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 Table of Contents  
Year : 2022  |  Volume : 38  |  Issue : 1  |  Page : 58-62

Association of depression/anxiety and quality of life in patients with chronic kidney disease undergoing hemodialysis: a study from Western Rajasthan

1 Department of Psychiatry, Dr. S.N. Medical College, Jodhpur, Rajasthan, India
2 Department of Psychiatry, Government Medical College, Pali, Rajasthan, India

Date of Submission08-Apr-2020
Date of Decision25-May-2020
Date of Acceptance08-Jul-2020
Date of Web Publication08-Oct-2021

Correspondence Address:
Dr. Ankit Awasthi
Department of Psychiatry, Government Medical College, Pali, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_58_20

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Context: Chronic kidney disease (CKD) is emerging as a public health problem globally. Depression and anxiety are commonly seen in patients with CKD who are undergoing hemodialysis, and these ailments deteriorate the quality of life (QoL) of these patients. Aims: The present study aimed to determine the association between depression/anxiety and QoL in CKD patients. Settings and Design: This cross-sectional study was conducted at the nephrology department of the institution on 100 patients with CKD undergoing hemodialysis, who fulfilled the inclusion criteria for this study. Informed consent was taken prior to enrollment for the study. Materials and Methods: After seeking sociodemographic information, the Hospital Anxiety and Depression Scale was applied to screen for and to assess the severity of anxiety and depression, while the World Health Organization-QOL Assessment BREF questionnaire was administered to measure the subjective QoL. Data collected were subjected to suitable statistical analysis. Results: The prevalence of depression and anxiety among CKD patients was 66% and 61%, respectively. CKD patients with depression and anxiety had worse scores on all domains of QoL questionnaire. Both depression and anxiety negatively correlated with all domains of QoL. Conclusions: Depression and anxiety are highly prevalent in patients with CKD, and patients afflicted with the above had impaired QoL.

Keywords: Anxiety, chronic kidney disease, depression, hemodialysis, quality of life

How to cite this article:
Gadia P, Koolwal GD, Awasthi A. Association of depression/anxiety and quality of life in patients with chronic kidney disease undergoing hemodialysis: a study from Western Rajasthan. Indian J Soc Psychiatry 2022;38:58-62

How to cite this URL:
Gadia P, Koolwal GD, Awasthi A. Association of depression/anxiety and quality of life in patients with chronic kidney disease undergoing hemodialysis: a study from Western Rajasthan. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Jun 30];38:58-62. Available from: https://www.indjsp.org/text.asp?2022/38/1/58/327749

  Introduction Top

Chronic kidney disease (CKD) is the progressive loss in renal function over a period of months or years. CKD is a worldwide public health problem, with adverse outcome of kidney failure and premature death. CKD is classified into different stages as the disease progresses; the final stage is often called end-stage renal disease (ESRD) and is synonymous with the older term “chronic renal failure”. ESRD is characterized by the individual requiring either a kidney transplant or some form of dialysis in order to survive.[1] According to the World Health Report 2002 and Global Burden of Disease (GBD) project, diseases of the kidney and urinary tract contribute to the GBDs, with approximately 850,000 deaths every year and 15,010,167 disability-adjusted life years. They are the 12th cause of death and the 17th cause of disability.[2] In India, given its population >1 billion, the rising incidence of CKD is likely to pose major problems for both health care and the economy in future years. Indeed, it has been recently estimated that the age-adjusted incidence rate of ESRD in India is 229 per million population and >100,000 new patients enter renal replacement programs annually in India.[3],[4] Although various renal replacement therapies have enhanced the survival of ESRD patients, long-term dialysis therapy often results in caregiver dependence and disrupted family and social life.[5],[6]

Depressive symptoms are among the most frequent comorbidity among patients with ESRD. Early diagnosis of depression is often missed, owing to the similarities between depressive symptoms and uremic symptoms. This might explain the lower prevalence of depressive disorder in the early stages of CKD.[7] In patients with ESRD, depression is up to three times more prevalent than that in the general population. Furthermore, the strong emotional burden of severe illness may have profound effects on the quality of life (QoL).[8] Anxiety disorder is another common psychiatric morbidity in patients with CKD. Patients who met criteria for an anxiety disorder had lower perception of QoL as measured by the Kidney Disease QoL-Short-Form, compared with those without anxiety disorders.[9] The exact prevalence of anxiety disorders in hemodialysis patients is unclear, but estimates have ranged from approximately 12% to 52% in various studies.[10]

Renal failure is a chronic condition, and if it leads to ESRD, it may have destructive effects on the overall health and QoL of the patient.[11] Hemodialysis aims to help patients lead a normal life; however, the limitations and associated stress could reduce the QoL involuntarily.[12] Patients on hemodialysis are more prone to psychological consequences such as anxiety, depression, and social deficits compared to healthy individuals.[13]

With this background, it can be inferred that psychiatric morbidity (particularly depression and anxiety) is very common in CKD patients undergoing hemodialysis. However, studies regarding this are very few in India and especially in western Rajasthan. The present study aimed to determine the association between psychiatric morbidity and QoL in these patients.

Study settings and design

This cross-sectional study was conducted at the nephrology department of the institution. Ethical approval was taken from the ethical committee of the institution before conducting the study. A total of 150 patients with CKD visiting for hemodialysis were initially selected; out of them, 100 patients who fulfilled the inclusion criteria (diagnosed cases with CKD, undergoing hemodialysis for at least 3 months, and aged between 18 and 60 years) were involved in the study. Patients who had psychiatric illness prior to the diagnosis of CKD and those having chronic, serious, and unstable comorbid medical/surgical illness were excluded from the study. A written informed consent was taken from each patient before enrollment for the study.

  Materials and Methods Top

Sociodemographic details, historical data, and illness characteristics of the study participants were obtained using a specially designed semi-structured pro forma. The participants underwent physical examination and comprehensive psychiatric evaluation. A diagnosis of depressive and anxiety disorder was made by using standard criteria of International Classification of Diseases and related health problem-10. The Hospital Anxiety and Depression Scale (HADS) was used to assess the severity of these disorders. HADS is a 14-item self-report screening scale with 7 items each for depression (HADS-D subscale) and anxiety (HADS-A subscale). A score of 0–7 is considered normal; 8–10 indicates mild illness, 11–15 moderate illness, and score 16–21 is suggestive of severe illness.[14] To assess the QoL of the participants, the short version of the World Health Organization QOL Assessment (WHOQOL-BREF) instrument was used. WHOQOL-BREF consists of 26 items and is grouped into four domains of QoL (physical health, psychological health, social relationships, and environment) and two items which measure the overall QoL and general health.[15]

Statistical analysis

The data collected using the above-mentioned tools were tabulated, analyzed, and subjected to suitable statistical analysis using SPSS Statistics for Windows, version 16.0 (SPSS Inc., Chicago, Ill., USA). Frequencies and percentages were used for categorical variables. Mean and standard deviation were used for quantitative variables. To assess correlation between different variables, Pearson's coefficient of correlation was applied.

  Results Top

[Table 1] shows the sociodemographic and clinical characteristics of the patients. Majority of the patients (54%) were above 40 years old. Male patients (70%) predominated in the study. Most of the patients (81%) were Hindus, which reflects the prevailing religious affiliation in this region. Nearly 66% of the study participants were educated, and an equal number of patients belonged to urban background. Most of the patients were married (90%) and were from nuclear family (58%). Almost 88% of the patients were afflicted with CKD from the last 3 years or lesser duration.
Table 1: Sociodemographic characteristics of the study population

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In the present study, 66% of the patients with CKD undergoing hemodialysis had depression and 61% of the patients had anxiety. Based on the HADS-D scores, 38 (57.6%) patients had mild depression, 19 (28.8%) had moderate depression, whereas 9 (13.6%) had severe depression. The HADS-A scores revealed mild, moderate, and severe anxiety in 36 (59%), 15 (24.6%), and 10 (16.4%) patients, respectively [Table 2].
Table 2: Prevalence and severity of depression and anxiety in patients with chronic kidney disease based on the Hospital Anxiety and Depression scale - Depression and Hospital Anxiety and Depression scale - Anxiety scores

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[Table 3] exhibits the correlation between QoL and depression or anxiety. Depression was negatively correlated with psychological domain (r = 0.043), social interrelationship domain (r = 0.71), environmental domain (r = 0.08), health satisfaction domain (0.16), and total QoL score (0.22). The findings revealed a negative correlation between anxiety and physical domain (r = 0.04)/overall QoL domain (r = 0.07) of the QoL scale.
Table 3: Correlation between depression, anxiety, and quality of life

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[Table 4] shows the correlation matrix of anxiety, depression, and various domains of QoL. A statistically significant negative correlation was found between anxiety and depression and all the domains (physical, psychological, social interrelationship, environment, overall, and health satisfaction) of the WHOQOL-BREF scale.
Table 4: Correlation matrix of anxiety (Hospital Anxiety and Depression scale - Anxiety), depression (Hospital Anxiety and Depression scale - Depression), and quality of life domain scores (n=100)

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  Discussion Top

The present study was aimed to find the association between QoL and psychiatric morbidity (depression/anxiety) among CKD patients. [Table 2] shows that the prevalence of depression and anxiety was 66% and 61%, respectively. Hou et al. and Kumar et al. also found high prevalence of depression and anxiety in patients on hemodialysis in their respective studies.[16],[17] Hou et al. found that around 69% of the patients had depression and around 37% of the patients had anxiety.[16] In another study from southern Rajasthan, Kumar et al. found that 61.3% of patients had depression and 28% of patients had anxiety.[17] Although the prevalence of depression is almost similar in our study, the prevalence of anxiety is more in our study. This variation in prevalence rates may be attributed to different instruments and methodology used and to the varied population characteristics.[18],[19] Few other studies from different regions of India have also evaluated psychiatric morbidity in CKD patients. Gupta et al. found increased prevalence of depression and suicidal ideations in CKD patients in southern Indian state of Karnataka.[20] In a study conducted in New Delhi, Rai et al. concluded that depression and insomnia are highly prevalent in patients on maintenance hemodialysis.[21] The results from other Indian studies are consistent with our findings. [Table 3] and [Table 4] suggested that patients with depression experienced poor QoL (including all domains, viz., physical, psychological, social interrelationship, and environmental) than those without depression. This finding is supported by Barros et al. who found that patients with ESRD undergoing hemodialysis and having depressive symptoms reported significantly lower QoL compared with patients without depressive symptoms.[22] Belayev et al. also found that depressive symptoms were independently and inversely associated with QoL scores in CKD patients.[23] In the present study, CKD patients with anxiety also experienced poor QoL, as depicted in [Table 3] and [Table 4]. Moreira et al. in their study on pediatric CKD patients also found that there was a negative correlation between anxiety/depressive symptoms and all domains (including psychological, educational, and psychosocial subdomains) of QoL.[24] These findings are in line with the study done by Vasilopoulou et al. who found that patients with low levels of anxiety or depression had better QoL. In their study, multiple linear regression showed that the overall QoL score was statistically associated with the levels of depression after adjusted for possible confounders.[18] [Table 4] shows that both depression and anxiety were negatively correlated with all domains of WHOQOL-BREF, which is consistent with earlier studies. Lee et al. found that depression correlated positively with age, employment, income, education, comorbidity index, hemoglobin level, albumin concentration, and anxiety score and negatively with all WHOQOL-BREF domain scores. Anxiety correlated significantly with QoL, but not with socioeconomic factors.[25] Shafipour et al. also found a significant inverse correlation between the physical and mental domains of SF-36 questionnaire with depression (r = −0.38 and r = −0.29), anxiety (r = −0.48 and r = −0.45), and stress (r = −0.5 and r = −0.57), respectively.[26] Shimizu et al. in their study on older hemodialysis patients found that higher HADS scores (regression coefficient, −0.467; P < 0.001), reduced walking ability (−0.201; P < 0.001), duration of hemodialysis (−0.175; P < 0.001), age (−0.143; P < 0.001), and subjective symptoms (−0.128; P < 0.001) showed a significant negative correlation with the EuroQol five-dimensional-5 L score.[27] Jankowska-Polańska et al. further underscored this finding in their study and concluded that higher intensity of depressive and anxiety symptoms leads to lower QoL scores in chronic dialysis patients.[28] Hmwe et al. in their study concluded that therapeutic intervention to reduce depression, anxiety, and stress enhances the psychological wellness of patients on hemodialysis, which subsequently improves their QoL.[29]

The authors acknowledge the following limitations of the study. The study population may be regarded as small sized. It was a single-center study carried out at a tertiary care medical college hospital, whereas the city has other hemodialysis facilities available, hence the results cannot be generalized. Further, hospital-based studies tend to have selection bias, which may be present in this study as well.

  Conclusions Top

The present study demonstrated that depression and anxiety are highly prevalent in CKD patients undergoing hemodialysis, and presence of these ailments deteriorates the QoL of these patients. These findings are consistent with those of previous studies. It is recommended that comprehensive psychiatric evaluation should be incorporated into the routine care of these patients so that timely diagnosis and appropriate interventions can be made and the overall QoL can be improved.


The authors would like to thank Dr. Manish Chaturvedi, Professor and Head, Department of Nephrology, Dr. S. N. Medical College, Jodhpur and all the study participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

National Kidney Foundation: Clinical Practice Guidelines for Chronic Kidney Disease; 2002. Available from: http://www.kidney.org/professionals/KDOQUI guidelines ckd. [Last acessed on 2012 Dec 05].  Back to cited text no. 1
World Health Organisation. Global Burden of Disease. Available from: http://www.who.int/whosis/menu.cfm?path [Last accessed on 2013 Nov 11].  Back to cited text no. 2
Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.  Back to cited text no. 3
Kher V. End-stage renal disease in developing countries. Kidney Int 2002;62:350-62.  Back to cited text no. 4
Hudson JQ, Johnson CA. Chronic kidney disease. In: Koda Kimble MA, Young LY, Kradjan WA, Guglielmo BJ, Alldredge BK, Corelli RL, editors. Applied Therapeutics. 8th ed.. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 32-1.  Back to cited text no. 5
Lin CC, Lee BO, Hicks FD. The phenomenology of deciding about hemodialysis among Taiwanese. West J Nurs Res 2005;27:915-29.  Back to cited text no. 6
Palmer S, Vecchio M, Craig JC, Tonelli M, Johnson DW, Nicolucci A, et al. Prevalence of depression in chronic kidney disease: Systematic review and meta-analysis of observational studies. Kidney Int 2013;84:179-91.  Back to cited text no. 7
Hedayati SS, Finkelstein FO. Epidemiology, diagnosis, and management of depression in patients with CKD. Am J Kidney Dis 2009;54:741-52.  Back to cited text no. 8
Scott DC, Daniel C, Paul LK. Anxiety in patients treated with hemodialysis. Clin J Am Soc Nephrol 2016;11:2250-5.  Back to cited text no. 9
Murtagh FE, Addington-Hall J, Higginson IJ. The prevalence of symptoms in end-stage renal disease: A systematic review. Adv Chronic Kidney Dis 2007;14:82-99.  Back to cited text no. 10
Juergensen PH, Juergensen DM, Wuerth DB, Finkelstein SH, Steele TE, Kliger AS, et al. Psychosocial factors and incidence of peritonitis. Adv Perit Dial 1996;12:196-8.  Back to cited text no. 11
Song YS, Yang HJ, Song ES, Han DC, Moon C, Ku JH. Sexual function and quality of life in Korean women with chronic renal failure on hemodialysis: Case-control study. Urology 2008;71:243-6.  Back to cited text no. 12
Morsch CM, Gonçalves LF, Barros E. Health-related quality of life among haemodialysis patients--relationship with clinical indicators, morbidity and mortality. J Clin Nurs 2006;15:498-504.  Back to cited text no. 13
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 14
World Health Organization. Division of Mental Health.WHOQOL-BREF: Introduction, Administration, Scoring and Generic Version of the Assessment: Field Trial Version. Geneva: WHO; 1996.  Back to cited text no. 15
Hou Y, Li X, Yang L, Liu C, Wu H, Xu Y, et al. Factors associated with depression and anxiety in patients with end-stage renal disease receiving maintenance hemodialysis. Int Urol Nephrol 2014;46:1645-9.  Back to cited text no. 16
Kumar V, Khandelia V, Garg A. Depression and anxiety in patients with chronic kidney disease undergoing hemodialysis. Ann Indian Psychiatry 2018;2:115-9.  Back to cited text no. 17
  [Full text]  
Vasilopoulou C, Bourtsi E, Giaple S, Koutelekos I, Theofilou P, Polikandrioti M. The impact of anxiety and depression on the quality of life of hemodialysis patients. Glob J Health Sci 2015;8:45-55.  Back to cited text no. 18
Brito DC, Machado EL, Reis IA, Carmo LP, Cherchiglia ML. Depression and anxiety among patients undergoing dialysis and kidney transplantation: A cross-sectional study. Sao Paulo Med J 2019;137:137-47.  Back to cited text no. 19
Gupta S, Patil NM, Karishetti M, Tekkalaki BV. Prevalence and clinical correlates of depression in chronic kidney disease patients in a tertiary care hospital. Indian J Psychiatry 2018;60:485-8.  Back to cited text no. 20
[PUBMED]  [Full text]  
Rai M, Rustagi T, Rustagi S, Kohli R. Depression, insomnia and sleep apnea in patients on maintenance hemodialysis. Indian J Nephrol 2011;21:223-9.  Back to cited text no. 21
[PUBMED]  [Full text]  
Barros A, Costa BE, Mottin CC, d'Avila DO. Depression, quality of life, and body composition in patients with end-stage renal disease: A cohort study. Braz J Psychiatry 2016;38:301-6.  Back to cited text no. 22
Belayev LY, Mor MK, Sevick MA, Shields AM, Rollman BL, Palevsky PM, et al. Longitudinal association of depressive symptoms and pain with quality of life in patient receiving chronic hemodialysis, Hemodialysis Int 2015;19:216-24.  Back to cited text no. 23
Moreira JM, Bouissou Morais Soares CM, Teixeira AL, Simões E Silva AC, Kummer AM. Anxiety, depression, resilience and quality of life in children and adolescents with pre-dialysis chronic kidney disease. Pediatr Nephrol 2015;30:2153-62.  Back to cited text no. 24
Lee YJ, Kim MS, Cho S, Kim SR. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. Int J Clin Pract 2013;67:363-8.  Back to cited text no. 25
Shafipour V, Alhani F, Kazemnejad A. A survey of the quality of life in patients undergoing hemodialysis and its association with depression, anxiety and stress. J Nurs Midwifery Sci 2015;2:29-35.  Back to cited text no. 26
  [Full text]  
Shimizu U, Aoki H, Sakagami M, Akazawa K. Walking ability, anxiety and depression, significantly decrease EuroQol 5-Dimension 5-Level scores in older hemodialysis patients in Japan. Arch Gerontol Geriatr 2018;78:96-100.  Back to cited text no. 27
Jankowska-Polańska B, Duczak A, Świątoniowska N, Karniej P, Seń M, Rosińczuk J. The influence of selected psychological variables on quality of life of chronically dialysed patients. Scand J Caring Sci 2019;33:840-7.  Back to cited text no. 28
Hmwe NT, Subramanian P, Tan LP, Chong WK. The effects of acupressure on depression, anxiety and stress in patients with hemodialysis: A randomized controlled trial. Int J Nurs Stud 2015;52:509-18.  Back to cited text no. 29


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


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