**4. Anxiety**

Anxiety is another frequent and overlooked psychiatric disorder in patients undergoing hemodialysis. Less clinical attention has been given to anxiety in hemodialysis compared with depression [39]. It is defined as anticipation of a potential danger or threat [83]. Anxiety is an emotional condition characterized by excessive nervousness, fear, worry, and tension [84]. It may also cause physiological manifestations such as sweating and an increase in heart rate and blood pressure. According to American Psychiatric Association, there are different types of anxiety disorder, which include generalized anxiety, panic disorder, phobia, agoraphobia, social anxiety disorder, and separation anxiety disorder (**Table 2**), [84]. When anxiety exceeds what would be predicted given a usual response to a certain incident, its severity and duration are considered disorders. Most anxiety disorders have a minimum 6-month duration, and the severity is considered excessive compared with the real level of threat [83]. Studies have found that anxiety is often associated with depression [80, 85]. Thus, other psychiatric disorders (e.g., depression and post-traumatic stress disorder) may display anxiety as a diagnostic sign [83].


**Table 2.** *Types of anxiety disorder.*

### **4.1 Screening and diagnostic measures**

There are limited studies reporting the prevalence of anxiety and its associated factors among patients undergoing hemodialysis. Anxiety prevalence ranges from 25.9–50% [20, 80, 85–87]. The discrepancy in range is probably due to variations in the applied methodology for screening for anxiety and the diversity of patient populations. Some studies rely on a general measure designed for symptom assessment that includes anxiety as one component, such as the Dialysis Symptom Index and the Chronic Kidney Disease Symptom Burden Index [88, 89]. Others use specific measures for anxiety assessment, such as HADS, the Beck Anxiety Inventory, and the Primary Care Evaluation of Mental Disorders (PRIME-MD). The BAI contains 21 items based on a 4-point Likert scale that examine the severity of anxiety [90]. Each question is scored between 0 (not at all) and 3 (severely it bothered me a lot). A high score suggests an increased level of anxiety symptoms. Low anxiety is indicated by a score between 0 and 21. A score range of 22–35 indicates moderate anxiety, while a score of 36 or above indicates a severe anxiety level [90]. The BAI is a valid and reliable measure. The psychometric analysis showed a high level of internal consistency, and the discrimination validity of the scale was demonstrated when it differentiated between those who were anxious and those who were not anxious but had other psychiatric issues, such as depression [90]. Numerous studies used the BAI to assess anxiety levels among patients undergoing hemodialysis [91–94]. Nadort et al. compared the diagnostic accuracy of BAI and HADS and concluded that both scales were valid for anxiety screening in hemodialysis but that HADS is more useful in routine dialysis care [95]. Regarding the PRIME-MD, it is one of the primary screening tools for mental health. It consists of two parts. The first part is a one-page questionnaire (PQ ) that should be filled out by the patient, and the second part is a 12-page clinician evaluation guide that should be completed by clinicians using a structured interview form [96]. The PRIME-MD-PQ is a self-administered tool that contains 26 questions based on yes/no choices regarding the existence of symptoms related to mood, anxiety, somatoform, eating disorders, and alcohol abuse [96]. Some studies use the PRIME-MD to assess anxiety in hemodialysis [97, 98].

A semistructured clinical interview was also used for anxiety diagnosis. The prevalence of moderate-to-high levels of anxiety is reported at 35.9%, with 17.1% reporting a high level of anxiety [80]. A prior study that surveyed 395 hemodialysis patients in Greece using HADS found that 47.8% of patients suffer from anxiety [20]. Similarly, a study conducted in Saudi Arabia using the same instrument found that the prevalence of anxiety was 50% [85].

On a dialysis unit, there are numerous factors that could stimulus anxiety; for instance, cannulation in hemodialysis, dialysis machine alarms, lack of control over treatment, and feeling dependent [99, 100]. Anxiety has a significant negative effect on the quality of life of hemodialysis patients [85, 93, 101]. It is correlated with negative clinical results, for example, increased hospitalization frequency and length of stay and high mortality rates [93]. Sometimes, it can influence the ability to focus and the way to process information. This may cause some disruptive behaviors that contradict healthcare professionals [83].

## **4.2 Management of anxiety in hemodialysis**

Treatment options for anxiety are similar to those for depression and include both nonpharmacological and pharmacological treatments. The nonpharmacological interventions include psychotherapy and cognitive behavioral therapy. Furthermore, using relaxation techniques is a useful method to reduce anxiety in hemodialysis patients [80]. Prior research found the effectiveness of Benson relaxation training in reducing the level of anxiety among eighty patients on hemodialysis [102]. A recent systematic review that examined the benefit of Benson relaxation training in managing anxiety on hemodialysis found that Benson relaxation was an effective method of management [103]. A randomized controlled trial that was implemented to examine the effectiveness of acupressure therapy in patients receiving hemodialysis also found a significant reduction in anxiety levels [104]. Apart from these methods, the social support derived from family, clinicians, and the community can improve psychological status and alleviate anxiety [80].

If those methods were unsuccessful, different types of medications could be used. Short-acting benzodiazepines (e.g., lorazepam or alprazolam) are recommended for limited periods at low doses. From this class, lbrium (chlordiazepoxide) and valium (diazepam) should be avoided in patients undergoing hemodialysis [16]. In a severely anxious patient, antipsychotic medications (e.g., haloperidol) may be clinically feasible [16]. However, there is still window for future studies to explore the best management options for anxiety in hemodialysis.
