Antidepressant Usage in Haemodialysis Patients: Evidence of Sub-Optimal Practice Patterns

Abstract

Background: Depression is common in patients on haemodialysis and associated with adverse outcomes. Antidepressant use is widespread though evidence of efficacy is limited.

Objectives: To study antidepressant management practices in patients on haemodialysis with reference to NICE guidelines on management of depression in adults with chronic physical health problems.

Design: Prospective, multicentre, longitudinal cohort study with 6-15 month follow-up.

Participants: Patients on haemodialysis established on antidepressant medication.

Measurements: Baseline assessment of mood was undertaken using Beck Depression Inventory (BDI-II). Demographic, clinical and medication data were also collected. Changes in clinical and life circumstances and medication during follow-up were recorded. At follow-up, BDI-II was reassessed and diagnostic psychiatric assessment undertaken.

Results: Forty-one patients were studied. General practitioners were the main prescribers (68%). Ten agents were in use, the commonest being Citalopram (39%). Doses were often suboptimal. At baseline, 30 patients had high BDI-II scores (≥16) and 22 remained high at follow-up. Eleven had BDI-II < 16 at baseline. In five, this increased on follow-up to ≥16. Sixteen patients (39%) had no medication review during follow-up, 14 (34%) had a dose review, and 11 (27%) a medication change. On psychiatric assessment at follow-up, eight patients had current major depressive disorder (MDD), seven recurrent and 20 evidence of past MDD. Six displayed no evidence of ever having MDD.

Conclusions: Antidepressant management in patients on haemodialysis reflected poor drug selection, overprescription, under-dosing and inadequate follow-up suggesting sub-optimal adherence to NICE guidelines. Most patients had high depression scores at follow-up. Antidepressant use in haemodialysis requires reappraisal.

Keywords: Antidepressants; Chronic kidney disease; Clinical practice guidelines; Depression; Haemodialysis; Major depressive disorder; Selective serotonin reuptake inhibitors.