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Left Unchecked, Pain and Depression Worsen Outcomes in Hemodiaylsis Patients

October 17, 2014
Pain and depression lead to missed appointments, abbreviated treatments, and increased visits to ER, hospitalization, and death.

Being depressed and in pain often leads to poor adherence to medical treatments. But for patients requiring chronic hemodialysis, pain and depression were directly linked to missed treatments, hospitalizations, and even death.

Because pain and depression are often treatable, clinicians should evaluate interventions, like analgesic and anti-depressant therapies, for patients with pain and depression. These remedies “can significantly improve patient outcomes,” noted Steven Weisbord, from the Center for Health Equity Research and Promotion at the Veterans Affairs Pittsburgh Healthcare System.1

Dr. Weisbord and colleagues recently published an article that evaluated depression and pain symptoms in 286 chronic hemodialysis patients. They then analyzed the symptom scores to see if any associations existed with various negative outcomes, including missed and abbreviated treatments, visits to the emergency room, hospitalizations, and mortality.

Study Findings

After more than 4,400 patient assessments, the researchers identified the incidence of pain (79%) and moderate-to-severe depressive symptoms (18%) among the 286 patients.

While previous studies have shown these symptoms, among others, are common in hemodialysis patients,2-5 Dr. Weisbord and colleagues were able to show that patients with severe pain were 58% more likely to end up in the emergency room, with a 16% hospitalization rate.

In addition, patients with depression were 40% more likely to die. Dr. Weisbord said that the strong association between depressive symptoms and mortality wasn't surprising. "Prior studies have demonstrated an association of depression with mortality in patients receiving chronic dialysis," he said, noting that some researchers propose there are "pathophysiological mechanisms" that could explain this association.

"However, it is not known whether this association is causal or whether the treatment of depression in patients receiving chronic hemodialysis reduces mortality," Dr. Weisbord said. Left unchecked, depressed patients also were 24% more likely to have emergency room visits and symptoms of depression were associated with 19% increased hospitalization rate.

Therefore, Dr. Weisbord and colleagues emphasized the need to identify these symptoms before they affect patient outcomes. "Physical and emotional symptoms are prevalent, can be severe, and are correlated directly with impaired quality of life and depression in maintenance hemodialysis patients," Dr. Weisbord and colleagues wrote. "Incorporating a standard assessment of symptoms into the care provided to maintenance hemodialysis patients may provide a means to improve quality of life in this patient population."

Pain and Depression Affect Dialysis Care

These symptoms were also linked to issues with dialysis care, where patients with severe pain were 16% more likely to have abbreviated treatments, while patients with depressive symptoms were 21% more likely to miss their treatments altogether.

This isn't the first study to find associations of dialysis nonadherence with pain and depressive symptoms. A Canadian study found hemodialysis patients with moderate to severe chronic pain had a prevalence of depression and insomnia symptoms and were more likely to consider withdrawing from their dialysis treatments.2

In addition, many patients undergoing hemodialysis had inadequate pain management for their underlying pain. In a study by Davison, the causes of pain among dialysis patients were diverse.3 Musculoskeletal pain was most common, occurring in half of the patients, and equal in severity to pain associated with peripheral neuropathy and peripheral vascular disease. “Thirty-two percent of patients with pain were administered no analgesics, 29.1% were administered nonopioid analgesics, 26.2% were administered weak opioids, and 9.7% were administered strong opioids,” reported Davison.

In previous research, Dr. Weisbord investigated the prevalence of symptoms in hemodialysis patients, asserting that nephrologists and primary care physicians should actively assess patients' symptoms to prevent dialysis nonadherence and other negative outcomes.6

Despite these findings, many clinicians don’t assess for pain and depression. "One possible explanation for this is the multiple issues and problems that nephrologists have to address in this highly comorbid patient population. This may limit the time allotted to the assessment and treatment of some symptoms," Dr. Weisbord said.

Symptom Assessment Key

Despite this, Dr. Weisbord said symptom assessment could be the key to helping hemodialysis patients toward better outcomes. "Symptom assessment should be a standard practice in the care of patients on chronic hemodialysis," Dr. Weisbord said. 

"Routine assessment of pain and depression by clinicians and identification of patients who are interested in receiving symptom-alleviating treatment may reduce the severity of these symptoms and their effects on dialysis nonadherence."

Researchers now need to test the efficacy of medical interventions for patients with these symptoms. "Trials of treatment interventions for pain and depression in those patients who are eligible for and willing to receive treatment are the logical next steps," Dr. Weisbord said.

For more information on pain management in patients undergoing dialysis: continue reading Dialysis, Opioids, and Pain Management

Dr. Weisbord and colleague's study was supported by an award from the US Department of Veterans Affairs Health Services Research and Development.

Last updated on: May 18, 2015