Joseph Chilcot

Depression on Dialysis

Depression is the most common psychopathological condition among patients with end-stage renal disease (ESRD), yet it is still under-recognized and misdiagnosed. Depression reduces quality of life and has a negative clinical impact upon sufferers with chronic illness, including ESRD. This article discusses the negative effects of depression among the ESRD population treated with dialysis, the prevalence of the condition, the methodological issues involved with screening and treatment, and the possible psychological and somatic causes. There is a need to identify the prevalence of the disorder by effective methods, overcome the current issues surrounding depression assessment and to undertake trials of suitable treatments.

Screening for depression while patients dialyse : an evaluation

BACKGROUND The lack of routine depression screening among the haemodialysis (HD) population may contribute to depression being under-recognised. While screening patients could be beneficial, the optimum screening procedure remains unclear. One method would be to screen HD patients while they receive their treatment. The purpose of this investigation was to determine whether the Beck Depression Inventory-II (BDI) could be administered while patients dialysed. METHODS Forty HD patients completed the BDI while dialysing and again at a time when off-dialysis. Level of agreement analysis (Bland and Altman) was undertaken to determine if the assessment condition influenced BDI scoring. The off-dialysis assessment also involved a short clinical interview that was compared with the BDI assessment. RESULTS There was a high level of agreement between the on- and off-dialysis assessments, but differences in response to the somatic items on the BDI scale were apparent between the conditions. The clinical interview revealed that 22% of the sample met the DSM-IV criteria for major depressive disorder. The optimal cut-off value for the BDI as determined by receiver operating characteristic curves was >or=16, with 88.9% sensitivity and 87.1% specificity. CONCLUSION The results indicate that the procedure of on-dialysis assessment using the BDI is a viable screening procedure. The practicality of employing this screening procedure may facilitate improved detection of depression in the dialysis population.

Illness representations are associated with fluid nonadherence among hemodialysis patients

OBJECTIVE Patients with end-stage renal disease are required to limit fluid and salt intake. We examined illness representations [common-sense model (CSM)] among a sample of hemodialysis (HD) patients, investigating whether fluid-adherent patients held illness representations different from those of nonadherent patients. We also explored the utility of illness perceptions in predicting fluid nonadherence after controlling for clinical parameters, including residual renal function (KRU). METHODS Illness perceptions were assessed [Revised Illness Perception Questionnaire (IPQ-R)] in 99 HD patients. Clinical parameters were collected and averaged over a 3-month period prior to and including the month of IPQ-R assessment. Depression scores, functional status, and comorbidity were also collected. Fluid nonadherence was defined using interdialytic weight gain (IDWG) and dry weight (ideal weight). Patients in the upper quartile of percent weight gain were defined as nonadherent (IDWG> or =3.21% dry weight). RESULTS Nonadherent patients had timeline perceptions significantly lower than those of adherent patients. Logistic regression models were computed in order to identify predictors of fluid nonadherence. After several demographic and clinical variables, including age, gender, and KRU, had been controlled for, lower consequence perceptions predicted nonadherence. CONCLUSIONS Illness representations appear to predict fluid nonadherence among HD patients. Extending the CSM to investigate specific perceptions surrounding treatment behaviors may be useful and merits attention in this setting.

Nonadherence in Dialysis Patients: Prevalence, Measurement, Outcome, and Psychological Determinants

Nonadherence to aspects of the management of End‐Stage Kidney Disease (ESKD) is common. Estimates of nonadherence vary with assessment method. Whilst readily available and free from report bias, physiological proxies—frequently used as measures of adherence—are often confounded by clinical factors including residual kidney function and dialysis adequacy. Despite variation in estimates of its prevalence, it is clear that suboptimal adherence to dialysis prescriptions, medication and diet can lead to adverse clinical outcomes. Several factors can help explain nonadherence in ESKD including mood, self‐efficacy, social support, illness, and treatment perceptions. Psychological interventions have been shown to improve ESKD adherence, yet achieving long‐term behavior change remains challenging. Identifying individuals who struggle to adhere to aspects of the dialysis regime, and tailoring theory‐led interventions to improve and support adherence is a clear clinical need requiring further empirical enquiry.

Illness Perceptions Predict Survival in Haemodialysis Patients

Background: Illness perceptions have been shown to be important determinants of functional and psychosocial outcomes, including quality of life and treatment adherence in end-stage renal disease patients. The aim of this prospective study was to determine whether haemodialysis patients’ illness perceptions impact upon survival. Methods: Haemodialysis patients from a UK renal service completed the Revised Illness Perception Questionnaire. Over the study period (May 2007 to December 2010), all-cause mortality was recorded as the endpoint. Results: 223 patients were followed up for a median of 15.9 months (min. 10 days, max. 42.7 months). The median dialysis vintage was 17.6 months (min. 4 days, max. 391.3 months). Treatment control perceptions demonstrated a significant association with mortality (HR = 0.91, 95% CI: 0.83–0.99, p = 0.03). After controlling for covariates, including age, albumin, extra renal comorbidity and depression scores, perception of treatment control remained a significant predictor of mortality (HR = 0.89, 95% CI: 0.80–0.99, p = 0.03). Conclusions: Patients’ perceptions of treatment control (dialysis therapy) predict survival independently of survival risk factors, including comorbidity. Studies are required to test whether psychological interventions designed to modify maladaptive illness perceptions influence clinical outcomes in this patient setting.

Fatigue in advanced kidney disease.

Fatigue is commonly experienced in patients with advanced kidney disease and associated with poor outcomes. The prevalence of fatigue ranges from 42% to as high as 89% according to treatment modality and the measurement instruments used. This paper reviews studies examining sociodemographic, biological, and psychological factors associated with fatigue in advanced kidney disease. The association between fatigue and psychological factors, such as depression and anxiety, behavioral factors, such as sleep and nutrition, and cytokines, such as IL-6 and CRP corroborates the view of fatigue as a multidimensional and multifactorial problem. Although depression and fatigue are related, the relationship is typically moderate in size, thus fatigue should not simply be seen as a symptom of distress. Accordingly, it is important for treatment plans to address the complex etiology of fatigue through pharmacological and nonpharmacological interventions. To date, results of nonpharmacological interventions are promising, with physical exercise and cognitive-behavioral therapy showing beneficial results. Work conducted in other patient populations highlights the importance of cognitions and behaviors in the prediction and maintenance of fatigue. Such work could be applied to advanced kidney disease allowing a model of fatigue to be developed from which to base suitable interventions in this setting.

Depression and kidney transplantation.

While kidney transplantation offers several advantages in terms of improved clinical outcomes and quality of life compared to dialysis modalities, depressive symptoms are still present in approximately 25% of patients, rates comparable to that of the hemodialysis population. Correlates of depressive symptoms include marital status, income, kidney function, history of affective illness, malnutrition, and inflammation. Depressive symptoms are also associated with poor outcomes following kidney transplantation including nonadherence to immunosuppressant medication, graft failure, and all-cause mortality. Efforts to detect and treat depression should be a priority if one is to improve treatment adherence, quality of life, and outcomes in transplant recipients.

Depression in End‐Stage Renal Disease: Current Advances and Research

Depression or the presence of significant depressive symptoms remains common in patients with end‐stage renal disease (ESRD). It is thought that 20–30% of ESRD patients have significant depressive symptoms, although there are issues surrounding the assessment of depression among patients with physical illness. Screening tools may be useful in this setting to identify patients with low affect, accompanied by formal diagnostic approaches which are important to consider following a positive screen. Recent evidence highlights the impact of depression upon mortality, and its association with non‐adherence and immune parameters, work that supports past investigations. Further studies are required to better our understanding of the mechanisms behind depression in patients with ESRD identifying both psychological and clinical antecedents. A focus on the treatment of depression is now critical given the evidence that depression impacts upon outcome in ESRD. Antidepressants seem effective, but the prevalence of negative side effect profiles and drug–drug interactions suggest a role for psychotherapeutic approaches. Of these, cognitive behavioral therapy shows real promise.

Changes in illness-related cognitions rather than distress mediate improvements in irritable bowel syndrome (IBS) symptoms and disability following a brief cognitive behavioural therapy intervention

OBJECTIVE A previous randomised controlled trial demonstrated that a cognitive behavioural therapy (CBT) self-management intervention significantly improved irritable bowel syndrome (IBS) symptoms and disability compared to treatment as usual (TAU). The current study analysed additional data to establish whether; 1) cognitive, behavioural and emotional factors hypothesized to perpetuate IBS symptoms and disability changed following CBT and, 2) ascertain if changes in these factors over the intervention period mediated treatment effects 6-months later. METHOD IBS patients (CBT = 31, TAU = 33) completed measures pre-and-post intervention including: Brief Illness Perception Questionnaire, Hospital Anxiety & Depression Scale and Cognitive and Behavioural Responses to Symptoms Questionnaire. Path models were evaluated to determine whether changes in cognitive and behavioural factors over the treatment period mediated treatment effects. RESULTS Compared to TAU, CBT patients showed significant positive changes on several cognitive variables but not anxiety and depression following intervention. Positive change in illness perceptions following intervention mediated the treatment effect on improved IBS symptom severity and social adjustment six months later. Changes in damaging beliefs mediated the effect on social adjustment. CONCLUSIONS Change in cognition rather than mood mediated treatment related improvements. Changing negative perceptions of IBS appears to be a particularly important treatment mechanism.

A confirmatory factor analysis of the beck depression inventory-II in end-stage renal disease patients

OBJECTIVE We sought to examine several competing factor structures of the Beck Depression Inventory-II (BDI) in a sample of patients with End-Stage Renal Disease (ESRD), in which setting the factor structure is poorly defined, though depression symptoms are common. In addition, demographic and clinical correlates of the identified factors were examined. METHODS The BDI was administered to clinical sample of 460 ESRD patients attending 4 UK renal centres. Competing models of the factor structure of the BDI were evaluated using confirmatory factor analysis. RESULTS The best fitting model consisted of general depression factor that accounted for 81% of the common variance between all items along with orthogonal cognitive and somatic factors (G-S-C model, CFI=.983, TLI=.979, RMSEA=.037), which explained 8% and 9% of the common variance, respectively. Age, diabetes, and ethnicity were significantly related to the cognitive factor, whereas albumin, dialysis adequacy, and ethnicity were related to the somatic factor. No demographic or clinical variable was associated with the general factor. CONCLUSION The general-factor model provides the best fitting and conceptually most acceptable interpretation of the BDI. Furthermore, the cognitive and somatic factors appear to be related to specific demographic and clinical factors.