Prevalence of depression and associated factors among haemodialysis patients at government and private hospitals in Addis Ababa

Background: Depression is the most common psychiatric disorder in long-term dialysis patients and a risk factor for morbidity and mortality. Depression in haemodialysis patients has been persistently underdiagnosed and under-treated. There are negative consequences for the individual in respect of family roles, work competence, sexual function and mobility. We aimed to assess the prevalence of depression and associated factors among haemodialysis patients at government and private hospitals in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted from May to June 2017 at government and private hospitals in Addis Ababa. The Patient Health Questionnaire (PHQ-9) was used to assess depression and the Oslo Social Support Scale (OSLO-3) was employed to assess social support. Results: A total of 426 patients were included. The mean age was 45.6 ± 15.0 years and 65.3% were male. The prevalence of depression was 60.3%. Factors associated with depression included being female (adjusted odds ratio (OR) 1.7; 95% CI 1.3–5.5), a diagnosis of another medical illness (OR 1.9; CI 1.1–3.0), poor social support (OR 3.7; CI 2.1–6.6), and medium income (OR 2.8; CI 1.38–5.60). Conclusions: Depression is very common among haemodialysis patients in Ethiopia and should always be considered in their management. Being female, having poor social support, being subject to other medical illnesses and a medium level of income were risk factors for depression. Future studies should assess the adequacy of dialysis as under-treatment may contribute to the high rate of depression observed.

Many factors are associated with depression in haemodialysis patients, including older age, lower haemoglobin and hospitalization [6].Changing family roles, reduced work competence, fear of death and dependence on treatment may exacerbate feelings of loss of control and adversely affect quality of life [18].
We assessed the prevalence of depression and associated factors among patients on haemodialysis at hospitals In Addis Ababa, to provide useful data for mental health professionals, nephrologists and other staff members caring for these patients.

MEtHODs
A cross-sectional study was conducted from April to May 2017 in Addis Ababa, the capital of Ethiopia.The population of the city is estimated at approximately 3.1 million by the Central Statistics Agency.The participants were adult patients with ESRD receiving regular haemodialysis treatments at 11 centres in the city.Two of these are government centres and nine are privately owned.The usual schedule of dialysis treatment in stable patients comprises sessions of three to four hours, two to three times per week.The cost of treatment is borne by the patient and their families.
Data were coded and entered into EPI info version 3.5.3[21], then exported to SPSS version 20 [22].We generated descriptive statistics to describe the variables of interest and to estimate the prevalence of depression.Bivariate and multivariate logistic regressions were used to identify factors associated with depression.The strength of association was estimated using crude and adjusted odds ratios (COR and AOR) with 95% confidence intervals (CI).Variables associated with outcomes at the p < 0.2 level in the bivariate regression were included in multivariate regression models.Variables that were significant at the p < 0.05 level in the multivariate logistic regression are reported as independent factors associated with the outcome.

Ethical considerations
Ethical clearance was obtained from the Institutional Review Board of the College of Medicine and Health Sciences, University of Gondar, and from Amanuel Mental Specialized Hospital and Addis Ababa Health Bureau Ethical Review Committee.Permission was also obtained from each participating hospital.

rEsULts
Of the 435 patients eligible for the study, the response rate was 426 (98%).Table 1 summarizes the demographic characteristics of the study population.Of these participants, 278 (65%) were male.The mean age was 45.6 ± 15.0 years.Most were Orthodox Christians (52.3%) and married (53.3%).One-third had college-level education and 45.3% were unemployed.
Table 2 summarizes some clinical factors in our study population.Three-quarters had comorbid medical illness, with hypertension and diabetes the most common, and approximately 40% had been on dialysis for two or more years.

DIscUssION
The prevalence of depression in our study was 60.3%, about three times higher than the prevalence in the general population [3] and also much higher than that reported for dialysis patients in many other countries.However, it was lower than the prevalence reported in some studies from Saudi Arabia (83.5%) and the UK (68%) [12,8].
Regarding the associated factors, females were about twice as likely to have depression than males.This is similar to the findings in other studies [9].Possible reasons for this might include a genetic predisposition to develop depression, hormonal factors and higher levels of stress.We found that having a medium level of income was associated with depression.Inadequate income is a common problem among patients on dialysis and may be linked to the difficulty in maintaining employment, reduced physical function and energy, and diminution of cognitive skills [4,18].Patients who had other medical illnesses, especially hypertension and diabetes, were more likely to have depression.This is similar to findings reported from Egypt [16].Patients who had poor social support were about four times more likely to have depression.
Our study had several limitations.A cross-sectional study design was used, and we could therefore report associations only between possible risk factors and depression, and not cause-and-effect relationships.The delivery of adequate dialysis was also not evaluated in our study.Under-dialysis Depression in Ethiopian haemodialysis patients may well have contributed to the high rate of depression we observed as treatments were funded by patients and their families.Financial constraints are likely to have resulted in fewer treatment sessions being delivered per week, and in limited access to important medications such as intravenous iron and erythropoietin.
In conclusion, there is a high prevalence of depression among Ethiopian patients with ESRD who are treated with chronic haemodialysis and it is important to consider this in the holistic management of our patients.Female patients, those with poor social support, with additional comorbid illnesses, and those with medium and lower levels of income may be at greater risk for depression.We recommend that screening for depression be integrated into the routine care of patients who present with ESRD and in those already on dialysis.Future studies should formally assess the adequacy of the dialysis delivered, as undertreatment may contribute to the high rate of depression observed.
Depression in Ethiopian haemodialysis patients Table 4  summarizes the factors associated with depression on multivariate logistic regression analysis.The odds of developing depression among patients with medium income were nearly three times those of patients with a Depression in Ethiopian haemodialysis patients higher level of income.The odds ratio among patients with comorbid medical illness was close to 2, as was the odds ratio for females.The odds ratio among patients who had poor social support was close to 4. Substance use, age, employment, marital status, religion, family history of mental illness and urban/rural residence were not independently associated with depression.

table 3 .
Bivariate logistic regression of factors associated with depression among haemodialysis patients in Addis Ababa.

table 4 .
Multivariate analysis of baseline factors associated with depression among haemodialysis patients in Addis Ababa.