Depressive affect in incident hemodialysis patients

Depressive affect in incident hemodialysis patients Background: The prevalence of depressive affect is not well defined in the incident hemodialysis (HD) population. We inves- tigated the prevalence of and associated risk factors and hospitalization rates for depressive affect in incident HD patients. Methods: We performed a prospective investigation using the Patient Health Questionnaire 2 (PHQ2) depressive affect assessment. From January to July of 2013 at 108 in-center clinics randomly selected across tertiles of baseline quality meas- ures, we contacted 577 and 543 patients by telephone for depressive affect screening. PHQ2 test scores range from 0 to 6 (scores 3 suggest the presence of depressive affect). The prevalence of depressive affect was measured at 1–30 and 121– 150 days after initiating HD; depressive affect risk factors and hospitalization rates by depressive affect status at 1–30 days after starting HD were computed. Results: Of 1120 contacted patients, 340 completed the PHQ2. In patients screened at 1–30 or 121–150 days after starting HD, depressive affect prevalence was 20.2% and 18.5%, respectively (unpaired t-test, P¼ 0.7). In 35 patients screened at both time points, there were trends for lower prevalence of depressive affect at the end of incident HD, with 20.0% and 5.7% of patients positive for depressive affect at 1–30 and 121–150 days, respectively (paired t-test, P¼ 0.1). Hospitalization rates were higher in patients with depressive affect during the first 30 days, exhibiting 1.5 more admissions (P< 0.001) and 10.5 additional hos- pital days (P¼ 0.008) per patient-year. Females were at higher risk for depressive affect at 1–30 days (P¼ 0.01). Conclusions: The prevalence of depressive affect in HD patients is high throughout the incident period. Rates of hospital admissions and hospital days are increased in incident HD patients with depressive affect. Key words: depression, hospital admission, hospital days, incident dialysis, patient health questionnaire 2 Introduction population, the prevalence of depressive affect with or without a Clinical depression and symptoms of depressive affect are com- diagnosis of depression has been reported to be between 8.9% and mon in hemodialysis (HD) patients but have not been well charac- 45% within 1 –120 days after initiation of dialysis [1–6]. In compari- terized in the incident HD population early after initiation of son, in the general population depressive affect with or without a dialysis and through the incident period [1–6]. In the incident HD diagnosis of depression has been reported to have a prevalence of Received: March 1, 2017; Editorial decision: May 15, 2017 V C The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 124 | K.A. McDougall et al. 2–10% [7]; the depressive affect prevalence in the prevalent dialy- affect occurring during the prior 2 weeks [22]. PHQ2 scores of 3 sis population with or without a diagnosis of depression has been have a 75% probability of identifying the presence of ‘any documented to be between 20% and 55% [4, 8–10]. depressive disorder’ in the prior 2 weeks but only a 38% proba- Identification of depressive affect does not discretely diag- bility of a ‘major depressive disorder’ [22]. nose clinical depression but does indicate a high probability of The PHQ2 has been validated and shown to be effective in any depressive disorder without a precise degree of severity. screening for depressive affect in primary care, hospital outpa- Clinical depression must be diagnosed by a physician through tient and coronary heart disease patients [22–24]. The PHQ2 test medical assessment of the patient’s psychological status and has not been validated specifically in the dialysis population; clinical symptoms of depressive affect. In the end-stage renal however, it has been used to screen for depressive affect in inci- disease (ESRD) population, depressive affect has been assessed dent dialysis patients [4] and appears to be a simple and effec- using several survey methods that include the Patient Health tive method to determine the occurrence of depressive affect. Questionnaires [4, 11], Beck Depression Inventory (BDI) [11, 12], Notably, identification of the presence of depressive affect using Center for Epidemiologic Studies Depression Screening Index the PHQ2 cannot determine the discrete magnitude of severity [13], Hospital Anxiety and Depression Scale [14] and the two for depressive symptoms, which can be further evaluated by questions associated with depressive symptoms within the 36- the clinical judgment of the treating physician. Item Short Form Health Survey (SF-36) [3, 15]. The in-center HD clinics utilized for this study were ran- Depressive affect with or without a diagnosis of depression domly selected to equally represent each FMCNA division and has been observed in incident dialysis patients to be linked to were distributed across tertiles of quality levels at baseline. increases in withdrawing from HD in the first 3 months of treat- FMCNA dialysis clinic quality is determined by UltraScores, ment [3], as well as increases in risk for mortality in the first which, at the time, were based on levels of albumin, hemoglo- year of dialysis [3, 16, 17]. It has been identified in prevalent bin, phosphorous, estimated Kt/V, as well as rates of catheter dialysis patients that depressive affect is associated with risks use and mortality. Small clinics (HD census <50 patients) or of decreases in quality of life and increases in morbidities, car- those that had limitations in the ability to translate for language diovascular events, hospitalizations and mortality [9, 18–20]. In barriers were excluded from the study. a recent large observational study of incident HD patients All patients who completed a depressive affect screening by within 120 days after starting dialysis, depressive affect was PHQ2 during 1–30 days or 121–150 days after initiation of HD found to be associated with increased rates of hospital admis- were included in the analyses. For this investigation, data for the sions and hospital days [1]. PHQ2 scores was recorded by telephone survey operators and The aims of this study were to characterize the prevalence patient demographics, clinical parameters and rates of hospital of depressive affect early after the initiation of dialysis and at admissions and hospital days were captured from patient data the end of the incident period, determine the risk factors for available in the FMCNA Knowledge Center Data Warehouse. depressive affect and investigate hospitalization rates related to Depressive affect scores during 1–30 and 121–150 days and hospi- depressive affect in incident HD patients. talization rates 1–150 days after initiating HD were utilized for comparisons. Additionally, clinical and laboratory parameters were collected up to the first 30 and 150 days of HD. Materials and methods Analyses included descriptive statistics of patient demo- graphics, clinical characteristics and PHQ2 scores. The mean clin- This study was a prospective investigation performed at 108 ical and demographic parameters in patients assessed for outpatient HD centers in the USA and conducted as a compo- depressive affect at either 1–30 and/or 121–150 days after starting nent of the Fresenius Medical Care North America (FMCNA) HD were compared using an unpaired Student’s t-test for contin- RightStart program [21]. From January to July 2013, 577 patients uous variables and chi-square test for categorical variables. within 1–30 days after initiation of HD and 543 patients at 121– Comparisons in a select group of the same patients screened for 150 days after initiating HD were contacted by telephone for depressive affect at both time points were made using a paired depressive affect screening. Upon determination of a positive Student’s t-test for continuous variables and a McNemar test for depressive affect screening score, the patient’s clinical care staff categorical variables. Associations between depressive affect at was notified for further assessment and/or intervention. the time of assessment and demographic and clinical character- For this investigation, depressive affect was assessed by tele- istics were studied using t-tests and chi-square tests. A Poisson phone using the Patient Health Questionnaire 2 (PHQ2). Survey regression analysis was utilized for comparisons of rates of hos- operators were trained in survey processes, observed during pital admissions and hospital days. Unpaired Student’s t-tests training and provided with written training materials. The were performed for comparison of the prevalence of depressive PHQ2 surveys were administered to patients in either English or affect at 1–30 days versus 121–150 days after initiation of HD in Spanish by bilingual survey operators depending on the patients assessed at one of the time points; paired Student’s t- patient’s native language; non-English-or non-Spanish-speak- tests were used for analyzing comparisons in a select group of ing patients were excluded. The PHQ2 is a two-question assess- the same patients screened for depressive affect at both time ment that can screen patients for the presence of depressed points. All analyses were performed using SAS software version mood and anhedonia occurring during the previous 2 weeks [22, 9.4 (SAS Institute, Cary, NC, USA). 23]. The questions of the PHQ2 are as follows: ‘Over the last 2 weeks, how often have you been bothered by any of the fol- lowing problems?’ (i) ‘Little interest or pleasure in doing things’ Results and (ii) ‘Feeling down, depressed, or hopeless’. Each question of the PHQ2 has four possible responses with scores ranging from Of the overall population of 1120 incident HD patients who con- 0 to 3 and include (i) ‘Not at all’ (score¼ 0), (ii) ‘Several days’ tacted for telephonic depressive affect screening, 340 PHQ2 (score¼ 1), (iii) ‘More than half the days’ (score¼ 2) and (iv) assessments were completed by 305 unique patients. The over- ‘Nearly every day’ (score¼ 3). The overall scoring for the PHQ2 all depressive affect screening response rate was 30.4% and test ranges from 0 to 6; scores 3 are suggestive of depressive there was a mean of 1.6 calls performed to complete the PHQ2 Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Depressive affect in HD | 125 Table 1. Demographics and clinical characteristics for patients sur- Table 2. Demographics and clinical characteristics for the patients veyed at one of the time points (n ¼ 35)surveyed at both time points Parameters 1–30 days 121–150 P-value Parameters 1–30 days after 121–150 days P-value after days incident HD incident HD incident HD incident HD Average age, years (SD) 64.2 (613.3) NA Number of patients 178 92 NA Female (%) 37.1 NA (total ¼ 270) Diabetes (%) 64.7 NA Average age, years (6SD) 64.1 (616.3) 63.7 (613.6) 0.829 Hypothyroidism (%) 2.9 NA Female (%) 39.9 41.3 0.822 Race, White (%) 71.4 NA Diabetes (%) 67.1 67.9 0.909 Ethnicity, not Hispanic (%) 85.7 NA Hypothyroidism (%) 8.4 8.7 0.940 BMI, kg/m (6SD) 29.3 (66.5) 29.0 (66.4) 0.092 Race, White (%) 74.2 63.0 0.058 Catheter access (%) 44.1 17.7 0.004 Ethnicity, not Hispanic (%) 80.9 95.7 0.001 Albumin, g/dL (6SD) 3.6 (60.5) 3.9 (60.4) 0.003 BMI, kg/m (6SD) 29.6 (68.1) 30.2 (67.8) 0.608 Log of creatinine (6SD) 1.8 (60.4) 1.9 (60.4) 0.087 Catheter access (%) 52.7 15.5 <0.0001 OLC (6SD) 1.3 (60.3) 1.5 (60.3) <0.0001 Albumin, g/dL (6SD) 3.5 (60.5) 3.8 (60.5) 0.001 PreSBP, mmHg (6SD) 147.7 (622.6) 149.6 (621.5) 0.428 Log of creatinine (6SD) 1.6 (60.4) 1.9 (60.4) <0.0001 Percent IDWG (6SD) 2.2 (60.90) 2.8 (61.0) 0.001 OLC (6SD) 1.4 (60.3) 1.6 (60.3) <0.0001 Average PHQ2 score 1.3 (62.0) 0.7 (61.3) 0.091 PreSBP, mmHg (6SD) 145.0 (620.3) 150.3 (620.0) 0.058 Patients with positive 20.0 5.7 0.125 Percent IDWG (6SD) 2.1 (61.1) 2.9 (61.0) <0.0001 PHQ2 scores (3) (%) Average PHQ2 score 1.2 (62.0) 1.2 (61.6) 0.705 Summary of incident HD patient demographics, diabetes comorbidity, dialysis Patients with positive 20.2 18.5 0.731 access characteristics and PHQ2 assessment parameters for patients assessed PHQ2 scores (3) (%) for depressive affect at both the study time points. Summary of incident HD patient demographics, diabetes comorbidity, dialysis access characteristics and PHQ2 scores in patients that responded to the depres- Over the 150-day period after initiation of HD, the hospital sive affect screening at either 1–30 days or 121–150 days after initiating dialysis. admission rate for depressive affect–positive patients at the 1–30 day time point was 2.86 admissions per patient-year (ppy) survey. During 1–30 days after initiation of HD, there were 213 and for depressive affect–negative patients was 1.32 admissions responders to depressive affect screening and at 121–150 days ppy (Figure 1). Depressive affect–positive patients spent 17.8 there were 127 responders; there was a 36.9% and 23.4% days in hospitals ppy and depressive affect–negative patients response rate at 1–30 and 121–150 days, respectively spent 7.3 days in hospitals ppy (Figure 1). A Poisson regression (Supplementary data, Table S1). Among patients who were con- model with adjustment for factors commonly associated with tacted and asked to complete a PHQ2 assessment, 89.4% agreed hospitalization rates showed significantly higher rate of admis- to perform the screening and 10.6% refused. sion [relative rate (RR) 2.08; P¼ 0.005; Table 4] and hospital days The clinical and demographic characteristics of the 270 (RR¼ 1.87; P¼ 0.005; Table 5) in DA positive patients, as com- unique patient responders to the depressive affect screening at pared with depressive affect–negative patients. The outcomes one of the two time points are shown in Table 1. The population were adjusted for the covariates of age, sex, diabetes, access of patients responding to depressive affect screening at either 1– type, ethnicity, race, body mass index (BMI), albumin, log of cre- 30 days or 121–150 days after starting HD was mostly similar in atinine, OLC, predialysis systolic blood pressure (preSBP) and clinical and demographic characteristics, with the exception of IDWG. more non-Hispanics and higher online clearance (OLC) at the later time point as well as the anticipated changes happening in incident patients, such as increases in albumin, higher log of cre- Discussion atinine, higher percent of interdialytic weight gain (IDWG) and lower catheter utilization rates at 121–150 days after starting HD. This study investigated the prevalence of depressive affect in The prevalence of depressive affect was observed to be 20.2% incident HD patients determined by telephonic PHQ2 assess- in patients in the first 30 days after initiation of HD and 18.5% at ments during the first month of HD and at the end of the inci- the end of the incident period (121–150 days after initiation of dent period. Our findings identified that depressive affect is HD); there were no differences between time points (P¼ 0.7). In a common and unchanged throughout the incident period, gener- select group of 35 patients who were screened for depressive ally affecting 19–20% of incident HD patients, and is associated affect at both time points, the depressive affect prevalence was with increases in rates of hospital admissions and days consis- observed to be lower at 121–150 days (5.7% depressive affect posi- tent with other findings in the incident [1] and prevalent [15] tive) as compared with 1–30 days (20.0% depressive affect posi- dialysis populations. Female sex was identified to be a risk fac- tive), albeit non-significant (P¼ 0.1), as shown in Table 2. tor associated with depressive affect occurrence 1–30 days after As detailed in Table 3, the analysis of risk factors in incident initiation of HD in this cohort of patients, which is consistent HD patients showed that females have a higher risk for depres- with our previous interim findings [25, 26] and other reports in sive affect 1–30 days after initiation of HD (P¼ 0.01), but there the literature [13]. were no differences between sexes for 121–150 days after start- We observed that the prevalence of depressive affect in inci- ing HD (P¼ 0.8). Also, there were trending risks for depressive dent HD patients is high throughout the incident period, with affect in patients with higher BMI 121–150 days after initiating 20.2% of patients screening positive for depressive affect in the HD (P¼ 0.054). No other clinical and demographic characteris- first month of HD and 18.5% at the end of the incident period. tics were identified to be associated with depressive affect in These findings are very consistent with other reports that iden- incident HD patients. tified depressive affect using the mental health domain items Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 126 | K.A. McDougall et al. Table 3. Depressive affect status and patient demographics, characteristics and PHQ2 scores Parameters of responders 1–30 days 1–30 days P-value 121–150 days 121–150 days P-value to depressive affect screening depressive depressive depressive depressive affect negative affect positive affect negative affect positive Number of patients 170 43 NA 108 19 NA Average age, years (SD) 64.5 (615.6) 62.8 (616.8) 0.537 64.5 (614.0) 60.0 (69.4) 0.176 Female (%) 35.3 55.8 0.014 39.8 42.1 0.851 Diabetes (%) 66.7 66.7 1.000 64.0 84.2 0.085 Race, White (%) 75.9 65.1 0.152 67.6 52.6 0.206 Ethnicity, not Hispanic (%) 82.4 79.1 0.619 91.7 100.0 0.192 BMI, kg/m (6SD) 29.4 (67.7) 30.2 (68.3) 0.547 29.4 (67.3) 33.0 (67.4) 0.054 Catheter access (%) 51.4 50.0 0.882 17.0 10.5 0.480 Albumin, g/dL (6SD) 3.5 (60.5) 3.5 (60.5) 0.8892 3.8 (60.5) 3.7 (60.3) 0.337 Average PHQ2 score 0.3 (60.7) 4.8 (61.3) NA 0.5 (60.8) 4.1 (61.0) NA Risk factor analysis of demographic and clinical patient parameters associated with depressive affect. Figure 1. Hospital admission rates ppy in the first 150 days of HD in patients positive for depressive affect (solid black column) versus negative for depressive affect (slash line column). Table 4. Associations of 150-day hospital admission rates and depressive affect in incident HD patients Parameter Estimate Standard error 95% LCL 95% UCL Wald chi-square P-value Intercept 3.314 1.998 0.603 7.230 2.75 0.097 Depressive affect positive at 1–30 days after incident HD 0.730 0.259 0.221 1.238 7.91 0.005 Age 0.004 0.009 0.022 0.014 0.19 0.664 Male 0.197 0.283 0.358 0.752 0.48 0.486 Diabetes 0.212 0.366 0.506 0.930 0.34 0.562 Race, White 0.508 0.451 0.377 1.392 1.27 0.261 Ethnicity, not Hispanic 0.433 0.342 0.237 1.102 1.6 0.205 BMI 0.001 0.020 0.041 0.038 0 0.957 Catheter access at 30 days after incident HD 0.001 0.246 0.483 0.482 0 0.998 Albumin 0.060 0.245 0.540 0.419 0.06 0.805 Log of creatinine 0.362 0.312 0.973 0.248 1.35 0.245 OLC 0.113 0.439 0.974 0.749 0.07 0.798 PreSBP 0.004 0.006 0.016 0.008 0.43 0.513 Percent IDWG 0.120 0.119 0.114 0.354 1.01 0.315 Poisson regression analysis of rates of hospital admissions in patients who were depressive affect–positive at 1–30 days after initiation of HD. LCL, lower confidence limit; UCL, upper confidence limit. in the SF-36; of 6415 US patients during 10–90 days after initiat- Contrary to the findings noted above, other reports in the lit- ing HD, 20.8% were positive for depressive affect [3], and in the erature have found the prevalence of depressive affect in inci- US Dialysis Outcomes and Practice Patterns Study (DOPPS) dent patients utilizing the SF-36 to be at 8.9% in Dutch patients cohort, depressive affect was identified in 17.5% of 2562 patients at 90 days after starting dialysis [2], 41% in US patients at 1–120 during the first 3 months of HD [15]. Additionally, a previous days after starting dialysis [1] and 45% in US patients [6] at 60– investigation of depressive affect based on PHQ2 assessment in 90 days after starting dialysis. These differences are likely influ- 585 US patients at 60–90 days after starting HD or peritoneal enced by decreasing rates of catheter use in studies that utilize dialysis found that 12.1–32.8% of patients were positive for longer incident periods, as well as differences in geography, cul- depressive affect dependent on employment status [4]. tural habits and treatment patterns between the Dutch and US Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Depressive affect in HD | 127 Table 5. Associations of 150-day hospitalization rates and depressive affect in incident HD patients Parameter Estimate Standard error 95% LCL 95% UCL Wald chi-square P-value Intercept 3.299 1.767 0.164 6.762 3.49 0.062 Depressive affect positive at 1–30 days after incident HD 0.626 0.223 0.189 1.062 7.88 0.005 Age 0.025 0.008 0.042 0.009 8.93 0.003 Male 0.722 0.232 1.177 0.268 9.71 0.002 Diabetes 1.061 0.329 0.416 1.705 10.4 0.001 Race, White 1.061 0.328 0.418 1.703 10.46 0.001 Ethnicity, not Hispanic 0.452 0.284 0.105 1.008 2.53 0.112 BMI 0.041 0.017 0.074 0.009 6.33 0.012 Catheter access at 30 days after incident HD 0.506 0.221 0.074 0.939 5.27 0.022 Albumin 0.213 0.240 0.683 0.258 0.79 0.375 Log of creatinine 0.269 0.285 0.827 0.289 0.9 0.344 OLC 0.529 0.355 1.226 0.167 2.22 0.136 PreSBP 0.003 0.005 0.014 0.007 0.39 0.531 Percent IDWG 0.098 0.102 0.102 0.297 0.92 0.337 Poisson regression analysis of rates of hospital days in patients who were depressive affect positive at 1–30 days after initiation of HD. LCL, lower confidence limit; UCL, upper confidence limit. health care systems, which requires further studies. Notably, access; these findings were not significant (P¼ 0.48; Table 3). the Dutch study did include incident HD and peritoneal dialysis Further investigations are warranted to evaluate whether early patients, which may be a factor associated with the lower prev- identification of depressive affect leads to interventions and alence of depressive affect observed as compared with the US improved outcomes. Future studies could include analysis of fol- studies. Another report identified that depressive affect deter- low-up depressive affect assessments with higher specificity and mined by assessment with the BDI was present in 44% of sensitivity than the PHQ2, physician-based diagnosis of clinical patients during the first 10 days after starting dialysis [5]. depression and the specific interventions performed, such as Although the observed differences in the prevalence of depres- pharmaceutical and psychosocial therapies. sive affect in dialysis patients could be related in part to depres- Our examination of associations in depressive affect and sive affect assessment methods, patient geography, dialysis patient demographics and clinical parameters in this group of modality, timeframe of the study and cohort size, the findings incident HD patients identified that females have a higher risk by Lacson et al. in 2012 and 2014 using the SF-36 in similar large for experiencing depressive affect 1–30 days after starting HD as cohorts of HD patients from the same dialysis provider and dur- compared with males; however, we did not observe differences ing concurrent periods during 2006 reveals a 20.2% variance, 121–150 days after the start of HD. While we only found sex to be with depressive affect in 20.8% of 6415 patients at 10–90 days a significant risk factor for depressive affect and BMI to be a after HD [3] and 41% of 8776 patients at 1–120 days after HD [1]. trending risk factor at the end of the incident period, other stud- Overall, the prevalence of depressive affect is very high in inci- ies have reported that depressive affect is associated with several dent HD patients and appears to have noteworthy differences in risk factors, including age [3], race [5], lower albumin levels [3], observed prevalence in the literature due to possible selection diabetes and catheter use [27]. In the general population, compre- bias. Based on our findings, the prevalence of depressive affect hensive reviews have identified that the presence of diabetes is is not significantly changed from the beginning to the end of associated with an up to 2-fold increase in the risk of depression the incident HD period and the timing of depressive affect [28]. Conversely, patients in the general population with depres- assessment during the incident HD period is not expected to sion have been shown to exhibit a 10% higher incidence of diabe- significantly alter the rates of depressive affect in the incident tes [29]. Despite these findings, a recent investigation in HD HD population. However, the results of our study were per- patients did not find any difference in the prevalence of depres- formed in a limited number of patients and need to be further sive affect in those with and without the presence of diabetes investigated and confirmed. [30]. Additional studies investigating the risk factors associated In a subanalysis of a small number of paired patients with depressive affect in incident HD patients should be per- screened for depressive affect at the initiation of and end of the formed in an attempt to identify potential predictors of depres- incident period, the occurrence of depressive affect was found to sive affect in this population. be reduced from 20.0% in the first month of dialysis to 5.7% at the We found that incident HD patients positive for depressive end of the incident period, albeit non-significant (P¼ 0.1). While affect during the first month of dialysis exhibited an 2-fold adjustment to HD and patient selection might have contributed increase in rates of hospital admissions (RR 2.08; P¼ 0.005) and to this finding, early identification of depressive affect and subse- hospital days (RR 1.87; P¼ 0.005); this is consistent with the find- quent interventions by dialysis care teams could be a factor. In ings by Lacson et al. [1] in 2014 using a large study cohort of 8776 this cohort there was a 26.4% decrease in catheter use from the patients at 1–120 days after HD. These findings further identify first 30 days of dialysis to the end of the incident period that from the initiation of dialysis, depressive affect in the HD (P¼ 0.004), which may be influencing these findings (Table 2). In population is related to worsened outcomes that could poten- the overall study population, rates of catheter use were similar tially be modifiable through interventions. Whether enhanced between patients with and without depressive affect 1–30 days early identification of depressive affect and treatment of depres- after starting dialysis. At 121–150 days after starting dialysis there sive symptoms in incident HD patients has the potential to were 6.5% fewer patients using a catheter who were positive for improve patient hospitalization outcomes has not been depressive affect compared with those with a permanent dialysis determined. Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 128 | K.A. McDougall et al. There is consensus in the literature that improvements are FUNDING needed in screening for depressive affect and clinical depres- This study was funded by Fresenius Medical Care North sion in the ESRD population [1, 4, 5, 18, 19, 31]. The striking prev- America through the RightStart quality improvement alence of depressive affect observed in incident and prevalent initiative. dialysis patients represents a population with notable risk for worsened outcomes that could potentially be improved through treatment of depressive symptoms. Treatment options that Conflict of interest statement have been reported to be associated with improvements in the Company: The RightStart quality improvement initiative is a symptoms of depression in ESRD patients include antidepres- sant pharmaceuticals [32], cognitive behavioral therapy [33], registered trademark program of Fresenius Medical Care exercise training programs [9] and music therapy [9]. In the US North America. DOPPS cohort, it was shown that antidepressant medications Authors: K.A.M.: employed by Fresenius Medical Care North were only prescribed for 38.9% of HD patients with clinical America. J.W.L.: employed by Fresenius Medical Care North depression diagnosed by a physician and 28.9% of HD patients America. R.L.W.: employed by Fresenius Medical Care North with depressive affect [13]. It was found in an investigation of America; stock ownership in Fresenius Medical Care. S.R.: 98 HD patients assessed for clinical depression that only 54% of employed by Fresenius Medical Care North America. Y.J.: depressed patients identified in the study were diagnosed with employed by Fresenius Medical Care North America. L.M.: the disease previously during routine care and 23% had an anti- employed by Fresenius Medical Care North America. L.A.U.: depressant medication prescribed [18]. Additionally, in a study employed by Fresenius Medical Care North America; stock of 123 incident dialysis patients by Watnick et al. [5], it was ownership in Fresenius Medical Care. F.W.M.: employed by shown that only 16% of patients with depressive affect received Fresenius Medical Care North America; stock ownership in an antidepressant treatment. Despite the fact that major Fresenius Medical Care. improvements in care are apparently needed, the ability to Other non-financial conflicts of interest: F.W.M.: directorships in improve clinical outcomes via identification and treatment of American National Bank & Trust, Mid-Atlantic Renal depressive affect and clinical depression has not been firmly Coalition, Specialty Care Inc and Sound Physicians; chair- established in the dialysis population and needs to be eluci- man Pacific Care Renal Foundation 501(c)(3) nonprofit; dated [9]. chairr Kidney Care Partners; founder Scholarships This study did have some key limitations that include a Expanding Education 501(c)(3) non-profit. potential selection bias secondary to the design that assessed Support: This research was conducted as part of the patients at both the 1–30 day and 121–150 day time points; how- RightStart quality improvement program. K.A.M., J.W.L., ever, this did not yield a notable cohort of patients who repeated the survey at both time points. Additionally, the study R.L.W., Y.J., S.R., L.M., L.A.U. and F.W.M. are employed by included only 305 unique patients and further studies are Fresenius Medical Care North America. All authors, as needed that include larger patient numbers. Another limitation employees of Fresenius Medical Care North America, assisted is that patients were assessed using telephone interviews and it in the study and the analytical design, medical writing of the has not been determined if this method is as accurate as in-per- study-related documents and composition of the article. son depression screening methods. Furthermore, this analysis did not assess the impacts of antidepressant use on PHQ2 References scores or assess the number of patients identified with depres- sive affect who might have been prescribed antidepressant 1. Lacson E Jr, Bruce L, Li NC et al. Depressive affect and hospi- therapies by their physicians. talization risk in incident hemodialysis patients. Clin J Am In conclusion, depressive affect is common in incident HD Soc Nephrol 2014; 9: 1713–1719 patients and did not change significantly throughout the inci- 2. van Dijk S, van den Beukel TO, Kaptein AA et al. How base- dent period. Increases in rates of hospital admissions and hos- line, new-onset, and persistent depressive symptoms are pital days are significantly associated with depressive affect in associated with cardiovascular and non-cardiovascular incident HD patients, and this further identifies the imperative mortality in incident patients on chronic dialysis. need for improved screening and treatment. It is evident that J Psychosom Res 2013; 74: 511–517 the development of enhanced interventional paradigms for the 3. Lacson E Jr, Li NC, Guerra-Dean S et al. Depressive symptoms treatment of depressive affect and clinical depression in dialysis associate with high mortality risk and dialysis withdrawal in patients will be essential in reducing the worsened outcomes incident hemodialysis patients. Nephrol Dial Transplant 2012; observed in this population. 27: 2921–2928 4. Kutner NG, Zhang R, Huang Y et al. Depressed mood, usual activity level, and continued employment after starting dial- Supplementary data ysis. Clin J Am Soc Nephrol 2010; 5: 2040–2045 5. Watnick S, Kirwin P, Mahnensmith R et al. The prevalence Supplementary data are available online at http://ckj.oxford and treatment of depression among patients starting dialy- journals.org. sis. Am J Kidney Dis 2003; 41: 105–110 6. Walters BA, Hays RD, Spritzer KL et al. Health-related quality of life, depressive symptoms, anemia, and malnutrition at Acknowledgements hemodialysis initiation. Am J Kidney Dis 2002; 40: 1185–1194 We would like to thank and acknowledge Eduardo K. Lacson, 7. Kessler RC, Berglund P, Demler O et al. National Comorbidity Jr, MD, for his notable contributions to the study design, as Survey Replication. The epidemiology of major depressive well as the staff and physicians who assisted in conducting disorder: results from the National Comorbidity Survey the RightStart program at participating dialysis clinics. Replication (NCS-R). JAMA 2003; 289: 3095–3105 Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Depressive affect in HD | 129 21. Wingard RL, Chan KE, Lazarus JM et al. The ‘right’ of passage: 8. Rosenthal Asher D, Ver Halen N, Cukor D. Depression and nonadherence predict mortality in hemodialysis treated end- surviving the first year of dialysis. Clin J Am Soc Nephrol 2009; stage renal disease patients. Hemodial Int 2012; 16: 387–393 4(Suppl 1): S114–S120 9. Hedayati SS, Yalamanchili V, Finkelstein FO. A practical 22. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney Med Care 2003; 41: 1284–1292 Int 2012; 81: 247–255. 23. Arroll B, Goodyear-Smith F, Crengle S et al. Validation of 10. Zalai D, Szeifert L, Novak M. Psychological distress and PHQ-2 and PHQ-9 to screen for major depression in the pri- depression in patients with chronic kidney disease. Semin mary care population. Ann Fam Med 2010; 8: 348–353 Dial 2012; 25: 428–438 24. Gilbody S, Richards D, Brealey S et al. Screening for depres- 11. Watnick S, Wang PL, Demadura T et al. Validation of 2 sion in medical settings with the Patient Health depression screening tools in dialysis patients. Am J Kidney Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Dis 2005; 46: 919–924 Med 2007; 22: 1596–1602 12. Kimmel PL, Peterson RA, Weihs KL et al. Multiple measure- 25. Larkin JW, McDougall KA, Wingard RL et al. Risk factors asso- ments of depression predict mortality in a longitudinal ciated with depressive affect in incident hemodialysis study of chronic hemodialysis outpatients. Kidney Int 2000; patients [ASN abstract SA-PO1043]. J Am Soc Nephrol 2014; 25: 57: 2093–2098 883A 13. Lopes AA, Albert JM, Young EW et al. Screening for depression in 26. Larkin JW, McDougall KA, Usvyat LA et al. Depressive affect hemodialysis patients: associations with diagnosis, treatment, in incident hemodialysis patients: prevalence and risk fac- and outcomes in the DOPPS. Kidney Int 2004; 66: 2047–2053 tors [ASN abstract TH-PO539]. J Am Soc Nephrol 2013; 24: 225A 14. Riezebos RK, Nauta KJ, Honig A et al. The association of 27. Nowak L, Adamczak M, Wie ˛ cek A. Is inflammation a new depressive symptoms with survival in a Dutch cohort of risk factor of depression in haemodialysis patients? Int Urol patients with end-stage renal disease. Nephrol Dial Transplant Nephrol 2013; 45: 1121–1128 2010; 25: 231–236 28. Lustman PJ, Clouse RE. Depression in diabetic patients: the 15. Lopes AA, Bragg J, Young E et al. Depression as a predictor of relationship between mood and glycemic control. J Diabetes mortality and hospitalization among hemodialysis patients Complications 2005; 19: 113–122 in the United States and Europe. Kidney Int 2002; 62: 199–207 29. Nichols GA, Moler EJ. Cardiovascular disease, heart failure, 16. Chilcot J, Davenport A, Wellsted D et al. An association chronic kidney disease and depression independently between depressive symptoms and survival in incident dial- increase the risk of incident diabetes. Diabetologia 2011; 54: ysis patients. Nephrol Dial Transplant 2011; 26: 1628–1634 523–526 17. Boulware LE, Liu Y, Fink NE et al. Temporal relation among 30. Yoong RK, Mooppil N, Khoo EY et al. Prevalence and determi- depression symptoms, cardiovascular disease events, and nants of anxiety and depression in end stage renal disease mortality in end-stage renal disease: contribution of reverse (ESRD). A comparison between ESRD patients with and with- causality. Clin J Am Soc Nephrol 2006; 1: 496–504 out coexisting diabetes mellitus. J Psychosom Res 2017; 94: 18. Hedayati SS, Bosworth HB, Briley LP et al. Death or hospital- 68–72 ization of patients on chronic hemodialysis is associated 31. Abdel-Kader K, Unruh ML, Weisbord SD. Symptom burden, with a physician-based diagnosis of depression. Kidney Int depression, and quality of life in chronic and end-stage kid- 2008; 74: 930–936 ney disease. Clin J Am Soc Nephrol 2009; 4: 1057–1064 19. Chilcot J, Norton S, Wellsted D et al. Distinct depression 32. Hedayati S, Finkelstein FO. Epidemiology, diagnosis, and symptom trajectories over the first year of dialysis: associa- management of depression in patients with CKD. Am J tions with illness perceptions. Ann Behav Med 2013; 45: 78–88 Kidney Dis 2009; 54: 741–752 20. Drayer RA, Piraino B, Reynolds CF 3rd et al. Characteristics of 33. Duarte PS, Miyazaki MC, Blay SL et al. Cognitive-behavioral depression in hemodialysis patients: symptoms, quality of group therapy is an effective treatment for major depression life and mortality risk. Gen Hosp Psychiatry 2006; 28: 306–312 in hemodialysis patients. Kidney Int 2009; 76: 414–421 Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Clinical Kidney Journal Oxford University Press
Free
7 pages

Loading next page...
 
/lp/ou_press/depressive-affect-in-incident-hemodialysis-patients-VO8PHjHoL8
Publisher
European Renal Association - European Dialysis and Transplant Association
Copyright
© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA.
ISSN
2048-8505
eISSN
2048-8513
D.O.I.
10.1093/ckj/sfx054
Publisher site
See Article on Publisher Site

Abstract

Background: The prevalence of depressive affect is not well defined in the incident hemodialysis (HD) population. We inves- tigated the prevalence of and associated risk factors and hospitalization rates for depressive affect in incident HD patients. Methods: We performed a prospective investigation using the Patient Health Questionnaire 2 (PHQ2) depressive affect assessment. From January to July of 2013 at 108 in-center clinics randomly selected across tertiles of baseline quality meas- ures, we contacted 577 and 543 patients by telephone for depressive affect screening. PHQ2 test scores range from 0 to 6 (scores 3 suggest the presence of depressive affect). The prevalence of depressive affect was measured at 1–30 and 121– 150 days after initiating HD; depressive affect risk factors and hospitalization rates by depressive affect status at 1–30 days after starting HD were computed. Results: Of 1120 contacted patients, 340 completed the PHQ2. In patients screened at 1–30 or 121–150 days after starting HD, depressive affect prevalence was 20.2% and 18.5%, respectively (unpaired t-test, P¼ 0.7). In 35 patients screened at both time points, there were trends for lower prevalence of depressive affect at the end of incident HD, with 20.0% and 5.7% of patients positive for depressive affect at 1–30 and 121–150 days, respectively (paired t-test, P¼ 0.1). Hospitalization rates were higher in patients with depressive affect during the first 30 days, exhibiting 1.5 more admissions (P< 0.001) and 10.5 additional hos- pital days (P¼ 0.008) per patient-year. Females were at higher risk for depressive affect at 1–30 days (P¼ 0.01). Conclusions: The prevalence of depressive affect in HD patients is high throughout the incident period. Rates of hospital admissions and hospital days are increased in incident HD patients with depressive affect. Key words: depression, hospital admission, hospital days, incident dialysis, patient health questionnaire 2 Introduction population, the prevalence of depressive affect with or without a Clinical depression and symptoms of depressive affect are com- diagnosis of depression has been reported to be between 8.9% and mon in hemodialysis (HD) patients but have not been well charac- 45% within 1 –120 days after initiation of dialysis [1–6]. In compari- terized in the incident HD population early after initiation of son, in the general population depressive affect with or without a dialysis and through the incident period [1–6]. In the incident HD diagnosis of depression has been reported to have a prevalence of Received: March 1, 2017; Editorial decision: May 15, 2017 V C The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 124 | K.A. McDougall et al. 2–10% [7]; the depressive affect prevalence in the prevalent dialy- affect occurring during the prior 2 weeks [22]. PHQ2 scores of 3 sis population with or without a diagnosis of depression has been have a 75% probability of identifying the presence of ‘any documented to be between 20% and 55% [4, 8–10]. depressive disorder’ in the prior 2 weeks but only a 38% proba- Identification of depressive affect does not discretely diag- bility of a ‘major depressive disorder’ [22]. nose clinical depression but does indicate a high probability of The PHQ2 has been validated and shown to be effective in any depressive disorder without a precise degree of severity. screening for depressive affect in primary care, hospital outpa- Clinical depression must be diagnosed by a physician through tient and coronary heart disease patients [22–24]. The PHQ2 test medical assessment of the patient’s psychological status and has not been validated specifically in the dialysis population; clinical symptoms of depressive affect. In the end-stage renal however, it has been used to screen for depressive affect in inci- disease (ESRD) population, depressive affect has been assessed dent dialysis patients [4] and appears to be a simple and effec- using several survey methods that include the Patient Health tive method to determine the occurrence of depressive affect. Questionnaires [4, 11], Beck Depression Inventory (BDI) [11, 12], Notably, identification of the presence of depressive affect using Center for Epidemiologic Studies Depression Screening Index the PHQ2 cannot determine the discrete magnitude of severity [13], Hospital Anxiety and Depression Scale [14] and the two for depressive symptoms, which can be further evaluated by questions associated with depressive symptoms within the 36- the clinical judgment of the treating physician. Item Short Form Health Survey (SF-36) [3, 15]. The in-center HD clinics utilized for this study were ran- Depressive affect with or without a diagnosis of depression domly selected to equally represent each FMCNA division and has been observed in incident dialysis patients to be linked to were distributed across tertiles of quality levels at baseline. increases in withdrawing from HD in the first 3 months of treat- FMCNA dialysis clinic quality is determined by UltraScores, ment [3], as well as increases in risk for mortality in the first which, at the time, were based on levels of albumin, hemoglo- year of dialysis [3, 16, 17]. It has been identified in prevalent bin, phosphorous, estimated Kt/V, as well as rates of catheter dialysis patients that depressive affect is associated with risks use and mortality. Small clinics (HD census <50 patients) or of decreases in quality of life and increases in morbidities, car- those that had limitations in the ability to translate for language diovascular events, hospitalizations and mortality [9, 18–20]. In barriers were excluded from the study. a recent large observational study of incident HD patients All patients who completed a depressive affect screening by within 120 days after starting dialysis, depressive affect was PHQ2 during 1–30 days or 121–150 days after initiation of HD found to be associated with increased rates of hospital admis- were included in the analyses. For this investigation, data for the sions and hospital days [1]. PHQ2 scores was recorded by telephone survey operators and The aims of this study were to characterize the prevalence patient demographics, clinical parameters and rates of hospital of depressive affect early after the initiation of dialysis and at admissions and hospital days were captured from patient data the end of the incident period, determine the risk factors for available in the FMCNA Knowledge Center Data Warehouse. depressive affect and investigate hospitalization rates related to Depressive affect scores during 1–30 and 121–150 days and hospi- depressive affect in incident HD patients. talization rates 1–150 days after initiating HD were utilized for comparisons. Additionally, clinical and laboratory parameters were collected up to the first 30 and 150 days of HD. Materials and methods Analyses included descriptive statistics of patient demo- graphics, clinical characteristics and PHQ2 scores. The mean clin- This study was a prospective investigation performed at 108 ical and demographic parameters in patients assessed for outpatient HD centers in the USA and conducted as a compo- depressive affect at either 1–30 and/or 121–150 days after starting nent of the Fresenius Medical Care North America (FMCNA) HD were compared using an unpaired Student’s t-test for contin- RightStart program [21]. From January to July 2013, 577 patients uous variables and chi-square test for categorical variables. within 1–30 days after initiation of HD and 543 patients at 121– Comparisons in a select group of the same patients screened for 150 days after initiating HD were contacted by telephone for depressive affect at both time points were made using a paired depressive affect screening. Upon determination of a positive Student’s t-test for continuous variables and a McNemar test for depressive affect screening score, the patient’s clinical care staff categorical variables. Associations between depressive affect at was notified for further assessment and/or intervention. the time of assessment and demographic and clinical character- For this investigation, depressive affect was assessed by tele- istics were studied using t-tests and chi-square tests. A Poisson phone using the Patient Health Questionnaire 2 (PHQ2). Survey regression analysis was utilized for comparisons of rates of hos- operators were trained in survey processes, observed during pital admissions and hospital days. Unpaired Student’s t-tests training and provided with written training materials. The were performed for comparison of the prevalence of depressive PHQ2 surveys were administered to patients in either English or affect at 1–30 days versus 121–150 days after initiation of HD in Spanish by bilingual survey operators depending on the patients assessed at one of the time points; paired Student’s t- patient’s native language; non-English-or non-Spanish-speak- tests were used for analyzing comparisons in a select group of ing patients were excluded. The PHQ2 is a two-question assess- the same patients screened for depressive affect at both time ment that can screen patients for the presence of depressed points. All analyses were performed using SAS software version mood and anhedonia occurring during the previous 2 weeks [22, 9.4 (SAS Institute, Cary, NC, USA). 23]. The questions of the PHQ2 are as follows: ‘Over the last 2 weeks, how often have you been bothered by any of the fol- lowing problems?’ (i) ‘Little interest or pleasure in doing things’ Results and (ii) ‘Feeling down, depressed, or hopeless’. Each question of the PHQ2 has four possible responses with scores ranging from Of the overall population of 1120 incident HD patients who con- 0 to 3 and include (i) ‘Not at all’ (score¼ 0), (ii) ‘Several days’ tacted for telephonic depressive affect screening, 340 PHQ2 (score¼ 1), (iii) ‘More than half the days’ (score¼ 2) and (iv) assessments were completed by 305 unique patients. The over- ‘Nearly every day’ (score¼ 3). The overall scoring for the PHQ2 all depressive affect screening response rate was 30.4% and test ranges from 0 to 6; scores 3 are suggestive of depressive there was a mean of 1.6 calls performed to complete the PHQ2 Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Depressive affect in HD | 125 Table 1. Demographics and clinical characteristics for patients sur- Table 2. Demographics and clinical characteristics for the patients veyed at one of the time points (n ¼ 35)surveyed at both time points Parameters 1–30 days 121–150 P-value Parameters 1–30 days after 121–150 days P-value after days incident HD incident HD incident HD incident HD Average age, years (SD) 64.2 (613.3) NA Number of patients 178 92 NA Female (%) 37.1 NA (total ¼ 270) Diabetes (%) 64.7 NA Average age, years (6SD) 64.1 (616.3) 63.7 (613.6) 0.829 Hypothyroidism (%) 2.9 NA Female (%) 39.9 41.3 0.822 Race, White (%) 71.4 NA Diabetes (%) 67.1 67.9 0.909 Ethnicity, not Hispanic (%) 85.7 NA Hypothyroidism (%) 8.4 8.7 0.940 BMI, kg/m (6SD) 29.3 (66.5) 29.0 (66.4) 0.092 Race, White (%) 74.2 63.0 0.058 Catheter access (%) 44.1 17.7 0.004 Ethnicity, not Hispanic (%) 80.9 95.7 0.001 Albumin, g/dL (6SD) 3.6 (60.5) 3.9 (60.4) 0.003 BMI, kg/m (6SD) 29.6 (68.1) 30.2 (67.8) 0.608 Log of creatinine (6SD) 1.8 (60.4) 1.9 (60.4) 0.087 Catheter access (%) 52.7 15.5 <0.0001 OLC (6SD) 1.3 (60.3) 1.5 (60.3) <0.0001 Albumin, g/dL (6SD) 3.5 (60.5) 3.8 (60.5) 0.001 PreSBP, mmHg (6SD) 147.7 (622.6) 149.6 (621.5) 0.428 Log of creatinine (6SD) 1.6 (60.4) 1.9 (60.4) <0.0001 Percent IDWG (6SD) 2.2 (60.90) 2.8 (61.0) 0.001 OLC (6SD) 1.4 (60.3) 1.6 (60.3) <0.0001 Average PHQ2 score 1.3 (62.0) 0.7 (61.3) 0.091 PreSBP, mmHg (6SD) 145.0 (620.3) 150.3 (620.0) 0.058 Patients with positive 20.0 5.7 0.125 Percent IDWG (6SD) 2.1 (61.1) 2.9 (61.0) <0.0001 PHQ2 scores (3) (%) Average PHQ2 score 1.2 (62.0) 1.2 (61.6) 0.705 Summary of incident HD patient demographics, diabetes comorbidity, dialysis Patients with positive 20.2 18.5 0.731 access characteristics and PHQ2 assessment parameters for patients assessed PHQ2 scores (3) (%) for depressive affect at both the study time points. Summary of incident HD patient demographics, diabetes comorbidity, dialysis access characteristics and PHQ2 scores in patients that responded to the depres- Over the 150-day period after initiation of HD, the hospital sive affect screening at either 1–30 days or 121–150 days after initiating dialysis. admission rate for depressive affect–positive patients at the 1–30 day time point was 2.86 admissions per patient-year (ppy) survey. During 1–30 days after initiation of HD, there were 213 and for depressive affect–negative patients was 1.32 admissions responders to depressive affect screening and at 121–150 days ppy (Figure 1). Depressive affect–positive patients spent 17.8 there were 127 responders; there was a 36.9% and 23.4% days in hospitals ppy and depressive affect–negative patients response rate at 1–30 and 121–150 days, respectively spent 7.3 days in hospitals ppy (Figure 1). A Poisson regression (Supplementary data, Table S1). Among patients who were con- model with adjustment for factors commonly associated with tacted and asked to complete a PHQ2 assessment, 89.4% agreed hospitalization rates showed significantly higher rate of admis- to perform the screening and 10.6% refused. sion [relative rate (RR) 2.08; P¼ 0.005; Table 4] and hospital days The clinical and demographic characteristics of the 270 (RR¼ 1.87; P¼ 0.005; Table 5) in DA positive patients, as com- unique patient responders to the depressive affect screening at pared with depressive affect–negative patients. The outcomes one of the two time points are shown in Table 1. The population were adjusted for the covariates of age, sex, diabetes, access of patients responding to depressive affect screening at either 1– type, ethnicity, race, body mass index (BMI), albumin, log of cre- 30 days or 121–150 days after starting HD was mostly similar in atinine, OLC, predialysis systolic blood pressure (preSBP) and clinical and demographic characteristics, with the exception of IDWG. more non-Hispanics and higher online clearance (OLC) at the later time point as well as the anticipated changes happening in incident patients, such as increases in albumin, higher log of cre- Discussion atinine, higher percent of interdialytic weight gain (IDWG) and lower catheter utilization rates at 121–150 days after starting HD. This study investigated the prevalence of depressive affect in The prevalence of depressive affect was observed to be 20.2% incident HD patients determined by telephonic PHQ2 assess- in patients in the first 30 days after initiation of HD and 18.5% at ments during the first month of HD and at the end of the inci- the end of the incident period (121–150 days after initiation of dent period. Our findings identified that depressive affect is HD); there were no differences between time points (P¼ 0.7). In a common and unchanged throughout the incident period, gener- select group of 35 patients who were screened for depressive ally affecting 19–20% of incident HD patients, and is associated affect at both time points, the depressive affect prevalence was with increases in rates of hospital admissions and days consis- observed to be lower at 121–150 days (5.7% depressive affect posi- tent with other findings in the incident [1] and prevalent [15] tive) as compared with 1–30 days (20.0% depressive affect posi- dialysis populations. Female sex was identified to be a risk fac- tive), albeit non-significant (P¼ 0.1), as shown in Table 2. tor associated with depressive affect occurrence 1–30 days after As detailed in Table 3, the analysis of risk factors in incident initiation of HD in this cohort of patients, which is consistent HD patients showed that females have a higher risk for depres- with our previous interim findings [25, 26] and other reports in sive affect 1–30 days after initiation of HD (P¼ 0.01), but there the literature [13]. were no differences between sexes for 121–150 days after start- We observed that the prevalence of depressive affect in inci- ing HD (P¼ 0.8). Also, there were trending risks for depressive dent HD patients is high throughout the incident period, with affect in patients with higher BMI 121–150 days after initiating 20.2% of patients screening positive for depressive affect in the HD (P¼ 0.054). No other clinical and demographic characteris- first month of HD and 18.5% at the end of the incident period. tics were identified to be associated with depressive affect in These findings are very consistent with other reports that iden- incident HD patients. tified depressive affect using the mental health domain items Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 126 | K.A. McDougall et al. Table 3. Depressive affect status and patient demographics, characteristics and PHQ2 scores Parameters of responders 1–30 days 1–30 days P-value 121–150 days 121–150 days P-value to depressive affect screening depressive depressive depressive depressive affect negative affect positive affect negative affect positive Number of patients 170 43 NA 108 19 NA Average age, years (SD) 64.5 (615.6) 62.8 (616.8) 0.537 64.5 (614.0) 60.0 (69.4) 0.176 Female (%) 35.3 55.8 0.014 39.8 42.1 0.851 Diabetes (%) 66.7 66.7 1.000 64.0 84.2 0.085 Race, White (%) 75.9 65.1 0.152 67.6 52.6 0.206 Ethnicity, not Hispanic (%) 82.4 79.1 0.619 91.7 100.0 0.192 BMI, kg/m (6SD) 29.4 (67.7) 30.2 (68.3) 0.547 29.4 (67.3) 33.0 (67.4) 0.054 Catheter access (%) 51.4 50.0 0.882 17.0 10.5 0.480 Albumin, g/dL (6SD) 3.5 (60.5) 3.5 (60.5) 0.8892 3.8 (60.5) 3.7 (60.3) 0.337 Average PHQ2 score 0.3 (60.7) 4.8 (61.3) NA 0.5 (60.8) 4.1 (61.0) NA Risk factor analysis of demographic and clinical patient parameters associated with depressive affect. Figure 1. Hospital admission rates ppy in the first 150 days of HD in patients positive for depressive affect (solid black column) versus negative for depressive affect (slash line column). Table 4. Associations of 150-day hospital admission rates and depressive affect in incident HD patients Parameter Estimate Standard error 95% LCL 95% UCL Wald chi-square P-value Intercept 3.314 1.998 0.603 7.230 2.75 0.097 Depressive affect positive at 1–30 days after incident HD 0.730 0.259 0.221 1.238 7.91 0.005 Age 0.004 0.009 0.022 0.014 0.19 0.664 Male 0.197 0.283 0.358 0.752 0.48 0.486 Diabetes 0.212 0.366 0.506 0.930 0.34 0.562 Race, White 0.508 0.451 0.377 1.392 1.27 0.261 Ethnicity, not Hispanic 0.433 0.342 0.237 1.102 1.6 0.205 BMI 0.001 0.020 0.041 0.038 0 0.957 Catheter access at 30 days after incident HD 0.001 0.246 0.483 0.482 0 0.998 Albumin 0.060 0.245 0.540 0.419 0.06 0.805 Log of creatinine 0.362 0.312 0.973 0.248 1.35 0.245 OLC 0.113 0.439 0.974 0.749 0.07 0.798 PreSBP 0.004 0.006 0.016 0.008 0.43 0.513 Percent IDWG 0.120 0.119 0.114 0.354 1.01 0.315 Poisson regression analysis of rates of hospital admissions in patients who were depressive affect–positive at 1–30 days after initiation of HD. LCL, lower confidence limit; UCL, upper confidence limit. in the SF-36; of 6415 US patients during 10–90 days after initiat- Contrary to the findings noted above, other reports in the lit- ing HD, 20.8% were positive for depressive affect [3], and in the erature have found the prevalence of depressive affect in inci- US Dialysis Outcomes and Practice Patterns Study (DOPPS) dent patients utilizing the SF-36 to be at 8.9% in Dutch patients cohort, depressive affect was identified in 17.5% of 2562 patients at 90 days after starting dialysis [2], 41% in US patients at 1–120 during the first 3 months of HD [15]. Additionally, a previous days after starting dialysis [1] and 45% in US patients [6] at 60– investigation of depressive affect based on PHQ2 assessment in 90 days after starting dialysis. These differences are likely influ- 585 US patients at 60–90 days after starting HD or peritoneal enced by decreasing rates of catheter use in studies that utilize dialysis found that 12.1–32.8% of patients were positive for longer incident periods, as well as differences in geography, cul- depressive affect dependent on employment status [4]. tural habits and treatment patterns between the Dutch and US Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Depressive affect in HD | 127 Table 5. Associations of 150-day hospitalization rates and depressive affect in incident HD patients Parameter Estimate Standard error 95% LCL 95% UCL Wald chi-square P-value Intercept 3.299 1.767 0.164 6.762 3.49 0.062 Depressive affect positive at 1–30 days after incident HD 0.626 0.223 0.189 1.062 7.88 0.005 Age 0.025 0.008 0.042 0.009 8.93 0.003 Male 0.722 0.232 1.177 0.268 9.71 0.002 Diabetes 1.061 0.329 0.416 1.705 10.4 0.001 Race, White 1.061 0.328 0.418 1.703 10.46 0.001 Ethnicity, not Hispanic 0.452 0.284 0.105 1.008 2.53 0.112 BMI 0.041 0.017 0.074 0.009 6.33 0.012 Catheter access at 30 days after incident HD 0.506 0.221 0.074 0.939 5.27 0.022 Albumin 0.213 0.240 0.683 0.258 0.79 0.375 Log of creatinine 0.269 0.285 0.827 0.289 0.9 0.344 OLC 0.529 0.355 1.226 0.167 2.22 0.136 PreSBP 0.003 0.005 0.014 0.007 0.39 0.531 Percent IDWG 0.098 0.102 0.102 0.297 0.92 0.337 Poisson regression analysis of rates of hospital days in patients who were depressive affect positive at 1–30 days after initiation of HD. LCL, lower confidence limit; UCL, upper confidence limit. health care systems, which requires further studies. Notably, access; these findings were not significant (P¼ 0.48; Table 3). the Dutch study did include incident HD and peritoneal dialysis Further investigations are warranted to evaluate whether early patients, which may be a factor associated with the lower prev- identification of depressive affect leads to interventions and alence of depressive affect observed as compared with the US improved outcomes. Future studies could include analysis of fol- studies. Another report identified that depressive affect deter- low-up depressive affect assessments with higher specificity and mined by assessment with the BDI was present in 44% of sensitivity than the PHQ2, physician-based diagnosis of clinical patients during the first 10 days after starting dialysis [5]. depression and the specific interventions performed, such as Although the observed differences in the prevalence of depres- pharmaceutical and psychosocial therapies. sive affect in dialysis patients could be related in part to depres- Our examination of associations in depressive affect and sive affect assessment methods, patient geography, dialysis patient demographics and clinical parameters in this group of modality, timeframe of the study and cohort size, the findings incident HD patients identified that females have a higher risk by Lacson et al. in 2012 and 2014 using the SF-36 in similar large for experiencing depressive affect 1–30 days after starting HD as cohorts of HD patients from the same dialysis provider and dur- compared with males; however, we did not observe differences ing concurrent periods during 2006 reveals a 20.2% variance, 121–150 days after the start of HD. While we only found sex to be with depressive affect in 20.8% of 6415 patients at 10–90 days a significant risk factor for depressive affect and BMI to be a after HD [3] and 41% of 8776 patients at 1–120 days after HD [1]. trending risk factor at the end of the incident period, other stud- Overall, the prevalence of depressive affect is very high in inci- ies have reported that depressive affect is associated with several dent HD patients and appears to have noteworthy differences in risk factors, including age [3], race [5], lower albumin levels [3], observed prevalence in the literature due to possible selection diabetes and catheter use [27]. In the general population, compre- bias. Based on our findings, the prevalence of depressive affect hensive reviews have identified that the presence of diabetes is is not significantly changed from the beginning to the end of associated with an up to 2-fold increase in the risk of depression the incident HD period and the timing of depressive affect [28]. Conversely, patients in the general population with depres- assessment during the incident HD period is not expected to sion have been shown to exhibit a 10% higher incidence of diabe- significantly alter the rates of depressive affect in the incident tes [29]. Despite these findings, a recent investigation in HD HD population. However, the results of our study were per- patients did not find any difference in the prevalence of depres- formed in a limited number of patients and need to be further sive affect in those with and without the presence of diabetes investigated and confirmed. [30]. Additional studies investigating the risk factors associated In a subanalysis of a small number of paired patients with depressive affect in incident HD patients should be per- screened for depressive affect at the initiation of and end of the formed in an attempt to identify potential predictors of depres- incident period, the occurrence of depressive affect was found to sive affect in this population. be reduced from 20.0% in the first month of dialysis to 5.7% at the We found that incident HD patients positive for depressive end of the incident period, albeit non-significant (P¼ 0.1). While affect during the first month of dialysis exhibited an 2-fold adjustment to HD and patient selection might have contributed increase in rates of hospital admissions (RR 2.08; P¼ 0.005) and to this finding, early identification of depressive affect and subse- hospital days (RR 1.87; P¼ 0.005); this is consistent with the find- quent interventions by dialysis care teams could be a factor. In ings by Lacson et al. [1] in 2014 using a large study cohort of 8776 this cohort there was a 26.4% decrease in catheter use from the patients at 1–120 days after HD. These findings further identify first 30 days of dialysis to the end of the incident period that from the initiation of dialysis, depressive affect in the HD (P¼ 0.004), which may be influencing these findings (Table 2). In population is related to worsened outcomes that could poten- the overall study population, rates of catheter use were similar tially be modifiable through interventions. Whether enhanced between patients with and without depressive affect 1–30 days early identification of depressive affect and treatment of depres- after starting dialysis. At 121–150 days after starting dialysis there sive symptoms in incident HD patients has the potential to were 6.5% fewer patients using a catheter who were positive for improve patient hospitalization outcomes has not been depressive affect compared with those with a permanent dialysis determined. Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 128 | K.A. McDougall et al. There is consensus in the literature that improvements are FUNDING needed in screening for depressive affect and clinical depres- This study was funded by Fresenius Medical Care North sion in the ESRD population [1, 4, 5, 18, 19, 31]. The striking prev- America through the RightStart quality improvement alence of depressive affect observed in incident and prevalent initiative. dialysis patients represents a population with notable risk for worsened outcomes that could potentially be improved through treatment of depressive symptoms. Treatment options that Conflict of interest statement have been reported to be associated with improvements in the Company: The RightStart quality improvement initiative is a symptoms of depression in ESRD patients include antidepres- sant pharmaceuticals [32], cognitive behavioral therapy [33], registered trademark program of Fresenius Medical Care exercise training programs [9] and music therapy [9]. In the US North America. DOPPS cohort, it was shown that antidepressant medications Authors: K.A.M.: employed by Fresenius Medical Care North were only prescribed for 38.9% of HD patients with clinical America. J.W.L.: employed by Fresenius Medical Care North depression diagnosed by a physician and 28.9% of HD patients America. R.L.W.: employed by Fresenius Medical Care North with depressive affect [13]. It was found in an investigation of America; stock ownership in Fresenius Medical Care. S.R.: 98 HD patients assessed for clinical depression that only 54% of employed by Fresenius Medical Care North America. Y.J.: depressed patients identified in the study were diagnosed with employed by Fresenius Medical Care North America. L.M.: the disease previously during routine care and 23% had an anti- employed by Fresenius Medical Care North America. L.A.U.: depressant medication prescribed [18]. Additionally, in a study employed by Fresenius Medical Care North America; stock of 123 incident dialysis patients by Watnick et al. [5], it was ownership in Fresenius Medical Care. F.W.M.: employed by shown that only 16% of patients with depressive affect received Fresenius Medical Care North America; stock ownership in an antidepressant treatment. Despite the fact that major Fresenius Medical Care. improvements in care are apparently needed, the ability to Other non-financial conflicts of interest: F.W.M.: directorships in improve clinical outcomes via identification and treatment of American National Bank & Trust, Mid-Atlantic Renal depressive affect and clinical depression has not been firmly Coalition, Specialty Care Inc and Sound Physicians; chair- established in the dialysis population and needs to be eluci- man Pacific Care Renal Foundation 501(c)(3) nonprofit; dated [9]. chairr Kidney Care Partners; founder Scholarships This study did have some key limitations that include a Expanding Education 501(c)(3) non-profit. potential selection bias secondary to the design that assessed Support: This research was conducted as part of the patients at both the 1–30 day and 121–150 day time points; how- RightStart quality improvement program. K.A.M., J.W.L., ever, this did not yield a notable cohort of patients who repeated the survey at both time points. Additionally, the study R.L.W., Y.J., S.R., L.M., L.A.U. and F.W.M. are employed by included only 305 unique patients and further studies are Fresenius Medical Care North America. All authors, as needed that include larger patient numbers. Another limitation employees of Fresenius Medical Care North America, assisted is that patients were assessed using telephone interviews and it in the study and the analytical design, medical writing of the has not been determined if this method is as accurate as in-per- study-related documents and composition of the article. son depression screening methods. Furthermore, this analysis did not assess the impacts of antidepressant use on PHQ2 References scores or assess the number of patients identified with depres- sive affect who might have been prescribed antidepressant 1. Lacson E Jr, Bruce L, Li NC et al. Depressive affect and hospi- therapies by their physicians. talization risk in incident hemodialysis patients. Clin J Am In conclusion, depressive affect is common in incident HD Soc Nephrol 2014; 9: 1713–1719 patients and did not change significantly throughout the inci- 2. van Dijk S, van den Beukel TO, Kaptein AA et al. How base- dent period. Increases in rates of hospital admissions and hos- line, new-onset, and persistent depressive symptoms are pital days are significantly associated with depressive affect in associated with cardiovascular and non-cardiovascular incident HD patients, and this further identifies the imperative mortality in incident patients on chronic dialysis. need for improved screening and treatment. It is evident that J Psychosom Res 2013; 74: 511–517 the development of enhanced interventional paradigms for the 3. Lacson E Jr, Li NC, Guerra-Dean S et al. Depressive symptoms treatment of depressive affect and clinical depression in dialysis associate with high mortality risk and dialysis withdrawal in patients will be essential in reducing the worsened outcomes incident hemodialysis patients. Nephrol Dial Transplant 2012; observed in this population. 27: 2921–2928 4. Kutner NG, Zhang R, Huang Y et al. Depressed mood, usual activity level, and continued employment after starting dial- Supplementary data ysis. Clin J Am Soc Nephrol 2010; 5: 2040–2045 5. Watnick S, Kirwin P, Mahnensmith R et al. The prevalence Supplementary data are available online at http://ckj.oxford and treatment of depression among patients starting dialy- journals.org. sis. Am J Kidney Dis 2003; 41: 105–110 6. Walters BA, Hays RD, Spritzer KL et al. Health-related quality of life, depressive symptoms, anemia, and malnutrition at Acknowledgements hemodialysis initiation. Am J Kidney Dis 2002; 40: 1185–1194 We would like to thank and acknowledge Eduardo K. Lacson, 7. Kessler RC, Berglund P, Demler O et al. National Comorbidity Jr, MD, for his notable contributions to the study design, as Survey Replication. The epidemiology of major depressive well as the staff and physicians who assisted in conducting disorder: results from the National Comorbidity Survey the RightStart program at participating dialysis clinics. Replication (NCS-R). JAMA 2003; 289: 3095–3105 Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Depressive affect in HD | 129 21. Wingard RL, Chan KE, Lazarus JM et al. The ‘right’ of passage: 8. Rosenthal Asher D, Ver Halen N, Cukor D. Depression and nonadherence predict mortality in hemodialysis treated end- surviving the first year of dialysis. Clin J Am Soc Nephrol 2009; stage renal disease patients. Hemodial Int 2012; 16: 387–393 4(Suppl 1): S114–S120 9. Hedayati SS, Yalamanchili V, Finkelstein FO. A practical 22. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney Med Care 2003; 41: 1284–1292 Int 2012; 81: 247–255. 23. Arroll B, Goodyear-Smith F, Crengle S et al. Validation of 10. Zalai D, Szeifert L, Novak M. Psychological distress and PHQ-2 and PHQ-9 to screen for major depression in the pri- depression in patients with chronic kidney disease. Semin mary care population. Ann Fam Med 2010; 8: 348–353 Dial 2012; 25: 428–438 24. Gilbody S, Richards D, Brealey S et al. Screening for depres- 11. Watnick S, Wang PL, Demadura T et al. Validation of 2 sion in medical settings with the Patient Health depression screening tools in dialysis patients. Am J Kidney Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Dis 2005; 46: 919–924 Med 2007; 22: 1596–1602 12. Kimmel PL, Peterson RA, Weihs KL et al. Multiple measure- 25. Larkin JW, McDougall KA, Wingard RL et al. Risk factors asso- ments of depression predict mortality in a longitudinal ciated with depressive affect in incident hemodialysis study of chronic hemodialysis outpatients. Kidney Int 2000; patients [ASN abstract SA-PO1043]. J Am Soc Nephrol 2014; 25: 57: 2093–2098 883A 13. Lopes AA, Albert JM, Young EW et al. Screening for depression in 26. Larkin JW, McDougall KA, Usvyat LA et al. Depressive affect hemodialysis patients: associations with diagnosis, treatment, in incident hemodialysis patients: prevalence and risk fac- and outcomes in the DOPPS. Kidney Int 2004; 66: 2047–2053 tors [ASN abstract TH-PO539]. J Am Soc Nephrol 2013; 24: 225A 14. Riezebos RK, Nauta KJ, Honig A et al. The association of 27. Nowak L, Adamczak M, Wie ˛ cek A. Is inflammation a new depressive symptoms with survival in a Dutch cohort of risk factor of depression in haemodialysis patients? Int Urol patients with end-stage renal disease. Nephrol Dial Transplant Nephrol 2013; 45: 1121–1128 2010; 25: 231–236 28. Lustman PJ, Clouse RE. Depression in diabetic patients: the 15. Lopes AA, Bragg J, Young E et al. Depression as a predictor of relationship between mood and glycemic control. J Diabetes mortality and hospitalization among hemodialysis patients Complications 2005; 19: 113–122 in the United States and Europe. Kidney Int 2002; 62: 199–207 29. Nichols GA, Moler EJ. Cardiovascular disease, heart failure, 16. Chilcot J, Davenport A, Wellsted D et al. An association chronic kidney disease and depression independently between depressive symptoms and survival in incident dial- increase the risk of incident diabetes. Diabetologia 2011; 54: ysis patients. Nephrol Dial Transplant 2011; 26: 1628–1634 523–526 17. Boulware LE, Liu Y, Fink NE et al. Temporal relation among 30. Yoong RK, Mooppil N, Khoo EY et al. Prevalence and determi- depression symptoms, cardiovascular disease events, and nants of anxiety and depression in end stage renal disease mortality in end-stage renal disease: contribution of reverse (ESRD). A comparison between ESRD patients with and with- causality. Clin J Am Soc Nephrol 2006; 1: 496–504 out coexisting diabetes mellitus. J Psychosom Res 2017; 94: 18. Hedayati SS, Bosworth HB, Briley LP et al. Death or hospital- 68–72 ization of patients on chronic hemodialysis is associated 31. Abdel-Kader K, Unruh ML, Weisbord SD. Symptom burden, with a physician-based diagnosis of depression. Kidney Int depression, and quality of life in chronic and end-stage kid- 2008; 74: 930–936 ney disease. Clin J Am Soc Nephrol 2009; 4: 1057–1064 19. Chilcot J, Norton S, Wellsted D et al. Distinct depression 32. Hedayati S, Finkelstein FO. Epidemiology, diagnosis, and symptom trajectories over the first year of dialysis: associa- management of depression in patients with CKD. Am J tions with illness perceptions. Ann Behav Med 2013; 45: 78–88 Kidney Dis 2009; 54: 741–752 20. Drayer RA, Piraino B, Reynolds CF 3rd et al. Characteristics of 33. Duarte PS, Miyazaki MC, Blay SL et al. Cognitive-behavioral depression in hemodialysis patients: symptoms, quality of group therapy is an effective treatment for major depression life and mortality risk. Gen Hosp Psychiatry 2006; 28: 306–312 in hemodialysis patients. Kidney Int 2009; 76: 414–421 Downloaded from https://academic.oup.com/ckj/article-abstract/11/1/123/3956640 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Clinical Kidney JournalOxford University Press

Published: Feb 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off