An evaluation of illness, treatment perceptions, and depression in hospital- vs. home-based dialysis modalities

Abstract

Objectives

Depressive symptoms are common among patients with end-stage renal disease (ESRD). In order to better understand what factors influence these symptoms, we examined the impact of illness and treatment cognitions on emotional adjustment and the influence of dialysis modality (hospital- vs. home-based dialysis) on this relationship.

Methods

A cross-sectional sample of 145 ESRD patients on four different dialysis modalities [hospital hemodialysis (HD), n=52; home HD, n=25; continuous ambulatory peritoneal dialysis (CAPD), n=45; automated PD (APD), n=23] completed the Illness Perceptions Questionnaire, the Illness Effects Questionnaire, the Treatment Effects Questionnaire, and the Beck Depression Inventory. Measures of ESRD severity/comorbidity and biochemistry were also collected.

Results

Perceptions of treatment disruptiveness and attributions to poor medical care were significantly greater in CAPD. Home-based treatments were not found to confer an emotional adjustment advantage compared to hospital HD. There were marked differences across home-based modalities, with n=22 (44.4%) CAPD meeting the clinical cutoff of depression (≧16) vs. n=6 (26.1%) in APD and n=2 (8%) in home HD. After adjusting for case-mix differences, the mean levels of depressed mood remained significantly higher in CAPD patients compared to APD and home HD (P<.01). On multiple regression analysis, 42.5% of the variance in depression was explained by the End-Stage Renal Severity Index, dialysis modality, perceived treatment disruptiveness, and beliefs about illness consequences and the extent to which the illness could be controlled.

Conclusion

The findings suggest that the benefits of self-care are not uniformly manifested across dialysis modalities and that patients' cognitions are important determinants of depressed mood with implications for future research and clinical practice.

Introduction

Depression is quite prevalent in the end-stage renal disease (ESRD) population [1]. While it is important to distinguish between the presence of depressive symptoms as assessed by self-report questionnaires and a psychiatric diagnosis of clinical depression/depressive disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria) that requires a carefully based, structured interview [2], the recent recognition of patient as major stakeholder in modern health care has led to increased use of patient-reported outcome measures. Despite methodological differences in assessment, the literature is consistent in showing that both depressed mood and clinical depression may detract substantially from quality of life (QOL) [3] and may represent another morbidity and risk factor for mortality [4], [5].

The exact prevalence of depressive symptoms across dialysis modalities remains contentious as research has tended to focus on the hemodialysis (HD) population and neglected patients receiving peritoneal dialysis (PD). PD requires placement of a catheter into the abdominal cavity. This is used for daily repeated instillation and drainage of sterile dialysate administered by the patients typically three or four times a day [continuous ambulatory PD (CAPD)] or performed automatically overnight by a machine [automated PD (APD)]. This is different to HD which requires access to circulatory system and is performed intermittently either at home by patients or in the hospital by medical staff. Increasingly, patients are expected to self-administer treatment while at home or at work through CAPD, APD, and home HD instead of receiving more expensive hospital-based HD. Home-based dialysis modalities afford greater autonomy for patients but necessitate a greater level of involvement in their treatment.

An understanding of whether and how treatment-related differences may influence the prevalence of depression and levels of depressed mood merits further study. Previous studies have produced mixed findings as to which of the treatment modalities may confer emotional adjustment or QOL advantage. They are further limited by comparing mainly hospital HD to CAPD [6], [7], [8] with little consideration of the other home-based modalities. The increasing emphasis on home-based management protocols away from overburdened tertiary centers makes it important to explore whether home-based dialysis modalities may promote or undermine emotional well-being. It is possible that the ability to administer one's own treatment at home/own environment as opposed to having it done by medical staff at a hospital may have a positive effect on emotional adjustment, or on the other hand, the responsibility for such crucial treatment may be seen as burden. The question of how the different home-based dialysis modalities may affect emotional well-being has not been fully explored. Although APD has been shown to afford better QOL relative to CAPD [9], there have been no comparisons of any of the PD treatments with home HD. It is likely that the relative simplicity of CAPD and APD may foster emotional adjustment as opposed to the technical challenges of home HD (e.g. self-cannulation) or it may be that the intensive rigorous routine of daily treatment may have the inverse effect.

In order to understand patients' emotional responses to their treatment, it is important to assess how they perceive and evaluate the different treatment modalities. It has recently been recognized that patients' illness and treatment beliefs are important determinants of adjustment outcomes in chronic conditions in general and ESRD in particular [10], [11]. The extent to which illness and treatment beliefs influence adjustment in ESRD especially in relation to the different treatment modalities is less well understood [12]. The aim of the present study was to explore illness and treatment beliefs of ESRD patients treated with different dialysis modalities and to investigate the relationship of these beliefs to depression.