Should You Treat Depression Differently

About 1 in 7 adults in the U.S. has chronic kidney disease, in which the kidneys are damaged or can’t properly filter blood. This can lead to excess waste remaining in the body, kidney failure and the need for dialysis or a kidney transplant, and raise one’s risk of dying from heart disease and other causes.

In short, there’s a lot to think about. But complicating treatment and undermining quality of life even further, past research finds 1 in 4 people with CKD suffers from depression. In fact, depression is more common in people with chronic medical conditions of all kinds from chronic pain to respiratory diseases – such as asthma and chronic obstructive pulmonary disorder, or COPD – to heart disease. Depression can put a person at greater risk for some chronic health issues and vice versa; and very often people end up dealing with those issues simultaneously. “They end up co-occurring,” says Dr. Silvia Martins, an associate professor of epidemiology at the Columbia University Mailman School of Public Health in New York City.

Martins was the senior author of a study published in the Journal of Affective Disorders earlier this year, which assessed mood disorders like depression and anxiety disorders in people in with chronic physical conditions in São Paulo, Brazil. Half of those studied with chronic pain had a mood disorder, as did one-third of those with respiratory diseases and 10 percent who had cardiovascular disease. “We would expect … very similar findings if we had done [the same type of] analysis with U.S. data,” Martins reflects.

Managing a chronic condition can be challenging on its own, and experts say depression – which can sap motivation and make it harder to keep perspective – can further complicate things. Previous research published in the Journal of the American Medical Association found that for people with CKD, experiencing a major depressive episode (which is marked by things like depressed mood and feelings of worthlessness) was associated with an increased risk of poor outcomes, including dialysis, hospitalization or death within a year of the depression diagnosis.

Experts say that’s all the more reason depression should not only be treated in people with chronic conditions – but that those individuals should be seen by clinicians even more regularly. “No matter what, depression should not be ignored and symptoms and effects [should be] monitored closely,” says Dr. Madhukar Trivedi, director for the Center for Depression Research and Clinical Care at UT Southwestern Medical Center in Dallas.

However, there may be a case to be made – at least in some cases – for tailoring the approach to treating depression for people with chronic conditions. For these patients, non-medication approaches, such as cognitive therapyexercise and transcranial magnetic stimulation may also need to be considered, he says; and selective serotonin reuptake inhibitors – medications commonly prescribed to treat depression – or “SSRIs, may not be the ideal choice,” he says.

Trivedi was the senior author of research published online in JAMA in November that analyzed a group of 193 patients with CKD, who weren’t dependent on dialysis, who had major depressive disorder. Of those, 97 patients were given the SSRI sertraline for 12 weeks, while the other 96 patients were given a placebo. “Treatment with sertraline did not improve depressive symptoms or quality of life” in patients studied, the researchers found – while some still had to deal with nausea, vomiting and diarrhea. “Although sertraline did not result in increased serious adverse events or bleeding, it did increase the rate of adverse gastrointestinal symptoms,” the researchers noted. “These types of adverse events are particularly undesirable among patients with advanced CKD because they are already prone to uremic symptoms such as nausea and vomiting.”

More study is needed to better understand the implications of the findings for treating depression in people with CKD (including studying those who are dependent on dialysis) and other chronic conditions. However, the “findings are in line with increasing evidence from well-powered trials among patients with other chronic medical conditions, such as asthma, ischemic heart disease, and congestive heart failure, that found SSRIs were no more efficacious than placebo for treating depression,” the researchers said. Though future research needs to determine whether non-SSRI or non-medication approaches work better for depression in those with CKD.

Dr. Gregory Simon, a psychiatrist and researcher at Kaiser Permanente Washington Health Research Institute in Seattle, says he doesn’t view the latest JAMA study as an outlier. But he says research generally supports standard treatment for depression in people who also have chronic conditions. “It is, I would say, not uniform; it is not completely homogenous,” Simon says. “But in general, I would say that literature supports the idea that depression is common in people with chronic medical illness, and that the depression treatments that we would think of that work in other people – people without chronic medical illness – also work in people with chronic medical illness. So I’d say the preponderance of the evidence supports that.”

However, he says the findings in the JAMA study might make him less likely to persist in treating a patient who has CKD with medication if it didn’t work initially – like trying a second or third different medication. “Would I say based on the results of this study, I would never try an antidepressant medicine? Probably not. I don’t think that this would convince me that that is a completely futile undertaking or should never be tried,” Simon says. “But it might give me maybe a somewhat lower expectation that an antidepressant is going to be helpful.”

In addition to medication, other standard therapies may be used. Simon notes that there has been a lot of research on adapting psychotherapies used in the treatment of depression for people with particular chronic conditions. He was involved in research on so-called problem-solving therapy to treat depression in people with diabetes. “The core principles of problem-solving therapy are the same: People feel overwhelmed, you need to help them take a step back from problems, break them down into small pieces, develop some specific steps to do [that],” Simon says. “But people with diabetes often chose to work on problems related to diabetes – although not uniformly – sometimes they would work on problems related to other things in life.”

The point is not to overhaul a common therapeutic approach to depression, for someone with a chronic condition, but to take that condition into account. “I would say that very often if someone has a chronic condition that will be one of the dominant things that concerns them, and that would be one of the things they would talk about,” Simon says. “It is not a huge stretch.” In the same way, other psychotherapies, such as cognitive therapy or behavioral therapy or behavior activation can be adapted; those therapies “very easily fit to various life circumstances; it’s not that you have to start totally fresh and make a new treatment,” he says.

Martins adds that if a patient is taking medication to treat depression, it’s important to consider how that may interact with other medications and any risks specifically related to the chronic condition. Some antidepressants, like venlafaxine, “can increase risk of arrhythmias in patients with chronic cardiovascular diseases, and interfere with drugs that treat such disease,” Martins says. “Several antidepressants may worsen hypertension and higher doses of hypertension medication are needed; and SSRIs increase risk of central nervous system toxicity with opioids in the treatment of chronic pain.”

As research continues into optimal treatment approaches, experts say it’s important to stick with evidence-based approaches for depression, and not to treat it as an afterthought. Martins says not only patients but doctors need to be cognizant of the link between chronic conditions and mental health issues like depression. “Because once people have two of these conditions happening at the same time – two or more – the prognosis is worse,” she says. “It gets debilitating, and it’s harder to treat both.”

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