Psychosocial Aspects of Chronic Kidney Disease

Exploring the Impact of CKD, Dialysis, and Transplantation on Patients

Daniel Cukor, Scott D. Cohen, Paul L. Kimmel

• Publisher: Academic Press
• Year: 2020
• Print ISBN: 9780128170809
• eBook ISBN: 9780128170816
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Psychosocial Aspects of Chronic Kidney Disease: Exploring the Impact of CKD, Dialysis, and Transplantation on Patients provides an overview of the emotional and psychological challenges faced by people with renal disease. This book outlines the epidemiology and treatment of the psychosocial factors affecting them. The sections in the book cover psychiatric illness in the earlier and middle stages of chronic kidney disease, end-stage renal disease treated with dialysis, and renal transplantation. The book concludes with a section on special considerations, delving into topics such as treating children and adolescents, quality of life, caregiver burden, challenges in psychosocial research in kidney disease, and future directions for intervention. - Includes chapters that are written by a leading group of international researchers - Emphasizes practical approaches to patient care and treatment issues - Explores psychosocial issues related to hemodialysis and peritoneal dialysis - Discusses available treatment for anxiety, depression, sleep disturbances, pain, nonadherence, cognitive dysfunction, palliative care, and other psychosocial concerns

Section III

Patients With ESRD Treated With Dialysis

Chapter 7: Depression in patients with CKD and ESRD

Davin K. Quinn^a; Daniel Cukor^{b a} Associate Professor, Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, NM, United States
^b Director, Behavioral Health, The Rogosin Institute, New York, NY, United States

Abstract

Depression is disproportionally prevalent in end-stage renal disease (ESRD) populations. The screening for depression is complicated by the overlap of symptoms of uremia and dialysis treatment and the lack of information regarding screening techniques and the utility of instruments for diagnosis of depression in patients with ESRD. The major screening instruments used are reviewed, and recommendations about their utility in this population are made. The literature on the pharmacological treatment of depression is reviewed in depth. The chapter includes consideration of the major classes of antidepressants and their use in ESRD populations. There is a discussion of the nonpharmacological approaches to treating comorbid depression in ESRD patients, focusing on cognitive behavioral therapy and exercise interventions. The chapter ends with a discussion of the challenges and offers solutions for the widespread adoption of depression treatment in dialysis centers.

Keywords

Depression; Chronic kidney disease (CKD); End-stage renal disease (ESRD); Major depressive disorder (MDD); Antidepressant; Neuromodulation

Epidemiology of depression in chronic kidney disease

Depression occurs in up to 20% of patients with chronic kidney disease (CKD), end-stage renal disease (ESRD), and those who are hemodialysis (HD) dependent, a value significantly greater than the point prevalence in the general population.^1,2 Major depressive disorder (MDD) and symptoms of depression have been shown to be associated with an increased risk of hospitalization,³ morbidity,⁴ and mortality in CKD/ESRD/HD patients.^5–8 There are several possible explanations for this association, including reduced compliance with treatment, existential demoralization, and nutritional deficits.^9,10 Depression can also contribute to hypothalamic-pituitary-axis dysregulation, immune dysfunction, cytokine-related inflammation, sympathetic nervous system dysregulation, and alterations in kynurenine and tryptophan handling.^{11, 12} Therefore the diagnosis and treatment of depression in CKD patients continues to be an area requiring further inquiry and intervention.

Even with appropriate awareness of and attention to diagnosis and management, MDD is frequently undertreated in medical populations, in general.^13,14 Patient-related factors contributing to undertreatment may include a reluctance to accept a behavioral health diagnosis, reluctance to undergo treatment with therapy or medications out of anxiety or concern for side effects, and low rates of compliance with treatment regimens, a perception that symptoms of depression or anxiety are an expected symptom of ESRD that should simply be tolerated and are not treatable and a sense of overburdening with further medications and appointments.^15,16 Provider-related factors contributing to undertreatment may include a lack of familiarity, experience, or confidence with treating MDD, a concern for medication complications in ESRD patients, or low prioritization of depression treatment in relation to other aspects of medical care. Finally, there is likely significant contribution to undertreatment from a general lack of access to behavioral health consultation and treatment, due to low numbers of providers or their physical distance from dialysis centers or nephrology clinics and their prohibitive costs, in some regions of the country.

Screening for and diagnosis of depression in CKD

The US Preventive Services Task Force (USPSTF) in 2016 recommended widespread depression screening in primary care settings, in recognition of the large impact major depression has on overall health and disease-specific outcomes.¹⁷ Similar guidelines had already been issued by National Institute for Health and Care Excellence (NICE)in the United Kingdom in 2009, including a separate guideline recommending depression screening and treatment in the chronically medically ill. Unfortunately the current ability to provide adequate treatment for depression once detected and diagnosed has not kept pace with the recommendation for universal screening, owing to an ongoing shortage of specialist behavioral health providers. Increasingly, providers in medical settings are being tasked with not only screening but also initiating and monitoring response to first-line treatments for depression.¹⁸

In the ESRD/HD patient population, the direct provision of psychiatric care at the dialysis center has numerous advantages, despite the added burden this may impose on dialysis staff. First, integrated care acknowledges that depression, just like hypotension, electrolyte abnormalities, infection, pain, or encephalopathy, is a concomitant of dialysis and should be actively addressed like any other physical sign or symptom. Second, it avoids imposing a further burden on patients to see another provider in a different location and having to work around their dialysis schedule. Third, dialysis staff develop close therapeutic relationships with patients and are uniquely positioned to be able to detect exacerbations of depression or complications of antidepressant treatment early, before they become severe. Fourth the familiarity and trust that patients develop with dialysis staff, just as in primary care, can lead to better rates of acceptance and compliance with psychological or psychiatric treatment, counteracting some of the societal stigma associated with seeking treatment at a stand-alone behavioral health clinic.

Complicating the task of screening for MDD in ESRD is the fact that kidney disease is often accompanied by myriad physical symptoms that overlap with the somatic manifestations of depression, such as fatigue, poor concentration, appetite change, and sleep disturbance.¹⁹ This symptom overlap can lead to errors both of underrecognition (e.g., where somatic symptoms of MDD are attributed to ESRD, and antidepressant therapy is withheld) and overrecognition (e.g., psychotherapy is prescribed, instead of an adjustment in dialysis parameters to treat encephalopathy). Screening instruments relying on patient report can frequently manifest false-positive results due to drug effects, cognitive impairment, or distress from pain. For these reasons, positive screens for depressive symptoms should not automatically trigger a referral for behavioral health consultation. Instead the screening staff should query patients about their reasons for responding as they did, for informed clinical decisions can be made with regard to appropriate next steps. Frequently the issue at hand can be dealt with swiftly and without need for additional behavioral intervention (Table 7.1).

Table 7.1

Screening instruments for major depression.

Scale	Advantages	Disadvantages	Standard scoring
Patient Health Questionnaire (PHQ-9)^20	• Free • Patient administered • Widely studied in primary care and disease populations • Linked to DSM criteria for depression	• Less used by specialist clinicians	0–4: none 5–9: mild 10–14: moderate 15–19: moderate-severe 20–27: severe
Quick Inventory of Depressive Symptomatology (QIDS-SR/CR)^21	• Free • Patient or clinician administered forms • Used in recent studies (ASCEND) • Linked to DSM criteria • Validated in CKD		1–5: none 6–10: mild 11–15: moderate 16–20: severe 21–27: very severe
Center ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Contributors
• Preface
• Abbreviations
• Section I: Introduction
• Section II: Chronic Renal Disease
• Section III: Patients With ESRD Treated With Dialysis
• Section IV: Renal Transplantation
• Section V: Special Considerations
• Index