Nephrol Dial Transplant (2000) 15: Editorial Comments
Nephrol Dial Transplant (2000) 15: 1911–1913
Depression in chronic dialysis patients: assessment and treatment
Fredric O. Finkelstein and Susan H. Finkelstein
New Haven CAPD, Renal Research Institute and Departments of Medicine and Psychiatry, Yale University, New Haven,
CT, USA
Keywords: depression, chronic peritoneal dialysis,
treatment
Introduction
The impact of psychosocial factors on the outcome of
patients with end-stage renal disease ( ESRD) has been
receiving more attention recently [1–4]. The progress-
ive increase in both the incidence and prevalence of
patients with ESRD throughout the world, the high
mortality rate and rising costs of providing care for
patients with ESRD [1] have focused research interest
on those aspects of ESRD care which affect patient
outcomes and are potentially amenable to modification
to improve these outcomes.
Psychological factors—important predictions of
patient outcome
Although the psychological and social difficulties
experienced by patients maintained on dialysis have
been noted and commented on for some time, it has
been only recently that researchers have begun to
demonstrate that psychosocial factors are important
predictors of patient outcome [2–5]. For example, as
the SF-36 Quality of Life and the Kidney Disease
Quality of Life ( KdQofL) questionnaires have become
widely used, it is apparent that dialysis patients have
higher scores on the emotional components of these
assessments than controls, indicating, perhaps not sur-
prisingly, that emotional difficulties are present in
dialysis patients. However, what is particularly note-
worthy is that scores on the emotional components of
these questionnaires are in fact strong predictors of
patient outcome [6 ]. Thus, in the data base of Fresenius
Medical Care in the United States, Lowrie et al. have
demonstrated that dialysis patients with scores lower
than 51 on the Mental Component Scale of the SF-36
have progressively increasing risks of death. In fact,
the patients with scores of 0–37 have twice the relative
risk of death than those patients with scores of 51 or
higher [6 ].
Correspondence and offprint requests to: Fredric O. Finkelstein,
136 Sherman Avenue, New Haven, CT 06511, USA.
1911
Characteristics of depression and its prevalence in
dialysis patients
Depression is generally accepted to be the most
common psychological problem encountered in
patients with ESRD [2–5]. Although the reported
incidence of depression in patients maintained on
dialysis varies widely, these differences have been
attributed to the differing criteria and methodology
used to diagnose depression [2,5]. It is important to
be clear what exactly is meant by depression. Although
depressive symptomatology is commonly encountered
in dialysis patients, the syndrome of clinical depression
consists of the presence of a constellation of symptoms
including anhedonia and feelings of sadness, help-
lessness, guilt, hopelessness, etc. and is accompanied
by changes in sleep, appetite, and libido. Recent studies
that have employed the Beck’s Depression Inventory
(BDI )—a standard self-administered questionnaire
commonly used in psychiatric practice to screen
patients for depression—have reported remarkably
similar findings [4,5,7]. These studies note that between
one-third and one-half of dialysis patients have scores
suggesting the presence of at least a moderate degree
of depression (BDI scores of 11 or greater).
Furthermore, Wuerth et al. observed that when these
patients were then evaluated by a trained psychiatric
interviewer for the presence of clinical depression, 85%
of dialysis patients with BDI scores of 11 or greater
met the DSM IV criteria for the diagnosis of major
depression and had scores of 17 or more on the 21-item
Hamilton Depression Scale (unpublished observation).
These patients were, therefore, candidates for anti-
depressant medication by standard psychiatric practice
guidelines.
Depression scores (BDI ) predict survival in
dialysed patients
Does depression in fact impact on long term patient
morbidity and/or mortality in patients maintained on
dialysis? Depression has clearly been demonstrated to
predict mortality in a variety of medical conditions
[8,9]. However, demonstrating the impact of depres-
sion on morbidity and mortality in patients with ESRD
has proved to be more difficult [10]. Of particular
note, however, are three recent studies [4,7,11,12].
Kimmel et al. have recently performed a detailed
1912
analysis in a large cohort of hemodialysis patients in
whom BDI questionnaires were administered every 6
months [4]. Since the BDI scores change over time,
these authors used a time-varying covariate analysis
and were able to clearly demonstrate a significant
correlation between depression scores and mortality
with both a single variable and multivariable analysis
[4]. BDI scores predicted mortality with a relative risk
of 1.24 [95% CI: 1.05–1.46, P=0.01]. Juergensen et al.
examined a large cohort of patients maintained on
chronic peritoneal dialysis (CPD) and demonstrated a
relationship between a variety of psychosocial para-
meters and the incidence of peritonitis [11,12]. In these
studies, patients who had more than one episode of
peritonitis had higher levels of anxiety and depression
and a poorer overall quality of life assessment than
patients with lower rates of peritonitis [11].
Furthermore, patients who had scores on the BDI of
11 or greater had peritonitis rates that were twice the
rate of patients with low BDI scores [12]. Since periton-
itis is the major reason for technique failure and
hospitalization for patients maintained on CPD [13],
these data may well suggest an association between
these psychosocial factors and hospitalization and tech-
nique failure rates in patients maintained on CPD.
Finally, Steele et al. examined the relationships between
patient assessed quality of life and a variety of medical
and psychological variables and observed that depress-
ive symptoms (as assessed by the BDI ) proved to be
a much stronger correlate of overall quality of life than
dialysis adequacy [7].
Treatment of depression
But is the clinical depression of the patient maintained
on dialysis amenable to therapy or does it just represent
an untreatable manifestation of the patient’s chronic
illness? Does the higher mortality and morbidity in
ESRD patients with depression simply reflect a psycho-
logical response to a poorer overall medical condition?
The treatment of depression in patients with ESRD
with anti-depressant medication presents challenging
problems and has been addressed in few studies system-
atically. Kennedy et al. described the successful treat-
ment of major clinical depression in a small group of
dialysis patients using desipramine in five patients and
maprotiline in one patient, with a significant reduction
in BDI scores observed after seven weeks of therapy
[14]. The more recent study by Wuerth et al. describes
the successful treatment of depression in a cohort of
patients maintained on CPD while underscoring the
difficulty in successfully using antidepressant medica-
tion in dialysis patients (unpublished observations). In
this study, about 130 patients completed BDI question-
naires and about half had scores of 11 or greater,
suggesting at least a moderate degree of depression.
Of those patients who were felt to be candidates for
further investigation, only half agreed to further evalu-
ation by a trained psychiatric team. Of those patients,
half successfully completed a 12 week course of anti-
Nephrol Dial Transplant (2000) 15: Editorial Comments
depressant medication with a 50% reduction in their
scores on the BDI from a mean±SD score of 17.1±6.9
to 8.6±3.2 (P=0.003). Thus, although 50% of the
patients had BDI scores suggesting at least a moderate
degree of depressive symptomatology, only 11 of these
60 patients (18%) completed a 12 week course
of therapy. Many patients refused either further
psychological evaluation or were unwilling to take
anti-depressant drugs in addition to their standard
medications. The anti-depressants used in this study
[sertraline, nefazodone, and bupropion] were well toler-
ated with few side effects, although the doses used
were relatively low. In this study, the investigators did
not comment on the correlation between the treatment
of depression and patient outcomes. It must be kept
in mind that careful follow-up and outcome studies of
patients with ESRD treated for depression are essen-
tial, particularly in view of the recent reports describing
an association between the use of antidepressant med-
ication and various adverse medical outcomes. For
example, Cohen et al and Roose et al. observed an
increased risk of myocardial infarction or adverse
cardiac events in patients receiving tricyclic antide-
pressants, but not selective serotonin reuptake inhib-
itors (SSRI ) [15,16 ]. Thapa et al. noted an increased
risk of falls in nursing home residents receiving both
tricyclic and SSRI anti-depressants compared to resid-
ents not receiving anti-depressant medication [17].
Conclusions
In summary, the available information would suggest
that: i ] clinical depression is commonly encountered in
patients with ESRD, ii] the BDI is an easily adminis-
tered questionnaire that is a useful screen for poten-
tially treatable clinical depression in this patient
population, iii ] it is challenging to organize an effective
medication treatment program of depression for
patients with ESRD, iv] anti-depressant medication
can result in a significant improvement in depressive
symptomatology, v] anti-depressant medication is
often well tolerated by patients with ESRD, vi ] whether
this improvement in depressive symptomatology even-
tually results in improved patient outcomes requires
further investigation.
Based on these observations, we have instituted a
program in our dialysis units of screening patients
every 6 months with the BDI. Patients with scores of
11 or greater are referred to a trained psychiatric
interviewer. If the patient has a score on the 21-item
Hamilton Depression Scale of 17 or greater and meets
the DSM-IV criteria for depression, anti-depressant
medication is prescribed and the patient is carefully
monitored.
It is hoped that if the personnel (nurses, physicians,
social workers, nephrology trainees) caring for patients
with ESRD in the dialysis centers are made increasingly
aware of the possible treatment options available for
patients with clinical depression, effective treatment
strategies can be devised and at least some of the
Nephrol Dial Transplant (2000) 15: Editorial Comments
suffering, morbidity and mortality of the patients
diminished.
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