Oral Papers: Medical Specialties I: Cardiology, Endorine, Renal
Depression is common in patients on haemodialysis (HD) with a prevalence of 30-40% (Palmer 2013). A high proportion of HD patients takes antidepressant medication, though there is a major potential for adverse events, and there are doubts about the efficacy of these agents in this condition (Friedli 2017). In addition, there is sparse evidence about the quality of depression management in HD patients. We set out to explore the natural history of antidepressant medication in HD patients with particular reference to adherence to NICE recommendations.
Of 536 patients screened using the Beck Depression Inventory (BDI-II) in four UK renal units, 62 were taking antidepressant medication. These patients were followed approximately 12 months later at which point an assessment of baseline parameters was repeated together with a Psychiatric interview based on the Mini-International Neuropsychiatric Interview (MINI).
Of the original 62 patients, 41 (66%) were available for restudy (12 had died, six had been transplanted, one transferred, and two did not consent). Ten different antidepressant agents were being taken - the most common being citalopram (39%). The primary prescribers of antidepressants were Primary Care Physician (68%), Nephrologist (22%) and Psychiatrist (10%). A significant proportion (24%) were taking doses that might be considered sub-therapeutic or agents that were contraindicated or cautioned against in HD patients. At baseline 30 patients had a BDI-II score ≥16 indicating high depressive symptoms. Of these, 22 remained with high depressive symptoms at follow-up whilst 8 improved (BDI-II < 16 at follow up). Of the 11 with BDI-II < 16 at baseline, 5 had increased their score to ≥16 at follow up. Although 27 of 41 patients (66%) either deteriorated or failed to improve during follow-up, a change in medications took place in only 11 patients (27%). MINI examination at follow-up revealed 15 patients with current or recurrent depression, 20 with past depression and 6 with no evidence of ever having been depressed.
Multiple types of antidepressants were being used, some of which are contraindicated in this setting. There was over-prescription and inadequate follow-up – 15% had never had depression. There was sub-optimal adherence to NICE guidelines.
Even when depression is recognised in HD patients it is frequently sub-optimally managed. Antidepressants are often prescribed inappropriately for patients who are not depressed. These finding raise major issues of safety and efficacy, which need to be addressed by education and further empirical study.
Palmer S, et al. Prevalence of depression in chronic kidney disease: Systematic review and meta-analysis of observational studies. Kidney Int 2013;84:179–91.
Friedli K, Guirguis A, et al. Sertraline versus placebo in patients with major depressive disorder and undergoing haemodialysis (ASSertID): a randomised, controlled feasibility trial. Clin J Am Soc Nephrol 2017;12