Antidepressants for treating depression in adults with end-stage kidney disease treated with dialysis

Background

People treated with dialysis frequently experience depression and anxiety. Depression in this situation is linked to poor quality of life and increased complications, such as needing to be admitted to hospital, or stopping dialysis treatment. Patients, their families, and health care workers agree that caring for depression symptoms appropriately and finding effective treatments is really important. Antidepressant drugs may not be removed from the body as quickly for people with kidney disease and so may cause more side effects. Despite depression being very common and treatment having potentially different side-effects compared with people without kidney disease, a previous version of this review in 2005 found only a single research study. It is unknown whether antidepressant treatment works and is safe for people with kidney failure.

A summary of whether antidepressant therapy works and is safe in people with kidney failure would be relevant to patients and their families, health care workers, and policy makers to generate patient-centred treatment policies.

This review looks at whether we know whether drug treatment works to improve symptoms of depression in adults treated with dialysis without causing common and severe side effects.

Study characteristics

We included all studies which have looked at drug treatment against placebo (sugar pill) or other kinds of mental health support. People included in the studies had an equal chance of receiving either treatment.

Key results

Unfortunately, even though depression is very common and finding good treatments for depression are highly valued by patients on dialysis, there are only a few small studies to tell us about whether drug treatments are both safe and reduce symptoms. Based on this information, we still don't know whether depression treatment works well for people treated with dialysis and is safe (doesn't cause excess and serious side effects).

Quality of the evidence

The question of whether drugs can reduce symptoms of depression and improve quality of life for people on dialysis is still important. We need a big study that involves dialysis patients and assesses a commonly-used antidepressant drug with a placebo and measures the treatment effects based on what patients and their families value most.

Authors' conclusions: 

Despite the high prevalence of depression in dialysis patients and the relative priority that patients place on effective treatments, evidence for antidepressant medication in the dialysis setting is sparse and data are generally inconclusive. The relative benefits and harms of antidepressant therapy in dialysis patients are poorly known and large randomised studies of antidepressants versus placebo are required.

Read the full abstract...
Background: 

Depression affects approximately one-quarter of people treated with dialysis and is considered an important research uncertainty by patients and health professionals. Treatment for depression in dialysis patients may have different benefits and harms compared to the general population due to different clearances of antidepressant medication and the severity of somatic symptoms associated with end-stage kidney disease (ESKD). Guidelines suggest treatment of depression in dialysis patients with pharmacological therapy, preferably a selective serotonin reuptake inhibitor. This is an update of a review first published in 2005.

Objectives: 

To evaluate the benefit and harms of antidepressants for treating depression in adults with ESKD treated with dialysis.

Search strategy: 

We searched Cochrane Kidney and Transplant's Specialised Register to 20 January 2016 through contact with the Information Specialist using search terms relevant to this review.

Selection criteria: 

Randomised controlled trials (RCTs) comparing antidepressant treatment with placebo or no treatment, or compared to another antidepressant medication or psychological intervention in adults with ESKD (estimated glomerular filtration rate < 15 mL/min/1.73 m2).

Data collection and analysis: 

Data were abstracted by two authors independently onto a standard form and subsequently entered into Review Manager. Risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data were calculated with 95% confidence intervals (95% CI).

Main results: 

Four studies in 170 participants compared antidepressant therapy (fluoxetine, sertraline, citalopram or escitalopram) versus placebo or psychological training for 8 to 12 weeks. In generally very low or ungradeable evidence, compared to placebo, antidepressant therapy had no evidence of benefit on quality of life, had uncertain effects on increasing the risk of hypotension (3 studies, 144 participants: RR 1.72, 95% CI 0.75 to 3.92), headache (2 studies 56 participants: RR 2.91, 95% CI 0.73 to 11.57), and sexual dysfunction (2 studies, 101 participants: RR 3.83, 95% CI 0.63 to 23.34), and increased nausea (3 studies, 114 participants: RR 2.67, 95% CI 1.26 to 5.68). There were few or no data for hospitalisation, suicide or all-cause mortality resulting in inconclusive evidence. Antidepressant therapy may reduce depression scores during treatment compared to placebo (1 study, 43 participants: MD -7.50, 95% CI -11.94 to -3.06). Antidepressant therapy was not statistically different from group psychological therapy for effects on depression scores or withdrawal from treatment and a range of other outcomes were not measured.

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