It took a long time for the nephrology community to appreciate depression as an important problem in patients with kidney failure treated by maintenance dialysis. Some believed that dialysis patients were depressed because dialysis is depressing. Although the pioneering work of Burton and colleagues1 and perhaps more importantly, Norman Levy,2 in psychonephrology conferences and publications, highlighted the ubiquity and gravity of the problem, independent relationships between a diagnosis of major depressive disorder or between depressive symptoms and adverse outcomes, including mortality, took decades to establish.