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Controversies in Nephrology Nursing

Who Should Be Diagnosing, Prescribing, and Managing Depression in Patients with ESRD?
Christy Price Rabetoy, Department Editor

Nephrology Professionals Are Not Mental Health Experts
Christy Price Rabetoy, NP
Nephrology Nurse Practitioner
Salt Lake City, UT
Editorial Board Member, Nephrology Nursing Journal
ANNA Past President

There are numerous reasons why a patient with kidney disease might be depressed. This is not a disputed point, as it is quite common for individuals with chronic disease to be depressed about their situations. There is a longing human desire to be healthy and free of disease and disability. There are also a variety of reasons why someone with kidney disease might suffer from acute situational depression, such as death of a spouse, recent divorce, financial troubles, or even poverty. The question is, who is the most clinically competent professional to assess the degree of depression, design a therapeutic intervention plan, and provide consistent follow-up care with routine reevaluation for the diagnosis and treatment?

Nephrologists, nephrology nurse practitioners (NP), nephrology clinical nurse specialists (CNS), and clinical nephrology nurses have an incredible work load diagnosing and managing chronic kidney disease (CKD). During CKD Stages 1-4 the primary focus is preventing the disease progression, or at least, preserving kidney function as long as possible and delaying the onset of Stage 5 with the need for dialysis or transplantation. During these phases of chronic disease, the patient also must be visiting with his/her primary care professional physician (PCP) for the management of any other comorbidities. Nephrologists are recognized as subspecialists of Internal Medicine, and generally they prefer not to manage all other concurrent illnesses that the patient may have. In many states, some type of collaborative practice agreement exists between nephrologists and nephrology NPs or CNSs, which essentially means they practice as a partnership either with or without a requirement for supervision or oversight. Legally, this implies that either, or all, can and will be sued in a potential malpractice situation. As a team, they often establish the medical problems of patients who will be cared for by themselves or referred to other subspecialists. In general, nephrologists are not comfortable with managing any mental illness disorders or conditions, as it is poorly addressed in their medical or subspecialist training. Additionally, general nursing curriculum is not intended to provide nurses, generalists or NPs, the extensive expertise required for the treatment of mental illnesses. The involvement of nephrology social workers in patient care is mandated by the Medicare conditions of coverage, but there are many reports of the large patient loads that these providers carry, that is, possibly 200 patients with ESRD.

Once a patient advances to CKD Stage 5, the necessary medical interventions are numerous in order to achieve the desired quality and quantity of life for the patient. Hypertension, diabetes, anemia, malnutrition, cardiomyopathy, neuropathy, renal osteodystrophy, vascular disease, volume overload, and mental illness are just some of the concurrent medical conditions that a patient may present with or develop during the course of dialysis. Problems associated with dialysis further complicate the management of patients, including vascular accesses failures, PD catheter malfunction, treatment inadequacy, patient noncompliance, local and systemic infections, appropriate end of life care, and other adverse or side effects of dialysis. Nephrology professionals have developed evidenced-based guidelines and protocols to assist them with their therapeutic interventions in these areas of concern. Standards of care have been created to further guide the objectives and goals of CKD care. Patients often are also being followed by PCPs, cardiologists, diabetic specialists, rheumatologists, vascular surgeons, and others. It stands to reason that diagnoses other than CKD are referred to the appropriate subspecialists who can best manage the patient, and, in this light, any and all mental illnesses are also better diagnosed and managed by those who have the expertise, time, and motivation to treat these diseases, including depression.

More to the point of assessing and managing depression, these patients need the expertise of those professionals who are skilled with treating this condition. Depression, or any other mental illness, should not be treated by simply prescribing a pill. No drug is adequate without the essential therapeutic milieu of consistent counseling, recommended individualized patient treatment plans with reevaluation and follow-up care, as necessary, should the prescribed regimen not be meeting the goals. Documentation is required of all patient-provider interactions. This type of environment is simply not available within the physical space of most dialysis units. The machine noise, clamoring of staff and patients, and ever-present risk for a patient cardiopulmonary arrest cannot foster the necessary quiet and relaxed atmosphere required for addressing the personalized dynamics of mental illnesses. Furthermore, discussion of personal problems with a patient where the conversation might be overheard by other patients and staff is inappropriate and possibly malpractice.

Finally, nephrology professionals are comfortable prescribing drugs in the necessary loading dose and follow-up maintenance dose as they observe the patient’s response to the medication. They know the pharmacodynamics and pharmacokinetics of the drugs that they customarily prescribe to treat CKD and/or the effects of dialysis. They are familiar with the absorption, metabolism, distribution and elimination of the drugs. They are also familiar with the drug interactions, therapeutic effect, possible side effects, and potential toxicity. This comfort level does not extend to drug prescribing for mental illnesses like depression. They are not as familiar with the above dynamics of these drugs, nor do they routinely monitor for the black box warnings of these drugs.

CKD Stages 1-5 with dialysis or transplantation are all encompassing disease states that demand a comprehensive knowledge of the disease and its treatment. Certainly this statement could be made for all acute and chronic diseases. In the American health care system it has become necessary for physician and nursing professionals to specialize in order to remain abreast of all the intricacies of the condition they have chosen as a career path. Equally important in heath care, mental health experts have the necessary skill sets to treat mental illness. Our patients with CKD deserve referral to these professionals in order to achieve the best demonstrated practices.

Nephrology Is Best At Diagnosing And Managing Depression In Patients With ESRD
Stephanie Johnstone, MSW, LCSW
Lead Social Worker
Fresenius Medical Care North America
San Diego, CA
Member, Nephrology Social Workers’ Northern California Chapter

The decision regarding who should manage depression in the patient with ESRD is an important one. The unwillingness of the nephrology team to screen for and manage depression at the facility level is often based on the team’s lack of knowledge of resources available to them. In the past, easy to apply screening tools and outlined interventions designed to manage depression in the ESRD treatment environment have not been available; however, they are now.

As the need presented, nephrology professionals have developed protocols and guidelines directed towards specific areas of care, such as appropriate initiation and withdrawal of dialysis, interventions for behaviorally disruptive patients, and diabetic feet inspection and management, to list a few. Our scope of practice has progressed to meet these challenges. For each of these, and many other challenges, we might have preferred another subspecialist be consistently available to manage these sensitive and delicate areas of care, where we felt unsure of ourselves or lacked the time to focus on appropriate interventions. Yet the ESRD population continues to be complicated and fragile, and often poorly served outside of the dialysis clinic. It is this recognized reality that calls upon nephrology professionals to think outside of the box and continue to find creative and brief approaches for serving the underserved needs of this unique population. In managing depression the decision to expand our scope of practice to address underserved needs is no different.

A study examining a large sample of patients on hemodialysis at two time intervals,1998 and 2006, confirmed what the nephrology community strongly suspected. Patients rarely follow through on referrals to seek treatment for depression outside of the dialysis clinic (Roberts & Johnstone, 2006). Only 36% of patients interviewed in a multicenter inquiry reported they were willing to seek treatment for depression from anyone outside the dialysis clinic, while 87% of patients reported they were willing to receive treatment if it were offered by their nephrology social worker. In actuality, only 22% of patients followed through with referrals made to a mental health professional outside the dialysis clinic for depression management.

Efforts to manage depression in patients with ESRD by bringing mental health practitioners into the dialysis clinic environment have failed. Similar to the results when attempting to bring cardiology or endocrinology services into the dialysis center, liability, privacy (HIPAA), and Medicare compliance risks hindered this approach. Services provided in dialysis centers are our legal responsibility. Privacy screens and sound machines offer little protection from chair side consultations on private matters. Patients are rarely willing to arrive before or remain after treatment times to seek care from another provider. Medicare directives call for licensed clinical nephrology social workers to provide mental health services that are related to a patient’s adjustment to ESRD under the composite rate, creating the risk of “double-dipping,” if an outside referral is requested. Finally, the initiation and termination of services provided by visiting subspecialists are also cumbersome. This can lead to patient harm when services provided are withdrawn because of insurance coverage or these services are delivered without consistency. These realities have led to the development of more focused nephrology social work interventions that, along with nephrology nurses, better address the mental health needs and other clinical challenges of patients with ESRD.

The link between depression and treatment outcomes in the ESRD population has been demonstrated in the literature. In one study, DOPPS, the finding on prevalence of depression was nearly 20% and there were significant links established between depression, mortality, and hospitalization (Lopes et al., 2004; Lopes et al., 2002). A screening instrument (CES-D 10-item short form) was found to be more effective in identifying depression in patients on hemodialysis than physician diagnosis, with the instrument identifying nearly twice as many depressed patients in a large U.S. sample. Often depression was missed by physicians across all patient age groups. Even when depression was identified, the majority of patients were not provided with treatment. Only 38.9% of patients that were identified by U.S. physicians to be depressed received antidepressant medication therapy. Only 28.9% of the patients in the same study group, who were identified as depressed using the CES-D, were treated with antidepressant medication.

This data demonstrates our possible lack of confidence and knowledge as a nephrology team in diagnosing and managing depression in the ESRD population. The lack of intervention in this area may have tragic consequences. When the data from DOPPS II was adjusted for several co-morbidities, the patients identified as depressed by the CES-D had higher relative risks of death (1.42), hospitalization (1.12), and dialysis withdrawal (1.55).

In examining the questions of whom and what practice environment should guide the screening and intervention efforts to make certain that depression is effectively managed, it is apparent that the ESRD clinic treatment environment provides the best potential for success with nephrology professionals directing the care. The time to treat depression has arrived. Screening for and managing depression at the CKD treatment site will be increasingly important in our efforts to decrease federal program costs and improve the survival and quality of life outcomes of patients with CKD. Depression management interventions at the clinic level are likely to offer additional benefits, such as reducing patient-provider conflict and improving functional rehabilitation outcomes, which are important aspects of staff retention and the conditions for coverage. As nephrology professionals, let us move forward and take the necessary risk of another necessary protocol. Our willingness to advance in our care, as always, will impact both the wellness of our patients and the fiscal resilience of the industry.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.