Identification of depression in patients with CKD remains a challenge for nephrologists

Issue: June 2019

ByDaniel Cokor, PhD

Among its many purposes, one of the primary goals of palliative care is to relieve symptoms and stress and improve patient quality of life.¹ However, even for clinicians who are committed to helping their patients maximize their quality of life, the management of depression can often present unique challenges. Some of these challenges are due to patient factors and some may be attributed to the clinician’s level of comfort and skill in addressing psychiatric difficulty. Often, there may be a tacit agreement to avoid discussing the patient’s mental health or to discuss it only perfunctorily.

To be able to meaningfully address depression in the chronic kidney disease population, the clinician must have familiarity with the following three core concepts:

the sources of discomfort with the conversation that may be preventing honest communication;
how to determine if someone is truly depressed; and
how to treat depression if it is identified.

The following case is meant to highlight some of the challenges of identifying and treating depression.

Daniel Cukor, PhD, director of behavioral health at The Rogosin Institute in New York, emphasizes that screening patients for depression should be more than having them check off a survey instrument, but part of a comprehensive focus on their holistic well-being.

A 48-year-old African American woman with a 20-year history of type 2 diabetes and a 5-year history of kidney failure, was being treated with thrice weekly in-center hemodialysis. Her adjustment to dialysis had been unremarkable and she denied any mental health difficulty.

After missing two dialysis treatments during a 2-week period, the social worker inquired about the change in the patient’s regular attendance. The patient reported her father had recently had a stroke and she had been spending more time at her parents’ house, which was why she missed the treatments.

When asked how she was coping, she acknowledged it was a challenging time, but she would make more of an effort to attend her treatments. The social worker administered the two-question version of the patient health questionnaire (see Table 1) on which she scored the first question as a 0, saying she was tired all the time, but not depressed. However, she scored a 3 on the second question, saying she had not had much interest in doing anything for herself during these past 2 weeks.

The social worker alerted the consulting psychologist who followed up with a full diagnostic interview and determined that the patient had a major depressive disorder. After she was explained the diagnosis and its potential negative effect on her ability to care for her parents and for herself, she agreed to treatment, but did not want to take any more medication than the 17 pills she was already taking daily. Chairside psychotherapy focused on the stressful situation at her parents’ home, the implications for the future, and how the difficulties would only be compounded if Johnson neglected her own health. After eight sessions, Johnson was coping more effectively and no longer qualified for a depression diagnosis.

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Patient factors

Clinicians must go beyond simply saying there is “stigma” when it comes to discussing mental health issues² and understand the diversity of reasons people do not want to discuss their emotional health. Mental illness is often perceived as personal and intimate. If someone’s kidneys are failing, a person can often maintain some psychological distance and not identify their true inner being with their kidneys. However if a person is depressed, it can feel that the illness is a part of the person’s core, not a condition that one is going through.

Consider the language frequently used and how it reflects this perception. People often say they “have kidney disease,” implying some sort of psychological distance from the condition (ie, there is a “me” and that “me” has an outside condition). Few people say they “have depression;” most say, “I am depressed,” implying that their true self is what is experiencing the illness.

A conversation about a patient’s mood can be interpreted as being more about the true person, then, for example, one about a patient’s GFR or hemoglobin value. Relatedly, many patients believe they should have the power to “snap out of it” and the reason they are struggling is due to some type of emotional or spiritual weakness. Acknowledging depression in their mind, therefore, would be akin to admitting some type of essential shortcoming.

Another theme as to why people can be reticent about their mental health issues is they themselves do not understand what is happening, so it becomes even more difficult to cogently express the experience. Many people do not know they are depressed, especially if the onset was insidious and contemporaneous with a developing medical condition. Even if people are aware of their low mood, they are often at a loss for why they are feeling that way and therefore discussing their mood represents an increased vulnerability that can make it more difficult to open up about feelings.

Additionally, many people who are depressed struggle with feelings about their usefulness and may avoid discussion of their mental state to avoid placing more burden on those who care for them. In the presented case, the patient did not think of herself as having a problem and even denied being depressed. The standardized assessment was still able to detect the mood disorder and a key component of the treatment was to help expand her emotional vocabulary, so she could more clearly identify her own reactions.

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Clinical factors

Beyond the reluctance of the patient to share his or her experience, there are often beliefs and behaviors of the clinician that discourage honest communication about mood.³ Clinicians, as well as many people, may have discomfort discussing parts of a person that are considered personal or intimate.

Similarly, nephrologists may feel underqualified to delve into their patient’s emotional universe and may therefore, consciously or unconsciously, send signals to their patient that they are not the appropriate person with whom to discuss their mental health. A bit of reflection should convince the clinician that patient-centered care calls us to engage in dialogue with our patient about the issues meaningful to him or her, not just the ones in which the clinician has advanced training and comfort.

Screen for depression

The word “depression” is often used colloquially and should be precisely defined in the medical context. The experience of depression is manifested in a variety of psychiatric diagnoses.⁴ In general terms, it is defined as a mood state characterized by a sense of sadness with related emotional, cognitive and behavioral symptoms. Depending on the features, severity and duration, depression can serve as the hallmark symptom of an adjustment reaction, chronic depression or major depression. Presentations will differ across people but may include anhedonia, sleep disturbances, fatigue, appetite changes, neurocognitive slowing, feelings of worthlessness, morbid thoughts and suicidality.⁴ The varying presentations of depression depend on factors such as inherited susceptibility, social support, cognitive style, personal reserves and comorbid conditions, such as anxiety.⁵

There are a wide range of depression screening instruments utilized in CKD populations.⁶ Recently, the two-question version of the patient health questionnaire (PHQ-2)⁷ has become an unofficial industry standard (see Table 1). The purpose of any screening instrument is to identify who would benefit from a more comprehensive assessment, not to serve as the basis of treatment or referral. An important question to consider is the true purpose of the screening. Is the clinician’s intent on identifying people who are not adjusting well, have elevated amounts of depressive affect or have a diagnosable major depression diagnosis? If compliance with regulatory requirements is the primary goal (for example, depression screening in the ESRD Quality Incentive Program), then, clearly, the least burdensome method would be preferred. If, however, clinical decisions are being made, one should also consider the rates of false negatives.

Beyond the selection of the appropriate instrument, one must also consider the proper administration of the questionnaire. Consider the impact on patient responses that the tone and context of the questions may have. There will be differences in the thoughtfulness and meaningfulness of patient responses if the questions are presented as a genuine inquiry into the patient’s mental state as opposed to a pro-forma inquiry stemming from reporting requirements. Despite the heterogeneous methods of assessment and the great diversity in ESRD populations, a rough estimate is 10% to 20% of prevalent patients may have a diagnosable major depression and upward of 30% to 40% may have significantly elevated levels of depressive affect.⁸

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Treatment

In treating depression, a stepped approach is universally recommended.⁹ Depending on patient presentation, treatment history, available resources and patient preference, different strategies should be considered. Treatment for depression in general populations may take the form of psychotherapy, antidepressive medication or their combination.¹⁰ Although there is limited clinical trials data specifically in patients with CKD, preliminary evidence is growing. In general populations, treatment resistant depression also can be treated by brain stimulation therapies, including electroconvulsive therapy or repetitive transcranial magnetic stimulation and vagus nerve stimulation,⁵ but there are limited data on these technologies in patients with renal disease.

Although the evidence for psychotropic medications’ effectiveness in the ESKD populations is limited, early evidence of antidepressant management has consistently found both selective serotonin re-uptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) to be beneficial.¹¹ TCAs as antidepressants have largely been supplanted by the newer generation of drugs, but imipramine and amitriptyline continue to be used for analgesia in neuropathic pain, and trazodone is commonly used in low doses as a sedative for insomnia.

Even though SSRIs are commonly used in ESRD, there has been little systematic research.¹² Fluoxetine and sertraline are commonly used as these are metabolized hepatically. When patients with ESRD are being initiated on a new SSRI, it is often advisable to start at the recommended initiation dose and then titrate up slowly. The Chronic Kidney Disease Antidepressant Sertraline Trial¹³ was a well-designed study with more than 200 nondialysis-dependent patients with CKD. Participants were randomized to sertraline or matching placebo. Surprisingly, treatment with sertraline for 12 weeks did not significantly improve depressive symptoms when compared with placebo. More studies are required to place this study in context.

The most studied form of psychotherapeutic intervention for depression is cognitive behavioral therapy (CBT). There is a strong evidence base that CBT is effective for treating depression in a variety of patient populations.¹⁴ The evidence supporting CBT in patients with CKD and ESKD is encouraging.¹⁵ The greatest challenges to providing CBT to patients with CKD are the high illness burden, preventing patients from seeking additional appointments, and the relative scarcity of trained CBT therapists with familiarity with CKD. As depression assessment and treatment are becoming part of standard nephrological care, novel models of providing access to this care will need to be developed. In our case, the patient was fortunate that her dialysis center had a qualified mental health provider available to provide an evidence based-based treatment.

Depression is common in patients with CKD, especially ESKD (see Table 2). Clinicians who are trying to maximize patients’ quality of life need to be mindful of the barriers to open communication around mental illness. Screening patients for depression should be more than having them check off a survey instrument, but part of a comprehensive focus on their holistic well-being. If the clinician decides depression treatment is warranted, prescription of an SSRI or CBT both appear to be suitable first-line options.

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References:
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14. Butler AC, et al. Clin Psychol Rev. 2006;doi:10.1016/j.CPR.2005.07.003.
15. Cukor D, et al. J Am Soc Nephrol. 2014;doi:10.1681/ASN.2012111134.

For more information:
Daniel Cukor, PhD, is the director of behavioral health at The Rogosin Institute in New York.

Disclosure: Cukor reports no relevant financial disclosures.