Treatment of depression for people with end-stage kidney disease undergoing hemodialysis
In a recent clinical trial testing therapies for depression in people undergoing hemodialysis for kidney failure, researchers found that an engagement interview had no effect on acceptance of depression treatment, while depression scores were modestly improved with the drug sertraline compared with cognitive behavioral therapy (CBT). Kidney disease can worsen over time and may lead to kidney failure. If less than 15 percent of the kidney is working normally, that’s considered kidney failure—also referred to as end-stage renal disease (ESRD). Hemodialysis is a treatment in which a machine filters wastes and water from the blood, as the kidneys did when they were healthy; but it has limitations and does not totally replace the function of normal kidneys. Hemodialysis sessions usually last several hours each, on multiple days each week. A common condition associated with people on hemodialysis is depression. Depression is a serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. Many people on hemodialysis do not receive treatment for depression, possibly because of their reluctance to accept a diagnosis for this condition and/or receive treatment. In addition, the effectiveness of antidepressant therapies in people undergoing hemodialysis has not been properly evaluated in clinical trials, making depression treatment in this patient population difficult.
A recent two-phase, randomized, controlled clinical trial assessed therapies for depression in women and men, ages 21 years and older, who had depression and ESRD and were receiving hemodialysis at any of 41 dialysis centers. The first phase of the trial investigated whether an engagement interview would increase the 184 participants’ willingness to accept the diagnosis of and treatment for depression. The engagement interview was conducted face to face by trained therapists while participants received their hemodialysis treatment. The participants in the engagement interview were also given a DVD to improve their understanding of depression and its treatment. The researchers’ findings indicated that the engagement interview had no effect on their acceptance of treatment for depression compared to a control group, which had a visit from a research team member during which they discussed the diagnosis of depression and associated treatment options. The 120 participants in the second phase of the trial were divided into two groups of 60 to receive either individual CBT or sertraline therapy. CBT teaches a person different ways of thinking, behaving, and reacting to situations. Participants in the CBT group were scheduled for 10 sessions of 60 minutes each over 12 weeks while undergoing hemodialysis. Sertraline is used to treat depression and is in a class of antidepressants called selective serotonin reuptake inhibitors. It works by increasing the amount of serotonin—a natural chemical in the brain that is implicated in the regulation of many behaviors, mental processes, and mood. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment compared to CBT. Sertraline use, however, was associated with mild to moderate adverse events related to the digestive, heart, and nervous systems.
These results provide a foundation on which healthcare providers and patients on hemodialysis can enter into the shared decision-making process to choose between CBT and sertraline to treat depression. It may also pave the way for potential future research on other depression treatments for people on hemodialysis.
Mehrotra R, Cukor D, Unruh M,…Hedayati SS. Comparative efficacy of therapies for treatment of depression for patients undergoing maintenance hemodialysis: a randomized clinical trial. Ann Intern Med 170:369-379, 2019.