The effectiveness of acceptance and commitment therapy on clinical symptoms and treatment adherence in dialysis patients

Abstract

BACKGROUND:

Clinical symptoms and treatment adherence are one of the most important problems in dialysis patients. Psychological treatments can be effective in reducing the problems of these patients. Therefore, this study aimed at investigating the effectiveness of acceptance and commitment therapy (ACT) on clinical symptoms and treatment adherence in these patients.

MATERIALS AND METHOD:

This study was a quasi-experimental study with the experimental and control groups in the dialysis clinic of Torbat-e Heydarieh City in 2012. The sample consisted of 40 people who were referred to the dialysis clinic, and the available sampling method was used to randomly assign participants to the experimental and control groups. In the experimental group, ACT was performed in eight sessions of 90 minutes. Questionnaires of Depression, Anxiety, and Stress Scale (DASS-21) and general adherence scale were used. Data were analyzed using Statistical Package for the Social Sciences (SPSS 21) software and multivariate analysis of covariance (MANCOVA) test.

RESULTS:

There was a significant difference between the mean scores of clinical symptoms and treatment adherence variables in the experimental and control groups (P < 0.05). The effect of this treatment on reducing the clinical symptoms score was 48%, and on increasing the treatment, the adherence score was 44%.

CONCLUSION:

ACT can reduce clinical symptoms and increase treatment adherence in dialysis patients, so it is suggested to use this intervention in the design of treatment plans for dialysis patients.

Introduction

Chronic kidney failure is a progressive and irreversible disorder.[1] The prevalence of this disease in the world is 242 cases per one million population, which increases by about 8% annually, and its incidence varies in different countries,[2] and hemodialysis is the most common treatment used in these patients.[3]

According to Heidaranlu et al.’s[4] research, one of the most important problems of dialysis patients is high clinical symptoms including anxiety, stress, and depression. Patients with chronic kidney failure, in addition to numerous physiological changes, face many psychological stresses.[5] On the one hand, due to the awareness of the deterioration of their disease, these patients are forced to bear the stress of grueling treatment measures, including dialysis, and however, with the prolongation of the disease, their psychosocial functioning is severely affected,[6] and most patients do not adapt to problems and tensions and suffer behavioral changes such as anxiety, depression, and isolation.[7] Studies have shown that rapid diagnosis and treatment of anxiety, depression, and stress increase the quality of life of patients undergoing hemodialysis treatment.[8]

However, depression, anxiety, and stress are important factors in reducing treatment adherence.[9] Moreover, anxiety prevents adherence to recommended diets and treatments and has a negative effect on self-care and treatment results. Patients who have higher social support and lower levels of anxiety have higher levels of self-care.[10] The result’s study of Tayebi et al., showed that there was a significant relationship between depression, anxiety, and stress and noncompliance of hemodialysis patients with the recommended diet and even necessary treatments, and this can endanger the patient’s health and accelerate his/her death, so maintaining mental health and controlling depression, anxiety, and stress are very important in these patients.[11]

To reduce clinical symptoms and increase treatment adherence in dialysis patients, various psychological treatments have been provided, and one of the effective approaches in this field is acceptance and commitment therapy (ACT). Karimi et al.’s[12] research indicated the effectiveness of ACT on treatment adherence in dialysis patients. ACT was created in 1986 by Hayes. This approach is a third-wave behavioral therapy, which obviously accepts changing the function of thoughts and feelings instead of changing their content or frequency.[13] ACT allows clients to take steps by accepting inner experiences, increasing flexibility in the path of action according to values, and reducing experiential avoidance.[14]

According to the research, if people’s mental health is disturbed, it affects their physical recovery process. Among the psychological factors that affect people’s physical and mental health, high clinical symptoms[4] and low treatment adherence in these patients can be named.[9] Moreover, the high level of anxiety, depression, and pain in dialysis patients leads to the reduction and non-follow-up of patients regarding the treatment process and treatment adherence.[15]

As a result, considering the sensitivity and importance of the health of dialysis patients and the high clinical symptoms and low treatment adherence in these patients and the lack of comprehensive and integrated research on this issue, to solve this research and treatment gap, the researchers in this research tried to investigate the effectiveness of ACT on clinical symptoms and treatment adherence in dialysis patients.

Materials and Methods

Study design and setting

This study was a quasi-experimental study with the experimental and control groups in the dialysis clinic of Torbat-e Heydarieh City in 2012. The statistical population included all people who were referred to Musa Ibn Jafar Clinic. Before starting the intervention, the necessary explanations were given to the subjects about the objectives of the research, and after obtaining their informed consent, they entered the project. This article is the result of a research project with the ethics committee code IR.AUI.TJ.REC.1401.072.

Study participants and sampling

The statistical sample was determined based on the statistical formula and similar studies[16,17,18] of 40 people (20 people in each group), as shown in Figure 1. The simple sampling method was used to randomly assign participants to the experimental and control groups. At the beginning of the study, patients were randomly assigned to one of the two groups by the permutation block method. The results of the Kolmogorov–Smirnov test showed the normality of the distribution (P > 0.05). The criteria for entering the study included dialysis patients, high clinical symptoms score (score above 40 using the DASS-21 questionnaire), and low treatment adherence score (score lower than 5 using the General Adherence Scale), and the exclusion criteria also included not participating in other treatment programs at the same time, not receiving individual counseling or drug therapy, missing more than two sessions in training sessions, no satisfaction and cooperation of people, and not doing the specified tasks in the training process.

Figure 1.

The study CONSORT diagram

Data collection tool and technique

At the beginning of the study, both groups were pretested by DASS-21 and treatment adherence scale. The ACT intervention[19] was implemented in the experimental group during eight 90-minute sessions (two sessions per week) as face-to-face sessions according to the ACT protocols in Eight Session, developed by Hayes in 2004,[20] and social distancing and using personal protective equipment.

During the implementation of the therapeutic intervention, the control group was on the waiting list. After the last treatment session, a posttest was conducted for both groups and the data were analyzed based on the covariance analysis test in Statistical Package for the Social Sciences (SPSS) Version 21 software. After the end of the study, ACT was also held in the form of face-to-face meetings for the control group, observing social distancing and using personal protective equipment. The content of therapy sessions is reported in Table 1.

Table 1.

Acceptance and commitment therapy session titles[20]

Session	Content
First	Acquaintance and communication of members with each other, preliminary explanations, problem conceptualization, client preparation, and preexamination implementation. Providing explanations about dialysis, clinical symptoms, pain control, and following doctor’s orders. Also, preparing a list of enjoyable activities and including it in the weekly schedule.
Second	Acquaintance with ACT therapeutic concepts (psychological flexibility, psychological acceptance, psychological awareness, cognitive separation, clarifying values, and committed action), discussing experiences, and evaluating them.
Third	Mindfulness training (emotional awareness and wise awareness), training clients about what skills are observed and described, and how skills are not judged, remain focused, and that how these skills work. Also, the use of time-out technique by members when increasing responsibility and commitment and expressing control is a measurement problem.
Fourth	First, the focus is on increasing psychological awareness, and then, people are taught how to properly respond and face their mental experiences and create a goal, enjoy social lifestyle, and have a practical commitment. Examining the positive and negative points of the members and weakening the self-concept and true self-expression without any judgment and emotional reaction and behavioral commitment.
Fifth	Training to tolerate distress and increasing tolerance and responsibility (skills to persevere in crises, diverting senses, and self-soothing using the six senses and practicing awareness). Reviewing previous meetings and giving feedback to each other.
Sixth	Emotion management training (goals of this training, knowing why emotions are important, recognizing emotions, increasing positive emotions (changing emotions through action opposite to the recent emotion, practical training of what has been learned, providing feedback by the group and the therapist).
Seventh	Increasing individual and interpersonal efficiency, training interpersonal skills (describing and expressing, and expressing oneself and having courage, open trust, negotiation, and self-esteem). Measuring performance, introducing the concept of value, and showing the risks of focusing on results.
Eighth	Understanding the nature of desire and commitment, determining suitable action patterns with values, and summarizing and conducting post-examination.

DASS-21

This scale contains 21 items with a 4-degree Likert spectrum (no, slightly, sometimes, and always from 0 to 3) made by Lovibond. This scale consists of three components: depression, anxiety, and stress. The individual’s pronunciation spectrum in each subscale will range from 0 to 21, with higher results in these scales indicating more severe symptoms. Lovibond obtained Cronbach’s alpha coefficient of this questionnaire for three subscales of anxiety, stress, and depression, which were 0.91, 0.84, and 0.90, respectively.[21] The 21-item form of this questionnaire has been validated by Sahebi et al. for the Iranian population. They analyzed this scale as a factor whose results confirmed three factors of depression, anxiety, and stress, and Cronbach’s alpha coefficient for these three factors was 0.97, 0.92, and 0.95, respectively. In this study, the internal consistency with Cronbach’s alpha method for these three factors was 0.84, 0.78, and 0.83, respectively.[22]

General adherence scale

The general adherence scale was designed by Hayes in 1994, which measures the patient’s willingness to follow the doctor’s recommendations in general. The scale has five items. The subject can answer the items of this scale within 2 to 3 minutes on a 6-point Likert scale from always, most of the time, at a suitable time, sometimes, and a few times to never. The grades of two subjects of the test (items 1 and 3) are reversed. Obtaining a higher score in this scale indicates more adherence to treatment, and obtaining a lower score indicates less adherence to treatment. In Hayes’ study, the validity of the test through construct validity with the internal consistency method was reported as 0.81, and the reliability of this scale was 0.77 based on a retest with an interval of two years.[23] In the research of Fahimi et al.,[24] Cronbach’s alpha coefficient was used to check the reliability of the questionnaire, which was equal to 0.68.

Ethical consideration

This article is the result of an investigation of the code of the ethics committee IR.AUI.TJ.REC.1401.072. before performing the study, and informed consent was obtained verbally. Participation in the research did not have any financial burden for the participants. The respondents were fully informed of the purpose of the study and were ensured of the confidentiality of their personal data. Participants were also free to withdraw from the study at any stage.

Results

The demographic variables of the control and experimental groups are presented in Table 2. According to the Chi-square test results, there were no significant differences between the studied groups in terms of age, marital status, occupation, and education level, and they were homogeneous (P > 0.05).

Table 2.

Descriptive statistics of demographic variables

Variable		Case Frequency (%)	Control Frequency (%)	Value (Chi-squared)	P
Age, years	20 to 29	3 (15%)	2 (10%)	0.563	1.364
	30 to 39	7 (35%)	5 (25%)
	40 to 49	6 (30%)	7 (35%)
	50 to 59	4 (20%)	6 (30%)
Marital status	Single	5 (25%)	3 (15%)	0.476	0.725
	Married	8 (40%)	7 (35%)
	Divorce	9 (45%)	8 (40%)
Employment type	Employee	5 (25%)	4 (20%)	0.612	1.269
	Freelance job	10 (50%)	8 (40%)
	Homemaker	6 (30%)	7 (35%)
Education	Sub-diploma	10 (50%)	8 (40%)	0.438	1.417
	Diploma	8 (40%)	9 (45%)
	Academic	2 (10%)	3 (15%)

The mean and standard deviation of the scores of the variables of clinical symptoms and adherence to treatment, separated by pretest and posttest in the two experimental and control groups, are shown in Table 3. Multivariate analysis of covariance (MANCOVA) to compare the experimental and control groups on dependent variables was also presented in Tables 4 and 5. In this research, MANCOVA was used for the inferential analysis of the results. First, the required assumptions were examined. The presuppositions of the normality of the distribution of grades, homogeneity of variances of grades, and equality of covariances of grades were investigated. The results of the Kolmogorov–Smirnov test showed the normality of the distribution (P > 0.05). Levene’s test on clinical symptoms variable (P = 2.603, F = 3.547) and adherence to treatment (P = 1.351, F = 2.241) showed that the assumption of equality of variances was confirmed in all research variables. Based on the results of the box test (P = 0.816, F = 0.490, M box = 3.331), the presumption of equality of covariances was confirmed. Due to the confirmation of all presuppositions, the MANCOVA method can be used to examine research hypotheses.

Table 3.

Mean and standard deviation of clinical syndrome and treatment adherence variables separately from the experimental and control groups

Variable		Group	Posttest Mean±SD	Pretest Mean±SD
Clinical syndrome	Depression	Case	48.20±1.37	44.27±1.40
		Control	50.65±1.01	50.20±1.01
	Anxiety	Case	14.80±0.62	13.80±0.64
		Control	16.71±0.53	16.73±0.25
	Stress	Case	17.00±0.69	15.47±0.75
		Control	16.03±0.52	16.05±0.032
	Total score	Case	16.40±0.41	15.00±0.51
		Control	16.37±0.46	16.27±0.60
Treatment adherence	Case		6.47±0.62	8.40±0.81
	Control		5.87±0.83	5.73±1.26

Table 4.

Results of multivariate analysis of covariance of group effects on clinical symptoms and treatment adherence scores

Test	Value	F	Partial eta-squared	df hypothesis	Error df	P	Observed power
Pillai’s trace	0.667	14.042	3.000	21.000	0.001	0.66	1.000
Wilk’s lambda	0.333	14.042	3.000	21.000	0.001	0.66	1.000
Hotelling’s trace	2.006	14.042	3.000	21.000	0.001	0.66	1.000
Roy’s largest root	2.006	14.042	3.000	21.000	0.001	0.66	1.000

Table 5.

Multivariate variance analysis to compare the effect of treatment on research variables

Depended variable	Sum of squares	df	Mean square	F	P	Partial eta-squared	Observed power
Clinical syndrome	117.773	1	117.773	18.774	0.0001	0.48	0.999
Follow the treatment	21.778	1	21.778	18.600	0.0001	0.44	0.978

According to Table 3, the mean and standard deviation of clinical syndrome scores including depression, anxiety, and stress decreased in the experimental group after the intervention, but there was no difference in the control group before and after the intervention. Also, the score of treatment adherence increased in the experimental group after the intervention, but there was no difference in the control group before and after the intervention.

In this research, MANCOVA was used for the inferential analysis of the results. First, the required assumptions were examined. The presuppositions of the normality of the distribution of grades, homogeneity of variances of grades, and equality of covariances of grades were investigated. The results of the Kolmogorov–Smirnov test showed the normality of the distribution (P > 0.05). Levene’s test on clinical symptoms variable (P = 2.603, F = 3.547) and adherence to treatment (P = 1.351, F = 2.241) showed that the assumption of equality of variances was confirmed in all research variables. Based on the results of the box test (P = 0.816, F = 0.490, M box = 3.331), the presumption of equality of covariances was confirmed. Due to the confirmation of all presuppositions, the MANCOVA method can be used to examine research hypotheses.

MANCOVA test related to the difference in research variables is statistically significant (P < 0.05). Therefore, the two experimental and control groups have significant differences in at least one of the two variables compared; in other words, acceptance and commitment intervention has had at least one of the variables dependent on the mean of the experimental group compared with the control group in the posttest stage. The rate of this effect or difference is 0.66%; in other words, 0.66% of individual differences in the clinical score and adherence to physician’s instructions are related to the effect of a group membership. A statistical power of 1 also indicates high statistical accuracy.

Based on the results of Table 5, by removing the effects of the pretest scores, the difference between the mean posttest scores in clinical symptoms variables and adherence to treatment in the two experimental and control groups was significant (P < 0.05). The effect of this treatment on reducing the clinical symptoms score was 48%, and on increasing the treatment, the adherence score was 44%. The statistical power of 0.9 also indicates high statistical accuracy.

Discussion

This study was conducted with the aim of investigating the effectiveness of ACT on clinical symptoms and adherence to treatment in dialysis patients. The results showed that ACT reduced clinical symptoms in patients, which was in line with the results of similar studies such as Shawyer et al.,[25] Mahdavi et al.,[26] and Mousavi and Dasht-Gorgi[27] that ACT has an effect on reducing anxiety, stress, and depression. One of the factors that can affect the mental health of kidney patients is anxiety, depression, and stress in the treatment process. Experiencing different levels of quality of life, these patients show a high degree of stress with wide and varied physical and psychosocial problems, and they use different adaptation mechanisms in facing stressful factors throughout their lives.[28]

The purpose of acceptance-based techniques was to weaken the learning of social support to behave in such a way that personal events cause the individual’s behavior. The therapist actively creates a structure in which the client has the opportunity to experience personal events, without engaging in any behavior to control personal events.[14] ACT with acceptance and noninterference techniques help people to increase their cognitive flexibility, and as a result, they use more efficient strategies against mental problems and life injuries. They will be more tolerant of distress, and finally, the possibility of depression, anxiety, and stress will be less in them.[29]

The next finding of the study showed the effects of ACT on treatment adherence in dialysis patients, which is in agreement with the results of similar studies including As’hab et al.,[30] Nelson et al.,[31] and Rahnama et al.[32] that ACT had an effect on increasing adherence to treatment. Adherence to treatment in patients with chronic diseases is very important, and patients can influence their comfort, functional abilities, and disease processes by acquiring self-care skills. Adherence to treatment in various diseases implies such things as diet and medicine, the amount of permitted activities, daily weighing and searching, and decision-making for appropriate treatment measures when the disease is severe.[33] The important principle in self-care is participation and acceptance of responsibility on the part of the patient himself, so that many of the complications of the disease can be controlled by correct behavior. In most chronic patients, such as dialysis patients, they face obstacles in following the treatment and poor self-care. This can lead to repeated hospitalization and their low quality of life.[9]

Commitment and acceptance are an important alternative to avoidance based on experience, which includes active and conscious acceptance of personal events, and in committed activity, a person is encouraged to use his utmost activity and effort to achieve the goal. This has two parts of mindfulness and action and experience in the present time, and people are taught to live in the present moment by accepting their feelings and emotions and refraining from experiential avoidance and better dealing with everyday challenges.[34]

The overall goal of treatment is based on acceptance and commitment, enriching, and meaningfulness of people’s lives. ACT teaches people to accept uncontrollable problems, and besides this acceptance, they should think about making their lives and goals worthwhile. Treatment leads people to accept and be aware of their internal events. Therefore, these people are more likely to follow their medical and medical instructions to improve their illness.[17]

Limitation and Recommendation

The limitations of this study included the following: The statistical population was limited to the study population, any previous contact, and familiarity of the control group with the intervention outside of the treatment sessions that may have affected the treatment results of this study; also, as the control group did not receive a different intervention, it was not possible to compare the psychological interventions with each other, which is suggested to be considered in future researches.

Conclusion

The findings of this research showed that ACT can reduce clinical symptoms and increase adherence to treatment in dialysis patients. Therefore, considering the high importance of compliance with treatment and reduction in clinical symptoms in these patients, it is suggested that this psychological intervention can be used in the design of treatment programs for dialysis patients by clinical psychologists and therapists. The weaknesses of this study included a limited statistical population to the study population, previous contact, and familiarity of the control group with the intervention group outside the treatment sessions, which is suggested to be considered in future research studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.