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

Psychosocial interventions in the new economic Depression and dialysis


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

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SOCIAL WORK

working relationship with the patient. Thus, some of the


Table 1. The decreased risk of death and hospitalization
with improved mental and physical component scores therapeutic relationship upon which good clinical work is
(SF-36) done has been developed.
Each 1 point improvement Each 1 point improvement
Second, patients prefer to receive mental health servic-
in PCS score in MCS score es from their nephrology social worker.20 The relationship
Reduces relative risk of Reduces relative risk of
between the patient and nephrology social worker is with-
death 2% death 2% out the stigma often associated with mental health treat-
Reduces relative risk of Reduces relative risk of
ment. There are no transportation or financial barriers for
hospitalization 2% hospitalization 1% the patient, who comes to dialysis on a regular schedule
and has access to a social worker funded by the facil-
Conditions for Coverage, revised in 2008 and subsequently ity’s Medicare reimbursement for dialysis. This allows the
in the Interpretive Guidance (V552), that nephrology social worker to provide more frequent, brief treatment
social workers and other interdisciplinary team members interventions, to monitor outcomes, and to alter subse-
administer a standardized health-related quality of life quent interventions accordingly until the patient’s symp-
survey to assess physical and mental functioning and use toms improve. It also promotes a first line or adjunctive
the results in planning care for dialysis patients. According form of treatment for depression alongside the nephrolo-
to the Conditions, social workers, as part of the interdis- gists’ consideration of antidepressant medication.
ciplinary team, are required to help patients “cope with Third, there is no focus on clinical diagnosis of the
kidney failure, follow the treatment plan, and achieve the


patient’s goals for rehabilitation.”13
The dialysis literature has called the prevalence of Dialysis patients are often
depression in dialysis patients an urgent priority in ESRD overwhelmed by a myriad of
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-
psychosocial problems. Without a
specific focus, interactions with the
social worker can easily be derailed...

pared social worker. CMS’ Conditions for Coverage requires
nephrology social workers to hold a masters degree from
an accredited graduate school. The Interpretive Guidance depressed patient when using STI. Interventions address
(V681) states that the coursework of masters- prepared the symptom that is most problematic for the patient;
social workers prepares them to provide clinical services.13 it is irrelevant whether the symptom is caused by an
adjustment disorder, dysthymia, a recurrent depressive
Promise of symptom-targeted intervention episode, or another mood disorder. For this reason, STI is
Developed by nephrology social worker Melissa McCool, appropriate for almost all patients suffering from symp-
symptom-targeted intervention (STI) brings forward new toms of depression.
methods to treat symptoms of depression in dialysis
patients. With STI, the most salient or problematic symp- How STI works
tom of the depression is identified and treated using cog- The intellectual premise for STI is based on systems
nitive, behavioral, and mindfulness techniques. Since the theory, which is part of the core training of the masters-
focus is very specific, interactions with the patient are brief prepared social worker. Systems theory considers a system
and can be done chair-side at the dialysis clinic. as a set of interacting and independent parts; when one
Dialysis patients are often overwhelmed by a myriad of part of the system is altered, the entire system changes.
psychosocial problems. Without a specific focus, interac- If depression is a system comprised of various symptoms,
tions with the social worker can easily get derailed and when one of the symptoms improves, the entire trajectory
turn into lengthy, unproductive sessions. STI seeks to iden- of the depressive episode is transformed.
tify and manage one symptom at a time. This approach With STI, once a depressive episode is identified, the
allows the social worker and patient to focus their inter- social worker and patient, through a series of questions,
actions. By targeting the most problematic symptom, ses- identify the most urgent symptom of the depression.
sions are brief, manageable, and productive. The social worker and the patient then contract to work
STI has been designed for and is well suited to the dialy- together on resolving the symptom, recognizing that it
sis setting for a variety of reasons. First, in the dialysis envi- often requires more than one session and may require
ronment, the nephrology social worker has an established, [ 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- We continue to learn more about what mediates depres-
sion in dialysis patients to improve survival and quality of sion in ESRD. Positive and negative illness schemas and
life outcomes.1-5 As an interdisciplinary team, we remain social support have been isolated as predictors of depres-
cautious about providing treatment for depression at the sion in dialysis patients.7 Cognitive behavioral therapy has
dialysis clinic. With the patient barriers to accessing com- been shown to improve mood in the dialysis patient.8
munity mental health treatment,6 however, where does Interpersonal and problem-solving therapy in the dial-
that leave the team? As nurses, technicians, dietitians, ysis clinic have also demonstrated some positive out-
and social workers, we feel helpless as we see the health comes with depression, though larger samples are needed
of a depressed patient deteriorate. Our interdisciplinary for those studies.9-10 The field is hungry for a consistent
plans of care struggle to set rehabilitation goals with these approach to this dangerous and disabling condition.
patients, who often have difficulty even getting out of bed Symptom Targeted Intervention may show promise in
in the morning and spend their non-dialysis days isolat- reaching the many depressed patients that are waiting for
ed from friends and family. 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 The majority of social workers in the pilot
trained to provide clinics to provide an MSW whose degree, license, or certification allows felt prepared to provide clinical interven-
counseling. him/her to counsel patients.13 The master’s-level curriculum in social work tion.11 All social workers delivered STI
provides an additional 900 hours of specialized clinical training. MSWs are interventions after one brief DVD training.
trained in conducting empirical evaluations of their own practice interven- STI training will now be easily accessible
tions and to autonomously provide diagnostic, preventive, and treatment to all nephrology social workers.
services for individuals, families, and groups in the context of their respec-
tive life situations.14,15

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 ]

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SOCIAL WORK

Table 1 displays points from the ongoing debate of whether J Kidney Dis 2003; 41(1):105-110.
we should treat depression in the dialysis clinic. The table 6. Roberts J, Johnstone S. Screening and treating depression: patient
also demonstrates how the availability of Symptom Targeted preferences and implications for social workers. Nephrol News
Intervention impacts this debate. Nephrology social workers Issues 2006; 20(13):43, 47-49.
are anxious to have their skills re-directed toward improving 7. Guzman SJ, Nicassio PM. The contribution of negative and positive
fiscal and quality outcomes. illness schemas to depression in patients with end-stage renal
The field might be wise to support their use of STI to man- disease. Journal of Behavioral Medicine, 2003; 26(6):517-534.
age depression. We have little to lose while our patients have 8. Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral
so much to gain. Could treating depression on-site do more group therapy is an effective treatment for major depression in
than just reduce hospital days and improve health-related
hemodialysis patients. Kidney Int 2009; 76(4):414-421.
quality of life scores? Could it also promote rehabilitation and
9. Weiner S, Kutner NG, Bowles T, Johnstone S. Improving psycho-
the energy to consider dialysis at home? Now, with the intro-
social health in hemodialysis patients after a disaster. Soc Work
duction of STI, this may be the time to find out.
Health Care 2010; 49(6):513-25.
—Stephanie Johnstone, LCSW
10. Johnstone S Wellness programming: Nephrology social work
References expands its role in renal disease management. Nephrology News
1. Kimmel, PL and Peterson, RA. Depression in patients with end- and Issues 19 (12) 59-71, 2005.
stage renal disease treated with dialysis: Has the time to treat 11. McCool M, Johnstone S, Sledge R, Witten B. The promise of
arrived? Clin J Am Soc Nephrol 1: 349–352, 2006. symptom targeted intervention to manage depression in dialysis
2. Boulware LE, Liu Y, Fink NE, Coresh J, Ford DE, Klag MJ, Powe patients. Nephrology News and Issues 25:6:2011.
NR. Temporal relation among depression symptoms, cardiovas- 12. Medicare and Medicaid Programs; Conditions for Coverage for
cular disease events, and mortality in end-stage renal disease: End-Stage Renal Disease Facilities; Final Rule 73 FR 20406
Contribution of reverse causality. Clin J Am Soc Nephrol 1: 496– (2008-04-15).
504, 2003. 13. Centers for Medicare & Medicaid Services. Interpretive Guidance
3. Finkelstein F, Wuerth D, Troidle L, Finkelstein SH. Depression and Interim Final Version 1.1, October 3, 2008.
end-stage renal disease: A therapeutic challenge. Kidney Int 2008; 14. Council on Social Work Education, Commission on Accreditation.
74(7):843-845. Handbook of Accreditation Standards and Procedures (4th Ed).
4. Mapes DL, Bragg-Gresham JL, Bommer J, et al. Health-related Subsection B5.7.9 and M5.7.11, and Subsection B5.7.7 and M5.7.8,
quality of life in the Dialysis Outcomes and Practice Patterns Study pp 99, 137.
(DOPPS). Am J Kidney Dis 2004; 44(5 Suppl 2):54-60. 15. Harris. N. Social work education and public human services part-
5. Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence nerships: A technical assistance document. A Report of a Ford
and treatment of depression among patients starting dialysis. Am Foundation-Funded Project. Alexandria, Va.: CSWE, 1995.

[STI, continued from page 33 ]


more than one brief intervention to resolve the symptom. While cognitive therapy techniques seek to change auto-
The patient-social worker partnership supports an impor- matic thoughts, the goal of MBCT is to attend to cogni-
tant sense of patient empowerment and self-efficacy, tions fully as they arise. This by itself is healing.
where the patient is in control of his or her own mental The case examples (see page 37) demonstrate the fea-
health outcomes. tures of STI. The social worker uses multiple interventions
to assist the patient in addressing their targeted symp-
Symptom-targeted interventions toms. The sessions are collaborative and brief, averaging
Various cognitive and behavioral techniques are uti- 30 minutes each. The nephrology social worker chooses
lized, including behavior activation, cognitive restructur- interventions that apply to the patient’s unique situation.
ing, relaxation techniques, and mindfulness. STI interven-
tions usually include psycho-education, instruction, and References
patient homework. 1. U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of
Several studies demonstrate that cognitive behavioral Chronic Kidney Disease and End-Stage Renal Disease in the United
therapy is an effective intervention in treating depression States, National Institutes of Health, National Institute of Diabetes
in people on dialysis.3,21,22,23,24 Mindfulness-based cognitive and Digestive and Kidney Diseases, Bethesda, MD, 2010
therapy (MBCT) is an approach that has been proven to 2. Cukor D, Peterson RA, Cohen SD, Kimmel PL. Depression in end-
bolster recovery from depression and to prevent relapse.25 stage renal disease hemodialysis patients. Nat Clin Pract Nephrol

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SOCIAL WORK

2006; 2(12):678-687. end-stage renal disease: a therapeutic challenge. Kidney Int 2008;
3. Cukor D. Use of CBT to treat depression among patients on hemodi- 74(7):843-845.
alysis. Psychiatr Serv 2007; 58(5):711-712. 15. Kimmel PL, Weihs KL, Peterson RA. Survival in hemodialysis
4. Troidle L, Watnick S, Wuerth DB, et al. Depression and its associa- patients: the role of depression. J Am Soc Nephrol 1993; 4(1):12-27.
tion with peritonitis in long-term peritoneal dialysis patients. Am J 16. Kimmel PL. Depression in patients with chronic renal disease:
Kidney Dis 2003; 42(2):350-354. what we know and what we need to know. J Pscyhosom Res 2002;
5. Cukor D, Rosenthal D, Jindal R, et al. Depression is an important 53(4):951-956.
contributor to low medication adherence in hemodialyzed patients 17. Singer, J B (Host). (2009, April 13). Social workers and depres-
and transplant recipients. Kidney Int 2009; 75(11):1223-1229. sion: Interview with Mark Meier, MSW, LICSW [Episode 49]. Social
6. Kimmel PL, Peterson RA, Weihs KL, et al. Multiple measurements Work Podcast. Podcast retrieved from http://socialworkpodcast.
of depression predict mortality in a longitudinal study of chronic com/2009/04/social-workers-and-depression-interview.html.
hemodialysis outpatients. Kidney Int 2000; 57(5):2093-2098. 18. Merighi JR, Ehlebracht K. Unit-based patient services and sup-
7. Hedayati SS, Bosworth HB, Briley LP, et al. Death or hospitalization portive counseling provided by renal social workers in the U.S. A
of patients on chronic hemodialysis is associated with a physician- Survey/Part III. Nephrol News Issues 2004 18(7):55, 59-63.
based diagnosis of depression. Kidney Int 2008; 74(7):930-936. 19. Johnstone S. Depression management for hemodialysis patients:
8. Lopes AA, Bragg J, Young E, et al. Depression as a predictor of mor- Using DOPPS data to further guide nephrology social work interven-
tality and hospitalization among hemodialysis patients. Kidney Int tion. J Nephrol Soc Work 2007; 26:18-31.
2002; 62(1):199-207. 20. Roberts J, Johnstone S. Screening and treating depression: patient
9. Mapes DL, Bragg-Gresham JL, Bommer J, et al. Health-related preferences and implications for social workers. Nephrol News
quality of life in the Dialysis Outcomes and Practice Patterns Study Issues 2006; 20(13):43, 47-49.
(DOPPS). Am J Kidney Dis 2004; 44(5 Suppl 2):54-60. 21. Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral
10. McDade-Montez EA, Christensen AJ, Cvengros JA, et al. The role of group therapy is an effective treatment for major depression in
depression symptoms in dialysis withdrawal. Health Psychol 2006; hemodialysis patients. Kidney Int 2009; 76(4):414-421.
25(2):198-204. 22. Johnstone S. Depression management for hemodialysis patients:
11. DeOreo PB. Hemodialysis patient-assessed functional health status Using DOPPS data to further guide nephrology social work interven-
predicts continued survival, hospitalization, and dialysis-atten- tion. J Nephrol Soc Work 2007; 26:18-31
dance compliance. Am J Kidney Dis 1997; 30(2):204-12. 23. Weiner S, Kutner NG, Bowles T, Johnstone S. Improving psychosocial
12. Lowrie EG, Curtin RB, LePain N, Schatell D. Medical Outcomes health in hemodialysis patients after a disaster. Soc Work Health
Study Short Form-36: A consistent and powerful predictor of mor- Care 2010; 49(6):513-25.
bidity and mortality in dialysis patients. Am J Kidney Dis 2003; 24. National Kidney Foundation. Living longer, living better: A heart
1(6):1286-1292. healthy wellness program for patients on dialysis. New York, NY.
13. Centers for Medicare & Medicaid Services. Interpretive Guidance 25. Segal Z, Williams J Mark,Teasdale J. Mindfullness-based cognitive
Interim Final Version 1.1, October 3, 2008. therapy for depression. The Guilford Press, New York 2002.
14. Finkelstein F, Wuerth D, Troidle L, Finkelstein SH. Depression and

A nephrologist’s perspective is disengaged and not taking much of anything.


It’s time to collaborate on The frustrations and challenges surrounding this com-
mon encounter for the team members (including the patient
depression and family) are complex. Although many factors can be at
By Dylan Steer, MD play, depression, an under-recognized disorder in the dialysis
population, clearly lays the foundation for non-adherence to
“Yeah, I take my binders,” says “Joe” to me on rounds. therapy. Integrating depression management into core clinical
Joe is a somewhat withdrawn, 28-year-old patient, two treatment measures for end-stage renal disease could improve
years into dialysis. The problem is, despite the engagement patient outcomes.
of an enthusiastic dietitian and support from his nurse and Depression is common in the ESRD population but remains
physician, Joe’s phosphorus is sky-high and it is clear that he difficult to diagnose and treat. It is insidious in its effect and
reach. Various studies estimate that 20%-25% of prevalent
Dr. Steer is affiliated with Balboa Nephrology Medical ESRD patients have a co-morbid diagnosis of depression.
Group, San Diego. 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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SOCIAL WORK

Case studies using STI


Sue appears to be suffering from symptoms of depression.
Case #1 Since Sue is not interested in seeking outside mental health
Jason is a 43-year-old male on in-center dialysis after a failed treatment or trying an antidepressant, the social worker sug-
transplant. During his annual assessment he had a low MCS gests Sue use STI. Sue agrees, and is relieved at the thought
score on the KDQOL-36. While reviewing the scores with of getting help for her symptoms. The social worker asks a
Jason, the social worker discovers that he has been unhappy series of questions that progress from general to more spe-
for the last few months. Jason has been isolating himself, cific to identify the most troubling symptom. Sue reports that
watching TV all day and rarely leaving the house. There are no she has insomnia. After further questioning, it is noted that
acute psychosocial stressors involved. Jason is not interest- Sue suffers from insomnia as a result of rumination at night
ed in going to a psychiatrist or therapist outside of the dialysis about her divorce several years ago.
center, so the social worker suggests he try STI to treat the
symptoms. Jason agrees to work with the social worker. Targeted Symptom: Rumination
Intervention: The first intervention is negative practice. A
Targeted symptom: Social isolation few days later, the social worker checks in with Sue during
Intervention: Working together, the patient and social worker dialysis, who reports that the intervention was unsuccessful;
conduct an analysis on how Jason is spending his time out- she is still ruminating. The social worker then applies a sec-
side the dialysis unit. The social worker then educates the ond intervention called positive imagery. Sue and the social
patient on the thought-mood-behavior connection using the worker learn about and practice the technique in the clinic.
Beck Cognitive Triad. After the psycho-education, the social Upon Sue’s next visit, she again reports no success; she is
worker and patient develop a plan for behavior activation, still unable to sleep at night and can’t take her mind off the
creating an alternate daily schedule. divorce. The social worker and Sue agree to continue experi-
Outcomes: A week later, the social worker and Jason discuss menting, as it is not uncommon to try multiple interventions in
the results. Jason is following the new schedule; he is feeling the STI process. The third and final tool applied to Sue’s situ-
much more hopeful, less isolated, and more confident in his ation is mindfulness. The social worker taught the technique
ability to help himself. His depressive symptoms demonstrate to Sue during dialysis and she was instructed to practice it
significant improvement. at home.
Outcomes: After a week practicing mindfulness, Sue reports
Case #2 the she is sleeping a lot better. Sue also notes that she is
Sue is a 55-year-old female who has a low MCS score on her less irritable and her mood has improved. She is feeling more
KDQOL-36 administered with her annual assessment. After hopeful about the future and more confident about her ability
speaking with her more in depth, the social worker notes that to solve problems.

high levels of depressive affect have an associated increase integrated comprehensive care of the ESRD patient—after all,
in mortality. nephrologists have become principal care providers for many
There are several hurdles to treating the ESRD patient ESRD patients—treatment of depression will move from a
with depression. First and foremost is proper identification back-burner issue to a core measure. A dialysis clinic-based
and screening of at-risk patients throughout their life cycle. approach to treatment makes sense, and a robust platform of
Patients with high depressive affect scores typically have social worker-initiated depression management interventions
multiple somatic complaints that often-mimic uremia and can combined with medication management by the nephrolo-
mask the underlying depression. Diagnosing depression can gist serves as a good start toward treating mental health in
be difficult, time-consuming, and inconvenient for the nephrol- ESRD patients.
ogist, particularly when managing a wide variety of other The impact of this ongoing collaboration between the
“core” ESRD clinical measures. Good, valid screening tools, nephrologist and social worker may be measured in terms
administered longitudinally in the dialysis clinic by trained of QOL, adherence to therapy, fewer missed treatments and,
social workers at important patient-derived time points, could perhaps, an overall reduction in the cost of care. Screening at-
both identify depressed patients and provide an initial entrée risk dialysis patients for depression throughout their life cycle,
to treatment. combined with a dialysis clinic-based approach to treatment,
But who should provide treatment? As we move closer to can serve as a model for collaborative integrated care.

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