Patients With CKD Should Be Screened Routinely for Depression
Laurie Barclay, MD Authors and Disclosures
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September 11, 2009 — Patients with chronic kidney disease (CKD) have a high prevalence of depression and should be screened routinely for this condition, according to the results of an observational cross-sectional study reported in the September issue of the American Journal of Kidney Diseases.
"Depression is prevalent in long-term dialysis patients and is associated with death and hospitalization," write S. Susan Hedayati, MD, MHSc, from the University of Texas Southwestern and the Dallas Veterans Affairs Medical Center, and colleagues. "Whether depression is present through all.CKD stages or appears after dialysis therapy initiation is not clear. We determined the prevalence of a major depressive episode and other psychiatric illnesses by using a structured gold-standard clinical interview and demographic and clinical variables associated with major depressive episode in patients with CKD."
At a Veterans Affairs CKD clinic, trained persons administered the Mini International Neuropsychiatric Interview, which is a structured interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, to 272 consecutive participants with stages II to V CKD not treated by dialysis. Demographic and clinical variables associated with a major depressive episode meeting these criteria were identified with use of multivariable logistic regression.
Mean participant age was 64.5 ± 12.0 years, mean hemoglobin level was 12.5 ± 2.0 g/dL, 38% were African American, and 55% had diabetes mellitus. Percentages of patients with stages II, III, IV, and V CKD were 6%, 38%, 41%, and 14%, respectively.
One in 5 participants had a major depressive episode (prevalence, 21%), and this prevalence was statistically similar among all CKD stages. Diabetes mellitus, unemployment, and comorbid psychiatric illness (other than depression or drug or alcohol abuse) were predictive of a major depressive episode. Patients with diabetes were twice as likely to be depressed as those without diabetes, 63% of depressed patients had at least 3 other comorbid medical conditions, and 41% had at least 4 other comorbidities.
"Because patients in the early stages of chronic kidney disease are at increased risk for clinical depression, we as nephrologists should consider screening our patients for depression in clinic," Dr. Hedayati said in a news release. "Chronic kidney disease patient depression numbers may be higher due to the presence of the same simultaneously occurring conditions that resulted in progressive kidney disease, such as diabetes and atherosclerotic vascular disease. Alternatively, patients such as diabetics, who are depressed, may develop progressive kidney disease because of non-adherence to medications and physicians' advice."
Limitations of this study include its setting in a single center; relatively small sample size; and participants mostly male veterans, limiting generalizability. To determine the safety and efficacy of antidepressant medication in patients with CKD, the Chronic Kidney Disease Antidepressant Sertraline Trial (CAST) is now underway by Dr. Hedayati and colleagues.
"Special emphasis should be placed on the depression screening of patients with CKD with diabetes mellitus because diabetic participants with CKD were twice as likely to have a major depressive episode compared with nondiabetic participants with CKD," the study authors conclude. "Future large prospective studies are warranted to investigate whether depression also is related to poor outcomes in patients with CKD as in patients with ESRD [end-stage renal disease] on long-term dialysis therapy and whether treatment of depression will make a difference in the quality of life and clinical outcomes of patients with CKD before and after dialysis therapy initiation."
The views expressed in the journal article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The Veterans Integrated Systems Network 17, Veterans Affairs North Texas Health Care System Research Corporation, the National Institutes of Health, and the University of Texas Southwestern O'Brien Kidney Research Core Center funded this study. The study authors have disclosed no relevant financial relationships.
Am J Kidney Dis. 2009;54:424-432. Abstract
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