Mental Health Impact On Patients of ESRD On Renal Replacement Therapy: A Cross Sectional Survey Using Beck and Deck Inventory

Introduction: Chronic kidney disease (CKD) affects approximately 8 to 16% of population worldwide. With increasing incidence of diabetes mellitus and an aging population, CKD is putting an enormous burden on health care resources. The prevalence of CKD in Pakistan has been estimated to vary between 5%-12.5%. Depression can be found in 25% to 42% of hemodialysis patients. There are no previous studies done in Pakistan to know the mental health impact in End-stage renal disease (ESRD)patients undergoing dialysis. Aims &Objectives: To assess the mental health impact on patients of ESRD on renal replacement therapy using Beck and Deck inventory in our population. Place and duration of study: Department of Medicine, Ayub Teaching Hospital, Abbottabad from February 2019 to July 2019. Material & Methods: 97 patients were enrolled using non-probability, consecutive sampling. Patients having CKD and on dialysis for 3 months from both genders from ages 15 to 60 years were included in the study. Patients were assessed using DSM-IV/BDI criteria for presence of depression. Data was entered and analyzed using SPSS version 20 Results: Of the 97 patients included in the study 57 (58.8%) were male and 40 (41.2%) were females. The mean age of patients was 45.00 ±14.82 years. The mean length of time since the patients were on dialysis was 20.47 ±22.81 months. Hypertension was the commonest cause of CKD (75.3%). The mean BDI score was 15.25 ±7.46. The number of patients who had no or minimal depression was 40 (41.2%). The number of patients having mild, moderate and severe depression was 57 (58.8%) patients. Single patients were more likely to be normal (77.8%) compared to married individuals (37.5%). Of the patients who were on dialysis for more than 48 months, 75% were normal with no element of depression. Of the patients who were on dialysis for less than a year, 59.6% had depression. This was statistically significant. Conclusion: Depression is more prevalent in ESRD patients on hemodialysis. It is more prevalent than found in other major illnesses and in the general population. It should be recognized earlier so that these patients can be treated, and they can have a better quality of life.


INTRODUCTION
Chronic kidney disease (CKD) is rapidly becoming a global health concern.There has been a steep rise in the number of patients reaching Endstage renal disease (ESRD).CKD affects an approximately 8 to 16% of population worldwide 1 .CKD, as a cause of death, has climbed from 27 th to 18 th position in two decades 2 .This has translated to 82.3% rise in the number of deaths caused by CKD in the last twenty years.This is the third largest increase among the top 25 causes of deaths, paralleled only by AIDS and diabetes 3 .CKD is an alarming public health priority also because of the fact that the number of ESRD patients on renal replacement therapy is approximately 1.4 million and this number is increasing by 8% annually 4 .
With increasing incidence of diabetes mellitus and an aging population, CKD is putting an enormous burden on health care resources 5 .In Western countries, the prevalence of CKD varies between 5.8% (Poland) to 14.8% (United States) in the adult population 6 .However, prevalence of CKD increases in diabetic people, in whom it varies between 34.7 and 45.4% according to different populations 7 .The prevalence of CKD in Pakistan has been studied very sparsely.It has been estimated to vary between 5% to 12.5% in a review published by Imtiaz S. et al.in 2018 8 .Most of the ESRD patients undergo renal replacement therapy (hemodialysis) in a hospital setting.Although this has increased life expectancy in CKD patients, many studies suggest that these patients often suffer from poor quality of life 9,10 .

INTRODUCTION
Globally, acute generalized peritonitis ranks among the top surgical emergencies 1 .It is more common in Third World nations.The prevalence of perforation is low (0.6% -4.9%) in developed nations but high (33% -63%) in West Africa 2 .554 persons were discovered to have peritonitis in a study that took place over three years in India 3 .Researchers in Pakistan have conducted studies with similar methods, with one study reporting 650 cases in a just 9 months 4 .Most cases of peritonitis are caused by a gastrointestinal perforation or anastomotic leak 5 .In the case of peritonitis, anaerobes and gramnegative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins 5 .Clinical evidence is used to identify peritonitis.Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan.This is often done through diagnostic laparoscopy nowadays 6 .Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL) 7,8 .Regular IOPL is performed to lessen bacterial contamination and burden.Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high.Another method Depression is frequently associated with hemodialysis in CKD patients 11 .According to the American Psychological Association's Diagnostic and Statistical Manual-V, depression is characterized by low mood, a decreased interest or pleasure in activity, and at least three of seven other co-occurring symptoms present for a period of more than two weeks 12 .Depression can be found in patients in 25% to 42% of hemodialysis patients 13,14 .Further, depression frequently goes unrecognized in CKD patients on dialysis and it significantly affects the quality of life in such patients 15 .There are no previous studies done in Pakistan to know the mental health impact in ESRD patients undergoing dialysis.Therefore, this study was planned to assess the problem in our population.

MATERIAL AND METHODS
This cross-sectional study was conducted in the Department of Medicine, Ayub Teaching Hospital, Abbottabad from February 2019 to July 2019.IRB Clearance was received vide letter number (884-1) Sample size was calculated to be 97 cases with 95% confidence level, 4% margin of error and taking expected frequency depression in CKD patients on dialysis as 7.8% 16 .Non-probability, consecutive sampling used.All patients having ESRD who were on dialysis for 3 months from both genders from ages 15 to 60 years were included in the study.Patients having previous history of depressive illness or mood disorders, antidepressant or antipsychotic use, history of stroke, bed ridden patients or having any malignancy were excluded from the study.After taking consent, patients were assessed using DSM-IV/Beck and Deck Inventory (BDI) criteria for presence of depression.Demographic data was also collected on a proforma.Data was analysed by using SPSS-20.

RESULTS
A total of 97 patients were included in the study of which 57 (58.8%) were male and 40 (41.2%) were females.The mean age of the patient's was 45.00 ±14.82 years and the age ranged between 11 years and 80 years.The mean length of time since the patients were on dialysis was 20.47 ± 20.0 months.The mean time since the patients were diagnosed as having ESRD was 24.20 ± 24.08 months.Hypertension was the commonest cause of CKD (75.3%).Most of the patients, 93 (96%), were on twice weekly dialysis.The average time the patients travelled to the hospital for dialysis was 2.35 ±1.91 hours.Only 2% of patients were either Hepatitis B or C positive before the initiation of dialysis.44.3% patients contracted Hepatitis C after being put on dialysis.No patient contracted Hepatitis B after starting dialysis.85.6% patients did not associate any adverse outcomes with previous dialysis.The mean BDI score was 15.25 ±7.46.The number of patients who had no or minimal depression was 40 (41.2%).The number of patients having mild, moderate and severe depression was 57 (58.8%) patients.(Table -1).Results show significant association between adverse outcome during previous dialysis and the level of depression.Patients who did not experience any adverse outcome in previous sessions of dialysis were more likely to be normal (30%) compared to those that had an adverse outcome (7%).Marital status was also associated with a significant difference in the level of depression.Single patients were more likely to be normal (77.8%) compared to married individuals (37.5%).Mean BDI scores were 9.5 in single individuals and 15.8 in married individuals.This association was statistically significant, indicating that married individuals were more likely to be depressed.There was no significant difference in mean BDI scores in educated and uneducated individuals.Results showed significant association between total duration the patient was on dialysis and the level of depression.Of the patients who were on dialysis for more than 48 months, 75% were normal with no element of depression..In the case of peritonitis, anaerobes and gramnegative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins 5 .Clinical evidence is used to identify peritonitis.Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan.This is often done through diagnostic laparoscopy nowadays 6 .Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL) 7,8 .Regular IOPL is performed to lessen bacterial contamination and burden.Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high.Another method A systemic review and meta-analysis which included 249 populations and 55,982 participants showed that prevalence of depression to be 39.3% in ESRD patients 21 .In a study done by Chi-Ken Chen et al, on 200 patients on hemodialysis, depression was present in 35.0% of patients 22 .However, the estimates of depression in ESRD on hemodialysis patients have varied between 5% to 58% 23 .The prevalence of depression in our study is 58.8%.This rate is higher than that reported in many western populations.However, it corresponds to the levels of depression in Indian sub-continent.A study done in Western Rajasthan, India showed the prevalence of depression in hemodialysis patients to be 61% 24 .Similarly, Kumar et al. showed a prevalence of depression to be 61.3% in CKD patients on hemodialysis 25 .In our study, married people were likely to be depressed that single individuals.This is in contrast to some other studies which found that married people were less likely to be depressed and had better QoL than widowed/divorced individuals 26,27 .However, Amjad Khan et al., found that married people were more likely to be depressed than single individuals.They found 85.6% of married people to be depressed 28 .In our study, 62.5% married individuals were depressed.The difference could be explained by the fact that the first two studies compared married to widowed/divorced individuals, whereas Amjad Khan et al. and our study compared married to single unmarried individuals.A study done in Pakistan by Anees M et al. also showed that married individuals are more likely to be depressed than single individuals 29 .In our social setup, a married individual is usually a guardian of 4-8 dependents.As the disease process affects their employment status, this leads to increased mental stress as there is no social support for the family.This could cause higher levels of depression.In our study, the duration of dialysis was associated with the level of depression in an individual.Of the patients who were on dialysis for less than a year, 59.6% were found to have depression, whereas patients who were on dialysis for more than 4 years, 75% of them had no element of depression.This corresponds to findings of some other studies which propose that the commencement of dialysis puts a significant emotional and social stress on an individual, and as the duration increases the patient gradually adapts to the burden of the disease 30,31 .Although treatment can be challenging, it is very important to identify depression early in ESRD patients.Pharmacological and Cognitive Behavioral Therapy (CBT) can lead to improved quality of life in these patients 32,33 .

CONCLUSION
Depression is more prevalent in ESRD patients on hemodialysis.It is more prevalent than found in other major illnesses and in the general population 29,31 .It should be recognized earlier so that these patients can be treated and they can have a better quality of life.