Official journal of the Pacific Rim College of Psychiatrists
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Asia-Pacific Psychiatry ISSN 1758-5864
ORIGINAL ARTICLE
Major depressive disorder in hemodialysis patients in China Aimin Hu1,2 MSc, Zhimin Xue1 MD PhD, Tumbwene E Mwansisya1,3 MSc, An Zhou4 MD, Weidan Pu1 PhD, Xudong Chen1 MD, Meng Sun1 MD, Peng Wang1 MD, Hua Fan1 MD, Zheng Wang1 MD, Xuan Ouyang1 MD PhD, Zhening Liu1 MD PhD & Robert Rosenheck5 MD PhD 1 Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha, China 2 Department of Medicine, Jishou University, Jishou, China 3 College of Health Sciences, University of Dodoma, Dodoma, Tanzania 4 Blood Purification Center, The Second Xiangya Hospital of Central South University, Changsha, China 5 Department of Psychiatry, Yale University, New Haven, CT, USA
Keywords China, comorbidity, hemodialysis, major depressive disorder, prevalence Correspondence Zhimin Xue, MD PhD, Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha 410011, China. Tel: +86 731 85292136 Fax: +86 731 85292470 Email: [email protected] Received 16 April 2013 Accepted 29 September 2013 DOI:10.1111/appy.12110
Abstract Introduction: Major depressive disorder (MDD) has been regarded as the most common psychiatric disorder among hemodialysis (HD) patients. However, few studies have investigated MDD in HD patients in Mainland China. This study sought to investigate the prevalence and treatment of MDD, as well as the sociodemographic and clinical characteristics in this population. Methods: Two hundred sixty HD patients were screened with the nineitem Patient Health Questionnaire, and the formal diagnosis of MDD was further assessed using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Severity of depressive symptoms was assessed with Hamilton Rating Scale for Depression. Finally, patients meeting diagnostic criteria were compared with those who did not on demographic and clinical characteristics. Results: Among the 260 subjects, 26.2% screened positively and 10% were confirmed to have a diagnosis of MDD. Among HD patients with MDD, 69.2% had severe or very severe depressive symptoms. There was no evidence of a clinical diagnosis or of treatment for MDD in any of the patients’ medical records. Those with shorter duration of HD, lower monthly income, and lower levels of blood urea nitrogen were significantly more likely to have a diagnosis of MDD. Discussion: MDD is frequent in HD patients. Regular screening and professional diagnosis should be undertaken to increase the detection and treatment of MDD in HD patients. The effectiveness of interventions for MDD in HD patients deserves further research.
Introduction Depression in hemodialysis (HD) patients has been found to be related to disturbances of quality of life, functional impairment, increased hospitalization, medical costs, withdrawal from dialysis, and mortality (Kurella et al., 2005; Szeifert et al., 2010), and is regarded as the most common psychiatric abnormality in HD patients (Kimmel & Peterson, 2005). Using the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, Craven et al. (1987) found major depressive disorder (MDD) in 8.1% of HD patients in
78
Canada, and Hinrichsen et al. (1989) found 6.5% in the US. Hedayati et al. (2006) found a prevalence of 17.3%, while Cukor et al. (2007) documented a 20% rate with the Structured Clinical Interview for Diagnosis (SCID). A more recent study in Taiwan observed a 23.5% prevalence of MDD with the M.I.N.I.International Neuropsychiatric Interview (Chen et al., 2010). Although the reported rates of MDD have thus varied in different HD population, all studies have found rates to be higher than those in the general population. However, we are unaware of any similar reports using DSM criteria from Mainland China.
Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd
A. Hu et al.
Although a growing body of empirical evidence points to the adverse consequence and the high prevalence of MDD in HD patients, MDD remains underdiagnosed and undertreated (Chilcot et al., 2010). A study of 70 HD patients found 20% with MDD and 9% with dysthymia, but only 12% of these patients were currently receiving treatment (Cukor et al., 2007). In a survey of depressive disorder in HD population across 12 countries, Lopes et al. (2004) reported the highest rate of clinical diagnosis by physicians of 21.4% in the US and the highest rate of treatment among those diagnosed was 52.8% in Sweden. The data, thus, show consistently low rates of diagnosis and treatment of depressive disorder in HD patients. In Mainland China, there are few studies using formal psychiatric diagnostic criteria to evaluate the prevalence rate of MDD in HD patients, and the rates of treatment of MDD in HD patients are unknown. We conducted a cross-sectional study to explore the prevalence and treatment of MDD in HD patients in Changsha, China, and sought to identify correlated sociodemographic and clinical characteristics of MDD. These data may be of use in the management of MDD in HD patients and form a background for much needed, well-designed interventions for MDD in HD patients.
MDD in hemodialysis patients
Data collection and measurements Demographic characteristics were collected from a general information questionnaire, and clinical characteristics were supplemented by electronic medical records of the hospital and patients’ charts. All subjects underwent the assessment of the nine-item Patient Health Questionnaire (PHQ-9), which documents the nine criteria for depression from DSM-IV (Spitzer et al., 1999). PHQ-9 is a self-report instrument and is effective for detecting depressive disorders in various ethno-cultural groups (Huang et al., 2006). It is brief and can be administered by non-professionals. To improve the efficiency of assessment, we used the PHQ-9 to screen patients by study psychiatrists before conducting SCID assessments. Patients with PHQ-9 scores of ≥10 were, thus, further assessed by an experienced psychiatrist with the SCID interview (First, 2007). Among those who met diagnostic criteria, the severity of MDD symptoms was assessed using the Hamilton Rating Scale for Depression (HRSD) (17 items) (Hamilton, 1960; Zheng et al., 1988). Standard severity levels for the HRSD with none (0–7), mild (8–13), moderate (14– 18), severe (19–22), and very severe (≥23) (Pincus et al., 2000) were used.
Data analysis
Methods Subjects Patients were recruited from February to March 2012 from a list of patients in HD treatment at a blood purification center of Second Xiangya Hospital. All subjects were aged 18 years or older and had attended at least two weeks of HD treatments. Patients were excluded if they refused to participate, or suffered from other concurrent severe physical diseases (e.g. active neoplasm, hearing disorder) or concurrent mental illnesses (e.g. delirium, dementia) that could inhibit their participation and response to study measurements. HD patients (n = 306) who were listed at the center on February 20, 2012 were screened for the study. Among them, three patients were younger than 18 years of age, nine could not hear or speak clearly, and 34 could not finish the questionnaires. The final sample included 260 HD patients. Ethical approval for the study was obtained from the Ethical and Publication Committee of Second Xiangya Hospital. All participants provided written informed consent for participation in the study.
Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd
Descriptive statistics were calculated for the sample population. Categorical variables were analyzed using chi-square test, and continuous variables were analyzed using Mann–Whitney U-test to compare the sociodemographic and clinical characteristics between patients with and without MDD. Variables that showed significant associations were further entered into logistic regression model to identify independent correlates of MDD. To improve the quality of our analyses, missing values were included with estimated values using regression-based imputation available through SPSS for Windows (Version 16.0., SPSS Inc., Chicago, IL, USA). All analyses were two-tailed, and the level of significance was P < 0.05.
Results Among the 260 subjects, 26.2% (68/260) screened positive on the PHQ-9, and 38.2% (26/68) of the positive screening people were diagnosed with MDD using DSM-IV criteria, which account for 10% (26/ 260) of all subjects. In MDD patients, 30.8%, 50.0%, and 19.2% were in the range of moderate, severe, and
79
MDD in hemodialysis patients
A. Hu et al.
very severe depression, respectively, based on HSRD scores. There was no evidence of any clinical diagnosis or treatment of MDD in any of the patients’ medical records. Mean age of this study population was 56.9 (± 15.8) years and 66.2% were men. The average duration of HD treatment was 54.63 (± 55.49) months. The average blood urea nitrogen and creatinine levels were 24.97 (± 7.78) mmol/L and 950.90 (± 312.52) μmol/L, respectively. The clinical and sociodemographic characteristics of HD patients were compared between patients with MDD and those without MDD, as shown in Table 1. In the analyses of chi-square test and Mann–Whitney U, MDD was significantly associated with greater age, less education and lower monthly incomes, less than one year of HD treatment, greater likelihood of cardiac comorbidity, and with lower levels of blood urea nitrogen. In further multivariate analysis, those patients with lower levels of blood urea nitrogen (20.85 ± 6.79), duration of HD treatment ≤12 months, and lower monthly incomes (High school Monthly income 4000 yuan Diabetes Cardiac disease Hypertension Duration (months) 0–12 ≥13 Blood urea nitrogen (mmol/L) Creatinine (μmol/L)
MDD (n = 26)
NMDD (n = 234)
61.19 ± 13.74 2 (7.7) 3 (11.5) 21 (80.8)
56.42 ± 15.98 40 (17.1) 62 (26.5) 132 (56.4)
χ2 or Z
P-value
6.263
0.044*
16 (61.5) 10 (38.5)
156 (66.7) 78 (33.3)
0.275
0.600
20 (76.9) 6 (23.1)
194 (82.9) 40 (17.1)
0.238
0.626
5.650
0.017*
(29.1) (45.7) (25.2) (21.6) (10.8) (53.9)
14.393
0.001**
1.439 4.663 1.820
0.230 0.031* 0.177
(17.1) (82.9) (± 6.78) (± 291.13)
12.350
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Asia-Pacific Psychiatry ISSN 1758-5864
ORIGINAL ARTICLE
Major depressive disorder in hemodialysis patients in China Aimin Hu1,2 MSc, Zhimin Xue1 MD PhD, Tumbwene E Mwansisya1,3 MSc, An Zhou4 MD, Weidan Pu1 PhD, Xudong Chen1 MD, Meng Sun1 MD, Peng Wang1 MD, Hua Fan1 MD, Zheng Wang1 MD, Xuan Ouyang1 MD PhD, Zhening Liu1 MD PhD & Robert Rosenheck5 MD PhD 1 Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha, China 2 Department of Medicine, Jishou University, Jishou, China 3 College of Health Sciences, University of Dodoma, Dodoma, Tanzania 4 Blood Purification Center, The Second Xiangya Hospital of Central South University, Changsha, China 5 Department of Psychiatry, Yale University, New Haven, CT, USA
Keywords China, comorbidity, hemodialysis, major depressive disorder, prevalence Correspondence Zhimin Xue, MD PhD, Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha 410011, China. Tel: +86 731 85292136 Fax: +86 731 85292470 Email: [email protected] Received 16 April 2013 Accepted 29 September 2013 DOI:10.1111/appy.12110
Abstract Introduction: Major depressive disorder (MDD) has been regarded as the most common psychiatric disorder among hemodialysis (HD) patients. However, few studies have investigated MDD in HD patients in Mainland China. This study sought to investigate the prevalence and treatment of MDD, as well as the sociodemographic and clinical characteristics in this population. Methods: Two hundred sixty HD patients were screened with the nineitem Patient Health Questionnaire, and the formal diagnosis of MDD was further assessed using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Severity of depressive symptoms was assessed with Hamilton Rating Scale for Depression. Finally, patients meeting diagnostic criteria were compared with those who did not on demographic and clinical characteristics. Results: Among the 260 subjects, 26.2% screened positively and 10% were confirmed to have a diagnosis of MDD. Among HD patients with MDD, 69.2% had severe or very severe depressive symptoms. There was no evidence of a clinical diagnosis or of treatment for MDD in any of the patients’ medical records. Those with shorter duration of HD, lower monthly income, and lower levels of blood urea nitrogen were significantly more likely to have a diagnosis of MDD. Discussion: MDD is frequent in HD patients. Regular screening and professional diagnosis should be undertaken to increase the detection and treatment of MDD in HD patients. The effectiveness of interventions for MDD in HD patients deserves further research.
Introduction Depression in hemodialysis (HD) patients has been found to be related to disturbances of quality of life, functional impairment, increased hospitalization, medical costs, withdrawal from dialysis, and mortality (Kurella et al., 2005; Szeifert et al., 2010), and is regarded as the most common psychiatric abnormality in HD patients (Kimmel & Peterson, 2005). Using the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, Craven et al. (1987) found major depressive disorder (MDD) in 8.1% of HD patients in
78
Canada, and Hinrichsen et al. (1989) found 6.5% in the US. Hedayati et al. (2006) found a prevalence of 17.3%, while Cukor et al. (2007) documented a 20% rate with the Structured Clinical Interview for Diagnosis (SCID). A more recent study in Taiwan observed a 23.5% prevalence of MDD with the M.I.N.I.International Neuropsychiatric Interview (Chen et al., 2010). Although the reported rates of MDD have thus varied in different HD population, all studies have found rates to be higher than those in the general population. However, we are unaware of any similar reports using DSM criteria from Mainland China.
Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd
A. Hu et al.
Although a growing body of empirical evidence points to the adverse consequence and the high prevalence of MDD in HD patients, MDD remains underdiagnosed and undertreated (Chilcot et al., 2010). A study of 70 HD patients found 20% with MDD and 9% with dysthymia, but only 12% of these patients were currently receiving treatment (Cukor et al., 2007). In a survey of depressive disorder in HD population across 12 countries, Lopes et al. (2004) reported the highest rate of clinical diagnosis by physicians of 21.4% in the US and the highest rate of treatment among those diagnosed was 52.8% in Sweden. The data, thus, show consistently low rates of diagnosis and treatment of depressive disorder in HD patients. In Mainland China, there are few studies using formal psychiatric diagnostic criteria to evaluate the prevalence rate of MDD in HD patients, and the rates of treatment of MDD in HD patients are unknown. We conducted a cross-sectional study to explore the prevalence and treatment of MDD in HD patients in Changsha, China, and sought to identify correlated sociodemographic and clinical characteristics of MDD. These data may be of use in the management of MDD in HD patients and form a background for much needed, well-designed interventions for MDD in HD patients.
MDD in hemodialysis patients
Data collection and measurements Demographic characteristics were collected from a general information questionnaire, and clinical characteristics were supplemented by electronic medical records of the hospital and patients’ charts. All subjects underwent the assessment of the nine-item Patient Health Questionnaire (PHQ-9), which documents the nine criteria for depression from DSM-IV (Spitzer et al., 1999). PHQ-9 is a self-report instrument and is effective for detecting depressive disorders in various ethno-cultural groups (Huang et al., 2006). It is brief and can be administered by non-professionals. To improve the efficiency of assessment, we used the PHQ-9 to screen patients by study psychiatrists before conducting SCID assessments. Patients with PHQ-9 scores of ≥10 were, thus, further assessed by an experienced psychiatrist with the SCID interview (First, 2007). Among those who met diagnostic criteria, the severity of MDD symptoms was assessed using the Hamilton Rating Scale for Depression (HRSD) (17 items) (Hamilton, 1960; Zheng et al., 1988). Standard severity levels for the HRSD with none (0–7), mild (8–13), moderate (14– 18), severe (19–22), and very severe (≥23) (Pincus et al., 2000) were used.
Data analysis
Methods Subjects Patients were recruited from February to March 2012 from a list of patients in HD treatment at a blood purification center of Second Xiangya Hospital. All subjects were aged 18 years or older and had attended at least two weeks of HD treatments. Patients were excluded if they refused to participate, or suffered from other concurrent severe physical diseases (e.g. active neoplasm, hearing disorder) or concurrent mental illnesses (e.g. delirium, dementia) that could inhibit their participation and response to study measurements. HD patients (n = 306) who were listed at the center on February 20, 2012 were screened for the study. Among them, three patients were younger than 18 years of age, nine could not hear or speak clearly, and 34 could not finish the questionnaires. The final sample included 260 HD patients. Ethical approval for the study was obtained from the Ethical and Publication Committee of Second Xiangya Hospital. All participants provided written informed consent for participation in the study.
Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd
Descriptive statistics were calculated for the sample population. Categorical variables were analyzed using chi-square test, and continuous variables were analyzed using Mann–Whitney U-test to compare the sociodemographic and clinical characteristics between patients with and without MDD. Variables that showed significant associations were further entered into logistic regression model to identify independent correlates of MDD. To improve the quality of our analyses, missing values were included with estimated values using regression-based imputation available through SPSS for Windows (Version 16.0., SPSS Inc., Chicago, IL, USA). All analyses were two-tailed, and the level of significance was P < 0.05.
Results Among the 260 subjects, 26.2% (68/260) screened positive on the PHQ-9, and 38.2% (26/68) of the positive screening people were diagnosed with MDD using DSM-IV criteria, which account for 10% (26/ 260) of all subjects. In MDD patients, 30.8%, 50.0%, and 19.2% were in the range of moderate, severe, and
79
MDD in hemodialysis patients
A. Hu et al.
very severe depression, respectively, based on HSRD scores. There was no evidence of any clinical diagnosis or treatment of MDD in any of the patients’ medical records. Mean age of this study population was 56.9 (± 15.8) years and 66.2% were men. The average duration of HD treatment was 54.63 (± 55.49) months. The average blood urea nitrogen and creatinine levels were 24.97 (± 7.78) mmol/L and 950.90 (± 312.52) μmol/L, respectively. The clinical and sociodemographic characteristics of HD patients were compared between patients with MDD and those without MDD, as shown in Table 1. In the analyses of chi-square test and Mann–Whitney U, MDD was significantly associated with greater age, less education and lower monthly incomes, less than one year of HD treatment, greater likelihood of cardiac comorbidity, and with lower levels of blood urea nitrogen. In further multivariate analysis, those patients with lower levels of blood urea nitrogen (20.85 ± 6.79), duration of HD treatment ≤12 months, and lower monthly incomes (High school Monthly income 4000 yuan Diabetes Cardiac disease Hypertension Duration (months) 0–12 ≥13 Blood urea nitrogen (mmol/L) Creatinine (μmol/L)
MDD (n = 26)
NMDD (n = 234)
61.19 ± 13.74 2 (7.7) 3 (11.5) 21 (80.8)
56.42 ± 15.98 40 (17.1) 62 (26.5) 132 (56.4)
χ2 or Z
P-value
6.263
0.044*
16 (61.5) 10 (38.5)
156 (66.7) 78 (33.3)
0.275
0.600
20 (76.9) 6 (23.1)
194 (82.9) 40 (17.1)
0.238
0.626
5.650
0.017*
(29.1) (45.7) (25.2) (21.6) (10.8) (53.9)
14.393
0.001**
1.439 4.663 1.820
0.230 0.031* 0.177
(17.1) (82.9) (± 6.78) (± 291.13)
12.350
