1. Depression in chronic kidney disease 신장내과 R4 정우진 Mini topic

2. Introduction Depression: m/c psychiatric illness in patients with ESRD Wide range of somatic symptoms ↑, Involvement in social, occupational, and recreational activities ↓  QoL ↓ The association between depression and mortality risk in dialysis population has been extensively studied. Depression may result in adverse clinical outcomes Compliance with dialysis and medication regimes Alteration of immune system function,and its detrimental effect on nutritional status. Clinicians remain cautious when managing depression in those with CKD Nephrology 2016 Feb 10. doi: 10.1111/nep.12742

3. Association Between Major Depressive Episodes in Patients With Chronic Kidney Disease and Initiation of Dialysis, Hospitalization, or Death JAMA, May 19, 2010—Vol 303, No. 19

4. Association Between Depression and Mortality in Patients Receiving Long-term Dialysis: A Systematic Review and Meta-analysis Am J Kidney Dis. 2014;63(4):623-635

5. Why is depression more common in CKD? Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6) 530–541

6. Depression and its effect on medical outcomes Clin J Am Soc Nephrol 2: 1332–1342, 2007

7. Screening of depression in ESRD patients Depression, anxiety, and hostility should be identified and treated in dialysis patients. (B) Every dialysis patient should be seen by the dialysis social worker at initiation of dialysis, and at least biannually thereafter, to assess the patient’s psychological state, with specific focus on the presence of depression, anxiety, and hostility. (C) Dialysis patients should be treated for depression, anxiety, and hostility if they are experiencing these psychological states. (C) American Journal of Kidney Diseases, Vol 45, No 4, Suppl 3 (April), 2005: pp S60-S67

8. Screening of depression in ESRD patients The best screening tool for depression in dialysis population remains uncertain. Currently, BDI, PHQ-9 and CSED are the three validated and most commonly used questionnaires in this regard. Clin J Am Soc Nephrol 2: 1332–1342, 2007 Nephrology 2016 Feb 10. doi: 10.1111/nep.12742

9. Beck Depression Inventory(BDI) 9: no depression 10 ~ 15: mild depression; 16 ~ 23: moderate depression; 24 ~: severe depression ESRD Patients who scored ≥14 using BDI should be referred to psychiatrist for early evaluation.

10. Diagnosis Diagnostic and Statistical Manual of Mental Disorders V (DSM-V)

11. Treatment Non-pharmacological treatment Cognitive behavioral therapy (CBT) The most studied psychotherapy for depression in general population Data on the effectiveness of psychosocial interventions in the treatment of depression in the dialysis population have been limited until recent years Exercise Effective for reducing symptoms of depression in patients with CKD Dialysis patients tend to have worse exercise tolerance(anemia, uremia, hyperparathyroidism, vitamin D deficiency,and poor cardiovascular function) Specially designed exercise programs have been shown to alleviate depressive symptoms and improve physical health in the dialysis population. Nephrology 2016 Feb 10. doi: 10.1111/nep.12742

12. Treatment Non-pharmacological treatment Electroconvulsive therapy (ECT) Highly effective treatment for severe depression, including medication-resistant depression Not studied in RCTs in CKD, but there are case reports of excellent response to ECT in patients with CKD and severe depression refractory to antidepressant medication Special precautions: abrupt increases in blood pressure, adequate muscle relaxation, subsequent risk of fractures in an osteopenic patient Change in dialysis regimen It is not clear whether increasing the frequency of dialysis improves depression rates FREEDOM study: Dialysis frequency three times weekly  six times weekly. Significant decrease in BDI values was found Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6) 530–541

13. Treatment Pharmacological treatment Patients with ESRD were often excluded from clinical trials because of safety concerns Generally highly protein bound  Not removed significantly by the dialysis procedure/ Hepatically metabolized Drug-drug interactions in the presence of polypharmacy SSRI Believed to be safer in patients with ESRD because of their more favorable adverse effect profiles Fluoxetine is the only one completed RCT of antidepressant medication in CKD If the diagnosis of an MDD is uncertain, they may enhance the risk for mania in patients who have bipolar disorder SSRI may exacerbate preexisting uremic symptoms, bleeding risk Clin J Am Soc Nephrol 2: 1332–1342, 2007

14. Treatment Pharmacological treatment The latest recommendations from European Renal Best Practice(ERBP) suggests a trial of SSRI for 8 to 12 weeks in dialysis patients who have moderate major depression. Treatment effect should be re-evaluated after 12 weeks to avoid prolonging ineffective medication Nephrology 2016 Feb 10. doi: 10.1111/nep.12742

15. Reference Nephrology 2016 Feb 10. doi: 10.1111/nep.12742; Depression in dialysis patients JAMA, May 19, 2010—Vol 303, No. 19; Association Between Major Depressive Episodes in Patients With Chronic Kidney Disease and Initiation of Dialysis, Hospitalization, or Death Am J Kidney Dis. 2014;63(4):623-635; Association Between Depression and Mortality in Patients Receiving Long-term Dialysis: A Systematic Review and Meta-analysis Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6) 530–541; Depression and chronic kidney disease:A review for clinicians Clin J Am Soc Nephrol 2: 1332–1342, 2007; Screening, Diagnosis, and Treatment of Depression in Patients with End-Stage Renal Disease American Journal of Kidney Diseases, Vol 45, No 4, Suppl 3 (April), 2005: pp S60-S67; Guidelines On Evaluation And Management Of Cardiovascular Disease