Comparative Efficacy of Therapies for Treatment of Depression for Patients Undergoing Maintenance Hemodialysis: A Randomized Clinical Trial.

Background: Although depression is common among patients receiving maintenance hemodialysis, data on their acceptance of treatment and on the comparative efficacy of various therapies are limited. Objective: To determine the effect of an engagement interview on treatment acceptance (phase 1) and to compare the efficacy of cognitive behavioral therapy (CBT) versus sertraline (phase 2) for treating depression in patients receiving hemodialysis. Design: Multicenter, parallel-group, open-label, randomized controlled trial. (ClinicalTrials.gov: NCT02358343). Setting: 41 dialysis facilities in 3 U.S. metropolitan areas. Participants: Patients who had been receiving hemodialysis for at least 3 months and had a Beck Depression Inventory-II score of 15 or greater; 184 patients participated in phase 1, and 120 subsequently participated in phase 2. Intervention: Engagement interview versus control visit (phase 1) and 12 weeks of CBT delivered in the dialysis facility versus sertraline treatment (phase 2). Measurements: 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. Results: The proportion of participants who initiated treatment after the engagement or control visit did not differ (66% vs. 64%, respectively; P = 0.77; estimated risk difference, 2.1 [95% CI, -12.1 to 16.4]). Compared with CBT, sertraline treatment resulted in lower QIDS-C depression scores at 12 weeks (effect estimate, -1.84 [CI, -3.54 to -0.13]; P = 0.035). Adverse events were more frequent in the sertraline than the CBT group. Limitation: No randomized comparison was made with no treatment, and persistence of treatment effect was not assessed. Conclusion: An engagement interview with patients receiving maintenance hemodialysis had no effect on their acceptance of treatment for depression. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment than with CBT. Primary Funding Source: Patient-Centered Outcomes Research Institute, Dialysis Clinic, Kidney Research Institute, and National Institute of Diabetes and Digestive and Kidney Diseases.

A Pilot Randomized Controlled Trial to Promote Immunosuppressant Adherence in Adult Kidney Transplant Recipients.

BACKGROUND: Nonadherence to immunosuppressant medication is a prevalent practice among kidney transplant recipients and has been associated with increased risk for graft failure and economic burden. The aim of this pilot study was to test whether a culturally sensitive cognitive-behavioral adherence promotion program could significantly improve medication adherence to tacrolimus prescription as measured by telephone pill counts among kidney transplant recipients. METHODS: Thirty-three adult transplant recipients were less than 98% adherent to tacrolimus prescription based on 3 telephone pill counts and were randomized either to the 2-session cognitive-behavioral adherence promotion program or to standard care. The curriculum was developed from an iterative process with transplant recipients into a 2-session group program that provided psychoeducation, addressed barriers to adherence, fostered motivation to improve adherence behavior, and discussed cultural messages on adherence behavior. RESULTS: The intervention group displayed significantly higher levels of adherence when compared to the control group (t = 2.2, p = 0.04) and. similarly, when the amount of change was compared between the groups, the intervention group showed more change than the control condition (F (22,1) = 12.005, p = 0.003). Tacrolimus trough concentration levels were used as a secondary measure of adherence and, while there were no significant between-group differences for mean trough concentration levels, the variability in the trough levels did significantly decrease over time indicating more consistent pill-taking behavior in the intervention group. CONCLUSIONS: There is preliminary support for the pilot program as a successful intervention in helping patients with their immunosuppressant medication.

Sleep health in a black community sample.

BACKGROUND: Poor sleep health is a major health disparity and public health concern. The primary goal of this study was to accurately obtain the rates of self-reported sleep disorders, sleep dysfunction, and daytime sleepiness in a true community sample of black adults. METHODS: We used a community-based participatory research design to identify a health priority to design a study that could (a) provide an accurate assessment of the problem, (b) help to better understand the barriers to treatment, and (c) provide the community with access to care. Subsequently, 470 black adults, approached at salons, barber shops, and churches throughout Brooklyn participated. They underwent anthropometric measurement and completed a self-reported sleep assessment. RESULTS: Sleep disorders (insomnia, obstructive sleep apnea) were found in 34% of the sample, and 75% of the population that had a sleep disorder was unaware of it. Fourteen percent of the sample self-identified as having obstructive sleep apnea, 38.0% reported having Insomnia, and 38% reported having excessive daytime somnolence. People with a sleep disorder described less satisfaction with their sleep quality and poorer health than did those without a sleep disorder. CONCLUSION: The variability in the reported rates of sleep disorders in black samples suggests that the true rates of these conditions are not well-known. However, the large number of black individuals who have sleep disturbances warrants increased scientific and public health attention. In addition, with increased community involvement in research, there can be increased buy-in and greater accuracy in the assessments and reduced barriers to treatment.

Psychosocial intervention improves depression, quality of life, and fluid adherence in hemodialysis.

Patients with ESRD have high rates of depression, which is associated with diminished quality of life and survival. We determined whether individual cognitive behavioral therapy (CBT) reduces depression in hemodialysis patients with elevated depressive affect in a randomized crossover trial. Of 65 participants enrolled from two dialysis centers in New York, 59 completed the study and were assigned to the treatment-first group (n=33) or the wait-list control group (n=26). In the intervention phase, CBT was administered chairside during dialysis treatments for 3 months; participants were assessed 3 and 6 months after randomization. Compared with the wait-list group, the treatment-first group achieved significantly larger reductions in Beck Depression Inventory II (self-reported, P=0.03) and Hamilton Depression Rating Scale (clinician-reported, P<0.001) scores after intervention. Mean scores for the treatment-first group did not change significantly at the 3-month follow-up. Among participants with depression diagnosed at baseline, 89% in the treatment-first group were not depressed at the end of treatment compared with 38% in the wait-list group (Fisher's exact test, P=0.01). Furthermore, the treatment-first group experienced greater improvements in quality of life, assessed with the Kidney Disease Quality of Life Short Form (P=0.04), and interdialytic weight gain (P=0.002) than the wait-list group, although no effect on compliance was evident at follow-up. In summary, CBT led to significant improvements in depression, quality of life, and prescription compliance in this trial, and studies should be undertaken to assess the long-term effects of CBT on morbidity and mortality in patients with ESRD.

A pilot investigation of cognitive improvement across a single hemodialysis treatment.

BACKGROUND: Uremia has long been associated with cognitive deficits. This study explored the importance of the time of measurement of neurocognitive functioning, by directly comparing changes in neurocognitive functioning from immediately after hemodialysis treatment to immediately before treatment. METHODS: Twenty-five hemodynamically stable hemodialysis patients and 6 peritoneal dialysis controls completed 2 computer-based assessment batteries (ANAM), one immediately before dialysis and the second upon completion of that dialysis session. Paired sample t-tests were used to compare postdialysis with predialysis neurocognitive functioning scores for both a composite measure of global functioning and the neurocognitive subtests. RESULTS: There was significant improvement in global neuropsychological functioning from predialysis to postdialysis (t (24) = -7.5, p<0.001), showing an average of 18% improvement in the hemodialysis group, with no significant change in the peritoneal dialysis group. CONCLUSION: This study suggests that computer-based testing can offer information on the cognitive fluctuations of medically complex populations and suggests that the end of the session may be a better time to discuss important and complex health messages with hemodialysis patients. It further implies that some of the neurocognitive impairment that is associated with end-stage renal disease is a consequence of uremia and is improved by hemodialysis.

Depression and nonadherence predict mortality in hemodialysis treated end-stage renal disease patients.

The scientific evaluation of depression's impact on mortality in hemodialysis (HD) patients has yielded mixed results, with the more recent, more rigorous studies detecting a significant relationship. In this study, 130 HD patients from an urban North American hospital were evaluated for depressive affect and then observed for up to 5 years. In a corrected Cox regression model, which held constant age, gender, dialysis vintage, illness severity and diabetic status, depressive affect emerged as a modest but significant predictor of mortality (relative risk = 1.05, 95% confidence interval = 1.01-1.08). When the subjects were divided according to depressive affect severity, those with severe depressive affect had significantly shorter time to death (ß = 0.452, P = 0.044). In a subgroup of 85 subjects, self-reported medication adherence was also predictive of mortality, with higher rates of nonadherence being associated with increased mortality risk. This paper lends support to the burgeoning literature on depression and reduced survival in HD populations, as well as begins the investigation of understanding the underlying mechanisms.

A preliminary investigation of depression and kidney functioning in patients with chronic kidney disease.

BACKGROUND: The incidence and prevalence of Chronic Kidney Disease (CKD) is growing rapidly. Understanding the factors associated with declining renal function is of clinical significance. The current study's main goal was to identify variables that could predict decline in glomerular filtration rate (GFR) over time in outpatients with varying stages of CKD. METHODS: Seventy CKD patients completed psychological questionnaires and medical variables were extracted from the medical charts. Follow-up GFR was collected 6 months later. CKD patients with elevated depression scores were compared to patients with subclinical depression on medical and psychological variables. RESULTS: Average Beck Depression Inventory (BDI) score was 10.0 ± 7.8, placing the mean below the cut-off for clinical elevation. GFR was significantly different for the two groups (nondepressed, 40.0 ± 11.3 vs. depressed 29.6 ± 8.9; p < 0.05). Similarly, patients with elevated depression scores reported lower quality of life (Short Form 36 Health Survey; p < 0.05) inferior social support (Interpersonal Support Evaluation List; p < 0.05), and worse community integration (Community Integration Questionnaire; p < 0.05). Utilizing a regression, with a model correcting for baseline GFR, the BDI explained 19% of the variance in GFR score (t = -2.0, p < 0.05) for subjects with decreased GFR. CONCLUSIONS: Increased levels of preexisting depression were associated with inferior quality of life, social support and kidney functioning. Depression scores explained a significant amount of variance in GFR scores at 6 months even when corrected for baseline variability. Elevated depression scores are prevalent in CKD populations and further research on the impact of depression interventions is warranted.

Coping with racism: a selective review of the literature and a theoretical and methodological critique.

Racism is a stressor that contributes to racial/ethnic disparities in mental and physical health and to variations in these outcomes within racial and ethnic minority groups. The aim of this paper is to identify and discuss key issues in the study of individual-level strategies for coping with interpersonal racism. We begin with a discussion of the ways in which racism acts as a stressor and requires the mobilization of coping resources. Next, we examine available models for describing and conceptualizing strategies for coping with racism. Third, we discuss three major forms of coping: racial identity development, social support seeking and anger suppression and expression. We examine empirical support for the role of these coping strategies in buffering the impact of racism on specific health-related outcomes, including mental health (i.e., specifically, self-reported psychological distress and depressive symptoms), self-reported physical health, resting blood pressure levels, and cardiovascular reactivity to stressors. Careful examination of the effectiveness of individual-level coping strategies can guide future interventions on both the individual and community levels.