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Comprehensive Psychiatry xx (2010) xxx xxx www.elsevier.com/locate/comppsych

Factors associated with risk of suicide in patients with hemodialysis

Camila Martiny, Adriana Cardoso de Oliveira e Silva, Jos Pedro Simes Neto, Antonio Egidio Nardi
Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), INCT Translational Medicine, Brazil 22410-003

Abstract Suicide risk (SR) has been associated to several factors; one of them is the presence of psychiatric disorders. This study has the objective of investigating the relationship between the risk factors for suicidal behavior in patient bearers of chronic renal illness who are undertaking hemodialysis treatment. Sixty-nine undertook a short, structured diagnostic interview. The prevalence of some psychiatric disorders showed itself greater in the sample than that in the population in general. A significant positive correlation was found between SR, major depressive episode, and agoraphobia without panic disorder. The religiosity of the patient was also evaluated as an influencing factor of SR. Nonreligious patients had 8 times more chance to have SR compared to religious patients. However, the referred effect only occurred in nondepressed religious patients. The latter indicated that religiosity had its effect annulled in depressed patients. This study shows the importance of measures of intervention in mental health, mainly in relation to prevention and treatment of major depressive episode with a view to reducing SR. 2010 Elsevier Inc. All rights reserved.

1. Introduction Hemodialysis treatment obliges the patient to remain in a restricted ambience, linked to the equipment and with limited mobility for hours, several times a week, which interferes directly in his or her daily routine. Patients undertaking this treatment have to follow strict dietary and fluid intake restrictions. Changes in the subject's routine and adaptation to new conditions of life are stress factors [1]. Studies show that 55% of patients with chronic kidney disease (CKD) report that dealing with the disease was the most difficult emotional experience in their lives [2]. Patients with long-term health problems show more prevalence of psychiatric disorders, mainly anxiety and depression, than the population in general [3-5]. Among patients with chronic renal problems [6,7], social and family problems were found, which are directly related to the particularities of the clinical condition and the hemodialysis
This research project is supported by the Brazilian Council for Scientific and Technological Development (CNPq). Corresponding author. Universidade Federal do Rio de Janeiro, Instituto de Psiquiatria, Laboratrio de Pnico e Respirao, Rua Visconde de Piraj, 407/702, Rio de Janeiro, RJ, CEP: 22410-003, Brasil. Tel.: +55 21 2521 6147; fax: +55 21 2523 6839. E-mail address: camartiny@hotmail.com (C. Martiny). 0010-440X/$ see front matter 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2010.10.009

[8] treatment, negatively affecting the patients' quality of life [9-11]. Suicide rates are also greater among patients with renal conditions in treatment with hemodialysis [12-14] than those in the general population. Suicide risk can be prompted by a failure to cope with the stress of dialysis in the context of maladaptative patient and environmental psychosocial factors rather than by declining health status [13]. Despite that several studies are showing a relationship between psychiatric disorders and SR [15,16], it is necessary for a better comprehension of some factors. An important point is how becoming ill and the subsequent treatment could affect this relationship. This study has as its objective the investigation of the prevalence of psychiatric disorders in patients under treatment using hemodialysis and its correlations with SR. We hypothesize that patients with CKD have a higher prevalence of SR than the general population, and it is possible that the presence of some disorders such as depression could be a factor involved in this relationship.

2. Methodology Transversal, descriptive, observational research was completed in which 69 patient bearers of chronic renal

C. Martiny et al. / Comprehensive Psychiatry xx (2010) xxxxxx

Table 1 Matrix of correlation between suicide risk and psychiatric disorders MDE SR Correlation coefficient Significance (2 tailed) N 0.445 .000 69 PDA 0.073 .549 69 AwPD 0.397 .001 69 Social phobia 0.049 .690 69 Use of substance 0.072 .560 68 GAD 0.112 .361 69

Significant correlation with 99% confidence interval.

illness participated, all under treatment with hemodialysis in a nephrology center. The following inclusion criterion was adopted: 18 years or older, undertaking hemodialysis sessions 3 times a week for more than 30 days. The following were the exclusion criteria: patient bearers of HIV, hepatitis C virus, and psychotic disorder. The participants undertook the Mini International Neuropsychiatric Interview [17] and gave information for a clinical data register referring to sociodemographic data. The Mini International Neuropsychiatric Interview was applied by a professional trained in mental health for this purpose. Statistical analysis to determine the prevalence of the different psychiatric disorders in this specific population as well as the correlation between the different disorders was carried out. Cross-analysis of the comorbidity variations, measured dicotomically with other independent variables, and application of the square-root test, Fisher exact test, and analysis of variance to verify the dependency relationships between the variables were applied. This study received the approval of the committee of ethics in research, and all the patients who agreed to voluntarily participate in the study signed a term of free and clarified consent. 3. Results 3.1. Sociodemographic data The population studied showed a slightly higher predominance of men (55%), with an average age around 50 years, most being married (53%), with low levels of education (65% with primary education), and having religiosity (RE) (93%). Most received family support (94%), and 64% did not work. Apart from the latter, 6% did not have any income via family. Among those who had income, a relationship between income and the level of education of the patient was observed: 77% of the patients with primary education had low income (up to R$1000.00); among those who had secondary education, 68.4% had an intermediary income (NR$1001.00); and among patients with university education, all had high income (NR$1500.00) 3.2. Comorbidities About health aspects, the predominance was a medium to low dialysis time (90% between 1 and 6 years); 68% were

waiting to undertake a transplant, 54% had hypertension, 75% had diabetes, and 13% had other illnesses. As for the prevalence of mental disorders in the sample, the following results were encountered: major depressive episode (MDE), 23.2%; agoraphobia without panic disorder (AwPD), 13%; social phobia, 8.7%; generalized anxiety disorder (GAD), 8.7%; use of substances without characterizing dependency, 7.4%; dependency on substances, 1.5%; panic disorder with agoraphobia (PDA), 7.4%; hypomania episode, 4.3%; manic episode, 2.9%; obsessive-compulsive disorder, 2.9%; dysthymia, 1.4%; panic disorder without agoraphobia, 1.4%; and use of alcohol, 1.4%. The value encountered for SR was 11.6%. In analyzing the matrix of correlation between SR and psychiatric disorders identified and that possessed prevalence higher than 4.3% in the sample (Table 1), a significant correlation with a 99% confidence interval with MDE and AwPD was found. 3.3. Suicide risk In concerning patients with SR, 3 correlated variables were identified: MDE, AwPD, and RE. Thus, a logistic binary regression was made, in which the dependent variable was SR, seeking to identify the amount that each one of the independent variables increased the chances of a person to be subject to SR. Table 2 shows the distribution of subjects concerning religion. Suicide risk was found to be almost 8 times greater among atheists than those who have RE (Fisher exact test = 0.010; P .01). Table 3 shows that AwPD loses its explanatory power when analyzed together with the 2 other variables. The main explanation for the increase of likelihood of a person being subject to SR is linked to MDE. So, patients who have MDEs have more than 1.600% of chance of having SR than patients who do not have MDE when controlling AwPD and RE. Those who have RE have the chance of having SR reduced
Table 2 Distribution according to possessing or not a religion, among subjects with suicide risk Religion SR No Do not have a religion Have a religion Total 40.0 92.2 88.4 Yes 60.0 7.8 11.6 Total 100.0 100.0 100.0

C. Martiny et al. / Comprehensive Psychiatry xx (2010) xxxxxx Table 3 Logistic binary regression (suicide risk as dependent variable) B Step 1 MDE PDAs Religion Constant 2.879 1.669 3.580 0.635 SE 1.182 1.157 1.542 1.184 Wald test 5.933 2.080 5.388 0.288 df 1 1 1 1 Significance .015 .149 .020 .592 Exp (B) 17.801 5.309 0.028 0.530

by 97.2% when MDE and AwPD were controlled. Thus, the absence of MDE and the presence of RE reduce the chance of someone being subject to SR. However, the table presents polarization between those who have MDE, increasing enormously the chance of SR and also reducing it significantly if the person has RE. To verify the consistency of the dichotomy, an alternative table was created including an interactive factor associated to MDE and RE. In the alternative table, apart from the variables mentioned in the previous table, an interaction between MDE and RE was inserted. Thus, the increase of SR was measured considering 4 groups: those who have MDE, those who have RE, those who have AwPD, and those who have MDE and RE. Table 4 showed Nagelkerke R2 = 0.511; however, it did not increase significantly the explanatory power of the previous table. In the alternative table, only the variable RE showed a significant result with 95% confidence interval. To have RE without having MDE and controlling via AwPD reduces SR by 96.9%. Thus, the tables constructed were capable of showing that although AwPD is positively correlated with SR, it, however, loses significance when controlled by the variables MDE and RE. Although MDE is correlated with SR, when controlled by the other variables and by the interactive factor, it loses its explanatory power. Apart from the latter, the interactive factor showed that MDE, when associated with RE, also does not alter the variation of SR. Only when the patient has RE and not MDE there is a significant reduction of SR, but the presence of MDE annuls the effect of RE.

4. Discussion and conclusion The sample studied showed that elderly and unemployed patients predominated, and although the last 2 are considered factors that predispose the onset of psychopathologic
Table 4 Alternative model, including the interaction between depression and religion B Step 1 MDE Religion Rel_Dep PDAs Constant 20.281 3.465 17.459 1.615 0.693 SE 28 420.716 1.625 284 290.716 1.180 1.225 Wald 0.000 4.544 0.000 1.873 0.320 df 1 1 1 1 1 Significance .999 .033 1.000 .171 .571 Exp (B) 6.428 0.031 0.000 5.027 0.500

conditions, on the other hand, it showed family support, which is considered a protecting factor in mental health. The treatment period predominantly encountered in this sample (1-6 years) is considered a middle time for dialysis, and it is sufficient for the patient to have already been through a lifestyle adaptation. So, the real interference of the dialysis treatment can be evaluated. As for the prevalence of psychiatric conditions, we found values higher than the population in general [18,19] for major depression, GAD, bipolar disorder, and obsessivecompulsive disorder. The value assessed for SR was 11.6%, with a significant positive correlation with MDE and panic disorder without agoraphobia. Studies indicate RE as a protecting factor against suicide [20,21]. People that have RE showed a lower likelihood of depression symptoms; on the other hand, depressed people [22], when involved in religious practices, showed greater remission of symptoms than atheists [23,24]. A greater social interaction, as a consequence of religious practices, could also act in a prophylactic way as much as in the prevention of depressive conditions as well as in relation to SR itself [25]. In the sample studied, SR was found to be almost 8 times greater among those without any religion than those who had a religion. However, the study showed, as a limiting aspect, the fact of RE being self-referential and not being differentiated in the question of whether the individual is fully active or if he or she maintains religious beliefs in his or her lives without, however, being linked to entities or religious groups that would deprive the individual of the social support factor that could be offered by them. By carrying out a more detailed analysis of the relationship between the factors analyzed and their influence on SR, we observed that if, on one hand, the religious patient showed less risk, this effect was annulled by the factor of depression that when controlled in this specific population effectively reduced SR. There is clear evidence of the importance of investigating aspects linked not only to mental health but also to the RE of the patient. The CKD causes wide changes in patients' lives, prompting in quality of life. Fluid and dietary restrictions, social and work impairment, difficulty to find a compatible donor, extended waiting list for kidney transplantation, and psychologic distress are challenges that can be linked to presence of psychiatric disorders. Mental illness, especially depression, is a factor of SR in many long-term conditions. However, there are differences in rates of SR when comparing several chronic diseases. The burden of physical illness is linked to the differences of SR ranges [13,26,27]. Taking this fact, it is reasonable to understand the results found in this study. Once encountered a link between MDE, RE, and SR, the development of intervention policies in mental health with a view to depression therapy for patients who are undergoing treatment of hemodialysis would be a question of fundamental importance-enabling. Psychiatric treatment and

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