I T I S O K AY TO A S K F O R H E L P

There are newchanges toMedicare’s pre-scription drugcoverage.

—Page 16

Help is outthere—all youhave to do is ask.

—Page 9

Check out thesetips to managingyour kidney diet.

—Page 7

Tips to Coping with Chronic Kidney DiseaseBy Karren King, MSW, ACSW, LCSW

This publication is a part of the National Kidney Foundation’s Kidney Learning System (KLS)™

and is made possible through an educational grant from .

Inside this issue:

30 East 33rd Street

New

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Permit No.211

M E N T A L H E A L T HDON’T LET YOUR DIET GET YOU DOWN!

M E D I C A R E P A R T D U P D AT E

A publication of the National Kidney

Foundation

Vol 14, No 3Summer 2005

NEXT ISSUEK/DOQI™ GUIDELINES ON

CARDIOVASCULAR DISEASE

Receiving

support from

family and friends

is one way you can

cope with

having CKD.

Respondents who shared thetype of emotional challengesthey face referred often todepression. Research hasshown that depression is themost common emotion felt by

those who are on dialysis.When someone is confrontedwith having CKD, there maybe many losses— health, fami-ly roles, work, income, socialoutlets. If losses occur, it is

natural to grieve, which caninvolve depression. Anxietyand anger or frustration arealso emotions individuals mayfeel. There is no “right way” to feel when you have CKD, aswe cannot help how we feel.However, it is what we doabout what we feel that canmake a big difference in our lives.

Your Own Kind of FaithSpirituality is what gets many of youthrough the tough times. It takes manyforms, depending on one’s faith, and caninclude prayer, meditation, belief in a high-er power and/or attending aplace of worship such as achurch, temple or mosque.One person shared, “I real-ized there was just somuch I could do…so Iturned it over to the Lordand let Him handle it.”

Reach Out For SupportSupport from family and friends is also very impor-tant; one respondent described it as a “must.” Severalshared that expressing feelings—and not keepingthem “bottled up”—to family and friends was helpful.One individual suggested surrounding yourselfwith those who love and support you whenyou feel down. Simply enjoying family helpslift another respondent’s emotions. Oneman said that not only is his family a sup-port for him, but he is a major figure intheir lives. Knowing how much theyneed him keeps him going.

Continued on page 3

HOW DO YOU COPE WITH THE MENTALHEALTH CHALLENGES related to having chronickidney disease (CKD)? That was the question we

asked this quarter and you shared—a lot! This is obviously aquestion to which many of our readers could relate.

AGREAT DEAL OF TIME AND MONEY are devoted

to physical health, both for theprevention and treatment ofillness, in our society. In com-parison, very little attention isgiven to our mental or emo-tional health. There is a cycli-cal effect between physical and mental health. Researchhas shown that our mentalhealth can affect our physicalwell-being. For example, thereis much evidence that depres-sion may play a part in thedevelopment of cardiac dis-ease. We also know that ouremotional state may makeexisting physical problemsworse. Also, when we live withphysical problems, especiallythose that are chronic, it isvery natural and normal toreact with changes, at least

temporarily,in our emo-tional state.

Most of uswill experi-ence sometype of emotionalproblem, suchas depressionor anxiety, atsome point inour lives. Yet, all too often, wewill attempt to continue onwith our lives, ignoring howwe feel emotionally. There aremany reasons for this. Somemay believe there is a stigmaattached to having emotionalproblems, feeling that othersmay think they are weak orless than capable. For others,there may be a lack of infor-

mation as towhere to turnfor help. It isnot alwayseasy to askfor help, yet Istronglybelieve it ismuch harderto deal withour depres-sion, anxietyor anger

alone. If we ignore our emo-tional pain, it not only cantake its toll on our physicalwell-being but it can alsoimpact our relationships, activ-ities and practically all otheraspects of our lives.

It is our hope with this issuethat you will realize you arenot alone if you find yourself

experiencing emotional prob-lems. We also want you to beaware of the various optionsavailable to help you facethem. Know that you do notneed to suffer in silence andthere is help available.

Lastly, it is almost that time ofyear again when the FamilyFocus Editorial Board will beappointed for 2006 and we willbe convening to plan nextyear’s issues. As always, wewant our information to be rel-evant and timely. We urge youto share with us your ideas forfuture newspaper topics.

Here’s to an emotionallyhealthy summer!

Karren King, MSW, ACSW, LCSW

For the Editorial Board

EDITOR-IN-CHIEF: Karren King,MSW,ACSW,LCSWKansas City, MO

FITNESS EDITOR: Pedro Recalde,MS,ACSMDowney, CA

MEDICAL EDITOR: Wendy W.Brown,MD,Nashville, TNNURSING EDITOR: Bobbie Knotek,RN,BSN, Plano, TX

NUTRITION EDITOR: Lori Fedje,RD,LD,Portland, ORPATIENT EDITOR: David Jones, Glen Ellyn, IL

PEDIATRIC EDITOR: Barbara Fivush,MD,Baltimore, MDSOCIAL WORK EDITOR: Mary Beth Callahan,ACSW/LMSW-ACP

Dallas, TXTRANSPLANT EDITOR: Nancy Swick,RN,BSN,CCTC

Santa Rosa, CAESRD NETWORK LIAISON: Roberta Bachelder,MA

Woodbridge, CT

EDITORIAL OFFICE: NATIONAL KIDNEY FOUNDATION30 E. 33rd Street, New York, NY 10016800-622-9010 • 212-889-2210www.kidney.orgE-mail: info@kidney.org

EDITORIAL DIRECTOR: Gigi PolitoskiEDITORIAL MANAGER: Sheila Weiner,MSW,LCSW

VICE PRESIDENT OF HEALTH POLICY AND RESEARCH: Dolph Chianchiano,JD,MPA

EXECUTIVE EDITOR: Sara Kosowsky MANAGING EDITOR: Helen Packard

PRODUCTION DIRECTOR: Sunil VyasDESIGN DIRECTOR: Oumaya Abi Saab

2 FAMILY FOCUS • Volume 14, Number 3

NKF Family Focus is published quarterlyby the National Kidney Foundation.

Opinions expressed in this newspaper donot necessarily represent the position of

the National Kidney Foundation.

F R O M T H E E D I T O R

Karren King

nn In the last issue of Family Focus the number of dialysis centersoffering nocturnal home hemodialysis was quoted as “approximately50” in one article and “81” in another. The actual number variesdepending on the source. For more information on home hemodialysisgo to www.medicare.gov and click on “Compare Dialysis Facilities”or www.homedialysiscentral.org

Corrections: nn Some readers felt that the article “A New Look at Home Dialysis: APsychosocial Perspective” in the last issue of Family Focus unfairly criti-cized dialysis technicians’ training. The authors did not intend their com-ments to put into question technicians’ training. The authors’ goal was toencourage people with chronic kidney disease to believe they could do theirown dialysis at home if they received training similar to what new techni-cians learn. The authors believe that if more individuals were urged to takeon an active role in their care and did dialysis at home, they and clinicswould both benefit.

ON JULY 25, 2005, People Like Us repre-sentative Alice McCall, along with NationalKidney Foundation (NKF) staff, presentedthe United States (U.S.) Department ofHealth and Human Services SecretaryMichael Leavitt with a proclamation offi-cially thanking the U.S. government forproviding dialysis and other life-savingtherapies to countless people for more than30 years through the End Stage Renal Disease (ESRD) program.

This moving ceremony to thank the government followed the kick-offof People Like Us, the NKF's patient empowerment initiative, held inthe Nation's Capitol in early May. More than 100 people with chronickidney disease (CKD), transplant recipients, living organ donors,donor families and loved ones gathered from around the country tolearn how to become their own best advocates through training work-shops and public policy briefings. Interactive and role-playing exercis-es prepared participants to become proactive advocates and effectivespokespeople. At a special reception on Capitol Hill, People Like Usmingled with members of the Congressional Kidney Caucus, andsome participants met with their Congressional representatives.

Plans for ongoing People Like Us activities are underway as we con-tinue to build what we hope will become the largest, strongest andmost effective patient advocacy group in the country. For more infor-mation, please e-mail peoplelikeus@kidney.org

People Like Us Thanksthe Federal Government

NKF's Dolph Chianchiano;kidney transplant recipient

and People Like Us advocateAlice McCall; U.S. Health

and Human ServicesSecretary Michael Leavitt;and NKF’s Tracy Fortson

and Troy Zimmerman. (HHS photo by Chris Smith.)

FAMILY FOCUS • Volume 14, Number 3 3

F A M I L Y F O C U S V O I C E S

Have Goals and a PurposeHaving something to strive for, such asgoing to school, helps one person cope withCKD. Several individuals mentioned thatbeing employed helps them feel more posi-tive emotionally. Many of you said doingsomething you care about and giving to oth-ers are important ways of dealing withdepression. Several are involved in advoca-cy groups for those with CKD or other ill-nesses, and some share with others whatthey can do to prevent CKD or about theneed for organ donation. Another personhas been active in his children’s school andathletic activities. One member of theNational Kidney Foundation’s Patient andFamily Council Executive Committeeshared how good it feels to simply con-tribute and feel a part of something.Whatever form volunteer activities take,the constant theme is “giving back.” Oneindividual shared her belief that doingsomething to feel productive is the key toliving with CKD. Enjoyable activities, suchas gardening or reading, are helpful toanother person because it takes her mindoff of her concerns.

Take Care of YourselfTaking care of themselves helps some copebetter with the challenges of CKD. Manystressed the importance of exercise, follow-ing a healthy diet and taking medications

as prescribed. Anotherperson shared herbelief that beingproactive with yourcare is important andthat includes not only educating yourselfabout all aspects of CKD but also puttingwhat is learned into practice. Educationallows you to take more control over yourtreatment and engage in self-care activitiesand both education and involvement withcare were identified as beneficial.

Get Professional HelpSeeking professional help, either individu-ally or in a group, was identified as useful.One individual suggested that a mentalhealth specialist in each dialysis centerwould be helpful, and it is important topoint out that the dialysis social worker isjust that person! In addition, it wasstressed that talking to others who aregoing through what you are experiencingcan be a great help. Also mentioned wasthe importance of sharing your feelingswith your doctors to allow them to deter-mine if medication for depression or anxi-ety could be beneficial for you.

Have a Positive AttitudeLastly, the importance of keeping a positiveattitude was mentioned many times.Several suggested taking life one day at atime, doing what you can and trying not todwell on issues that you can do nothingabout. A woman shared that she begins

every morning with thinking how thankful she is to have another day, rather thanthinking “another day to have to live withCKD.” She stressed that choosing to makethe most of every day was a daily choice.Others echoed her sentiments by writing “Ichoose to live my life to the fullest!” and “Ichoose to get up each day and have a goodattitude….You have to find the positive inlife and focus on the good things.” Theneed to be flexible and willing to adjust wasstressed. One person believes it is impor-tant to not only set goals for your life butalso take the time to appreciate it when thegoal is reached. Another shared that ithelps to view dialysis like “cleaning yourteeth, something you just have to do!” Awoman who has another illness in additionto CKD shared that she had determinedthe purpose of her life was in the living ofevery day and doing it with grace. One gen-tleman summed it up by sharing, “I do notlive for dialysis. I use dialysis to live.”

There is no doubt that life with CKD canpresent great challenges, and with it feel-ings such as sadness and anxiety. Yet, asone individual pointed out, it can also bevery rewarding, as it can help you discoverwhat is really important in your life. Here’s wishing you that reward.

Go to www.familyfocusvoices.orgto read other readers’ responses.

Tips to Coping…Continued from page 1

Dear Family Focus:I started dialysis in July 2002.During dialysis at my first unit, Inever saw Family Focus. I trans-ferred to my current center inAugust 2004. I began readingFamily Focus and really enjoyed theissue. Family Focus has given me somany things to be thankful for. Ithas answered so many of my ques-tions and yet it gave me so muchinformation on issues of concern.This is a well-informed newspaper. Iam very grateful for Family Focusbecause it advises, updates, informs,teaches and stimulates the reader.

Volume 2, “Fun and Fabulous Foodsfor Your Dialysis Friends” andVolume 3, “Finding Kidney DiseaseEarly” were excellent. They coveredso many areas and were very helpfulto me on activities, hobbies, travel-ing, school, employment, kidneycamps, exercise and dining out. The

issues have enriched my life, and Iplan to follow some of the ideas.Thank you for Family Focus. I lookforward to reading each issue.

Sincerely,Billy Carmon

Dear Family Focus:I am the wife of a person who hasnot one but two transplants, a kid-ney and a pancreas. My reason forwriting this letter is because I wouldlike to do something with what myfamily has been through. I also wantto say my husband was given thegreatest gift that so many people donot even think about.

The last issue of Family Focus hithome for me about wanting tobecome involved in being an advo-cate. Can you please send me infor-mation on becoming a seriousadvocate? This is something I feelgood about.

Thank you.Judy Klingensmith

letters tothe editor Dear Mrs. Klingensmith:

I am glad that the Family Focus issue on advocacy inspired you to become involved. That was our goal! I would suggest that anexcellent place would be to contact your localNational Kidney Foundation affiliate and offeryour services. If you do not know how to reachthem, you may contact the NKF national officefor information (800-622-9010) or visit the Web site, www.kidney.org Another avenue would be to contact the hospital where yourspouse received his transplant and offer to be available to others whose spouses are awaitinga transplant.

Thank you for writing and for your concern for others.

Sincerely,

Karren King, MSW, ACSW, LCSWEditor-in-ChiefFamily Focus

4 FAMILY FOCUS • Volume 14, Number 3

Y O U R D I A L Y S I S C E N T E R

IF YOU LISTEN TO PEO-PLE TALKING ABOUT

DIALYSIS, what do they talkabout? They talk about clinicalthings like adequate dialysis,calcium and phosphorus man-agement and hemoglobin levels. As a dialysis communi-ty, we have come a long way inimproving the care of peoplewith kidney failure. Until thelast few years, however, a veryimportant part of dialysiscare—the “emotional health” ofthe dialysis clinic itself—hasbeen overlooked.

The emotional health of thedialysis clinic is the attitude(positive or negative) that peo-ple in the dialysis clinic havetowards each other. Thinkabout your dialysis clinic—is itemotionally healthy or emo-tionally sick? Does your dialy-sis clinic have positive “vibes”(feelings) or negative vibes? Doyou and your dialysis stafftrust and respect each other?Can you discuss problemsopenly and honestly? Or dopeople in your clinic walkaround on “tiptoe” worryingthat something they say or docould make someone mad?

Keeping a dialysis clinic emo-tionally healthy takes a lot ofhard work on everyone’s part.Everyone in the dialysis clinic—staff and people coming infor treatment—has a responsi-bility to do their part. It is atwo way street—you, as thecustomer, have the right to betreated with respect and digni-ty by the dialysis staff, and thedialysis staff has the right tobe treated with respect anddignity by you, the customer.

Dialysis clinics can be veryemotionally charged places.There are a number of reasonswhy this is so and all of thesereasons apply to dialysis staff,as well as to people on dialysis.Sometimes we get so wrappedup in our own lives that we donot consider the emotions andfeelings of the other people inthe dialysis clinic. Or, if we are

stressed, worried or not feelingwell, we do not always put ourbest foot forward. To add tothat, because we spend somuch time around the samepeople, we often treat eachother too casually, possiblywith less respect. Over time,“little things” that are said ordone which might not usuallybother us turn into “bigthings,” especially if they arerepeated time after time.Small disagreements, person-ality conflicts, hurt feelings ormisunderstandings can turninto anger or suspicion, caus-ing us to strike out at the people around us.

You may find that having achronic medical problem, likechronic kidney disease (CKD)makes it even harder for you tostay emotionally balanced.CKD may change your life—what you eat and drink, howmuch energy you have, whattype of work and/or hobbies youdo and many other things.Treatments and travel timetake up a lot of your time ifyou go to an outpatienthemodialysis clinic. Besides thetime commitment, many peoplesay they feel they are “puttingtheir lives in someone else’shands” during dialysis.

Trying to consider other peo-ple’s feelings and emotions isone of the keys to an emotion-ally balanced dialysis clinic.Unfortunately, during periodswhen we are having a hardtime keeping our emotions andfeelings balanced, it is difficultto consider other people’s feel-ings and emotions. This is truewhether you are a personreceiving treatment, a familymember or friend or dialysisstaff member. The good news

is there are a lot of littlethings you can do to show con-sideration to people at the clin-ic that do not take a lot ofeffort or energy. Over time,these little things can have abig impact on the emotionalhealth of your dialysis clinic.

Here are some suggestionsyou can try in your clinic: 1. REMEMBER the “golden

rule”—treat other peoplethe way you would like to be treated.

2. TRY to find the good in people.

3. TRY to find the good in situ-ations, even when theredoes not seem to be any.

4. APPRECIATE people whocare and who try to do theright thing.

5. TELL people “Good morn-ing” or “Good afternoon.”

6. GIVE people compliments—everyone likes to be appreci-ated!

7. BE patient with people,especially new dialysis staffin your clinic. A friend ofmine likes to take new dial-ysis staff “under his wing.”He volunteers to let newstaff cannulate his access sohe can teach them cannula-tion from the patient’s pointof view. (He also ends upwith staff members heknows will do a good jobcannulating his access).

8. THANK dialysis staff whoencourage you to ask questions.

9. IF YOU DO NOT LIKE whatsomeone is doing, point outthe actions, but do not criti-cize him or her personally.

10. WHEN THERE IS a disagreement:• Try to look at both sides

of the story.

• Do not talk about peoplebehind their backs. Talkto the person with whom you have a disagreement.

• Do not ignore or makelight of other people’sfeelings.

• Offer possible solutionsto problems.

11.FINALLY, AFTER YOUREAD this article, do yourclinic a favor and pass it on.Share it with your peers atthe clinic and with yourdialysis team.

Remember: It takes everyoneworking together to keep yourdialysis clinic emotionallyhealthy!

Is Your Dialysis Unit Emotionally Healthy?

By Bobbie Knotek, RN, BSN, CNN

Teamwork will make your unit emotionally healthy.

Over the last few years inthe United States, conflictand violence in all medicalsettings have become moreand more of an issue. In aneffort to decrease conflict indialysis and transplant clin-ics, the Centers for Medicaidand Medicare Services, theESRD Networks, kidneyprofessional organizationsand the dialysis corporationscame together to develop astaff training programknown as DPC or DialysisPatient-Provider ConflictResolution Initiative. DPCwas “launched” across theU.S. during the summer of2005. Social workers andclinic managers in everydialysis unit across thecountry were asked to traintheir staff using posters,pocket cards and videos provided by the ESRDNetworks. If your clinic is participating in thisgroundbreaking staff education program, cheerthem on!

Decreasing DialysisPatient-Provider Conflict

FAMILY FOCUS • Volume 14, Number 3 5

M E D I C A L C O R N E R

MANY PEOPLE WHO ARE ON DIALYSIS

have the same signs and symp-toms of emotional problems aspeople without chronic kidneydisease (CKD). In addition, thestress of dialysis and the feel-ing of loss of control over one’slife, not to mention the physi-cal effects of CKD, can put astrain on most people and maylead to depression, difficultysleeping, anxiety and othermental health challenges.Depression and anxiety arevery common for people ondialysis just as they are in thegeneral population. When psy-chological counseling and othermeasures such as a completemedical review including possi-ble medication side effects arenot enough, drug treatmentmay be necessary. This articlewill review the major types ofdrugs that are used to treatemotional problems and willprovide information aboutindividual drugs in each drugclass specifically for people on dialysis.

It is important to rememberthat mental health treatmentis very individual and is beststarted in a discussion withyour kidney doctor about yoursymptoms and the risks andbenefits of any treatment.Occasionally, a formal psychi-atric evaluation may be neces-sary. People on dialysis usuallytake a number of medicines,which may either interferewith or add to the effects ofother prescription drugs youare taking. Another importantpoint for individuals on dialy-sis is the fact that non-pre-scription treatments such assupplements, vitamins andherbs may interact with pre-scribed medicines. Your doctorneeds to know if you are tak-ing any of these to avoid badside effects and assure theability of your medicines towork well.

DRUGS FOR DEPRESSIONNot all peoplewith depres-sion needmedica-tion, sincemanybecomedepressed only fora short period because of whatis happening in their lives atthe time. This type of depres-sion is called reactive depres-sion and may go away overtime. Longer periods of depres-sion, however, can improvewith medication. Most antide-pressive medications (medi-cines that fight depression) aremetabolized in the liver beforethey leave the body and there-fore dialysis seems to have lit-tle effect on how they work ortheir safety.

The most popular group ofdrugs used to fight depressionis the selective serotonin reup-take inhibitor (SSRI) group ofdrugs. The first of its kind ofthis type of drug is fluoxetine(Prozac®). Other drugs of thistype include sertraline(Zoloft®), paroxetine (Paxil®),citalopram (Celexa®), tra-zodone generic and escitalo-pram (Lexapro®). These drugsshould be started at smalldoses. Positive results areoften seen about three to sixweeks after starting the drug.Side effects may include sexualdysfunction, such as the inabil-ity to reach orgasm or having alower sex drive, nightmares,nausea and headache. Thesedrugs usually work better thanthe older antidepressants, suchas amitriptyline andimipramine (Elavil® and Tofranil®). These older

medicines begin to work very slowly, may cause heart prob-lems and generally do notwork as well as SSRIs.However, they cost less andare available as generics (med-icines that are off patent andmade by more than one drugcompany). Many people stilluse them for the treatment ofdepression. If these older med-icines are stopped, they shouldbe stopped slowly under a doc-tor’s supervision to avoid therisk of depression coming back and the risk of seizures(convulsions).

There are other medicinescalled atypical antidepres-sants. They are called atypicalbecause they work differentlythan SSRIs. An example of anatypical antidepressant isnefazodone (Serzone®). This isa cousin of trazodone and canhelp people with depressionsleep better. They can also beused safely by people on dialy-sis. Another atypical antide-pressant drug used more oftenin the treatment of depressionfor individuals on dialysis isbuproprion (Wellbutrin®). Itcan also be used to help peoplestop smoking. A sustained-release form of the medication(which means small amountsof the medicine are releasedinto the body over a period oftime) can be taken once a day.Dialysis treatments do notaffect the ability of buproprionto do its job in treating depres-sion. Its main drawback is thatit raises the possibility of hav-ing a seizure and probablyshould not be used by peoplewho have a history of seizuresor who are on antiseizure medications.

ANXIETYAnxiety isrelativelycommon inpeople ondialysis.Drugs in thebenzodiazepine class of drugssuch as alprazolam (Xanax®)and diazepam (Valium®) arecommonly used. While thesedrugs do not build up in indi-viduals with CKD and are notlost during the dialysis proce-dure, they have increasedeffects in some people on dialy-sis, particularly those withproblems in the nervous sys-tem such as previous strokesor brain atherosclerosis. Thesemay include excessive seda-tion, confusion and, rarely,seizures. Another member ofthis class is clonazepam(Klonopin®), sometimes usedto treat restless leg syndromein people on dialysis. If thesedrugs are taken for a longtime, they should not bestopped quickly; instead, likethe antidepressants describedabove, they should be stoppedgradually under a doctor’sguidance to avoid withdrawalsymptoms. New benzodi-azepines may cause drugdependence; thus, they arebest used for short-term prob-lems. These should be avoidedin people withalcohol anddrug prob-lems.

DRUGS FOROTHER ILLNESSESDrugs given forother mental health diagnosessuch as schizophrenia, obses-sive-compulsive disorder(OCD) or bipolar disorder ingeneral can be given safely topeople on dialysis.

Lithium, a drug used to treatbipolar disorder (also known asmanic depression) is monitoredby measuring the level of thedrug in your blood. While someof the medication is lost

Drug Treatment for EmotionalProblems for Individuals on Dialysis

By William M. Bennett, MD

Sometimes medication is necessary in treating emotional problems.

Read on for the facts.

Continued on page 6

6 FAMILY FOCUS • Volume 14, Number 3

K E E P I N G F I T

MANY PEOPLE WITHKIDNEY DISEASE FIND

IT HARD to give up habits thatmay be harmful to their health.However, there are some peoplewho make major changes intheir lifestyle, despite feelingsof low energy and sadness thatmay go along with dialysis ses-sions. These changes mayinclude stopping smoking, eating better or getting helpfrom an exercise specialist toimprove physical conditioning.Some people make changes ontheir own without the help ofanother person and others get support from a friend, family member or health care professional.

So what triggers change? Whatmotivates people? Why aresome people more ready tochange than others? These arenot easy questions to answer.Clinical psychologists such asDr. James Prochaska from theUniversity of Rhode Island andDr. William Miller from theUniversity of New Mexico havebeen studying human behaviorfor the past 30 years in aneffort to find some answers.

Dr. Prochaska’s research hasshown that when it comes tobehavior change, people havedifferent levels of motivation to

change, which he calls theStages of Change. People mightbe in one of five stages of readi-ness to change, ranging fromnot wanting to change in thefuture to having taken actionand stayed with the changes forat least six months. Here arethe Stages of Change describedby Dr. Prochaska:

People who reach the point oftaking action may fall off trackand relapse back into one ofthe earlier stages. However,that is not to say that all is lost and the person cannottake action again in the future. For example, it has been

shown that a smoker will typi-cally quit seven times beforeeventually quitting for good.

Dr. Prochaska suggests that itis helpful to know which stageof change a person is in beforetrying to help him or herchange some aspect of his orher lifestyle. Efforts to helppeople change tend to fail

when the strategies that areused to help do not match theperson’s stage of readiness tochange. For example, in theearlier stages of change(Stages 1-2), it is a good ideato help the person take a closerlook at his or her lifestyle in

an effort to get him or her tothink about some of the not sogood things about the behav-ior. Whereas in the laterstages of change (Stages 3-5),it may be better to help the person set goals and devel-op the skills necessary to put aplan into action.

At some point we have all feltthe frustration of being on thereceiving end of someone try-ing to convince us to changesome aspect of our behavior,and the harder they try to per-suade us, the less interestedwe become. Dr. Miller’sresearch has shown that inhealth care, providers willoften give advice in an effortto get patients to changeharmful behaviors. This caneasily lead to conflict andmay result in resistance, par-ticularly when we are unsureabout changing our behavior.

Consequently, when it comesto behavior change, it is cru-cial that you communicate

your feelings to help the healthcare provider understand yourpoint of view. To achieve this, itis usually more effective to takepart in the conversation ratherthan letting someone order youto try something new. Forexample, before starting anexercise program, share yourconcerns about your physicaland emotional limitations aswell as your strengths and yourfeelings about some of the sacri-fices you will have to make.This discussion will help yourhealth care provider understandwhere you are in the changeprocess, giving you a betterchance of moving closer to theday where you will be ready,willing and able to change yourbehavior and start to feel better.

Robert Scales, Ph.D. is an experienced trainer in motiva-tional counseling and teachesworkshops to help health careprofessionals improve their communication skills withpatients.

Are You Ready, Willing and Able toLive a Healthy Lifestyle?

By Robert Scales, PhD

Making big changes does not happen overnight.

through the dialysis treatment, it still does agood job of treating bipolar disorder in peopleon dialysis. The drug level test should be donebefore a dialysis session. While lithium has badeffects on the kidneys when taken over manyyears, this is not a concern for people on dialy-sis. However, too much lithium in the blood canbe dangerous to dialysis patients also because itaccumulates and can cause seizures and braindamage. You should discuss this with yourphysician if you are taking lithium.

All individuals who are taking any medicines fordepression and other mental health problemsshould have regularly scheduled appointmentswith their doctor to discuss ongoing care andtreatment. Any changes in medication, amount ofmedication and its effect on blood pressure or

other medicines used in your treatment shouldbe carefully followed by your doctor.

SUMMARYDepression, anxiety and other mental illnessescan be safely treated in people on dialysis. Whenstarting treatment, the individual should reviewall of the medications he or she is taking withhis or her nephrologist, including prescribed andover-the-counter drugs, to make sure there areno bad effects between the medicines. The ruleof thumb is “go low and go slow.” You should tellyour doctor about new symptoms as soon as younotice them. With care, most emotional problemscan be treated successfully.

William M. Bennett, MD, is a transplant physi-cian at the Legacy Good Samaritan Hospital inPortland, OR.

Drug Treatment for Emotional Problems…Continued from page 5

STAGE 3STAGE 1ready

tochange

takingaction

to change

notthinking

aboutchange STAGE 4

STAGE5

maintainingthe behavior

to change STAGE2

unsureabout

change

FAMILY FOCUS • Volume 14, Number 3 7

E A T I N G R I G H T

“OKAY, SO YOU ARE SAYINGI SHOULD EAT MORE MEAT,drink less milk, avoid cannedsoups, lunch meats, hot dogs,pickles and olives and limitoranges, bananas, potatoes andtomatoes. I need to increase thenumber of binders I take: threeafter each meal and two aftereach snack. Is that it?”

Does this sound familiar?Month after month, you arecounseled by your dietitian toachieve lab results within thedesirable ranges. Due to thelimitations of the kidney diet,you may find it difficult, or evendepressing, to follow such adiet. “Sometimes I just want togive up eating. By the time Ifigure out something to eat, Iam not even hungry anymore,”commented one person on dialy-sis. “Or I want to eat everythingin my kitchen to rebel againstthe diet!” she added.

Dealing with the complexities ofthe kidney diet and otherlifestyle changes may contributeto feelings of hopelessness, pes-simism, sadness and othersymptoms of depression, whichcan make you apathetic andless likely to care for your ownphysical needs.

Depression is not a weakness ora character flaw; it, too, is amedical illness. Depression canaffect your ability to sleep, workand get along with others.People who are depressed mayfind daily tasks such as mealplanning, shopping, food prepa-ration and even eating to be abig struggle. As a result of pooreating due to depression, youmay lose weight, have a lowprotein (albumin) level, or, insome cases, you may overeatand have unplanned or unwant-ed weight gain.

Psychological counseling andsometimes antidepressant med-ications can be helpful in treat-ing depression. Medication cangive relatively quick symptomrelief for some individuals andcounseling helps one learn more

effective ways to deal with life’sproblems. Ask your social work-er to refer you to a mentalhealth professional if you feelyou need help with depression.

In the past few years, there hasbeen much interest in the use ofherbs to treat depression. St.John’s Wort (hypericum perfora-tum) is becoming popular in theUnited States as an alternativeto prescription medication totreat depression. In general, theuse of herbs to treat depressionor other medical condi-tions can be dan-gerous and is notadvised for peo-ple with CKD.Specifically,research hasshown that St.John’s Wort mayinteract with anti-rejection drugs, maybe a source of hidden potas-sium[1] and may also interferewith iron absorption and causegastrointestinal irritation[2].The use of any type of herbal orover-the-counter depression“remedy” should always be dis-cussed with your nephrologist(kidney doctor) and other mem-bers of your health care team.

If you think you might bedepressed over your diet, talk toyour dietitian about how youare feeling. Together you candevelop ideas about how to helpyou stay positive about yourdiet. These could include:

n Setting short-term goalsfor your lab values.Perhaps the idea of eatingmore protein, eating lesspotassium and phosphorusand drinking less fluid isoverwhelming. Work withyour health care team todecide where to prioritize. Itmay be easier for you tochoose one lab value that is

not within goal range andtake steps to improve it. Forexample, you may decide towork on reducing your phos-phorus level first. Try substi-tuting one low phosphorusfood item for one higher inphosphorus (try sherbet orsorbet instead of ice cream.)Achieving a series of small,easy goals helps build yourconfidence and improve yourhealth.

n Looking through kidneycookbooks at your

local library orbookstore for

menu ideas.There are alsoWeb sites thatoffer manykidney-friendly

recipes. Trywww.kidney.

org/patients/cookbook, www.culinary

kidneycooks.com orwww.ikidney.com Decideto try a new recipe once perweek and share yourfavorites with other peoplewho are on dialysis and yourdietitian. You will also behelping others who are deal-ing with the same challengesof the kidney diet.

n Preparing larger quanti-ties of food and freezingleftovers. Quickly reheatingis a breeze when you are feel-ing too tired to cook fromscratch. Some people findthey are worn out after theirtreatment, causing them toskip meals. Enjoying leftoversafter treatment can be aquick and easy way toimprove nutrition and boostyour energy level.

n Buying frozen dinnersthat are lower in sodium,potassium and phospho-rus. Some nutrition labels

now also list the food’s potas-sium content. If you find oneyou like without nutrientinformation, see your dieti-tian for guidance.

n Eating with others if pos-sible. Pleasant conversationleads to a relaxed environ-ment. If you live alone, con-sider inviting an under-standing friend, relative oreven another person who ison dialysis over for compan-ionship during mealtime. Donot be afraid to ask them tobring a dish to share. Youmay find that many peoplewant to lend a helping hand.

n Eating several small mealsthroughout the day mayhelp increase the amount youeat, making sure that youtake in enough calories dur-ing times you may have asmaller appetite or might notfeel so hungry. Try a mid-morning and/or mid-afternoon snack.

Many factors come into playwith both the causes and thesolutions for depression, includ-ing nutrition and diet. Having apositive attitude toward yourkidney diet, while forming neweating habits (what, where,when and with whom you eat)can play a role in improvingyour physical health and yourmental outlook.

REFERENCES:1. Pocket Guide to Nutrition

Assessment of the Patientwith Chronic KidneyDisease. Third Edition,National KidneyFoundation, New York, NY,2002, p. 2-27.

2. Myhre, MJ: HerbalRemedies, Nephropathies,and Renal Disease.Nephrology Nursing Journal27 (5): 473-480, 2000.

Cathy Keller, RD, LDN is adietitian at Renal Care Group-South Suburban Dialysis inOlympia Fields, IL.

Don’t Let Your Diet Get You Down!By Cathy Keller, RD, LDN

Taking control of your kidney diet could reduce your chances of feeling depressed.

“Sometimes

I just want to give

up eating. By the time

I figure out something to

eat, I am not even hun-

gry anymore.”

8 FAMILY FOCUS • Volume 14, Number 3

N K F R E S E A R C H

DEPRESSION IS COM-MON AMONG PEOPLE

WHO ARE ON DIALYSIS.NKF is currently sponsoringtwo studies of depression conducted by members of the Council of Nephrology

Social Workers.

The goal of these investiga-tions is to provide informationthat will help to improve thetreatment and outlook forthose on dialysis who sufferfrom depression.

Estimates of depression amongpeople on hemodialysis rangefrom 25 percent in some cen-ters to 100 percent in othercenters.[1,2] Research has alsoshown that depression is asso-ciated with increased risk ofdeath and hospitalizationamong individuals on hemo-dialysis [1,3,4] No large sur-veys have been conducted onthe prevalence of depression inpeople on peritoneal dialysis.

This study aimsto determine whether a cogni-tive-behavioral interventionadministered to small groupsof individuals on dialysiswould make a difference intheir emotional health. Theproject team headed by JessicaCabness, DSW, assistant pro-fessor at the University ofSouth Florida (USF) in St.Petersburg, includes CindyMiller, LCSW, nephrologysocial worker; Kia Flowers,

MSW, Intern; and StephanieJohnstone, LCSW, who hasconsulted on the research. Thestudy duplicates earlierNational Kidney Foundation-funded research by Johnstone,which provided data in supportof the current study. “We knowthat end of stage renal diseaseis a life-altering condition and,under the circumstances, it isnormal for people to experiencesituational depression which, ifleft untreated, is potentiallydangerous,” says Dr. Cabness.

At USF Dialysis Center inTampa, 23 people from eachshift participated in the study.The intervention, designed byStephanie Johnstone for a pre-vious NKF-funded researchproject, lasts for six weekswith the individuals meetingweekly in a structured module.The intervention involves themtalking about their hopes andfears in the safety and privacyof a small group of people fac-ing similar issues. The aim isfor individuals with chronickidney disease to learn newways to regain control overtheir lives.

After giving informed consent,they were given several shortquestionnaires including adepression screen for medicalpatients, a widely used healthoutcomes survey and a screenmeasuring social support.Some information was collect-ed to see if there were any dif-ferences by age, gender,ethnicity or length of time ondialysis. Cabness reports that“preliminary findings look verypromising and suggest empiri-cal evidence of the effective-ness of nephrology social workintervention in dialysis

centers.” The project team ishopeful that social work inter-ventions with people onhemodialysis will ultimatelydemonstrate a clear relation-ship between what socialworkers do in dialysis centers,lower rates of hospital read-mission and higher quality oflife for those on dialysis.Before the project ends inSeptember 2005, Cabnesshopes to recruit a second cen-ter for comparative research.

“We’re hoping that more socialworkers will replicate thestudy—the more data we have,the better we are able to drawconclusions about the general-izability of the study,” Cabnesssays. The study will be pub-lished in the Journal ofNephrology Social Work by2006.

DIALYSIS SOCIAL WORK-ERS AIM TO MAXIMIZETHE FUNCTIONING andwell-being of people onhemodialysis. However, withthe growth of dialysis facili-ties and increasing socialwork caseloads, many socialworkers find themselves inthe role of financial counselorand transportation/travelexpert, leaving them less timeto function in their intendedrole of providing psychologicalcounseling and emotionalsupport to individuals on dial-ysis and their families.

The purpose of this researchproject, conducted by AmyFreeman, LMSW, and LauraRoot, LCSW, of SaintAlphonsus Nephrology Center

in Boise, Idaho, is to examinethe relationship between sixpsychosocial risk factors andlevel of depression in peoplenew to hemodialysis. The sixpsychosocial risk factors are:gender, age, level of educa-tion, ethnicity, possession ofmedical insurance andamount of time individuals

knew theywould bestarting dialy-sis prior to their first treat-ment. The study period beganin July 2004 and ended June2005. The study includedapproximately 60 partici-pants. In order to gather thenecessary information, theresearchers used two ques-tionnaires with each person.One questionnaire containedinformation including ques-tions about the six psychoso-cial risk factors. The otherquestionnaire used was theBeck Depression Inventory-Fast Screen for medicalpatients to measure depres-sion level. The final results ofthis research study areexpected to be published inthe Journal of NephrologySocial Work in April 2006.

“We hope to use the results ofthis research to assist inpromptly identifying whichpeople who are new tohemodialysis to be at higherrisk for depression,” says Root.This would allow dialysissocial workers to more quicklyassess for depression and pro-vide the needed intervention/

Two NKF-Sponsored Research Projects Study Depression

in Dialysis PatientsBy Jessica Cabness, DSW, Amy Freeman, LMSW and Laura Root, LCSW

AmyFreeman,

LMSW andLaura Root,

LCSW

Evaluation of Group Cognitive BehavioralIntervention on Depression, SocialSupport and Quality of Life for Patientson Hemodialysis

JessicaCabness,

DSW

Psychosocial Risk Factors for Depression in New Hemodialysis Patients

Continued on page 11

FAMILY FOCUS • Volume 14, Number 3 9

P A T I E N T & F A M I L Y C O R N E R

WHEN IT COMES TOCHRONIC KIDNEY

DISEASE (CKD) we routinelyexpect doctors and otherhealth care providers to helpsolve medical complicationssuch as high blood pressure,anemia or bone disease. Onthe other hand, when mentalhealth problems arise, weoften ignore them despite howthese problems can directlyimpact the medical challengesof CKD and dialysis. You donot need to be a social workeror psychologist or even spendmuch time with people like mewho have CKD to understandhow widely depression andother emotional problems canoccur with chronic illnessessuch as CKD.

Although having CKD does notmean a person will be unableto work, it is a reality thatCKD often magnifies the fearof losing a job and incomesource. In addition, we canhave a loss of self-worth andfeelings of anger surface as thequestion “Why me?” arises. Weoften have less energy to tack-le issues that would normallynot seem so difficult. Wherenormally we have had self-confidence about the future,suddenly it feels like we havelost control over large parts ofour daily lives. I have feltthese feelings.

The effects of CKD are notalways obvious to others.

Although I may be having aterrible day in terms ofenergy, pain and uremiaside effects, there is no signon my forehead that tellseveryone how I feel. I didnot want to always com-plain, especially at my job.While my family was gener-ally supportive and sympa-thetic, they had needs oftheir own and I was embar-rassed to lean too heavily on

them. Recognizing all theseconflicting feelings, it is notsurprising that individualswith CKD and their familiesmay benefit from professionalhelp when dealing withemotional and socialproblems. This is partic-ularly true during thefirst months of dialysiswhen new experiences,demands and fears comefrom all directions.

Unfortunately, peoplewho experience depres-sion or other mentalhealth challenges oftenstruggle along and denythe need for help eventhough many valuablesupport resources areavailable—all they needto do is ask for the help.Perhaps individualshave difficulty seeing howemotional problems interferewith getting back on track. Itis also likely most of us areafraid to share our deepestthoughts and feelings withfamily and outsiders to avoidthe vulnerability created bysuch openness. Like most, Iwas reluctant to discuss mydarkest thoughts with friendsor family members. Who wouldwant to expose such unaccept-able thinking? It took severalyears before I could evenadmit help was needed.Finally, I recognized I couldnot rebuild my past sense of

self-confidence without help,and the desire to move aheadbecame stronger than a ten-dency to stand still. Reliefcame when I discovered thebenefit of being able to expressmy fears with a trained profes-sional without worry of beingjudged or lectured! Knowingthe relief I felt, my hope isthat others will become con-scious of their emotional prob-lems and act more quickly toget help than I did.

Often, the hardest first step isspeaking with someone whocan show you the way to find

help. First, we often questionwhether life can get better.Second, trying to change ourway of thinking and beingopen about our inner thoughtsis not easy. My message for fel-low patients and families isthat it is okay to openly admitthat you need help coping withemotional problems. After all,CKD is a tough burden! Oneexcellent place for advice onwhere to find help is right inyour dialysis unit with thesocial workers and thenephrologists. Social workersare generally able to providethe professional counseling

and support you need to helpyou get started on addressingyour emotional concerns. Insome cases, the social workermay refer you to a mentalhealth professional in yourcommunity. Fortunately,Medicare and many otherinsurance programs may payfor professional counseling. Besure to check with your insur-ance provider in advance.

While mental health profes-sionals cannot create instantsolutions for your problems,my experiences showed methat working with them in an

open and sincere mannerhelped me to find ways of cop-ing, allowing me to move on toa better quality of life. Sure, itcan be painful to expose per-sonal doubts and fears that wetry to deny. The first stepbegins the healing process.Surprisingly, as you begin eachstep, the process of healingbecomes easier as your lifebegins to take on more mean-ing. Your family, too, can sharein that healing and optimism.

It Is Okay To Ask For HelpBy David Jones

David Jones

Support is available from the social worker at your dialysis unit.

IT IS EASY TO WATCH THECLOCK when you are wait-

ing for something to happen.When it comes to waiting for atransplant, it is a calendar thatis ticking away the months andnot a clock with minutes orhours! The months and yearsmay go by, and it feels as if thewaiting will never end. How canyou be patient when the wait is so long?

Waiting times for a kidneytransplant average betweenthree and five years dependingon your blood type and antibodylevel. Yet enduring the wait andbeing called for a transplantmay not mean the final wait isover. You may be called to thetransplant center for a possibletransplant, then sent home ifthe kidney is found not to besuitable for transplant or doesnot match you. And sometimesthe kidney does not work rightaway and you may need to con-tinue dialysis while waiting forthe transplanted kidney tobegin to work. Waiting forsomething you want so badly isalways hard and often emotion-ally draining. You may evenwonder if transplantation isworth all of this.

Gary Costly from Santa Rosa,California received a livingrelated kidney transplant in1989 from his brother. Thetransplant lasted untilFebruary 2000 when it faileddue to reoccurrence of the origi-nal disease that had affectedGary’s kidneys. His first trans-plant had required that he wait

only a few months for his broth-er to donate a kidney. The waitfor the second transplant wasvery different from his firsttransplant experience. He foundhimself waiting his turn for a

transplant in a longline of others whowere in need of akidney. He knew howgood he could feelwith a successfultransplant, whichmade the wait evenharder. After the firstmonths on the wait-ing list, though, herealized he must con-

tinue with his life andnot put everything on hold

while waiting for another trans-plant. He continued to planvacations with his family andwork as a chemist while await-ing the call from the transplantcenter.

“The one thing I tried to dowhile on dialysis was lead asnormal a life as possible and notlet kidney failure or dialysisconsume me. But, knowing thecall could come at any timebrought a little anxiety to themix. When I was called to thehospital for a transplant andthen sent home after being toldthe kidney was going to go toanother person, I was extremelydisappointed. That was shortlived, though, as I soon began tofeel happy for the person whoreceived the kidney. As I reflect-ed on the process I realized thatgetting called for a possibletransplant, even though I endedup without it, meant I must becloser to actually getting atransplant!”

About two months later, Garyreceived another call from thetransplant center and was suc-

cessfully transplanted. “Myfamily is happy, and I am elat-ed,” says Gary. “The biggestchallenge for me while I wasawaiting a transplant was keep-ing a positive attitude.”

Besides waiting, it can also bedifficult watching others leavethe dialysis unit when they arecalled for a transplant whileyou continue to wait. Althoughyou are happy for them, youmost likely will find it hard tokeep from asking yourself,“When am I going to get mychance for a kidney transplant?”Waiting time varies for individ-uals due to the degree of diffi-culty in matching. Some mayhave a high antibody level (per-cent reactive antibody level,commonly referred to as PRA).Although some new therapiescan remove these antibodies,the waiting time is generallylonger due to difficulty finding acompatible match.

There are sources for supportwhile waiting. One will be yourtransplant center staff. Call

them to check on your status.Make sure you are active on thelist and that there is nothingmore they or you need to do tokeep your status active. Checkfor local support groups.Talking with others who arealso waiting or who haveendured the wait can be helpfulboth to you and your family. Get a copy of Waiting for aTransplant, published by theNational Kidney Foundation.Waiting for a Transplant is fullof ideas and insights fromtransplant recipients across thecountry on how to keep “livinglife” while waiting for a trans-plant. The goal while waiting isto stay as mentally and physi-cally healthyas possible sothat when thewait is finallyover you willenhance yourchances for asuccessfultransplant.

Additional information on the Internet is available at:www.transplantrecipients.org, sponsored by the National Kidney Foundation,and www.transplantliving.org, sponsored by the United Network of OrganSharing.

10 FAMILY FOCUS • Volume 14, Number 3

Surviving the Wait By Nancy Swick, RN, BSN, CCTC

How can you cope with the wait for your trans-plant? Gary knows from first-hand experience.

T R A N S P L A N T A T I O N

Nancy Swick and Gary Costly

My Cycler and IBy Cynthia D. Miller

My Cycler and I, we have become oneNine hours of therapy, by morning I’m done.Sometimes I get up, sometimes I lay still, All depending on how I feel.Sometimes I feel bad, sometimes I feel good,Sometimes I feel happy, sometimes I feel blue. But most of all I feel blessed, when I open my eyes,With the help of my Cycler, another morning I’m alive.As my day goes on, I do what I can To make myself feel better and chase away the blues.I thank everyone who truly helps me, But next to GOD I thank “CAPD!”

Cynthia D. Miller receives her CAPD in New Haven, CT.

FAMILY FOCUS • Volume 14, Number 3 11

S P O T L I G H T O N M E D I C A R E

MANY PEOPLE WITHCHRONIC KIDNEY DISEASE (CKD) and

their family members wonderabout Medicare coverage forhealth care. If you have kidneyfailure and receive Medicarebecause of your ESRD (EndStage Renal Disease), you areentitled to the full range ofcoverage allowed underMedicare Parts A (hospitalcare) and B (outpatient care).It is important to know thatMedicare helps not just withpayment for your physicalhealth needs, such as dialysistreatment or transplantation,but also for some of the costsfor mental health care. Takingcare of your mental healthneeds is an important part ofadjusting to life with CKD. Aswith most Medicare coverage,there are certain deductiblesand co-payments, in additionto the monthly premium forPart B benefits.

Medicare covers mental healthcare given by a doctor or aqualified mental health profes-sional, such as licensed socialworkers, physicians and psy-chologists. Before a patient

gets treatment, he or sheshould ask the doctor, psychologist, social worker orother health professional if heor she accepts Medicare pay-ment (sometimes referred to asMedicare “assignment”).Medicare assignment meansthat the doctor or professionaldelivering the care has a certi-fied Medicare provider numberand has agreed to accept theamount that Medicare reim-burses for that particular service.

Medicare requires an annualdeductible of $100.00 for out-patient mental health care.This means that you have topay $100.00 of your mentalhealth care expenses beforeMedicare starts to pay. Onceyou have paid $100.00 underPart B during a calendar year

for this particular service,Medicare pays the rest of itscoordinated portion. Once thedeductible is met, Medicarecovers 50 percent of theMedicare-approved amount forthe mental health professional.

Either the patient, Medicaid oranother source of insurancepays the remaining cost. If anindividual wishes to use theservices of a doctor or mentalhealth professional who doesnot accept Medicare assign-ment, then the costs are likelyto be more. Check with yoursupplemental health insuranceplan to find out about mentalhealth coverage with thatplan. For mental health carein a general hospital or psychi-atric hospital, Medicare paysfor services in the same waythat it pays for all other inpa-

tient hospital care. If an indi-vidual with kidney failurereceives mental health care ina psychiatric hospital, there isa lifetime limit of 190 days ofinpatient care covered byMedicare. In any type of hospi-tal, the patient pays the sameco-payments and deductiblesas with all other hospital services.

Consider mental health treat-ment as a natural part of anoverall healthy adjustment tothe increased emotionaldemands of dialysis or trans-plantation. Medicare can helpyou by sharing the costs, asdescribed above. For moreinformation or help in findingmental health resources inyour community, consult yourdialysis or transplant socialworker. Take care of yourself,your kidneys and your mentalhealth!

Portions of this article are taken fromCMS Publications’ “Your MedicareBenefits” # 10116 and “Medicare andYour Mental Health Benefits” CMS #10148. To download a copy, visit theMedicare Web site,www.medicare.gov

Medicare Coverage for Mental Health Services By Roberta Bachelder, MA

Medicare covers portions of mental health services, just as it does for hospital

and patient care.

monitoring for the people iden-tified. This is not intended toreplace the social worker’s clini-cal assessment for depression.It is intended to provide ameans for early detection ofdepression risk factors in newindividuals on hemodialysis.“Hopefully, this will enable dial-ysis social workers to be moreeffective and efficient as westrive to meet the psychosocialneeds of those in our dialysiscenters,” Root adds.

REFERENCES:1. Kimmel PL, Peterson RA,

Weihs KL, Simmens SJ,Alleyne S, Cruz L & Veis JH.(1998). Psychosocial factors,behavioral compliance andsurvival in urban hemodialy-sis patients. KidneyInternational, 54, 245-254.

2. Kimmel PL (2002)Depression in patients withchronic renal disease.Journal of PsychosomaticResearch, 53(4), 951-956.

3. Soykan A, Arapasian B &Kumbasar H (2003). Suicidalbehavior, satisfaction with life and perceived social sup-port in end-stage renal dis-ease. TransplantationProceedings. 25(4), 1290-1291.

4. Kimmel PL, Peterson RA,Weihs KL, Simmens SJ,Alleyne S, Cruz L & Veis JH(2000). Multiple measure-ments of depression predictmortality in a longitudinalstudy of chronic hemodialysispatients. KidneyInternational, 57(5), 2093-2098.

Jessica Cabness, DSW, is anassistant professor of socialwork at the University of SouthFlorida in St. Petersburg. Dr.Cabness is a member of NKF’sCouncil of Nephrology SocialWorkers, Gulf Coast Chapter.

Amy Freeman, LMSW, conductsher studies on depression atSaint Alphonsus NephrologyCenter in Boise, ID. She is amember of NKF’s Council ofNephrology Social Workers.

Laura Root, LCSW, has beena social worker for 10 years.

She is a member of NKF’sCouncil of Nephrology Social Workers.

Two NKF-Sponsored Research Projects…Continued from page 8

12 FAMILY FOCUS • Volume 14, Number 3

Y O U R C H I L D A N D Y O U

WHY IS PARENTAL MENTAL HEALTHIMPORTANT?While many parents make thejob look easy, taking care of achild with kidney problems isactually very demanding. Ittakes dozens of hours eachmonth to go to doctor’sappointments, supervise medical care and take in infor-mation. It is very important forparents to stay in touch withthe amount of stress they arefeeling and to take steps tolower their stress before it getstoo high. For parents to takethe best care of their child,they first need to make surethat their own mental healthneeds are being met.

WHAT IS MENTAL HEALTH?Mental health is more thanjust the absence of a mentaldisorder. Mental health is astate of well-being in which anindividual is aware of his orher own abilities and can man-age the stresses that comealong with life. Getting andkeeping good mental health,like good physical health,takes attention and work.

MONITORING STRESS TAKES PRACTICEUnfortunately, no one hasinvented a device that can tellyou if your stress is dangerous-ly high. Sometimes we recog-nize stress only when there arenegative consequences. Somewarning signs of high stresslevels include: more troublethan usual making decisions;difficulty managing anger; lesspatience with family, friendsand health care providers;increased trouble with timemanagement; sadness over lit-tle disappointments; changesin sleeping habits, such asinsomnia (trouble fallingasleep or staying asleep) or toomuch sleeping; and changes ineating habits (eating too muchor too little).

PROBLEMS ASSOCIATED WITH HIGHLEVELS OF STRESSHigh levels of stress that lastfor many weeks and/or months

can lead to serious physicalhealth issues including heart,stomach, bowel and/or bladderproblems. Mental health prob-lems such as depression andanxiety with panic attacks canalso be caused by high stress.High parental stress can alsocause more stress in children.

HOW TO LOWER YOUR STRESS LEVELSDevelop a support system ofpeople who can help you.Although it is sometimes hardto ask others for help, manypeople find great joy in helpingothers. Make a list of the kindof things people in your sup-port system could do to helpyou so that when someoneasks, you will be ready with ananswer. If people do not askabout how they can be support-ive, let them know!

Get enough sleep. You need tofeel rested to be able to dealwith parenting challenges.Work out a bedtime routinethat allows you to have sometime to “put to rest” the day’sfinished and unfinished tasksbefore you physically get intobed.

Take time for yourself. Dosomething for yourself eachday that is unrelated to whatyour child needs and to whatother people expect from you.For some parents, exercise isan essential component tomanaging stress. Once you getin the habit of taking a briefbreak each day for yourself youwill see the value this has foreveryone around you!

Enjoy your child. Take pleas-ure in spending time with yourchild each week doing some-thing that is not related to hisor her kidney problems. Eventhough it might seem likethere are not enough hours ina day to take time just for play,playing is a valuable activitywith both short- and long-termbenefits for you and your child.Board games, card games,throwing a ball, reading abook, coloring a picture orplaying a video game areexamples of some playtimeactivities that most kids enjoydoing with a parent.

GETTING PROFESSIONAL HELP If parenting stress causes youto have physical or emotionalproblems that interfere withtaking care of your dailyresponsibilities, you should calla professional for help. Yourchild’s doctor or social workercan direct you to mental healthresources in your community.Your minister or rabbi mayalso offer advice aboutwhat kind of treatmentand support is available.It is absolutely normal forparents of children withkidney problems to becomeoverwhelmed with stressfrom time to time and it isimportant not to feelembarrassed to ask forhelp. Many parents getsupport from a counseloror psychotherapist (psy-chologist, social worker, orpsychiatrist) experiencedin working with parents who have medically illchildren. Be sure to check

with your health insuranceprovider to find out about yourpolicy’s coverage for mentalhealth services.

Internet resources aboutemotional stress and theimportance of good mentalhealth:

www.cdc.gov/niosh/stresswk.html: The NationalInstitute for OccupationalSafety and Health (NIOSH)

www.surgeongeneral.gov/library/mentalhealth:Reports of the SurgeonGeneral on Mental Health

www.who.int/mediacentre/factsheets/fs220/en/print.html: World HealthOrganization (WHO) fact sheeton mental health

Arlene Gerson, PhD, is a pedi-atric behavioral psychologist atthe Johns Hopkins Children’sCenter in Baltimore, Maryland,and an Assistant Professor ofPediatrics. She has been alicensed psychologist workingwith children who have med-ical problems for 13 years andhas been with the Division ofPediatric Nephrology for thepast six years.

MONITORING AND MANAGING STRESS:The Importance of Good Parental MentalHealth for Children with Kidney Disease

By Arlene C. Gerson, PhD and Barbara A. Fivush, MD

Taking care of yourself is just as important astaking care of your child with CKD.

Family Focus is available on the Web.

To find this issue or back issues of the newspaper go to

www.readfamilyfocus.org

ADJUSTING TO A DIAG-NOSIS of chronic kidney

disease (CKD) can be an over-whelming experience. Thoughall people with CKD are cer-tainly not the same, and indi-viduals respond to thediagnosis in different ways, it is common for people to have strong emotions whenfaced with the reality of need-ing to start dialysis. You mayfeel anger, guilt and shock. Youmay notice changes in yourability to work, your role inyour family or your sociallife—all of these add to theconfusion and upset that mostpeople report feeling as theylearn to cope with CKD. Forsome, both physical and emo-tional treatment and rehabili-tation is necessary.

Most people are able to adjustand return to many of theactivities that were present intheir lives before CKD, includ-ing family, travel, leisure andwork. To live well with kidneydisease, it is important to carefor both the physical and emo-tional issues that you mayexperience. Talking with some-one about these changes andhow they affect you can helpyou manage your feelings andlower your chances of becom-ing depressed or anxious,while increasing your chancesof making a positive adjust-ment to living with CKD.

KNOWING WHEN TO GET HELP Statistics show that up to 40percent of people with CKDexperience depression at sometime [1] [2]. Signs of depres-sion include trouble enjoyingthings that used to be fun,staying away from social situations such as time withfamily and friends, having ahard time concentrating andfeeling sad or down most of thetime. If you have one or moreof these symptoms it does notalways mean that you are suf-fering from depression, but itis important to discuss yoursymptoms with a professional

who can help you. Other symp-toms commonly experienced bypeople suffering from depres-sion, such as difficulty sleepingand low appetite, can also besymptoms of uremia.

Usually, depression is easilytreated. Many people find thattalking about their feelingswith the dialysis unit socialworker or doctor, taking anti-depressant medication or see-ing a counselor on a regularbasis can make a big differ-ence. Usually, a combination ofcounseling and medication ismost effective in preventing ormanaging depression.

Some people living with achronic illness have a greatdeal of anxiety or nervousness.People who have an anxiousemotional response to a diag-nosis or treatment of CKD cansometimes have trouble sleep-ing and feel nervous and wor-ried much of the time, oftenover things that they normallywould not worry about.Anxiety can be quite disrup-tive to people’s lives, making itdifficult to relax, concentrateand become involved in every-day activities. Some symptomsof depression and anxiety aresimilar, and anxiety itself issometimes a sign of depres-sion, so a proper evaluation

by your medical team is important. Anxiety is alsotreatable with counseling and medication.

THE ROLE OF THE DIALYSIS SOCIAL WORKEREvery dialysis center has ateam on site to handle therange of challenges that thosepeople on dialysis or with akidney transplant face. It isimportant for you to partnerwith the members of your dial-ysis team to make use of theskills that each has to offer.Fortunately, to find out aboutsocial support, professionalcounseling and to learn moreabout a variety of treatmentoptions for depression, anxietyor difficulty adjusting to dialy-sis and CKD management, youneed look no further than yourdialysis social worker. Thedialysis social worker is theone member of the health careteam with training and experi-ence in dealing with mentalhealth issues. His or her mainrole is to counsel people withCKD and their family mem-bers to help them adjust to thechanges and challenges. Socialworkers can give brief therapyin the dialysis unit to help peo-ple better understand andmanage some of the feelingsand thoughts that can lead todepression or anxiety. Thesocial worker can partner withindividuals to identify andsolve problems that often comealong with the changes of living with CKD and helpthem develop better copingstrategies.

TREATMENT OPTIONSThere are a variety of treat-ment options available to helpwith the emotional reactions to a CKD diagnosis. First, you

should talk to your socialworker about how you are feel-ing. In addition to helping youunderstand your feelings, yoursocial worker may be able tohelp you learn the best treat-ment options for your uniqueexperiences.

Among the treatment optionsavailable for depression andanxiety are individual andfamily counseling offeredthrough many counseling cen-ters in the community. Socialworkers can give you resourcesfor group counseling and sup-port groups for people facingsimilar challenges. There are agrowing number of books,magazines, Web sites andother materials from organiza-tions like the National KidneyFoundation (NKF) which offereducational and emotionalsupport, inspirational materi-als and information about living with CKD. CopingEffectively: A Guide forPatients and Their Familiesis one brochure availablethrough the NKF by calling800-622-9010 or visitingwww.kidney.org

Dialysis social workers canhelp you find these resourcesand taking advantage of themcan help you feel less aloneand more like an importantpart of the large network ofpeople living well with CKD.

REFERENCES:1. Watnick S., Kirwin P.,

Mahnensmith R., et al: Theprevalence and treatment ofdepression among patientsstarting dialysis. AmericanJournal of Kidney Disease41 (1): 105-110, 2003.

2. Guzman S.J., Nicassio P.M.:The contribution of negativeand positive illness schemasto depression in patientswith end-stage renal dis-ease. J Behav Med. Dec. 26(6):517-34, 2003.

Megan Prescott has been arenal social worker for threeyears. She works for FMC-NAin Santa Ana, CA.

FAMILY FOCUS • Volume 14, Number 3 13

T A K I N G C O N T R O L

Emotional Rehabilitation After theDiagnosis of CKD

By Megan Prescott, MSW, FMC-NA

Adjusting to a new life with CKD can be difficult. But there are resources available.

Most people are able toadjust and return to many of the

activities that were present intheir lives before CKD.

14 FAMILY FOCUS • Volume 14, Number 3

CONGRESS AND MEDICARE STAFF are

paying more attention to themental health of Medicare bene-ficiaries these days. This isclear in the Medicare Prescrip-tion Drug, Improvement andModernization Act of 2003, andin two draft regulations pub-lished on February 4, 2005 bythe Centers for Medicare andMedicare Services (CMS).

The Medicare PrescriptionDrug, Improvement andModernization Act of 2003makes many changes inMedicare. Notably it providesthat new beneficiaries are enti-tled to a “Welcome to Medicare”initial preventive examination.(In the past, Medicare has paidfor a doctor’s office visit only if abeneficiary was sick.) Benef-iciaries who get their first pre-ventive examination within six

months after the effective dateof their Medicare Part B cover-age period are eligible for thisservice. Not only is the preven-tive examination a welcomeadvance in the Medicare pro-gram but the rules that carryout this law state that the firstpreventive examination shouldinclude a review of the benefi-ciary’s risk factors for depres-sion (including past history ofdepression or other mood disor-ders) based on the use of anappropriate screening instru-ment, which the doctor or otherqualified non-physician healthcare professional may selectfrom various available screen-ing tests for this purpose.Medicare will not pay for a

visit to both a doctor and a non-physician health care professional, however, for thisscreening.

One of the Proposed Rules con-cerns dialysis clinics and theother relates to transplant cen-ters. Both recognize the need toevaluate the psychosocial issuesfaced by individuals who areserved by these facilities.

The first reference to psychoso-cial concerns in the ProposedRule, “Conditions for Coveragefor End Stage Renal DiseaseFacilities” would make dialysisfacilities: (a) inform people ondialysis of their right to betreated with respect and digni-ty, and (b) recognize each per-son’s individuality and personalrequirements, as well as alertstaff to be sensitive to the indi-viduals’ psychosocial needs andability to cope with end stagerenal disease (ESRD).

In another draft section, CMScalls for a comprehensiveassessment of all people whoare new to dialysis and periodicre-assessment of those alreadyon dialysis. CMS states that itis fitting and necessary forevery assessment to focus notonly on the person’s medicalneeds, but also on his or herpsychosocial and rehabilitationneeds. In fact, evaluation of psy-chosocial needs is one of 13assessment criteria that theagency proposes to require.Although the existing regula-tions require a patient careplan, they do not require a com-prehensive assessment beforethe development of the careplan. The addition of an assess-ment is one of the major

improvements that would comefrom the Proposed Rule. Someof the other criteria include evaluation of family and other support systems and evaluation of vocational andphysical rehabilitation statusand potential.

Monthly re-assessment wouldbe required if an individualexperiences very long or fre-quent hospitalizations, a majorsetback in health status, a sig-nificant change in psychosocialneeds or poor nutrition. Underthe Proposed Rule, newpatients have to have anassessment within 20 days andanother assessment after threemonths. Stable patients haveto be re-assessed annuallythereafter. However, as per theProposed Rule, patients who arenot stable should be re-assessedon a monthly basis. CMSacknowledges that mentalhealth should be taken intoaccount when consideringwhether a person is stable.

A third section in the ProposedRule for dialysis clinics wouldrequire that the plan of care forthe person on dialysis includemeasurable and expected out-comes and estimated timetablesto meet his or her medical andpsychosocial needs as identifiedin the first and followingassessments. When completed,this section would also statethat the plan of care must out-line all of the services thatwould be given to reach andkeep up the expected outcomesof care.

The Proposed Rule would alsorequire dialysis units to have aquality assessment and quality

improvement program. In itsresponse to the draft regulation,the National KidneyFoundation insisted that suchquality assessment and qualityimprovement programs includemental health.

The second Proposed Rule,“Requirements for Approval andReapproval of TransplantCenters To Perform OrganTransplants” also addressespsychosocial concerns. It saysthat transplant centers mustuse a qualified social worker toevaluate a transplant recipient’spsychosocial needs, participatein care planning for the trans-plant recipient and identifycommunity resources to assistthe person and his or her family.

A new provision in the ProposedRule for transplant centerswould require that a likelytransplant candidate receive apsychosocial evaluation beforebeing placed on the waitlist. Inexplaining this requirement,CMS states: “Although a personmay be medically suitable fortransplantation, he or she mayhave inadequate social supportor coping abilities, or may beunable to demonstrate adequateadherence to a therapeutic regi-men, which could then put thegraft, and ultimately the trans-plant recipient, at risk.”

Family Focus readers whowould like more informationabout the Medicare issues discussed in this article can send an e-mail to:info@kidney.org

Legislative and RegulatoryDevelopments Affecting the Mental

Health of People with CKDBy Dolph Chianchiano, JD, MPH

An update on Congress and Medicare.

L E G I S L A T I V E U P D A T E

Dolph Chianchiano, JD, MPH

One of theProposed Rules

concerns dialysisclinics and theother relates to transplant

centers.

FAMILY FOCUS • Volume 14, Number 3 15

H E L P I N G Y O U R S E L F

FEELING WELL EMO-TIONALLY may be chal-

lenging when coping withphysical illness. For many peo-ple, how an illness will affectone’s independence, family life,ability to work and financialpicture becomes nearly asimportant as the physical symp-toms or treatment of the illness.Poor physical health and theworries that go with eitherchronic kidney disease (CKD) orbeing on dialysis may bringabout feelings of depression.Depression is not just feelingdown in the dumps or blue nowand again. And it does not affectonly your mood, as it is a truemedical disorder that mayaffect your thoughts, feelings,physical health and behaviors.It is common for people whohave a chronic illness, such asCKD, to also experience depres-sion. It is not a sign of weak-ness, nor is it something thatyou can will yourself to snap out of.

Understanding more aboutdepression may be helpful inovercoming it. Here are somefacts and figures that show howcommon depression is: nnDepression is the leading

cause of disability in theUnited States.[1]

nnDepression is now the leadingcause of disability in theworld.[2]

nnChronic illness increasesone’s chance for depres-sion.[3]

nnSome studies have shownthat 20-25 percent of peopleon dialysis are depressed.[4,5]

nnDepression is treatable andmost people who are treatedshow improvement.[3]

Kidney disease experts thinkthat depression among peopleon dialysis is both underdiag-nosed and undertreated.[6,7]When untreated, depression cancause unnecessary pain and suf-fering for those on dialysis andtheir families and symptomscan last for weeks, months oreven years. Among its manyeffects, depression can impact

your ability or desire to followtreatment recommendations,such as following a proper dietand getting adequate dialysis,and to take part in your overallplan of care. In addition, it hasbeen shown that depression inpeople with kidney failure canlead to a higher chance of earlydeath compared to people ondialysis who are not diagnosedwith depression.[8]

Learning about the signs andsymptoms of depression may bea good first step in the pursuitof feeling better. Here are somethings to look for, especially ifthey have occurred nearly everyday for at least two weeks:nn FEELING sad or empty

most of the day nn LOSS of interest or

pleasure in life nn DIFFICULTY concentrating

or inability to make decisions nn FEELING worthless nn THOUGHTS of suicide.

It is often useful to talk to fami-ly members or friends to see ifthey have noticed changes inyour moods or behaviors thatyou may not have noticed.

If you are on dialysis, your facil-ity health care team hasresources and expertise to helpyou deal with your mentalhealth issues and emotionalwellness. In particular, there isa master’s-prepared socialworker who has the trainingand background to help youaddress the complex issues ofadjusting to a chronic disease.The Medicare guidelines fordialysis and kidney transplantprograms mandate the duties oflicensed master’s-preparedsocial workers in dialysis andtransplant facilities to “supportand maximize the social func-tioning and adjustment of thepatient.” The social worker canhelp you find ways to bettercope with the challenges youmay be facing. There are impor-

tant things you can do to helpyourself when facing depres-sion. (See sidebar: How to HelpYourself If You Are Depressed.)

If you think you may bedepressed, understand thatdepression is treatable. Talk toyour doctor or social workerabout your concerns, and to see if you could benefitfrom treatment for depres-sion. Treatment options may include prescription antidepressant medication from your doctor, supportivecounseling from your dialysisfacility social worker or counsel-ing from other professionals inyour community. Depression ismost effectively treated whenyou work with your care teamto decide on the best treatmentmethod for you and when youare committed to sticking withthe treatment plan.

You CAN regain feelings ofemotional well-being. Takeaction today to feel better.

Barb Campbell works as theDirector of Patient Services inthe Intermountain End StageRenal Disease Network (ESRDNetwork #15) in Denver, CO.She began work in the field as a dialysis facility social worker in 1977.

REFERENCES:1 US Department of Health and Human

Services. Mental Health: A Report of theSurgeon General Executive Summary.Rockville, MD: US Department ofHealth and Human Services, SubstanceAbuse and Mental Health ServicesAdministration, Center for MentalHealth Services, National Institutes ofHealth, National Institute of MentalHealth, 1999.

2 World Health Organization Web site. The World Health Report 2001/MentalHealth: New Understanding, NewHope. [Message from the Director-General]. Retrieved from www.who.int/whr/2001/dj_message/en/

3 US Department of Health and HumanServices. Fact Sheet: Depression Co-Occurring with General MedicalDisorders. Bethesda, MD. NationalInstitutes of Health, National Instituteof Mental Health. 1999.

4 Goodkin DA, Mapes DI, Combe C, Piera,L, Held, PJ: Psychiatric disease is asso-ciated with increasing mortality andhospitalization among hemodialysis

(HD) patients. J Am Soc Nephrol 10:281, 1999.

5 DeOreo PB: Hemodialysis patient-assessed functional health status pre-dicts continued survival, hospitalization,and dialysis-attendance compliance. AmJ Kidney Dis 30 (2): 204-12, 1997.

6 Watnick S, Kirwin P, Mahnensmith R,Concato, J: The Prevalence andTreatment of Depression AmongPatients Starting Dialysis. Am J KidneyDis 41 (1): 105-10, 2003.

7 al-Hihi E, Awad A, Hagedorn A.:Screening for depression in chronichemodialysis patients. (Abstract). MoMed 100 (3): 266-8, 2003.

8 Kimmel PL, Peterson RA, Weihs KL,Simmens SJ, Alleyne S, Cruz I, Veis JH:Multiple measurements of depressionpredict mortality in a longitudinal studyof chronic hemodialysis outpatients.Kidney Int 57 (5): 2093-8, 2000.

Drive Out Depression and Feel BetterBy Barbara K. Campbell, MSW, ACSW, LSW

Learning about depression can help you to overcome it.

DEPRESSIVE DISORDERSmay make one feel exhausted,worthless, helpless and hope-less. Such negative thoughtsand feelings make some peoplefeel like giving up. It is impor-tant to realize that these nega-tive views are part of thedepression and typically do notaccurately reflect the actual cir-cumstances. Negative thinkingfades as treatment begins totake effect. Some things youcan do include:

SETTING realistic goals inlight of the depression andassume a reasonable amountof responsibility. BREAKING large tasks intosmall ones, setting prioritiesand doing what you can asyou can. TRYING to be with other peo-ple and to confide in someone;it is usually better than beingalone and isolated. PARTICIPATING in activitiesthat make you feel better. EXERCISING, going to amovie, a ballgame, or partici-pating in religious, social orother activities may help. EXPECTING your mood toimprove gradually, not imme-diately. Feeling better takestime.

Taken from Depression, a 2002brochure from the NationalInstitute of Mental Health.

how

to helpy

ourself?if you are depressed

16 FAMILY FOCUS • Volume 14, Number 3 01-65-1403

YOU MAY ALREADYHAVE HEARD ABOUTTHE NEW MEDICARE

PRESCRIPTION DRUGCOVERAGE (also calledMedicare “Part D”). If you haveMedicare, you can join a Part Dplan. Your income, drugs youneed and plan choice will affecthow much you save with PartD. Sign up from November 15to December 31, 2005 to get cov-erage as early as January 1,2006. After May 15, 2006 youmay have to pay a higher premium.

YOU MAY QUALIFY for extrahelp under a “limited incomesubsidy.” If you are approved,your income will affect whetherthe subsidy pays all or part ofyour monthly Part D premium,your deductible and how muchyour co-pay will be. You couldpay as little as $1 to $5 perdrug. If you have both Medicareand Medicaid, SSI or get helpfrom your state payingMedicare premiums and you gota letter from the Centers forMedicare and Medicaid Services(CMS), you do not need to applyfor this extra help. Otherwise,

you can apply at your SocialSecurity or Medicaid office.

MEDICARE PART D can workwith or replace other drug cov-erage you have now. If you haveboth Medicare and Medicaid,Medicare Part D will replaceMedicaid starting January 1,2006. If you have a Medigapplan, union, employer, or retireeplan, your plan will let youknow how it compares withMedicare Part D. If it is at leastas good as Medicare Part D andyou wait to sign up for Part D,you can join later without pay-ing a higher premium. But ifyour current plan is not at leastas good as Part D, you may paymore for Part D when you join.

IF YOU HAVE CHRONIC KID-NEY DISEASE (CKD), take thetime you need to choose the bestplan for you. Think about whatdrugs you take now. Ask yourdoctor what drugs you shouldtake to keep you healthy andwhat drugs you may need if youchange treatments or yourhealth changes. You will savemore money with a “kidneyfriendly” plan, one that covers

most of the drugs your doctortells you. Some drugs coveredby Medicare Part D that peoplewith CKD often take includethose for bone disease, high cho-lesterol, diabetes, heart prob-lems, high blood pressuredepression and anxiety.

STARTING OCTOBER 13,2005, you will be able to call800-MEDICARE or visitwww.medicare.gov to seewhat Part D plans insurancecompanies offer in your areaand what drugs they cover. Youwill have a choice of at least two plans.

You will have different dead-lines to join Part D based onyour income and assets.Ô Join between November 15,

2005 and December 31, 2005 to get coverage onJanuary 1, 2006.

Ô If you have Medicare andMedicaid, and do not sign upby December 31, 2005,Medicare will choose a planfor you. What Medicarechooses may not cover asmany drugs as a plan youchoose.

Ô If you do not have Medicaid,but have SSI or your statehelps you pay your Medicarepremium, you must sign upby May 15, 2006 or Medicarewill choose a plan for you.Again, it is best to choose theplan that works best for you.

Ô Anyone else who has Medi-care and other drug coveragethat is not at least as goodas Part D must join by May15, 2006 to pay the lowestpremium.

Ô If you get Medicare later andhave drug coverage that isnot at least as good as Part D,you will have six months tojoin Part D for the lowest premium.

THE NATIONAL KIDNEYFOUNDATION (NKF) wants tohelp people with CKD, like you,learn how Medicare Part D may affect their health care.Look for more on Part D infuture issues of Family Focus.To find out more, call 800-MEDICARE (800-633-4227) or visit www.medicare.gov,www.medicarerights.org orwww.kidneydrugcoverage.org

What You Should Know About Medicare’s New Drug Coverage