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Psychiatric illnesses prevalent in hospitalized patients with ESKD, associated with increased mortality
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A recently published study found psychiatric illnesses, common among patients with ESKD hospitalized within their first year of dialysis treatment, were associated with higher patient mortality after discharge.
“The presence of depression or anxiety is associated with lower quality of life in adult and pediatric kidney disease patients,” Paul L. Kimmel, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases, NIH, and colleagues wrote. “Additionally, depression in adults with ESKD is associated with lower treatment adherence, more frequent hospitalizations and increased mortality. In pediatric hemodialysis patients, anxiety was associated with increased disease duration and hospitalizations. How common psychiatric illnesses are in the hospitalized ESKD hemodialysis population and their associations with outcomes is unknown.”
To assess the prevalence of hospitalizations with psychiatric diagnoses within 1 year of treatment initiation for ESKD, as well as to determine the associations between these factors and mortality after discharge, researchers used the United States Renal Data System to perform a retrospective cohort study of 214,225 patients who began treatment from 1996 to 2013. Patients were categorized into pediatric (0 to 21 years) adult (22 to 65 years) and elderly (65 years or more) groups.
Researchers found that, within the first year of treatment, 72% of elderly adults, 66% of adults and 64% of children had at least one hospitalization. Of hospitalized adults, 2% had a primary psychiatric diagnosis and 25% had a secondary psychiatric diagnosis. For children, 1% had a primary psychiatric diagnosis and 15% had a secondary diagnosis. The most common primary psychiatric diagnosis in both hospitalized children and adults was depression/affective disorders (4% and 3%, respectively). Alcohol-related and drug disorders followed this as most common for adults (in 1%). Hospitalized elderly adults were most commonly diagnosed with organic disorders/dementias (3%).
Regarding mortality after hospital discharge, researchers found the mortality rate was 237.4 deaths per 1,000 person-years in patients hospitalized without psychiatric diagnoses, 252.1 in patients with primary psychiatric diagnoses and 275.3 in patients with secondary psychiatric diagnoses. In addition, hazard ratios of all-cause death were higher in all adults who were hospitalized with either primary (HR = 1.29) or secondary (HR = 1.11) psychiatric diagnoses than those without these diagnoses.
“This study updates our understanding of the prevalence of and outcomes associated with hospitalizations with psychiatric diagnoses in adult ESKD patients and expands that understanding to a large sample of pediatric patients for perhaps the first time, across a spectrum of psychiatric diagnoses,” the researchers wrote. “Between 1996 and 2013, approximately 27% of adults and 21% of elderly adults in the U.S. ESRD program had hospitalizations with psychiatric diagnoses. Prevalence was slightly lower in pediatric patients at 16%. This represents a substantial increase from the 8.9% of patients hospitalized with psychiatric diagnoses found in 1998 ... The findings suggest clinicians who care for hospitalized dialysis patients should be aware of and prepared to mange psychiatric disorders and associated negative outcomes within these populations.”
According to Michael J. Fischer, MD, MSPH, and James P. Lash, MD, providing the best quality of care for patients who have psychiatric conditions in addition to ESKD remains challenging. In a related editorial, they wrote: “The diversity and severity of psychiatric illnesses among ESKD patients necessitates the involvement of mental health professionals. Although changes to the care model for maintenance dialysis have been examined and shown to be associated with improvements in quality of life, ESKD patients continue to have fragmented and poorly coordinated care that hinders effective management of their complex multimorbidity including psychiatric illness.”
Sasha Couch provided a patient voice to complement the study, in which she expressed her concern that medical professionals understand depression in a strictly clinical sense that often misses the complex reality of the person experiencing it.
“Most doctors see depression as a ‘psychiatric illness’ and have been taught to treat it clinically,” she wrote. “As a former person (‘patient’) with ESKD who is now 2 [plus] years post-transplant, I believe what’s missing is empathy. Though doctors deal with their own daily stressors, they often fail to use them as critical indicators in ESKD patient treatment. Treating all ESKD patients who exhibit depression and/or anxiety with the same structured psycho-pharmaceutical protocol is a disservice to present and future ESKD patients ... Technology was critical in my ESKD journey. There are many internet groups for ESKD patients. Seeing the support and empathy shared between patients, family members, caregivers, and most importantly, survivors, made me confident and optimistic that you can experience depression and still decide to accept your fate with a positive outlook on the future.” – by Melissa J. Webb
Disclosures: Kimmel reports being the editor of a textbook published by Elsevier. Please see the study for all other authors’ relevant financial disclosures.
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