Depression and the Vital Role of Home Therapies

So, here’s a non-shocker: a new metaanalysis of 12 observational studies has found that depression increases the risk of death on dialysis by 45%. [1] Is anyone really surprised that getting dialysis that only provides about 12% of normal kidney function—on a treatment day—while taking away personal control, favorite foods, energy, sleep quality, sex drive, and more might be, oh, I don’t know…depressing?

No, right?!

An unhappy statistic in the USRDS 2013 ADR[2] is that 11.4% of deaths among incident dialysis patients, and 11.1% among prevalent patients are due to withdrawing from dialysis. This makes choosing to stop a life-saving treatment the number two identified cause of death on dialysis. We don’t know why people choose to stop, but it’s quite sobering to think that at least some of those decisions could be about poor quality of life related to standard in-center hemodialysis (HD).

As two different people recently said on Facebook:

“I've been on dialysis for 4 years now and still waiting for a kidney. I won't lie, it's depressing and sometimes it feels like a transplant is never going to happen. It's hard to live like this. So here's my question: Is there a path for just quitting treatment? Do I have to file paperwork or notify anyone? Are there legal ramifications?”

“The last couple of weeks I have been seriously thinking of ending dialysis........I am just not saying this to get pity or attention........this is my 2nd time on dialysis n I'm just tired of feeling like crap......watching what I eat what I drink n how much.........I'm just tired of living life like this..........I feel I'm getting closer to a decision n I'm going to talk with my Dr in the next week or two........guess I just wanted to get this off my chest.........talking with my family n non dialysis friends would be fruitless...........nothing against them but they have no idea what we deal with…”

It’s clear to everyone who works in the renal community that transplant is the Great White Hope of kidney failure—the best chance at a near-normal life, though unfortunately not a cure. But, the only study of hope and dialysis that I’ve been able to find (with a lot of searching!), which involved giving questionnaires to 103 people on dialysis, concluded that hope is a significant predictor of adjustment to dialysis—reducing anxiety and depression. [3]

So, what happens to folks who can’t get a transplant? Or are just coming off of a failed transplant? Or, for whatever reason, don’t want a transplant? They need a source of hope, too. And, home dialysis can be that hope—at least for some of them. Finding out that some forms of dialysis can allow a freer diet, fewer fluid limits and medications, fewer symptoms, fewer days in the hospital, more energy, and even longer survival is a hopeful thing!

It’s high time that we:

1). Routinely assess all people on dialysis for depression. The KDQOL-36 can be used for this purpose,[4] following up with a formal depression screener when there is an index of suspicion. Don’t assume that people must look depressed to be depressed—it’s unfortunately possible to hide depression,[5] and the consequences of untreated depression, as we have learned, can be deadly.

2). Specifically assess those on dialysis who want to stop or have a failed transplant. Both groups may be at an even higher risk than the general dialysis population.

3). Consider the full gamut of effective ways to combat depression. Besides antidepressant medications (sertraline, in particular, has evidence of improved quality of life in those on PD[6] and HD[7]), these include exercise[8]—and offering an improved fit of dialysis to lifestyle through a change of modality. Here’s a free tool to help! http://www.mydialysischoice.org.

We can hardly do worse than a 45% increase in mortality—so there is a lot of room for improvement. And, there is a lot we can do to instill hope.