Kidney Research and Clinical Practice 2018 Mar; 37(1): 77-84
Effectiveness of group cognitive behavioral therapy with mindfulness in end-stage renal disease hemodialysis patients
Bo Kyung Sohn1,2,*, Yun Kyu Oh3,4,*, Jung-Seok Choi5,6, Jiyoun Song7, Ahyoung Lim5, Jung Pyo Lee3,4, Jung Nam An3,8, Hee-Jeong Choi9, Jae Yeon Hwang10,11, Hee-Yeon Jung5,6, Jun-Young Lee5,6, and Chun Soo Lim3,4
1Department of Psychiatry, Sanggye Paik Hospital, Seoul, Korea, 2Department of Psychiatry, Inje University College of Medicine, Busan, Korea, 3Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea, 4Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea, 5Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, Korea, 6Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul, Korea, 7Police Trauma Center, Seoul, Korea, 8Department of Critical Care Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea, 9Choi Hee-Jeong Internal Medicine Clinic, Seoul, Korea, 10Department of Psychiatry, Kangdong Sacred Heart Hospital, Seoul, Korea, 11Department of Psychiatry, Hallym University College of Medicine, Chuncheon, Korea
Correspondence to: Chun Soo Lim, Department of Internal Medicine, SMG-SNU Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea. E-mail: ORCID:
Received: August 17, 2017; Revised: February 9, 2018; Accepted: February 20, 2018; Published online: March 31, 2018.
© The Korean Society of Nephrology. All rights reserved.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Many patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) experience depression. Depression influences patient quality of life (QOL), dialysis compliance, and medical comorbidity. We developed and applied a group cognitive behavioral therapy (CBT) program including mindfulness meditation for ESRD patients undergoing HD, and measured changes in QOL, mood, anxiety, perceived stress, and biochemical markers.


We conducted group CBT over a 12-week period with seven ESRD patients undergoing HD and suffering from depression. QOL, mood, anxiety, and perceived stress were measured at baseline and at weeks 8 and 12 using the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF), the Beck Depression Inventory II (BDI-II), the Hamilton Rating Scale for Depression (HAM-D), the Beck Anxiety Inventory (BAI), and the Perceived Stress Scale (PSS). Biochemical markers were measured at baseline and after 12 weeks. The Temperament and Character Inventory was performed to assess patient characteristics before starting group CBT.


The seven patients showed significant improvement in QOL, mood, anxiety, and perceived stress after 12 weeks of group CBT. WHOQOL-BREF and the self-rating scales, BDI-II and BAI, showed continuous improvement across the 12-week period. HAM-D scores showed significant improvement by week 8; PSS showed significant improvement after week 8. Serum creatinine levels also improved significantly following the 12 week period.


In this pilot study, a CBT program which included mindfulness meditation enhanced overall mental health and biochemical marker levels in ESRD patients undergoing HD.

Keywords: Cognitive behavioral therapy, Depression, Mindfulness, Quality of life, Renal dialysis

Many patients with end-stage renal disease (ESRD) are faced with lifestyle restrictions in diet, fluid intake, and medication. They must also adhere to hemodialysis (HD) or peritoneal dialysis schedules. Therefore, they often feel they have lost control of their lives and experience poor quality of life (QOL) [1,2]. These feelings induce non-adherence to medical guidelines, which may exacerbate medical problems [1].

The rate of non-adherence to diet, fluid intake, and medication regimens has been reported to range from 30% to 60% in ESRD patients receiving dialysis [1]. Depression is common in ESRD patients (20–30%) [3,4], and causes reduced QOL [5,6], poor adherence to dialysis treatment [7], and increased mortality [8] and suicidality [9].

Pharmacological intervention for depression is ineffective for many ESRD patients [10]; therefore, non-pharmacological interventions have been used to treat psychiatric problems including depression. Strategic self-presentation, kidney disease education, supportive psychotherapy, and group intervention have been shown to reduce depression and progression of renal disease [1115]. Individual cognitive behavioral therapy (CBT) has been shown to improve depressive mood and QOL [12]. Mindfulness-based cognitive therapy (MBCT) [16], which is related to mindfulness-based stress reduction (MBSR) [17], also shows efficacy in preventing relapse of depression. MBSR can enhance adaptation to distress from chronic illness, and has a strong potential for benefit for ESRD patients [17]. A previous study described telephone-adapted MBSR for patients awaiting kidney transplantation [18], but few studies have applied MBSR or MBCT to patients with ESRD.

Patients with ESRD need intervention focused on their psychological characteristics to reduce medical non-adherence. Individual CBT programs are difficult to apply in clinical settings due to lack of time and the limited number of experts available. Therefore, in this pilot study, we developed a 12-week group CBT program that included mindfulness meditation, anger management, and communication skills training based on conventional CBT [19]. We measured overall QOL, mood, anxiety, and distress in ESRD patients undergoing HD and suffering from depression, at baseline and after eight and 12 weeks of group CBT to evaluate its effectiveness and feasibility.



Seven participants (three women and four men) were enrolled in the study. Due to their HD schedules, we divided them into three groups of 2 to 3 participants each. Participants completed 12 one-hour sessions with the same psychologist once a week in the same room. All participants underwent HD for four hours, three times per week. Participants were patients at the SMG-SNU Boramae Medical Center and at one local clinic connected to this center. Inclusion criteria were age ≥ 20 years, ESRD treatment with HD for ≥ 3 months, Beck Depression Inventory (BDI-II) score ≥15, and major depressive disorder diagnosed by a single psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition, text revision (DSM-IV-TR) [20]. Exclusion criteria were HD due to acute renal failure, current hospitalization, current ongoing chemotherapy or radiotherapy, kidney transplantation planned within a few months, cognitive dysfunction or mental retardation, current substance abuse, lack of fluency in Korean, and current use of psychotropic medication.

This study was approved by the Institutional Review Board of the SMG-SNU Boramae Medical Center (IRB No. 16-2013-71). Informed consent was obtained from all participants after providing full information about the study. This study was registered on (NCT02011139).

Organization of the CBT program (Table 1)

We modified the conventional CBT program because patients with ESRD have unique psychological characteristics. We organized the CBT program into three parts: In the initial phase (sessions 1–3), the program included an introduction, motivation, and muscle relaxation. In this phase, to raise participants’ motivation, we helped them set goals and provided information on the influence of stress on the body. Muscle relaxation included preparation for mindfulness meditation in the next phase. In the middle phase (sessions 4–7), skills for controlling negative feelings and pain were included with a body scan and mindfulness meditation [16,21]. In this phase, we encouraged participants to identify automatic thinking related to their emotions. The mindfulness meditation was divided into two parts: breathing and movement [16]. Through the meditation and self-soothing techniques, we helped participants overcome obsession with physical pain or automatic thinking and encouraged positive feelings. In the final phase, social skills training was included with anger management. For effective communication with their caregivers or medical staff, we included conversation skills training and practice in common situations with other participants [15,22]. To increase participants’ motivation and program effectiveness, we included a brief homework assignment between every session. We administrated the program once a week with the same psychologist.

Assessment measures

Except for self-rating questionnaires, all assessments were performed by a single psychiatrist who did not attend group CBT. Assessments were made on the same day as CBT, before the first and eighth sessions, and after the 12th session. Participants underwent HD after each group CBT. We evaluated QOL using the World Health Organization QOL assessment, WHOQOL-BREF [23]. WHOQOL-BREF total score was the sum of physical, psychological, social, and environmental domains, and two general items. Higher scores indicate better QOL. Depressive symptom severity was measured using BDI-II [24], a self-rating assessment, and by the Hamilton Rating Scale for Depression (HAM-D) [25], rated by a clinician. The BDI-II assessment has 21 items with a maximum score of 63, and the HAM-D assessment has 17 items with a maximum score of 52; higher scores indicate more severe depression. To evaluate anxiety and stress, participants completed the Beck Anxiety Inventory (BAI) [26] and 10 items of the Perceived Stress Scale (PSS) [27]. BAI is a self-reported questionnaire of 21 items on a four-point Likert scale, where a higher score indicates more severe anxiety. PSS is also a self-reported survey on a four-point Likert scale, where a higher score indicates a more stressful state. The Temperament and Character Inventory (TCI) [28] was included at baseline to evaluate the patients’ characteristics before group CBT. TCI is a self-rated assessment consisting of 240 yes-no questions. It has seven dimensions, including four traits (novelty seeking, NS; harm-avoidance, HA; reward-dependence, RD; and persistence, PE) and three characteristics (self-directedness, SDT; cooperativeness, CO; and self-transcendence, ST). Higher scores indicate that the participant has a greater degree of the specific characteristic, with a score of ≥ 55 classified as High, ≤ 45 as Low, and others as Medium, according to the TCI manual [28].

We evaluated the biochemical variables, Kt/V, albumin, serum creatinine (sCr), calcium/phosphorus (Ca/P), and interdialytic weight gain (IDWG), before and after 12 weeks of group CBT.

Statistical analysis

Generalized estimating equations (GEE) were used to compare BDI-II, HAM-D, BAI, PSS, and WHOQOL-BREF scores across the 12-week period. GEE have the benefit of analyzing correlations of repeated results within-subject. We used the Wilcoxon signed-rank test to compare biochemical marker levels before and after group CBT. All statistical analyses were performed using IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA).


The demographic characteristics of the participants are summarized in Table 2. Mean age was 56.4 ± 7.9 years (range, 48–67 years), mean education level was 10.4 ± 2.5 years (range, 6–13 years), and only one participant had a current occupation. Four participants had diabetes mellitus as the main underlying disease related to HD; other underlying diseases were hypertension or other/unknown cause. Although most of the participants had combined medical diseases including chronic lung disease, peptic ulcer, cerebrovascular disease, and coronary artery disease, their overall physical states were stable during CBT. Mean dialysis vintage was 2.5 ± 0.6 years (range, 1.7–3.5 years). One participant had a history of kidney transplantation.

At baseline, mean Kt/V was 1.3 ± 0.2 (range, 1.0–1.6); serum albumin was 4.0 ± 0.3 g/dL (range, 3.7–4.7 g/dL); sCr was 11.5 ± 3.5 mg/dL (range, 7.4–17.2 mg/dL); Ca/P was 8.4/5.1 ± 0.5/2.2 mg/dL (range, 7.5/2.7–8.8/8.7 mg/dL); IDWG was 2.6 ± 0.6 kg (range, 1.5–3.0 kg) (Table 2).

Before group CBT, participants had moderate to severe depressive moods as measured by self-rating (BDI-II; mean score, 32.0 ± 8.1; range, 22–43) and clinician rating (HAM-D; mean score, 19.4 ± 4.4; range, 14–26) (Fig. 1). The mean total QOL score measured by WHOQOL-BREF was 61.9 ± 11.3 (range, 48–82). Anxiety levels were mild (BAI; mean, 14.0 ± 10.4; range, 0–27), and stress levels were moderate (PSS; mean, 19.4 ± 7.1; range, 9–28). In the TCI, participants showed high HA (mean, 57.4 ± 11.4; range, 41–69), low RD (mean, 42.0 ± 10.1; range, 28–54), low SDT (mean, 41.4 ± 11.4; range, 25–56), and low CO (mean, 42.9 ± 4.4; range, 38–52) (Fig. 2).

After participants completed all 12 CBT sessions, mean Kt/V was 1.5 ± 0.3 (range, 1.2–2.0); serum albumin was 4.0 ± 0.2 g/dL (range, 3.8–4.3 g/dL); sCr was 10.3 ± 2.7 mg/dL (range, 7.2–13.5 mg/dL); Ca/P was 8.8/4.9 ± 0.6/1.0 mg/dL (range, 7.9/3.5–9.7/6.5 mg/dL); and IDWG was 2.4 ± 0.7 kg (range, 1.5–3.0 kg). In a Wilcoxon signed-rank test, Kt/V and sCr showed significant improvement (P = 0.063 and 0.043, respectively). Other variables did not show a significant change (Table 2).

Participants showed significant improvement in all rating scores compared to baseline (Fig. 1). QOL by WHOQOL-BREF showed significant improvement (mean, 84.1 ± 8.7; range, 71–92; P < 0.001). In mood scales, both BDI-II and HAM-D scores significantly decreased to normal or minimal depressive levels (BDI-II: mean, 6.1 ± 3.8; range, 2–12; P < 0.001 and HAM-D: mean, 5.7 ± 1.5; range, 4–8; P < 0.001). BAI and PSS scores also showed significant improvement after 12 weeks of group CBT (BAI: mean, 4.3 ± 3.4; range, 0–8; P < 0.001 and PSS: mean, 12.3 ± 3.0; range, 7–16; P < 0.001). WHOQOL-BREF scores and the self-rating BDI-II and BAI scales showed significant improvement continuously across the 12 weeks. HAM-D scores showed significant improvement by week 8; PSS showed significant improvement after week 8 (Fig. 1).


After our 12-week group CBT program, ESRD patients undergoing HD showed significant improvements in WHOQOL-BREF, BDI-II, HAM-D, BAI, and PSS scores, and in sCr levels. WHOQOL-BREF, BDI-II, and BAI scores showed continuous improvement at each evaluation over the 12-week period. HAM-D scores improved at week 8 but not during last four weeks; PSS scores showed significant improvement after week 8.

We suspect that these results are related to the themes of the CBT program. Until the second evaluation period (starting at week 8), patients experienced mainly mindfulness meditation, correction of automatic thinking, and self-soothing techniques. Scores on objective mood (HAM-D) showed significant improvement in depressive symptoms starting at week 8, after the second period containing conventional CBT and mindfulness meditation. We expect that, with the accumulated effect of prior sessions, the terminal themes of the program such as anger management and communication skills help participants gain feelings of self-control, and these feelings might improve perceived stress. For QOL and subjective improvement of depression and anxiety, we think that most themes of our group CBT program might be helpful.

Mean baseline scores of BDI-II and HAM-D were 32 ± 8.10 and 19.43 ± 4.43, respectively. These scores are much higher than the suggested cut-off values for depression for ESRD patients undergoing HD in other studies (14–16 for BDI [22], and 10 for HAM-D [29]). The mean total score on the WHOQOL-BREF in our participants was 61.9 ± 11.3 at baseline. This score was similar to or higher than scores reported in other studies of elderly patients with chronic kidney disease or depression [30,31]. Compared with a QOL study of chronic kidney disease patients, our patients reported relatively low social domain and high environmental domain scores. We suppose that our patients’ relatively severe depressive symptoms and regular HD schedule might have caused a lower social domain score, while a stable national medical insurance and care system for ESRD in Korea might have caused a higher environmental score.

In TCI, participants showed high HA and low RD in trait dimensions and low SDT and low CO in character dimensions. High HA, low SDT, and low CO are related to depression [32]. Therefore, our participants had traits and characteristics consistent with depression. Throughout our program, they reported improvement of mood and QOL.

It is common for ESRD patients undergoing HD to experience low QOL, feelings of loss of control in their lives, depressive mood, and anxiety. These feelings often induce non-adherence to medical treatment [33]. In this study, improvement of the biochemical variables sCr and Kt/V suggests that our program induced better medical adherence. A previous study also reported improved IDWG following conventional CBT [12].

The main psychological mechanism in which mindfulness meditation reduces psychiatric problems including depression is reperceiving [34,35]. In mindfulness practice, moment-by-moment nonjudgmental awareness is essential. Through nonjudgmental awareness, one reperceives problems with objectivity and greater clarity [35]. This process helps one to control unpleasant sensations. This process is also related to self-regulation, decreased emotional reactivity, clarification of values, and cognitive-behavioral flexibility. Self-regulation provides coping skills and prevents maladaptive responses. Cognitive and behavioral flexibility induce adaptive responses. Values clarification facilitates choosing behaviors more congruent with one’s core values [34,35]. It has been reported that mindfulness is related to cortical midline structures (CMS), the amygdala, anterior insula, and lateral prefrontal cortex [35]. As the CMS is involved in emotional processing, this structure may have a role in self-referential thinking and emotional dysregulation in mood disorders [35,36]. Modifying the CMS has been suggested to be one of the key mechanisms of mindfulness [35].

We developed a group CBT program for ESRD patients undergoing HD who experience depression that addressed the patients’ psychological character. In our program, patients experienced psychoeducation, correction of automatic thinking, mindfulness meditation, and communication skills practice. As a result, participants showed significant improvements in QOL, depressive mood, anxiety, perceived stress, and biochemical marker levels. In a clinical situation, this group CBT program would be helpful for all depressive patients, especially those who cannot take psychiatric medications due to physical conditions or who show no significant improvement following medication. We expect that it would be easier to manage such a program if group members have a similar age and educational level.

Although our group CBT program was feasible and effective, some limitations exist. First, the sample size was small. Second, our participants had less comorbid illness and more medical stability than many other patients with ESRD. Additionally, we used small groups of 2 to 3 participants. These characteristics may have affected participant compliance and improvement. Third, this study was not controlled and did not use a blinded test. Fourth, we did not carry out a longitudinal follow-up after our group CBT program and therefore could not confirm the long-term effect. In the future, a randomized controlled study with a larger sample size and long-term observation will be needed.

In conclusion, our group CBT program, including mindfulness meditation and practical distress-relieving methods such as self-soothing, anger management, and communication skills practice in the framework of conventional CBT, was feasible and effective. Our program was applied to chronic ESRD patients undergoing HD and resulted in improvement in overall psychiatric problems such as low QOL, depressive mood, anxiety, and stress, which might influence patients’ medical compliance.


This work was supported by a clinical research grant-in-aid from the SMG-SNU Boramae Medical Center (16-2013-71).

Conflicts of interest

All authors had no conflicts of interest to declare.

Fig. 1. BAI, Beck Anxiety Inventory; BDI-II, Beck Depression Inventory II; HAM-D, Hamilton Rating Scale for Depression; PSS, Perceived Stress Scale; WHOQOL-BREF, World Health Organization Quality of Life scale, abbreviated version.
Fig. 2. CO, cooperativeness; HA, harm-avoidance; NS, novelty seeking; PE, persistence; RD, reward-dependence; SDT, self-directedness; ST, self-transcendence; TCI, Temperament and Character Inventory.

Summary of group cognitive behavioral therapy (CBT) themes

1Introduction of CBT program, therapist, and group members
2Talking about stress regarding chronic kidney disease and hemodialysisUnderstanding of stress and depressionProgressive muscular relaxation
3Finding valuesSetting goalsProgressive muscular relaxation
4Recognizing automatic thinking and relationship between thinking and emotionBody scan practice
5Mindfulness meditation I (breathing)
6Mindfulness meditation II (movement)
7Self-soothing techniques: self-comfort for experiencing positive feelings
8Anger management
9Effective communication skills I (introduction)
10Effective communication skills II (practicing): delivery of feeling, needs, favor
11Effective communication skills III (practicing): listening, compromising, acceptance
12Summary of the program themesMaking goalsPlanning for stress management

Demographic data and biochemical variables during the group cognitive behavioral therapy (CBT)

ParticipantSex/age (yr)Education (yr)OccupationMain disease associate HDPrevious KTDialysis vintage (yr)Kt/VAlbumin (g/dL)sCr* (mg/dL)Ca/P (mg/dL)IDWG (kg)


Ca/P, calcium/phosphorus; DM, diabetes mellitus; F, Female; HD, hemodialysis; HTN, hypertension; IDWG, interdialytic weight gain; KT, kidney transplantation; M, male; sCr, serum creatinine. Before, before group CBT; After, after group CBT.

*P = 0.043 by Wilcoxon signed ranks test.

  1. Christensen, AJ, and Ehlers, SL (2002). Psychological factors in end-stage renal disease: an emerging context for behavioral medicine research. J Consult Clin Psychol. 70, 712-724.
    Pubmed CrossRef
  2. Perlman, RL, Finkelstein, FO, and Liu, L (2005). Quality of life in chronic kidney disease (CKD): a cross-sectional analysis in the Renal Research Institute-CKD study. Am J Kidney Dis. 45, 658-666.
    Pubmed CrossRef
  3. Cukor, D, Coplan, J, and Brown, C (2007). Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol. 2, 484-490.
    Pubmed CrossRef
  4. Hedayati, SS, Bosworth, HB, Kuchibhatla, M, Kimmel, PL, and Szczech, LA (2006). The predictive value of self-report scales compared with physician diagnosis of depression in hemodialysis patients. Kidney Int. 69, 1662-1668.
    Pubmed CrossRef
  5. Kimmel, PL, Emont, SL, Newmann, JM, Danko, H, and Moss, AH (2003). ESRD patient quality of life: symptoms, spiritual beliefs, psychosocial factors, and ethnicity. Am J Kidney Dis. 42, 713-721.
    Pubmed CrossRef
  6. Drayer, RA, Piraino, B, and Reynolds, CF (2006). Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk. Gen Hosp Psychiatry. 28, 306-312.
    Pubmed CrossRef
  7. Cukor, D, Rosenthal, DS, Jindal, RM, Brown, CD, and Kimmel, PL (2009). Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int. 75, 1223-1229.
    Pubmed CrossRef
  8. Hedayati, SS, Bosworth, HB, and Briley, LP (2008). Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression. Kidney Int. 74, 930-936.
    Pubmed CrossRef
  9. Kurella, M, Kimmel, PL, Young, BS, and Chertow, GM (2005). Suicide in the United States end-stage renal disease program. J Am Soc Nephrol. 16, 774-781.
    Pubmed CrossRef
  10. Kimmel, PL, Weihs, K, and Peterson, RA (1993). Survival in hemodialysis patients: the role of depression. J Am Soc Nephrol. 4, 12-27.
  11. Binik, YM, Devins, GM, and Barre, PE (1993). Live and learn: patient education delays the need to initiate renal replacement therapy in end-stage renal disease. J Nerv Ment Dis. 181, 371-376.
    Pubmed CrossRef
  12. Cukor, D, Ver Halen, N, and Asher, DR (2014). Psychosocial intervention improves depression, quality of life, and fluid adherence in hemodialysis. J Am Soc Nephrol. 25, 196-206.
    KoreaMed CrossRef
  13. Friend, R, Singletary, Y, Mendell, NR, and Nurse, H (1986). Group participation and survival among patients with end-stage renal disease. Am J Public Health. 76, 670-672.
    Pubmed KoreaMed CrossRef
  14. Hener, T, Weisenberg, M, and Har-Even, D (1996). Supportive versus cognitive-behavioral intervention programs in achieving adjustment to home peritoneal kidney dialysis. J Consult Clin Psychol. 64, 731-741.
    Pubmed CrossRef
  15. Leake, R, Friend, R, and Wadhwa, N (1999). Improving adjustment to chronic illness through strategic self-presentation: an experimental study on a renal dialysis unit. Health Psychol. 18, 54-62.
    Pubmed CrossRef
  16. Ma, SH, and Teasdale, JD (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 72, 31-40.
    Pubmed CrossRef
  17. Kabat-Zinn, J (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Bantam Books
  18. Reilly-Spong, M, Reibel, D, Pearson, T, Koppa, P, and Gross, CR (2015). Telephone-adapted mindfulness-based stress reduction (tMBSR) for patients awaiting kidney transplantation: Trial design, rationale and feasibility. Contemp Clin Trials. 42, 169-184.
    Pubmed KoreaMed CrossRef
  19. Beck, AT, Rush, AJ, Shaw, BF, and Emery, G (1979). Cognitive Therapy of Depression. New York: Guilford Press
  20. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association
  21. Williams, M, and Penman, D (2011). Mindfulness: A Practical Guide to Finding Peace in a Frantic World. London: Piatkus Books
  22. Hedayati, SS, Yalamanchili, V, and Finkelstein, FO (2012). A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney Int. 81, 247-255.
    KoreaMed CrossRef
  23. The WHOQOL Group (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med. 28, 551-558.
  24. Beck, AT, Steer, RA, and Brown, GK (1996). Maunal for the Beck Depression Inventory-II. San Antonio: The Psychological Corporation
  25. Hamilton, M (1960). A rating scale for depression. J Neurol Neurosurg Psychiatry. 23, 56-62.
    Pubmed KoreaMed CrossRef
  26. Beck, AT, Epstein, N, Brown, G, and Steer, RA (1988). An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 56, 893-897.
    Pubmed CrossRef
  27. Cohen, S, and Williamson, G (1988). Perceived stress in a probability sample of the United States. The Social Psychology of Health: Claremont Symposium on Applied Social Psychology, Spacapan, S, and Oskamp, S, ed. Newbury Park: Sage, pp. 31-67
  28. Cloninger, RC, Przybeck, TR, Svrakic, DM, and Wetzel, RD (1994). The Temperament and Character Inventory (TCI): A Guide to Its Development and Use. Center for Psychobiology of Personality. St. Louis: Washington University
  29. Gençöz, F, Gençöz, T, and Soykan, A (2007). Psychometric properties of the Hamilton Depression Rating Scale and other physician-rated psychiatric scales for the assessment of depression in ESRD patients undergoing hemodialysis in Turkey. Psychol Health Med. 12, 450-459.
    Pubmed CrossRef
  30. Chang, YC, Ouyang, WC, Lu, MC, Wang, JD, and Hu, SC (2016). Levels of depressive symptoms may modify the relationship between the WHOQOL-BREF and its determining factors in community-dwelling older adults. Int Psychogeriatr. 28, 591-601.
  31. Tsai, YC, Hung, CC, and Hwang, SJ (2010). Quality of life predicts risks of end-stage renal disease and mortality in patients with chronic kidney disease. Nephrol Dial Transplant. 25, 1621-1626.
  32. Hirano, S, Sato, T, and Narita, T (2002). Evaluating the state dependency of the Temperament and Character Inventory dimensions in patients with major depression: a methodological contribution. J Affect Disord. 69, 31-38.
    Pubmed CrossRef
  33. Christensen, AJ, Smith, TW, Turner, CW, and Cundick, KE (1994). Patient adherence and adjustment in renal dialysis: a person x treatment interactive approach. J Behav Med. 17, 549-566.
    Pubmed CrossRef
  34. Shapiro, SL, Carlson, LE, Astin, JA, and Freedman, B (2006). Mechanisms of mindfulness. J Clin Psychol. 62, 373-386.
  35. Marchand, WR (2013). Mindfulness meditation practices as adjunctive treatments for psychiatric disorders. Psychiatr Clin North Am. 36, 141-152.
    Pubmed CrossRef
  36. Northoff, G, and Bermpohl, F (2004). Cortical midline structures and the self. Trends Cogn Sci. 8, 102-107.


This Article


Indexed/Covered by