MENTAL HEALTH AND ADHERENCE IN MAINTENANCE HEMODIALYSIS PATIENTS.

Chronic kidney disease (CKD) is a progressive disease and an important contributor to the global burden of disease. The patients often need dialysis, for an extended period of time as a life sustaining treatment. This regular, lifelong treatment often has an impact on their mental health which can lead to non-compliance to therapy. Evidence in literature  shows that mental health disorders like depression, anxiety, and cognitive impairment largely impact the adherence of the patient. Hence, addressing  adherence to the components of dialysis therapy is critical for better clinical outcome.  This study thus aims to evaluate the quality of life in patients with CKD on dialysis, and looks into the impact of mental health on adherence to therapy.

The study was an observational, cross sectional study conducted in the dialysis unit of a tertiary care hospital. Seventy-five subjects were interviewed and their socio demographic data and clinical history were recorded. Kidney Disease Quality of Life instrument - 36 (KDQOL-36), End Stage Renal Disease Adherence Questionnaire (ESRD-AQ), and Depression, Anxiety and Stress Scale (DASS-21) were used to assess quality of life, treatment adherence, depression, anxiety and stress among the patients. 

A total of 75 patients participated in the study. Mean age of the subjects was 54.61  years. These patients were comparatively younger than the cohorts studied in literature. There were almost equal numbers of males and females in this study group(male to female ratio of 1.14:1). Median duration of hemodialysis was 11 months [Interquartile range (IQR): 5-24 months]. 26 patients (34.6%) subjects undergoing dialysis (with CKD) screened positive on DASS-21 (presence of depression, anxiety and/or stress). Sixteen subjects  (21.3%) screened positive for depression (with 6 patients had moderate to severe depression) with median score of 3 and IQR 0-9. Eight subjects (10.6%) were screened positive for anxiety [mild (3), moderate (4), severe (1)] with median score of 2 and IQR 0.5-4. 2 subjects were screened positive for stress [mild (1), moderate (1)] with median score of 4 and IQR 2-8. The mean scores of KDQOL-36 subscales burden of kidney disease (BKD), symptoms/ problems due to kidney disease (SPKD), effects of kidney disease (EKD), physical and mental component summary (PCS, MCS) found to be 32.83 +/- 24.45, 77.94 +/- 17.76, 70.67 +/- 19.54, 35.9 +/- 7.55, 40.7 +/- 10.46 respectively. Sixty- nine (92%) subjects had good adherence with a mean score of 1111.33 +/- 117.33 SD (IQR: 1100-1200). About 93.33%, 89.33%,  58.67%, 53.33% had good adherence to their dialysis schedule (attendance and duration), medications, diet and fluid restrictions respectively as per ESRD-AQ scale. Mean score obtained on attitude and perception subscale was 10.19 +/- 3.55 SD (IQR: 8-11). Despite the evidence of mental stress and depression, the impact on various aspects of hemodialysis therapy was limited.

Most of the patients on maintenance dialysis have multiple emotional issues associated with their treatment and medical comorbidities. Despite challengers, most of the patients had better than expected compliance and adherence to their schedule. Only a few found it emotionally and physically challenging to follow their strict medication and dialysis regimen. The findings thus highlight routine mental screening, counselling, and education integrated within nephrology care may help improve the quality of life of these patients and also improve their mental health.