Depression undertreated in chronic dialysis patients

Depressive symptoms are common in patients receiving chronic hemodialysis, but new research suggests several barriers—including patients themselves—may hinder successful treatment.    

In a new study published in the Clinical Journal of the American Society of Nephrology (CJASN), researchers found that many patients with depressive symptoms who received chronic hemodialysis do not wish to receive aggressive treatment. In addition, patients who were willing to accept treatment were often not prescribed it by their nephrologist.

A team of researchers led by Steven Weisbord, MD, MSc and Julio Pena-Polanco, MD, of the VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, PA, asked approximately 100 hemodialysis patients taking part in a clinical trial to complete a monthly questionnaire regarding depressive symptoms.

Thirty-nine patients met the criteria for depression and reported depression on 147 of 373 (39%) of the monthly assessments. In 70% of the 147 assessments, patients were receiving therapy with antidepressants. In 51 of 70 assessments, patients did not accept recommendations to intensify antidepressant treatment.

In 44 assessments, researchers found that patients with depressive symptoms were not receiving antidepressant therapy, and in 40 of those instances, the patients did not accept recommendations to start treatment.

Patients’ primary reason for refusing recommended treatment was that they felt the depressive symptoms were attributable to an acute event, chronic illness, or the dialysis itself. In 11 of 18 instances in which patients accepted the recommendation, kidney specialists were unwilling to provide treatment.

Dr. Weisbord noted that The Centers for Medicare and Medicaid Services’ Quality Improvement Program for end-stage renal disease recently mandated that all dialysis facilities report individual patient screening and treatment plans for depression.

“However, there is a paucity of evidence documenting the effectiveness of antidepressant treatment in this patient population and it remains unknown whether patients on dialysis want treatment for depression,” he explained. “Our study demonstrated that many patients on chronic hemodialysis have depressive symptoms but do not wish to receive aggressive treatment to alleviate these symptoms. We also noted that when patients are willing to accept treatment, renal providers commonly do not prescribe treatment.”

In an editorial that accompanied the study, Maree Hackett, PhD, and Meg Jardine, PhD, both of the University of Sydney Medical School, Australia, said that potential underlying reasons for the high rates of depression in patients receiving dialysis include the overlap of some risk factors for depression and kidney failure, as well as changes in physiological and psychological processes as a result of living with kidney failure.

“Depression in people receiving dialysis treatment is associated with lower quality of life, increased hospitalizations and, in all likelihood, shortened survival,” they wrote. “The importance of the inner experience may get lost…in a setting of intensive medical intervention, intercurrent comorbidities, and high rates of unwelcome events.”