- Email: [email protected]
Cross-sectional assessment of psychiatric disorders in renal transplantation patients in Turkey: a preliminary study
Cross-Sectional Assessment of Psychiatric Disorders in Renal Transplantation Patients in Turkey: A Preliminary Study B. Arapaslan, A. Soykan, C. Soykan, and H. Kumbasar ABSTRACT Background. Psychiatric disorders such as depression and anxiety may be seen after a successful renal transplantation (RTx). The aim of this cross-sectional study was the assessment of psychiatric disorders after RTx in Turkey. The value of self-report scales in predicting depression and anxiety was also assessed. Patients and methods. The study group consisted of 20 male and 20 female RTx patients (mean age 35.42 ⫾ 10.09 years), with a mean duration of 61.65 ⫾ 48.30 months of follow-up after transplantation. All patients were assessed with the validated Turkish versions of Structured Clinical Interview for the DSM-IV (SCID-I), Beck Depression Inventory (BDI), Hospital Anxiety Depression Scales (HADS), Spielberger Trait Anxiety Inventory (STAI-I), and Beck Hopelessness Scale (BHS). Results. Twenty of the 40 patients warranted a DSM-IV psychiatric diagnosis with SCID-I evaluation. Major depression was observed in 25% of patients. The remaining diagnoses were within the affective and/or anxiety spectrum disorders. The set of age, gender, education, income, marital status, employment, type of transplantation, duration of illness, and duration after the transplantation was not significantly different between patients with or without psychiatric diagnoses. BDI, HADS, STAI-I, and BHS were significantly higher among patients with psychiatric diagnoses at P ⫽ .001 level using Student t test. Even after control of the variance explained by the set of demographic variables, hierarchical regression analysis revealed that HADS scores significantly predicted the psychiatric morbidity (P ⫽ .003). Conclusion. The frequency of psychiatric disorders is quite high in renal transplantation patients. Additionally, HADS, which significantly predicts depression and anxiety, may be used for screening purposes.
H
IGH RATES OF EMOTIONAL distress and psychiatric morbidity have been reported following renal transplantation (RTx).1,2 Anxiety associated with transplantation, observed in almost two-thirds of cases, usually involves a fear of postoperative renal rejection, which decreases with time.3–5 Additionally, some studies report that more than 50% of patients may suffer from anxiety even some years after RTx.6,7 Depression is also common in RTx patients5,6,8; higher levels of depression are associated with increased mortality in ESRD patients.7,9 Patients with higher depression scores tended to be noncompliant to treatment regimens,10 and have higher risk for rejection,11 and greater total pain scores,12 as well as lower level of quality of and satisfaction with life.1,2 Several studies on psychiatric morbidity after RTx have included self-rating
scales for the evaluation of psychiatric disorders. However, not many studies have been conducted with clinical diagnostic instruments specifically designed to assess psychiatric illnesses in RTx patients. The aim of this cross-sectional study was the accuracy of assessment and the frequency of psychiatric disorders after RTx in Turkey. SUBJECTS AND METHODS The subjects were 40 patients with ESRD who were followed after kidney transplantation. Patient selection criteria were reported From the Division of Consultation Liaison Psychiatry, Ankara University, School of Medicine, Ankara, Turkey. Address reprint requests to Doc¸ Dr Atilla Soykan, A.U.T.F. Psikiyatri AD, Dikimevi, Ankara, Turkey. E-mail: [email protected]
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.04.087
Transplantation Proceedings, 36, 1419 –1421 (2004)
1419
1420 elsewhere13: in summary, it was performed randomly among outpatient transplant recipients who came for scheduled follow-up visits from December 2000 to February 2001. Only medically stable patients with good graft functioning were included in the study. Exclusion criteria were age younger than 18 years, less than 6 months of posttransplantation follow-up, and signs of cognitive impairment. After obtaining informed consent, the Structured Clinical Interview for the DSM-IV, Clinical Version (SCID-I) was administered by an experienced psychiatrist to assess overall morbidity. All subjects were given self-report symptom rating scales including the Beck Depression Inventory (BDI), the Hospital Anxiety Depression Scales (HADS), the Spielberger Trait Anxiety Inventory (STAI-I), and the Beck Hopelessness Scale (BHS). The BDI is a 21-item scale with a series of statements rated 0, 1, 2, and 3, denoting increased severity of current depressive symptoms. The HADS is a 14-item scale consisting of seven anxiety items alternating with seven depression items; its aim is to assess the presence and severity of both anxious and depressive symptoms. Each patient’s level of the anxiety assessed with the STAI-I, which consists of 20 items each representative of a category of anxiety symptoms. The BHS consists of 20 true or false statements that measure the degree of pessimism and negativity about the future. Validity and reliability studies of Turkish versions of SCID-I, BDI, HADS, STAI-I, and BHS were already completed; all scales have been used in many other studies in Turkey. All analyses were performed with SPSS software. Confidence intervals were 95% (two-sided) for all analyses.
RESULTS
The study group consisted of 20 male and 20 female patients of mean age 35.42 ⫾ 10.09 years (range, 18 to 60). Twenty-five patients were employed, 10 were housewives, and five were unemployed; 21 were married, 14 were single, and five were divorced. Their total mean length of follow-up for ESRD was 121.81 ⫾ 72.72 months (range, 22 to 305 months). The mean length of dialysis prior to RTx was 15.75 ⫾ 3.45 months (range, 2 to 48 months). The mean duration of follow-up after the RTx was 61.65 ⫾ 48.30 months (range, 8 to 187 months). Two types of kidney transplants were performed: 32 living and eight cadaveric. The 32 living donors consisted of mothers (n ⫽ 13), brothers and sisters (n ⫽ 12), fathers (n ⫽ 5), and other relatives (n ⫽ 2). None of these clinical and sociodemographic variables were significantly different among patients with or without psychiatric diagnoses. Twenty of the 40 patients (50%) warranted a DSM-IV psychiatric diagnosis according to the SCID-I evaluation. DSM-IV psychiatric diagnoses are summarized in Table 1. Mean scores for self-rating scales for depression and anxiety (BDI, HADS, STAI-I) as well as hopelessness (BHS) were significantly higher among patients with psychiatric diagnoses at P ⬍ .001 level. These results were congruent with the physicians assessment with SCID (data not shown). Additionally, all symptom rating scales (BDI, HADS, STAI-I, and BHS) significantly correlated with each other at the P ⬍ .01 level. A hierarchical regression analysis was conducted to test for the predictive values of BDI, HADS, STAI-I, and BHS (self-rating scales) measures on the diagnostic status of patients defined as “patients with or
ARAPASLAN, SOYKAN, SOYKAN ET AL Table 1. The Results of SCID-I Assessment; DSM-IV Psychiatric Diagnoses in Renal Transplantation Patients
DSM-IV psychiatric diagnoses
Affective disorders Major depression Dysthymia Affective disorders ⫹ anxiety disorders Major depression ⫹ obsessive compulsive disorder Dysthymia ⫹ obsessive compulsive disorder Dysthymia ⫹ panic disorder with agoraphobia Dysthymia ⫹ panic disorder without agoraphobia Anxiety disorders Agoraphobia Panic disorder without agoraphobia Generalized anxiety disorder Social phobia Total No DSM-IV psychiatric diagnosis
Renal Transplantation Patients, n (%)
10 (25) 9 (20) 1 (2.5) 4 (10) 1 (2.5) 1 (2.5) 1 (2.5) 1 (2.5) 6 (15) 2 (5) 2 (5) 1 (2.5) 1 (2.5) 20 (50) 20 (50)
without psychiatric diagnoses” (psychiatric diagnoses). At the first step, the set of age, gender, education, income, marital status, employment, type of transplantation, duration of illness, and duration after the RTx were entered into the equation. All these step 1 variables only explained 18% of the total variance, and none of the variables made a significant contribution to the prediction of “psychiatric diagnoses” (F (9, 30) ⫽ 0.68, NS). After controlling for the variance accounted for by these control variables, BDI, HADS, STAI-I, and BHS scores were entered into a second step through the stepwise method. This method put HADS scores into the equation, which increased the total explained variance to 56% (F (10, 29) ⫽ 3.71, P ⫽ .003). Based on final step values, HADS, a scale covering both depressive and anxiety symptoms, significantly (t ⫽ 5.02, P ⬍ .001) predicted the diagnostic status of the patients. When compared with SCID diagnosis, a HADS cutoff point of 10 classified 79% of cases with or without psychiatric diagnoses. DISCUSSION
We studied psychiatric aspects of RTx patients. Half of our subjects received at least one psychiatric diagnosis with SCID-I evaluation. The most common diagnosis—major depression—was observed in 25% of all patients. The remaining diagnoses were within the affective and/or anxiety spectrum disorders. The frequency of psychiatric disorders after RTx varied widely among available studies; most reports indicate high rates similar to our study.5,6,8 However, lower rates close to general population were also reported.3,7 All self-rating scale scores were significantly higher among RTx patients with psychiatric diagnosis. Additionally, the highly significant predictive value of the HADS
PSYCHIATRIC DISORDERS IN RENAL PATIENTS
implies that this test may be useful for screening purposes. It could significantly contribute to the detection of most RTx patients with depression and anxiety disorders. For example, in our sample, if a HADS cutoff point of 10 were used for screening purposes, 79% of cases with or without psychiatric diagnoses would be classified correctly. Other studies also support the value of HADS or other self-rating scales for better identification of psychiatric patients in the RTx population.9,14 Age, gender, education, income, marital status, employment, the type of transplantation, duration of illness, and duration after the RTx neither predicted nor were significantly different among transplant patients with versus without a psychiatric diagnosis. In their natural epidemiology, both depression and anxiety spectrum disorders are more prevalent in women. It is surprising that we and others14 could not find such an association in ESRD patients. However, larger sample sizes with better statistical power might be needed to detect such differences. Improvement in patient quality of life is a central goal of RTx. Unfortunately, although it is evident that psychiatric morbidity significantly predicts poor prognostic factors,5,6,8 guidelines about the psychosocial assessment and follow-up of posttransplantation patients are rarely found in textbooks on ESRD. In conclusion, the frequency of psychiatric disorders was observed to be quite high among renal transplant patients. Additionally, HADS significantly predicted psychiatric morbidity and may be used for screening purposes. REFERENCES 1. Cameron JI, Whiteside C, Katz J, et al: Differences in quality
1421 of life across renal replacement therapies. A meta-analytic comparison. Am J Kidney Disease 35:629, 2000 2. Matas AJ, Halbert RJ, Barr ML, et al: Life satisfaction and adverse effects in renal transplant recipients: a longitudinal analysis. Clin Transplant 16:113, 2002 3. Fukunishi I: Anxiety associated with kidney transplantation. Psychopathology 26:24, 1993 4. Baines LS, Joseph JT, Jindal RM: Emotional issues after kidney transplantation: a prospective psychotherapeutic study. Clin Transplant 16:455, 2002 5. Schlebusch L, Pillay BJ, Louw J: Depression and self-report disclosure after live related donor and cadaver renal transplants. S Afr Med J 75:490, 1989 6. Muthn FA: Postoperative course of patients during hospitalization following renal transplantation. Psychother Psychosom 42: 133, 1984 7. Sensky T: Psychiatric morbidity in renal transplantation. Psyhother Psychosom 52:41, 1989 8. Johnson JP, McCauley CR, Copley JB: The quality of life of life of haemodialysis and transplant patients. Kidney Int 22:286, 1982 9. Wuert D, Finkelstein SH, Ciarcia J, et al: Identification and treatment of depression in a cohort of patients maintaiened on chronic peritoneal dialysis. Am J Kidney Disease 37:1011, 2001 10. Kiley D, Lam CS, Pollak R: A study of treatment compliance following kidney transplantation. Transplantation 55:51, 1993 11. Surman OS: Psychiatric aspects of organ transplantation. Am J Psychiatry 146:972, 1989 12. Forsberg A, Lorenzon U, Nilsson F, et al: Pain and health related quality of life after heart, kidney, and liver transplantation. Clin Transplant 13:453, 1999 13. Soykan A, Arapaslan B, Kumbasar A: Suicidal behavior, satisfaction with life and perceived social support in end-stage renal disease. Transplant Proc 35:1290, 2003 14. O’Donnell K, Chung JY: The diagnosis of major depression in end-stage renal disease. Psychother Psychosom 66:38, 1997
H
IGH RATES OF EMOTIONAL distress and psychiatric morbidity have been reported following renal transplantation (RTx).1,2 Anxiety associated with transplantation, observed in almost two-thirds of cases, usually involves a fear of postoperative renal rejection, which decreases with time.3–5 Additionally, some studies report that more than 50% of patients may suffer from anxiety even some years after RTx.6,7 Depression is also common in RTx patients5,6,8; higher levels of depression are associated with increased mortality in ESRD patients.7,9 Patients with higher depression scores tended to be noncompliant to treatment regimens,10 and have higher risk for rejection,11 and greater total pain scores,12 as well as lower level of quality of and satisfaction with life.1,2 Several studies on psychiatric morbidity after RTx have included self-rating
scales for the evaluation of psychiatric disorders. However, not many studies have been conducted with clinical diagnostic instruments specifically designed to assess psychiatric illnesses in RTx patients. The aim of this cross-sectional study was the accuracy of assessment and the frequency of psychiatric disorders after RTx in Turkey. SUBJECTS AND METHODS The subjects were 40 patients with ESRD who were followed after kidney transplantation. Patient selection criteria were reported From the Division of Consultation Liaison Psychiatry, Ankara University, School of Medicine, Ankara, Turkey. Address reprint requests to Doc¸ Dr Atilla Soykan, A.U.T.F. Psikiyatri AD, Dikimevi, Ankara, Turkey. E-mail: [email protected]
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.04.087
Transplantation Proceedings, 36, 1419 –1421 (2004)
1419
1420 elsewhere13: in summary, it was performed randomly among outpatient transplant recipients who came for scheduled follow-up visits from December 2000 to February 2001. Only medically stable patients with good graft functioning were included in the study. Exclusion criteria were age younger than 18 years, less than 6 months of posttransplantation follow-up, and signs of cognitive impairment. After obtaining informed consent, the Structured Clinical Interview for the DSM-IV, Clinical Version (SCID-I) was administered by an experienced psychiatrist to assess overall morbidity. All subjects were given self-report symptom rating scales including the Beck Depression Inventory (BDI), the Hospital Anxiety Depression Scales (HADS), the Spielberger Trait Anxiety Inventory (STAI-I), and the Beck Hopelessness Scale (BHS). The BDI is a 21-item scale with a series of statements rated 0, 1, 2, and 3, denoting increased severity of current depressive symptoms. The HADS is a 14-item scale consisting of seven anxiety items alternating with seven depression items; its aim is to assess the presence and severity of both anxious and depressive symptoms. Each patient’s level of the anxiety assessed with the STAI-I, which consists of 20 items each representative of a category of anxiety symptoms. The BHS consists of 20 true or false statements that measure the degree of pessimism and negativity about the future. Validity and reliability studies of Turkish versions of SCID-I, BDI, HADS, STAI-I, and BHS were already completed; all scales have been used in many other studies in Turkey. All analyses were performed with SPSS software. Confidence intervals were 95% (two-sided) for all analyses.
RESULTS
The study group consisted of 20 male and 20 female patients of mean age 35.42 ⫾ 10.09 years (range, 18 to 60). Twenty-five patients were employed, 10 were housewives, and five were unemployed; 21 were married, 14 were single, and five were divorced. Their total mean length of follow-up for ESRD was 121.81 ⫾ 72.72 months (range, 22 to 305 months). The mean length of dialysis prior to RTx was 15.75 ⫾ 3.45 months (range, 2 to 48 months). The mean duration of follow-up after the RTx was 61.65 ⫾ 48.30 months (range, 8 to 187 months). Two types of kidney transplants were performed: 32 living and eight cadaveric. The 32 living donors consisted of mothers (n ⫽ 13), brothers and sisters (n ⫽ 12), fathers (n ⫽ 5), and other relatives (n ⫽ 2). None of these clinical and sociodemographic variables were significantly different among patients with or without psychiatric diagnoses. Twenty of the 40 patients (50%) warranted a DSM-IV psychiatric diagnosis according to the SCID-I evaluation. DSM-IV psychiatric diagnoses are summarized in Table 1. Mean scores for self-rating scales for depression and anxiety (BDI, HADS, STAI-I) as well as hopelessness (BHS) were significantly higher among patients with psychiatric diagnoses at P ⬍ .001 level. These results were congruent with the physicians assessment with SCID (data not shown). Additionally, all symptom rating scales (BDI, HADS, STAI-I, and BHS) significantly correlated with each other at the P ⬍ .01 level. A hierarchical regression analysis was conducted to test for the predictive values of BDI, HADS, STAI-I, and BHS (self-rating scales) measures on the diagnostic status of patients defined as “patients with or
ARAPASLAN, SOYKAN, SOYKAN ET AL Table 1. The Results of SCID-I Assessment; DSM-IV Psychiatric Diagnoses in Renal Transplantation Patients
DSM-IV psychiatric diagnoses
Affective disorders Major depression Dysthymia Affective disorders ⫹ anxiety disorders Major depression ⫹ obsessive compulsive disorder Dysthymia ⫹ obsessive compulsive disorder Dysthymia ⫹ panic disorder with agoraphobia Dysthymia ⫹ panic disorder without agoraphobia Anxiety disorders Agoraphobia Panic disorder without agoraphobia Generalized anxiety disorder Social phobia Total No DSM-IV psychiatric diagnosis
Renal Transplantation Patients, n (%)
10 (25) 9 (20) 1 (2.5) 4 (10) 1 (2.5) 1 (2.5) 1 (2.5) 1 (2.5) 6 (15) 2 (5) 2 (5) 1 (2.5) 1 (2.5) 20 (50) 20 (50)
without psychiatric diagnoses” (psychiatric diagnoses). At the first step, the set of age, gender, education, income, marital status, employment, type of transplantation, duration of illness, and duration after the RTx were entered into the equation. All these step 1 variables only explained 18% of the total variance, and none of the variables made a significant contribution to the prediction of “psychiatric diagnoses” (F (9, 30) ⫽ 0.68, NS). After controlling for the variance accounted for by these control variables, BDI, HADS, STAI-I, and BHS scores were entered into a second step through the stepwise method. This method put HADS scores into the equation, which increased the total explained variance to 56% (F (10, 29) ⫽ 3.71, P ⫽ .003). Based on final step values, HADS, a scale covering both depressive and anxiety symptoms, significantly (t ⫽ 5.02, P ⬍ .001) predicted the diagnostic status of the patients. When compared with SCID diagnosis, a HADS cutoff point of 10 classified 79% of cases with or without psychiatric diagnoses. DISCUSSION
We studied psychiatric aspects of RTx patients. Half of our subjects received at least one psychiatric diagnosis with SCID-I evaluation. The most common diagnosis—major depression—was observed in 25% of all patients. The remaining diagnoses were within the affective and/or anxiety spectrum disorders. The frequency of psychiatric disorders after RTx varied widely among available studies; most reports indicate high rates similar to our study.5,6,8 However, lower rates close to general population were also reported.3,7 All self-rating scale scores were significantly higher among RTx patients with psychiatric diagnosis. Additionally, the highly significant predictive value of the HADS
PSYCHIATRIC DISORDERS IN RENAL PATIENTS
implies that this test may be useful for screening purposes. It could significantly contribute to the detection of most RTx patients with depression and anxiety disorders. For example, in our sample, if a HADS cutoff point of 10 were used for screening purposes, 79% of cases with or without psychiatric diagnoses would be classified correctly. Other studies also support the value of HADS or other self-rating scales for better identification of psychiatric patients in the RTx population.9,14 Age, gender, education, income, marital status, employment, the type of transplantation, duration of illness, and duration after the RTx neither predicted nor were significantly different among transplant patients with versus without a psychiatric diagnosis. In their natural epidemiology, both depression and anxiety spectrum disorders are more prevalent in women. It is surprising that we and others14 could not find such an association in ESRD patients. However, larger sample sizes with better statistical power might be needed to detect such differences. Improvement in patient quality of life is a central goal of RTx. Unfortunately, although it is evident that psychiatric morbidity significantly predicts poor prognostic factors,5,6,8 guidelines about the psychosocial assessment and follow-up of posttransplantation patients are rarely found in textbooks on ESRD. In conclusion, the frequency of psychiatric disorders was observed to be quite high among renal transplant patients. Additionally, HADS significantly predicted psychiatric morbidity and may be used for screening purposes. REFERENCES 1. Cameron JI, Whiteside C, Katz J, et al: Differences in quality
1421 of life across renal replacement therapies. A meta-analytic comparison. Am J Kidney Disease 35:629, 2000 2. Matas AJ, Halbert RJ, Barr ML, et al: Life satisfaction and adverse effects in renal transplant recipients: a longitudinal analysis. Clin Transplant 16:113, 2002 3. Fukunishi I: Anxiety associated with kidney transplantation. Psychopathology 26:24, 1993 4. Baines LS, Joseph JT, Jindal RM: Emotional issues after kidney transplantation: a prospective psychotherapeutic study. Clin Transplant 16:455, 2002 5. Schlebusch L, Pillay BJ, Louw J: Depression and self-report disclosure after live related donor and cadaver renal transplants. S Afr Med J 75:490, 1989 6. Muthn FA: Postoperative course of patients during hospitalization following renal transplantation. Psychother Psychosom 42: 133, 1984 7. Sensky T: Psychiatric morbidity in renal transplantation. Psyhother Psychosom 52:41, 1989 8. Johnson JP, McCauley CR, Copley JB: The quality of life of life of haemodialysis and transplant patients. Kidney Int 22:286, 1982 9. Wuert D, Finkelstein SH, Ciarcia J, et al: Identification and treatment of depression in a cohort of patients maintaiened on chronic peritoneal dialysis. Am J Kidney Disease 37:1011, 2001 10. Kiley D, Lam CS, Pollak R: A study of treatment compliance following kidney transplantation. Transplantation 55:51, 1993 11. Surman OS: Psychiatric aspects of organ transplantation. Am J Psychiatry 146:972, 1989 12. Forsberg A, Lorenzon U, Nilsson F, et al: Pain and health related quality of life after heart, kidney, and liver transplantation. Clin Transplant 13:453, 1999 13. Soykan A, Arapaslan B, Kumbasar A: Suicidal behavior, satisfaction with life and perceived social support in end-stage renal disease. Transplant Proc 35:1290, 2003 14. O’Donnell K, Chung JY: The diagnosis of major depression in end-stage renal disease. Psychother Psychosom 66:38, 1997