Expressive Writing in Kidney Transplant Patients
Condition: Kidney Transplant Rejection
Study type: Interventional

Summary: 
      Kidney transplantation is a replacement treatment for chronic renal failure that improves
      quality of life. However, it can be experienced as traumatic in relation to the changes it
      entails in terms of lifestyle, redefinition of one's body and social and family role. A
      negative personal experience could affect adherence to the treatment, a protective factor in
      reducing the risk of organ rejection and mortality. Some studies have shown the effectiveness
      of expressive writing in reducing the symptoms and management of the disease in patients
      undergoing surgery or suffering from cancer. It is hypothesized that this technique allows
      the processing of traumatic events linked to the disease, favoring an improvement in the
      expression and emotional regulation skills.

      The aim of the present study was to evaluate the effectiveness of a psychological
      intervention focused on expressive writing on the post-operative course in patients underwent
      to kidney transplantation. Thirty-five patients were recruited at the kidney transplant
      center of the Policlinico Umberto I, Rome. The sample was divided into 2 groups: the
      psychological intervention focused on expressive writing group and the control group which
      carried out a neutral writing task. Each patient filled some self-report questionnaires and
      carried out blood analysis, before the operation, the day of discharge and at 3 month
      follow-up. The psychological intervention group was expected to have a greater improvement in
      the emotional skills, adherence and renal function, and a lower level of healthcare costs
      compared to the control group.
    

Detailed description: 
      Kidney transplantation is a replacement therapy in chronic renal failure which could allow a
      better quality of life. However, renal transplantation also represents an emotionally strong
      experience, which is associated with feelings of acceptance of the transplanted organ, change
      in lifestyle, side effects of pharmacotherapies, anxiety, depression, redefinition of one's
      body, as well as one's own social and family role. For these reasons it can be experienced as
      a traumatic event and be associated with an unfavorable post-operative course, in particular
      with regard to adherence to medical prescriptions and the consequent increase in the
      possibility of rejection.

      Adherence, in fact, implies the correct management of drugs and the constant and assiduous
      presence at pre-established check-ups at the transplant center, taking the required exams and
      promptly reporting any complications. In kidney transplant patients, adherence to
      immunosuppressive therapies becomes fundamental to reduce the risk of organ rejection or, in
      the most extreme cases, the risk of death. Several studies show the importance of adherence
      to post-operative course treatment in different types of transplant. Furthermore, it has been
      shown that poor levels of adherence, recognized as a risk factor for organ rejection, are
      associated with an increase in healthcare costs.

      Young age, depression, anxiety and avoidant-type adaptation strategies (eg avoiding the
      stressful event) are some of the risk factors of non-adherence in kidney transplant patients.
      Also alexithymia (known as the inability to identify and describe emotions), the inability to
      regulate intense emotional states, and attachment style, are associated with poor levels of
      post-transplant adherence.

      Possemato and collaborators (2010), showed the efficacy of an intervention that uses
      expressive writing in the reduction of post-traumatic stress symptoms in kidney transplant
      patients. This technique seems to be effective also in patients with chronic pathologies and
      cancer, in particular in the reduction of symptoms , in the management of disease and
      psychophysical symptoms in cancer patients. The ways in which this technique acts are not yet
      clear, however it is hypothesized that the externalization and processing of traumatic events
      linked to the disease may favor an improvement in the ability to express emotions, and the
      reduction of negative thoughts and feelings associated. These studies suggest that using the
      technique of expressive writing in kidney transplant patients would allow them to externalize
      and process emotions, feelings and thoughts related to illness, transplantation and
      consequent changes (constant controls and therapies, sudden life style change, drug therapies
      and its effects, physical modifications), and this can favor a mental reorganization of
      negative events, a greater expression and emotions regulation, and an improvement in the
      interpersonal skills with family members and medical staff. Furthermore, this could be
      associated with a greater ability to cope with the consequences and psychophysical changes
      following transplantation and encourage greater levels of adherence with effects on the risk
      of organ rejection and health costs.

      The objective of the study was to verify the effects of the expressive writing, on the
      post-operative course, in term of organ rejection, psychological well-being, adherence and
      healthcare spending in patients undergoing kidney transplantation.

      Thirty-five patients were recruited at the kidney transplant center of the Policlinico
      Umberto I, Sapienza University of Rome. Each participant completed an informed consent form.
      The sample was divided into two groups in a randomized way. Of the 35 patients, 3 were
      excluded for not completing the task, due to logistical problems and due to the hospital
      situation, 1 refuse to perform the writing task, and finally 3 dropped to T2 (3rd
      post-transplant month). Of the remaining 28, 2 had an acute rejection before starting the
      writing task. The final sample is n = 26.

      The study had 3 phases:

        1. Pre-operative phase (T0)

           The time of admission, just before the kidney transplant. In this phase to all
           participants were asked socio-demographic information and specific characteristics of
           the pathology in progress (eg.duration of dialysis treatment, date of transplantation,
           onset of disease). Then, they completed the following self-administered questionnaires:

           Beck Depression Inventory (BDI) for the evaluation of depression, State Trait Anxiety
           Inventory I and II (STAI Y1 - STAI Y2) for the evaluation of trait and state anxiety,
           Toronto Alexythymia Scale 20-item (TAS-20) for assessing the ability to identify and
           describe one's emotions, Interpersonal Reactivity index (IRI) for the evaluation of
           empathy and the Health Locus of Control for the evaluation of the patient's beliefs on
           his state of health and a questionnaire for the evaluation of healthcare costs, built ad
           hoc.

           To assess the level of adherence, each patient answered to the following question: "Have
           you ever forgotten to take drugs prescribed by your treatment plan? "with dichotomous
           answer yes / no. Finally, in order to assess the pre-transplant renal function values,
           such as Creatinine, CDK-EPI and azotemia were collected.

        2. Writing Phase (WP) Five days after the operation, patients belonging to the experimental
           group, performed the writing task related to their deepest emotions, thoughts and
           concerns focused on the disease and the transplant itself, for 3 consecutive days, for
           20 minutes a day. They performed the writing session in a closed and silent room, which
           guaranteed their privacy. The instructions were according to the standard delivery by
           Pennebaker, creator of the technique, translated and adapted for the specific hospital
           situation already proposed in a study on urological patients by Solano et al. (2007).
           Instead, the control group performed the neutral writing task, related to the
           description of an object in their room, without mentioning emotions, but just describing
           in a neutral way what they saw, for 3 consecutive days, 20 minutes each day.

        3. The day of discharge Phase (T1) and 4) three months follow up (T2) All participants
           filled the questionnaire completed before the operation and they had the blood analysis
           according to the hospital protocol for transplanted patients.
    

Intervention name(s): Expressive Writing; Neutral Writing
Intervention type(s): Other; Other
Intervention description(s): The expressive writing is a form of writing therapy developed primarily by James W. Pennebaker in the late 1980s consisting of writing about stressful and traumatic experience for 15-20 min for 3 consecutive days, including one's thoughts and feelings. The expressive writing allows people to express and process emotions, feelings, and thoughts related to the life events and consequent changes and this may favor a mental reorganization of the negative events, a greater expression and regulation of the emotions related to them. This intervention could provoke social, emotional, and consequently, psychophysical changes as is showed in patients with chronic diseases and cancer. In the present study, to all participants in the writing group, 5 days after the transplant, has been asked to write for 3 consecutive days, 20 minutes each days about their deepest emotions and feelings related to the chronic failure, the transplant and their expectations after that.; Five days after the transplant, to the control group participants has been asked to write for 3 consecutive days 20 minutes a day on an assigned neutral theme (eg. describe 1 object in the room) as objectively as possible, without mentioning their emotions or thoughts related to it.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Five days after the transplant, to the expressive writing group participants has been asked to write for 3 consecutive days, for 20 minutes a day, their deepest emotions, thoughts and concerns about the disease and the transplant. They wrote in a silent room that guaranteed their privacy. The instructions followed the standard task of Pennebaker, creator of the technique (1986), translated and adapted for the specific hospital situation already proposed in a study on urological patients by Solano et al, 2007.
Similarly, five days after the transplant, to the control group participants has been asked to write for 3 consecutive days 20 minutes a day on an assigned neutral theme (eg. describe 1 object in the room) as objectively as possible, without mentioning their emotions or thoughts related to it.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Expressive writing; Kidney transplant; Adherence; Alexithymia; Healthcare spending