People living with chronic kidney disease (CKD) are at significant risk of developing mental health conditions, such as depression and anxiety, particularly in the later stages of CKD (1). Symptoms of depression and anxiety can include fatigue, loss of motivation (avolition), loss of pleasure (anhedonia), sleep disturbances, changes in appetite, feelings of hopelessness, and thoughts that life is not worth living (2). These symptoms can make it substantially more difficult for people to adhere to treatment and self-management strategies for CKD aimed at preventing progression. Unsurprisingly, depression is therefore an independent predictor of mortality in people with CKD (3).
Typical treatment for depression and anxiety can include the use of antidepressant medication. Although prevalent antidepressants are not known to be nephrotoxic, there are some limitations in the evidence base for using them as monotherapy to manage depression in people with CKD. One large trial of antidepressants for people with depression and CKD showed that sertraline was no more effective than a placebo at reducing symptoms of depression but did have higher rates of adverse effects (4). This is an important consideration, particularly for people living with kidney failure who are already experiencing substantial symptom and treatment burdens. Concerns about needing to take additional medication and the associated side effects can act as a barrier to people with CKD seeking help for their mental health (5). Therefore, it is important to consider alternative approaches to managing depression in this population.
There is mounting evidence that nonpharmacologic interventions could be an acceptable and effective option for people with CKD and depression. Cognitive behavioral therapy, an evidence-based psychotherapy focused on supporting people to restructure thoughts and change behavior, has shown initial promise in small studies of people with CKD and depression (6). Lower-intensity alternatives, such as peer support groups, physical activity interventions, and behavioral activation, have been recommended for people with mild to moderate depression and long-term conditions and may be appropriate for people with CKD (7).
Overall, there is a need for interventions that account for the profound psychosocial impacts that result from living with CKD. Mental health support for people with depression and CKD should be provided within a collaborative care model underpinned by multidisciplinary communication (7). Research must continue in this area so that people with CKD can receive high-quality, evidence-based care to improve their mental health.
Footnotes
References
- 1.↑
Palmer S, et al. Prevalence of depression in chronic kidney disease: Systematic review and meta-analysis of observational studies. Kidney Int 2013; 84:179–191. doi: 10.1038/ki.2013.77
- 2.↑
World Health Organization. ICD-11: International Classification of Diseases, 11th Revision, 2021. https://icd.who.int/
- 3.↑
Wu P-H, et al. Depression amongst patients commencing maintenance dialysis is associated with increased risk of death and severe infections: A nationwide cohort study. PLoS One 2019; 14:e0218335. doi: 10.1371/journal.pone.0218335
- 4.↑
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
- 5.↑
Farrokhi F, et al. Patient-perceived barriers to a screening program for depression: A patient opinion survey of hemodialysis patients. Clin Kidney J 2017; 10:830–837. doi: 10.1093/ckj/sfx047
- 6.↑
Pearce CJ, et al. Approaches to the identification and management of depression in people living with chronic kidney disease: A scoping review of 860 papers. J Ren Care 2024; 50:4–14. doi: 10.1111/jorc.12458
- 7.↑
National Institute for Health and Care Excellence (NICE). Depression in adults with a chronic physical health problem: Recognition and management. October 28, 2009. Accessed August 28, 2023. https://www.nice.org.uk/guidance/cg91
