Daniel Cukor

Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients

End-stage renal disease (ESRD) is a growing public health concern and non-adherence to treatment has been associated with poorer health outcomes in this population. Depression, likely to be the most common psychopathology in such patients, is associated with increased morbidity and mortality. We compared psychological measures and self-reported medication adherence of 94 kidney transplant recipients to those of 65 patients receiving hemodialysis in a major medical center in Brooklyn, New York. Compared to the transplant group, the hemodialysis cohort was significantly more depressed as determined by the Beck Depression Inventory score. They also had a significantly lower adherence to medication as reported on the Medication Therapy Adherence Scale. Using hierarchical multiple regression analysis, the variance in depression was the only statistically significant predictor of medication adherence beyond gender and mode of treatment, accounting for an additional 12% of the variance. Our study strongly suggests that a depressive affect is an important contributor to low medication adherence in patients with ESRD on hemodialysis or kidney transplant recipients.

Depression and anxiety in urban hemodialysis patients.

Depression is well established as a prevalent mental health problem for people with ESRD and is associated with morbidity and mortality. However, depression in this population remains difficult to assess and is undertreated. Current estimates suggest a 20 to 30% prevalence of depression that meets diagnostic criteria in this population. The extent of other psychopathology in patients with ESRD is largely unknown. The aim of this study was to expand the research on psychiatric complications of ESRD and examine the prevalence of a broad range of psychopathology in an urban hemodialysis center and their impact on quality of life. With the use of a clinician-administered semistructured interview in this randomly selected sample of 70 predominately black patients, >70% were found to have a psychiatric diagnosis. Twenty-nine percent had a current depressive disorder: 20% had major depression, and 9% had a diagnosis of dysthymia or depression not otherwise specified. Twenty-seven percent had a current major anxiety disorder. A current substance abuse diagnosis was found in 19%, and 10% had a psychotic disorder. The mean Beck Depression Inventory score was 12.1 +/- 9.8. Only 13% reported being in current treatment by a mental health provider, and only 5% reported being prescribed psychiatric medication by their physician. A total of 7.1% had compound depression or depression coexistent with another psychiatric disorder. The construct of depression was also disentangled from the somatic effects of poor medical health by demonstrating a unique relationship between depressive affect and depression diagnosis, independent of health status. This study also suggests the utility of cognitive variables as a meaningful way of understanding the differences between patients who have ESRD with clinical depression or other diagnoses and those who have no psychiatric comorbidity. The findings of both concurrent and isolated anxiety suggest that the prevalence of psychopathology in patients with ESRD might be higher than previously expected, and the disorders may need to be treated independently. In addition, the data suggest that cognitive behavioral therapeutic techniques may be especially advantageous in this population of patients who are treated with many medications.

Depression in end-stage renal disease hemodialysis patients

Depression has been identified as a complicating comorbid diagnosis in a variety of medical conditions, including end-stage renal disease (ESRD). Despite this, the psychological health of hemodialysis patients is understudied. The purpose of this paper is to review the research and issues involved in the assessment of depression and its sequelae in ESRD. Accurate estimation of the prevalence of depression in the ESRD population has been difficult due to the use of different definitions of depression and varied assessment techniques, the overlap of depressive symptomatology with symptoms of uremia, and the confounding effects of medications. We suggest that depressive affect is a more important construct to study than diagnosis of depression syndromes per se in patients with chronic kidney disease. The Beck Depression Inventory is a reasonable measure of depressive affect in the ESRD population, if a higher than usual cutoff score is used or if its somatic components are omitted. Several pathways link depression and ESRD, and are probably bidirectional. As such, treatment of depressive affect could impact medical as well as psychological outcomes. The need for treatment intervention trials is great. Limited evidence regarding the safety and efficacy of treatment of hemodialysis patients with selective serotonin reuptake inhibitors is available, and cognitive behavioral therapy holds promise as an intervention for depression in this complex medical population.

Course of Depression and Anxiety Diagnosis in Patients Treated with Hemodialysis: A 16-month Follow-up

BACKGROUND AND OBJECTIVES There is growing identification of the need to seriously study the psychiatric presentations of end-stage renal disease patients treated with hemodialysis. This study reports on the course of depression and anxiety diagnoses and their impact on quality of life and health status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The 16-mo course of psychiatric diagnoses in 50 end-stage renal disease patients treated with hemodialysis was measured by structured clinical interview. RESULTS Three different pathways were identified: one subset of patients not having a psychiatric diagnosis at either baseline or 16-mo follow-up (68% for depression, 51% for anxiety), one group having an intermittent course (21% for depression, 34% for anxiety), and one group having a persistent course (11% for depression, 15% for anxiety), with diagnoses at both time 1 and time 2. For depression, the people with the persistent course showed marked decreases in quality of life and self-reported health status compared with the nondepressed and intermittently depressed cohorts. The most powerful predictor of depression at time 2 is degree of depressive affect at time 1(P < 0.05). CONCLUSIONS Patients at risk for short- and long-term complications of depression can be potentially identified by high levels of depressive affect even at a single time point. As nearly 20% of the sample had chronic depression or anxiety, identifying a psychiatric diagnosis in hemodialysis patients and then offering treatment are important because, in the absence of intervention, psychiatric disorders are likely to persist in a substantial proportion of patients.

The Relationship Between Parenting Style, Cognitive Style, and Anxiety and Depression: Does Increased Early Adversity Influence Symptom Severity Through the Mediating Role of Cognitive Style?

Despite the central role accorded to cognitive style in mediating the relationship between negative parenting and the development of anxiety and depression, few studies have empirically examined this relationship. Using a clinical sample, this study examined the relationship between early experiences with low care, increased control, abuse and neglect, and symptoms of anxiety and depression, via the mediating effects of cognitive style. It was found that individuals who rate their parents as being more abusive and neglectful reported a greater degree of depression and that this relationship was mediated by dysfunctional cognitive style. These findings contribute to the growing literature by providing support for the role of cognitions in mediating the link between negative parenting and psychopathology.

Psychosocial Intervention Improves Depression, Quality of Life, and Fluid Adherence in Hemodialysis

Patients with ESRD have high rates of depression, which is associated with diminished quality of life and survival. We determined whether individual cognitive behavioral therapy (CBT) reduces depression in hemodialysis patients with elevated depressive affect in a randomized crossover trial. Of 65 participants enrolled from two dialysis centers in New York, 59 completed the study and were assigned to the treatment-first group (n=33) or the wait-list control group (n=26). In the intervention phase, CBT was administered chairside during dialysis treatments for 3 months; participants were assessed 3 and 6 months after randomization. Compared with the wait-list group, the treatment-first group achieved significantly larger reductions in Beck Depression Inventory II (self-reported, P=0.03) and Hamilton Depression Rating Scale (clinician-reported, P<0.001) scores after intervention. Mean scores for the treatment-first group did not change significantly at the 3-month follow-up. Among participants with depression diagnosed at baseline, 89% in the treatment-first group were not depressed at the end of treatment compared with 38% in the wait-list group (Fishers exact test, P=0.01). Furthermore, the treatment-first group experienced greater improvements in quality of life, assessed with the Kidney Disease Quality of Life Short Form (P=0.04), and interdialytic weight gain (P=0.002) than the wait-list group, although no effect on compliance was evident at follow-up. In summary, CBT led to significant improvements in depression, quality of life, and prescription compliance in this trial, and studies should be undertaken to assess the long-term effects of CBT on morbidity and mortality in patients with ESRD.

History of child abuse and severity of adult depression: the mediating role of cognitive schema

ABSTRACT The link between childhood abuse, adult depression, and anxiety has been well studied, but few studies have empirically explored the mechanism of that link. Using a clinical sample of women, this study examined the relationship between retrospectively measured childhood abuse and neglect and current adult symptoms of anxiety and depression, via the mediating effects of cognitive style. This study found that women who reported a positive abuse history were significantly more depressed and exhibited more maladaptive schemas than women who did not report a history of abuse. Specifically, it would appear that cognitive styles marked by interpersonal disconnection and rejection are particularly pathogenic. These findings contribute to the growing literature by providing support for the role of cognitions in mediating the link between childhood abuse and psychopathology.

Depression and nonadherence predict mortality in hemodialysis treated end-stage renal disease patients.

The scientific evaluation of depressions impact on mortality in hemodialysis (HD) patients has yielded mixed results, with the more recent, more rigorous studies detecting a significant relationship. In this study, 130 HD patients from an urban North American hospital were evaluated for depressive affect and then observed for up to 5 years. In a corrected Cox regression model, which held constant age, gender, dialysis vintage, illness severity and diabetic status, depressive affect emerged as a modest but significant predictor of mortality (relative risk = 1.05, 95% confidence interval = 1.01–1.08). When the subjects were divided according to depressive affect severity, those with severe depressive affect had significantly shorter time to death (β = 0.452, P = 0.044). In a subgroup of 85 subjects, self‐reported medication adherence was also predictive of mortality, with higher rates of nonadherence being associated with increased mortality risk. This paper lends support to the burgeoning literature on depression and reduced survival in HD populations, as well as begins the investigation of understanding the underlying mechanisms.

Depression and Non-adherence Predict Mortality in Hemodialysis Treated ESRD Patients

The scientific evaluation of depressions impact on mortality in hemodialysis (HD) patients has yielded mixed results, with the more recent, more rigorous studies detecting a significant relationship. In this study, 130 HD patients from an urban North American hospital were evaluated for depressive affect and then observed for up to 5 years. In a corrected Cox regression model, which held constant age, gender, dialysis vintage, illness severity and diabetic status, depressive affect emerged as a modest but significant predictor of mortality (relative risk = 1.05, 95% confidence interval = 1.01–1.08). When the subjects were divided according to depressive affect severity, those with severe depressive affect had significantly shorter time to death (β = 0.452, P = 0.044). In a subgroup of 85 subjects, self‐reported medication adherence was also predictive of mortality, with higher rates of nonadherence being associated with increased mortality risk. This paper lends support to the burgeoning literature on depression and reduced survival in HD populations, as well as begins the investigation of understanding the underlying mechanisms.

Depression and mortality in end-stage renal disease.

End-stage renal disease is growing in prevalence and incidence. With technical advancements, patients are living longer on hemodialysis. Depression is the most prevalent comorbid psychiatric condition, estimated at about 25% of end-stage renal disease samples. The identification and assessment of depression are confounded by the overlap between depression symptomatology and uremia. Several recent studies have employed time-varying models and identified a significant association between depression and mortality. Due to the high prevalence of depression and the potential impact on survival, well-constructed investigations are warranted.