Dr. Cukor is assistant professor in the Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, 450 Clarkson Ave., Box 1203, Brooklyn, NY 11203 (e-mail: firstname.lastname@example.org).
The rapid pace at which medical technologies are being developed and utilized is staggering, but responses to the mental health implications of these innovations often lag behind. Before hemodialysis, there were few treatment options for patients with kidney failure. Currently more than 275,000 Americans receive ongoing hemodialysis, which represents 80% of the population with end-stage renal disease (ESRD), or kidney function below 10%. Life on dialysis shares aspects of illness burden with other chronic disorders: threats to autonomy, burden of illness, and changes in functional status. However, there are also unique challenges faced by hemodialysis patients: the demanding schedule of treatment, dietary restrictions, and ongoing secondary medical complications.
Editor's Note: Cognitive-behavioral interventions, long used for treating depression, have begun to be more widely used for an array of disorders. These three reports, all representing work done by faculty at Downstate Medical Center, State University of New York, in Brooklyn, represent examples of using cognitive-behavioral interventions with medically ill patients—those with both psychiatric and substance use disorders and with histories of violence and psychosis.—Stephen M. Goldfinger, M.D.
Depression is second only to hypertension as a comorbid condition among ESRD patients, affecting 20% to 30%. Yet there has been little systematic investigation of treatment strategies. Although the newer antidepressants are generally considered to be safe for dialysis patients, both patients and physicians seem to believe that unless the mood problem is unbearable, it is better not to prescribe additional medication. Thus a hemodialysis center is an excellent place for psychosocial interventions.
Downstate Medical Center, located in central Brooklyn, New York, has a long and proud history in the treatment of hemodialysis patients. Downstate housed the first federally funded dialysis center in New York State and has continued to be an innovative force in the treatment of ESRD. However, staff social workers have administrative responsibilities and are often not afforded ample time to address all of the patients' clinical issues. We created a model in which social workers serve as liaisons between patients and consulting psychologists, identifying and referring patients in need.
Many models for the delivery of treatment were piloted, including appointments at the outpatient psychology service, meetings at the dialysis center on nondialysis days, appointments before or after the patients' treatments and, finally, meetings during dialysis. Clinical experience taught us that psychosocial intervention during dialysis represented the most effective model. With some adjustment, the dialysis center offered more privacy than most inpatient settings. Because of patients' medical severity and treatment burden, adding another weekly outpatient appointment was onerous, and intervening while patients were being dialyzed was both practical and appreciated by the patients. No patients were lost to follow-through—100% of those who consented to a consultation were evaluated, a significant improvement over the usual rates of follow-up on psychiatric referrals.
Over the first year of this program, beginning in 2005, about 75 dialysis patients were evaluated and 50 were engaged in group and individual treatment. Group treatments were conducted in a conference room at the dialysis center and typically consisted of six to ten people. The sessions were scheduled immediately preceding a shift, so that patients could come early to their appointments and attend the group. This timing enabled patients who required ambulette transportation to attend and also fostered supportive relationships between people on the same shift.
We chose cognitive-behavioral therapy (CBT) as our intervention. Its focus on symptom reduction and its time-limited nature made it palatable to patients, and CBT fits well into the medical model of treatment that patients are accustomed to. The initial phase of the program was spent identifying the psychological issues unique to this population. Two overarching themes emerged: patients believe that depression is part of the illness "package," and they believe that disability prevents them from enjoying life. Believing that depression is a necessary comorbid disorder is an example of "dysfunctional thinking" (70% to 80% of patients with ESRD are not depressed), and the belief is amenable to the CBT technique of cognitive restructuring.
The limitations that ESRD disability places on people are often a combination of both true physical limitations and depressed attitude. The goal was to have patients attempt modified versions of the activities that they used to enjoy, and a combination of cognitive restructuring and behavioral assignments was used. In a nonstandardized protocol, 16 ESRD patients who had major depression were treated individually with a 15-week CBT intervention that focused on the techniques of challenging distorted thoughts and encouraging behavioral activation. All patients showed a significant decrease in their Beck Depression Inventory (BDI-II) scores at the conclusion of treatment. The average BDI-II score fell from 28.9 to 18.5 at the end of treatment and to 18.8 at a three-month follow-up, indicating both a significant and sustained reduction in depressive affect. (Possible scores on the BDI-II range from 0 to 63, with higher scores representing more depression.)
ESRD patients have great need for psychiatric services and are often underserved. Individual treatment that is conducted by consulting therapists "chair-side" at the hemodialysis center is a novel method of psychotherapeutic intervention that alleviates many of the obstacles of traditional referral-based outpatient services. CBT promises to be a good treatment choice for treating depression among ESRD patients.