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Depression prevalence among end stage renal disease patients in maintenance hemodialysis

How to cite this article: Murillo-Zamora E, Macías-de la Torre AA, Higareda-Almaraz MA. [Depression prevalence among end stage renal disease patients in maintenance hemodialysis]. Rev Med Inst Mex Seg Soc 2016 Jul-Aug;54(4):429-33.



Received: April 16th 2015

Accepted: July 13rd 2015

Depression prevalence among end stage renal disease patients in maintenance hemodialysis

Efrén Murillo-Zamora,a Aída Anahí Macías-de la Torre,b Martha Alicia Higareda-Almarazc

aDepartamento de Epidemiología, Unidad de Medicina Familiar 19, Colima

bUnidad de Medicina Familiar 17, Manzanillo

cCoordinación Auxiliar de Investigación en Salud, Jefatura de Servicios de Prestaciones Médicas, Colima

Instituto Mexicano del Seguro Social, Colima, México

Communication with: Martha Alicia Higareda-Almaraz

Telephone: (312) 314 6199


Background: Depression is a common morbidity in end- stage kidney disease (ESKD) patients and impacts negatively on treatment outcomes. This study aimed to assess the prevalence of depression among Mexican ESKD patients in maintenance hemodialysis (MHD) and to evaluate the relationship with elapsed time (< 1 year or ≥ 1 year) since the beginning of therapy.

Methods: A cross-sectional study took place in a urban hospital from the Mexican Institute of Social Security and 81 subjects aged 30 - 69 years old were enrolled. Beck depression inventory (BDI) was applied and a stratified analysis was made.

Results: The overall prevalence of depression (≥ 16 points, BDI) was 42.0 % and 35.6 % and 50.0 % in the group with < 1 and ≥ 1 year on treatment respectively (p = 0.191).

Conclusions: Our findings suggest that depression prevalence is high among adult patients undergoing MHD and it seems to be independent from elapsed time since the beginning of therapy.

Keywords: Chronic kidney failure; Renal dialysis; Depression; Chronic renal insufficiency

End-stage renal disease (ESRD) is a public health problem whose prevalence has increased in recent decades.1,2 The economic and social burden of renal replacement therapy represents a major challenge for health systems.3

The development of neuropsychiatric conditions is common among patients with ESRD on maintenance hemodialysis (MHD), as the disease is associated with dramatic changes in the patient’s physical, cognitive, and social spheres.4-6 Because of its high morbidity and impact on quality of life, depression is the most important of these complications.7-10 The prevalence of depression among patients on MHD is greater than that of the general population and often goes unnoticed by health professionals.5,11,12

Depression negatively impacts the expected results of treatment, as it is associated with poor adherence to drug treatment, impaired immune function, and poor nutritional status.5,11-14 It is also associated with an increased number of hospital admissions, longer stays, and increased mortality.15-17

The Beck Depression Inventory (BDI) has been used to measure the presence of depressive symptoms among patients with ESRD;4,18,19 it consists of 21 items, each with four possible answers ordered in increasing severity, which are summed to obtain the corresponding total score.20

A cutoff of ≥ 16 points in the BDI in patients with ESRD, rather than the cutoff used in the general population (≥ 10 points) is associated with increased sensitivity and specificity, since the symptoms of uremia can potentially mimic depressive symptoms.4,19

There is no published scientific evidence, to our knowledge, regarding screening for depression among Mexican patients on MHD using the BDI. The aim of this study was to estimate the prevalence of depression among adult patients with ESRD in MHD and to evaluate the possible relationship between depression and time elapsed since the start of replacement therapy.


Study design

An observational epidemiological cross-sectional study was conducted in a secondary care hospital of the Instituto Mexicano del Seguro Social, from January to March 2014. Eligible subjects were selected by random procedure (random number generation) from the list of names of hemodialysis users provided by the Área de Informática Medica y Archivo Clínico (ARIMAC) of the study unit.

The study selected individuals from 30 to 69 years old with a previous diagnosis of ESRD (GFR < 15 ml/min/1.73 m2) who started MHD ≥ 3 before the start of study.21 Non-ambulatory enrollees and those with altered states of consciousness were excluded. This analysis included 81 individuals (97.6% of the eligible population).

Information collection

After informed consent was reviewed and signed by all participants, they were interviewed and the information was collected. The interview was conducted by standardized personnel. The time from the start of MHD was obtained from medical records and was categorized (< 1 year or ≥ 1 year). Participants self-reported items from the BDI, and a score of 0 (no problem) to 3 (severe problem) was assigned to each of them.

This study was approved by the Local Research and Ethics Committee on Health Research (CLIEIS).

Statistical analysis

Relative frequencies and arithmetic means were assessed. The statistical significance of the difference of proportions and means was evaluated with Chi-squared or Student’s t-test according to need; p-values ​​< 0.05 were considered statistically significant. The total score of the BDI was estimated by the arithmetic sum of the 21 items (range 0 to 63 points), and a cutoff point ≥ 16 was used.20 All procedures were performed with the statistical package Stata SE 13.0 (StataCorp, Lakeview, TX).


Table I shows the characteristics of the population for selected variables. In the study sample, 45 (55.6%) and 36 (44.4%) subjects reported < 1 year and ≥ 1 year of MHD, respectively. Participants with less time in MHD were younger than those with longer treatment (51.4 ± 8.8 versus 58.0 ± 8.0 years, respectively, p = 0.001).

Table I Characteristics of 81 patients with end-stage kidney disease on maintenance hemodialysis
All participants < 1 year in MHD ≥ 1 year in MHD -value *
n = 45 n = 36
Male 32 (39.5%) 16 (35.6%) 16 (44.4%) 0.416
Female 49 (60.5%) 29 (64.4%) 20 (55.6%)
Age (years)** 54.3 (9.0) 51.4 (8.8) 58.0 (8.0) 0.001
(Age, quartiles)
33 - 48 26 (32.1%) 20 (44.4%) 6 (16.7%) 0.039
49 - 58 27 (33.3%) 14 (31.1%) 13 (36.1%)
60 - 67 24 (29.7%) 10 (22.2%) 14 (38.9%)
68 - 69 4 (4.9%) 1 (2.2%) 3 (8.3%)
Absolute (n) and relative (%) frequencies are presented unless otherwise specified
* p-value of Student's t test or Chi-squared as appropriate. *Arithmetic mean (standard deviation)
MHD = maintenance hemodialysis

The mean BDI score was 14.8 ± 7.2 (Table II), and there were no statistically significant differences between groups (p = 0.213). The BDI score stratified by sex was 14.3 ± 7.0 and 15.1 ± 7.5 in men and women, respectively (p = 0.510). The overall prevalence of depression (≥ 16 points) was 42.0%. In stratified analysis, the prevalence of depression was 35.6 and 50.0% among participants with < 1 year and ≥ 1 year of MHD; this difference was not statistically significant (p = 0.191).

Table II Beck Depression Inventory score
All participants < 1 year in MHD ≥ 1 year in MHD
n = 45 n = 36 -value *
Total score** 14.8 (7.2) 13.9 (6.6) 15.9 (7.9) 0.213
Screening in patients with ESRD
< 16 points 47 (58.0%) 29 (64.4%) 18 (50.0) 0.191
≥ 16 points 34 (42.0%) 16 (35.6%) 18 (50.0)
Absolute (n) and relative (%) frequencies are presented unless otherwise specified
* p-value of Student's t test or Chi-squared as appropriate. *Arithmetic mean (standard deviation)
MHD = maintenance hemodialysis


The estimated prevalence of depression (42.0%) in the study sample was high and similar to that reported in the populations of Spain and Brazil.4,22 In other studies, the prevalence ranges from 25.0 to 72.3%,23-28 We did not find a statistically significant difference in the proportion of individuals with BDI ≥ 16 points between the study groups (< 1 year and ≥ 1 year of treatment), consistent with other findings previously published.8

The BDI was selected as a tool because of its high consistency.29 Other tools, such as the PHQ-9 (Patient Health Questionnaire) are available for the measurement of depressive symptoms among patients with chronic diseases.30 The BDI and the PHQ-9 have similar clinical utility according to recent findings.31

The BDI cutoff used in this study is associated with a high sensitivity and specificity (91 and 86%, respectively) among dialysis patients.32 A standard cutoff used in the general population overestimates the event frequency and reduces specificity and negative predictive value (NPV).32 The prevalence of depression in this study using a standard cutoff point was 72.8%. 

The estimated prevalence of depression in this study is almost ten times the estimated prevalence in the general Mexican population (4.5%).33 However, the screening is not included in the medical care protocols for patients with ESRD.34

The practical benefit of doing a depression screening in a susceptible population is controversial.35 In general, screening has a measurable benefit when it identifies patients with a neuropsychiatric disorder that would otherwise go unnoticed by health professionals.36 Implementing relaxation techniques in MHD patients reduces levels of psychological stress and anxiety, but the impact on perceived depression is limited.37

In Mexico, diabetes mellitus type 2 (DM2) is the leading cause of ESRD and is identified in up to 38-42% of adult patients.DM238,39 shows epidemic proportions in Mexico; according to data from the 2012 Encuesta Nacional de Salud y Nutrición, there are 6.4 million (9.4%) adults aged 20 or more with this chronic degenerative disease. Estimates from similar surveys conducted in 2006 and 2000 were 3.7 million (7.3%) and 2.1 million (4.6%) adults with DM2, respectively.40

Actions to prevent chronic complications of DM2 are applied inadequately.40 A recently published study found that 14.6% of the subjects studied, 18 to 30 years old, had prediabetes (8-12 hours fasting plasma glucose 100-125 mg/dl or impaired glucose tolerance with 140-199 mg/dl 2 hours after an oral glucose tolerance test).41 DM2 represents a major challenge for planning mental health services related to the prevention of neuropsychiatric disorders associated with ESRD.42


The methodological limitations characteristic of an epidemiological cross-sectional study should be considered when evaluating our findings. Other particular limitations must be mentioned. First, the analysis included a relatively small sample size and a small number of covariates; this study represents an exploratory approach to the event of interest and emphasizes the need for further research in this population. Second, the subjects came from a single hospital and had health services and social security; the study sample is representative of MHD users at the hospital site but is not entirely representative of the population of origin. Third, no additional screening tools were used; the BDI was selected for its high sensitivity and specificity. Fourth, biomarkers of depression were not quantified; this measurement must be considered in the assessment of risk factors associated with depression.


Our findings suggest that the prevalence of depression is high among adults with ESRD. We found no statistical evidence of a relationship between the prevalence of the event of interest and time elapsed since the start of therapy.


The research group is grateful to all the medical and nursing staff of the hemodialysis department of the study site hospital for the facilities provided.

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Conflict of Interest Statement: The authors declared that there is no personal or institutional conflict of interest of a professional, financial, or commercial nature, during the planning, execution, writing of this article.

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