Depression: A Side Effect of CKD

My CKD journey is rather unique. It began while I was deployed to Afghanistan, halfway through my career as a US Marine Corps combat camera videographer. After four combat deployments, one would think I would be prepared for anything. Although I do believe my military training benefits me in some ways, it still did not prepare me for all I have experienced within the past 9 years.

Before being diagnosed with membranoproliferative GN, type 1, idiopathic in 2011, I had returned from a third deployment to Iraq when I received a post-traumatic stress disorder diagnosis. I was fortunate to have mentors who believed in seeking mental health treatment. As a result, I had routine visits with a mental health care professional and I mitigated the postdeployment issues, carried on with my military career, and was an effective leader for my Marines.

However, when I could not continue to serve in the Marine Corps due to an illness beyond my control, I felt as if I was losing not just a job, but also my identity. After receiving a medical retirement in 2013, and despite not being on dialysis yet, the Veterans Affairs Medical Review Board diagnosed me with depression while I was going through the benefits process.

On being screened for depression, I filled out the Patient Health Questionnaire 9 assessment tool. Although this was effective enough to identify a proper diagnosis, there is still a need for an assessment tool that caters to the kidney disease patient. When I began dialysis, I was already feeling depressed; it was not a gradual occurrence because of the treatment. That factor, and many others unique to CKD, is missing from any current assessment tool used. There is limited research evaluating the diagnostic accuracy of most screening tools for depression in patients with kidney failure, and existing studies may not be generalizable to US populations (1).

I have often wondered why many patients are not told about the prevalence of depression in CKD patients at the time of diagnosis, and how pre-existing mental health ailments can further exacerbate depression, and how depression can affect them post-transplant. What if the nephrologist required the patient to make an appointment with a mental health care professional, alongside consulting a dietitian, when given the diagnosis?

As important as it is to monitor a kidney patient’s creatinine, BP, and albumin, keeping an eye on the patient’s mental health may prevent nonadherence to treatment and higher risk of mortality. Many patients cannot effectively communicate with their medical team about the challenges they may have with treatment because, emotionally, they may experience something they have never felt before. If one feels prepared for what may happen and is given the initial guidance that comes with the first visit to a mental health care specialist on diagnosis, then it may be easier to describe whether a CKD-related symptom is based on mental or physical ailments, or a combination of both.

This mental health monitoring does not end when a kidney patient receives a transplant. Although it truly is a donation of life, a kidney transplant is also a major responsibility that comes with its own stressful challenges and obstacles that may cause, or increase, a patient’s depression. Researchers are aware that although the depression that is coexistent with CKD may have important additional adverse effects on functional status and physical health, to date, there are insufficient high-quality data to show that screening for, or treatment of, depression in CKD populations improves clinical symptoms and quality of life (2).

In my own journey, the 5 years since having a kidney transplant from an altruistic living donor have been a rollercoaster ride due to having such a rare autoimmune disease. I am closely monitored by my nephrologist, have undergone many hospitalizations, and had two kidney rejection scares because of membranoproliferative GN, type 1, idiopathic reoccurring in my transplanted kidney through no fault of my own. It is mentally taxing when random medical issues occur that produce more questions than solutions. When I ask my nephrologist what I can do to improve my current condition and am told that “There is nothing more you can do,” the pain I feel is indescribable.

I will be forever grateful to my living donor, my kidney sister, for what she has done for me, but we need to acknowledge that a stigma has developed within the kidney disease community that if one receives a transplant, the recipient does not have the right to share any of the negative aspects or it will look as if the recipient is complaining and ungrateful. This stigma may prevent transplant recipients from seeking needed mental health treatment.

Instead, depression should be treated as a side effect that is constantly monitored throughout every stage of CKD. This approach could erase stigmas and could change the outcome of so many kidney patients who are suffering from the physical and mental effects daily.

Disclosures

J. Jones, USMC, ret., serves as a member of the Board of Directors and a member of the Veterans Health Initiative for the American Association of Kidney Patients, a member of the Quality Insights Renal Network 5 Patient Advisory Committee, a member of the Veterans Transplantation Association, a member of the American Kidney Fund Advocacy Network, and is an American Kidney Fund Kidney Health Coach.

Funding

None.