Anxiety Disorders in Adults Treated by Hemodialysis:

A Single-Center Study
Daniel Cukor, PhD,1 Jeremy Coplan, MD,1 Clinton Brown, MD,2 Steven Friedman, PhD,1
Howard Newville, BA,1,3 Michal Safier, BA,1,3 Lisa A. Spielman, PhD,4 Rolf A. Peterson, PhD,5
and Paul L. Kimmel, MD6
Background: Anxiety is a complicating comorbid diagnosis in many patients with medical illnesses.
In patients with end-stage renal disease (ESRD), anxiety disorders often are perceived to represent
symptoms of depression rather than independent conditions and therefore have been relatively
understudied in this medical population.
Study Design: To evaluate the psychosocial impact of anxiety disorders on patients with ESRD, we
sought to identify the rates of these disorders in a sample of patients receiving hemodialysis at a single
center by using a structured clinical interview. We also compared a commonly used screening measure,
the Hospital Anxiety and Depression Scale (HADS), with these clinical diagnoses to determine the
measures criterion validity or ability to predict a psychiatric diagnosis in ESRD populations. Finally, we
examined the relationship between anxiety diagnosis and perceptions of quality of life (QOL) and health
status.
Setting & Participants: A sample of 70 randomly selected hemodialysis patients from an urban
metropolitan center.
Predictor: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) Axis I Diagnosis (SCID-I).
Outcomes: HADS and Kidney Disease Quality of Life Short Form.
Results: Using the SCID, 71% of the sample received a DSM-IV Axis I diagnosis, with 45.7% of
subjects meeting criteria for an anxiety disorder and 40% meeting criteria for a mood disorder. The
concordance between DSM-IV anxiety disorders and anxiety scores acquired by using the HADS was
not significant. Thus, although the HADS may provide an acceptable measure of overall psychic
distress compared against the SCID-I, it has poor predictive power for anxiety diagnoses in patients
with ESRD. Additionally, the presence of an anxiety disorder was associated with an overall perceived
lower QOL (t 2.4; P 0.05).
Limitations: Single-center study and a population not representative of US demographics.
Conclusions: A substantial proportion of participating patients met criteria for an anxiety disorder.
The utility of the HADS as a screening tool for anxiety in patients with ESRD should be questioned. The
finding that anxiety disorders negatively impact on QOL and are not merely manifestations of depression in patients with ESRD emphasizes the importance of accurate diagnosis and effective treatment.
Strategic options are necessary to improve the diagnosis of anxiety disorders, potentially enhancing
QOL and medical outcome in patients with ESRD.
Am J Kidney Dis 52:128-136. 2008 by the National Kidney Foundation, Inc.
INDEX WORDS: Anxiety; chronic kidney disease; dialysis; screening; quality of life.

nxiety disorders have been shown to be a

complicating comorbid diagnosis in many
patients with medical illness.1,2 According to the
World Health Organization,3 anxiety is a major
cause of years lost to disability in the United
States. Recently, Kroenke et al1 and Sareen et al4
highlighted the negative impact that anxiety dis-

orders can have on quality of life (QOL) and

disability across multiple illnesses.
The study of psychosocial aspects of nephrology is still relatively new despite the more than
300,000 US patients living on hemodialysis (HD)
therapy and increasing numbers of patients with
chronic kidney disease.5 Within the psychoneph-

From the 1Departments of Psychiatry and Behavioral

Sciences and 2Medicine, SUNY Downstate Medical Center,
Brooklyn; 3Ferkauf Graduate School of Psychology, Yeshiva
University, Bronx; 4Independent Consultant, Congers, NY;
and 5Departments of Psychology and 6Medicine, George
Washington University, Washington, DC.
Received August 10, 2007. Accepted in revised form
February 26, 2008. Originally published online as doi:
10.1053/j.ajkd.2008.02.300 on April 25, 2008.

Address correspondence to Daniel Cukor, PhD, Assistant

Professor of Psychiatry, SUNY Downstate Medical Center,
450 Clarkson Ave Box 1203, Brooklyn, NY 11203-2098.
E-mail: daniel.cukor@downstate.edu
2008 by the National Kidney Foundation, Inc.
0272-6386/08/5201-0017$34.00/0
doi:10.1053/j.ajkd.2008.02.300

128

American Journal of Kidney Diseases, Vol 52, No 1 (July), 2008: pp 128-136

Anxiety in ESRD

129

rology literature, depression has received almost

all the clinical attention.6-8 Clinical depression
has an estimated prevalence of 10% to 30% in
HD patients. However, data are scarce about
rates of anxiety in this population.6 One Turkish
study9 found a 30% rate of anxiety disorders in
HD patients by using the Primary Care Evaluation of Mental Disorders as a diagnostic tool. We
reported a 27% prevalence of major anxiety
disorders in an HD population by using a clinician-based semistructured interview to provide
diagnosis.10 The full impact of anxiety diagnoses
in patients with end-stage renal disease (ESRD)
is unknown.
In addition to the lack of knowledge of rates
and impact of anxiety disorders on US patients
with ESRD, effective instruments that screen
for anxiety disorders in this population have
not been identified. The Hospital Anxiety and
Depression Scale (HADS)11 is a widely used
self-report measure for screening for anxiety
and depression in hospital, outpatient, and
community settings.12 Although it was suggested as a possible screening tool for patients
with ESRD because of good internal reliability
and test-retest reliability,13 there is some question regarding its diagnostic validity.14
We previously reported rates of psychopathology in an urban HD population,10 with 71%
having a psychiatric diagnosis and 27% of the
sample having a diagnosis of a major anxiety
disorder. The primary aim of this analysis is to
examine the distribution of anxiety disorders in
an HD population and the impact of having a
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV)15 anxiety
diagnosis on patients perceived QOL. We sought
to examine the criterion validity of the HADS as
an anxiety disorder screening tool in HD populations by comparing it with the gold standard of
psychiatric diagnostic tools, the Structured Clinical Interview for DSM-IV Axis I Diagnosis
(SCID-I).16 Our secondary hypothesis is that
anxiety disorders have a unique negative association with QOL over and above that associated
with depression.

METHODS
This study was approved by the SUNY Downstate (Brooklyn, NY) Institutional Review Board. This study was part of
a broader project examining psychosocial variables in pa-

tients with ESRD.10 As described previously,10 participants

were randomly selected from adult HD patients at a major
urban dialysis center in central Brooklyn. In total, 85 patients of the possible 123 at the dialysis center were approached. Subjects were asked a broad screening question
that inquired about their desire to participate in psychosocial
research. Of those who wanted to hear more about details of
the study, all 73 patients agreed to participate. Seventy of
these 73 patients completed the assessment. No information
is available for the 12 individuals who declined to participate. Patients in each time shift were assigned a number,
then numbers were randomly drawn to determine the order
in which patients were approached. All selected patients
were approached while being dialyzed, and informed consent was obtained. Patients were compensated $20 for their
time on successful completion of all measures, which took 2
to 2.5 hours. This study was part of a broader project
investigating mental health in HD populations.

Measures
The SCID-I
The SCID16 is a semistructured interview used for diagnosing the major Axis I DSM-IV disorders. It uses a decision
tree approach, guiding the clinician through an interview
testing diagnostic hypotheses. The SCID reports the presence or absence of each of the disorders being considered for
the current episode (past month). It has variable, but acceptable, reliability and validity and is accepted as the gold
standard for deriving psychiatric diagnoses in research studies.17 It previously was used in ESRD populations.18-20
Interviews were audiotaped and then independently reviewed for diagnostic accuracy, with an overall excellent
level of agreement between raters ( 0.94). Because of the
extended time most patients were treated with dialysis
(5.0 5.2 years), it was impossible to accurately determine
the chronological sequence of the disorders; therefore, only
data reflecting current psychopathological states were used.

The HADS
The HADS11 was developed as a tool for the identification
of anxiety disorders and depression in patients in nonpsychiatric hospital clinics. The HADS consists of 14 items equally
divided between Anxiety and Depression subscales. Each
item is rated on a scale from 0 to 3. Respondents choose the
response that most accurately describes how they have been
feeling during the past week. The developers excluded
somatic symptoms of anxiety and depression to prevent
crossover from physical illnesses unrelated to anxiety or
depression. A review of more than 700 studies using the
HADS found that it had good psychometric properties and
effectively assessed anxiety and depressive disorders in
various health settings and in the general population.21 The
HADS was suggested as a possible screening tool for anxiety and depression in patients with ESRD because of its
good internal reliability and test-retest reliability.13 However, a later study questioned its clinical utility in patients
with ESRD because a unified factor structure failed to
emerge.22

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Cukor et al

Kidney Disease QOL Short Form

The Kidney Disease QOL Short Form (KDQOL-SF)23
assesses the QOL of patients with kidney disease. This
questionnaire comprises 43 disease-specific items, 36 generic (SF-36) items, and an overall health-ranking item.
Items of the KDQOL-SF are thematically arranged in these
subscales: kidney diseasespecific items (Symptom/Problems, Effects of Kidney Disease on Daily Life, Burden of
Kidney Disease, Work Status, Cognitive Function, Quality
of Social Interaction, Sexual Function, Sleep, Social Support, Dialysis Staff Encouragement, and Patient Satisfaction), generic items (Physical Functioning, General Health,
Pain, Role Limitations Caused by Physical Health Problems,
Role Limitations Caused by Emotional Health Problems,
Social Functioning, Emotional Well-Being, Pain, Energy/
Fatigue, and General Health Perceptions), and items regarding the patients background information. The KDQOL has
been used widely in ESRD populations.24-27

Data Analysis
All data were analyzed using the computer-based statistical software package SPSS, version 14.0 (SPSS Inc, Chicago, IL). Descriptive statistics were calculated for the
sample population, and group differences were compared
for continuous variables by using t-test and Pearson 2 test
for comparing binary variables. Pearson correlations were
derived, and level for tests of significance was set at 0.05.
Multiple regression was used to predict HADS scores and
QOL values from SCID diagnoses. Data are reported as
mean SD.

RESULTS
Half the sample was born in the United States
and 53% were women (Table 1). Average age for

the entire sample was 53.3 15.0 years. Eightynine percent identified themselves as black; 3%,
Hispanic; 1%, white; and 7%, other. Average
amount of education was 12.7 2.7 years. The
sample was medically ill, averaging 1.9 2.6
hospitalizations within the last year. Average
duration that patients were treated with dialysis
was 61.0 62.6 months. Only 14% of the
sample was employed.
The sample was divided between those with an
anxiety diagnosis and everyone else and then in
separate analyses as those with depression compared with everyone else. This was done to explore
the unique contributions of anxiety and depression
in the sample. There were no statistically significant differences in age (P 0.9), education (P
0.1), number of hospitalizations in the past year (P
0.4), sex (Pearson 2, P 0.2), being American
born (P 0.2), proportion working (P 0.3), or
previous mental health treatment use (P 0.1)
between those with and without a depression diagnosis. Similarly, when patients with an anxiety
diagnosis were compared with those without an
anxiety diagnosis, there were no statistically significant differences in age (P 0.1), education (P
0.9), number of hospitalizations in the past year (P
0.7), sex (P 0.2), being American born (P 0.5),
proportion working (P 0.1), or previous mental
health treatment use (P 0.1) between groups.

Table 1. Demographic Information

Anxiety Diagnosis

Variable

Age (y)
Men (%)
Time on dialysis (mo)
Education (y)
No. of hospitalizations
in last year
Born in the United
States (%)
Ethnicity (self-report)
Black (%)
Hispanic (%)
White (%)
Other (%)
History of mental health
treatment (%)

Depression Diagnosis

Total Sample
(n 70)

Yes
(n 32)

No
(n 38)

Yes
(n 20)

No
(n 50)

53.3 15.0
47.1
61.0 62.6
12.7 2.7

48.3 15.8
37.5
54.3 57.3
12.7 2.7

57.4 12.9
55.3
66.6 66.9
12.8 2.6

53.5 15.2
57.1
65.9 56.3
11.9 3.2

53.2 15.0
44.6
59.7 65.5
12.9 2.5

1.9 2.6

2.0 2.3

1.7 2.8

2.6 3.9

1.6 2.1

50

43.7

54.3

42.9

51.8

88.6
2.9
1.4
7.1

81.3
3.1
3.1
12.5

92.7
2.6
0
2.6

92.9
0
7.1
0

87.5
3.6
0
8.9

12.9

21.9

5.3

21.4

10.7

Note: Values expressed as mean SD or percent. Diagnosis defined according to Structured Clinical Interview for
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Anxiety in ESRD

131

Table 2. Diagnostic Frequency

DSM-IV Axis I Diagnosis

Mood disorders
Major depressive disorder
Dysthymic disorder
Depressive disorder NOS
Anxiety disorders
Specific phobias
Panic disorder ( agoraphobia)
Obsessive compulsive disorder
Anxiety disorder NOS
Posttraumatic stress disorder
Generalized anxiety disorder
Social phobia
Schizophrenia and other psychotic disorders
Substance-related disorders
Substance abuse
Alcohol abuse
Adjustment disorder

Sample
(%)*

19.6
9.8
2.8
26.6
21.0
2.8
7.0
4.2
1.4
4.2
10.2
18.0
19.4
1.4

Abbreviations: DSM-IV, Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition; NOS, not otherwise
specified.
*Percentages do not add up to 100% because of psychiatric comorbid conditions.

Anxiety Disorder Prevalence

Overall, 71% of the sample had a DSM-IV diagnosis (SCID), with 45.7% (n 32) qualifying for
an anxiety disorder based on the SCID-I interview.
The distribution of anxiety and mood disorders is
listed in Table 2. Eleven participants had comorbid
anxiety and depression diagnoses. In comparison,
only 13% (n 9) of the sample had a solitary
depressive disorder, for a total of 29% (n 20) of
the sample with a depressive disorder. Nineteen
percent had a current substance-related disorder,
and 10% had a current psychotic disorder.
Utility of the HADS in Screening
The HADS, KDQOL, and SF-36 are all highly
intercorrelated (Table 3). Higher scores on the

HADS scales are associated with decreased QOL

measured by using the KDQOL and SF-36. Hierarchical multiple regression was used to test
relationships among HADS total score, Depression and Anxiety subscales, and SCID diagnosis
of anxiety or depression, controlling for sociodemographic characteristics. HADS score was the
dependent variable, sociodemographic variables
were entered in the first step, and SCID diagnosis
variables (anxiety and depression) were entered
in the second step. Results of this analysis are
listed in Table 4. In the first step, sociodemographic variables (specifically sex, age, and time
on dialysis therapy) accounted for 5% of the
variance in HADS total score. The model at this
step was not statistically significant (F 1.11; P
0.35). In the second step, SCID variables
accounted for an additional 38% of the variance
in HADS total score. Depression was a statistically significant predictor (t 4.30; P 0.001)
of HADS total score. Neither anxiety diagnosis (t
0.85, not significant [NS]) nor the interaction
of anxiety and depression (comorbidity; t
0.92, NS) were significant predictors of HADS
total score.
A similar pattern emerged in hierarchical multiple regressions used to test relationships among
HADS Depression and Anxiety subscales and
SCID diagnosis of anxiety or depression. In the
first step of the HADS Depression Scale regression, sociodemographic variables explained only
5% of the variance and the model at this step was
not significant (F 1.22; P 0.3). In the second
step of the model, SCID variables accounted for
an additional 21% of the variance in HADS
Depression Scale score. Depression was a statistically significant predictor (t 3.0; P 0.001)
of the HADS Depression Scale. Again, neither
anxiety diagnosis (t 0.26, NS) nor the interac-

Table 3. Correlation Coefficients for the HADS, KDQOL, and SF-36

HADS total
HADS Depression
HADS Anxiety
KDQOL
SF-36

HADS Total

HADS Depression

HADS Anxiety

KDQOL

SF-36

0.903*

0.891*
0.610*

0.713*
0.732*
0.542*

0.582*
0.543*
0.497*
0.676*

Abbreviations: HADS, Hospital Anxiety and Depression Scale; KDQOL, Kidney Disease Quality of Life; SF-36, 36 generic
items of the KDQOL.
*P 0.001.

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Cukor et al
Table 4. Multiple Regressions of HADS With Depression and Anxiety Diagnoses
R2

Dependent variable: HADS total score (n 70)

Step 1
Sex
Age
Length of time on dialysis
Step 2
Depression
Anxiety
Comorbid anxiety and depression
Dependent variable: HADS Depression Scale (n 70)
Step 1
Sex
Age
Length of time on dialysis
Step 2
Depression
Anxiety
Comorbid anxiety and depression
Dependent variable: HADS Anxiety Scale (n 70)
Step 1
Sex
Age
Length of time on dialysis
Step 2
Depression
Anxiety
Comorbid anxiety and depression

0.048

1.11
2.61
0.005
0.002

0.38

0.21

0.035

0.44

1.68
0.099
0.142

6.38
9.65
1.33
2.74

0.053

4.30*
0.846
0.923

1.22
1.60
0.025
0.000

1.91
0.875
0.050

4.07
0.250
1.78

2.97*
0.260
0.981

1.01
0.019
0.001

1.12
0.64
0.200

5.57
1.08
0.966

4.60*
1.27
0.600

2.80

0.801

8.38

Abbreviation: HADS, Hospital Anxiety and Depression Scale.

*P 0.05.

tion of anxiety and depression (comorbidity; t

0.98, NS) were significant predictors of the
HADS Depression Scale. Finally, in the HADS
Anxiety Scale regression, sociodemographic variables explained only 4% of the variance, and the
model at this step was not significant (F 0.801;
P 0.5). In the second step of the model, SCID
variables accounted for an additional 44% of the
variance in HADS Anxiety Scale score. Surprisingly, depression was a statistically significant
predictor (t 4.6; P 0.001) of the HADS
Anxiety Scale, but neither anxiety diagnosis (t
1.27, NS) nor the interaction of anxiety and
depression (comorbidity; t 0.60, NS) were
significant predictors.
To further extend the finding that SCID anxiety diagnosis was not a significant predictor of
the HADS Anxiety Scale, but SCID depression
was significantly associated with variability in
the HADS scale, we compared scores on each
subscale and item for patients meeting criteria
for an SCID diagnosis of a depressive disorder

with those who met criteria for an anxiety disorder (Table 5). To avoid type I error caused by
multiple comparisons, Bonferroni correction was
used, and only P less than 0.0035 is reported as
significant. Patients who were depressed had
higher scores on the total HADS scale and both
the Depression and Anxiety subscales. Evaluation of individual HADS items shows an unexpected pattern in which depressed patients score
higher on more items of the Anxiety subscale
than the Depression subscale. Conversely, patients who had an anxiety disorder did not show
higher scores on the HADS total or either the
Depression or Anxiety subscales. Anxiety patients only differed from nonanxiety patients on
a measure of panic.
Impact on QOL
Mean score for all subjects on the KDQOL-SF
was 65.8 13.5, whereas mean score on the
SF-36 was 50.1 70.3. These results are similar
to those of Fukuhara et al,28 who reported a mean

Anxiety in ESRD

133
Table 5. Comparisons of HADS Scale, Subscales, and Items by SCID Diagnosis
Depression Diagnosis

HADS total score

HADS Depression Subscale
I still enjoy the things I used to enjoy
I can laugh and see the funny side of
things
I feel cheerful
I feel as if I am slowed down
I have lost interest in my appearance
I look forward with enjoyment to things
I can enjoy a good book or radio or
television program
HADS Anxiety Subscale
I feel tense or wound up
I get a sort of frightened feeling as if
something awful is about to happen
Worrying thoughts go through my mind
I can sit at ease and feel relaxed
I get a sort of frightened feeling like
butterflies in the stomach
I feel restless as if I have to be on the move
I get sudden feelings of panic

Anxiety Diagnosis

Yes
(n 20)

No
(n 50)

Yes
(n 32)

No
(n 38)

16.1 5.9*
7.5 3.3*
1.2 0.9

7.6 5.0*
4.3 3.2*
0.9 0.9

10.9 6.9
5.3 3.5
1.1 0.9

9.2 6.1
5.2 3.6
0.9 0.9

1.1 1.1
0.6 0.7
1.4 1.1
1.1 1.0
1.4 1.1

0.5 0.9
0.3 0.5
1.1 0.8
0.6 1.0
0.6 0.9

0.5 0.8
0.5 0.6
1.3 1.0
0.6 0.9
0.8 0.9

0.8 1.1
0.3 0.5
1.1 0.9
0.8 1.1
0.9 1.1

0.8 1.1
8.6 3.3*
1.3 1.0

0.3 0.7
3.2 2.6*
0.5 0.7

0.5 0.9
5.6 3.9
0.8 0.9

0.4 0.8
4.0 3.5
0.6 0.9

1.1 0.8
1.1 1.2
1.6 0.8*

0.4 0.7
0.5 0.7
0.6 0.8*

0.8 0.8
0.8 1.0
1.0 0.9

0.5 0.8
0.5 0.8
0.7 1.0

1.4 1.0
1.1 0.8*
1.1 0.8*

0.4 0.7
0.5 0.6*
0.4 0.6*

0.8 1.0
0.7 0.7
0.8 0.8

0.7 0.8
0.6 0.7
0.3 0.6

Note: Values expressed as mean SD.

Abbreviations: HADS, Hospital Anxiety and Depression Scale; SCID, Structured Clinical Interview for Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition.
*P 0.001.

score of 62.9 on the KDQOL-SF from a large US

sample of patients with ESRD.
Subjects with an anxiety disorder reported significantly lower QOL (61.8 14.8) than those without
an anxiety disorder (69.9 11.5; t 2.4; P
0.05), although the 2 groups rated their physical
health (SF-36) as similar (anxiety group, 47.0
17.9 versus no anxiety group, 52.6 16.5; t 1.3;
P 0.2)
Hierarchical multiple regression analyses were
used to test relationships between QOL and SCID
diagnosis of anxiety or depression while accounting for sex, age, and length of time on dialysis
therapy. Results of these analyses are listed in
Table 6. Total KDQOL score was the dependent
variable and sociodemographic variables were
entered first. This step of the model was not
significant (F 1.13; P 0.3) and accounted for
only 5% of the variance in QOL. In the second
step, SCID diagnosis variables (anxiety and depression) accounted for an additional 49% of the
variance in KDQOL total score. Both depression
(t 4.1; P 0.001) and anxiety diagnoses

(t 2.4; P 0.05) were statistically significant predictors of QOL score. The interaction of
anxiety and depression (comorbidity; t 0.32,
NS) was not significantly associated with QOL.
Similarly, a hierarchical multiple regression
analysis was used to test relationships between
self-reported health status and SCID diagnosis of
anxiety or depression while controlling for sex,
age, and length of time on dialysis therapy (Table
6). SF-36 score was the dependent variable and
sociodemographic variables were entered in the
first step. This step of the model was not significant (F 0.095; P 0.9) and explained less
than 1% of the variance in self-reported health
status. In the second step, SCID diagnosis variables (anxiety and depression) were entered and
accounted for 18% of the variance in SF-36
score. Depression (t 2.58; P 0.001) was a
statistically significant predictor of health status,
but neither anxiety diagnosis (t 0.92, NS)
nor the interaction of anxiety and depression
(comorbidity; t 0.51, NS) were associated
significantly with variability in health status.

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Cukor et al
Table 6. Multiple Regressions of QOL and Health Status With Depression and Anxiety

Dependent variable: QOL (KDQOL-SF; n 70)

Step 1
Sex
Age
Length of time on dialysis
Step 2
Depression
Anxiety
Comorbid anxiety and depression
Dependent variable: self-reported health status (SF-36; n 70)
Step 1
Sex
Age
Length of time on dialysis
Step 2
Depression
Anxiety
Comorbid anxiety and depression

R2

0.049

1.13

4.17
0.136
0.007
0.49

4.09*
2.40*
0.317

0.095
1.43
0.033
0.002

0.18

1.28
0.124
0.264

10.05
17.36
4.18
1.78

0.004

0.333
0.229
0.067

2.23
17.7
4.44
4.74

2.58*
0.918
0.513

Abbreviations: QOL, quality of life; KDQOL-SF, Kidney Disease QOL Short Form; SF-36, 36 generic items of the KDQOL.
*P 0.05.

DISCUSSION
Comorbid anxiety disorders are a complicating factor for patients with many medical illnesses.1,2 The rate of these disorders in our
ESRD sample is proportionally more than double
the rates of the national average29 and significantly increased compared with reported rates
for other medical illnesses.2 Because this is the
first known report of DSM-IV anxiety diagnosis
in a US ESRD population and there are few
comparative data, the generalizability of these
results is uncertain. However, it is similar to the
rate of anxiety in a recent review by Murtagh et
al,30 who found that 38% (range, 12% to 52%) of
patients with ESRD endorsed substantial anxiety
symptoms. It would seem that the intrusiveness
of ESRD into multiple life domains,6,31 as well
as its substantial daily demands, have a substantial impact on the psyche of patients and explain
the greater than expected rates of anxiety.
This study uses stringent criteria based on
DSM-IV criteria for the definition of an anxiety
disorder. Subthreshold anxiety and psychic distress were not included, thereby contributing to
the method rigor of these findings. However,
some limitations of the study include its small
sample size, collection of all data from 1 dialysis
center, and a population not representative of US

demographics. Therefore, one must exercise caution in generalizing these results.

The call for depression screening in hemodialysis patients is growing,32,33 but little is known
about anxiety screening or the appropriate screening tools in an ESRD population. This study also
suggests that the HADS is an acceptable measure
of what has been termed psychic distress,27 but
that it does not serve as an effective screen for
anxiety disorders. Patients with an SCID diagnosis of depression scored higher than nondepressed patients on both the Depression and
Anxiety subscales, indicating that the HADS
cannot differentiate between depressive and anxious symptoms in depressed patients. Also, individual items of the Anxiety subscale performed
poorly in differentiating patients with or without
an SCID diagnosis of an anxiety disorder. It
appears that in this patient population, even the
Anxiety Subscale detects depressive symptoms
more than anxiety symptoms because this scale
correlated more with SCID diagnosis of depression than SCID diagnosis of anxiety.
These data also suggest that an anxiety diagnosis negatively impacts on QOL independent of
depression. Anxiety and depression are distinct
clinical entities that have differing causes, pathophysiological processes, and treatments.34 It is
important to distinguish between their individual

Anxiety in ESRD

135

and combined effects to properly understand the

relationship between various types of psychopathological states and chronic kidney disease. It
also is essential to correctly identify the type of
psychopathological state so that appropriate treatment can be initiated and research can be furthered in this area. Both psychopharmacological
and psychotherapeutic interventions differ for
anxiety, depression, or their combination, and
both types of intervention show promise in ESRD
populations.35-37 Future research needs to identify appropriate screening measures for anxiety
in ESRD populations. Large-scale multisite studies that compare screening instruments with structured psychiatric diagnoses would be able to
describe how the measures perform in ESRD
populations and identify clinical cutoff values.
Additional research is required to understand the
pathways linking psychopathological states and
ESRD and determine the long-term impact of
successful psychiatric treatment on outcome.

ACKNOWLEDGEMENTS
Support: Dr Cukor is currently supported by a K-23
(DK076980-01) award from the National Institute of Diabetes and Digestive and Kidney Diseases. This project was
supported in part by a Promoting Psychological Research
and Training on Health-Disparities Issues at Ethnic MinorityServing Institutions Grants (ProDIGs) awarded to Dr Cukor
from the American Psychological Association.
Financial Disclosure: None.

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