Journal Article Annotations
2020, 2nd Quarter

Psychonephrology

Annotations by Sahil Munjal, MD and Sarah Andrews, MD
June 24, 2020

Higher Dose Weekly Fluoxetine in Hemodialysis Patients: A Case Series Report.
Opinions of hemodialysis and peritoneum patients regarding depression and psychological problems which they experience: A qualitative study.

PUBLICATION #1 — Psychonephrology

Higher Dose Weekly Fluoxetine in Hemodialysis Patients: A Case Series Report.

Kelley M Kauffman, Jacqueline Dolata, Maria Figueroa, Douglas Gunzler, Anne Huml, Julie Pencak, Ashwini R Sehgal, Martha Sajatovic .

Abstract: Int J Psychiatry Med. 2020 Mar 26;91217420913399. doi: 10.1177/0091217420913399.

Objective
The antidepressant medication fluoxetine at 90 mg dosed weekly is as effective and safe as standard formulation fluoxetine 20 mg dosed daily in patients with major depressive disorder. Weekly fluoxetine has not been well studied in hemodialysis patients, and doses beyond 90 mg/week have not been described in this population. This case series, derived from a larger study on depression in hemodialysis patients, describes the use of weekly fluoxetine at dosages beyond 90 mg/week.

Method
Hemodialysis patients with depressive symptom severity scored ≥10 on the 9-item Patient Health Questionnaire and major depressive disorder confirmed with Mini International Neuropsychiatric Interview were initially prescribed daily fluoxetine for two weeks and then transitioned to weekly fluoxetine. Dosage titration was made at the discretion of the prescribing clinician. Fluoxetine was continued for a total of 12 weeks.

Results
Four women, aged 24 to 65 years, on hemodialysis for 1 to 18 years, were started on weekly fluoxetine that was increased over several weeks up to 180 mg. Side effects included restlessness, dry mouth, sedation, and lightheadedness. Two patients ultimately had their weekly fluoxetine decreased back to 90 mg. However, all four continued weekly fluoxetine as part of poststudy aftercare and no longer met diagnostic criteria for major depressive disorder, current episode.

Conclusions
Weekly fluoxetine at doses of 180 mg may be a reasonable treatment consideration for hemodialysis patients who have partial or insufficient antidepressant response. Side effects may limit tolerance of the 180 mg dose in some individuals. Future research should investigate longer term health outcomes of weekly fluoxetine in this population.

Keywords
chronic kidney disease; depression; end-stage renal disease; fluoxetine; hemodialysis.

PMID: 32216496

Annotation

The finding
This case series of four patients (part of a larger study) with MDD on HD is the first study to describe observed treatment with weekly fluoxetine at dosages beyond 90mg/week. All patients received the 180mg dose which was lowered to 90mg in two patients due to tolerability. All patients achieved remission.

Strength and weaknesses
Diagnosis of MDD in patients with baseline PHQ9 scores of 10 was confirmed by MINI and clinical assessment by the mental health nurse practitioner. Nevertheless this was a small case series of four patients. All were female, and there is a possibility of gender differences in fluoxetine metabolism. The report is of a short time frame of 12 weeks.

Relevance
Approximately a third of HD patients have MDD which is associated with poor outcomes. This study highlights the advantages of weekly fluoxetine including decreased pill burden, increased adherence, and no requirement of dose adjustments in kidney failure patients. This study also makes a case for directly observed medication administration given the high rate of medication nonadherence in this population even as patients attend dialysis treatment three times weekly. 90mg weekly fluoxetine was well tolerated but patients with partial response may benefit from a higher dose (180mg) due to individual differences in fluoxetine metabolism. Common side effects included restlessness, dry mouth, sedation, and lightheadedness which may limit tolerance of the 180 mg dose in some individuals.

Type of study
Case series

PUBLICATION #2 — Psychonephrology

Opinions of hemodialysis and peritoneum patients regarding depression and psychological problems which they experience: A qualitative study.

Avdal E, Ayvaz I, Uran B, Yildrim J, Sofulu F, Pamuk G. .

Abstract: J Infect Public Health. 2020 Apr 28;S1876-0341(20)30400-7. doi: 10.1016/j.jiph.2020.02.041.

BACKGROUND
Dialysis are the treatment modalities that affect the quality of life. The objective of this qualitative study is to reveal how hemodialysis and peritoneal dialysis patients perceive depression and psychological problems which they experience.

METHODS
An interpretative phenomenological analysis approach, as espoused by Smith and Osborn provided the framework for this study. The study was performed in hemodialysis and peritoneal dialysis units of a university hospital. 10 adult hemodialysis patients and 10 adult peritoneal dialysis patients, selected. In-depth, semi-structured, face-to-face interviews were held with the patients. All interviews were digitally recorded and subjected to qualitative analysis after transcription.

RESULTS
Analysis revealed themes suggesting that hemodialysis and peritoneal dialysis patients frequently experienced depression as well as psychological problems such as decreased social support, burnout, despair, and anxiety.

CONCLUSIONS
It was concluded as a result of this study that the prolonged hemodialysis and peritoneal dialysis process negatively affected patients with chronic kidney disorders.

PMID: 32359926

Annotation

The Findings
Depression is one of the most common psychiatric disorders among patients with kidney failure. Depression can lead to significant complications in renal failure including decreased quality of life, increased hospitalization rates, and increased mortality. This study focused how patients undergoing hemodialysis and peritoneal dialysis experience psychological issues as evaluated through semi-structured interviews. The major themes identified in these population included depression, anxiety, burnout, despair, and decreased social supports. Patients identified that their negative psychological impact occurred even prior to starting dialysis, specifically at the time of losing kidney function.

Strengths and weaknesses
This study completed in-depth interviews using semi-structured questions with 20 patients. The narratives provided in this study are powerful descriptions about their experiences with kidney failure and dialysis. This study identified several themes that are vital to address with patients. Although this study identify themes patients discussed in their semi-structured interviews, including depression and anxiety, there were no structured scales or further evaluation to determine if these patients suffered from an affective or anxiety disorder.

Relevance
Consult-liaison psychiatrists are often consulted on patients suffering from depression and anxiety. In the dialysis population, even though patients may not meet criteria for an affective or anxiety disorder, there are still struggles they experience that decrease quality of life and negatively impact psychological well-being.

Type of study
Qualitative study