By Danny Bonvissuto

Three years after Toddra Liddell, APRN, FNP-C, PMHNP-BC, became a family nurse practitioner at Vanderbilt Dialysis Clinic – East, she decided to seek a Psychiatric Mental Health Nurse Practitioner (PMHNP) certificate. The more patients she saw, the more she realized how many had mental health issues either brought on or exacerbated by their chronic condition.

“I thought, ‘these patients are struggling. This is depression I’m seeing,’” Liddell said. “But to understand it, and to know how to help them, I needed additional training. I didn’t just want to learn how to write a prescription, but how to recognize mental health issues and manage them.”

Liddell earned her certificate from Western Kentucky University in 2021 and has been slowly integrating mental health education and support into patient care.

While some patients in the clinic have an acute kidney injury and do dialysis during recovery, most have end-stage renal failure. Dialysis is their lifeline, or they will die.

“Often these are new patients who may have known they had a kidney disease, but now it’s time for them to go to dialysis, or younger patients who can’t do what they want, eat what they want, drink how they want and now they’re thrust into dialysis,” Liddell said. “Some of our patients have had a transplant, the transplant failed, and they have to come back to dialysis. That’s very challenging.”

All new patients are given a two-point depression screener. If the answer to either of those questions is yes, they are given an additional nine-point screener. Referring a patient who shows signs of a mental health issue, like depression, anxiety or bipolar disorder, often requires a two- to three-month wait, or longer, for an appointment.

“Many times, our patients don’t have three months to wait,” said Liddell, who’s able to take action quicker. “They don’t have the coping skills to deal with what they’re going through. With their approval, we talk through their issues while they’re on dialysis from 45 minutes to an hour either once a week or once every other week on my non-rounding days.”

Common issues Liddell sees involve fear of death, job loss and concerns with finances, adult children or transportation to and from the clinic. Liddell, along with social worker Judson Abernathy, tries to connect patients to resources, helps them set achievable goals and follows up from week to week while they’re on dialysis. Some issues require medication while others do not.

“I have a patient who was on an antidepressant prior to dialysis: I could tell she had anxiety because she’d pick at her skin. She said the medication didn’t work,” Liddell said. “I told her I could see she was struggling, gave her some literature to read and told her she could talk with me when she was ready. One day while I was rounding, she said she’d like to start back on a SSRI, so I wrote her a prescription, and she’s improving.”

Liddell has seen the connection between mental health issues and dialysis from a personal perspective as well: She has an uncle on dialysis, a niece on peritoneal dialysis who recently received a kidney transplant from VUMC, and a brother with kidney disease who died.

“Prior to starting dialysis, my brother worked and had a family like most of our patients,” Liddell said. “After starting dialysis, he grappled with many things, including his manhood, his ability to be the support his wife and child needed at the time, and his independence. Seeing it from the other side opened my eyes to what I do at the clinic because of issues families have to deal with and the depression I saw in my own family.”

Ed Gould, MD, medical director of Vanderbilt Dialysis – East, sees significant value in providing mental health services while patients are on dialysis.

“These folks spend so much of their life traveling to and receiving their dialysis treatments,” he said. “When Toddra can provide this care to them where they are, it helps minimize the overall burden they have to bear.  This type of support should serve as model for care delivery across the dialysis space.”

Liddell is fine-tuning her program at Vanderbilt Dialysis Clinic – East with plans to bring it to Vanderbilt Dialysis One Hundred Oaks Clinic.

“This really is my passion,” she said. “A lot of our patients are African American, and I think sometimes we are reluctant to share. I’m grateful some of them are sharing instead of keeping everything inside. I don’t know what outcomes will change, but I do know it benefits people to talk and feel heard and helped.”