Mental illness is common among individuals with chronic illnesses, and this holds true among those with chronic kidney disease (CKD) and kidney failure. The prevalence of depression is particularly high, affecting approximately 20% to 25% of patients (1). Dauntingly, depression in individuals with CKD is associated with an increased risk of death, hospitalization, and cardiovascular events (2, 3). Among those with CKD who are not yet requiring dialysis, depression poses an increased risk for progression to dialysis (2). Similarly, symptoms of anxiety are extremely common among those with kidney diseases. It is estimated that approximately 20% of these individuals may have anxiety disorders, and as high as 43% may have elevated anxiety symptoms. People living with kidney diseases experience an increased burden of anxiety when compared with both the general population and people with other chronic diseases, including diabetes mellitus and malignancy (4, 5). Like depression, anxiety is associated with mortality, dialysis initiation, and hospitalization (6). Importantly, depression and anxiety correlate with poor patient-centered outcomes such as decreased quality of life and health care noncompliance (7).
Given the pervasiveness of both anxiety and depression and the overlap in symptoms manifested in later stages of kidney diseases, screening for these disorders is of utmost importance. There are no current guidelines for screening these individuals. Self-report screening instruments can be used for both, but each disorder is formally diagnosed based on Diagnostic and Statistical Manual of Mental Disorders criteria, which also allow for identification of concomitant mental health disorders and complications such as suicidal ideation (4).
Few randomized controlled trials exist to guide the pharmacologic treatment of anxiety and depression in patients with CKD (8). A recent observational study of patients with non-dialysis CKD stages G3–5 reported a trend toward a higher risk of hip fractures and upper gastrointestinal bleeding that was not statistically significant with initiation of antidepressant medications (9). Despite observational studies suggesting potential safety concerns, sertraline, a selective serotonin reuptake inhibitor (SSRI), was shown in two 12-week randomized trials to be safe, although associated with an increased risk of nausea and vomiting, among patients with CKD and kidney failure who were treated with hemodialysis (10, 11). Even though SSRIs are commonly used to treat anxiety and depression in the general population, data are mixed regarding their efficacy in the setting of kidney diseases. It is reasonable to try SSRIs in people living with kidney diseases, using sertraline as the drug of choice given its safety profile (1). Benzodiazepines and beta-blockers are often used in the general population to treat transient anxiety. Caution is advised with these medications in individuals with kidney diseases, with special consideration given to renal clearance and accumulation of toxic metabolites (5).
Doses for many antidepressants also differ from the general population, and possible adverse effects need to be considered when prescribing these medications (Table) (12). Non-pharmacologic treatments for anxiety and depression include psychologic interventions, of which cognitive behavioral therapy is the most well-studied. Chairside cognitive behavioral therapy was shown to be effective among patients with kidney failure who undergo dialysis. The benefit is less clear for anxiety in patients with CKD, although efficacy was established for the treatment of anxiety in the general population (1, 5).
Dosing considerations of commonly prescribed antidepressants
Given the high prevalence and independent associations with both adverse clinical and patient-centered outcomes, depression and anxiety are important comorbidities to be recognized and managed. Patient preferences and shared decision-making are essential when considering treatments for these conditions.
Footnotes
References
- 1.↑
Gregg LP, et al. Diagnosis and management of depression in patients with kidney disease. Semin Nephrol 2021; 41:505–515. doi: 10.1016/j.semnephrol.2021.10.003
- 2.↑
Hedayati SS, et al. Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death. JAMA 2010; 303:1946–1953. doi: 10.1001/jama.2010.619
- 3.↑
Fischer MJ, et al.; AASK Study Group. Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease. Kidney Int 2011; 80:670–678. doi: 10.1038/ki.2011.153
- 4.↑
Huang CW, et al. Prevalence and risk factors for elevated anxiety symptoms and anxiety disorders in chronic kidney disease: A systematic review and meta-analysis. Gen Hosp Psychiatry 2021; 69:27–40. doi: 10.1016/j.genhosppsych.2020.12.003
- 5.↑
Cohen SD, et al. Anxiety in patients treated with hemodialysis. Clin J Am Soc Nephrol 2016; 11:2250–2255. doi: 10.2215/cjn.02590316
- 6.↑
Loosman WL, et al. Association of depressive and anxiety symptoms with adverse events in Dutch chronic kidney disease patients: A prospective cohort study. BMC Nephrol 2015; 16:155. doi: 10.1186/s12882-015-0149-7
- 7.↑
Lee Y-J, et al. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. Int J Clin Pract 2013; 67:363–368. doi: 10.1111/ijcp.12020
- 8.↑
Hedayati SS. Safety of antidepressant medications to treat comorbid depression in CKD: Are we there yet? Clin J Am Soc Nephrol 2024; 19:142–144. doi: 10.2215/cjn.0000000000000391
- 9.↑
Zhu N, et al. Comparative safety of antidepressants in adults with CKD. Clin J Am Soc Nephrol 2023; 19:178–188. doi: 10.2215/cjn.0000000000000348
- 10.↑
Hedayati SS, et al. Effect of sertraline on depressive symptoms in patients with chronic kidney disease without dialysis dependence: The CAST randomized clinical trial. JAMA 2017; 318:1876–1890. doi: 10.1001/jama.2017.17131
- 11.↑
Mehrotra R, et al. Comparative efficacy of therapies for treatment of depression for patients undergoing maintenance hemodialysis: A randomized clinical trial. Ann Intern Med 2019; 170:369–379. doi: 10.7326/m18-2229
- 12.↑
Hedayati SS, et al. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney Int 2012; 81:247–255. doi: 10.1038/ki.2011.358
