Identifying and Addressing Anxiety in Dialysis
It will come as no surprise that anxiety has become more prevalent during the COVID-19 pandemic—not to mention the political and social climate. Those who have never had a history of anxiety may be finding themselves affected. While people living with ESKD may have comorbidities that increase their risk for anxiety, one doesn’t need to have a DSM diagnosis to be affected by anxiety—imagine yourself in a situation where you have felt extremely anxious…
What did you feel?
How clearly could you think or concentrate?
How thoroughly could you have received and retained information that is essential for living—like learning a PD or HHD regimen?
Regardless of our clinical experience or role, it’s important for the interdisciplinary care team (IDT) to recognize if anxiety could be affecting our patients and their ability to manage their kidney disease and treatment.
Prevalence of Anxiety:
Anxiety is common in the general population:
31% of adults experience anxiety disorder at some point in their lives.
COVID may increase risk of mental illness by as much as 50%.
4 in 10 adults reported symptoms of anxiety or depression during the pandemic.
Existing literature points to increased levels of anxiety in patients with CKD, with the prevalence of anxiety in patients with ESKD ranging from 12% to 52%. However, the exact prevalence remains unclear, mostly due to the limited number of studies, different sample populations, and different screening methods used.
Types of Anxiety Disorders
Generalized anxiety disorder (GAD)
Social anxiety disorder
Body dysmorphic disorder (BDD)
Post-traumatic stress disorder (PTSD)
Physical Signs & Symptoms of Anxiety
Psychological Signs & Symptoms of Anxiety
Emotional Signs & Symptoms of Anxiety
Medical Comorbidities & Risk factors
Chronic kidney disease
Psychological Comorbidities & Personal Risk Factors
Nearly 50% of all patients diagnosed with depression also have symptoms of anxiety.
Anxious depression can worsen prognosis and is associated with increased suicidality, greater functional impairment, poorer health-related quality of life, longer treatment duration, and poorer response to treatment
Substance use disorder
Personality traits (shy)
History of trauma
History of abuse
It’s no wonder the pandemic has elevated rates of anxiety—we’re all in the middle of global persistent stress!
There are a number of screening tools for anxiety, such as the following:
General Anxiety Disorder-7 (GAD-7)
Beck Anxiety Inventory (BAI)
Impact of anxiety on ESKD self-management
Patients may experience situational anxiety while adjusting to ESKD diagnosis or learning a new treatment regimen, like home dialysis. The IDT should keep in mind that a patient’s health literacy may be impacted by anxiety—imagine if you had to learn or remember something if you were really anxious. Anxiety can impact:
Diet & fluid adherence
Choice of dialysis type or interest in transplant (body image disorder)
Ability to follow the treatment plan (prescription for in-center or home dialysis, home dialysis infection control, ordering supplies, managing technical steps, labs, etc.)
Decision to pursue a transplant or to retain active waitlist status
Interaction w/care team
Quality of life
Increase risk of depression
A team approach is essential! Physicians manage medications for anxiety. While a patient may have a psychiatrist, it’s more common for the primary care physician to prescribe medications if the nephrologist does not feel comfortable doing so. All providers should evaluate patients for contraindications and/or dosage adjustments for ESKD. Common medications for anxiety include:
Benzodiazepines (addictive and intended for short-term use)
The IDT should monitor patients taking benzodiazepines for the following common side effects that could impact a patient’s ability to manage their dialysis at home:
Poor balance or coordination
Worsening depression symptoms
Common Types of Psychotherapy to Treat Anxiety
Cognitive Behavioral Therapy (cognitive restructuring, behavioral activation, and self-soothing skills)
Dialectical Behavior Therapy (mindfulness & visualization)
Systematic Desensitization (needle phobia, coming to clinic)
Eye Movement Desensitization and Reprocessing (EMDR)
Lifestyle changes, such as exercise, sleep hygiene, elimination or reduction of caffeine and nicotine, and limiting social media can improve the symptoms of anxiety. Social connections can strengthen resilience and promote well-being. Interacting with family, friends, and others with ESKD can help. If it is not possible to gather in person, video conferences or phone calls can be effective. Virtual support groups like those offered by the Renal Support Network, Dialysis Patient Citizens, and the Home Dialysis Central Facebook Discussion Group reassure patients that they are not alone and offer helpful coping techniques.
Dialysis nurses and dietitians can provide education and support to promote medication management and healthy lifestyle changes. As the behavioral health specialists on the IDT, dialysis social workers (MSWs) are qualified to provide supportive counseling. Patients tend to prefer to receive counseling from their trusted MSW at the clinic versus an external provider. If in-person visits are impacted by COVID 19 precautions, social workers may need to use telehealth preferably with video. Some of the techniques they may use to address patients’ symptoms of anxiety include cognitive restructuring, coping thoughts, breathing exercises, mindfulness, and visualization.
While depression screening is required by CMS, formal screening for anxiety is not yet required for patients with ESKD. One silver lining of the pandemic is the bright spotlight on behavioral health and effects on outcomes, so dialysis providers may want to consider expanding screenings to include anxiety surveys which are readily available and user-friendly.
With the prolonged impact of the pandemic, we as healthcare professionals have an obligation to “practice what we preach” and maintain our own self-care. Normalizing healthy self-care practices among our peers not only improves our quality of life, but also strengthens our clinical practice so we can improve the quality of life of our in-center and home dialysis patients.
Therapist aid: https://www.therapistaid.com/
National Alliance on Mental Illness (NAMI): 800-950-NAMI (800-950-6264)
Anxiety and Depression Association of America (ADAA): 40-485-1001.
National Institute of Mental Health (NIMH): 866-615-6464.
Centers for Disease Control and Prevention, Division of Mental Health (CDC); 800-CDC-INFO (800-232-4636)
Renal Support Network - https://www.rsnhope.org/health-library/when-fear-wont-go-away-anxiety/
Panchal N, Kamal R, Cox C, Garfield R. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. Feb 10, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
Haridy R. Oxford study links COVID-19 with increased rates of mental illness. Nov 10, 2020. https://newatlas.com/health-wellbeing/oxford-coronavirus-mental-illness-depression-anxiety/
Morin A. How to cope with anxiety about Coronavirus (COVID-19). Mar 20, 2020. https://www.verywellmind.com/managing-coronavirus-anxiety-4798909
I’m So Stressed Out ! (Infographic). National Institute of Mental Health. https://www.nimh.nih.gov/sites/default/files/documents/health/publications/so-stressed-out-infographic/imsostressed-infographic-508.pdf
National Institute of Mental Health. Any anxiety disorder. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml
Mosleh, H., Alenezi, M., Al Johani, S., Alsani, A., Fairaq, G., & Bedaiwi, R. (2020). Prevalence and Factors of Anxiety and Depression in Chronic Kidney Disease Patients Undergoing Hemodialysis: A Cross-sectional Single-Center Study in Saudi Arabia. Cureus, 12(1), e6668. https://doi.org/10.7759/cureus.6668. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6968827/
Goh, Z. S., & Griva, K. (2018). Anxiety and depression in patients with end-stage renal disease: impact and management challenges - a narrative review Int J Nephrol Renovasc Dis, 11, 93–102. https://doi.org/10.2147/IJNRD.S126615 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856029/
Murtagh FE, Addington-Hall J, Higginson IJ. The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis. 2007;14(1):82–99. https://pubmed.ncbi.nlm.nih.gov/17200048/
Sartorius N, Holt RIG, Maj M (eds): (2015) Comorbidity of Mental and Physical Disorders. Key Issues Ment Health. Basel, Karger, 179:81-87. doi: 10.1159/000365538 https://www.karger.com/Article/Fulltext/365538
Anxiety & Depression Association of America. https://adaa.org/