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Comparing the Effectiveness of Depression Treatments for Patients Undergoing Maintenance Hemodialysis

What is the problem and what is known about it so far? Depression is a common problem that has many effective treatments, including cognitive behavioral therapy (CBT) (a form of talk therapy that helps patients learn problem-solving skills and behavioral modification strategies) and antidepressant medicines. About one third of patients with end-stage renal disease who are undergoing maintenance dialysis have depression, but most of them do not receive treatment for it. Why did the researchers do this particular study? The study had 2 purposes. First, the researchers wanted to see whether patients would be more willing to accept a diagnosis of depression, as well as treatment for it, if they first had a discussion with a therapist about the condition and options for treating it. Second, they wanted to compare the effects of CBT and sertraline (an antidepressant medicine) in depressed patients receiving maintenance dialysis. Who was studied? Patients older than 21 years with end-stage renal disease and major depression or dysthymia who were receiving maintenance dialysis at 1 of 41 dialysis facilities in Dallas, Texas; Albuquerque, New Mexico; or Seattle, Washington. Of 184 people who participated in part 1 of the trial (the interview), 120 continued on to part 2 (treatment comparison). How was the study done? Patients having hemodialysis were screened for depression, and those with a result indicating major depression or dysthymia were invited to participate in the trial. The patients who agreed to take part were randomly assigned to an intervention or a control interview, which took place while they were receiving hemodialysis. During the intervention interview, trained therapists discussed depression and its treatment with the patients and helped ease their concerns about their diagnosis and therapy options. During the control interview, patients talked with a member of the research team about depression and were told about treatment options outside the study. After the interviews, patients in both groups were asked if they wanted to participate in the second half of the study. Those who agreed were randomly assigned to receive either CBT or sertraline. Members of the CBT group had 10 one-hour sessions with a trained therapist over 12 weeks while they received hemodialysis. Those in the sertraline group were prescribed a dosage of 25 mg per day to start. It was increased gradually to a stable dosage over 6 weeks, which was maintained for another 6 weeks. Patients in both groups completed questionnaires to measure depression symptoms at baseline and at 6 and 12 weeks. The researchers measured the proportion (or rate) of patients who decided to start depression treatment after they completed the first interview (intervention or control). They then compared the difference in depression scores at 12 weeks between the CBT and sertraline groups. What did the researchers find? After comparing the group interviewed by a therapist with the group that received only general information about depression, the researchers found no difference in the proportion of patients who agreed to start depression treatment. Although depression scores improved in both the CBT and sertraline groups, improvement was slightly greater among the patients who received sertraline. However, side effects were more frequent in the sertraline than in the CBT group. What were the limitations of the study? The study did not include a group of patients randomly assigned to receive no treatment. What are the implications of the study? For patients receiving dialysis, an interview with a therapist had no effect on their willingness to start depression treatment. Although patients who received sertraline had slightly more improvement in their depression scores than those who had CBT, they also had more side effects.