Podcast – Managing Depression to Improve CKD Care and Outcomes

In this episode of Kidney Health Connections, Dr. George Hart and Jessica Demaline, senior vice president of healthcare operations at Interwell Health, discuss the critical issue of managing depression among individuals with chronic kidney disease (CKD). People with CKD are at a significantly higher risk for depression, which can severely impact their ability to manage their kidney disease and related comorbidities. The conversation emphasizes the importance of screening for depression regularly, the role of primary care providers in supporting patients, and tools to assess depression and anxiety symptoms.

The episode also explores the advantages of value-based care over fee-for-service models in enabling healthcare providers to take a more comprehensive approach to patient care, addressing not only kidney disease but also mental health, social determinants of health (SDoH), and overall well-being. This holistic approach includes offering additional resources like counseling, social work, and community support, which can help improve patients’ mental health and treatment adherence. 

Transcript

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift of value-based care, where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: Hello everyone. Recently, we've seen an important shift toward the acknowledgement that mental healthcare is healthcare. This is especially true for people with chronic kidney disease, who are three times more likely to experience depression than those who do not have kidney disease.

In this episode of Kidney Health Connections, we're joined by Jessica Demaline, senior vice president of healthcare operations at Interwell Health, and she and I are going to have an important conversation on what it means to manage depression amongst people with kidney disease. A licensed social worker, Jessica now leads the care management services for tens of thousands of patients at Interwell.

Jessica, thanks for joining us today for this important conversation.

Jessica Demaline: Thanks for having me today, George.

Dr. George Hart: It's not a surprise to me that patients who have kidney failure struggle with depression. They manage a severe disease. The impact of the treatment is life changing, sometimes painful, and struggling, I think, through that is completely understandable. Tell me, what is the impact on their quality of life and what can we do to try and help them in this regard?

Jessica Demaline: There is a large impact on patients and the impact is actually larger with chronic kidney disease patients than in the general population. In the general United States population, around 8 percent of people experience a depressive episode in each year. For patients with chronic kidney disease, that can be up to 30 percent. So it does affect a large number of our patients—their physical health, their emotional and mental health, their ability to adhere to treatments, and their quality of life and relationships.

Dr. George Hart: So knowing that, what is the sense of why this depression is so important as patients try and manage their kidney disease?

Jessica Demaline: Depression is important because, again, it can affect a patient's ability to manage their chronic kidney disease as well as their other comorbid diagnoses, such as diabetes, hypertension. So often you'll find a chronic kidney disease patient will not only have chronic kidney disease, but will have depression, anxiety, diabetes, hypertension, many other diagnoses. And the symptoms of depression may cause a patient to feel helpless, hopeless, have low energy, low motivation, an inability to be able to manage those diagnoses.

Dr. George Hart: My own experience was that, you know, patients who were depressed and kind of overwhelmed at times disengage or even shut down. Is that pretty much what you see as well?

Jessica Demaline: It is. So one of the symptoms of depression is isolating oneself. And that could be isolating oneself from dialysis treatments, isolating oneself from their caregivers, their family members, really pulling away from things that they used to be able to do on a daily basis. And again, if you're not doing the things that you need to do in regards to your chronic kidney disease, you're not seeing your nephrologist regularly, you're not managing your diabetes well, or taking your medications, your disease may progress faster than it would otherwise.

Dr. George Hart: Yeah, I mean, I think that all kind of ties together when you withdraw, when you become disengaged, you don't manage your diabetes, you don't take your blood pressure medicines, you might not go to your doctor appointments. And that isolation and withdrawal certainly can contribute to the worsening outcomes that we see in these circumstances. So how can we screen these patients better than maybe what we've done in the past?

Jessica Demaline: In the past, I would say probably stigma played a big part in not screening patients for depression. And what I mean by stigma is a fear of asking someone about their depression. What are they going to say back? Then how am I going to address what they say back to me? And that fear can come again from family members, from caregivers, from nephrologists such as yourself, or from other care team members that the patient may be seeing.

And so the first step is screening patients and screening patients regularly. So we've seen in holistic programs, like the one at Interwell Health, we need to screen patients regularly not only for depression, but also for anxiety, also for social determinants of health. And we need to train the providers that are seeing those patients regularly to do the same in utilizing those screenings.

Dr. George Hart: I practiced, for the most part, in a fee-for-service world. Everything you just said was never available to me. I didn't have the resources; I didn't have the ability to draw on other caregivers. Value-based care changes that in a lot of different ways. Can you maybe walk us through what the advantages are in a value-based care approach to depression versus what happens in a fee-for service world?

Jessica Demaline: I can. So value-based care is focused on improving a patient's quality of care and, of course, reducing costs. To do that, we need to be able to look at the patient holistically. So in a fee-for-service world that you just described, you might be again focused on just the patient's chronic kidney disease. You didn't worry about the other diagnoses or again, the patient's depression or other behavioral health symptoms. Now with value-based care, again we can focus on the whole patient. Also, we can focus on the patient within their environment. What social determinants of health are affecting them. The ability to do that then is able to provide a better quality of care for the patient.

We can also provide additional resources. So again you, the nephrologist, screen a patient for depression. But now what do I do? With value-based care we can offer nurses, social workers, dietitians, coordinators who can assist the patient. We can call the patient on the telephone and provide cognitive behavioral counseling. We can reach out to the community resources and make sure the patient is seeing a psychiatrist or a therapist regularly.

Dr. George Hart: All of that I think is really helpful. What role can primary care play in offering this?

Jessica Demaline: Primary care is very important. As we screen patients for depression, we then want to refer them out to behavioral health specialists. But often seeing a behavioral health specialist can take time, weeks, sometimes even months depending on a patient's geography and the resources in their community. So while we're getting a patient connected to a behavioral health specialist, I often recommend a patient be seeing their primary care physician.

First, the primary care physician again can do a head to toe on the patient, really assess the patient again holistically identifying, “Are they experiencing depression?” Maybe there's something medically going on that looks like depression but really is a physical health diagnosis. And then the PCP can start treating the patient while we're getting them to that behavioral health specialist.

Dr. George Hart: Everyone's thinking and talking about depression and behavioral health issues these days. I'm a nephrologist, I'm focused on specific things. I'm possibly going to miss the early symptoms and it would be nice to have tools that help quantify the severity of illness. What are some of the tools that are out there that we can take advantage of and use?

Jessica Demaline: There's a wide range of tools. We here at Interwell Health focus on evidence-based tools that have been utilized in large populations. we utilize a PHQ4, that's a Patient Health Questionnaire Four. It has four questions in it—two questions assess depression, two questions assess anxiety. Based on a patient's answers to those questions, we then provide additional screenings: a Patient Health Questioner 9 looking at depression, a generalized anxiety disorder screening looking at anxiety. We can then identify if the patient is experiencing symptoms and then start on the interventions to decrease and address those symptoms.

Dr. George Hart: Well, that's very helpful, you know, and I think there's some recent studies that are out there now, that are certainly suggesting some correlation and association between treating depression and better outcomes in kidney disease. Does that make sense to you?

Jessica Demaline: It does. So we recently, in 2022, utilized the PHQ9 on over 30,000 patients. Of those 30,000 patients, we found about 1,500 were experiencing moderate to severe depressive symptoms. Of those, then when we did a subsequent screening around six to eight months later, we were able to identify that 71 percent of the patients experienced a reduction in their symptoms, so their depression improved.

Those improvements in depression are able to help then the patient address their chronic kidney disease easier. They can be more adherent to their treatments, they can be taking care of their diabetes, their hypertension, seeing their providers regularly.

Dr. George Hart: It occurs to me that we need to address the root cause of what’s causing depression here, which is someone's kidney disease, the fact they don't feel well, the loss of autonomy, you know, working, being able to be a father, a husband, a wife, mother. Can you speak to a little bit of the hope and the opportunity that early referral for transplantation might bring for these patients?

Jessica Demaline: Yeah. One of the main symptoms of depression is hopelessness, or helplessness. And so offering a patient early education on what is happening with their chronic kidney disease, on some of the options, such as transplant, is going to decrease that helplessness, because again, now they're knowing with that education what they can do. Then we need to focus on the hope. With transplant, knowing that, okay, now I have a new kidney, I can get back to my quality of life, I can get back to my family, maybe I can even get back to working, it's going to increase that hope.

Dr. George Hart: Oh, that was certainly my experience caring for patients as a transplant nephrologist and would totally agree with all that you just said. We've talked a lot now about, you know, how we can help patients within CKD world by bringing early education, helping them manage some of the realities of having to deal with CKD. But some of these patients will end up on dialysis. They have a whole different set of issues. What are some of the resources and the ways that we can help patients who are on dialysis and may be on it for a significant amount of time?

Jessica Demaline: Educating the patient on what to expect, educating the patient so they're prepared for dialysis, they know what's going to happen, they've already chosen their modality and they're not crashing in through the hospital or with a catheter in place. And then again, offering those additional resources that focus on not just the patient within the four walls of the dialysis clinic, but on the patient holistically. So what's happening on their non-dialysis days? Are they attending their appointments regularly? Are they receiving support for their family? Does their family need education on what's going in around the dialysis clinic and some of the symptoms the patient may be experiencing?

Dr. George Hart: We talk a lot about the patient. Certainly that's where a lot of the focus should be. But it's not just the patient. Families are impacted too. Maybe, you know, give us a little bit of how does a social worker like you've been and ones that are in the clinics these days, or even those that are helping us in the CKD world, how do we support families?

Jessica Demaline: The first thing I would say in supporting families is identifying a patient's protective factors. So we talked about how do we screen for depression, how do we screen for anxiety? We also need to screen a patient for what's protecting them. What are the protective factors? One of those main protective factors is a patient who has a strong support system: family, friends, caregivers, churches, communities that are surrounding them and supporting them. Once we identify who those are, we need to bring them into the patient's care plan. We need to bring them into those interventions. We need to educate them about the patient's chronic kidney disease, about the patient's depression, and on how they can help that patient address their needs.

Dr. George Hart: Yeah, totally agree. And again, in my experience, families make the difference. It takes a village. And I think that's certainly something we see in our world.

I don't think we can leave this topic without weaving in the importance of some of the health equity barriers that I think tie into depression, food insecurity, housing insecurity. Maybe help us understand better what the resources are that we have that we can bring to bear to solve some of those issues so that we get to the root causes.

Jessica Demaline: First we need to screen patients, and it's often with social determinants of health, which came first, the chicken or the egg? Was it the depressive symptoms that maybe were correlated or a cause of some of the social determinants of health? A patient who loses their job because they're not able to get out of bed in the morning to go to work? Or again, is it the patient's social determinants of health that might be affecting their mood, their helplessness, their hopelessness?

And so we need to identify what social determinants of health are affecting the patient first, then we need to address those. And so utilizing our social workers, our coordinators, we're able to connect the patient to local community resources. That might be a place that's able to provide food regularly to the patient, housing that's more stable than the housing that they have today, financial resources.

Dr. George Hart: I think that's exactly what we need to focus on because it never made sense for me to tell someone not to be so depressed when they didn't have a place to live or they were hungry and all of those things.

This has been a great conversation. You have brought, I think, quite a bit of expertise and shed the light on all the importance of screening for depression and what some of the tools are that we now have that a value-based care world brings versus the world I lived in which was fee-for-service.

Jessica, I'm sure that with all the experience you have dealing with health equity issues, you probably have a great example of what can go on with a patient and then how we can intervene.

Jessica Demaline: One of our social workers was serving a patient in Chicago and that patient was experiencing not only depressive symptoms, but also challenges with food insecurity as well as housing. So our social worker was able to provide again, telephonic interventions to the patient addressing their depressive symptoms, but also connect them to local community resources. The patient is now receiving food regularly and has more stable housing because of the work we were able to do with that patient.

Dr. George Hart: That's awesome. This was great. Jessica, thank you so much for joining us today. This is such an important topic. I think you really helped shed some insight on the importance of value of screening patients and what we can offer in a value-based care world.

And thanks to you for joining us on Kidney Health Connections. For more episodes, please subscribe to Kidney Health Connections on the listening app of your choice or visit our website at interwellhealth.com. Thank you very much.