Depression and Other Psychological Issues in CKD

Depression, anxiety, and other psychological issues are more prevalent among patients with chronic diseases such as chronic kidney disease (CKD) compared to the general population and patients in primary care settings. Nearly one out of four or five patients with kidney disease experiences a major depressive disorder (MDD), which is greater than the proportion with depression reported for other chronic diseases, such as diabetes mellitus, coronary artery disease, or congestive heart failure. It is well-established that the presence of either high scores on depressive symptom severity scales or a clinical diagnosis of MDD is not only associated with increased morbidity and mortality among patients with CKD or those treated with maintenance dialysis but also associated with adverse patient-centered outcomes, such as sleep disturbance, fatigue, and poor QOL. Therefore, recognizing depressive symptoms, diagnosing MDD, and excluding other conditions such as anxiety, pain, dementia, delirium, and somatic symptoms of uremia are very important to develop appropriate management strategies for such patients. Validated tools can be used to screen for depressive symptoms on a regular basis in CKD and a clinical diagnosis of depression should be confirmed in those who screen positive either by using a structured clinician-administered interview or by referral to mental health, based on complexity of the presentation and presence of comorbid psychiatric illnesses, such as bipolar disorders. Risk for suicide should be ascertained and triaged appropriately. Various pharmacological and non-pharmacological interventions can be applied to treat MDD in patients with CKD, with new data emerging regarding treatment of MDD in this patient population. Cognitive behavioral therapy (CBT), physical activity, antidepressant medications, or a combination of these modalities can be considered for treating MDD in CKD patients. If antidepressant medications are considered, they should be initiated at a low dose and titrated up based on frequent monitoring to ensure tolerability and response to treatment.