There is a growing literature on the bidirectional relationship between depression and various medical illnesses but depression in end stage renal disease has been understudied. In this paper we review the literature on the relationship between end stage renal disease and depression and then present a framework for the cognitive behavioral treatment of the depressed patient on dialysis. Case material from three different clients is then used to demonstrate some of the representative issues that arise in treatment in this population. This paper also explores the utility of using a subset of the Beck Depression Inventory [1] that focus on the cognitive factors of depression as a more sensitive measure for depression within the medically ill. Implications of the paper as well as indications for future research are discussed. Introduction There are a variety of biological, psychological and social pathways that have been suggested between medical illness and depression [2], but there has also been increasing evidence that this relationship is bidirectional [3]. There is a growing literature in the fields of cardiovascular health [4], cancer [5], diabetes [6], and stroke [7], but depression in end stage renal disease has been understudied [8]. End Stage Renal Disease End stage renal disease (ESRD) is defined as the point when kidney function is at 10% of baseline [9]. According to the most recent estimates [10], ESRD affects some 20 million Americans, and 20 million more are at risk for developing chronic kidney disease. The leading causes of ESRD are diabetes, which accounts for 44% of new cases, and uncontrolled high blood pressure, which accounts for 35% of new cases. The treatment options for ESRD fall into two broad categories: hemodialysis or kidney transplantation. Transplantation is a complex process that often involves waiting for years for an appropriate match. Subsequent to the transplantation there are often medical complications and transplanted kidneys remain viable only for an average of 5 years [11]. Dialysis is a medical procedure designed to remove wastes, toxins and fluids from the blood when the kidneys have failed. Living on dialysis is a perpetual challenge, due to its demanding schedule of treatment, dietary restrictions and changes in function (See [12] for a patient's description). Life on dialysis also shares similarities with other chronic disorders in that there are threats to autonomy, depression, burden of illness, and change in functional status [13]. The life expectancy of dialysis patients is one- third to one- sixth of the normal US population [10]. Depression in ESRD Despite the medical severity of kidney failure, the obvious challenges that life on dialysis poses, and the extraordinary medical cost of treatment, relatively little is known about the mental health of this population. The consensus in the literature is that depression is a common comorbid mental disorder for a subgroup of patients with ESRD [14,15,16,17,18,19]. However, the actual reported prevalence rates vary widely from 20% [17] to 44% [19]. Kimmel [14] points out that this wide variation can be attributed primarily to two factors. First, operational definitions of depression and measurement techniques are quite varied. Some studies [17] use clinical diagnosis of depression, or Likert-scale responses to a single question about depression, while others [19] use the Beck Depression Inventory (BDI) with a cutoff of 15. Second, and perhaps more importantly, there is an overlap of symptoms of depression with symptoms of chronic medical illness [14,16]. For example, there is an overlap of depressive and uremic symptoms. The depressive symptoms of psychomotor agitation or retardation, decreased appetite or weight change, sleep disturbance and aches and pains are also often difficult to distinguish from the uremic symptoms of encephalopathy, anorexia/edema, sleep apnea/anemia/volume overload/congestive heart failure and neuropathy/arthro
展开▼
