COMMENTARY

Two Therapies Show Promise in Treating Depression in Patients on Dialysis

Nisha Bansal, MD, MAS

Disclosures

April 01, 2019

Depression is common in patients with end-stage renal disease treated with hemodialysis (HD) and is linked to poor outcomes in this population, including nonadherence to treatment, reduced quality of life, greater health care use, and higher risk for mortality. Patients have identified treatment of depression as a priority in their care, yet many HD patients with depression do not receive treatment.

In the general population, first-line treatment for depression includes either cognitive-behavioral therapy (CBT) or antidepressant medications such as sertraline; both have been shown to provide similar efficacy.[1] However, few studies have evaluated treatment of depression in HD patients specifically to guide clinicians and patients.

Mehrotra and colleagues[2] conducted a clinical trial of patients receiving HD to determine the effect of an engagement interview on depression treatment acceptance (phase 1) and to compare the efficacy of CBT vs sertraline (phase 2) for treating depression in patients receiving HD. To be included in the study, patients had to have been receiving HD for at least 3 months and had to have a Beck Depression Inventory-II score of at least 15. Overall, 184 patients participated in phase 1 of the study and 120 subsequently participated in phase 2.

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

Small Differences in Efficacy Not Clinically Meaningful

The proportion of participants who initiated treatment after the engagement versus a control visit did not differ (66% vs 64%, respectively; P = .77; estimated risk difference, 2.1 [95% confidence interval (CI), 12.1 -16.4]). Compared with CBT, sertraline treatment resulted in modestly lower QIDS-C depression scores at 12 weeks (effect estimate, 1.84 [CI, 3.54 -0.13]; P = .035); however, both CBT and sertraline led to improvements in QIDS-C depression scores. Rates of serious adverse events were similar in both treatment groups. Rates of nonserious adverse events (such as gastrointestinal intolerance) were more frequent in the sertraline group than in the CBT group.

Findings from this paper suggest that:

  1. Patients receiving HD are willing to accept treatment for depression

  2. Symptoms of depression improved with either CBT or sertraline therapy for 12 weeks, but were modestly better for the sertraline group

  3. Nonserious adverse events occurred more frequently in the sertraline group than in the CBT group

As mentioned, the magnitude of difference in efficacy between CBT and sertraline was small. A change of 1.0 to 2.0 or more points, or a 17.5% change in QIDS-C score, is considered clinically meaningful.[3,4] In this study, the QIDS-C difference at 12 weeks was 1.84 points; however, the percent difference was only 11% to 14% of baseline values.

The authors of the study speculated about potential reasons to explain the greater efficacy of sertraline in the HD population. Sertraline may preferentially target the somatic symptoms of depression, such as insomnia, hypersomnia, and fatigue, which are common in patients on HD. Another possibility is that the high burden of disease and treatment in HD patients makes engagement in CBT challenging.

Final Thoughts on the Strengths and Weaknesses of the Study

The strengths of this study included a geographically diverse population, systematic screening for depression, and good adherence to the regimen with little loss to follow-up. The limitations of the study included lack of a placebo arm and relatively short follow-up.

Even with these limitations, this trial provides important information on the treatment of depression in patients on HD, who should be evaluated for depression and offered treatment if appropriate. This study suggests that sertraline and CBT are both acceptable treatment options, with the choice depending on patient acceptability and tolerance. Individualized patient and provider decisions are needed to improve rates of treatment and outcomes associated with depression in patients receiving HD in the United States.

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