Cognitive therapy found to cut dialysis side effect burden

Manisha Jhamb (Photo credit: UPMC)

A new patient-guided intervention using telemedicine to treat the side effects of dialysis including fatigue and depression has delivered “results that persist for several months after the intervention ends” in a randomised clinical trial published in JAMA Internal Medicine by researchers at the University of Pittsburgh (Pittsburgh, USA) and University of New Mexico (Albuquerque, USA).

“Our patients and their caregivers report pain, fatigue and depression as major issues related to dialysis that affect their participation in life,” said lead author Manisha Jhamb (University of Pittsburgh, Pittsburgh, USA). “It’s the nephrology community’s responsibility to study interventions that address patients’ mental health and quality of life concerns; otherwise, we are failing our patients. This study is a step in that direction.” A press release states that, at a recent US National Institutes of Health workshop, patient stakeholders “emphasised that post-dialysis fatigue is a serious concern”.

Jhamb and her colleagues developed the Technology Assisted Stepped Collaborative Care (TACcare) trial to test whether 12 weekly sessions of cognitive behavioural therapy delivered via telemedicine either while patients receive their dialysis or at home could improve symptoms. To ensure the results weren’t simply an effect of the added attention from the tele-sessions, they had a comparison group of patients receive weekly health education via telemedicine.

Jhamb and colleagues recruited a diverse pool of 160 participants from Pennsylvania and New Mexico who were receiving dialysis and had clinically significant levels of fatigue, pain or depression. They averaged 58 years old, and 28% were Black, 13% American Indian and 18% Hispanic.

The intervention allows the patient to set goals and tailor the care to address their specific concerns. For example, if the patient is concerned about pain, they can focus on psychotherapies to manage that pain and also receive medications.

“It was initially surprising that very few participants wanted medication for their symptoms—they were much more focused on the behavioural therapy,” Jhamb said. “But when you think about it, it makes sense: these patients are taking 10 or more medications per day. They don’t want another pill.”

Compared to those who received educational materials, patients who received TACcare had a 6% improvement in energy levels and a 10% improvement in pain severity, both of which were sustained for six months following therapy. They also had an improvement in depression symptoms, but it was “very small”, something Jhamb partially attributes to only a small number of participants initially having clinically significant depression.

“These results are really promising and in the range seen by similar interventions for cancer patients,” said Jhamb. “Until now, analgesic medications for pain and recommendations for better sleep and exercise to address fatigue have been the main suggestions we’ve been able to offer our patients, and they haven’t been satisfactory.”

The diversity of study participants also indicates that the results are generalisable to broad populations, the press release adds. Additionally, the successful use of telemedicine with rural participants in New Mexico provides an opportunity to offer TACcare to patients who might otherwise not have access to these specialised behavioural therapy services.

Jhamb says the next steps involve a cost-benefit analysis so that US policymakers and health insurers can consider mandating and paying for the intervention, as well as trials to test if “booster” sessions could prolong the results beyond six months.


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