How Are People Undergoing Dialysis Expected to Benefit From Cognitive Behavioural Therapy? A Realist Analysis

Depressive symptoms remain inadequately addressed and undertreated in people who receive life-prolonging dialysis treatment. Cognitive behavioural therapy (CBT) has been shown to be effective for treating depression; however, we lack an understanding of how and under what circumstances people with depressive symptoms receiving dialysis may benefit from it. The aim of this study is to identify ideas underlying CBT in general and develop an initial programme theory that explains how these ideas might apply to people receiving dialysis. It is the first step of a theory-driven explanatory realist synthesis and realist evaluation.

This study included a broad literature search and interviews with seven CBT therapists across Canada and the United States. Search terms were derived from CBT and refined to theory-based literature, literature reviews and book chapters. Therapists were recruited through team collaborators and had experience in developing or providing CBT to adults with depressive symptoms, including those receiving dialysis. Qualitative analysis of data from the literature and interviews focused on identifying mechanisms through which CBT is expected to reduce depressive symptoms in people receiving dialysis and the circumstances that may shape these mechanisms.

Based on our findings from 30 documents and the interview data, individuals living with dialysis treatment and experiencing depressive symptoms may benefit from CBT through (1) cognitive changes related to their illness and self; (2) experiencing pleasant emotions; and (3) feeling seen, understood and accepted. However, people's capacity to engage with CBT may be limited due to significant illness and treatment burdens, as well as the perceived stigma of mental health issues. Our findings can be explained by the cognitive behavioural model, illness adjustment theories such as the common-sense model of self-regulation, response shift theory, client-centred therapy, and the cumulative complexity model.

This study contributes to knowledge by explaining how the illness context of dialysis treatment might shape the mechanisms through which CBT is expected to work. Understanding the dialysis illness context when developing psychosocial interventions such as CBT can advance the provision of person-centred mental health kidney care.

This patient-oriented research leveraged established partnerships including a Community Advisory Committee, an equity, diversity, inclusivity (EDI) champion, industry partner, kidney administrators and clinicians, and CBT experts. The Community Advisory includes 10 people who have met monthly for over 10 years; the Committee itself is co-chaired by a person with lived experience. The Community Advisors collaborated on the original study idea, participated in grant proposal development, gave feedback on ethics applications and study design, provided input on the initial programme theory, and co-presented at provincial Nephrology Grand Rounds and Research days. They continue to lead in the next phases of this project.