I have to agree with Marlene, I thought this weeks discussion regarding the use of sertraline and CKD was very thought provoking and insightful. What I didn’t realize before the discussion was that this was the only study that compared a SSRI with MDD and patients with CKD. The results and conclusion of the study showed that Sertraline did not decrease depressive symptoms in this patient population. I enjoyed that we were able to critically think about the study and break down some of the components (ie. Methods, results, etc).
Seth brought up a good point when he asked, “What SSRI would you use in this patient population with comorbid conditions if Sertraline was not efficacious?” The answer was that no other study compared another SSRI with MDD in this patient population. What we do know is that is medication is safe to use and would not cause harm. I would still feel comfortable prescribing it in this setting because we don’t know what else would work.
The other question that was brought up was what other SSRI could we use instead? From our discussion, it sounded like escitalopram would be an appropriate choice because it is well tolerated in patients with less side effects and less drug-drug interactions. It was also interesting that this study just came out this past November. I hope that it will be used as a foundation for further research with SSRIs and MDD with patients with complex medical conditions. I’ve attached a link to an interesting article by Kirino, E. (2012) Escitalopram for the management of MDD; a review of its efficacy, safety, and patient acceptably. It’s a quick read that highlights the tolerability and acceptability of this medication by patients.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526882/pdf/ppa-6-853.pdf
I really enjoyed the journal club and our subsequent discussion. It brings to light that there are many areas that the medications are not tested in. I would guess that this is mostly due to generalizability and practicality, but it is an important endeavor nonetheless. One thing that came up in our discussion as well was the fact that bringing in CKD with SSRI’s was that there were then multiple other comorbid conditions being brought into the equation such as alcohol and other substance use disorders. As we add more variables, interpretation of results becomes more convoluted and leads to less direct correlational results. I enjoyed our discussion during the session, and I would love to continue the discussion as to how to design research that is true to the real world (most people have more than one diagnosis, which subsequently interacts with results), yet also works to eliminate variables that could be changing results.
In terms of alternate therapies, I also wanted to mention how much I valued our brief discussion of alternate therapies for non-emergent cases. Marlene had mentioned even the emerging idea of a therapy involving a hyperoxegenation. I think this serves as a reminder to consider alternates, especially in populations where there isn’t substantiative research on medications, such as in a population like this where metabolism is altered and they are already on a slew of other medications. What else could be contributing to these psychiatric symptoms? Is it the disease process, lack of oxygen, chemical imbalances, genetic, a combination of them all? Looking more into this can help us decide on therapy as well.
Really enjoyed the discussion and perspective from pharmacology, looking forward to more!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526882/pdf/ppa-6-853.pdf
Marlene,
You've summed up this whole study and discussion pretty well. It appeared that the study had some gaps that could have contributed or answered some questions vital to the progression of MDD and CKD. Just like you said, there were factors such as educating the patients on how to take the medications (i.e with food) were eliminated from the study. And like we discussed, food helps SSRI's metabolize properly, therefore enhancing it's action. There are many things to consider other than SSRIs for CKD patients with MDD. Just like you've said, we could try a different class of antidepressants, or other non-pharmacological approaches such as exercise therapy or psychotherapy. I looked up other studies and the majority of the limited studies reported low efficacy of the different anti-depressants in people with CKD. It is also crucial to think of dosages and drug clearance in people with CKD. Could we be causing more harm than good by increasing antidepressant doses and potentially causing some side effects, or better to just completely avoid antidepressants? I think there is a high need for further research and studies, and I'm hopeful that an answer will be found in the near future.
Hedayati, S. S., Yalamanchili, V., & Finkelstein, F. O. (2012). A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney International, 81(3), 247–255. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.1038/ki.2011.358
Hedayati, S. S., Gregg L., Carmody T., Jain N., Toups M., Rush A., Toto R., Trivedi MH. (2017) Effect of Sertraline on Depressive Symptoms in Patients With Chronic Kidney Disease Without Dialysis DependenceThe CAST Randomized Clinical Trial. JAMA. 2017;318(19):1876–1890. doi:10.1001/jama.2017.17131
Marlene,
I agree with you in feeling comfortable to start Sertraline among individuals with CKD. Among the SSRI's, Sertraline does not have any recommendations for dose adjustment (Hedayati, Yalamanchili, and Finklestein, 2011). Due to the CKD, I would like to monitor the patient more closely by seeing them every two weeks. In addition to medication, I would also offer counseling, encourage exercise therapy, and cognitive behavior therapy.
One criticism I have for the study we read pertained to the quality of life ratings. I would want to know if the participant's depression resulted secondary to complications of CKD. In this particular study, I could see all the participants not reporting any improvement in their quality of life if the condition of their CKD remained the same. Hence, their depression is directly related to their comorbid conditions. I believe if studies focused on improving the participants CKD or comorbid conditions, they would ultimately improve the participants quality of life.
Yacharter Yang
Reference: Hedayati, S. S., Yalamanchili, V., & Finkelstein, F. O. (2011). A Practical Approach to the Treatment of Depression in Patients with Chronic Kidney Disease and End-Stage Renal Disease. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258342/ on 2/6/18.
Yacharter -
You make a good point in wanting to know more about their quality of life ratings. When studying a population with a comorbidities medical condition that is known to be related to development of feelings of depression, it is important to know more about their disease process in general and their status during this research. In that way, a qualitative arm may be a warranted break out study to accompany the medication results. I can understand their desire to really look more in depth at the safety and efficacy of prescribing Zoloft, but I do think that this could be a very beneficial next step in this research. The more complex (and subsequently “real life”) the patients in these studies are, the more variables that we are left wondering about in examining their implications in the results. This is not necessarily a study that will ever be able to prove causation, but it can show correlation.
For such a new topic of research, I think the authors did an excellent job bringing an issue to light. But I am, as everyone has stated or eluded to, left with a sense of wanting to know more about what is really driving the car of these results. Did the patient’s clinical status deteriorate medically? Did the numerous other comorbidities listed play too much of a role in individual patients that results could never become significant? These are questions that only further research will be able to answer! I look forward to reading up on this the next time I have a patient with comorbid CKD and MDD, and I hope that what I choose ends up being effective for their needs!
Hey Marlene,
I have to say, after reading the attached article, I too would be comfortable prescribing Sertraline for depression in CKD patient, to an extent. You summed up the article very well, and what I found interesting is that the article did not mention any Pharmacokinetics of Antidepressant medications. It briefly mentioned in the article that Sertraline is metablized in the liver. However, impaired kidney functions can also change the way an antidepressant is metabolize. I found an article by Shriazian, et al. (2017) that the "gastric alkalinization caused by elevated urea levels and changes in gastrin, as well as the use of phosphate binders or antacids, can decrease the oral bioavailability of antidepressants. Volume overload often observed in patients with CKD and ESRD can alter the volume of distribution of antidepressants" (pp. 100). With that said, does that mean we increase the dosage of sertraline? But then we increase the chances of adverse effects? I think as providers, we should really look at the patient as a whole, and assess further what would be beneficial.
Another important factor that article did not mention was the use of other modalities to treat depression. The use of antidepressant medications in combination with CBT for CKD patients. We already know that in depressive patient, there is a great rate in response to symptoms reduction when it comes to combining both therapies. There has not been any published information regarding, but it would be interesting too the efficiacy of the two treatment combined in CKD patients (Hedayati, et al., 2012). In the meantime, if we plan to prescribe a CKD patient with any antidepressants, we should be in contact with the patients nephrologist, and be aware of the possible risks of prescribing. I attached a Information Sheet from the BC Regency, that we can use in our practice, as well as URL link in the reference. I hope it can be helpful.
Sarishma Lal
References:
Hedayati, S. S., Yalamanchili, V., & Finkelstein, F. O. (2012). A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney International, 81(3), 247–255. https://ucsf.idm.oclc.org/login?url=http://doi.org/10.1038/ki.2011.358
http://www.bcrenalagency.ca/resource-gallery/Documents/Antidepressant%20Use%20in%20Adults%20with%20Chronic%20Kidney%20Disease.pdf
Shirazian, S., Grant, C. D., Aina, O., Mattana, J., Khorassani, F., & Ricardo, A. C. (2017). Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management. Kidney International Reports,2(1), 94-107. doi:10.1016/j.ekir.2016.09.005
Hello colleagues!
Thank you for your rich feedback in this post. I appreciate your thoughtfulness and dedication to wrestling with this complex clinical issue. Sarishma, I particular appreciated your observation that this article did not touch on the efficacy of antidepressants + CBT for CKD patients. Indeed, based our learning, it would make sense that this combination would prove most efficacious in addressing these patients' depressive symptoms. However, it seems that this article wanted to delve deeper into the specific issues of antidepressant medication treatment and so it follows that talk therapies were not addressed.
I appreciate the opportunity to glean what others feel comfortable prescribing in the context of CKD. It appears that, as a whole, the most important point is prescribe cautiously, monitor frequently and check the literature regularly for any updates!
Hello Everyone,
Catching up after having the flu for a couple of weeks.
I found this article very informative. I have to agree with many of you. The study was a good randomized control trial, but the study was relatively short term, and many factors were left out. Sarishma made a good point about using or testing alternative treatment modalities such as therapy. Charter brought up a good point about comorbidities and quality of life ratings. I read all the post and it got me thinking about how the research was conducted.
I began to wonder if the way the data is collected by researchers can affect the responses of the participants in the study. I found literature that supports the idea that the way people are interviewed for their data can impact their responses. According to Rossetto (2014), conducting research interviews can be therapeutic to people because it allows the participants to express themselves, to non-judgmental active listeners. However researchers, and data collectors can create negative spaces that may negatively impact responses, especially in individuals that have a mental illness such as depression.
It would be nice to see a study where multiple treatment modalities were used concurrently with medications to see how effective they can be together to treat depression in patients with CKD. I’m sure creating such a study could be a daunting task. CKD patients with depression are more likely to be noncompliant with their medication regimen (Bautovich et al. 2014). Ultimately, yes I would prescribe Sertraline to a CKD patient with depression. The effectiveness of medications varies person to person in my experience so monitoring the patient closely and having multiple back up plans would make me comfortable enough to prescribe Sertraline.
References
Bautovich, A., Katz, I., Smith, M., Colleen, K. L., & Samuel, B. H. (2014). Depression and chronic kidney disease: A review for clinicians. Aust N Z J Psychiatry, 48(6), 530-541. 10.1177/0004867414528589 Retrieved from https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1177/0004867414528589
Rossetto, K. R. (2014). Qualitative research interviews: Assessing the therapeutic value and challenges. Journal of Social and Personal Relationships, 31(4), 482-489. 10.1177/0265407514522892 Retrieved from https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1177/0265407514522892
I really enjoyed reading everyone's posts related to this article. For me, this article was very interesting because it directly relates to a client who I am seeing. The client is taking several medications for bipolar disorder and has been on the same regimen for several years. However, he is very depressed, and has been considering trying an antidepressant (it has been a discussion for a while and because of his history of mania, we are moving slowly and cautiously). While I have been seeing him, we have also discovered a new diagnosis of chronic kidney disease. At this point, we have to make a lot of decisions around his kidney function and his current medications and potential new antidepressant. This article has been helpful to have new information around utilizing sertraline with CKD. I know that my client's case is different from those in the article, but it was helpful to understand some of the recent information available about Sertraline. I, too, feel comfortable still prescribing sertraline to client's with CKD, but I wonder if when picking a medication for someone with CKD, if you wouldn't start with escitalopram first since there isn't similar research (because the research hasn't been performed). I think that this article definitely gives me something to think about when moving forward in treatment planning with this client. Thank you to everyone for the compelling conversation.