Anxiety and depression are not infrequent in children with chronic illnesses. Chronic kidney disease might be life-disturbing, with hospital visits, challenging therapy procedures, complications, and other unexpected circumstances. Therefore, not only anxiety and depression but other psychological problems should be investigated in this patient population. Also, social and digital media have both negative and positive impacts on adolescents. So, we aimed to determine which psychological problems affect adolescents with CKD and the ways they cope with these problems regarding behavioral or social/digital media platform preferences.

Anxiety is a common problem in adolescents with CKD. A study conducted with 8 to 12-year-old children under routine hemodialysis therapy reported higher anxiety than the control group [17]. Similarly, Elorza et al. [18] reported high anxiety levels in adolescents with CKD. By contrast, Stahl et al. [19] suggested that anxiety scores were lower in children with CKD than in healthy ones. However, a meta-analysis reported anxiety symptoms at 31% and 42% ratios for children with CKD and children on hemodialysis therapy, respectively [20]. In contrast, a study performed by the Child Depression Inventory evaluated separation anxiety in children with CKD and found higher scores than in healthy children, but general anxiety was not statistically different between the groups [13]. In our study, separation anxiety, general anxiety, and total anxiety scores were statistically higher in adolescents with CKD than in the control group; but similarly, the elevated general anxiety rates were not different between the two groups. Another aspect of our study was that we found general anxiety scores higher in girls and at younger ages. Gender is known as a prominent factor in anxiety disorders [21], and a study reported that anxiety is more frequent in girls [22], where our results were concordant with this finding in comparison of the CKD group with the control group (separation and total anxiety) and within the CKD group (general anxiety). According to these results, we think that separation and total anxiety should be evaluated in these patient groups, especially in girls.

Another possible mood disorder seen among patients with CKD is depression [4]. Among patients with CKD, about 30% with anxiety symptoms have depression, which might be a result of sharing the same symptomatology [21, 23]. Ten percent of all children in the world have a psychiatric disorder; however, most of these patients have no psychiatric support or treatment [24]. A literature review revealed a study which reported that depressive symptoms were higher in children with CKD than healthy controls [13]. Other studies suggested that depression was more frequent in the CKD group [18, 19]. Depression rates were too high, up to 65% and 67% (mild, moderate, and severe) in children who need routine hemodialysis and peritoneal dialysis groups, respectively [25]. However, a study reported lower depression rates of 17% in children with CKD and young adults and 5% had elevated depressive symptoms [4]. In our study group, the depression scales (depression and total depression) were elevated in about 35%, comparable with the literature. We picked up patients who were not under and had never received psychiatric support, which might be the cause of the high rates, but we think depression remains a prominent concern in clinical practice.

Our results suggest that age and gender also might affect depression rates. As we investigated age and depression association in the literature, a study reported that depressive symptoms were higher in adolescents [26]. The gender of the child is also an influential factor regarding depression, as girls are affected more than boys [21]. In our study, the total depression rate was higher in girls in the whole study group, but we did not find a significant effect of gender regarding depression scales (depression and total depression) within the patient group diagnosed with CKD. However, depression rates decreased with age in our study. According to these data, age seems to be an influential factor in depression, but girls do not seem to be an under-risk subgroup within the patient group diagnosed with CKD.

As we focus on social functioning and panic dysfunctions, Berney-Martinet et al. reported a 15% rate of social competence issues in patients with CKD, higher than in healthy peers [12]. We found that younger ages and emotionally reactive children (crying in tears/yelling) had increased social phobia scores among CKD patients in our study group; however, there was no difference as defined by elevated results between the groups. Another study investigated panic disorder and found it to not alter significantly from healthy children [13], similar to our results. However, panic disorder was more frequent in adolescents with CKD compared with the control group. Family issues and young age increased the vulnerability among the patients with CKD in our study. A study reported that panic disorder has an association with separation anxiety [27]. As our separation anxiety results were higher in the CKD group, we concluded that this might affect the high panic disorder rates. These results suggest that adolescents with CKD do not present social phobia problems but exhibit high panic disorder rates. The under-risk sub-group for panic disorder was a young age, but the attention-grabbing entity was that the adolescents with higher panic disorder results reported that they had family issues.

There are limited studies about obsession, another mood dysfunction, in children with CKD. Yousefichaijan et al. [28] reported that obsessive–compulsive disorder rates were significantly higher in the CKD group than in healthy controls. In our study, girls and younger adolescents had higher scores on the obsession scale, and family issues/problems increased this more. So, it may be concluded that family issues increase mental health problems in adolescents with CKD.

As we assessed the background of the reactions against issues, we found data that emotional reactions were coping mechanisms affected by anxiety or depression, where bad emotion regulation might occur because of elevated anxiety or depression symptoms in children with CKD [21, 29]. If the children think that a situation is not under control, this might result in increased stress, which causes anxiety and depression [21]. Among the patient groups with CKD in our study, crying-in-tears/yelling children had more separation anxiety scores. In this aspect, adolescents diagnosed with CKD with crying in tears/yelling response against a problem shall undergo psychiatric evaluation for anxiety.

Another aspect of the mental health of patients with CKD is the family role, as the support of parents has an influential role in mental health [29]. Panic disorder, obsession, depression, total anxiety, and total depression scores were higher in the children with CKD encountering family issues than friendship issues and educational success in our study group. Children focus on messaging to share their problems and seek support they cannot get from their families. We concluded that adolescents diagnosed with CKD with family issues/problems, especially those who need communication and aid from others that they cannot obtain from their families, have more risk for mental health issues and should undergo psychiatric evaluation.

Peer support is also an influential factor in the mental health of patients with CKD, and relationships with friends decrease in patients on routine hemodialysis, and focusing on self-esteem might increase life quality and decrease anxiety and depression [29, 30]. Social media preferring children had significantly lower anxiety and depression scores (separation anxiety, total anxiety, depression, and total depression) than those who preferred messaging and video applications. Although there are studies about social media causing depression, it may serve as an opportunity for adolescents with CKD to form friendships by creating enhanced opportunities for communication with people with similar adverse conditions [7, 9]. We think this condition affected decreased anxiety and depression scores in our study group.

The last aspect we should mention is that social media might serve as an opportunity for setting friendships. However, younger kids should be appropriately monitored by their parents, and social media use should be limited to a time that does not interfere with adolescents’ sleep or physical activity [31].