SOCIAL WORK

The promise of symptom-targeted intervention

to manage depression in dialysis patients
By Melissa McCool, LCSW, Stephanie Johnstone, LCSW, Renata Sledge, LCSW, Beth Witten, MSW, ACSW, LSCSW,
Michelle Contillo, MSW, LCSW, Kathryn Aebel-Groesch, MSW, LCSW, and Jim Hafner, MSW, LSCSW, LCSW

Abstract
Research with tens of thousands
of dialysis patients has established
a link between depression, health-
related quality of life scores, survival,
and hospitalizations. In fact, physical
and mental functioning scores are as
predictive of death and hospitaliza-
tion as Kt/V and albumin.
Some models for managing depres-
sion in the dialysis clinic have been
developed. These models address
barriers to accessing community
mental health services. They also
promote collaboration between
the nephrology social worker and
nephrologist to assurethat patients
receive counseling and/or antide-
pressant medications when they
need them.
Part 1 of this article will introduce
a promising new method designed
for nephrology social workers to
help patients manage depression.
This method, known as Symptom-
Targeted Intervention (STI),
can be used in brief intervals with
patients while they are receiving
dialysis treatments to help reduce
depressive symptoms and improve
quality of life.
The second part of this article,
which will appear in the June issue
of Nephrology News & Issues, will
report the outcomes of a 17-state
pilot study in which more than 45
nephrology social workers used brief,
focused STI methods with more than
75 patients in the dialysis clinic set-
ting. The impact of STI on depres-
sion and quality of life in this sample
will be explored as well as how those
outcomes may impact hospitaliza-
tions, improve patient survival, and
contain costs in a bundled reim-
bursement environment.

Psychosocial interventions in the new economic Depression and dialysis

landscape of ESRD
In January, Medicare reimbursement for dialysis facili-
ties moved from the fee-for-service reimbursement system
that has been in effect since 1983 to a bundled prospective
payment system. In 2012, Medicare will begin to pay facili-
ties based on performance using quality-based measures.
With these reimbursement changes, the disease manage-
ment needs of the dialysis patient have taken on a new
focus. In 2008, it cost 5.9% of the total Medicare budget to
treat approximately 1% of the 45 million Medicare benefi-
ciaries, namely, individuals with end-stage renal disease.1
The focus of dialysis care has shifted to interventions
that minimize hospitalizations and limit other costly
expenditures. This change has led nephrology social work-
ers to examine new psychosocial interventions to use with
patients that help improve patient quality of care and qual-
ity of life while helping providers control costs.
Studies suggest at least 25% of dialysis patients have
clinical depression and at least 35% more have symp-
toms that put them at risk for depression.2,3 Depression
increases the risk of infection and failure to follow treat-
ment recommendations4,5 and is linked with an increase
risk of hospitalization and death.6-8 Depression adversely
affects quality of life,9 is a predictor of withdrawal from
dialysis,10 and is associated with shortening and skipping
dialysis, all of which contribute to increased risk of hospi-
talizations and death.11 Low mental component summary
(MCS) scores on the SF-36 and Kidney Disease Quality of
Life survey identify depression in dialysis patients.8 A one
point higher MCS score reduces the relative risk of death
and hospitalization.12
Regulatory requirements pertaining to mental
functioning
Publication of these studies led to a requirement in the

The authors are collectively dedicated to the value of nephrology social work in CKD disease management. Any comments made or opinions expressed are
of the authors and do not necessarily reflect those of, nor are they necessarily endorsed by, their employers. Ms. McCool was previously a nephrology social
worker at Renal Advantage Inc., and is in private practice in San Diego. Ms. Johnstone, an NN&I Editorial Advisory Board member, has 27 years’experience in
nephrology social work and is with Fresenius Medical Care North America in San Diego, Calif. Ms. Sledge is a nephrology social worker for RAI Care Center-
Lincoln in Fairview Heights, Ill. Ms. Witten has been in nephrology social work for 33 years and is with Witten and Associates, LLC in Overland Park, Kan.
Ms. Contillo is a nephrology social worker for Fresenius Medical Services in Honolulu. Ms. Aebel-Groesch is a regional point social worker for DaVita Inc.
in St. Louis, Mo. Mr. Hafner is a nephrology social worker for Davita Northland in Kansas City, Mo.

32 Nephrology News & Issues
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Table 1. The decreased risk of death and hospitalization
with improved mental and physical component scores
(SF-36)
Each 1 point improvement Each 1 point improvement
in PCS score in MCS score
Reduces relative risk of Reduces relative risk of
death 2% death 2%
Reduces relative risk of Reduces relative risk of
hospitalization 2% hospitalization 1%
Conditions for Coverage, revised in 2008 and subsequently
in the Interpretive Guidance (V552), that nephrology
social workers and other interdisciplinary team members
administer a standardized health-related quality of life
survey to assess physical and mental functioning and use
the results in planning care for dialysis patients. According
to the Conditions, social workers, as part of the interdis-
ciplinary team, are required to help patients “cope with
kidney failure, follow the treatment plan, and achieve the
patient’s goals for rehabilitation.”13
The dialysis literature has called the prevalence of
depression in dialysis patients an urgent priority in ESRD
disease management.14-16 Nephrology social workers can
provide needed intervention to accomplish these goals by
redirecting their time and scope of services.17-19 Managing
depression is within the scope of practice of a masters-pre-
pared social worker. CMS’ Conditions for Coverage requires
nephrology social workers to hold a masters degree from
an accredited graduate school. The Interpretive Guidance
(V681) states that the coursework of masters- prepared
social workers prepares them to provide clinical services.13
Promise of symptom-targeted intervention
Developed by nephrology social worker Melissa McCool,
symptom-targeted intervention (STI) brings forward new
methods to treat symptoms of depression in dialysis
patients. With STI, the most salient or problematic symp-
tom of the depression is identified and treated using cog-
nitive, behavioral, and mindfulness techniques. Since the
focus is very specific, interactions with the patient are brief
and can be done chair-side at the dialysis clinic.
Dialysis patients are often overwhelmed by a myriad of
psychosocial problems. Without a specific focus, interac-
tions with the social worker can easily get derailed and
turn into lengthy, unproductive sessions. STI seeks to iden-
tify and manage one symptom at a time. This approach
allows the social worker and patient to focus their inter-
actions. By targeting the most problematic symptom, ses-
sions are brief, manageable, and productive.
STI has been designed for and is well suited to the dialy-
sis setting for a variety of reasons. First, in the dialysis envi-
ronment, the nephrology social worker has an established,
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Social Work_NN&I_0511_FINAL.indd 33
SOCIAL WORK
working relationship with the patient. Thus, some of the
therapeutic relationship upon which good clinical work is
done has been developed.
Second, patients prefer to receive mental health servic-
es from their nephrology social worker.20 The relationship
between the patient and nephrology social worker is with-
out the stigma often associated with mental health treat-
ment. There are no transportation or financial barriers for
the patient, who comes to dialysis on a regular schedule
and has access to a social worker funded by the facil-
ity’s Medicare reimbursement for dialysis. This allows the
social worker to provide more frequent, brief treatment
interventions, to monitor outcomes, and to alter subse-
quent interventions accordingly until the patient’s symp-
toms improve. It also promotes a first line or adjunctive
form of treatment for depression alongside the nephrolo-
gists’ consideration of antidepressant medication.
Third, there is no focus on clinical diagnosis of the
“
Dialysis patients are often
overwhelmed by a myriad of
psychosocial problems. Without a
specific focus, interactions with the
social worker can easily be derailed...
“
depressed patient when using STI. Interventions address
the symptom that is most problematic for the patient;
it is irrelevant whether the symptom is caused by an
adjustment disorder, dysthymia, a recurrent depressive
episode, or another mood disorder. For this reason, STI is
appropriate for almost all patients suffering from symp-
toms of depression.
How STI works
The intellectual premise for STI is based on systems
theory, which is part of the core training of the masters-
prepared social worker. Systems theory considers a system
as a set of interacting and independent parts; when one
part of the system is altered, the entire system changes.
If depression is a system comprised of various symptoms,
when one of the symptoms improves, the entire trajectory
of the depressive episode is transformed.
With STI, once a depressive episode is identified, the
social worker and patient, through a series of questions,
identify the most urgent symptom of the depression.
The social worker and the patient then contract to work
together on resolving the symptom, recognizing that it
often requires more than one session and may require
[ STI, continued on page 35 ]
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 SOCIAL WORK

Commentary
Should we treat depression in the dialysis clinic? The impact of STI
Research continues to call for the treatment of depres-
sion in dialysis patients to improve survival and quality of
life outcomes.1-5 As an interdisciplinary team, we remain
cautious about providing treatment for depression at the
dialysis clinic. With the patient barriers to accessing com-
munity mental health treatment,6 however, where does
that leave the team? As nurses, technicians, dietitians,
and social workers, we feel helpless as we see the health
of a depressed patient deteriorate. Our interdisciplinary
plans of care struggle to set rehabilitation goals with these
patients, who often have difficulty even getting out of bed
in the morning and spend their non-dialysis days isolat-
ed from friends and family.
We continue to learn more about what mediates depres-
sion in ESRD. Positive and negative illness schemas and
social support have been isolated as predictors of depres-
sion in dialysis patients.7 Cognitive behavioral therapy has
been shown to improve mood in the dialysis patient.8
Interpersonal and problem-solving therapy in the dial-
ysis clinic have also demonstrated some positive out-
comes with depression, though larger samples are needed
for those studies.9-10 The field is hungry for a consistent
approach to this dangerous and disabling condition.
Symptom Targeted Intervention may show promise in
reaching the many depressed patients that are waiting for
our help.11

Table 1. Should we treat depression in the dialysis clinic?

Arguments Against Arguments For Onsite Treatment The Influence of STI
Onsite treatment on the Argument

Social workers don’t Brief interventions work. Social work time can be redirected toward pro- STI is brief. Each treatment session aver-
have time to provide viding brief interventions to improve outcomes. ages 20-30 minutes and can be deliv-
counseling. ered chair-side at the dialysis clinic.

Social workers aren’t CMS states an MSW has sufficient clinical training. CMS requires dialysis
trained to provide clinics to provide an MSW whose degree, license, or certification allows
counseling. him/her to counsel patients.13 The master’s-level curriculum in social work
provides an additional 900 hours of specialized clinical training. MSWs are
trained in conducting empirical evaluations of their own practice interven-
tions and to autonomously provide diagnostic, preventive, and treatment
services for individuals, families, and groups in the context of their respec-
tive life situations.14,15
The majority of social workers in the pilot
felt prepared to provide clinical interven-
tion.11 All social workers delivered STI
interventions after one brief DVD training.
STI training will now be easily accessible
to all nephrology social workers.

Social workers and The Medicare prospective payment for dialysis reimburses a dialysis clinic STI is based on CBT and other models
dialysis clinics are for the services of an MSW to reduce psychosocial barriers to treatment of mental health intervention that have
not reimbursed for outcomes. 12 MSW plans of care must reflect these efforts. Cognitive been provided in primary care settings.
psychotherapy. behavioral therapy (CBT) is a brief and effective method used in most STI interventions are designed for the
primary medical care settings. CBT is not analytical, nor does it involve dialysis setting and are ideal interven-
a psychodynamic exploration of a patient’s past. Motivational interview- tions for addressing mood barriers on
ing (MI) is technique currently used by MSWs, RNs and RDs in dialysis the patient plan of care.
settings. CBT is similar to MI in its psychotherapeutic implications and
scope.

Dialysis clinics are Disease management models integrate behavioral and medical practices STI was well received by dialysis patients
supposed to treat to maximize health outcomes. CMS requires the interdisciplinary team in the pilot and is a brief treatment meth-
kidney failure, not (IDT) to monitor patients’ physical and mental functioning through the use od well-suited to the dialysis clinic to
provide mental health of a standardized health related quality of life survey. Mental compos- improve MCS scores.
treatment. ite scores from that survey must be integrated into the patient’s plan of
care to help patients to achieve and sustain an appropriate psychosocial
status. Low mental component summary (MCS) scores predict death
and hospitalization. Patients with low MCS scores are more likely to be
depressed, skip or shorten dialysis sessions, and have poorer outcomes.
Studies show that patients prefer to seek mental health treatment from
their social worker at the dialysis clinic due to barriers in accessing com-
munity mental health treatment.6

Antidepressant medi- Referrals to psychiatry for medication management lack patient follow up. STI uses CBT to manage depression.
cations can be used to Barriers to accessing psychiatry include transportation, time, cost/ inad-
reduce depression. equate coverage, lack of community psychiatrists and the stigma associ-
ated with seeking mental health services. Nephrologists are called upon to
prescribe antidepressant therapy, but often prefer to offer counseling first
or in conjunction with medication for depression. CBT has been shown in
many chronic illnesses, including ESRD, to effectively manage depressive
symptoms alone or alongside antidepressant medication.

[ VIEWPOINT, continued on page 32 ]

34 Nephrology News & Issues
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Table 1 displays points from the ongoing debate of whether
we should treat depression in the dialysis clinic. The table
also demonstrates how the availability of Symptom Targeted
Intervention impacts this debate. Nephrology social workers
are anxious to have their skills re-directed toward improving
fiscal and quality outcomes.
The field might be wise to support their use of STI to man-
age depression. We have little to lose while our patients have
so much to gain. Could treating depression on-site do more
than just reduce hospital days and improve health-related
quality of life scores? Could it also promote rehabilitation and
the energy to consider dialysis at home? Now, with the intro-
duction of STI, this may be the time to find out.
—Stephanie Johnstone, LCSW
References
1. Kimmel, PL and Peterson, RA. Depression in patients with end-
stage renal disease treated with dialysis: Has the time to treat
arrived? Clin J Am Soc Nephrol 1: 349–352, 2006.
2. Boulware LE, Liu Y, Fink NE, Coresh J, Ford DE, Klag MJ, Powe
NR. Temporal relation among depression symptoms, cardiovas-
cular disease events, and mortality in end-stage renal disease:
Contribution of reverse causality. Clin J Am Soc Nephrol 1: 496–
504, 2003.
3. Finkelstein F, Wuerth D, Troidle L, Finkelstein SH. Depression and
end-stage renal disease: A therapeutic challenge. Kidney Int 2008;
74(7):843-845.
4. Mapes DL, Bragg-Gresham JL, Bommer J, et al. Health-related
quality of life in the Dialysis Outcomes and Practice Patterns Study
(DOPPS). Am J Kidney Dis 2004; 44(5 Suppl 2):54-60.
5. Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence
and treatment of depression among patients starting dialysis. Am
[STI, continued from page 33 ]
more than one brief intervention to resolve the symptom.
The patient-social worker partnership supports an impor-
tant sense of patient empowerment and self-efficacy,
where the patient is in control of his or her own mental
health outcomes.
Symptom-targeted interventions
Various cognitive and behavioral techniques are uti-
lized, including behavior activation, cognitive restructur-
ing, relaxation techniques, and mindfulness. STI interven-
tions usually include psycho-education, instruction, and
patient homework.
Several studies demonstrate that cognitive behavioral
therapy is an effective intervention in treating depression
in people on dialysis.3,21,22,23,24 Mindfulness-based cognitive
therapy (MBCT) is an approach that has been proven to
bolster recovery from depression and to prevent relapse.25
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Social Work_NN&I_0511_FINAL.indd 35
SOCIAL WORK
J Kidney Dis 2003; 41(1):105-110.
6. Roberts J, Johnstone S. Screening and treating depression: patient
preferences and implications for social workers. Nephrol News
Issues 2006; 20(13):43, 47-49.
7. Guzman SJ, Nicassio PM. The contribution of negative and positive
illness schemas to depression in patients with end-stage renal
disease. Journal of Behavioral Medicine, 2003; 26(6):517-534.
8. Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral
group therapy is an effective treatment for major depression in
hemodialysis patients. Kidney Int 2009; 76(4):414-421.
9. Weiner S, Kutner NG, Bowles T, Johnstone S. Improving psycho-
social health in hemodialysis patients after a disaster. Soc Work
Health Care 2010; 49(6):513-25.
10. Johnstone S Wellness programming: Nephrology social work
expands its role in renal disease management. Nephrology News
and Issues 19 (12) 59-71, 2005.
11. McCool M, Johnstone S, Sledge R, Witten B. The promise of
symptom targeted intervention to manage depression in dialysis
patients. Nephrology News and Issues 25:6:2011.
12. Medicare and Medicaid Programs; Conditions for Coverage for
End-Stage Renal Disease Facilities; Final Rule 73 FR 20406
(2008-04-15).
13. Centers for Medicare & Medicaid Services. Interpretive Guidance
Interim Final Version 1.1, October 3, 2008.
14. Council on Social Work Education, Commission on Accreditation.
Handbook of Accreditation Standards and Procedures (4th Ed).
Subsection B5.7.9 and M5.7.11, and Subsection B5.7.7 and M5.7.8,
pp 99, 137.
15. Harris. N. Social work education and public human services part-
nerships: A technical assistance document. A Report of a Ford
Foundation-Funded Project. Alexandria, Va.: CSWE, 1995.
While cognitive therapy techniques seek to change auto-
matic thoughts, the goal of MBCT is to attend to cogni-
tions fully as they arise. This by itself is healing.
The case examples (see page 37) demonstrate the fea-
tures of STI. The social worker uses multiple interventions
to assist the patient in addressing their targeted symp-
toms. The sessions are collaborative and brief, averaging
30 minutes each. The nephrology social worker chooses
interventions that apply to the patient’s unique situation.
References
1. U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of
Chronic Kidney Disease and End-Stage Renal Disease in the United
States, National Institutes of Health, National Institute of Diabetes
and Digestive and Kidney Diseases, Bethesda, MD, 2010
2. Cukor D, Peterson RA, Cohen SD, Kimmel PL. Depression in end-
stage renal disease hemodialysis patients. Nat Clin Pract Nephrol
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 SOCIAL WORK
2006; 2(12):678-687.
3. Cukor D. Use of CBT to treat depression among patients on hemodi-
alysis. Psychiatr Serv 2007; 58(5):711-712.
4. Troidle L, Watnick S, Wuerth DB, et al. Depression and its associa-
tion with peritonitis in long-term peritoneal dialysis patients. Am J
Kidney Dis 2003; 42(2):350-354.
5. Cukor D, Rosenthal D, Jindal R, et al. Depression is an important
contributor to low medication adherence in hemodialyzed patients
and transplant recipients. Kidney Int 2009; 75(11):1223-1229.
6. Kimmel PL, Peterson RA, Weihs KL, et al. Multiple measurements
of depression predict mortality in a longitudinal study of chronic
hemodialysis outpatients. Kidney Int 2000; 57(5):2093-2098.
7. Hedayati SS, Bosworth HB, Briley LP, et al. Death or hospitalization
of patients on chronic hemodialysis is associated with a physician-
based diagnosis of depression. Kidney Int 2008; 74(7):930-936.
8. Lopes AA, Bragg J, Young E, et al. Depression as a predictor of mor-
tality and hospitalization among hemodialysis patients. Kidney Int
2002; 62(1):199-207.
9. Mapes DL, Bragg-Gresham JL, Bommer J, et al. Health-related
quality of life in the Dialysis Outcomes and Practice Patterns Study
(DOPPS). Am J Kidney Dis 2004; 44(5 Suppl 2):54-60.
10. McDade-Montez EA, Christensen AJ, Cvengros JA, et al. The role of
depression symptoms in dialysis withdrawal. Health Psychol 2006;
25(2):198-204.
11. DeOreo PB. Hemodialysis patient-assessed functional health status
predicts continued survival, hospitalization, and dialysis-atten-
dance compliance. Am J Kidney Dis 1997; 30(2):204-12.
12. Lowrie EG, Curtin RB, LePain N, Schatell D. Medical Outcomes
Study Short Form-36: A consistent and powerful predictor of mor-
bidity and mortality in dialysis patients. Am J Kidney Dis 2003;
1(6):1286-1292.
13. Centers for Medicare & Medicaid Services. Interpretive Guidance
Interim Final Version 1.1, October 3, 2008.
14. Finkelstein F, Wuerth D, Troidle L, Finkelstein SH. Depression and
A nephrologist’s perspective
It’s time to collaborate on
depression
By Dylan Steer, MD
“Yeah, I take my binders,” says “Joe” to me on rounds.
Joe is a somewhat withdrawn, 28-year-old patient, two
years into dialysis. The problem is, despite the engagement
of an enthusiastic dietitian and support from his nurse and
physician, Joe’s phosphorus is sky-high and it is clear that he
Dr. Steer is affiliated with Balboa Nephrology Medical
Group, San Diego.
36 Nephrology News & Issues
r
May 2011
Social Work_NN&I_0511_FINAL.indd 36
end-stage renal disease: a therapeutic challenge. Kidney Int 2008;
74(7):843-845.
15. Kimmel PL, Weihs KL, Peterson RA. Survival in hemodialysis
patients: the role of depression. J Am Soc Nephrol 1993; 4(1):12-27.
16. Kimmel PL. Depression in patients with chronic renal disease:
what we know and what we need to know. J Pscyhosom Res 2002;
53(4):951-956.
17. Singer, J B (Host). (2009, April 13). Social workers and depres-
sion: Interview with Mark Meier, MSW, LICSW [Episode 49]. Social
Work Podcast. Podcast retrieved from http://socialworkpodcast.
com/2009/04/social-workers-and-depression-interview.html.
18. Merighi JR, Ehlebracht K. Unit-based patient services and sup-
portive counseling provided by renal social workers in the U.S. A
Survey/Part III. Nephrol News Issues 2004 18(7):55, 59-63.
19. Johnstone S. Depression management for hemodialysis patients:
Using DOPPS data to further guide nephrology social work interven-
tion. J Nephrol Soc Work 2007; 26:18-31.
20. Roberts J, Johnstone S. Screening and treating depression: patient
preferences and implications for social workers. Nephrol News
Issues 2006; 20(13):43, 47-49.
21. Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral
group therapy is an effective treatment for major depression in
hemodialysis patients. Kidney Int 2009; 76(4):414-421.
22. Johnstone S. Depression management for hemodialysis patients:
Using DOPPS data to further guide nephrology social work interven-
tion. J Nephrol Soc Work 2007; 26:18-31
23. Weiner S, Kutner NG, Bowles T, Johnstone S. Improving psychosocial
health in hemodialysis patients after a disaster. Soc Work Health
Care 2010; 49(6):513-25.
24. National Kidney Foundation. Living longer, living better: A heart
healthy wellness program for patients on dialysis. New York, NY.
25. Segal Z, Williams J Mark,Teasdale J. Mindfullness-based cognitive
therapy for depression. The Guilford Press, New York 2002.
is disengaged and not taking much of anything.
The frustrations and challenges surrounding this com-
mon encounter for the team members (including the patient
and family) are complex. Although many factors can be at
play, depression, an under-recognized disorder in the dialysis
population, clearly lays the foundation for non-adherence to
therapy. Integrating depression management into core clinical
treatment measures for end-stage renal disease could improve
patient outcomes.
Depression is common in the ESRD population but remains
difficult to diagnose and treat. It is insidious in its effect and
reach. Various studies estimate that 20%-25% of prevalent
ESRD patients have a co-morbid diagnosis of depression.
ESRD patients with low depression scores enjoy a significantly
improved quality of life (QOL) over patients with high depres-
sion scores. From a longitudinal perspective, patients with
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4/12/11 2:49 PM

Case studies using STI
Case #1
Jason is a 43-year-old male on in-center dialysis after a failed
transplant. During his annual assessment he had a low MCS
score on the KDQOL-36. While reviewing the scores with
Jason, the social worker discovers that he has been unhappy
for the last few months. Jason has been isolating himself,
watching TV all day and rarely leaving the house. There are no
acute psychosocial stressors involved. Jason is not interest-
ed in going to a psychiatrist or therapist outside of the dialysis
center, so the social worker suggests he try STI to treat the
symptoms. Jason agrees to work with the social worker.
Targeted symptom: Social isolation
Intervention: Working together, the patient and social worker
conduct an analysis on how Jason is spending his time out-
side the dialysis unit. The social worker then educates the
patient on the thought-mood-behavior connection using the
Beck Cognitive Triad. After the psycho-education, the social
worker and patient develop a plan for behavior activation,
creating an alternate daily schedule.
Outcomes: A week later, the social worker and Jason discuss
the results. Jason is following the new schedule; he is feeling
much more hopeful, less isolated, and more confident in his
ability to help himself. His depressive symptoms demonstrate
significant improvement.
Case #2
Sue is a 55-year-old female who has a low MCS score on her
KDQOL-36 administered with her annual assessment. After
speaking with her more in depth, the social worker notes that
high levels of depressive affect have an associated increase
in mortality.
There are several hurdles to treating the ESRD patient
with depression. First and foremost is proper identification
and screening of at-risk patients throughout their life cycle.
Patients with high depressive affect scores typically have
multiple somatic complaints that often-mimic uremia and can
mask the underlying depression. Diagnosing depression can
be difficult, time-consuming, and inconvenient for the nephrol-
ogist, particularly when managing a wide variety of other
“core” ESRD clinical measures. Good, valid screening tools,
administered longitudinally in the dialysis clinic by trained
social workers at important patient-derived time points, could
both identify depressed patients and provide an initial entrée
to treatment.
But who should provide treatment? As we move closer to
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SOCIAL WORK
Sue appears to be suffering from symptoms of depression.
Since Sue is not interested in seeking outside mental health
treatment or trying an antidepressant, the social worker sug-
gests Sue use STI. Sue agrees, and is relieved at the thought
of getting help for her symptoms. The social worker asks a
series of questions that progress from general to more spe-
cific to identify the most troubling symptom. Sue reports that
she has insomnia. After further questioning, it is noted that
Sue suffers from insomnia as a result of rumination at night
about her divorce several years ago.
Targeted Symptom: Rumination
Intervention: The first intervention is negative practice. A
few days later, the social worker checks in with Sue during
dialysis, who reports that the intervention was unsuccessful;
she is still ruminating. The social worker then applies a sec-
ond intervention called positive imagery. Sue and the social
worker learn about and practice the technique in the clinic.
Upon Sue’s next visit, she again reports no success; she is
still unable to sleep at night and can’t take her mind off the
divorce. The social worker and Sue agree to continue experi-
menting, as it is not uncommon to try multiple interventions in
the STI process. The third and final tool applied to Sue’s situ-
ation is mindfulness. The social worker taught the technique
to Sue during dialysis and she was instructed to practice it
at home.
Outcomes: After a week practicing mindfulness, Sue reports
the she is sleeping a lot better. Sue also notes that she is
less irritable and her mood has improved. She is feeling more
hopeful about the future and more confident about her ability
to solve problems.
integrated comprehensive care of the ESRD patient—after all,
nephrologists have become principal care providers for many
ESRD patients—treatment of depression will move from a
back-burner issue to a core measure. A dialysis clinic-based
approach to treatment makes sense, and a robust platform of
social worker-initiated depression management interventions
combined with medication management by the nephrolo-
gist serves as a good start toward treating mental health in
ESRD patients.
The impact of this ongoing collaboration between the
nephrologist and social worker may be measured in terms
of QOL, adherence to therapy, fewer missed treatments and,
perhaps, an overall reduction in the cost of care. Screening at-
risk dialysis patients for depression throughout their life cycle,
combined with a dialysis clinic-based approach to treatment,
can serve as a model for collaborative integrated care.
May 2011 t
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