Does this patient have chronic kidney disease with depression?

Depression has a lifetime incidence of 10% in the general population, but is more common among patients with chronic kidney disease (CKD). Up to 1/3 of hemodialysis patients have depressive symptoms consistent with the diagnosis of depression. Depression among patients with chronic kidney disease has been associated with earlier initiation of dialysis. Depression among those already on dialysis has been associated with higher rates of hospitalization and death.

The standard for diagnosis of depression is direct interviewing. The criteria for making a diagnosis of major or minor depression are outlined by the DSM IV. The depressive symptoms outlined in these criteria may have overlap with uremic symptoms. For this reason, clinicians should focus on the presence of the emotional aspects of depression and clarify whether apects of physical health are contributing to the neurovegative symptoms.

The overlap between uremia, other concurrent health conditions, and depressive symptoms may require a formal psychiatric consult to assist in making a diagnosis. Besides using a formal interview to make a diagnosis of depression, clinicians may consider using screening questions as a first step. The PHQ-2 and the Geriatric Depression Scale have been shown to effectively screen for depression in the general population. If a patient screens in using these simple instruments, then the team can make a more formal assessment of depression.

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If the patient is ascertained to have depression, the clinician should do a thorough screen for suicidal ideation. A clinician should ask about suicidal thoughts, plans, and behaviors. In addition, clinicians may want to assess the access to and lethality of means, past history of suicidal behavior, substance abuse and adequacy of social support. The clinician may then plan for follow-up with the patient with options ranging from reevaluation at the next visit, to outpatient psychiatric evaluation or emergent inpatient admission. If there are red flags and concerns for lethality, then the clinician should arrange emergent psychiatric evaluation.

What tests to perform?

The patient with apparent depression should have a thorough history and physical exam. The medical history should focus on the common medical causes of depressive affect such as hypothyroidism, cardiovascular disease, and cerebrovascular disease. The psychiatric history should include an assessment of the patient for substance abuse, sleep disorders, anxiety and cognitive impairment.

A review of the medications should include ascertainment of hypnotics, pain medication, steroids, anti-histamines, and any other mediation which may promote depression. A family history should be taken for depression, suicide, and other psychiatric disorders. Lastly, clinicians should assess functional impairment and level of social support.

Laboratory studies that may help to explain depressive symptoms include a complete blood count (CBC), serum sodium, calcium,phosphate, creatinine, thyroid stimulating hormone (TSH), liver function tests, rapid plasma reagin (RPR) and B12/folate levels. Among patients with end stage renal disease (ESRD), it is important to assess dialysis clearance. In addition, drug levels may be helpful to measure since calcinurin inhibitors, digoxin, and anti-epileptic medications may have neurocognitive effects.

In patients with a suspicion of a neurologic event, magnetic resonance imaging (MRI) may provide adquate neuroimaging. In patients with advanced CKD and ESRD, it is best to avoid the use of gadolinium. If gadolinium is required to make a diagnosis, then the patient and radiologist should participate in the decision to perform the testing after weighing the risks and benefits from the imaging procedure.

How should chronic kidney disease patients with depression be managed?

The approach to treatment of depression is framed by the severity of depression, suicidal ideation, presence of social support and other chronic health conditions. One of the first steps may be the education of the CKD patient with depression. It may be highlighted that depression is common and may explain some of their physical symptoms relating to sleep, energy and appetite. Education tools such as pamphlets and trusted web-sites may augment the face-to-face education from a clinician.

Patients should be encouraged to adopt a healthy lifestyle by increasing exercise, reducing stress, and avoiding drugs and alcohol. The drug clearance of patients with CKD and the efficacy of antidepressants merit special consideration (Table 1).

Table 1n

Characteristics of antidepressants used in patients with renal impairment

Mild depression may be addressed with psychotherapy in addition to lifestyle changes and close observation. These approaches can be used alone or in combination with anti-depressant medications. Psychotherapy includes a number of approaches such as cognitive therapy, behavioral therapy, family therapy, couples therapy, interpersonal therapy, and problem-solving approaches. There have been studies on using cognitive behavioral therapy as an approach to treating depression in patients with ESRD.

Major depression should be treated with an anti-depressant. Some patient may benefit from drug therapy combined with pscyhotherapy. The classes of medications widely used to treat depression include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and inhibitors of the reuptake of both serotonin and norepinephrine (SNRIs). Most studies of these medications find similar side effect profiles and efficacy among depressives in the general population.

What happens to patients with depression and chronic kidney disease?

The studies of depression in CKD are small and have short-term follow-up. Patients with depression will need to be followed longitudinally for outcomes of therapy and side effects of the treatment regimen. Both psychotherapy and pharmacologic approaches take time to improve depression severity. If there is no improvement after 4 to 6 weeks, then an alternative approach should be considered. If there is improvement with medications, then the medications should be continued for at least 6x months in order to avoid relapse.

How to utilize team care?

Referral to psychiatry should be considered when there is: uncertainty regarding diagnosis, refractory depression, active suicidal or homicidal ideation, mania, schizophrenia, substance abuse, relapsing depression, psychotherapy.

Nurses play a key role recognizing assessing and educating patients. The nurse and support staff play a particularly large role in the setting of in-center and peritoneal dialysis where these staff members are following the patient closely for medical adherence and functional status.

Pharmacists are important in the management of patients with chronic kidney disease, given the changes in both renal and extra-renal clearance. In addition, CKD patients often use multiple medications requiring careful atttention to drug-drug interactions.

Social workers are affiliated with dialysis treatment and have training to help clinicians manage depression. In the setting of an in-center hemodialysis clinic, social workers are available to help with ascertainment for mood disorders and can also mobilize resources to help patients with depression.

Are there clinical practice guidelines to inform decision making?

American Psychiatric Association Practice Guidelines: Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, Third Edition. The application of these guidelines to this patient population should be carefully considered since these guidelines were not designed to address patients with CKD.

Other considerations


What is the evidence?

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