Managing Depression in Dialysis Patients

Last year, the Centers for Medicare & Medicaid Services (CMS) began to require semiannual depression screenings. Several questions were raised among my nephrologist colleagues. How important are depression screenings and are they necessary? Are they our responsibility? What can we do about it? Do we have adequate tools to deal with depression?

In the recent years, health care has shifted toward patient-centered care and experience. For example, in 2013, Allen R. Nissenson, MD, created the DaVita Patient-Centered Quality Pyramid (in collaboration with clinical thought leaders, industry associations, CMS and patients) as a strategic framework to address end stage renal disease (ESRD) complexities—with a focus on patient quality of life. In addition, physician reimbursement is shifting to focus on quality of care, with patient experience and improved health outcomes as the goal. Integrated health care provides the pathway in this transition. The integration of care cannot be achieved without a comprehensive approach to patients’ mental and physical health, the first of which has been ignored most in the past.

Two decades ago, when the use of the Kidney Disease Quality of Life (KDQOL) survey became more prevalent, it was noted that patients on dialysis have higher scores on emotional components than controls—which indicates these patients experience more emotional difficulty. It was also noted that patients with more emotional problems have poorer outcomes and higher mortality.

Depression is the most common psychological problem in patients undergoing dialysis. It is twice more common in patients on hemodialysis than in patients on continuous ambulatory peritoneal dialysis (CAPD)—and among patients on CAPD, those with peritonitis experience higher levels of anxiety and depression. The prevalence of depression among patients with ESRD, depending on the instrument used and the severity of depression, has been estimated to be between 21 to 40 percent.

It is not surprising that the incidence and prevalence of depression is higher in the first year after initiation of dialysis. In this first year, most patients have uremic symptoms, such as anorexia, fatigue and sleep disturbances, and they also deal with a great shift in their lifestyle and the flow of their daily activities. Both the uremic symptoms and dialysis stress should improve in the first six months.

Anxiety and depression have been observed to impact quality of life, adherence, cognition, morbidity and mortality. The risk of hospitalization is higher with depression. Although increased mortality due to depression has been noted in observational studies, and although it clearly impacts behavior and adherence, longitudinal studies have failed to prove a causal relationship. Depression may cause decline in patient’s health status but this effect could be bidirectional and it would be difficult to prove the cause and effect relationship.

Detection and diagnoses of depression requires teamwork and a multidisciplinary approach. There are several instruments for depression screening. The following tools are validated and more commonly used:

• Beck Depression Inventory (BDI)
• Patients Health Questionnaire (PHQ-9)
• Center Epidemiologic Studies Depression Scale (CSED)

These tools could be administered by social worker in the dialysis facility. However, the screening would be more fruitful if obtained when depression is suspected and symptoms are identified. Depression symptoms, which are present nearly every day, include:

• Depressed mood most of the day
• Markedly decreased interest or pleasure in almost all daily activities
• Significant weight loss or gain (more than five percent of body weight in a month)
• Increase or decrease in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feeling of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate or indecisiveness
• Recurrent thoughts of death (not just fear of dying) or suicidal ideation without specific plan or attempt

These symptoms could be self-reported or observed by family, friends or health care providers—such as  dialysis nurses, who assess each patient at least three times a week, and  dietitians, who probably have the most interaction with the patients. Assessing patients’ nutrition and educating on appropriate diet could not be achieved without conversation about patients’ social status, support, habits, interests, home situation and ability to cook. Many dietitians have been trained in motivational interviewing, which is the most effective way to communicate and support behavioral modification.

Treatment of depression is most effective with a multidisciplinary approach, and needs cooperation among nephrologists, dialysis nurses and social workers (who are trained in psychiatry), physical and occupational therapists and patient support groups. As mentioned earlier, dietitians can play a great role in assessing status and improvement.

The non-pharmacological treatments for depression include:

• Cognitive behavioral therapy, which has shown to be effective in several studies, and
• Exercise, which has shown to alleviate symptoms of depression in patients who are able to carry out aerobic and resistance exercises.

Pharmaceutical drugs used to treat depression include:

• Fluoxetine, which has been reviewed in a few small, non-randomized studies, and
• Sertraline, which was associated with significant improvement in depression over 12 weeks in one randomized, double-blinded control study from Iran. In addition, a study of sertraline in dialysis (ASSertID) is currently being conducted to review the efficacy of a Sertraline protocol in patients with major depressive disorder.

The European Renal Best Practice (ERBP) suggests a trial on selective serotonin reuptake inhibitors (SSRIs) for 8 to 12 weeks in patients with moderate to severe depression. If there is no improvement, the medication needs to be discontinued.

In summary, depression is one of the major and underappreciated parts of dialysis patients’ health. It deserves more attention by all health care providers and requires a multidisciplinary approach and teamwork both for diagnosis and treatment. Alleviation of depression may improve patient quality of life, reduce morbidities, improve patient outcomes and possibly improve mortality.