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Improving hemodialysis in patient care: Critical areas
Patient Education and Counseling 81 (2010) 3–4
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Commentary
Improving hemodialysis in patient care: Critical areas Rolf A. Peterson Department of Psychology, George Washington University, 2125 G. St., N.W., Washington, DC 20052, USA
Two papers are reported in this issue of Patient Education and Counseling regarding dialysis patient adjustment and patient care. One, Kaptein et al. [1] focuses on a review of recent behavioral research and develops a recommended research agenda, while the other, by Ekelund and Andersson [2] involves extensive interviews and a qualitative approach to classifying major issues/concerns of dialysis patients. A vast majority of the proposed research agenda [1] directly relates to the primary areas of concern determined by the extensive patient interviews [2]. The Kaptein et al. research agenda includes a ‘‘common sense model) with a focus on illness perceptions and treatment perceptions. This model relates well to the Ekelund and Andersson report of patient concerns about treatment, consequences of treatment and illness and etc. All of the Ekelund and Andersson defined concerns/issues involve beliefs and perceptions and their recommendation to do individual depth interviews and develop a close working relationship between the patient and a multidisciplinary team should provide for support for the patient (and family) and greatly assist in improving quality of life. When moving beyond identifying factors related to, or a part of, poor psychological adjustment to the treatment and side effects of dialysis, the Kapstein et al. agenda includes ‘‘self-management interventions’’, which will be one very important approach to improving psychosocial functioning and quality of life. In one sense, the Eklund and Andersson interviewing method may serve as a selfmanagement intervention for some areas of the patient’s life. On the other hand, when it comes to dealing with some patient issues and problems, the interviewing information will need to lead to particular skill training, counseling, pharmacological treatment or formal psychotherapy therapy to change illness and treatment perceptions (a key future research area for Kaptein et al. and to deal with particular medical or psychological conditions. In both studies, the focus is on general adjustment and quality of life and I would suggest some key problem areas need to be integrated into the focus of the two articles to insure therapy is available for certain conditions and diagnosed psychopathology. Briefly, a major focus of research and patient care activities should include screening and treatment of pain problems [3], anxiety and depression disorders [4], as well as non-diagnostic levels of anxiety and depression which interfere with treatment and may exacerbate the side effects of treatment and greatly reduce quality of life. It has been reported that a significant number
E-mail address: [email protected]. 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.07.023
of dialysis patients experience levels of pain which interfere with functioning and quality of life [3] and 71% have a DSM-IV Axis 1 diagnosis (45.7% with anxiety disorder and 40% with a mood disorder) [4]. These conditions can result in a significant reduction in quality of life and can negatively impact physical health and exacerbate treatment side-effects. Thus, if these levels of pain and psychological problems are replicated, even if at somewhat lower levels, then they must be a significant focus of identification and treatment along with the themes identified by Kaptein et al. and Eklund and Andersson, who do include itching and pain as an issue. In terms of treatment, both psychopharmacological and psychotherapy treatments for pain, anxiety and depression, and probably also sleep [3], with dialysis patients need to be evaluated. On a positive note, and in line with the Kaptein et al. focus on changing illness and treatment perceptions, a recent study [5] has found that cognitive–behavioral group therapy effectively reduced depression among dialysis patients. Cognitive–behavioral and other treatment approaches need to be evaluated with anxiety as well depression. If 71% of dialysis patients have a diagnostic disorder (or even if it is only 30 or 40%), providing treatment for these disorders will be critical to quality of life and longevity of life for the dialysis patient. The final issue, which I think researchers and patient care professionals are fully aware, is a continued recognition of the burden imposed by the illness, treatment requirements and negative side-effects the dialysis patient must cope with on a daily basis. One way to not add to the demands on the patient is to develop service models in which information, interviews and therapy can be provided during the dialysis session. If models can be developed to provide services during dialysis, this should also increase the patient’s willingness to engage in discussions, training and/or therapy. On a personal note, when our research team tried to evaluate the effects of a social support group, even though over 60% of dialysis population we surveyed expressed a desire for such a group, almost all patients declined to attend when the sessions were held on non-dialysis days or involved any major change in their schedule. Thus, developing ‘‘during dialysis’’ service and treatment models should be added as a high priority for both research and patient care activities. References [1] Kaptein AA, van Dijk S, Broadbent E, Falzon L, Thong M, Dekker FW. Behavioural research in patients with end-stage renal disease: a review and research agenda. Patient Educ Couns 2010;81.
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R.A. Peterson / Patient Education and Counseling 81 (2010) 3–4
[2] Ekelund M-L, Andersson SI. ‘‘I need to lead my own life in any case’’. A study of patients in dialysis with or without a partner. Patient Educ Couns 2010;81. [3] Shayamsunder AK, Patel SS, Vivek J, Peterson RA, Kimmel PL. Sleepiness, sleeplessness and pain in end-stage renal disease: distressing symptoms for patients. Semin Dial 2005;18:109–18.
[4] Cukor D, Coplan J, Brown C, Friedman S, Newville H, Safier M, et al. Anxiety disorders in adults treated by hemodialysis: a single-center study. Am J Kidney Dis 2008;52:128–36. [5] Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive–behavioral group therapy is an effective treatment for major depression in hemodialysis patients. Kidney Int 2009;76:414–21.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Commentary
Improving hemodialysis in patient care: Critical areas Rolf A. Peterson Department of Psychology, George Washington University, 2125 G. St., N.W., Washington, DC 20052, USA
Two papers are reported in this issue of Patient Education and Counseling regarding dialysis patient adjustment and patient care. One, Kaptein et al. [1] focuses on a review of recent behavioral research and develops a recommended research agenda, while the other, by Ekelund and Andersson [2] involves extensive interviews and a qualitative approach to classifying major issues/concerns of dialysis patients. A vast majority of the proposed research agenda [1] directly relates to the primary areas of concern determined by the extensive patient interviews [2]. The Kaptein et al. research agenda includes a ‘‘common sense model) with a focus on illness perceptions and treatment perceptions. This model relates well to the Ekelund and Andersson report of patient concerns about treatment, consequences of treatment and illness and etc. All of the Ekelund and Andersson defined concerns/issues involve beliefs and perceptions and their recommendation to do individual depth interviews and develop a close working relationship between the patient and a multidisciplinary team should provide for support for the patient (and family) and greatly assist in improving quality of life. When moving beyond identifying factors related to, or a part of, poor psychological adjustment to the treatment and side effects of dialysis, the Kapstein et al. agenda includes ‘‘self-management interventions’’, which will be one very important approach to improving psychosocial functioning and quality of life. In one sense, the Eklund and Andersson interviewing method may serve as a selfmanagement intervention for some areas of the patient’s life. On the other hand, when it comes to dealing with some patient issues and problems, the interviewing information will need to lead to particular skill training, counseling, pharmacological treatment or formal psychotherapy therapy to change illness and treatment perceptions (a key future research area for Kaptein et al. and to deal with particular medical or psychological conditions. In both studies, the focus is on general adjustment and quality of life and I would suggest some key problem areas need to be integrated into the focus of the two articles to insure therapy is available for certain conditions and diagnosed psychopathology. Briefly, a major focus of research and patient care activities should include screening and treatment of pain problems [3], anxiety and depression disorders [4], as well as non-diagnostic levels of anxiety and depression which interfere with treatment and may exacerbate the side effects of treatment and greatly reduce quality of life. It has been reported that a significant number
E-mail address: [email protected]. 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.07.023
of dialysis patients experience levels of pain which interfere with functioning and quality of life [3] and 71% have a DSM-IV Axis 1 diagnosis (45.7% with anxiety disorder and 40% with a mood disorder) [4]. These conditions can result in a significant reduction in quality of life and can negatively impact physical health and exacerbate treatment side-effects. Thus, if these levels of pain and psychological problems are replicated, even if at somewhat lower levels, then they must be a significant focus of identification and treatment along with the themes identified by Kaptein et al. and Eklund and Andersson, who do include itching and pain as an issue. In terms of treatment, both psychopharmacological and psychotherapy treatments for pain, anxiety and depression, and probably also sleep [3], with dialysis patients need to be evaluated. On a positive note, and in line with the Kaptein et al. focus on changing illness and treatment perceptions, a recent study [5] has found that cognitive–behavioral group therapy effectively reduced depression among dialysis patients. Cognitive–behavioral and other treatment approaches need to be evaluated with anxiety as well depression. If 71% of dialysis patients have a diagnostic disorder (or even if it is only 30 or 40%), providing treatment for these disorders will be critical to quality of life and longevity of life for the dialysis patient. The final issue, which I think researchers and patient care professionals are fully aware, is a continued recognition of the burden imposed by the illness, treatment requirements and negative side-effects the dialysis patient must cope with on a daily basis. One way to not add to the demands on the patient is to develop service models in which information, interviews and therapy can be provided during the dialysis session. If models can be developed to provide services during dialysis, this should also increase the patient’s willingness to engage in discussions, training and/or therapy. On a personal note, when our research team tried to evaluate the effects of a social support group, even though over 60% of dialysis population we surveyed expressed a desire for such a group, almost all patients declined to attend when the sessions were held on non-dialysis days or involved any major change in their schedule. Thus, developing ‘‘during dialysis’’ service and treatment models should be added as a high priority for both research and patient care activities. References [1] Kaptein AA, van Dijk S, Broadbent E, Falzon L, Thong M, Dekker FW. Behavioural research in patients with end-stage renal disease: a review and research agenda. Patient Educ Couns 2010;81.
4
R.A. Peterson / Patient Education and Counseling 81 (2010) 3–4
[2] Ekelund M-L, Andersson SI. ‘‘I need to lead my own life in any case’’. A study of patients in dialysis with or without a partner. Patient Educ Couns 2010;81. [3] Shayamsunder AK, Patel SS, Vivek J, Peterson RA, Kimmel PL. Sleepiness, sleeplessness and pain in end-stage renal disease: distressing symptoms for patients. Semin Dial 2005;18:109–18.
[4] Cukor D, Coplan J, Brown C, Friedman S, Newville H, Safier M, et al. Anxiety disorders in adults treated by hemodialysis: a single-center study. Am J Kidney Dis 2008;52:128–36. [5] Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive–behavioral group therapy is an effective treatment for major depression in hemodialysis patients. Kidney Int 2009;76:414–21.