Psychonephrology

Article information
Title: Depression in dialysis patients with end-stage kidney disease: investigating the role of psychosocial stressors, co-occurring medical conditions and demographic influences
PubMed ID: 42109130
First Author Last Name: Bhui

Abstract:
Background:
Depression is common in end-stage kidney disease (ESKD) and is associated with poorer outcomes and higher mortality. However, treatment guidance is inconsistently applied.

Aims:
To investigate screening measures, somatic symptoms, comorbidities and psychosocial and cultural influences on depression diagnosis in ESKD patients.

Method:
We recruited 300 people with ESKD receiving maintenance hospital haemodialysis in a deprived ethnically diverse area. We assessed depression using validated screening tools (Hamilton Depression Rating Scale and Patient Health Questionnaire 2) and a definitive ICD-10 diagnosis using a structured interview (Clinical Interview Schedule-Revised). We considered the role of adverse life events, co-occurring medical conditions, as well as age, sex and ethnicity, using descriptive statistics and multiple logistic regression.

Results:
An ICD-10 diagnosis of moderate or severe depression was made in 8% of the sample, taking care to exclude potentially confounding symptoms associated with chronic kidney disease and depression. Applying validated thresholds on commonly used screening tools yielded substantially higher prevalence estimates. An ICD-10 diagnosis of moderate and severe depression associated with loss events: death of a spouse, child or parent (odds ratio 3.62, 95% CI: 1.09-12, p = 0.04), financial strain (odds ratio 3.51, 95% CI: 1.04-11.87, p = 0.04), type 2 diabetes (odds ratio 5.32, 95% CI: 1.34-20.76, p = 0.02) and education, whereby university graduates were less likely to have depression than school-only attendees (odds ratio 0.18, 95% CI: 0.03-1.02, p = 0.05). Ethnicity and sex were not significantly associated with moderate or severe depression.

Conclusions:
We found a lower prevalence of moderate to severe depression than commonly reported. Future research should consider careful diagnostic assessment, financial strain, loss events and physical co-occurring medical conditions such as diabetes.

Annotation
The finding:
This cross-sectional study of 300 patients with ESKD (end stage kidney disease) receiving in-center hemodialysis used the Clinical Interview Schedule-Revised (CIS-R) with ICD-10 criteria and identified an 8% prevalence of moderate-to-severe depression. The authors intentionally excluded somatic confounders (e.g., appetite, weight and social impairment changes) that may overlap with ESKD physiology, thereby providing a more accurate estimate of primary depressive disorders rather than symptom burden from end organ disease. Key risk factors for moderate-to-severe depression included financial strain (OR 3.5; 95% CI 1.09-12), bereavement (OR 3.6; 95% CI 1.04-11.9), and Type 2 diabetes (OR 5.3; 95% CI 1.34-20.8). Demographic variables including sex and ethnicity were not significant predictors of moderate-to severe depression in this cohort.

Strength and weaknesses:
In terms of strengths, this study used a validated structured psychiatric interview rather than relying solely on screening tools (HAM-D and PHQ-2) and carefully considered somatic variable overlap to distinguish between ESKD-related somatic symptoms from symptoms inherent to primary depressive disorder. The study also systematically assessed the impact of other variables such as financial strain, adverse life events, and medical conditions and used multiple logistic regression to adjust for demographic and other variables when examining associations with depression. Finally, the authors also recruited the study population from a deprived, ethnically diverse urban area which increases generalizability to real-world safety-net and public hospital settings.

In terms of weaknesses, the cross-sectional design of the study may limit causal and temporal inference. In addition, all participants were hospital hemodialysis patients in a single demographic region, which may limit generalizability to patients on peritoneal dialysis or home hemodialysis, pre-emptive kidney transplant populations, patients who are less deprived, patients living in rural settings, and different social safety net hospitals. There was also potential selection bias, as this study was conducted during the COVID-19 pandemic and patients too unwell may have been underrepresented. It is also unclear if prior psychiatric history, current use of psychotropic medications, or engagement in psychotherapy impacted the prevalence of depression.

Relevance:
This study reveals a significantly lower prevalence of moderate-to-severe depression in hemodialysis patients compared to the historical aggregate often cited in nephrology literature (8% versus ~22.8%, respectfully). This discrepancy underscores that much of the previously reported depression in this population may be an artifact of using screening tools that fail to distinguish between somatic symptoms of ESKD and primary depressive disorders. Ultimately, screening tools in the dialysis population serve effectively as a triage mechanism rather than a diagnostic endpoint. Every positive screen requires an in-depth clinical evaluation to avoid the over-diagnosis of depression and the subsequent risk of unnecessary, and potentially harmful, pharmacotherapy in patients already burdened by complex polypharmacy, as well as impaired renal clearance, altered protein binding, and changes in volume of distribution, all of which could affect the pharmacokinetics of many antidepressants. In addition, given that financial instability, type 2 diabetes, and recent bereavement, rather than demographic variables like sex or ethnicity, were the primary predictors of moderate-to-severe depression, C-L services should shift toward stressor-informed screening. Moreover, rather than relying solely on universal screening, we should prioritize proactive assessment for patients facing these specific psychosocial crises. This approach necessitates integrating multidisciplinary care pathways within dialysis units, specifically leveraging social workers and financial counselors to address the root causes of distress, thereby reducing the reliance on medication when psychosocial interventions are more appropriate.

Article information
Title: Diagnostic accuracy and practical utility of depression screening questionnaires across renal replacement therapy modalities
PubMed ID: 41653586
First Author Last Name: Vazquez

Abstract:
Background:
Depression is common yet underdiagnosed in patients receiving renal replacement therapies (RRT). Several questionnaires have shown utility for depression screening, mainly among in-centre haemodialysis patients; however, no instruments have been evaluated for diagnostic accuracy in home dialysis or kidney transplant populations. This study aimed to assess the diagnostic performance of the Beck Depression Inventory-Second Edition (BDI-II), the Beck Depression Inventory-Fast Screen (BDI-FS), and the Depression Subscale of the Hospital Anxiety and Depression Scale (HADS-D) across RRT modalities and to identify the most efficient tool for clinical use.

Methods:
Adult patients across RRT modalities completed the BDI-II, BDI-FS, and HADS-D, and were evaluated with the Structured Clinical Interview as the reference standard.

Results:
Among the 203 included patients (mean age 67.3 years; 65% male), 18.2% met SCID-I criteria for depression. Optimal cut-offs were BDI-II ≥15 for in-centre haemodialysis and ≥ 16 for home dialysis and transplantation; BDI-FS ≥3 for in-centre and home dialysis and ≥ 4 for transplantation; and HADS-D ≥ 5 for in-centre haemodialysis and ≥ 6 for home dialysis and transplantation. Sensitivity and negative predictive values exceeded 90% for all instruments except the HADS-D, which showed lower sensitivity in transplanted (86.7%) and home dialysis patients (70%).

Conclusions:
The BDI-II, BDI-FS, and HADS-D are useful for depression screening in renal populations, though the HADS-D demonstrated reduced performance in home dialysis. Standard cut-offs were inadequate, and modality-specific thresholds improved diagnostic accuracy. The BDI-FS, combining strong accuracy with brevity and ease of use, emerged as the most efficient tool for routine screening across RRT modalities.

Annotation
The finding:
In this prospective cohort study of 203 adults (65 receiving in-center hemodialysis, 59 receiving home dialysis, 79 transplant recipients), the authors describe an very high concordance between a diagnosis of MDD (established by the SCID-I) and self-report survey scores (BDI-II, BDI-SF, HADS-D), when using adjusted cut-off values, all of which differed from those established for non-kidney disease populations [BDI-II >/= 15 (in-center dialysis), >/= 16 (home dialysis and transplant); BDI-SF >/= 3 (in-center and home dialysis), >/= 4 (transplant); HADS-D >/= 5 (in-center dialysis), >/= 6 (home dialysis and transplant)]. When comparing performance across the three self-report surveys, the HADS demonstrated the weakest performance, especially for the home dialysis and transplant recipient populations [for BDI-II and BDI-SF: sensitivity > 90%, NPV > 90%, with slightly lower (>70%) specificity; for HADS-D: sensitivity >/= 70%, NPV > 90%, with >70% specificity].

Strength and weaknesses:
Limitations of this study include a moderate sample size, though there was relatively even representation across the three treatment modalities. The authors only explored diagnostic accuracy of three self-report surveys (one of which, the BDI-II, had already been studied extensively in the dialysis population, and another of which, the HADS-D, may require a fee for use), so the inclusion of other freely available measures could have expanded to application of the work. The study population lived in Spain, potentially reducing transferability of findings to a US population.
Strengths of this study include use of a validated diagnostic interview (SCID-I) completed by a highly trained clinician (psychologist), within a week of the self-report surveys, as the gold standard, as well as inclusion of individuals receiving three different kidney replacement treatment modalities.

Relevance:
To accurately screen for and track symptom severity in medically ill populations for both clinical and research purposes, C-L psychiatrists require self-report measures that can accurately capture psychiatric symptom severity, while minimizing “noise” generated by symptoms of the underlying medical condition. In this manuscript, the authors provide a detailed and helpful description of the performance of three self-report measures for individuals with chronic kidney disease, across three treatment modalities.

Article information
Title: Compulsive Skin Picking in Anorexia Nervosa: A Qualitative Study of Emotional and Interoceptive Dysregulation
PubMed ID: 41978120
First Author Last Name: Mariusz

Abstract:
Background:
Body-focused repetitive behaviors (BFRB), including compulsive skin picking, are observed in patients with anorexia nervosa (AN). However, their functional significance remains unclear. AN is characterized by chronic energy restriction and altered interoceptive processing, which may contribute to persistent internal tension beyond overt eating symptoms. This study aimed to explore the functional meaning of compulsive skin picking as a potential behavioral marker of emotional and interoceptive dysregulation relevant to clinical assessment and treatment planning.

Methods:
A qualitative descriptive study was conducted among 33 hospitalized patients with AN who reported recurrent skin picking leading to tissue damage. Patients were undergoing structured nutritional rehabilitation. Individual semi-structured interviews were performed.

Results:
Patients with AN described a consistent emotional and physiological sequence preceding skin picking: increased internal tension followed by short-term relief and subsequent self-directed negative emotions. Episodes occurred in contexts of emotional overload, understimulation, reduced emotional awareness, and, in some cases, hunger- or meal-related stress. Participants described the behavior as partly intentional, serving to reduce tension, but at times occurring almost automatically. It was closely connected with eating-related anxiety and dissatisfaction with the body.

Conclusions:
The findings indicate that compulsive skin picking in AN may reflect underlying emotional and interoceptive instability, instead of being an unrelated co-occurring symptom. In the broader context of chronic energy restriction, such behaviors may reflect attempts to modulate internally generated physiological arousal. Incorporating routine assessment of BFRB into clinical practice could improve the identification of ongoing emotional instability and support more coordinated multidisciplinary care. Future studies combining qualitative insights with physiological measures would help clarify the mechanisms underlying this association.

Annotation:
This was a qualitative study exploring whether skin picking could be a potential behavioral indicator of emotional and interoceptive dysregulation in anorexia nervosa (AN), based on a known significant association between AN and skin picking. Individuals with AN are hypothesized to have altered interoceptive processing, potentially caused by chronic energy deficiency, which activates neuroendocrine stress pathways. They further describe difficulties reconciling the dissonance between bodily signals (indicating hunger) and the need to exert cognitive control over their food intake. Some authors have posited that maladaptive behavioral strategies may be implemented to resolve this conflict. Semi-structured interviews were conducted with 33 hospitalized patients with AN who had recurrent skin picking with tissue damage. The majority of subjects described a similar course of increased internal tension leading to skin picking, followed by short-term relief of tension and subsequent onset of self-directed negative emotions. The study investigators concluded that skin picking, rather than being an unrelated, comorbid condition, was an indicator of emotional instability and interoceptive dysfunction. Limitations included a small sample size comprised only of females from a single center, limiting the generalizability of the results. Standardized, quantitative measures of skin picking severity and interoceptive awareness were not performed. The cross-sectional study design precluded determining cause-effect between the metabolic state and skin picking behaviors.