Effectiveness of Acceptance and Commitment Therapy on Difficulties in Emotion Regulation in Depressed Dialysis Patients

EXTENDED ABSTRACT

Background

Chronic kidney disease (CKD) is a major public-health problem characterized by progressive pathological changes in renal structure and function [1]. Global prevalence has been estimated at approximately 9.1%, and the burden has continued to rise [2]. For patients with end-stage kidney disease, hemodialysis, peritoneal dialysis, and kidney transplantation are used as renal replacement therapies [1]. Despite their life-sustaining role, dialysis treatments are accompanied by substantial psychological and emotional burdens, including lifestyle restrictions, persistent symptom burden, and fear of death [3]. Depression is therefore common in this population; studies cited in the source article reported rates as high as 69%, and depression appears to be more frequent among patients receiving dialysis than among patients with CKD who are not receiving renal replacement therapy or who undergo transplantation [4–7]. Emotional distress may also be accompanied by impaired emotion regulation, which can adversely affect quality of life, treatment adherence, and adaptation to long-term illness [8–12]. Acceptance and Commitment Therapy (ACT) is a psychological intervention designed to increase psychological flexibility through acceptance, cognitive defusion, self-as-context, present-moment awareness, values clarification, and committed action [15]. Evidence summarized in the article indicates that ACT and other psychosocial interventions can improve depression, anxiety, emotional processing, and quality of life in several clinical populations, including patients receiving dialysis [10, 12, 13, 17–21]. However, the authors identified no prior experimental study specifically evaluating ACT for difficulties in emotion regulation among depressed dialysis patients. The present study therefore examined the effectiveness of ACT in reducing emotion-regulation difficulties in depressed patients undergoing dialysis.

Methods

This semi-experimental study used a pretest-posttest design with an unequal control group. The study population comprised depressed patients undergoing dialysis at Shahid Hasheminejad Hospital in Tehran during 2020-2021. Initially, 130 dialysis patients completed the Beck Depression Inventory (BDI). Forty-two patients with severe depression, defined in the study as a BDI score greater than 29 and supported by psychological interview, were selected by purposive homogeneous sampling and randomly assigned to experimental and control conditions. Because of incomplete questionnaires and eligibility-related exclusions, the final analysis compared 21 participants in the ACT group with 17 participants in the control group. Eligibility required current dialysis treatment, severe depression, willingness to participate, basic literacy sufficient to complete the questionnaires, and absence of a known disabling physical or psychological condition. Participants were excluded for incomplete questionnaires, absence from more than two therapy sessions, or failure to maintain other eligibility requirements. Depression screening was performed with the 21-item BDI, which yields scores from 0 to 63 and has established psychometric properties [22–24]. Emotion-regulation difficulties were measured with the 36-item Difficulties in Emotion Regulation Scale (DERS), covering nonacceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse-control difficulties, lack of emotional awareness, limited access to emotion-regulation strategies, and lack of emotional clarity; higher scores indicate greater difficulty [25–27]. Both groups completed the DERS at pretest. The experimental group then received eight 90-minute ACT sessions, delivered twice weekly online through the Skyroom platform, while the control group remained on a waiting list. The intervention followed established ACT principles and a group-treatment protocol previously used with dialysis patients [10, 15, 28]. Session content included therapeutic orientation and creative hopelessness, distinguishing internal and external experiences, values and goals clarification, cognitive defusion, self-as-context, mindfulness and present-moment contact, life-story review, and committed action. The program was delivered by a trained master's-level therapist under the supervision of two faculty members with doctoral degrees in psychology. After completion, both groups repeated the DERS. Because the study included multiple related dependent variables and a pretest covariate, data were analyzed using multivariate analysis of covariance (MANCOVA), followed by univariate ANCOVA. The study was registered with the Ethics Committee of Arak University of Medical Sciences under code IR.ARAKMU.REC.1400.036.

Results

The final experimental group included 21 participants, comprising 10 men (47.6%) and 11 women (52.4%), whereas the control group included 17 participants, comprising 10 men (58.8%) and seven women (41.2%). The two groups did not differ significantly in mean age (t36=0.618, P=0.540) or duration of dialysis (t36=-0.132, P=0.895), and both groups entered the study with severe depression. Descriptive DERS results showed clear post-treatment reductions in the ACT group. The total DERS score decreased from 105.33 ± 4.85 at pretest to 81.38 ± 4.23 at posttest in the ACT group, compared with a change from 104.35 ± 3.69 to 101.82 ± 3.94 in the control group. Similar reductions were observed across all six DERS components. For example, the ACT group's lack-of-awareness score decreased from 20.48 ± 3.33 to 14.00 ± 1.14, limited strategies from 23.00 ± 2.21 to 17.62 ± 1.72, goals from 15.62 ± 1.50 to 11.43 ± 1.75, and clarity from 14.33 ± 1.32 to 11.33 ± 0.86. In contrast, the corresponding control-group scores changed only modestly.

Table 2. Pretest and posttest mean scores for difficulties in emotion regulation in the experimental and control groups.

Assumption testing supported use of covariance analysis. Box's M test did not indicate a significant difference between covariance matrices (M=45.928, P=0.051). After adjustment for pretest scores, group membership had a significant multivariate effect on the linear combination of emotion-regulation components (Pillai's Trace=0.904, F(6,25)=39.070, P=0.001, partial eta squared=0.904, power=0.999). Subsequent univariate ANCOVAs showed significant between-group differences for every DERS component (all P=0.001). The reported F values were 15.561 for nonacceptance, 24.415 for goals, 36.445 for impulse, 86.550 for awareness, 60.377 for strategies, and 92.763 for clarity. Corresponding partial eta-squared values were 0.342, 0.449, 0.548, 0.743, 0.668, and 0.525, respectively, with statistical power ranging from 0.968 to 0.999. These findings indicate that, after controlling for baseline scores, participants who received ACT experienced significantly greater reductions in emotion-regulation difficulties than those in the waiting-list control group.

Table 4. Between-group ANCOVA effects for components of difficulties in emotion regulation after adjustment for pretest scores.

Conclusion

ACT produced significant improvement across all assessed dimensions of emotion regulation in depressed dialysis patients. The intervention was associated with large adjusted group effects and a substantial reduction in total DERS scores, supporting ACT as a potentially useful psychological treatment for this population. The study authors recommend incorporating interventions such as ACT into care for dialysis patients with depression and difficulties managing negative emotions, alongside treatment of the underlying renal disease.

Keywords: Acceptance and Commitment Therapy, Depression, Dialysis, Emotion Regulation

REFERENCES

1. Yakaryılmaz FD, Pembegül İ. Sleep quality, depression, hopelessness, and quality of life in elderly hemodialysis patients. Eur J Geriatr Gerontol. 2022;4(2):97-102. DOI: 10.4274/ejgg.galenos.2022.2022-1-4
2. Cockwell P, Fisher LA. The global burden of chronic kidney disease. Lancet. 2020;395:662-4. DOI: 10.1016/S0140-6736(19)32977-0
3. Nataatmadja M, Evangelidis N, Manera KE, Cho Y, Johnson DW, Craig JC, Baumgart A, Hanson CS, Shen J, Guha C, Scholes-Robertson N. Perspectives on mental health among patients receiving dialysis. Nephrology Dialysis Transplantation. 2021;36(7):1317-25. DOI: 10.1093/ndt/gfaa346
4. Li X, Gao W, Yu J, Mao Y, Gu H, Li F, Ren D. Mental health and quality of life in chronic kidney disease patients with mild-to-moderate depression: A retrospective cohort study of mindfulness-based stress reduction therapy. Actas Esp Psiquiatr. 2024;52(2):138-48. PMID: 38622007 DOI: 10.62641/aep.v52i2.1600
5. Aggarwal HK, Jain D, Dabas G, Yadav RK. Prevalence of depression, anxiety and insomnia in chronic kidney disease patients and their co-relation with the demographic variables. Prilozi. 2017;38:35-44. DOI: 10.1515/prilozi-2017-0020
6. Palmer S, Vecchio M, Craig JC, Tonelli M, Johnson DW, Nicolucci A, Pellegrini F, Saglimbene V, Logroscino G, Fishbane S, Strippoli GF. Prevalence of depression in chronic kidney disease: Systematic review and meta-analysis of observational studies. Kidney Int. 2013;84(1):179-91. DOI: 10.1038/ki.2013.77
7. Kimmel PL, Weihs K, Peterson RA. Survival in hemodialysis patients: The role of depression. J Am Soc Nephrol. 1993;4(1):12-27. DOI: 10.1681/ASN.V4112
8. Kaul S, Ahsan A, Singh NP, Gupta AK. Emotion regulation in chronic kidney disease: A systematic review. J Int Med Sci Acad. 2023;36(1):107-10. Link
9. Gross JJ. Emotion regulation: Current status and future prospects. Psycholo Inq. 2015;26(1):1-26. DOI: 10.1080/1047840X.2014.940781
10. Dehghani Y. The Effectiveness of acceptance and commitment group therapy on depression and quality of life in women dialysis patients. J Clin Psychol. 2016;8(3):1-10. Link
11. Alhawatmeh H, Alshammari S, Rababah JA. Effects of mindfulness meditation on trait mindfulness, perceived stress, emotion regulation, and quality of life in hemodialysis patients: A randomized controlled trial. Int J Nurs Sci. 2022;9(2):139-46. PMID: 35509694 DOI: 10.1016/j.ijnss.2022.03.004
12. Rouhi M, Manzari Tavakoli AR, Tajrobehkar M. Comparing the effectiveness of acceptance and commitment therapy and dialectical behavioral therapy on coherent self knowledge, emotional regulation and life quality of hemodialysis patients. Shenakht J Psychol and Psychiatr. 2023;10(2):131-46. DOI: 10.32598/shenakht.10.2.131
13. Pascoe MC, Thompson DR, Castle DJ, McEvedy SM, Ski CF. Psychosocial interventions for depressive and anxiety symptoms in individuals with chronic kidney disease: systematic review and meta-analysis. Front Psychol. 2017;8:992. DOI: 10.3389/fpsyg.2017.00992
14. Fahlekar A, Faal M, Zahedzadeh F, Amani O, Askari M. The effect of acceptance and commitment therapy on emotional regulation and coping strategies in patients with generalized anxiety disorder. J Child Ment Health. 2020;6(4):253-65. DOI: 10.29252/jcmh.6.4.23
15. Hayes SC, Strosahl KD. A practical guide to acceptance and commitment therapy. Translated to Persian by Khamse A. Tehran: Arjmand; 2020. Link
16. George B, de Guzman RG. Effectiveness of Acceptance and Commitment Therapy based intervention Program (ACTP) on perceived stress and emotion regulation among alcoholics in Kerala, India. Indian J Posit Psychol. 2015;6(1):10-18. Link
17. Zarling A, Lawrence E, Marchman J. A randomized controlled trial of acceptance and commitment therapy for aggressive behavior. J Cons Clinical Psychol. 2015;83(1):199. Link
18. Ferreira MG, Mariano LI, de Rezende JV, Caramelli P, Kishita N. Effects of group Acceptance and Commitment Therapy (ACT) on anxiety and depressive symptoms in adults: A meta-analysis. J Affect Disord. 2022;309:297-308. DOI: 10.1016/j.jad.2022.04.134
19. Amirian K, Mami Sh, Ahmadi V, Mohamadzadeh J. Effectiveness of group psychotherapy based on acceptance and commitment therapy on difficulties in emotion regulation and distress tolerance in substance abusers. J Educ Community Health. 2018;5(2):53-61. DOI: 10.21859/jech.5.2.53
20. Darvish Baseri L, DashtBozorgi Z. Effectiveness of group therapy based on acceptance and commitment on cognitive emotion regulation and alexithymia of patients with type 2 diabetes. Iran J Psychiatr Nurs. 2017;5(1):7-14. DOI: 10.21859/ijpn-05012
21. Hamdi Elzeiny H, Mahmoud Mohamed El-Emary F. Efficacy of psychological interventions in reducing the prevalence and intensity of depression in patients with long-term hemodialysis. Egypt J Health Care. 2023;14(1):132-43. Link
22. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatr. 1961;4:561-71. PMID: 13688369 DOI: 10.1001/archpsyc.1961.01710120031004
23. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psychol Rev. 1988;8(1):77-100. Link
24. Rajabi Gh, Atari Y, Haghighi J. Factor analysis of Beck's questionnaire on male students of Shahid Chamran University of Ahwaz. J Educ Sci Psychol. 2001;8(3,4):49-66. PMID: 28409168
25. Gratz KL, Roemer L. Multidimentional assessment of emotion regulation and dysregulation development, factor structure and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess. 2004;26(1):41-54. DOI: 10.1023/B:JOBA.0000007455.08539.94
26. Alavi K, Modarres Gharavi M, Amin-Yazdi SA, Salehi Fadardi J. Effectiveness of group dialectical behavior therapy (based on core mindfulness, distress tolerance and emotion regulation components) on depressive symptoms in university students. J Princ Ment Health. 2012;2(13):124-35. Link
27. Kermani Mamazandi Z, Talepasand S. Psychometric characteristics of difficulties in emotion regulation scale in Semnan university students. J Instr Eval. 2018;11(42):117-42. Link
28. Doosti P, Ghodrati G, Ebrahimi MS. The manual of group therapy based on acceptance and commitment therapy. Tehran: Amin Negar; 2018.