Psychosocial Issues in Patients Treated With Dialysis

This chapter reviews the growing scientific literature on the psychosocial challenges patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) confront, concentrating on psychopathology, sleep disturbances, quality of life (QOL), and barriers to adherence to the medical prescription.

Patients' responses to the onset of ESRD and its continued treatment can alter their course, prognosis, and QOL. The psychological landscape shapes the patient's perception of his or her ability to cope with the diagnosis and the treatment's ongoing demands. Patients' state of mind, level of support, understanding of the disease, and adherence behaviors are all factors determining how patients adjust. Although the extent of one's physical illness affects one's psychosocial functioning, conversely, the strength of one's ability to cope can affect the course of medical illness. For example, increased depression and social strain can lead an ESRD patient to a cycle of decreased adherence, increased illness severity, and greater symptom burden.

Psychopathology

Depression

Depression is defined by the latest version of the Diagnostic and Statistical Manual for Psychiatric Disorders ( DSM-5 ) as being present when an individual displays either a subjective depressed mood or a diminished interest or pleasure in activities, most of the day, nearly every day over a 2-week period, plus any four of the following additional symptoms: significant weight loss, insomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, or recurrent thoughts of death. These symptoms should cause impairment to the individual and be unrelated to a medication or medical condition. These last caveats could significantly complicate the diagnosis of depression in ESRD patients because they are typically treated with a variety of medications for kidney disease or other comorbid conditions that may have side effects that mimic depression. Furthermore, uremia and dialysis treatment itself can be the cause of somatic symptoms such as fatigue, insomnia, and inability to concentrate.

Despite the challenges in the accurate assessment of depression in patients treated with HD, a prevalence of depression of approximately 20% to 30% in HD patients has been reported when using rigorous clinician-administered diagnostic interviews. The rate is typically somewhat higher, toward 50%, if depressive effect is measured using a self-report measure.

Treatment

Despite these relatively high prevalence rates, depression may be undertreated in HD patients. There is also a paucity of studies evaluating depression treatment in HD patients. There are generally two approaches to treatment of depression in HD patients: pharmacologic and nonpharmacologic.

Pharmacologic Treatment

In an early study of a selective serotonin reuptake inhibitor (SSRI), 14 maintenance HD patients with major depression were randomly assigned to either treatment with fluoxetine or placebo. The antidepressant outperformed placebo at 4 weeks but not at 8 weeks. Improvement in depressive symptoms was reported in two observational studies of the effects of antidepressants in 136 peritoneal dialyses (PD) patients. These studies, however, had no control arm, had a small sample size, and had high medication discontinuation rates. Atalay et al. reported that treatment with sertraline (50 mg a day) for 12 weeks led to a decrease in depressive symptoms in 25 long-term PD patients. Similarly, this study did not have a control arm.

In a Korean study, paroxetine and individual supportive counseling were assessed in 34 depressed dialysis patients. There was a statistically significant but clinically mild response to the treatment. This study also suffered from a small sample size, lack of a placebo-control group, and absence of follow-up information.

A recent multisite study, the ASCEND trial, compared the efficacy of sertraline and cognitive-behavioral therapy (CBT) for depression in ESRD patients treated with maintenance HD. Both interventions proved to be efficacious and reduced depression scores. There was a slightly greater improvement in the medication group, but there was also a higher rate of minor side effects. The authors concluded that both treatments appear to be effective, and treatment recommendations should depend on risk profile, patient preference, and availability of resources.

Nonpharmacologic Treatment

Nonpharmacologic treatment interventions for depression in HD patients have been evaluated as well. Two primary interventions include CBT and exercise therapy.

Cognitive Behavioral Therapy

CBT is a type of psychotherapy that helps patients to dissect the relationships among their emotions, cognitions, and behaviors in order to identify and reframe irrational and self-defeating thoughts. These changes can improve their mood and, in turn, can empower people to control their unhelpful cognitive and behavioral patterns. CBT can be performed in groups or individually. CBT attempts to empower individuals to control their negative cognitive and behavioral patterns.

Three randomized controlled trials (RCTs) have rigorously examined CBT in patients treated with HD. Cukor et al. compared patients who received 10 CBT sessions administered chair side during regular HD treatments with a wait-list control group using a crossover design. CBT resulted in a significant reduction in depressive effect, increased perception of QOL, and better treatment adherence compared with control participants. In another RCT of 85 HD patients with major depressive disorder, CBT was compared with standard care. The CBT group demonstrated a more significant reduction in depressive effect than the standard care group, both at the end of treatment and at follow-up.

As before, in the ASCEND trial, chair-side CBT proved to be an efficacious treatment of depression. In this trial, participants received 10 sessions over 12 weeks of individual CBT, with significant reductions in clinician-administered and self-report measures of depression. CBT appears to be a promising intervention for reducing depression in ESRD patients treated with HD.

Exercise Therapy

The ability of exercise programs to improve mood in dialysis patients was recently tested in three small-scale studies. Across the studies, depression was statistically significant but modestly reduced in patients who engaged in physical activity. However, a limitation of these studies was low retention rates across the exercise programs, suggesting limited efficacy of this intervention as a broad-based strategy. Furthermore, these studies have not recruited formally diagnosed patients with depression into their studies but, instead, observed the effect of exercise on the full spectrum of mood scores.

Anxiety

The DSM-5 classifies anxiety disorders by their common feelings of overwhelming fearfulness, dread, and uncertainty. Unlike relatively mild brief anxiety reactions, a true anxiety disorder must last at least 6 months. There was a significant change in the categorization of anxiety disorders with the recent update to DSM 5. Obsessive-compulsive disorders and posttraumatic stress disorders are no longer classified as anxiety disorders. Similar to depression, the assessment of anxiety is complicated by symptoms overlapping with uremia, multiple measurement tools, and imprecise definitions and cut-offs for clinical diagnosis.

Anxiety is a relatively common experience for HD patients. In studies, patients treated with HD exhibit significantly greater symptoms of anxiety compared with transplant patients and control participants. A systematic review of 55 studies of anxiety symptoms in ESRD patients indicated an overall prevalence rate of 38%, with levels of prevalence in individual studies ranging from 12% to 52%. Still, numerous studies have demonstrated that the role of anxiety in ESRD patients treated with HD remains underappreciated and understudied. It has also been suggested that anxiety contributes to dialysis nonadherence. A recent European study suggested that anxiety was associated with higher hospitalizations and mortality in dialysis patients. As of yet, there are no clinical trials testing the efficacy of anxiety treatments in ESRD populations. RCTs are certainly needed in this field because anxiety is associated with negative effects on general health, QOL, and a variety of psychosocial parameters in both ESRD patients and the general population. Only a well-designed RCT employing an effective intervention for anxiety in ESRD patients can determine if anxiety is causally related to poor outcomes in these patients.

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