Approximately one in five women and one in 10 men will suffer from depression over the course of their lives (1). Chronic illness generally confers an even greater risk for depression. Patients with chronic kidney disease (CKD) and in particular, those who are on hemodialysis (HD) are at a relatively high risk for depression. It is difficult to determine the exact rate of major depressive disorder (MDD) in patients with CKD because the somatic symptoms of depression are similar to the symptoms of uremia (e.g., decreases in appetite, energy, sexual interest, and sleep). Aches and pains are common in patients with CKD, patients on HD, and patients with MDD.
Depression is thought to be the most common psychiatric abnormality in HD patients, with the prevalence likely between 5% and 10% (2). Depression in patients on HD can stem from the variety of losses that these patients suffer, including loss of kidney function, employment, physical strength, and social function (3). Patients on HD with MDD are twice as likely to die or require hospitalization within a year as those without depression (4). The suicide rate in ESRD patients is also higher than that of the general population (5). Recently, the Centers for Medicare & Medicaid Services added a new requirement in its Quality Incentive Program to screen and follow up as indicated for depression in all patients 12 years of age and older with CKD on HD. The Centers for Medicare & Medicaid Services Quality Incentive Program does not require use of a specific screening tool, and it does not define which member of the care team must do the screening. Identifying and appropriately treating MDD can have an extraordinary effect on quality of life for patients with CKD.
Generally, it makes sense to screen for depression anyone who looks unhappy, bearing in mind that not everyone who looks unhappy has a psychiatric disorder. It is important to differentiate between MDD and an appropriate sad reaction to a difficult life situation, because the therapeutic approach will be different. Patients who have just received a difficult diagnosis or who have had a recent health crisis may be quite upset; however, this reaction often does not progress to MDD (i.e., a psychiatric disorder). People who are ill but not depressed will retain interest in things that have historically brought them joy. For example, a devoted Yankees fan who is chronically ill but not depressed may be sad, because he cannot stay awake to watch a game on television; however, he will still be interested in the score. When that same patient seems completely uninterested in baseball season for days at a time, depression may be the culprit.
Any health care provider can do a basic screening for depression. To start, ask the patient how things are going and how he has been sleeping. Any patient who has had difficulty falling or staying asleep in the absence of difficulty breathing, frequent nighttime urination, pain, etc., should then be asked if he is feeling sad or blue and if he has lost interest or pleasure in things he usually finds fun. These two questions, each rated on a scale of zero to three over the last 2 weeks with zero being never and three being nearly every day, constitute the Patient Health Questionnaire-2 (PHQ-2). The PHQ-2 is a very brief, basic version of the more comprehensive PHY-9, a nine-question screening tool commonly used to quickly assess for symptoms of depression (Figure 1). The PHQ-9 is available in many languages. A patient who scores three or more on the PHQ-2 should be asked to fill out a PHQ-9. The PHQ-2 has 97% sensitivity and 67% specificity in adults, whereas the PHQ-9 has 61% sensitivity and 94% specificity in adults (6). Almost 90% of patients who score 10 or higher on the PHQ-9 have MDD; generally, scores of 5, 10, 15, and 20 correspond to mild, moderate, moderately severe, and severe depression, respectively (7).
Patient Health Questionnaire for Depression
Citation: Kidney News 8, 10/11
The most concerning outcome of MDD is suicide. Some people worry that assessing for suicide can give a patient the idea to kill himself. This fear is unfounded; there is no evidence that screening for suicide leads to an increased risk of suicide. Another concern that can lead health care providers to avoid screening for depression is the fear that asking the patient about sadness will lead to an emotional crisis (opening Pandora’s box), which the provider will be obligated to manage. This fear is not accurate; sometimes probing an emotional subject can lead to an expression of feelings by the patient, but this outcome, although potentially intimidating to the provider, is optimal in that it can lead to the patient getting necessary treatment for depression.
Treating major depressive disorder
In general, the two strategies for treating MDD are psychotherapy and medication. Choosing a treatment strategy depends on a variety of factors, including the severity of the illness, the patient’s preference, treatment availability, and the patient’s ability to engage in certain forms of psychotherapy. For patients with very mild depression or who are reacting to a recent health crisis, having a space to talk about their experience with a compassionate listener is most helpful; medication alone is typically not effective in symptom reduction for these patients (8). For patients with mild to moderate depression, psychotherapy alone or in combination with medication can be useful. There are multiple types of psychotherapy that can be helpful for patients with CKD and MDD; for example, cognitive behavioral therapy can help patients address overvalued fears and misconceptions about themselves and their illness while providing patients with coping mechanisms to use in times of stress. Coping mechanisms such as deep breathing can also be taught alone. The advantages of psychotherapy are that there are no medical downsides and that the techniques learned can be remembered and used at later times (9). The disadvantages of psychotherapy are that it requires a skilled psychotherapist, a minimum level of patient engagement (including cognitive capacity and motivation), and regular, relatively frequent sessions.
Antidepressant medication should, with minimal exception, be prescribed to patients with severe depression and may be helpful either alone or in combination with psychotherapy in patients with mild to moderate depression. Psychotherapy alone is not useful in patients with severe depression. Medications that are metabolized by the kidneys, such as paroxetine and venlafaxine, should be avoided in patients with CKD. Citalopram and sertraline can be considered first-line medications, and duloxetine can be considered for patients with coexisting neuropathic pain. Dosages of most antidepressants should be initially reduced given that the kidney generally excretes the liver metabolites of antidepressants (10). It is important to remember that antidepressant medication can take 6 to 8 weeks to be maximally effective and that many patients will require doses higher than the starting dose to get better. When patients do not respond to therapeutic doses of antidepressants, are suicidal, or have a history of episodes of mania or hypomania (bipolar disorder), consider consulting with a psychiatrist in managing the care of the patient.
Screening for MDD is a simple process that can be accomplished by any health care provider. Although discussing emotions in the setting of a difficult medical diagnosis can be intimidating, treatment for MDD is effective, and the positive effect on patient outcomes can be tremendous.
References
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Hasin DS, et al.. Epidemiology of major depressive disorder: Results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry 2005; 62:1097–1106.
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Kimmel P. Psychosocial factors in adult end-stage renal disease patients treated with hemodialysis: Correlates and outcomes. Am J Kidney Dis 2000; 35[4 Suppl 1]:S132–S140.
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Hedayati SS, et al.. Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression. Kidney Int 2008; 74:930–936.
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Kurella M, et al.. Suicide in the United States end-stage renal disease program. J Am Soc Nephrol 2005; 16:774–781.
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Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606–613.
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Barbui C, et al.. Efficacy of antidepressants and benzodiazepines in minor depression: Systematic review and meta-analysis. Br J Psychiatry 2011; 198:11–16.
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Parikh SV, et al.. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord 2009; 117[Suppl 1]:S15–S25.
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Cohen SD, et al.. Screening, diagnosis, and treatment of depression in patients with end-stage renal disease. Clin J Am Soc Nephrol 2007; 2:1332–1342.
