Depression is under-treated in patients receiving chronic dialysis
Many patients with kidney failure who are receiving chronic hemodialysis have depressive symptoms but do not wish to receive aggressive treatment to alleviate them, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). The study also found that when patients were willing to accept treatment for depression, kidney specialists commonly do not prescribe it.
Depression is common in patients receiving chronic hemodialysis but may be ineffectively treated. To investigate the acceptance of anti-depressant treatment by patients on chronic hemodialysis and their doctors, a team led by Steven Weisbord, MD, MSc and Julio Pena-Polanco, MD (VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine) asked 101 hemodialysis patients in a clinical trial to complete a monthly questionnaire asking about depressive symptoms.
Of the 101 patients who were followed for at least 1 year, 39 met criteria for depression based on their answers in the questionnaire. These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 70% of these 147 assessments, patients were receiving anti-depressant therapy and in 51 of 70 (70%) assessments, patients did not accept nurses' recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving anti-depressant therapy and in 40 instances (91%) did not accept recommendations to start treatment. The primary reason patients refused the recommendations was because they felt their depression was attributable to an acute event, chronic illness, or dialysis. In 11 of 18 instances (61%) in which patients accepted the recommendation, kidney specialists were unwilling to provide treatment.
"The Centers for Medicare and Medicaid Services' Quality Improvement Program for end-stage renal disease recently mandated that all dialysis facilities report individual patient screening and treatment plans for depression; however, there is a paucity of evidence documenting the effectiveness of anti-depressant treatment in this patient population and it remains unknown whether patients on dialysis want treatment for depression," said Dr. Weisbord. "Our study demonstrated that many patients on chronic hemodialysis have depressive symptoms but do not wish to receive aggressive treatment to alleviate these symptoms. We also noted that when patients are willing to accept treatment, renal providers commonly do not prescribe treatment."
In an accompanying editorial, Maree Hackett, PhD and Meg Jardine, PhD (University of Sydney, in Australia) noted that potential underlying reasons for the high rates of depression in dialysis patients include the overlap of some risk factors for depression and kidney failure, as well as changes in physiological and psychological processes as a result of living with kidney failure. "Depression in people receiving dialysis treatment is associated with lower quality of life, increased hospitalizations and, in all likelihood, shortened survival," they wrote. "The importance of the inner experience may get lost... in a setting of intensive medical intervention, intercurrent comorbidities, and high rates of unwelcome events," they added.