![]() It is important to note that in many regions of the world, this is an off-label prescription, with current US product labeling recommending that the drug not be administered if creatinine clearance (CrCl) is < 30 mL/min. Treatment doses of duloxetine need to be adjusted and, based on data from a small pharmacokinetic study in HD patients, 136 ideally given at 48-hour intervals. Paroxetine may be useful when treating a depressed patient with concomitant intractable pruritus because of its antipruritic actions drugs such as duloxetine may be prescribed, off-label for those with concomitant pain. 134,135 Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided in older patients with (or without) kidney disease because of cardiac and central nervous system side effects, including prolonged QTc, arrhythmia, anticholinergic effects, and orthostatic hypotension. Based on current data, selective serotonin reuptake inhibitors (SSRIs), such as sertraline, escitalopram, and paroxetine, should be considered first-line for pharmacologic treatment for depression in patients with kidney disease. Although they commonly undergo hepatic metabolism, the active metabolites are excreted via the kidney, and consequently dosing should be adjusted to the eGFR level ( Table 84.4). 132,133 Most antidepressant medications are highly protein-bound and are not removed by dialysis. Pharmacologic therapies have been used in patients with CKD or ESKD however, there is little information on safety, efficacy, and optimal dosing. Several studies have shown low treatment acceptance and, on average, only one-third of patients who may benefit actually receive antidepressant medication. Despite the high prevalence and clinical implications of depression, many patients remain untreated. 126 However, little is known about the influence of physical diseases, frailty, and cognitive impairment on the efficacy or feasibility of psychotherapy. Several studies have shown CBT to be successful in patients with ESKD 123–125 and, where possible, it should be considered the first-line treatment for patients with mild to moderate depression. ![]() The mainstay treatments are depression-specific psychotherapies, such as cognitive- behavioral therapy (CBT) or interpersonal therapy, and pharmacologic treatment with an antidepressant. The approach to treating depression in older patients is the same as for younger patients. 116 Furthermore, depression is associated with increased hospitalization and mortality in both CKD and ESKD. In addition to the well-recognized impact on QOL, 112–115 individuals who are maintained on dialysis and are older than 75 years are among those at highest risk of suicide. The recognition of depression in the older individual is important for several reasons. In addition often co-occurring with other GSs, depression can be associated with a high burden of pain, fatigue, poor sleep, pruritus, and nausea. Age-specific data are not available, but depression is often more common in socially isolated individuals and those with functional or cognitive impairment placing frail older individuals at increased risk. 110 These estimates may, however, be influenced by the observation, from a number of studies, that patients on dialysis are often unwilling to undergo formal psychiatric evaluation or treatment. ![]() Prevalence estimates of major depressive episodes, using formal psychiatrist interview assessments, are lower, ranging from 21% in earlier stages of CKD to 23% in those undergoing maintenance dialysis. ![]() The prevalence of depression varies, depending on the assessment tools used and the population studied, but, using self-report or screening questionnaires, it is estimated that close to 40% of those undergoing maintenance dialysis have some depressive symptomatology, even if they do not fulfill all criteria for a major depressive episode. Yu MB, BChir, in Brenner and Rector's The Kidney, 2020 Depressionĭepressive symptoms and clinical depression are common in patients across the complete spectrum of CKD.
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