Early identification, treatment of depression in patients with CKD has long-term benefits
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Managing patients with an illness like chronic kidney disease can be difficult at times for caregivers, but Michelle Rowlett, MSW, LICSW, knows that for patients grappling with a disease that can last a lifetime, it poses many challenges.
“Certainly, I have seen social workers come into this setting and have to leave it because of the permanency of this illness,” Rowlett, social work supervisor and CKD program lead for social services at Puget Sound Kidney Centers in Mountlake Terrace, Washington, told Healio | Nephrology News & Issues. “It’s demanding; emotionally, it can be exhausting. You need to have incredible reserve and understand the fragile nature of this disease.”
Photo courtesy of Michelle Rowlett, MSW, LICSW
Identifying the signs of depression early in patients with kidney disease who face the anxieties of a long-term illness – “transplant is a great treatment but it is not a cure,” Rowlett said – can often times be evident: a change in mood, irritability and snapping at staff, Rowlett said. “I have a patient who is crying all the time when I provide counseling,” Rowlett said. “Other patients can be really flat – they aren’t engaging, they don’t have interest in doing anything. They aren’t taking their medications – it is the polar opposite of moodiness.”
Depression and CKD
A connection between depression and accelerated progression of CKD has been shown in several studies. In an analysis of 4,763 adults in China with normal kidney function at baseline, the presence of high depressive symptoms was associated with a 39% increased risk for rapid decline in kidney function in a 4-year period.
“CKD is a leading risk factor for cardiovascular disease, kidney failure and mortality worldwide. Therefore, the identification of more modifiable risk factors may possibly reduce the huge burden of CKD and its related complications by leading to early detection and prevention,” study co-author Xianhui Qin, MD, of Nanfang Hospital at Southern Medical University in China, said in a press release about the research, which was published in the Clinical Journal of the American Society of Nephrology. “While our study does not show causality, it demonstrated that high depressive symptoms were significantly associated with rapid decline in kidney function among Chinese adults with normal kidney function.”
In a perspective on the study for Healio | Nephrology News & Issues, Kathryn Aebel-Groesch, MSW, LCSW, wrote the pandemic brought the presence of depression among patients with chronic illness to the forefront.
“A silver lining from the pandemic has been a focus on the importance of physical and psychological wellness. When talking about our feelings, seeking counseling and practicing coping skills, like mindfulness, we are normalized and the stigma around behavioral health is reduced,” Aebel-Groesch, senior manager of social work services for DaVita Kidney Care and a Healio | Nephrology News & Issues Editorial Advisory Board Member, wrote.
Social isolation
A study by Zhou and colleagues looked at the impact of social isolation on the risk of developing CKD. The investigators analyzed data from 3,031 participants aged 45 years and older with a baseline eGFR of 60 mL/min/1.73 m2 or more.
“In the fully adjusted model, high social isolation was significantly related to an increased risk of experiencing a rapid decline in renal function (OR 1.805, 95% CI 1.310-2.487) and CKD onset (OR 1.842, 95% CI 1.084-3.129),” the researchers wrote. “Among the five components of social isolation, being unmarried, not participating in social activities, and living alone independently predicted declined renal function.”
Showing a lack of interest in social activities is one indicator that CKD is leading to depression, Daniel Cukor, PhD, told Healio | Nephrology News and Issues. He offered a list of symptoms that caregivers can use to screen patients for depression (see Table).
“These are the hallmark signs of a major depression diagnosis,” Cukor, associate professor at NYU Grossman School of Medicine in the department of internal medicine in the division of nephrology, department of psychiatry, said. “Sometimes, however, it is hard to know, for the patient and the clinician, whether a particular symptom is due to physical effects of the illness, the treatment or the emotional toll.”
Rowlett and Cukor agreed that defining the clinical cause of depression is less important than developing a treatment plan to resolve the symptoms. “Certainly, understanding the causes of depression – whether it is being influenced by a lack of family support or problems with relationships, financial issues or the impact of chronic illness itself – are helpful in making a diagnosis and focusing on resolving those issues,” Rowlett said.
“I often encourage staff not to spend too much time worrying about etiology, as most symptoms are probably due to multifactorial etiologies, and behavioral or psychological treatment can be effective even if the etiology is predominantly physical,” Cukor said. “As an example, if someone is fatigued due to dialysis treatment, that does not mean that behavioral coping strategies will not be useful in helping that person manage their fatigue.”
Other tools that can be used to evaluate depression are available from pharmacists who focus on medication management.
“Depression can greatly reduce an individual’s ability to manage their medications,” Wendy St. Peter, PharmD, told Healio | Nephrology News & Issues. “With multiple new medications that can be used to slow progression of CKD, it is essential to address depression, anxiety and pain symptoms.”
Pharmacists providing comprehensive medication management can assist with identifying patients who have depression vs. having a medication or disease adverse event, St. Peter said.
“They can help manage those patients through collaborative practice agreements with providers and shared decision-making with the patient. When symptoms of depression, anxiety and pain are addressed, patients can focus on lifestyle changes and guideline-directed medical therapy that reduces CKD progression,” St. Peter said.
Providers, physicians
Dialysis providers screen patients annually for depression as part of the CMS Quality Incentive Program (QIP). The depression screening falls under the care coordination subset of the QIP, one of four established by CMS that includes patient and family engagement, clinical care and safety measures. Using different screening tools as CMS does not require specific ones, dialysis providers evaluate patients for depression and determine if an action plan is needed.
In its most recent proposal rule for the Medicare Physician Fee Schedule (PFS), CMS has offered several new CPT codes for assessing behavioral health in Medicare patients.
“For [calendar year] CY 2025, we are proposing to establish separate coding and payment under the PFS describing safety planning interventions for patients in crisis, including those with suicidal ideation or at risk of suicide or overdose,” CMS wrote in the proposed rule. “Specifically, we are proposing to create an add-on G-code that would be billed along with an [evaluation/management] E/M visit or psychotherapy service when safety planning interventions are personally performed by the billing practitioner in a variety of settings,” CMS wrote.
Identifying depressive symptoms in patients contemplating a start on dialysis can help guide clinicians in understanding patients’ decision-making, Alvin Moss, MD, a professor of medicine in the sections of nephrology and palliative medicine at West Virginia University School of Medicine in Morgantown, West Virginia, told Healio | Nephrology News & Issues.
“Since the first Renal Physicians Association/American Society of Nephrology clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis, nephrologists have been encouraged to evaluate patients who are thinking about not starting or stopping dialysis for reversible treatable factors such as depression,” Moss said. “Depending on the study, depression has been diagnosed in between 20% to 40% of patients with chronic kidney disease and kidney failure. Screening for and treating depression is one way nephrology clinicians can improve the quality of life of their patients.”
When to intervene
The impact of CKD is long lasting; Cukor said patients should be evaluated regularly for depression. Nephrologists, he said, are not always the best equipped to determine signs of depression.
“In the dialysis setting, teams are lucky to have their social worker, a trained mental health professional, to serve as the primary contact for mental health issues,” Cukor said. “Sometimes, patients may also feel comfortable sharing with their physician, but some nephrologists would rather not expand their scope of practice to include depression.”
Cukor is working with University of Washington nephrologist Rajnish Mehrotra, MD, in a study funded by a Patient-Centered Outcomes Research Institute award “in which we partner with a dialysis provider to empower the nephrologists to prescribe sertraline as needed and to train a cadre of social workers who are able to provide depression treatment to the dialysis patients without the need for an outside referral,” he said.
In the program, which is being conducted at Satellite Health Care and U.S. Renal Care facilities, dialysis social workers screen patients for symptoms of depression and assess patients identified through screening. Patients with depression then receive information to help them choose a treatment — either medicine or cognitive behavioral therapy (CBT). If a patient in the study decides on CBT, the therapy is offered via telehealth.
“This project will demonstrate what is required to put a depression screening and treatment program in place at dialysis units,” according to the PCORI project summary. “Through this program, more than 8,000 patients will receive screening for depression. More than 650 staff, including social workers, medical directors, and clinicians, will receive training.”
If the project succeeds, patients will have regular access to depression screenings. Cukor said that is important.
“In my mind all patients should be screened for depression regularly. It is increasingly common for primary care physicians to screen patients at their annual visit,” Cukor said. “Depression should be the entire treatment team’s concern, and overlapping screening strategies should not be a concern. If depression, or any mental health issue is identified, care should be coordinated.”
Typically, depression screening is recommended when patients start dialysis care and regularly afterward – or if there is a significant change in the person’s health status or circumstance, he said.
“Kidney disease, or the person’s health in general, may be only a contributing piece to their overall psychological strain, but every touchpoint with the medical team is an opportunity to identify if the patient is in need of help,” Cukor said.
- References:
- CMS End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Calendar Year (CY) 2025 Measure Technical Specifications. https://www.cms.gov/files/document/cy-2025-proposed-technical-specificationspdf.pdf. Accessed July 23, 2024.
- HHS proposes physician payment rule to drive whole-person care and improve health quality for all individuals with Medicare. https://www.hhs.gov/about/news/2024/07/10/hhs-proposes-physician-payment-rule-drive-whole-person-care-improve-health-quality-all-individuals-medicare.html. Accessed July 23, 2024.
- https://www.healio.com/news/nephrology/20210604/depressive-symptoms-may-hasten-kidney-function-decline-in-adults-without-kidney-disease.
- Putting a depression screening and treatment program in place for patients on dialysis. https://www.pcori.org/research-results/2023/putting-depression-screening-and-treatment-program-place-patients-dialysis. Accessed July 23, 2024.
- Zhou W, et al. Front. Med. 2021;doi:10.3389/fmed.2021.782624.
- For more information:
- Daniel Cukor, PhD, can be reached at daniel.cukor@nyulangone.org.
- Alvin Moss, MD, can be reached at amoss@hsc.wvu.edu.
- Michelle Rowlett, MSW, LICSW, can be reached at micheller@pskc.net.