Chronic kidney failure is defined as a progressive and irreversible deterioration in kidney functions. Hemodialysis, which can be applied 2–3 times a week for 4–6 h, is commonly used in the treatment of chronic kidney failure. In the hemodialysis process, toxic substances accumulated in the patient's blood due to kidney failure are removed. Although this treatment has vital importance, it usually affects the daily routines and quality of life of the patient and his family. In addition, it significantly restricts the patient and his family in terms of social, economic, and psychological functions. Having a family member who receives hemodialysis treatment brings new responsibilities and dynamics to the family. In these families, the spouses often become a primary caregivers and have to deal with all dialysis-related problems. Fort the patients, dialysis procedures could give rise to break some of their habits and replace older ones with newer and more adaptive habits. This process can be also considered as a transition for both the patient and his spouse. For the spouse, dialysis treatment for their partners represents the process that changes in all areas of their lives, along with adapting to newer living conditions.
Studies have shown that the caregivers of hemodialysis patients, especially spouses, have difficulty with time management for themselves. They mostly have difficulty with meeting the patient's care needs and feel insufficient from time to time. Moreover, due to the disease burden that the family currently encounters, they can have financial difficulties. Due to their increasing responsibilities, the spouses of the patients could feel deprived and restricted for not being able to get together with other members of the family and their friends. Therefore, social isolation is mostly observed among them.
Based on the previous studies regarding the psychosocial outcomes of the dialysis process for the patients' family, this study was aimed to compare the psychological symptoms including depression, anxiety, and anger levels of the spouses whose partners had hemodialysis and the healthy controls.
Materials and Methods
This study was performed in line with the principles of the Declaration of Helsinki, as revised in 2013. The compatibility of the study with the Principles of Helsinki Declaration was ensured and the approval of the ethics committee was obtained by Üsküdar University Non-Invasive Research Ethics Committee with the number B.08.6. YÖK.2. ÜS.0.05.0.01/2018/013. The research was carried out in March 2018 at Kosuyolu Ata Dialysis Center and Atasehir and Umraniye Fresenius Medical Care Dialysis Centers located in the city center of Istanbul. All participants were informed about the research in the written and oral form for their consent.
The study group of the research consisted of 50 healthy participants who are between the ages of 25–65, and spouses of hemodialysis patients. The control group consisted of 50 healthy participants who were matched with the spouses in the research group in terms of age and gender, and spouses of people without any chronic diseases. While the study group was selected from the spouses accompanying the hemodialysis patients in the treatment sessions, the control group was formed from healthy spouses of healthy people living in Istanbul.
Beck Depression Inventory
It was developed in 1961 by Beck et al. Turkish adaptation of the scale was done by Hisli in 1988.
The highest score that can be obtained from the scale is 63.
Beck Anxiety Inventory
It was developed in 1988 by Beck et al. It measures the number of anxiety symptoms. It was adapted to Turkish by Ulusoy et al. Beck Anxiety Inventory (BAI) consists of 21 Likert-type items and each item has a score range of 0–3. The highest score that can be taken from the inventory is 63.
Spielberger Trait Anger and Anger Expression Inventory
It was developed in 1988 by Spielberger et al. It was adapted into Turkish by Özer in 1994. The scale consists of two main subscales: Trait Anger and Anger Expression Style Subscales. Trait Anger Subscale consists of items that show what the individual generally feels in his life or to what extent they feel angry. The Anger Expression Style Subscale is divided into three subcategories: expressing anger, suppressed anger, and controlling anger. Spielberger Trait Anger and Anger Expression Inventory (STAXI) is a Likert-type scale with 34 items.
The data obtained in the research were subjected to statistical analysis with SPSS v. 21 (Statistical Package for Social Sciences, IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) software. In comparative analysis, independent sample t-test was used for scores with normal distribution and Mann–Whitney U-test was used fort the comparison of mean scores which do not have normal distribution. Pearson correlation analysis was used for examining the relationship among depression, anxiety, and anger in both research groups. In addition, due to the differences observed between the distributions in terms of the problems experienced after hemodialysis, depending on the existence or disappearance of any problem, the Mann-Whitney U test was also used to compare the average scores obtained from the scales in terms of presence of the problems experienced after hemodialysis.
The findings obtained from the research are listed in detail in the tables below. The frequency distributions, percentages, and the Chi-square findings for the comparison of demographic characteristics of the hemodialysis patients' spouses and the control group are shown in Table 1.
As indicated in Table 1, a significant difference was found between the educational status of the hemodialysis patient spouses and the control group. While the number of university graduates was higher in the healthy control group, the number of high school graduates was higher in the research group including the patients' spouses (χ2 = 10.802; P =0.029).
According to the frequencies in Table 2, 52% of spouses of hemodialysis patients had economic problems and 66% had psychological problems.
Table 3 indicates the average scores, standard deviations, and independent-sample t-test findings of the spouses of hemodialysis patients and the control group with their scores in BAI, Beck Depression Inventory (BDI), and STAXI. Based on the findings, a significant difference was found between the mean scores of hemodialysis patients' spouses and the control group in their anxiety scores ([98 = 9.610; P = 0.000). The mean anxiety (X[Combining Overline] = 20.92 ± 10.62) of the spouses of the patients was found to be significantly higher than the mean of the control group (X[Combining Overline] = 5.06 ± 4.82). A significant difference was found between the mean scores of hemodialysis patient spouse and control group obtained from BDI (t98 = 9.465; P < 0.01). The mean depression scores (X[Combining Overline] = 18.50 ± 9.002) of the patients' spouses were found to be significantly higher than the mean scores of the control group (X[Combining Overline] = 5.42 ± 3.80). A significant difference was found between the mean scores of the hemodialysis patient spouse and the control group in the Trait Anger and Anger Expression Inventory Trait Anger Subscale (t98 3.614; P < 0.01). The mean trait anger of the spouses (X[Combining Overline] = 23.96 ± 6.40) was found to be significantly higher than the mean of the control group (X[Combining Overline] = 19.82 ± 4.96).
Table 4 shows the Pearson correlation analysis findings between the hemodialysis patients' spouses' and the control group's anxiety, depression, and trait and state anger and anger expression styles.
It was observed that the anxiety level of the spouses of the patients was associated with trait anger (r = 0.336) and expressing anger (r = 0.452), while the anxiety level of the control group was associated with trait anger (r = 0.344) and depression with suppressed anger (r = 0.351).
Hemodialysis affects the patient's working capacity, physical activity, family life, and individuals who support the patients during the treatment process negatively, despite it is a treatment that prolongs life. In this study, people with healthy spouse were compared with people with hemodialysis patient spouse in terms of depression, anxiety, and anger levels; in demographic characteristics, the education level and working status of the study group including the spouses of the patients were lower than those of the control group and when the problems experienced after hemodialysis were examined, it was seen that 52% of the spouses of the patients had economic problems and 66% had psychological problems.
There was a significant difference between the spouses of hemodialysis patients and the control group in terms of anxiety (t = 9.610; P = 0.000), depression (t = 9.465; P = 0.000), trait anger (t = 3.614; P = 0.000), state anger (t = 3.292; P = 0.000), anger retained (t = 4.777; P = 0.000), anger expressed (t = 2.133; P =0.036) levels, and the levels of the spouses of the patients was found to be significantly higher than the control group. It was observed that the control group was significantly higher than the spouses of the patients in the controlled anger (t = [FIGURE DASH]3.072; P = 0.003). The difference between the control group and the spouses of the patients may occur due to factors such as the care burden of the spouses of the patients and the distress caused by this, their social limitations, nostalgia for the past, the chronicity of the disease, and the fear of losing their spouse. At the same time, the higher level of education in the control group was compared to the patient's spouse group and the fact that most of them are in working positions can be counted among the effective reasons for controlling anger. In another study on the relationship between the burden of care and anger expression styles of family members caring for cancer patients, it was shown that as the burden of care increases, trait anger, suppressed anger, and expressing anger increase, and anger control decreases in relatives and spouses of the patient.
Negative effects on social life, increased responsibility, emotional burnout, and efforts to support the diseased spouse psychologically cause an increase in the level of anger and cause difficulties in controlling anger in the spouses of the patients compared to the control group. It is seen that the process and the requirements of the process affect the anger level of the person, the way of dealing with anger and the ability to control anger. In another study conducted to determine the anger and anxiety levels of the spouses of patients, it was observed that the individuals included in the research group had high levels of anxiety and trait anger.
It has been reported in studies that the hemodialysis process, which causes psychological symptoms, causes changes in the lives of the patient's relatives and spouses. In the study conducted by Keçecioğlu et al., on patients who receiving hemodialysis and chronic ambulatory peritoneal dialysis, and their spouses, it was found that the level of anxiety and depression is high in spouses of patients receiving hemodialysis treatment.
In another study conducted in the same direction, a positive and significant relationship was found between anxiety levels and depression levels in the relatives of the patients. In Ozsaker's study on the quality of life of kidney patients and their relatives, it was found that the spouses of patients without depressive symptoms had a high quality of life in physical, mental, social, and environmental areas, while anxiety scores were found to be high in spouses of patients with depressive symptoms. In the same study, there was a significant relationship between depressive symptoms and social area in the healthy control group, but no significant relationship was found in the level of anxiety.
Participation of the patient's spouses in the treatment process, accompanying the patient, following the medication, not allocating enough time for their own physical, mental and social needs, and concurrent problems cause depression, anxiety, and anger symptoms in the spouses of the patients. As stated in Meric and Oflaz's study, the psychological problems experienced by the patient revealed that the patient's spouse also experienced emotional and experiential tides and anxiety about the future.
The study has limitations considering that it was conducted only with 50 patients and their spouses who were treated in two dialysis centers in Istanbul, Turkey. It is thought that the findings to be obtained by including the spouses who are not with the dialysis patient during the treatment process and by studies with a larger sample will provide more detailed information in terms of evaluating the psychological symptoms.
This research was conducted to reveal how the treatment process of patients receiving hemodialysis treatment affects their mental health as well as their spouses' in terms of their depression, anxiety, and anger levels. Based on the findings, the anxiety levels of the spouses in the clinical group were significantly higher than the spouses in the control group. Furthermore, the patients' spouses reported significantly higher scores in depression as compared to the control group. According to the findings indicating the relationship between patients' spouses' the anxiety and depression levels, it was found that there was a positive significant relationship between the spouses' anxiety and depression scores. According to the study, it can be understood that the spouses of the patients can be exposed to certain stressors related to the course of illness and treatment. In this stressful process which basically starts with the diagnosis of chronic renal failure, it is important to cooperate with doctors, nurses, and other health-care workers about the treatment process and home care requirements. Patient–family group meetings, support meetings for the spouses of patients, and psychoeducation for the caregivers will be beneficial in terms of increasing awareness about the effects of the disease and coping with the disease. In addition, programs can be organized to strengthen social relations of the patients and the caregivers. Through these effective interventions, patients' spouses will maintain their functionality, adaptive emotions, and behaviors. Besides, they can be prevented from having psychological symptoms in this process. The success in these intervention strategies is mainly based on revealing functional coping methods for the stressors that the caregivers may encounter.
Patient informed consent
Informed consent was obtained.
Ethics committee approval
The ethics committee approval has been obtained from the Uskudar University Committee on Non-Interventional Research Ethics (B.08.6.YÖK.2.ÜS.0.05.0.01/2018/013).
Financial support and sponsorship
No funding was received.
Conflicts of interest
There are no conflicts of interest to declare.
Author contribution subject and rate
- Rahel Karako Kampeyas (35%): Design the research, data collection and analyses and wrote the whole manuscript.
- Huseyin Unubol (25%): Designed and organized the research and supervised the article write-up.
- Busra Ozdogan (10%): Contributed with comments on manuscript organization and write-up.
- Remziye Keskin (10%): Contributed with comments on research design.
- Idil Arasan Dogan (%10): Contributed with comments on research design.
- Gokben Hizli Sayar (%10): Contributed with comments on research design.
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