Research Article: Social support as a mediator between sleep disturbances, depressive symptoms, and health-related quality of life in patients undergoing hemodialysis

Date Published: April 29, 2019

Publisher: Public Library of Science

Author(s): Kuei-Ching Pan, Shih-Yuan Hung, Chun-I Chen, Chu-Yun Lu, Mei-Ling Shih, Chiung-Yu Huang, Rachel A. Annunziato.


The hemodialysis regimen is an inevitable and mandatory treatment for patients with end-stage renal disease (ESRD). During the dialysis journey, patients may experience maladaptation in terms of sleep disturbances, depressive symptoms, and reduced health-related quality of life (HRQOL). Psychosocial resources such as social support may have beneficial influences on health outcomes, but studies have rarely analyzed the integrated relationships among risk factors which include pain, sleep disturbances, duration since diagnosis and various health outcomes in Taiwan. This study aimed to bridge this gap by investigating the relationships among related risk factors, social support, sleep disturbances, depressive symptoms, and HRQOL, which is composed of physical quality of life (PQOL) and mental quality of life (MQOL), in ESRD patients.

A correlational design was used, and 178 patients aged 20 years or older were recruited via convenience sample. The relationships among the risk factors, the mediators, depressive symptoms, PQOL, and MQOL were analyzed using structural equation modeling.

The findings showed that more than 70% of the participants reported poor sleep quality, and 32% reported depressive symptoms. When participants had greater pain and more sleep disorders, they were more likely to be depressed. When participants had more appraisal support; they had better PQOL and fewer depressive symptoms. Overall, the structural equation model explained 31.8% of the variance in self-reported depressive symptoms, 29.4% of the variance in PQOL, and 5.7% of the variance in MQOL. Moreover, appraisal support enhanced PQOL and reduced depressive symptoms by exerting its two mediating effects on sleep disturbances.

Our findings indicate that patients with ESRD who have more social support have better PQOL and MQOL and fewer depressive symptoms than those with less social support.

Partial Text

End-stage renal disease (ESRD), which is highly prevalent worldwide, is a complication of the primary disease of diabetes or the cardiovascular system [1], and patients must accept permanent dialysis for the remainder of their lives if they do not accept further aggressive treatment such as kidney transplant. Psychological problems may occur when patients with ESRD undergo long-term dialysis, and depressive symptoms have been reported to be highly prevalent in patients with ESRD [2, 3]. Moreover, the loss of bodily control among patients with ESRD is accompanied by depressive symptoms and results in negative outcomes in terms of economic burden, family dysfunction, and worse health-related quality of life (HRQOL) [4–8].

This research focused on the relationships among individual demographic and clinical characteristics, including four types of social support, depressive symptoms, and HRQOL. The results showed that 32% of the participants reached the cut point for depressive symptoms. This result coincides with the findings of a previous study [17] that showed that the prevalence of depressive symptoms in patients with ESRD in long-term dialysis was 18–35% and that patients with more social support were less likely to experience depressive symptoms than those with less social support.

The study had some sampling and methodological limitations. First, convenience sampling was adopted, which might constrain the applicability of the research findings to the population in southern Taiwan; thus, generalizability may be limited. In the future, researchers can extend the research setting to different locations. Second, the subjective nature of self-reported questionnaires including social support or quality of life is also the concern. Third, the cross-sectional nature of the current study was a limitation, and the time effects of the study variables were unclear. Another limitation exists, regarding the exclusionary criteria; we exclude patients with pre-existing depression and serious medical disease, which may also limit the participants to attend this study. Therefore, it was not appropriate to develop inferences regarding the longitudinal influences of the independent variables on the HRQOL of patients with ESRD.

The results revealed a high prevalence of depression and sleep disturbances in patients with ESRD in Taiwan, which is consistent with reported rates in Taiwan but higher than rates reported in the US. Social support played an important role as a mediator between sleep disturbances and depressive symptoms in patients with ESRD in this study. Our findings offer healthcare professionals a better understanding of ways to utilize social support, especially appraisal support, based on the finding that appraisal support promotes PQOL. Additionally, the findings provide general support for the hypotheses regarding the effect of social support on depressive symptoms. Further research should be carried out with nurses in renal departments to investigate their perceptions and knowledge of how to evaluate social support in patients with ESRD, which could lead to better health outcomes for patients with ESRD.