1. Introduction

Depression is a mental state which is marked by sadness, emptiness, hopelessness and loss of interest for most of the time [1]. It is characterized by a persistently depressed mood lasting for a minimum of two weeks [2]. Depression affects 322 million people around the world [3]. Evidence showed that depression is an important cause of disability worldwide [4]. Depression occurs more frequently in patients with chronic illness than in the general population [5]. Depression involves both cognitive and somatic features. The somatic characteristics of depression are very similar to the symptoms of uremia; such as anorexia, sleep disturbances, fatigue and gastrointestinal disorders [6]. These similarities make the recognition of depression difficult in chronic kidney disease (CKD) patients. CKD is a global health problem equally affecting the people of developed countries as well as developing countries. CKD causes enormous economic losses, and also triggers major challenges in regards to health. CKD is associated with increased social and psychological problems. Life-long treatment, recurrent symptoms, diet restriction, the high cost of treatment, deprived kidney function over time and limited capacity to work are some of the factors that alter the daily lifestyle and social functioning of CKD patients which may predispose them to increased risks of depression [7].

The prevalence of depression among general population ranges from 20% to 25% in women and 7% to 12% in men [8]. While the prevalence of depression among CKD patients has varied widely in different populations [9]. The reported prevalence of depression among CKD patients ranged between 20% and 46% in developed countries [10-13]. On the other hand this prevalence was 44.1% to 92.7% in developing countries [14-16]. Worldwide CKD is increasingly prevalent day by day. In Bangladesh approximately 100-120 CKD patients per million populations reach end stage renal disease (ESRD) every year [17]. The incidence of CKD is increasing rapidly in this country. But there is scarce evidence to assess the depression among CKD patients in Bangladesh.

Therefore, many cases of depression in the CKD patients remain undiagnosed and untreated. Proper screening and early diagnosis help in decreasing this burden and improve patient’s quality of life. In this background this study aimed to describe the depression of CKD patients at a tertiary level hospital in Bangladesh.

2. Methods

2.1 Study design

This descriptive study was carried out to describe the depression among chronic kidney disease (CKD) patients at Bangabandhu Sheik Mujib Medical Universiy (BSMMU), Dhaka, Bangladesh. The study was conducted from July 2019 to June 2020. This study was approved by the ethical review committee BSMMU, Dhaka, Bangladesh.

2.2 Participants

The study was carried out among 112 CKD patients who were admitted at Bangabandhu Sheik Mujib Medical Universiy (BSMMU) hospital in Dhaka, Bangladesh. Participants were selected by convenient sampling technique following selection criteria. Adult patients (age >18 years) of both sexes, having chronic kidney disease and willing to participate in this study were included. Renal transplant patients, patients’ having any types of malignancy, patients having previous history of any psychiatric disorder were excluded from the study.

2.3 Instruments

Two instruments were used for data collection. These were (I) Demographic Questionnaire and (II) Zung Self-Rating Depression Scale (SDS).

1. Demographic Questionnaire: The demographic questionnaire consists of 12 items including: age, gender, marital status, education level, religious belief, occupation, monthly family income, economic dependency to others, place of residence, regular physical exercise, family history of depression, duration of illness etc.
2. Zung Self-Rating Depression Scale: The Zung Self-Rating Depression Scale which was developed by Romera et al. to assess the level of depression for patients diagnosed with depressive disorder [18]. The Zung Self-Rating Depression Scale is a short, self-administered survey to quantify the depression status of a patient. There are 20 items on the scale that rate the four common characteristics of depression: the pervasive effect, the physiological equivalents, other disturbances, and psychomotor activities. There are ten positively worded and ten negatively worded questions. Each question is scored on a scale of 1-4 (a little of the time, some of the time, good part of the time, most of the time).The score ranged form 20-80. Score <50= normal range, 50-59= mild depression, 60-69= moderate depression and ≥70 severe depression.

2.4 Data collection methods

Data were collected by face-to-face interview. Before collecting data, each participant was explained about the research objectives and asked to sign the consent form only if they were willing to participate in this study. Then, each participant was requested to response particular questions of the questionnaires. Then screening of the questionnaires to check the completeness of each question was done. Confidentiality and anonymity were strictly maintained.

2.5 Data analysis

Data were analyzed using Statistical Package for Social Science (SPSS) software version 23. Categorical data were presented as frequency/percentage and continuous variables were expressed as mean ± SD (standard deviation). Statistical analyses of data were done by using independent t-test, Pearson’s correlation test and ANOVA. A p value <0.05 was considered statistically significant.

3. Results

A total of one hundred twelve (112) chronic kidney disease (CKD) patients were participated in this study. Their age ranged from 21 to 92 years and the mean age was 46.75 ( ± 14.80) years. Majority (60.71%) of the participants was male and most of them had religious belief (79.46 %). Among the total study participants; 83.93 % was married and more than half (62.50 %) of the study participants had higher secondary and above level of education.

^*BDT= Bangladesh taka

Table 1: Basic data of the study participants (N=112).

The data also reveals that 43.76 % of the participants were service-holder, the mean monthly family income of the study participants was 46214.29 ( ± 48810.24) Bangladesh taka (BDT) and 53.58% was economically independent. Nearly two third (61.60 %) of the participants lived in urban areas. Regarding regular physical exercise, it was revealed that 63.40% participants were not doing regular exercise. It was found that, almost one third of the participants (34.82 %) had family history of depression and the mean duration of illness of the study participants was 41.37 ( ± 53.07) months (Table 1).

In this study depression was observed in 90 (80.36%) participants among total 112 CKD patients. From the total number of participants; 61.61% participants have mild depression, followed by 17.86% have moderate depression, only 0.89% have severe depression and 19.64% participants had no depression. The mean Zung score of the study participants was 54.43 ( ± 6.34) (Table 2).

Table 2: Level of depression among chronic kidney disease participants (N= 112).

Relationship between different socio-demographic characteristics and depression in chronic kidney disease patients are shown in Table 3. It was observed that, there were significant relationship between some demographic characteristics and depression of CKD patients. The data analysis revealed that participants having religious belief were significantly more likely for depression (p=0.04). Unemployed participants were significantly depressed than employed participants (p=0.00). Economically independent participants were significantly more depressed than economically dependent participants (p=0.01). Participants who not doing regular physical exercise were significantly depressed than participants on regular physical exercise (p=0.01). The results indicated that participants who have no family history of depression were significantly depressed (p=0.02). The duration of illness was significantly correlated with depression among CKD patients (p=0.02). However, there were no significant relationship was observed between depression and other demographic variables of the study participants such as age (p=0.20), gender (p=0.30), marital status (p=0.39), education level (p=0.14), monthly family income (p=0.44) and place of residence (p=0.30).

p value reached from *Pearson’s correlation test, **independent t-test, and ***ANOVA

Table 3: Relationship between socio-demographic characteristics and depression of chronic kidney disease participants (N=112).

4. Discussion

Depression is becoming a very important issue in modern society. It occurs more frequently in patients with chronic illnesses than in the general population. Due to the irreversible nature and poorer prognostic outcomes, depression is frequently common among patients with chronic kidney disease (CKD). The aim of this study was to describe the depression of chronic kidney disease patients at a tertiary level hospital in Bangladesh.

A total of one hundred twelve chronic kidney disease patients were participated in this study. Their mean age was 46.75 ( ± 14.80) years. A couple of previous studies conducted in Saudi Arabia found that the mean age of CKD patients having depression were 43.6 ( ± 15.1) years and 46.55 ( ± 12.09) years respectively which were consistent with this current study [19. 20]. However, our finding was not comparable with the study carried out in Taiwan which revealed that the mean age of participants’ was 65.70 ± 12.37 years [21]. The majority (60.71%) of our participants were male and this finding was consistent with previous studies as reported that male participants was 69.6%, 61.9% and 52% respectively [16, 19, 22]. In this study, most (82.14 %) of the participants were married; in accordance Chiang et al. found 93% married in their study population [21]. In contrast Uzzal et al. found 7.9% married subjects suffering depression in their study population [16]. In our study more than half (62.50 %) of the study participants had higher secondary and above level education; in this series one third (33.2%) of the participants was illiterate and half (50%) of them had education up to secondary school level as showed by Uzzal, et al. which was consistence with this present study [16]. Nearly two third (61.60 %) of our study participants lived in urban area; in accordance Uzzal, et al. observed that most of their study participants (64.9%) were lived in urban area [16]. The data of this study also revealed that 34.82% study participants were unemployed. While Uzzal et al. reported that 72.2% study participants were unemployed which was not comparable with this current study [16]. Regarding the physical exercise, it was observed that 63.40% of our study participants were not doing regular physical exercise; in contrast Chiang et al. found 64.1% of their study participants were regularly engaged in exercise [21]. Additionally, most of our study subjects (79.46%) having religious beliefs; nearly similar results (93.3%) were shown in a previous study [23].

There are many tools to determine the validity and optimal cut-off scores for depression. In this current study the level of depression was assessed by the Zung Self –Rating Depression Scale (SDS). It was revealed that the mean Zung score of the study participants was 54.43 ( ± 6.34) and 80.36% CKD patients categorized as depressed. This finding was consistent with previous studies as reported that depression was commonly observed among CKD patients [16, 20]. The higher prevalence of depression among CKD patients could be the huge financial burden of treatment along with uncertainties about disease consequences coupled with the fear of death and complications. On the other hand, in some previous studies it was found that depression was 23.7% and 53.50% among the CKD patients; these findings were much lower than current study [19, 24]. The possible reason may be they use different scale to score the level of depression in CKD patients. In our study mild depression was more prevalent among the study participants. This finding was consistent with a previous study [16]. But severity of depression of this study was not consistent with similar previous studies probably due to socio-economic diversity [15, 24].

Several previous studies showed different types of results related to depression with different socio-demographic variables in CKD patients. In this study religious belief, unemployment, economic independency, lack of regular physical exercise, family history of depression and duration of illness were significantly associated with depression. These findings were not comparable with related previous studies; the possible explanation could be the socio-economic, cultural and ethnic diversity [21, 22, 25].

The result of this study showed that most of the CKD patients are depressed and mild depression is more prevalent. These findings alert us to the importance of the routine screening of depression in CKD patients. An early diagnosis and proper management of depression could be helpful in improving the quality of life of CKD patients.

5.Conclusion

This study demonstrated that depression is frequently common in CKD patients. Mild depression is more frequent among CKD patients. Depression is significantly associated with different socio-demographic variables. The findings of this study may help to evaluate the CKD patients in psychological background.

Limitations of the Study

It was a single center study with a relatively small sample size.

Recommendations

A population based multi-center study with large sample size should be done for better evaluation of depression in CKD patients.

Conflict of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

Authors’ Contributions

Mosammet Khaleda Akter provided administrative support and participated in providing comments on the manuscript drafts. Mohammad Nurul Anowar contributed to the interpretation of data and providing comments on the final draft of the manuscript. Jinnat Rehana comments on the manuscript drafts. Bipula Roy was responsible for the study conception, design, data collection, data analysis, and drafting of the work. All authors read and approved the final manuscript.

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