Journal: American Journal of Kidney Disease, Vol 41. No 5
Date of publication: May
2003
Introduction:
Depression is the most common
psychological complication which increases mortality in chronic hemodialysis
patients (Khalil, & Frazier, 2010). Depression
is believed to be associated with poor oral intake leading to cause
malnutrition. It is also believed that depression is associated with activation
of proinflammatory cytokines which
increase protein
metabolism and cause protein energy malnutrition (Khalil, & Frazier, 2010). This paper is reviewed to gain insight about the impact of depression on nutritional status in chronic hemodialysis patients.This study on association of depression with malnutrition in chronic hemodialysis patients was conducted at the outpatient hemodialysis unit of Hallym University Hospital, Chounchon, Korea.
All patients were administered a Beck Depression Inventory (BDI)
questionnaire, which include 21 items self-report rating, four point Likert
scale measuring characteristic attitudes and symptoms of depression. From these
21 items 15 items accounted to thoughts feelings related to depression were selected
to form Cognitive Depression Index (CDI).
Overall protein-energy nutritional status of the patients under study had
been evaluated by using modified Subjective Global Assessment (SGA). The SGA
includes four items scored on seven-point Likert scale, which items are weight
loss during the past six months, anorexia, subcutaneous fat, and muscle mass.
For anthropometric measurements, body mass index and midarm circumference were
evaluated. Dialysis adequacy and biochemical
analyses were included for intact parathyroid hormone (iPTH), urea, albumin,
hematocrit and urea.
Findings:
The result showed that 56.5% (n=35) of the participants had BDI above 21, the cut of score for the diagnosis of depression for Korean population. There was a significant positive correlation between severity of depressive symptoms and degree of malnutrition among hemodialysis patients.
There was a significant correlation between age and severity of depression and diabetic patients has higher BDI and CDI scores compared to non-diabetics patients. Both BDI and CDI scores are negatively associated with nutritional parameters, while these score did not correlate with BUN, plasma bicarbonate level and iPTH. This study also could rule out the high incidence of depression among hemodialysis patients that 34 out of 62 patients (54.8%) had major depressive disorders.
In terms of validity, depression is measured by Beck Depression Inventory
(BDI) questionnaires, which is well-validated index of depression and
correlated well with diagnostic criteria. According to the authors, BDI
questionnaires are frequently used to assess depression in patients with ESRD.
The 21 items in BDI are answered on four Likert scale in which 0 represents the
absence of problem and 3 represents extreme problem, with total score range of
0-63.
Level of depression is classified as normal score, 5-9; mild to moderate
depression, 10-18, moderate and severe depression, 19-29, and severe
depression, 30-60. BDI score more than 18, classified as moderate to severe
depression, were referred to an independent psychiatrist for clinical interview
to confirm the diagnosis depression using DSM-IV criteria.
To control for the possible
confounding contribution of somatic symptoms of physical illness and/or
treatment effects to the physical symptoms of depression, a subset of 15 cognitive
depression items from the total 21 items of the BDI were selected to form a
Cognitive Depression Index (CDI). Using the CDI, cognitive beliefs (15
questions regarding thoughts and feelings related to depression) could be
distinguished from somatic symptoms (6 questions related to physical symptoms
associated with depression).
This study has some limitations with small sample size. There also has
diagnostic dilemma for depression; important somatic symptoms for diagnosis of
depression such as fatigue, anorexia, and sleep and bowel disorders could be
due to uremia. Therefore, it is not clear for generalizibility of the finding.
In hemodialysis patients,
depressive symptoms lead to poor clinical outcomes by biological and
behavioural pathway (Khalil, Lennie, & Frazier, 2010). In biological pathway,
depressive symptoms produced serious consequences related to nutritional status
and cardiovascular risk. Behavioural pathway is related to the effect of
depression on adherent to fluid and diet restriction, hemodialysis attendance
and medication. Review of quantitative research evidence also showed that
depressive symptoms are dietary non adherent in patients with end stage renal
failure (Khalil & Frazier, 2010). Biological pathway could be treated with antidepressants,
and adherent behaviours can be improved by cognitive behavioural therapy,
exercise, positive thinking and individually targeted educational program (Khalil, et al., 2010).
Study conducted by Rahimi, Ahmadi & Gholyaf (2008) showed that application
of Continuous Care Model made significant differences in level of depression,
anxiety and stress in hemodialysis patients. Therapeutic use of self and
emotional support is essential practice in daily care of the patients.
Counselling services and appropriate referral are important intervention for
hemodialysis patients with moderate and severe depression.
Conclusion:
This study gives important insight for the association between depression and malnutrition. Conducting this research has discovered a high incidence of depression among hemodialysis patients. This paper, is therefore, very useful to recognize that major attention is needed to address with integrated psychological interventions for hemodialysis patients.
Further research with larger sample size is required to generalize the
finding of association between psychological factors and patient outcomes.
Based on the study evidence, interventional trials for depression and other
psychological problems are recommended to study.
References:
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