Anxiety, Depression and Suicidal Ideation in Lebanese Patients Undergoing Hemodialysis Gabrielle Macaron, Mario Fahed, Dany Matar, Rami Bou-Khalil, Francois Kazour, Dania Nehme-Chlela & Sami Richa Community Mental Health Journal ISSN 0010-3853 Volume 50 Number 2 Community Ment Health J (2014) 50:235-238 DOI 10.1007/s10597-013-9669-4
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Author's personal copy Community Ment Health J (2014) 50:235–238 DOI 10.1007/s10597-013-9669-4
ORIGINAL PAPER
Anxiety, Depression and Suicidal Ideation in Lebanese Patients Undergoing Hemodialysis Gabrielle Macaron • Mario Fahed • Dany Matar • Rami Bou-Khalil • Francois Kazour Dania Nehme-Chlela • Sami Richa
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Received: 16 November 2012 / Accepted: 30 November 2013 / Published online: 13 December 2013 Ó Springer Science+Business Media New York 2013
Abstract Anxiety, depression and suicidal thoughts are highly prevalent comorbidities of end-stage-renal-disease (ESRD). There are no studies in Lebanon on the prevalence of these symptoms in Lebanese end-stage-renal-disease patients. Moreover, the association between ESRD on one hand, and anxiety, depression and suicidal ideation on the other has never been established in Lebanon. Groups of patients at a high-risk of development of these symptoms are not determined. The Hospital Anxiety and Depression Score and M.I.N.I (module C) were used to measure the prevalence of anxiety, depression and suicidal ideation in 51 patients from the dialysis center of Hotel-Dieu de France Hospital in Lebanon. In our sample, 45 % of included patients suffered from symptoms of anxiety and 50 % presented symptoms of depression.The prevalence of suicidal ideation as detected by the M.I.N.I. is at 37 %. No patients presented with a high risk of suicide. There was a statistically significant correlation between the existence of organic comorbidities and the presence of symptoms of depression and suicidal ideation. As for anxiety, the association was marginally significant. The results obtained by our study are consistent with those found in studies performed in other societies. The profile of depression- and suicidal ideation-prone patients has been determined. It consists of patients with at least one medical comorbidity to the ESRD. This, in turn, should lead to increased G. Macaron M. Fahed D. Matar R. Bou-Khalil F. Kazour S. Richa (&) Department of Psychiatry, Faculty of Medicine, Hoˆtel-Dieu de France Hospital, Saint-Joseph University, Beirut, Lebanon e-mail:
[email protected] D. Nehme-Chlela Department of Nephrology, Hoˆtel-Dieu de France Hospital, Saint-Joseph University, Beirut, Lebanon
awareness and better treatment of these psychiatric ailments, considering their impact on morbidity and mortality in ESRD. Keywords Hemodialysis Lebanon Depression Anxiety Suicide
Introduction In the past two decades, remarkable advances have been made in the field of end-stage renal disease (ESRD) and dialysis; albeit mostly centered on the organic aspects of the disease. More recently, the psychosocial aspects of dialysis have been explored, even going as far as creating new fields such as ‘‘psychonephrology’’, a term coined by (Beard 1985). Patients in ESRD are faced with situations that make it more likely for them to develop anxiety or mood disorders, or exacerbate an existing condition (Feroze et al. 2010). It has been established that depression is thrice more prevalent in dialysis patients when compared to the general population (Feroze et al. 2010). In fact, depression and anxiety disorders are the most common psychiatric disorders in patients in ESRD (Cukor et al. 2008a). The prevalence of depression in ESRD ranges from 10 to 50 %, depending on the tools used to evaluate it (Untas et al. 2009; Cukor et al. 2007; Fukuhara et al. 2006; Kutner et al. 1985; Cukor et al. 2008b). In a study conducted by Johnson and Dweyer, 70 % of patients in ESRD that exhibited symptoms of depression or anxiety were found to be unaware of their symptoms or the necessity to treat them, and thus refused psychiatric treatment (Johnson 2008). This raises the concern that anxiety and mood disorders are underestimated and it is difficult for health care workers
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that have not been trained in psychiatric evaluation to spot these comorbidities in their patients. The impact anxiety has on patients on dialysis hasn’t been properly studied yet, though it is clear that anxiety symptoms make for a lesser quality of life, especially when it is associated with depression (Cukor et al. 2008b). Acts of self-harm, ranging from self-mutilation to completed suicide, are the most dreaded occurrences in ESRD psychiatry (Crosby et al. 2011). Several studies have demonstrated that patients on dialysis are more likely to attempt suicide (Chen et al. 2010; De Sousa 2008). For a patient on dialysis, one only needs to miss a few sessions of dialysis or eat foods with high levels of potassium to attempt suicide (De Sousa 2008).Several studies have established the link between suicidal ideation and chronic diseases, irrespective of social considerations, type of disease or psychiatric comorbidities (Marusic and Goodwin 2006). Numerous studies have considered the ethical implications of voluntary withdrawal from dialysis (De Sousa 2008; Cohen et al. 2000). Studies show that 90 % of nephrologists approve of discontinuation of treatment, and offer it to their patients (Singer 1992). In the United States, one in every five patients chooses to stop their dialysis before their death (Bostwick and Cohen 2009). Two studies including a meta-analysis done by Hackney and Snaders 2003, showed that religious devotion has been found to be highly correlated with proper psychological functioning while involvement in religious institutions protects from suicide(Hackney and Sanders 2003; Chaaya et al. 2007). Our study aims to identify the psychosocial impacts of dialysis on the Lebanese ESRD patients. It also attempts to identify patients at an increased risk of developing symptoms of depression, anxiety, as well as suicidal ideation.
Methods Our target population consists of the patients receiving treatment at the dialysis center of Hotel Dieu De France Hospital during the month of January 2012. Hotel Dieu de France in Beirut is the largest teaching hospital center in Lebanon. Out of the 83 patients that presented to the center during the study period, 51 were included in the study with respect to the inclusion and exclusion criteria and taking into account the refusals to take part in the study. Inclusion criteria are the following: 18 or above of age, and an understanding of the French or English language. Exclusion criteria: patients less than 18 years of age, patients that do not understand English or French, patients diagnosed with a psychiatric illness other than mood disorders, patients in acute renal failure on temporary dialysis. After complete description of the study to the subjectsby the investigators responsible for the administration of the
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questionnaires (who are the first two authors of this manuscript), written informed consent was obtained. The questionnaires were filled by the patients during dialysis, and an investigator was present at all times to answer any questions that may arise. The variables studied are the following: age, sex, marital status, education, religiosity, duration of dialysis, smoking, and alcohol consumption. Comorbid illnesses screened are: neoplasms, diabetes, cardiac, hepatic or respiratory failure, rheumatoid diseases, history of strokes, hypothyroidism, and Parkinson’s disease. All questions were close-ended except those pertaining to organic comorbidities and duration of dialysis which were taken from the patient’s medical file in the dialysis department. The Hospital Anxiety and Depression Scale (HADS) by Zigmond and Snaith (Untas et al. 2009; Zigmond and Snaith 1983)was chosen to screen depression and anxiety symptoms. The questionnaire is in French and English and is validated in both languages (Untas et al. 2009). It consists of concise, easy to understand questions that the patients fill by themselves (Feroze et al. 2010; Untas et al. 2009; Razavi et al. 1989). It has been widely used to screen for anxiety and depression in the ESRD population (Feroze et al. 2010; Untas et al. 2009; Cukor et al. 2008b; Bjelland et al. 2002). The M.I.N.I. is a diagnostic tool of high specificity (84 %) and sensibility (86 %) based on the diagnostic criteria of the DSM-IV and ICD-10. Module C was used to evaluate suicidal risk (Martiny et al. 2011; Sheehan et al. 1998). Since this is a hetero-questionnaire, it was administered by the investigators. Three independent variables were studied: Suicide, Depression and Anxiety. They have been dichotomized based on results obtained in the questionnaires. HADS scores above 7 on both depression and anxiety were considered to be positive for depressive symptomatology and anxiety respectively. Suicidality was considered positive whenever the C module of the M.I.N.I indicated the presence of suicidal ideation. The association of the dependent variables with the independent variables listed above, (namely the demographic characteristics and the absence or presence of comorbidities) is evaluated using Chi2 test and logistic regressions. Results are reported with percentages, confidence intervals (CI) and Odds ratios. The value of alpha is fixed at 5 % (p \ 0.05). Stata/IC11.2 is used for the statistical analysis.
Results Mean age of participants is 64 years old with a standard deviation (SD) of 13.2. The sample is comprised of 60 % males (31 patients) and 40 % females (20 patients). 87 % are or were married (45 patients), and 13 % are single (6 patients). Half the patients had an education ending at or
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before the ninth grade (26 patients), 25 % graduated high school (13 patients), and 25 % had a college degree (13 patients). 74 % of patients had at least one other medical comorbidity with ESRD (36 patients), most of them have only one comorbidity (51 %) (26 patients). The mean time since the start of dialysis is 71 months (SD: 60.2). Ninety-eight per cent of participants (50 patients) are believers in God, while 2 % (1 patient) said they were neutral to the existence of God. 68 % stated that they prayed on daily basis. Thirty-one per cent of patients (16 patients) are smokers with an average of 14 cigarettes per day and a mean duration of smoking of 22.4 months (SD: 17.9). The mean alcohol consumption is 0.39 drinks per day (SD: 0.66). The HADS permitted the determination of the following findings: 45 % of patients presented symptoms of anxiety (22 patients) and 50 % had depressive symptoms (25 patients). The C module of the MINI came back positive for suicidal ideation in 37 % of patients (19 patients), of whom 31 %(16 patients) were at low risk of suicide and 6 % at moderate risk(3 patients). In this study, no statistically significant association between any of the demographic variables (sex, age, marital status, educational level, religious belief and frequency of prayer) and the depression, anxiety or suicidality scores was found. However, there was a clear correlation between the presence of organic comorbidities and the existence of depression and suicidal ideation (p values of 0.026 for depression and 0.022 for suicide) with odds ratios of 4.3 and 5.8 respectively. As for anxiety, the association tended towards significance with a p value of 0.08 and an odds ratio of 3.
Discussion Relatively high rates of symptoms of depression (50 %) and anxiety (45 %) were found. These numbers concur with prior studies in other countries (Cukor et al. 2008a, b). A study conducted in 2008 on 2857 randomly chosen Lebanese subjects found rates of 16.7 % anxiety symptoms (Karam et al. 2008). The prevalence of depression in the ESRD population varies greatly with studies. Cukor et al. found rates of 29 % of current depressive disorder (Cukor et al. 2007), while others report rates as high as 50 % of depression or depressive symptoms (Montinaro et al. 2010). The results our study found concur with the results found in other studies (Montinaro et al. 2010). As for suicidal ideation, we found a prevalence of 37 % in our sample, with 31 % having a low-risk of suicide and 6 % having a moderate risk. In a study evaluating suicide ideation and attempts in nine countries, Lebanon was found
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to have lifetime prevalence rates/100 for suicide ideation of 2.09 in contrast to 18.51 in New Zealand, and lifetime prevalence rates/100 for suicide attempts of 0.72 in Lebanon contrasting with 5.93 in Puerto Rico (Weissman et al. 1999). We did however find a correlation between having a comorbid organic disease and the existence of depressive symptomatology. In fact, the presence of organic disease increases four-fold the risk of having symptoms of depression (CI [1.147, 16.276], p \ 0.026, OR = 4.3). Elsewhere, patients with at least one comorbidity presented a six-fold risk of suicidal ideation compared to the group without comorbidities (CI [1.143, 29.569], p \ 0.02, OR = 5.8). The same could be said about anxiety, but the results were marginally significant with an OR equal to 3 (CI [0.8225, 11.4852], p \ 0.08, OR = 3). Several studies have mentioned this correlation. A retrospective study by David N. Juurlink et al. in 2004 concluded that the increase in suicidal risk is almost parallel to the increase in number of diseases currently treated; as such a patient with 3 diseases has a threefold increase in suicidal risk (Juurlink et al. 2004). These results allow us to identify a subgroup which is at a higher risk of developing depressive symptomatology and suicidal ideation which in turn are a major risk factor for suicide attempts. This is also of prime importance when it is taken into account how depression or anxiety worsen morbidity and mortality in ESRD (Feroze et al. 2010; Untas et al. 2009; Cukor et al. 2006, 2008b; Kimmel et al. 2000; Kimmel 2001). Our study has several limitations. First, the size of the sample is somewhat limited. This results in a diminished statistical power. It could explain why it failed to find more statistically significant correlations. Second, our sample came from one dialysis center residing in the capital, but we have no reason to believe that this constitutes a selection bias seeing as it is frequented by people from all regions, age groups, and communities. We have no proof that the rates of organic comorbidities are higher in other centers. However, of the 83 patients at the dialysis center, 51 accepted to take part in the study with respect to the inclusion criteria. These patients could have had significant psychiatric illnesses that were left undiagnosed. This is an inevitable selection bias that is a direct consequence of the stigma that psychiatry carries in Lebanon. The obligatory Late-Look Bias could be held partially responsible for not finding patients at a high risk of suicide as they would have passed away already. We do not believe that confining the sample to English or French speaking patients impacts generalizability, as the Lebanese population is largely bilingual. In conclusion, our study is the first to examine the prevalence of anxiety, depression and suicidal ideation in the Lebanese ESRD population and its correlation with organic comorbidities. It allowed us to determine a subtype of patients on dialysis who are at increased risk of
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developing symptoms of depression, anxiety as well as suicidal ideation. These patients consist of those that have at least one other organic comorbidity such as neoplasms, diabetes, cardiac, hepatic or respiratory failure, rheumatoid diseases, history of strokes, hypothyroidism, and Parkinson’s disease. It is worth noting that there are no studies on the impact of these factors on the morbidity and mortality. Mental health is heavily stigmatized in Lebanon. Mental diseases are under-estimated by health care providers. It is crucial to look for these ailments in the populations at risk. A psychiatric consultation should be systematically considered in patients on dialysis with multiple comorbidities, with or without clinical suspicion. The high reliability of the HADS and the consistency of our results with other studies should encourage its use on the individual level to orient patients towards psychiatrists. Conflict of interest This study was conducted with no financial support or third-party involvement and thus does not present any conflict of interest or any possible bias resulting from such association.
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