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November 20, 2020
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Limited research, guidance on depression screening tools for patients with kidney failure

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Disclosures: The authors report no relevant financial disclosures.
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Contending that “no clear guidance exists” regarding depression screening for patients with kidney failure, researchers determined there is also limited research assessing the accuracy of available tools.

“The Centers for Medicare and Medicaid Services requires routine depression screening for patients with kidney failure as part of their ESRD Quality Incentive Program (ESRD-QIP),” Karli Kondo, PhD, of the evidence synthesis program at the Veterans Affairs Portland Health Care System in Oregon, and colleagues wrote.However, there is no system-wide screening protocol, leading to wide variation in the way depression is assessed.”

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In a related press release, Kondo commented on the rationale behind conducting the study.

“Our hope was that we’d find evidence that pointed to an optimal screening tool,” she said. “This was optimistic of course, for if there was one that had strong evidence, it would already be in use.”

Kondo and colleagues conducted a systematic review of 16 studies focused on the performance of depression assessment tools utilized in patients with kidney failure.

With a total of nine studies examining its performance, the researchers determined the Beck Depression Inventory II (BDI-II) was “by far the most extensively studied.” They found other tools, such as patient health questionnaire 9 [PHQ] and the geriatric depression scale 15, showed good performance but were not well-studied.

“We ... hoped that we’d find some evidence to support the use of the tools that are common in practice,” Kondo said in the release. “And we didn’t. The PHQ-2 and -9 are widely used in medical settings and are free. The [Center for Epidemiologic Studies – Depression Scale] CES-D is another that is commonly used. We found only one study each of the PHQ-9 and the CES-D, and no studies of the PHQ-2.”

In a related editorial, L. Parker Gregg, MD, MS, and S. Susan Hedayati, MD, commended the authors for “undertaking this overdue task,” but argued that knowledge gaps still exist primarily with regard to patients on peritoneal dialysis (this study only included those on maintenance hemodialysis). Further, they stressed the importance of studying depression screening tools in patients with chronic kidney disease before they advance to kidney failure as to intervene earlier and possibly prevent adverse outcomes.

According to Gregg and Hedayati, because the BDI-II is longer and more time-consuming than some other screening tools, and also requires a fee, “freely available measures” like the [quick inventory of depressive symptomatology] QIDS-SR or the PHQ-9 might be better options in practice.

Jennifer Jones, on the board of directors for the American Association of Kidney Patients in Tampa, Florida, and a transplant recipient, also provided commentary in an accompanying patient voice.

“I have often wondered why many patients are not told about the prevalence of depression in CKD patients at the time of diagnosis, and how preexisting mental health ailments can further exacerbate depression, and how depression can affect them post-transplant,” she wrote. “What if the nephrologist required the patient to make an appointment with a mental health care professional, alongside consulting a dietitian, when given the diagnosis?”

In an attempt to erase associated stigma, Jones suggests depression be treated as a side-effect of the disease, one that is constantly monitored through each stage of CKD.