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Psicologia: teoria e prática

Print version ISSN 1516-3687

Psicol. teor. prat. vol.20 no.3 São Paulo Sept./Dec. 2018 



Depression and chronic kidney disease: an integrative literature review


Depresión y enfermedad renal crónica: revisión integrativa de la literatura



Gabriela da Silva Cremasco; Makilim Nunes Baptista

Sao Francisco University - USF, SP, Brazil

Mailling address




Brazilian and international scientific studies on depression and chronic kidney disease published between 2006 and 2016 in the PsycINFO and LILACS databases were analyzed. In total, 269 publications were analyzed against the inclusion and exclusion criteria, so that 21 articles remained for analysis. The studies were evaluated for the year of publication, periodicals, objectives, sample, results, associated constructs, and instruments of depression. The prevalence of depressive symptoms varied from 7.8% to 83.49%. Also, most samples were small and included both sexes. The year with most publications was 2011, and the Beck Depression Inventory was used in 66.67% of the studies. It is important to evaluate depression using instruments that take into account the specificities of the context in order to reduce bias and to permit a correct identification of the depressive symptoms in this population.

Keywords: depressive symptomatology; depressive disorder; chronic renal failure; hemodialysis; integrative review.


Se analizaron producciones científicas brasilenas e internacionales sobre la depresión y la enfermedad renal crónica entre los anos 2006 y 2016, en las bases PsycINFO y LILACS. 269 publicaciones fueron analizadas ante los criterios de inclusión y exclusión, restando 21 artículos para análisis. Los estudios fueron evaluados en cuanto al ano de publicación, periódicos, objetivos, muestra, resultados, constructos asociados e instrumentos de depresión. Se verificó que la prevalencia de sintomatologia depresiva varía de 7,8% a 83,49%, además de que gran parte de las muestras eran de tamano reducido e incluían ambos sexos. El ano con más publicaciones fue 2011 y el Beck Depression Inventory fue utilizado en el 66,67% de los estudios. Es importante evaluar la depresión con instrumentos que tengan en cuenta las especificidades del contexto para reducir sesgos y permitir la identificación correcta de la sintomatología depresiva en esa población.

Palabras clave: sintomatología depresiva; trastorno depresivo; insuficiencia renal crónica; hemodiálisis; revisión integrativa.




It is estimated that there are currently 112,004 people with Chronic Kidney Disease (CKD) in Brazil (Sesso, Lopes, Thomé, Lugon, & Martins, 2016). It is a silent disease, which in most cases has no symptoms, which prevents the early diagnosis. Thus, when the symptoms become evident, the kidney function is usually already compromised, with possible physical, psychological, economic and social impact in the life of these patients (Ramos, Queiroz, & Jorge, 2008).

The CKD tends to cause limitations and a decrease in the quality of life, turning this population prone to the development of mental disorders, depression is one of the most reported conditions in renal patients. Nevertheless, depression is often underdiagnosed, mainly due to the overlapping of symptoms with CKD, such as changes in appetite and sleep, weight loss, slowing down, fatigue, among others, making their identification in these patients a complex and challenging process (Condé et al., 2010; Kimmel, 2002).

The depressive disorder is considered the main mental cause of disability and affects people of different age groups. It mainly includes depressed mood and loss of interest or pleasure in previously pleasurable activities, in addition to other symptoms, such as low concentration, disturbance of appetite and sleep, guilt, low self-esteem, hopelessness, among others. This fact is a public health problem, given that people affected by the disease have their quality of life and daily life considerably impaired, influencing the professional, school and family spheres, and may result in suicide (World Health Organization, 2017).

Finger et al. (2011) reported some hypotheses for the development of depression in people with CKD on hemodialysis, indicating that these patients tend to report several losses, among them the loss of function in the family, professional, physical, cognitive, and sexual dysfunction. The authors also indicated that although studies in the literature on the subject indicate that people in renal therapy have greater depressive symptoms compared to individuals with other chronic diseases or the general population, there is no precision regarding the prevalence rate of depression in this population.

Moreira et al. (2014) pointed out that the prevalence rates of depression in people with CKD vary according to the criteria and instruments used with the samples included in the studies. Depressive symptoms tend to impair treatment compliance, leading to nutritional problems, impaired immunity, and increased mortality. Patients with CKD have 1.5 to 3 times more hospitalizations due to psychiatric conditions compared to other chronic diseases, depression, dementia, and substance abuse being the most frequent causes.

In a systematic review and meta-analysis, Palmer et al. (2013) investigated the prevalence of depression symptoms in adults with CKD, based on a survey in the MEDLINE and Embase databases. The study included 249 samples, with a total of 55,982 patients. The authors restricted the analysis to studies in which clinical interviews were used and found a prevalence of 20.3% of depression. It was also pointed out that, when using self-report scales, the prevalence of depression symptoms tends to be higher, and it is necessary to evaluate these data with caution, mainly due to the frequency of somatic symptom indicators that frequently affect renal patients.

Integrative reviews of the literature permit organizing and synthesizing the results of research carried out on a given topic, which contributes to the expansion of the knowledge on the research subject. Thus, a critical discussion of the methods, objectives, and results found is possible, which permits reaching general conclusions on the field of knowledge in question (Mendes, Silveira, & Galvão, 2008).



Based on these considerations, this study aimed to analyze the Brazilian and international scientific production on depression in chronic renal patients. Therefore, the levels of depression symptoms obtained in the studies, the main constructs associated with depression and renal disease and the samples used in the research were verified. Besides, the study analyzed whether the evaluation instruments of the depression symptoms used in the studies are suitable for the outpatient and/or hospital context.



An integrative review of the literature on depression and chronic kidney disease was conducted in the PsycINFO and LILACS databases. For the LILACS database, the following search terms were used with Boolean operators: "(depressão OR transtorno depressivo OR transtornos do humor) AND (doença renal OR diálise renal OR insuficiência renal OR falência renal)". For the PsycINFO database, the same descriptors were used in the English language: "(OR) or" OR "(kidney disease OR renal dialysis OR renal insufficiency OR kidney failure)."

The inclusion criteria were: articles published between 2006 and 2016, written in Portuguese, English or Spanish, empirical studies and samples composed of people aged 18 years and over. We excluded studies that had no direct relation with the proposed theme, other review articles, as well as reports in the form of dissertations, theses, book chapters, comments, or criticism. The procedures described were carried out in December 2016.



In total, 269 publications were obtained in the databases (PsycINFO = 235; LILACS = 34). After reading the abstracts, 85 papers were selected with the theme of chronic kidney disease and depression (PsycINFO = 82; LILACS = 3). Subsequently, the complete texts of the selected studies were retrieved and, after reading them and based on the initially established criteria, 64 were excluded. Therefore, 21 studies were included in the integrative review, as shown in Figure 1.



The studies included in the review were read in full and evaluated for authorship, year of publication, journal, objectives, sample, instruments used, and main results obtained. These characteristics are presented in Table 1.

Table 1 indicates that the main objectives of the studies were to verify the prevalence of depression symptoms, as well as their association with other constructs. The prevalence of depression symptoms ranged from 7.8% to 83.49%, with different intensities, that is, mild, moderate and severe. Table 2 presents the associated constructs and the depression instruments used in the studies.

According to Table 2, the most associated constructs in the studies were anxiety and quality of life and, concerning the instruments, the BDI (I and II) was present in most of the studies. Among the self-report instruments, the Beck Depression Inventory (BDI) consists of 21 items; the Hospital Anxiety and Depression Scale (HADS), consisting of 14 items, 7 of which were subscales of depression; the Geriatric Depression Scale (GDS) with 30 items and the Center for Epidemiologic Studies Depression Scale (CES-D), which contains 20 items. Finally, the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), which is a structured interview, in which the mood evaluation module consists of 15 questions.

The sample size was classified according to the proposal of Prieto & Muniz (2000), who defined that a sample considered small contains less than 200 subjects, a moderate sample between 200 and 500 and a large sample more than 500 participants. In this study, most articles (N = 16, 76.19%) were classified as small samples, followed by the moderate category (N = 4, 19.04%), and (N = 1, 4.76 %) presented a large sample.

Regarding the type of the sample, in 76.19% (N = 16) of the articles, the participants composed were only patients on hemodialysis treatment, while the rest of the studies (N = 5, 23.80%) contained, in addition to patients on hemodialysis, patients in other types of treatment, such as conservative treatment and peritoneal dialysis, as well as post-transplant and healthy subjects. Most of the articles included samples of men and women, except for one study with only males. In addition, the minimum age of the study participants was 18 years old. The number of articles published per year was verified, and the studies were retrieved between the years 2006 and 2015. Most of the publications occurred in 2011 (N = 6, 28.57%), followed by the years 2010 and 2012 (N = 3, 14.29%), with a decrease in subsequent years.

The 21 articles analyzed were published in 16 journals in Psychology and other areas of health. The journals with the highest number of publications in the research period were the Brazilian Journal of Psychiatry (N = 3, 14.29%), the General Hospital Psychiatry (N = 3, 14.29%), and the Psychology (N = 2; 9.52%).



The objective of this study was to analyze the scientific production on depression in chronic renal patients, based on an integrative review of the literature. It was observed that the most used depression instruments were the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), the Geriatric Depression Scale (GDS), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I).

The BDI is the most applied depression symptom evaluation tool in the studies, both in clinical and nonclinical populations. The inventory was published in 1961 and is a pioneering tool in screening from these symptoms, and several psychometric studies have used it over the years (Argimon, Paloski, Farina, & Irigaray, 2016; Baptista & Borges, 2016). It is important to consider that BDI, present in 14 of the 21 studies evaluated, contains approximately 29% of items that assess vegetative symptoms of depression. According to Conde et al. (2010) and Kimmel (2002), it is important to be cautious when evaluating vegetative aspects, as the symptoms between depression and CKD could be overlapping. An alternative that has been applied for the application of BDI in CKD patients is the cutoff equal to or greater than 16/17 (Preljevic et al., 2012; Watnick, Wang, Demadura, & Ganzini, 2005).

Most of the instruments used (BDI, HADS, GDS and CES-D) were self-reported, in which the subject responds to the items with or without the aid of the applicator. We also used a structured interview (SCID-I), which consists of a set of preset questions, held by a trained professional. As reported by Lutz, Stahl, Howard, Grissom, & Joske (2002), structured interviews offer the opportunity to investigate the direction of the disorder, while the screening scales are more practical and allow a quick identification of possible cases, at a lower cost than the others. These scales do not provide the amount of information necessary to reach a proper diagnosis, such as the most affected areas of the subject's life and duration of the symptoms for example (Baptista, Cardoso, & Gomes, 2012).

The prevalence of depressive symptoms in different degrees of severity (mild, moderate and severe) in the studies ranged from 7.8% to 83.49%. As indicated by Moreira et al. (2014), the prevalence of depression symptoms varies according to the criteria stipulated by the researcher. In this sense, as reported by Palmer et al. (2013), the prevalence of depressive symptoms tends to be higher when evaluated using self-report instruments, emphasizing the importance of carefully investigating these results, mainly due to the somatic symptoms common to depression and chronic kidney disease, which are present in most of the evaluation scales of depression symptoms. In this study, except for HADS and GDS, the instruments used in the studies analyzed contain items that evaluate somatic characteristics, raising caution as to the prevalence found.

The constructs most associated with depression were anxiety and quality of life. Some authors have reported that anxiety in renal patients is common, due to the very process of adaptation to a treatment routine. Also, the disease intimidates the subjects, who perceive that their life and body integrity are constantly threatened (Dias, Shiozawa, Miorin, & Cordeiro, 2015; Valle, Souza, & Ribeiro, 2013). Ottaviani et al. (2016) indicated that kidney disease and its treatment could lead to losses and changes in the patient's life, not only physically but also emotionally, which would lead to a worsening in the subject's quality of life. Most of the study samples were categorized as small in size, based on the criteria by Prieto & Muniz (2000). Thus, one hypothesis for the reduced sample number is the cost to carry out studies with more extensive samples, as well as the difficulty to get access to certain samples.

The limitations in this integrative review include the reduced number of databases consulted, as well as the restriction to articles published only between 2006 and 2016. Thus, we do not intend to reach conclusions about the current scenario of knowledge about depression in renal patients, but to investigate the field of the subject in question. The literature has demonstrated the importance of treating not only physical but also mental aspects in chronic renal patients, given the consequences of depression in these patients. Based on the analyses, studies are necessary that aim at providing effective interventional proposals in the treatment of depression in chronic kidney patients, considering their high prevalence, as verified in the studies included in this review. Also, it is fundamental to choose instruments that have been developed for outpatient/hospital use, that is, instruments that cover the specificities of the investigated context, in order to reduce possible biases.



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Mailling address:
Gabriela da Silva Cremasco
R. Waldemar César da Silveira, 105, Jardim Cura D'Ars (SWIFT)
Campinas, SP, Brasil. CEP: 13045-510

Submission: 4.10.17
Acceptance: 27.7.18

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