As defined (DSM-5 2013), delirium is a disturbance in attention and cognition usually developed over a short period of time. It is one of the most overlooked/underdiagnosed syndromes in the medically ill, especially in people with renal failure. Its many causes include that produced by medication and that by a medical condition. Dialysis patients are prone to many medical complications such as anemia, fluid overabundance, secondary hyperparathyroidism and uremia. Concerning the latter and its treatment, people with renal failure before and often during treatment are uremic. We know that it is not the overabundance of urea that causes this problem. For example, if one injects urea into an experimental animal it will not produce what we consider to be a uremic state. Rather, it is an accumulation of various toxic substances that are removed by a normal kidney that gives rise to it. Unlike the person with normal 24/7 kidney function, the dialysis patient is intermittently uremic, due to intermittent kidney-like function. Also, the process of dialysis in relatively rapidly shifting electrolytes and fluids may give rise to what is termed “disequilibrium syndrome” which is not uncommonly seen during and after dialysis runs.

Depressive and anxiety disorders are common complications of medical and surgical illnesses (Levy 1989). Most often the depressive disorders are precipitated by a loss that is real, threatened, or fantasized.

Patients with renal failure, especially those on dialysis sustain many such losses. Most never return to the outside work, household, or school activities they had prior to suffering from kidney failure (Cukor et al. 2013). The loss of a job is a major event in that it not only results in a loss of money, but it usually is associated with a loss of self esteem as well as a loss of the sense of masculinity in men and femininity in women. Further, patients on dialysis have a loss of personal freedom, a loss of independence, a loss of life expectancy, and a loss in their healthy appearance (Rosenthal et al. 2012). The medical regimen of these patients involves a loss of the freedom to choose the foods they like to eat and restraint in fluid intake (Gressel et al. 2014). There is usually a loss in appearance. Patients on dialysis usually have a change in their complexion in which they appear almost sun tanned, but not of a healthy looking brown. Because the avenue of access to the circulatory system involves the surgical creation of arterio-venous fistulas, both the scars of these procedures as well as the often snake-like bulging caused by the arterialization of the venous system compromises their appearance.

From the earliest days of dialysis, it was noted that the incidence of suicide in these patients seemed to be higher than in the general population or in other chronic medical illnesses. The earliest systematic study of this observation was conducted by Abram and his colleagues (Abram et al. 2001). They sent out questionnaires to all of the existing hemodialysis centers in the US at that time. With about half of the questionnaires returned and poor statistics as to comparisons, they, nevertheless concluded that suicide in dialysis patients was 500 times greater than in the general population. Although this study is a flawed one, in its somewhat dramatic conclusion it brought attention to the subject of suicide in these patient populations. To the best of knowledge of the authors of this chapter, there has been no valid study to date of suicide in dialysis or renal failure patients. The problem here is in the accuracy of statistics concerning suicide. To illustrate, in 1961 when the Nobel Prize novelist, Ernest Hemmingway left treatment for depression at the Mayo clinic and went home to Ketchum, Indiana and shot himself in his mouth, the coroner in that town registered his death as due to natural causes. Less dramatically, is not voluntary withdrawal from dialysis, a self-death? There is also a large gray area in people not adhering to diet and fluid restriction. These and other methods of self-destructive behavior, whether conscious or not border on methods of self-death.

Interestingly, when one looks as who does the act of suicide, one is confronted with interesting conclusions. For example, each year more New York City policemen die from suicide than in the line of duty. For the past several years more US servicemen and servicewomen die due to self-injury than in battle. Although there are no credible statistics, most would agree than more members of health professions kill themselves than the general population. The obvious reason seems to be that if the individual has a means of suicide at hand, there is a greater chance that the individual will meet his/her death by that means. This is the case of the dialysis patient. In years past when the portal of delivery of hemodialysis was the external arterio-venous shunts, many patients died by their disconnecting the arterial portion of their shunt. Now, as then, a method of suicide is going on a high potassium diet and/or not showing up for a few hemodialysis runs.

The accepted ideal treatment of the depressive disorders is by the use of antidepressant medications and psychotherapy. Unfortunately, the ideal and the practical treatment often do not meet in this group of patients. It has been observed and initially described (Reichsman and Levy 1972) that people with kidney failure are among the most resistive toward a psychological view of their lives. It is often rationalized by, “If you had my illness, you would be as sad as I am”. Nevertheless, the more insightful patient may be amenable to a talking therapy. Cukor and his associates have done some groundbreaking studies on modified cognitive behavioral therapy (CBT) on dialysis patients (Cukor et al. 2013). They have shown that this form of therapy reduces depressive affect, improves quality of life, and promotes treatment adherence well within statistical significance. Medication, namely antidepressants are usually more acceptable than talk because they adhere to the traditional medical model of illness and are viewed by many as less spooky than talking therapy. A discussion of their use appears later in this chapter.

Where there is depression there is often anxiety as well (Cukor et al. 2007). But it may also exist by itself because anxiety is the body’s protective mechanism against threats to its integrity, again real, threatened, and/or fantasized. The patient treated for renal failure has many potential reasons to be anxious. For the person who has been transplanted, there is the continual fear of organ rejection. Dialysis invokes many potential fears. Since the procedure involves continual removal of blood into an apparatus and then its return, there is always the possibility of blood loss. As previously mentioned the relatively rapid removal of electrolytes and fluid often produces a transient disequilibrium syndrome, making the patient borderline delirious and possibly anxious. In center hemodialysis units it is not uncommon to see major medical problems among fellow patients including cardiac emergencies and occasionally death of patient being dialyzed. In addition, changes in staffing and waiting for medical procedures usually are associated with anxiety. Quality of life is materially affected by anxiety (De Sousa 2008).

When consultation-liaison psychiatrists or other behavioral professionals are asked to speak to a group of nephrology professionals, more often than not, the subject will be “the noncompliant patient”. That observation underscores the commonality of this problem for nephrology staff. As to its definition, “noncompliance” is a subjective conclusion and may vary from one observer to another. It is being used in this chapter not to include the patient who is just annoying, questioning staff, or requesting second opinions, but rather to include the very distressing, extremely demanding person including people who continually does not adhere to their medical regimen to the extreme degree.

Two factors need to be considered in studying this subject. First, renal failure patients do not represent the crosssection of society. They are heavily weighted in the direction of lower class, impoverished people, those who did not adhere to their medical regimen as hypertensives and diabetics, and people with addictive disorders. The antisocial person is overrepresented in this group of patients. Therefore, one can see why these patients, as a group may be different from the general population or other people with chronic medical illnesses in adherence to diet and other aspects of the medical regiment of renal failure. The second factor is understanding how different personality types adjust or fail to adjust to chronic medical illness. As previously mentioned the very independent or very dependent patient will respond differently to different forms of renal failure therapy. Once again, we wish to underscore the importance of the behaviorally trained professional to be involved in advising nephrology staff as the selection of a modality of treatment that compliments the personality type of the individual. Again, the very independent person should be steered in the direction of self-care or transplantation. Factors that may be helpful in the treatment of noncompliant persons include an understanding that failure to adhere to the medical regimens will result in possible hospitalizations and, more likely, a decrease in life expectancy. When noncompliance involves missing dialysis runs or aggressive behavior, it is important for staff to maintain minimal tolerance for it. Again, early on, it is important for the unit to make it clear any behavior that affects the safety of staff and patients will be treated as a police matter. Further, chronic offenders including people who repeatedly miss dialysis runs should be transferred to other units if feasible.

Many years ago Belding Scribner, an early pioneer in treating chronic renal failure observed that one-third of men on dialysis were totally impotent, one-third are partially impotent, and one-third have no impotence problem (Levy et al. 1974). This led to a few studies, most of which were conducted by questionnaires that showed that Scribner was almost correct. When women were asked about their sexual functions, a significant group, but less than men, said that they had issues of sexual dysfunction, in particular, a decrease in libido and decrease in orgasm. Renal transplant patients also have similar problems with sexual function, but at a far lesser degree than dialysis patients (Levy 1973).

There are several modalities of treatment of sexual problems in these patients. Since depression is often closely associated with sexual dysfunction, the relief of depression can reduce and even cure sexual problems in a significant group of these patients. Masters and Johnson techniques (Masters and Johnson 1970) have been used with success on selected patients. In men, the use of agents that increase the release of nitric oxide in the corpus cavernosum of the penis such as sildenafil (Viagra) and similar medications have been received as a gift to many patients.

End Stage Renal Disease patients live with protracted somatic discomfort. As a group, patients have been described as suffering an average of 10.5 symptoms at any given time, including most prominently fatigue, pruritis, pain, cramps, sleep disruption, anorexia, and constipation (Merkus et al. 1999; Valderrqabano et al. 2001; Weisbord et al. 2003). Sexual dysfunction is also common and is discussed elsewhere in this chapter. Remedies are available for most symptoms, but are limited in efficacy and tolerability. Issues of comfort and palliation have a direct impact on the course of intercurrent psychiatric conditions. Consulting psychiatrists should be aware of some common issues in renal palliative care and should tailor interventions to add to patient comfort during life-prolonging treatment as well as during the dying process.

Fatigue is common and multifactorial in etiology. Sleep disturbance, anemia, physical deconditioning, and depression may contribute, in addition to hyperparathyroidism, uremia, and effects of dialysis itself (Murtagh and Weisbord 2010). Exercise, cognitive interventions, and other nonpharmacological measures should be integrated into treatment where possible (Murtagh and Weisbord 2010). Other nonpsychiatric issues such as hypothyroidism should be ruled out, and treatment of kidney disease-related anemia with erythropoietin-stimulating agents considered (Murtagh and Weisbord 2010). Existing psychotropic medications should be reviewed in order to minimize those with potential for contributing to sedation, anergia, and abulia. A psychostimulant like methylphenidate may be used symptomatically (Cohen et al. 2006).