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Nephrol Dial Transplant (2000) 15: Editorial Comments 1911

Nephrol Dial Transplant (2000) 15: 1911–1913

Depression in chronic dialysis patients: assessment and treatment


Fredric O. Finkelstein and Susan H. Finkelstein

New Haven CAPD, Renal Research Institute and Departments of Medicine and Psychiatry, Yale University, New Haven,
CT, USA

Keywords: depression, chronic peritoneal dialysis, Characteristics of depression and its prevalence in
treatment dialysis patients

Depression is generally accepted to be the most


common psychological problem encountered in
Introduction patients with ESRD [2–5]. Although the reported
incidence of depression in patients maintained on
The impact of psychosocial factors on the outcome of dialysis varies widely, these differences have been
patients with end-stage renal disease ( ESRD) has been attributed to the differing criteria and methodology
receiving more attention recently [1–4]. The progress- used to diagnose depression [2,5]. It is important to
ive increase in both the incidence and prevalence of be clear what exactly is meant by depression. Although
patients with ESRD throughout the world, the high depressive symptomatology is commonly encountered
mortality rate and rising costs of providing care for in dialysis patients, the syndrome of clinical depression
patients with ESRD [1] have focused research interest consists of the presence of a constellation of symptoms
on those aspects of ESRD care which affect patient including anhedonia and feelings of sadness, help-
outcomes and are potentially amenable to modification lessness, guilt, hopelessness, etc. and is accompanied
to improve these outcomes. by changes in sleep, appetite, and libido. Recent studies
that have employed the Beck’s Depression Inventory
(BDI )—a standard self-administered questionnaire
Psychological factors—important predictions of commonly used in psychiatric practice to screen
patient outcome patients for depression—have reported remarkably
similar findings [4,5,7]. These studies note that between
Although the psychological and social difficulties one-third and one-half of dialysis patients have scores
experienced by patients maintained on dialysis have suggesting the presence of at least a moderate degree
been noted and commented on for some time, it has of depression (BDI scores of 11 or greater).
been only recently that researchers have begun to Furthermore, Wuerth et al. observed that when these
demonstrate that psychosocial factors are important patients were then evaluated by a trained psychiatric
predictors of patient outcome [2–5]. For example, as interviewer for the presence of clinical depression, 85%
the SF-36 Quality of Life and the Kidney Disease of dialysis patients with BDI scores of 11 or greater
Quality of Life ( KdQofL) questionnaires have become met the DSM IV criteria for the diagnosis of major
widely used, it is apparent that dialysis patients have depression and had scores of 17 or more on the 21-item
higher scores on the emotional components of these Hamilton Depression Scale (unpublished observation).
assessments than controls, indicating, perhaps not sur- These patients were, therefore, candidates for anti-
prisingly, that emotional difficulties are present in depressant medication by standard psychiatric practice
dialysis patients. However, what is particularly note- guidelines.
worthy is that scores on the emotional components of
these questionnaires are in fact strong predictors of
patient outcome [6 ]. Thus, in the data base of Fresenius Depression scores (BDI ) predict survival in
Medical Care in the United States, Lowrie et al. have dialysed patients
demonstrated that dialysis patients with scores lower
than 51 on the Mental Component Scale of the SF-36 Does depression in fact impact on long term patient
have progressively increasing risks of death. In fact, morbidity and/or mortality in patients maintained on
the patients with scores of 0–37 have twice the relative dialysis? Depression has clearly been demonstrated to
risk of death than those patients with scores of 51 or predict mortality in a variety of medical conditions
higher [6 ]. [8,9]. However, demonstrating the impact of depres-
sion on morbidity and mortality in patients with ESRD
has proved to be more difficult [10]. Of particular
Correspondence and offprint requests to: Fredric O. Finkelstein, note, however, are three recent studies [4,7,11,12].
136 Sherman Avenue, New Haven, CT 06511, USA. Kimmel et al. have recently performed a detailed
1912 Nephrol Dial Transplant (2000) 15: Editorial Comments

analysis in a large cohort of hemodialysis patients in depressant medication with a 50% reduction in their
whom BDI questionnaires were administered every 6 scores on the BDI from a mean±SD score of 17.1±6.9
months [4]. Since the BDI scores change over time, to 8.6±3.2 (P=0.003). Thus, although 50% of the
these authors used a time-varying covariate analysis patients had BDI scores suggesting at least a moderate
and were able to clearly demonstrate a significant degree of depressive symptomatology, only 11 of these
correlation between depression scores and mortality 60 patients (18%) completed a 12 week course
with both a single variable and multivariable analysis of therapy. Many patients refused either further
[4]. BDI scores predicted mortality with a relative risk psychological evaluation or were unwilling to take
of 1.24 [95% CI: 1.05–1.46, P=0.01]. Juergensen et al. anti-depressant drugs in addition to their standard
examined a large cohort of patients maintained on medications. The anti-depressants used in this study
chronic peritoneal dialysis (CPD) and demonstrated a [sertraline, nefazodone, and bupropion] were well toler-
relationship between a variety of psychosocial para- ated with few side effects, although the doses used
meters and the incidence of peritonitis [11,12]. In these were relatively low. In this study, the investigators did
studies, patients who had more than one episode of not comment on the correlation between the treatment
peritonitis had higher levels of anxiety and depression of depression and patient outcomes. It must be kept
and a poorer overall quality of life assessment than in mind that careful follow-up and outcome studies of
patients with lower rates of peritonitis [11]. patients with ESRD treated for depression are essen-
Furthermore, patients who had scores on the BDI of tial, particularly in view of the recent reports describing
11 or greater had peritonitis rates that were twice the an association between the use of antidepressant med-
rate of patients with low BDI scores [12]. Since periton- ication and various adverse medical outcomes. For
itis is the major reason for technique failure and example, Cohen et al and Roose et al. observed an
hospitalization for patients maintained on CPD [13], increased risk of myocardial infarction or adverse
these data may well suggest an association between cardiac events in patients receiving tricyclic antide-
these psychosocial factors and hospitalization and tech- pressants, but not selective serotonin reuptake inhib-
nique failure rates in patients maintained on CPD. itors (SSRI ) [15,16 ]. Thapa et al. noted an increased
Finally, Steele et al. examined the relationships between risk of falls in nursing home residents receiving both
patient assessed quality of life and a variety of medical tricyclic and SSRI anti-depressants compared to resid-
and psychological variables and observed that depress- ents not receiving anti-depressant medication [17].
ive symptoms (as assessed by the BDI ) proved to be
a much stronger correlate of overall quality of life than
dialysis adequacy [7]. Conclusions

In summary, the available information would suggest


Treatment of depression that: i ] clinical depression is commonly encountered in
patients with ESRD, ii] the BDI is an easily adminis-
But is the clinical depression of the patient maintained tered questionnaire that is a useful screen for poten-
on dialysis amenable to therapy or does it just represent tially treatable clinical depression in this patient
an untreatable manifestation of the patient’s chronic population, iii ] it is challenging to organize an effective
illness? Does the higher mortality and morbidity in medication treatment program of depression for
ESRD patients with depression simply reflect a psycho- patients with ESRD, iv] anti-depressant medication
logical response to a poorer overall medical condition? can result in a significant improvement in depressive
The treatment of depression in patients with ESRD symptomatology, v] anti-depressant medication is
with anti-depressant medication presents challenging often well tolerated by patients with ESRD, vi ] whether
problems and has been addressed in few studies system- this improvement in depressive symptomatology even-
atically. Kennedy et al. described the successful treat- tually results in improved patient outcomes requires
ment of major clinical depression in a small group of further investigation.
dialysis patients using desipramine in five patients and Based on these observations, we have instituted a
maprotiline in one patient, with a significant reduction program in our dialysis units of screening patients
in BDI scores observed after seven weeks of therapy every 6 months with the BDI. Patients with scores of
[14]. The more recent study by Wuerth et al. describes 11 or greater are referred to a trained psychiatric
the successful treatment of depression in a cohort of interviewer. If the patient has a score on the 21-item
patients maintained on CPD while underscoring the Hamilton Depression Scale of 17 or greater and meets
difficulty in successfully using antidepressant medica- the DSM-IV criteria for depression, anti-depressant
tion in dialysis patients (unpublished observations). In medication is prescribed and the patient is carefully
this study, about 130 patients completed BDI question- monitored.
naires and about half had scores of 11 or greater, It is hoped that if the personnel (nurses, physicians,
suggesting at least a moderate degree of depression. social workers, nephrology trainees) caring for patients
Of those patients who were felt to be candidates for with ESRD in the dialysis centers are made increasingly
further investigation, only half agreed to further evalu- aware of the possible treatment options available for
ation by a trained psychiatric team. Of those patients, patients with clinical depression, effective treatment
half successfully completed a 12 week course of anti- strategies can be devised and at least some of the
Nephrol Dial Transplant (2000) 15: Editorial Comments 1913

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