Quality of Life and Depression in CKD: Improving Hope and Health
nying editorial mentioned that quality of life is
Related Articles, pp. 424 and 433
L ife on dialysis is difficult. Dialysis patients
are burdened with a part-time job they
never applied for and cannot quit unless they
undergo transplantation or withdraw from care.
Their income from this “profession” is nil at
best. In comparison to healthier counterparts,
they carry a 5- to 500-fold greater risk of death,
cannot eat what they please, can take pleasure
trips only with extensive advanced planning,
have a poor sex life, and must work all major
holidays except Thanksgiving and Christmas.1,2
It is no wonder that the quality of life on dialysis
therapy is poor and depression rates are high.3,4
In comparison, one might hypothesize a much
brighter outlook for patients with chronic kidney
disease (CKD) who are not burdened with the
job of dialysis therapy. However, they also are
treated to colorless diets, complementary comor-
bid conditions, curtailed life spans, and clear
socioeconomic disadvantage versus the general
population.5,6 Previously unaware of their rela-
tively silent affliction, many are surprised to find
that their kidney function is less than half of what
is considered normal. Nonetheless, these patients
have not been well known to experience high
rates of depression or lack of quality in their lives
because few descriptive data previously existed.
In this issue of the American Journal of Kid-
ney Diseases, Hedayati et al7 offer new insights
in the area of depression, a major component in
quality-of-life assessment, in non–dialysis-depen-
dent patients with CKD. The article beginning on
page 433 validates simple instruments to assess
depression in veterans with CKD against gold-
standard tools.7 The article beginning on page
424 determines the prevalence of major depres-
sion in patients with CKD and describes factors
associated with major depression in this popula-
tion.8 Thus, these articles establish trunks from
which fruitful branches of further understanding
can grow.
Interestingly, the first known medical use of
the term “quality of life” originated in a 1966
article about patients on maintenance dialysis
therapy. The procedure was life saving, but the
investigators questioned whether the patient’s
quality of life was acceptable.9,10 The accompa-
American Journal of Kidney Diseases, Vol 54, No 3 (September), 2009: pp 399-402
difficult to define. They borrow Sir Francis Ba-
con’s definition, which is “the harmony within a
man, and between a man and world”11; the
quantification of such harmony poses measure-
ment difficulties.10 More than 40 years later, our
profession still struggles with the challenges cre-
ated when trying to generate hypotheses regard-
ing quality of life and depression as a cause or
result of an intervention. Even the current defini-
tion of health-related quality of life put forth by
the World Health Organization (“A complete
state of physical, mental, and social well-being
and not merely the absence of disease and infir-
mity”12) is difficult to translate into readily mea-
sured entities (ie, metrics of depression).
Tools to assess factors impacting on corollar-
ies of quality of life, such as depression, have
since been used and validated, primarily in dialy-
sis patients. Early assessments in the late 1960s
and early 1970s showed rates of depression of
0% to 100%, questioning the true validity of the
instruments available at the time.3,13-15 Since
then, many other instruments have been used.
Rates of depressive disorder are as high as 26%
to 29% in recent cohorts of patients with CKD,
with rates of major depressive disorder ranging
from 17% to 19% in comparison to 4% to 6% in
the general and 6% to 10% in primary care clinic
populations.7,16 Major depression is defined as
lasting for 2 weeks or more, during which time
patients experience anhedonia or depressed mood
and at least 5 of the 9 Diagnostic and Statistical
Manual of Mental Disorders (Fourth Edition)
criteria symptom domains, which include weight
loss, sleep disturbances, psychomotor abnormali-
ties, fatigue, feelings of worthlessness or guilt,
inability to concentrate, and thoughts of death.
These symptoms are not supposed to be attrib-
utable to a general medical condition, which
Address correspondence to Suzanne Watnick, MD, Or-
egon Health and Science University, Portland Veterans
Affairs Medical Center, Portland, OR. E-mail: watnicks@
ohsu.edu
Published by Elsevier Inc on behalf of the National
Kidney Foundation, Inc. This is a US Government Work.
There are no restrictions on its use.
0272-6386/09/5403-0002$0.00/0
doi:10.1053/j.ajkd.2009.06.009
399
400 Suzanne Watnick

Box 1. Components of the Quick Inventory of Depression in the CKD population is tightly
Depressive Symptomatology (Self Report) correlated with poor quality of life,22,23 and it is
1. Falling asleep an independent risk factor for a greater rate of
2. Sleeping during the night illness and death in dialysis patients. However,
3. Waking up too early
research in the nondialysis CKD population,
4. Sleeping too much
5. Feeling sad including the articles by Hedayati et al,7,8 is not
6. Decreased appetite longitudinally based and therefore is unable to
7. Increased appetite draw such conclusions. Nonetheless, the article
8. Decreased weight in this issue of AJKD shows that an association
9. Increased weight
exists between depression and factors that may
10. Concentration/decision making
11. View of self lead to poor outcomes, including diabetes, prior
12. Thoughts of death or suicide psychiatric illness, drug and alcohol use, and use
13. General interest of antidepressant medications.8
14. Energy level The biological rationale for poor outcomes
15. Feeling slowed down
with depressive symptoms is unclear. Depression
16. Feeling restless
results in abnormal hypothalamic-pituitary axis
Note: The 16 questions are self-reported on a scale of 0 activity, with increased norepinephrine and corti-
to 3 based on the past 7 days, with higher scores indicating
sol secretion, which may have adverse conse-
greater severity of symptoms.
Reproduced with permission.18 quences in a population with exorbitant rates of
cardiovascular disease.24 Altered autonomic tone
makes the diagnosis very difficult in patients has been found in depressed patients after myo-
with CKD.17 cardial infarction.25 Additional abnormalities in
Not everyone with CKD is depressed; thus, serotonin levels lead to upregulation of platelet
robust screening tools are essential to focus re- activation, with further potential for adverse car-
sources. Hedayati’s group validates 2 of these diac events. The uremic milieu may cause a
screening tools against gold-standard criteria in unique biological perturbation in patients with
the nondialysis CKD population: the Quick In- depression, with possible synergistic cardiac ab-
ventory of Depressive Symptomatology and Self- normalities. Uremia also may make patients more
Report (QIDS-SR16) and Beck Depression Inven- susceptible to mood disorders, but this is conjec-
tory (BDI).18,19 The Patient Health Questionnaire, ture. The additional stressors faced by patients
which has been validated in dialysis patients, with CKD may both lead to depressive symp-
also has been used in patients with non–dialysis- toms and hinder medical compliance, leading to
dependent CKD16,20 (Boxes 1 and 2). Using the worse care and outcomes.26
QIDS-SR16 and BDI alongside gold-standard Research translating into improved care sur-
assessments for depression, Hedayati et al7 re- rounding quality of life and depression is mini-
port the incidence of major depressive disorder
to be 21% in this population, although there was Box 2. Components of the Patient
Health Questionnaire
no control group. Others looking at rates of
depressive symptoms in the CKD population 1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
have shown rates similar to either a general
3. Trouble falling or staying asleep or sleeping too much
medical population22 or dialysis patients in their 4. Feeling tired or having little energy
systems; however, gold-standard evaluations of 5. Poor appetite or overeating
depression were not included.20 Given this limi- 6. Feeling bad about yourself
tation, the relative contribution of nondialysis 7. Trouble concentrating on things
8. Moving or speaking slowly or the opposite (restless or
CKD to the diagnosis of major depression previ-
fidgety)
ously was unclear. The use of gold-standard 9. Thoughts that you would be better off dead or of
assessments identified the relatively high preva- hurting yourself
lence of depression in Dr Hedayati’s target popu-
Note: The 9 questions can be self-administered on a
lation; this moves the field forward by validating scale of 0 to 3 based on the past 2 weeks, with higher
short easily administered instruments to assess scores indicating greater severity of symptoms.
depressive symptoms. Reproduced with permission.21
Editorial
mal, in part because of a paucity of outcome data
for baseline issues.27 How this information trans-
lates to the 26 million non–dialysis-dependent
patients with CKD in this country is unclear.28
Improvement in care is unlikely to occur until an
entity is recognized, studied, and treated. In 1
group of patients initiating dialysis therapy with
BDI scores of 15 or higher, only 16% were
receiving therapy.29 In another group of dialysis
patients, only half those offered treatment for de-
pression accepted it.30 In prior large randomized
controlled trials, such as the Sertaline Antidepres-
sant Heart Attack Randomized Trial (SADHART),
patients with kidney disease were excluded.31 Be-
cause our patients rarely are included in adequate
trials of antidepressant therapy, we do not know
the efficacy of treatment. Antidepressant trials of
dialysis patients have had small sample sizes,
lack of control groups, and inadequate follow-
up. Side effects can compound symptoms and
signs that our patients already experience. Cen-
tral nervous system depression, increased bleed-
ing risks, worsening nausea, sexual dysfunction,
electrocardiogram abnormalities, and accumula-
tion of toxic metabolites could be described in a
brochure about either antidepressant side effects
or advanced CKD. Other therapies, such as exer-
cise and cognitive behavioral intervention, sug-
gest a minimal positive effect.32,33 Sadly, as we
wonder about improvement in outcomes after
therapy for depression in patients with CKD, we
remain blinded.
The state of affairs regarding care for these
patients, simply put, is depressing. Extensive
guidelines have been established addressing many
of the numbers that go awry for our patients with
CKD. However, when a patient walks through
the door of the dialysis unit or a provider’s
office, the patient’s first thought is not whether
he or she has met Kidney Disease Outcomes
Quality Initiative guidelines. A first thought might
be: How will I feel today? How is this impacting
my life? This reminds us to consider such issues
as depression and quality of life alongside the
traditional guidelines. Our goal is the betterment
of the lives of our patients, and depression as it
impacts on quality of life clearly is a field that
requires further exploration. Future studies must
assess long-term outcomes in patients with CKD
and depression so that we better understand the
implication of such a diagnosis. Subsequently,
401
randomized controlled trials need to address the
efficacy and tolerability of therapy as it pertains
to our patients. The articles by Hedayati et al7,8
are a first step toward the day when our patients
can not only hope for, but also expect, treatments
for their kidney disease that encompass their
physical and mental well-being.
Suzanne Watnick, MD
Oregon Health and Science University
Portland Veterans Affairs Medical Center
Portland, Oregon
ACKNOWLEDGEMENTS
Financial Disclosure: None.
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