Depression and quality of life in patients on long term hemodialysis at a national hospital in Ghana: a cross-sectional study

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INTRODUCTION
Studies on End Stage Renal Disease (ESRD) have reported an increase in the burden of the disease worldwide due to increasing prevalence of diabetes and hypertension. 1,2Studies have reported an increase in ESRD cases by approximately 70% in the past 20 years. 3ESRD is accompanied by increased mortality and escalating costs of providing care for patients. 4,5Despite the advances in the treatment of ESRD, affected individuals still report low quality of life. 6ESRD results in a decline in physical functioning, poor psychological health and medical complications such as anemia and neurological disorders. 7 addition, complications of hemodialysis (i.e., hypotension, headache and air embolism) may contribute to diminished working capacity and adversely affect individual productivity. 7Factors such as financial dependence, inability to carry out family responsibilities, and engage in active social life, have been attributed to reduced quality of life in patients on long-term hemodialysis.These factors may result in mental health issues such as depression, anxiety and impaired cognition. 8epression is reported to be one of the most common psychological conditions among ESRD patients on hemodialysis. 9A study in a tertiary hospital among hemodialysis patients in Nigeria found the prevalence of depression to be 34.5% 10 compared to a prevalence of 27% among African American hemodialysis patients. 11Another study conducted on depression among ESRD patients in Sudan reported a prevalence of 72%. 12 The risk factors for depression among ESRD patients include low compliance to medications, poor nutritional status and marital problems. 13Depression may be linked to significant restrictions in independent living due to the hemodialysis treatment modality.Patients on dialysis are connected to the hemodialysis machine for at least 2 hours per session with a minimum of three sessions per week. 14cio-demographic variables such as age and family support have been reported to play a significant role in the psychological wellbeing of haemodialysis patients. 15Patients with varying times on dialysis have also reported differences in their accounts of perceived consequences of treatment (i.e., depression). 16e burden of ESRD is rising and presents a challenge for both developed and emerging economies.Psychological problems among these patients have been largely understudied in Africa, and to our knowledge, there is no data on this subject in Ghana.The present study examined the prevalence of depression and quality of life status among patients with ESRD on hemodialysis.Further, it explored the impact of demographic characteristics on depression and quality of life.

METHODS
The study design was cross-sectional and was conducted at the two renal dialysis units (Department of Medicine and Cardiothoracic Center) of the Korle-Bu Teaching hospital in Accra, Ghana.These renal dialysis units serve as referral centres and offer only haemodialysis for all kidney disease patients.Recruitment of the participants was based on these criteria: 1) Clinical diagnosis of endstage renal disease; 2) Hemodialysis treatment; 3) Age 18 years and above; 4) Voluntary participation and signed consent form.
Participants were briefed on the nature of the study and made aware that they could decide at any point in time to discontinue without any negative consequences.Participants who gave consent were included in the study and they completed the self-administered questionnaires.
Self-administered questionnaires used included the World Health Organization Quality of Life (WHOQOL BREF) 17 and the Patient Health Questionnaire (PHQ-9) comprising 9 items. 18e PHQ-9 is one of the most commonly used tests for screening depression in many settings. 19It consists of 9items that measure the incidence of depressive thoughts and feelings in individuals over the previous two weeks.The PHQ-9 is a 4-point Likert scale with a range from 0 to 3. Zero for "not at all" responses and 3 for "nearly every day" responses.Scores range from 0 to 27.The interpretation of the scores were done along these dimensions: a score less than 10 demonstrated no symptoms of depression; scores from 10 to 14 demonstrated symptoms of moderate depression; scores 15 to 19 depicted symptoms of moderately severe depression, and scores from 20 to 27 depicted symptoms of severe depression.The Cronbach's alpha of the PHQ-9 for the present sample was 0.815.
The WHOQOL-BREF, a shorter form of the WHOQOL-100 was administered.It assessed four domains of QoL; namely, physical, psychological, social and environmental.Items on this measure were scored on a 5-point Likert scale.The scores range from 1 (low) to 5 (high) with increasing scores from 1 to 5 denoting higher QoL.The raw domain scores obtained from the WHOQOL-BREF were transformed to a 4-20 score and then scaled in a positive direction (i.e. higher scores denoting higher quality of life).The mean score within each domain is used to calculate the domain score and these are linearly transformed to a 0-100 scale. 20The Cronbach's alpha of the WHOQOL-BREF for the present sample was 0.815.

Statistical analysis
SPSS statistical software version 20.0 was used for data cleaning and analysis.Categorical variables were analyzed and presented as frequencies and percentages.The continuous variables were presented as means and standard deviations.Preliminary analyses were conducted to ascertain the normality of the data.The results showed that all the variables (depression, the total and domain scores of QoL) had skewness and kurtosis values that fell within +2 and -2, thus, indicating that the data was close to normal in line with the criteria proposed by George and Mallery. 21Inferential statistics were carried out using the independent sample t-test to compare participants with differences in demographic characteristics on scores of depression, overall QoL and the four domains of QoL.Bonferroni adjustment was used to adjust the alpha level 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 life, dialysis treatment duration and income.Standard linear multiple regression was used to explore selected variables that would predict overall quality of life.Significance level for all other analysis was set at a p-value less than 0.05.

Ethics statement
This study was approved by the Ethical and Protocol Review Committee of the College of Health Sciences, University of Ghana with protocol identification number MS-Et/M.5 -P 3.2/2012-2013.

RESULTS
At the time of the study, there were 129 ESRD patients on dialysis at the Korle-Bu Teaching Hospital.Of the 129 ESRD patients, 106, aged between 21-79 years (mean = 48.7;SD=1.33).consented and participated in the study, giving a response rate of 82%.Table 1 shows the demographic characteristics of the participants.
As illustrated in Table 2, the prevalence of depressive symptoms among the participants was approximately 44% with about 6% screening positive for severe depression.Eighty-six (81%) of the respondents obtained high scores on the WHO-QOL BREF while 20 (19%) had low scores.In terms of the domains of quality of life, 104 participants (98%) scored low on social relationship wellbeing while 18 (17%) had poor psychological wellbeing.

Comparisons of Depression and QoL scores for the various demographic variables
The independent t-test was computed to examine between-group differences on education (high vs low), income (high vs low) and participants' scores on depression, overall QoL and the four domains of QoL.As shown in Table 3, participants with higher levels of education reported higher scores on overall QoL and the four domains of QoL than those with low levels of education.With regards to transportation, significant differences emerged on all the variables.Those who used private transportation reported less depressive symptoms than those who used public transportation (See Table 3).

DISCUSSION
This study revealed that depressive symptoms were high (prevalence of 44%) among ESRD patients.In addition, about 20% of these patients reported poor quality of life.Overall, there were significant relationships between respondent's overall QoL and depression, educational level of respondents, employment status, levels of income and means of transportation.The presence of depressive symptoms was negatively correlated with overall QoL and treatment duration.
The prevalence of depressive symptoms amongst our patients was lower than the prevalence of 72% reported in similar study in Sudan. 12However, prevalence of depressive symptoms was higher in our study compared to a prevalence of 20.1% reported in another study from the United States of America. 22The prevalence of depressive symptoms found among hemodialysis patients in the present study could have resulted from the influence of factors such as loss of jobs, low levels of income.
The drastic changes of one's lifestyle as a result of spending about 3 hours per day on dialysis machine is a contributory factor to the high prevalence rate of depression.Previous studies reported substantial variation in the incidence rate of moderate to severe depression ranging from 33.3% to 78.8% among ESRD patients on haemodialysis treatment. 23,24is might be due to socio-cultural and economic differences amongst study populations in addition to the use of different tools in assessing depression.Majority of our patients (91.5%) had supportive family members and most patients had received at least, nine years of education (84.9%).These factors might have enhanced their coping skills about long standing debilitating illness and the subsequent treatment.A similar finding has been reported in a study among African American patients on dialysis in the United States. 25The significant number of participants with good family support may stem from the fact that majority of them (76.4%) were married.Being married is linked to better physical and emotional well-being and might not be associated with depression. 26However, our study did not support previous studies. 26Almost 50% of our dialysis population (45.3%) were not actively working.The findings are similar to outcomes from other studies in which unemployment rate amongst patients was 66%. 27r study revealed that income correlated positively with overall QoL, physical health and environmental well-being, but negatively correlated with depression.This is not surprising since most of our patients had limited funds for dialysis treatment and they could only afford a session or two of hemodialysis treatment per week.Similarly, other studies have shown significant association between depression and level of income. 28ghteen percent of the participants in the present study reported poor quality of life.The changes in patients' social relationship and psychological wellbeing due to illness symptoms have been recognized as factors contributing to the poor quality of life.Our explanation supports reports from other studies which suggested that patients on haemodialysis suffer psychological problems in addition to the physical challenges. 29Having higher scores for depression were associated with poorer QoL.The present findings also support the association between depression and poor QoL. 24,30r study revealed that there is a significant relationship between income and QoL; this is supported by previous studies. 31Similarly, low socio-economic status of these patients have been reported by some studies to significantly affect patients' QoL. 23,29e awareness of one's chronic disease which helps in coping with the disease has reportedly been affected positively by a higher level of education. 32Our findings of a significant association between level of education and the physical wellbeing, psychosocial wellbeing and environmental wellbeing domains are similar to other studies. 33riables Β 95% CI Depression -0.483 -.998 --.47 Income (Ghana Cedis) 0.096 .000-.001 Treatment duration (months) 0.124 Further, we noted a significant relationship between employment and QoL and our findings further support findings from other studies. 33,34Employment is reported to improve QoL of ESRD patients probably due to the regular income which caters for the costs of treatment. 33,34ere are limitations in the present study.Some of the patients were interviewed during dialysis; therefore, immediate effects of dialysis on symptom reporting such as hypotension cannot be ruled out.Second, the use of a cross-sectional design limited the assessment of the development of symptoms across the continuum of chronic kidney disease stages.Therefore, we could not assess the associations of ESRD symptoms, depression and impaired quality of life with severe adverse patients' outcomes.Third, our study did not include a qualitative design which would have delineated some of the pertinent issues.
Nevertheless, our study has highlighted significant findings of depression, poor QoL and associated factors with poor QoL.A more integrated and holistic approach to treatment which would embrace psychologists, nurses, clinicians and other health professionals should be considered.Intervention programmes should be instituted and should include components that identify and treat depression, in addition to adjusting physiological factors to improve the QoL in ESRD patients on hemodialysis.Additionally, our study emphasizes the need for social workers and clinical psychologists in renal care.Their roles would include addressing patients' emotional needs; enhancement of their coping skills; helping patients with insurance support; adjustment to treatment plans and dietary changes.
This collaborative work with the clinical psychology unit has helped to foster a congenial working relationship.As a result, psychologists now work closely with renal team and regularly attend to the psychological needs of our patients.
Findings from this study should be used to inform healthcare providers responsible for ESRD patients on hemodialysis regarding ways to improve their psychological wellbeing in Ghana.However, future studies on the qualitative aspect of this study would be conducted using focus group discussions and interviews with health service providers and patients.This would highlight the exceptional features of dialysis care on the African continent.
Anecdotal evidence from our study indicate that cultural issues such as religiosity and spirituality have been observed to be good predictors of coping in our part of the world.We recommend that future studies should consider these factors.

Table 1
Distributions of demographic characteristics of participants.(N = 106)

Table 2
Distribution of depression and quality of life among End Stage Renal Disease patients on haemodialysis at a tertiary hospital in Ghana, 2013.

Table 3 T
-test results for the differences between ESRD patients on haemodialysis on selected demographic characteristics.

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

Table 5
Standard linear regression analysis for selected predictors of quality of life in ESRD patients at a tertiary hospital in Ghana, 2013.