Effectiveness of Social Work Intervention on Depression and Adjustment of Dialysis Patients

Dialysis as a Life-saving Treatment

Task:

In this economy of managed health care and cost-benefit, social workers are particularly compelled to evaluate their professional ac- tivities as allocations for funding are more rigorously reviewed. The evaluation of social work activity on behalf of the dialysis patient is timely and warranted both for the profession, to advance knowledge on behalf of the consumers we serve, and to stand the test of scrutiny in times of budget analysis and downsizing.

Using an experimental design, the research described in this article examined the effectiveness of a dedicated, timed, recurring social work intervention with newly admitted dialysis patients to the dialysis center of a local mid-sized suburban hospital.

The major hypothesis of the study was that there would be a statisti- cally significant change in levels of depression and adjustment for those patients receiving the weekly M.S.W. psychosocial intervention. A goal of the study was to be able to provide existing dialysis pro- grams with a statistically supported model of service.

Dialysis as a life-saving treatment was introduced in 1960 by Dr. Belding H. Scribner, the developer of the dialysis machine. Patients with kidney failure cannot cleanse their bodies of the wastes normally flushed by the kidneys in urine. Dialysis is a way to cleanse those toxins and wastes that build up in the blood which normally would be excreted through urination. During dialysis treatment, a patient’s blood is carried from the arm through plastic tubing to an artificial plastic kidney (dia- lyzer) which removes wastes (salt and urea) from the blood. The blood is returned to the body through a second tube. In the United States, dialysis usually is performed three times a week for a minium of three hours each session. Without the treatment or a kidney transplant, the patient with end-stage renal disease will die within weeks.
Dialysis machines do not replace nor are they as efficient as normal kidneys. As such, while they sustain life, serious changes in life style and personal independence occur. The dialysis machine enables the
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patient to make up for some bodily functions but serves as proof of the patient’s inability to control some of their bodily functions and have a sense of control over their lives (Ilic, Djordjevic, & Stefanovic, 1997). Dialysis patients require special dietary care and medications; there is change in body image and function including the loss of urination and physical energy, loss or change in sexual function, changed appearance due to surgery and other signs of physical deterioration, are typical (Ber- kow, 1987). Many dialysis patients are unable to work because of their illness and the demands of the scheduled treatments (Frazier, 1981).

Psychosocial Stresses in Dialysis Patients

The emotional strain of dialysis is manifested in many patients with ‘‘ . . . deteriorating levels of self-esteem, a gross reduction in social, recreational and sexual activity with associated loss of interest and involvement, and disappointing levels of vocational rehabilitation {often reported below 50 percent}’’ (Nichols & Springford, 1984, p. 563).

Psychosocial stresses are a fixed feature of the lives of dialysis patients. The psychosocial literature on the effects of dialysis are generally divided into two major areas: studies on the prevalence and impact of depression on the patient and studies on patient adjustment described as quality of life issues.

As the quality of dialysis treatment has improved since its inception in 1960, psychological factors have become an important aspect of treatment and are often used as a predictor of the patient’s ability to cope with the rigors of treatment. The study of depression in dialysis patients has become a concern for health care providers because of the role that depression plays in patient compliance and their ability to return to their pre-illness level of activity and functional status.

A review of the literature reveals that the incidence and prevalence of depression among dialysis patients is estimated to vary from 20 to 100 percent. Beginning in the 1970s, the literature on depression and dialysis began to document the incidence of depression in dialysis patients. Early studies tended to report a high incidence of depression with psychiatric complications as the norm. The generalizability of these studies may be debatable as sample size was usually small. A sampling of the literature shows a study by Shea, Bogdan, Freeman and Schreiner (1965) who noted degrees of depression in 6 of 9 patients. Reischman and Levy (1972) reported 100% depression in all 25 of their patients beginning dialysis; and Kaplan de Nour and Czaczkes (1976) found a 50% incidence in 89 dialysis patients.

More recent studies, often using larger sample sizes, standardized test materials and more comparative reporting between medical staff and patient perception, continue to document this relationship. A sam- pling of these studies include: Smith, Hong and Robson (1985) 78% of 60 patients were depressed; Hinrichsen, Lieberman, Polack and Stein- berg (1989) 24.2% of 124 patients; Sacks, Peterson, and Kimmel (1990) 60% of 57 patients; Kimmel, Peterson, Weihs, Simmens, Boyle, Verme, Umana, Veis, Alleyne and Cruz (1995) 100% of 149 patients with symptoms of depression. This data continues to support the prev- alence of depression in dialysis patients.

Depression in Dialysis Patients

Several of the above mentioned studies used the Beck Depression Inventory (Beck, Ward, Mendelsohn, Mock & Erbaugh, 1961) as one of the methods of assessing depression (Kimmel et al., 1995; Sacks et al., 1990; Smith et al., 1985) in their patient cohorts. Health related quality of life is an inclusive term which emphasizes physical, social, and psychological variables inherent in adjustment to illness (Mozes, Shabtai, & Zucker, 1996). Satisfaction with quality of life in dialysis patients is related to adjustment (Morris & Jones, 1989); adjustment is related to compliance and the ability of the pa- tient to return to their pre-illness functional status.

Adjustment to dialysis is frequently described in relation to how the patient adapts to the multitude of stressors posed by the routine and restrictions of treatment. Several studies have documented the chal- lenges faced by dialysis patients and, depending upon which study, have rank ordered the stressors according to severity. They include: weakness, having to reduce work, fluctuating health, dependence on others (Matthews, 1980); fluid limitation (Baldree, Murphy, & Pow- ers, 1982); loss of energy, insomnia, decreased sexual interest (Cra- ven, Rodin & Johnson, 1987); fatigue and boredom (Bihl, Ferrans & Powers, 1988); muscle cramps and disruption of work (Fuchs & Schreiber, 1988). Several of the studies used the Psychosocial Adjust- ment to Illness Scale as one of the measures of adjustment.

For the patient on dialysis, it is estimated that one third to one half do not comply with either dietary or fluid restrictions and/or do not spend the requisite amount of time each week on the dialysis machine (Rocco & Burkhart, 1993). Either of these situations can have a pro- found impact on the well-being of the patient and can result in deterio- ration of the individual, hospitalization and protracted health prob- lems.
Adjustment and depression are important concerns in health care for dialysis patients as they relate to functionality on the micro level and allocation of health care resources on the macro level (Ferrans & Powers, 1993). For this reason, these variables–adjustment and de- pression–were chosen as the measurable dependent variables of this study.

As with most diagnoses of chronic illness, the patient is prone to feelings of profound emotional upheaval upon receiving the news of their condition and the need for on-going dialysis treatment. Even though most dialysis patients have known of the deteriorating condi- tion of the their kidneys, the impact of being informed that they will require dialysis is shocking. Indeed, Gorman and Anderson (1982), M.S.W. social workers in a dialysis unit, observe that ‘‘The immediate reaction of the patient to the diagnosis of chronic renal disease (neces- sitating dialysis) is that of incomprehension. It is impossible for the person concerned to take in the full meaning of the diagnosis at its first telling’’.

For the patient who is beginning dialysis, several assumptions about their physical and emotional condition can be made. The individual is sickly, usually ailing for a protracted period of time; the individual is frightened, distressed and unsure. Depression is common, quality of life is deteriorated or in flux.