Depression Is Undertreated in Patients Receiving Hemodialysis

Patients receiving chronic hemodialysis who appear to suffer from depression are commonly not interested in initiating or modifying existing treatment for depression when indicated, according to a new study.

“Furthermore, when patients are interested in starting or changing treatment, their kidney providers are commonly reluctant to implement such treatment,” said study author Steven D. Weisbord MD, MSc, from the renal-electrolyte division of the University of Pittsburgh School of Medicine.
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As part of a clinical trial of symptom management in patients on chronic hemodialysis conducted from 2009-2011, researchers assessed depression monthly using the Patient Health Questionnaire 9 (PHQ-9). For depressed patients (PHQ-9 score ≥10), trained nurses generated treatment recommendations and helped implement therapy if patients and providers accepted the recommendations. The investigators assessed patients’ acceptance of recommendations, reasons for refusal, and provider willingness to implement anti-depressant therapy and then analyzed data at the level of the monthly assessment.

Of 101 patients followed for ≤12 months, 39 met criteria for depression (PHQ-9 score ≥10 on ≥1 assessment). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 assessments (70%), patients were receiving anti-depressant therapy and in 51 of 70 (70%) assessments, patients did not accept nurses’ recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving anti-depressant therapy and in 40 instances (91%) did not accept recommendations to start treatment.

The primary reason patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 instances (61%) in which patients accepted the recommendation, renal providers wouldn’t provide treatment.

“We were surprised by the degree to which patients were not interested in receiving or modifying treatment for depression when it appears to be clinically indicated,” Dr Weisbord said. “We were also surprised to learn that many patients on chronic hemodialysis attribute their depression to an acute illness, their chronic illnesses, and/or to their dialysis treatment and that this explains why many patients are not interested in modifying or initiating treatment for their depression.”

For primary care providers, the biggest takeaway from this study should be they may need to more actively engage with nephrology/dialysis providers to better understand patients' depression and how to best manage it, he said.

“We hope to conduct future studies to better understand how providers who care for patients receiving chronic dialysis can more effectively approach the management of depression in their patients interested in receiving treatment,” Dr Weisbord said.

—Mike Bederka

Reference:

Pena-Polanco JE, Mor MK, Tohme FA, et al. Acceptance of anti-depressant treatment by patients on hemodialysis and their renal providers [published online Jan. 26, 2017]. Clin J Am Soc Nephrol. doi: 10.2215/CJN.07720716.