional and situational determinants, little is known about how individuals' anxiety-related sensitivities and their expectations about stressful events actually combine to determine anxiety. This research used Information Integration Theory and Functional Measurement to assess how participants' physical concerns sensitivity (PCS) and event expectancy are cognitively integrated to determine their anxiety about physical pain. Two studies were conducted - one with university students and other with anxiety clinic patients - in which participants were presented with multiple scenarios of a physically painful event, each representing a different degree of event probability from which subjective expectancies were derived. Independent variables included PCS (low, moderate, and high) and event expectancy (low-, medium-, high-, and non-probability information). Participants were asked to indicate their projected anxiety (dependent measure) in each expectancy condition in this 3 × 4 mixed, quasi-experimental design. The results of both studies strongly suggest that PCS and event expectancy are integrated additively to produce these pain anxiety scores. Additional results and their implications for the treatment of anxiety-related disorders are also discussed.

Course of depression and anxiety diagnosis in patients treated with hemodialysis: a 16-month follow-up.

BACKGROUND AND OBJECTIVES: There is growing identification of the need to seriously study the psychiatric presentations of end-stage renal disease patients treated with hemodialysis. This study reports on the course of depression and anxiety diagnoses and their impact on quality of life and health status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The 16-mo course of psychiatric diagnoses in 50 end-stage renal disease patients treated with hemodialysis was measured by structured clinical interview. RESULTS: Three different pathways were identified: one subset of patients not having a psychiatric diagnosis at either baseline or 16-mo follow-up (68% for depression, 51% for anxiety), one group having an intermittent course (21% for depression, 34% for anxiety), and one group having a persistent course (11% for depression, 15% for anxiety), with diagnoses at both time 1 and time 2. For depression, the people with the persistent course showed marked decreases in quality of life and self-reported health status compared with the nondepressed and intermittently depressed cohorts. The most powerful predictor of depression at time 2 is degree of depressive affect at time 1(P < 0.05). CONCLUSIONS: Patients at risk for short- and long-term complications of depression can be potentially identified by high levels of depressive affect even at a single time point. As nearly 20% of the sample had chronic depression or anxiety, identifying a psychiatric diagnosis in hemodialysis patients and then offering treatment are important because, in the absence of intervention, psychiatric disorders are likely to persist in a substantial proportion of patients.

Spirituality, social support, and survival in hemodialysis patients.

BACKGROUND AND OBJECTIVES: No studies have evaluated the relationship among spirituality, social support, and survival in patients with ESRD. This study assessed whether spirituality was an independent predictor of survival in dialysis patients with ESRD after controlling for age, diabetes, albumin, and social support. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A total of 166 patients who had ESRD and were treated with hemodialysis completed questionnaires on psychosocial variables, quality of life, and religious and spiritual beliefs. The religious variables were categorized into three scores on a 0 to 20 scale (low to high levels): Spirituality, religious involvement, and religion as coping. Social support was assessed using the Multidimensional Scale for Perceived Social Support. Analyses were also performed including and excluding patients with HIV infection. Religious variables were categorized on the basis of means, medians, and tertiles. RESULTS: In analyses that used religious variables, only the responses on the spirituality scale split at the mean were associated with survival. The association of other religious variables with survival did not reach significance. Social support correlated with spirituality, religion as coping, and religious involvement measures. Only social support and age were associated with survival when controlling for diabetes, albumin concentration, HIV infection, and spirituality. CONCLUSIONS: These data suggest that the effects of spirituality may be mediated by social support. Larger, multicenter, prospective studies that use well-validated tools to measure religiosity and spirituality are needed to determine whether there is an independent association of spirituality variables with survival in patients with ESRD.

Pain, sleep disturbance, and quality of life in patients with chronic kidney disease.

BACKGROUND AND OBJECTIVES: Few studies have assessed sleep disturbances or perception of pain in patients with early-stage chronic kidney disease. It was hypothesized that perception of pain and sleep disturbance would increase with chronic kidney disease stage, that pain and sleep disturbance would correlate with psychosocial variables, and that there would be a higher prevalence of pain and sleep disturbances in patients with chronic kidney disease compared with general medical patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A total of 92 predialysis patients with chronic kidney disease and 61 general medical outpatients were evaluated using the Beck Depression Inventory, Illness Effects Questionnaire, Multidimensional Scale of Perceived Social Support, Satisfaction with Life Scale, Karnofsky Scale, Pittsburgh Sleep Questionnaire, and McGill Pain questionnaire. RESULTS: With the exception of expected differences in serum creatinine, estimated GFR, Karnofsky score, albumin, and hemoglobin, there were no significant differences between groups. A total of 69% of patients with chronic kidney disease experienced pain; 55.2% had disordered sleep. Pain was associated with quality-of-life indicators, including depression, burden of illness, and life satisfaction. Disordered sleep correlated with depression, illness burden, social support, and pain frequency. There were no differences in perception of pain or sleep disturbance between patients with chronic kidney disease and control patients. CONCLUSIONS: Pain is common in patients with early-stage chronic kidney disease and is associated with patients' perception of lower quality of life. The prevalence of pain, sleep disturbance, and abnormal psychologic status of patients with chronic kidney disease may be similar to outpatients with other chronic medical illnesses.

Depression and anxiety in urban hemodialysis patients.

Depression is well established as a prevalent mental health problem for people with ESRD and is associated with morbidity and mortality. However, depression in this population remains difficult to assess and is undertreated. Current estimates suggest a 20 to 30% prevalence of depression that meets diagnostic criteria in this population. The extent of other psychopathology in patients with ESRD is largely unknown. The aim of this study was to expand the research on psychiatric complications of ESRD and examine the prevalence of a broad range of psychopathology in an urban hemodialysis center and their impact on quality of life. With the use of a clinician-administered semistructured interview in this randomly selected sample of 70 predominately black patients, >70% were found to have a psychiatric diagnosis. Twenty-nine percent had a current depressive disorder: 20% had major depression, and 9% had a diagnosis of dysthymia or depression not otherwise specified. Twenty-seven percent had a current major anxiety disorder. A current substance abuse diagnosis was found in 19%, and 10% had a psychotic disorder. The mean Beck Depression Inventory score was 12.1 +/- 9.8. Only 13% reported being in current treatment by a mental health provider, and only 5% reported being prescribed psychiatric medication by their physician. A total of 7.1% had compound depression or depression coexistent with another psychiatric disorder. The construct of depression was also disentangled from the somatic effects of poor medical health by demonstrating a unique relationship between depressive affect and depression diagnosis, independent of health status. This study also suggests the utility of cognitive variables as a meaningful way of understanding the differences between patients who have ESRD with clinical depression or other diagnoses and those who have no psychiatric comorbidity. The findings of both concurrent and isolated anxiety suggest that the prevalence of psychopathology in patients with ESRD might be higher than previously expected, and the disorders may need to be treated independently. In addition, the data suggest that cognitive behavioral therapeutic techniques may be especially advantageous in this population of patients who are treated with many medications.

Screening, diagnosis, and treatment of depression in patients with end-stage renal disease.

Depression is common in patients with end-stage renal disease and has been linked to increased mortality. Screening for depression in the general medical population remains controversial; however, given the high prevalence of depression and its significant impact on morbidity and mortality, a strong case for depression screening in patients with end-stage renal disease can be made. Several studies have been performed to validate the more common depression screening measures in patients with chronic kidney disease. The Beck Depression Inventory, the Hamilton Rating Scale for Depression, the Nine-Question Patient Health Questionnaire, and the Center for Epidemiologic Studies Depression Scale are some of the measures that have been used to screen for depression in patients with end-stage renal disease. Data suggest a higher Beck Depression Inventory cutoff score, of >14 to 16, will have increased positive predictive value at diagnosing depression in patients with end-stage renal disease. There are limited data on the treatment of depression in this patient population. Pharmacotherapy, including selective serotonin reuptake inhibitors, can be used if deemed clinically indicated, and no active contraindication exists. There are even fewer data to support the role of cognitive behavioral therapy, social support group interventions, and electroconvulsive therapy for treatment of depression in patients with chronic kidney disease. Larger randomized, controlled clinical trials aimed at the treatment of depression in patients with end-stage renal disease are desperately needed.

Depression in end-stage renal disease patients: a critical review.

Depression is the most common psychological disorder in end-stage renal disease (ESRD) patients with a prevalence rate as high as 20% to 25% by some contemporary estimates. There are several studies linking depression with mortality in ESRD, making early diagnosis and treatment essential. The mechanisms linking depression with survival in ESRD patients are unclear but may be related to treatment compliance, improvement in nutritional parameters, increased perception of social support, and modulation of the immune system. Although the best methods for depression screening remain controversial, recent research has validated cutoff values for some of the more common depression screening questionnaires for evaluation in ESRD hemodialysis (HD) patients. A cutoff score of 14 to 16 for the Beck Depression Inventory is believed to have the most sensitivity and specificity at making the psychiatric diagnosis of depression in ESRD HD patients. There are limited data regarding the treatment of depression in ESRD patients. Selective serotonin reuptake inhibitors, at initial low starting doses, may be used in close consultation with mental health providers if no active contraindication to their use exists. Data on the mechanisms linking depression and mortality and the optimal treatment of depression in ESRD patients await the performance of randomized controlled clinical trials.

Social support and chronic kidney disease: an update.

Social support is an understudied, yet important, modifiable risk factor in a number of chronic illnesses, including end-stage renal disease (ESRD). Increased social support has the potential to positively affect outcomes through a number of mechanisms, including decreased levels of depressive affect, increased patient perception of quality of life, increased access to health care, increased patient compliance with prescribed therapies, and direct physiologic effects on the immune system. Higher levels of social support have been linked to survival in several studies of patients with and without renal disease. Higher perceived spousal support among women on dialysis was linked to improved compliance and survival in subgroup analyses. Few studies have examined the impact of social support interventions in ESRD patients. Studies have been limited by small sample size, retrospective analyses, and lack of control populations. Given the potential link with survival, a large, prospective, randomized controlled trial is needed to evaluate the impact of a social support group intervention in ESRD patients.

Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs.

Depression has been thought to be the most common psychiatric abnormality in hemodialysis (HD) patients. There are few data using psychiatric diagnostic criteria and a lack of large, well-designed epidemiologic research studies in patients with end-stage renal disease (ESRD) that can render definitive results on this topic. The prevalence of major depression or a defined psychiatric illness in ESRD patients is unknown, but is probably between 5% and 10%. The prevalence of increased levels of depressive affect is greater. Estimates of the prevalence will vary according to the screening techniques used. Depression could affect medical outcomes in ESRD patients through several mechanisms. Correlational analyses suggest stressors and protective factors play roles in mediating the level of depressive affect and associated outcomes. Although early studies suggested a deleterious effect of depression on survival in ESRD patients, more recent studies had failed to confirm such findings. The use of longitudinal analyses and larger samples has confirmed an association of depressive affect and morbidity and mortality in more contemporary ESRD populations. The importance of depressive affect compared with the presence of a defined psychiatric syndrome in mediating clinically important outcomes in patients with chronic kidney disease has not been determined. Studies of interventions designed to reduce levels of depressive affect in ESRD patients are urgently needed.