Sertraline Modestly Better Than CBT for Treating Dialysis Patients With Depression

A 2-part study of patients receiving hemodialysis found that sertraline was modestly more effective at treating depression than cognitive behavioral therapy (CBT). But a more important finding may be that patients in this group had the same resistance to accepting mental health care as the rest of the population, and interviews to engage them in seeking help seemed to make no difference on their willingness to seek care.

The findings, published in Annals for Internal Medicine,¹ arise from a directive from CMS to screen dialysis patients for depression and document plans to treat those who need care. Authors led by Rajnish Mehrota, MD, MS, of the University of Washington School of Medicine, conducted the randomized clinical trial at 41 dialysis centers in 3 US cities, with the following steps:

• Patients who had been receiving dialysis at least 3 months were screened for depression.
• In the first phase, patients were randomized 1:1 to have an engagement interview or a control visit to see if the interview would increase patients’ willingness to seek treatment for depression. At the control visit, patients discussed treatment options. Researchers found the engagement interview made no difference in patients’ decisions.
• Of the 184 patients who took part in phase 1, 120 took part in phase 2, in which patients were randomized to receive sertraline or CBT.

The researchers measured the effectiveness of medication or CBT after 12 weeks; as Mehrota explained in an email to The American Journal of Managed Care^®, this is the conventional length of a CBT course, which is designed to teach behavioral skills to improve depressive symptoms.

At this point, patients were assessed using Quick Inventory of Depressive Symptomatology; those who had CBT improved symptoms by 29% and those who had sertraline improved symptoms by 40%. An accompanying editorial does not find that sertraline is clearly superior but rather calls for engagement and shared decision making to honor patient preferences.²

The article points out the possibility that patients could receive CBT during the dialysis session itself, although some have raised the issue that patients receiving dialysis can experience cognitive deficits. Mehrota, in his email, said that CBT was effective in the study, but there are issues with cognition for people undergoing dialysis, especially the longer they receive treatment. “During a 4-hour treatment session, changes occur in executive function. Many of these changes are subclinical,” he said, “While it is possible that subclinical cognitive problems can affect effectiveness of CBT, it is speculative.”

The authors pointed out the limited data on treating depression among patients undergoing dialysis treatment, even though this population is significant and growing. More patients are expected to develop end-stage renal disease as the population ages and become increasingly obese, with a higher percentage developing type 2 diabetes. Patients who are perceived as having a bad day are perceived as going through a phase rather than being recognized as being depressed.

Mehrota said much more work is needed in this area. “There are 3 important areas of investigation,” he said. “First, in this study, 30% to 40% of the patients had remission of depression. We need treatments that induce remission in a larger proportion of patients, and this may include combination therapy.”

“Second,” he continued, “we need studies that test if the effect of a treatment persists after 12 weeks.” Finally, addressing the problem of patients being perceived as going through a phase during dialysis instead of having depression, “We need studies that test if any treatment is better than no treatment or treatment with a placebo.”

References

1. Mehrota R, Cukor D, Unruh M, et al. Comparative efficacy of therapies for treatment of depression for patients undergoing maintenance hemodialysis [published online February 25, 2019]. Ann Intern Med. doi:10.7326/M18-2229.
2. Flythe JE. ASCENDing to new heights in our understanding of depression among individuals receiving hemodialysis [published online February 25, 2019]. Ann Intern Med.