Depression and CKD

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Introduction   

Depression is a common but serious mood disorder and can be exacerbated by chronic conditions such as chronic kidney disease (CKD). It is also a comorbidity that is prevalent in people with chronic kidney disease (CKD). Due to the similarities in presentation of symptoms, including fatigue, insomnia, and unplanned weight loss, depression is often an overlooked complication of CKD. There is a direct correlation between depression and kidney disease as it can lead to poor health outcomes by increasing mortality rates and decreasing one’s quality of life [2].  

Background 

CKD is a condition that causes the kidneys to lose their function over time and can lead to end-stage renal. CKD is a growing global health concern that affects more than 35.5 million people in the US. 1 in 7 adults in the United States has CKD. CKD is irreversible and is known as a silent killer because it can occur without one knowing that they suffer from the disease. The main causes of CKD are hypertension and uncontrolled diabetes [2].  

CKD can contribute to other life stressors that affect people mentally, physically, and socially, which leads to poor health outcomes. Also, the progression of CKD can have effects on one’s mental health, which can lead to depression. When left untreated, CKD can lead to stress, anxiety, substance use, and depression. This can be mainly due to some of the following: inability to work, financial burden, dietary restrictions, and isolation. Depression in patients with chronic kidney disease has negative effects known to contribute to poor health outcomes, occupational role function, increased hospitalization, and a decrease in quality of life [1][9].  

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), depression, also known as a major depressive disorder or clinical depression, is a serious but common mood disorder that causes persistent feelings of sadness and loss of interest in life. People affected by depression often experience sadness and feelings of hopelessness and have no interest in day-to-day activities that they previously enjoyed. Depression can cause severe symptoms that affect a person, i.e., how they think, perform daily activities, their diet, and work. Depression can also contribute to substantial functional and decreased quality of life in patients with CKD [4].  

Epidemiology of Depression in Chronic Kidney Disease 

The prevalence of depression in patients with CKD is 20% – 30% compared to 2% – 10% of the general population with other chronic diseases such as heart failure.  According to the World Health Organization, depression is a common mental disorder that affects 5% of the global population. Depression can occur at any age, although it is often seen in adulthood. People with CKD are three or four times more prone to having depression, which is known to increase the risk of morbidity and mortality rates [9]. 

There is a higher mortality rate in patients with depressive symptoms, which also accounts for 40,000 suicidal deaths in the United States annually. Patients with CKD are affected by clinical depression, which is a larger percentage compared to those with other chronic diseases such as heart failure. Depression tends to affect women more than men. Depression in CKD can affect anyone, although it is more prevalent in minorities and unrecognized in racial and ethnic minorities [4].  

Etiology 

Etiology of Chronic Kidney Disease 

There are a variety of factors that contribute to the progression of kidney disease, which can lead to CKD and eventually end-stage renal disease (ESRD). Kidney disease can occur due to a primary or secondary cause. Primary causes would be disease processes such as glomerulonephritis, pyelonephritis, and congenital hyperplasia. A secondary cause can be systemic causes such as diabetes or lupus erythematosus. Injury to the kidneys’ hyperfiltration system and the nephrons can be irreversible and progress in severity, leading to chronic kidney disease [6].  

CKD occurs when there is damage to the kidneys and a decrease in the kidney’s function for three months or more. CKD can be staged based on the etiology and a decline in the glomerular filtration rate (GFR), which is known as a hallmark of progression with kidney disease and is used to measure one’s kidney function [5][6]. There are physiologic changes that happen due to CKD. These are somatic symptoms, impairment in one’s quality of life, and their role with family, which increases their risk for depression [4]. 

Etiology of Depression 

Depression is a complex disorder that can occur due to multifactorial reasons that are either biological, psychological, or environmental. Different types of depression can occur due to different circumstances. Life events such as chronic illness can trigger stressors that can cause an onset of depression.  

Although the pathophysiology of depression is not well understood, it has also been linked to an increase in cortisol and other neurohormones in the body [4][7]. 

• Biological: Due to genetic predisposition, neurologic and hormonal.  
• Psychological factors: Chronic illness, anxiety, substance abuse, behavioral, grief, and social isolation.  
• Environmental factors: finances, chronically stressful life events, exposure to depression as a child, and low socioeconomic situations. 

Risk Factors 

There are several risk factors associated with the development is CKD: History of acute kidney injury (AKI), obesity, smoking, substance abuse, sedentary lifestyle, dehydration, heart disease, liver disease and medications, infections, age 60 and above, and family history [5].  

Several contributing factors can lead to the development of depression. These can be due to genetic predisposition, biological, environmental, and psychological reasons. Family history and major changes to one’s life events such as an illness, trauma, and stress [4][9] 

Symptoms of Depression and CKD 

Chronic kidney disease and depression have overlapping symptoms, which makes it challenging to differentiate. These symptoms include fatigue, weight loss due to poor appetite, difficulty concentrating, and insomnia. Although there are some differences in both conditions, these are some symptoms that can be present in both depression and chronic kidney disease, therefore, it is important to diagnose them separately [4][9].  

• Depression: Weight loss, psychomotor agitation and retardation, insomnia or psychomotor agitation, fatigue, feelings of worthlessness, decreased ability to think or concentrate, suicidal ideation [4]. 
• CKD: More pronounced in moderate to severe stages of CKD. Generalized malaise, forgetfulness, loss of libido, nausea, hypertension, and shortness of breath [6].  

Diagnosis of Depression 

Often, validated self-reported questionnaires such as the Patient Health Questionnaires (PHQ -9) are used to diagnose depression in patients with CKD [4]. The gold standard to diagnose depression clinically is through the following:  

• Structured Clinical Interview for DSM disorders (SCID) 
• The Mini-International Neuropsychiatric Interview (MINI) 
• The Composite International Diagnostic Interview (CIDI).  

To be diagnosed with depression, the person must be experiencing some of the following symptoms within 2 weeks and at least one of the following symptoms listed below [4].  

• Feelings of depression for most of the day and nearly daily. 
• Unplanned significant weight loss is due to decreased appetite.  
• Feelings of fatigue, restlessness, and slowing down with daily activities.  

Diagnosing depression in patients with CKD can be challenging due to the overlapping physical symptoms that are associated with both disease processes. Symptoms of depression are commonly seen in patients with CKD [7][8]. 

Often, the two disease processes are not differentiated due to some of the following reasons.  

• There is a lack of screening tools and techniques that are used to rule out depression in patients diagnosed with CKD. Screening 6 to 12 months through utilization of self-reported questionnaires. 
• A lack of a system-wide protocol on the assessment of depression in patients with comorbidities such as depression.  
• Limitations in the criteria of depressive symptoms of the self-reporting questionnaires for diagnosing CKD.  
• Varying attitudes and beliefs about depression can sometimes influence stigma, which may contribute to people not seeking help when they are experiencing depression. 

Treatment and Management of Depression in Patients with CKD 

The treatment and management of depression in patients with CKD come with unique challenges that can easily lead to psychological stressors that make patients more vulnerable to psychopathologies such as depression, cognitive impairment, anxiety, and sleep disorders [8]. It is important to recognize that depression in patients with CKD can manifest later due to the patient’s inability to cope with the expected treatment regimen. Although depression has negative impacts on this patient population, it is a health problem that is often overlooked in healthcare. The consequences of not managing depression in CKD are underestimated, and studies suggest that more attention is needed to include depression screening as part of routine in CKD patients [8][9]. 

Even though the prevalence of CKD is large, depression in patients continues to be undertreated. Two of the following approaches can assist with the treatment of depression in patients with CKD.  

• Early recognition and treatment of depression: This can lead to better health outcomes. Treatment is usually through medication and psychotherapy or both.  
• Treatment must be tailored to the patient’s needs. That is due to concerns related to medication interference with the clearance in the kidneys with patients with CKD. For example, the patient’s dosage on medication can be tailored to their GFR score to prevent AKI [6] [7].  

Other ways of managing depression in patients with kidney disease include: 

• Modifying one’s lifestyle, i.e., exercise, smoking cessation, limiting alcohol intake, and eating a healthy diet, can help improve kidney function. 
• Management of depression in patients with CKD requires a collaborative effort. These can include nephrologists, psychiatrists, social workers, patients, and their families or support systems. 
• A combination of therapies is known to improve symptoms of depression, quality of life, and better compliance to CKD and prevent relapse. This can include medication and psychotherapy such as cognitive-behavioral therapy (CBT) [4][9] 
  • Cognitive behavioral therapy (CBT) – structured treatment that assists with logic and organization of thoughts [4]. 
  • Antidepressants and antianxiety: Commonly used medications are used to treat depression as a comorbidity. These may take up to 4 – 8 weeks to work. Antidepressants and anti-anxieties: A collaborative effort is needed between the neurologist and mental health doctor because it will be helpful to have the patient on the right medication that won’t cause any further damage to the kidneys.  
  • Electroconvulsive therapy is helpful in patients that have challenges in responding to medication or have suicidal thoughts.  
  • Exercise training programs to help relieve stress. 

Nursing Interventions 

• Listen to the patient in a calm and unhurried manner. This can assist in developing a rapport with the patient.  
• Assess whether the depression is sudden or has been ongoing. 
• Attempt to find out whether the patient has had suicidal thoughts. This can be accomplished through self-reported screenings, i.e., asking the patients if they have any plan to harm themselves or take their life. 
• Give medications, i.e., antidepressants and anti-anxieties as ordered. 
• Encourage smoking cessation in patients who smoke. 
• Reassure patients that depression is treatable. 
• Offer supportive ideas or services to patients. 
• Assist with consultation for psychiatric evaluation. 
• Anticipate that some patients are suicidal. 

Patient Education 

Healthcare workers need to be more aware of the serious implications that depression has on patients, such as the risk of self-harm. Therefore, there is a need for awareness and knowledge about depression [2].  

• Patient awareness of depression: Misconceptions about depression – it is sometimes perceived as a weakness or failure in life which could be a reason as to why people are hesitant to seek help.  
• Exercise: Can assist with improving one’s health  
• Diet: Eating foods that promote better kidney health that can help with slowing the progression of kidney disease i.e. decreasing the intake of foods high in sodium or potassium.  
• Sleep promotion: getting enough sleep to assist one with having a clear mind and reduce fatigue. 
• Antidepressants: Patients must be instructed not to stop medications abruptly or without informing the health care provider to prevent suicidal ideation. Patients must also be educated that medications can cause suicidal thoughts before they work effectively. 
• Alcohol limitation and smoking cessation: These can help with managing blood pressure and improve overall health. Patients must be encouraged to maintain BP below 140/90. 
• Maintaining open communication between interprofessional teams – Helps patients to build self-esteem.  

Conclusion

Depression is common in patients with CKD and is known to be associated with poor health outcomes if left untreated. The disease is more prevalent in minority groups like Hispanics and blacks. More studies and better screening tools on depression in CKD need to be developed to assist in evaluating the effects of depression in these patient populations. 

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