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Depression
in chronic kidney disease
신장내과 R4 정우진
Introduction
Depression: m/c psychiatric illness in patients with ESRD

Wide range of somatic symptoms ↑, Involvement in social,
occupational, and recreational activities ↓  QoL ↓
The association between depression and mortality risk in dialysis
population has been extensively studied.
Depression may result in adverse clinical outcomes


Compliance with dialysis and medication regimes
Alteration of immune system function,and its detrimental effect on
nutritional status.
Clinicians remain cautious when managing depression in those
with CKD
Nephrology 2016 Feb 10. doi: 10.1111/nep.12742
Association Between Major Depressive Episodes in
Patients With Chronic Kidney Disease and Initiation
of Dialysis, Hospitalization, or Death
JAMA, May 19, 2010—Vol 303, No. 19
Association Between Depression and
Mortality
in Patients Receiving Long-term Dialysis:
A Systematic Review and Meta-analysis
Am J Kidney Dis. 2014;63(4):623-635
Why is depression more common in CKD?
Australian & New Zealand
Journal of Psychiatry
2014, Vol. 48(6) 530–541
Depression and its effect on medical
outcomes
Clin J Am Soc Nephrol 2: 1332–1342, 2007
Screening of depression in ESRD patients
Depression, anxiety, and hostility should be identified and treated
in dialysis patients. (B)


Every dialysis patient should be seen by the dialysis social worker at
initiation of dialysis, and at least biannually thereafter, to assess the
patient’s psychological state, with specific focus on the presence of
depression, anxiety, and hostility. (C)
Dialysis patients should be treated for depression, anxiety, and
hostility if they are experiencing these psychological states. (C)
American Journal of Kidney Diseases, Vol 45, No 4, Suppl 3 (April), 2005: pp S60-S67
Screening of depression in ESRD patients
The best screening tool for depression in dialysis population
remains uncertain.
Currently, BDI, PHQ-9 and CSED are the three validated and most
commonly used questionnaires in this regard.
Nephrology 2016 Feb 10. doi: 10.1111/nep.12742
Clin J Am Soc Nephrol 2: 1332–1342, 2007
Beck Depression Inventory(BDI)
9: no depression
10 ~ 15: mild depression;
16 ~ 23: moderate
depression;
24 ~: severe depression
ESRD Patients who
scored ≥14 using BDI
should be referred to
psychiatrist for early
evaluation.
Diagnosis
Diagnostic and Statistical
Manual of Mental Disorders V
(DSM-V)
Treatment
Non-pharmacological treatment

Cognitive behavioral therapy (CBT)



The most studied psychotherapy for depression in general
population
Data on the effectiveness of psychosocial interventions in the
treatment of depression in the dialysis population have been
limited until recent years
Exercise



Effective for reducing symptoms of depression in patients with
CKD
Dialysis patients tend to have worse exercise tolerance(anemia,
uremia, hyperparathyroidism, vitamin D deficiency,and poor
cardiovascular function)
Specially designed exercise programs have been shown to
alleviate depressive symptoms and improve physical health in the
dialysis population.
Nephrology 2016 Feb 10. doi: 10.1111/nep.12742
Treatment
Non-pharmacological treatment

Electroconvulsive therapy (ECT)




Highly effective treatment for severe depression, including
medication-resistant depression
Not studied in RCTs in CKD, but there are case reports of
excellent response to ECT in patients with CKD and severe
depression refractory to antidepressant medication
Special precautions: abrupt increases in blood pressure, adequate
muscle relaxation, subsequent risk of fractures in an osteopenic
patient
Change in dialysis regimen


It is not clear whether increasing the frequency of dialysis
improves depression rates
FREEDOM study: Dialysis frequency three times weekly  six
times weekly. Significant decrease in BDI values was found
Australian & New Zealand Journal of Psychiatry
Treatment
Pharmacological treatment

Patients with ESRD were often excluded from clinical trials
because of safety concerns



Generally highly protein bound  Not removed significantly by the
dialysis procedure/ Hepatically metabolized
Drug-drug interactions in the presence of polypharmacy
SSRI




Believed to be safer in patients with ESRD because of their more
favorable adverse effect profiles
Fluoxetine is the only one completed RCT of antidepressant
medication in CKD
If the diagnosis of an MDD is uncertain, they may enhance the risk
for mania in patients who have bipolar disorder
SSRI may exacerbate preexisting uremic symptoms, bleeding risk
Clin J Am Soc Nephrol 2: 1332–1342, 2007
Treatment
Pharmacological treatment


The latest recommendations from European Renal Best
Practice(ERBP) suggests a trial of SSRI for 8 to 12 weeks in
dialysis patients who have moderate major depression.
Treatment effect should be re-evaluated after 12 weeks to
avoid prolonging ineffective medication
Nephrology 2016 Feb 10. doi: 10.1111/nep.12742
Reference
Nephrology 2016 Feb 10. doi: 10.1111/nep.12742; Depression in
dialysis patients
JAMA, May 19, 2010—Vol 303, No. 19; Association Between
Major Depressive Episodes in Patients With Chronic Kidney
Disease and Initiation of Dialysis, Hospitalization, or Death
Am J Kidney Dis. 2014;63(4):623-635; Association Between
Depression and Mortality in Patients Receiving Long-term Dialysis:
A Systematic Review and Meta-analysis
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6)
530–541; Depression and chronic kidney disease:A review for
clinicians
Clin J Am Soc Nephrol 2: 1332–1342, 2007; Screening, Diagnosis,
and Treatment of Depression in Patients with End-Stage Renal
Disease
American Journal of Kidney Diseases, Vol 45, No 4, Suppl 3
(April), 2005: pp S60-S67; Guidelines On Evaluation And
Management Of Cardiovascular Disease