Correlation between anxiety, depression, self-perceived burden, and psychological resilience in patients with chronic renal failure on maintenance hemodialysis

Abstract

BACKGROUND

Research examining the relationships among anxiety, depression, self-perceived burden (SPB), and psychological resilience (PR), along with the determinants of PR, in patients with chronic renal failure (CRF) receiving maintenance hemodialysis (MHD) is limited.

AIM

To investigate the correlation between anxiety, depression, SPB, and PR in patients with CRF on MHD.

METHODS

This study included 225 patients with CRF on MHD who were admitted between June 2021 and June 2024. The anxiety level was evaluated using the Self-Rating Anxiety Scale (SAS); the depression status was assessed using the Self-Rating Depression Scale (SDS); the SPB was measured using the SPB Scale (SPBS); and the PR was determined using the Connor–Davidson Resilience Scale (CD-RISC). The correlations among the SAS, SDS, SPB, and CD-RISC were analyzed using Pearson’s correlation coefficients. Univariate and multivariate analyses were performed to identify the factors that influence the PR of patients with CRF on MHD.

RESULTS

The SAS, SDS, SPB, and CD-RISC scores of the 225 patients were 45.25 ± 15.36, 54.81 ± 14.68, 32.31 ± 11.52, and 66.48 ± 9.18, respectively. Significant negative correlations were observed between SAS, SDS, SPB, and CD-RISC. Furthermore, longer dialysis vintage (P = 0.015), the absence of religious beliefs (P = 0.020), lower monthly income (P = 0.008), higher SAS score (P = 0.013), and higher SDS score (P = 0.006) were all independent factors that adversely affected the PR of patients with CRF on MHD.

CONCLUSION

Patients with CRF on MHD present with varying degrees of anxiety, depression, and SPB, all of which exhibit a significant negative correlation with their PR. Moreover, longer dialysis vintage, the absence of religious beliefs, lower monthly income, higher SAS score, and higher SDS score were factors that negatively affected the PR of patients with CRF on MHD.

Key Words: Chronic renal failure; Maintenance hemodialysis; Anxiety; Depression; Self-perceived burden; Psychological resilience

Core Tip: Our investigation demonstrated clinically significant associations between psychological well-being and psychological resilience (PR) in patients with chronic renal failure undergoing maintenance hemodialysis. We observed an inverse relationship between psychological distress severity and PR levels. The multivariate analysis revealed several independent predictors of diminished PR: Extended dialysis duration, absence of religious beliefs, lower monthly income, and elevated anxiety/depression scores. These findings highlight the need for increased clinical vigilance in these vulnerable subgroups. We recommend incorporating routine mental health screening (e.g., using the Self-Rating Anxiety/Depression Scale) into standard management protocols for this patient population. Furthermore, targeted PR-enhancing interventions should be developed, particularly for long-term dialysis patients, those without religious affiliation, and those with lower socioeconomic status.

INTRODUCTION

Chronic renal failure (CRF) is a chronic progressive impairment of the renal parenchyma, characterized by disorders in metabolites, water, electrolyte, and acid–base homeostasis, and clinically presents with nonspecific symptoms, including weight loss, polyuria/polydipsia, and ventral edema[1,2]. Statistical analyses have revealed that chronic kidney disease (CKD) affects at least 10.0% of the global population, leading to > 800 million individuals being afflicted with this condition[3]. CRF, which is an advanced stage of CKD, can progress to end-stage renal disease if left untreated in a timely manner, further intensifying the threat to patients’ lives[4]. At present, the predominant therapeutic approach for CRF is maintenance hemodialysis (MHD), which functions by filtering metabolites and toxins from the patient’s blood to facilitate the restoration of the body’s metabolic equilibrium and subsequently improve renal function[5]. Although this modality exhibits a certain degree of efficacy, the protracted nature of the treatment process may induce substantial mental stress in patients, leading to adverse psychiatric states, including anxiety and depression[6]. Concomitant anxiety and depression not only compromise treatment outcomes and augment the risk of mortality but also exert a negative influence on the quality of life of patients with CKD, particularly elderly patients[7,8]. Nevertheless, numerous patients with CKD exhibit remarkable psychological resilience (PR) against treatment-related crises and challenges, which allows them to mobilize more positive adaptive and coping capacities and robust stress resistance[9]. Conversely, patients with CRF undergoing MHD frequently exhibit a certain level of self-perceived burden (SPB), which is associated with factors such as the substantial treatment costs entailed by the disease and potential treatment-related complications (e.g., anemia and malnutrition)[10]. SPB is a negative perception of “being a burden on others”, which may not only exacerbate patients’ anxiety and depressive symptoms but also exert an adverse influence on their treatment decisions, will to survive, and quality of life[11,12]. Currently, research on the correlation between anxiety, depression, SPB, and PR and the factors that influence the PR of patients with CRF on MHD is limited. This study aimed to perform relevant analyses to provide more valuable clinical practice guidelines for managing patients with CRF undergoing MHD.

MATERIALS AND METHODS

General information

This study enrolled 225 patients with CRF on MHD admitted to Yijishan Hospital of Wannan Medical College as research participants between June 2021 and June 2024. The inclusion criteria were as follows: Patients were diagnosed based on urine tests and imaging examinations and conformed to the diagnostic criteria of CRF[13]; the duration of dialysis treatment was ≥ 3 months; they were in a lucid mental state without cognitive impairment; and their clinical data were comprehensive. The exclusion criteria were as follows: The occurrence of major life events in the preceding 6 months; concurrent impairment of cardiac, pulmonary, renal, or other organ functions; recurrent exacerbations of the disease; and long-term use of medications and alcohol abuse, among others.

Collected indicators

Depression: The patients’ depressive status was evaluated using the Self-Rating Depression Scale (SDS). The standard score was obtained by multiplying the raw score by 1.25. In particular, scores of 53–62 indicated mild depression, scores of 63–72 corresponded to moderate depression, and scores exceeding 73 signified severe depression.

Anxiety: The level of anxiety was determined using the Self-Rating Anxiety Scale (SAS). The standard score was computed as the product of the raw score and 1.25. Scores of 50–59 denoted mild anxiety, scores of 60–69 represented moderate anxiety, and scores exceeding 69 indicated severe anxiety.

SPB: The SPB Scale (SPBS), with a Cronbach’s α coefficient of 0.85 and a content validity index of 0.91, was adopted for assessment. This scale comprised 10 items, with each item scored on a five-point Likert scale, ranging from 1 to 5. The total score of the scale ranged from 10 to 50. Total scores of < 20 represented no significant SPB, scores of 20–29 indicated mild SPB, scores of 30–39 corresponded to moderate SPB, and scores of ≥ 40 indicated severe SPB.

PR: The Connor–Davidson Resilience Scale (CD-RISC) was used to evaluate the patients’ PR. This scale comprised 25 items, each scored on a 5-point Likert scale, ranging from 0 to 4, with a total cumulative score of 100 points. A higher score implied better PR. Furthermore, CD-RISC scores of 0–56 indicated low-level PR, scores of 57–70 corresponded to medium-level PR, and scores > 71 indicated high-level PR.

Statistical analysis

Statistical Package for the Social Sciences (version 20.0) was used for the comprehensive data analysis. Measurement data are presented as means ± SD, whereas count data are presented as numbers of cases and percentages. The χ² test was used to compare two groups of count data. Pearson’s correlation coefficient was used to explore the correlations among the SDS, SAS, SPBS, and CD-RISC. Univariate and multivariate binary logistic regression analyses were performed to identify the significant factors affecting the patients’ PR. P-values < 0.05 were used to indicate statistical significance.

RESULTS

Anxiety and depression status among the 225 patients with CRF on MHD

The SAS and SDS were used to assess anxiety and depression. Among the 225 patients with CRF on MHD, 131 (58.22%) presented with no anxiety, 52 (23.11%) manifested mild anxiety, 31 (13.78%) exhibited moderate anxiety, and 11 (4.89%) displayed severe anxiety. The average SAS score was 45.25 ± 15.36. Regarding depression, 104 patients (46.22%) demonstrated no depression, 50 patients (22.22%) exhibited mild depression, 43 patients (19.11%) presented with moderate depression, and 28 patients (12.44%) showed severe depression. The average SDS score was 54.81 ± 14.68. See Table 1 for details.

Table 1 Anxiety and depression status of 225 patients with chronic renal failure on maintenance hemodialysis, n (%)/mean ± SD.

Indicators	No	Mild	Moderate	Severe
Self-Rating Anxiety Scale	131 (58.22)	52 (23.11)	31 (13.78)	11 (4.89)
	45.25 ± 15.36
Self-Rating Depression Scale	104 (46.22)	50 (22.22)	43 (19.11)	28 (12.44)
	54.81 ± 14.68

SPB of the 225 patients with CRF on MHD

The SPB of the patients was evaluated using the SPBS. The data indicated that 25 patients (11.11%) presented with no SPB, 56 patients (24.89%) had mild SPB, 77 patients (34.22%) exhibited moderate SPB, and 67 patients (29.78%) demonstrated severe SPB. The mean SPBS score was 32.31 ± 11.52. See Table 2 for details.

Table 2 The self-perceived burden of 225 patients with chronic renal failure on maintenance hemodialysis, n (%)/mean ± SD.

Indicators	No	Mild	Moderate	Severe
Self-Perceived Burden Scale	25 (11.11)	56 (24.89)	77 (34.22)	67 (29.78)
	32.31 ± 11.52

PR of the 225 patients with CRF on MHD

The CD-RISC revealed that 47 patients had low resilience (20.89%), 101 patients had medium resilience (44.89%), and 77 patients had high resilience (34.22%). The average CD-RISC score was 66.48 ± 9.18 (Table 3 for details).

Table 3 Psychological resilience in 225 patients with chronic renal failure on maintenance hemodialysis, n (%)/mean ± SD.

Indicators	Low	Medium	High
Connor-Davidson Resilience Scale	47 (20.89)	101 (44.89)	77 (34.22)
	66.48 ± 9.18

Correlation between anxiety, depression, SPB, and PR

Significant negative correlations were identified between SAS (r = −0.285, P < 0.001), SDS (r = −0.326, P < 0.001), and SPBS (r = −0.337, P < 0.001) using the CD-RISC. See Table 4 for details.

Table 4 Correlation between anxiety, depression, self-perceived burden, and psychological resilience.

Correlation analysis	r	P value
SAS and CD-RISC	-0.285	< 0.001
SDS and CD-RISC	-0.326	< 0.001
SPBS and CD-RISC	-0.337	< 0.001

SAS: Self-Rating Anxiety Scale; CD-RISC: Connor-Davidson Resilience Scale; SDS: Self-Rating Depression Scale; SPBS: Self-Perceived Burden Scale.

Factors influencing the PR of patients with CRF on MHD

The univariate analysis revealed that age, dialysis vintage, religious beliefs, monthly income, SAS, SDS, and SPBS were significantly associated with the PR of patients with CRF on MHD (P < 0.05). These factors with significant differences were designated as independent variables. Patients with a CD-RISC score of < 56 were categorized as the low PR group, whereas those with a score of ≥ 56 were assigned to the high PR group. PR served as the dependent variable. The data indicated that dialysis vintage (P = 0.014), religious beliefs (P = 0.025), monthly income (P = 0.003), SAS (P = 0.015), and SDS (P = 0.006) were independent correlated factors influencing the PR of patients with CRF on MHD. See Tables 5 and 6 for details.

Table 5 Univariate analysis of factors influencing psychological resilience in chronic renal failure patients on maintenance hemodialysis, n (%).

Variable	n	Low psychological resilience group (n = 47)	High psychological resilience group (n = 178)	χ2	P value
Sex				0.440	0.507
Male	110	25 (53.19)	85 (47.75)
Female	115	22 (46.81)	93 (52.25)
Age (years)				5.307	0.021
< 60	110	30 (63.83)	80 (44.94)
≥ 60	115	17 (36.17)	98 (55.06)
Dialysis vintage (years)				4.308	0.038
< 3	135	22 (46.81)	113 (63.48)
≥ 3	90	25 (53.19)	65 (36.52)
Marital status				0.543	0.461
Single	76	18 (38.30)	58 (32.58)
Married	149	29 (61.70)	120 (67.42)
Education level				1.478	0.224
Below senior high school	137	25 (53.19)	112 (62.92)
Senior high school or above	88	22 (46.81)	66 (37.08)
Religious belief				6.226	0.013
Without	182	44 (93.62)	138 (77.53)
With	43	3 (6.38)	40 (22.47)
Monthly income (CNY)				5.286	0.022
< 5000	145	37 (78.72)	108 (60.67)
≥ 5000	80	10 (21.28)	70 (39.33)
SAS (points)				8.606	0.003
< 45	100	12 (25.53)	88 (49.44)
≥ 45	125	35 (74.47)	90 (50.56)
SDS (points)				7.296	0.007
< 55	116	16 (34.04)	100 (56.18)
≥ 55	109	31 (65.96)	78 (43.82)
SPBS (points)				5.590	0.018
< 30	81	10 (21.28)	71 (39.89)
≥ 30	144	37 (78.72)	107 (60.11)

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SPBS: Self-Perceived Burden Scale.

Table 6 Multivariate analysis of factors influencing psychological resilience in chronic renal failure patients on maintenance hemodialysis.

Variable	β	SE	Wald	P value	Exp (β)	95%CI
Age (years)	-0.591	0.371	2.536	0.111	0.554	0.268-1.146
Dialysis vintage (years)	0.911	0.372	6.006	0.014	2.486	1.200-5.151
Religious belief	-1.460	0.650	5.040	0.025	0.232	0.065-0.831
Monthly income (CNY)	-1.269	0.425	8.922	0.003	0.281	0.122-0.646
SAS (points)	0.961	0.395	5.913	0.015	2.614	1.205-5.673
SDS (points)	1.050	0.378	7.695	0.006	2.856	1.361-5.996
SPB (points)	0.732	0.413	3.139	0.076	2.080	0.925-4.674

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SPB: Self-Perceived Burden.

DISCUSSION

In this study, the proportions of patients with anxiety and depression among the 225 patients with CRF on MHD were 41.78% and 53.78%, respectively, which were comparable to those reported in the study on patients undergoing MHD by Nagy et al[14] (with the prevalence rates of anxiety and depression being 49.6% and 55.0%, respectively). The mean SAS and SDS scores of the 225 patients with CRF on MHD were 45.25 ± 15.36 and 54.81 ± 14.68, respectively, suggesting an overall absence of significant anxiety and mild depression. In a study by Hou et al[15], the mean SAS and SDS scores of patients undergoing MHD were 52.96 and 46.71, respectively, which were similar to our findings. Jiang et al[16] also indicated that during the coronavirus disease 2019 (COVID-19) epidemic, the average SAS and SDS scores of patients undergoing hemodialysis were 48.03 ± 5.02 and 48.12 ± 5.42, respectively, corroborating the accuracy of our data. Peng et al[17] further reported that anxiety and depression in patients undergoing MHD may be associated with abnormally elevated levels of serum neurotrophin-3 and serotonin. Furthermore, they highlighted that factors such as rural household registration, economic deterioration, fatigue, insomnia, and vascular pain increase the risk of depression. Regarding SPBS scores, the percentage of patients with SPB was 88.89%, and the mean SPBS score was 32.31 ± 11.52, indicating an overall moderate degree of SPB. In a study by Liu et al[18], the mean SPB score among 329 renal transplant recipients was 29.09 ± 11.10, which was comparable to our data. Correlation analysis revealed that anxiety (r = −0.285, P < 0.001), depression (r = −0.326, P < 0.001), and SPB (r = −0.337, P < 0.001) exhibited significant negative correlations with the PR of patients with CRF on MHD. According to Chen et al[19], the PR of isolated hospitalized patients with COVID-19 was inversely associated with anxiety and depression, corroborating our observations. Previous investigations have indicated that anxiety, depression, and PR in women with endometriosis also have an inverse association, which is similar to our research results[20]. In a study by Yuan et al[21], a significant negative correlation was observed between PR and frailty in patients undergoing MHD, and PR also served as an independent protective factor against frailty, suggesting that enhancing patients’ PR can ameliorate their physical frailty.

The univariate and multivariate analyses revealed a close association between age, dialysis vintage, religious beliefs, monthly income, SAS, SDS, and SPBS and the PR of patients with CRF on MHD. Among them, dialysis vintage, religious beliefs, monthly income, SAS, and SDS served as independent correlated factors influencing the PR of such patients. Notably, religious beliefs and higher monthly income were protective factors for the PR of patients with CRF on MHD. Patients with a longer dialysis vintage typically endure more pronounced physical and mental pain and stress associated with the treatment. Factors such as treatment-related complications and treatment costs further intensify psychological distress, predisposing them to more intensified negative emotions and a subsequent reduction in PR[22]. To a certain extent, having religious beliefs can provide patients with spiritual sustenance, consolation, adaptive coping, and social support from religious communities, all of which can enhance their PR[23]. A relatively high monthly income can, to some degree, alleviate the economic burden and family-related guilt stemming from treatment costs. It also reflects, to some degree that the patient may have received certain social support at work, and these factors can jointly enhance the patient’s PR[24]. The negative influence of SAS and SDS on the PR of patients with CRF on MHD predominantly originates from the distress inflicted on patients’ physical and mental well-being by negative emotions. This further indicates that the implementation of psychological interventions to progressively alleviate patients’ negative psychological states can help augment their PR. A study by Meng et al[25] identified a high family income level of ≥ 1415 USD/month as an independent protective factor against depression in patients undergoing MHD, which was congruent with our research results. In the report presented by Zhang et al[26], age, religious beliefs, per capita family monthly income, and baseline family resilience were independent correlated factors for the PR of patients undergoing MHD, consistent with the results of our study. Although this study did not explore intervention strategies for patients with CRF on MHD, Hargrove et al[27] noted that aerobic exercise for patients undergoing MHD not only helped relieve depressive symptoms but also exhibited significant ameliorative effects against fatigue, muscle cramps, restless legs syndrome, and other conditions, suggesting the clinical effectiveness of aerobic exercise in patients with CRF on MHD.

This study has several limitations that should be acknowledged. First, because of the study’s cross-sectional design, the findings only demonstrated associations rather than causality between anxiety, depression, SPB, and PR. Longitudinal studies are necessary to explore potential causal pathways. Second, unmeasured confounders—including social support, marital status, and coexisting psychiatric conditions—may influence PR, suggesting the need for more comprehensive models in future studies. Third, PR was assessed using a relatively narrow framework; supplementing quantitative measures with qualitative approaches would provide deeper insights into the multidimensional nature of PR in this population. Fourth, the sample was drawn from a single hospital and excluded individuals with significant life events or organ dysfunction, which may have introduced selection bias and reduced generalizability. Expanding recruitment to multiple centers and including a more diverse patient population would strengthen the validity of future findings. Subsequent investigations will integrate these perspectives to provide more robust analysis.

CONCLUSION

In summary, the 225 patients with CRF on MHD presented with varying degrees of anxiety and depression, accompanied by a moderate level of SPB and a medium level of PR. A statistically significant inverse correlation was observed between anxiety, depression, SPB, and PR. In particular, patients with longer dialysis vintage, those without religious beliefs, those with low monthly income, and those with elevated SAS and SDS scores tended to have a lower PR level.