Depression and cognitive distortions in hemodialysis patients with end stage renal disease: A case-control study

Abstract

Background and objectives

Identifying cognitive distortions is essential for Cognitive Behavioral Therapy (CBT) that plays a key role in the treatment of depression. Depression seen in patients with End-Stage Renal Disease (ESRD) has not been sufficiently diagnosed and treated. This study aimed to examine the cognitive distortions and schemas of patients diagnosed with ESRD.

Methods

Fifty-six patients undergoing hemodialysis and forty-seven controls were enrolled in the study. A sociodemographic and clinic data form, Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Hospital Anxiety and Depression Scale (HADS), Dysfunctional Attitudes Scale (DAS), Automatic Thoughts Questionnaire (ATQ) were applied to all participants.

Results

The prevalence of the psychiatric disorder in the case group was significantly higher than the prevalence of the psychiatric disorder in the control group. Compared with the control group, the HADS depression subscale was significantly high in the patient group. There was a positive correlation between the duration of hemodialysis and total scores of DAS as well as the “dependency attitudes” factor among the case group. The “helplessness” subscale scores of the ATQ were significantly higher in the case group compared to the control group.

Conclusions

The duration of hemodialysis was related to dependency attitudes of cognitive distortions among patients with ESRD. Studies investigating cognitive modalities are needed to treat depression more successfully in this population. It will contribute to the Cognitive Behaviour Therapy of ESRD patients when these factors are taken into consideration.

Introduction

End-Stage Renal Disease (ESRD) is an important public health problem with high morbidity and mortality, adversely affecting the quality of life, imposing a great economic burden, low awareness and early diagnosis.¹ According to the United States Renal Data System’s 2019 Annual Data Report, the prevalence of ESRD continues to rise and reached 746,557 in 2017 (versus 727,912 in 2016).² This represents a 2.6% increase since 2016, which is the result of decreasing death rates in the ESRD population. The European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2016 reported that the incidence of renal replacement therapy (RRT) for ESRD was 121 per million population (pmp) in 2016, ranging from 29 pmp in Ukraine to 251 pmp in Greece.³

Psychiatric disorders, particularly depression, commonly appear in patients with ESRD.^4–6 The impairment in functioning was strongly associated with the severity of depression in patients with ESRD.^7,8 Depression in ESRD is associated with negative outcomes such as poor adaptation to dialysis, malnutrition, decreased quality of life, and increased mortality.^9,10 Although current evidence emphasizes the clinical significance of depression in ESRD, many depressed patients with ESRD are not recognized and do not receive adequate psychiatric treatment.¹¹ Depression also could be presented by non-specific cognitive or somatic symptoms, including anorexia, sleeping difficulties, fatigue, and gastrointestinal complaints, which can be seen in uremia.¹² These overlapping symptoms can mimic a depressive disorder among patients with ESRD and cognitive symptoms of depression should be thoroughly evaluated for an adequate diagnosis.⁴ Accordingly, timely diagnosis and treatment of patients with ESRD had utmost importance. Both pharmacological approaches and cognitive behavioral therapy (CBT) was recommended to alleviate depressive symptoms in this population.^13,14 Psychotherapies could be an effective treatment option for patients with ESRD diagnosed with comorbid depression.^15,16

CBT is an evidence-based treatment option used for the treatment of depression. CBT could be applied in hospital settings to reduce the severity of depressive symptoms.^13,17–19 In a meta-analysis by Wang et al., results also suggested the effectiveness of CBT to alleviate depressive symptoms compared to treatment as usual in patients with diabetes.²⁰ Although there were many studies for CBT applications for the treatment of depression comorbid with medical conditions, CBT for depression in the ESRD population was not widely investigated.^18,19,21 Some promising results have been provided from observational studies and relatively small randomized controlled studies.²² In a study performed by Duarte et al.¹³ on 85 dialysis patients diagnosed with depression, a significant decrease in depression severity and an increase in the quality of life have been observed at the end of a 12-week CBT program. A study investigated the therapeutic efficacy of CBT to reduce depressive symptoms in patients receiving hemodialysis treatment. In this study, Individual CBT was given for three months by a psychologist in ten sessions. After three months, there was a significant reduction in the CBT arm compared to the controls on the waiting list. Depressive symptoms were less commonly present in patients receiving CBT compared to the waiting list group (11% vs. 62%).²³

According to the cognitive model of depression, there is a negative bias in the cognitive processing of internal stimuli or external events, which gives rise to cognitive distortions.²⁴ By biased interpretation of data, cognitive distortions lead to dysfunctional automatic thoughts increasing emotional distress.²⁵ The main target of cognitive interventions is to guide the individual to challenge these automatic thoughts with more objective and functional thoughts and beliefs.²⁴ In the extant literature, cognitive distortions are closely associated with the severity of depression and depressive feelings.^26–29

Dysfunctional beliefs and attitudes were related to depressive symptoms across several physical illnesses.^30,31 Güner et al. showed the relationship between automatic thoughts/dysfunctional attitudes and depressive symptoms among patients newly diagnosed with multiple sclerosis.³² In another study, patients with breast cancer showed higher scores in dysfunctional attitudes as well as stress, anxiety, and depression domains.³⁰

Investigating cognitive distortions and dysfunctional schemas in patients with ESRD are crucial for CBT applications. Given the depressive disorders characterized by cognitive distortions and dysfunctional schemas as per the cognitive theory,³³ to our knowledge, no study investigated the relationship between depression and cognitive distortions using a psychometrically valid tool to measure the cognitive schemas in patients with ESRD.

To this end, we aimed to examine the relationship between the cognitive distortions determined with “dysfunctional attitudes” and “automatic thoughts” and some clinical characteristics on patients diagnosed with ESRD, and compare those with the control group. We also investigate the frequency and severity of depressive mood-related disorders among patients with ESRD. As far as we know, this study is the first study investigating cognitive distortions and schemas of patients diagnosed with ESRD.

Materials and methods

Among patients receiving ongoing hemodialysis treatment between February and April in a dialysis center within the Turkish Kidney Foundation, subjects meeting the inclusion criteria have been consecutively included in the study. The inclusion criteria of the study consisted of (i) being between age 18–65, (ii) being literate, (iii) having sufficient mental and physical capacity to understand and answer tests, and (iv) receiving hemodialysis treatment for at least 12 months. Exclusion criteria were (i) mental retardation, (ii) the presence of alcohol/substance use disorder, (iii) disability or language problems impairing diagnostic psychiatric interviews, (iv) a diagnosis of dementia, delirium, or a psychotic disorder, (v) history of hospitalization or acute exacerbation within the last 3 months and (vi) inability to complete the scales used in the study. A control group who was a volunteer for participating in the study and did not have renal failure have been included in the study as a control group. We posted ads to find the control group and we had interviews random with applicants until we reached a sufficient number. The study protocol has been approved by the Local Ethics Committee. All subjects have given written informed consent for the study.

Clinical assessments

Structured clinical interview for DSM-IV axis I disorders (SCID-I)

Structured Clinical Interview for DSM- IV, Clinical Version (SCID-I) was originally named and developed by First and his friends SCID-I was a semi-structured clinical interview applied by an interviewer to determine the diagnosis of Axis I psychiatric disorders according to DSM-IV.³⁴ The validation study of SCID-I in the Turkish population was performed by Özkürkçügil et al.³⁵ The psychiatric status of all subjects was evaluated by the first author by implementing the SCID-I.

Hospital anxiety and depression scale (HADS)

Hospital Anxiety and Depression Scale (HADS) was developed to measure the levels of anxiety and depression in individuals with somatic disease.³⁶ A Likert-type scale involving 14 questions to measure anxiety and depression symptoms in a 4-point range. The reliability and validity study for the Turkish version of HAD was performed by Aydemir et al.³⁷

Automatic thoughts questionnaire (ATQ)

Automatic Thoughts Questionnaire measures the frequency of negative automatic thoughts associated with depression.³⁸ A Likert type scale consists of thirty items scored between “1 = never” and “5 = always”. Reliability and validity analyses of the scale in Turkey have been performed in two different studies.^39,40 ATQ has a five-factor structure listed as “negative self-concept”, “confusion/escape fantasies”, “personal maladjustment and desire for change”, “loneliness/isolation” and “giving up/helplessness”.³⁸

Dysfunctional attitude scale (DAS)

Dysfunctional Attitude Scale measures the level of dysfunctional attitudes associated with depression. The attitudes can be considered as “intermediate beliefs” of “schemas” manifested by “negative automatic thoughts”. These attitudes reflect the absolute and strict standards of individuals to evaluate themselves and the world.⁴¹ DAS was designed as a Likert-type scale consisting of forty items scored from “1 = totally disagree” to “7 = totally agree”. The total score of the scale indicates the levels of dysfunctional attitudes.⁴² Turkish validation study of DAS was performed⁴³ and the DAS has a predictive value to show cognitive vulnerability to depression.²⁷ It has four sub-scales consisting of “perfectionist attitude”, “approval by others”, “dependency attitude” and “variable attitude”.

Statistical analysis

Statistics Package for Social Sciences Version 24.0 (IBM Corporation, Armonk, NY) program was used for the statistical evaluation of data. Kolmogorov-Smirnov method was used to assess normal distribution. The student t-test was used for the comparison of two groups with continuous variables meeting parametric test assumptions. For continuous variables not meeting parametric test assumptions, the Mann Whitney U test was implemented to compare study groups. The Chi-square test and Fisher’s exact test were used for comparing categorical variables. Pearson correlation analyses were performed between clinical variables. Statistical significance was set at p < 0.05 as two-sided.

Results

Sociodemographic information and research diagnoses of the study participants are shown in Table 1. The age of study groups at the time of participation was comparable (50.1 ± 11.3 years in the case group vs. 50.3 ± 9.8 years in the control group, p = 0.942). No statistically significant difference was found between the case and control group regarding sex, marital status, smoking, and the presence of comorbid medical diseases. When compared for their employment status, patient groups yielded higher rates of unemployment compared to the control group (80.4% vs. 40.4%, p < 0.001). The average duration of education also did not differ between study groups (8.5 ± 3.5 years in the case group vs. 8.5 ± 3.3 years in the control group, p = 0.970). Patients with ESRD had higher rates of comorbid Axis-I diagnoses compared to community controls (50.0% vs. 25.5%, p = 0.020). Depressive mood-related disorders (MDD and adjustment disorder with depressive mood) was higher among patients with ESRD than community controls (39.3% vs. 14.9%, p = 0.012).

Table 1.

Sociodemographic information and research diagnoses of the study participants.

	ESRD, n = 56	Control, n = 47	t/Z/ X²	p*
Age, mean ± SD	50.1 ± 11.4	50.3 ± 9.8	0.7	0.942
Sex, male n (%)	33 (58.9)	27 (57.4)	0.0	0.879
Education, years, mean ± SD	8.5 ± 3.5	8.5 ± 3.3	0.0	0.970
Married, n (%)	41 (73.2)	34 (72.3)	0.0	0.921
Unemployed, n (%)	45 (80.4)	19 (40.4)	15.7	<0.001
Smoking, n (%)	14 (25.0)	14 (29.8)	0.1	0.748
Alcohol intake, n (%)	5 (8.9)	4 (8.5)	0.0	1.0
Comorbid medical illness n (%)	26 (46.4)	19 (40.4)	0.2	0.680
Any SCID-I diagnosis (present), n (%)	28 (50.0)	12 (25.5)	5.5	0.020*
Depressive mood-related disorders (i.e major depressive disorder and adjustment disorder with depressive mood) (present), n (%)	22(39.3)	7 (14.9)	6.4	0.012*

ESRD: End-Stage Renal Disease, MDD: MDD, SCID-I: Structured Clinical Interview Scale for DSM-IV Axis I disorders, SD: standard deviation.

*

Chi-square was considered significant at p < 0.05.

Table 2 summarizes the comparison of study groups in terms of the total scores of the scales used in the study. Total HADS-Depression and the “helplessness” subscale scores of the ATQ were significantly higher in the case group compared to the control group. (For depression subscale of the HADS, 7.5 ± 4.3 vs. 5.9 ± 3.6, p = 0.048; and for helplessness subscale of ATQ, 8.7 ± 4.0 vs. 7.2 ± 3.2, p = 0.039, respectively). Other scales used in the study did not differ between study groups.

Table 2.

Comparison of study groups in terms of the total scores of HADS, DAS and ATQ.

	ESRD, n = 56	Control, n = 47
Total scale scores	mean ± SD	mean ± SD	t	p*
HADS Depression	7.5 ± 4.3	5.9 ± 3.6	−2.0	0.048
DAS Total	135.3 ± 29.8	132.3 ± 23.4	0.3	0.576
ATQ Total	59.9 ± 23.5	52.9 ± 20.2	−1.6	0.113
DAS “perfectionist attitude”	48.7 ± 16.8	47.8 ± 14.1	−0.3	0.768
DAS “approval by others”	43.5 ± 12.0	41.6 ± 9.4	−0.9	0.363
DAS “dependency attitude”	19.9 ± 6.9	20.5 ± 6.6	0.4	0.689
DAS “variable attitude”	18.3 ± 4.2	19.0 ± 4.9	0.8	0.414
ATQ “negative self-concept”	17.9 ± 7.8	16.3 ± 7.0	−1.3	0.262
ATQ “confusion/escape fantasies”	11.7 ± 5.2	10.3 ± 4.8	−1.4	0.184
ATQ “personal maladjustment and desire for change”	7.5 ± 3.2	6.7 ± 2.6	−1.4	0.184
ATQ “loneliness/isolation”	8.0 ± 3.3	6.9 ± 2.6	−1.9	0.065
ATQ “helplessness”	8.7 ± 4.0	7.2 ± 3.2	−2.1	0.039

ATQ: Automatic Thoughts Questionnaire, DAS: Dysfunctional Attitude Scale, ESRD: End-Stage Renal Disease, HADS: Hospital Anxiety and Depression Scale, SD: standard deviation.

*

p < 0.05 was considered significant for independent sample t-test.

Pearson correlation between cognitive assessment and HADS-Depression scores were also implemented (Table 3). No statistically significant correlation was found between HADS-Depression scores and total DAS scores in the control group (p = 0.052). HADS-Depression score was found positively correlated with the “Dependency Attitude” subscale score of the DAS in the case group (r = 0.377, p = 0.004). In both groups, a significant positive correlation was found between the HADS-Depression scores and total scores of the ATQ. In addition, age, the total duration of education, and the duration of renal illness were not correlated with the total scores of the scales used in the study. The duration of the dialysis period was correlated with total DAS scores (r = 0.273, p = 0.042) and the “Dependency Attitude” subscale scores (r = 0.339, p = 0.011) (Table 4).

Table 3.

Correlations of total depression subscale scores of HADS.

	Total depression scores of the HADS
	ESRD		Control
	r*	P	r*	P
DAS total	0.313**	0.019	0,285	0,052
ATQ total	0.503***	0,000	0,520***	0,000
DAS “perfectionist attitude"	0,230	0,088	0.322**	0,027
DAS “approval by others	0,235	0,081	0,049	0,743
DAS “dependency attitude”	0.377***	0,004	0,084	0,576
DAS “variable attitude”	0,105	0,442	0,117	0,434
ATQ “negative self-concept”	0.459***	< 0,001	0.483***	0,001
ATQ “confusion/escape fantasies”	0.403***	0.002	0.440***	0.002
ATQ “personal maladjustment and desire for change”	0.393***	0.003	0.588***	< 0.001
ATQ “loneliness/isolation”	0.490***	< 0.001	0.423***	0.003
ATQ “helplessness”	0.483***	< 0.001	0.488***	0.001

ATQ: Automatic Thoughts Questionnaire, DAS: Dysfunctional Attitude Scale, ESRD: End-Stage Renal Disease, HADS: Hospital Anxiety and Depression Scale.

*

Pearson correlation analysis.

**

<0.05.

***

<0.01, p < 0.05 was considered significant.

Table 4.

Correlation of Renal Disease Period and Dialysis Period with Hospital Anxiety and Depression, Dysfunctional Attitude and Automatic Thoughts Questionnaire Scores among case group.

	Renal disease period		Dialysis period
	Case (n = 56)		Case (n = 56)
	r*	P	r*	P
HADS depression	0.218	0.107	0.215	0.112
DAS Total	0,098	0,471	0,273	0,042
ATQ Total	0,036	0,793	0,099	0,466
DAS “perfectionist attitude”	0.053	0,697	0,061	0,654
DAS “approval by others”	0,099	0,466	0,230	0,088
DAS “dependency attitude”	0,071	0,601	0,339	0,011
DAS “variable attitude”	0,105	0,440	0,203	0,133

HADS: Hospital Anxiety and Depression Scale, DAS: Dysfunctional Attitude Scale, ATQ: Automatic Thoughts Questionnaire.

*

Pearson correlation (p < 0.05 was considered significant).

Discussion

This study investigated cognitive distortions in patients with ESRD in comparison to community controls. In the previous literature, psychiatric disorders were found higher in patients with ESRD compared to the general population.^44,45 Of these, depression was relatively prevalent among patients with ESRD.^4,46 In line with the previous literature^44,45,47 patients with ESRD had higher levels of psychopathology in our study compared to community controls with the interviews with SCID-I. Half of the individuals with ESRD were diagnosed with Axis-I disorders in our study, and 39.3% of them suffered from depressive mood-related disorders (that included MDD and adjustment disorder with depressive mood). Considering the number of patients with medical conditions who have adjustment disorder in the course of the illness,⁴⁸ adjustment disorder with depressive mood and MDD were on the same continuum for this population under the title of depressive mood-related disorders. In this context, we could conclude patients with ESRD had more commonly depressive mood-related disorders compared to the people not diagnosed with ESRD. Nevertheless, only one study suggested ESRD was not related to depressive symptoms.⁴⁹ The point prevalence of depression rate in the general population was found between 2–10% in community settings.^50,51 Surprisingly, in our sample, the control group also yielded a higher level of depressive symptoms than expected. This result is not surprising considering that the depression prevalence in ESRD patients is rather assessed according to the cut-off points of self-report scales in the literature.^52–55 This is because these scales are instruments recommended for determining the severity of depressive symptoms and their follow-up, rather than diagnosing depression or adjustment disorder.⁵⁶

Higher DAS and ATQ scores have been somewhat associated with depressive mood.^27,33,43,57 Recent studies focused on the association between cognitive distortions and depressive symptoms in patients with physical comorbidities.^31,32 Lam et al. also showed the link between cognitive distortions and depressive symptoms among patients with an early-stage malignancy.³¹ Guzman et al. also demonstrated illness-related negative schemas and social support were related to depression scores among patients with ESRD.²² In parallel with the previous literature, the results of our study suggested total HADS was correlated with total ATQ and DAS scores in patients with ESRD. In this context, cognitive distortions and dysfunctional attitudes were also associated with depression in the ESRD population. This result supports the cognitive model also in ESRD cases, which states that the presence of depressive schemas makes individuals delicate and vulnerable against depression, "negative automatic thoughts" are generated in any way when a depressive schema is activated and thus cognitive distortions are created. It can be suggested that this finding will contribute to cognitive therapy modalities, which have been successful in chronic medical conditions.²⁴

Moreover, in our study total helplessness subscale scores of ATQ were higher in the case group than those in the control group. ESRD patients could experience the feeling of helplessness, frequently stated as “I don't think I can go on”, “There is no joy in anything anymore”, “I feel very helpless”, “I can't take this anymore” in the ATQ. In the previous literature, patients with physical illness commonly reported helplessness across studies.^58,59 Besides, the symptoms of physical illnesses were correlated with the feeling of helplessness among patients with diabetes mellitus, multiple sclerosis, and chronic pain.^60–62 Likewise, arthralgia observed in rheumatoid arthritis was closely related to the scores of helplessness.⁶³ Smallheer et al. found a correlation between the severity of perceived helplessness and depressive symptoms.⁶⁴ Helplessness and despondency was reported by previous studies focusing on depression seen in patients with ESRD.⁶⁵ Therefore, helplessness had a major impact on depressive symptomatology among individuals suffering from physical illnesses. In line with previous observations, the results of this study specifically emphasized the role of dysfunctional attitudes related to helplessness among subjects with ESRD, which could be seen as a therapeutic target in treatment.

Total DAS scores and total DAS “dependency attitude” sub-scale scores were correlated with the duration of the dialysis treatment. These attitudes reflect absolute and strict standards the individual uses while evaluating themselves and the world.⁴¹ Longer duration of dialysis treatment might give rise to an impairment in self-efficacy. Accordingly, some patients could develop a more dependent attitude in many areas of life.⁶⁶ Statements of this sub-scale are somewhat an extension of the belief of “not being loved”, which is one of the core beliefs playing an efficient role in the formation of depression.²⁵ Due to this core belief, the individual requires to be liked and approved by others. Patients depending on dialysis lose their financial power and suffer from impairments in their role at home, work, and the social circle; thus, they might not be capable of taking independent actions, even need a caregiver.⁶⁷ As being dependent on dialysis machines and dealing with health problems, patients treated with hemodialysis restricted their social activities.⁶⁸ Schmidt-Busby et al. investigated self-management and motivation among subjects with ESRD. In addition to the feeling of dependence stemming from chronic illness, both patients with ESRD and their family members feel responsible to mutually support each other.⁶⁹ In parallel with our findings, Chilcot et al. also showed the duration of dialysis treatment predicted depression among patients with ESRD.⁷⁰ Taken together, modifying dependent attitude might be a vital treatment goal of CBT applications in chronic medical illnesses since the longer hemodialysis treatment was correlated with increased dependency beliefs. In this context, CBT applications should seek dependency attitudes among individuals receiving dialysis for longer periods.

There was a significant positive correlation between the scores of “independent attitude” and the severity of depression in the case group. Of cognitive distortions and dysfunctional attitudes, independent attitudes interact with depressive symptoms and cause more disability within individuals with ESRD. Studies suggested hemodialysis was related to a poorer quality of life compared to peritoneal dialysis.^71,72 However, a recent-meta analysis did not support the relationship between the dialysis type and quality of life.⁷³ On the other hand, a recent study showed that hemodialysis restricted work- or study-related activities and the changes in life plans, leading to a feeling of dependency.⁷⁴ Therefore, the hemodialysis treatment seemed to impede the social roles of patients with ESRD,^67–69 thereby undermining beliefs of self-sufficiency and independence.

While there is a limited number of articles on ESRD cases for cognitive therapy modalities,^13,17 to the best of our knowledge, no study in the literature evaluated the dysfunctional attitudes of patients with ESRD by using standardized psychometric tools. More comprehensive treatment approaches targeting illness-specific interventions are still needed. Better characteriz3ation of cases with ESRD will be instructive for an illness-oriented approach.

Limitations of our study should be acknowledged when interpreting our results. The small number of subjects from a single dialysis center reduced statistical power. The cross-sectional design of the study was a limitation. Cognitive schemas remained relatively stable over time. Nevertheless, we assumed dialysis treatment had a major impact on schemas. Overall, despite our limitations, our study provided important information regarding cognitive schemas and negative automatic thoughts to develop illness-oriented CBT applications in the future.

Conclusions

ESRD culminated in impairments in the quality of life, as a chronic illness requiring hemodialysis treatment. Psychiatric disorders, mainly depression, were not uncommon in these patients. The role of CBT gradually increases in the treatment of depression and anxiety disorders among patients with a chronic medical condition. In our study, ESRD showed specific alterations in the schema and automatic thought scales, which could pave the way for illness-specific interventions.

Funding

There was no funding for this work.

Ethical statement

Ethics approval of the original study had been obtained from the İstanbul Bakirkoy Training and Research Hospital for Psychiatry, Neurology and Neurosurgery Authority Cluster Research Ethics Committee before collecting the data.

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgment

None.