Patients on dialysis often live for years with diabetes or hypertension—with their burdensome medication regimens and lifestyle constraints. Combined with four-hour, thrice-weekly dialysis, patients can easily become depressed if they aren’t so already.
A recent Annals of Internal Medicine study indicates that cognitive behavioral therapy (CBT) and sertraline effectively reduce depression in people undergoing maintenance hemodialysis. Sertraline proved slightly more effective, although both treatments seemed to work for patients, according to the researchers. They recommend that physicians choose whichever treatment is available and acceptable to the patient, recognizing that both have a downside: CBT must be given once a week for 10 sessions, and sertraline is a daily pill with a higher risk for adverse events such as nausea and dizziness.
The multicenter, randomized controlled trial included 184 patients with kidney failure at 41 dialysis facilities in three U.S. metropolitan areas. All had been screened and identified as having depression.
The two-phase trial first determined the effect of an “engagement interview” on patients’ acceptance of a treatment offer, then compared the efficacy of both therapies. Half the participants were randomly assigned to receive an interview in which the patient’s depressive signs were more fully explored and discussed; the other half received a simplified statement of their depression diagnosis and a treatment offer.
The approach had no bearing on patients: 66% of the engagement group and 64% of the control group opted for treatment. The numbers surprised the researchers, who contrasted this finding with earlier research that indicated only 17% of patients on dialysis with depression had opted for treatment.
The patients amenable to treatment were randomly assigned 10 CBT sessions over 12 weeks (delivered during their dialysis sessions) or prescribed daily sertraline for 12 weeks.
A disproportionate number of patients on dialysis represent racial and ethnic minorities, and the median age for beginning treatment is 62 years. The number of people with end-stage renal disease also is increasing. Today, more than half a million Americans receive hemodialysis and current literature suggests that at any time, nearly one in three such patients meets the clinical criteria for depression. But many never receive treatment for the condition.
Researchers say this could be a result of three things: a lack of recognition and diagnosis by health care providers; patients’ reluctance to acknowledge depression because of its persistent stigma; and a lack of quality data that depression treatments in the general population are effective among this patient population in particular.
The Centers for Medicare and Medicaid Services addressed the situation in 2016 when it began requiring Medicare patients on dialysis to be screened annually for depression. However, many such patients have no primary care doctor, and nephrologists have not been trained in treating depression and/or making the treatments available.
Source: MedicalXpress, February 25, 2019