Mental health of hemodialysis patients in the Philippines amid COVID-19 crisis: A call for action

Chronic kidney disease is the seventh leading cause of death in the Philippines,¹ with the most number of deaths due to renal failure in Southeast Asia.² If left untreated, people with this disease require hemodialysis (i.e. a procedure to clean a person's blood through a machine) or a renal transplant.¹ The current COVID-19 pandemic has further exacerbated the already life-threatening and expensive situation of hemodialysis patients as they are immunocompromised and therefore highly vulnerable. For instance, a recent study conducted during the early phase of the COVID-19 outbreak in the Philippines (between 1 April to 31 July 2020 at a tertiary hospital in Manila) revealed that 25% death rate among hemodialysis patients admitted with COVID-19.³ Hemodialysis patients manifesting COVID-19 symptoms needed to pay for the reverse transcription-polymerase chain reaction tests, nurses’ personal protective equipment (PPE), and hazard pay⁴ on top of their already costly hemodialysis session fees. Such a financial obstacle and the lack of dialysis clinics that can accommodate COVID-infected dialysis patients have led to missed dialysis sessions, eventually leading to death due to complications (e.g. pulmonary complications).⁴

While some governmental efforts are in place to ensure the health and safety of the hemodialysis patients during the COVID-19 pandemic (e.g. increasing coverage of annual benefit package from 90 sessions to 144 hemodialysis sessions covered and increasing capacity of hemodialysis clinics),^4,5 their mental health has been largely neglected in terms of research and policies especially in the time of pandemic where they are most at risk. This is not surprising as mental health is often not perceived as a priority or urgent concern. The detrimental impact of their declining health condition on their mental health⁶ is aggravated by the financial need to support their hemodialysis sessions. For a developing country like the Philippines, financial problems were found to be a strong antecedent of higher depression, anxiety, stress, and lower levels of wellbeing during the COVID-19 crisis.^7,8

As the mental health of hemodialysis patients in the Philippines has been long neglected, several important sociopolitical and structural changes are needed to ensure that this vulnerable and marginalized group can preserve their mental health and optimize their wellbeing at this stage of their lives. First, local and national governments in the Philippines must prioritize establishing a more resilient healthcare system (i.e. through increased hospital capacity, safer hospital spaces and COVID-19 protocols, available and reliable facilities, etc.) that can accommodate the needs of all Filipinos including hemodialysis patients. Increasing hospital and dialysis centers’ capacity is particularly important to ensure that quality care remains available for COVID-19-infected patients. A stronger healthcare package for hemodialysis patients through free or more affordable dialysis fees, which eliminates the necessity to pay the PPEs and hazard fees of their attending medical staff on top of the already expensive regular dialysis expenses can go a long way.

The mental health of hemodialysis patients in the country must be given sufficient attention as this group is prone to experiencing mental health problems and declining wellbeing and quality of life.⁶ While promising progress is happening in the mental health issue in the country such as the newly passed Mental Health Act of 2018 (or the Republic Act 10036) that aims to improve the delivery of integrated mental health services to all Filipinos,⁹ further provisions are needed to address the mental health needs of vulnerable groups including hemodialysis patients. Given the pandemic situation, provisions must include free and accessible virtual mental health services (online individual and group therapy sessions, psychiatric consultations, support groups, etc.) as these can help address the psychological needs of patients while ensuring their safety from COVID-19 infection.

Moreover, there is a dire need to increase the number of mental health professionals (e.g. psychologists and counselors) in the country, especially those who specialize in mental health care for chronically and terminally ill patients. For instance, existential psychotherapeutic approaches such as logotherapy and spiritual approaches were found helpful in helping patients in meaning-making, resulting in improved mental health and psychological wellbeing amid their health conditions.¹⁰ Meaning-centered group psychotherapy can also be utilized as an additional intervention for chronically ill individuals including hemodialysis patients.¹⁰ Recognizing that provisions in the new law could take time and the economic capacity of the Philippines as a low-income country, creating and implementing grass-roots community-based mental health programs can offer free and accessible psychosocial support interventions to hemodialysis patients and all Filipinos.

As the COVID-19 pandemic serves as a reminder of our common humanity, it also showed us that some people are more vulnerable than others and therefore need more protection. Creating systems and environments that safeguard physical health and preserve the mental health and quality of life of hemodialysis patients in the Philippines would not only demonstrate inclusivity but also foster compassion for the weak and vulnerable sectors of our society.