Psychosocial Interventions for Depressive and Anxiety Symptoms in Individuals with Chronic Kidney Disease: Systematic Review and Meta-Analysis

Global prevalence of depression in chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is commonly associated with psychosocial problems, especially depression, contributing to poor overall outcomes. Depression has not been given adequate priority in the management of CKD patients despite its significant adverse impact on all major outcomes. This systematic review and meta-analysis determined the pooled prevalence of clinical depression in the global CKD population and sub-populations.

METHODS

PubMed, African Journals Online (AJOL), and EMBASE were systematically searched to identify published articles with relevant data. The pooled prevalence of clinical depression in the global CKD population was determined using random effects meta-analytic techniques. The study protocol was registered with PROSPERO (CRD42022382708).

RESULTS

Sixty-five articles were included in this review, comprising 80,932 individuals with CKD from 27 countries. The participants' mean age ranged from 11.0 to 76.3 years. Most (70.4%) of the studies had medium methodological quality. The overall pooled prevalence of depression was 26.5% (95% CI 23.1-30.1%). Studies using the Diagnostic Statistical Manual for Mental Diseases (DSM) and International Classification of Disease (ICD) returned a pooled prevalence of 25.5% and 39.6%, respectively, p = 0.03. There was a significant difference in the pooled prevalence across regions; p = 0.002.The prevalence of depression was higher among individuals on chronic hemodialysis compared to pre-dialysis patients (29.9% versus 18.5%; p = 0.01) and among those on hemodialysis compared to peritoneal dialysis (30.6% versus 20.4%; p = 0.04). There was no significant difference between adults and children (26.8% versus 15.9%, p = 0.21). There was an increasing temporal trend in depression prevalence, though this did not achieve statistical significance (p = 0.16).

CONCLUSION

Depression is common in patients with CKD. The findings of this study highlight the need for clinicians to make efforts to evaluate individuals with CKD for depression, especially those with advanced stages of the disease.

Pharmacological and psychological treatment of depression and anxiety among hemodialyzed patients - a review

Purpose

An overview of the current pharmacological treatment and psychosocial interventions, such as cognitive-behavioral therapy and breathing exercises, for depression and anxiety among hemodialyzed patients (HD).

Views

Depression and anxiety are common problems among HD patients, influencing their mortality and morbidity; however, they are often under-recognized and under-treated. Even though the topic is attracting more scientific attention there are still only few studies about methods of treatment for those disorders. Moreover, there are no clear guidelines on pharmacological therapy, which may prove to be difficult among patients with decreased renal function. Psychological interventions such as cognitive-behavioral therapy may be useful in treatment of these mental disorders among HD patients, though reports on the effects of such interventions are scarce.

Conclusions

This review outlines some of the current approaches to the treatment of mental disorders among HD patients that use both antidepressants and therapeutic methods. There is an urgent need for randomized clinical trials of both psychosocial and pharmacological interventions in treatment of depressive and anxiety disorders. Currently, both methods seem to be useful; however, they should be implemented with caution until clear guidelines are developed.

Development of a competency framework for the Assistant Wellbeing Practitioner (Renal) role

BACKGROUND

Many people with kidney disease experience comorbid mental health difficulties that result in worse physical health outcomes alongside greater personal, treatment and societal costs.

PROBLEM

Workforce expansion to treat comorbid mental health difficulties has focussed on psychological practitioners. This fails to capitalise on benefits arising from embedding roles to address biopsychosocial outcomes directly within the renal specialty. A competency framework to inform development and training for such a role has not been developed.

METHODS

Five-phase process to develop a competency framework for an Assistant Wellbeing Practitioner (Renal) role. Following identification of competency frameworks for roles in psychological practice, health and social care, relevant competencies were synthesised to create a draft competency framework. This framework was revised through consultation events with professionals associated with the renal specialty and Kidney Patient Involvement Network with the framework informing a competency map.

RESULTS

The competency map comprised three categories-Knowledge, Values and Principles, Core Skills and Meta-Competencies with specific competencies for an assistant practitioner role to work within the renal specialty identified. Core knowledge and skills included awareness of kidney treatments and common psychosocial difficulties, collaborative care and supporting evidence-based prevention approaches.

CONCLUSIONS

Competencies associated with the Assistant Wellbeing Practitioner (Renal) role have the potential to promote mental wellbeing, better physical health and generate social and economic benefits. The competency map can inform training and role evaluation, although addressing implementation issues associated with commissioning physical and mental healthcare is required.

Effect of psychosocial interventions for depression in adults with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

People with chronic kidney disease (CKD) treated with dialysis are frequently affected by depression. Psychotherapy has been reported to decrease depressive symptoms in various chronic diseases and is a potential treatment option for depression. We aimed to perform a systematic review and meta-analysis to evaluate the effect of psychotherapy on depression in adults with CKD.

METHODS

We searched MEDLINE, Embase, Web of Science, and Cochrane for published studies up to October 31, 2023. Two investigators independently reviewed the included studies and extracted relevant data. Randomized controlled trials (RCTs) assessing the impact of interventions that provide psychological, emotional, or social support without the use of pharmacological substances on depressive symptoms in people with CKD were included and summarized. Scores on different tools for depressive assessment and quality of life were pooled.

RESULTS

A total of 19 RCTs published between 2004 and 2023 were included and analyzed. The weighted mean difference (WMD) for all included studies with regard to depression was - 2.32 (95%CI=-3.83, -0.80, P = 0.003). The WMD for Beck Depression Inventory (BDI) score of depression was - 3.27 (95%CI=-7.81, 1.27, P = 0.158) with significant heterogeneity (I2 = 95.1%). Significant WMD was detected for the Hospital Anxiety and Depression Scale (HADS) tool: WMD=-1.90, 95%CI=-2.91, -0.90, P < 0.001. The WMD for all included studies regarding quality of life was 1.21 (95%CI=-0.51, 2.93, P = 0.168). The WMD for Kidney Disease Quality of Life Short Form (KDQOL-SF) score was 4.55 (95%CI = 0.50, 8.60, P = 0.028). The WMD for SF-36 score was 0.02 (95%CI=-10.33, 10.36, P = 0.998). Significant difference on outcomes of S-PRT scale was observed (WMD = 2.42, 95%CI = 1.07, 3.76, P < 0.001).

CONCLUSIONS

Psychosocial interventions probably reduce the depression level among CKD patients. Preliminary evidence suggests that psychosocial interventions might be beneficial for the quality of life in CKD patients. Our results provide medical facilities with an evidence-based basis for establishing psychosocial interventions in kidney care settings.

Sleep quality and associated factors among patients with chronic kidney disease in Nigeria: a cross-sectional study

OBJECTIVE

Poor sleep quality adversely affects the overall well-being and outcomes of patients with chronic kidney disease (CKD). However, it has not been well studied in Africans with CKD. We determined the prevalence of poor sleep quality and associated factors among patients with CKD.

DESIGN

This was a cross-sectional study that involved patients with CKD .

SETTINGS

The study was carried out in the outpatient clinic of nine hospitals in Nigeria.

METHODS

Sleep quality, depressive and anxiety symptoms and quality of life (QoL) were assessed among 307 patients with CKD using Pittsburgh Sleep Quality Index Questionnaire, Hospital Anxiety Depression Scale Questionnaire and 12-item Short Form Health Survey Quality of Life Questionnaire, respectively. The prevalence of poor sleep quality and associated factors were determined. A p<0.05 was considered as statistically significant.

RESULTS

The mean age of the study participants was 51.40±15.17 years. The male:female ratio was 1.5:1 One hundred and twenty-one (39.4%) of the patients were on maintenance haemodialysis (MHD). The prevalence of poor sleep quality, anxiety symptoms and depressive symptoms among the patients was 50.2%, 37.8% and 17.6%, respectively. The prevalence of poor sleep quality in the CKD stages 3, 4, 5 and 5D was 38.1%, 42.6%, 52.2% and 58.7%, respectively. The prevalence of poor sleep quality was significantly higher in MHD patients compared with predialysis CKD (59.5% vs 43.6%; p=0.008). Factors associated with poor sleep quality were CKD stage (p=0.035), anaemia (p=0.003), pruritus (p=0.045), anxiety symptoms (p≤0.001), depressive symptoms (p≤0.001) and reduced QoL (p≤0.001). On multivariate analysis, factors associated with poor sleep were anxiety (AOR 2.19; 95% CI 1.27 to 3.79; p=0.005), anaemia (AOR 5.49; 95% CI 1.43 to 21.00;p=0.013) and reduced physical component of QoL (AOR 4.11; 95% CI 1.61 to 10.47; p=0.003).

CONCLUSION

Poor sleep quality is common among patients with CKD especially in the advanced stage. The significant factors associated with poor sleep quality were QoL, anaemia and anxiety symptoms. These factors should be adequately managed to improve the overall outcomes of patients with CKD.

The effect of psychosocial interventions on depression, anxiety, and quality of life in hemodialysis patients: a systematic review and a meta-analysis

PURPOSE

Hemodialysis has become a standard therapy for adults with end-stage renal diseases. Adults undergoing hemodialysis have to cope with unique psychological issues that make their care journey particularly fatiguing. In this systematic review and meta-analysis, we aimed to summarize and evaluate the effects of psychosocial interventions on the reduction of anxiety and depression in adults with HDs.

METHODS

We included randomized controlled trials and quasi-experimental studies that measure change in depression, anxiety, and quality of life.

RESULTS

We identify three categories of psychosocial interventions delivered to adults undergoing hemodialysis. Based on our analysis, there was a medium effect of psychosocial intervention on depression (SMD - 0.85, 95%CI - 1.17; - 0.52, I2 = 80%, p < 0.01) and anxiety (SMD - 0.99, 95%CI - 1.65; - 0.33, I2 = 88%, p < 0.01) in adults undergoing hemodialysis.

CONCLUSIONS

Psychosocial interventions, such as psychological support or relaxation-based therapy, seems all to reduce depression and anxiety in adults undergoing HD. Preliminary evidence suggests that there may be a benefit of psychosocial interventions on the quality of life for adults undergoing HD.

Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis

An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.

Child and caregiver perspectives on access to psychosocial and educational support in pediatric chronic kidney disease: a focus group study

BACKGROUND

Children with chronic kidney disease (CKD) generally have worse educational and psychosocial outcomes compared with their healthy peers. This can impair their ability to manage their treatment, which in turn can have long-term health consequences through to adulthood. We attempted to capture the experiences of children with CKD and to describe the perspectives of their parents and caregivers on access to educational and psychosocial support.

METHODS

Children with CKD (n = 34) and their caregivers (n = 62) were sampled via focus groups from pediatric hospitals in Australia, Canada, and the USA. Sixteen focus groups were convened and the transcripts were analyzed thematically.

RESULTS

We identified four themes: disruption to self-esteem and identity (emotional turmoil of adolescence, wrestling with the sick self, powerlessness to alleviate child's suffering, balancing normality and protection); disadvantaged by lack of empathy and acceptance (alienated by ignorance, bearing the burden alone); a hidden and inaccessible support system (excluded from formal psychological support, falling behind due to being denied special considerations); and building resilience (finding partners in the journey, moving towards acceptance of the illness, re-establishing childhood).

CONCLUSIONS

Children with CKD and their caregivers encountered many barriers in accessing psychosocial and educational support and felt extremely disempowered and isolated as a consequence. Improved availability and access to psychosocial and educational interventions are needed to improve the wellbeing and educational advancement of children with CKD. A higher resolution version of the Graphical abstract is available as Supplementary information.

eHealth to Improve Psychological Functioning and Self-Management of People With Chronic Kidney Disease: A Randomized Controlled Trial

OBJECTIVE

Psychological distress is common among patients with chronic kidney disease and can interfere with disease self-management. We assessed the effectiveness of the personalized E-GOAL electronic health care pathway with screening and cognitive-behavioral therapy including self-management support, aimed to treat psychological distress and facilitate self-management among people with chronic kidney disease not on dialysis ( N = 121).

METHODS

Primary outcome of the open two-arm parallel randomized controlled trial in four Dutch hospitals was psychological distress at posttest directly after the intervention and at 3-month follow-up. Secondary outcomes were physical and mental health-related quality of life, self-efficacy, chronic disease self-management, and personalized outcomes, that is, perceived progress compared with the previous time point on functioning (e.g., mood or social functioning) and self-management (e.g., dietary or medication adherence) outcomes that were prioritized by each individual.

RESULTS

Linear mixed-effects analyses showed no significant time-by-group interaction effects for psychological distress, health-related quality of life, self-efficacy, and chronic condition self-management, whereas analyses of covariance showed significantly more perceived progress in the intervention group at posttest on personally prioritized areas of functioning ( b = 0.46, 95% confidence interval = 0.07-0.85) and self-management ( b = 0.55, 95% confidence interval = 0.16-0.95), with Cohen d values of 0.46 and 0.54 (medium effects), respectively. Effects on personalized outcomes were maintained at follow-up.

CONCLUSIONS

Compared with regular care only, the electronic health intervention did not reduce psychological distress, whereas personalized outcomes did improve significantly after intervention. Future studies could consider personalized outcomes that reflect individually relevant areas and treatment goals, matching person-tailored treatments.

TRIAL REGISTRATION

Registered at the Netherlands Trial Register with study number NTR7555 ( https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7555 ).

Validation of Two Screening Tools for Anxiety in Hemodialysis Patients

Background: Symptoms of anxiety are often unrecognized and untreated in dialysis patients. We investigated the diagnostic accuracy of two widely used screening tools for anxiety in hemodialysis patients. Methods: For this cross-sectional validation study, chronic hemodialysis patients from eight dialysis centers in the Netherlands were included. The Beck Anxiety Inventory (BAI) and Hospital Anxiety and Depression Scale—Anxiety subscale (HADS-A) were validated by the Mini International Neuropsychiatric Inventory (MINI) diagnostic interview. Receiver operating characteristic curves were used to determine the optimal cut-off values. Results: Of 65 participants, 13 (20%) were diagnosed with one or more anxiety disorders on the MINI, of which 5 were included in the analysis. ROC curves showed a good diagnostic accuracy of the BAI and HADS-A. The optimal cut-off value for the BAI was ≥13 (sensitivity 100%, specificity 85%) and for the HADS-A was ≥10 (sensitivity 80%, specificity 100%). Conclusions: Based on our limited data, both the BAI and the HADS-A seem to be valid screening instruments for anxiety in hemodialysis patients that can be used in routine dialysis care. The HADS-A consists of fewer items and showed fewer false-positive results than the BAI, which might make it more useful in clinical practice.

Effectiveness of a brief positive skills intervention to improve psychological adjustment in patients with end-stage kidney disease newly initiated on haemodialysis: protocol for a randomised controlled trial (HED-Start)

INTRODUCTION

Initiation onto haemodialysis is a critical transition that entails multiple psychosocial and behavioural demands that can compound mental health burden. Interventions guided by self-management and cognitive-behavioural therapy to improve distress have been variably effective yet are resource-intensive or delivered reactively. Interventions with a focus on positive affect for patients with end-stage kidney disease are lacking. This study will seek (1) to develop a positive life skills intervention (HED-Start) combining evidence and stakeholder/user involvement and (2) evaluate the effectiveness of HED-Start to facilitate positive life skills acquisition and improve symptoms of distress and adjustment in incident haemodialysis patients.

METHODS AND ANALYSIS

This is a single/assessor-blinded randomised controlled trial (RCT) to compare HED-Start to usual care. In designing HED-Start, semistructured interviews, a codesign workshop and an internal pilot will be undertaken, followed by a two-arm parallel RCT to evaluate the effectiveness of HED-Start. A total of 148 incident HD patients will be randomised using a 1:2 ratio into usual care versus HED-Start to be delivered in groups by trained facilitators between January 2021 and September 2022. Anxiety and depression will be the primary outcomes; secondary outcomes will be positive and negative affect, quality of life, illness perceptions, self-efficacy, self-management skills, benefit finding and resilience. Assessments will be taken at 2 weeks prerandomisation (baseline) and 3 months postrandomisation (2 weeks post-HED-Start completion). Primary analyses will use an intention-to-treat approach and compare changes in outcomes from baseline to follow-up relative to the control group using mixed-effect models.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nanyang Technological University Institutional Review Board (IRB-2019-01-010). Written informed consent will be obtained before any research activities. Trial results will be disseminated via publications in peer-reviewed journals and conference presentations and will inform revision(s) in renal health services to support the transition of new patients to haemodialysis.

TRIAL REGISTRATION NUMBER

NCT04774770.

Brief Mindfulness Intervention vs. Health Enhancement Program for Patients Undergoing Dialysis: A Randomized Controlled Trial

Background: Between 20–50% of patients undergoing maintenance dialysis for end-stage kidney disease experience symptoms of depression and/or anxiety, associated with increased mortality, greater health care utilization, and decreased quality of life. It is unknown whether mindfulness-based interventions can improve depression and anxiety symptoms in patients receiving this treatment. Methods: We conducted an 8-week multicenter randomized controlled trial comparing a brief mindfulness intervention (BMI) vs. an active control (Health Enhancement Program [HEP]) in 55 patients receiving dialysis with symptoms of depression and/or anxiety. The primary outcome was change in Patient Health Questionnaire-9 (PHQ-9) depression scores, with a primary analysis in participants with baseline PHQ-9 ≥ 10, and a secondary analysis including all participants. The secondary outcome was change in Generalized Anxiety Disorder-7 (GAD-7) anxiety scores with corresponding primary and secondary analyses. Results: Both BMI and HEP reduced depressive symptoms, with no difference between trial arms (PHQ-9 change = −7.0 vs. −6.1, p = 0.62). BMI was more effective than HEP in reducing anxiety (GAD-7 change = −8.7 vs. −1.4, p = 0.01). Secondary analyses revealed no differences between arms. Conclusions: For patients undergoing dialysis, both BMI and HEP may be helpful interventions for depression symptoms, and BMI may be superior to HEP for anxiety symptoms. Mindfulness-based and other psychosocial interventions may be further evaluated in those undergoing dialysis as treatment options for symptoms of depression and anxiety.

Prevalence and risk factors for elevated anxiety symptoms and anxiety disorders in chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

Anxiety is associated with poor health outcomes among chronic kidney disease (CKD) patients. This review summarizes the prevalence and risk factors associated with elevated anxiety symptoms and disorders among CKD patients.

METHODS

Articles evaluating the prevalence and risk factors associated with elevated anxiety symptoms and disorders among CKD patients, as diagnosed via DSM 4th or 5th edition criteria, clinical interviews or validated questionnaires, were searched in Medline®, Embase®, PsychINFO® and CINAHL®. Using random-effects meta-analyses, the prevalence of elevated anxiety symptoms and disorders were estimated. A narrative review on the risk factors associated with elevated anxiety symptoms and disorders was presented.

RESULTS

From 4941 articles, 61 studies were included. The pooled prevalence of anxiety disorders (9 studies, n = 1071) among CKD patients across studies was 19% while that of elevated anxiety symptoms (52 studies, n = 10,739) was 43%. Across continents, prevalence of elevated anxiety symptoms was highest in Europe and Asia. Between pre-dialysis and dialysis patients, the prevalence of elevated anxiety symptoms was not statistically different at 31% and 42% respectively. Common risk factors associated with elevated anxiety symptoms included concomitant depression, lower parathyroid hormone levels, increased comorbidities, increased duration of hospitalization, reduced perceived quality of life, and decreased vitality levels.

CONCLUSION

Given the high prevalence of anxiety disorders and elevated anxiety symptoms, more studies are required to assess the role and outcomes of anxiety screening among CKD patients. This could facilitate early identification of at-risk patients and potentially improve their clinical outcomes.

Assessment of psychological distress in end stage renal disease: is it spirituality related?

Introduction

Patients undergoing hemodialysis (HD) are faced with bearing this burden and report poor mental health. Spirituality can be a key factor in managing these problems among HD patients.

Aim

This cross-sectional study aimed at exploring possible factors that are associated with psychological distress among HD patients and testing its relation to spirituality.

Methods

HD patients were recruited from six dialysis units in Greece. Psychological distress was assessed using the scale Symptom Check List 90-R and spirituality using the Facit Sp-12 questionnaire. In addition, a special design questionnaire regarding demographic, social, and clinical characteristic was administrated.

Results

According to the results, factors such age, gender, marital status and area of residence are associated with psychological distress, while dimensions of spirituality such Meaning in Life and Peace can have a positive influence on psychological distress.

Conclusion

This study highlights the vital role of spirituality, which can act as a mechanism for managing stressful situations. In particular, this study highlights the positive effect of the meaning and purpose of life, as well as the role of peace and harmony.

A psychosocial intervention for individuals with advanced chronic kidney disease: A feasibility randomized controlled trial

AIM

The current study evaluated the feasibility and preliminary efficacy of a psychosocial intervention, the Kidney Optimal Health Program, in reducing symptoms of depression and anxiety in individuals with advanced chronic kidney disease.

METHODS

Patients with stage 4 or 5 chronic kidney disease were randomized to either a nine-session psychosocial intervention programme or usual care. Feasibility was assessed through recruitment and retention rates and programme acceptability. Participants completed assessments of depression, anxiety and psychosocial health at baseline and at 3-, 6- and 12-month follow-up. A repeated-measures analysis of variance was used to compare groups on outcomes over time.

RESULTS

One hundred and twenty-eight patients were screened for eligibility; 84 consented to participant and were randomized to receive the intervention (N = 42) or usual care (N = 42). 27 (32.1%) participants withdrew prior to baseline assessment. Of those who completed the baseline assessment (N = 57), trial retention was high (75.4% at 3-month, 80.7% at 6-month and 70.2% at 12-month follow-up). Participants reported high levels of programme acceptability. The patients who completed the intervention (N = 17) demonstrated significantly decreased depression at 12-month follow-up compared to the usual care group (N = 13).

CONCLUSION

The results support the feasibility of the Kidney Optimal Health Program intervention in recruitment, retention and programme acceptability with an improved screening protocol. Preliminary support is provided for improvement in depressive symptoms in patients with advanced chronic kidney disease. Further investigation through a fully powered randomized controlled trial is warranted.

The effects of cognitive behavioural therapy on depression and quality of life in patients with maintenance haemodialysis: a systematic review

BACKGROUND

Depression is highly prevalent among Haemodialysis (HD) patients and is known to results in a series of adverse outcomes and poor quality of life (QoL). Although cognitive behavioural therapy (CBT) has been shown to improve depressive symptoms and QoL in other chronic illness, there is uncertainty in terms of the effectiveness of CBT in HD patients with depression or depressive symptoms.

METHODS

All randomised controlled trials relevant to the topic were retrieved from the following databases: CINHAL, MEDLINE, PubMed, PsycINFO and CENTRAL. The grey literature, specific journals, reference lists of included studies and trials registers website were also searched. Data was extracted or calculated from included studies that had measured depression and quality of life using valid and reliable tools -this included mean differences or standardised mean differences and 95% confidence intervals. The Cochrane risk of bias tool was used to identify the methodological quality of the included studies.

RESULTS

Six RCTs were included with varying methodological quality. Meta-analysis was undertaken for 3 studies that employed the CBT versus usual care. All studies showed that the depressive symptoms significantly improved after the CBT. Furthermore, CBT was more effective than usual care (MD = - 5.28, 95%CI - 7.9 to - 2.65, P = 0.37) and counselling (MD = - 2.39, 95%CI - 3.49 to - 1.29), while less effective than sertraline (MD = 2.2, 95%CI 0.43 to 3.97) in alleviating depressive symptoms. Additionally, the CBT seems to have a beneficial effect in improving QoL when compared with usual care, while no significant difference was found in QoL score when compared CBT with sertraline.

CONCLUSIONS

CBT may improve depressive symptoms and QoL in HD patients with comorbid depressive symptoms. However, more rigorous studies are needed in this field due to the small quantity and varied methodological quality in the identified studies.

Enhancement of Adherence to Therapeutic and Lifestyle Recommendations Among Hemodialysis Patients: An Umbrella Review of Interventional Strategies

Objective

To systematically retrieve and condense the best possible evidence on the successful interventions that targeted enhancement of therapeutic and lifestyle recommendations adherence in hemodialysis patients (HDPs).

Design

An umbrella review of interventional studies.

Data Sources

A comprehensive search of the Cochrane Database of Systematic Reviews, Ovid, PubMed, Scopus, EMBASE and Web of science databases to identify relevant publications in 2000–2018 (June) timeframe.

Study Selection

Two reviewers independently applied inclusion criteria to select potential systematic reviews assessing the successful interventions that targeted enhancement of therapeutic and lifestyle recommendations adherence in HDPs. Data were summarized for information about the first author(s)’ names, year of publication, type(s) of the intervention and output variables, main findings and also the applied quality appraisal tools in the retrieved research evidence.

Data Extraction

Eligible studies were selected and data were extracted independently by two reviewers. The Joanna Briggs Institute (JBI)’s critical appraisal tool for systematic reviews was used to assess the quality of the identified publications, and discrepancies were resolved by consensus with a third reviewer.

Data Synthesis

Thirteen systematic reviews (12 solely systematic reviews and 1 systematic review with meta-analyses) were eligible to be enrolled in the study. The range of interventions that had been reported to boost therapeutic and lifestyle recommendations adherence in HDPs’ included psycho-educational programs, physical activity enhancement initiatives, information technology (IT)-based interventions and aromatherapy. Depression, diet biomarkers and interdialytic weight gain (IDWG) were among the myriad of output variables that had been measured as proxies to assess impacts of the implemented interventions. Psycho-educational interventions were among the prevalent initiatives to boost therapeutic and lifestyle recommendations adherence among the HDPs.

Conclusion

This umbrella review revealed that various intervention approaches and strategies can be used for HDPs' better therapeutic and lifestyle recommendations adherence with considerable methodological heterogeneity. The pinpointed research evidence is also supporting application of multifaceted interventional modalities to reach an improved acquiescence form the patients’ side and their families. Further studies are recommended to address the interactions across various interventions in discordant socio-cultural contexts.

Psychosocial interventions for preventing and treating depression in dialysis patients

BACKGROUND

People with end-stage kidney disease (ESKD) treated with dialysis are frequently affected by major depression. Dialysis patients have prioritised depression as a critically important clinical outcome in nephrology trials. Psychological and social support are potential treatments for depression, although a Cochrane review in 2005 identified zero eligible studies. This is an update of the Cochrane review first published in 2005.

OBJECTIVES

To assess the effect of using psychosocial interventions versus usual care or a second psychosocial intervention for preventing and treating depression in patients with ESKD treated with dialysis.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Register of Studies up to 21 June 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of psychosocial interventions for prevention and treatment of depression among adults treated with long-term dialysis. We assessed effects of interventions on changes in mental state (depression, anxiety, cognition), suicide, health-related quality of life (HRQoL), withdrawal from dialysis treatment, withdrawal from intervention, death (any cause), hospitalisation and adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results for continuous outcomes were expressed as a mean difference (MD) or as a standardised mean difference (SMD) when investigators used different scales. Dichotomous outcomes were expressed as risk ratios. All estimates were reported together with 95% confidence intervals (CI).

MAIN RESULTS

We included 33 studies enrolling 2056 participants. Twenty-six new studies were added to this 2019 update. Seven studies originally excluded from the 2005 review were included as they met the updated review eligibility criteria, which have been expanded to include RCTs in which participants did not meet criteria for depression as an inclusion criterion. Psychosocial interventions included acupressure, cognitive-behavioural therapy, counselling, education, exercise, meditation, motivational interviewing, relaxation techniques, social activity, spiritual practices, support groups, telephone support, visualisation, and voice-recording of a psychological intervention. The duration of study follow-up ranged between three weeks and one year. Studies included between nine and 235 participants. The mean study age ranged between 36.1 and 73.9 years. Random sequence generation and allocation concealment were at low risk of bias in eight and one studies respectively. One study reported low risk methods for blinding of participants and investigators, and outcome assessment was blinded in seven studies. Twelve studies were at low risk of attrition bias, eight studies were at low risk of selective reporting bias, and 21 studies were at low risk of other potential sources of bias. Cognitive behavioural therapy probably improves depressive symptoms measured using the Beck Depression Inventory (4 studies, 230 participants: MD -6.10, 95% CI -8.63 to -3.57), based on moderate certainty evidence. Cognitive behavioural therapy compared to usual care probably improves HRQoL measured either with the Kidney Disease Quality of Life Instrument Short Form or the Quality of Life Scale, with a 0.5 standardised mean difference representing a moderate effect size (4 studies, 230 participants: SMD 0.51, 95% CI 0.19 to 0.83) , based on moderate certainty evidence. Cognitive behavioural therapy may reduce major depression symptoms (one study) and anxiety, and increase self-efficacy (one study). Cognitive behavioural therapy studies did not report hospitalisation. We found low-certainty evidence that counselling may slightly reduce depressive symptoms measured with the Beck Depression Inventory (3 studies, 99 participants: MD -3.84, 95% CI -6.14 to -1.53) compared to usual care. Counselling reported no difference in HRQoL (one study). Counselling studies did not measure risk of major depression, suicide, or hospitalisation. Exercise may reduce or prevent major depression (3 studies, 108 participants: RR 0.47, 95% CI 0.27 to 0.81), depression of any severity (3 studies, 108 participants: RR 0.69, 95% CI 0.54 to 0.87) and improve HRQoL measured with Quality of Life Index score (2 studies, 64 participants: MD 3.06, 95% CI 2.29 to 3.83) compared to usual care with low certainty. With moderate certainty, exercise probably improves depression symptoms measured with the Beck Depression Inventory (3 studies, 108 participants: MD -7.61, 95% CI -9.59 to -5.63). Exercise may reduce anxiety (one study). No exercise studies measured suicide risk or withdrawal from dialysis. We found moderate-certainty evidence that relaxation techniques probably reduce depressive symptoms measured with the Beck Depression Inventory (2 studies, 122 participants: MD -5.77, 95% CI -8.76 to -2.78). Relaxation techniques reported no difference in HRQoL (one study). Relaxation studies did not measure risk of major depression or suicide. Spiritual practices have uncertain effects on depressive symptoms measured either with the Beck Depression Inventory or the Brief Symptom Inventory (2 studies, 116 participants: SMD -1.00, 95% CI -3.52 to 1.53; very low certainty evidence). No differences between spiritual practices and usual care were reported on anxiety (one study), and HRQoL (one study). No study of spiritual practices evaluated effects on suicide risk, withdrawal from dialysis or hospitalisation. There were few or no data on acupressure, telephone support, meditation and adverse events related to psychosocial interventions.

AUTHORS' CONCLUSIONS

Cognitive behavioural therapy, exercise or relaxation techniques probably reduce depressive symptoms (moderate-certainty evidence) for adults with ESKD treated with dialysis. Cognitive behavioural therapy probably increases health-related quality of life. Evidence for spiritual practices, acupressure, telephone support, and meditation is of low certainty . Similarly, evidence for effects of psychosocial interventions on suicide risk, major depression, hospitalisation, withdrawal from dialysis, and adverse events is of low or very low certainty.

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review

Background:

Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear.

Objective:

To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics.

Design:

Scoping review.

Setting:

Databases included Medline, EMBASE, Cochrane, and CINAHL.

Patients:

Patients followed in multidisciplinary CKD clinics globally.

Measurements:

Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes.

Methods:

We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes.

Results:

40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m² or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported.

Limitations:

Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom.

Conclusions:

There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics.

Trial registration:

Not applicable.

Psychosocial interventions for stroke survivors, carers and survivor-carer dyads: a systematic review and meta-analysis

Objective: To evaluate the effectiveness of psychosocial interventions on depressive symptoms, anxiety symptoms, quality of life, self-efficacy, coping, carer strain and carer satisfaction among stroke survivors, carers and survivor-carer dyads. Data sources: MEDLINE, CINAHL, PsycINFO, SocINDEX, Cochrane Library, Web of Science and Scopus databases and the grey literature were searched up to September 2018. Methods: A systematic review and meta-analysis of randomized controlled trials of psychosocial interventions for stroke survivors, carers and survivor-carer dyads, compared to usual care. Outcomes measured were depressive symptoms, anxiety symptoms, quality of life, coping, self-efficacy, carer strain, and carer satisfaction. Results: Thirty-one randomized controlled trials (n = 5715) were included in the systematic review which found improvements in depressive symptoms, anxiety symptoms, quality of life and coping, though the number of trials assessing each outcome varied. A meta-analysis (11 trials; n = 1280) on depressive symptoms found that in seven trials psychosocial interventions reduced depressive symptoms in stroke survivors (SMD: -0.36, 95% CI -0.73 to 0.00; p = .05) and in six trials reduced depressive symptoms in carers (SMD: -0.20, 95% CI -.40 to 0.00; p = .05). Conclusion: Psychosocial interventions reduced depressive symptoms in stroke survivors and their carers. There was limited evidence that such interventions reduced anxiety symptoms, or improved quality of life and coping for stroke survivors and carers and no evidence that they improved self-efficacy, carer strain or carer satisfaction.

Nonpharmacological Interventions for Depressive Symptoms in End-Stage Renal Disease: A Systematic Review

Depressive symptoms are common in patients with end-stage renal disease, which can affect treatment and prognosis. We aimed to evaluate the effects of nonpharmacological interventions for depressive symptoms in end-stage renal disease. Eligible studies were identified using PubMed, Web of Science, the Cochrane Library, Embase, and PsycNET (up to March 2019). We identified 24 studies including 1,376 patients. We found that psychological intervention (-0.60, 95% confidence interval [CI] = [-0.87, -0.33]), exercise (-1.13, 95% CI = [-1.56, -0.69]), and manual acupressure (-0.26, 95% CI = [-0.50, 0.03]) were associated with a significant effect on depressive symptoms. However, few studies reported adverse events, and conclusions about safety should be drawn cautiously. While the available data show that nonpharmacological interventions are potential strategies to alleviate depressive symptoms of patients with end-stage renal disease, recommendation of the most efficacious interventions for this population will require future randomized controlled trials with large-scale, long-term intervention.

"I Try Not to Even Think About My Health Going Bad": a Qualitative Study of Chronic Kidney Disease Knowledge and Coping Among a Group of Urban African-American Patients with CKD

CONTEXT

African-Americans with chronic kidney disease (CKD) are more likely to progress to end-stage renal disease (ESRD). However, African-Americans are less likely to receive care to delay progression of their CKD and to prepare for ESRD treatment.

OBJECTIVE

The objectives of the study are to understand knowledge among urban, African-American patients diagnosed with CKD and to discover ways they managed their illness and prepared for kidney disease progression.

DESIGN

A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation. All 23 participants identified as African-American and had CKD but had not yet reached ESRD requiring renal replacement therapy (RRT). Over half of the participants were women (57%), and the mean age was 53 years old.

RESULTS

Three themes emerged from the data. African-Americans often did not know the severity of their CKD. They struggled to complete all of the diet, exercise, and medication tasks recommended to manage their health conditions, including CKD. Finally, participants, even those with stage 5 CKD, viewed progression to RRT in the next 12 months as unlikely.

CONCLUSION

African-Americans face many barriers to CKD self-care and preparation for ESRD. Improving outcomes requires clinicians to help patients understand the severity of their CKD, to make informed choices about their care, all the while motivating patients to take actions to prevent CKD progression.

Assessment of Quality of Life in Chinese Patients With Inflammatory Bowel Disease and their Caregivers

BACKGROUND

Chronic diseases such as inflammatory bowel disease (IBD) usually affect the psychological status and health-related quality of life (HRQOL) of patients and their caregivers. The aim of this study was to evaluate the level of anxiety, depression, and HRQOL and find the risk factors predictive of HRQOL in IBD patients and their caregivers in a Chinese population.

METHODS

One hundred four adult patients with IBD, 102 family caregivers, and 99 healthy controls were enrolled. They completed self-administered surveys related to QOL and psychological questionnaires, including the Short Inflammatory Bowel Disease Questionnaire (patients only), the Short Form-36 Health Survey (SF-36), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS).

RESULTS

Both the mean SAS total score and the mean SDS total score among the patients and the caregivers were found to be significantly higher than those among the general population (P < 0.05). Total SF-36 score was significantly different between the patients and the general population (P = 0.001), and between caregivers and the general population (P = 0.011). The result showed that the total SF-36 score of the patients had a significant negative correlation with SAS score in the patients (P = 0.040), SDS score in the patients (P = 0.004), annual income (P = 0.036), use of biologicals (P = 0.028), frequency of hospitalization in the last year (P = 0.033), and severity of IBD (P = 0.021). The total SF-36 score of the caregivers was significantly and negatively correlated with SDS score in the caregivers (P = 0.010), SDS score in the patients (P = 0.010), use of biologicals (P = 0.013), and frequency of hospitalization in the last year (P = 0.010) of the patients.

CONCLUSIONS

A large proportion of IBD patients and their caregivers experience a high level of anxiety and depression and an impaired HRQOL. Higher levels of anxiety and depression, annual income, use of biologicals, higher frequency of hospitalization in the last year, and disease activity were independent predictors of reduced patient HRQOL; higher levels of depression in both caregivers and patients, use of biologicals, and frequency of hospitalization in the last year of the patients were independent predictors of reduced caregiver HRQOL.

Sense of meaning influences mental functioning in chronic renal patients

In this preliminary study, we examined whether aspects of spiritual well-being accounted for mental and physical health-related quality of life in 68 patients with end-stage renal disease, when controlling for age, type of treatment, physical symptoms, and worries. Hierarchical multiple regressions showed that meaning was associated with better mental health, while worry and physical symptoms also accounted for poor mental health. Faith and peace did not contribute to mental health. Older age, type of treatment (hemodialysis), and physical symptoms accounted for poor physical health. Our findings suggest that clinicians should include spiritual well-being in future interventions for end-stage renal disease patients.

Anxiety and depression in patients with end-stage renal disease: impact and management challenges - a narrative review

Psychiatric disorders commonly co-exist with the diagnosis of chronic kidney disease (CKD). Research on depression and CKD has increased to a great extent. Multiple studies have demonstrated that depression is more prevalent in CKD and that end-stage renal disease is a robust risk factor for adverse outcomes such as hospitalization and mortality, yet these are often underdiagnosed or untreated. This review provides a selective overview on the prevalence rates of depression and anxiety in patients with CKD and across renal replacement therapies, the factors most consistently associated with symptoms of distress and their clinical implications. Finally, treatment and management strategies from relevant literature are appraised and discussed.

Agomelatine versus paroxetine in treating depressive and anxiety symptoms in patients with chronic kidney disease

OBJECTIVE

Depressive and anxiety symptoms could affect the quality of life and prognostic outcomes in chronic kidney disease (CKD) patients, but only a few studies focus on the interventions to manage or prevent these symptoms in CKD patients. Therefore, this study was conducted to compare the efficacy and acceptability of agomelatine versus paroxetine in treating depressive and anxiety symptoms in CKD patients.

METHODS

CKD stage 2-4 patients with depressive and anxiety symptoms were included. The first patient was randomized in April 2013 and the last clinic visit occurred in March 2017. The included patients were randomly assigned to receive paroxetine 20-40 mg/day or agomelatine 25-50 mg/day. The treatment was continued for 12 weeks. The Hamilton Depression Rating Scale (HDRS) (17-item) and Hamilton Anxiety Rating Scale (HARS) were the primary outcome measures, and the response rate, remission rate, and Activities of Daily Living (ADL) scale were the secondary outcome measures. Meanwhile, the adverse events were recorded during the whole treatment period.

RESULTS

At baseline and week 4, both groups had similar average HDRS and HARS scores. But at week 8 and 12, compared to the patients receiving paroxetine, the patients receiving agomelatine had significantly lower average HDRS scores (p=0.002, p=0.001, respectively) and HARS scores (p<0.00001, p<0.00001, respectively). At week 12, the patients receiving agomelatine had a non-significantly lower average ADL score, and non-significantly higher response and remission rates. The adverse events in both groups were mild and transient.

CONCLUSION

These results demonstrated that the agomelatine had some advantages over par-oxetine in treating CKD stage 2-4 patients with depressive and anxiety symptoms, and future studies are needed to further explore its efficacy and acceptability.