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Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management

2016; Elsevier BV; Volume: 2; Issue: 1 Linguagem: Inglês

10.1016/j.ekir.2016.09.005

2468-0249

Shayan Shirazian, Candace Grant, Olufemi Aina, Joseph Mattana, Farah Khorassani, Ana C. Ricardo,

Blood Pressure and Hypertension Studies

Depression is highly prevalent and is associated with poor quality of life and increased mortality among adults with chronic kidney disease (CKD), including those with end-stage renal disease (ESRD). However, there are several important differences in the diagnosis, epidemiology, and management of depression between patients with non−dialysis-dependent CKD and ESRD. Understanding these differences may lead to a better understanding of depression in these 2 distinct populations. First, diagnosing depression using self-reported questionnaires may be less accurate in patients with ESRD compared with CKD. Second, although the prevalence of interview-based depression is approximately 20% in both groups, the risk factors for depression may vary. Third, potential mechanisms of depression might also differ in CKD versus ESRD. Finally, considerations regarding the type and dose of antidepressant medications vary between CKD and ESRD. Future studies should further examine the mechanisms of depression in both groups, and test interventions to prevent and treat depression in these populations. Depression is highly prevalent and is associated with poor quality of life and increased mortality among adults with chronic kidney disease (CKD), including those with end-stage renal disease (ESRD). However, there are several important differences in the diagnosis, epidemiology, and management of depression between patients with non−dialysis-dependent CKD and ESRD. Understanding these differences may lead to a better understanding of depression in these 2 distinct populations. First, diagnosing depression using self-reported questionnaires may be less accurate in patients with ESRD compared with CKD. Second, although the prevalence of interview-based depression is approximately 20% in both groups, the risk factors for depression may vary. Third, potential mechanisms of depression might also differ in CKD versus ESRD. Finally, considerations regarding the type and dose of antidepressant medications vary between CKD and ESRD. Future studies should further examine the mechanisms of depression in both groups, and test interventions to prevent and treat depression in these populations. Depression is well known to affect adults with end-stage renal disease (ESRD), in part attributed to psychosocial and biologic changes that accompany dialysis.1Kimmel P.L. Psychosocial factors in dialysis patients.Kidney Int. 2001; 59: 1599-1613Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 2Sonikian M. Metaxaki P. Papavasileiou D. et al.Effects of interleukin-6 on depression risk in dialysis patients.Am J Nephrol. 2010; 31: 303-308Crossref PubMed Scopus (0) Google Scholar Recent studies have shown that patients with chronic kidney disease (CKD) who are not on dialysis have rates of depression up to 3 times higher than those in the general population.3Palmer S. Vecchio M. Craig J.C. et al.Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies.Kidney Int. 2013; 84: 179-191Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Furthermore, depression has been associated with poor quality of life and adverse medical outcomes in patients with CKD or ESRD.4Cukor D. Fruchter Y. Ver Halen N. et al.A preliminary investigation of depression and kidney functioning in patients with chronic kidney disease.Nephron Clin Pract. 2012; 122: 139-145Crossref PubMed Google Scholar, 5Lee Y.J. Kim M.S. Cho S. et al.Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease.Int J Clin Pract. 2013; 67: 363-368Crossref PubMed Scopus (0) Google Scholar, 6Tsai Y.C. Chiu Y.W. Hung C.C. et al.Association of symptoms of depression with progression of CKD.Am J Kidney Dis. 2012; 60: 54-61Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 7Fischer M.J. Kimmel P.L. Greene T. et al.Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease.Kidney Int. 2011; 80: 670-678Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 8Belayev L.Y. Mor M.K. Sevick M.A. et al.Longitudinal associations of depressive symptoms and pain with quality of life in patients receiving chronic hemodialysis.Hemodial Int. 2015; 19: 216-224Crossref PubMed Scopus (0) Google Scholar In this narrative Review, we will examine existing data and explore the similarities and differences in the diagnosis, epidemiology, and management of depression in patients with CKD and those with ESRD treated with maintenance dialysis (renal transplant recipients and patients who chose conservative management over dialysis or transplantation were excluded from this Review). In addition, we will suggest areas for future research aimed at furthering our understanding of the causal pathways of depression in CKD and ESRD, and evaluating interventions to prevent and/or treat depression in these populations. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the standard set of criteria used to diagnose mental disorders in the United States.9American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.Google Scholar The majority of studies examining the prevalence of unipolar depression (without mania or psychosis) in CKD and ESRD through clinical interview have used the DSM to define depressive disorders.3Palmer S. Vecchio M. Craig J.C. et al.Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies.Kidney Int. 2013; 84: 179-191Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar These studies have often used a broad definition of depression that encompasses several different depressive disorders from the DSM, including persistent depressive disorder (PDD), depressive disorder not otherwise specified (NOS), and major depressive disorder (MDD). These depressive disorders are briefly defined in Table 1.Table 1DSM-V classification of depressive disorders9American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.Google Scholar- Major depressive disorder (MDD): a clinical syndrome lasting at least 2 weeks, where patients experience either depressed mood or anhedonia, and at least 4 other symptoms of depression.aSymptoms of depression include weight loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think, concentrate, or make decisions, and recurrent suicidal ideation. Symptoms need to cause significant distress and impairment in one’s life, and cannot be caused by substance abuse or another psychological or medical condition including mania.- Persistent depressive disorder (PDD): depressed mood that occurs most days for at least 2 years, and the presence of at least 2 of the following 6 symptoms: change in appetite, insomnia or hypersomnia, fatigue, low energy, poor concentration or difficulty making decisions, and feelings of hopelessness. These symptoms may not be caused by substance abuse or a general medical condition, and must cause significant distress or impairment in one’s life. Previously known as dysthymia.- Depressive disorder NOS: any depressive disorder that does not meet criteria for a specific depressive disorder like PDD or MDD. Depressive disorder NOS was previously broken up into distinct depressive disorders including minor depressive disorder.- Minor depression: no longer a diagnostic classification and now classified as depressive disorder NOS in DSM-V. Previously defined as a clinical syndrome of depressed mood that lasted at least 2 weeks with at least 2 but fewer than 5 of the symptoms required to diagnose MDDDSM-V, Diagnostic and Statistical Manual of Mental Disorders, 5th edition; NOS: not otherwise specified.a Symptoms of depression include weight loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think, concentrate, or make decisions, and recurrent suicidal ideation. Open table in a new tab DSM-V, Diagnostic and Statistical Manual of Mental Disorders, 5th edition; NOS: not otherwise specified. The gold standard to diagnose depression is the clinical interview, including the following: (1) the Structured Clinical Interview for DSM Disorders (SCID)10Spitzer R.L. Williams J.B. Gibbon M. et al.The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description.Arch Gen Psychiatry. 1992; 49: 624-629Crossref PubMed Google Scholar; (2) the Composite International Diagnostic Interview (CIDI)11Wittchen H.U. Reliability and validity studies of the WHO−Composite International Diagnostic Interview (CIDI): a critical review.J Psychiatr Res. 1994; 28: 57-84Abstract Full Text PDF PubMed Scopus (0) Google Scholar; and (3) the Mini-International Neuropsychiatric Interview (MINI).12Sheehan D.V. Lecrubier Y. Sheehan K.H. et al.The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.J Clin Psychiatry. 1998; 59 Suppl 20 ([quiz: 34–57]): 22-33PubMed Google Scholar However, self-reported questionnaires are often used in clinical and research settings for screening of depressive symptoms. The most commonly used depression screening questionnaires that have been validated for use in patients with CKD and ESRD are as follows: Patient Health Questionnaire (PHQ-9)13Watnick S. Wang P.L. Demadura T. et al.Validation of 2 depression screening tools in dialysis patients.Am J Kidney Dis. 2005; 46: 919-924Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar; Beck Depression Inventory (BDI)13Watnick S. Wang P.L. Demadura T. et al.Validation of 2 depression screening tools in dialysis patients.Am J Kidney Dis. 2005; 46: 919-924Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 14Hedayati S.S. Bosworth H.B. Kuchibhatla M. et al.The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients.Kidney Int. 2006; 69: 1662-1668Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar; Center for Epidemiologic Studies Depression Scale (CESD)14Hedayati S.S. Bosworth H.B. Kuchibhatla M. et al.The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients.Kidney Int. 2006; 69: 1662-1668Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar; and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR).15Hedayati S.S. Minhajuddin A.T. Toto R.D. et al.Validation of depression screening scales in patients with CKD.Am J Kidney Dis. 2009; 54: 433-439Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Several studies have validated depression-screening questionnaires in patients with ESRD.13Watnick S. Wang P.L. Demadura T. et al.Validation of 2 depression screening tools in dialysis patients.Am J Kidney Dis. 2005; 46: 919-924Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 14Hedayati S.S. Bosworth H.B. Kuchibhatla M. et al.The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients.Kidney Int. 2006; 69: 1662-1668Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 16Craven J.L. Rodin G.M. Littlefield C. The Beck Depression Inventory as a screening device for major depression in renal dialysis patients.Int J Psychiatry Med. 1988; 18: 365-374Crossref PubMed Google Scholar In a study of 98 patients with ESRD on hemodialysis by Hedayati et al., the BDI and CESD scales were validated against the SCID for diagnosing a depressive disorder (MDD, dysthymia, or minor depression).14Hedayati S.S. Bosworth H.B. Kuchibhatla M. et al.The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients.Kidney Int. 2006; 69: 1662-1668Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar A BDI cutoff of 14 had a sensitivity of 62% and a specificity of 81% for identifying a depressive disorder. The corresponding sensitivity and specificity for a CESD cutoff of 18 were 69% and 83%, respectively. Both cutoff scores were higher than cutoffs set for the general population (10 for the BDI and 16 for the CESD). In a similar study by Watnick et al., the BDI and PHQ-9 were validated against the SCID for the diagnosis of a depressive disorder (MDD, dysthymia or minor depression).13Watnick S. Wang P.L. Demadura T. et al.Validation of 2 depression screening tools in dialysis patients.Am J Kidney Dis. 2005; 46: 919-924Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar A BDI score of 16 and a PHQ-9 cutoff of 10 had sensitivity of 91% and 92%, respectively, and specificity of 86% and 92%, respectively. As in the study by Hedayati et al., the most accurate cutoff score for diagnosing a depressive disorder using the BDI was higher than in the general population. This was attributed to the overlap between somatic symptoms of depression and symptoms related to ESRD, including anemia, fatigue, difficulty concentrating, difficulty sleeping, and poor appetite. Thus, patients with uremic symptoms may screen positive for depression with a self-reported questionnaire. However, these uremic symptoms can be distinguished from depressive symptoms during a clinical interview. For this reason, the clinical interview remains the gold standard for diagnosing depression in patients with ESRD. Only 1 study has validated questionnaires to screen for depression in patients with CKD.15Hedayati S.S. Minhajuddin A.T. Toto R.D. et al.Validation of depression screening scales in patients with CKD.Am J Kidney Dis. 2009; 54: 433-439Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In this study of 272 patients with stage 2 to 5 CKD, Hedayati et al. validated the BDI, and QIDS-SR(16) against the MINI.15Hedayati S.S. Minhajuddin A.T. Toto R.D. et al.Validation of depression screening scales in patients with CKD.Am J Kidney Dis. 2009; 54: 433-439Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The authors found that the optimal cutoffs for diagnosing a major depressive episode using the BDI and QIDS-SR(16) were the same as the general population, ≥11 and ≥10, respectively. However, the inclusion of patients with CKD stages 2 and 3, who are less likely to experience symptoms related to kidney disease, could have influenced the results. Future studies to validate depression-screening questionnaires in patients with advanced CKD (stages 4 and 5) for depressive disorders are needed. Two potential strategies for screening depression in patients with CKD and ESRD are generally used.17Cohen S.D. Norris L. Acquaviva K. et al.Screening, diagnosis, and treatment of depression in patients with end-stage renal disease.Clin J Am Soc Nephrol. 2007; 2: 1332-1342Crossref PubMed Scopus (0) Google Scholar, 18Hedayati S.S. Yalamanchili V. Finkelstein F.O. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease.Kidney Int. 2012; 81: 247-255Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The first, a conservative approach, is to screen only patients with signs of depression. These signs may include social isolation (withdrawal from family, friends, and social gatherings), changes in mood or physical functioning, and/or increasing physical complaints (sleep disturbance, decreased self-care, including poorer compliance with medical follow-up and dialysis). The second, a more aggressive strategy, is to screen all new CKD or ESRD patients periodically (every 6 months to 1 year) for depression with screening questionnaires (either the PHQ-9 or BDI). Specific health care providers, namely, a nurse, social worker or physician, should be trained on a protocol for administering depression screening questionnaires, including how to appropriately triage patients. Questionnaires, particularly items evaluating suicidal ideation, should be reviewed prior to patients leaving the clinic or dialysis center. Patients who screen positive for depression should be referred to a qualified professional to confirm the diagnosis with a clinical interview. Patients who require immediate referral to a mental health professional or emergency psychiatric services include those with suicidal ideation, plan, or intent and those with depression complicated by psychosis or mania.18Hedayati S.S. Yalamanchili V. Finkelstein F.O. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease.Kidney Int. 2012; 81: 247-255Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Depression is highly prevalent in patients with CKD and ESRD. A recent systematic review and meta-analysis by Palmer et al. examined the prevalence of depression in these populations.3Palmer S. Vecchio M. Craig J.C. et al.Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies.Kidney Int. 2013; 84: 179-191Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The authors identified 216 studies of 55,982 patients with CKD or ESRD. Among patients with ESRD receiving dialysis, the summary prevalence of depression was 39.3% when evaluated by screening questionnaires, and 22.8% when evaluated by clinical interview. In patients with CKD, the summary prevalence of depression was 26.5% when evaluated by screening questionnaires, and 21.4% when evaluated by clinical interview. Prevalence rates were higher in ESRD than in CKD when questionnaires were used to diagnose depression (39.3% vs. 26.5%), but were similar when depression was diagnosed by clinical interview (22.8% vs. 21.4%). This difference is likely related to uremic symptoms (fatigue, insomnia, poor appetite) in ESRD populations that could overlap with somatic symptoms of depression when measured using questionnaires.18Hedayati S.S. Yalamanchili V. Finkelstein F.O. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease.Kidney Int. 2012; 81: 247-255Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Since the publication of this meta-analysis, several studies evaluating the prevalence of depressive symptoms in CKD using screening questionnaires have been published (Table 2).4Cukor D. Fruchter Y. Ver Halen N. et al.A preliminary investigation of depression and kidney functioning in patients with chronic kidney disease.Nephron Clin Pract. 2012; 122: 139-145Crossref PubMed Google Scholar, 5Lee Y.J. Kim M.S. Cho S. et al.Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease.Int J Clin Pract. 2013; 67: 363-368Crossref PubMed Scopus (0) Google Scholar, 6Tsai Y.C. Chiu Y.W. Hung C.C. et al.Association of symptoms of depression with progression of CKD.Am J Kidney Dis. 2012; 60: 54-61Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 7Fischer M.J. Kimmel P.L. Greene T. et al.Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease.Kidney Int. 2011; 80: 670-678Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 19Kop W.J. Seliger S.L. Fink J.C. et al.Longitudinal association of depressive symptoms with rapid kidney function decline and adverse clinical renal disease outcomes.Clin J Am Soc Nephrol. 2011; 6: 834-844Crossref PubMed Scopus (0) Google Scholar, 20Fischer M.J. Xie D. Jordan N. et al.Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies.Am J Kidney Dis. 2012; 60: 27-38Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 21Yu M.K. Katon W. Young B.A. Diabetes self-care, major depression, and chronic kidney disease in an outpatient diabetic population.Nephron Clin Pract. 2013; 124: 106-112Crossref PubMed Scopus (0) Google Scholar, 22Hedayati S.S. Minhajuddin A.T. Afshar M. et al.Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death.JAMA. 2010; 303: 1946-1953Crossref PubMed Scopus (0) Google Scholar, 23Chiang H.H. Guo H.R. Livneh H. et al.Increased risk of progression to dialysis or death in CKD patients with depressive symptoms: a prospective 3-year follow-up cohort study.J Psychosom Res. 2015; 79: 228-232Abstract Full Text Full Text PDF PubMed Google Scholar The largest study to date, by Fischer et al., reported a prevalence of depressive symptoms of 27.4% using a BDI cutoff of 11 among 3853 individuals with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic CRIC (HCRIC) studies.20Fischer M.J. Xie D. Jordan N. et al.Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies.Am J Kidney Dis. 2012; 60: 27-38Abstract Full Text Full Text PDF PubMed Scopus (0) Google ScholarTable 2Recent studies evaluating prevalence and outcomes of depression in CKDFirst author, year, refSample characteristicsMeasurement tool for depressionDepression prevalenceFollow-upOutcomes of depressionHedayati, 201022Hedayati S.S. Minhajuddin A.T. Afshar M. et al.Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death.JAMA. 2010; 303: 1946-1953Crossref PubMed Scopus (0) Google Scholar267 Patients with stage 2–5 CKDDSM-IV interview(MDE diagnosis)21%1 yr-Composite of death, hospitalization, or ESRD: HR = 1.86-Hospitalization: HR = 1.90-ESRD: HR 3.51Fischer, 20117Fischer M.J. Kimmel P.L. Greene T. et al.Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease.Kidney Int. 2011; 80: 670-678Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar628 Patients with stage 2–4 CKDBDI-II score > 14 or ≥1126 or 42%5 yr-Composite of CV death or hospitalizationKop, 201119Kop W.J. Seliger S.L. Fink J.C. et al.Longitudinal association of depressive symptoms with rapid kidney function decline and adverse clinical renal disease outcomes.Clin J Am Soc Nephrol. 2011; 6: 834-844Crossref PubMed Scopus (0) Google Scholar5785 Patients, average GFR 78CES-D ≥ 821.2%14 yr-AKICukor, 20124Cukor D. Fruchter Y. Ver Halen N. et al.A preliminary investigation of depression and kidney functioning in patients with chronic kidney disease.Nephron Clin Pract. 2012; 122: 139-145Crossref PubMed Google Scholar70 Patients with stage 1–4 CKDBDI-II score ≥1430%6 mo-Worse QOL, social support, community integration-Greater decline in GFRFischer, 201220Fischer M.J. Xie D. Jordan N. et al.Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies.Am J Kidney Dis. 2012; 60: 27-38Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar3853 Patients with stage 2–4 CKDBDI-II score ≥ 1127.4%NoneTsai, 20126Tsai Y.C. Chiu Y.W. Hung C.C. et al.Association of symptoms of depression with progression of CKD.Am J Kidney Dis. 2012; 60: 54-61Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar428 Patients with stage 3–5 CKDBDI-II score ≥ 1137%4 yr-Composite of ESRD or death: HR = 1.66-First hospitalization: HR = 1.59-Faster GFR decline-Initial dialysis at a higher GFRLee, 20135Lee Y.J. Kim M.S. Cho S. et al.Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease.Int J Clin Pract. 2013; 67: 363-368Crossref PubMed Scopus (0) Google Scholar208 Patients with stage 3–5 CKDHADS-D ≥ 847.1%None-Worse QOLChiang, 201523Chiang H.H. Guo H.R. Livneh H. et al.Increased risk of progression to dialysis or death in CKD patients with depressive symptoms: a prospective 3-year follow-up cohort study.J Psychosom Res. 2015; 79: 228-232Abstract Full Text Full Text PDF PubMed Google Scholar262 Patients (60.3% stage 4 and above)Taiwanese Depression Questionnaire21%3 yr-Composite of dialysis or death: HR = 2.95-ESRD: HR = 2.25-Mortality: HR 3.08AKI, acute kidney injury; BDI, Beck Depression Inventory; CESD, Center for Epidemiologic Studies Depression Scale; CKD, chronic kidney disease; DSM IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; ESRD, end-stage renal disease; GFR, glomerular filtration rate; HADS-D, Hospital Anxiety and Depression Scale−depression subscale; HR, hazard ratio; MDE, major depressive episode; QOL, quality of life; ref, reference. Open table in a new tab AKI, acute kidney injury; BDI, Beck Depression Inventory; CESD, Center for Epidemiologic Studies Depression Scale; CKD, chronic kidney disease; DSM IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; ESRD, end-stage renal disease; GFR, glomerular filtration rate; HADS-D, Hospital Anxiety and Depression Scale−depression subscale; HR, hazard ratio; MDE, major depressive episode; QOL, quality of life; ref, reference. People who belong to a minority racial/ethnic group (e.g., black, Hispanic) have been shown to have higher incident rates of CKD and ESRD compared with non-Hispanic white individuals.24Smith S.R. Svetkey L.P. Dennis V.W. Racial differences in the incidence and progression of renal diseases.Kidney Int. 1991; 40: 815-822Abstract Full Text PDF PubMed Google Scholar, 25Cowie C.C. Port F.K. Wolfe R.A. et al.Disparities in incidence of diabetic end-stage renal disease according to race and type of diabetes.N Engl J Med. 1989; 321: 1074-1079Crossref PubMed Google Scholar Unfortunately, few studies have evaluated the prevalence of depressive symptoms in minority patients with CKD or ESRD.7Fischer M.J. Kimmel P.L. Greene T. et al.Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease.Kidney Int. 2011; 80: 670-678Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 19Kop W.J. Seliger S.L. Fink J.C. et al.Longitudinal association of depressive symptoms with rapid kidney function decline and adverse clinical renal disease outcomes.Clin J Am Soc Nephrol. 2011; 6: 834-844Crossref PubMed Scopus (0) Google Scholar, 20Fischer M.J. Xie D. Jordan N. et al.Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies.Am J Kidney Dis. 2012; 60: 27-38Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 26Lopes A.A. Bragg J. Young E. et al.Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe.Kidney Int. 2002; 62: 199-207Abstract Full Text Full Text PDF PubMed Scopus (318) Google Scholar, 27Fischer M.J. Kimmel P.L. Greene T. et al.Sociodemographic factors contribute to the depressive affect among African Americans with chronic kidney disease.Kidney Int. 2010; 77: 1010-1019Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 28Weisbord S.D. Mor M.K. Sevick M.A. et al.Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis.Clin J Am Soc Nephrol. 2014; 9: 1594-1602Crossref PubMed Scopus (0) Google Scholar In their analysis of 1600 black and 490 Hispanic patients from the CRIC and HCRIC studies, Fischer et al. found that Hispanics had a 1.65 times higher odds of depression, and that blacks had a 1.43 times higher odds of depression compared with non-Hispanic white participants.20Fischer M.J. Xie D. Jordan N. et al.Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies.Am J Kidney Dis. 2012; 60: 27-38Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Furthermore, both black and Hispanic individuals were significantly less likely to use antidepressant medications compared with non-Hispanic whites. Similarly, an analysis of 628 black individuals with CKD and HTN from the African-American Study of Kidney Disease and Hypertension (AASK) cohort found a 42% depression prevalence, much higher than that observed in other mixed race/ethnicity CKD populations.3Palmer S. Vecchio M. Craig J.C. et al.Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies.Kidney Int. 2013; 84: 179-191Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 7Fischer M.J. Kimmel P.L. Greene T. et al.Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease.Kidney Int. 2011; 80: 670-678Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar A higher risk of depression has been seen in other studies examining minorities with CKD19Kop W.J. Seliger S.L. Fink J.C. et al.Longitudinal association of depressive symptoms with rapid kidney function decline and adverse clinical renal disease outcomes.Clin J Am Soc Nephrol. 2011; 6: 834-844Crossref PubMed Scopus (0) Google Scholar but has not been seen in ESRD populations.