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Saudi J Kidney Dis Transpl 2017;28(2):341-348

© 2017 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Renal Data from the Arab World

Depression and Anxiety Disorders in Chronic Hemodialysis Patients

and their Quality of Life: A Cross-sectional Study about 106 Cases in
the Northeast of Morocco
Abdelilah El Filali1, Yassamine Bentata2, Naima Ada3, Bouchra Oneib1

Departments of 1Psychiatry, 2Nephrology and 3Community Health and Epidemiology, Faculty of

Medicine, CHU Mohammed VI, University Mohammed I, Oujda, Morocco

ABSTRACT. Hemodialysis (HD) has a severe impact on the life of HD patients. The aim of this
work was to assess the prevalence of depression and anxiety disorders, suicidal ideation, and the
quality of life among HD patients. Associated factors were also studied. A cross-sectional study
was carried out among 103 HD patients treated at the HD Center of Al Farabi Hospital of Oujda
during a period of six months in 2015. The Mini-International Neuropsychiatric Interview and
European Quality of Life-5 Dimensions (EQ-5D) were used for the assessment. Major depressive
episode (MDE) was found in 34% of our patients, whereas anxiety disorder was observed in
25.2%. Suicidal ideation was found in 16.5% and 1.9% of our patients planned their suicide. The
EQ-5D index was 0.41 ± 0.36 and the EQ-Visual Analog Scale score was 45.73 ± 14.
Multivariate analysis showed that MDEs were associated with three factors: marital status, pain,
and anxiety disorder. There was also an association between anxiety disorder and age and EQ-
Visual Analog Scale score. Suicidal ideation was associated with marital status and anxiety
disorders. Together, these results underline the importance of the collaboration between
nephrologists and psychiatrists for a better care of HD patients.

Introduction on renal replacement therapy.3 In France, the

End-stage renal failure (ESRD) is a major
public health issue in both developed and
developing countries.1,2
In the United States, there are 615,899 patients
Correspondence to:
Dr. Bouchra Oneib,
Department of Psychiatry,
Faculty of Medicine, CHU Mohammed VI,
University Mohammed I, Oujda, Morocco.
E-mail: boucha82@hotmail.com
prevalence of the ESRD is 1127 cases per
million population.4 In North Africa, the pre-
valence of ESRD treated by dialysis ranged
between 47 and 680 cases per million popu-
lation.5 In Morocco, it was estimated at 267.1
to be cases per million population in four
regions according to the first annual report of
the Magredial register.6
Patients on hemodialysis (HD) many psycho-
logical disturbances due to psychological
distress7 including depression and anxiety,8-10
with increased symptom load and a poor qua-
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342
lity of life (QoL).11
There are few studies on psychological
disorders and QoL have been reported from
Morocco.
The aim of this study was to assess the
prevalence of depressive and anxiety dis-
orders, suicidal ideation, and the QoL among
HD patients and their associations with socio-
demographic characteristics.
Materials and Methods
This is a cross-sectional study carried out at
the Center of hemodialysis of Al Farabi
Hospital of Oujda, Morocco, during a period
of six months between July and December
2015, among 103 HD patients.
All recruited patients were over 18-year-old,
who had been on HD for at least one month
and who have no known psychiatric disorder.
They were all informed by their physicians
about the purpose of the study, and they gave
their verbal consent. We excluded from the
study, all patients with an intellectual disabi-
lity or do not speak Moroccan dialect or those
who have a sensory deficit which prevents
them from having the psychiatric interview.
For each patient, the data were collected by a
psychiatric resident from medical records and
dialysis notebook, as well as by an inquiry
conducted by nurses and physicians, and also
through a confidential personal, 30 min inter-
view which takes place during the dialysis
session.
The following are the four parts of the survey
questionnaire.
The first one related to demographic charac-
teristics including age, gender, profession,
marital status, socioeconomic level, and edu-
cation level.
To determine the socioeconomic level of the
participants, we used the problems meeting
basic needs scale which is composed of five
items specifying, if in the last 30 days, the
participants met serious problems concerning
food, transportation, finance, housing, and
clothing.
The second part was about the clinical and
dialytic data for each patient. We determined
El Filali A, Bentata Y, Ada N, et al
comorbidities such as diabetes, hypertension,
heart disease, glomerular disease, and family
history of psychiatric disorders.
The third part of the survey concerned the
assessment of anxiety and depressive disorders
using a semi-structured interview based on the
Diagnostic and Statistical Manual of Mental
Disorders Fourth Edition (DSM-IV) which is
the Mini-International Neuropsychiatric Inter-
view (MINI) translated and validated into
Moroccan dialect.12 It allows identifying a
current major depressive episode (MDE), a
previous depressive episode, melancholic
features, a current panic disorder, agoraphobia,
social phobia, generalized anxiety disorder
(GAD), suicidal ideations during the last
month, and suicide risk.
The MINI sensitivity varied between 45%
and 96%, specificity of 86%–100%, and the
correlation coefficient (kappa) between 0.43
and 0.90. It is particularly good for the diag-
nosis of depressive disorders, panic disorders,
and agoraphobia.13
The validity study demonstrated a satisfac-
tory quantitative assessment. The data suggest
that the Moroccan version of the MINI has
managed to raise the validity of the symptoms
of criteria used in the DSM-IV diagnoses.
The last part included the assessment of the
QoL of patients using an interview based on
the five dimensions of Morocco of the Euro-
pean Quality of Life-5 Dimensions (EQ-5D)
and the Visual Analog Scale (EQ-VAS), trans-
lated and validated in Moroccan dialect.14 This
scale is relatively short and therefore more
simple and fast to complete, and the infor-
mation obtained could be converted into a
single index. As it is frequently used in pa-
tients with ESRD.15-17 This scale was collected
by the investigator.
Statistical Analysis
Statistical analysis was performed using
Statistical Package for Social Sciences (SPSS)
software version 21.0 for Windows (SPSS Inc,
Chicago, IL, USA). All variables were summa-
rized using descriptive statistics. Qualitative va-
riables were described in terms of proportions,
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Depression and QoL in HD patients 343

Table 1. Socio-demographic characteristics of the sample.

Characteristics Number (%)
Age (year) 49.7 ± 14.7*
Sex
Male 56 (54.4)
Female 47 (45.6)
Marital status
Married 66 (64.1)
Living alone 37 (35.9)
Job
Employed 15 (14.6)
Unemployed 88 (85.4)
Socioeconomic level
Low 85 (82.5)
Average 18 (17.5)
Education level
Illiterate 40 (38.8)
Elementary 34 (33)
Secondary 21 (20.4)
University 8 (7.8)
*Mean±standard deviation.

and the quantitative variables were described psychiatric disorder.

in terms of means and standard deviations.
Multivariate analysis was conducted by step-
down logistic regression. Variables signifi-
cantly associated to the 20% threshold in the
univariate analysis were selected to be intro-
duced into an initial model. P <0.05 was
considered statistically significant, and the
results have been expressed by the odds ratio
and its 95% confidence interval.
Results
One hundred and sixteen chronic HD patients
were recruited, 13 of them were excluded for
these reasons: death in one case, mental retar-
dation in five cases, and deafness in six cases,
whereas the last case was a non-Moroccan
dialect speaker (Table 1). Nearly 10.7% of
HD patients had a member of the family with a
Table 2. Prevalence of depressive and anxiety disorders.
Prevalence (n=103)
Current major depressive episode
Anxiety disorders
Panic disorder
Agoraphobia
Social phobia
Generalized anxiety disorder
Combination of two disorders or more
Among 103 participants, 35 patients had a
current MDE, of whom 65.7% had melancholic
features, whereas 25.7% had a recurrent
depressive disorder while the prevalence of
anxiety disorders was 26% (Table 2).
During the last month before the study,
16.5% of patients had thoughts about suicide,
1.9% planned their suicide, and none attemp-
ted suicide.
The mean of EQ-5D index value was 0.41 ±
0.36 (Table 3).
The median of EQ-5D index value was 0.52
(0.20; 0.68). It was lower for patients with
current MDE, anxious patients, and in those
with suicidal ideation, whereas it was higher in
patients with no anxious-depressive disorder
(Figure 1).
The EQ-VAS score for these patients was
45.73 ± 14.
n (%)
35 (34)
26 (25.2)
8 (7.8)
6 (5.8)
10 (9.7)
19 (18.4)
10 (10)
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344 El Filali A, Bentata Y, Ada N, et al

Table 3. EQ-5D descriptive system in chronic hemodialysis patients.

EQ-5D Reponses n (%)
5 Dimensions No problems Moderate problems Extreme problems
Mobility 29 (28.2) 67 (65) 7 (6.8)
Self-care 71 (68.9) 15 (14.6) 17 (16.5)
Usual activities 24 (23.3 71 (68.9) 8 (7.8)
Pain/discomfort 42 (40.8) 51 (49.5) 10 (9.7)
Anxiety/depression 35 (34) 44 (42.7) 24 (23.3)

Figure 1. Median of EQ-5D index.

Multivariate analysis showed that the current
MDE was associated with three factors: living
alone, the presence of pain, and anxiety
disorder. Suicidal ideations were correlated
with patients living alone and having anxiety
disorders. While anxiety disorders were
combined with age and pain (Table 4).
Discussion
To the best of our knowledge, this is the first
study in Morocco that has studied the psycho-
pathology of depressive and anxiety disorders
in chronic HD patients and assessed the
suicidal risk in these patients.
The prevalence of the current MDE in the ge-
neral population is about 1.1%–15% among
men and 1.8%–23% among women.13 In our
study, these rates were significantly higher in
the HD patients (34%), which is similar to the
rate reported in a systematic review.18 How-
ever, this rate is distinctly lower than two
previous studies, one from Morocco and the
other from Tunisia (67%19 and 46.2%,20 respec-
tively). It should be noted that both studies
used the Hospital Anxiety and Depression Scale
to explore depression in HD patients; however,
another study using the Beck Depression
Inventory and Beck Anxiety Inventory found a
lower rate (25.7%).21 This variation can be
explained by the use of different methodo-
logies.22 A diagnostic interview provides better
information about having psychiatric disorders
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Depression and QoL in HD patients

Table 4. Associated factors of the current MDE, anxiety disorder, and suicidal ideation: uni- and multi-variate analysis.
Major depressive episode Anxiety disorder Suicidal ideation
Characteristics Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis
OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P
1.01 1.03 1.05 1.03
Age 0.48 - - 0004 0.009 0.1 - -
(0.98; 1.04) (1.001; 1.07) (1.01; 1.08) (0.99; 1.07)
0.59 0.97 0.7
Sex 0.21 - - 0.95 - - 0.51 - -
(0.26; 1.34) (0.4; 2.37) (0.25; 2)
Marital status
Married 1 - - - 1 - - - 1 - - -
2.27 3.64 0.70 3.12 3.86
Living alone 0.06 0.03 0.43 - - 0.04 0.03
(0.98; 5.27) (1.15; 11.52) (0.28; 1.73) (1.07; 9.08) (1.11; 13.48)
Socioeconomic level
Low 1 - - - 1 - - - 1 - - -
0.20 0.36 0.54 0.25
Average 0.04 0.25 0.36 - - 0.19
(0.04; 0.91) (0.06; 2.04) (0.14; 2.04) (0.03; 2.05)
Education level
Illiterate 1 0.19 - - 1 0.64 - - 1 0.75 - -
0.21 0.88
Elementary - - - - - - - - - -
(0.02; 1.91) (0.15; 5.03)
0.20 0.8
Secondary - - - - - - - - - -
(0.02; 1.85) (0.14; 4.66)
0.61 2
University - - - - - - - - - -
(0.06; 6.44) (0.27; 14.98)
3.90 0.63 3.11
Job 0.09 - - 0.44 - - 0.29 - -
(0.83; 18.38) (0.19; 2.04) (0.38; 25.4)
Psychiatric family 0.68 0.97 0.85
0.13 - - 0.9 - - 0.58 - -
history (0.42; 1.12) (0.57; 1.66) (0.48; 1.5
Usual activities
No problems 1 0.06 - - 1 0.54 - - 1 0.21 - -
Moderate 4.2 1.67 3.29
0.13 0.60 - - 0.42 - -
problems (0.65; 27.36 (0.2; 11.45) (0.18; 59.6)
Extreme 0.87 0.85 0.53
0.86 0.85 - - 0.57 - -
problems (0.19; 3.92) (0.16; 4.58) (0.06; 4.68)
Pain
No problems 1 0.002 - - 1 0.54 - - 1 0.02 - -
Moderate 20 17.51 2.13 9.5 6.61
0.001 0.02 0.31 - - 0.006 0.009
problems (3.48; 114.99) (1.62; 189.17) (0.5; 9.1) (1.9; 47.61) (0.75; 58,25)
Extreme 6.2 4.11 2.17 5.38 3.39
0.03 0.19 0.29 - - 0.02 0.2
problems (1.19; 32.23) (0.51; 33.35) (0.52; 8.97) (1.26; 22.94) (0.53; 21.56)
1.06 1.04 1.03 1.05 1.05 1.03
EQ-VAS 0.001 0.12 0.05 0.01 0.02 0.35
(1.03; 1.1) (0.99; 1.08) (1; 1.07) (1.01; 1.08) (1.01; 1.09) (0.97; 1.08)
10.35 14.27 6.25 5.87
Anxiety disorder 0 0 - - - - 0.001 0.005
(3.71; 28.89) (3.86; 52.83) (2.06; 18.93) (1.71; 20.07)

345
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346
compared to a self-reported questionnaire.
Moreover, the assessment of somatic symp-
toms of depression is particularly difficult in
chronic renal failure patients because they can
be caused by uremic symptoms.20
Anxiety disorders were also found to be
common (25.2%), social phobia at 9.7%, panic
disorder at 7.8%, agoraphobia at 5.8%, and
GAD at 18.4%. A similar study using the same
scale (MINI) found similar prevalence for
social phobia and panic disorder, a higher rate
for agoraphobia and a lower rate for the
GAD.23 This difference in rates can be linked
to the small sample size of the study referred
to.
Regarding the suicidal risk, our study showed
that suicidal ideations were greater among HD
patients, with a rate estimated at 16.5%. This
result was also shown a systematic review.18 In
a study from Lebanon carried out among 51
HD patients using the same instrument (MINI)
reported a rate of 37%.24 This difference in
rates can be due to the small sample size of the
study mentioned.
For QoL, the majority of our patients has
reported moderate-to-extreme problems in
usual activities, mobility, anxiety/depression,
and pain/discomfort (76.7% and 71.8%, 66%,
and 59.2%, respectively). However, only
31.1% reported the same degree of problems
in self-care. This result differs from a study
from Malaysia in 654 patients, which showed
that the majority of patients reported no
problems in terms of the five dimensions of
the EQ-5D system.25 This variation can be
explained by ethnic difference, the delay in
diagnosis, at delay of treatment, and poor
adequacy of dialysis.
As regards of EQ-5D index, the mean score
was 0.41 ± 0.36 which is similar to that
reported by Lee et al,15 whereas it was lower
than those found by Wasserfallen et al,26
Roderick et al,27 and Yang et al.28
The EQ-VAS score among our patients was
45.73 ± 14. This is lower than rates reported
from England and Ireland (58.3± 23.9).11
Many other researchers using different tools
reported reduced QoL in HD patients.29,30 We
have shown that patients with a current MDE
El Filali A, Bentata Y, Ada N, et al
had a lower QoL score than the nondepressed
patients (P = 0.04). On the other hand, there
was no association between anxiety on QoL (P
= 0.8). Vázquez et al31 have previously shown
that depression affects the physical compo-
nents of QoL, whereas the anxiety affects the
emotional and social components of QoL which
are not assessed by the EQ-5D. Untas et al
have demonstrated, using Kidney Disease
Quality of Life (KDQoL), that patients with
high depressive and/or anxious symptoma-
tology had a low physical and mental QoL, but
with a low correlation between physical QoL
and anxiety.32
It should be mentioned that our suicidal
patients had a low QoL compared with other
patients (P = 0.008).
Multivariate analysis in our study has shown
that the MDE was associated with three factors
living alone, presence of pain, and anxiety
disorders. Evans et al33 and Mingardi34 also
found that married HD patients have a better
QoL than those living alone.
A previous study from our center showed that
depression was more prevalent in patients with
pain.35 Similar results have been reported.36
Association of depressive disorder to anxiety
disorder was described both in our study and
in literature data.19
We also found an association between adult-
hood and low EQ-VAS score and anxiety
disorder. For this age group, we can explain
this by the fact that adults are still building
their future in fear of death and living thus in
painful and permanent psychological suffering.
Multivariate analysis has also shown, as in
the depression case, that suicidal ideation was
associated with living and anxiety disorder.
It behooves health-care staff looking after
chronic HD patients to remember that they
constitute a population at risk of having
depressive and anxiety disorders as well as
suicidal ideation and that taking care of the
HD patients must include psychiatric assess-
ment and treatment if required.
Conclusion
Our study confirms the high prevalence of
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Depression and QoL in HD patients
depressive and anxiety disorders and suicidal
ideations among chronic HD patients and their
association with an altered QoL.
Conflict of interest: None declared.
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