Ckd patients of lack of appetite associated with depression, dialysis dose and length of haemodialysis
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The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the standard set of criteria used to diagnose mental disorders in the United States.9 The majority of studies examining the prevalence of unipolar depression (without mania or psychosis) in CKD and ESRD through clinical interview have used the DSM to define depressive disorders.3 These studies have often used a broad definition of depression that encompasses several different depressive disorders from the DSM, including persistent depressive disorder (PDD), depressive disorder not otherwise specified (NOS), and major depressive disorder (MDD). These depressive disorders are briefly defined in Table 1.

Table 1
DSM-V classification of depressive disorders9
The gold standard to diagnose depression is the clinical interview, including the following: (1) the Structured Clinical Interview for DSM Disorders (SCID)10; (2) the Composite International Diagnostic Interview (CIDI)11; and (3) the Mini-International Neuropsychiatric Interview (MINI).12 However, self-reported questionnaires are often used in clinical and research settings for screening of depressive symptoms. The most commonly used depression screening questionnaires that have been validated for use in patients with CKD and ESRD are as follows: Patient Health Questionnaire (PHQ-9)13; Beck Depression Inventory (BDI)13, 14; Center for Epidemiologic Studies Depression Scale (CESD)14; and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR).15
Several studies have validated depression-screening questionnaires in patients with ESRD.13, 14, 16 In a study of 98 patients with ESRD on hemodialysis by Hedayati et al., the BDI and CESD scales were validated against the SCID for diagnosing a depressive disorder (MDD, dysthymia, or minor depression).14A BDI cutoff of 14 had a sensitivity of 62% and a specificity of 81% for identifying a depressive disorder. The corresponding sensitivity and specificity for a CESD cutoff of 18 were 69% and 83%, respectively. Both cutoff scores were higher than cutoffs set for the general population (10 for the BDI and 16 for the CESD). In a similar study by Watnick et al., the BDI and PHQ-9 were validated against the SCID for the diagnosis of a depressive disorder (MDD, dysthymia or minor depression).13 A BDI score of 16 and a PHQ-9 cutoff of 10 had sensitivity of 91% and 92%, respectively, and specificity of 86% and 92%, respectively. As in the study by Hedayati et al., the most accurate cutoff score for diagnosing a depressive disorder using the BDI was higher than in the general population. This was attributed to the overlap between somatic symptoms of depression and symptoms related to ESRD, including anemia, fatigue, difficulty concentrating, difficulty sleeping, and poor appetite. Thus, patients with uremic symptoms may screen positive for depression with a self-reported questionnaire. However, these uremic symptoms can be distinguished from depressive symptoms during a clinical interview. For this reason, the clinical interview remains the gold standard for diagnosing depression in patients with ESRD.
Only 1 study has validated questionnaires to screen for depression in patients with CKD.15In this study of 272 patients with stage 2 to 5 CKD, Hedayati et al.validated the BDI, and QIDS-SR(16) against the MINI.15 The authors found that the optimal cutoffs for diagnosing a major depressive episode using the BDI and QIDS-SR(16) were the same as the general population, ≥11 and ≥10, respectively. However, the inclusion of patients with CKD stages 2 and 3, who are less likely to experience symptoms related to kidney disease, could have influenced the results. Future studies to validate depression-screening questionnaires in patients with advanced CKD (stages 4 and 5) for depressive disorders are needed.

Table 1
DSM-V classification of depressive disorders9
The gold standard to diagnose depression is the clinical interview, including the following: (1) the Structured Clinical Interview for DSM Disorders (SCID)10; (2) the Composite International Diagnostic Interview (CIDI)11; and (3) the Mini-International Neuropsychiatric Interview (MINI).12 However, self-reported questionnaires are often used in clinical and research settings for screening of depressive symptoms. The most commonly used depression screening questionnaires that have been validated for use in patients with CKD and ESRD are as follows: Patient Health Questionnaire (PHQ-9)13; Beck Depression Inventory (BDI)13, 14; Center for Epidemiologic Studies Depression Scale (CESD)14; and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR).15
Several studies have validated depression-screening questionnaires in patients with ESRD.13, 14, 16 In a study of 98 patients with ESRD on hemodialysis by Hedayati et al., the BDI and CESD scales were validated against the SCID for diagnosing a depressive disorder (MDD, dysthymia, or minor depression).14A BDI cutoff of 14 had a sensitivity of 62% and a specificity of 81% for identifying a depressive disorder. The corresponding sensitivity and specificity for a CESD cutoff of 18 were 69% and 83%, respectively. Both cutoff scores were higher than cutoffs set for the general population (10 for the BDI and 16 for the CESD). In a similar study by Watnick et al., the BDI and PHQ-9 were validated against the SCID for the diagnosis of a depressive disorder (MDD, dysthymia or minor depression).13 A BDI score of 16 and a PHQ-9 cutoff of 10 had sensitivity of 91% and 92%, respectively, and specificity of 86% and 92%, respectively. As in the study by Hedayati et al., the most accurate cutoff score for diagnosing a depressive disorder using the BDI was higher than in the general population. This was attributed to the overlap between somatic symptoms of depression and symptoms related to ESRD, including anemia, fatigue, difficulty concentrating, difficulty sleeping, and poor appetite. Thus, patients with uremic symptoms may screen positive for depression with a self-reported questionnaire. However, these uremic symptoms can be distinguished from depressive symptoms during a clinical interview. For this reason, the clinical interview remains the gold standard for diagnosing depression in patients with ESRD.
Only 1 study has validated questionnaires to screen for depression in patients with CKD.15In this study of 272 patients with stage 2 to 5 CKD, Hedayati et al.validated the BDI, and QIDS-SR(16) against the MINI.15 The authors found that the optimal cutoffs for diagnosing a major depressive episode using the BDI and QIDS-SR(16) were the same as the general population, ≥11 and ≥10, respectively. However, the inclusion of patients with CKD stages 2 and 3, who are less likely to experience symptoms related to kidney disease, could have influenced the results. Future studies to validate depression-screening questionnaires in patients with advanced CKD (stages 4 and 5) for depressive disorders are needed.
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