The Prevalence of Depression in Chronic Kidney Disease

Andrew Kowalski, MD, FASN

As CKD progresses, patients face numerous obstacles such as physical complications, psychological, and emotional challenges that can profoundly impact their quality of life. One of the most common and concerning psychological comorbidities associated with CKD is depression. This blog briefly delves into the prevalence of depression in CKD, its impact on patient outcomes, and the critical need for early recognition and management of this mental health disorder in individuals living with kidney disease.

CKD as a disease has a complex pathophysiology, often linked to conditions like hypertension, diabetes, and glomerulonephritis. Alongside these physical challenges, CKD patients experience a broad spectrum of psychological issues, with depression being the most prevalent mental health disorder in this population. Unfortunately, importance of a healthy mind and emoptional stability frequently goes unknoticed, ignored and poorly addressed in this population. I can claim guilt myself for not being diligent in addressing these issues with my patients. I suspect that the energy and emotional rollercoaster discussing CKD progression and approaching ESRD overshadows the mental trauma that this condition causes our patients. I hope that this post becomes a voice for those patients and reminds us, the providers, that there is more burden behind the scenes than just weak functioning kidneys.

The Prevalence of Depression in CKD

Studies show that the prevalence of depression among individuals with CKD is significantly higher than in the general population. While depression affects approximately 7-10% of the general population, the rates among CKD patients can be as high as 20-40%, depending on the stage of the disease and the patient’s overall health status.

In patients with ESRD who are undergoing dialysis, the prevalence can be even higher, reaching up to 50%. This elevated prevalence is associated with the multifactorial nature of depression in CKD patients, which is influenced by both biological and psychosocial factors.

A systematic review and meta-analysis by Adejumo et al. found that the overall pooled prevalence of clinical depression in the global CKD population is approximately 26.5%. This prevalence is higher among individuals on chronic hemodialysis compared to pre-dialysis patients (29.9% vs. 18.5%) and among those on hemodialysis compared to peritoneal dialysis (30.6% vs. 20.4%).

Another study by Palmer et al. reported that the prevalence of interview-based depression in ESRD patients is 22.8%, while self or clinician administered rating scales suggest a higher prevalence of 39.3% for ESRD patients. This discrepancy highlights the potential overestimation of depression when using self-report scales, particularly in the dialysis setting.

Finally a study conducted in Jordan, Alshelleh et al. found that more than half of the CKD patients had depression, with a prevalence of 58.3%. This study also noted a significant negative correlation between depression scores and quality of life domains

Factors Contributing to Depression in CKD

Several factors contribute to the high rates of depression in CKD patients, which can vary in their intensity and impact depending on the stage of the disease.

1. Physical Illness and Symptoms: The physical burden of CKD itself, including fatigue, pain, sleep disturbances, and difficulty performing daily activities, can contribute to feelings of hopelessness and helplessness, common in depression. As kidney function declines, patients may experience worsening symptoms, exacerbating their emotional distress.

2. Treatment-Related Stress: Dialysis, a common treatment for those with ESRD, involves significant lifestyle changes and can be a source of constant stress. Dialysis sessions can be physically exhausting, require frequent hospital visits, and often lead to disruptions in patients’ social and work lives. The burden of adhering to strict dietary and medication regimens can further increase the emotional toll on patients.

3. Social and Economic Strain: CKD can lead to financial strain due to the high costs of treatment, loss of employment, and reduced ability to engage in physical activities. Social isolation is another significant contributor, as patients may withdraw from social interactions due to physical limitations, feelings of embarrassment, or a lack of energy.

4. Biological Factors: There is evidence suggesting that CKD itself may contribute to depression through biological mechanisms. Kidney dysfunction can affect the balance of neurochemicals in the brain, such as serotonin and dopamine, which are critical for mood regulation. Moreover, inflammation, oxidative stress, and hormonal imbalances associated with CKD may exacerbate depressive symptoms.

5. Psychosocial Factors: The chronic nature of CKD requires patients to cope with an ongoing disease trajectory, which often leads to emotional distress. Feelings of uncertainty about the future, fear of dialysis, and anxiety about potential organ failure or transplant eligibility can also trigger or worsen depressive symptoms.

A gentleman during one of three weekly, four-hour dialysis sessions at the Northwest Kidney Centers in Kirkland, Wash. Article in NY Times by Reed Abelson, 2020

Impact of Depression on CKD Outcomes

The presence of depression in CKD is not merely a matter of mental well-being, it has far reaching implications for the physical health of patients. Depression in CKD is associated with a range of negative outcomes, including.

• Poor Treatment Adherence: Depressed patients may struggle with adhering to prescribed treatment regimens, including medication schedules, dialysis appointments, and lifestyle changes. This non-compliance can lead to worsened kidney function and other health complications.

• Increased Mortality Risk: Depression in CKD patients has been shown to increase the risk of mortality. Studies suggest that the combination of depression and kidney disease may lead to worse cardiovascular health outcomes, as depression is a known risk factor for cardiovascular disease, which is prevalent in CKD patients.

• Reduced Quality of Life: Depression has a profound impact on the quality of life, leading to feelings of despair, lack of motivation, and diminished ability to engage in everyday activities. Patients with CKD and depression often experience greater difficulty managing the demands of their condition, leading to increased distress and a diminished sense of well-being.

• Cognitive Decline: Both CKD and depression are associated with cognitive impairments. When these two conditions coexist, patients are at higher risk for cognitive decline, which can further complicate disease management and reduce their capacity for independent living.

Screening for Depression in CKD

Early recognition of depression in CKD patients is crucial, as untreated depression can exacerbate the physical, emotional, and social burden of the disease. However, depression is often underdiagnosed in CKD patients due to the overlap of symptoms between the two conditions. Fatigue, sleep disturbances, and changes in appetite are common in both CKD and depression, making it difficult to differentiate between the two without a thorough evaluation.

Routine screening for depression should be integrated into the care of CKD patients, especially those with advanced stages of the disease or those undergoing dialysis. Several screening tools, such as the Patient Health Questionnaire (PHQ-9), are widely used to identify symptoms of depression in clinical settings.

Currently, Nephrologists are encouraged to routinely screen CKD patients utilizing this questionaire at least twice a year. Although this may seem somewhat time consuming in the beginning, the value that it brings is insurmountable with early depression recognitions and treatment initiation.

Management of Depression in CKD

Addressing depression in CKD requires a multifaceted approach that incorporates both pharmacological and non-pharmacological treatments.

1. Pharmacological Interventions: Antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs), are commonly prescribed to CKD patients with depression. However, the choice of medication must be carefully considered due to potential drug interactions and side effects, particularly in patients with impaired kidney function.

2. Psychotherapy: Cognitive-behavioral therapy (CBT) and other forms of psychotherapy can be highly effective in managing depression in CKD patients. Therapy can help patients cope with the emotional and psychological challenges of CKD, develop healthier coping mechanisms, and address negative thought patterns.

3. Social Support: Encouraging strong social support networks and engaging patients in support groups can help combat isolation and provide emotional and psychological support.

4. Lifestyle Modifications: Promoting physical activity, healthy eating, and proper sleep hygiene can have a positive impact on both physical and mental health. A holistic approach to care that includes managing both the physical and psychological aspects of CKD is essential.

5. Dialysis-Specific Interventions: For patients undergoing dialysis, addressing the unique challenges they face, such as fatigue and social withdrawal, can help alleviate feelings of depression. Support from dialysis teams and a focus on improving the overall patient experience can reduce the burden of treatment.

Conclusion

Depression is a prevalent and serious comorbidity in individuals with Chronic Kidney Disease, significantly impacting both mental and physical health. Recognizing and addressing depression in CKD patients is critical for improving outcomes, enhancing quality of life, and providing comprehensive care. Given the high prevalence of depression in this population, healthcare providers must be vigilant in screening, diagnosing, and treating depression, while also providing the necessary support to help patients navigate the complex challenges associated with CKD. Effective management of depression not only improves emotional well-being but also contributes to better long-term health outcomes for individuals with CKD.

References

1. Global Prevalence of Depression in Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Adejumo OA, Edeki IR, Sunday Oyedepo D, et al. Journal of Nephrology. 2024;37(9):2455-2472. doi:10.1007/s40620-024-01998-5.

2. Prevalence of Depression in Chronic Kidney Disease: Systematic Review and Meta-Analysis of Observational Studies. Palmer S, Vecchio M, Craig JC, et al. Kidney International. 2013;84(1):179-91. doi:10.1038/ki.2013.77.

3. Prevelance of Depression and Anxiety With Their Effect on Quality of Life in Chronic Kidney Disease Patients. Alshelleh S, Alhouri A, Taifour A, et al. Scientific Reports. 2022;12(1):17627. doi:10.1038/s41598-022-21873-2.