Value-based solutions can improve depression management for patients with CKD
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Depression is one of the most common complications of chronic illness. Depressive symptoms can have a negative effect on a person’s overall health and quality of life, while the hardships of a chronic illness can take a toll on mental health, creating a vicious cycle of deteriorating behavioral and physical health.
The National Institute of Mental Health reports that patients with chronic illness have higher rates of depression than the general population. That rate is even higher among patients with chronic kidney disease. According to a study in Kidney International, those with CKD are three to four times more likely to experience depression compared with the general population.
A review of 216 studies published in Kidney International Reports found that 27% of patients with CKD screened were considered depressed, compared with 39% for patients with end-stage kidney disease. This is up to four times higher than the general population, and higher than those individuals with other chronic conditions. Underrepresented racial and ethnic groups, including Black and Hispanic patients, have demonstrated even higher rates of depression.
Increasingly, researchers are analyzing the link between depression and CKD. A study published in the Clinical Journal of the American Society of Nephrology revealed that patients with frequent depressive symptoms were nearly 40% more likely to experience rapid kidney function decline than patients with infrequent symptoms. In another study, published in the Clinical Kidney Journal, researchers analyzed data from more than 150,000 patients and found that those diagnosed with depression showed a 38% higher rate of kidney function decline, a 32% higher rate of replacement therapy such as dialysis and an 84% higher mortality rate.
In that report, the authors suggested several explanations for the associations observed in the study, including a possible relationship to inflammatory and immune–metabolic pathways, the associated higher risks of cardiovascular and cerebrovascular disease with depression and changes in social, lifestyle and medical behaviors, which can accelerate decline in kidney function.
Difficult to identify
While additional research on the connection between depression and CKD is needed, these initial studies demonstrate that CKD care must include identification and managment of depression. An increasing number of providers treating CKD are moving to value-based care (VBC) models, which incentivize holistic care to keep a patient as healthy as possible during the long term rather than focusing on treating an immediate single health issue. VBC models put greater emphasis on integrated care, making it easier for providers to work together to address a patient’s physical, mental, behavioral and social needs.
Depression can be difficult to identify in patients with kidney disease because some of its symptoms, like insomnia, low energy and loss of appetite, can also be caused by kidney disease itself.
A recent data analysis by Interwell Health shows the right interventions can help combat depressive symptoms in patients with CKD.
We analyzed almost 30,000 Interwell patients who completed a PHQ-9 screening test, a highly effective and well-established series of questions to identify early signs of depression. In line with industry estimates, it showed 27% had signs of at least mild depressive symptoms, with 8% of those reporting signs of moderate or severe symptoms. Of 1,561 patients identified with signs of moderate to severe depressive symptoms in 2022, more than 71% (1,111) improved to mild or no symptoms during a subsequent screening.
Identifying depression is the critical initial step that prompts the care team to implement proper engagement and treatment. In addition to providing any necessary medications, an effective VBC program also offers wraparound support from social workers, nurses and dietitians who educate and empower patients to better manage their depression and their kidney disease, along with any other conditions.
A value-based approach also helps care teams identify and address social determinants of health, such as lack of transportation or access to healthy food, that can be among the root causes of behavioral health and/or CKD symptoms. Early screening combined with VBC can help health care providers connect patients with the support they need sooner.
Government and private payers have recognized the importance of depression screening for patients with kidney disease and have begun incentivizing providers to evaluate patients for symptoms. Addressing depression is a critical component of the government’s value-based initiative for kidney disease and is designed to reduce Medicare expenditures while increasing the quality of care for beneficiaries managing CKD. This program specifically measures depression remission as a key metric of success.
To be broadly effective, however, nephrologists need training, support and tools to effectively screen patients and manage appropriate interventions. This includes the following:
- workflows to help evaluate patients, guide referrals to outpatient counseling and monitor treatment;
- support developing individualized patient care plans;
- access to robust, standardized learning materials;
- connections to integrated care team members;
- a strong physician referral network; and
dedicated tools designed specifically for kidney care, including a nephrology-specific electronic health record that alerts providers when screening and interventions are needed.
VBC, when done well, addresses behavioral health challenges as a critical aspect of whole-person care. We now have data to show that early and regular depression screenings for patients with kidney disease can help improve patient outcomes. We all must advocate for similar interventions as we strive to improve quality and outcomes while taking costs out of our health care system.
- References:
- Managing depression in patients with chronic kidney disease to slow progression. www.interwellhealth.com/insights/managing-depression-in-patients-with-chronic-kidney-disease-to-slow-progression.
- Palmer S, et al. Kid. Int. 2013; doi:10.1038/ki.2013.77.
- Understanding the link between chronic disease and depression. https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health.
- Zhang Z, et al. Clin J Am Soc Nephrol. 2021;doi:10.2215/CJN.18441120.
- Zhu N, et al. Clin Kid Jrnl. 2023;doi.org/10.1093/ckj/sfad127.
- For more information:
- Jessica Demaline, MSW, LSW, is senior vice president of health care operations for Interwell Health. She can be reached at jessica.demaline@interwellhealth.com.
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