Psychological Interventions for End-Stage Renal Disease Patients’ Receiving Hemodialysis

Abstract

Hemodialysis is the lifesaving treatment for End-Stage Renal Disease (ESRD) patients; however, the treatment’s nature impacts the patient’s quality of life and mental health. Focusing on the mental health of patients receiving hemodialysis, the chapter draws attention to the psychological interventions that can improve patient’s quality of life. The mental health of ESRD patients receiving hemodialysis can be improved with cognitive-behavioral therapy, psychoeducation, relaxation techniques, peer support groups, spiritual therapy, and technology-based psychological interventions.

1. Introduction

Globally, hemodialysis is one of the most common forms of renal replacement therapy for End-Stage Renal Disease (ESRD) patients. Around 69% of all kidney replacement therapies and 89% of all dialysis treatments are performed via hemodialysis (HD) [1, 2]. HD is performed in the center; hence, the procedure requires frequent visits to the hospital or HD centers, often three times a week for three to four hours, as a result, patients’ normal living patterns are substantially altered [3, 4]. Moreover, HD treatment leads to weakness and fatigue along with the limitations of fluid and diet [5, 6]. In addition to these limitations, HD patients face social and financial challenges [7]. Hence, the logical implications of HD influence the patients’ life overall and impact their quality of life [8, 9, 10].

HD patients are not the only ones affected by the magnitude of change, but also their families, as they depend largely on their families to care for them and provide them with financial support [11, 12, 13, 14]. Even though HD treatment improved health maintenance and life extension, the quality of life of the patients is compromised by their survival treatment [15]. In a study [16], untreated depression in high prevalence among HD patients was reported and one of the main reason was the reluctance of patients toward psychotherapy.

A high proportion of patients receiving HD experience a compromised quality of life [17] and report mental health challenges due to adaptive difficulties during disease management [15, 18, 19]. Mental and emotional distress is associated with HD due to restrictions in lifestyle, the constant threat of death, and other physical symptoms that can discourage self-management among patients [20]. According to an estimation, one in five HD patients experience depression [21, 22]. Other commonly reported symptoms are stress, anxiety, fatigue, lowered self-esteem, and social isolation [23, 24, 25]. HD patients experience anxiety, depression, and poor quality of life [26]. These mental health problems impact the response of HD patients to their treatment [27]; hence, needs attention.

2. Psychological interventions

Psychological interventions are set of strategies that can be used to change behavior, cognition, or emotions [28]. It refers to relationships designed to increase an individual’s ability to adapt to a situation and optimize his or her personal resources in relation to autonomy, self-knowledge, and self-help [29]. Psychological interventions not only have the potential to reduce depression and anxiety among patients receiving hemodialysis [30] but also improves their quality of life [31, 32]. In other words, psychological interventions can promote mental health that can prevent the occurrence of psychological disorders, for example, depression. It is extremely important to understand that mental health is more than just the absence of mental disorders [33]. According to World Health Organization, mental health is described as:

“Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in” [33].

Therefore, it is important to improve the quality of life even in the absence of any mental health problem by fostering healthy thoughts and behaviors [34], which can be possible by incorporating psychological interventions in health care of HD patients. Hence, the use of psychological intervention with ESRD patients on maintenance HD is extremely important.

3. Psychological interventions for ESRD patients receiving HD

Psychological interventions can be effectively improving the mental health of ESRD patients receiving HD. These interventions are delivered either individually [35], in groups [36, 37], or by guided self-help [38, 39]. Cognitive-behavioral therapy (CBT), psychoeducation/educational interventions, relaxation techniques, peer support groups, spiritual therapy, technology-based psychological interventions, and other psychotherapeutic techniques are effective in improving the mental health of ESRD patients receiving HD (Figure 1) [40, 41].

Figure 1.

Psychological interventions for ESRD patients receiving HD.

3.1 Cognitive-behavioral therapy (CBT)

CBT is the widely used psychological intervention for HD patients [32]. It aims to develop a positive attitude toward hemodialysis by countering negative thoughts and improving the patients’ acceptance and understanding of their disease and HD [42]. Moreover, CBT helps to internalize HD patients’ locus of control [43]. Therefore, reduce depression [44, 45] and anxiety and improves quality of life of the patients undergoing HD [46, 47]. CBT is effective in increasing hope among ESRD patients receiving HD and dealing with their death anxiety [48].

The benefits of CBT extend into physical health as well. For instance, HD patients can benefit from CBT techniques, including sleep hygiene, to reduce their sleep disturbances [49, 50]. Furthermore, fluid control, which is integral to HD [51], can be achieved by using techniques such as reinforcement, self-monitoring, self-contracting, and other CBT techniques [52, 53]. Moreover, mindfulness meditation improves the biological markers of ESRD patients receiving HD [54]. BReF is specially designed CBT to reduce fatigue among ESRD patients receiving HD by creating consistent activity and rest routines throughout the day [55].

In a systematic review [56], it was concluded that the most promising psychological interventions were thought to be those that have cognitive and behavioral components. These findings highlight the importance of CBT for ESRD patients receiving HD. However, despite the evidence from the literature for the effectiveness of CBT in improving the quality of life and self-management among patients receiving HD patients, it is not being incorporated into practice [57].

3.2 Psychoeducation

Psychoeducation educates patients about the nature of their illness and how to manage the problems associated with illness [58]. These education-based psychological interventions for ESRD patients receiving HD are aimed to surge their capability of goal setting and health literacy [32]. ESRD patients receiving HD were when psycho-educated, it changed their understanding and some beliefs about their survival treatment; hence, improves adherence behavior toward treatment [59]. In the case of HD, psychoeducation is beneficial at any stage of HD, but when used either before starting HD or in the initial stage exhibits significant advantages [60]. Psychoeducation can be used to address anxiety and depression among hemodialysis [61]. Al saraireh, Aloush [62] preferred psychoeducation over CBT for depression among patients receiving HD. Family-based psychoeducation program is beneficial for HD patients and their families [63]. In most studies [61, 62, 64, 65], ESRD patients undergoing HD were educated about normal kidney function and renal failure, demonstration of the dialysis procedure, diet and fluid, hygiene, essential needed care, and renal replacement options. However, only a few studies included information about potential problem-solving skills, individual stress management, adaptive responses, such as muscle relaxation [61, 62] and emotion-focused coping strategies [64].

3.3 Relaxation techniques

Patients with ESRD who receive HD can benefit from relaxation techniques. Psychological interventions based on relaxation promote self-regulation, emotional, cognitive, and behavioral flexibility among ESRD patients receiving HD [32]. Moreover, literature illustrates that relaxation technique can improve sleep quality [66, 67, 68], activity level [69], adherence to HD and other biomedical markers [70] and reduces pain [71, 72], fatigue [73], depression [74], and anxiety [75] among patients’ receiving HD.

Relaxation techniques, including Benson’s relaxation technique [66, 67, 69, 70, 72, 74], progressive muscle relaxation [71, 75, 76], and music relaxation therapy [77], can help ESRD patients undergoing HD. These techniques can be used in combination with other relaxation techniques, for instance, Benson relaxation with progressive muscle relaxation [78] and music therapy [79]. Aerobic exercise with relaxation techniques can improve the psychological health of ESRD patients undergoing HD [80]. However, relaxation techniques were suggested to use consistently for longer time, for example, one month among hemodialysis patients [81]. Relaxation techniques can effectively reduce psychological symptoms and improve the quality of life among elderly ESRD patients receiving HD. Hence, it is recommended to use these relaxation techniques in hospitals or HD centers [67].

3.4 Peer support

Peer-to-peer support improves the quality of life [82], self-management [83], hope [84], and mental health [85, 86] of the HD patients undergoing. Moreover, physical outcomes among HD patients receiving were also reported due to peer support [87]. Patient’s “real knowledge” can be more beneficial to other patients undergoing hemodialysis if they share it with other fellow patients [83].

Peer to support benefits both; mentors and mentees in terms of knowledge, self-efficacy, and social support [88]. However, mentors should be trained prior to peer-to-peer mentoring about kidney disease, active listening, communication skills, privacy, and confidentiality [88]. Peer support sessions can also be moderators with the help of facilitators [84]. Generally, patients’ can be benefited from informational, spiritual, instrumental, and emotional support from their fellow patients undergoing maintenance hemodialysis [84]. Moreover, peer support groups promoting self-transcendence were found to improve physical health status and quality of life among HD patients [37].

Peer support for ESRD patients undergoing HD can be done face-to-face or remote. However, HD patients prefer face-to-face peer support instead of remote telephonic peer support [89]. Online peer support was found effective for adolescents [90] and pediatric HD patients [91]. In a study [83], peer support programs were suggested to introduced in the early phase of HD to ESRD patients. Early support from their peers can help them manage their problems and themselves. Although peer support is found effective in improving physical health and psychological well-being, it is not taken advantage of this psychological intervention [92].

3.5 Spiritual practices

ESRD undergoing HD who use their religious beliefs and practices to cope with their lifelong survival treatment are less likely to experience psychological problems [23, 93, 94]. Spiritual therapy was effectively used with patients’ receiving HD to improve their well-being [95], lifestyle [96], hope [97], resilience [98], and reducing their stress, anxiety, depression [99, 100].

In cases of HD, spiritual therapy proved especially effective since HD patients’ lifestyle changes have affected their quality of life and researchers found that spirituality improves quality of life [101, 102]. In this context, spiritual interventions became increasingly important for HD patients [103]. Through religious practices, reading religious books, listening to spiritual music, and changing perspectives, spiritual therapy promotes optimism, hope, gratitude, contemplation, patience, raising awareness, and addressing problems through religious beliefs [91, 95, 99, 104, 105]. Further, Hosseini, Naseri-Salahshour [106] found that HD-related fear of death can be addressed through religious counseling. Therefore, spiritual therapy should be utilized as a complement to health care to increase treatment effectiveness [99].

3.6 Tech-based psychological intervention

Digital technologies (e.g., websites, applications, VR, and telephone) have been increasingly incorporated to optimize HD patients’ quality of life. The use of technology-based psychological interventions is accepted, feasible, and needs minimum additional resources to address the mental health of patients on maintenance HD [107]. With the help of technology, it is possible to manage depression, anxiety, fatigue, self-efficacy, and self-management among patients receiving HD [108].

Psychological interventions with the help of digital technologies were tested in various forms with ESRD patients undergoing HD. The use of internet-based positive psychological interventions is an effective therapeutic option for HD patients with depression [109]. Internet-delivered CBT can reduce depression and anxiety among HD patients [110]. Further, therapist-guided Internet-based cognitive-behavioral therapy interventions address the problems associated with HD patients’ experience [111]. Video-based ACT can also help HD patients to cope with the challenges associated with HD [112]. App-based self-management intervention can potentially improve the self-efficacy and basic psychological needs of elderly HD patients [113]. Additionally, immersed virtual reality during HD proved to be an active detraction and has the potential to address dialysis-related problems [114].

On the other hand, in tablet-based educational and motivational interviewing interventions when used with patients during HD, certain problems were reported in the user interface [115]. Similarly, HD patients with depression seem not to benefit from guided internet-based self-help problem-solving therapy [116]. In a systematic review, Marin and Redolat [108], the majority of the tech-based psychological intervention studies focused on psychological symptoms associated with HD, and there is a scarcity of literature aiming to target the cognitive functioning of patients’ receiving HD. Hence, there is a need to carefully design the content and approachability of the psychological intervention of HD patients.

4. Conclusion

Psychological intervention in several forms also positively changes the HD experience for ESRD patients. Social activity, for instance, participating in theater play reduces depression and improves self-esteem among HD patients [117]. Motivational interviewing can improve the well-being of ESRD patients undergoing HD [32]. Counseling of ESRD patients undergoing HD can improve their quality of life [118]. Guided imagery has the potential to influence the psychological and physical health of hemodialysis patients [119]. These non-pharmacological psychological interventions are extremely important and should be part of the health care for ESRD patients undergoing HD [15] because HD is not merely a treatment procedure for ESRD it actually leads to the major lifestyle change that challenges patients’ mental health [19].