End-stage kidney disease (ESKD) is a chronic condition associated with substantial physical, psychological and social burden. Patients receiving maintenance haemodialysis (HD) experience prolonged dependence on a life-sustaining treatment, frequent dialysis sessions, dietary and fluid restrictions, polypharmacy and limitations in daily activities. These factors can adversely affect emotional well-being and quality of life (QoL). Depression, anxiety and stress are increasingly recognised among patients undergoing maintenance HD and may contribute substantially to the overall burden of illness. [1-3] Psychological distress in patients undergoing HD is multifactorial and may arise from the chronic nature of ESKD, dependence on dialysis, uncertainty regarding prognosis, financial difficulties, altered social roles and persistent physical symptoms. Depression, anxiety and stress may occur concurrently and can influence coping, treatment adherence and perceived health status. A systematic review by García-Llana et al. highlighted the important role of these psychological factors in determining health-related QoL among patients undergoing dialysis. [4] Recent evidence has further demonstrated the coexistence of depression, anxiety and stress symptoms with impaired health-related QoL among patients receiving haemodialysis. [2] Sleep disturbance represents another important component of the clinical burden in patients receiving maintenance HD. Uraemic symptoms, physical discomfort, dialysis-related factors and psychological distress may contribute to poor sleep quality. Psychological symptoms and sleep disturbance may also have a bidirectional relationship, with depression and anxiety adversely affecting sleep while persistent sleep problems may further impair emotional well-being. Al Naamani et al. reported the coexistence of fatigue, anxiety, depression and poor sleep quality among patients undergoing haemodialysis. [5] Similarly, recent studies have demonstrated relationships between sleep quality, depressive symptoms and other psychological factors in patients receiving maintenance HD. [1,6] Quality of life is a multidimensional outcome encompassing physical, psychological, social and environmental well-being. Studies using the WHOQOL-BREF have demonstrated that patients undergoing haemodialysis experience impairment across different QoL domains, highlighting the importance of assessing QoL beyond traditional clinical and biochemical parameters. [7,8] Sleep quality has also been associated with QoL among patients with ESKD, suggesting that sleep disturbance may represent an important, potentially modifiable contributor to overall well-being. [9,10] Evidence from South Asian populations similarly indicates the coexistence of sleep-related problems, psychological concerns and impaired QoL among patients with chronic kidney disease. [3] Despite the substantial burden of these problems, psychological distress may remain under-recognised in routine dialysis care, where clinical attention is often focused on physical and biochemical parameters. Simultaneous assessment of depression, anxiety and stress, sleep quality and QoL may therefore provide a more comprehensive understanding of the patient's overall disease burden. The present study was undertaken to assess depression, anxiety and stress among patients with ESKD receiving maintenance HD using the Depression, Anxiety and Stress Scale-21 (DASS-21), and to evaluate their correlation with sleep quality and QoL.

Study Design and Study Population This hospital-based cross-sectional study was conducted among 50 patients with end-stage kidney disease (ESKD) receiving maintenance haemodialysis (HD) at a tertiary care hospital in Rajasthan a period of 12 months. Adult patients undergoing maintenance HD who were willing to participate and provide informed consent were included in the study. Patients with severe cognitive impairment, altered sensorium, or an inability to understand and complete the study questionnaires were excluded. Patients who declined participation were also excluded. Sociodemographic and relevant clinical information was collected using a structured proforma. The study was initiated after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants before data collection. Confidentiality of the collected information was maintained throughout the study. Assessment of Psychological Distress, Sleep Quality and Quality of Life Psychological distress was assessed using the Depression, Anxiety and Stress Scale-21 (DASS-21), a 21-item self-report instrument comprising three subscales: depression, anxiety and stress, with seven items in each subscale. Each item is scored on a four-point scale from 0 to 3 according to the severity or frequency of symptoms experienced during the preceding week. The scores for each subscale were summed and multiplied by two to obtain scores comparable with the full 42-item version of the scale. The resulting scores were classified into standard severity categories for depression, anxiety and stress. DASS-21 measures the severity of psychological symptoms and does not independently establish a formal psychiatric diagnosis. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), which evaluates sleep-related difficulties over the preceding month. The questionnaire generates a global score, with higher scores indicating poorer sleep quality. A global PSQI score greater than 5 was considered indicative of poor sleep quality. Quality of life was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire. This instrument assesses four domains: physical health, psychological health, social relationships and environment. Higher domain scores indicate better quality of life. Overall quality of life and general health were assessed using the relevant WHOQOL-BREF items, where available in the study dataset. The relationship of psychological distress with sleep quality and quality-of-life measures was subsequently evaluated. Statistical Analysis Data were entered into Microsoft Excel and analysed using IBM SPSS Statistics, version 25.0. Continuous variables were summarised as mean and standard deviation or median and interquartile range, depending on the distribution of the data. Categorical variables were presented as frequencies and percentages. The distribution of continuous variables was assessed before selecting appropriate statistical tests. Spearman's rank correlation coefficient was used to assess the relationships of depression, anxiety and stress scores with the global PSQI score and WHOQOL-BREF quality-of-life measures. Correlations with individual quality-of-life domains were also examined. Appropriate tests, including the Chi-square test or Fisher's exact test, were used for comparisons involving categorical variables, wherever applicable. All statistical tests were two-sided, and a p-value of less than 0.05 was considered statistically significant.

A total of 50 patients receiving maintenance haemodialysis were included in the analysis. The mean age of the study participants was 51.54±12.93 years (range, 19–71 years). There were 31 (62.0%) males and 19 (38.0%) females. Most participants were married (44, 88.0%) and resided in urban areas (33, 66.0%). Sixteen (32.0%) participants were graduates, while 10 (20.0%) had secondary education and 10 (20.0%) had postgraduate education. Thirty-one (62.0%) patients underwent haemodialysis twice weekly, while 16 (32.0%) underwent dialysis three times weekly. Arteriovenous fistula was the predominant dialysis access, present in 45 (90.0%) participants, whereas five (10.0%) had a temporary catheter. The mean dialysis adequacy was 1.26±0.06. Psychological Distress Among Study Participants The mean depression score was 14.08±10.67, the mean anxiety score was 9.60±7.24 and the mean stress score was 12.40±9.16. Based on the recorded DASS-21 severity categories, 24 (48.0%) participants had normal depression scores, while 26 (52.0%) had some degree of depressive symptoms. Anxiety symptoms of varying severity were recorded in 30 (60.0%) participants, whereas 19 (38.0%) had mild to extremely severe stress symptoms. Table 1. DASS-21 scores and severity categories among study participants (n=50) DASS-21 parameter Depression Anxiety Stress Mean score ± SD 14.08±10.67 9.60±7.24 12.40±9.16 Normal, n (%) 24 (48.0) 20 (40.0) 31 (62.0) Mild, n (%) 3 (6.0) 5 (10.0) 6 (12.0) Moderate, n (%) 10 (20.0) 11 (22.0) 8 (16.0) Severe, n (%) 4 (8.0) 9 (18.0) 4 (8.0) Extremely severe, n (%) 9 (18.0) 5 (10.0) 1 (2.0) Sleep Quality and Quality of Life The mean global Pittsburgh Sleep Quality Index (PSQI) score was 6.68±4.25, with a median of 5.5. Poor sleep quality, defined as a global PSQI score greater than 5, was observed in 25 (50.0%) participants. The mean sleep efficiency was 85.23±16.98%. The mean WHOQOL-BREF domain scores were 52.26±13.83 for physical health, 52.30±14.46 for psychological health, 65.00±20.82 for social relationships and 60.08±13.54 for environment. The social relationships domain had the highest mean score, whereas the physical and psychological domains had comparatively lower mean scores. Correlation of Psychological Distress with Sleep Quality and Quality of Life Spearman's rank correlation analysis demonstrated a statistically significant positive correlation between depression and global PSQI scores (ρ=0.424, p=0.002), anxiety and global PSQI scores (ρ=0.434, p=0.002), and stress and global PSQI scores (ρ=0.504, p<0.001). Thus, higher psychological distress scores were associated with poorer sleep quality. Depression scores showed significant negative correlations with all four quality-of-life domains: physical health (ρ=−0.431, p=0.002), psychological health (ρ=−0.298, p=0.038), social relationships (ρ=−0.464, p<0.001) and environment (ρ=−0.492, p<0.001). Anxiety scores were significantly negatively correlated with social relationships (ρ=−0.311, p=0.028) and environmental QoL (ρ=−0.287, p=0.046), but not with physical or psychological QoL. Stress scores were significantly negatively correlated with physical health (ρ=−0.444, p=0.001), social relationships (ρ=−0.397, p=0.004) and environmental QoL (ρ=−0.374, p=0.008). The correlation between stress and psychological QoL was not statistically significant (p=0.132). Table 4. Correlation of DASS-21 scores with sleep quality and quality-of-life domains Outcome Depression score ρ (p-value) Anxiety score ρ (p-value) Stress score ρ (p-value) Global PSQI 0.424 (0.002) 0.434 (0.002) 0.504 (<0.001) Physical health QoL −0.431 (0.002) −0.246 (0.088) −0.444 (0.001) Psychological health QoL −0.298 (0.038) −0.106 (0.467) −0.218 (0.132) Social relationships QoL −0.464 (<0.001) −0.311 (0.028) −0.397 (0.004) Environmental QoL −0.492 (<0.001) −0.287 (0.046) −0.374 (0.008) ρ: Spearman's rank correlation coefficient; PSQI: Pittsburgh Sleep Quality Index; QoL: quality of life. P-values are two-sided.

The present study assessed depression, anxiety and stress among patients with end-stage kidney disease (ESKD) receiving maintenance haemodialysis (HD) and examined their relationships with sleep quality and quality of life (QoL). The findings demonstrate a considerable burden of psychological symptoms, with 52.0% of participants reporting depressive symptoms, 60.0% reporting anxiety symptoms and 38.0% reporting stress symptoms of varying severity. Poor sleep quality was observed in 50.0% of participants. Importantly, higher depression, anxiety and stress scores were significantly associated with poorer sleep quality, while several psychological distress scores showed significant negative correlations with the physical, social and environmental domains of QoL. These findings highlight the interrelationship between psychological well-being, sleep and perceived QoL in patients undergoing maintenance HD. Psychological Distress Among Patients Receiving Haemodialysis In the present study, depressive symptoms were observed in just over half of the participants, while anxiety symptoms were reported by three-fifths of the study population. Stress symptoms were less frequent but remained an important concern. These findings are consistent with the broader literature indicating that psychological distress is common among patients receiving maintenance HD. The systematic review by García-Llana et al. emphasised the relevance of depression, anxiety and stress to treatment adherence and health-related QoL in dialysis patients [4]. Similarly, Luca et al. reported a substantial burden of depression, anxiety and stress symptoms among patients undergoing HD, reinforcing the importance of assessing these dimensions together rather than considering depression in isolation [2]. Differences in the reported frequency of psychological symptoms across studies may reflect variations in patient characteristics, clinical settings, assessment instruments, scoring procedures and thresholds used to classify symptom severity. In addition, the psychological burden of ESKD may be influenced by dependence on regular dialysis, restrictions on daily activities, financial pressures, uncertainty regarding prognosis and reduced participation in social and occupational roles. The present findings support incorporating structured psychological assessment into routine dialysis care. However, the DASS-21 identifies the severity of self-reported symptoms and does not independently establish psychiatric diagnoses; patients with substantial symptoms may require further clinical evaluation. Relationship Between Psychological Distress and Sleep Quality One of the principal findings of this study was the significant positive correlation between all three DASS-21 domains and global PSQI scores. Depression showed a correlation coefficient of 0.424, anxiety 0.434 and stress 0.504, with all associations reaching statistical significance. As higher PSQI scores indicate poorer sleep quality, these findings suggest that increasing psychological distress was associated with greater sleep-related difficulties. The strongest observed association was between stress and sleep quality. These results are consistent with Du et al., who specifically examined the relationship between anxiety, depression and sleep quality among patients with ESKD undergoing maintenance HD [1]. Al Naamani et al. also described the coexistence of fatigue, anxiety, depression and sleep disturbances in haemodialysis patients [5]. More recently, Tan et al. investigated the relationship between sleep quality, fatigue and depressive symptoms in maintenance HD patients, further highlighting the close association between sleep-related and psychological symptoms in this population [6]. Several factors may contribute to these associations. Physical discomfort, nocturnal symptoms, dialysis-related fatigue and disturbances in daily routines may interfere with sleep. Concurrently, persistent worry, low mood and stress may make it more difficult to initiate or maintain sleep. Poor sleep may, in turn, contribute to fatigue, reduced coping ability and worsening emotional well-being. Although the present cross-sectional study cannot establish the direction of these relationships, the findings suggest that sleep quality and psychological distress should be assessed together during the care of patients undergoing HD. Relationship Between Psychological Distress and Quality of Life The present study also identified significant negative correlations between depression scores and all four WHOQOL-BREF domains. The correlations were observed for physical health (ρ=−0.431), psychological health (ρ=−0.298), social relationships (ρ=−0.464) and environment (ρ=−0.492). This indicates that higher depressive symptom scores were associated with lower perceived QoL across several aspects of daily life, with the strongest association observed in the environmental domain, followed closely by social relationships. The positive correlations observed between depression, anxiety and stress scores and PSQI scores suggest that greater psychological distress was associated with poorer sleep quality in the present study. The strongest association was observed for stress (r=0.504), followed by anxiety (r=0.434\)) and depression (r=0.424). These findings are consistent with research by Wang et al. [11], which examined anxiety and sleep quality among patients receiving maintenance haemodialysis. Similarly, a study using DASS-21 and PSQI among haemodialysis patients reported positive correlations between poor sleep quality and depression, anxiety and stress [12]. These findings support the value of assessing sleep and psychological symptoms together in patients receiving maintenance haemodialysis. However, the cross-sectional design of the present study does not establish whether psychological distress contributes to sleep disturbance or whether poor sleep exacerbates psychological symptoms. Previous research using the WHOQOL-BREF has demonstrated the multidimensional nature of QoL among patients receiving haemodialysis [7,8]. The systematic review by García-Llana et al. also highlighted the contribution of psychological factors to health-related QoL in dialysis patients [4]. Luca et al. similarly examined psychological symptoms alongside health-related QoL in an HD population [2]. The present study adds to this evidence by examining the relationships between three separate psychological symptom domains, sleep quality and the four WHOQOL-BREF domains within the same sample. The relatively strong negative associations between depressive symptoms and social and environmental QoL may reflect the broader impact of emotional distress on interpersonal engagement, perceived support, financial circumstances and satisfaction with the surrounding environment. Nevertheless, these interpretations remain possible explanations rather than mechanisms directly tested in the present study. The correlations also do not establish that psychological symptoms caused lower QoL; poorer perceived QoL may itself contribute to psychological distress. Relationship Between Psychological Distress and Quality of Life In the present study, depressive symptoms were significantly associated with lower scores across all four WHOQOL-BREF domains. Stress was negatively correlated with physical, social and environmental quality-of-life scores, while anxiety showed significant negative correlations with social and environmental domains. These findings indicate that the relationship between psychological distress and quality of life may vary according to the psychological dimension and quality-of-life domain assessed. A 2024 cross-sectional study from Chennai assessed health-related quality of life among patients receiving haemodialysis and provides relevant Indian evidence for interpreting the quality-of-life burden in this population [13]. The results of the present study reinforce the importance of considering psychological well-being alongside physical and social functioning when assessing quality of life in patients with end-stage kidney disease. In the present study, poor sleep quality was significantly associated with all three psychological distress domains. These findings suggest that sleep assessment may help identify patients experiencing a broader burden of psychological symptoms. However, because this study did not examine the effect of sleep-directed or psychological interventions, it cannot determine whether improving sleep would lead to a corresponding improvement in psychological well-being or QoL. Clinical Implications The findings have practical implications for routine haemodialysis services. Monitoring biochemical parameters and dialysis adequacy remains essential, but these measures do not fully capture the psychological and functional burden experienced by patients. Brief, structured assessments of depression, anxiety, stress, sleep quality and QoL may help clinicians identify patients who could benefit from further assessment, counselling, psychosocial support or referral to appropriate mental health services. The observed correlations also support a multidimensional approach to patient care. Patients reporting poor sleep may warrant assessment for coexisting psychological symptoms, while those with substantial depressive, anxiety or stress symptoms may benefit from evaluation of sleep-related difficulties and perceived QoL. Such screening should complement, rather than replace, individual clinical assessment and appropriate referral. Limitations The cross-sectional design does not establish causal relationships or determine whether psychological distress precedes sleep disturbance and reduced QoL. DASS-21, PSQI and WHOQOL-BREF are questionnaire-based instruments, and their scores may be influenced by individual perceptions and reporting. DASS-21 symptom categories should not be interpreted as confirmed psychiatric diagnoses. Finally, multiple correlations were examined, and the possibility of chance findings should be considered when interpreting individual p-values

The present study demonstrated a considerable burden of psychological distress among patients with end-stage kidney disease receiving maintenance haemodialysis, with anxiety being the most frequently reported symptom, followed by depression and stress. Half of the participants had poor sleep quality. Psychological distress was significantly associated with poorer sleep quality, while depressive symptoms showed significant negative correlations with all four WHOQOL-BREF domains. Stress was associated with lower physical, social and environmental quality-of-life scores, whereas anxiety was significantly associated with lower social and environmental scores. These findings highlight the importance of integrating routine assessment of psychological well-being, sleep quality and health-related quality of life into the comprehensive care of patients undergoing haemodialysis. Larger longitudinal studies are warranted to confirm these associations and evaluate whether targeted psychological and sleep interventions improve patient-reported outcomes

1. Du Z, Chu T, Dai F, Mao H, Zhao J. Correlation analysis of anxiety, depression, and sleep quality in end-stage renal disease patients undergoing maintenance hemodialysis. Medicine (Baltimore). 2025;104(42):e44433. 2. Luca AL, Militaru F, Văduva CM, Dinu IR, Maria DT, Mușat MI, Rădulescu VM, Udriștoiu I, Moța E. Depression, Anxiety, Stress Symptoms and Health-Related Quality of Life in Hemodialysis Patients: Cross-Sectional Findings from a Romanian Cohort. Medicina (Kaunas). 2026;62(2):242. 3. Jayasingha UC, Kumarage SW, Niroshani KSR, et al. Quality of life, sleep quality, and psychological wellbeing of patients with chronic kidney disease in Sabaragamuwa Province, Sri Lanka: a descriptive cross-sectional study. Sci Rep. 2026;16:14620. 4. García-Llana H, Remor E, Del Peso G, Selgas R. The role of depression, anxiety, stress and adherence to treatment in dialysis patients' health-related quality of life: a systematic review of the literature. Nefrologia. 2014;34(5):637-57. 5. Al Naamani Z, Gormley K, Noble H, Santin O, Al Maqbali M. Fatigue, anxiety, depression and sleep quality in patients undergoing haemodialysis. BMC Nephrol. 2021;22(1):157. 6. Tan H, Ma X, Zhang H, Zhang Y, Li L. The relationship between sleep quality, fatigue, and depressive symptoms in maintenance hemodialysis patients: a cross-lagged analysis. BMC Nephrol. 2026;27:139. 7. Sathvik BS, Parthasarathi G, Narahari MG, Gurudev KC. An assessment of the quality of life in hemodialysis patients using the WHOQOL-BREF questionnaire. Indian J Nephrol. 2008;18(4):141-9. 8. Joshi U, Subedi R, Poudel P, Ghimire PR, Panta S, Sigdel MR. Assessment of quality of life in patients undergoing hemodialysis using WHOQOL-BREF questionnaire: a multicenter study. Int J Nephrol Renovasc Dis. 2017;10:195-203. 9. Yoshida N, Tanaka T, Suzuki Y, Takahashi S, Hitaka M, Ishii S, et al. Sleep Quality and Its Association with Quality of Life and Mortality in Hemodialysis Patients. J Clin Med. 2025;14:8729. 10. Tawale S, Khan N, Shinde R, Thote M, Joshi A. An Observational Analysis of Sleep and Quality of Life in Patients with End-Stage Renal Disease. Indian J Pharm Pract. 2026;19(2):304-10. doi:10.5530/ijopp.20260551. 11. Wang G, Yi X, Fan H, Cheng H. Anxiety and sleep quality in patients receiving maintenance hemodialysis: multiple mediating roles of hope and family function. Sci Rep. 2024;14:15073. doi:10.1038/s41598-024-65901-9. 12. Tanriverdi Ö, Soylu A. The moderating role of life satisfaction and searching for meaning in life in the relationship between sleep quality and stress, anxiety, and depression in patients undergoing hemodialysis treatment. BMC Psychol. 2026;14:913. doi:10.1186/s40359-026-04777-y. 13. Rajendran KP, Anbazhagan R, Ramalingam S, Rajamohan S, et al. A cross-sectional study to assess the health-related quality of life of patients on haemodialysis in Chennai. Egypt J Intern Med. 2024;36:89. doi:10.1186/s43162-024-00356-y.