A Mobile-Based Mindfulness Intervention for Reducing Demoralization in Patients on Maintenance Hemodialysis: Randomized Controlled Trial.

Abstract

Patients with end-stage renal disease receiving maintenance hemodialysis experience a substantial symptom burden, and demoralization syndrome-characterized by helplessness, hopelessness, and loss of meaning-is highly prevalent and strongly associated with impaired quality of life. However, the psychological mechanisms linking symptom burden to demoralization remain poorly understood, and scalable, evidence-based interventions targeting demoralization in this population are limited. This study aimed to (1) examine the mechanisms linking symptom burden to demoralization through coping strategies and trait mindfulness and (2) evaluate the efficacy of a mobile-based mindfulness intervention (MMI) in reducing demoralization. Using an explanatory sequential mixed methods design, study 1 involved a cross-sectional survey (N=305) and semistructured interviews (n=14) among patients receiving hemodialysis to identify psychological pathways and clinical intervention needs. Study 2 was a randomized controlled trial in which 72 patients with moderate-to-severe demoralization (Demoralization Scale-II ≥10) were randomized (1:1) to a 6-week WeChat-delivered MMI (n=36) or usual care (n=36). Quantitative data were analyzed using moderated mediation and repeated-measures ANOVA, and qualitative data were analyzed via content analysis. Study 1 quantitative results showed that trait mindfulness negatively moderated the paths from the symptom burden to demoralization (β=-0.11, 95% CI -0.17 to -0.05) and from avoidance coping to demoralization (β=-0.07, 95% CI -0.12 to -0.01). Qualitatively, 4 themes emerged: the psychological experience of demoralization, barriers to the alleviation of demoralization, facilitators of demoralization alleviation, and a strong preference for dialysis-adapted, flexible psychological support. In the study 2 randomized controlled trial, compared with the control group, the MMI group showed significant postintervention improvements in demoralization (mean difference [MD] -5.06, 95% CI -6.92 to -3.20), symptom burden (MD -29.15, 95% CI -46.93 to -11.37), and trait mindfulness (MD 6.48, 95% CI 4.65 to 8.31). Avoidance coping represents an important pathway associated with demoralization among patients with end-stage renal disease receiving maintenance hemodialysis, and trait mindfulness may serve as a protective psychological resource. A tailored MMI showed promising effects in reducing demoralization and improving related psychological outcomes. These findings highlight the potential of scalable digital mindfulness approaches to support psychological care in routine hemodialysis management.