Major depressive disorder in hemodialysis patients in China

Official journal of the Pacific Rim College of Psychiatrists bs_bs_banner Asia-Pacific Psychiatry ISSN 1758-5864 ORIGINAL ARTICLE Major depressive disorder in hemodialysis patients in China Aimin Hu1,2 MSc, Zhimin Xue1 MD PhD, Tumbwene E Mwansisya1,3 MSc, An Zhou4 MD, Weidan Pu1 PhD, Xudong Chen1 MD, Meng Sun1 MD, Peng Wang1 MD, Hua Fan1 MD, Zheng Wang1 MD, Xuan Ouyang1 MD PhD, Zhening Liu1 MD PhD & Robert Rosenheck5 MD PhD 1 Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha, China 2 Department of Medicine, Jishou University, Jishou, China 3 College of Health Sciences, University of Dodoma, Dodoma, Tanzania 4 Blood Purification Center, The Second Xiangya Hospital of Central South University, Changsha, China 5 Department of Psychiatry, Yale University, New Haven, CT, USA Keywords China, comorbidity, hemodialysis, major depressive disorder, prevalence Correspondence Zhimin Xue, MD PhD, Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha 410011, China. Tel: +86 731 85292136 Fax: +86 731 85292470 Email: x.zhimin@163.com Received 16 April 2013 Accepted 29 September 2013 DOI:10.1111/appy.12110 Abstract Introduction: Major depressive disorder (MDD) has been regarded as the most common psychiatric disorder among hemodialysis (HD) patients. However, few studies have investigated MDD in HD patients in Mainland China. This study sought to investigate the prevalence and treatment of MDD, as well as the sociodemographic and clinical characteristics in this population. Methods: Two hundred sixty HD patients were screened with the nineitem Patient Health Questionnaire, and the formal diagnosis of MDD was further assessed using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Severity of depressive symptoms was assessed with Hamilton Rating Scale for Depression. Finally, patients meeting diagnostic criteria were compared with those who did not on demographic and clinical characteristics. Results: Among the 260 subjects, 26.2% screened positively and 10% were confirmed to have a diagnosis of MDD. Among HD patients with MDD, 69.2% had severe or very severe depressive symptoms. There was no evidence of a clinical diagnosis or of treatment for MDD in any of the patients’ medical records. Those with shorter duration of HD, lower monthly income, and lower levels of blood urea nitrogen were significantly more likely to have a diagnosis of MDD. Discussion: MDD is frequent in HD patients. Regular screening and professional diagnosis should be undertaken to increase the detection and treatment of MDD in HD patients. The effectiveness of interventions for MDD in HD patients deserves further research. Introduction Depression in hemodialysis (HD) patients has been found to be related to disturbances of quality of life, functional impairment, increased hospitalization, medical costs, withdrawal from dialysis, and mortality (Kurella et al., 2005; Szeifert et al., 2010), and is regarded as the most common psychiatric abnormality in HD patients (Kimmel & Peterson, 2005). Using the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, Craven et al. (1987) found major depressive disorder (MDD) in 8.1% of HD patients in 78 Canada, and Hinrichsen et al. (1989) found 6.5% in the US. Hedayati et al. (2006) found a prevalence of 17.3%, while Cukor et al. (2007) documented a 20% rate with the Structured Clinical Interview for Diagnosis (SCID). A more recent study in Taiwan observed a 23.5% prevalence of MDD with the M.I.N.I.International Neuropsychiatric Interview (Chen et al., 2010). Although the reported rates of MDD have thus varied in different HD population, all studies have found rates to be higher than those in the general population. However, we are unaware of any similar reports using DSM criteria from Mainland China. Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd A. Hu et al. Although a growing body of empirical evidence points to the adverse consequence and the high prevalence of MDD in HD patients, MDD remains underdiagnosed and undertreated (Chilcot et al., 2010). A study of 70 HD patients found 20% with MDD and 9% with dysthymia, but only 12% of these patients were currently receiving treatment (Cukor et al., 2007). In a survey of depressive disorder in HD population across 12 countries, Lopes et al. (2004) reported the highest rate of clinical diagnosis by physicians of 21.4% in the US and the highest rate of treatment among those diagnosed was 52.8% in Sweden. The data, thus, show consistently low rates of diagnosis and treatment of depressive disorder in HD patients. In Mainland China, there are few studies using formal psychiatric diagnostic criteria to evaluate the prevalence rate of MDD in HD patients, and the rates of treatment of MDD in HD patients are unknown. We conducted a cross-sectional study to explore the prevalence and treatment of MDD in HD patients in Changsha, China, and sought to identify correlated sociodemographic and clinical characteristics of MDD. These data may be of use in the management of MDD in HD patients and form a background for much needed, well-designed interventions for MDD in HD patients. MDD in hemodialysis patients Data collection and measurements Demographic characteristics were collected from a general information questionnaire, and clinical characteristics were supplemented by electronic medical records of the hospital and patients’ charts. All subjects underwent the assessment of the nine-item Patient Health Questionnaire (PHQ-9), which documents the nine criteria for depression from DSM-IV (Spitzer et al., 1999). PHQ-9 is a self-report instrument and is effective for detecting depressive disorders in various ethno-cultural groups (Huang et al., 2006). It is brief and can be administered by non-professionals. To improve the efficiency of assessment, we used the PHQ-9 to screen patients by study psychiatrists before conducting SCID assessments. Patients with PHQ-9 scores of ≥10 were, thus, further assessed by an experienced psychiatrist with the SCID interview (First, 2007). Among those who met diagnostic criteria, the severity of MDD symptoms was assessed using the Hamilton Rating Scale for Depression (HRSD) (17 items) (Hamilton, 1960; Zheng et al., 1988). Standard severity levels for the HRSD with none (0–7), mild (8–13), moderate (14– 18), severe (19–22), and very severe (≥23) (Pincus et al., 2000) were used. Data analysis Methods Subjects Patients were recruited from February to March 2012 from a list of patients in HD treatment at a blood purification center of Second Xiangya Hospital. All subjects were aged 18 years or older and had attended at least two weeks of HD treatments. Patients were excluded if they refused to participate, or suffered from other concurrent severe physical diseases (e.g. active neoplasm, hearing disorder) or concurrent mental illnesses (e.g. delirium, dementia) that could inhibit their participation and response to study measurements. HD patients (n = 306) who were listed at the center on February 20, 2012 were screened for the study. Among them, three patients were younger than 18 years of age, nine could not hear or speak clearly, and 34 could not finish the questionnaires. The final sample included 260 HD patients. Ethical approval for the study was obtained from the Ethical and Publication Committee of Second Xiangya Hospital. All participants provided written informed consent for participation in the study. Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd Descriptive statistics were calculated for the sample population. Categorical variables were analyzed using chi-square test, and continuous variables were analyzed using Mann–Whitney U-test to compare the sociodemographic and clinical characteristics between patients with and without MDD. Variables that showed significant associations were further entered into logistic regression model to identify independent correlates of MDD. To improve the quality of our analyses, missing values were included with estimated values using regression-based imputation available through SPSS for Windows (Version 16.0., SPSS Inc., Chicago, IL, USA). All analyses were two-tailed, and the level of significance was P < 0.05. Results Among the 260 subjects, 26.2% (68/260) screened positive on the PHQ-9, and 38.2% (26/68) of the positive screening people were diagnosed with MDD using DSM-IV criteria, which account for 10% (26/ 260) of all subjects. In MDD patients, 30.8%, 50.0%, and 19.2% were in the range of moderate, severe, and 79 MDD in hemodialysis patients A. Hu et al. very severe depression, respectively, based on HSRD scores. There was no evidence of any clinical diagnosis or treatment of MDD in any of the patients’ medical records. Mean age of this study population was 56.9 (± 15.8) years and 66.2% were men. The average duration of HD treatment was 54.63 (± 55.49) months. The average blood urea nitrogen and creatinine levels were 24.97 (± 7.78) mmol/L and 950.90 (± 312.52) μmol/L, respectively. The clinical and sociodemographic characteristics of HD patients were compared between patients with MDD and those without MDD, as shown in Table 1. In the analyses of chi-square test and Mann–Whitney U, MDD was significantly associated with greater age, less education and lower monthly incomes, less than one year of HD treatment, greater likelihood of cardiac comorbidity, and with lower levels of blood urea nitrogen. In further multivariate analysis, those patients with lower levels of blood urea nitrogen (20.85 ± 6.79), duration of HD treatment ≤12 months, and lower monthly incomes (<2000 yuan) were significantly associated with an increased risk for MDD (Table 2). Discussion This study explored the prevalence and treatment of MDD among HD patients in clinical practice in Mainland China. MDD was noted to be seriously underdiagnosed and undertreated as none of the identified cases had document diagnosis or treatment of MDD. Some psychosocial and clinical factors, such as low blood urea nitrogen, short duration of HD treatment, and low monthly incomes, were significantly correlated with MDD in HD patients. MDD in HD patients has strongly associated with poorer health-related quality of life and higher mortality risk (Hedayati et al., 2008). In the current study, 26.2% of the HD patients were screened positively for depressive disorder using the PHQ-9. These findings indicate depressive disorder to be common in HD patients. These findings are similar with other studies that have screened depression in HD patients using PHQ-9. For instance, one study from Korea found prevalence of 25.34% (Son et al., 2009), and another study from America found 28% prevalence of depression on HD patients (Drayer Table 1. Characteristics of hemodialysis patients by MDD status Characteristic Age (years) 18–39 40–54 55–87 Gender Male Female Marital status Married/common-law Single/separated/widowed Education level ≤Primary education >High school Monthly income <2000 yuan 2000–4000 yuan >4000 yuan Diabetes Cardiac disease Hypertension Duration (months) 0–12 ≥13 Blood urea nitrogen (mmol/L) Creatinine (μmol/L) MDD (n = 26) NMDD (n = 234) 61.19 ± 13.74 2 (7.7) 3 (11.5) 21 (80.8) 56.42 ± 15.98 40 (17.1) 62 (26.5) 132 (56.4) χ2 or Z P-value 6.263 0.044* 16 (61.5) 10 (38.5) 156 (66.7) 78 (33.3) 0.275 0.600 20 (76.9) 6 (23.1) 194 (82.9) 40 (17.1) 0.238 0.626 5.650 0.017* (29.1) (45.7) (25.2) (21.6) (10.8) (53.9) 14.393 0.001** 1.439 4.663 1.820 0.230 0.031* 0.177 (17.1) (82.9) (± 6.78) (± 291.13) 12.350 <0.001** –3.092 –1.932 0.002** 0.053 17 (65.4) 9 (34.6) 17 7 2 8 7 17 12 14 20.85 844.17 (65.4) (26.9) (7.7) (32.0) (28.0) (68.0) (46.2) (53.8) (± 6.79) (± 321.16) 96 (41.0) 138 (59.0) 68 107 59 50 25 125 40 194 25.42 964.05 *P < 0.05; **P < 0.01. Values expressed as no. (%) or mean (±standard deviation). MDD, major depressive disorder; NMDD, without major depressive disorder. 80 Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd A. Hu et al. MDD in hemodialysis patients Table 2. Logistic regression analysis showing the risk factors associated with MDD Wald χ2 Variables Beta SE (df = 1) P-value OR (95% CI) Age Monthly income Duration Cardiac disease Education level Blood urea nitrogen Constant 1.070 –1.805 –1.144 1.272 –0.267 –0.083 1.678 0.649 0.506 0.557 0.686 0.558 0.041 1.801 2.716 12.713 4.224 3.435 0.228 4.145 0.869 0.099 <0.001** 0.040* 0.064 0.633 0.042* 0.351 2.914(0.817-10.397) 0.164(0.061-0.444) 0.318(0.107-0.948) 3.568(0.929-13.693) 0.766(0.257-2.286) 0.921(0.850-0.997) 5.357 *P < 0.05; **P < 0.01. CI, confidence interval; MDD, major depressive disorder; OR, odds ratio. et al. 2006). The consistency of the current study findings with other studies suggests the PHQ-9 to be an efficient measurement tool for screening depressive disorders in HD patients. Moreover, Watnick et al. (2005) indicated a score of ≥10 on the PHQ-9 to be associated with 92% sensitivity and 92% specificity for depressive disorder in dialysis patients when compared with DSM-IV, which is the gold standard. Thus, with limited resources and psychiatrists, PHQ-9 instrument is feasible for screening depressive disorder in HD patients because it has acceptable brevity and validity. We found a 10% rate of MDD in HD patients, in which 5%, 4.8%, and 15.9% were reported to be prevalent in HD patients aged 18–39, 40–54, and older than 54 years, respectively. This finding though was consistent with other previous studies, but is substantially higher than the reported rate of 1.15%, 2.72%, and 3.82% of the same age strata in general population in Mainland China (Phillips et al., 2009). High prevalence of MDD might be associated with increased mortality and poor prognosis in HD patients (Lopes et al., 2002). Therefore, the routine screening of MDD should be supported in order to achieve a better therapeutic regimen for HD patients with MDD. Although MDD was frequent in HD patients, and 69.2% of MDD patients were in the range of severe and very severe depression based on HSRD scores, MDD was seriously underdiagnosed and undertreated in this sample. Similar results have been seen in the US and Europe, where only 17% and 6% of depression patients were treated, respectively (Lopes et al., 2004), but undertreatment was more extreme in our sample in which no HD patients with MDD received any kind of formal diagnosis or treatment of MDD. The observed findings in this study may reflect the high level of stigma attached to mental illness in Chinese culture. Compared with other parts of the world, in Mainland China many depressed Chinese Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd tend to express their psychological distress through somatic symptoms, such as boredom, discomfort, feelings of inner pressure, pain, dizziness, or fatigue, but often with no expression of sad mood (Kleinman, 2004). Since there is a strong overlap between uremic somatic symptoms and depressive symptoms, there could be confusion in diagnosing MDD in the HD population (Cukor et al., 2007), and clinicians may assume that depressive symptoms are just a temporary consequence of HD or HD medications, thus ignoring the MDD interventions (Koenig et al., 1997). Moreover, it is well known that individuals with mental illness are stigmatized in China (Yang, 2007). Neurasthenia has been the culturally acceptable way of presenting depressive symptoms in Mainland China (Kleinman, 1982). It is possible that psychologically distressed individuals present with somatization to conceal their illness and to avoid the burden of stigma (Goldberg and Bridges, 1988). Thus, HD patients may have denied expression of their psychological symptoms and presented with more somatic symptoms that are socially more acceptable in Mainland China, and consequently confound the scores in the used rating scales. Measuring depressive symptoms or psychological well-being in China may require a specific set of methods that would be less stigmatizing in the Chinese cultural contextual. Levels of blood urea nitrogen and creatinine in HD patients were distinctly abnormal, but were lower in HD patients with MDD than in those without MDD. One possible explanation for this phenomenon is that depression symptoms were usually related to poor appetite and poor nutrition in HD patients with MDD (Kalantar-Zadeh et al., 2005; Huang et al., 2008; Çelik et al., 2011). Interestingly, the present study showed that lower blood urea nitrogen levels were significantly associated with MDD, while elevated creatinine was not. This might be associated with the culture of Chinese diet. In comparison with the Western diets, 81 MDD in hemodialysis patients the Chinese diet is generally lower in fat and higher in fiber content (Lee, 1991), which might influence the associations between these biochemical parameters and MDD. The potential biochemical mechanism linking blood urea nitrogen, creatinine, and MDD warrants further investigation. This study also found that monthly income was inversely related to MDD in HD patients, a finding consistent with other studies (Kao et al., 2009; Kessler et al., 2003; Sesso et al., 2003). Due to the high cost of HD treatment, financial burden is prominent in many HD patients. Moreover, when patients just began to receive HD treatment, this urgent life-saving treatment no doubt provokes considerable stress. Shorter duration of HD treatment was associated with increased risk of MDD, perhaps reflecting this stress. Early diagnosis and interventions to MDD in patients just beginning HD treatment may be especially helpful in preventing MDD. It is noteworthy that although female patients have been believed to have higher rates of depression than men (Weisbord et al., 2005; Cukor et al., 2006), the present study found no statistical differences between genders in relation to MDD among HD patients. We found that female patients had higher monthly incomes than males, and that gender was significantly associated with monthly income. Thus, differences in socioeconomic status seemed to be more important factor in determining MDD risk in HD patients than gender differences, at least in this sample. The present study finding of 10% MDD in HD patients means that 90% HD patients were still without MDD. We speculate that this may be related to an individual’s resilience in facing serious medical disease. It has been reported that resilience plays an important role in mediating patient responses to stress from biological, psychological, and social sources. Biologically, genetic factors, developmental factors, and neurobiological factors have been reported to regulate resilience to stress and trauma (Southwick and Charney, 2012). Psychologically, resilience has been associated with positive emotions and optimism, having loving caretakers and sturdy role models, along with a history of mastering challenges and cognitive flexibility that might impact positively on patient health outcomes (Southwick et al., 2005). Socially, strong social skills and diverse social networks could be positively influential factors on individuals’ responses to stressful situations, such as depression (Segrin and Flora, 2000). Thus, it is possible that resilience gave some HD patients the strength to exhibit positive behavioral adaptation and overcome the 82 A. Hu et al. adversity of depressive symptoms. However, future studies are warranted to explore the impact of resilience on coping with MDD in HD patients. Limitations Several limitations to this study deserve comment. First, the samples were from a single general hospital in Hunan, Mainland China. The results, therefore, do not necessarily represent the whole of Mainland China, let alone other countries in Asia. Second, the patients may have had other mental health problems in addition to MDD, which was the sole focus of this study. Third, our investigation was cross-sectional in design, which precludes proof of causal relationships. Fourth, we did not identify underlying biochemical and physiological mechanisms of MDD, which should be a focus for further research. Conclusion This study found a high prevalence of MDD among HD patients in Mainland China, and appeared to be seriously underdiagnosed and undertreated. To the best of our knowledge, there has been little or no research on treatment of MDD in HD patients, and there is a great need for such research so that clinicians and policy makers can establish evidence-based protocols for the management and effective treatments of MDD in such patients. Routine screening of MDD in HD patients should be undertaken, and comprehensive care should be identified and made available. Our data on factors associated with MDD in HD patients may be of some help in recognizing at-risk HD patients. Considerable further research is needed to better understand the biochemical and physiological mechanisms linking blood urea nitrogen and creatinine with MDD. References Çelik G., Oc B., Kara I., Yılmaz M., Yuceaktas A., Apiliogullari S. (2011) Comparison of nutritional parameters among adult and elderly hemodialysis patients. Int J Med Sci. 8(7), 628. Chen C.K., Tsai Y.C., Hsu H.J., et al. (2010) Depression and suicide risk in hemodialysis patients with chronic renal failure. Psychosomatics. 51(6), 528–528. Chilcot J., Wellsted D., Farrington K. (2010) Depression in end-stage renal disease: current advances and research. Semin Dial. 23(1), 74–82. Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd A. Hu et al. Craven J.L., Rodin G.M., Johnson L., Kennedy S.H. (1987) The diagnosis of major depression in renal dialysis patients. Psychosom Med. 49(5), 482–492. Cukor D., Coplan J., Brown C., et al. (2007) Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephro. 2(3), 484–490. Cukor D., Peterson R.A., Cohen S.D., Kimmel P.L. (2006) Depression in end-stage renal disease hemodialysis patients. Nat Clin Pract Nephr. 2(12), 678–687. Drayer R.A., Piraino B., Reynolds C.F. III et al. (2006) Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk. Gen Hosp Psychiat. 28(4), 306–312. First M.B. (2007) Structured Clinical Interview for DSM-IV-TR Axis I Disorders: SCID-I. Biometrics Research Department, New York State Psychiatric Institute, New York. Goldberg D.P., Bridges K. (1988) Somatic presentations of psychiatric illness in primary care setting. J Psychosom Res. 32(2), 137–144. Hamilton M. (1960) A rating scale for depression. J Neurol Neurosur Ps. 23(1), 56–62. Hedayati S.S., Bosworth H., Kuchibhatla M., Kimmel P., Szczech L. (2006) The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients. Kidney Int. 69(9), 1662–1668. Hedayati S.S., Bosworth H.B., Briley L.P., et al. (2008) Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression. Kidney Int. 74(7), 930–936. Hinrichsen G.A., Lieberman J.A., Pollack S., Steinberg H. (1989) Depression in hemodialysis patients. Psychosomatics. 30(3), 284–289. Huang F.Y., Chung H., Kroenke K., Delucchi K.L., Spitzer R.L. (2006) Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med. 21(6), 547–552. Huang M.C., Chen M.E., Hung H.C., et al. (2008) Inadequate energy and excess protein intakes may be associated with worsening renal function in chronic kidney disease. J Renal Nutr. 18(2), 187–194. Kalantar-Zadeh K., Abbott K.C., Salahudeen A.K., et al. (2005) Survival advantages of obesity in dialysis patients. Am J Clin Nutr. 81(3), 543–555. Kao T.W., Lai M.S., Tsai T.J., Jan C.F., Chie W.C., Chen W.Y. (2009) Economic, social, and psychological factors associated with health-related quality of life Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd MDD in hemodialysis patients of chronic hemodialysis patients in northern Taiwan: a multicenter study. Artif Organs. 33(1), 61–68. Kessler R.C., Berglund P., Demler O., Jin R., Koretz D., Merikangas K.R. (2003) The epidemiology of major depressive disorder. JAMA. 289(23), 3095–3105. Kimmel P.L., Peterson R.A. (2005) Depression in end-stage renal disease patients treated with hemodialysis: tools, correlates, outcomes, and needs. Semin Dial. 18(2), 91–97. Kleinman A. (1982) Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry. 6(2), 117–190. Kleinman A. (2004) Culture and depression. New Engl J Med. 351, 951–952. Koenig H.G., George L.K., Peterson B.L., Pieper C.F. (1997) Depression in medically ill hospitalized older adults: prevalence, characteristics, and course of symptoms according to six diagnostic schemes. Am J Psychiatry. 154(10), 1376–1383. Kurella M., Kimmel P.L., Young B.S., Chertow G.M. (2005) Suicide in the United States end-stage renal disease program. J Am Soc Nephrol. 16(3), 774–781. Lee S. (1991) Anorexia nervosa in Hong Kong: a Chinese perspective. Psychol Med. 21(03), 703–711. Lopes A.A., Albert J.M., Young E.W., et al. (2004) Screening for depression in hemodialysis patients: associations with diagnosis, treatment, and outcomes in the DOPPS. Kidney Int. 66(5), 2047–2053. Lopes A.A., Bragg J., Young E., et al. (2002) Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int. 62(1), 199–207. Phillips M.R., Zhang J., Shi Q., et al. (2009) Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet. 373(9680), 2041–2053. Pincus H.A., Rush A.J., First M.B., McQueen L.E. (2000) Handbook of Psychiatric Measures. American Psychiatric Association, Washington, DC. Segrin C., Flora J. (2000) Poor social skills are a vulnerability factor in the development of psychosocial problems. Human Commun Res. 26(3), 489–514. Sesso R., Rodrigues-Neto J.F., Ferraz M.B. (2003) Impact of socioeconomic status on the quality of life of ESRD patients. Am J Kidney Dis. 41(1), 186–195. Son Y.J., Choi K.S., Park Y.R., Bae J. S., Lee J.B. (2009) Depression, symptoms and the quality of life in patients on hemodialysis for end-stage renal disease. Am J Nephrol. 29(1), 36–42. 83 MDD in hemodialysis patients A. Hu et al. Southwick S.M., Charney D.S. (2012) The science of resilience: implications for the prevention and treatment of depression. Science. 338(6103), 79–82. Watnick S., Wang P.L., Demadura T., Ganzini L. (2005) Validation of 2 depression screening tools in dialysis patients. Am J Kidney Dis. 46(5), 919–924. Southwick S.M., Vythilingam M., Charney D.S. (2005) The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annu Rev Clin Psychol. 1, 255–291. Weisbord S.D., Fried L.F., Arnold R.M., et al. (2005) Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis patients. J Am Soc Nephrol. 16(8), 2487–2494. Spitzer R.L., Kroenke K., Williams J.B. (1999) Validation and utility of a self-report version of the PRIME-MD. JAMA. 282(18), 1737–1744. Yang L. (2007) Application of mental illness stigma theory to Chinese societies: synthesis and new direction. Singap Med J. 48, 977–985. Szeifert L., Molnar M.Z., Ambrus C., et al. (2010) Symptoms of depression in kidney transplant recipients: a cross-sectional study. Am J Kidney Dis. 55(1), 132. Zheng Y.P., Zhao J.P., Phillips M., et al. (1988) Validity and reliability of the Chinese Hamilton Depression Rating Scale. Br J Psychiatry. 152(5), 660–664. 84 Asia-Pacific Psychiatry 7 (2015) 78–84 © 2013 Wiley Publishing Asia Pty Ltd Copyright of Asia-Pacific Psychiatry is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.