Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial

BACKGROUND

Chronic insomnia is common in patients undergoing in-center hemodialysis, yet there is limited evidence on effective treatments for this population.

OBJECTIVE

To compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), trazodone, and placebo for insomnia in patients undergoing long-term hemodialysis.

DESIGN

Randomized, multicenter, double-blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT03534284).

SETTING

26 dialysis units in Albuquerque, New Mexico, and Seattle, Washington.

PARTICIPANTS

Patients with Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months.

INTERVENTION

Participants were randomly assigned to 6 weeks of CBT-I, trazodone, or placebo.

MEASUREMENTS

The primary outcome was the ISI score at 7 and 25 weeks from randomization.

RESULTS

A total of 923 patients were prescreened, and of the 411 patients with chronic insomnia, 126 were randomly assigned to CBT-I (n = 43), trazodone (n = 42), or placebo (n = 41). The change in ISI scores from baseline to 7 weeks with CBT-I or trazodone was no different from placebo: CBT-I, -3.7 (95% CI, -5.5 to -1.9); trazodone, -4.2 (CI, -5.9 to -2.4); and placebo, -3.1 (CI, -4.9 to -1.3). There was no meaningful change in ISI scores from baseline to 25 weeks: CBT-I, -4.8 (CI, -7.0 to -2.7); trazodone, -4.0 (CI, -6.0 to -1.9); and placebo, -4.3 (CI, -6.4 to -2.2). Serious adverse events (SAEs), particularly serious cardiovascular events, were more frequent with trazodone (annualized cardiovascular SAE incidence rates: CBT-I, 0.05 [CI, 0.00 to 0.29]; trazodone, 0.64 [CI, 0.34 to 1.10]; and placebo, 0.21 [CI, 0.06 to 0.53]).

LIMITATION

Modest sample size and most participants had mild or moderate insomnia.

CONCLUSION

In patients undergoing hemodialysis with mild or moderate chronic insomnia, there was no difference in the effectiveness of 6 weeks of CBT-I or trazodone compared with placebo. The incidence of SAEs was higher with trazodone.

PRIMARY FUNDING SOURCE

National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

The design and baseline characteristics for the HOPE Consortium Trial to reduce pain and opioid use in hemodialysis

The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis (HOPE Trial) is a multicenter randomized trial addressing chronic pain among patients receiving maintenance hemodialysis for end-stage kidney disease. The trial uses a sequential, multiple assignment design with a randomized component for all participants (Phase 1) and a non-randomized component for a subset of participants (Phase 2). During Phase 1, participants are randomized to Pain Coping Skills Training (PCST), an intervention designed to increase self-efficacy for managing pain, or Usual Care. PCST consists of weekly, live, coach-led cognitive behavioral therapy sessions delivered by video- or tele-conferencing for 12 weeks followed by daily interactive voice response sessions delivered by telephone for an additional 12 weeks. At 24 weeks (Phase 2), participants in both the PCST and Usual Care groups taking prescription opioid medications at an average dose of ≥20 morphine milligram equivalents per day are offered buprenorphine, a partial opioid agonist with a more favorable safety profile than full-agonist opioids. All participants are followed for 36 weeks. The primary outcome is pain interference ascertained, for the primary analysis, at 12 weeks. Secondary outcomes include additional patient-reported measures and clinical outcomes including falls, hospitalizations, and death. Exploratory outcomes include acceptability, tolerability, and efficacy of buprenorphine. The enrollment target of 640 participants was met 27 months after trial initiation. The findings of the trial will inform the management of chronic pain, a common and challenging issue for patients treated with maintenance hemodialysis. NCT04571619.

Social and Behavioral Barriers to Effective Care During the Transition to End-Stage Kidney Care

Individuals living with CKD are disproportionately burdened by a multitude of adverse clinical and person-centered outcomes. When patients transition from advanced kidney disease to kidney failure, the psychosocial effects as well as social determinants of health challenges are magnified, making this a particularly difficult time for patients beginning kidney replacement therapy. The key social determinants of health challenges often include food and housing insecurity, poverty, unreliable transportation, low level education and/or health literacy, lack of language interpreters and culturally concordant educational materials, lack of health care insurance coverage, and mistrust of the health care system. Psychosocial and physical stressors, such as depression, anxiety, sexual dysfunction, sleep difficulty, fatigue, and pain, are often part of the illness burden among individuals living with CKD and can interact synergistically with the social challenges making the transition to kidney replacement therapy particularly challenging. To better support patients during this time, it is critical that social and structural determinants of health as well as mental health be assessed and if needs are identified, that services be provided.

Comparison of the accuracy of the 7-item HADS Depression subscale and 14-item total HADS for screening for major depression: A systematic review and individual participant data meta-analysis

The seven-item Hospital Anxiety and Depression Scale Depression subscale (HADS-D) and the total score of the 14-item HADS (HADS-T) are both used for major depression screening. Compared to the HADS-D, the HADS-T includes anxiety items and requires more time to complete. We compared the screening accuracy of the HADS-D and HADS-T for major depression detection. We conducted an individual participant data meta-analysis and fit bivariate random effects models to assess diagnostic accuracy among participants with both HADS-D and HADS-T scores. We identified optimal cutoffs, estimated sensitivity and specificity with 95% confidence intervals, and compared screening accuracy across paired cutoffs via two-stage and individual-level models. We used a 0.05 equivalence margin to assess equivalency in sensitivity and specificity. 20,700 participants (2,285 major depression cases) from 98 studies were included. Cutoffs of ≥7 for the HADS-D (sensitivity 0.79 [0.75, 0.83], specificity 0.78 [0.75, 0.80]) and ≥15 for the HADS-T (sensitivity 0.79 [0.76, 0.82], specificity 0.81 [0.78, 0.83]) minimized the distance to the top-left corner of the receiver operating characteristic curve. Across all sets of paired cutoffs evaluated, differences of sensitivity between HADS-T and HADS-D ranged from -0.05 to 0.01 (0.00 at paired optimal cutoffs), and differences of specificity were within 0.03 for all cutoffs (0.02-0.03). The pattern was similar among outpatients, although the HADS-T was slightly (not nonequivalently) more specific among inpatients. The accuracy of HADS-T was equivalent to the HADS-D for detecting major depression. In most settings, the shorter HADS-D would be preferred. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

How Are Albertans "Adjusting to and Coping With" Dialysis? A Cross-Sectional Survey

Background:

Depression and anxiety are commonly reported (40% and 11%-52%) among adults receiving dialysis, compared with ~10% among all Canadians. Mental health in dialysis care is underrecognized and undertreated.

Objective:

(1) To describe preferences for mental health support reported by Albertans receiving dialysis; (2) to compare depression, anxiety, and quality-of-life (QOL) domains for people who would or would not engage in support for mental health; and (3) to explore sociodemographic, mental health, and QOL domains that explain whether people would or would not engage in support for mental health.

Design:

A cross-sectional survey.

Setting:

Alberta, Canada.

Patients:

Adults receiving all modalities of dialysis (N = 2972).

Measurements:

An online survey with questions about preferences for mental health support and patient-reported outcome measures (Patient Health Questionnaire–9 [PHQ-9], Generalized Anxiety Disorder–7 [GAD-7], and Kidney Disease QOL Instrument–36 [KDQOL-36]).

Methods:

To address objectives 1 and 2, we conducted chi-square tests (for discrete variables) and t tests (for continuous variables) to compare the distributions of the above measures for two groups: Albertans receiving dialysis who would engage or would not engage in support for mental health. We subsequently conducted a series of binary logistic regressions guided by the purposeful variable selection approach to identify a subset of the most relevant explanatory variables for determining whether or not people are more likely to engage in support for mental health (objective 3). To further explain differences between the two groups, we analyzed open-text comments following a summative content analysis approach.

Results:

Among 384 respondents, 72 did not provide a dialysis modality or answer the PHQ-9. The final data set included responses from 312 participants. Of these, 59.6% would consider engaging in support, including discussing medication with a family doctor (72.1%) or nephrologist (62.9%), peer support groups (64.9%), and talk therapy (60%). Phone was slightly favored (73%) over in person at dialysis (67.6%), outpatient (67.2%), or video (59.4%). Moderate to severe depressive symptoms (PHQ-9 score ≥10) was reported by 33.4%, and most respondents (63.9%) reported minimal anxiety symptoms; 36.1% reported mild to severe anxiety symptoms (GAD-7 score ≥5). The mean (SD) PHQ-9 score was 8.9 (6.4) for those who would engage in support, and lower at 5.8 (4.8) for those who would not. The mean (SD) GAD-7 score was 5.2 (5.6) for those who would engage in support and 2.8 (4.1) for those who would not. In the final logistic regression model, people who were unable to work had 2 times the odds of engaging in support than people who are able to work. People were also more likely to engage in support if they had been on dialysis for fewer years and had lower (worse) mental health scores (odds ratios = 1.06 and 1.38, respectively). The final model explained 15.5% (Nagelkerke R²) of the variance and with 66.6% correct classification. We analyzed 146 comments in response to the question, “Is there anything else you like to tell us.” The top 2 categories for both groups were QOL and impact of dialysis environment. The third category differed: those who would engage wrote about support, whereas those who would not engage wrote about “dialysis is the least of my worries.”

Limitations:

A low response rate of 12.9% limits representativeness; people who chose not to participate may have different experiences of mental health.

Conclusions:

Incorporating patients’ preferences and willingness to engage in support for mental health will inform future visioning for person-centered mental health care in dialysis.

Anxiety Presentations and Treatments in Populations With Kidney Disease

Anxiety is common in patients with chronic kidney disease, but in its extreme expressions, anxiety can also be a complicating comorbid psychiatric illness. There is only a small literature base on anxiety disorders in patients with renal disease, and many of the studies are not sufficiently specific about which anxiety disorders are being studied. Larger epidemiological studies are required to delineate the incidence, prevalence, and outcomes associated with the varied anxiety disorders. In addition, the impact of the co-occurrence of anxiety with other chronic psychiatric or medical problems, needs further study. Anxiety is a clinical condition that warrants treatment, primarily due to its association with mortality in end-stage renal disease patients, and its negative impact on perceived quality of life. Therapeutic options for patients with anxiety and kidney disease include both pharmacologic and nonpharmacologic approaches. Current treatment strategies for anxiety specific to patients with renal disease are provided.

Applying A Biopsychosocial Framework to Achieve Durable Behavior Change in Kidney Disease

Chronic disease self-management is the establishment and maintenance of behaviors needed to be an active participant in one's health care and experience the best health outcomes. Kidney disease self-management behaviors to slow disease progression include engaging in exercise or physical activity; adhering to a diet low in sodium, potassium, and phosphorus; monitoring laboratory parameters; managing complex medication regimens; coping with disease-related emotional distress; and communicating effectively with providers. Durable behavior change has been difficult to achieve in kidney disease, in part because of an incomplete understanding of the multilevel factors determining chronic disease self-management in this patient group. The biopsychosocial model of chronic illness care posits that an individual's health outcomes result from biological, psychological, social, and environmental factors as part of a multilevel systems hierarchy. Although this theoretical model has been used to comprehensively identify factors driving self-management in other chronic conditions, it has been applied infrequently to behavioral interventions in kidney disease. In this scoping review, we apply the biopsychosocial model of health to identify individual, interpersonal, and systems-level drivers of kidney disease self-management behaviors. We further highlight factors that may serve as novel, impactful targets of theory-based behavioral interventions to understand and sustain behavior change in kidney disease.

Social and Cultural Challenges in Caring for Latinx Individuals With Kidney Failure in Urban Settings

IMPORTANCE

Latinx individuals with end-stage kidney disease (ESKD) constitute 19% of US patients receiving in-center scheduled hemodialysis. Compared with non-Latinx White patients, Latinx individuals often face poor economic, environmental, and living circumstances. The challenges for health care professionals engendered by these circumstances when Latinx individuals present with ESKD and possible solutions have not been well described.

OBJECTIVE

To examine the perceptions of interdisciplinary health care professionals who work in dialysis centers in urban settings with large racial and ethnic minority populations about how social challenges affect the care of Latinx patients with ESKD.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study administered semistructured interviews of interdisciplinary health care professionals at 4 urban dialysis centers in Denver, Colorado, from April 1 to June 30, 2019. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis.

MAIN OUTCOMES AND MEASURES

Themes and subthemes of barriers to care.

RESULTS

Thirty interdisciplinary dialysis center health care professionals (23 [77%] female; mean [SD] age, 42.0 [11.6] years) participated. Four themes were identified. The first 3 themes and their respective subthemes (in parentheses) describe challenges to kidney care: compromised quality of care attributable to communication and cultural barriers (language interpretation by telephone, in-person language interpretation, burden of ad hoc interpretation, low-quality health care, lack of language- and culturally concordant materials, and health literacy levels), difficulty with health care access (unreliable transportation, economic instability, and loss of insurance benefits), and concerns about patient psychosocial well-being (social isolation, hopelessness, stigma of illness, and balancing personal social challenges). The fourth theme describes solutions to improve care (culturally responsive care, patient empowerment and activation, supporting primary caregivers, and peer support with navigation of the health care system).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that dialysis center policies are needed that require high-quality language interpretation and the availability of culturally concordant educational materials. Community-based interventions that improve patient activation and provide peer support as well as culturally responsive care may improve the care of Latinx patients with ESKD receiving in-center scheduled hemodialysis.

Racial and Neighborhood-Level Disparities in COVID-19 Incidence among Patients on Hemodialysis in New York City

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected socially disadvantaged populations. Whether disparities in COVID-19 incidence related to race/ethnicity and socioeconomic factors exist in the hemodialysis population is unknown.

METHODS

Our study involved patients receiving in-center hemodialysis in New York City. We used a validated index of neighborhood social vulnerability, the Social Vulnerability Index (SVI), which comprises 15 census tract-level indicators organized into four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. We examined the association of race/ethnicity and the SVI with symptomatic COVID-19 between March 1, 2020 and August 3, 2020. COVID-19 cases were ascertained using PCR testing. We performed multivariable logistic regression to adjust for demographics, individual-level social factors, dialysis-related medical history, and dialysis facility factors.

RESULTS

Of the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly increased odds of COVID-19 compared with non-Hispanic White patients. Census tract-level overall SVI, modeled continuously or in quintiles, was not associated with COVID-19 in unadjusted or adjusted analyses. Among non-Hispanic White patients, the socioeconomic status SVI theme, the minority status and language SVI theme, and housing crowding were significantly associated with COVID-19 in unadjusted analyses.

CONCLUSIONS

Among patients on hemodialysis in New York City, there were substantial racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social vulnerability. Neighborhood-level socioeconomic status, minority status and language, and housing crowding were positively associated with acquiring COVID-19 among non-Hispanic Whites. Our findings suggest that socially vulnerable patients on dialysis face disparate COVID-19-related exposures, requiring targeted risk-mitigation strategies.

359 Tailoring of Cognitive Behavior Therapy for Insomnia for Patients with Kidney Failure Undergoing Hemodialysis: The SLEEP-HD Study

Introduction

Patients with kidney failure treated with hemodialysis (HD) frequently report insomnia symptoms. Cognitive-behavior therapy for insomnia (CBT-I) is a first line treatment for insomnia but there are unique issues surrounding kidney failure and HD that impact patients’ ability to access CBT-I and follow standard treatment recommendations. This presentation describes CBT-I protocol modifications made to address these issues as part of an ongoing multi-center clinical trial testing the efficacy of telehealth CBT-I compared to trazodone or medication placebo control.

Methods

CBT-I protocol modifications were made prior to starting the SLEEP-HD randomized trial based upon unique clinical considerations for HD patients, e.g., irregular sleep-wake scheduling that HD treatment demands, and napping during HD sessions or afterwards due to post-HD treatment fatigue. Participants in the SLEEP-HD study are undergoing thrice-weekly maintenance hemodialysis for >3 months and have baseline Insomnia Severity Index scores >10 with sleep disturbances >3 nights/week for >3 months. Participants randomized into the modified CBT-I protocol receive six weekly sessions, delivered by trained CBT-I therapists (1 MSW, 1 PhD) face-to-face via a HIPPA-compliant video telehealth platform. Participants keep a daily sleep diary throughout the CBT-I treatment period.

Results

To date, 91 patients (mean age=56.5 years [SD=14.7], 48.4% female) recruited from community-based dialysis facilities in Seattle and Albuquerque have been randomized into the SLEEP-HD study (n=31 CBT-I). Forty-eight percent of CBT-I clients have chosen to conduct their telehealth sessions during dialysis with the remainder choosing a different location. CBT-I adaptations include therapists developing weekly bed restriction recommendations based on non-dialysis treatment days; allowing shifts in dialysis day “bed window” scheduling for patients with very early or very late dialysis schedules so long as a consistent total time in bed in maintained; and including napping during early/late dialysis sessions as part of the allowable bed window duration. Treatment modifications were also designed to accommodate the diverse socioeconomic circumstances of dialysis patients, including housing instability, which can impact adherence to some standard stimulus control and bed restriction CBT-I recommendations.

Conclusion

It is feasible to deliver CBT-I via telehealth to HD patients but modifications to standard protocols are required.

Support (if any)

This work was supported by PHS grant 5R01AG053221.

The challenge of insomnia for patients on haemodialysis

Insomnia is common among patients on maintenance haemodialysis and may be exacerbated by the challenges of the COVID pandemic. However, data on the efficacy of insomnia interventions in this population are limited. Efforts are needed to address this important problem and increase access to insomnia interventions for patients on haemodialysis.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.

Depression prevalence using the HADS-D compared to SCID major depression classification: An individual participant data meta-analysis

OBJECTIVES

Validated diagnostic interviews are required to classify depression status and estimate prevalence of disorder, but screening tools are often used instead. We used individual participant data meta-analysis to compare prevalence based on standard Hospital Anxiety and Depression Scale - depression subscale (HADS-D) cutoffs of ≥8 and ≥11 versus Structured Clinical Interview for DSM (SCID) major depression and determined if an alternative HADS-D cutoff could more accurately estimate prevalence.

METHODS

We searched Medline, Medline In-Process & Other Non-Indexed Citations via Ovid, PsycINFO, and Web of Science (inception-July 11, 2016) for studies comparing HADS-D scores to SCID major depression status. Pooled prevalence and pooled differences in prevalence for HADS-D cutoffs versus SCID major depression were estimated.

RESULTS

6005 participants (689 SCID major depression cases) from 41 primary studies were included. Pooled prevalence was 24.5% (95% Confidence Interval (CI): 20.5%, 29.0%) for HADS-D ≥8, 10.7% (95% CI: 8.3%, 13.8%) for HADS-D ≥11, and 11.6% (95% CI: 9.2%, 14.6%) for SCID major depression. HADS-D ≥11 was closest to SCID major depression prevalence, but the 95% prediction interval for the difference that could be expected for HADS-D ≥11 versus SCID in a new study was -21.1% to 19.5%.

CONCLUSIONS

HADS-D ≥8 substantially overestimates depression prevalence. Of all possible cutoff thresholds, HADS-D ≥11 was closest to the SCID, but there was substantial heterogeneity in the difference between HADS-D ≥11 and SCID-based estimates. HADS-D should not be used as a substitute for a validated diagnostic interview.

Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis

BACKGROUND

Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD.

METHODS

This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy.

DISCUSSION

This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD.

TRIAL REGISTRATION

NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).

Probability of major depression diagnostic classification based on the SCID, CIDI and MINI diagnostic interviews controlling for Hospital Anxiety and Depression Scale - Depression subscale scores: An individual participant data meta-analysis of 73 primary studies

OBJECTIVE

Two previous individual participant data meta-analyses (IPDMAs) found that different diagnostic interviews classify different proportions of people as having major depression overall or by symptom levels. We compared the odds of major depression classification across diagnostic interviews among studies that administered the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D).

METHODS

Data accrued for an IPDMA on HADS-D diagnostic accuracy were analysed. We fit binomial generalized linear mixed models to compare odds of major depression classification for the Structured Clinical Interview for DSM (SCID), Composite International Diagnostic Interview (CIDI), and Mini International Neuropsychiatric Interview (MINI), controlling for HADS-D scores and participant characteristics with and without an interaction term between interview and HADS-D scores.

RESULTS

There were 15,856 participants (1942 [12%] with major depression) from 73 studies, including 15,335 (97%) non-psychiatric medical patients, 164 (1%) partners of medical patients, and 357 (2%) healthy adults. The MINI (27 studies, 7345 participants, 1066 major depression cases) classified participants as having major depression more often than the CIDI (10 studies, 3023 participants, 269 cases) (adjusted odds ratio [aOR] = 1.70 (0.84, 3.43)) and the semi-structured SCID (36 studies, 5488 participants, 607 cases) (aOR = 1.52 (1.01, 2.30)). The odds ratio for major depression classification with the CIDI was less likely to increase as HADS-D scores increased than for the SCID (interaction aOR = 0.92 (0.88, 0.96)).

CONCLUSION

Compared to the SCID, the MINI may diagnose more participants as having major depression, and the CIDI may be less responsive to symptom severity.

Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial

BACKGROUND

Although depression is common among patients receiving maintenance hemodialysis, data on their acceptance of treatment and on the comparative efficacy of various therapies are limited.

OBJECTIVE

To determine the effect of an engagement interview on treatment acceptance (phase 1) and to compare the efficacy of cognitive behavioral therapy (CBT) versus sertraline (phase 2) for treating depression in patients receiving hemodialysis.

DESIGN

Multicenter, parallel-group, open-label, randomized controlled trial. (ClinicalTrials.gov: NCT02358343).

SETTING

41 dialysis facilities in 3 U.S. metropolitan areas.

PARTICIPANTS

Patients who had been receiving hemodialysis for at least 3 months and had a Beck Depression Inventory-II score of 15 or greater; 184 patients participated in phase 1, and 120 subsequently participated in phase 2.

INTERVENTION

Engagement interview versus control visit (phase 1) and 12 weeks of CBT delivered in the dialysis facility versus sertraline treatment (phase 2).

MEASUREMENTS

The primary outcome for phase 1 was the proportion of participants who started depression treatment within 28 days. For phase 2, the primary outcome was depressive symptoms measured by the Quick Inventory of Depressive Symptoms-Clinician-Rated (QIDS-C) at 12 weeks.

RESULTS

The proportion of participants who initiated treatment after the engagement or control visit did not differ (66% vs. 64%, respectively; P = 0.77; estimated risk difference, 2.1 [95% CI, -12.1 to 16.4]). Compared with CBT, sertraline treatment resulted in lower QIDS-C depression scores at 12 weeks (effect estimate, -1.84 [CI, -3.54 to -0.13]; P = 0.035). Adverse events were more frequent in the sertraline than the CBT group.

LIMITATION

No randomized comparison was made with no treatment, and persistence of treatment effect was not assessed.

CONCLUSION

An engagement interview with patients receiving maintenance hemodialysis had no effect on their acceptance of treatment for depression. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment than with CBT.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute, Dialysis Clinic, Kidney Research Institute, and National Institute of Diabetes and Digestive and Kidney Diseases.

Differences in Attitudes Toward Immunosuppressant Therapy in a Multi-ethnic Sample of Kidney Transplant Recipients

Barriers for renal transplant patients to immunosuppressant medication adherence are poorly understood, despite the high rate and toll of non-adherence. We sought to assess factors that contribute to barriers to immunosuppressive medication adherence in an ethnically diverse sample of 312 renal transplant patients recruited from three transplant centers across New York City. Transplant patients who were at least 6 months post-transplant completed questionnaires while waiting for their medical appointment. Ethnic differences were observed on barriers to immunosuppressant adherence. Black and Hispanic participants reported significantly more barriers to adherence compared to Caucasian participants. Differences in perception about the potential harm and necessity of immunosuppressant medications also were present. Using hierarchical multiple regression, age and income were significant predictors of reported barriers to adherence, even while controlling for ethnicity. The most robust predictor of reported barriers was the perception of the medication cost-benefit differential, i.e., the balance between concerns about immunosuppressant medications and their perceived helpfulness (B = - 0.5, p < .001), indicating that varying beliefs about the medication's necessity and utility rather than ethnicity explain the differences in barriers to medication adherence. Future interventions targeting non-adherence should aim to reduce the barriers to adherence by addressing perceived risks and benefits of taking immunosuppressant medication.

Sleep Knowledge and Behaviors in Medical Students: Results of a Single Center Survey

OBJECTIVE

There is little known about the demands of medical school on students' sleep behavior. The study's main goal was to examine the interplay between medical students' sleep knowledge, personal attitudes towards sleep, and their sleep habits.

METHODS

An anonymous online survey was created and emailed to all students enrolled at a large metropolitan medical school. Data on demographics, sleep perception, and habits in addition to self-reported measures of students' sleep knowledge, beliefs, and sleepiness were collected.

RESULTS

There were 261, out of a possible 720, responses to the survey. While 71.5% of respondents believed that they needed >7 h of sleep, only 24.9% of respondents stated they average >7 h of sleep. During the week of an examination, only 15.3% of students stated they averaged >7 h of sleep. A comparison of pre-clinical and clinical students revealed that reported median sleep during a school or rotation night was significantly lower in clinical students as compared to pre-clinical students while mean sleep during examination weeks between the two groups was not statistically different. In regard to sleep knowledge, clinical students were more knowledgeable (65.53% correct) than pre-clinical students (39.83% correct) (t(1) = -8.9, p = .00). However, there was no difference in the assessment of dysfunctional beliefs between the two groups (66.0 for preclinical students, 64.7 for clinical students (t(1) = 0.37, p = .71)) while clinical students had a higher score of sleepiness compared to pre-clinical students (9.12 to 7.83, t(1) = -2.3, p = .023).

CONCLUSIONS

A majority of medical students are sleeping an inadequate amount of time during their 4 years, and as they progress from the pre-clinical to the clinical years, the amount of time they sleep decreases even though their knowledge about sleep increases. Increased awareness around sleep health is required beyond sleep education, as medical students appear to need help translating knowledge into strategies to improve their own sleep and well-being.

Association of restless legs syndrome and mortality in end-stage renal disease: an analysis of the United States Renal Data System (USRDS)

Background

Objective of the study is to assess prevalence and survival among end stage renal disease patients with restless legs syndrome (RLS) within a national database (USRDS).

Methods

A case-control, retrospective analysis was performed. Differences in characteristics between the groups, RLS and those with no sleep disorder (NSD), were determined using χ2 tests. Cox proportional hazard regression was used to assess survival between those with RLS and propensity score matched controls.

Results

Cases of restless legs syndrome were defined as patients that had received an ICD-9 code of 333.94 at any point during their treatment (n = 372). RLS group demonstrated a significantly higher proportion of patients with major depressive disorder, dysthymic disorder, anxiety, depression, minor depressive disorder, and psychological disorder. The difference between the survival was not statistically significant in those without sleep disorder as compared to those with RLS (HR =1.16±0.14, p = 0.3).

Conclusions

True prevalence of RLS in dialysis patients can only be estimated if knowledge gap for care providers in diagnosis of RLS is addressed. RLS patients also have increased incidence of certain psychological disorders which needs to be addressed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0660-0) contains supplementary material, which is available to authorized users.

Sleep disturbance and depressive affect in patients treated with haemodialysis

BACKGROUND

Sleep disorders and depression are prevalent conditions in patients with end-stage kidney disease. These co-morbidities have significant overlap and compounded morbidity and mortality burden. This overlap presents challenges to optimal clinical assessment and treatment. The goal of this study was to assess the prevalence of sleep disturbance in patients on maintenance haemodialysis, and to assess the impact of depressive affect.

OBJECTIVES

This was a single-site, single group, cross-sectional study of 69 English-speaking patients undergoing maintenance haemodialysis. Self-reported assessments included those of sleep quality (Pittsburgh Sleep Quality Index), depression (Beck Depression Inventory), daytime sleepiness (Epworth's Sleepiness Scale), a dialysis-specific sleep questionnaire, and standard laboratory values. No objective sleep information was collected.

METHOD

All participants were well dialysed, and represented all four daily shifts. Fifty-eight per cent reported clinically significant sleep difficulty, with elevated yet sub-threshold daytime sleepiness. Mean depressive affect was also elevated, yet sub-diagnostic and was positively correlated with increased age.

RESULTS

Participants scoring above the diagnostic threshold for depression had significantly more disturbed sleep quality, more daytime sleepiness and had more problems sleeping due to restless leg syndrome than people with minimal depressive affect.

CONCLUSION

Poor sleep quality is prevalent in patients on maintenance haemodialysis, and is associated with increased daytime sleepiness. Depression further compounds this relationship, and is significantly associated with increased daytime sleepiness and restless leg syndrome.

Anxiety in Patients Treated with Hemodialysis

Anxiety is a common yet frequently overlooked psychiatric symptom in patients with ESRD treated with hemodialysis (HD). Anxiety is characterized by disruptive feelings of uncertainty, dread, and fearfulness. A variety of common medical complaints may be manifestations of an anxiety disorder, including palpitations, tremors, indigestion, numbness/tingling, nervousness, shortness of breath, diaphoresis, and fear. It is essential for the clinician to rule out specific medical conditions, including cardiovascular, pulmonary, and neurologic diseases, before ascribing these symptoms to an anxiety disorder. In addition, there is considerable overlap between the symptoms of anxiety and those of depression and uremia. This psychiatric condition has a significant adverse impact on patients' perception of quality of life. Little is known regarding the prevalence and impact of anxiety disorders in patients with ESRD treated with HD; however, many of the seemingly irrational behaviors of patients, or behaviors which place them in conflict with staff and physicians, such as behavioral noncompliance, may be the expression of an underlying anxiety disorder. In this review, we present three clinical vignettes, highlighting the impact of anxiety disorders in patients with ESRD treated with HD.

A Pilot Randomized Controlled Trial to Promote Immunosuppressant Adherence in Adult Kidney Transplant Recipients

BACKGROUND

Nonadherence to immunosuppressant medication is a prevalent practice among kidney transplant recipients and has been associated with increased risk for graft failure and economic burden. The aim of this pilot study was to test whether a culturally sensitive cognitive-behavioral adherence promotion program could significantly improve medication adherence to tacrolimus prescription as measured by telephone pill counts among kidney transplant recipients.

METHODS

Thirty-three adult transplant recipients were less than 98% adherent to tacrolimus prescription based on 3 telephone pill counts and were randomized either to the 2-session cognitive-behavioral adherence promotion program or to standard care. The curriculum was developed from an iterative process with transplant recipients into a 2-session group program that provided psychoeducation, addressed barriers to adherence, fostered motivation to improve adherence behavior, and discussed cultural messages on adherence behavior.

RESULTS

The intervention group displayed significantly higher levels of adherence when compared to the control group (t = 2.2, p = 0.04) and. similarly, when the amount of change was compared between the groups, the intervention group showed more change than the control condition (F (22,1) = 12.005, p = 0.003). Tacrolimus trough concentration levels were used as a secondary measure of adherence and, while there were no significant between-group differences for mean trough concentration levels, the variability in the trough levels did significantly decrease over time indicating more consistent pill-taking behavior in the intervention group.

CONCLUSIONS

There is preliminary support for the pilot program as a successful intervention in helping patients with their immunosuppressant medication.

Patient and Other Stakeholder Engagement in Patient-Centered Outcomes Research Institute Funded Studies of Patients with Kidney Diseases

Including target populations in the design and implementation of research trials has been one response to the growing health disparities endemic to our health care system, as well as an aid to study generalizability. One type of community-based participatory research is "Patient Centered-Research", in which patient perspectives on the germane research questions and methodologies are incorporated into the study. The Patient-Centered Outcomes Research Institute (PCORI) has mandated that meaningful patient and stakeholder engagement be incorporated into all applications. As of March 2015, PCORI funded seven clinically-focused studies of patients with kidney disease. The goal of this paper is to synthesize the experiences of these studies to gain an understanding of how meaningful patient and stakeholder engagement can occur in clinical research of kidney diseases, and what the key barriers are to its implementation. Our collective experience suggests that successful implementation of a patient- and stakeholder-engaged research paradigm involves: (1) defining the roles and process for the incorporation of input; (2) identifying the particular patients and other stakeholders; (3) engaging patients and other stakeholders so they appreciate the value of their own participation and have personal investment in the research process; and (4) overcoming barriers and challenges that arise and threaten the productivity of the collaboration. It is our hope that the experiences of these studies will further interest and capacity for incorporating patient and stakeholder perspectives in research of kidney diseases.

Sleep disorders and chronic kidney disease

Sleep disorders have a profound and well-documented impact on overall health and quality of life in the general population. In patients with chronic disease, sleep disorders are more prevalent, with an additional morbidity and mortality burden. The complex and dynamic relationship between sleep disorders and chronic kidney disease (CKD) remain relatively little investigated. This article presents an overview of sleep disorders in patients with CKD, with emphasis on relevant pathophysiologic underpinnings and clinical presentations. Evidence-based interventions will be discussed, in the context of individual sleep disorders, namely sleep apnea, insomnia, restless leg syndrome and excessive daytime sleepiness. Limitations of the current knowledge as well as future research directions will be highlighted, with a final discussion of different conceptual frameworks of the relationship between sleep disorders and CKD.

Rationale and design of A Trial of Sertraline vs. Cognitive Behavioral Therapy for End-stage Renal Disease Patients with Depression (ASCEND)

Major Depressive Disorder (MDD) is highly prevalent in patients with End Stage Renal Disease (ESRD) treated with maintenance hemodialysis (HD). Despite the high prevalence and robust data demonstrating an independent association between depression and poor clinical and patient-reported outcomes, MDD is under-treated when identified in such patients. This may in part be due to the paucity of evidence confirming the safety and efficacy of treatments for depression in this population. It is also unclear whether HD patients are interested in receiving treatment for depression. ASCEND (Clinical Trials Identifier Number NCT02358343), A Trial of Sertraline vs. Cognitive Behavioral Therapy (CBT) for End-stage Renal Disease Patients with Depression, was designed as a multi-center, 12-week, open-label, randomized, controlled trial of prevalent HD patients with comorbid MDD or dysthymia. It will compare (1) a single Engagement Interview vs. a control visit for the probability of initiating treatment for comorbid depression in up to 400 patients; and (2) individual chair-side CBT vs. flexible-dose treatment with a selective serotonin reuptake inhibitor, sertraline, for improvement of depressive symptoms in 180 of the up to 400 patients. The evolution of depressive symptoms will also be examined in a prospective longitudinal cohort of 90 HD patients who choose not to be treated for depression. We discuss the rationale and design of ASCEND, the first large-scale randomized controlled trial evaluating efficacy of non-pharmacologic vs. pharmacologic treatment of depression in HD patients for patient-centered outcomes.

Psychosocial intervention improves depression, quality of life, and fluid adherence in hemodialysis

Patients with ESRD have high rates of depression, which is associated with diminished quality of life and survival. We determined whether individual cognitive behavioral therapy (CBT) reduces depression in hemodialysis patients with elevated depressive affect in a randomized crossover trial. Of 65 participants enrolled from two dialysis centers in New York, 59 completed the study and were assigned to the treatment-first group (n=33) or the wait-list control group (n=26). In the intervention phase, CBT was administered chairside during dialysis treatments for 3 months; participants were assessed 3 and 6 months after randomization. Compared with the wait-list group, the treatment-first group achieved significantly larger reductions in Beck Depression Inventory II (self-reported, P=0.03) and Hamilton Depression Rating Scale (clinician-reported, P<0.001) scores after intervention. Mean scores for the treatment-first group did not change significantly at the 3-month follow-up. Among participants with depression diagnosed at baseline, 89% in the treatment-first group were not depressed at the end of treatment compared with 38% in the wait-list group (Fisher's exact test, P=0.01). Furthermore, the treatment-first group experienced greater improvements in quality of life, assessed with the Kidney Disease Quality of Life Short Form (P=0.04), and interdialytic weight gain (P=0.002) than the wait-list group, although no effect on compliance was evident at follow-up. In summary, CBT led to significant improvements in depression, quality of life, and prescription compliance in this trial, and studies should be undertaken to assess the long-term effects of CBT on morbidity and mortality in patients with ESRD.

A preliminary investigation of depression and kidney functioning in patients with chronic kidney disease

BACKGROUND

The incidence and prevalence of Chronic Kidney Disease (CKD) is growing rapidly. Understanding the factors associated with declining renal function is of clinical significance. The current study's main goal was to identify variables that could predict decline in glomerular filtration rate (GFR) over time in outpatients with varying stages of CKD.

METHODS

Seventy CKD patients completed psychological questionnaires and medical variables were extracted from the medical charts. Follow-up GFR was collected 6 months later. CKD patients with elevated depression scores were compared to patients with subclinical depression on medical and psychological variables.

RESULTS

Average Beck Depression Inventory (BDI) score was 10.0 ± 7.8, placing the mean below the cut-off for clinical elevation. GFR was significantly different for the two groups (nondepressed, 40.0 ± 11.3 vs. depressed 29.6 ± 8.9; p < 0.05). Similarly, patients with elevated depression scores reported lower quality of life (Short Form 36 Health Survey; p < 0.05) inferior social support (Interpersonal Support Evaluation List; p < 0.05), and worse community integration (Community Integration Questionnaire; p < 0.05). Utilizing a regression, with a model correcting for baseline GFR, the BDI explained 19% of the variance in GFR score (t = -2.0, p < 0.05) for subjects with decreased GFR.

CONCLUSIONS

Increased levels of preexisting depression were associated with inferior quality of life, social support and kidney functioning. Depression scores explained a significant amount of variance in GFR scores at 6 months even when corrected for baseline variability. Elevated depression scores are prevalent in CKD populations and further research on the impact of depression interventions is warranted.

Depression and nonadherence predict mortality in hemodialysis treated end-stage renal disease patients

The scientific evaluation of depression's impact on mortality in hemodialysis (HD) patients has yielded mixed results, with the more recent, more rigorous studies detecting a significant relationship. In this study, 130 HD patients from an urban North American hospital were evaluated for depressive affect and then observed for up to 5 years. In a corrected Cox regression model, which held constant age, gender, dialysis vintage, illness severity and diabetic status, depressive affect emerged as a modest but significant predictor of mortality (relative risk = 1.05, 95% confidence interval = 1.01-1.08). When the subjects were divided according to depressive affect severity, those with severe depressive affect had significantly shorter time to death (β = 0.452, P = 0.044). In a subgroup of 85 subjects, self-reported medication adherence was also predictive of mortality, with higher rates of nonadherence being associated with increased mortality risk. This paper lends support to the burgeoning literature on depression and reduced survival in HD populations, as well as begins the investigation of understanding the underlying mechanisms.

Depression and mortality in end-stage renal disease

End-stage renal disease is growing in prevalence and incidence. With technical advancements, patients are living longer on hemodialysis. Depression is the most prevalent comorbid psychiatric condition, estimated at about 25% of end-stage renal disease samples. The identification and assessment of depression are confounded by the overlap between depression symptomatology and uremia. Several recent studies have employed time-varying models and identified a significant association between depression and mortality. Due to the high prevalence of depression and the potential impact on survival, well-constructed investigations are warranted.

Course of depression and anxiety diagnosis in patients treated with hemodialysis: a 16-month follow-up

BACKGROUND AND OBJECTIVES

There is growing identification of the need to seriously study the psychiatric presentations of end-stage renal disease patients treated with hemodialysis. This study reports on the course of depression and anxiety diagnoses and their impact on quality of life and health status.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The 16-mo course of psychiatric diagnoses in 50 end-stage renal disease patients treated with hemodialysis was measured by structured clinical interview.

RESULTS

Three different pathways were identified: one subset of patients not having a psychiatric diagnosis at either baseline or 16-mo follow-up (68% for depression, 51% for anxiety), one group having an intermittent course (21% for depression, 34% for anxiety), and one group having a persistent course (11% for depression, 15% for anxiety), with diagnoses at both time 1 and time 2. For depression, the people with the persistent course showed marked decreases in quality of life and self-reported health status compared with the nondepressed and intermittently depressed cohorts. The most powerful predictor of depression at time 2 is degree of depressive affect at time 1(P < 0.05).

CONCLUSIONS

Patients at risk for short- and long-term complications of depression can be potentially identified by high levels of depressive affect even at a single time point. As nearly 20% of the sample had chronic depression or anxiety, identifying a psychiatric diagnosis in hemodialysis patients and then offering treatment are important because, in the absence of intervention, psychiatric disorders are likely to persist in a substantial proportion of patients.

Anxiety disorders in adults treated by hemodialysis: a single-center study

BACKGROUND

Anxiety is a complicating comorbid diagnosis in many patients with medical illnesses. In patients with end-stage renal disease (ESRD), anxiety disorders often are perceived to represent symptoms of depression rather than independent conditions and therefore have been relatively understudied in this medical population.

STUDY DESIGN

To evaluate the psychosocial impact of anxiety disorders on patients with ESRD, we sought to identify the rates of these disorders in a sample of patients receiving hemodialysis at a single center by using a structured clinical interview. We also compared a commonly used screening measure, the Hospital Anxiety and Depression Scale (HADS), with these clinical diagnoses to determine the measure's criterion validity or ability to predict a psychiatric diagnosis in ESRD populations. Finally, we examined the relationship between anxiety diagnosis and perceptions of quality of life (QOL) and health status.

SETTING & PARTICIPANTS

A sample of 70 randomly selected hemodialysis patients from an urban metropolitan center.

PREDICTOR

Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Diagnosis (SCID-I).

OUTCOMES

HADS and Kidney Disease Quality of Life Short Form.

RESULTS

Using the SCID, 71% of the sample received a DSM-IV Axis I diagnosis, with 45.7% of subjects meeting criteria for an anxiety disorder and 40% meeting criteria for a mood disorder. The concordance between DSM-IV anxiety disorders and anxiety scores acquired by using the HADS was not significant. Thus, although the HADS may provide an acceptable measure of overall "psychic distress" compared against the SCID-I, it has poor predictive power for anxiety diagnoses in patients with ESRD. Additionally, the presence of an anxiety disorder was associated with an overall perceived lower QOL (t = 2.4; P < 0.05).

LIMITATIONS

Single-center study and a population not representative of US demographics.

CONCLUSIONS

A substantial proportion of participating patients met criteria for an anxiety disorder. The utility of the HADS as a screening tool for anxiety in patients with ESRD should be questioned. The finding that anxiety disorders negatively impact on QOL and are not merely manifestations of depression in patients with ESRD emphasizes the importance of accurate diagnosis and effective treatment. Strategic options are necessary to improve the diagnosis of anxiety disorders, potentially enhancing QOL and medical outcome in patients with ESRD.