A recent study of patients with kidney failure receiving outpatient hemodialysis1,2 found similar effectiveness between nonpharmacological and pharmacological treatments for depression.

Depression is common among patients with kidney failure and is associated with poor outcomes including higher risk of kidney function decline, hospitalization, and death. In the United States, the Centers for Medicare & Medicaid Services (CMS) requires dialysis facilities to screen patients for depression. Positive screenings require kidney care teams to create a follow-up plan for further assessment and treatment.3

American College of Physicians practice guidelines for treating depression in the general population4 recommend either cognitive behavioral therapy (CBT) or drug treatment as first-line therapy for mild or moderate depression. But few major studies have assessed the effectiveness of these depression treatments among patients with kidney failure. A recent PCORI-funded study is the first randomized controlled trial comparing CBT and sertraline for treating major depressive disorder or dysthymia in patients with kidney failure receiving maintenance hemodialysis.

Findings

A PCORI-funded study of patients with kidney failure undergoing maintenance hemodialysis found that patients with depression who received sertraline, compared with patients with depression who received CBT, had modestly better depression scores and improvements in other patient-reported outcomes but also reported more frequent mild to moderate adverse events.

Addressing Challenges to Depression Treatment in Patients with Kidney Failure

Patients with kidney failure receiving maintenance hemodialysis may be unaware of their depression or hesitant to pursue depression treatment. Patients often believe their depression symptoms, which may include loss of appetite, headaches, muscle aches, insomnia, fatigue, and having a hard time concentrating, are part of living with kidney failure and cannot be improved.5 Also, adding more medication and medical visits may increase burden and costs for patients who already face many challenges.

To address these issues, the kidney care team can discuss the benefits of treating depression with their patients, including how to choose a treatment that best fits patients’ preferences and lifestyle. Kidney care staff can, for example, help patients find therapists outside the dialysis center.

Talking with Patients about Depression

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A consumer-friendly version of this update is available here to help support conversations with patients and caregivers about treating depression while receiving maintenance hemodialysis. Topics clinicians may wish to discuss with patients include:

  • How symptoms of untreated depression can mimic the symptoms of kidney failure.
  • How treating depression may improve both quality of life and kidney care outcomes.
  • How to weigh the benefits and trade-offs of talk therapy versus taking additional medication.
  • Opportunities for individual or group support, including peer mentoring, for improving the recognition and treatment of depression.

Clinicians may also wish to make their patients aware of available resources, including the following:

  • The Dialysis Patient Depression Toolkit available through The National Forum of ESRD (End Stage Renal Disease) Networks.
  • The national hotline for Substance Abuse and Mental Health Services Administration (SAMHSA) at 1-800-662-HELP (4357). This hotline is a confidential, free, 24-hour information service in English and Spanish that provides referrals to treatment facilities, support groups, community-based organizations, and publications.

About the Study

Researchers enrolled 120 patients ages 21 and older with kidney failure and major depressive disorder or dysthymia who were receiving outpatient hemodialysis. This randomized controlled trial compared daily sertraline versus 10 individual CBT sessions administered during dialysis visits over 12 weeks of treatment. The primary outcome was severity of depressive symptoms as measured by the Quick Inventory of Depressive Symptomatology (Clinician Rated) (QIDS-C).

Read more about this study at www.pcori.org/Mehrotra209

Download this Evidence Update


Sources

1. © 2011–2021 Patient-Centered Outcomes Research Institute. “Comparing Two Treatments for Depression among Patients with Kidney Failure Receiving Hemodialysis -- The ASCEND Study.” Last updated May 14, 2020. www.pcori.org/Mehrotra209

2. Mehrotra R, Cukor D, Unruh, M et al. Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial. Annals of Internal Medicine 2019;170(6):369–379. https://doi.org/10.7326/M18-2229

3. Garcia T. “Addressing Depression in Dialysis Patients: A New ESRD QIP Reporting Initiative.” Presentation at the 2015 CMS Quality Conference, Baltimore, MD, December 1, 2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/ESRD-QIP-Policy-Update-and-Depression-Screening-CMS-Quality-Conference-v1_5-508.pdf

4. Qaseem A, Barry MJ, Kansagara D, et al. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2016;164(5):350–359. https://doi.org/10.7326/M15-2570

5. The National Forum of ESRD Networks, Kidney Patient Advisory Council. Dialysis Patient Depression Toolkit, 2018. https://www.esrdnetwork.org/sites/default/files/Dialysis%20Patient%20Depression%20Toolkit.pdf

The information in this publication is not intended to be a substitute for professional medical advice. This update summarizes findings from a PCORI research award to the University of Washington.

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