Screening for depression in hemodialysis patients:: Associations with diagnosis, treatment, and outcomes in the DOPPS

Background. Depressive symptoms and depression are the most frequent psychologic problems reported by hemodialysis patients. We assessed the prevalence of depressive symptoms and physician-diagnosed depression, their variations by country, and associations with treatment by antidepressants among hemodialysis patients. We also assessed whether depressive symptoms were independently associated with mortality, hospitalization, and dialysis withdrawal. Methods. The sample was represented by 9382 hemodialysis patients randomly selected from dialysis centers of 12 countries enrolled in the Dialysis Outcomes and Practice Patterns Study (DOPPS II). Depressive symptoms were assessed by the short version of the Center for Epidemiological Studies Depression Screening Index (CES-D), using greater than or equal to10 CES-D score as the cut-off value. Results. Overall prevalence of physician-diagnosed depression was 13.9%, and percentage of CES-D score greater than or equal to10 43.0%. While the smallest prevalence of physician-diagnosed depression was observed in Japan (2.0%) and France (10.6%), the percentage of CES-D score 10 in these counties was similar to the whole sample. Patients on antidepressants also varied by country, 34.9% and 17.3% among those with physician-diagnosed depression and CES-D scores greater than or equal to10, respectively. In Cox models adjusted for several comorbidities, CES-D scores greater than or equal to10 were associated with significantly higher relative risks (RR) of death (RR=1.42; 95% CI=1.29 to 1.57), hospitalization (RR=1.12; 95% CI=1.03 to 1.22), and dialysis withdrawal (RR=1.55; 95% CI=1.29 to 1.85). Conclusion. The data suggest that depression is underdiagnosed and undertreated among hemodialysis patients. CES-D can help identify hemodialysis patients who are at higher risk of death and hospitalization. Interventions should target these patients with the goal to improve survival and reduce hospitalizations.