Journal Article Annotations
2019, 4th Quarter
Annotations by Sahil Munjal, MD and Sarah Andrews, MD
The study looked at the association of selective serotonin reuptake inhibitors (SSRIs) (both short- and long-term exposure) on hip fracture risk among patients on maintenance hemodialysis (HD). Eligible cases meeting inclusion criteria were selected from the US Renal Data System from 2006 to 2015. SSRIs (including any, low, moderate and high use) were corelated with increased hip fracture risk with adjusted conditional OR ranging from 1.20-1.31. The link was stronger for new short-term use (defined as starting use in the 6 months before fracture), with OR of 1.43.
Strength and weaknesses:
They selected 10 controls per case on each index date. Series of sensitivity analyses were undertaken during analysis.
Lacked information about participants’ frailty, alcohol use, markers of mineral and bone disorder along with specific indication for medication use. Around 20% of the sample exhibited either any exposure to SSRIs or non-SSRIs despite lacking a diagnosis of depression. Reliance on diagnosis codes. Requirement of Medicare coverage presents a potential selection bias linked with survivorship.
Maintenance HD patients have increased short- and long-term mortality, poor quality of life along with 4 times higher rates of hip fracture compared with the general population. About a third of these patients have depression. Even though SSRI’s are commonly prescribed in this population (about 20% of patients), their utility is still not fully established. SSRI’s have been linked to increased fracture risk in general population due to their proposed effects on bone metabolism (serotonin transporters are also found in osteocytes, osteoblasts, and osteoclasts) and falls, highest risk being within 6 weeks of SSRI treatment initiation which the study findings confirmed as well. This may indicate an acute mechanism potentially associated with falls. The study authors highlight and attest to the European Renal Best Practice guideline which suggests that among patients with CKD stages 3 to 5, antidepressant treatment effect should be reevaluated after 8 to 12 weeks to avoid prolonging ineffective medication, given the efficacy of SSRIs remains equivocal. This study adds another factor to consider for the CL psychiatrists when they provide treatment to depressed patients on HD given the moderate increase in hip fracture risk associated with SSRI’s. SSRI use should be reconsidered, particularly if they are not beneficial after appropriate duration of use. This is in addition to paying attention for side effects potentially attributable to SSRIs (hyponatremia, orthostasis, QTc prolongation, and arrhythmias) that may contribute to fall risk.
Type of study:
Cochrane Database Syst Rev. 2019 Dec 2;12:CD004542. doi: 10.1002/14651858.CD004542.pub3.
After reviewing 33 studies with over 2000 participants, the authors of this Cochrane Review concluded that three different treatment modalities, excluding medication management, with moderate-certainty evidence reduce depressive symptoms in dialysis patients. These modalities of treatment include cognitive-behavioral therapy, exercise, and relaxation skills. There is low-certainty that other specific modalities, including spiritual practices, telephone support, meditation, and acupressure offer a reduction in depressive symptoms. Psychosocial interventions for depression and suicide are also of low or very low certainty.
This review incorporated studies up until June 2019 that evaluated different treatment modalities for dialysis patients. Since there are so many different treatment modalities available to address depression in the general population, this review focused on which of these modalities works best for dialysis patients based on 33 different studies.
One weakness of this study is the limitations of the methods of the studies included in the review. Furthermore, it is challenging to control for different treatment modalities, specifically the quality patients receive, between studies.
Relevance to consult liaison psychiatrist:
As a consult-liaison psychiatrist, we have been asked about best treatment modalities for patients with depression with different medical co-morbidities. It is helpful for us to have some evidence as to what has shown to be most effective in a certain population. Dialysis patients are a unique set of patients with different challenges.
Type of study:
Systematic review / meta-analysis