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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 828-836
Associations between phosphate binders prescription, illness perception, and depression in hemodialysis patients

Department of Pharmacy, Jerantut Hospital, Jerantut, Pahang, Malaysia

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Date of Submission24-Aug-2017
Date of Decision21-Sep-2017
Date of Acceptance24-Sep-2017
Date of Web Publication28-Aug-2018


Studies among hemodialysis (HD) patients have looked into relationships between illness perception (IP), depression, and adherence yet rarely looked further into medication factors. Those studies were also conducted at urban HD centers leaving out those from a smaller town. Our objective is to determine phosphate binders (PBs) influences on IP and depression among HD population in smaller town. One hundred and thirteen patients from three Central Pahang Cluster Hospitals, Malaysia on HD were interviewed using Malay version of the Brief IP Questionnaire and Beck Depression Inventory II (BDI-II). This study found a significant positive correlation between PBs daily dose frequency with consequence, timeline, and illness concern. Type of PBs used influenced personal control significantly. History of PBs side effects resulted in significantly lower treatment control and lower emotional representation. There was a significant negative relationship between dialysis vintage with both identity and IP score. Depressed patients had significantly higher emotional representation compared to healthy controls. Meanwhile, there was a positive correlation between BDI-II score with coherence, consequence, and emotional representation. Around 23.9% of the patients reported symptoms of depression. Depressed patients had significantly shorter dialysis vintage compared to healthy controls. They tended to report a significant history of hospital admission in the past six months that peaked among those on HD between four to six years. The current study showed the effect of PBs therapy on IP while depression was associated with HD duration and hospital admission. This information can be used to formulate a better treatment approach by health-care practitioners toward better patients treatment hence outcomes.

How to cite this article:
Mohamed Koya SM, Zulkepli NA. Associations between phosphate binders prescription, illness perception, and depression in hemodialysis patients. Saudi J Kidney Dis Transpl 2018;29:828-36

How to cite this URL:
Mohamed Koya SM, Zulkepli NA. Associations between phosphate binders prescription, illness perception, and depression in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2022 Aug 14];29:828-36. Available from: https://www.sjkdt.org/text.asp?2018/29/4/828/239656

   Introduction Top

Hemodialysis (HD) population has a higher illness and medication burden. One of the most commonly prescribed drugs in the HD population is phosphate binder (PB) and it contributes toward almost 50% of the total daily pill burden.[1] High total daily pill burden together with factors such as higher daily dose frequency[2] tend to compromise medication adherence (MA) and quality of life (QOL).[1]

QOL was also related to depression.[3] Numbers of patients on HD with reported depression range between 30% to 70% both locally[4],[5] and abroad.[3],[6] Depression was common in the female, widowed, patients with lower education[3] and influenced by races[5] and has affected therapeutic regimen adherence negatively.[3] Besides, it also interacted with factors such as illness perception (IP).[3],[5] On the other hand, IP which was a reflection of how the patients perceived the chronicity or severity of their illness had affected therapeutic adherence positively.[3],[7]

Available studies focused mainly on IP, depression, and adherence yet rarely looked further into medication factors. Available studies also were conducted at urban HD centers. Hence, this study aimed to find associations between PBs therapy, IP, and depression among patients from smaller town on HD.

   Materials and Methods Top

Study design and setting

This was a cross-sectional survey conducted in April 2017 at three HD units of Central Pahang Government Cluster Hospitals in Malaysia convenient sampling.


Sample size was determined using Raosoft software at www.raosoft.com/samplesize.html. Among the inclusion criteria were participants must be older than 18 years, had at least 80% HD sessions attendance within the past three months and did not miss the last nephrologists follow-up, received 4 h HD thrice weekly, had been on HD treatment for a minimum of three months before the study and taking any type of PBs. Participants with the language barrier, refused to participate or having mental illness, speech and hearing disabilities were excluded. There were 156 patients undergoing HD on PBs at the time of the study, and we aimed for 119 sample size. However, 24 patients were excluded due to the language barrier.

Ethical approval

This study was approved by Medical Research and Ethics Committee (MREC) with NMRR ID: NMRR-17-101-34100 (IIR).

Data collection

Patients were approached and invited to participate in the survey after they were briefed orally regarding this study by researchers. Those willing to participate were enrolled into the study once written consent given by participants. Researchers allocated between 15 and 30 min conducting the survey for each subject. Investigators work at center one and they were not known to participants from centers two and three.


Demographic and medical information such as date they were started on HD, home address to determine the distance traveled, type of PBs prescribed, and history of PBs side effects was obtained from patients during survey or extracted from their medical charts. Those information were included in a separate demographic form prepared by researchers.

The Malay version of Beck Depression Inventory II (BDI-II) was used to measure depression. It consists of 20 questions and question 21 was eliminated due to cultural and religious sensitivity.[8] In the original BDI-II, the first 13 questions measure cognitive/affective subscale, and the last eight items measure somatic/performance.[8] Cronbach's alpha for the Malay version BDI-II ranges from 0.71 to 0.91.[8] Total score of 0–13, 14–19, 20–28, and 29–63 were considered to indicate minimal, mild, moderate, and severe depression respectively.[5] However for this study, “minimal” was classified as “normal” and “moderate” to “severe depression” were categorized into depressed.

IP was measured using the Malay version of Brief IP questionnaire.[9] It consisted of eight questions and question nine was eliminated because we were not looking into the subject's perception toward end-stage renal disease (ESRD) causes. Each question was scored between zero and ten, and it carried the total mark of 80. Personal control, treatment control, and illness understanding were reverse scored. Higher IP score indicated the more threatening view of the illness.

Estimated distance from home to HD centers was determined orally with patients during the interview and confirmed with Google Maps application.

Total pill burden was defined as total daily pills taken by patients.[1] Total number of medications was defined as the count of different oral medications the subject was taking at home and parenteral medications administered either at home or in the dialysis unit.[1] Daily dose frequency referred to number of times subjects had to take or administer their drugs. Side effects to calcium carbonate that compromised adherence and requiring changing in brand or formulation from tablet to capsule include stomach pain, nausea, and vomiting.

   Statistical Analysis Top

The analysis was performed using the Statistical Package for Social Sciences (SPSS) Statistics for Windows, Version 18.0 (SPSS Inc., Chicago, IL, USA). Chi-square test was used for analysis between categorical variables. Mann–Whitney U-test or Kruskal–Wallis tests were used to determine relationships for scores between categorical and numerical variables. Pearson correlation was utilized to find an association between numerical variables. Continuous variables were expressed as mean and SD, or median with interquartile range (IQR) where applicable. P <0.05 was considered statistically significant.

   Results Top

One hundred and thirty-two patients were approached for interview, and 10 refused to participate while nine had communication barrier. Response rate was 85.6%.

At center 1, 29 of the 36 (80.6%) eligible patients were enrolled; at center 2, 53 of the 63 (84.1%) eligible patients were enrolled; and at center 3, 47 of the 72 (65.3%) eligible patients were enrolled. Thus, 113 patients formed the study cohort. The key characteristics of the cohort are summarized in [Table 1]. There were no significant differences in demographic features between all three centers. The medians total medications and total pill burden for the cohort were eight (IQR, 2) and 13.9 (IQR, 8.0), respectively. Median percentage pill burden from PB was 42.6 (IQR, 26.4). One of the centers had significantly higher PB and total daily pill burden.
Table 1: Centers' characteristics, IP and depression

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Illness perception

As shown in [Table 1], there was no significant difference in IP scores between all three centers. However, one of the centers had significantly higher personal control dimension compared to others.

Using Pearson correlation, we found several factors that influenced IP dimension and IP score significantly. From [Table 2], we observed positive correlation between consequence dimension with PB daily dose frequency (r = 0.202, P = 0.032) and BDI-II score (r = 0.226, P =0.016). Timeline dimension was positively correlated with PB daily dose frequency (r = 0.232, P = 0.013). There was negative relationship between identity dimension and dialysis vintage (r = -0.203, P =0.031). Positive relationship was observed between illness concern dimension and PBs daily dose frequency (r = 0.228, P = 0.015). There was positive relationship between coherence and BDI-II score (r = 0.189, P = 0.049). Finally, negative relationship was observed between IP score and dialysis vintage (r = -0.204, P = 0.030). However, it was positively correlated with BDI-II score (r = 0.359, P = <0.001).
Table 2: Correlation between IP components, demographic and PB profile.

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As shown in [Table 3], personal control dimension was significantly influenced by type of PB used (χ2 = 7.531, df = 2, P = 0.023). Treatment control dimension was significantly lower for patients with a history of PB side effects, median 0.5 (IQR, 1.0) compared to those without, median 2.0 (IQr, 2.0), P = 0.039. On the other hand, emotional representation dimension was significantly higher for subjects with a history of PB side effects, median 8.5 (IQR, 7.0) compared to those without, median 5.0 (IQR, 6.0), P = 0.047.
Table 3: Relationships between IP components, demographic and PB profile.

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From [Table 4], emotional representation dimension was also higher in depressed, median 6 (IQR, 4) compared to healthy controls, median 5 (IQR, 6), P = 0.004.
Table 4: Factors influencing depression status.

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As shown in [Table 1], we did not observe any significant differences between centers with regard to BDI score and depression. BDI-II score for this cohort was quiet low, median 8.0 (IQR, 8.0) and only 23.9% (n = 27) of the patients were categorized as depressed.

As shown in [Table 4], depressed subjects had significantly shorter dialysis vintage, median 52 months (IQR, 86) compared to healthy controls, median 79 months (IQR, 68), P = 040. They also reported significant history of hospital admission in the past six months, compared to healthy controls, (χ2 = 4.972, df = P = 0.026). Depressed patients scored significantly higher emotional representation dimension, median 6 (IQR, 4) compared to healthy controls, median 5 (IQR, 6), P = 0.004. From [Figure 1], we observed decreasing trend for depression with increasing dialysis vintage (χ2 = 8.381, df = 3, P = 0.039). On the other hand, [Figure 2] shows decreasing trend for the history of hospital admissions within the past six months with increasing dialysis vintage even though it peaked among subjects who have been on HD between four to six years (X[2]= 15.682, df = 3, P = 0.001).
Figure 1: Years on hemodialysis versus the percentage of subjects with depression.

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Figure 2: Years on hemodialysis versus percentage reported hospital admission.

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   Discussions Top

Illness perception

Tasmoc et al observed decreased IP over time indicating optimistic view after few years on HD.[10] Similarly, we observed decreased IP with increasing dialysis vintage.

In the current study, increased PBs daily dose frequency triggered significantly higher timeline, consequence, and illness concern dimensions. Higher PBs daily dose frequency might be a constant reminder of the illness due to ESRD that subjects were facing. This, in turn, produced higher realization on the chronicity nature and serious implications that ESRD had on their lives.[11]

According to Petrie and Weinman patients with chronic perceptions with regard to timeline dimension were more likely to adhere to their medications compared to those with acute perceptions.[7] In contrast, other evidence have shown that increased daily dose frequency reduced adherence.[2],[12] Hence, further study is needed to confirm either increased daily dose frequency in this population actually produce better adherence or otherwise. This is important since intervention in IP results in improved adherence[13] and it is possible that its effectiveness can be optimized when coupled with alteration in PB daily dose frequency.

A significantly different personal control dimension between patients taking different PBs indicated poor ability to control the effect of ESRD on their health. According to Chen et al, hypertensive patients who perceived their illness as controllable had significantly better adherence to self-management such as healthy diet.[14] High phosphate diet in HD subjects could contributes toward increased phosphate value and as reported by Luis et al, almost 80% of them consuming excess phosphate from their diet.[15] In our opinion, it was possi-ble that poor self-management or knowledge related to high phosphate diet partially contributed toward uncontrolled phosphate level that triggers the use of one of the PBs in this group in the first place.

Those with a history of calcium carbonate side effects scored lower in treatment control after switching of brand or formulation to current regimen indicating higher faith on effectiveness of treatment yet emotionally scarred as reflected by the higher score in emotional representation dimension. Side effects play important role in determining MA. Decreased MA to corticosteroid in asthmatic patients whom experienced greater number of side effects[16] and also in hypertensive patients with higher IP scores have been shown before.[17] Hence, healthcare practitioners should be aware of PBs intolerance history since it might compromise the patient's adherence and emotion.


Data regarding depression among HD population from a smaller town in Malaysia is scarce. It tended to be underreported, and many patients did not receive appropriate treatment.[18] Prevalence of depression in the current study was 23.9% only. None of the patients received any type of antidepressant. Our patients came from a small town as evidenced by longer distance between patients homes and respective HD centers. Most studies looking into depression among rural areas patients did not include those with ESRD either locally[19] or abroad.[20] Besides, it was reported that patients from rural areas tended to be more affected by depression compared to those from urban areas.[19],[20] In contrast, our finding indicated the smaller percentage of ESRD patients undergoing HD from smaller town experienced depression compared to between 40% to 70% for those from urban areas.[3],[4],[5] This is not surprising since Alcock et al has reported that patients living in greener areas have reported significantly better mental health compared to patients living in less green areas.[21]

Association between dialysis vintage and depression has never been reported before in Malaysia. It is important to recognize the dialysis period during which patients are at most vulnerable so that proper intervention can be provided. In the current study, we found that depression was more prominent in patients who have only been on HD for less than two years. This figure then decreased in patients with longer dialysis vintage. Study by Chwastiak et al in patients with advanced multiple sclerosis found that those diagnosed within one year have reported significantly higher depressive symptoms.[22]

As reported by Teles et al, depressed ESRD patients undergoing HD had 4.5 times higher risk of hospitalization compared to normal ESRD subjects.[23] Similarly, the current study found that those patients with depression had reported significant history of hospital admission in the previous six months. Frequent hospitalization occurred in those with dialysis vintage between four to six years. Once patients exceeded six years, both depression and hospitalization decreased. In our opinion, the first two to six years was a challenging time for the patient's health. Hence, it is a vital period to monitor and provide intensive care for them.

Illness perception and depression

Among IP dimensions in current study, only emotional representation showed significant difference between normal and depressed subjects. This observation is in parallel with Ibrahim et al whom reported emotional representation as strongest predictor of depression.[5] However, emotional representation was not related to any other factors.

   Strengths and Limitations Top

The strength of this study is that it is the first study to look into associations between PBs with IP dimensions and depression. One of the limitations was that we did not measure uremia in our patients. Uremic symptoms during early years of HD could be mistaken for depression hence causing misinterpretation of the findings. However, we have used a higher cut-off point for BDI-II to avoid this.

   Conclusion Top

The current study shows that several factors such as PBs type and frequency, history of PBs side effects and social support have influenced IP dimensions significantly. However, none of these factors had any significant effect on depression. On the other hand, depression was more prominent during the early years of HD and in those with a history of recent hospital admission and significantly related to emotional representation dimension. Percentage of depression also varied between patients from urban and smaller town areas. Healthcare practitioners can manipulate this information to provide better treatment for ESRD patients on HD.

Conflict of interest: None declared.

   References Top

Chiu YW, Teitelbaum I, Misra M, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol 2009;4:1089-96.  Back to cited text no. 1
Coleman CI, Limone B, Sobieraj DM, et al. Dosing frequency and medication adherence in chronic disease. J Manag Care Pharm 2012;18: 527-39.  Back to cited text no. 2
Nabolsi MM, Wardam L, Al-Halabi JO. Quality of life, depression, adherence to treatment and illness perception of patients on haemodialysis. Int J Nurs Pract 2015;21:1-10.  Back to cited text no. 3
Ibrahim N, Chiew-Thong NK, Desa A, Razali R. Depression and coping in adults undergoing dialysis for end-stage renal disease. Asia Pac Psychiatry 2013;5 Suppl 1:35-40.  Back to cited text no. 4
Ibrahim N, Desa A, Chiew-Tong NK. Illness perception and depression in patients with endstage renal disease on chronic hemodialysis. Soc Sci 2011;6:221-6.  Back to cited text no. 5
Ossareh S, Tabrizian S, Zebarjadi M, Joodat RS. Prevalence of depression in maintenance hemodialysis patients and its correlation with adherence to medications. Iran J Kidney Dis 2014;8:467-74.  Back to cited text no. 6
Petrie KJ, Weinman J. Why illness perceptions matter. Clin Med (Lond) 2006;6:536-9.  Back to cited text no. 7
Mukhtar F, Oei TP. Exploratory and confirmatory factor validation and psychometric properties of the beck depression inventory for Malays (BDI-Malay) in Malaysia. Malays Psychiatry J 2008;17(1).  Back to cited text no. 8
Norfazilah A, Samuel A, Law P, et al. Illness perception among hypertensive patients in primary care centre UKMMC. Malays Fam Physician 2013;8:19-25.  Back to cited text no. 9
Tasmoc A, Hogas S, Covic A. A longitudinal study on illness perceptions in hemodialysis patients: Changes over time. Arch Med Sci 2013;9:831-6.  Back to cited text no. 10
Kim Y, Evangelista LS. Relationship between illness perceptions, treatment adherence, and clinical outcomes in patients on maintenance hemodialysis. Nephrol Nurs J 2010;37:271-80.  Back to cited text no. 11
Laliberté F, Bookhart BK, Nelson WW, et al. Impact of once-daily versus twice-daily dosing frequency on adherence to chronic medications among patients with venous thromboembolism. Patient 2013;6:213-24.  Back to cited text no. 12
Seyyedrasooli A, Parvan K, Rahmani A, Rahimi Z. Effect of illness perception promoting interventions on treatment adherence in hemodialysis patients: A randomized controlled trial. Iran J Crit Care Nurs 2013;6:7-86.  Back to cited text no. 13
Chen SL, Tsai JC, Lee WL. The impact of illness perception on adherence to therapeutic regimens of patients with hypertension in Taiwan. J Clin Nurs 2009;18:2234-44.  Back to cited text no. 14
Luis D, Zlatkis K, Comenge B, et al. Dietary quality and adherence to dietary recommendations in patients undergoing hemodialysis. J Ren Nutr 2016;26:190-5.  Back to cited text no. 15
Cooper V, Metcalf L, Versnel J, Upton J, Walker S, Horne R. Patient-reported side effects, concerns and adherence to cortico-steroid treatment for asthma, and comparison with physician estimates of side-effect prevalence: A UK-wide, cross-sectional study. NPJ Prim Care Respir Med 2015;25:15026.  Back to cited text no. 16
Ross S, Walker A, MacLeod MJ. Patient compliance in hypertension: Role of illness perceptions and treatment beliefs. J Hum Hypertens 2004;18:607-13.  Back to cited text no. 17
Lopes AA, Albert JM, Young EW, et al. Screening for depression in hemodialysis patients: Associations with diagnosis, treatment, and outcomes in the DOPPS. Kidney Int 2004;66:2047-53.  Back to cited text no. 18
Sidik SM, Zulkefli NA, Mustaqim A. Prevalence of depression with chronic illness among the elderly in a rural community in Malaysia. Asia Pac Fam Med 2003;2:196-9.  Back to cited text no. 19
Probst JC, Laditka SB, Moore CG, Harun N, Powell MP, Baxley EG. Rural-urban differrences in depression prevalence: Implications for family medicine. Fam Med 2006;38:653-60.  Back to cited text no. 20
Alcock I, White MP, Wheeler BW, Fleming LE, Depledge MH. Longitudinal effects on mental health of moving to greener and less green urban areas. Environ Sci Technol 2014; 48:1247-55.  Back to cited text no. 21
Chwastiak L, Ehde DM, Gibbons LE, et al. Depressive symptoms and severity of illness in multiple sclerosis: Epidemiologic study of a large community sample. Am J Psychiatry 2002;159:1862-8.  Back to cited text no. 22
Teles F, Azevedo VF, Miranda CT, Miranda MP, Teixeira Mdo C, Elias RM. Depression in hemodialysis patients: The role of dialysis shift. Clinics (Sao Paulo) 2014;69:198-202.  Back to cited text no. 23

Correspondence Address:
Mr. Saiful Nizam M. V. Mohamed Koya
Department of Pharmacy, Jerantut Hospital, 27000 Jerantut, Pahang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.239656

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  [Table 1], [Table 2], [Table 3], [Table 4]


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