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Year : 2014  |  Volume : 7  |  Issue : 6  |  Page : 722-727  

Psychiatric morbidity, quality of life and caregiver burden in patients undergoing hemodialysis

Department of Psychiatry, K J Somaiya Hospital, Medical College and Research Centre, Sion, Mumbai, Maharashtra, India

Date of Web Publication18-Nov-2014

Correspondence Address:
Bindoo S Jadhav
Department of Psychiatry, K J Somaiya Hospital, Medical College and Research Centre, Sion, Mumbai - 400 022, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.144858

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Background: Psychiatric illnesses such as, depression, adjustment disorders, delirium, and anxiety disorders are common in dialysis patients and are likely to reduce patient's quality of life (QOL). Presence of chronic medical and psychiatric illness in patients increases burden on caregivers. Aims: The aim was to assess sociodemographic profile and to estimate the prevalence and type of psychiatric morbidity, QOL in patients undergoing hemodialysis. Furthermore, the study aimed to assess perceived burden in caregivers of these patients. Materials and Methods: This was a cross-sectional observational study conducted at hemodialysis unit of an urban tertiary care hospital. Fifty consecutive patients undergoing hemodialysis were included. Sociodemographic profile was assessed through semi-structured proforma. Psychiatric morbidity was assessed using Diagnostic and Statistical Manual IV Text Revised Criteria and World Health Organization QOL Scale-BREF scale was used to measure patient's QOL. Perceived burden in caregiver was assessed using Zarit Burden Interview. Data obtained were tabulated and analyzed using the SPSS software version 17. Results: Majority of patients was males, in middle-age group, secondary educated, unemployed and married. Psychiatric diagnosis was observed in 64% of the patients. Most common psychiatric diagnoses were major depressive disorder, adjustment disorder with depressed mood. Overall QOL score in patients was significantly low in those with psychiatric morbidity. Caregiver's burden was significantly high in those caring for patients with co-morbid psychiatric illness. Conclusions: Psychiatric morbidity in hemodialysis patients is high and impairs their QOL. Perceived burden of care in their caregivers is high in the presence of psychiatric co-morbidity.

Keywords: Caregiver burden, hemodialysis, psychiatric morbidity, quality of life

How to cite this article:
Jadhav BS, Dhavale HS, Dere SS, Dadarwala DD. Psychiatric morbidity, quality of life and caregiver burden in patients undergoing hemodialysis. Med J DY Patil Univ 2014;7:722-7

How to cite this URL:
Jadhav BS, Dhavale HS, Dere SS, Dadarwala DD. Psychiatric morbidity, quality of life and caregiver burden in patients undergoing hemodialysis. Med J DY Patil Univ [serial online] 2014 [cited 2021 Dec 6];7:722-7. Available from:

  Introduction Top

In India, it is estimated that about 7.85 million people are suffering from chronic kidney disease (CKD). [1] CKD, also called as end-stage renal disease (ESRD) are chronic, complicated situations that affect somatic and mental status of patients. Hemodialysis is the most common method used to treat ESRD. Hemodialysis imposes a variety of physical and psychosocial stressors that challenge not only the patients but also the caregivers. [2]

A patient on dialysis is in a situation of object dependence on a machine, the procedure and a group of qualified medical professionals for the rest of his/her life. [3] No other medical condition has such a degree of dependence for the maintenance treatment of chronic illness. [4] Patients with renal failure often suffer from many other medical conditions like cardiovascular disorders, pulmonary diseases, neuropathy, electrolyte disturbances etc., and are on many different medications. All these factors play an important role in the emergence of various psychiatric morbidities in these patients. Almost a full range of psychiatric disorders are seen. In a review study, the mental disorders frequently observed in dialysis patients are affective disorders, particularly depression, organic brain diseases (e.g., dementia and delirium), drug-related disorders (such as alcoholism), schizophrenia and other psychoses, personality disorders etc. [5]

Various psychological factors, in turn, affect patient's long-term physical outcome. Various co-morbid disorders are likely to reduce adherence with the complex dietary and medication regimens prescribed. Long-term dialysis therapy itself often results in loss of freedom, dependence on caregivers, disruption of marital, family, and social life, and reduced financial income. Due to these reasons, the physical, psychological, socioeconomic, and environmental aspects of life are negatively affected, leading to compromised quality of life (QOL). [6],[7]

Providing long-term help to severely ill and disabled person on an everyday basis may be a serious physical and psychological burden for the caregiver. Caregivers report feelings of dependence and the resulting frustration and worry, which then lead to negative feelings of guilt and perception of burden in them. The demand of caregiving, especially in managing the dialysis has a profound and pervasive effect on family and friends, exert a toll on the physical, social and emotional well-being of caregivers. [8]

The current study aimed at assessing sociodemographic profile of patients undergoing hemodialysis, to study prevalence and type of psychiatric morbidity in these patients, to study QOL in these patients and to study perceived burden of caregiving in their caregivers.

  Materials and Methods Top

This was a cross-sectional study conducted in a hemodialysis unit of a tertiary care hospital. An approval from Institutional Ethics Committee was obtained. Study objectives were explained and informed written consent was taken from all the participants of the study.


Fifty consecutive patients of ESRD, undergoing hemodialysis were included in the study. Patients with preexisting psychiatric illness, that is diagnosed with psychiatric illness before the onset of ESRD were excluded.


A relative living with the patient for more than 1-year, spending more time with the patient than other relative, responsible for patient's care and one willing to give informed consent was included as caregiver.

Sociodemographic details of patients as well as caregiver including age, gender, residence, cause of ESRD, socioeconomic status, education, dialysis data (initiation of dialysis, frequency of dialysis, and duration of dialysis), were collected using self-designed semi - structured questionnaire.

Psychiatric diagnosis in patients was made using Diagnostic and Statistical Manual IV Text Revised [9] diagnostic criteria.

World Health Organization quality of life scale

This scale was used to assess QOL in these patients. The World Health Organization-QOL (WHO-QOL) Scale-BREF [10] is an abbreviated 26-item version of the WHO-QOL-100. It is currently scored in four domains: Physical health, psychological health, social relations, and environment. The other two items measure overall QOL and general health. Respondents rate the intensity, frequency or evaluation of the selected attributes of QOL during the previous 2 weeks on a 5 point Likert - scale.

Zarit burden inventory

Caregiver's perceived burden was assessed using Zarit Burden Interview. [11]

It is one of the most commonly used burden measures and has been validated in many culturally or ethnically different populations. [11],[12],[13],[14] The revised version contains 22 items. Each item is scored using a 5-point scale. Response options range from 0 (never) to 4 (nearly always). More the score, greater is the burden perceived.

Statistical analysis

The data were pooled and subjected to statistical analysis using SPSS 17 package (Polar Engineering & Consulting). Descriptive analysis using mean and percentage, Chi-square test were applied to the data. P < 0.05 was considered as significant. Mann-Whitney test was used to compare mean ranks of QOL-BREF scale with psychiatric morbidity.

  Results Top

[Table 1] shows sociodemographic profile of patients in the study. Mean age of the patient was 45.70 years. As seen in this table, 42% of the patients belonged to age group of 46-60 years, followed by 34% of the patients in age group of 31-45 years. Males (68%) predominated over female patients. More than half, that is 56% of the patients had secondary education, while 28% of patients were primary studied, were unemployed (54%) and 30% were housewives. Majority (78%) of the patients were married.
Table 1: Sociodemographic profi le of patients and caregivers

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[Table 1] describes sociodemographic profile of the caregivers. Mean age of caregiver was 44 years. Among caregivers, 42% were in age group 46-60 years, 62% of the caregivers were females, while 38% were males. Approximately, half, that is 44% of the caregivers had secondary education and were housewives. Spouses comprised of 62% of the caregivers. Majority, that is 88% of the caregivers were married.

As shown in Chart 1, psychiatric morbidity was observed in 32 (64%) of the patients.

Chart 2 shows type of psychiatric morbidity in the study sample. In our study, the most common psychiatric diagnosis was depression. Major depressive disorder (MDD) was diagnosed in 40.6% and adjustment disorder with depressed mood in 37.5% of the patients. Adjustment disorder with anxious mood was observed in 12.4% of the patients. Psychosis secondary to general medical condition (GMC) was diagnosed in 6.2% of the patients.

[Table 2] shows WHO-QOL-BREF scores of the patients. In our study population, overall QOL score was average to good on all domains of QOL-BREF scale.
Table 2: QOL score in patients

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[Table 3] shows the correlation between QOL and psychiatric diagnosis in patients. As seen in the table, mean rank of QOL score was significantly low in patients with psychiatric morbidity when compared to patients without a psychiatric diagnosis.

Chart 3 shows perceived burden in caregivers. High burden of caring was perceived in 26 (52%) of the caregivers.
Table 3: Correlation between psychiatric diagnosis and QOL score

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[Table 4] shows the correlation between psychiatric diagnosis in patients and perceived burden in caregivers. As shown in [Table 4], significant high-burden score was seen in caregivers caring for patients having psychiatric morbidity.
Table 4: Correlation between psychiatric morbidity in patients
and burden in their caregivers

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  Discussion Top

Chronic kidney disease, also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. Hemodialysis is the most common method used to treat advanced and permanent kidney failure.

Sociodemographic findings observed in our study are similar to findings observed in a study by Raju et al. [15] which showed that 31.7% of dialysis patients were in the age group of 61-70 years. Majority (68.3%) of the patients was males, 85% were married, 46.7% of them had completed secondary and higher secondary education, 55% of them were unemployed. Presence of chronic, debilitating illness like ESRD which requires dialysis carry a major impact on patient's functioning and results in the lack of employment. In another study by Rana et al., [16] mean age of the patient was 57 years, 61% were males and 80% were married.

Caregivers play a very important role in treatment plan of patients suffering through chronic illnesses, especially CKD. In Asian countries, with intact family structure, families of dialysis patients play a responsible role in dialysis therapy of the patients. In an Asian study of dialysis patients and their caregivers, mean age of the caregivers was 46.6 years. Spouses constituted majority of caregivers (55.9%), followed by children (26.5%) and parents (14.7%) and 47.0% of them were employed. [17] The findings highlight the caregiver system in Asian countries where females usually assume the caregiving role in the presence of chronic illnesses.

Hemodialysis involves an important change in the life of patients, affecting their social, occupational, physical, and personal circumstances. The physical and psychological stress in hemodialysis patients leads to the development of psychiatric morbidity. The important repercussions of emotional disorders upon patient well-being, and their possible influence upon morbidity - mortality, make their diagnosis and management essential. Various studies have found that prevalence of psychiatric diagnosis in hemodialysis patients ranges from 44% to 71%. [16],[18]

Among the various psychiatric morbidity observed in hemodialysis patients, depression is common and can be secondary to loss of a primary role in their occupation or family, decreased physical function, diminution of cognitive skills, or a decline in sexual function. Depressive symptoms are difficult to diagnose due to denial of symptoms and overlap of symptoms with GMC like uremia. The exact incidence of depression in dialysis patients is unclear, reportedly ranging from 10% to 66%. [19-24] In keeping with above findings, the most common psychiatric diagnosis in our study was depression that is 40.6% of them were diagnosed with MDD and 37.5% of the patients had adjustment disorder with depressed mood.

A major medical crisis can be a contributing factor in the onset or exacerbation of an anxiety disorder. Uncertainty about treatment options, outcome, worries about health, finances, schedule of treatment and change in appearance etc., along with medical conditions like uremia, anemia etc., can contribute to the development of anxiety. In our study, 12.4% of the patients were diagnosed with adjustment disorder with anxious mood. This finding is in conscience with that of a study by Sagduyu et al. which has found anxiety disorder to be present in 11.8% of dialysis patients. [25]

There are many potential causes of cerebral dysfunction in renal diseases. Fluctuating GMC, vascular changes, various drugs used, e.g., steroids can lead to behavioral disturbances and psychosis. Psychosis secondary to GMC was diagnosed in 6.2% of the patients in our study. This is in accordance with the findings of a study by Cukor et al. [18] which showed psychosis to be present in 10% of patients. Insomnia secondary to GMC was seen in 3.1% of the patients.

Furthermore, in a similar study by Rana et al., [16] psychiatric morbidity observed was: 42% - anxiety disorders, 40% - depression, 36% - anxiety and depression, and 2% - psychosis.

In our study population, overall QOL score was average to good on all domains of QOL-BREF scale. Similarly, in a study by Raju and Latha [15] majority of patients (68.3%) had QOL score in the average range. Hemodialysis is not a cure for CKD but helps to prolong and improve patients' QOL. [26],[27] Moreover, the development of knowledge on renal physiology and the treatment of various kidney diseases had prolonged the life and improved patients' QOL. [26],[27],[28]

Mean rank of QOL score was significantly low in patients with psychiatric morbidity as compared to patients without psychiatric diagnosis in our sample population. In a Turkish study, it was seen that as psychological morbidity decreased, the QOL increased. [25] Presence of psychiatric morbidity along with chronic illness may have a significant impact on patient's functioning in their personal, social, and occupational areas.

Caregivers have to look after patient's dialysis schedule, medications, and strict diet, accompany patients to hospital, monitor them until they recover after the dialysis session and most importantly manage their financial and psychological problems. These responsibilities can create a burden while caring their loved ones. In a study of caregiver burden by Gill et al., [29] significantly higher burden was perceived by caregivers of dialysis patients than those of nondialysis patients suffering from ESRD. Additional difficulties such as change in their social activity and work plans can contribute to the high burden in these caregivers.

Behavioral disturbances in addition to existing physical illness can cause burn out of the caregivers. Most of the times, presence of a psychiatric illness can be perceived as "uncooperative" or "hostile" behavior by the relatives and can add up to their burden in their care - giving role. Significantly high-burden score was observed in caregivers caring for patients having psychiatric morbidity in our study.

  Conclusions Top

Majority of the patients were males belonging to middle-age group, secondary educated, unemployed, and married. Among caregivers, majority of the caregivers were female spouses of age group 46-60 years with secondary education and were housewives.

Psychiatric illness is common among patients with chronic disorders, particularly in those with ESRD having negative impact on patients' QOL. Psychiatric diagnosis was observed in 32 (64%) of the patients. Most common psychiatric diagnosis in studied patients was depression, including 40.6% of them diagnosed with MDD and adjustment disorder with depressed mood in 37.5% of the patients. Adjustment disorder with anxious mood was observed in 12.4% of the patients, psychosis secondary to GMC in 6.2% of the patients.

Overall QOL score was average to good on all domains of QOL-BREF scale with significantly low mean score in patients with psychiatric morbidity as compared to patients without a psychiatric diagnosis.

Significant high burden of caring was perceived in 26 (52%) of the caregivers and especially those caring for patients having psychiatric morbidity.

  Recommendations Top

It is extremely important to evaluate patients with chronic illnesses, especially those on dialysis, for the presence of psychiatric morbidity and initiate prompt treatment. This can improve compliance, long-term outcome and prognosis in these patients. In order to improve the QOL of ESRD patients on hemodialysis and reduce the burden on their caregivers, the government and NGOs need to develop special support groups that consist of patients, caregivers as well as health staff where they can share their knowledge, experiences, ways to handle a crisis, and improve treatment compliance.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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