




































 
 

Aatir H. Rajput 7 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Original Article 

Depression, Anxiety & Stress among Patients of End Stage 

Renal Disease Undergoing Hemodialysis 
Aatir H. Rajput1, Maryam Shaikh2& Sooraj Kumar3 

Virtual University of Pakistan1 

Liaquat University Hospital, Hyderabad2& 3 

Liaquat University of Medical & Health Sciences, Jamshoro1, 2 &3 

Corresponding Author: aatirh.rajput@gmail.com 

 

Abstract 

Objective This study is projected to check the prevalence of depression, anxiety and stress in the 

patients of End Stage Renal Disease (ESRD) undergoing hemodialysis at centers in Hyderabad 

and investigate the reasons behind it. Methodology This observational, multi-center study 

comprised of a sample of 100 patients of ESRD undergoing hemodialysis selected (via simple 

random sampling) from different hospitals of Hyderabad. The data was collected using interview 

based structured questionnaires, after taking informed consent, from 1st Dec 2014 to  10th Feb 

2015. Levels of depression, anxiety and stress were gauged using the DAS scale approved by the 

Australian Center for Posttraumatic Mental Health. Results According to the mean scores 

obtained, moderate levels of depression and stress while severe levels anxiety prevailed. 69% 

patients declared diet control rules as bothersome. Although, 50% of respondents were on dialysate 

for more than a year and 83% underwent dialysis twice per week yet the mean levels of serum 

albumin and urea were not within normal range. Conclusion On the basis of this result we come 

to know that great numbers of patients of ESRD undergoing hemodialysis were suffering from 

anxiety depression and stress and uremia. 

 

Keywords 
End Stage Renal Disease, Hemodialysis, Psychological Distress, Depression, Anxiety and Stress 

 

Introduction 

Researchers from far and wide, have 

recognized depression to be the chief mental 

health concern among patients struggling 

with End Stage Renal Disease (ESRD) 

(Kimmel, 2008 & Hedayati, 2006). Fresh 

statistics hint towards a staggering twenty to 

thirty percent prevalence of psychological 

distress (Depression, anxiety and stress) in 

the ESRD patients undergoing hemodialysis 

(Cukor, et al., 2006). Second only to 

hypertension, depression is the most frequent 

comorbid diagnosis among ESRD patients 

(US Renal data system, 2004) but sadly, this 

grave issue still remains under-researched 

(Kimmel, 2002) and is rarely, if at all, dealt 

with appropriately in patients of ESRD 

undergoing hemodialysis (Kimmel, et al., 

2006). In addition to that, depression has the 

potential to stall the process of healing and 

heighten the mortality rate of the ailments 

(Katon, 2002 & Evans, 2003) and 

particularly in ESRD (Kimmel, 2003 

&1993).  

Anxiety and stress, two of the common 

comorbid psychological conditions were 

found slightly mentioned in published 

literature but we believe that they too, like 

depression, need to be taken seriously.   

In spite of the heightened incidence of 

depression and the abundant scientific proof 

of its complications, clinical interventions of 

http://www.aeirc-edu.com/
mailto:aatirh.rajput@gmail.com


 
 

Aatir H. Rajput 8 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

the problem are seldom researched among 

patients struggling with ESRD 

(Rabindranath, 2005). While the reason of 

lack of interventionist approach against 

anxiety and stress is its absence from 

academic literature, unavailability of baseline 

statistics and information about them as 

significant comorbidities.  

 

One problem however, that may obstruct 

effective investigation of this issue, is the fact 

that depressive symptoms are very similar to 

uremic symptoms, and a clear diagnosis is 

thus often put in doubt against the backdrop 

of the uremic illness (Kimmel, 2001, 2004, 

2000 & 2002). For instance, it is difficult to 

identify whether the cognitive dysfunction, 

encephalopathy or plain irritability is 

stemming from a psychological cause, 

uremia, and inadequate dialysis or due to the 

effect of drugs (Kimmel, et al.,  2001, 2004, 

2000, 1993) in their work, revealed that 

anxiety disorder was common in patients 

struggling with ESRD, but in our thorough 

and detailed literature review, we did not find 

any parallels to our own study that screens 

patients with ESRD for multiple psychiatric 

complaints and not just one.  

 

We therefore attempted to screen the ESRD 

patient population for a range of comorbid 

psychiatric complaints at various 

hemodialysis centers across the city that cater 

to the needs of patients from all socio-

demographic backgrounds. We did not 

attempt to dissociate the symptoms of 

depression from those of uremia, however 

further research can be conducted using a 

novel approach based on the identification of 

depression-specific cognitive schema. 

 

 

 

 

 

Methodology 

This observational, multi-center study 

comprised of a sample of 100 patients, 

undergoing hemodialysis at major 

professional hemodialysis centers (namely; 

Maaji hospital, Liaquat University Hospital, 

K.K Dialysis center, Bhittai Hospital, 

Rajputana Hospital, Hafeez Memorial 

Dialysis Centre, Mohinibai hospital and M.K 

hospital) located in different strata of 

Hyderabad, selected (via simple random 

sampling) from different hospitals of 

Hyderabad. The data was collected using 

interview based structured questionnaires, 

after taking informed consent, from 1st Dec 

2014 to  10th Feb 2015. Levels of depression, 

anxiety and stress were gauged using the 

DAS scale approved by the Australian Center 

for Posttraumatic Mental Health. Data was 

analyzed using SPSS v. 19.0 and Microsoft 

Excel 2013. 

 

Results 

The sample hemodialysis patient population 

we selected had varied socio-demographic 

background. We recorded the superficial 

factors and the figure 1 below depicts them in 

detail.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 9 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Figure 1 showed that a greater proportion of male patients (70.7%) visited hemodialysis 

centers as compared to females (29.3%). The diseased patients rarely belonged to the 

higher socioeconomic class (18.2%). Middle class was the predominant socioeconomic 

fraction that reported at hemodialysis centers (61.6%) and this is worrisome since this 

fraction that thrives on limited earning. The uneducated patients (68.3%) patients were far 

more than educated patients (31.3%) owing to our low national literacy rate. 

 

 

 
According to the mean scores obtained, moderate levels of depression and stress while severe 

levels of anxiety prevailed. The combined psychological effect of the three problems takes a big 

toll on the patients. Figure 2 below further describes this fact. 

 

Figure 2 shows the effects of depression, anxiety and stress were marked in the patient 

population that we studied. The Depression, Anxiety & Stress Score (DASS), approved by 

the Australian center for post traumatic health, validated our hypothesis by confirming 

that these three were indeed present at significant levels. 

 

 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 10 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

The factors leading up to such levels of depression, anxiety and stress, other than the chronicity of 

the illness, were investigated. The findings we reached, showed that the need to frequently visit 

and pay for the clinics, diet control rules and the chronicity of the illness were the main culprits.  

 

 

Figure 3 shows a very handsome percentage of the population (69%) were bothered by the 

diet control rules and identified them as important stressors that and sources of anxiety 

that triggered depression. Serious thought must be put into modifying these rules so that 

they not only ensure good physical but mental health. 

 

 
 
 

 

Figure 4 shows 50% of the respondents were on dialysate for more than a year. The 

general trend observed is exhibited by the dotted trend-line above. The respondents were 

divided into 4 groups and the groups increased in size as time increased. We believe that 

the longer patients endure their medical problems, the greater their chances of falling prey 

to depression, anxiety and stress. 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 11 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

 
 

Figure 5 shows that 83% of the patients were required to pay two visits to the dialysis 

centers per week. 11% of the patients visited the dialysis center almost every other day and 

only 6% of the patients paid single visits to the dialysis center per week. Dialysis, in itself is 

not a very comfortable process, and the deed to get a dialysate often indicate failure of 

treatment, heightened symptoms and problems. Hence the greater the frequency, the 

greater the psychological impact. 

 

 

 
 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 12 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

 

Figure 6 showed Uremia was common as the average serum urea levels were well above 

normal. Hyper-albuminemia was also marked in the entire sample. Hemoglobin was, 

however, worryingly low. Such levels, despite the frequent dialysate treatment indicate 

failure of treatment and hence give birth to negative psychological factors such as 

depression, anxiety and depression. But, as discussed above, symptoms of uremia match 

those of depression closely and often overlap. Giving rise to doubt and suspicion over the 

validity of presence of depression and other closely resembling psychiatric comorbidities. 

 

 
 

 

Discussion 

Our research attempted to investigate a 

greater range of psychopathology in patients 

struggling with ESRD then what has been 

reported earlier in literature. Our sample 

comprised of urban patients from Hyderabad 

suffering from End Stage Renal Disease 

(ESRD) and currently being treated to 

hemodialysis. A total of one hundred such 

patients from the different Hemodialysis 

Center were included in the study and their 

data was utilized to obtain our results. Our 

study population reported higher incidence 

and prevalence of uremia with average levels 

reaching above 100g/dl, as determined by 

pathology reports. Rates of depression too far 

exceeded the levels reported by most authors 

but it is important  

 

 

to point out that there have been instances 

when even higher rates of depression have 

been reported in literature and a few 

examples include Watnick et al., (twenty six 

percent), Hedayati et al., (twenty seven 

percent) and Kimmel et al., (twenty five 

percent). 

None of the patients diagnosed with 

depression reported receiving mental health 

treatment, neither did any patient with a 

diagnosis of anxiety or stress were currently 

receiving treatment. This highlights how 

under-recognized depression, stress and 

anxiety are and perhaps suggests a tolerance 

of depression, stress and anxiety by 

physicians and staff, accepting them as part 

of the ESRD experience. The average level of 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 13 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

comorbid depression, stress and anxiety (20.7 

for depression, 16.1 for stress and 15.1 for 

anxiety disorder) was found. It is possible 

that the depression demonstrated in ESRD 

populations is causally linked to ESRD, 

because there has been some research 

suggesting a causative link through 

inflammatory processes (Cukor, 2000) and a 

psychodynamic literature linking depression 

and dialysis.  

 

Literature suggests that the health related 

quality of life (HrQoL) score of ESRD 

patients that do not suffer from either 

depression, anxiety or stress is significantly 

higher than those patients that do suffer from 

comorbid psychological distress (i.e. either 

depression, anxiety or stress), (Kimmel, 

2006). This suggests that despite undergoing 

hemodialysis, patients (without comorbid 

psychological distress), especially 

depression, can benefit from a higher quality 

of life. These results re-iterate the strong and 

increasingly important need for 

psychiatric/psychological help for ESRD 

patients, since clear indications have now 

been unearthed that such help may not only 

decrease depression and other forms of 

psychological distress, but also improve 

health related quality of life (Cukor, 2005 & 

Rabindranath, 2005). 

 
 

Conclusion 

On the basis of our result, we conclude that 

depression, anxiety and stress are a marked 

feature in end stage renal disease (ESRD). 

Often, uremia can mimic the depressive 

symptoms and may lead to a false diagnosis 

but the main concern we wish to highlight by 

this study is towards the psychological health 

of the patients that both comorbid depression, 

anxiety, stress and uremia put at a high risk. 

Further research is advised to differentiate 

and separately gauge the effects of 

depression, anxiety, stress & uremia. 

However, main focus should be directed 

towards countering the adverse effects 

caused by psychological comorbidities and 

uremia that subdue the will to live and the 

will to recover.  

 

Acknowledgements 

We would like to acknowledge the 

intellectual assistance and technical support 

provided by Dr. Muhammad Muneeb and 

LUMHS Research Forum during the 

preparation of this manuscript. 

 

 

 

Conflict of interests 

All the authors disclosed that there is no 

competing interest associated with the 

preparation of this article.   

 

Funding 

We declare that we did not acquire funding 

from any source for any aspect of this 

research. 

 

References  

 Black, D. W., Winokur, G., & Nasrallah, 

A. (1987). Treatment and outcome in 

secondary depression: a naturalistic study 

of 1087 patients. Journal of Clinical 

Psychiatry. 

 Cukor, D. (2007). The hemodialysis 

center: a model for psychosocial 

intervention. PsychiatrServ, 58, 711-712. 

 Cukor, D., &   Friedman, S. (2005). 

Towards the psychosocial treatment of 

depressed patients on dialysis. Internet J 

Nephrol, 2(2), 3. 

 Cukor, D., Peterson, R. A., Cohen, S. D., 

& Kimmel, P. L. (2006). Depression in 

end-stage renal disease hemodialysis 

patients. Nature clinical practice 

Nephrology, 2(12), 678-687. 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 14 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

England Journal of Medicine, 353(17), 

1819-1834. 

 Evans, D. L., & Charney, D. S. (2003). 

Mood disorders and medical illness: a 

major public health problem. Biological 

psychiatry, 54(3), 177-180. 

 Gorodetskaya, I., Zenios, S., Mcculloch, 

C. E., Bostrom, A., Hsu, C. Y., Bindman, 

A. B., & Chertow, G. M. (2005). Health-

related quality of life and estimates of 

utility in chronic kidney disease. Kidney 

international, 68(6), 2801-2808. 

 Hedayati, S. S., Bosworth, H. B., 

Kuchibhatla, M., Kimmel, P. L., & 

Szczech, L. A. (2006). The predictive 

value of self-report scales compared with 

physician diagnosis of depression in 

hemodialysis patients. Kidney 

international, 69(9), 1662-1668. 

 Katon, W., & Ciechanowski, P. (2002). 

Impact of major depression on chronic 

medical illness. Journal of psychosomatic 

research, 53(4), 859-863. 

 Keith, D. S., Nichols, G. A., Gullion, C. 

M., Brown, J. B., & Smith, D. H. (2004). 

Longitudinal follow-up and outcomes 

among a population with chronic kidney 

disease in a large managed care 

organization. Archives of internal 

medicine, 164(6), 659-663. 

 Kessler, R. C., Chiu, W. T., Demler, O., 

& Walters, E. E. (2005). Prevalence, 

severity, and comorbidity of 12-month 

DSM-IV disorders in the National 

Comorbidity Survey Replication. 

Archives of general psychiatry, 62(6), 

617-627. 

 Kimmel, P. L. (2001). Psychosocial 

factors in dialysis patients. Kidney 

international, 59(4), 1599-1613. 

 Kimmel, P. L. (2002). Depression in 

patients with chronic renal disease: what 

we know and what we need to know. 

Journal of psychosomatic research, 53(4), 

951-956. 

 Kimmel, P. L., & Peterson, R. A. (2004). 

Depression in end-stage renal disease 

patients treated with hemodialysis: tools, 

correlates, outcomes, and needs. In 

Seminars in dialysis (Vol. 18, No. 2, pp. 

91-97). 

 Kimmel, P. L., & Peterson, R. A. (2006). 

Depression in patients with end-stage 

renal disease treated with dialysis: has the 

time to treat arrived? Clinical Journal of 

the American Society of Nephrology, 

1(3), 349-352. 

 Kimmel, P. L., Patel, S. S., & Peterson, 

R. A. (2002). Depression in African-

American patients with kidney disease. 

Journal of the National Medical 

Association, 94(8 Suppl), 92S. 

 Kimmel, P. L., Peterson, R. A., Weihs, K. 

L., Simmens, S. J., Alleyne, S., Cruz, I., 

& Veis, J. H. (2000). Multiple 

measurements of depression predict 

mortality in a longitudinal study of 

chronic hemodialysis outpatients. Kidney 

international, 57(5), 2093-2098. 

 Kimmel, P. L., Peterson, R. A., Weihs, K. 

L., Simmens, S. J., Alleyne, S., Cruz, I., 

& Veis, J. H. (1998). Psychosocial 

factors, behavioral compliance and 

survival in urban hemodialysis patients. 

Kidney international, 54(1), 245-254. 

 Kimmel, P. L., Peterson, R. A., Weihs, K. 

L., Simmens, S. J., Boyle, D. H., Umana, 

W. O., & Veis, J. H. (1996). Psychologic 

functioning, quality of life, and 

behavioral compliance in patients 

beginning hemodialysis. Journal of the 

American Society of Nephrology, 7(10), 

2152-2159. 

 Kimmel, P. L., Thamer, M., Richard, C. 

M., & Ray, N. F. (1998). Psychiatric 

illness in patients with end-stage renal 

disease. The American journal of 

medicine, 105(3), 214-221. 

 Kimmel, P. L., Weihs, K., & Peterson, R. 

A. (1993). Survival in hemodialysis 

http://www.aeirc-edu.com/


 
 

Aatir H. Rajput 15 

  

Annals of Psychophysiology                                                                                                                Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

patients: the role of depression. Journal of 

the American Society of Nephrology, 

4(1), 12-27. 

 Klein, D. N., Taylor, E. B., Harding, K., 

& Dickstein, S. (1988). Double 

depression and episodic major 

depression: demographic, clinical, 

familial, personality, and 

socioenvironmental characteristics and 

short-term outcome. Am J Psychiatry, 

145(10), 1226-1231. 

 Mann, J. J. (2005). The medical 

management of depression. New   

 McGinn, L. K., Young, J. E., & 

Sanderson, W. C. (1995). When and how 

to do longer term therapy… without 

feeling guilty. Cognitive and Behavioral 

Practice, 2(1), 187-212. 

 Rabindranath, K. S., Butler, J., Roderick, 

P. J., Wallace, S. A., Daly, C., & 

MacLeod, A. M. (2005). Physical 

measures for treating depression in 

dialysis patients. The Cochrane Library. 

 Sharp, J., Wild, M. R., Gumley, A. I., & 

Deighan, C. J. (2005). A cognitive 

behavioral group approach to enhance 

adherence to hemodialysis fluid 

restrictions: a randomized controlled 

trial. American Journal of Kidney 

Diseases, 45(6), 1046-1057. 

 Stenvinkel, P., Ketteler, M., Johnson, R. 

J., Lindholm, B., Pecoits-Filho, R., 

Riella, M., & Girndt, M. (2005). IL-10, 

IL-6, and TNF-α: central factors in the 

altered cytokine network of uremia—the 

good, the bad, and the ugly. Kidney 

international, 67(4), 1216-1233. 

 Stokes, P. E. (2001). New 

psychopharmacologic treatment 

strategies. Annals of internal medicine, 

135(11), 1008. 

 Watnick, S., Kirwin, P., Mahnensmith, 

R., & Concato, J. (2003). The prevalence 

and treatment of depression among 

patients starting dialysis. American 

journal of kidney diseases, 41(1), 105-

110. 

 Whooley, M. A., & Simon, G. E. (2000). 

Managing depression in medical 

outpatients. New England Journal of 

Medicine, 343(26), 1942-1950. 

http://www.aeirc-edu.com/

