When you are first diagnosed with a chronic condition such as CKD, it can change the way you, see yourself, and create feelings of anxiety, disbelief or denial. These feelings are normal and perfectly okay to experience, and acknowledging that you feel this way can be the first step towards controlling these thoughts. You are still the person that you see in the mirror, that is a parent, a friend, a son/daughter, brother/sister, and you aren’t the condition that you have been diagnosed with. Ignoring these feelings though could lead to additional problems down the road.

Just because you have anxiety or experience mood changes, doesn’t mean you have a mental health disorder. As we know, mood swings happen and can be influenced by many things like a long line at the post office or someone cutting you off in traffic. However, there is a linkage between mental health and chronic health disorders. According to The National Institute of Mental Health an estimated 26.2% of Americans suffer from mental disorders [1]and 68% of adults with mental disorders also have chronic medical conditions.[2] Mental disorders and chronic medical conditions can go hand in hand. Please, do not feel ashamed if you are having any mental condition symptoms, as the number above illustrates, you are not alone.

Even though patients with kidney disease are at an increased risk for mental health issues, the numbers that are reported are likely still low due to underreporting and missed diagnoses. Out of the 26% of Americans who suffer with mental disorders, an estimated additional 8 million are still walking around undiagnosed[3]. This could be due to many factors, but the negative view of mental health disorders at least plays a role in this.

Since mental health and chronic diseases are closely related it is important to note that having a chronic disease can increase symptoms of mental disorders and can also lead to the development of another chronic disease[4]. Positively, most mental health conditions are highly treatable and treatments can range from just talking to others in a support group to receiving medications and other professional services.  

The potential effects that may occur if you have an untreated mental condition could be:

• Difficulty engaging in physical activity - One of the symptoms of mental condition is fatigue. If you are suffering from this symptom it will make it hard to participate in healthy, physical activity.
• Trouble complying with your medication regimen - Non-compliance to treatment is recognized as a problem for people with a mental health condition, estimates of poor adherence range from 40%-80%[5]. If you do not take your medication properly your treatment will not be as affective.
• Eating healthily - When your mental state is comprised you are less likely to make healthy food choices and this has the potential to lead to poor nutritional status.
• May alter your immune system function - If you are stressed, your body’s hormonal response alters your immune system function influencing your susceptibility (ability to get sick) to becoming ill. Can lead to a decline in serum albumin levels in patients with ESRD[6] and lead to increased conditions and death in ESRD patients.[7]
• Can diminish quality of life - Having a mental health condition can mean that you have a chemical imbalance in your brain therefore your overall mental state is comprised. If your brain is not happy, you are not happy and it will make it difficult for you to have a positive outlook on life. This can affect your ability to make good life choices.
• Can lead to longer condition duration - When your mental state is comprised your medical regime may not be consistent and your immune system could be negatively affected. If this happens it will make it difficult for you to improve your outcome.

Having a positive mental status can allow you to have a better attitude or perspective about your diagnosis and can really help improve your results of your kidney treatments. Positive thinking has been attributed to longer, healthier lives in people with chronic conditions and decline in stress, which can overall reduce any chance of having more medical problems. [8]

There is no shame in feeling frustrated or down about having kidney disease. These feelings are completely normal and the following chapters will help walk you through steps towards diagnosis, provide tools to reduce any negative feelings and empower you to take control of your treatment.

If you had a sore throat, swollen glands, and a fever you would tell the doctor your symptoms so they could treat you properly and you can get better. It is easy to tell the doctor symptoms of strep throat, a stomach bug, or any common condition because most of us are familiar with the symptoms. However, not everyone knows the symptoms of mental conditions. It is important for you to become aware of signs and symptoms of mental conditions so you know when it is appropriate to seek additional help.

Early treatment of mental disorders is important, especially as you are trying to handle kidney disease.  The sooner you are able to receive help, the less you need to worry about it impacting the outcome of your kidney treatment. The following are lists of general symptoms and just because you have one or more of the symptoms, doesn’t mean you need to seek help. These are meant for your guidance. Also, just because you don’t have anything listed below doesn’t mean you can’t seek help from friends, family or a professional resource. 

The following is an adapted list from Mental Health America (MHA)[1]:

In adults:

• Confused thinking
• Prolonged depression (sadness or irritability)
• Feelings of extreme highs and lows
• Excessive fears, worries and anxieties
• Social withdrawal
• Dramatic changes in eating or sleeping habits
• Strong feelings of anger
• Delusions or hallucinations
• Growing inability to cope with daily problems and activities
• Suicidal thoughts
• Denial of obvious problems
• Numerous unexplained physical ailments
• Substance abuse

In older children and pre-adolescents:

• Substance abuse
• Inability to cope with problems and daily activities
• Changes in sleeping and/or eating habits
• Excessive complaints of physical ailments
• Defiance of authority, truancy, theft, and/or vandalism
• Intense fear of weight gain
• Prolonged negative mood, often accompanied by poor appetite or thoughts of death
• Frequent outbursts of anger

In younger children:

• Changes in school performance
• Poor grades despite strong efforts
• Excessive worry or anxiety (i.e. refusing to go to bed or school)
• Hyperactivity
• Persistent nightmares
• Persistent disobedience or aggression
• Frequent temper tantrums

If you have experienced any of the symptoms above, the next step is to have a conversation with your family or friends. There you can decide what to do next. In many instances the next step is to talk to your doctor. They are familiar with your medical condition and life situation and serve as a source of information. When you have kidney disease or are on dialysis there could be side effects from the treatment such as tiredness that may leave you thinking that you could have a mental disorder. However, a symptom such as tiredness could instead be due to anemia, which is common in kidney disease patients. Your doctor will help you determine if additional testing is needed.

[1] Mental Health America. Mental Illness and the Family: Recognizing Warning Signs and How to Cope. Retrieved from http://www.nmha.org/go/information/get-info/mi-and-the-family/recognizing-warning-signs-and-how-to-cope [10]

Talking about your condition with your loved ones

Explaining your mental condition to friends and family is one of the hardest tasks to face when you’re newly diagnosed. You of course don’t need to tell anyone, but if you do it is best to take it slowly. If you are comfortable you should plan on telling your family and closest friends. Talking with your friends and family may be your most valuable resource because they are the ones that care about you the most and want to help. Your family and friends might be all that you need and sometimes just talking to another person can make a situation drastically better. If this isn’t a good option for you of if you need additional help there are plenty of other resources.

Local resources

Check with your local health department’s Mental Health Division for help. Even if you have no health insurance, you pay what you can afford based on your income. Click here to find your local health department or clinic. http://findahealthcenter.hrsa.gov/Search_HCC.aspx [11]

You can also check with your local ESRD Network. They may be able to provide support for your needs. The ESRD Network encourages self-care dialysis and kidney tranpslantation and will clarify reimbursement procedures in order to help control the costs of the renal disease program. http://www.esrdnetworks.org/ [12]

Social Workers

If you haven’t figured it out already, your social worker is a sort of do it all resource. They are a great place to start if you have questions about available resources. Many are also trained in basic counseling and could be the only resource that you need. In addition to helping you understand your feelings, your social worker should be able to show you the best treatment options available. They can also give you resources for group counseling and support groups for people facing similar challenges.

Online support groups

Support groups are a place for you to give and receive both emotional and practical support as well as to exchange information with one another. Some people find online support groups to be a valuable resource because it allows you to share as much information as you are comfortable with. Most resources are also free and you can get help from someone across the country from home as long as you have a computer and internet connection.  

Yahoo Health groups - Yahoo Health groups are a series of online support groups where you will find free online forums to connect with others who are experiencing some of the same issues you are. Simply type into the “search” box: Mental health, kidney disease, or what other groups you are interested in joining. Click here to visit http://groups.yahoo.com/ [13]

Renal Support Network (RSN) - is a nonprofit organization that provides non-medical services to those affected by chronic kidney disease (CKD). Click here to visit http://www.rsnhope.org/ [14]

MD Junction – A great online center that provides support groups for any issue you are facing. Click here to visit http://www.mdjunction.com/ [15]

American Society of Health System Pharmacists - Provides easy-to-understand information about medications. Click here to visit www.safemedication.com [16]

Daily Strength – Offers support groups and chat rooms for patients and family members. Click here to visit http://www.dailystrength.org/c/Dialysis/support-group [17]

Healthy Place – Has online communities/support groups regarding mental health conditions. Click here to visit www.healthyplace.com [18]

Psychotherapy

Psychotherapy is a method of talking in person with a therapist. Here are a few types of therapy available:

• Behavior therapy – Includes stress management, biofeedback and relaxation training in order to change thinking patterns and behavior.
• Psychoanalysis – Long term therapy to recognize unconscious thoughts and early patterns to resolve issues and become aware of how those issue influences your actions and feelings.
• Cognitive therapy – Identifies and corrects thinking patterns that can lead to troublesome feelings and behavior.
• Family therapy – Includes discussions and problem solving skills with members of your family.
• Group therapy – Includes a small group of people to discuss individual issues in a group setting in order to help each other with their problems.

Types of Mental Health Professionals[1]:

If you decide you would like to seek help from a professional, talk with your medical team about which one may be right for you. Below are some professionals that specialize in mental health counseling:

• Psychiatrist – medical doctor who specializes in the diagnosis and treatment of mental disorders. These doctors are allowed to prescribe medication.
• Child/Adolescent Psychiatrist – medical doctor who specializes in the diagnoses and treatment of emotional and behavioral problems in children. These doctors are allowed to prescribe medications.
• Psychologist – A psychologist has a doctoral degree in psychology. These doctors specialize in diagnoses and are able to provide individual and group therapy. However, a psychologist cannot prescribe medication.
• Clinical Social Worker – a counselor with a master’s degree in social work. These counselors are trained to make diagnoses and provide individual and group therapy. A clinical social worker cannot prescribe medication.
• Mental Health Counselor – a counselor with a master’s degree and several years of clinical work experience. Trained to diagnose and provide individual and group therapies.

Medication Therapy

Medications can be helpful to people with a diagnosed mental or emotional health disorder. If medications are prescribed, it is important that you talk with your doctor to learn about possible side effects or drug interaction with your kidney disease or other medications.

There are several types of drugs available to treat mental conditions. There are anti-depressants, anti-anxiety, and anti-psychotic medications.

Depression

Dialysis and depression are commonly linked. As we talked about earlier, learning that you have kidney disease or kidney failure is a trying situation. Many patients have difficulty coping with the news or lack a proper support structure. Devon Osborne, a DPC Patient Ambassador, shared his story in a recent article for Renal Business Today. The article can be found here http://www.renalbusiness.com/blogs/experts-eyes/2012/09/dialysis-and-depression-a-patients-perspective.aspx [19].

Antidepressants are medications that treat depression by balancing the natural chemicals like serotonin and dopamine in your brain.

The most commonly prescribed anti-depressants are called selective serotonin reuptake inhibitors (SSRI). This is a process in which neurotransmitters (the chemicals responsible for good and bad feelings) in your brain are absorbed back into nerve cells. A reuptake inhibitor prevents this from happening. So instead of getting reabsorbed, the neurotransmitter stays longer in the gap between the nerves allowing for better communication between the nerve cells.  

In the case of depression, neurotransmitters such as serotonin are lacking and therefore they can’t send out the next message. If you take a selective serotonin reuptake inhibitor or a serotonin norepinephrine reuptake inhibitor (SNRI) it will slow down the process of returning the chemical to the end of the neuron. In turn, this will boosts your mood because it will change the balance of your serotonin levels.[2] Both types are very popular these days because they have fewer side effects than older classes of medications.

The several main neurotransmitters:

• Dopamine – helps control motivation and voluntary movement, emotional responses and the ability to feel pain and pleasure
• Epinephrine – also known as adrenaline and is stimulated during the flight or fight response that happens when you are startled or threatened
• Glutamate – is an excitatory neurotransmitter and it is required for learning and memory
• Norepinephrine – is also excitatory and helps control stress, blood pressure and general activity
• Serotonin – plays a role in mood fluctuations, anxiety and arousal

Common SSRI drugs and their side effects:

• Prozac – Nausea, agitation, insomnia, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety, weight gain or loss, sexual dysfunction, runny nose, muscle plain, rash. [3]
• Zoloft - Nausea, agitation, insomnia, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety, weight gain or loss, sexual dysfunction, runny nose, muscle plain, rash. [4]
• Lexapro - Nausea, agitation, insomnia, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety, weight gain or loss, sexual dysfunction, runny nose, muscle plain, rash.[5]

Common SNRI drugs and their side effects:

• Effexor – Nausea, vomiting, anorexia, headache, sweating, rash, anxiety, dizziness, fatigue, hypertension, tremors. [6]
• Cymbalta – Nausea, dry mouth, constipation, decreased appetite, sweating, sweating, insomnia, sleepiness, tiredness, blurred vision, tremors. [7]
• Pristiq – Nausea, loss of appetite, insomnia, dizziness, dry mouth, headache, weakness, sweating, high blood pressure, pupil dilation.[8]

As with any medicine, there will be side effects. Side effects differ from medication to medication and from person to person. If you are prescribed any medicine, alert your doctor immediately if you have a reaction. It is also important that you take the medication as prescribed and don’t stop if you start to feel better. Talk with your doctor and they will determine if you need to continue with your medication.

Anxiety Disorders

Antianxiety and antidepressant medications are used to treat many types of anxiety disorders. In some instances medications knows as beta blockers are also given.

The most commonly diagnosed anxiety disorders are:

• Generalized anxiety disorder (GAD)
• Obsessive compulsive disorder (OCD)
• Panic disorders
• Post-traumatic stress disorder (PTSD)
• Social phobias

Since dealing with a chronic condition can be stressful there is an increased risk to develop an anxiety disorder.  Many of the above antidepressants are also useful for anxiety disorders. Prozac, Zoloft and Laxapro are commonly described for panic disorders. Paxil and Celexa can be used for OCT, PTSD and social phobias as well.[9]

 Benzodiazepines are a group of medications that have a sedative (calming) effect. This means that it calms your body down by slowing down the brain activity to reduce anxiety.

Benzodiazepines and their side effects:

• Valium – Drowsiness, dizziness, loss of memory, headache, hangover feeling in the morning, slurred speech, unpleasant dreams.[10]
• Xanax – Drowsiness, dizziness, clumsiness, slurred speech, loss of appetite, gastrointestinal problems, headache, blurred vision, change in sex drive.[11]
• Ativan – Drowsiness, dizziness, sleepiness, clumsiness, weakness, loss of memory. [12]

Beta-blockers can help control some of the symptoms of anxiety such as sweating and trembling. Controlling the physical signs associated with anxiety can help reduce anxiety. For example, if giving a speech makes you anxious the beta-blocker can help mask some of your symptoms and give you the confidence to face the audience.

General side effects include:

• Cold hands
• Dizziness
• Fatigue
• Weakness

Please note that beta-blockers are not recommended for those with diabetes as it can worsen the symptoms.

Psychotic Disorders[13]:

This is a group of disorders that cause you to have abnormal thinking or cause you to perceive the world in a non-normal way. People that suffer with psychotic disorders often report, seeing, hearing or feeling that something or someone is there or watching them. The disease could also cause them to believe that a TV character is out to get them.

Common illnesses are:

• Schizophrenia
• General delusional disorder
• Schizophrniform disorder
• Shared psychotic disorders

These medications are commonly used to treat psychotic disorders and sometimes mood disorders such a bipolar disorder or major depression.

• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• Perphenazine (generic only)
• Fluphenazine (generic only)

The drugs listed above are from the older generation of drugs developed in the 1950s. In the 90’s new drugs were developed and the one most commonly prescribed is clozapine (Clozaril). Although clozapine has been a very effective medication, it has been known to cause agranulocytosis, which is a condition that impacts white blood cell production. White blood cells are the main defenders in your body that help you fight infections.

Other newer generation drugs were developed and don’t cause agranulocytosis.

These include:

• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)

Like the other medications, there are side effects.

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women

Additional warnings can include changes in metabolism and weight gain. Patients with conditions such as diabetes should be extra careful if prescribed an antipsychotic medication. Additionally, antipsychotics are known to have other drug interactions. It is important to share any over the counter or other prescription medications that you currently take. Your doctor will understand these issues, but it is still important to point out your condition to your medical team.  

Drug interactions:

It is important for you to remember that any drug you take can have an adverse effect with other drugs that you may be taking. A drug interaction is a reaction caused by a combination of drugs that can potentially cause harmful side effects to the person who is taking the drug. Be sure that the professional that prescribes your medication is aware of your kidney disease and every drug that you take for this and any other health problems. With any drug there is a possibility that they will interact with your current medicine. Your medical team will work with your pharmacist to make sure there isn’t an issue.

Now that you have made it this far, you would like to know how mental health services are covered under your insurance plan likely private insurance, Medicare, or Medicaid.

Medicare

Medicare can help assist you in paying for your mental health services. If you need to learn about Medicare or just need to revisit the program you can visit our Medicare/Medicaid classroom site before continuing on to learn how Medicare can help you with your payments for mental health services. http://dpcedcenter.org/classroom/medicare-and-part-d-donut-hole/medicare-101 [32]

To qualify for Medicare[1]:

• You have been diagnosed with ESRD

Or

• You have had a previous Medicare-covered kidney transplant

And

• You paid into social security yourself

Or

• You are the child or spouse of someone who has worked under the Railroad Retirement Board or as government employee or the child or spouse of someone who has worked for the government.

Or

• You are already receiving Social Security

If you qualify for Medicare, then you are entitled to the full coverage under the program. Medicare Parts A (hospital care) and B (outpatient care) will help with coverage for physical health needs such as dialysis treatment or transplantation, but also for some of the cost for mental health care.

Medicare will cover hospital and outpatient care as well as prescription drug coverage. Medicare drug plans have a list of medications that the plan will cover, called a formulary. Make sure your doctor is aware that you are covered under Medicare to ensure that you are prescribed a drug that will be covered.

Medicare will cover mental health care given by a professional such as, licensed social workers, doctors, and psychologists just as long as they will accept Medicare payments. Make sure before you make an appointment with the doctor of your choice, you check to see if their services will accept Medicare payments or you may end up having to pay for the services yourself or through private insurance.

What you pay

After you pay your yearly Medicare Part B deductible, how much you pay for your mental health services will depend on whether your visit with the doctor is to diagnose your condition or to get treatment.

• Visits to a doctor or other health care provider to diagnose your condition, you pay 20% of the Medicare-approved amount.
• Outpatient treatment of your condition (like psychotherapy), you pay 40% of the Medicare approved amount in 2012.
• Congress passed legislation that reduces how much people with Medicare pay for outpatient mental health treatment to be consistent with coinsurance amounts for other medical services.
• How much you pay for these services will decrease to 35% in 2013 and 20% in 2014.[2]

Inpatient Care: Part A covers inpatient mental health care services. These services can be given in hospitals, or in specialized psychiatric hospitals.

Outpatient Care: Part B covers mental health services on an outpatient basis when provided by any medical professional in an office or hospital setting. What you have to pay will depend on whether you are being diagnosed and monitored for your condition or whether you’re getting treatment.

Partial Hospitalization: Part B also covers partial hospitalization. These outpatient services for psychiatric treatment are more in-depth than the care you would normally get in your doctor’s or therapist’s office. To be eligible for a partial hospitalization program, a doctor must validate that you would otherwise need inpatient treatment.[3]

Resources for Medicare

To order a free booklet from Medicare you can click here [33]. (http://www.socialsecurity.gov/pubs/EN-05-10043.pdf [34]) or call 1-800-633-4227. Hearing impaired can call TTY 1-877-486-2048

The home page for the Medicare program can be found here.   [35](http://www.medicare.gov/ [36]) (To learn more about the different parts of Medicare

Additional general information about Medicare can be found here. http://www.medicare.gov/coverage/inpatient-mental-health-care.html [37]

Or here

http://www.medicare.gov/pubs/pdf/10184.pdf [38]

Medicaid

Medicaid provides services to children, pregnant woman, low-income adults and families, and those who have disabilities. Coverage is meant to be affordable for those eligible and helps provide a safety net of coverage. The program is the largest contributor for mental health services in the United States[4]. Over the years, Medicaid has become a major source of financing for state mental health agencies and other community health resources.

Federal law doesn’t contain specific language on exactly what services are covered just that Medicaid services in each state, must provide coverage. States can choose to support mental health programs through their state plan services, waivers, managed care or through the Early Period Screening, Diagnostic and Testing (ESPTD) benefit. Each state develops a plan defining their coverage and this plan is reviewed and approved by the Centers for Medicare and Medicaid Services (CMS). Once approved, the plan must be available to all eligible individuals and the definition of mental illness must align with federal laws and regulations.

The ESPTD benefit requires states to provide medically needed services found during routine screenings of Medicaid eligible children under the age of 21. This means that once screened, children can receive needed services even if they aren’t directly covered under their state’s plan. Although individuals are entitled to services that are medically necessary, states have the ability to define medical necessity and sometimes this can lead to coverage gaps.

Interestingly, in many cases Medicaid coverage is often more generous than that of private health insurance. Medicaid generally doesn’t exclude those with preexisting conditions, normally allows the use of community based services and doesn’t contain a lifetime cap for services. All of which isn’t guaranteed in private plans. This allows you to bring services to your home and use resources such as drop-in centers, crisis services, mental health rehabilitation services and other prevention programs.[5]

Medicaid reimbursement is available for mental and behavioral health services covered under these categories:

• Case management - are services that help individuals with mental illnesses to gain access to medical, social and educational services
• Licensed practitioners services – are normally services at the individual level and could range from counseling to full psychiatric care
• Clinics – can be inpatient or outpatient and must be overseen by a licensed mental health professional
• Prescription medications coverage – even though coverage is optional, all states cover prescription drugs for mental illnesses in some capacity
• Rehabilitative services - are another resource covered by almost all states that help individuals restore functions and gain control of their life
• Inpatient psychiatric hospital services – are clinical services that are generally meant for individuals with severe forms of mental illness

The eligibility rules for Medicaid will be different for each state. Starting in 2014, most American adults under the age of 65 with an individual income up to $15,000 per year will qualify for Medicaid in every state[6]. Also with the Affordable Care Act, states have the option to expand their coverage and can apply for waivers to cover additional services or beyond minimum standards.

Resources for Medicaid:

To receive more information about your state Medicaid program, please visit, Medicaid.gov.

To learn about program eligibility click here. (http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Eligibility.html [39])

For a basic overview and to learn about coverage click here. (http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/By-Topic.html [40])

To learn about Medicare/Medicaid coordination click here [41]. (https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-MedicaidCoordination.html [41])

To review the Federal Poverty Level guidelines used to determine eligibility click here.  (http://www.cms.gov/smdl/downloads/SMD10005.PDF [42]).

Private health insurance

Each private insurance company varies in their coverage for mental health services. According to recent workplace surveys, 85% of private insurance plans have some form of coverage for mental health services. The first step is to review your insurance policy with a plan expert to determine what is and isn’t covered. When you signed up for your health insurance you should have been given a copy of your insurance policy. If you do not have the policy then you can call your insurance company and ask for another one and someone will be able to walk you through your coverage. Your social worker should also be able to either guide you through coverage or point you towards someone that can help you.

Through the Mental Health Parity and Addiction Equity Act (MHPAEA) it requires private health insurance to give an equal amount of mental and physical health insurance. Before this act, many private plans would provide 80% of coverage for a physical ailment like a broken bone, but only provide 50% coverage for mental health services. This act doesn’t mean that private insurance policies cover mental health services, but most employer sponsored plans do. To learn more about the act you can visit the resource here (http://www.apa.org/helpcenter/federal-parity-law.aspx [43]).

In many cases private insurance will be the primary payer and any additional coverage such as Medicare/Medicaid will help pick up costs that your primary insurance doesn’t cover.

With any insurance though, there is still the reality that some clinics won’t accept private or any form of insurance. When this is the case, you can be left with expensive out of pocket claims or have trouble even finding a provider. While there have been great strides in mental health care coverage, some treatments are still deemed experimental or are seen as too expensive.

Additional resources for payment help[7]

The Partnership for Prescription Assistance   - This program will help patients without prescription drug coverage. For more information, call 1-888-477-2669 or visit https://www.pparx.org/ [44]

Together RX Access [45] – This group can help patients without prescription drug coverage save on name brand and generic prescription. For more information, call 1-800-444-4106 or visit http://www.togetherrxaccess.com/ [45]

RX Hope – this program is for helping people who cannot afford to pay for prescriptions. https://www.rxhope.com/ [46]

RX Assist – is a patient assistance program directory that also includes information about any programs that include drug discount cards, prescription assistance programs, programs that help with medication co-pays, programs that provide free and low cost health care, also information for Medicare Part D beneficiaries. Click here to visit http://www.rxassist.org/ [47]

Needy Meds [48] – is a directory that has a list of disease assistance programs with the program description and contact information. Click here to visit http://www.needymeds.org/ [49]

Below are some additional resources for individuals with kidney disease.

American Association of Kidney Patients (AAKP) [53] – is another kidney patient organization that can offer helpful educational resources on mental health conditions.

American Mental Health Alliance (AMHA) [54] – is a group that provides information about psychotherapy, counseling and mental health services.

American Psychological Association (APA) [55] – is a scientific organization that represents psychologists, but also has helpful resources for patients.

DaVita [56] – is one of the largest dialysis providers in the US and provides a lot of education resources for patients.

National Alliance on Mental Illness (NAMI) [57] – is another nonprofit organization dedicated to improving the mental health of Americans.

National Institute of Mental Health (NIMH) [58] – is the largest scientific organization in the world dedicated to research on mental health conditions.

Mental Health America (NMHA) [59] – is a nonprofit advocacy organization that works on mental health and substance use conditions.

World Health Organization (WHO) [60] – is the United Nation’s public health arm. This is another good source of basic information about mental health issues.

Center for Disease Control (CDC) [61] – is the national public health institute in the United States. They also have a lot of good basic scientific information for patients.