Role of Melatonin as an Adjunctive Treatment for Depression and Cognitive Impairment in Hemodialysis Patients: A Randomized, Double-Blind Clinical Trial
Abstract
Objective: Chronic kidney disease (CKD) is a pervasive health issue associated with various complications, including cognitive impairment and depression among patients undergoing hemodialysis. This study aimed to assess the impact of melatonin on depression and cognitive function in hemodialysis patients.
Method: A randomized, double-blinded, placebo-controlled clinical trial was conducted in 50 hemodialysis patients, with half of the patients receiving 3 mg daily melatonin and the other half receiving a placebo for two months. Depression and cognitive function were evaluated using the Beck Depression Inventory (BDI) and Mini-Mental State Examination (MMSE) questionnaire, respectively. Quantitative variables were analyzed using a t-test. The Chi-square test also evaluated qualitative variables. Quantitative data were analyzed by covariance analysis before and after the intervention.
Results: Hypertension was the most prevalent underlying condition among study participants, affecting 40% of the intervention group. The intervention group exhibited baseline depressive symptoms (mean BDI score: 16.12 ± 7.12), which significantly improved post-intervention (13.6 ± 6.6). Notably, both the intervention and control groups demonstrated significant reductions in depressive symptoms, as assessed by paired t-tests (P = 0.033 and P = 0.02, respectively). Cognitive function, as measured by the MMSE, improved in both groups (1.28 ± 0.81 for melatonin, 1.52 ± 0.1 for placebo), with significant within-group differences (P = 0.048 and P = 0.002, respectively). ANCOVA analysis revealed no significant between-group differences in BDI scores (F(1,47) = 0.196, P = 0.66, partial eta-squared = 0.004). and in MMSE scores (F(1,47) = 0.003, P = 0.954, partial eta-squared = 0.00) post-intervention.
Conclusion: While this study did not demonstrate significant effects of melatonin on depression and cognitive impairment in hemodialysis patients, positive changes were observed, warranting further research to optimize treatment regimens and explore the potential therapeutic benefits of melatonin in this patient population.
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2. Oh SW, Yang JH, Kim MG, Cho WY, Jo SK. Renal hyperfiltration as a risk factor for chronic kidney disease: A health checkup cohort study. PLoS One. 2020;15(9):e0238177.
3. Wahyudi YI, Fitriana LA, Ningrum TP, Natasya N. Hemodialysis Therapy Compliance in Chronic Kidney Disease Patients. Indonesian Journal of Community Development.3(1):24-36.
4. Shanmukham B, Varman M, Subbarayan S, Sakthivadivel V, Kaliappan A, Gaur A, et al. Depression in Patients on Hemodialysis: A Dilapidated Facet. Cureus. 2022;14(9):e29077.
5. Fan L, Sarnak MJ, Tighiouart H, Drew DA, Kantor AL, Lou KV, et al. Depression and all-cause mortality in hemodialysis patients. Am J Nephrol. 2014;40(1):12-8.
6. Zammit AR, Katz MJ, Bitzer M, Lipton RB. Cognitive Impairment and Dementia in Older Adults With Chronic Kidney Disease: A Review. Alzheimer Dis Assoc Disord. 2016;30(4):357-66.
7. Hobson P, Kumwenda M, Shrikanth S, Nair H, Wong S. Risk and incidence of cognitive impairment in patients with chronic kidney disease and diabetes: the results from a longitudinal study in a community cohort of patients and an age and gender-matched control cohort in North Wales, UK. BMJ open. 2022;12(3):e053008.
8. Alkubati SA, Al-Sayaghi KM, Salameh B, Halboup AM, Ahmed WAM, M JA, et al. Prevalence of Depression and Its Associated Factors Among Hemodialysis Patients in Hodeida City, Yemen. J Multidiscip Healthc. 2024;17:689-99.
9. Raduan NJN, Ali NF, Amalia E, Salleh MR. Factors contributing to depression and cognitive impairment among patients on Hemodialysis. Journal of ASIAN Behavioural Studies. 2021;6(19):27-44.
10. Pearson O, Uglik-Marucha N, Miskowiak KW, Cairney SA, Rosenzweig I, Young AH, et al. The relationship between sleep disturbance and cognitive impairment in mood disorders: A systematic review. J Affect Disord. 2023;327:207-16.
11. Crowe K, Quinn TJ, Mark PB, Findlay MD. "Is It Removed During Dialysis?"-Cognitive Dysfunction in Advanced Kidney Failure-A Review Article. Front Neurol. 2021;12:787370.
12. Kvetnoy I, Ivanov D, Mironova E, Evsyukova I, Nasyrov R, Kvetnaia T, et al. Melatonin as the Cornerstone of Neuroimmunoendocrinology. Int J Mol Sci. 2022;23(3):1835.
13. Tonon AC, Pilz LK, Markus RP, Hidalgo MP, Elisabetsky E. Melatonin and Depression: A Translational Perspective From Animal Models to Clinical Studies. Front Psychiatry. 2021;12:638981.
14. Feybesse C, Chokron S, Tordjman S. Melatonin in Neurodevelopmental Disorders: A Critical Literature Review. Antioxidants (Basel). 2023;12(11):2017.
15. Liu J, Clough SJ, Dubocovich ML. Role of the MT(1) and MT(2) melatonin receptors in mediating depressive- and anxiety-like behaviors in C3H/HeN mice. Genes Brain Behav. 2017;16(5):546-53.
16. Favero G, Franceschetti L, Bonomini F, Rodella LF, Rezzani R. Melatonin as an Anti-Inflammatory Agent Modulating Inflammasome Activation. Int J Endocrinol. 2017;2017:1835195.
17. Zhu D, Ma Y, Ding S, Jiang H, Fang J. Effects of Melatonin on Intestinal Microbiota and Oxidative Stress in Colitis Mice. Biomed Res Int. 2018;2018:2607679.
18. Zisapel N. New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation. Br J Pharmacol. 2018;175(16):3190-9.
19. Mirsepassi Z, Saedi S, Behpournia H, Shadloo B, Artounian V, Yahyavi ST, et al. Comparing Effects of Melatonin versus Trazodone on Sleep Quality in Major Depressed Patients Receiving Sertraline. Journal of Pharmaceutical Care. 2016:52-7.
20. Mohammadi MR, Mostafavi SA, Keshavarz SA, Eshraghian MR, Hosseinzadeh P, Hosseinzadeh-Attar MJ, et al. Melatonin effects in methylphenidate treated children with attention deficit hyperactivity disorder: a randomized double blind clinical trial. Iran J Psychiatry. 2012;7(2):87.
21. Mostafavi SA, Solhi M, Mohammadi MR, Akhondzadeh S. Melatonin for Reducing Weight Gain Following Administration of Atypical Antipsychotic Olanzapine for Adolescents with Bipolar Disorder: A Randomized, Double-Blind, Placebo-Controlled Trial. J Child Adolesc Psychopharmacol. 2017;27(5):440-4.
22. Hautzinger M, Keller F, Kühner C. Beck depressions-inventar (BDI-II): Harcourt Test Services; 2006.
23. Pereira AA, Weiner DE, Scott T, Sarnak MJ. Cognitive function in dialysis patients. Am J Kidney Dis. 2005;45(3):448-62.
24. Seyedian M, Fallah M, Noroozian M, Najat S, Delaware A, Ghasemzadeh H. Preparing and determining the reliability of the Persian version of the short test of mental status. Scientific Journal of the Medical Organization of the Republic of Islamic Iran. 2007;25(4):4.
25. Agganis BT, Weiner DE, Giang LM, Scott T, Tighiouart H, Griffith JL, et al. Depression and cognitive function in maintenance hemodialysis patients. Am J Kidney Dis. 2010;56(4):704-12.
27. Pépin M, Ferreira AC, Arici M, Bachman M, Barbieri M, Bumblyte IA, et al. Cognitive disorders in patients with chronic kidney disease: specificities of clinical assessment. Nephrol Dial Transplant. 2021;37(Suppl 2):ii23-ii32.
28. Collister D, Rodrigues JC, Mazzetti A, Salisbury K, Morosin L, Rabbat C, et al. Single Questions for the Screening of Anxiety and Depression in Hemodialysis. Can J Kidney Health Dis. 2019;6:2054358118825441.
29. Shahrokh S, Qobadighadikolaei R, Abbasinazari M, Haghazali M, Asadzadeh Aghdaei H, Abdi S, et al. Efficacy and Safety of Melatonin as an Adjunctive Therapy on Clinical, Biochemical, and Quality of Life in Patients with Ulcerative Colitis. Iran J Pharm Res. 2021;20(2):197-205.
30. Dávalos A, Alvarez-Sabín J, Castillo J, Díez-Tejedor E, Ferro J, Martínez-Vila E, et al. Citicoline in the treatment of acute ischaemic stroke: an international, randomised, multicentre, placebo-controlled study (ICTUS trial). Lancet. 2012;380(9839):349-57.
31. Najafi A, Keihani S, Bagheri N, Ghanbari Jolfaei A, Mazaheri Meybodi A. Association Between Anxiety and Depression With Dialysis Adequacy in Patients on Maintenance Hemodialysis. Iran J Psychiatry Behav Sci. 2016;10(2):e4962.
32. Ahmad HS, Leghari NU, Hussain W, Kareem O, Akram B, Asghar R. Assessment of sociodemographic determinants of depression among patients on hemodialysis. The Professional Medical Journal. 2020;27(04):836-41.
33. Ahmad HS, Leghari NU, Hussain W, Kareem O, Akram B, Asghar R. Assessment of sociodemographic determinants of depression among patients on hemodialysis. The Professional Medical Journal. 2020;27(04):836-41.
34. Vermani A, Marwale AV, Gokani NS. Psychiatric morbidity in end-stage renal disease patients’ on dialysis. MGM Journal of Medical Sciences. 2020;7(1):26-30.
35. Esposito S, Laino D, D'Alonzo R, Mencarelli A, Di Genova L, Fattorusso A, et al. Pediatric sleep disturbances and treatment with melatonin. J Transl Med. 2019;17(1):77.
36. De Crescenzo F, Lennox A, Gibson JC, Cordey JH, Stockton S, Cowen PJ, et al. Melatonin as a treatment for mood disorders: a systematic review. Acta Psychiatr Scand. 2017;136(6):549-58.
37. Ostadmohammadi V, Soleimani A, Bahmani F, Aghadavod E, Ramezani R, Reiter RJ, et al. The Effects of Melatonin Supplementation on Parameters of Mental Health, Glycemic Control, Markers of Cardiometabolic Risk, and Oxidative Stress in Diabetic Hemodialysis Patients: A Randomized, Double-Blind, Placebo-Controlled Trial. J Ren Nutr. 2020;30(3):242-50.
38. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al. National Sleep Foundation's sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-3.
39. Masters A, Pandi-Perumal SR, Seixas A, Girardin JL, McFarlane SI. Melatonin, the Hormone of Darkness: From Sleep Promotion to Ebola Treatment. Brain Disord Ther. 2014;4(1).
40. Opie LH, Lecour S. Melatonin has multiorgan effects. Eur Heart J Cardiovasc Pharmacother. 2016;2(4):258-65.
41. Ashour AM. The Effect of Melatonin Supplement on High Arterial Blood Pressure: An Overview from Clinicaltrials.gov. J Multidiscip Healthc. 2024;17:517-20.
42. Czuczejko J, Sielski Ł, Woźniak B, Woźniak A, Szewczyk-Golec K. Melatonin supplementation improves oxidative and inflammatory state in the blood of professional athletes during the preparatory period for competitions. Free Radic Res. 2019;53(2):198-209.
43. Sun X, Wang M, Wang Y, Lian B, Sun H, Wang G, et al. Melatonin produces a rapid onset and prolonged efficacy in reducing depression-like behaviors in adult rats exposed to chronic unpredictable mild stress. Neurosci Lett. 2017;642:129-35.
44. Carretero VJ, Ramos E, Segura-Chama P, Hernández A, Baraibar AM, Álvarez-Merz I, et al. Non-Excitatory Amino Acids, Melatonin, and Free Radicals: Examining the Role in Stroke and Aging. Antioxidants (Basel). 2023;12(10):1844.
45. Ikram M, Park HY, Ali T, Kim MO. Melatonin as a Potential Regulator of Oxidative Stress, and Neuroinflammation: Mechanisms and Implications for the Management of Brain Injury-Induced Neurodegeneration. J Inflamm Res. 2021;14:6251-64.
46. Mostafavi A, Solhi M, Mohammadi MR, Hamedi M, Keshavarzi M, Akhondzadeh S. Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Med Iran. 2014;52(10):734-9.
47. Xu X, Liu X, Ma S, Xu Y, Xu Y, Guo X, et al. Association of Melatonin Production with Seasonal Changes, Low Temperature, and Immuno-Responses in Hamsters. Molecules. 2018;23(3):703.
48. Markowska M, Niemczyk S, Romejko K. Melatonin Treatment in Kidney Diseases. Cells. 2023;12(6):838.
2. Oh SW, Yang JH, Kim MG, Cho WY, Jo SK. Renal hyperfiltration as a risk factor for chronic kidney disease: A health checkup cohort study. PLoS One. 2020;15(9):e0238177.
3. Wahyudi YI, Fitriana LA, Ningrum TP, Natasya N. Hemodialysis Therapy Compliance in Chronic Kidney Disease Patients. Indonesian Journal of Community Development.3(1):24-36.
4. Shanmukham B, Varman M, Subbarayan S, Sakthivadivel V, Kaliappan A, Gaur A, et al. Depression in Patients on Hemodialysis: A Dilapidated Facet. Cureus. 2022;14(9):e29077.
5. Fan L, Sarnak MJ, Tighiouart H, Drew DA, Kantor AL, Lou KV, et al. Depression and all-cause mortality in hemodialysis patients. Am J Nephrol. 2014;40(1):12-8.
6. Zammit AR, Katz MJ, Bitzer M, Lipton RB. Cognitive Impairment and Dementia in Older Adults With Chronic Kidney Disease: A Review. Alzheimer Dis Assoc Disord. 2016;30(4):357-66.
7. Hobson P, Kumwenda M, Shrikanth S, Nair H, Wong S. Risk and incidence of cognitive impairment in patients with chronic kidney disease and diabetes: the results from a longitudinal study in a community cohort of patients and an age and gender-matched control cohort in North Wales, UK. BMJ open. 2022;12(3):e053008.
8. Alkubati SA, Al-Sayaghi KM, Salameh B, Halboup AM, Ahmed WAM, M JA, et al. Prevalence of Depression and Its Associated Factors Among Hemodialysis Patients in Hodeida City, Yemen. J Multidiscip Healthc. 2024;17:689-99.
9. Raduan NJN, Ali NF, Amalia E, Salleh MR. Factors contributing to depression and cognitive impairment among patients on Hemodialysis. Journal of ASIAN Behavioural Studies. 2021;6(19):27-44.
10. Pearson O, Uglik-Marucha N, Miskowiak KW, Cairney SA, Rosenzweig I, Young AH, et al. The relationship between sleep disturbance and cognitive impairment in mood disorders: A systematic review. J Affect Disord. 2023;327:207-16.
11. Crowe K, Quinn TJ, Mark PB, Findlay MD. "Is It Removed During Dialysis?"-Cognitive Dysfunction in Advanced Kidney Failure-A Review Article. Front Neurol. 2021;12:787370.
12. Kvetnoy I, Ivanov D, Mironova E, Evsyukova I, Nasyrov R, Kvetnaia T, et al. Melatonin as the Cornerstone of Neuroimmunoendocrinology. Int J Mol Sci. 2022;23(3):1835.
13. Tonon AC, Pilz LK, Markus RP, Hidalgo MP, Elisabetsky E. Melatonin and Depression: A Translational Perspective From Animal Models to Clinical Studies. Front Psychiatry. 2021;12:638981.
14. Feybesse C, Chokron S, Tordjman S. Melatonin in Neurodevelopmental Disorders: A Critical Literature Review. Antioxidants (Basel). 2023;12(11):2017.
15. Liu J, Clough SJ, Dubocovich ML. Role of the MT(1) and MT(2) melatonin receptors in mediating depressive- and anxiety-like behaviors in C3H/HeN mice. Genes Brain Behav. 2017;16(5):546-53.
16. Favero G, Franceschetti L, Bonomini F, Rodella LF, Rezzani R. Melatonin as an Anti-Inflammatory Agent Modulating Inflammasome Activation. Int J Endocrinol. 2017;2017:1835195.
17. Zhu D, Ma Y, Ding S, Jiang H, Fang J. Effects of Melatonin on Intestinal Microbiota and Oxidative Stress in Colitis Mice. Biomed Res Int. 2018;2018:2607679.
18. Zisapel N. New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation. Br J Pharmacol. 2018;175(16):3190-9.
19. Mirsepassi Z, Saedi S, Behpournia H, Shadloo B, Artounian V, Yahyavi ST, et al. Comparing Effects of Melatonin versus Trazodone on Sleep Quality in Major Depressed Patients Receiving Sertraline. Journal of Pharmaceutical Care. 2016:52-7.
20. Mohammadi MR, Mostafavi SA, Keshavarz SA, Eshraghian MR, Hosseinzadeh P, Hosseinzadeh-Attar MJ, et al. Melatonin effects in methylphenidate treated children with attention deficit hyperactivity disorder: a randomized double blind clinical trial. Iran J Psychiatry. 2012;7(2):87.
21. Mostafavi SA, Solhi M, Mohammadi MR, Akhondzadeh S. Melatonin for Reducing Weight Gain Following Administration of Atypical Antipsychotic Olanzapine for Adolescents with Bipolar Disorder: A Randomized, Double-Blind, Placebo-Controlled Trial. J Child Adolesc Psychopharmacol. 2017;27(5):440-4.
22. Hautzinger M, Keller F, Kühner C. Beck depressions-inventar (BDI-II): Harcourt Test Services; 2006.
23. Pereira AA, Weiner DE, Scott T, Sarnak MJ. Cognitive function in dialysis patients. Am J Kidney Dis. 2005;45(3):448-62.
24. Seyedian M, Fallah M, Noroozian M, Najat S, Delaware A, Ghasemzadeh H. Preparing and determining the reliability of the Persian version of the short test of mental status. Scientific Journal of the Medical Organization of the Republic of Islamic Iran. 2007;25(4):4.
25. Agganis BT, Weiner DE, Giang LM, Scott T, Tighiouart H, Griffith JL, et al. Depression and cognitive function in maintenance hemodialysis patients. Am J Kidney Dis. 2010;56(4):704-12.
27. Pépin M, Ferreira AC, Arici M, Bachman M, Barbieri M, Bumblyte IA, et al. Cognitive disorders in patients with chronic kidney disease: specificities of clinical assessment. Nephrol Dial Transplant. 2021;37(Suppl 2):ii23-ii32.
28. Collister D, Rodrigues JC, Mazzetti A, Salisbury K, Morosin L, Rabbat C, et al. Single Questions for the Screening of Anxiety and Depression in Hemodialysis. Can J Kidney Health Dis. 2019;6:2054358118825441.
29. Shahrokh S, Qobadighadikolaei R, Abbasinazari M, Haghazali M, Asadzadeh Aghdaei H, Abdi S, et al. Efficacy and Safety of Melatonin as an Adjunctive Therapy on Clinical, Biochemical, and Quality of Life in Patients with Ulcerative Colitis. Iran J Pharm Res. 2021;20(2):197-205.
30. Dávalos A, Alvarez-Sabín J, Castillo J, Díez-Tejedor E, Ferro J, Martínez-Vila E, et al. Citicoline in the treatment of acute ischaemic stroke: an international, randomised, multicentre, placebo-controlled study (ICTUS trial). Lancet. 2012;380(9839):349-57.
31. Najafi A, Keihani S, Bagheri N, Ghanbari Jolfaei A, Mazaheri Meybodi A. Association Between Anxiety and Depression With Dialysis Adequacy in Patients on Maintenance Hemodialysis. Iran J Psychiatry Behav Sci. 2016;10(2):e4962.
32. Ahmad HS, Leghari NU, Hussain W, Kareem O, Akram B, Asghar R. Assessment of sociodemographic determinants of depression among patients on hemodialysis. The Professional Medical Journal. 2020;27(04):836-41.
33. Ahmad HS, Leghari NU, Hussain W, Kareem O, Akram B, Asghar R. Assessment of sociodemographic determinants of depression among patients on hemodialysis. The Professional Medical Journal. 2020;27(04):836-41.
34. Vermani A, Marwale AV, Gokani NS. Psychiatric morbidity in end-stage renal disease patients’ on dialysis. MGM Journal of Medical Sciences. 2020;7(1):26-30.
35. Esposito S, Laino D, D'Alonzo R, Mencarelli A, Di Genova L, Fattorusso A, et al. Pediatric sleep disturbances and treatment with melatonin. J Transl Med. 2019;17(1):77.
36. De Crescenzo F, Lennox A, Gibson JC, Cordey JH, Stockton S, Cowen PJ, et al. Melatonin as a treatment for mood disorders: a systematic review. Acta Psychiatr Scand. 2017;136(6):549-58.
37. Ostadmohammadi V, Soleimani A, Bahmani F, Aghadavod E, Ramezani R, Reiter RJ, et al. The Effects of Melatonin Supplementation on Parameters of Mental Health, Glycemic Control, Markers of Cardiometabolic Risk, and Oxidative Stress in Diabetic Hemodialysis Patients: A Randomized, Double-Blind, Placebo-Controlled Trial. J Ren Nutr. 2020;30(3):242-50.
38. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al. National Sleep Foundation's sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-3.
39. Masters A, Pandi-Perumal SR, Seixas A, Girardin JL, McFarlane SI. Melatonin, the Hormone of Darkness: From Sleep Promotion to Ebola Treatment. Brain Disord Ther. 2014;4(1).
40. Opie LH, Lecour S. Melatonin has multiorgan effects. Eur Heart J Cardiovasc Pharmacother. 2016;2(4):258-65.
41. Ashour AM. The Effect of Melatonin Supplement on High Arterial Blood Pressure: An Overview from Clinicaltrials.gov. J Multidiscip Healthc. 2024;17:517-20.
42. Czuczejko J, Sielski Ł, Woźniak B, Woźniak A, Szewczyk-Golec K. Melatonin supplementation improves oxidative and inflammatory state in the blood of professional athletes during the preparatory period for competitions. Free Radic Res. 2019;53(2):198-209.
43. Sun X, Wang M, Wang Y, Lian B, Sun H, Wang G, et al. Melatonin produces a rapid onset and prolonged efficacy in reducing depression-like behaviors in adult rats exposed to chronic unpredictable mild stress. Neurosci Lett. 2017;642:129-35.
44. Carretero VJ, Ramos E, Segura-Chama P, Hernández A, Baraibar AM, Álvarez-Merz I, et al. Non-Excitatory Amino Acids, Melatonin, and Free Radicals: Examining the Role in Stroke and Aging. Antioxidants (Basel). 2023;12(10):1844.
45. Ikram M, Park HY, Ali T, Kim MO. Melatonin as a Potential Regulator of Oxidative Stress, and Neuroinflammation: Mechanisms and Implications for the Management of Brain Injury-Induced Neurodegeneration. J Inflamm Res. 2021;14:6251-64.
46. Mostafavi A, Solhi M, Mohammadi MR, Hamedi M, Keshavarzi M, Akhondzadeh S. Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Med Iran. 2014;52(10):734-9.
47. Xu X, Liu X, Ma S, Xu Y, Xu Y, Guo X, et al. Association of Melatonin Production with Seasonal Changes, Low Temperature, and Immuno-Responses in Hamsters. Molecules. 2018;23(3):703.
48. Markowska M, Niemczyk S, Romejko K. Melatonin Treatment in Kidney Diseases. Cells. 2023;12(6):838.
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| Issue | Vol 20 No 1 (2025) | |
| Section | Original Article(s) | |
| Keywords | ||
| Chronic Kidney Disease Cognitive Dysfunction Depression Hemodialysis Melatonin Randomized Controlled Trial | ||
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How to Cite
1.
Hatamkhani S, Roshan S, Shiva A. Role of Melatonin as an Adjunctive Treatment for Depression and Cognitive Impairment in Hemodialysis Patients: A Randomized, Double-Blind Clinical Trial. Iran J Psychiatry. 2024;20(1):37-45.
