#NephMadness 2017: Commentary on Depression in Dialysis Patients

Adrian Covic

Dr. Covic, MD, PhD, is Professor of Nephrology and Internal Medicine at the “Grigore T. Popa” University of Medicine and Pharmacy, the Director of the Nephrology Clinic and the Dialysis and Transplantation Center in Iasi, Romania. His main areas of interest are cardiovascular complications in renal disease, CKD-MBD, renal anemia, peritoneal dialysis, and acute renal failure. Follow him @accovic.

Depression is the most common psychiatric illness in dialysis patients. The reported prevalence of depression fluctuates from 22.8% (interview-based diagnosis) to 39.3% (self- or clinician-administered rating scales). It is obvious that depression is much more prevalent in dialysis compared to the general population. Why? There are so many reasons! Almost all patients have a significant co-morbidity burden. Many are frail and elderly, forced to visit multiple physicians and to take as many as >15 drugs everyday. Going to dialysis three times a week brings a lot of anxiety in their flat and grim existence. Additionally, dialysis patients could no longer eat the same foods and must severely control their fluid intake. Merely looking in the mirror is a reason for depression as physical changes are tremendous. Skin becomes darker, extremely dry and flaky, often peeling and itching; fluid retention and skeletal/postural changes secondary to CKD-MBD may be significant.

Importantly – and the entire pool looking at social disparities supports this unrecognized cause – dialysis patients lack the social support to cope with all of the above challenges. In the modern world, more and more, the familial support that was an alternative for deprived patients is disappearing or missing.

Depression is extremely important in dialysis; more than anything else, it is associated with lower quality of life, increased hospitalizations, and, in the end, reduced survival. Structured Clinical Interview for DSM disorders (SCID) remains the gold standard for diagnosis. Other validated methods are The Beck Depression Inventory (BDI), Patient Health Questionnaire (PHQ), and Center for Epidemiologic Studies Depression Scale (CESD). However, the main questions remain: 1) Are patients interested in accepting and starting a therapy for their illness? 2) Do we know how to manage a depressed dialysis patient? Unfortunately, the honest answer is no. Recent data showed that patients frequently are not interested to start or to modify anti-depressant therapy, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Even more important, renal providers are often unwilling to modify or initiate antidepressant therapy.

If patients are willing to receive an antidepressant therapy, which methods are appropriate? Dialysis patients could try a non-pharmacological treatment option like cognitive behavioral therapy and exercise training programs; these non-pharmacological choices led to significant improvements in depression, quality of life, and prescription compliance in several trials. Cognitive behavioral therapy administrated during dialysis treatment could be a valid option. Selective serotonin reuptake inhibitors (SSRIs) are, in general, efficient and safe in ESRD patients, but most studies are small, non-randomized, and uncontrolled; the largest RCT included only 21 patients, who completed 6 months of therapy.

Depression is a significant concern for everyday life of dialysis patients. Survival without LIFE is not sufficient or acceptable. But, are WE and the patients ready to diagnose and treat depression?

Read more about Depression in the Dialysis region.

–  Guest Post written by Adrian Covic (@accovic)

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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