indeed , in 2009 , half of canadian patients initiating renal replacement were over 65 years old ( 1 ) . according to estimates ,
incidence of chronic renal failure is 242 individuals per one million worldwide ( 2 ) while over $ 1 trillion is spent for end - stage renal disease care , globally ( 3 ) . though , hemodialysis consists the most common treatment method for kidney failure , however , it is a stressful procedure that affects all dimensions of patients lives ( 1 , 2 , 3 ) .
interestingly , hemodialysis patients experience various changes and limitations in their daily lives including diet and fluid constrictions , physical and cognitive impairment as well as inadequacy to accomplish prior roles , duties or activities .
additionally , patients frequently experience heavy psychological burden mainly anxiety and depression that it exerts a negative influence on the outcome of the disease .
depression is related with morbidity , mortality , impairment of quality of life , shortness of lifespan and even worse with suicidal attempts ( 4 - 9 ) . nowadays
that increase in life expectancy of hemodialysis patients is not the ultimate goal in care , it has been slowly acknowledged that social support is a key element to achieve an effective treatment management ( 10 , 11 , 12 ) .
as support is defined the  offer and receive of aid by a network when a crisis appears .
support is usually obtained by family , friends or significant others such as health care professionals , peer group and others ( 11 , 12 ) .
support has been broadly linked to improved health outcomes in chronic illnesses through various mechanisms such as decreased levels of depression , stress alleviation , improvement of patients quality of life , assistance to access health care services , better compliance to the therapeutic regimen and direct physiologic benefits on the immune system ( 10 ) .
the extent of association between anxiety / depression and social support to hemodialysis patients has seldom been the subject of systematic enquiry .
purpose : of this study was to explore the effect of perceived social support on the levels of anxiety and depression of hemodialysis patients .
criteria for patients inclusion in the study were : a ) diagnosis of end - stage renal disease , b ) current hemodialysis , c ) native language - greek , and d ) volunteer participation .
all patients were included in the study after having been informed and given their signed consent .
the study was approved by the medical research ethics committee of each dialysis center and conducted in accordance with the declaration of helsinki ( 1989 ) of the world medical association .
data were collected through the completion of a specially designed questionnaire by the method of interview .
the data collected for each patient included : socio - demographic characteristics ( eg gender , age , education level , marital status , etc . ) , clinical therapy characteristics ( eg years from first hemodialysis , frequency of hemodialysis etc . ) , relations with medical - nursing staff and other patients and finally patients beliefs about the effect of illness on life ( eg life style has been affected , dependency on dialysis machine , etc . ) .
the multidimensional scale of perceived social support ( mspss ) which has been translated and culturally adapted to the greek standards ( 11 , 12 ) was used to evaluate the perceived social support of hemodialysis patients .
this scale has good internal reliability and test - retest reliability , in various samples ( 13 , 14 ) .
the scale is comprised of 3 groups depending on the source of support : a ) significant others b ) family and c ) friends .
more in detail , these are : family [ 3 , 4 , 8 , 11 ] , friends [ 6 , 7 , 9 , 12 ] and a significant person [ 1 , 2 , 5 , 10 ] . each item is rated using a 7 range scale varying between  definitely no and  definitely yes. in order to calculate the final score of each dimension of social support , we add the scores of questions corresponding to each dimension and divide by the number of questions included in each dimension .
higher scores indicate higher support . for the evaluation of depression and anxiety of patients  the hospital anxiety and depression scale ( hads )  was used .
this scale was proposed in 1983 by zigmond as & snaith rp ( 15 ) .
the scale consists of 14 questions that assess how patients felt during the previous week .
patients are able to answer every question in a 4-point likert scale from 0 - 3 .
seven of 14 questions assess the level of depression and the other seven the level of anxiety .
scores attributed to questions are summed separately for anxiety and depression , leading to two scores with range 0 - 21 .
in addition , it has been proposed and it is widely used in the literature , the following categorization : score 0 - 7 indicating no stress or depression , score 8 - 10 indicating moderate levels of anxiety or depression , and score>11 indicating high levels of anxiety or depression .
the scale hads has been translated and was tested for its validity and reliability in greek population by mistakidou al . , the 2004 .
categorical variables are presented by absolute and relative frequencies ( percentages ) , and quantitative variables are presented by median and interquartile range since they do not follow the normal distribution ( tested with kolmogorov- smirnov test ) . to test the existence of association between levels of anxiety / depression and social support
multinomial logistic regression was performed to estimate the effect of social support on the levels of anxiety / depression ( dependent variable ) , adjusted for potential confounders .
the analysis was performed with the statistical package spss , version 20 ( spss inc , chicago , il , usa ) .
the study sample was not representative of hemodialysis patients in greece , but a convenience sample .
also , the study was cross - sectional thus not allowing the causal relation between anxiety / depression and social support .
socio - demographic , clinical and other characteristics of patients are presented in table 1 .
 data presented with median ( iqr ) from table 2 we conclude that patients felt highly supported from their significant others and their family ( median 6 for both subscales ) and less from their friends ( median 4.5 , neutral support levels ) . regarding the levels of anxiety and depression , 32.9% of the patients had high levels of anxiety and 30.2% high levels of depression . on the contrary
, the majority of the patients did not have any anxiety ( 38.4% ) or depression ( 44.2% ) .
descriptive statistics for social support and levels of anxiety / depression of patients undergoing hemodialysis ( n=258 ) table 3 presents the results of the association between social support and levels of anxiety / depression .
there was a statistically significant association between anxiety / depression and social support from significant others , family and friends ( p=<0,001 , for all associations ) .
in particular , patients with high levels of anxiety and depression felt less support from their significant others , family and friends . from table 3
, it further appears that there was no statistically significant difference in support scores between patients with moderate levels of anxiety / depression and those with no anxiety /depression .
association between social support and levels of anxiety / depression of patients undergoing hemodialysis ( n=258 ) .
lastly , multinomial logistic regression was performed to assess the effect of social support on the levels of anxiety and depression , adjusted to various potential confounding factors affecting anxiety and depression . from table 4
we conclude that effect of confounders in the relationship between anxiety and social support we had in the case of support from significant others and family in high levels of anxiety . after adjusting for confounders ,
effect of social support on the levels of anxiety / depression of hemodialysis patients ( n=258 ) . * adjusted regression to the following factors : gender , marital status , educational level , years of problem , relations with nursing - medical staff and patients , and if their lifestyle has been affected .
furthermore , we conclude that after adjusting for confounding factors , statistically significant effect of social support from friends we had on anxiety levels ( p=0,004 ) and more specifically an one point increase in the support from friends , reduces by 57% the chances that patients will have high levels of anxiety in relation to not having at all anxiety . in addition , statistically significant effect of social support from significant others , family and friends we had on depression ( p = < 0,001 , p= 0,001 and p=0,003 , respectively ) .
in particular , an one point increase in support from significant others , family and friends reduces by 77% , 71% and 56% the chances that patients will have high levels of depression .
socio - demographic , clinical and other characteristics of patients are presented in table 1 .
from table 2 we conclude that patients felt highly supported from their significant others and their family ( median 6 for both subscales ) and less from their friends ( median 4.5 , neutral support levels ) . regarding the levels of anxiety and depression , 32.9% of the patients had high levels of anxiety and 30.2% high levels of depression . on the contrary
, the majority of the patients did not have any anxiety ( 38.4% ) or depression ( 44.2% ) .
descriptive statistics for social support and levels of anxiety / depression of patients undergoing hemodialysis ( n=258 )
table 3 presents the results of the association between social support and levels of anxiety / depression .
there was a statistically significant association between anxiety / depression and social support from significant others , family and friends ( p=<0,001 , for all associations ) .
in particular , patients with high levels of anxiety and depression felt less support from their significant others , family and friends . from table 3
, it further appears that there was no statistically significant difference in support scores between patients with moderate levels of anxiety / depression and those with no anxiety /depression .
association between social support and levels of anxiety / depression of patients undergoing hemodialysis ( n=258 ) .
lastly , multinomial logistic regression was performed to assess the effect of social support on the levels of anxiety and depression , adjusted to various potential confounding factors affecting anxiety and depression . from table 4
we conclude that effect of confounders in the relationship between anxiety and social support we had in the case of support from significant others and family in high levels of anxiety . after adjusting for confounders ,
effect of social support on the levels of anxiety / depression of hemodialysis patients ( n=258 ) . * adjusted regression to the following factors : gender , marital status , educational level , years of problem , relations with nursing - medical staff and patients , and if their lifestyle has been affected .
furthermore , we conclude that after adjusting for confounding factors , statistically significant effect of social support from friends we had on anxiety levels ( p=0,004 ) and more specifically an one point increase in the support from friends , reduces by 57% the chances that patients will have high levels of anxiety in relation to not having at all anxiety .
in addition , statistically significant effect of social support from significant others , family and friends we had on depression ( p = < 0,001 , p= 0,001 and p=0,003 , respectively ) .
in particular , an one point increase in support from significant others , family and friends reduces by 77% , 71% and 56% the chances that patients will have high levels of depression .
the results of the present study showed that hemodialysis participants felt highly supported from their significant others and their family and less from their friends .
nowadays , there is a growing interest in the relation between perceived social support and hemodialysis for the reason that this method of kidney replacement may become a barrier to patients social integration ( 17 ) . on the other end of spectrum ,
a supportive environment exerts a positive impact on the clinical outcome probably due to deeper understanding of illness and better self management ( 18 , 19 , 20 ) .
results also showed that 32.9% and 30.2% of participants experienced high levels of anxiety and depression , respectively .
similar results are coming from greece by vasilopoulou et al . , ( 7 ) who showed that 47.8% of hemodialysis patients experienced high levels of anxiety while 38.2% high level of depression .
raymond et al . , ( 8) claimed that up to one - third of patients with chronic kidney disease may experience depression .
taken into serious consideration , the high incidence of this psychiatric co - morbidity in hemodialysis patients , it is imperative to enhance systematic psychiatric evaluation in daily clinical practice .
failure to early diagnosis and treatment of depression in hemodialysis patients is mainly attributed to overlapping symptoms associated with uremia such as anorexia , fatigue and sleep disturbances ( 7 , 21 , 22 , 23 ) . in the present study ,
there are serious gaps in our knowledge why these patients either do not seek for help or there is usually no record for these psychiatric disorders during their treatment .
johnson et al . , ( 23 ) stated that untreated psychiatric illness in hemodialysis patients is associated with mortality , poor quality of life and increased risk of suicide while watnick al . , ( 24 ) demonstrated that only 16% of depressed participants received treatment when starting hemodialysis . in this line of thought , kimmel et al . ,
( 25 ) highlighted the importance of using a globally accepted tool to evaluate depression and anxiety in hemodialysis patients .
hads is a valid instrument widely used to assess anxiety / depression in end - stage renal disease patients ( 20 ) . according to stasiak et al . ,
( 22 ) hemodialysis patients experience high levels of anxiety and depression for reasons which limit their independence such as visits to dialysis center every three days , connection to dialysis machine , diet and fluids restrictions and loss of available time .
it is noteworthy that in the present study 89,2% of participants reported their life being  enough  and  very  depended on the dialysis machine while 43% believed that their life had been  very  affected .
moreover , participants had to spend 3 days per week ( 4 hours in each day ) in dialysis centers .
stasiak et al . , ( 22 ) also stated that among demographic and clinical characteristics , those related with anxiety and depression are age , diabetes and antidepressants or beta - blockers .
the results also revealed that patients with high levels of anxiety and depression felt less support from their significant others , family and friends .
( 26 ) illustrated that persistently high anxiety and depression are associated with reduced perceived social support .
similarly , genz et al . , ( 27 ) demonstrated that depressive symptoms were associated with lack of perceived social support .
vzquez et al . , ( 28 ) supported that trait anxiety was related to emotional disturbance and reduced social relationships .
tezel et al . , ( 29 ) showed that perceived social support from family was negatively correlated with depression .
the same researchers also claimed that patients who experience lack of support usually follow maladaptive ways to express their inner world .
bisschop et al . , ( 30 ) showed that psychosocial support alleviates depressive symptoms .
health professionals should be aware that family behaviors are beneficial on patients illness management ( 31 ) . in the present study ,
62,8% and 30,6% of the participants reported having  very good  and  good  relations with the nursing staff .
this finding is far too promising for health professionals who deeply wish to enhance patients support level .
social support from significant others , family and friends is associated with anxiety / depression .
firstly , it is essential for health professionals to develop intervention strategies to strengthen hemodialysis patients social networks and secondly , to encourage patients to express their feelings and address their psychological needs , thus confronting with the psychological burden of the disease .
 purpose : of this study was to explore the effect of social support on the levels of anxiety and depression of hemodialysis patients.material and methods:258 patients undergoing hemodialysis were enrolled . a questionnaire developed for the purpose of the study 
 was used to collect data through the interview process . apart from socio - demographic , clinical and other characteristics 
 , the questionnaire also included the multidimensional scale of perceived social support ( mspss ) to assess social support from significant others , family and friends , and the questionnaire hospital anxiety and depression scale ( hads ) to assess the levels of anxiety and depression of patients.results:53,9% of the participants were male while 34,1% of the participants were > 70 years old . 32,9% and 30,2% of the participants felt high levels of anxiety and depression , respectively . 
 analysis of data showed a statistically significant association between anxiety / depression and social support from significant others , family and friends ( p=<0,001 for all associations ) . 
 in particular , patients with high levels of anxiety and depression felt less support from their significant others , family and friends . 
 the multinomial logistic regression , showed a statistically significant effect of social support from friends in anxiety levels ( p=0,004 ) . 
 an one point increase of the support from friends seems to reduce by 57% the probability of having high levels of anxiety . in addition , statistically significant effect of social support from significant others , family and friends was observed on the levels of depression ( p=<0,001 , p=0,001 & p=0,003 , respectively ) . 
 specifically , an one point increase of the support from significant others , family and friends it was found to reduce by 77% , 71% and 56% respectively the probability of experiencing high levels of depression.conclusions:phyco-social evaluation is essential when providing holistic care to hemodialysis patients . 
1. INTRODUCTION
2. MATERIALS AND METHODS
3. RESULTS
3.1. Descriptive characteristics
3.2. Social Support and levels of Anxiety/Depression
3.3. Association between Social Support and levels of Anxiety/Depression
3.4. Effect of social support on levels of anxiety/depression
4. DISCUSSION
5. CONCLUSIONS