WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

Sanathan et al. World Journal of Pharmacy and Pharmaceutical Sciences

SJIF Impact Factor 2.786

Volume 3, Issue 8, 535-548. Research Article ISSN 2278 – 4357

DEPRESSIVE SYMPTOMS IN CHRONIC KIDNEY DISEASE

PATIENTS ON MAINTENANCE HEMODIALYSIS

Savitha R Sanathana*, Vineetha Bharathan Menonb, Phanisree Allab, Smitha Madhurib,

Manjunath S Shettyc, Dushad Ramd

a
Lecturer, Department of Pharmacy Practice, JSS College of Pharmacy, JSS University and
Clinical Pharmacist, JSS Hospital, Mysore, Karnataka, India
a
Pharm.D Intern, Department of Pharmacy Practice, JSS College of Pharmacy, JSS
University, Mysore, Karnataka, India
c
Professor and Head, Department of Nephrology, JSS Medical College and Hospital, Mysore,
Karnataka, India
d
Assistant Professor, Department of Psychiatry, JSS Medical College and Hospital, Mysore,
Karnataka, India

Article Received on
ABSTRACT
20 May 2014, Objective: The study was conducted to evaluate the pattern of
Revised on 15 June
2014, depressive symptoms in patients on maintenance hemodialysis and to
Accepted on 10 July 2014
identify the number of patients treated for these symptoms. The
patients’ clinical condition, pharmacotherapy, and various
*Correspondence for Author
demographic and socioeconomic variables and their possible
Savitha R Sanathan
Lecturer, Department of
association with depressive symptoms were also studied. Methods:
Pharmacy Practice, JSS We studied 126 patients with end stage renal failure, undergoing
College of Pharmacy, JSS hemodialysis treatment at the outpatient dialysis unit of two tertiary
University and Clinical care hospitals in Southern India over a period of 6 months. For the
Pharmacist, JSS Hospital,
evaluation of depressive symptoms, Beck Depression Inventory was
Mysore, Karnataka, India
used. The pharmacotherapy, clinical condition, demographic and
socioeconomic variables were also investigated. Results: Using Beck Depression Inventory,
depressive symptoms were identified in 65.07% patients. Significant associations were
observed between depressive symptoms and variables like female gender, being single,
advanced age, lower socioeconomic status, nuclear family status, increased financial
reliability, lower body mass index, dialysis duration less than 1 year and increased cost of
treatment. Clinical conditions like diabetes, fatigue, limb pain, poor appetite and sleep
quality, lower albumin levels and use of medications like Prazosin was also found to be
associated with depressive symptoms. Out of 65% of the patients with depressive symptoms,

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Sanathan et al. World Journal of Pharmacy and Pharmaceutical Sciences

none received anti-depressant medications. Conclusions: We observed high incidence of

depressive symptoms among the chronic kidney disease patients undergoing hemodialysis
treatment, however they were not appropriately treated. These symptoms were found to be
related with various clinical, therapeutic and socio demographic variables.

Key Words: Beck Depression Inventory; Chronic Kidney Disease; Depressive symptoms;
End Stage Renal Disease; Hemodialysis; Maintenance Hemodialysis.

INTRODUCTION
Depressive disorder has been identified as the primary mental health problem in maintenance
hemodialysis (MHD) population, affecting about 20% of the patients, prevalence being much
higher than that reported for chronic disorders like diabetes mellitus and congestive heart
failure (CHF).[1] Identification and treatment of depression during the early stages of chronic
kidney disease (CKD) is important since it can impair recovery, result in poor treatment
adherence and worsen the quality of life (QOL) and mental health.[2,3] Studies point out that
patients on hemodialysis (HD) with depression are twice as likely to die or require
hospitalization within a year compared to patients without depression.[1] Lopes et al
suggested a greater withdrawal rate from MHD in patients who developed depression while
on dialysis than in those who were not depressed.[4]

Few studies have investigated the relation between depressive symptoms in the HD patients
with their demographic and socioeconomic variables, however the data about its association
with co-morbidities, clinical symptoms and pharmacotherapy of the patients are limited,
especially from India. Compared to the population evaluated in previous studies,[2,4] Indian
patients have significant differences in their socioeconomic and cultural background. Higher
rates of illiteracy and lack of insurance could also affect the prevalence of depressive
symptoms in this population. Moreover in India, patients have limited access to mental
healthcare and there is considerable social stigma associated with psychiatric disorders.[3]
Thus the study was conducted to evaluate the actual pattern of depressive symptoms in the
Indian hemodialysis population and its relation with their pharmacologic therapy, clinical
condition, demographic and socioeconomic characteristics. An additional aim of the study
was to determine the number of patients treated for their depressive symptoms.

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MATERIALS AND METHODS

Study design
A total of 126 patients were selected and followed at the outpatient dialysis department of
two tertiary care hospitals in Mysore, India. Dialysis patients who had been on HD sessions
for end stage renal disease (ESRD) at least 3 times per week, lasting 4 hours each, for at least
3 consecutive months were included in the study. The patients were excluded if they were not
willing to participate, were undergoing HD for conditions other than ESRD, or had hearing,
speech or cognitive defects that would interfere with their ability to understand and answer
questions from the screening tools used in the study. Additionally, patients with history of
delirium, dementia or other psychiatric disorders prior to undergoing HD were also excluded.
Before enrolling the subjects, informed consents were obtained from the study subjects.

Ethical Approval
The protocol was approved by the institutional human ethical review board of JSS institution
prior to commencement of the study.

Procedures
Participants were interviewed when they came for their dialysis sessions. Using appropriate
data collection form designed for the study, relevant socio demographic data, details
regarding laboratory examinations, clinical conditions, medications and other dialysis details
were recorded.

Evaluation of depressive symptoms

Depressive symptoms were evaluated using the Beck Depression Inventory (BDI). It is a
validated screening tool to detect depression in ESRD, with sensitivity and specificity rates of
more than 90%.[5] This instrument has been used extensively for the assessment of depression
in patients with CKD.[2] According to BDI, grading of depression was done based on the
score levels: mild depression (14-19), moderate depression (20-28) and severe depression
(29-63).

Evaluation of socioeconomic status

The socioeconomic status of the patients was evaluated using revised Kuppuswamy’s
Socioeconomic Status Scale, which takes into consideration their education, occupation and
monthly income. Grading of socioeconomic status was based on score levels: upper class (>
26), middle class (11-25) and lower class (< 10).

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Evaluation of body mass index

The body mass index (BMI) of the participants were calculated using the patients estimated
dry weight and were divided into 3 categories, overweight (BMI: > 25), normal weight (BMI:
18.5-24.9) and underweight (BMI: < 18.5).

Before interviewing the patients, researchers underwent adequate training by the psychiatrist
with respect to administration of BDI. Although the questionnaire was largely self-
administered, it was read out to illiterate patients and their responses were recorded. The data
was collected privately and confidentiality was maintained on all data collection forms.

Statistics
Data was verified and analysed using Statistical Package for Social Sciences (SPSS) for
windows version 20.0. Results were evaluated using percentage value and mean ± standard
deviation. Comparisons between categorical variables were done using the chi squared test. A
p value < 0.05 was considered statistically significant.

RESULTS

Fig. 1: The demographic and socioeconomic characteristics of the study population (n=126)

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Fig. 2: Frequency of pattern of different depressive symptoms according to Beck

depression inventory (n=82)

The mean age of the dialysis population was 48.42±14.47 years, with age ranging between 20
years and 85 years. Patients were undergoing dialysis for a mean duration of 3.89±2.49 years.
CKD patients attending the outpatient dialysis unit had an average glomerular filtration rate
(GFR) of 8.51±1.52 ml/min/1.73 m2. In Figure 1, the socio demographic characteristics of the
participants are presented. The average BDI scores were found to be 16.02±17.45%. Among
the 82 depressed patients, 6% had severe depressive symptoms, while 26% and 68% had
moderate and mild depressive symptoms respectively. The pattern of various depressive
symptoms experienced by the depressed patients (n=82) is shown in Figure 2.

Table 1 summarises the socio demographic characteristics of depressed patients. Among the
study subjects, depressive symptoms were significantly more in patients living in nuclear
family and among those who were financially dependent on others and had to spend more
than Rs 10,000 per month for their HD treatment and medications. It was significantly lower
in males and younger patients and among those who were married.

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Table 1: Association of depressive symptoms with the demographics of study population

Demographic Categories Total patients Depressive symptoms p value

variables (n=126) (n=82)
n (%) n (%)
Age <50 years 60 (47.61) 32 (53.33) 0.008*
>50 years 66 (52.38) 50 (75.75)
Gender Male 75 (59.52) 35 (46.66) 0.000*
Female 51 (40.47) 47 (92.15)
Marital status Married 89 (70.63) 49 (55.05) 0.001*
Unmarried 12 (9.52) 10 (83.33)
Widowed 25 (19.84) 23 (92.00)
Family type Joint 26 (20.63) 7 (26.92) 0.000*
Nuclear 100 (79.36) 75 (75.00)
Level of financial Dependent 91 (72.22) 64 (70.32) 0.046*
reliability Independent 35 (27.77) 18 (51.42)
Cost of treatment <Rs 10,000 80 (63.49) 39 (48.75) 0.000*
per month >Rs 10,000 46 (36.50) 43(93.47)
(including HD
and medications)
* Indicates significant p value at 95% level of confidence interval (p≤0.05). HD:
Hemodialysis

As Table 2 and Table 3 shows, patients who were at risk of depression tended to belong to
the lower socioeconomic class and were underweight. Association between time of dialysis
and duration of dialysis with depressive symptoms is shown in Table 4. Notable relation was
observed between depressive symptoms and duration of dialysis, with more depressive
symptoms among patients who had been on dialysis for less than 1 year.

Table 2: Frequency of depressive symptoms based on Kuppuswamy’s socioeconomic

status scale

Total patients Depressive symptoms

Kuppuswamy’s SES p value
(n=126) (n=82)
Scale
n (%) n (%)
Upper class 4 (3.17) 0 (0.00)
Middle class 28 (22.22) 13 (46.42) 0.000*
Lower class 94(74.60) 69 (73.40)

* Indicates significant p value at 95% level of confidence interval (p≤0.05). Kuppuswamy’s

SES Scale: Kuppuswamy’s socioeconomic status scale

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Table 3: Occurrence of depressive symptoms according to body mass index of the

patients

Total patients Depressive symptoms

Variable Categories (n=126) (n=82) p value
n (%) n (%)
Underweight 61 (48.41) 54 (88.52)
BMI
Normal weight 51 (40.47) 17 (33.33) 0.000*
Categories
Over weight 14 (11.11) 11 (78.57)
* Indicates significant p value at 95% level of confidence interval (p≤0.05). BMI: Body mass
index

Table 4: Percentage of depressive symptoms according to the time and duration of

dialysis

Total patients Depressive symptoms

Variables (n=126) (n=82) p value
n (%) n (%)
Dialysis 6am-10am 42 (33.33) 28 (66.66)
Shift 11am-4pm 44 (34.92) 29 (65.90) 0.915
5pm-9pm 40 (31.74) 25 (62.50)
< 12 months 45 (35.71) 33 (73.33)
Duration of 13-24 months 36 (28.57) 21 (58.33) 0.015*
dialysis 25-36 months 16 (12.69) 7 (43.75)
>36 months 29 (23.01) 21 (72.41)
* Indicates significant p value at 95% level of confidence interval (p≤0.05).

With regard to the clinical conditions, depressive symptoms were significantly higher among
patients with diabetes, fatigue, limb pain, poor appetite and poor sleep quality (SQ) (Table 5).
Statistical analysis of results obtained showed significant association between depressive
symptoms and lower serum albumin levels (Table 6). Correlation between pharmacotherapy
of the patients with depressive symptoms is shown in Table 7. Among the medications
patients were receiving, strong link was observed between depressive symptoms and use of
Prazosin. Out of 65% patients with depressive symptoms, according to BDI, 18% of patients
were put on anxiolytics and none received antidepressant medications.

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Table 5: Association between depressive symptoms and co-morbidities in patients.

Total patients Depressive symptoms

Co-morbidities Yes/No (n=126) (n=82) p value
n (%) n (%)
Yes 49 (38.88) 47 (95.91)
Diabetes 0.000*
No 77 (61.11) 35 (45.45)
Yes 108 (85.71) 78 (72.22)
Fatigue 0.000*
No 18 (14.28) 4 (22.22)
Yes 115 (91.26) 79 (68.69) 0.005*
Limb pain
No 11 (8.73) 3 (27.27)
Positive 11 (8.73) 9 (81.81)
Hepatitis C virus 0.222
Negative 115 (91.26) 73 (63.47)
Yes 123 (97.61) 81 (65.85)
Hypertension 0.243
No 3 (2.38) 1 (33.33)
Yes 84 (66.66) 63 (75.00)
Poor appetite 0.000*
No 42 (33.33) 19 (45.23)
Yes 85 (67.46) 62 (72.94)
Poor sleep quality 0.007*
No 41 (32.53) 20 (48.78)
* Indicates significant p value at 95% level of confidence interval (p≤0.05).

Table 6: Occurrence of depressive symptoms according to the laboratory parameters of

patients

Total patients Depressive symptoms

Laboratory
Abnormalities (n=126) (n=82) p value
parameters
n (%) n (%)
Normal 0 (0.00) 0 (0.00)
Hemoglobin
Low 126 (100.00) 82 (65.07)
Normal 50 (39.68) 17 (34.00)
Albumin 0.000*
Low 76 (60.31) 65 (85.52)
Calcium Normal 23 (18.25) 11 (47.82)
0.054
Low 103 (81.74) 71 (68.93)
Normal 21 (16.66) 12 (57.14)
Phosphorous 0.403
High 105 (83.33) 70 (66.66)
Normal 89 (70.63) 57 (64.04)
Sodium High 2 (1.58) 2 (100.00) 0.570
Low 35 (27.77) 23 (65.71)
Normal 37 (29.36) 26 (70.27)
Potassium High 87 (69.04) 54 (62.06) 0.394
Low 2 (1.58) 2 (100.00)
Normal 39 (30.95) 24 (61.53)
Chloride High 82 (65.07) 55 (67.07) 0.812
Low 5 (3.96) 3 (60.00)
* Indicates significant p value at 95% level of confidence interval (p≤0.05).

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Table 7: Association between depressive symptoms and pharmacotherapy

Total patients Depressive symptoms

Drugs Yes/No (n=126) (n= 82) p value
n (%) n (%)
Yes 38 (30.15) 20 (52.63) 0.054
Amlodipine
No 88 (69.84) 62 (70.45)
Yes 7 (5.55) 5 (71.42)
Atenolol 0.716
No 119 (94.44) 77 (64.70)
Yes 22 (17.46) 17 (77.27) 0.186
Clonidine
No 104 (82.53) 65 (62.50)
Yes 6 (4.76) 4 (66.66) 0.933
Levothyroxine
No 120 (95.23) 78 (65.00)
Yes 22 (17.46) 14 (63.63) 0.875
Metoprolol
No 104 (82.53) 68 (65.38)
Yes 23 (18.25) 9 (39.13) 0.003*
Prazosin
No 103 (81.74) 73 (70.87)
Yes 8 (6.34) 6 (75.00)
Reserpine 0.543
No 118 (93.65) 76 (64.40)
* Indicates significant p value at 95% level of confidence interval (p≤0.05).

DISCUSSION
Our study identifies the occurrence of depressive symptoms in patients on MHD at tertiary
urban hospitals in India, using a cross sectional survey design. We found high percentage of
depressive symptoms among the HD patients (65%) using BDI. The incidence of depressive
symptoms in the current study was higher than that reported previously in Dialysis Outcomes
and Practice Patterns Study (DOPPS), which indicated 56.9% of their patients as depressed.[6]
Our results were also in accordance with those by Craven et al (1998), which determined
45% of their ESRD patients as depressed, using BDI.[7]

Many risk factors have been ascertained in literature to have significant relationship with the
development of depressive symptoms. In our study, depressive symptoms were more frequent
in females. The results were concurrent with the previous studies, where female patients were
reported to feel more depressed than males.[6,8,9] The higher frequency of depressive
symptoms among females may be due to their vulnerability to stressors and their greater
concern about the future.[8] Regarding marital status, patients who were single had higher
BDI scores than married patients. Being married is related to better QOL, enhanced physical
well-being and emotional health than single patients.[9] Statistically significant differences
were observed between younger and older age, with older patients having more mental

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distress. Older patients have higher scores of depression as they are more tired and have
decreased feelings of usefulness and satisfaction from general QOL.[10]

The socioeconomic status of most of study patients was low. As the socioeconomic status
deteriorates, patients tend to face poorer general health and mental health resulting in lower
social well-being.[9] Greater number of our patients had limited job opportunities due to their
low educational levels and work disability due to fatigue and limb pain as a result of dialysis.
Thus they were mostly unemployed and had low monthly income. Depressive symptoms
were more among patients with low monthly income and had to pay more than their gross
monthly salary towards their medications and HD treatment. Since majority of these patients
had no insurance cover and could not afford the treatment cost, they were financially reliable
on others and had more depressive symptoms. Andrade et al, in his study also reported a
higher percentage of depressive symptoms among patients who were unemployed and had
low monthly income.[2] Depressive symptoms were found to have strong correlation with
nuclear family status and dialysis duration less than 1 year. This was similar to the study by
Khaira et al, who reported patients living in nuclear family to be more depressed.[11] Our
results were consistent with the findings of Vasilios et al who reported that the period after
initial diagnosis of ESRD and the first year after initiation of HD is associated with a greater
risk of developing depression.[12]

The study demonstrates that depressive symptoms are significantly linked with co-morbid
illness like diabetes mellitus and limb pain. Research shows that diabetes doubles the risk of
depression.[13] In a Canadian study, the severity of pain was found to positively correlate with
the severity of self-reported depressive symptoms.[14] Majority of our depressed study
population experienced fatigue. Studies have identified strong correlation between depressive
symptoms and fatigue.[15,16,17] Depression itself may manifest as fatigue and lack of energy.[15]
As far as SQ is concerned, we found more than half of the depressed patients to have poor
SQ. Iliescu et al also found significant association between depression and poor SQ.[18] Since
SQ is a modifiable risk factor, there are implications that improving SQ can decrease
depression.[19] Concerning BMI, most of the patients with low BMI had depressive
symptoms. Strong correlation has been suggested between depression and low BMI. Low
BMI is found to be associated with decreased survival rate, increased risk of hospitalisation
and higher mortality rate in HD patients.[17] Several patients had depressive symptoms and
low albumin levels. Research suggests that depression influences the nutritional status of the

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patients leading to low albumin levels.[20] Majority of our depressed patients had reduced
appetite. The percentage of patients with poor appetite in our study was higher than that
reported by Bossola et al.[21]

Investigating sexual dysfunction, many patients with depressive symptoms had sexual
dysfunction. Soykan et al (2005) also pointed out that many of his ESRD patients had sexual
dysfunction and co-morbid depression.[22] In our study, several patients had suicidal
depression. Suicide is considered to be an adverse consequence of depression. Uncertainty
about the future and fear of losing control in life are common factors that result in emotional
instability leading to development of suicidal thoughts. Suicidal ideation is postulated to be
greater among Asian HD patients as they perceive their illness as a social and familial
burden.[17] We also observed significant association between occurrence of depressive
symptoms and use of medications like Prazosin. Although there have been previous studies
demonstrating relation between the use of antihypertensives with depressive symptoms,[23,24]
larger studies need to be conducted in HD population to establish the relation between
medication use and development of depressive symptoms.

Despite the high incidence of depressive symptoms, none of the patients were treated with
antidepressants. About 18% of patients were currently receiving treatment with only
anxiolytics. A study by Watnick et al reported that only 16% of ESRD patients on MHD with
BDI scores ≥ 15 were on antidepressants.[1] This highlights the extent of how under
recognised depression is and perhaps suggests the acceptance of depression as a part of HD
experience by the physicians. Several studies indicate that treatment with antidepressant,
Sertraline for 3 months, not only reduced the symptoms but also improved the QOL.[12]
However, the presence of frequent co-morbidities and drug interactions may limit the use of
antidepressants in ESRD patients.

Evaluating depression in its early stages is important since it is a significant predictor of

adverse outcomes in the progression of CKD, initiation of HD treatment, death and
hospitalization.[25] It seems that despite all the medical and psychological challenges of living
on dialysis, patients without co-morbid depression can enjoy a much greater QOL.[26] Thus
early psychiatric assessment of patients undergoing HD is necessary to detect depressive
symptoms and to initiate appropriate treatment programs, which will facilitate psychological
adaptation of patients and reduce treatment related costs by increasing treatment success and
decreasing hospitalisations.

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The study has several limitations. The cross sectional design of the study helped only to
determine the association between the variables and not any causal relationship. Some
patients were illiterate and had to be interviewed, which may have led to a form of
information bias. The study was conducted only for a short period and was conducted at only
two study sites. So the study population was limited. Use of diagnostic screening scale that
include somatic symptoms of depression like weight loss, sleep disturbances, fatigue etc. can
contribute to over diagnosis of depressive symptoms.

CONCLUSION
This study has shown high rates of depressive symptoms in patients on MHD and significant
correlation with variables like being single, older age, female gender, low socioeconomic
status, nuclear family status, increased financial reliability, low BMI, low albumin levels, HD
duration less than 1 year and increased cost of treatment. Clinical conditions like diabetes,
fatigue, limb pain, poor appetite and poor SQ and use of medications like Prazosin was also
found to be associated with depressive symptoms. Majority of the depressed population was
not treated adequately. These results provide useful information that certain variables
referring to the patients socioeconomic and demographic profile, co-morbid disease
conditions and pharmacotherapy may to some extent contribute to their mental health
unfavourably leading to the development of depressive symptoms.

ACKNOWLEDGEMENTS
The authors would like to thank support from JSS University, Principal of JSS College of
Pharmacy, Dean and Head of the Department of Pharmacy Practice for their constant
encouragement. We would also like to extend gratitude to the Director, CSI Holdsworth
Memorial Hospital, Mysore, for providing opportunity to conduct the study at their dialysis
units. We would also like to extend our heartfelt thanks to Dr. Kiran KK, Assistant Professor,
Department of Nephrology, JSS Hospital, Mysore, for his valuable suggestions and constant
support throughout the study. We also thank Dr Naganandini MN and Mr. DHP Gowda, staff
of JSS College of Pharmacy, for their helping hand in the study.

FUNDING
This is a no funding project.

CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.

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REFERENCES
1. Hedayati SS, Yalamanchili V, Finkelstein FO. A practical approach to the treatment of
depression in patients with chronic kidney disease and end stage renal disease. Kidney
Int, 2011; 81(3): 247-55.
2. Andrade CP, Sesso RC. Depression in chronic kidney disease and hemodialysis patients.
Psych, 2012; 3(11): 974-8.
3. Rai M, Rustagi T, Rustagi S, Kohli R. Depression, insomnia and sleep apnea in patients
on maintenance hemodialysis. Indian J Nephrol, 2011; 21(4): 223-9.
4. Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe C et al. Depression as a
predictor of mortality and hospitalization among hemodialysis patients in the United
States and Europe. Kidney Int, 2002; 62(1): 199-207.
5. Tamura MK. Recognizing delirium, dementia and depression. JASN, 2013; 6p.
6. Lopes AA, Albert JM, Young EW, Satayathum S, Pisoni RL, Andreucci VE et al.
Screening for depression in hemodialysis patients: Associations with diagnosis, treatment,
and outcomes in the DOPPS. Kidney Int, 2004; 66(5): 2047-53.
7. Cohen SD, Norris L , Acquaviva K, Peterson RA, Kimmel PL. Screening, diagnosis, and
treatment of depression in patients with end stage renal disease. CJASN, 2007; 2(6):
1332-42.
8. Erdenen F, Curuk S, Karsidag C, Muderrisoglu C, Besler M, Trabulus S et al. Evaluation
of disability, anxiety and depression in hemodialysis patients. Nobel Med, 2010; 6(1): 39-
44.
9. Theofilou P. Depression and anxiety in patients with chronic renal failure: The effect of
sociodemographic characteristics. Int J Nephrol, 2011; 16-22.
10. Iacovides A, Fountoulakis KN, Balaskas E, Manika A, Markopoulou M, Kaprinis G et al.
Relationship of age and psychosocial factors with biological ratings in patients with end
stage renal disease undergoing dialysis. Aging Clin Exp Res, 2002; 14(5): 354-60.
11. Khaira A, Mahajan S, Khatri P, Bhowmik D, Gupta S, Agarwal SK. Depression and
marital dissatisfaction among Indian hemodialysis patients and their spouses: A cross
sectional study. Ren Fail, 2012; 34(3): 316-22.
12. Vasilios K, Vasilios K. Depression in patients with CKD: A person centered approach. J
Psychol Psychother, 2012; 13(1): 26-34.
13. Depression and diabetes, National diabetes service scheme: Delivering products and
services to people with diabetes, http://www.diabetesaustralia.com.au/en/NDSS-
Content/Diabetes-Information-Sheets/Depression-and-Diabetes/.

www.wjpps.com Vol 3, Issue 8, 2014. 547

Sanathan et al. World Journal of Pharmacy and Pharmaceutical Sciences

14. Davison SN, Jhangri GS. The impact of chronic pain on depression, sleep, and the desire
to withdraw from dialysis in hemodialysis patients. J Pain Symptom Manage, 2005;
30(5): 465-73.
15. Patel ML, Sachan R, Nischal A, Surendra. Anxiety and depression: A suicidal risk in
patients with chronic renal failure on maintenance hemodialysis. IJSRP, 2012; 2(3): 6p.
16. Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A, Finkelstein FO.
Hemodialysis and peritoneal dialysis: Patients assessment of their satisfaction with
therapy and the impact of the therapy on their lives. CJASN, 2006; 1(6): 1191-6.
17. Chen CK, Tsai YC, Hsu HJ, Wu IW, Sun CY, Chou CC et al. Depression and suicide
risk in hemodialysis patients with chronic renal failure. Psychosomatics, 2010; 51(6): 7p.
18. Iliescu EA , Coo H, McMurray MH , Meers CL, Quinn MM, Singer MA et al. Quality
of sleep and health related quality of life in haemodialysis patients. Nephrol Dial
Transplant, 2003; 18 (1): 126-32.
19. Turkmen K, Erdur FM, Guney I, Gaipov A, Turgut F, Altintepe L et al. Sleep quality,
depression, and quality of life in elderly hemodialysis patients. Int J Nephrol Renovasc
Dis, 2012; 5: 135-42.
20. Friend R, Hatchett L, Wadhwa NK, Suh H. Serum albumin and depression in end stage
renal disease. Adv Perit Dial, 1997; 13: 155-7.
21. Bossola M, Ciciarelli C, Di Stasio E, Panocchia N, Conte GL, Rosa F et al. Relationship
between appetite and symptoms of depression and anxiety in patients on chronic
hemodialysis. J Ren Nutr, 2012; 22(1): 27-33.
22. Soykan A, Boztas H, Kutlay S, Ince E, Nergizoglu G, Dilekoz AY et al. Do sexual
dysfunctions get better during dialysis? Results of a six month prospective follow up
study from turkey. Int J Impot Res, 2005; 17(4): 359-63.
23. Beers MH, Passman LJ. Antihypertensive medications and depression. Drugs, 1990;
40(6): 792-9.
24. Botts S, Ryan M. Drug induced diseases, Drug induced psychiatric diseases: Depression,
http://www.ashp.org/DocLibrary/Policy/Suicidality/DID-Chapter18.aspx
25. Tsai YC, Chiu YW, Hung CC, Hwang SJ, Tsai JC, Wang SL et al. Association of
symptoms of depression with progression of CKD. AJKD, 2012; 60(1): 54-61.
26. Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA et al.
Depression and anxiety in urban hemodialysis patients. CJASN, 2007; 2(3): 484-90.

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