Depression is an all too common health condition that unfortunately goes untreated for many patients and undertreated for more. The End Stage Renal Disease (or ESRD) population is no exception to this fact. It is estimated that nearly 30 percent of dialysis patients suffer from depression in some way. While 30 percent may not sound like a significant free-standing figure, if you incorporate the fact that there are upwards of 400,000 ESRD patients in the United States and that group is about three times more likely to exhibit poor treatment compliance. In case that doesn’t resonate with you, consider that dialysis is a life-sustaining treatment for ESRD patients, meaning they will likely suffer physiologically (or die) without it. So what does all of this mean? Well, it means that when a patient is suffering from depression that is going either unreported, untreated, or undertreated, they may not be making the best possible “life-sustaining” choices.

Screening

These facts lead us to the current requirements in place to intervene and recognize Depression in the ESRD community. If you work with ESRD Patients, you are probably aware that one of the CMS QIP measures for 2018 requires an annual Depression Screening to be performed. There are multiple screening tools available for use in assessing Depression symptoms such as: 1) the Patient Health Questionnaire-2 (or PHQ-2), the Geriatric Depression Scale (or GDS), the Hamilton Depression Rating Scale (or HAM-D), and the Patient Health Questionnaire-9 (Or PHQ-9); just to name a few. While all of these are meant to be a resource for recognizing Depressive symptoms in patients through a series of questions, there are significant barriers to these screenings that are not readily acknowledged.

Barriers

Those barriers could range from patient understanding the questions being asked to the patient choosing not to report truthfully on current depressive symptoms. Some members may not have the appropriate amount of time to administer the screening. Others may worry about offending the patient or feel as though the physical symptoms are urgent are inhibit the responses. Maybe there is an intersection of depressive symptoms and a condition called Uremia (elevated levels of Urea in patients with kidney failure) discovered during screening, but the screening is positive for depression; if so, how should the screener proceed?

Preparation

Simply screening patients because it is required is not enough to support patients. Having some basic knowledge of mental health will aid the screener in applying interventions if met with a patient exhibiting signs of depression. Some of these preparation items could include: a listing of community mental health centers, knowing how and when to initiate a referral, crisis hotline information, and how to document all of the above.

Intervention: Goal Setting

You can refer a patient to a mental health specialist, but if you’re someone who works closely with the patient (such as a Dialysis Social Worker, Nephrologist, or Primary Care Physician) you might find yourself needing to do some of your own interventions until that patient is willing to proceed with a mental health professional or the option itself becomes available. One quick start intervention to introduce the patient to could be goal setting. In other words, find out what the patient wants to happen in his or her life. There are numerous tools available to start a patient on the path to setting and achieving personal goals.

Intervention: Exercise

It is a known fact that exercise, if completed regularly, at any ability level improves a person’s quality of life. This can present as physical manifestations such as: increases in energy level, increase in flexibility, improved digestion, and improved sleep. However it can also produce mental improvements that can be invaluable to renal patients such as: a sense of control, decreases in anxiety, and overall decreases in depression. As it should be, when beginning any activity a patient should always consult with a physician.

Transitions of Care

If you are not a provider that is familiar with the ins and outs of dialysis yet your patient is entering the ESRD realm, know who to contact in relation to a positive depression screening. Know what information can be shared between providers and what (if applicable) events are related to these depressive symptoms. Know what your patient understands about the signs and how they may affect him or her. Finally, know what your patient’s wishes are in changing their current mental health status.

Jazzmin Kennedy

Quality Improvement Coordinator

The Renal Network | ESRD Network 10

This blog is provided in conjunction with the collaborative Webinar “Depression, Uremia and Care Transition” hosted by atom Alliance and ESRD Networks 10 and 12. For more information about the Webinar, click here.