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Emmet O Flaherty - Centre for Psychiatric Nursing

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					Presenters:
 Emmet O’ Flaherty
 Kathleen Crowley
    This research project was funded by
beyondblue: the national depression initiative
The use of an intensive psychosocial
 intervention program (DOHP) during the early
 period of dialysis therapy will result in a
 reduction in anxiety and stress related
 conditions of patients on Dialysis.
chronic kidney disease (CKD) is increasing -
almost doubled in the past 4 years (1)

rise in chronic kidney disease related to
lifestyle; hypertension, obesity, associated
diabetes.
◦ E.g. 20 yrs ago diabetics accounted only for 2% of
  dialysis patients, now 37%

1 in 3 at risk, 1 in 7 has a clinical sign of CKD
– lifestyle factors (1)
the treatment;
◦ transplant
◦ Haemodialysis
◦ Peritoneal dialysis

challenging, especially in the first year, the
transition2,3,4
◦   economic
◦   time
◦   medications
◦   Routine

a recent study found that the kidney rejection
rate is doubled in patients who are depressed
travel to centre or
at home
3 x week 4hr
needles!
fluid / diet
restrictions
waiting lists
4yrs for transplant
every night, 9-
10hrs on the
machine or
4 exchanges per
day
Permanent catheter
Risk of infection
Weight gain
fatigue,
pain, muscle cramps,
difficulty with sleep,
sexual dysfunction
anxiety, fears
guilt, blame
hope
evaluating quality of life (12–15)
Acute
◦   Late diagnosis
◦   <10%
◦   Immediate start, longer admission
◦   HD via permcath

Chronic
◦   early diagnosis
◦   planned start, short admission
◦   dialysis of choice
◦   initiate psycho-social supports
We know dialysis patients experience high rates
of depression and anxiety that may effect;
◦   Treatment adherence
◦   Quality of life
◦   Intimate relationships
◦   Survival

VERY LITTLE HAS BEEN DONE TO ADDRESS THIS!

Whether interventions targeted at anxiety and
depression have the capacity to reverse such
effects in ESKD is at present unknown, but the
case for well-designed trials of such
interventions is compelling.
What is The OHP?

   A comprehensive structured and
  manualised therapeutic program for
  consumers, clinicians and others to
   work systematically towards the
     achievement of optimal health
              outcomes.
The program aims to:
 Provide education about stress and vulnerability and
how this impacts on health and well-being.

 Develop or maintain coping strategies necessary to
attain optimal health and/or prevent illness/relapse.

8 x weekly 1 hour sessions

Resources: Participant Workbook, Health Journal
DOHP!
Patients with ESKD commencing maintenance
dialysis for the first time.

Age 18 years or above.

Able to converse in English without an interpreter.

No developmental disability/amnestic syndrome.

Excluded if returned to dialysis following a failed
renal transplant or had suffered acute renal failure
due to ESKD.
                  St Vincent’s Hospital Dialysis Service

Rural Site – Shepparton                              Metropolitan Site
                                                     St Vincent’s Dialysis Centre

                                       Recruitment


                                        Randomised


Control Group
Control Group                                          Treatment Group
This group received routine supportive
This group received routine supportive
                                                       This group will also received
care which includes doctors, nurse,
care which includes doctors, nurse,
                                                       routine care same as control group
dietitian , pre-dialysis educator on
dietitian , pre-dialysis educator on
topics such as dietary management,
topics such as dietary management,
                                                       plus the Psychosocial Intervention
fluid intake, medication and dialysis
fluid intake, medication and dialysis                  (DOHP): Addressing symptoms and
management.
management.                                            developing goals of treatment


 • Monthly telephone calls - depression & anxiety scores
 • 3 month Face to Face (Mail Out) Assessments
Primary outcome was measured on
depression anxiety and quality of life.

Secondary outcomes were treatment
adherence, perceived social support, level of
function, episodes of psychiatric illness and
treatment, ,medical morbidity and health care
utilization (outpatient visits, hospitalization
rate).
MINI – Mini International Neuropsychiatric IV
DASS – Depression Anxiety & Stress Scale
OSA – Occupational Self Assessment Scale
PWI – Personal Wellbeing Index
PSS – Perceived Stress Scale
SF 36 – Short Form Health Survey
Baseline Assessment
◦ All measures

Monthly Phone Call
◦ MINI (depression and Anxiety)
◦ Treatment compliance
◦ Service Utilization

3 Month Assessment
◦   MINI (depression and Anxiety)
◦   Treatment compliance
◦   Service Utilization
◦   Quality of Life
◦   Perception of Stress
◦   Level of Functioning
                                              Population
                                               N = 41
•Language Barriers
                                                                       •Declined to participate (n=4)
•Limited ESKD patients no.               Referrals to RCT              •Unsuitable (n=2)
                                               (n = 28)                •Pending Dialysis (n=6)

                                                                       •Consents (n=16)
                                         Baseline Ax (n=12)            •4 Withdrew


                                            Randomisation
                                               (n = 1)2
          Allocated to Treatment                                          Allocated to Control
                   (n=5)                                                         (n=7)
                1 Deceased                                                    1 Deceased
               1 Withdrawal

                                       Follow Up Assessments
                                                 (n=9)
                                    Monthly Telephone Interviews
                                   Quarterly Self-reports (mail-out)




                                          Complete Data Ste
                                              (n = 9)
Comparison of baseline characteristics of
 treatment and control group.

Compared on a range of baseline variables
 including age, gender, level of education,
 relationship status and place of residence.

There were no significant differences at
 baseline.
Analysis of the incident of depression and
 anxiety trajectories (MINI) based on monthly
 phone calls after 3 month post baseline,
 baseline and 3 month face to face
 assessment.




           These results were not statistically significantly
The percentage of occasions depression
 averaged over participants.




           These results were not statistically significantly
Based on the linear regression analysis, there
were no statistically significant differences
between treatment and control. While this
null result was not surprising given the small
sample size, the high post baseline scores for
SF36 social functioning for the treatment
group are encouraging.
“I had a service I most wanted”
“I am very satisfied with the program”
“More information, new knowledge”
“Keep up the good work”
“A lot of information that I didn’t know
of”
As far as we are aware this is one of the first
studies of this kind in this area.

Use of self-management programs alongside
medical treatment may potentially ameliorate the
expression of depression and anxiety.

The need to do a further larger trial.

Importance of policy development to support the
delivery of self-management programs and
promote self-management by clients.
Training Nephrology staff to deliver self-
management programs could be see as:

◦ a preventative measure to reduce the burden of
  depression and anxiety in this population.
◦ beneficial across ESKD group as a health promotion,
  illness prevention initiative
◦ improved identification and response to Depression
  and Anxiety
◦ Increase in self-efficacy and QoL for consumers
◦ Possible reduction in carer burden as flow on effect
If we conduct a larger randomized study…….

Helped us identify how this program may be
delivered by services.

and time points where this program may be
delivered to consumers.
Acknowledge the
 contribution of consumers
 and staff.

				
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posted:4/12/2013
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