Depression In Chronic Kidney Disease Research Articles

Urea Level and Depression in Patients with Chronic Kidney Disease.

Depression is common in patients with chronic kidney disease (CKD). Experimental studies suggest the role of urea toxicity in depression. We assessed both the incidence of antidepressant prescriptions and depressive symptoms (measured by CESD (Center for Epidemiologic Depression) scale) in 2505 patients with CKD (Stage 3-4) followed up over 5 years in the Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) cohort. We used a joint model to assess the association between the serum urea level and incident antidepressant prescriptions, and mixed models for the association between the baseline serum urea level and CESD score over the 5-year follow-up. Among the 2505 patients, 2331 were not taking antidepressants at baseline. Of the latter, 87 started taking one during a median follow-up of 4.6 years. After adjustment for confounding factors, the hazard ratio for incident antidepressant prescription associated with the serum urea level (1.28 [95%CI, 0.94,1.73] per 5 mmol/L increment) was not significant. After adjustment, the serum urea level was associated with the mean change in the CESD score (β = 0.26, [95%CI, 0.11,0.41] per 5 mmol/L increment). Depressive symptoms burden was associated with serum urea level unlike depression events. Further studies are needed to draw firm conclusions and better understand the mechanisms of depression in CKD.

Global prevalence of depression in chronic kidney disease: a systematic review and meta-analysis.

Chronic kidney disease (CKD) is commonly associated with psychosocial problems, especially depression, contributing to poor overall outcomes. Depression has not been given adequate priority in the management of CKD patientsdespite its significant adverse impacton all major outcomes. This systematic review and meta-analysis determined the pooled prevalence of clinical depression in the global CKD population and sub-populations. PubMed, African Journals Online (AJOL), and EMBASE were systematically searched to identify published articles with relevant data. The pooled prevalence of clinical depression in the global CKD population was determined using random effects meta-analytic techniques. The study protocol was registered with PROSPERO (CRD42022382708). Sixty-five articles were included in this review, comprising 80,932 individuals with CKD from 27 countries. The participants' mean age ranged from 11.0 to 76.3years. Most (70.4%) of the studies had medium methodological quality. The overall pooled prevalence of depression was 26.5% (95% CI 23.1-30.1%). Studies using the Diagnostic Statistical Manual for Mental Diseases (DSM) and International Classification of Disease (ICD) returned a pooled prevalence of 25.5% and 39.6%, respectively, p = 0.03. There was a significant difference in the pooled prevalence across regions; p = 0.002.The prevalence of depression was higher among individuals on chronic hemodialysis compared to pre-dialysis patients (29.9% versus 18.5%; p = 0.01) and among those on hemodialysis compared to peritoneal dialysis (30.6% versus 20.4%; p = 0.04). There was no significant difference between adults and children (26.8% versus 15.9%, p = 0.21). There was an increasing temporal trend in depression prevalence, though this did not achieve statistical significance (p = 0.16). Depression is common in patients with CKD. The findings of this study highlight the need for clinicians to make efforts to evaluate individuals with CKD for depression, especially those with advanced stages of the disease.

Prevalence, patterns, and impacts of multimorbidity on adverse clinical outcomes in chronic kidney disease: A systematic review

Background: Multimorbidity is the concurrent presence of two or more long-term health conditions in the same individual. It fragments healthcare delivery and affects quality of life. Chronic kidney disease (CKD) often occurs with multimorbidity. The prevalence of CKD is rising; however, there is a lack of evidence on the prevalence, patterns, and impacts of multimorbidity on adverse clinical outcomes in patients with CKD.
 Methods: This was a systematically conducted literature review. A search was conducted in EMBASE, MEDLINE, CINAHL, and SCOPUS (2019-2023). The main search terms were “chronic kidney disease” and “multimorbidity.” The eligibility criteria were observational studies with adult participants with all stages of CKD (CKD stages 1-5, including those on renal replacement therapy). The exposure was multimorbidity quantified by measures. All-cause mortality, kidney disease progression, hospitalisation, and cardiovascular events were outcomes. The Joanna Briggs Institute (JBI) checklist was used for the risk of bias assessment. Due to heterogeneity in design and methods, Jennie Popay’s narrative synthesis was used for data synthesis.
 Results: Of 6879 papers, nine papers met the inclusion criteria. Most studies included participants with all stages of CKD (CKD stage 1-5). The prevalence of multimorbidity ranged from 86.6% to 99.1%. Hypertension was the most prevalent comorbidity. The combination of concordant multimorbidity (hypertension, diabetes, and cardiovascular diseases) was highly prevalent. Multimorbidity was significantly associated with mortality, cardiovascular events, kidney disease progression, and hospitalisation. While older people had more multimorbidity burdens, younger patients with CKD were at a higher risk of death from multimorbidity. Severe CKD with clusters of cardiovascular diseases, diabetes, chronic pain, and depression was significantly associated with all-cause mortality.
 Conclusion: There are associations between multimorbidity and adverse clinical outcomes in patients with CKD. However, there is a lack of data on Black, Asian, and Minority Ethnic participants from low- and middle-income countries. Further research is needed to investigate the high prevalence of chronic pain and depression in chronic kidney disease.

Approaches to the identification and management of depression in people living with chronic kidney disease: A scoping review of 860 papers.

Depression is prevalent across the spectrum of Chronic Kidney Disease and associated with poorer outcomes. There is limited evidence regarding the most effective interventions and care pathways for depression in Chronic Kidney Disease. To investigate how depression is identified and managed in adults with Chronic Kidney Disease. Scoping review. Systematic search of eight databases with pre-defined inclusion criteria. Data relevant to the identification and/or management of depression in adults with Chronic Kidney Disease were extracted. Of 2147 articles identified, 860 were included. Depression was most identified using self-report screening tools (n = 716 studies, 85.3%), with versions of the Beck Depression Inventory (n = 283, 33.7%) being the most common. A total of 123 studies included data on the management of depression, with nonpharmacological interventions being more frequently studied (n = 55, 45%). Cognitive Behavioural Therapy (n = 15) was the most common nonpharmacological intervention, which was found to have a significant effect on depressive symptoms compared to controls (n = 10). However, how such approaches could be implemented as part of routine care was not clear. There was limited evidence for antidepressants use in people with Chronic Kidney Disease albeit in a limited number of studies. Depression is commonly identified using validated screening tools albeit differences exist in reporting practices. Evidence regarding the management of depression is mixed and requires better-quality trials of both pharmacological and nonpharmacological approaches. Understanding which clinical care pathways are used and their evidence, may help facilitate the development of kidney care specific guidelines for the identification and management of depression.

Emotional and cognitive changes in chronic kidney disease

Chronic kidney disease (CKD) leads to cognitive impairment and emotional changes. However, the precise mechanism underlying the crosstalk between the kidneys and the nervous system is not fully understood. Inflammation and cerebrovascular disease can influence the development of depression in CKD. CKD is one of the strongest risk factors for cognitive impairment. Moreover, cognitive impairment occurs in CKD as patients experience the dysregulation of several brain functional domains due to damage caused to multiple cortical regions and to subcortical modulatory neurons. The differences in structural brain changes between CKD and non-CKD dementia may be attributable to the different mechanisms that occur in CKD. The kidney and brain have similar anatomical vascular systems, which may be susceptible to traditional risk factors. Vascular factors are assumed to be involved in the development of cognitive impairment in patients with CKD. Vascular injury induces white matter lesions, silent infarction, and microbleeds. Uremic toxins may also be directly related to cognitive impairment in CKD. Many uremic toxins, such as indoxyl sulfate, are likely to have an impact on the central nervous system. Further studies are required to identify therapeutic targets to prevent changes in the brain in patients with CKD.

Correlation Between Duration of Hemodialysis and Depression in Chronic Kidney Disease

Depression is commonly found in stage 5 CKD patients. However, depression in HD patients is usually neglected, underdiagnosed, and remains untreated. Duration of HD is reported to be significantly correlated with depression. Previously, there were several similar studies with varying results. This study is needed to detect depression and give early intervention to reduce hospitalization rates and patient mortality. This study aims to find the correlation between the duration of hemodialysis and depression in CKD patients. A cross-sectional was carried out on 52 patients with CKD undergoing HD in Dr. Soetomo General Academic Hospital using consecutive sampling. Beck Depression Inventory-II (BDI-II) questionnaire was used to measure the depression score. Data were analyzed with the Pearson correlation test. This study showed a significant negative correlation between the duration of hemodialysis and depression (p =0.005, p > 0,05; r= -0.094). Duration of hemodialysis was significantly correlated with depression. The longer duration of hemodialysis, the lower score of depression. Periodic evaluation of HD patients for depression is needed for early intervention to reduce morbidity.

Anxiety And Depression in Chronic Kidney Disease (CKD) Patients in The Initial Phase of Hemodialysis Therapy

Anxiety and depression are psychological conditions that hemodialysis patients often suffer. Unresolved anxiety can cause depression. The research aims to determine the description of anxiety and depression in chronic renal disease (CKD) patients who undergo hemodialysis (HD) therapy in the initial phase. The study was a quantitative descriptive with a survey approach involving 43 HD patients for less than eight months. The research instrument implemented was the Hospital Anxiety and Depression Scale (HADS) questionnaire. The data were analyzed using descriptive analysis by presenting frequency and category distributions. The results discovered that 29 (62.8%) respondents suffered from anxiety; mild (32.6%), moderate (25.6%), and severe category (4.7%). Furthermore, 16 respondents (37.2%) experience depression; mild (20.9%), moderate (40.0.6%), and severe (2.3%) categories. Anxiety and depression are common symptoms among male and female respondents with direct vascular access, respondents with two times per week HD in the first two months of HD process, adult, pre and elderly and aoccupied respondents. Screenings are carried out routinely to detect anxiety and depression as early as possible and to provide interventions according to the needs of patients through nursing care approaches.

Relationships between illness representations, physical activity and depression in chronic kidney disease.

Chronic Kidney Disease (CKD) is exacerbated by depression and confers significant healthcare costs. Whilst adverse impacts may be mitigated by physical activity, many patients with CKD remain physically inactive, with this physical inactivity potentially influenced by how CKD is appraised. The study aims to explore the relationship between physical activity, depression and illness representations in CKD. Patients with CKD but not requiring dialysis completed the Revised Illness Perception Questionnaire (IPQ-R), Beck Depression Inventory (BDI-II) and Short-Form International Physical Activity Questionnaire (IPAQ-SF). Demographic information was obtained via medical records. Correlation and regression analyses were conducted to determine the relationship of illness representations with levels of physical activity. Moderation and mediation analyses were performed to investigate the role of depression in any relationship between illness representations and physical activity levels. Seventy respondents, 60 % male, with a mean age of 60 ± 16 years, took part in the study. Of illness representation dimensions, personal control was positively associated with levels of physical activity whilst timeline cyclical (a subscale of the IPQ-R relating to patient beliefs about the nature of their illness) was a significant predictor. Severity of depression was neither a moderator nor a mediator of illness representations and levels of physical activity. Facets of illness representations had significant relationships with levels of physical activity. Future research concerning the development and validation of psychological interventions based on an illness representations framework for patients with CKD not requiring dialysis is proposed. The efficacy of such interventions could be then evaluated using a randomised controlled method.

Improved Detection and Evaluation of Depression in Patients with Chronic Kidney Disease: Validity and Reliability of Screening (PHQ-2) and Diagnostic (BDI-FS-Fr) Tests of Depression in Chronic Kidney Disease

Objective: Depression is underdiagnosed and thus undertreated. This study aimed to validate the French version of the PHQ-2 (Patient Health Questionnaire-2) and BDF-FS-Fr (Beck Depression Inventory-Fast Screen-France) on patients with chronic kidney disease (CKD) living in France. Method: A cross-sectional study was conducted on 109 patients of the Centre universitaire de maladies rénales, Centre Hospi­talier Universitaire (CHU) de Caen (37 patients with CKD on pre-dialysis and grafting stage, 36 grafted patients, and 36 dialyzed patients). Statistical Approach: Test parameters and statistical aspects of assessing diagnostic and screening tests were used, including knowledge of and ability to calculate, sensitivity, specificity, positive and negative predictive values, diagnostic odds ratios, and the use of ROC (receiver operating characteristic) curves. Results: PHQ-2 and BDI-FS-Fr statistical parameters for depression tested very positively and had a satisfactory AUC (area under the curve). The PHQ-2 had a satisfactory AUC > 0.70, sensitivity > 0.60, and specificity > 0.80. The BDI-FS-Fr had a satisfactory area under the curve (0.859) with sensitivity (83%) and specificity (0.859); and internal consistency (α = 0.668). The PHQ-2 and BDI-FS-Fr showed good internal and external validity of structure, construct validity, criterion validity, discriminant validity, internal consistency, and factorial validity. Conclusion: The French versions of the PHQ-2 and BDI-FS have highly favorable psychometric properties. These instruments are valid self-assessment tools for screening and evaluating depression, its intensity, and its evolution. The PHQ-2 and BDI-FS-Fr thus have very good psychometric properties and are useful tools for researchers and practitioners. Regarding clinical practice in the hospital, clinicians and nurses can use the PHQ-2 to screen quickly for depression during routine consultations, during hospitalization, and in dialysis centers. The 7 items of the BDI-FS-Fr enable us to assess the depressive state, thereby avoiding a false diagnosis of depression among CKD patients in a clinical setting.

Depressive symptoms in chronic kidney disease: A comparison between patients on dialysis versus conservative treatment

BackgroundPrevalence of depression in chronic kidney disease (CKD) is higher than in the general population and predicts a higher mortality risk. The aim of this study is to investigate the occurrence of depressive symptoms among individuals with CKD in conservative treatment and renal replacement therapy (hemodialysis). MethodsThis is a cross-sectional study conducted at three health centers specialized in CKD care, in Fortaleza-Ceara-Brazil, between June and October 2015. Patients with confirmed diagnosis of CKD were included, in hemodialysis and conservative treatment, older than 18 years. We have applied forms about socio-demographic questionnaire, including questions regarding mental health and the Beck depression inventory. ResultsA total of 147 patients were interviewed, with mean age of 54±16 years, and 61% were males. Regarding treatment, 65.3% were in hemodialysis and 34.6% in conservative treatment. Previous diagnosis of mental disturbance was reported by 12.9% of patients; 29 (19.7%) had follow-up with Psychologist or Psychiatrist; 61 (41.4%) demonstrated interest in having specialized treatment. According to Beck inventory score, 47 (31.9%) patients presented depressive symptoms, being 22 (14.9%) mild, 14 (9.5%) moderate and 7 (4.7%) severe symptoms. Among patients in hemodialysis, 30 (31.2%) had depressive symptoms, while among patients in conservative treatment, the frequency of depressive symptoms was 25.5% (p=0.2). ConclusionsThere were a significant number of patients with CKD with depressive symptoms, both in conservative treatment and hemodialysis, with no significant difference between these two groups. Further studies are necessary to evaluate the repercussion of depression in clinical outcome, as well as the impact of preventive and treatment measures.

Depression Among Dialysis Patients

Identification and treatment of depression in chronic kidney disease (CKD) is important, since it can impair recovery, treatment, self-management, and quality of life. One hundred and twenty-one people undergoing hemodialysis in a tertiary care center in southern India were included in this study to assess depression in this population. Depression was evaluated using the Beck Depression Inventory (BDI). Among the patients, 33 (27.3%) were suffering from mild depression, 49 (40.5%) were suffering from moderate depression, and 19 (15.7%) had severe depression. Lower educational status [OR 3.77 (95% CI 1.34-10.63)], longer duration of dialysis [OR 5.75 (95% CI 1.79-18.44)], and hospitalization for indications other than dialysis in the last year [OR 3.88 (95% CI 1.34-11.27)] were associated with higher depression scores. It is important that all patients on routine hemodialysis be screened for signs and symptoms of depression, and this study contributes an international perspective to this important psychosocial determinant of patient outcomes.

Treatment of depression in chronic kidney disease (CKD) patients on dialysis

Treatment of depression in chronic kidney disease (CKD) patients on dialysis

Depressive emotions investigation and analysis for stage 1-4 chronic kidney disease

Objective To explore current situation of depressive symptoms and analyze its influencing factors in stage 1-4 chronic kidney disease (CKD) patients. Methods From August 2014 to September 2014, a cross-sectional study was performed, and 214 outpatients chronic kidney disease (CKD) were recruited by convenience sampling method to evaluate depressive scores using the Zung self-rating depression scale in a grade A class three hospital of Sichuan province. Using single factor analysis method, a preliminary study was performed to explore the influencing factors of depression symptoms including gender, residence, education and the family income per capita. Results A total of 214 CKD depression scores was (47.98±10.38), which was significantly more than that of norm (t=20.472, P<0.01). Single factor analysis showed gender, residence, education and the family income per capita all influenced the depressive incidences (χ2=14.929, 5.413, 7.290, 9.917; P<0.05). Multiple stepwise regression analysis showed gender, residence, education and the family income per capita all were depression influencing factors (P<0.05). Conclusions Medical and health institutions should give great importance to depressive symptoms in CKD patients, especially for stage 1-4 CKD patients. Focus on assessment and early intervention can reduce the incidences of the depression and improve the prognosis. Key words: Chronic kidney disease; Depression; Investigation; Influencing factors

Depression and chronic kidney disease: A review for clinicians

To review the recent academic literature surrounding the prevalence, aetiopathology, associations and management of depression in chronic kidney disease (CKD), in order to provide a practical and up-to-date resource for clinicians. We conducted electronic searches of the following databases: MEDLINE, EMBASE and PsycINFO. The main search terms were: depression, mood disorders, depressive disorder, mental illness, in combination with kidney disease, renal insufficiency, dialysis, kidney failure. Separate searches were conducted regarding antidepressant use in CKD. A number of recent, large and well-conducted studies have confirmed markedly raised rates of depression amongst those with CKD, with meta-analysis suggesting the prevalence of interview-defined depression to be approximately 20%. The interactions between depression and CKD are complex, bidirectional and multifactorial. Depression in CKD has been shown to be associated with multiple poor outcomes, including increased mortality and hospitalisation rates, as well as poorer treatment compliance and quality of life. Clinical evaluation of depression in patients with CKD can be challenging; however, once a diagnosis is made, a range of treatment modalities can be considered. Depression is common in CKD and is associated with a significant risk of adverse outcomes. Given the importance of this issue, there is now an urgent need for well-conducted randomised trials of interventions for depression in CKD in order to provide information on the safety and efficacy of treatments.

Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies

Prevalence estimates of depression in chronic kidney disease (CKD) vary widely in existing studies. We conducted a systematic review and meta-analysis of observational studies to summarize the point prevalence of depressive symptoms in adults with CKD. We searched MEDLINE and Embase (through January 2012). Random-effects meta-analysis was used to estimate the prevalence of depressive symptoms. We also limited the analyses to studies using clinical interview and prespecified criteria for diagnosis. We included 249 populations (55,982 participants). Estimated prevalence of depression varied by stage of CKD and the tools used for diagnosis. Prevalence of interview-based depression in CKD stage 5D was 22.8% (confidence interval (CI), 18.6-27.6), but estimates were somewhat less precise for CKD stages 1-5 (21.4% (CI, 11.1-37.2)) and for kidney transplant recipients (25.7% (12.8-44.9)). Using self- or clinician-administered rating scales, the prevalence of depressive symptoms for CKD stage 5D was higher (39.3% (CI, 36.8-42.0)) relative to CKD stages 1-5 (26.5% (CI, 18.5-36.5)) and transplant recipients (26.6% (CI, 20.9-33.1)) and suggested that self-report scales may overestimate the presence of depression, particularly in the dialysis setting. Thus, interview-defined depression affects approximately one-quarter of adults with CKD. Given the potential prevalence of depression in the setting of CKD, randomized trials to evaluate effects of interventions for depression on patient-centered outcomes are needed.

Depression in Chronic Kidney Disease and Hemodialysis Patients

Depression is the most common psychiatric condition in Chronic Kidney Disease (CKD), but there are few studies that analyzed this condition in patients in different phases of disease. This article aims to evaluated depression in CKD patients, comparing patients in different phases of disease. Methods: We evaluated 134 patients with CKD submitted to conservative ambulatory treatment, and 36 patients with end-stage renal disease undergoing hemodialysis (HD). To evaluate depression, we used the Beck Depression Inventory (BDI), and the Beck Depression Inventory—SF (BDI-SF), a subscale that allows evaluate only the cognitive aspects of depression. Functional capacity was evaluated using the Karnofsky Performance Scale, and clinical and sociodemographic variables were also investigated. Results: Using BDI, depression was identified in 37.3% of patients in conservative treatment and in 41.6% in HD patients (p > 0.05). This percentage reduced when the BDI-SF was used, to 11.1% in conservative CKD patients and 13.8% in HD patients (p > 0.05). Depression was associated with marital status, professional activity, income, comorbidities and functional capacity. Discussion: We observed high prevalence of depression in patients with CKD undergoing conservative or hemodialysis treatment. Depression was associated with some clinical and sociodemografic variables and with functional capacity.

Depressive mood in pre-dialytic chronic kidney disease: Statistical parametric mapping analysis of Tc-99m ECD brain SPECT

The purpose of this study was to investigate depression-related regions in pre-dialytic patients with chronic kidney disease (CKD) patients. Participants comprised 33 patients with stage 4 and 5 CKD (age, 55 [42–63]) and 32 healthy volunteers (age, 53.5 [49.5–57]). Depressed mood was assessed in the patients, and both groups underwent Tc-99m-labeled ethylcysteinate dimer (Tc-99m ECD) single photon emission computed tomograpy (SPECT). Statistical parametric mapping identified 18 areas of hypoperfusion in the patients in comparison with the normal controls. The largest clusters were areas including left precentral gyrus, right superior and middle temporal gyrus, both cerebellar posterior lobes, both inferior frontal gyrus, right superior and middle frontal gyrus, right cuneus, right inferior parietal lobule, and right putamen. However, there were no specific hypoperfusion areas in CKD patients with depression compared with CKD patients without depression. Interestingly, several hypoperfusion areas in CKD patients (inferior frontal gyrus [BA46], superior temporal gyrus [BA42], anterior cingulate gyrus [BA24]) were concordant with hypoperfusion areas found in patients with major depression who were free of kidney disease. In conclusion, this study did not demonstrate specific depression-related cerebral hypoperfusion areas. However, the cerebral blood flow pattern in CKD patients was similar to that of patients with major depression in some areas. Although further investigations are needed in the future, we suggest that the causes of the higher prevalence of depression in CKD might be associated with this finding.

Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients

End-stage renal disease (ESRD) is a growing public health concern and non-adherence to treatment has been associated with poorer health outcomes in this population. Depression, likely to be the most common psychopathology in such patients, is associated with increased morbidity and mortality. We compared psychological measures and self-reported medication adherence of 94 kidney transplant recipients to those of 65 patients receiving hemodialysis in a major medical center in Brooklyn, New York. Compared to the transplant group, the hemodialysis cohort was significantly more depressed as determined by the Beck Depression Inventory score. They also had a significantly lower adherence to medication as reported on the Medication Therapy Adherence Scale. Using hierarchical multiple regression analysis, the variance in depression was the only statistically significant predictor of medication adherence beyond gender and mode of treatment, accounting for an additional 12% of the variance. Our study strongly suggests that a depressive affect is an important contributor to low medication adherence in patients with ESRD on hemodialysis or kidney transplant recipients.

Depression in Chronic Kidney Disease

Depression is the most frequent psychiatric problem in patients with chronic renal disease and may predict patient outcome and mortality. Depression is linked to stressful life characterized by many losses and by dependence, which even may lead to suicide. Despite the large number of patients with chronic kidney disease and the economic burden they represent, only a few of these patients receive adequate diagnosis and therapy. Diagnostic and Statistical Manual of Mental Disorders-IV criteria for major depression may help in differentiating symptoms of uremia and depression. Pharmacotherapy is available and antidepressants (tricyclic antidepressants and selective serotonin re-uptake inhibitors) have been used successfully in various studies. Finally, there is a need for further well-designed, longitudinal, survival studies to clarify the relationship better between depression and the different stages of renal dysfunction.

Health Locus of Control and Depression in Chronic Kidney Disease: A Dynamic Perspective

Participants in the present study were 207 patients with chronic kidney disease (CKD) who completed internal HLOC and depression measures at baseline and at an approximately 16-month follow-up period. Regression results indicated that after controlling for baseline level of depression, baseline internal HLOC was not a significant predictor of depression at follow-up. However, increases in internal HLOC over the 16-month follow-up were predictive of depression at follow-up. Furthermore, this relationship was qualified by an interaction between change in internal HLOC and disease progression. These results suggest that changes in internal HLOC over time may be a particularly important determinant of adjustment for individuals whose chronic illness progresses or becomes life threatening.