Original Article Depression and quality of life in patients on long term hemodialysis at a national hospital in Ghana: a cross-sectional study Vincent J. Ganu1, Vincent Boima2, David N. Adjei3, Joana S. Yendork5, Ida D. Dey2, Ernest Yorke2, Charles C. Mate-Kole4,5,6 and Michael O. Mate-Kole2 Ghana Med J 2018; 52(6): 22-28 DOI: http://dx.doi.org/10.4314/gmj.v52i1.5 1Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra 2Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra 3School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Box 4236, Accra 4Department of Psychiatry, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Box 4236, Accra 5Department of Psychology, University of Ghana, Legon 6Centre for Ageing Studies, University of Ghana, Legon Corresponding author: Vincent J Ganu E-mail: vincentjganu@gmail.com Conflict of interest: None declared SUMMARY The study examined quality of life and prevalence of depressive symptoms in patients on long term hemodialysis. Further, it explored the impact of socio-demographic characteristics on depression and quality of life. Design: Study design was cross-sectional. Setting: Study was conducted in the two renal dialysis units of the Korle-Bu Teaching hospital in Accra, Ghana. Participants and study tools: One hundred and six participants on haemodialysis were recruited for the study. The Patient Health Questionnaire and the World Health Organization Quality of Life instrument were used to assess de- pression and quality of life. Results Forty five percent of participants screened positive for symptoms of depression. Approximately 19% obtained low scores on overall quality of life. There were significant negative correlations between the following: Depression and overall QoL, Depression and duration of dialysis treatment and Depression and income level. There was positive correlation between overall QoL and duration of dialysis, treatment and income. Conclusion: Depressive symptoms were common amongst patients on long term hemodialysis. Haemodialysis pa- tients who obtained low scores on quality of life measures were more likely to screen positive for depressive symp- toms. Screening for depressive symptoms among these patients is critical as early treatment may improve their general wellbeing. Funding: Not indicayed Keywords: Depression, quality of life, hemodialysis, chronic kidney disease INTRODUCTION Studies on End Stage Renal Disease (ESRD) have re- In addition, complications of hemodialysis (i.e., hypoten- ported an increase in the burden of the disease worldwide sion, headache and air embolism) may contribute to di- due to increasing prevalence of diabetes and hyperten- minished working capacity and adversely affect individ- sion.1,2 Studies have reported an increase in ESRD cases ual productivity.7 Factors such as financial dependence, by approximately 70% in the past 20 years.3 ESRD is ac- inability to carry out family responsibilities, and engage companied by increased mortality and escalating costs of in active social life, have been attributed to reduced qual- providing care for patients.4,5 Despite the advances in the ity of life in patients on long-term hemodialysis. These treatment of ESRD, affected individuals still report low factors may result in mental health issues such as depres- quality of life.6 ESRD results in a decline in physical sion, anxiety and impaired cognition.8 functioning, poor psychological health and medical com- plications such as anemia and neurological disorders.7 22 www.ghanamedj.org Volume 52 Number 1 March 2018 Original Article Depression is reported to be one of the most common Self-administered questionnaires used included the psychological conditions among ESRD patients on he- World Health Organization Quality of Life (WHOQOL modialysis.9 A study in a tertiary hospital among hemo- BREF)17 and the Patient Health Questionnaire (PHQ-9) dialysis patients in Nigeria found the prevalence of de- comprising 9 items.18 pression to be 34.5%10 compared to a prevalence of 27% among African American hemodialysis patients.11 An- The PHQ-9 is one of the most commonly used tests for other study conducted on depression among ESRD pa- screening depression in many settings.19 It consists of 9- tients in Sudan reported a prevalence of 72%.12 items that measure the incidence of depressive thoughts and feelings in individuals over the previous two weeks. The risk factors for depression among ESRD patients in- The PHQ-9 is a 4-point Likert scale with a range from 0 clude low compliance to medications, poor nutritional to 3. Zero for “not at all” responses and 3 for “nearly status and marital problems.13 Depression may be linked every day” responses. Scores range from 0 to 27. The in- to significant restrictions in independent living due to the terpretation of the scores were done along these dimen- hemodialysis treatment modality. Patients on dialysis are sions: a score less than 10 demonstrated no symptoms of connected to the hemodialysis machine for at least 2 depression; scores from 10 to 14 demonstrated symptoms hours per session with a minimum of three sessions per of moderate depression; scores 15 to 19 depicted symp- week.14 toms of moderately severe depression, and scores from 20 to 27 depicted symptoms of severe depression. The Socio-demographic variables such as age and family sup- Cronbach’s alpha of the PHQ-9 for the present sample port have been reported to play a significant role in the was 0.815. psychological wellbeing of haemodialysis patients.15 Pa- tients with varying times on dialysis have also reported The WHOQOL-BREF, a shorter form of the WHOQOL- differences in their accounts of perceived consequences 100 was administered. It assessed four domains of QoL; of treatment (i.e., depression).16 namely, physical, psychological, social and environmen- tal. Items on this measure were scored on a 5-point Likert The burden of ESRD is rising and presents a challenge scale. The scores range from 1 (low) to 5 (high) with in- for both developed and emerging economies. Psycholog- creasing scores from 1 to 5 denoting higher QoL. The raw ical problems among these patients have been largely un- domain scores obtained from the WHOQOL-BREF were derstudied in Africa, and to our knowledge, there is no transformed to a 4-20 score and then scaled in a positive data on this subject in Ghana. The present study exam- direction (i.e. higher scores denoting higher quality of ined the prevalence of depression and quality of life sta- life). The mean score within each domain is used to cal- tus among patients with ESRD on hemodialysis. Further, culate the domain score and these are linearly trans- it explored the impact of demographic characteristics on formed to a 0-100 scale.20 The Cronbach’s alpha of the depression and quality of life. WHOQOL-BREF for the present sample was 0.815. METHODS Statistical analysis The study design was cross-sectional and was conducted SPSS statistical software version 20.0 was used for data at the two renal dialysis units (Department of Medicine cleaning and analysis. Categorical variables were ana- and Cardiothoracic Center) of the Korle-Bu Teaching lyzed and presented as frequencies and percentages. The hospital in Accra, Ghana. These renal dialysis units serve continuous variables were presented as means and stand- as referral centres and offer only haemodialysis for all ard deviations. Preliminary analyses were conducted to kidney disease patients. Recruitment of the participants ascertain the normality of the data. The results showed was based on these criteria: 1) Clinical diagnosis of end- that all the variables (depression, the total and domain stage renal disease; 2) Hemodialysis treatment; 3) Age 18 scores of QoL) had skewness and kurtosis values that fell years and above; 4) Voluntary participation and signed within +2 and -2, thus, indicating that the data was close consent form. to normal in line with the criteria proposed by George and Mallery.21 Inferential statistics were carried out using the Participants were briefed on the nature of the study and independent sample t-test to compare participants with made aware that they could decide at any point in time to differences in demographic characteristics on scores of discontinue without any negative consequences. Partici- depression, overall QoL and the four domains of QoL. pants who gave consent were included in the study and Bonferroni adjustment was used to adjust the alpha level they completed the self-administered questionnaires. for the results of the t-test to 0.008 in order to control for Type I error due to multiple analyses. In addition, the Pearson Correlation Coefficient was used to compute the relationship between symptoms of depression, quality of 23 www.ghanamedj.org Volume 52 Number 1 March 2018 Original Article life, dialysis treatment duration and income.Standard lin- Variable Frequency Percent ear multiple regression was used to explore selected var- Educational iables that would predict overall quality of life. Signifi- Status Primary 2 1.9 cance level for all other analysis was set at a p-value less Junior High School 14 13.2 than 0.05. Senior High School 35 33 Ethics statement Tertiary Education 55 51.9 This study was approved by the Ethical and Protocol Re- Employment view Committee of the College of Health Sciences, Uni- status Actively working 39 36.8 versity of Ghana with protocol identification number Not actively working 48 45.3 MS-Et/M.5 – P 3.2/2012-2013. Pensioners 12 11.3 Student 7 6.6 RESULTS Transporta- At the time of the study, there were 129 ESRD patients tion Private/Own car 37 34.9 on dialysis at the Korle-Bu Teaching Hospital. Of the 129 Public: Taxi 56 52.8 ESRD patients, 106, aged between 21-79 years (mean = 48.7; SD=1.33). consented and participated in the study, Public: Other 13 12.3 giving a response rate of 82%. Table 1 shows the demo- Disability Yes 7 6.6 graphic characteristics of the participants. No 99 93.4 As illustrated in Table 2, the prevalence of depressive Table 2 Distribution of depression and quality of life symptoms among the participants was approximately among End Stage Renal Disease patients on haemodial- 44% with about 6% screening positive for severe depres- ysis at a tertiary hospital in Ghana, 2013. sion. Eighty-six (81%) of the respondents obtained high scores on the WHO-QOL BREF while 20 (19%) had low Fre- Per- scores. In terms of the domains of quality of life, 104 par- Variable quency cent ticipants (98%) scored low on social relationship wellbe- Depression ing while 18 (17%) had poor psychological wellbeing. Normal 59 55.66 Moderate De- Comparisons of Depression and QoL scores for the pression 28 26.42 various demographic variables Moderately Se- The independent t-test was computed to examine be- vere Depression 13 12.26 tween-group differences on education (high vs low), in- Severe Depres- sion 6 5.66 come (high vs low) and participants’ scores on depres- sion, overall QoL and the four domains of QoL. Total 106 100 Table 1 Distributions of demographic characteristics of Quality of Very participants. (N = 106) Life good Good Poor Total Variable Frequency Percent n (%) n (%) n (%) n(%) 76 20 106 Age 20-29 10 9.4 Overall 10 (9.4) (71.7) (18.9) (100) 44 4 106 30-39 16 15.1 Physical 58 (54.7) (41.5) (3.8) (100) 40-49 29 27.4 73 18 106 Psychosocial 15 (14.2) (68.8) (17.0) (100) 50-59 24 22.6 Social relation- 1 104 106 ship 1 (0.9) (0.9) (98.2) (100) 60-69 21 19.8 21 3 105 70≥ 6 5.7 Environment 81 (77.1) (20.0) (2.9) (100) Sex Male 63 59.4 As shown in Table 3, participants with higher levels of Female 43 40.6 education reported higher scores on overall QoL and the Marital Status Single 15 14.15 four domains of QoL than those with low levels of edu- Married 81 76.41 cation. With regards to transportation, significant differ- ences emerged on all the variables. Those who used pri- Divorced 4 3.78 vate transportation reported less depressive symptoms Widow/Widower 6 5.66 than those who used public transportation (See Table 3). 24 www.ghanamedj.org Volume 52 Number 1 March 2018 Original Article Table 3 T-test results for the differences between ESRD patients on haemodialysis on selected demographic charac- teristics. Trans- Education portation Employment No ter- Unem- Em- tiary Tertiary Public Private ployed ployed Mean Mean Mean Mean Mean Mean Measure (SD) (SD) 95% CI (SD) (SD) 95% CI (SD) (SD) 95% CI 69.86 82.6 71.07 86.54 -21.61- - 71.84 84.44 Overall QoL (12.57) (15.81) 0.15–0.54 (12.82) (15.6) 9.87 (12.68) (17.14) -18.38- -6.82 40.74 53.38 -19.33- - 42.14 56.92 -21.67- - 41.95 56.49 Qol-Physical (15.69) (18.77) 5.95 (16.74) (17.68) 7.88 (15.21) (19.93) -21.36- -7.71 QoL-Psycho- 42.61 56.51 -20.6- - 45.23 58.89 45.01 58.67 logical (14.52) (17.78) 8.04 (14.71) (19.64) -20.3- -6.9 (14.17) (19.99) -20.26- -7.05 28.37 38.51 -18.12- - 30.05 40.32 -18.67- - 29.55 40.64 QoL-Social (17.84) (23.07) 2.15 (18.94) (23.83) 1.89 (20.84) (20.32) -19.34- -2.84 QoL-Environ- 48.57 59.76 -16.67- - 48.45 65.43 -22.24- - 51.82 58.77 ment (14.04) (14.49) 5.69 (12.7) (13.55) 11.73 (13.03) (17.86) -12.93- -0.41 On employment (actively working), significant differ- Actively working participants reported higher overall ences were noted on these variables; Overall QoL (t[104] QoL than those not actively working. Actively working = -4.32, 95% CI= -18.38 - -6.82), Physical health (t[104] participants reported better physical health than those not = -4.22, 95% CI = -21.36 - -7.71), Psychological health actively working. Actively working participants reported (t[104] = -4.1, 95% CI = -20.26 - -7.05), Social Relation- better psychological health than those not actively work- ship (t[104] = -2.67, 95% CI= -19.34 - -2.84) and Envi- ing. Actively working participants reported better social ronment (t[104] = -2.3, 95% CI = -12.93 - -0.41). Those relationships than those not actively working. Lastly, who were actively working reported less depressive those who were actively working reported better environ- symptoms than those who were not actively working. mental wellbeing than those not actively working. Table 4 Summary of inter-correlations for scores on WHOQOL_BREF, PHQ, Income and Treatment Duration in ESRD patients on haemodialysis a tertiary hospital in Ghana, 2013 Measures 1 2 3 4 5 6 7 8 1. WHOQOL-BREF Total 1 2. Physical Health .812** 1 3. Psych. Health .850** .757** 1 4. Social Relationships .722** .521** .628** 1 5. Environment .806** .729** .747** .515** 1 6. PHQ -.539** -.619** -.521** -.320** -.536** 1 7. Treatment duration .303** .317** .361** .296** .28** -.339** 1 8. Income .191* .186 .251** .043 .224* -.155 .162 1 Note. *p < .05; **p < .01 WHOQOL-BREF - World Health Organization Quality of Life PHQ - Patient Health Questionnaire Treatment duration is in months Income is in Ghana Cedis Relationship between QoL, Depression, Treatment 0.0001), environment (r = -0.54, p = 0.0001), and treat- duration and Income ment duration (r = -0.34, p = 0.0001). The Pearson’s correlation analyses were conducted to ex- plore relationships among the variables. The results, as There were, also, positive correlations between treatment shown in Table 4 revealed a negative correlation between duration and the following: overall QoL (r = 0.30; p = depression and overall QoL (r = -0.54, p = .0001), phys- 0.002), physical wellbeing (r = 0.32; p= 0.001), psycho- ical health (r = -0.62, p = 0.0001), psychological health social (r = 0.36; p = 0.0001), social relationships (r = (r = -0.52, p = 0.0001), social relationship (r = -0.32, p = 0.30; p = 0.005) and environmental wellbeing (r = 0.28; p = 0.004). 25 www.ghanamedj.org Volume 52 Number 1 March 2018 Original Article Additionally, income correlated positively with overall This might be due to socio-cultural and economic differ- QoL (r = 0.19, p = 0.05), physical health (r = 0.19, p = ences amongst study populations in addition to the use of 0.05) and environmental well-being (r = 0.22, p = 0.021). different tools in assessing depression. Selected predictors of overall QoL Majority of our patients (91.5%) had supportive family Standard linear regression analyses were performed to members and most patients had received at least, nine examine whether depression, income (assessed in Ghana years of education (84.9%). These factors might have en- Cedis) and treatment duration (in number of months on hanced their coping skills about long standing debilitat- dialysis) predicted overall quality of life. Table 5 shows ing illness and the subsequent treatment. A similar find- that depressive symptoms (β = -0.483, 95% CI = -0.998 ing has been reported in a study among African American – -0.47) emerged as a significant predictor of overall patients on dialysis in the United States.25 The significant QoL, but not income (β = -0.10, 95% CI = 0.000 – 0.001) number of participants with good family support may and dialysis treatment duration (β = -0.12, 95% CI = - stem from the fact that majority of them (76.4%) were 0.231 – 1.375). married. Being married is linked to better physical and emotional well-being and might not be associated with Table 5 Standard linear regression analysis for selected depression.26 However, our study did not support previ- predictors of quality of life in ESRD patients at a tertiary ous studies.26 Almost 50% of our dialysis population hospital in Ghana, 2013. (45.3%) were not actively working. The findings are sim- ilar to outcomes from other studies in which unemploy- ment rate amongst patients was 66%.27 Variables Β 95% CI Depression -0.483 -.998 – -.47 Our study revealed that income correlated positively with overall QoL, physical health and environmental well-be- Income (Ghana Cedis) 0.096 .000 – .001 ing, but negatively correlated with depression. This is not Treatment duration (months) 0.124 -.231 – 1.375 surprising since most of our patients had limited funds for dialysis treatment and they could only afford a session DISCUSSION or two of hemodialysis treatment per week. Similarly, This study revealed that depressive symptoms were high other studies have shown significant association between (prevalence of 44%) among ESRD patients. In addition, depression and level of income. 28 about 20% of these patients reported poor quality of life. Overall, there were significant relationships between re- Eighteen percent of the participants in the present study spondent’s overall QoL and depression, educational level reported poor quality of life. The changes in patients’ so- of respondents, employment status, levels of income and cial relationship and psychological wellbeing due to ill- means of transportation. The presence of depressive ness symptoms have been recognized as factors contrib- symptoms was negatively correlated with overall QoL uting to the poor quality of life. Our explanation supports and treatment duration. reports from other studies which suggested that patients on haemodialysis suffer psychological problems in addi- The prevalence of depressive symptoms amongst our pa- tion to the physical challenges. 29 Having higher scores for tients was lower than the prevalence of 72% reported in depression were associated with poorer QoL. The present similar study in Sudan.12 However, prevalence of depres- findings also support the association between depression sive symptoms was higher in our study compared to a and poor QoL. 24,30 prevalence of 20.1% reported in another study from the United States of America.22 The prevalence of depressive Our study revealed that there is a significant relationship symptoms found among hemodialysis patients in the pre- between income and QoL; this is supported by previous 31 sent study could have resulted from the influence of fac- studies. Similarly, low socio-economic status of these tors such as loss of jobs, low levels of income. patients have been reported by some studies to signifi- cantly affect patients’ QoL. 23,29 The drastic changes of one’s lifestyle as a result of spend- ing about 3 hours per day on dialysis machine is a con- The awareness of one’s chronic disease which helps in tributory factor to the high prevalence rate of depression. coping with the disease has reportedly been affected pos-32 Previous studies reported substantial variation in the in- itively by a higher level of education. Our findings of a cidence rate of moderate to severe depression ranging significant association between level of education and the from 33.3% to 78.8% among ESRD patients on haemo- physical wellbeing, psychosocial wellbeing and environ- dialysis treatment.23,24 mental wellbeing domains are similar to other studies. 33 26 www.ghanamedj.org Volume 52 Number 1 March 2018 Original Article Further, we noted a significant relationship between em- ACKNOWLEDGEMENT ployment and QoL and our findings further support find- We thank the staff and patients of the of the dialysis units ings from other studies.33,34 Employment is reported to of the Cardiothoracic and Renal units of the Korle-Bu improve QoL of ESRD patients probably due to the reg- Teaching Hospital for their invaluable contribution to ular income which caters for the costs of treatment.33,34 this study. There are limitations in the present study. Some of the REFERENCES patients were interviewed during dialysis; therefore, im- 1. 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