One in five patients with chronic kidney disease (CKD) will experience at least one major depressive episode, which is likely to be detrimental to the course of their kidney disease and significantly limit their quality of life. Most patients with major depressive disorder (MDD) in the setting of CKD are undiagnosed and untreated, which suggests a significant opportunity for psychiatrists to work collaboratively to optimize the treatment of depression in this high-risk population and provide guidance for both patients and their families around complex issues like dialysis withdrawal.
There is clearly a direct association between depression and hypertension as both have been identified as risk factors in precipitating the occurrence of the other. Psychiatrists should be vigilant about the appropriate management of hypertension and be familiar with medications that can exacerbate hypertension.
As many as four out of five adults in the United States report inadequate intake of fruits and vegetables according to national dietary standards and there are direct relationships between vitamin deficiencies and depressive symptoms. Psychiatrists have the opportunity to educate patients about appropriate nutrition and should be especially careful to recognize and appropriately treat nutritional deficiencies.
CHRONIC KIDNEY DISEASE AND DEPRESSION
Chronic kidney disease (CKD) is defined as the presence of kidney damage or decreased kidney function (glomerular filtration rate [GFR] <60 mL/min/1.73m2) for 3 or more months. It is a highly prevalent condition affecting over 8 million Americans each year.1 Common etiologies include diabetes mellitus, hypertension, generalized arteriosclerosis, lupus, AIDS, and primary renal diseases, such as chronic glomerulonephritis, polycystic kidney disease, and other congenital and hereditary renal disorders. Around 80,000 Americans will progress to end-stage renal disease (ESRD) each year joining the more than 500,000 who are being treated for ESRD. Seventy-five percent of those with ESRD are on maintenance dialysis. The majority of these are treated with hemodialysis (HD), with less than 10% by home peritoneal dialysis (PD). The remaining 25% have a functioning kidney transplant, which is the treatment of choice for patients as it increases survival and quality of life.2
Depression is the most common psychiatric disorder in the CKD and ESRD population, with prevalence rates as high as 20% to 25% in recent studies, although many of these studies have used nonstandard measures for assessing depression.3,4 In one study, 27.4% of CKD patients had evidence of depressive symptoms,5 while in others, 20% to 22% of patients with CKD have major depressive disorder.6,7 The prevalence does not appear to vary widely with the stage of renal disease.8 Variables associated with a major depressive episode were diabetes mellitus, comorbid psychiatric illness, and history of drug or alcohol abuse. Taken together, the current data suggest that one in five patients with CKD will have at least one major depressive episode.8