ISSN: 2378-3176 UNOAJ

Urology & Nephrology Open Access Journal
Research Article
Volume 3 Issue 6 - 2016
Depression in End-Stage Renal Disease Patients on Hemodialysis-A Single Center Experience in Saudi Arabia
Hassan Hakami1, Mohamed Said Abdelsalam1,2, Mohamed Rashwan1*, Mohammed Mahdi Althaf1, Nayyar Saleem1 Ihab A Ibrahim3,4 and Osman Alfurayh1
1Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Saudi Arabia
2Nephrology unit, Internal Medicine Department, Alexandria University, Egypt
3Department of Kidney and pancreas transplantation, King Faisal Specialist Hospital and Research Center, Saudi Arabia
4Division of Nephrology, Department of Internal Medicine, Cairo University School of Medicine, Egypt
Received: August 08, 2016 | Published: December 08, 2016
*Corresponding author: Mohamed Rashwan, Department of Medicine, Section of Nephrology, MBC #46, King Faisal Specialist Hospital and Research Center, PO Box 3354, Riyadh 11211, Saudi Arabia, Tel: +966-1-4647272; Ext: 44628; Fax: +966-1-4427499; Email:
Citation: Hakami H, Abdelsalam MS, Rashwan M, Althaf MM, Saleem N, et al. (2016) Depression in End-Stage Renal Disease Patients on Hemodialysis-A Single Center Experience in Saudi Arabia. Urol Nephrol Open Access J 3(6): 00103. DOI: 10.15406/unoaj.2016.03.00103


Background: It is known that hemodialysis patients suffer multiple comorbidities; prevalence of depression is higher than general population however it's underestimated. Addressing the problem of depression in those patients will help in management that will lead to improvement in their quality of life. Based on that we screened for depression in hemodialysis patients at King Faisal Specialist Hospital and Research center (KFSHRC).

Design and Setting: A prospective cross-sectional study using validated Beck’s Depression Inventory (BDI) to identify the prevalence of depression in hemodialysis patients, we looked for the effect of different variables gender, age, marital status, dialysis vintage and renal transplant fitness status.

Methods: 79 patients were screened, 67 patients met the inclusion, 32 were female. BDI scores were computed based on the patient responses to the questionnaire.

Results: 18 % of patients had a BDI score of >16 which is regarded as an indicator of moderate to severe depressive symptoms. BDI score of <16 among different categories assessed age, marital status, dialysis vintage, while patients who were deemed not transplantable ,female patients had (BDI score of 18%).

Conclusion: Prevalence of moderate to severe depression is high among hemodialysis patients. There was no significant effect of different variables assessed age, marital status, dialysis vintage except in patients who were deemed not transplantable; where female patients predominated.

Keywords: End-stage renal disease; Depression; Hemodialysis; Beck’s Depression Inventory


KFSHRC: King Faisal Specialist Hospital and Research center; BDI: Beck’s Depression Inventory; WHO: World Health Organization; DALYs: Disability-Adjusted Life-Years


The World Health Organization (WHO) has underscored unipolar depressive disorders as one of the leading causes of total disability-adjusted life-years (DALYs) worldwide [1]. Depression in combination with a medical or psychiatric illness; also known as ‘compound depression’ is of higher intensity and more difficult to manage than unipolar depression [2-4]. In patients with end-stage renal disease ESRD on hemodialysis HD depression is considered the most common psychiatric illness. The incidence of major depression in ESRD patients on HD has been estimated to be between 6% and 18% however, this variance is probably due to the different populations studied and methods of screening employed in earlier studies [5-7].

This is significantly greater than that of the general population, where the incidence of major depression is 2% to 4% in the community, 5% to 10% in primary care populations, and 10% to 14% in medical inpatients [8,9]. Recent studies have shown that depressive disorders are risk factors for morbidity and mortality in dialysis patients [10,11]. However, despite these statistics; depression is under recognized and underestimated in this sub-population [12]. Data reviewed from the Saudi Center for Organ Transplant revealed that around 13000 ESRD patients are currently on maintenance hemodialysis and 1200 on peritoneal dialysis across the Kingdom of Saudi Arabia. This study aims to identify the prevalence of depression in ESRD patients on our HD unit and look for the effect of the different variables on its prevalence that will help in better management.

Materials and Methods

A cross-sectional study to assess the prevalence of depression in established ESRD patients on maintenance HD in dialysis unit at King Faisal Specialist Hospital and Research Center in Riyadh, Kingdom of Saudi Arabia. The study was approved by our institutions ‘Office of Research Affairs’. Patients were screened using a validated questionnaire called the Beck’s Depression Inventory (BDI) [13] translated to the Arabic language. BDI is a validated measure of depression in ESRD patients [14]. BDI is comprised of a set of 21 items that the patient should respond to. It correlates with the diagnostic criteria for depression, quality of life, functional status and survival over time [3].

The BDI test employs 0 to 3 Likert scales that yield total scores ranging from 0 to 63. Higher the score the greater the degree of depression. A BDI score >16 is highly suggestive of the presence of moderate to severe depressive symptoms. The study was conducted over a period of 3 weeks. The BDI questionnaire was distributed to all chronic dialysis patients defined as; being on HD for a minimum period of 3 months or greater, aged 18 years or greater. For patients who were unable to read, a social worker was involved to verbally complete the questionnaire at the bedside.

Statistical considerations

Data was analyzed using SPSS statistical software version 19. Categorical data was reported as percentages. We divided the patients by gender looking for effect of Age, Marital Status, and Dialysis Vintage on prevalence of depression.


A total of 79 patients were screened, 67 patients met the inclusion criteria, 32 were female. Mean age (47.5±20.7 years), mean dialysis vintage was 42.5±21.3 months. 17.9 % of patients had a BDI score of >16(moderate to severe depressive symptoms). When patients were categorized by age groups, the prevalence of depression (patients had a BDI score of >16 was) 6% in the age group (18-24) years and age group (45-64) year, but did not differ on gender. For both age group (22-44 ) years and >65 years the prevalence was lower at 3% and again did not differ on gender. As regard marital status, those who are married had the highest prevalence at 9% compared to singles, divorced and widows and was similar regardless of gender. For dialysis vintage the prevalence of depression, was higher in relation to vintage of dialysis; 1.5%, 7.4% and 9% in the vintage of <1 year, 2-5 years and >5 years respectively. As regard transplant candidacy, those who are not candidate for renal transplantation had a higher prevalence of depression at 11.9% compared to 5.9% of those who are candidate for renal transplantation. Overall, female ESRD patients on HD who were not transplantable had the highest prevalence of depression at 18% (Table 1).


All Patients (n=67)
(% BDI Score >16)

Male (n=34)
(% BDI Score >16)

Female (n=33)
(% BDI Score >16)


18-24 years




22-44 years




45-64 years




>65 years


20.5 %


Marital Status

















Dialysis Vintage

<1 year




2-5 years




>5 years




Transplant Status





Not Transplantable




Table 1: Characteristics of the study population.


Dialysis patients suffer many social losses in addition to renal loss; these include loss of independence, loss of dominant/co-dominant family role, altered body image and decreased sexual function. These patients usually try hard to adapt to this lifestyle and demands of hemodialysis, however, each individual has their own ability to cope with circumstances and those fail to cope are at risk of depression [2,15]. Considering that depression is a risk factor for suicide, early screening and diagnosis of depression is crucial. Non-compliance and/or frequent shortening of dialysis treatment sessions, non-compliance to medications, non-adherence to dietary restrictions and disruption of vascular access are different mechanisms that depressed dialysis patients may employ in order to commit suicide [2,3,16,17].

McDade-Montez EA et al. [18] showed an increase in the total BDI score was associated with a 5.2% increase in the risk for withdrawing from dialysis in a predominately white population. One challenge of diagnosing depression in dialysis patients is deciding on which screening tool to use. Several studies have been conducted to determine the validity and accuracy of screening tools to diagnose depression in the dialysis population but the ideal screening tool still remains a matter of debate [14,19,20]. The Beck’s Depression Inventory (BDI) is a standard self-administered questionnaire [21], and has been used to detect the presence and severity of depression in dialysis patients. Many studies have validated BDI for in this population, [14,19,20] its total score is interpreted as follows: <9 no depression; 10 to 15 mild depression, 16 to 23 moderate depression and >24 severe depression [3,14,21,22].

Our data showed that prevalence of depression is correlated with dialysis vintage as the longer time on dialysis is associated with higher incidence of depression, this could be correlated to positive relationship between comorbidities and vintage of dialysis, that has been shown by carven et al. [23]. In contrast Asuwaida A AL wahhaibi F showed that there is no association of dialysis vintage and prevalence of depression [24]. We have found positive correlation between prevalence of depression and being not candidate patient for renal transplantation compared to those who are candidate’s especially female patients this could be correlated to more comorbidity in this group of patients.

Regarding marital status, depression was more prevalent in married patients; this could reflect the burden of the disease that hinders their family responsibilities mainly sexual dysfunction and infertility. Our data showed that there was no direct correlation between age and prevalence of depression in dialysis patients. Our study was limited by small number of patients and long list of queries to be answered which can be time consuming for both the patient and the physician; additionally assistance is required when a patient cannot read.


Prevalence of moderate to severe depression is high among hemodialysis patients and higher than general population. There was no significant effect of different variables assessed age, marital status, dialysis vintage except in patients who were deemed not transplantable; where female patients predominated. Regular screening and management of depression should be a part of standard dialysis care.


  1. Ustun TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray CJ (2004) Global burden of depressive disorders in the year 2000. Br J Psychiatry 184: 386-392.
  2. Kimmel PL (2001) Psychosocial factors in dialysis patients. Kidney Int 59(4): 1599-1613.
  3. Kimmel PL, Weihs K, Peterson RA (1993) Survival in hemodialysis patients: the role of depression. J Am Soc Nephrol 4(1): 12-27.
  4. Iosifescu DV, Nierenberg AA, Alpert JE, Smith M, Bitran S, et al. (2003) The impact of medical comorbidity on acute treatment in major depressive disorder. Am J Psychiatry 160(12): 2122-2127.
  5. Hinrichsen GA, Lieberman JA, Pollack S, Steinberg H (1989) Depression in hemodialysis patients. Psychosomatics. 30(3): 284-289.
  6. Wuerth D, Finkelstein SH, Finkelstein FO (2005) The identification and treatment of depression in patients maintained on dialysis. Semin Dial 18(2): 142-146.
  7. Kimmel PL, Peterson RA (2005) Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs. Semin Dial 18(2): 91-97.
  8. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, et al. (2003) The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 289(23): 3095-3105.
  9. Tossani E, Cassano P, Fava M (2005) Depression and renal disease. Semin Dial 18(2): 73-81.
  10. Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, et al. (2002) Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 62(1): 199-207.
  11. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, et al. (2000) Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney Int 57(5): 2093-2098.
  12. Watnick S, Kirwin P, Mahnensmith R, Concato J (2003) The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 41(1): 105-110.
  13. Beck A, Steer R, Brown G (1996) Manual for the BDI. Ц San Antonio, Tx: Psychological Corporation.
  14. Craven JL, Rodin GM, Littlefield C (1988) The Beck Depression Inventory as a screening device for major depression in renal dialysis patients. Int J Psychiatry Med 18(4): 365-374.
  15. Kimmel PL, Thamer M, Richard CM, Ray NF (1998) Psychiatric illness in patients with end-stage renal disease. Am J Med 105(3): 214-221.
  16. Kimmel PL (2002) Depression in patients with chronic renal disease: what we know and what we need to know. J Psychosom Res 53(4): 951-956.
  17. Abram HS, Moore GL, Westervelt FB (1971) Suicidal behavior in chronic dialysis patients. Am J Psychiatry 127(9): 1199-1204.
  18. McDade-Montez EA, Christensen AJ, Cvengros JA, Lawton WJ (2006) The role of depression symptoms in dialysis withdrawal. Health psycho 25(2): 198-204.
  19. Watnick S, Wang PL, Demadura T, Ganzini L (2005) Validation of 2 depression screening tools in dialysis patients. Am J Kidney Dis 46(5): 919-924 .
  20. Hedayati SS, Bosworth HB, Kuchibhatla M, Kimmel PL, Szczech LA (2006) The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients. Kidney Int 69(9): 1662-1668.
  21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4: 561-571.
  22. Cukor D, Peterson RA, Cohen SD, Kimmel PL (2006) Depression in end-stage renal disease hemodialysis patients. Nat Clin Pract Nephrol 2(12): 678-687.
  23. Craven JL, Rodin GM, Johnson L, Kennedy SH (1987) The diagnosis of major depression in renal dialysis patients. Psychosom Med 49(5): 482-492.
  24. Alsuwaida A, Alwahhabi F (2006) The Diagnostic Utility of Self-Reporting Questionnaire (SRQ) as a Screening Tool for Major Depression in Hemodialysis Patients Saudi J Kidney Dis Transpl 17(4): 503-510.
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