Depressive symptomatology and treatment in patients with end-stage renal disease

La dépression dans les populations médicales

La prévalence élevée des états dépressifs dans la clientèle du généraliste (environ 10% des consultants) et chez les patients de médecine interne (15 à 25% des hospitalisés) est maintenant bien établie. Ce fait a été longtemps négligé par les praticiens et les psychiatres; même actuellement son importance reste sous-estimée.

La proportion d’états dépressifs non-identifiés par les praticiens varie de 1/3 à 2/3 selon les études. Les dépressions méconnues sont source de surconsommation médicale (consultations répétées, examens paracliniques, hospitalisations pour bilans) et ont une évolution moins favorable, plus chronique, que les dépressions identifiées et correctement traitées. Des cas sévères de dépression échappent souvent au dépistage, ce qui n’est pas sans conséquences graves: on sait en effet que la majorité des gens qui se suicident ont consulté un médecin dans le mois qui a précédé leur décès.

Parmi les facteurs qui rendent compte de la méconnaissance des états dépressifs par les médecins non-spécialistes, les uns tiennent aux patients qui, dans leur dialogue avec le généraliste, utilisent davantage le langage de la somatisation qu’ils ne verbalisent explicitement un vécu dépressif. D’autres tiennent aux praticiens, à leur intérêt prévalent et parlois exclusif pour les problèmes somatiques, à leur souci légitime de ne pas passer à côté du diagnostic d’une affection médicale, à l’idée qu’ils se font de la dépression et des déprimés, à leur propension à considérer toutes les manifestations dysphoriques comme conséquences légitimes de la maladie physique. Il faut aussi compter avec les conditions d’exercice du généraliste, le temps très court de sa consultation où il n’est pas facile de différencier une réelle pathologie dépressive, généralement liée à des troubles anxieux et moins nette que dans les consultations Psychiatriques, de troubles émotionnels mineurs, situationnels et transitoires.

Les instruments habituellement utilisés pour le dépistage et le diagnostic de la dépression (échelles d’autoévaluation, critères de diagnostic type RDC ou critères du DSM III) n’ont pas été validés pour les populations de patients somatiques. Récemment deux nouveaux instruments viennent d’être mis au point pour la détection de la symptomatologie dépressive chez les patients somatiques: I'échelle HAD (Hospital Anxiety and Depression Scale) de Zigmond et Snaith (1983) et le Questionnaire Abrégé d’Auto-Évaluation de la Symptomatologie Dépressive (QD2A) de Pichot et al. (1984). Ces échelles, de passation rapide et bien acceptées par les patients, peuvent servir d’aide au diagnostic pour le praticien dans la perspective d’un meilleur dépistage de la dépression et d’une prise en charge plus efficace des déprimés.

Comorbidity of DSM–III–R Major Depressive Disorder in the General Population: Results from the US National Comorbidity Survey

General population data are presented on the prevalence and correlates of comorbidity between DSM–III–R major depressive disorder (MDD) and other DSM–III–R disorders. The data come from the US National Comorbidity Survey, a large general population survey of persons aged 15–54 years in the non-institutionalised civilian population. Diagnoses are based on a modified version of the Composite International Diagnostic Interview (CIDI). The analysis shows that most cases of lifetime MDD are secondary, in the sense that they occur in people with a prior history of another DSM–III–R disorder. Anxiety disorders are the most common primary disorders. The time-lagged effects of most primary disorders on the risk of subsequent MDD continue for many years without change in magnitude. Secondary MDD is, in general, more persistent and severe than pure or primary MDD. This has special public health significance because lifetime prevalence of secondary MDD has increased in recent cohorts, while the prevalence of pure and primary depression has remained unchanged.

Psychosocial Assessments and Outcomes in Organ Transplantation

A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.

Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review

CONTEXT

If access to effective palliative care is to extend beyond cancer patients, an understanding of the comparative prevalence of palliative care problems among cancer and non-cancer patients is necessary.

OBJECTIVES

This systematic review aimed to describe and compare the prevalence of seventeen palliative care-related problems across the four palliative care domains among adults with advanced cancer, acquired immune deficiency syndrome, chronic heart failure, end-stage renal disease (ESRD), chronic obstructive pulmonary disease, multiple sclerosis, motor neuron disease, Parkinson's disease, and dementia.

METHODS

Three databases were searched using three groups of keywords. The results of the extraction of the prevalence figures were summarized.

RESULTS

The electronic searches yielded 4697 hits after the removal of 1784 duplicates. Of these hits, 143 met the review criteria. The greatest number of studies were found for advanced cancer (n=57) and ESRD patients (n=47), and 75 of the 143 studies used validated scales. Few data were available for people living with multiple sclerosis (n=2) and motor neuron disease (n=3). The problems with a prevalence of 50% or more found across most of the nine studied diagnostic groups were: pain, fatigue, anorexia, dyspnea, and worry.

CONCLUSION

There are commonalities in the prevalence of problems across cancer and non-cancer patients, highlighting the need for palliative care to be provided irrespective of diagnosis. The methodological heterogeneity across the studies and the lack of non-cancer studies need to be addressed in future research.

Factors associated with risk of suicide in patients with hemodialysis

Suicide risk (SR) has been associated to several factors; one of them is the presence of psychiatric disorders. This study has the objective of investigating the relationship between the risk factors for suicidal behavior in patient bearers of chronic renal illness who are undertaking hemodialysis treatment. Sixty-nine undertook a short, structured diagnostic interview. The prevalence of some psychiatric disorders showed itself greater in the sample than that in the population in general. A significant positive correlation was found between SR, major depressive episode, and agoraphobia without panic disorder. The religiosity of the patient was also evaluated as an influencing factor of SR. Nonreligious patients had 8 times more chance to have SR compared to religious patients. However, the referred effect only occurred in nondepressed religious patients. The latter indicated that religiosity had its effect annulled in depressed patients. This study shows the importance of measures of intervention in mental health, mainly in relation to prevention and treatment of major depressive episode with a view to reducing SR.

Using the illness intrusiveness ratings scale to understand health-related quality of life in chronic disease

OBJECTIVE

Illness intrusiveness is a common, underlying determinant of quality of life in people affected by chronic disease. Illness intrusiveness results from disease- and treatment-induced disruptions to lifestyles, activities, and interests (i.e., interference with psychologically meaningful activity). This paper introduces the Illness Intrusiveness Ratings Scale (IIRS), a 13-item, self-report instrument. The IIRS can be scored to generate a total score or three subscale scores: relationships and personal development, intimacy, and instrumental. In addition to describing the IIRS, the paper presents the theoretical framework in which it is anchored, reviews the evidence, and reports psychometric properties.

METHODS

Qualitative literature review.

RESULTS

Findings support the IIRS's reliability (internal consistency and test-retest), validity (construct, criterion-related, and discriminant), sensitivity to change, and factorial invariance across numerous chronic-disease groups. The paper reports IIRS reliability coefficients and normative statistics for 36 chronic, medical and psychiatric patient populations.

CONCLUSION

The IIRS taps the extent to which disease- and treatment-related factors interfere with psychologically meaningful activity among people affected by chronic disease. It provides a valid, reliable measure that is easy to administer and unequivocally interpretable rendering it suitable for research designed to estimate the psychosocial impact of chronic disease and to document (and compare) the effectiveness of therapeutic interventions.

The prevalence of symptoms in end-stage renal disease: a systematic review

Symptoms in end-stage renal disease (ESRD) are underrecognized. Prevalence studies have focused on single symptoms rather than on the whole range of symptoms experienced. This systematic review aimed to describe prevalence of all symptoms, to better understand total symptom burden. Extensive database, "gray literature," and hand searches were undertaken, by predefined protocol, for studies reporting symptom prevalence in ESRD populations on dialysis, discontinuing dialysis, or without dialysis. Prevalence data were extracted, study quality assessed by use of established criteria, and studies contrasted/combined to show weighted mean prevalence and range. Fifty-nine studies in dialysis patients, one in patients discontinuing dialysis, and none in patients without dialysis met the inclusion criteria. For the following symptoms, weighted mean prevalence (and range) were fatigue/tiredness 71% (12% to 97%), pruritus 55% (10% to 77%), constipation 53% (8% to 57%), anorexia 49% (25% to 61%), pain 47% (8% to 82%), sleep disturbance 44% (20% to 83%), anxiety 38% (12% to 52%), dyspnea 35% (11% to 55%), nausea 33% (15% to 48%), restless legs 30% (8%to 52%), and depression 27% (5%to 58%). Prevalence variations related to differences in symptom definition, period of prevalence, and level of severity reported. ESRD patients on dialysis experience multiple symptoms, with pain, fatigue, pruritus, and constipation in more than 1 in 2 patients. In patients discontinuing dialysis, evidence is more limited, but it suggests they too have significant symptom burden. No evidence is available on symptom prevalence in ESRD patients managed conservatively (without dialysis). The need for greater recognition of and research into symptom prevalence and causes, and interventions to alleviate them, is urgent.

Factors contributing to sleep disturbance and hypnotic drug use in hemodialysis patients

OBJECTIVE

Sleep disturbance and the use of hypnotic medications are common in patients on hemodialysis. Factors that contribute to sleep disturbance and the use of hypnotic medications in hemodialysis patients were investigated.

METHODS

With the use of a questionnaire-based survey, we examined the prevalence of symptoms that reflect sleep disorders such as insomnia, restless legs syndrome (RLS), and snoring and use of hypnotic medications in 252 hemodialysis patients.

RESULTS

The overall prevalence of insomnia was 59.1%, with the prevalence of difficulty in initiating sleep (DIS), difficulty in maintaining sleep (DMS), and early morning awakening (EMA) being 47.6, 24.2, and 28.2%, respectively. Daytime sleepiness and habitual snoring were reported by 42.5 and 33.7%, respectively. The prevalence of routine use of hypnotic drugs was 25.8%. Both RLS and age were significantly associated with insomnia [odds ratio (OR), 3.75; p 0.001, OR, 1.03; p < 0.01]. RLS was a significant factor for DIS, DMS, and EMA (OR, 2.26; p < 0.05, OR, 3.44; p < 0.0005, OR, 4.25; p < 0.0005) and age was a significant factor for DMS and EMA (OR, 1.03; p = 0.053, OR, 1.05; p < 0.005). Both insomnia and snoring were associated with the use of hypnotic drugs (OR, 2.97; p < 0.001, 1.59; p=0.13).

CONCLUSION

Both RLS and sleep-disordered breathing may contribute to sleep disturbance in hemodialysis patients. RLS in particular may be an important factor in insomnia, which in turn is likely responsible for the high prevalence of hypnotic drug use in hemodialysis patients.

The Illness Trajectory of End-Stage Renal Disease Dialysis Patients

Chronic illness is the number one health problem in the United States. As a consequence, health care professionals have assumed an increasingly important role in helping patients and families manage illness over an extended period of time. Familiarity with the evolution of chronic illness is needed to increase the effectiveness of these efforts. The concept of a trajectory provides a way for clinicians to gain a fuller understanding of the changing nature of chronic illness. The trajectory model has not yet been used to define the experience of end-stage renal disease (ESRD). ESRD is typically viewed as the static end point of chronic renal failure. The new paradigm suggests that the experience of ESRD continues to evolve from the time of diagnosis until death and that it follows a trajectory that can be described. This article represents the first attempt to delineate the ESRD illness trajectory, including the characteristics of each phase relative to the dimensions of life. The significance of the trajectory for clinical practice is discussed as well as the need for further research to validate and refine the model.

Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation

Although poor psychological adjustment to organ transplantation appears to be a major contributor to reduced quality of life and increased physical morbidity, the prevalence and risk factors for psychiatric disorder have not been considered beyond the first 12-18 months after transplantation. The authors enrolled a representative sample of 191 heart transplant recipients in a prospective examination of the prevalence, clinical characteristics, and risk factors for DSM-III-R major depressive disorder (MDD), generalized anxiety disorder (GAD), associated adjustment disorders, and posttraumatic stress disorder related to transplant (PTSD-T) during the 3 years postsurgery. Survival analysis indicates that cumulative risks for disorder onset were MDD, 25.5%; adjustment disorders, 20.8% (17.7% with anxious mood); PTSD-T, 17.0%; and any assessed disorder, 38.3%. There was only one case of GAD. PTSD-T onset was limited almost exclusively to the first year posttransplant. Episodes of MDD (but not anxiety disorders) that occurred later posttransplant (8 to 36 months postsurgery) were more likely than early posttransplant episodes to be treated with psychotropic medications. For both MDD and anxiety disorders, later episodes were less likely to be precipitated by transplant-related stressors than other life stressors. Factors increasing cumulative risk for psychiatric disorder posttransplant included pretransplant psychiatric history, female gender, longer hospitalization, more impaired physical functional status, and lower social supports from caregiver and family in the perioperative period. Risk factors' effects were additive; the presence of an increasing number of risk factors bore a dose-response relationship to cumulative risk of disorder.

Stressors, coping and depression in haemodialysis patients

BACKGROUND

Depression is common in persons receiving outpatient haemodialysis, but little work has been done to explore the variables associated with depression.

AIMS

The primary purposes of this study were to (i) examine relationships among stressors, coping and depression and (ii) test the mediating role of coping.

DESIGN/METHODS

Data were collected at two points in time, three months apart in 1995/1996. The final convenience sample at Time 2 was 86 participants from two United States midwestern, inner-city dialysis units. Structured interviews were conducted using the Centre for Epidemiologic Studies Depression Scale, the haemodialysis stressor scale (HSS) and the coping strategy indicator.

RESULTS

At Time 1 more psychosocial stressors were associated with greater use of problem-solving, social-support and avoidance coping. Both avoidance coping and more psychosocial stressors at Time 1 were related to depression at Time 2. Finally, avoidance coping was found to explain much of the relationship between psychosocial stressors and depression.

CONCLUSIONS

Research is now needed that explicates the causal relationships among stress, coping and depression in haemodialysis patients.

Psychosocial assessments and outcomes in organ transplantation

A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.

Prevalence of sleep disturbances in chinese patients with end-stage renal failure on continuous ambulatory peritoneal dialysis

Patients with end-stage renal failure (ESRF) are reported to have a high prevalence of sleep disorders, such as daytime sleepiness, insomnia, restless legs syndrome (RLS), and obstructive sleep apnea syndrome (OSAS). However, there are few published data from Southeast Asia. A sleep questionnaire was administered to 201 patients (103 men) at the continuous ambulatory peritoneal dialysis (CAPD) outpatient clinic to assess sleep problems. Patients had a mean age of 56.7 +/- 12 (SD) years, with a mean body mass index (BMI) of 23.6 +/- 3.5 kg/m(2). Daytime sleepiness was the most frequent symptom (77.1%), and frequent awakening occurred in 69% of the patients. Sleep-onset insomnia and sleep-maintenance insomnia occurred in 73% and 60% of the patients, respectively. Sixty-two percent of the patients reported symptoms of RLS, which significantly correlated with sleep-onset insomnia (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.5 to 5.5; P = 0.001) and sleep-maintenance insomnia (OR, 2.1; 95% CI, 1.2 to 3.8; P = 0.014). The prevalence of OSAS was estimated by the frequency of the following symptoms: extremely loud snoring, 7 patients (3.5%); observed choking, 21 patients (10.5%); witnessed apnea, 11 patients (5.6%); snoring and witnessed apnea, 6 patients (3%); disruptive snoring, 29 patients (14.4%); and disruptive snoring and witnessed apnea, 3 patients (1.5%). This questionnaire survey confirmed a high prevalence of daytime sleepiness, insomnia, and RLS in patients with ESRF undergoing CAPD but showed a relatively low prevalence of OSAS of up to 14.4%, which may be related to the low BMI of these patients with ESRF compared with other populations. Whether this contributes to the overall better survival observed in some Asian patients with ESRF undergoing dialysis needs further investigation.

Fluoxetine and cyclosporine in organ transplantation. Failure to detect significant drug interactions or adverse clinical events in depressed organ recipients

Depression and anxiety disorders are common clinical problems in organ transplant recipients, but there is a paucity of clinical data to inform the selection of psychopharmacologic treatment. The authors retrospectively compared 13 depressed organ transplant recipients treated with fluoxetine with 13 nondepressed matched control recipients and 11 transplant recipients treated with tricyclic antidepressants (nortriptyline or desipramine). Blood level:dose ratios and dose-response relationships for cyclosporine were virtually identical in all three groups before and during treatment. No increase in adverse clinical events was detected in either active treatment group compared with the control subjects. Fluoxetine appeared to be well tolerated by this population of transplant patients, and the authors failed to detect significant alterations in cyclosporine levels or graft function.

Depressive disorders in the medically ill. An overview

Depressive disorders are far more serious than most people realize, and depressive disorders are disabling affected persons progressively earlier in life. Heavy utilization of medical services, extensive disability and morbidity, and high suicide risk exact a staggering economic toll in the United States annually. Depressive illness is, like pneumonia and septic shock, a dread complication of major medical illness, and depressive illness appears more frequently as the medical illness worsens; diseases affecting the brain may have the highest rates of depressive symptoms. Correctly diagnosing a depressive disorder in a medically ill patient is a clinical challenge that requires systematic, persistent clinical scrutiny. Compassion demands that depressive disorders, when diagnosed, be treated aggressively.

Psychopharmacology and neuropsychiatric syndromes in organ transplantation

The physiological imbalances associated with organ insufficiency and the complexity of organ transplant surgery and postoperative care puts patients at risk for psychiatric disorders. The brain is susceptible to a variety of insults as a result of these complex processes, including those secondary to medications and infections. We review literature relevant to organ transplant patients and also include empirical knowledge based on clinical practice. We first describe the physiologic and psychiatric issues for each major organ that is commonly transplanted, including liver, kidney, heart, bone marrow, and pancreas, as well as multiple organ transplantation. We then discuss the pharmacologic treatment and neuropsychiatric side effects of rejection with various immunosuppressants, including cyclosporine, azathioprine, OKT3, FK506, and corticosteroids. Certain bacterial, fungal, viral, and protozoal infections occur more frequently in the transplant population; their relationship to neuropsychiatric dysfunction is discussed. We then present details of psychopharmacotherapy of delirium, other organic mental disorders, depression, mania, anxiety, and insomnia, with attention to drug interactions and differential diagnosis. Particularly cautious monitoring of medication doses and serum levels is recommended in these patients.