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 Table of Contents  
Year : 2014  |  Volume : 35  |  Issue : 2  |  Page : 100-104

Assessment of depression and anxiety in children on regular hemodialysis

Department of Pediatrics; Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission01-Oct-2013
Date of Acceptance01-Dec-2013
Date of Web Publication11-Jun-2014

Correspondence Address:
Saber A. Mohamed
Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-1105.134196

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Depression and anxiety are well established as prevalent mental health problem in end-stage renal disease patients treated with hemodialysis. However, these problems remain difficult to assess and are undertreated.
The aim of the study was to estimate the prevalence of depression and anxiety and to evaluate their risk factors in children on regular hemodialysis.
Materials and methods
Forty pediatric patients with end-stage renal failure on regular hemodialysis and 20 healthy control children were studied. All participants were subjected to proper history taking, thorough medical and psychiatric examination, psychometric assessment by pediatric anxiety and children depression inventory scale, and laboratory investigations including serum urea, creatinine, serum albumin, serum iron, serum ferritin, serum calcium, serum phosphate, serum parathormone hormone, hemoglobin level, and PT and PTT levels.
There was a high prevalence rate of anxiety and depression among hemodialysis patients compared with that in healthy control children. Hemoglobin and serum albumin were found to be negatively correlated with both anxiety and depression.
Majority of pediatric patients undergoing hemodialysis were severely depressed and anxious. Pediatric patients on regular hemodialysis with anemia and hypoalbuminemia have more psychiatric disturbance than others.

Keywords: anxiety, depression, hemodialysis, renal failure

How to cite this article:
Abdel Salam MM, Abdo MA, Yousef UM, Mohamed SA. Assessment of depression and anxiety in children on regular hemodialysis. Egypt J Psychiatr 2014;35:100-4

How to cite this URL:
Abdel Salam MM, Abdo MA, Yousef UM, Mohamed SA. Assessment of depression and anxiety in children on regular hemodialysis. Egypt J Psychiatr [serial online] 2014 [cited 2024 Feb 29];35:100-4. Available from: https://new.ejpsy.eg.net//text.asp?2014/35/2/100/134196

  Introduction Top

Depression and anxiety are the primary psychiatric problems of end-stage renal disease (ESRD). Depression and anxiety symptoms have gaining increasing attention as an authorative measure of psychopathology in ESRD population [1] .

Hemodialysis (HD) significantly and adversely affects the lives of patients both physically and psychologically [2] .

Depression is a common psychological symptom in patients undergoing chronic HD. It affects the recovery process and mortality in patients with ESRD, especially those on HD [3] .

The prevalence of major depression in the general population is 1.1-15% in men and 1.8-2.3% in women, but the incidence of depression in ESRD has been reported to range from 10 to 100% in different series [4] .

The incidence of anxiety, a common disorder in HD patients, is 27-46% [5] .

The exact pathogenesis of depression is still unknown but the genetic and environmental factors are believed to be important [6] .

The higher prevalence of depression in chronic kidney disease (CKD) patients may be related to higher prevalence of comorbid chronic diseases, complications of anemia and vitamin B 12 deficiency, genetic factors, greater mental stress, and hyperinflammatory status. The presence of uremic products may also contribute to depression [7] .

The objective of this study was to evaluate the association between and prevalence of depression and anxiety in HD children.

  Materials and methods Top


In a cross-sectional study at Nephrodialysis Unit of Zagazig University Hospitals during 6-month period, 40 children with end-stage renal failure between the age of 6 and 16 years (group I) and 20 healthy children (group II as the control group) were enrolled in the study.

Inclusion criteria

Patients with age ranging from 6 to 16 years, who were cooperative enough during research, and patients with ESRD diagnosed, when creatinine clearance was less than 15 ml/min per 1.73 m 2 BSA by the Schwartz formula, were included in the study. They were on regular HD.

All patients were taking calcium-based phosphate binders, calcitriol, antacids, and erythropoietin subcutaneously. The control children were recruited from children who attended the outpatient clinic for mild illness.

Exclusion criteria

Patients who had chronic medical illness, major mental illness, who were using psychotropic medicines, or who had neurological disease were excluded from participation in the study.

  Methods Top

All studied patients were subjected to proper history taking, with particular attention to age and sex, symptoms of ESRD, duration of the disease, history of medications, and complications of behavior changes.

Careful medical and psychiatric examination were carried out with focus on general examination, weight, height, surface area, blood pressure, and manifestations of ESRD.

Laboratory investigations included routine investigations of hemodialyzed children, including serum urea, creatinine, serum albumin, serum iron, serum ferritin, serum calcium, serum phosphate, serum parathormone hormone, hemoglobin level, and PT and PTT levels.

Psychiatric assessment

After obtaining informed consent from the parents, psychiatrist conducted psychiometric assessment in a quiet room near the dialysis room after dialysis settings using the following tests:

(1) Children depression inventory: The children depression inventory depression test for pediatrics was completed by all patients in a standardized format, which measures the degree of depression among the children who were exposed to depressive condition in the last 2 weeks. The questionnaire consists of 27 statements, and it is a self-rated survey designed to assess the cognitive behavior and neurovegetative signs of depression in children.

The score of the test: the instruction for the standard version asks how much problem each item has given during the last 2 weeks. A three-point response scale is used (0 = never a problem, 1 = often a problem, 2 = almost always a problem).

Scoring: On summation of the results, scoring ranged from 0 to 54 [8] .

(a) 0-9 indicates normal (minimal) depressive status.

(b) 9-14 indicates mild depressive status for male.

(c) 9-16 indicates mild depressive status for female.

(d) 14-18 indicates moderate depressive status for male.

(e) 16-22 indicates moderate depressive status for female.

(f) Greater than 18 indicates severe depressive status for male.

(g) Greater than 22 indicates severe depressive status for female.

(2) Children anxiety scale: Children anxiety scale was completed by all patients. This scale was developed by Castaneda et al. [9] . It consists of 53 items and each item consists of one statement that has two answers: yes or no.

(a) If the answer is yes, the degree is 1.

(b) If the answer is no, the degree is 0.

Total score ranges from 0 to 53. According to their scores, they were classified into mild, moderate, and severe degrees [9] .

(a) Mild anxiety is less than 18.

(b) Moderate anxiety is from 19 to 28.

(c) Severe anxiety is more than 29.

Statistical analysis

Data were checked, entered, and analyzed using SPSS, version 20. Data were expressed as mean ± SD for quantitative variables and number and percentage for categorical variables. The χ2 or Fisher exact test, the t-test, analysis of variance (F-test), and Pearson correlation were used when appropriate.

P value less than 0.05 was considered statistically significant.

  Results Top

The mean age of the forty patients was 11.8 ± 2.8, with equal percentage of male and female patients [Table 1].
Table 1: Demographic and laboratory data among patients and controls

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There was highly significant difference between patients and controls with respect to urea, creatinine, parathormone hormone, ferritin, and serum albumin [Table 1].

There was highly significant difference between patients and controls with respect to mean score of anxiety and depression [Table 2].
Table 2: Psychic disturbance in the studied groups

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We found high prevalence of depression (severe '95%' and moderate '5%') and anxiety (severe '65%', moderate '27.5%', and mild '7.5%') [Table 3].
Table 3: Prevalence of depression and anxiety among patients

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There was highly significant negative correlation between anxiety and depression with respect to serum albumin and hemoglobin, whereas there was no correlation with sex, urea, duration of dialysis, and adequacy of dialysis among the patient group [Table 4] and [Table 5].
Table 4: Relationship between sex and anxiety or depression severity

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Table 5: Correlation between anxiety, depression, and other parameters

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  Discussion Top

A child's serious illness or disability can place psychological and social burdens on the child and the family [10] .

Depression is generally accepted to be the most common psychological problems in patients with ESRD. As somatic characteristics of depression is similar to the symptoms of uremia, it is usually neglected, undiagnosed, and remain untreated [11] .

The importance of anxiety may have been underestimated in HD patients. Notably, anxiety is a common psychological problem that may emerge during the initial course of dialysis. Thus, it is important to identify anxiety symptoms in dialysis patients [5] .

In the present study, we aimed to clarify the prevalence of depression and anxiety among children with CKD on maintenance HD and to evaluate their risk factors. The prevalence of moderate to severe depression and mild to severe anxiety was 100%, with a mean scale for them of 32.7 ± 3.4 and 29.25 ± 7.8, respectively.

Studies on psychiatric disorders among children with CRF are few in number [12],[13],[14],[15]. The results of these studies are variable because of the heterogeneicity of the cohort of the studied patients as well as the tool of psychiatric assessment.

Bakr et al. [14] reported that the prevalence rate of psychiatric disorders among children with CRF was 52.6% (depression 10.3% and anxiety 5.1%). Fukuniski et al. [13] reported that 17 of the 25 (65.4%) Japanese children with ESRD on continuous ambulatory peritoneal dialysis exhibited psychiatric disturbances [13] . However, psychiatric assessment of 26 British children with end-stage renal failure treated by home HD revealed psychiatric morbidity in 19.2% of the studied children [11] .

The high prevalence of these psychiatric disturbances may be explained by the fact that children on dialysis experience more distressing physical symptoms, more medication and investigations, and more dependence on machines that could possibly malfunction at any time [14] .

Meanwhile, the stress associated with CKD and its prolonged and intensive treatment may adversely affect the psychological well being of children [7] as well children's feeling of hopelessness and concerns about self-worth, and perceived competencies and maladaptive attribution style may contribute to elevated scores of depression among these patient [16] .

We did not find any significant correlation between depression or anxiety and age, sex, and duration and efficiency of HD; this is in accordance with the study by Bakr et al. [14] who did not find any significant correlation between the presence of psychiatric disorders and a number of factors such as age, sex, duration of CRF, or efficiency and duration of HD.

With respect to serum urea, we did not find any correlation between depression or anxiety and serum urea; this is in agreement with the study by Hsu et al. [7] who reported that there is no association between depression and serum urea.

However, we did not find significant correlation between depression or anxiety and the duration of HD. Roozbeh et al. [17] found that high scores of depression was present in patients undergoing HD for long duration (P < 0.05).

With respect to serum albumin, we found a negative correlation between serum albumin and depression or anxiety.

This is in accordance with the study by Anees et al. [18] and Huang and Chien-Te [19] . They stated that CRF patients who were hypoalbuminemic have negative correlation with all psychological parameters of depression.

However, Roozbeh et al. [17] found nonsignificant difference between the studied groups with respect to level of serum albumin.

Albumin is a very important marker of nutritional status in HD patients. The causes of hyperalbuminemia in our patients are anorexia and gastrointestinal disorders, which attributed to both depression and ESRD [18],[20]. Poor protein intake in malnutrition can lead to decreased level of protein bound indoxysulfate, which has a direct antidepressive effect [7] .

With respect to hemoglobin level, we found that it was negatively correlated with depression and anxiety scores (low hemoglobin was associated with increased depression and anxiety scores); this is in accordance with the study by Lew and Piraino [20] who found that anemia was associated with decreased quality of life and increased depression and anxiety in patients on maintainance HD. In contrast, Roozbeh et al. [17] found nonsignificant difference between the studied groups with respect to level of hemoglobin.

This negative correlation with respect to hemoglobin level may be related to malnutrition in depressed and anxious children.

With respect to serum ferritin, we observed that it was increased significantly in our patients (P > 0.05); this runs parallel to the study by Roozbeh et al. [17] and Huang and Chien-Te [19] who found that high serum ferritin was present in patients with depression.

Serum ferritin is frequently used as a marker of iron stores in uremic patients. However, a high serum ferritin level might be related to an acute phase reaction in dialysis patients [2] .

Some authors have also suggested that high serum ferritin is a reflection of the 'Malnutrition Inflammation Complex Syndrome' in dialysis patients [8] .

Our results can explain that psychiatric disturbances are not related to demographic and physical factors but are related to the difficulties encountered in living with chronic renal failure and its associated anemia and hypoalbuminemia.

  Conclusion and recommendations Top

As the prevalence of depression and anxiety was highest in our patients (all patients), this needs awareness on the importance of early diagnosis and management of these disorders and their risk factors, especially hypoalbuminemia and low serum hemoglobin, for early treatment of these disorders and better welfare of patients and to avoid catastrophic events such as suicidal attacks, malnutrition, and absenteeism from dialysis.[21]

  Acknowledgements Top

Conflicts of interest

There are no conflicts of interest.

  References Top

1.Weissman MM, Bland RC, Canino CJ (1996). Cross-sectional epidemiology of major depression and bipolar disorder. JAMA 276:293-299.  Back to cited text no. 1
2.Patel ML, Sachan R, Nischal A (2013). Anxiety and depression: a suicidal risk in patients with chronic renal failure on maintenance hemodialysis. Int J Sci Res 2:1-5.  Back to cited text no. 2
3.Kim DH, Min SK, Han DS (1994). The characteristics of depression in hemodialysis, patients and influencing factors. J Korean Neuropsychiatr Assoc 33:39-45.  Back to cited text no. 3
4.Cunha MP, Machado DG, Bettio LE (2008). Interaction of zinc with antidepressants in the tail suspention test. Prog Neuropsychopharmacol Biol Psychiatry 32:1913-1920.  Back to cited text no. 4
5.Cukor D, Rosenthal DS, Jindal RM, Brown CD, Kimmel PI (2009). Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int 75:1223-1229.  Back to cited text no. 5
6.Sullivan PF, Neale MC, Kendler KS (2000). Genetic epidemiology of major depression: review and meta analysis. Am J Psychiatry 157:1552-1562.  Back to cited text no. 6
7.Hsu HJ, Yen CH, Chen CK, Wu IW, Lee CC, Sun CY (2013). Association between uremic toxins and depression in patients with chronic kidney disease undergoing maintenance hemodialysis. Gen Hosp Psychiatry 35:23-27.  Back to cited text no. 7
8.Kovacs M, Beck A. J Schulterbrandt, A Raskin, eds. An empirical-clinical approach toward a definition of childhood depression. In: Depression in childhood: diagnosis, treatment and conceptual models. 1977. 1-26.  Back to cited text no. 8
9.Castaneda A, McCandless BR, Palermo DS (1956). The children's form of the manifest anxiety scale. Child Dev 27:317-326.  Back to cited text no. 9
10.Lavigne JV, Faier-Routman J (1992). Psychological adjustment to pediatric physical disorders: a meta-analysis review. J Pediatr Psychol 17:133-157.  Back to cited text no. 10
11.Wass VJ, Barratt TM, Howarth RV, Marshall WA, Chantler C, Ogg CS, et al (1977). Home dialysis in children. Lancet 1:242-246.  Back to cited text no. 11
12.Garralada ME, Jameson RA, Reynolds JM, Postlethwaite RJ. Psychiatric adjustment in children with chronic renal failure. J Child Psychol Psychiatry 29:79-90.  Back to cited text no. 12
13.Fukuniski L, Honda M, Kamiyama Y, Ito H (1993). Influence of mothers on school adjustment of continuous ambulatory peritoneal dialysis children. Perit Dial Int 13:232-235.  Back to cited text no. 13
14.Bakr A, Amr M, Sarhan A, Hammad A, Ragab M, El-Refaey A, El-Mougy A (2007). Psychiatric disorders in children with chronic renal failure. Pediatr Nephrol 22:128-131.  Back to cited text no. 14
15.Bennett DS (1994). Depression among children with chronic medical problems: a meta analysis. J Pediatr Psychol 19:149-169.  Back to cited text no. 15
16.Roozbeh J, Sharifian M, Ghanizadeh A, Sahraian A, Sagheb MM, Shabani S (2011). Association of zinc deficiency and depression in the patients with end-stage renal disease no hemodialysis. J Ren Nutr 21:184-187.  Back to cited text no. 16
17.Anees M, Bakri H, Masood M, Mumtaz A, Kausar T (2008). Depression in hemodialysis patients. Pak J Med Sci 24:560-565.  Back to cited text no. 17
18.Haung TL, Chien-Te L (2007). Low serum albumin and high ferritin levels in chronic hemodialysis patients with major depression. Psychiatry Res 152:277-280.  Back to cited text no. 18
19.Li ZJ, An X, Mao HP, et al (2011). Association between depression and malnutrition inflammation complex syndrome in patients with continuous ambulatory peritoneal dialysis. Int Urol Nephrol 43:875-882.  Back to cited text no. 19
20.Lew SQ, Piraino B (2005). Quality of life and psychological issues in peritoneal dialysis patients. Semin Dial 18:119-123.  Back to cited text no. 20
21.Cukor D, Coplan J, Brown C (2008). Course of depression and anxiety diagnosis in patients treated with hemodialysis: a 16-month follow up. Clin J Am Soc Nephrol 3:1752-1758.  Back to cited text no. 21


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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